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PHL6420 Principles of Chiropractic - Comprehensive Study Notes (Bullet Points)

Subluxation – Historical Definition

  • A bone (vertebra) out of place pressing on a nerve causing nerve interference

Is a Subluxation Visible on a Radiograph?

  • Consider… if a bone was truly out of place enough to create nerve root compression, would you expect it to be visible on a radiograph?

  • Remember that there are many other structures affecting the area – these are more likely to affect the nerve – discs, ligaments, degenerative changes, vasculature, other space-occupying lesions

  • Can a patient have a normal radiograph and still need an adjustment?

Joint Dysfunction

  • A joint that has lost a degree of normal movement (hypomobility)

  • Would you be able to detect this on a radiograph?

  • How would you detect this?

  • Can it be measured?

  • Can it be corrected?

Terminology Choices

  • Subluxation

  • Joint dysfunction

  • Vertebral subluxation complex (VSC)

  • Joint subluxation/Dysfunction syndrome

  • Joint restriction

  • Joint fixation

  • Subluxation syndrome

  • And more…

Does Terminology Matter?

  • Chiropractic perspective

  • Healthcare perspective

  • Patient perspective

Subluxation vs. Joint Dysfunction

  • Terminology choices – when explaining to patients vs. providers

  • The medical profession defines subluxation as a partial dislocation that is unstable and hypermobile due to a loss of ligamentous integrity

  • Contrast this with the definition of joint dysfunction as a hypomobility

The Vertebral Subluxation Complex (VSC)

  • A theoretical model of motion segment dysfunction (subluxation) that incorporates the complex interaction of pathologic changes in nerve, muscle, ligamentous, vascular and connective tissues. (Bergmann and Peterson, Box 3-1, page 37)

  • Key point: we are not limited to the bony structures – take into account all of the tissues in and surrounding the joint

Components of the VSC

  • Three main categories of effects (B&P): Mechanical, Vascular, Neurological

  • Five components (Gatterman): Neuropathophysiology, Kinesiopathology, Myopathology, Histopathology, Biochemical Changes

Mechanical (Kinesiopathology)

1) Joint restriction (hypomobility)

  • Decreased angular or linear joint motion

  • Damaged articular soft tissue - fibrosis, loss of elasticity

  • Chronic degenerative changes

  • Internal joint derangement

2) Joint hypermobility

  • Increased angular or linear joint motion

  • Usually maintains stability and function under load

  • Potentially reversible

  • Often compensatory to chronic hypomobility elsewhere (HVLA may be needed there!)

  • Candidate for stabilization exercises

3) Clinical joint instability

  • Increased linear and aberrant joint motion

  • Non-reversible changes

  • Abnormal patterns of coupled rotational & translational movement

  • Multiple planes of aberrant movement

  • Typically not a Chiropractic candidate for adjusting in that area or may need surgical stabilization (severity dependent)

    • Mechanical (Kinesiopathology) – What parts of our chiropractic examination can we use to identify the mechanical components?

Vascular (Histopathology/Biochemical)

  • Vascular congestion and venous stasis

  • Inflammatory response

  • Edema/swelling

  • Vascular (Histopathology/Biochemical) – What parts of our chiropractic examination can we use to identify the vascular components?

  • Note: Some of these signs may indicate a pathology that contraindicates chiropractic care!

Neurological (Neuropathophysiology)

  • Historical view: nerve root compression (garden hose theory), bone out of place pressing on a nerve

  • Current view: altered nociceptive and proprioceptive input, typically associated with increased nociception coupled with a decrease in mechanoreceptor activity

Is that all there is to chiropractic?

  • Do not limit the patient to a joint dysfunction diagnosis

  • Joint dysfunction can be a standalone diagnosis but…

  • Must investigate further – why is the joint dysfunctional?

  • Diagnosis is essential! i.e., Disc herniation vs. facet syndrome

  • Both may result in joint dysfunction in the surrounding areas

  • However pathomechanics differ as may treatment approach

  • Potential for contraindications…

Can Joint Dysfunction in the Spine Affect Non-MSK Tissues?

  • Meric chart – a view that mapped specific vertebrae to corresponding visceral structures

  • Clinical validity and implications still heavily debated

  • Based primarily on observation of early chiropractors and neuroscience understanding at the time

Can Joint Dysfunction in the Spine Affect Non-MSK Tissues? (continued)

  • Research and current views on chiropractic and non-musculoskeletal tissues focuses heavily on the role of the sympathetic nervous system

  • Still a poorly understood area that needs additional research

  • Chiropractic management of these conditions limited due to scope and the extent of the research

  • More details on these topics will be discussed at the end of the trimester and in future courses

Historical Overview

  • Spinal Irritation (title only; historical topic covered in slides)

Spinal Irritation

  • Spinal irritation became an entity in 1828 when Thomas Brown coined the term in the Glasgow Medical Journal

  • It appeared in the American Journal of Medical Sciences in 1832

  • The idea: tenderness of a vertebra corresponded to a diseased organ

Spinal Irritation – J. Evans Riadore

  • J. Evans Riadore – Irritation of Spinal Nerves; considered the contemporary father of the nerve compression hypothesis at the time

  • Quote: “if any organ is deficiently supplied with nervous energy or of blood, its functions immediately, and sooner or later its structure, become deranged.”

  • Riadore encouraged manipulation to treat spinal irritation (2 years before Palmer’s birth)

D.D. Palmer

  • “We adjust displaced vertebrae. Subluxations in the spine. The vertebrae are wrenched, displaced. Chiropractic is the adjustment of vertebrae. Spinal adjustments replace vertebrae into line. Stimulus occluded, normal and abnormal foramina.”

  • (D.D. Palmer, quoted from The Chiropractic Adjuster, p. 105)

  • Founder of Chiropractic

  • Subluxation terminology and idea of bone out of place (Palmer’s account of the first adjustment)

  • No radiographs used at the time to “see” a bone out of place

D.D. Palmer – Inflammation and Early Theories

  • Palmer’s first theory was focused on inflammation

  • Inflammation described as “the result of displacement of any body part: nerve, artery or vein…bone, ligament or muscle.”

  • Palmer manipulated any displaced anatomy to prevent or relieve friction, thought to trigger heat and inflammation

  • Within 3 years the inflammation hypothesis was refined and published as “Luxation of Bones Cause Disease”

  • Palmer believed muscles, nerves, and bones were key in displacement causing pressure, which could be relieved by adjustments

D.D. Palmer – Causes of Subluxation & Nerve Tone

  • Palmer hypothesized causes of subluxation: Trauma (Physical), Toxins (Chemical), Thoughts/Autosuggestion (Psychological/emotional)

  • Soon added vibratory theory, stating that nerves vibrated normally at 200 times per minute; this represented the TONE of the nervous system

Innate Intelligence

  • Quote by D.D. Palmer on Innate: “Innate - born with. And so far I would not change it except to replace it with the name of that individualized entity which really is a part or portion of that All Wise, Almighty, Universal Intelligence…the healing power of nature.” (1910)

B.J. Palmer

  • Considered the “Developer” of Chiropractic

  • In 1934 established 4 criteria for subluxation:

    • Misalignment of vertebra in relation to adjacent segments

    • Occlusion of a foramen (including the canal)

    • Pressure on spinal nerve roots (or the cord)

    • Interference to transmission of mental impulses (nerve function)

  • Later in his career he focused on the upper cervical region; a focus on C1 (atlas) resulted in his hypothesis that a C1 subluxation would cause compression of the spinal cord; this focus resulted in B.J.’s HIO technique

Should the development of Chiropractic Stop with the Palmers?

  • Question raised about whether the historical development should have stopped with the Palmers

Langworthy, Smith, and Paxon

  • Divisions in the profession sprung up in the early days

  • Graduates of Palmer’s chiropractic program

  • Published “Modernized Chiropractic” (1906) which rejected the “bone out of place” theory as too simplistic and favored a focus on joint fixation/motion restriction

  • This separate idea/text was used to defend chiropractors arrested for practicing medicine without a license (debated?)

C.O. Watkins

  • Primary advocate of applying the scientific method to chiropractic practice, research, and education

  • Believed chiropractors should generate clinical data and publish clinical research

  • Public relations should be modest and should not masquerade as science

Joint Fixation and Inflammation

  • Marcel and Henri Gillet – Belgian chiropractors – along with Swiss chiropractor Fred Illi revitalized the concept of lack of proper joint motion

  • An injured joint becomes fixated as edema develops around strained capsule and tissues

  • A focus on pelvic and spinal biomechanics led them to conclude that “one cannot put a vertebra back into place the way one does a fracture or dislocation. What one really does is: to restore the function of a vertebra.”

Illi’s Definition of Chiropractic

  • Quote: “The art and science concerned with the study and treatment of the mechanics, statics and dynamics of the human body, particularly of the vertebral column and pelvis, for the primary purpose of eliminating neuropathological reflexes and their consequences.” — Fred Illi