Gonstead Listings: short-hand



Gonstead: Dr. Cranwell (Fall 2005)

Gonstead Listings: short-hand

ASRA: (Atlas) Ant-Sup tubercle-Right side sup-Ant on right

Observe pt: Nose chin in air, lat flex to L, rotation to L

Fixations: restricted R rotation, restricted R flexion

Subluxation:

▪ Defn = a minor mis-alignment btwn two adjacent articulating surfaces that causes a problem (i.e; nervous system interference).

-Misalignment? Thickness of a hair (not usually seen on xray)

-Defining the prob: tenderness, irritation/inflammation, ↓ ROM, pain/radiations, spasm, numbness/tingling (paresthesia), heat, muscle weakness, etc

Motion palpation = most important tool

▪ Gonstead Criteria: look for indication of subluxation

1. Inflammation due to irritation (heat)

+ Instrumentation: find sublux’s accurately & reproducible

-heat sensitive: nervoscopes (temposcope), dermathermographs

2. Edema: spongy, fluid-filled

+Static palpation (inter-transverse process area = NR)

3. ↓ ROM (lose mobility- doesn’t have to be completely fixated to cause prob)

+Check all 6 ROM of jt: feel for loss of mobility, pain

+MOST IMPORTANT OF CRITERIA

9/20/05 What do you need to know about your patient before you treat them:

A. Case Hx:

▪ Past sx

▪ General Health: hot-flashes (Vit E: dry VitE for pt if gallbladder removed = can’t have fat)

▪ Rx they are taking: Lipitor (muscle aches/pains);

1. Beta Blockers/statin drugs (Mg deficiency ( affect mm’s)

2. Harvard Study: Spontaneous fatal heart attacks ( caused by Mg deficiency

3. Ca2+: must be balanced w/ Mg (↑ Ca : ↓ Mg) ( mm cramps (charlie horse)

▪ ***Any time you have same symptom, same dermatome, B/L at same time == Biochemistry problem (red flag – i.e; SOL, Cancer)

▪ Trauma: need to know biomechanics of the injury

▪ Occupation: ergonomics and related problems

B. Exam: Ortho & Neuro exams

C. Chiropractic exam:

▪ Visual & General Inspection

▪ Motion/static palpation,

▪ Accurate Vertebral count

D. Xray: full spine AP, Lat (14 X 36)

▪ Gonstead Xray technique: Lat taken in 2 (7 X 14) exposures – Primary ray through head of humerus while bottom is collamated out ( lower tube through iliac crest and collimate out top portion (WHY is this important?)

1. See disc spaces better (more through disc plane in C/S, L/S)

2. See C/S, L/S curves better

3. Problem: T7-T9 on top and bottom exposures (okay but need to take AP film to know accurate # of Vertebrae)

▪ We find the subluxation ON THE PATIENT but use Xray to CONFIRM findings!

1. If findings do not correlate: re-examine, re-Xray, etc

|FSAP |Vs |FS Lat***** most important view |

|*Scoliosis | |AAA: ant to VB’s (if treated can rupture!!!!) |

|Dysplastic Pedicle | |Spondylo L5/S1 relationship: can’t tell unless Xray ( if |

| | |treated, gets worse, ER xrays, think you caused it!! |

|Transitional segments (lumbarization, etc) | |Base Posterior: L/S fine but sacrum posterior |

|Tracheal deviation | |ADI instability |

|Pelvic un-leveling (short leg) | |**Stages of Disc degeneration |

|Lateralisthesis | |Blocked vertebrae/segments |

|Rotational sublux & wedging | |**AP curves |

|*Accurate vertebral count | |Fractures: compression |

|Listing of mis-alignment (wedge, etc) | | |

[pic]Grade 4 Spondylolisthesis ( can affect AA ant to VB

▪ NCMIC: risk management seminars (get discount on malpractice insurance)

▪ **If only have 1 piece of film left (25/box): should you take FSAP, FSLat, no xrays?

Should you treat the patient anyway with each diff option?

(( TAKE FSLat!! Most of the info from the AP you can find thru palpation on the patient, but the Lat shows you conditions you can’t evaluate w/out the Xrays!!

Always dependent on the situation and the severity of the patient complaint ( you can do PT on patient and have them come back next day when have more film.

▪ When to re-xray: new injury/trauma, findings don’t correlate w/ old xray, xrays 2-3 yrs old

E. Treatment: diff is that you believe what you do works!!!

▪ Chosen technique

F. Re-evaluate

G. Leave it alone!!!!!!

▪ Give the body a chance to heal itself!!

Dr. Gonstead’s Motto:

1. Find it (on the patient)

2. Accept it (where you find it)

3. Fix it (technique of choice)

4. Leave it alone!

6 Stages of Disc Degeneration: (D1-D6)

- Longer its been a problem, the longer tmt duration

|Stage |X-ray presentation |Time Period |Description |

|D1 |[pic] |2-3 days |Acute, disc bulge |

|D2 |[pic] |3-6 mos |↓ Posterior disc space |

|D3 |[pic] |3-5 yrs |↓ Anterior and Posterior disc spaces |

|D4 |[pic] |5-10 yrs |Posterior disc space is gone |

| | | |Anterior disc space ↓ |

|D5 |[pic] |10-15 yrs |PAPER THIN disc space between vertebrae |

|D6 |[pic] |15-20 yrs |NO disc is left between the vertebrae |

D6 – not getting disc back (tmt goal: improve mobility only)

9/29/05

History: Dr.Gonstead

- 1st to come up w/ a listing system (specific)

- Ronald Reagan: spoke at Parker seminar for chiropractic

o Radio announcer for WOC (Palmer station)

- VSC: “subluxation is an aberrant relationship between 2 adjacent articular structures that may have functional of pathological sequelae, causing an alteration in biomechanical…”

- “First, spend all the time necessary to carefully and precisely find and correct a patient’s problem. Do not be in a hurry. Check and re—check your x-ray, your palpation, instrumentation, and visualization. Second, remember that Chiropractic always works. When it does not seem to, examine your application, but do not question the principle. Third, be prepared when the demand for chiropractic care increases. Study the spinal column and NS every chance you get. Our future will be the results.” Dr. Gonstead

- How to have success

o Take care of your patient! Treat them as you would want to be treated.

▪ KISS: keep it simple stupid!

o Be there when your patient needs you (pain doesn’t take a holiday)

o The patient will take care of you!! (referral)

- Gonstead Clinic @ Mt Horab, Wisconsin (76 room hotel, golf course, camp ground, bowling alley, 250 person waiting room)

o Have separate dressing rooms (opens up the treatment rooms)

o Designed and built by Frank Lloyd Wright

- Xray Marking: use Gonstead parallel (bookstore):

o Stage 1: place dots (looking at xray R is on the R)

▪ #1,2: at sup aspect of B/L femur heads

▪ #3,4: up to sacral groove (L5 meets S1?)

▪ #5,6: sup aspect of iliac crests

▪ #7,8: inf aspect of ischiums

▪ #9: 1st sacral tubercle (could be S2 if widest sacral ala at that point)

▪ #10: center of symphosis pubis

Xray Marking- last class (PC document)

[pic]

Three Phases:

1. Draw parallel lines: All lines are parallel or perpendicular to femur head base line except 2: line over sup-femur head & sacral baselines

a. **Femur head base line: connect 2 femur heads

b. Sup to inf sacral groove

c. L iliac crest line ( repeat on R

d. L inferior ischium ( repeat on R

e. Line at sup femur head (roll from gridline or bottom of film up to sup femur head)

f. Parallel 90◦ to femur head base line ( roll over to dot #9 ( line straight down to center of sacrum and symphosis pubis???

i. (want to go thru dot # 10 for alignment - if not = pelvic rotation??)

g. Line thru lat aspect of R sacral ala

h. Line thru med aspect of R ilium

i. Repeat on L (9-12)

j. **Sacral base Line = line connecting 2 sacral grooves -should be parallel to femur head base line

k. Ideal situation = no pelvic/sacral rotation or femur head deficiency; therefore, all lines will be parallel or perpendicular to femur head base line!

2. Measure lines:

a. Msr between iliac crest line and the ischial line

* Msr L innominate measurement (write under ischium)

* this is the longer one

b. Repeat on R side

c. Msr distance between femur base line & inf femur head line

* L femur head deficiency

d. Place on dot 10 & msr pubic line

*Symp. pubis Msr

e. 6 lines of Sacrum Msr

*line #9-msr each sacral ala (btn center of sacrum and each lat. aspect of sacral ala)

*L sacral Ala msr --> repeat on R sacral ala

f. Msr ilium, (btn lines L 11-12; & R 13-14)

*Msr width of L ilium

*Ilium Shadow Msr

*Repeat on R

* What does it all mean?

Major objective = (Not to Straighten spines!) Restore optimum mobility

The letters used in Gonstead analysis, and the words they abbreviate, are given below:

|A |Anterior |I |Inferior |

|P |Posterior |S |Superior |

|In |Internal rotation (related to innominates|T (T/S) |Transverse process |

| |only) | | |

|Ex |External rotation |LA (C2-C7) |Laminae process |

|R |Right |M (L/S) |Mamillary |

|L |Left |Sp (C2-L/S) |Spinous process |

Ch. 1: AP Misalignment

* Reference pt for innominates = PSIS!! (listing system)

Motion of the Innominate: nutation w/ walking

• List 1 innominate in relationship to the other innominate!!!!

1. If one innominate listed as AS, other is listed as PI

2. Which one is subluxated? Find on patient (heat, edema, ↓ mobility)

3. Just because you have a listing, doesn’t mean that that bone/vertebrae is subluxated!!!! (listing only tells you the relationship that bone has with its neighbors)

• Every bone subluxates in relation to the bone it articulates with (innominate & sacrum)

• Innominate subluxates with the sacrum

• Listings appear on Xray:

|X-ray appearance |AS innominate |PI innominate |

|Obturator measure |Smaller vertically |Larger vertically |

|Innominate measure |Shorter |Longer |

|Edema |At PI portion of SI jt (clinically over |At Sup portion of SI jt |

| |whole jt) | |

|Lumbar Lordosis |↓ |↑ |

|Femur head level |Raises |Lowers |

|Sacrum on involved side (fact) |Posterior |Anterior |

*Listed in order of importance

*Sublux choices: L-AI, R-PI, neither, both

Ilium Subluxation - Compensation Relationship (find on Pt)

Ch 2: Horizontal alignment

Center sacral line should go thru center of symphosis pubis

• Innominate Rotation: (affects lower extremity)

1. Ex: PSIS goes away from center of sacrum

▪ Cause toe in

2. In: PSIS goes toward the center of sacrum

|Feature |EX ilium rotation |IN ilium rotation |

|PSIS |Goes away from center of sacrum |Goes toward center of sacrum |

|Symphisis Pubis |Cross over center sacral line |Away from center sacral line |

|Obturator Projection |Obturator larger horizontally |Obturator smaller |

|Ilium shadow |Narrows horizontally |Widens horizontally |

|Pubic bone |Widened |Narrowed |

|Toe |In |Out |

|Gluteal muscles |↑ Tone |↓ Tone |

|Spinal pain | | |

|Hip pain | | |

|Knee pain |Medial |Lateral |

|Foot & Ankle | | |

3. MD will brace feet to correct (treating symptom)

4. Hip & knee pain: put joint thru ROM – if not reproducible = pain is referred!!

5. Foot & Ankle pain

6. Spinal pain: due to torque to compensate for ilium rotation (even HA’s that won’t resolve)

7. Crytorchidism: undescended testicles (held up by EX ilium or tension pulling up w/ IN ilium)

8. Bed-wetting: vagus nerve, other nerves? (

▪ MD solutions: meds, pad & electrodes that shock baby when pad gets wet, sever nerve

▪ Chiro solutions: fix subluxations!! Restore nerve fx!!!

9. Female: not able to have children (twisted pelvis – torsion on reproductive organs

▪ Menstrual problems – look at L/S: painful menstruation ( supplement w/ Ca & Mg

4 Combinations (9 different innominate listings!!)

((Record only the ilium we found to be subluxated))

▪ PI, AS, EX, IN: correction of these, utilize LOD opp the subluxation and set up by the position of your forearm!

▪ IN-EX (both are subluxated!!)

▪ ASEx, ASIn, PIEx, PIIn

o When combined, LOD will still correct AS, PI component but the In/Ex eliminated thru torque when they are in combination w/ PI/AS.

▪ PIEx: contact point inf/lat & use counter-clockwise torque (or clockwise torque on opp ilium)

▪ Torque is accomplished by twist of your wrist

o m/c are the ASIn (up & in), PIEx (down & out):

|Feature |ASIn |ASEx |PIIn |PIEx |

|Innominate msr |Shorter |Shorter |Longer |Longer |

|Ilium Shadow |Larger |Smaller |Larger |Smaller |

|Obturator projected picture |Smaller both dimensions |Smaller vertically but |Larger vertically but |Larger, more circular |

| | |larger horizontally (can’t|smaller horizontally | |

| | |look at just obturator to | | |

| | |determine the listing) | | |

|Femur head |High | | |Lower |

|Femur insufficiency |Longer leg | | |Shorter leg |

Case Study: pain exacerbated by walking, going up and down stairs (pelvis or lumbars) – doesn’t hurt to sit for long periods of time (rules out lumbars)

• Find heat and edema over L SI jt

• Motion Palpation on R ilium (get reference pt of that patient)

• Motion Palpation on L ilium ( ↓ ROM, reproduce pt complaint of pain (L innominate is subluxated)

• XRAY: L innominate msr is shorter (AS), the ilium shadow larger (In), obturator is smaller both vertically & horizontally

4 Rules for your adjusting:

1. Patient positioning so they are comfortable (relaxed)

2. Dr Position is comfortable and relaxed (height of table – mid patella)

3. LOD correct – thru the disc plane line

4. Speed & Timing:

Ch 3: Femur head height changes w/ Ilium Misalignment

• 2 Sections of femur head insufficiency

1. Anatomical Leg deficiency: structural short leg due to – congenital, polio, osteomyelitis, acute fracture, knee replacement, etc

▪ Short leg on Xray w/out an innominate subluxation!

▪ Fix w/ Heel Lift

2. Physiological Leg deficiency: caused by subluxation (ilium, sacrum, knee, ankle, flat feet, etc)

▪ As innominate goes PIEx – femur head goes down & out ( appear lower on xray but changes angle of the leg making it shorter!!!

▪ Short leg due to ↑ angle of leg & Long leg due to ↓ (straightening) angle of leg

▪ Fix w/ Adjustment (If have both anatomical and physiological prob = fix subluxation first then address anatomical!)

Subscripts in listing: difference in innominate msr

* Innominate: subscript is the difference between the innominate msr’s

AS5 : L innominate is 250 therefore R innominate is 245 . (AS is shorter innominate msr)

Difference in the innominate measurements

* In5 : 5 mm msr between center of symphosis pubis and the L pubic bone (Ex side)

This comes from the symphysis pubis measurement

5-2 Rules for Correction: approximate affect we will have on the femur head as we correct the innominate (

1. For every 5 mm subscript of AS or In correction, the femur head height will be lowered 2 mm.

2. For every 5 mm subscript of PI or Ex correction, the femur head height will be raised 2 mm.

MD – measured deficiency (what deficiency is when 1st take the Xray – have not touched pt yet)

AD – actual deficiency

Ex 1: AS5In5 (see xray notes) : lower 2mm then another 2mm.

Was 10mm – lowered 4mm ( AD = 6 mm

[pic]

Ex 2: AS10Ex5 (L innominate listing); MD = 15mm (L femur head def)

[pic]

10/20/05

0 mm MD (femur heads same height)

AS5Ex10 (L): center sacral line crossing over the L pubic bone

What is the AD = 2mm on R. (AS down 2 and Ex up 4)

B/L equally subluxated innominates = not lat curves = AS, In, or ASIn

If lat curves = PI, Ex, or PIEx

Which one came 1st? most effect? = use lat AP curves

Ch 4: Sacral Misalignments:

Relation/subluxation in regard to the innominate (Sacro-iliac joint)

• Post sacral ala = wider

1. ↑ mm tone on one side; high TP’s all on one side (sacral ala post on that side)

• The central sacral line crosses pubic bone when = on side opp the post rotated sacral ala

1. or it could be Ex

2. spinouses are opposite of the post rotation

3. TPs high on post side

The four potential sacral misalignments involving the sacroiliac articulation are as follows: as relates to the ilium!

1) Posterior Rotated Sacral ala on the R (P-R)

a. Crosses the pubic bone on the left, and wider on the Right (A prime)

2) Posterior Rotated Sacral ala on the L (P-L)

a. Criteria: wider (6-7mm difference in width – look at clinical picture! ) sacral ala on L (one that went posterior); central sacral line crosses over opp pubic bone; SP’s rotated to the right (TP’s high and ↑ tone on L)

3) Posterior and Inferior Sacrum (PI-R)

a. Only concerned w/ inferiority ONLY if on same side as posterior rotation!! (Major misalignment is POSTERIOR for Gonstead listing)

4) Posterior and Inferior Sacrum on the L (PI-L)

PI-R:

[pic]

• If lines are not parallel to each other = think MALFORMATION.

• Correction: LOD (for inf = change direction of forearm)

Adjusting Sacrum to Ilium – only to be used when you find the innominates subluxated on the same side that you find the sacra ala has been rotated inferiorly

• if the ilium listing is As, In, or ASIn, adjust the sacrum to the ilium

• if the listing is ASEx, with the AS predominating, adjust the sacrum to the ilium

• if the listing is PIIn, with the In predominating, adjust the sacrum to the ilium

Final Material: 11/1/05

L5 and sacral joint: look on lat film at L5/S1 junction

Sacral Base Posterior

• On lat film, the base of sacrum has gone post

• Break in George’s line btn L5 & S1

• Base of sacrum becomes more horizontal

• Ant disc space ↓ ; Post disc space ↑

• As base of sacrum goes post, the rest of the lumbars goes (↓ lordosis)

• Apex of sacrum goes anterior (into rectum ( coccyedema)

• Can get coccyedemia (pain) due to base going posterior

• Gait will be affected – B/L Ex (most likely AS) ( B/L toe in (tripping over feet)

• Parasympathetic hypersensitivity (bed-wetting)

• Affect sciatic n B/L**

Spondylolistheis:

• ON lat film, prob is the L5

• Break in George’s line btn L4/L5 & L5/S1 (continuous at L1-L4 and sacrum)

• ↑ lumbar lordosis

• L5 disc: Post disc space ↓ and ant ↑ (opp of base posterior)

• Pain: B/L sciatica (won’t have coccyedemia – rectal pain)

• If it is asymptomatic, leave it alone!!!!!!!

Misalignment of the Coccyx (trauma)

• Three possible listings (all have A in common)

1. Anterior: lat film

2. A-Right, A-Left (A-L) – AP film

▪ Should ask which bone you are asking about (A-R, A-L also refer an atlas)

Ch. 5: Disc

• From L5, up to and including C2, the most important/major part of the subluxation complex is the POSTERIORITY/INFERIORITY (1st letter of all listings is P)

• List sublux vertebrae in how it relates to the vertebrae below it!! (i.e; L5 in relation to sacrum, C1 in relation to C2)

• 4 Things you want to see on Lat film: PI subluxation

1. Ant disc space ↑ (degree is dependent on PI of subluxation)

2. Post disc space ↓

3. ↑ superior interspinous space (can find/palpate)

4. ↓ inferior interspinous space

[pic]

• Find direction of misalignment

• Gonstead listing:

1. 1st letter: always P (C2-L5) – feel ↑ superior ISS, ↓ inf ISS

2. 2nd letter: Concerns spinous laterality listing (other techniques list body rotation)

▪ TP/mamillary high on opp side

3. 3rd: Concerned only w/ wedging on side of spinous laterality (find restriction)

▪ i.e: PRI (posterior, SP right, wedging inf)

▪ i.e; PRS (post, SP right, wedging sup)

▪ The listing is derived from your examination of the patient (find prob on the patient) ( Motion Palpation major tool

• Static palpation: determine what vert has done

• Motion palpation: find direction of restriction (restricted lat flexion in direction of open wedge which is opp SP laterality)

• To clarify these 2 diff conditions, the following summary is offered:

o If the SP is rotated to the open side of the wedge, the complete listings are PLS or PRS. It is not necessary to specify the contact point since it is always the SP

o If the SP rotated to the closed side of the wedge, it is listed PLI-M or PRI-M, and the point of contact, which is the mamillary process, is designated by the letter “M”. (if have I = list contact point)

Scoliosis:

• Rt/Lt (determined by side of convexity)

• Simple/Rotatory (determined by side SP goes to): simple = SP goes into the convexity; if SP goes into the concavity = rotatory

1. Anytime the 3rd letter is an “S” = have a simple scoliosis

2. Anytime the 3rd letter is an “I” = have rotatory scoliosis

• Adjusting: stand on and contact convex side

[pic]

11/3/05

Rules for Adjusting a Posterior-Rotating sacral ala (P-L/R) when it is on the same side as a subluxated innominate (Predominating = has larger subscript)

• Adjusting Sacrum to Ilium

1. If the ilium listing is AS, In, or ASIn, adjust the sacrum to the ilium

2. If the listing is ASEx, with the AS predominating, adjust the sacrum to the ilium

3. If listing is PIIn, with the In predominating (meaning has larger subscript), adjust sacrum to the ilium

• Adjusting Ilium to Sacrum

1. If the ilium listing is PI, Ex, or PIEx, adjust the ilium to the sacrum

2. If the ilium listing is PIIn, with the PI predominating, adjust the ilium to the sacrum

3. If the ilium listing is ASEx, with the Ex predominating, adjust the ilium to the sacrum

Summary of Vertebral listings/features:

|P: post |R/L: SP laterality |I/S: wedging on side of |Contact point (only for |

| | |SP laterality |“I”) |

|Sup interspinous space ↑ |Larger pedicle shadow on |Lat flex malposition on |C/S: LA |

| |opp side. |side of wedge |T/S: TP |

| | | |L/S: MA |

|ALWAYS the 1st letter of |Larger TP appearance on |Simple scoliosis when = S| |

|listing |same side (post TP looks |+/or SP rotated to side | |

|* Reason you lose AP |smaller) |of OW | |

|curves | |Rotatory scoliosis when =| |

| | |I +/or opp side of OW | |

| | | | |

To clarify these 2 different conditions, the following summary is offered:

1) If the SP is rotated to the open side of the wedge (simple scoliosis), the complete listings are PLS or PRS. It is not necessary to specify the contact point since it is always the spinous process. (Dr stands on side of OW, SP laterality)

a. 1st 2 letters (P/LorR) corrected by LOD by forearm (P to A and Lat to Med)

i. Needs to go thru the disc plane line

ii. Dr not over contact – off to side to get med LOD (hand crosses over the spine)

b. Wedging eliminated thru use of torque (twisting of the wrist)

i. Open wedge on R always clockwise torque!!!! (OW on L = counterclockwise torque)

ii. Correction: “set vertebrae back down on top of the vertebrae below it”

1. Use superior hand contact from T1-L3; inf hand L4/L5 (so you won’t jam L5 into L4) – “padded pisiform”

2. Stand/contact/thrust on side of OW, convex side

2) If the SP is rotated to the closed side of the wedge (rotatory scoliosis), it is listed PLI-M or PRI-M, and the point of contact, which is the mammillary process in L/S.

a. LOD is exclusively PA for rotatory scoliosis (standing over contact)

b. Dr hand doesn’t cross the spine

11/15/05

How do you know an injury was 20 yrs ago? – look at the disc

When you must list contact point:

1) Any time there was no 3rd letter (no wedging)

2) Any time the 3rd letter is an “I”

3) All L5 listings!!!! (to determine what situation looks like – chronic adaptation)

4)

Four L5 peculiar/characteristic listings: always in chronic situations – compensation)

1) PLS-M (normally would have SP listing w/ the “S”)

a. Must have contact point for all L5 listings

2) PRI-S (normal is PRI-M)

3) PRS-M (normal is PRS)

[pic]

4) PLI-S (normal is PLI-M)

Fix eye twitch = upper cervical on opp side

Good Nutritional book (Nutritional Healing)

Chart on L/S listings

C2-L4 = have 9 basic listings

L5 listings = 4

Total = 13

Know – how to draw it out, see Xray and attach listing to it

|Listing |Posterior |Sp laterality |Wedging |Scoliosis |Contact point |

|L1-L4, T/S (9) | | | | | |

|P (compression fx) |Yes |None |None |May be either |Sp |

|PR-Sp |Yes |Right |None |May be R |Sp |

|PRS |Yes |R |R |May be R |Sp |

|PRI-M |Yes |R |L |May be L |L Mam |

|PR-M |Yes |R |None |On L |L Mam |

|PL-Sp |Yes |L |None |May be L |Sp |

|PLS |Yes |L |L |May be L |Sp |

|PLI-M |Yes |L |R |May be R |R Mam |

|PL-M |Yes |L |N |On R |R Mam |

|L5 | | | | | |

|PRS-Sp |Yes |R |On R |May be R |Sp |

|PRS-M |Yes |R |ON R |On L |L Mam |

|PRI-Sp |Yes |R |ON L |On R |Sp |

|PRI-M |Yes |R |ON L |May be L |L Mam |

|PR-Sp |Yes |R |None |May be R |Sp |

|PR-M |Yes |R |None |On L |L Mam |

|PLS-Sp |Yes |L |ON L |May be L |Sp |

|PLS-M |Yes |L |On L |ON R |R mam |

|PLI-Sp |Yes |L |ON R |On L |Sp |

|PLI-M |Yes |L |ON R |May be R |R Mam |

|PL-Sp |Yes |L |None |May be L |Sp |

|PL-M |Yes |L |None |On R |R Mam |

** For L5: compensation causes wedging on opp side of SP laterality!!!!

Chart for diff listing systems: (not complete)

|Picture | |Gonstead listing | |

| |R Lat fexion malposition (RLF) |None |R inferior (RI) |

| |L rotational malposition (LR) |Posterior spinous R (PR | |

| | | | |

Column 3,4 say same thing but with diff reference points

9 basic listings for C2-L5

• P, PL or PR, Sp or M

• No third letter no wedging

Ex: PRS (problem in mid-T/S because of long SP = imbrication)

• T5-8: contact the base of SP right below the superior SP tip

1. Keeps you from jamming inferior vertebrae down on lower one (make sublux worse)

2. Puts LOD thru disc plane

• Law of 13 applies

UPPER CERVICAL SUBLUXATIONS

C1/occ: can cause everything to go wrong!!

Koch literature: Heart rate changes (vagus nerve)

The mechanism:

• C1/C2: have articular capsule can become irritated (edema ( lat mass goes Sup/lat)

1. C2 down: major misalignment is POST

2. C1: major misalignment is LATERAL (listed in regards to the axis)

3. C1/occ (condyle): head tilt to opp side when capsule becomes irritated

• Restriction: in lat flexion on side of edematous capsule

• Chiropractic is an art; an artist develops, expands, and unfolds. It doesn’t just happen. It takes time, commitment, and practice. Practice requires desire and determination. Practice requires a conscious effort, repetition, and a structural approach. Practice does make Perfect!!

• Atlas Misalignment (list atlas – look at lat film)

1. Odontoid Line: Dot at tip and base of odontoid process (line connecting 2 dots = bisect odontoid ant/post down the center)

2. Odontoid Perpendicular Line: Line perpendicular to odontoid line

3. **AP Atlas Plane Line: Dot at ant tubercle and at post tubercle (line connecting)

[pic]

• If see ↑ post disc space and ↓ ant space (opp) = compensated vertebrae!!

• S2 segment subluxated post/inf = symptoms would be bedwetting

• Atlas Misalignment (AP film)

1. Transverse Atlas Plane Line: line connecting 2 dots at the inf portions of the lat masses

2. Axis Plane Line: line connecting 2 dots at ….

3. 2 lines converge on one side and listing is opp side!!! (i.e; R listing if converge on the L)

4. If the 2 lines are parallel, tells us that neither side as gone superior and lateral (no 3rd letter and no atlas problem!!!!!!!!!!)

[pic]

• Atlas listings

1. 1st letter is always an “A” (same for coccyx, ilium) – off lat film

2. 2nd letter tells what the ant tubercle has done (come off the lat film)

▪ AI: AP atlas plane line and odontoid perpendicular line converge anteriorly (or diverge posteriorly)

• Head position down (not always an AI atlas)

▪ AS: lines converge posteriorly (or diverge anteriorly)

• Head position up

▪ A- : 2 lines are parallel

3. **3rd letter denotes laterality/superiority (R, L) – most important aspect of subluxation is the laterality (tells the side of involvement)

▪ Tells side of restricted lateral flexion (tells side that has gone superior and also the side of contact)

4. 4th letter is rotation (A, P, -)

▪ Don’t need to have a rotational component to have an atlas subluxation (may or may not have a 4th letter)

▪ Can have an atlas listing with either 2, 3, or 4 letters

▪ The wider atlas lat mass is the side that has rotated anteriorly

▪ ONLY concerned w/ rotation on the side of laterality

Clinical presentation

| |Head Position |Motion Palpation |

|ASRA |Chin/nose up; Lat flex to L; Rotated to R |Restricted R lat flexion and restricted |

| | |rotation to R |

|ASRP |Chin/nose up; Lat flex to L; rotated to R |Restricted R lat flexion and restricted |

| | |rotation to L |

| | | |

**Visual presentation, motion palpation, xray confirmation

** 1-2 letters come from the lat film; 3-4 letters come from the AP film

(all ASRP, A-RP, and AIRP look the same on AP film ( look at Lat film)

(all ASRA, A-RA, AIRA “”””” ”””””” ”””””” ””””””)

Patient will always have restricted rotation to the side that has rotated anteriorly

Upper C/S subluxation affects sympathetics ( hyper- symptoms!!! (adjustment causes relaxation)

• Leave other spine alone (may treat sacrum or pelvis – work for same result)

• Xray – loss of cervical lordosis: Subluxation is C7 (PI) and C4 is compensating

1. DON’T SEND HOME CERVICAL PILLOW until get some flexibility into the spine or won’t help and may exacerbate symptoms (if pt using 3 pillows, wean her down to using just one then do cervical pillow)

|Listing |Ant |Sup or Inf |Laterality |Rotation |Contact point |Direction of |

| | | | |(4th letter) | |Torque |

|A-R |Yes |None |R |None |R TP |None |

|ASR |“” |Sup |‘’ |None |R TP |Clockwise |

|AIR |‘’ |Inf |‘’ |None | |Counter |

|A-RA |“ |None |‘’ |Ant | |None |

|ASRA |‘’ |Sup |‘’ |‘’ | |Clockwise |

|AIRA |“ |Inf |‘’ |‘’ | |Counter |

|A-RP |“ |None |‘’ |Post | | None |

|ASRP |‘’ |Sup |‘’ |‘’ | |Clockwise |

|AIRP |‘’ |Inf |‘’ |‘’ | |Counter |

|A-L |‘’ |None |L |None |L TP |None |

|ASL |‘’ | |‘’ |‘’ |‘’ |Counter |

|AIL |‘’ | |‘’ |‘’ |‘’ |Clockwise |

|A-LA |‘’ | |‘’ |Ant |‘’ |None |

|ASLA |‘’ | |‘’ |‘’ |‘’ |Counter |

|AILA |‘’ | |‘’ |‘’ |‘’ |Clockwise |

|A-LP |‘’ | |‘’ |Post |‘’ |None |

|ASLP |‘’ | |‘’ |‘’ |‘’ |Counter |

|AILP |‘’ | |‘’ |‘’ |‘’ |Clockwise |

• Bold: repeating sequences

• Torque: None if no 2nd letter

12/8/05

Lat view cont…

• AP Atlas Plane Line

• Odontoid Perpendicular Line

1. If AP Atlas and Odontoid Per Lines are Parallel – Can still have Atlas sublux!!

• Foramen Magnum Line: line connecting 2 points behind the mastoid

[pic]

|AS |Vs |PS |

|Head has gone AS | |Head has gone PS |

|Presentation: nose & chin up (same as AS atlas – | |Presentation: nose & chin down (same as AI atlas) |

|differentiate thru motion palpation) | | |

|Foramen magnum line and AP atlas plane line will | |Formen magnum line and AP atlas plane line will converge anterior |

|converge posterior (diverge anterior) | |(diverge post) |

|↓ OA space (occ/atlas) – affect on TMJ/dental bite | |↑ OA space |

|AS condyle is predominately sustained in birth canal | |Hyper symptoms (cord pressure) – facial trauma – MVA, abuse, etc |

|trauma (suction, forceps, or thumbs in mouth) – puts | | |

|pressure on spinal cord (upper C/S sublux yields | | |

|hyper- symptoms; i.e – colicky ( ADHD if not | | |

|corrected!!) | | |

AP view: (see picture above)

• Transverse atlas parallel to Axis plane line = NO ATLAS SUBLUXATION!! (no third letter)

1. Atlas lat masses not same width = atlas rotation! (as condyle rotates, atlas will counter-rotate to compensate)

▪ R side Lat mass narrower ( therefore rotated post on the R (condyle has rotated anterior)

• Transverse Condyle Line: line connecting 2 dots at mastoid grooves- AP)

1. Can go 2 ways: ???????

• Listings:

1. AS-RS (differentiate btn an atlas subluxation on paper)

• Determine condyle rotation by looking at the atlas rotation

1. AS-RS-RA (most important is the AS)

▪ Looks same as PS-RS-RA (must look at the lateral film)

|1 |2 |3 |4 |5 |6 |

|A or P |Always be an S |Will be same as 5 (R/L) |Always be an S |Will be same as 3 (R/L) |A or P |

Severe trauma in order to sublux (4 jts):

1. Condyle

2. Coccyx

3. Sacrum

4. Ilium (Aggravated by walking = ilium/SI; aggravated by sitting = L/S)

Pediatrics:

• What to do about “head banging” – pushing against the glabella (AS condyle subluxation)

1. Innate trying to get pressure off the spinal cord

2. How to help: DON’T IGNORE IT!

3. Shaken baby syndrome – due to cord pressure causing them to cry non-stop

• Birth trauma

1. Spinal cord and brain stem injuries due to stretch, flex/ext, etc (MDs aware of problem but don’t know what to do about it!)

-----------------------

AS10: for every 5mm #ˆ[pic]}ˆ[pic]«ˆ[pic] ‰[pic]?‰[pic]7Š[pic]FŠ[pic]ŠŠ[pic]ÒŠ[pic]7‹[pic]c‹[pic]š‹[pic]«‹[pic]Å‹[pic]QŒ[pic]»Œ[pic]ÜŒ[pic]F?[pic]?[pic]À?[pic]õ?[pic]

Ž[pic]

Ž[pic]÷÷÷÷òêââÚÒÚÒÚâÚâÚÚÚÚÍÍ↓ 2mm (total of 4mm)

15 + 4 = 19

Ex5: for every 5mm ↑ 2mm

19 – 2 = 17 AD on R

All sacral foramina lines are parallel to one another

**Sacrum has dropped inf on that side

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