The Atlas Subluxation Complex in the Context of the Tensegral Array

This paper is reprinted from the November 2011 Quantum Spinal Mechanics Newsletter published by Dr. Russell Friedman.

Michael D. Thomas, D.C.

Note: Tensegrity is the way nature designs structures.  In a tensegral array, the compressive elements are said to be discontinuous.  This means they don’t touch each other.  Bones are compressive structures.  The tensional elements in a tensegrity array are continuous.  This means that the muscles and ligaments and the whole myofascial envelope is continuous and forces are dissipated evenly throughout the entire array.  Dr. Friedman has discussed tensegrity at some length in the past but this is a short explanation.  The reader is already aware of the historical definition for the Atlas Subluxation Complex.

Grostic and Wernsing contemporaneously and yet independently, according to the Orthospinology text, conceived of the possibility that the frontal plane rotation of the atlas under the skull, what we have called atlas side-slip, or atlas laterality, could be measured in degrees (a situation apparently analogous to Liebnitz and Newton who simultaneously but independently discovered the principles of calculus) .  This idea was one significant aspect of Grostic’s basic elemental relationship between the condylar and axial circles (C/A).

Grostic believed that atlas laterality was the primary cause of neurological interference.  Postural distortion is not measured in the absence of at least ¾ degree of atlas laterality.  This confluence of events came to be seen in upper cervical work as cause and effect.

The area is dense with neurology and the dentate (pia) ligaments often attach at the craniovertebral junction.    J.D. Grostic hypothesized a dentate ligament tractionization theory to explain the possible effects of upper cervical (atlas) misalignment.  It appears that even a small amount of atlas laterality is associated with changes in blood flow into and out of the head as well as associated tractional or torsional changes.  It is established that mechanical forces alter function at the cellular level as well as in the nuclei of the upper cord and brainstem.

Current studies in the chiropractic profession as well as medicine are examining the role of upper cervical misalignment and alteration in blood flow (compliance) into and out of the head.  CSF flow may also be altered.  Restoration of alignment appears to greatly improve compliance.  Misalignment is asymmetrical by its nature and therefore affects blood flow differently on each side.

The concept of tensegrity as promulgated by Levin and Ingber (as well as many others) was seen as debatable until fairly recently.  It seems now however, that the literature has been able to define the cell as a tensegral structure, although looking at the whole body biomechanically as a tensegral array remains a bit controversial.  Work has been done to define the pathways used in the array (Thomas Myers- Anatomy Trains).

Our perspective as orthogonally based upper cervical doctors predisposes us to see relationships that are not apparent to others who do not consistently look at the aspects we focus on.  The concept of tensegrity has been empirically accepted by Dr. Friedman who has expanded the concept of bone out of place, segmental misalignments, and other partial examinations of the soft tissue/skeletal system to include the whole organism.  His biomechanical conceptualization regarding the principle of tensegrity in the upper cervical area as well as the rest of the body has begun to make the longstanding understanding that the upper cervical adjustment is a full spine approach an integrated reality.

In a tensegral array there are no actual lever systems because there are no fulcrums.  When in proper apposition, the skeletal elements do not touch each other.  A lever arm must have a fulcrum with which to do its work.  It is the tensional elements (the muscles, ligaments and tendons and the whole myofascial envelope that are under continuous tension.  The skeletal (compressive) elements are discontinuous (separate) in the system.  When a tensegral array comes under axial tension, the compressive elements (the bones) line up with the tensional elements, stiffening the whole system in order to resist these deleterious torsional forces.

Bones do not lock out of place.  They don’t even touch each other unless there is local collapse of the tensegral array.  The tensional elements may, under deleterious forces, buckle or compress.  When this occurs in the low back, there is progressive degeneration of the spinal elements as they attempt to adapt to deleterious forces.  When this occurs at the craniovertebral junction it appears to cause a change in the symmetry of the paraspinal musculature with resulting reset of the individual elements.  This includes the position of the atlas.

We have long realized in orthogonally based upper cervical chiropractic that although the pelvis is the greatest mass in the kinetic chain of the spine, it is not necessary to address it’s misalignment by directly adjusting the pelvis.  We have long found that upper cervical adjustments can affect the whole system and restore alignment to ALL of the spinal elements (with respect to gravity) because the tensegral array that we ‘are’ is neurologically modulated.  A small amount of misalignment in this area is magnified due to its neurologically central location.

Embryologically, the nervous system arises out of the neural tube.  The anterior aspect goes on to form the brain. The caudal aspect becomes the spinal cord and connects to the rest of the body. The craniovertebral junction is the origin.  The nervous system begins right where we go to adjust.

Ghysen commented on the three dimensional nature of the nervous system:

“The central nervous system of all triploblasts is essentially a three-dimensional structure derived from a two-dimensional epithelium.  It is built along three axes, antero-posterior, dorso-ventral, and apico-basal.  Development along each axis relies on its own development mechanisms, and generates its own range of cell specificities.  The central nervous system is, therefore, basically an orthogonal structure.”(my emphasis).

[p. 556. Ghysen A. The origin and evolution of the nervous system. Int. J. Dev. Biol. 47:555-562 (2003).]

[Note: triploblasts are bilaterally symmetrical animals with three germ layers.]

So if bones do not lock out of place, what causes the atlas laterality and rotation that we can consistently measure on x-rays?

In the tensegral model the spinal elements (bones) are passive, they are utilized to maintain shape, but it is the soft tissue elements that are active.  Force is distributed throughout the whole system as evenly and as immediately as possible.  If the neurology has become imbalanced causing the tensegral array to have to deal with asymmetric non-anatomical forces, the whole body distorts.  When the center of mass in the pelvis moves away from the gravity line, the body immediately adapts, usually by leaning back toward the gravity line. The atlas, in its function as a coupling between the head and the C2-pelvis kinetic chain will move to equilibrate the forces of the kinetic chain and the head.  This is an effect not a cause.  (Small mass doesn’t rule big mass in terms of mechanics).  Again, measurement of ¾ of a degree or more of atlas laterality is certainly coincident with postural distortion.

Dr. Friedman is now showing, in an ever growing number of successive cases, that the misalignment we have recognized for the last 70 years is comprised not just of the upper and lower angles and rotation of C1 and 2, but also of a compressive component existing throughout the entire tensegral array that can impede and sometimes preclude correction of the linear elements.  If compression remains in the spine, the attempt to restore the skeletal elements to the vertical axis will only jam the structures into line.  This may and does reduce the neurological component regarding blood flow to the head as well as diminution of the tensional forces affecting the upper cervical spine and brainstem but the entire array can remain under adverse mechanical tension.  This can lead to chronic mechanical issues in other aspects of the array.

Friedman is finding that the bow (of the spinouses) we often see in the frontal plane, the loss of curve (or even reversal of curve in the sagittal plane)  as well was the rotation in the transverse plane all constitute radiographic evidence of this progressive, compressive force.  Another indicator is the presence of more weight on the side opposite the short leg.  The last blog by Dr. Friedman discussed the primary importance of decompressing the misalignment before attempting to restore it to the vertical axis.  We have long done with this type II’s (Into-the-Kink) when we drop the head so that we close the facets on the side opposite laterality and allow the circular forces to restore the lower angle to the vertical, taking the bow out.  Using the weight of the head to decompress the misalignment and restore the lower angle to the vertical axis has long been seen as a successful process.  Type II’s are also known for their emotional aspects which may have become obvious when the decompression opened up the system, literally taking tension off the brainstem and relieving the chronic compression.  However, believing that the atlas laterality is the CAUSE of the problem, we have had a more difficult time with opposite angle misalignments because to decompress the spine one would have to adjust the patient on the side opposite laterality.  If atlas laterality is the cause and not a critically significant effect (with the attendant neurological sequelae), then we would expect atlas laterality to increase and we would have no choice but to stay on the side of atlas laterality.  Indeed, many people have had to accept the continued presence of lower angles that won’t reduce when the head is supported in a neutral plane for this very reason.

Dr. Friedman reasoned that atlas laterality may be an effect of distortion in the whole tensegral array and that decompression of the array could facilitate not just improved reductions but improved stability and truly unencumber the whole system.  Up and open he calls it.  Over the last few months he has been working with many dozens of patients and this in fact is the bottom line.  He is restoring people to the vertical axis and unwinding previously intractable lower angles and rotations.  Properly used, this new system of biomechanics proportionately reduces all aspects of the misalignment including atlas laterality- even if the adjustment is on the side opposite atlas laterality.  Dr. Friedman showed several of these cases pre and post in his last webinar.

The cardinal rule in orthogonally based upper cervical work has always been that we must adjust on the side of atlas laterality.  This rule has been predicated on the assumption that atlas laterality is the cause of the postural distortion as well as other attendant effects of the ASC.  This harkens back to the HIO days when the adjustment consisted of a brief but significant thrust designed to direct and encourage the atlas on its journey back to its normal position.  Long ago we set the thrust aside and began to use the triceps ‘pull’.  Conceptually, we have continued to see the adjustment as directly moving the atlas back under the skull into a normal (midline) position.

The body is however an integrated system.  If you affect one part of the array, you affect the entire array.  The neurological and biomechanical consequences of atlas laterality are not in dispute. This conceptual shift occurs in understanding of the rest of the system.  Restoration of the head and lower angle to the vertical accompanied by orthogonal positioning of the atlas is only part of the resolution of subluxation.  This can be seen in posts which resolve the relationships of head and neck without return to the vertical axis (gravity line).  The elements cranial to the pelvis must coordinate with the position of the pelvis in order to create stability and agility for movement.  Since the pelvis constitutes the largest mass in the kinetic chain of the spinal elements (as well as being the center of mass for the whole body) the spine and head cannot return to the vertical axis if they are not positioned over the orthogonal pelvis.  Instead they will adapt and compensate.  Indeed, the excursion of the upper cervical misalignment is a direct function of pelvic misalignment.  It is a circular relationship since the pelvic obliquity occurs due to altered neurological modulation of the nuclei in the brainstem, which in turn occurs due to adverse mechanical tension from misalignment of the upper cervical spine.

Dr. Cockwill published a paper entitled, “Angular Measurement of the Upper Cervical Spine in the Neutral and Laterally Flexed Positions”, in The Upper Cervical Monograph 5(7):10-12, May 1996.  Cockwill was examining a critical point: “This study is simply an attempt to detect any angular change while the upper-cervical spine is in a state of motion.” (p.10)  The study took three patients and filmed them using the normal NUCCA procedures for nasiums.   After the nasium was taken, the patients were then placed in a (cervically) laterally flexed position (“Requiring the test subject to actively laterally flex the skull until the end range of motion is perceived is important in accurately determining if normal motion is present in this area.”) and the film retaken.  The patient’s heads remained vertical in the head-clamps and care was taken not to change head position.  The atlas laterality was calculated individually by three different experienced upper cervical practitioners.  Change in measured atlas laterality between the first and second nasium was measured to be between one and ½ degrees and four and ½ degrees.  Also noted was that average change in axis spinous was contralateral to the side of lateral flexion by seven millimeters.  The largest change seen was 14 millimeters.  On a 3 inch condylar circle, this equates to a change of 21 degrees.  These results follow the published results of others who have examined normal motion in the upper cervical spine.  Dr. Cockwill listed 15 different peer reviewed, indexed references for this point.  In 1997, Dr. Dickholtz, Sr. replied to these findings in The Upper Cervical Monograph.  He strongly rejected these findings and NUCCA has never examined this idea again.  However, in light of the principle of tensegrity, these findings only make sense.  There are no ‘locking’ joints in the upper cervical spine.  Bones do not touch each other.  Distribution of forces in a tensegral array always equalize throughout the entire system.  This new viewpoint allows a greatly expanded understanding of the biomechanics.

The primary finding here is that resolution of the atlas to orthogonal position does not constitute the entire answer to postural distortion and the other pathological consequences of upper cervical misalignment.  It is a critical component but incomplete by itself.  As historically utilized, the lines of misalignment on the films do not capture the entire process.  The bowing of the cervical spine, in the frontal plane is not adequately expressed by the marking of a line between the top and bottom of the cervical spine.  We have long made this line and that is what we tend to see when we look.  The frequently attendant bowing of the spinouses on the nasium is underappreciated as a significant indicator of distress in the system.  This bowing can still be seen on films where the head and lower angle line have returned to the vertical.   We have been looking at the lines we draw for a long time.  Perhaps it is time to re-examine what we are seeing.

It is also critical to acknowledge the importance of the pelvis in calculations regarding the biomechanics.  Upper cervical work has long noted its effects to be body-wide.  This has never been seen as a segmental adjustment at just one level.  However, the greatest potential resistance in the system (kinetic chain) is the pelvis.   It has the greatest mass and the center of gravity is centered within it.  This is an objective reality of the body.  If the pelvis is not centered on the vertical axis, the cranial components of the skeleton are unable to center on it.  They must adapt and compensate for the mis-position of the pelvis away from the vertical axis (gravity line).  In addition, the pelvis must be taken into consideration when the listing for spinal correction is calculated.   There are times when the upper cervical spine and the pelvis are counter-rotated to each other and a force that corrects one aspect has a much different effect at the other end of the chain.  Dr. Friedman’s biomechanics addresses this issue in a thorough and systematic manner.  This is not a simplistic plea to just ‘turn people over’.

Part of this misreading of the situation occurs because the nasium film as taken by NUCCA (and the other orthogonally based upper cervical techniques) only allows a relative position of the head, atlas and lower angle.  When the head is clamped in the center of the film by the self-centering head clamps any actual relationship to the true vertical axis arising from the center of mass of the pelvis is altered.  Therefore any return to the ‘vertical axis’ on the post nasium is without reference to the actual center of mass of the pelvis and may constitute local correction of the upper cervical elements (as defined by the line drawings) but not restoration and integration with the primary mass of the pelvis.  This why Dr. Friedman has altered the positioning protocol for x-ray placement to ‘build’ the film from the base (center of mass on the vertical axis) and not requiring  that the atlas be centered on the pre film.  This represents the actual excursion of the atlas from the true vertical axis (arising from the center of mass).  If a proper corrective adjustment has been delivered, the post film should find the atlas in midline on the vertical axis arising from the center of mass.  Dr. Gregory stated more than once that he didn’t care if you adjusted the big toe -if the post film showed proportional correction.

This work has always been driven by empirical results.  Dr. Friedman uses his practice as a laboratory to search for ways to improve the adjustment.  Long ago, it was common knowledge that the world was flat and if you sailed west from Europe that you would fall off the world.  It was once common knowledge that it wasn’t necessary to wash your hands between patients.  The spread of puerperal fever (childbed fever) was epidemic and loss of life was rampant.  Semmelweiz suggested washing hands between patients.  He had the audacity to suggest that doctors themselves might be transmitting the contagion.  The medical profession destroyed him and he eventually went insane and committed suicide.  It took more than 200 years for England to begin feeding their sailors citrus to prevent scurvy after it was recognized as a deficiency.  Mark Twain once said, “It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so.” All of us are blinded by what we think we know.  We tend to see what we believe and not the other way around.

The profundity of upper cervical correction has been shown in hundreds if not thousands of offices over many decades.  This new insight does not lessen the importance of the atlas.  It does help to integrate understanding of the atlas with the rest of the body and provide a more efficient way to reduce interference to the nervous system and restore the power of life in people.  The clinician who reads this has two choices: one, ignore this idea which is different than the way the work has been conceptualized for the past 70 years, or learn the biomechanics and see if it’s true.  Maybe we can do better.  Isn’t that why we came to upper cervical work in the first place?

Twain said something else that might be of pertinence here:

“Twenty years from now you will be more disappointed by the things that you didn’t do than by the ones you did do. So throw off the bowlines. Sail away from the safe harbor. Catch the trade winds in your sails. Explore.  Dream.  Discover.”

The Things We Can’t Measure: a clinical look at the phenomenology of posture

This paper was published as a pre-print of The Upper Cervical Monograph, November 2010.

Michael D. Thomas, D.C.

A scientist uses the experimental method to discern objective information about the physical world. A clinician works within a somewhat different sphere. He/she has a first responsibility to do no harm (primum non nocere) and secondly to facilitate return of optimal health in the individual being administered to. These are related but not identical spheres of focus. While a scientist may ignore subjective, non-measurable components of the subject at hand, the clinician does so at the patient’s peril. The concept that events such as posture, occur in a vacuum, unrelated to external (environmental) or internal (physical, emotional, mental, or spiritual) context is an artificial truncation of the actual massively complex interconnectivity that defines the real meanings of such a behavior in one’s life. Further, this oversimplification distorts and impedes full understanding of these events. A perspective that attempts to integrate these internal and external aspects is known in philosophy as ‘phenomenology’ and its importance is becoming more recognized in science and medicine. Phenomenology, founded by the German philosopher Edmund Husserl (1859-1938), is an empirical approach that rejects theories and preconceptions in favor of observation and description.

The idea that how we stand upon the Earth is a function of many factors has been well explored by Hubert Godard, a French dancer, teacher and Rolfer who developed the idea of ‘tonic function’, a term he developed to encompass the multimodal response of the human being to the influence of gravity. From this perspective, the posture of an individual standing in a neutral position, cannot be divorced from its many contexts. Kevin Frank, in his article ‘Tonic Function’ explores four basic categories that influence response to gravity. A human being must first contend with gravity in a physical, mechanical, structural sense. This would include the structural elements, and principles of tensegrity and hydraulics (fluid dynamics).(1)

There is in addition, an internal impression (perception) that modifies how an individual stands. Where am I? Which way is up? How do I feel about myself? How does this alter how I stand? In addition, the expression of an individual must be predicated on how the individual emotionally feels about the external environment. How do we greet the universe? Is the world perceived to be a safe place or a place in which one must protect oneself? Then there are also ‘acquired automatic subroutines’ that have developed in the course of living life. These patterns of movement can be seen as the temporally accumulated responses generated by internal, external, and gravity mediated events over time.(2) Walking gaits are, for instance, each unique and people can often be identified even from behind by the way they walk by those who know them.

Response to gravity is basic and primary in sensory development. It is the first learned response and is present in every activity of living. Like water to a fish, it is ubiquitous. In his chapter in Complex Motor Behavior (1988) Reed commented on this by asking a question. If you were standing on your feet and were told to raise your arm, which muscle would activate first? His answer, based on electrophysiological studies, were the gastrocnemius and the soleus. It is the muscles of the leg and ankle which fire first to appropriately shift the body’s center of gravity due to the incipient change created by moving the arm anteriorly. (3)

Godard noted that the gravity response is embedded in the nervous system and is not changed by direct voluntary control. It is only by fundamentally changing the context of the situation (perception, emotion, meaning) that the ennested gravity response is altered. Movement is not learned in an abstract way from an idealized notion. It is built over time as a result of the multimodal interactions of our being with the environment and within ourselves. The resulting movement is a result of all the thoughts, feelings and constructs (internally and externally) that have developed (been learned) in the individual’s life experience. (4) Anticipation is vital when your center of gravity is perched over bipedal, multi-jointed legs. In the human being, the line of gravity bisects the body in the frontal plane and almost does so in the sagittal. This allows a standing posture of ease with need for very little energy input to maintain. Of course, the ASC (Atlas Subluxation Complex) can change these dynamics greatly. Upright posture is a highly significant issue because it is imperative to survival. If an individual is not able to stand upright, he or she must depend upon others for the basic requirements to maintain life. It is often deeply associated in a moral sense with being good or being ‘upstanding’. Standing upright helps us to preserve our ongoing life.(5)

Our relationship with gravity is a fundamental, and as A. Newton notes, “a primordial, instinctive relationship that is so profound as to be almost invisible.” (6)
Human beings are characterized by their upright posture. Each of us finds a unique and individual way to stand upright. Each of us must become the person we are. Some functions are nearly automatic like our heartbeat or our respiration. Outside of occasional voluntary contribution, these functions don’t demand our constant vigilance. Gravity is however, never fully or permanently overcome; it requires constant vigilance. We must oppose the force of gravity to even stand up. We must always pay attention to it in nearly every activity of our lives. (7)

So how do we stand up? How do we evolve from a helpless infant to a fully functional adult? The most basic explanation involves the relationship between agonists and antagonists in the musculature. As Straus notes: “. A free flow of tension occurs when agonists are not met with counteraction by antagonists. The constraint in movement, called bound flow of tension, occurs when antagonists contract along with the agonistic muscles.” (8)

Anyone who has sat for a while with a baby has watched them throw their little arms and legs about in bursts of free flow of tension. You have watched their little fingers and toes contract in the tight flexion of bound flow. As Strauss again observes;” An influx of suddenly emerging free flow may bring his fist near his mouth, and the ensuing bound flow may enable him to hold his fist there for a brief moment.” (9) It is the beginning of purposeful movement. Bound flow can allow the positioning of our limbs. Free flow allows us to move from one position to another. Bound flow allows us to create form within us. While our bones act as spacers, it is the tonic tension of muscles, tendons, and other tensile elements down to the cellular level within our bodies that forms the relationships that enable us to eventually stand upright and move about in our external environment. Without this constant tension we would be more like jellyfish out of water; flaccid and immobile.

Newton comments:
“Tension flow and shape flow are the basis of movement patterns. Godard suggests that these patterns of movement are related to the tonic system. For a baby, learning to move and walk requires the development of the tonic system. Through learning to alternate bound flow and free flow in infancy, the baby develops control over movements that eventually lead to the ability to stand. But as Kestenberg shows, the alternating rhythm between bound flow and free flow also serves another purpose, as significant as locomotion: it is the first communication system.”(10) An amoeba moves through growing and shrinking in an asymmetrical manner. We grow and shrink with our respiration. We grow when we eat and we shrink when we expel urine and feces. Like all creatures, we move toward that which pleases us and away from that which does not. A baby learns to alternate between free and bound flow patterns in order to make purposeful movements and ultimately to stand upright. For Godard, tension flow and shape flow are the fundamental qualities that form the basis of movement, and even more, of internal self-regulation. This push and pull forms a basal rhythm that ultimately entrains our whole being. In the embryo, the first organ to form is the heart and this primordial heart sets up an initial rhythm that entrains the growing realization of our physical structures. Significantly, this primal tonic rhythm develops the eventual basis for communication. The push and pull of the pulsatile beat that comprises the early proto-heart is the first action we ever make in this world. It is how we are first known and is the first communications system with our external environment. As we become able to manipulate our environment through our movements, we begin to make the distinctions between ourself, our mother, and the rest of the environment. Independence also requires communication. Research by Kestenberg has shown “the relationship of the tension-flow patterns of the infant with the movement patterns of the mother through each phase of development.” (11) This intimate dance between mother and infant builds the internal ‘structure’ from which all future communication will take place. Pushing and pulling, tightening and releasing, dealing with gravity, expressing feelings; an infant finds a way to be embodied and to communicate the needs of this embodiment. From grasping and releasing behaviors, to expression of emotions and the gradual development of the self, this process forms the tapestry of, as Newton writes, “the first dialogue between mother and child, a tonic dialogue.”

Significantly, Godard teaches that the body does not recognize any difference between the gravity system and the expression system. They develop together and are indivisible. (13) We can often know what someone else is feeling long before they speak because of their body language, and often their body language is actually more accurate than the words that do come out of their mouth. Godard reiterates that whenever we work with the tonic system we are also working directly with how we express ourselves; how we communicate. This psychological consequence is intimately woven into the tonic system because of how it has formed. Anytime we significantly alter the function of the tonic system we are inevitably altering the psychological identity too. Newton noted that Ida Rolf and others have all resisted working on the emotional level with their clients. In McLean’s triune brain concept, emotions arise out of the limbic system, the old mammalian brain. The tonic functions are founded in the older, reptilian brain(stem) level. Newton remarks: “The theory is that by addressing the tonic function we can affect the basic senses of support and orientation without needing to talk about the associations involved. We can help build the basic sense of support in the body (instead of breaking down armor, as in a Reichian model).”(14) Upper cervical chiropractic understands this in a parallel fashion. We too, address tonic function. We too help build a basic sense of support in the body. The linking of posture and character is deeply embedded in our spoken and written communication.

“He’s an upstanding man. Her head is on straight. He’s a well balanced individual. She is level-headed. He’s a straight arrow.” Conversely, the language is also clear: “She was a twisted individual. He’s not on the level. There was something askew about her. He was crooked, she’s out of line.” Illness or distress is often understood as a deviation away from normal (and away from the vertical) , often with a structural connotation: You don’t have to get bent out of shape!, she’s taken a turn for the worse, he’s out of sync, she’s down with a cold, or under the weather. This doesn’t prove anything other than that in terms of long-standing semantic meaning, our structure and function share a close relationship. We would rather stand tall than be laid low.

Over a lifetime, behaviors become habitual. Traumas accumulate. Tension and stress must be dealt with and are often sublimated. No one has ever figured out how to not age, but the suffering of aging has been a principle focus of the healing arts for as long as there have been healing arts. For an interesting perspective on the progressive degeneration that seems to accompany aging it may be instructive to examine the work of Thomas Hanna (1928-1990), a founding figure in the field of Somatics. Hanna too, wondered why posture seems to worsen with age. He found that this was due to a sensory/motor amnesia. He developed a method to “reduce the effects of sensory-motor amnesia that normally occur by middle age.”(15) He called his program “Somatic Exercises” to differentiate it from mere physical exercise. His aim was to make changes in the sensory-motor area of the brain so “maximum conscious attention” is required. Hanna found that while there is an underlying tonus to the musculature, when a muscle is at rest, its electrical activity should fall to zero. Just as we may hold onto troubling thoughts, often in our subconscious, we also don’t allow our muscles to completely let go. Aside from the unhelpful over-usage of energy, he found that chronic stress causes us to go into two major reflexes. He saw these as archetypal postural patterns, dividing the variations into two polarized strategies. The first, he calls The Red Light Reflex. He characterizes this postural set as :
“From head to toe, the Red Light reflex involves the following movements: closing eyes, tensing jaw and face, pulling forward of neck, lifting of shoulders, flexing elbows, clenching fists, flat contracting diaphragm and holding breath, contracting perineum (including sphincters of anus and urethra), contracting gluteus minimus muscles to rotate thighs inward (feet are pigeon-toed), adduction of thighs, contraction of hamstrings to bend knees, flexing and supination of feet (each foot lifts and inverts, tilting up arch). The sensory feedback of all these movements constitutes the subjective feeling of the Red Light reflex: fear.”(16)

Hanna further describes the other end of the scale archetypal postural pattern as the Green Light reflex.
He characterizes it as:
“From head to toe, the Green Light reflex involves the following movements: opening eyes, jaw and face, pulling backward of neck, pulling downward of shoulders, extending elbows, opening hands, lifting chest, lengthening abdominal muscle, relaxing diaphragm and free breathing, relaxing anal and urethral sphincters in the perineum, contracting gluteus maximus muscles to extend thighs, contraction of gluteus medius muscles to extend thighs, contraction of gluteus medius muscles to rotate thighs outward (feet are duck-like), abduction of thighs, contraction of thigh extensors to straighten knees to hyper-extension, extension and pronation of feet. The sensory feedback of all these movements constitutes the subjective feeling of the Green Light reflex: effort.”(17)
Further Hanna found that life situations cause the two reflexes to recur a multitude of times, gradually becoming habitual. He notes: “Gradually the Red Light and Green Light reflexes interfere with each other. When one is partially contracted, the other cannot contract fully. This is the sum of neuromuscular stress, a state of muscular immobility caused by the gradual buildup of chronically opposing contractions.”(18)

He writes that the summation of these two postures over time is the senile posture which is common to many. As Hanna describes it: “The powerful contraction of the spinal muscles in the Green Light reflex continues its pulling of the lower back and neck into a curve. But the equally powerful pull of the abdominal and shoulder contractions in the Red Light reflex tilts the entire trunk forward, rounding the back and shoulders and projecting the head forward.” (19)
Sometimes the Green or the Red Light reflex predominates the senile reflex. Either way, it results in six pathologies identified by Hanna: stiff and limited movements, chronic pain, chronic fatigue, chronic shallow breathing, a negative self image, chronic high blood pressure and the “Dark Vise [static isometric contraction causing chronically high blood pressure and progressive physiological deterioration]”. (20)

We work with people of all ages and we see them though all the stages of their lives. The profound effect that the adjustment can have creates very strong bonds of relationship between the doctor and the patient. Because of the nature of the intervention, we can turn life on instead of turning it off like so many of their other physicians. This distinction is not lost on the patient. Many patients turn to their upper cervical chiropractor as their primary physician. How many times have you heard a patient remark that they came in to see if an adjustment would take care of whatever problem they are having before deciding to negotiate the medical bureaucracy? What other single procedure has the wide-ranging power of the upper cervical adjustment? It is primary healthcare.

Postural set is not simply a function of gravity and the integrated input of sensory receptors. The phenomenological factors briefly explored above reveal that mental, emotional, personal historical factors, and social environmental factors also contribute to postural set and muscular function. It would seem that the importance of these factors can vary dramatically over time and between individuals. As upper cervical chiropractors, we are able to see all of this in a very different way, but we are all looking at the same human beings. We all see the progressive degeneration that takes place in so many. We all see the cascade of suffering that robs us of our health. Identification of the Atlas Subluxation Complex coupled with the corrective biomechanics allows upper cervical chiropractors to intervene in a uniquely powerful and definitive way in the life of an individual. The changes wrought by the adjustment often greatly eclipse what can be measured in the posture or even in relief from pain. Anyone who has been in practice for even a short time knows exactly what I mean. It is obviously not possible to directly measure the subjective aspects of posture. The multifactoral nature of posture means that some aspects contributing to posture cannot be given quantitative values (or even if, at a moment in time, it is possible to place a precise value, there is no guarantee that this value remains stable over time.). Once again, when all of the aspects of a given element of study are examined, it is not possible to obtain precise measurements. It is however, possible to meaningfully model the system and measure patterns of movement that contribute to posture. The pertinent point here is that just because certain aspects of behavior cannot be measured, does not mean that they do not exist. At the same time, acknowledgement of these subjective factors does not preclude objective modeling of the behavior in question.

In orthogonally based upper cervical chiropractic we have become consumed by the task of removing neural interference to expedite the optimization of posture and function in relation to gravity. Like Rolf, Godard and many others, we too shy away from the emotional sphere in our work. We are aware that restoration to the vertical axis constitutes a self-organizing shift that fundamentally restores quality of life in those who are properly adjusted. We don’t ‘treat’ components whether they are emotional, psychological or musculoskeletal in nature. We remove interference and trust that Life finds a way to bloom. We see the power and the truth of this work every day in our offices. We must not ever forget the incredible nature of what it is we do. The person under your pisiform may never be the same after your adjustment. Acknowledging the subjective in our patients does not invalidate the objective, it just means we are more amazing than we have yet been able to measure.

References

1. Smith, John. The Oscillatory properties of the structural body. IASI Yearbook 2006 p. 68-76.
2. Frank, Kevin. Tonic Function –a gravity response model for rolfing structural and movement integration. Rolf
Lines 1995 Mar. 1995]
3. Reed, E. S., “Applying the Theory of Action Systems to the Study of Motion Skills,” Reprint of author, Dept. of
Humanities and Communications, Drexel Univ., Phila., Pa. p.53 in: Complex Motor Behavior, O.J. Meijer, K.
Roth, Elsevier Science Publishers, Netherlands, 1988]
4. Godard, H. Private correspondence to Aline Newton as recounted by Newton, A.C., in Basic Concepts in the
Theory of Hubert Godard. Rolf Lines. Mar 1995].
5. Straus, Erwin. Phenomenological Psychology. Basic Books. N.Y. 1966, p.139.
6. Newton, AC. “Basic Concepts in the theory of Hubert Godard”.Rolf Lines Mar. 1995.]
7. ibid.,Straus, E. 1966, p.141.
8. ibid, Straus, E. 1966, p. 196
9. ibid., Straus E. ,1966, p.196
10. ibid., Newton AC Mar. 1995
11. ibid., Newton AC. Mar 1995, p. 36
12. ibid, Newton AC, Mar. 1995 p. 36.
13. Godard, H. Workshop lecture, Philadelphia 1993. as noted by Newton, AC in Basic Concepts in the Theory of
Hubert Godard” Rolf Lines, Mar. 1995 p. 37.]
14. ibid, Newton, AC. Mar.1995 p.37
15. Hanna, T.Somatics: reawakening the mind’s control of movement, flexibility and health. Addison-Wesley
Publishing Company Reading Massachusetts, etc. 1988pp.68-75.]
16. ibid., Hanna 1988, p.68
.17. ibid., Hanna 1988, p.68.
18. ibid., Hanna 1988, p.69.
19. ibid., Hanna 1988, p.69.
20. ibid., Hanna 1988, p.70-73

NUCCA Synopsis and list of published papers

Chiropractors have long had difficulty getting published in the peer reviewed, indexed literature.  Some of this difficulty lay in the political animosity between chiropractic and medicine and some in the lack of educated individuals (researchers, etc.) that had the experience to do the appropriate studies, use proper statistical analysis and the money that is always needed to make things happen. 

 

Upper cervical doctors have had a doubly difficult time getting published becasue of the prejudice against upper cervical work in the chiropractic profession.  I wrote about this issue in the new e-newsletter that is published by ChiroAccess.com.  This group is associated with MANTIS which is a database of literature for professions that have traditionally not been included in the peer-reviewed, indexed literature.  These include acupuncture, massage therapy, and other groups.

The paper has been published by ChiroACCESS so I cannot include it here but I can give you the url:

http://www.chiroaccess.com/Articles/Chiropractic-Technique-Summary-NUCCA.aspx?id=0000152

This paper contains a link to all of the Upper Cervical Monographs in .pdf format and also lists the various papers and talks over the years that have been produced by NUCCA doctors. 

 

A Brief Look at Biedermann et al., and the “KISS” Syndrome

 Note:  This paper was originally published in the The Upper Cervical Monograph, Volume 7, number 2, September 2009. 

 

A Brief Look at Biedermann et al., and the “KISS” Syndrome.

 

Michael D. Thomas, D.C.

 

There is a developing body of literature on treatment of the upper cervical area (primarily in infants) that comes to us from Biedermann and others (Gutman, etc.) in Europe.  This body of work virtually constitutes a parallel system of upper cervical ‘adjustment’ (manipulation) developed over several decades that seems to be essentially separate from either the articular or orthogonal approaches developed in a similar (although initially earlier) time frame in North America.  Important similarities and differences exist. 

 

Biedermann, in a summary of his work in 1992, noted that the craniovertebral junction in newborn and young babies can be the site of a syndrome of problems that he termed “kinematic imbalances due to suboccipital strain” or KISS.  He detailed a wide variety of clinical signs and symptoms which have responded well to manual therapy.  The main signs of KISS being torticollis, unilateral microsomy, C-scoliosis, motor asymmetries, unilaterally retarded maturation of hip joints, and slowed motor development.  Etiological factors include intrauterine misalignment, application of extraction aids, prolonged labor and multiple fetuses.(1)

 

Biedermann has brought a variety of functional disorders and symptoms into his KISS concept.  As he notes: “The definition of a functional disorder that is caused primarily vertebrogenetically enables pediatricians, physiotherapists, speech therapists, and others to widen their scope of available therapeutic options and to include the “functional approach” in their therapeutic considerations.” (2)

 

Functional Medicine is growing in influence and has the potential to become a potentially guiding force in medicine here in the United States. (3) Biedermann’s approach  is consistent with the functional model.  Functional indications that the KISS syndrome may be present include:

Tilt posture of the head, torticollis, opisthotonos, uniform sleeping posture (baby cries if mother tries to change the posture), asymmetric motor patterns, asymmetric posture of trunk and extremities, sometimes combined with a tilting head position reminiscent of a persisting asymmetric tonic neck reflex, sleeping disorders (baby awakens every hour crying), extreme sensitivity of the neck, cranial scoliosis (swelling of facial soft tissues on one side), blockages of the iliosacral points, asymmetries of the gluteal muscles, asymmetric development and range of motion of the hips, fever of unknown origin, loss of appetite and other symptoms of central nervous system disorders.  Other examination findings include:  C-scoliosis, mobility of the vertebral spine reduced by more than 30%, feet deformities, pathological reflexes.(4)

 

Biederman has further subdivided his syndrome into two basic types.  KISS I is defined as a fixed lateral flexion posture and KISS II is defined as primarily a fixed retroflexion posture.  These postures involve the entire body of the infant.  KISS I clinical markers include “torticollis, unilateral microsomia, asymmetry of the skull, C-scoliosis of neck and trunk, asymmetry of gluteal area, asymmetry of motion of the limbs, retardation of motor development of one side.”(5)  Clinical marker for KISS II include: “hyperextension (during sleep), (asymmetric) occipital flattening, shoulders pulled up, fixed supination of the arms, cannot lift trunk from ventral position, orofacial muscular hypotonia, breast-feeding difficult on one side”(6)

 

Primary indications of the presence of KISS include asymmetry of posture and movement.  Hypersensitivity and restricted range of movement in the suboccipital structures should, Biedermann argues, result in referral of the infant to a ‘specialist’.(7)

 

Biedermann also has defined a KIDD syndrome.  It was noted over time that infants often recovered when they began to verticalize, which is a term Biedermann uses for the various maturation processes in which infants begin to get upright in preparation for walking.  It was found that the differentiation between KISS I and KISS II “loses its meaning after verticalization, as the influence of the upright stance modifies the basic conditions to such an extent that the fixed posture is almost abandoned.” (8).  The second to fourth years are perceived as a ‘silent’ period when few problems are noted.  From the fourth year to preadolescence, a variety of problems can occur including:

“imbalance of the muscular coordination with asymmetrical tonus of the postural muscles, shortened hamstrings, kyphotic posture with hyperlordosis of the cervical spine and hypotonus of the dorsal muscles of the thoracic area, often accompanied by orofacial hypotonia; scoliotic posture in sitting/standing position; shoulders at different height; sacroiliac(SI) joint mobility asymmetrical often with asymmetry of leg rotation; balance tests insufficient and mostly asymmetrical; insufficient coordination of vestibular input, e.g. standing with raised arms and closed eyes difficult; acoustic orientation laborious; locating the source of an ‘interesting’ noise difficult; combination of arm and leg movements difficult, e.g. jumping-jack test; fidgeting and restlessness, sometimes tics; using eye control to compensate for lack of proprioception, refusing to lie down supine, clinging with one hand to the examination table; decompensation when the close range is invaded by the examiner; wild resistance against palpation.”  

 

Biedermann’s protocol to define KIDD looks at four components:

“a case history with the relevant KISS symptoms during the first year; asymmetry of posture and movement during examination; a sufficient number of symptoms from the list above; the palpation of restricted movement to palpation in the suboccipital area.”(9)

 

Biedermann notes that the primary symptom causing parents to bring children in is headache.  There is advice to adjust these children in both the cervical area and also possibly in the sacral area. Biedermann notes a multitude of behavioral type therapies that can be helpful but notes they often have to be repeated with some frequency.  He finds that manual therapy usually doesn’t have to be repeated as often and he doesn’t usually follow up more than once a year.  (10)

 

Biedermann writes that Gutman, before him, looked at the upper cervical area as a cause of ‘pathogenetic significance”. (11)  He writes:

“As early as the 1950s and 1960s Gutmann published cases of what he called Atlas blockage syndrome.(12)  He drew attention to the pathogenetic significance of the cervico-occipital junction.  However C1 is not the only culprit and we cannot be certain to find a morphological substrate for a “blockage” in these immature soft joint tissues.  We prefer to use the term kinematic imbalances due to suboccipital strain (KISS syndrome).  It is well defined by well-defined clinical symptoms and anamnestic facts and its diagnosis gives the experienced effective access to a wide range of problems.” (13)

 

Biederman finds the birth process to be a greatly undervalued cause of trauma.  He points out previous studies revealing a high percentage of microtrauma in the periventricular areas of the brainstem.(14)  He also discusses the probability that the structures that lie exposed under the cranium suffer at least as much from traumas (such as the birth process) as the cranium.(15) In fact this has been shown in studies regarding the biomechanical forces involved in delivery.(16) Biederman writes that injury at birth may be the norm rather than the exception.  He further credits the incredible ability of the developing nervous system to overcome these traumas and repair much of the damage.”(17)

 

Biedermann utilizes what he terms, “functional and morphologic analysis of the “classic” radiographs of the cervical spine.” (18) He reports “If the desymmetrization of the occipito-cervical junction follows the established pattern…the direction of the impulse is confirmed.”  In his examples, a KISS I (A-P open mouth) radiograph showed what seems to be right laterality and a whole body lateral flexion to the right, including the right head tilt, somewhat similar perhaps, to our idea of a right type II.  Biederman apparently uses Gutmann’s protocol to x-ray the infants which is this A-P open mouth film.  There does not seem to be any attempt to radiographically measure rotation in the transverse plane.  Biedermann however does seem to reject the idea that it is possible to accurately and objectively measure misalignments the way we do in orthogonally based upper cervical work.  His analysis encompasses more than measurement of the osseous structures although he does state:

“Selection of the direction of the treatment without radiographs seems the most plausible cause for the less encouraging results of some colleagues.”(19)

 

Biedermann references Gutman (20) when discussing the films taken.    There are oblique references to ‘the classical techniques” and it appears that at least a lateral and AP open mouth film are taken.  He is also advocating taking full spine pictures too because that enters into his analysis.  There does not seem to be any visualization of the transverse or axial plane in the analysis of the cranio-vertebral junction.  He mentions MRI and other imaging techniques that might be used, but the application seems more to be ‘art’ and clinical experience in regard to the axial plane. 

 

If the x-rays and symptoms are in agreement, Biedermann uses the x-ray findings to direct the line of drive for manipulation.  He reports this occurs about 80% of the time.  “In those 20% of the cases where there is no match between radiological and clinical picture one has to be especially alert to find other discrete signs which might help to explain this discrepancy.  It is not always possible to come to a completely satisfactory explanation for this discrepancy but in most of these cases a central neurologic component is present.” (21)

 

Biedermann comments at some length on the emotional and scientific issues revolving around radiating patients.  He notes that fetuses and children are about twice as sensitive to radiation as adults but no more so.  He challenges the linear response curve that is usually regarded as the standard for damage from radiation which states that damage is proportional to dose, no matter how small the dose.  He adds that the dosages for cervical films on infants is one of the lowest dosages used in conventional radiology.   For him the risk-benefit analysis “clearly favors the standard procedure of taking radiographs before any treatment of the cervical spine regardless of the age of the patient.”(22) Even without the primacy of orthogonal analysis, Biedermann clearly sees the necessity of taking films before adjusting and sees no contest in terms of risk and benefit.

 

Apparently somewhat aware of the work done over the past century in chiropractic and osteopathy (or at least their origins) Biedermann finds little to help him there.  Although he invokes the names of Palmer and Still, he writes that although they had both remarked about the damage early traumas can create in development, there had not been given any specific signs that would illustrate this damage.  Therefore this early insight wasn’t, in Biedermann’s opinion, able to be practically applied at the time. (23)

 

Biedermann is convinced that the results of this work on infants far surpasses anything that is possible in the adult and cautions the reader not to assume that the reader’s experience of manipulation in the adult population  is comparative to MTC (Manual Therapy in Children).  An infant is in an extremely active phase of rapid growth and maturation.  The many osseous growth centers are very active and postural distortion from upper cervical misalignment creates structure that is asymmetrical and potentially less (or mal-) functional. This fundamentally changes the maturation of the structure of the body.  It is only at this early period that he believes real and permanent changes can be made that will affect the entire life of the individual.  He notes:

“Manual therapy in children bears only scant resemblance to the much less dramatic and well-known effects we see in adults.  We are aware that we often repair without being able to heal, thus condemning both therapist and patient to repeat this exercise sooner or later.”  (24)

 

As Dr. Scholten recently noted after speaking with Biederman, our concept of upper cervical work is that we are able to restore alignment to the osseous structures as they relate to each other.  The power of this procedure is well known to us.   Biedermann however, is more interested in working very early in life so that the discrete osseous structures themselves are formed properly (symmetrically).  Biederman sees functional (mal)function (KISS) affecting developing structure in the infant and young child.  Considering that most afferent proprioceptive signals come from the craniovertebral junction, any interference to normal signal flow will have extensive impact on the developing nervous system, much more than at any other time in life.  This has obvious importance throughout the entire lifespan of the individual.  As this developing structure is then laid down asymmetrically, it causes potentially permanent structural issues that can continue to cause problems through the whole lifespan.  Biedermann sees that in the early months of life, function therefore affects structure.  Once the structural development has been laid down, structure will affect function for the rest of the lifespan.  It is in these early months that Biedermann sees such outsized potential for phenomenal results.  (25)

 

In discussing the further maturational difficulties that can ensue due to upper cervical misalignment (our term): “Traumatization of the suboccipital structures inhibits functioning of the prioprioceptive feedback loops.  The motor development, though preprogrammed, cannot develop normally.  These systems are fault tolerant and able to overcome considerable difficulties and restricted working conditions.  But the price for this is a reduced capacity to absorb additional stress later on.  These children may show only minor symptoms in the first months of their life e.g., temporary fixation of the head in one position, and “recover” spontaneously.  Later on- at the age of 5 or 6 – they suffer from headaches, postural problems or diffuse symptoms like sleep disorders, being unable to concentrate, etc.” (27)

 

Biedermann thinks that the suboccipital joints are most likely to be involved when several issues are seen concurrently: asymmetry of motion, facial asymmetry, and sleeping disorders. (28)

 

The procedure to adjust is described as an impulse mechanism.  After examination, the clinical findings are compared with the radiographic findings.  “In most cases the direction of the manipulation is determined by the radiographic findings. In the other cases the orientation of the torticollis, the palpation of segmental dysfunction, or the local pain reaction helps to find the best approach.  The manipulation itself consists of a short thrust of the proximal phalanx of the medial edge of the second finger.  It is mostly lateral; in some cases the rotational component can be added.” (29)

 

Biedermann has further elucidated the concepts of MTC in a 2004 text, Manual Therapy in Children. Edited by Heiner Biedermann Churchill Livingstone 2004.  The text is extensive and has so much to offer our perspective that a review such as this cannot do it justice.  The text has five sections, ‘The theoretical base, Clinical insights, The different levels: practical aspects of manual therapy in children, Radiology in manual therapy in children, and Making sense of it all’, twenty seven chapters in total.  The discussions of embryological development,  neurophysiology and clinical insights alone are more than worth the price of the text. 

 

I will include a couple of quotes to whet your appetite.

 

“…a clear statement of the relation between orthopedic and orthodontic disorders is still missing.  Most studies are based on clinical impressions and have anecdotal features.  Only a few controlled studies have shown that anatomical features of the craniocervical junction are associated with head posture, mandibular growth and angulation of the cranial base. 

In general, there seems to be an association between Angle class II-i.e. distal position of the mandible in the skull – and lordosis, as well as a high incidence of lateral crossbite in patients with scoliosis and torticollis.” (31)

 

”In about two-thirds of cases the effect of the treatment shows in the first 48 hours after the manipulation, but the other third of the successfully treated children need between 2 and 4 weeks to display a change for the better, sometimes only after an initial rebound….it is tempting to try to combine several other modes of treatment to alleviate this phase – for example by using pharmaceuticals.

     As far as experience seems to indicate, this approach is ineffective.  It seems better to allow enough time for the results of the manual therapy to take effect; they tend to be more profound and stable when the organism is given the chance to re-adjust its functions to the post-manipulation situation without further stimuli.”  (32)

 

Biedermann uses his examination of complexity theory to begin to describe two kinds of therapy.  He finds humans to be nonlinear systems and while ‘robust’ therapies “therapies designed to correct disease entities” (33) are important at times (such as adjusting to remove a ‘pinch’ in the shoulder, for example, he finds MTC to be a kind of ‘subtle’ therapy “involving therapeutic inputs into the extended network” (34) that can operate in a broader way throughout the entire network and over an extended time.  Examples (besides MTC) included lifestyle issues such as psychological state, diet and exercise.  Lack of an objective analysis for KISS and KIDD does however, leave the clinicians in a somewhat nebulous, philosophical zone where art and intuition must make up for the lack of objective rigor. 

 

Overall, we find much that is familiar to us and much that is viewed from a very different perspective.  Biedermann allows us in orthogonally based upper cervical work to look at the field from a different perspective.  Seeing through another’s eyes can be very revealing and productive.  Our work has found objective ways to measure the osseous misalignment that we have (completely –at least to our satisfaction)) correlated with postural distortion.  Dr. Biedermann and his colleagues do not discern the biomechanical symmetry that we have found (we are aware that there is not absolute symmetry, but symmetry that allows biomechanical stability as noted first by Dr. Gregory) using properly taken radiographs on aligned equipment, using proper patient positioning.   As we further develop our communications with Dr. Biedermann, both of our groups may find fertile ground to move forward. 

 

References

 

1. Biedermann, H. “Kinematic imbalances due to suboccipital strain in newborns” Journal of Manual Medicine 1992.6:151-156.
2. Biedermann, H. “Manual Therapy in Children: Proposals for an Etiologic Model”               J Manipulative Physiol Ther Mar/Apr 2005.  2005:28:211.e1-211.e15.
3. Jones,DS.  Textbook of Functional Medicine. The Institute for Functional Medicine Gig Harbour, WA 2005.
4. ibid, Biederman 1992 :151.
5. ibid, Biedermann 2005: 211.e6.
6. ibid, Biedermann 1992:151.
7. ibid, Biedermann 2005: 211.e10
8. Biedermann H. Manual Therapy in Children.  Churchill Livingstone 2004: 303.
9. ibid, Biedermann 2004:306-7.
10. ibid, Biedermann 2004:307
11. ibid Biedermann 1992:153 (He ref: Gutman G (1953)Die obere HWS im Krankheitsgeschehen. Neuralmedizin 1:27-36., Gutman G (1968) HWS and HNO-Krankheiten. HNO Arzt 10:289-298., Gutmann G, Vele F (1970) Die Gelenke der oberen Halswirelsaule und ihre Einwirkung auf motorische Stereotypien. In Wolff HD (ed) Manuelle Medizin und ihre wissenschaftlichen Grundlagen. Verlag fur physikalische Medizin, Heidelberg.). 
12. ibid, Biedermann 1992:153-4
13. Valk J, van der Knaap MS, de Grauw T. The role of imaging modalities in the diagnosis of posthypoxic-ischaemic and haemorrhagic  conditions in infants. Klin Neuroradiol 1991; 2:83-140. 
14. Lierse W. Das Becken. In: Wachsmuth VL, editor. Praktische anatomie. Berlin: Springer; 1984. p. 337.)  Wischnik et al (Wischnik A, Nalepa E, Lehmann KJ. Zur prevention des menschlichen geburtraumas I. Mitteilung: die computergestutzte simulation des geburtsvorganges mit hilfe der kernspintomographie und der finiten-element-analyse. Geburtshilfte Frauen heilkunde 1993;53:35-41.
15. Govaert P, Vanhaesebrouck P, de-Praeter C. Traumatic neonatal intracranial bleeding and stroke. Arch Dis Child 1992;67:840-5.
16. ibid Biedermann 2005:211.e3
17. ibid Biedermann 2005:211.e10
18. ibid Biedermann 2005:211.e12
19. Gutman G 1969 Rontgendiagnostik der Occipito-Cervical-Gegen unter chirotherapeutischen Gesichtpunkten. Rontgenblatter 45-56.
20. ibid, Biedermann 2005:211.e11
21. ibid, Biedermann 2005:211.e11
22. ibid, Biedermann 2005: 211.e12
23. ibid, Biedermann 2005:211.e12
24. UCRF Board meeting, telephone conversation 7-9-09
25. ibid, Biedermann 1992:154
26. ibid, Biedermann 1992:155
27. ibid, Biedermann 1992:151
28. ibid, Biedermann 1992:151
29. ibid, Biedermann 2005:211.e12.

      30. ibid, Biedermann 2005:211.e11.  Within the quote, Biedermann references: Koch   LE, Koch H, Graumann-Brunt S, Stolle D, Ramirez JM, Saternus KS. Heart rate changes in response to mild mechanical irritation of the high cervical spinal cord region in infants. Forensic Sci Int 2002;128:168-76.]

      31.  ibid, Biedermann 2004:146

32.   ibid, Biedermann 2004:207

33.  ibid, Biedermann 2004:277

34.   ibid, Biedermann 2004:277

 

Upper cervical adjustments may improve mental function

J Manual Medicine (1992) 6:215-216
(c) Springer-Verlag

Clinical Note

Upper cervical adjustments may improve mental function

M.D. Thomas and J. Wood

Palmer College of Chiropractic Clinic, 1000 Brady Street, Davenport, Iowa 52803, USA

Summary. This report describes abrupt improvement in mental and motor deficits in a 14-year-old girl after the initiation of specific upper cervical chiropractic care. Cessation of this care for several months was associated with a return to the patient’s previous condition. Repeat manipulation was followed by recovery of the patient to the level of her previous improvement. This cycle of regression to pretreatment condition in the absence of care followed by recovery after specific upper cervical care has occurred three times to date.

Key words: Mental retardation – Chiropractic – Manipulation – Attention deficits – Atlanto-occipital joint – Atlanto-axial joint.
_________________________________

Periodic evaluations of a 14-year-old girl by her school psychologist were conducted between March 1984 and October 1989. The Leiter Performance Scale indicated severe mental, deficits, and the “Vine land Adaptive. Behavioral Scale indicated social adaptation within the trainable mentally handicapped range. Evaluations were most recently performed prior to initial chiropractic care in 1989. Informally, her teachers reported occasional moments of increased alertness and performance of tasks she normally did not perform.

Medical history

The birth of this patient followed an uncomplicated pregnancy. Apgar scores were seven after 1 min and nine after 5 min., well within normal ranges.
Speech problems were first noted at 30 months of age. In November 1978, the patient was admitted into an Early Childhood Education Program because of her deficiencies in speech and social development. She had developed behavioral problems by November 1979. She was evaluated by a neurologist who told the parents she would outgrow these problems by the age of 6 years. An electroencephalogram (EEG) performed in September 1980 was reported as normal.
The patient was enrolled in kindergarten in September 1981. She was transferred to a behavioral disability class in the next semester because of inattention in class and poor test scores. Initially, it was hoped the smaller class and more intense instruction would correct the inattention and test scores would improve. In September 1982, the patient’s teacher reported she was having “staring spells”. In January 1983 “slight abnormalities” were noted in a sleeping EEG. In February 1983 the diagnosis of psychomotor seizures was presented to the family. Tegretol and Dilantin were prescribed without positive results. By August 1983, the patient had been weaned off both medications. At this time the patient’s neurologist felt that there was a “degenerative neurological disorder,” and she was subsequently referred to the Mayo Clinic in Rochester, Minnesota. By January 1984, she had twice been examined at the Mayo Clinic without further definition except for acknowledgment that the sleeping EEG continued to be slightly abnormal. In May 1984, the patient was transferred from a behavioral disability class to a trainable mentally handicapped class.
In August 1985, she underwent a week-long evaluation at the National Institute of Health in Bethesda, Md. Again, all was normal (including MRI and various serum studies) except for slightly abnormal EEG. By July 1987, her EEG had improved and a degenerative neurological process was ruled out.
In October 1988 and August 1989, this patient was examined at the Children’s Hospital in Milwaukee. All findings were negative.

Chiropractic care
At the Palmer Public Clinic, interviews conducted in October 1989 with the parents and examination of available written records revealed a 13 -year-old female with a tested verbal ability at approximately 3 years of age. The patient reportedly spent most of every day sitting and staring into space while listening to the radio. She never made contact with others.
The patient tended to stay near her family and followed behind them when they went walking. She spoke very rarely, using single words, always nouns, which were occasionally appropriate and often echolalic. She often mumbled incoherently to herself. Given several choices, she always took the last choice offered.
The patient did not use her left arm or hand in situations where normal children would. In retrieving objects or grasping a swing while swinging she used only her right arm. The left arm did not swing appropriately as she walked, hanging flaccidly at her side while her right arm swung appropriately. We found adequate grip strength in both hands, with the right hand stronger than the left.
Orthopedic and neurologic evaluation was difficult due to patient noncompliance. The supine leg check showed leg length inequality, with the right leg 2 cm shorter. X-rays revealed osseous misalignment at the cranio-vertebral junction, with left atlas laterality and posterior rotation. This was accompanied by coupled motion of the inferior cervical vertebrae into the left frontal plane. Skull rotation was into the right frontal plane. Postural distortion was consistent with unilateral right extensor muscle hypertonicity.
Specific upper cervical adjustments using National Upper Cervical Chiropractic Association (NUCCA) procedures were given on 16, 17, and 19 October 1989. Leg length inequality and postural distortion were corrected after the third adjustment. Post manipulation X-rays on 19 October 1989 revealed a proportional 90% correction of the previous cranio-vertebral misalignment.
The patient began to make eye contact. On 19 October 1989 she returned with her parents to her home in Wisconsin. Within 2 weeks, the patient was forming sentences with personal pronouns, verbs, adjectives and nouns. The patient began standing straighter. She used her left arm in activities and swung her left arm normally during walking. These changes persisted for about 6 weeks, when her condition again began to deteriorate.
The patient was adjusted by a succession of three chiropractors near her home utilizing three techniques, different from the technique we employed. None of their interventions was effective. By June 1990, the patient’s condition was back to its previous baseline.
On 6 August 1990, the patient was again brought to our clinic. Upper cervical radiographs were again taken and specific upper cervical adjustment delivered. Radiographs obtained immediately after the adjustment revealed a proportional 95% correction. Immediately, the patient responded with eye contact, full sentences, and appropriate speech which she initiated. Left arm use was again regained. She stood straighter and walked more symmetrically. For tile first time, she engaged in family conversation and activities. When offered a choice, her decision was truly a decision and not agreement or a repeat of the last choice given.
The family returned home and these changes persisted for about 6 weeks before the patient began to return to her former condition. By the time the patient was next adjusted by a chiropractor using NUCCA procedures, in late June of 1991, she had lost much of the use of her left arm and was no longer speaking in sentences. Specific upper cervical adjustment again restored use of the left arm and ability to speak in complete sentences. As of 28 August 1991, the patient had not been again adjusted and no longer spoke in complete sentences, although active left arm use persisted.

Discussion

Interpretation of these results is difficult, because there is a correlation between upper cervical adjustments and apparent improvement in mental function. High correlation does not necessarily indicate a causative relationship,
Perhaps the mechanism that might most assist in explaining neural dysfunction accompanying upper cervical misalignments is altered input to the central nervous system from neck joint capsule receptors [1]. Some chiropractors who treat the upper cervical spine believe that upper cervical misalignments may alter neural function by causing longitudinal and transverse traction on the upper cervical spine and brain stem or on the upper cervical spine alone. Even in cases where stretching is not pathological, stretching of axons decreases their diameter. Conduction velocity decreases as fiber diameter is decreased [2]. Sufficient reduction of axon diameter completely blocks the transmission of nerve impulses.

References
1. Schwartz IL, Siegel GJ (1985) Excitation, conduction, and transmission of the nerve impulse. In: West JB (ed) Best and Taylor’s physiological basis of medical practice, 11 th edn, chap 3. Williams & Wilkins, Baltimore, pp 28-57
2. Wyke B (1979) Neurology of the cervical spinal joints. Physiotherapy 65:72-76