Gonstead Technique - Logan Class of December 2011



Gonstead Technique Alan Pan 1999 v.5

Crooked spines do not make people sick, subluxations make them sick

A-D-I-O Above - Down - Inside - Out

Get the big idea & all else will follow

World’s philosophy of Tylenol & Excedrin … wonder pain killer of Dz

Rem…. We treat the pax not the Dz … don’t ever treat based on the symptoms and don’t be

fooled by the signs

Gonstead concerns itself w/ the analysis of the pax & based upon this info proceeds

w/ a system of adjusting. Anyone can move a bone but you need to know

why & what will happen before you move it.

Level foundation …. Check the X-ray

IVD … we normalize the location thereby affecting function

Compensation …. May be subluxated in response to another segment

Fixation /Subluxation … primary findings wherever they may be

Listing …. PR, PL etc

Rem … chiropractic always works. When it does not seem to, question your application, but do

not question the principle

Chiropractic is the science which concerns itself w/ the relationship b/t structure, primarily the

spine & CNS

The body has recuperative powers to heal itself …. Innate intelligence

Gonstead formula . …Find the Subluxation … even if it is not where you thought

Accept it where you find it

Adjust it … ASAP … let the body heal

Leave it alone …. Let the body heal ADIO

Emphasis … fix the pax problem & dismiss them for that condition

Ie. C/o LBP … fix it …… now there is a closure => no more LBP

Signs of Subluxation … pain, swelling (inflam’n), immobilization (splinting/fix’n),

palpation tenderness, neurologic dysfunction

Tools for finding subluxations …..… instruments … BP cuff, scopes, nervoscope

Static palpation (swelling/point tenderness)

Motion palpation (fixation)

Visualization (antalgia, leaning, walking, moving)

Others … X-rays … not for finding sblx’ns

Cannot see soft tissues .. IVD

Can’t evaluate motion

Hx … 80% Dx is from history alone

PE … look for the telltale signs of sblx’n

You have a duty to be thorough b/c you are liable for the pax’s health so look @ the skin for lipoma, melanoma, inflammation or subluxation

What does an adjustment do ?

Joint cavitation (audible)

Increase active & passive ROM

Break adhesions …. Joint & ms receptor stimulation

Inhibition of pain

Relaxation of paraspinal ms

Stimulation of ANS

Gonstead adjustment classification … short lever, Pre-stressed, High velocity, Low amplitude

& sustained thrust

Gonstead adjustments . … Right place/location

Right direction

Right amount of force

Right time … AM, PM, day, month or even year

PI Ilium … findings include … tight hamstrings, C-sp syndrome, short leg or frozen sacrum

Motion palpation … you cannot find a subluxation w/o motion palpation ie. SIJ subluxation …

verified only by motion palpation

Which segment should we adjust …… the one that’s stuck

AS ilium => long leg

IN… describes an internal rotation of the ilium medially towards S 1 => toes flare out

EX … describes an external rotation away from the midline => toes flare in

| |Height of shadow |Width of shadow |Crest of ilium |

|AS Ileum |Shorter |Wider |Lower |

|PI Ileum |Longer |Narrower |Higher |

Since the pelvis is pretty much like a bowl, the pubic symphysis always goes IN

| |Obturator foramen |innominate bone |Sacral centre line |

|EX ilium |Wider |Narrower |Moves away from |

|IN ilium |Narrower |Wider |Moves towards |

Sacral line …dot @ centre of pubic symphysis through S 2 tubercle perpendicular to

the femoral head line …. Mark the X-ray to determine IN or EX

Femoral head line …. Should be parallel to the floor or the bottom of the X-ray

Crosses over femoral heads & assumes film is parallel to floor

Ilial dimensions … from top of iliac crests to the line across the ischial tubes

Width of ilium … from sacral ala to the lateral border of the ilium

Landmarks to examine on X-ray …. PSIS, Pubic symphysis & ischial tuberosities

Femoral head line

S2 tubercle line

Aka Sacral line

Adjusting … normalize the joint Fx

SIJ … ilium & sacrum … position & Fx relative position needs to be normalized

We adjust so that the dysfunctional joint moves & looks like the functional

IN … adjust w/ affected side up and contact the inside border … push outwards

EX … adjust w/ affected side down and contact the outside border … pull inward

Pelvic listings …. Various combinations of AS/PI and IN/EX … 16 in all

Pivot point …. Superior acetabulum … AS & PI pivot about this point

Correcting AS or PI ….. PI ilium … contact above pivot point in AS direction

AS ilium … contact below pivot point in PI direction

AS ilium … DC contact …. Pisiform

Pax contact …. Gonstead tubercle .. ischial spine

X-ray findings … short innonimate & obturator but long leg

PI ilium …. Stuck posterior & inferior on the sacrum

DC contact …. Pisiform

Pax contact …. Inferior PSIS

LOD …. Anterior & inferior to re-approximate the sacrum & ilium

X-ray findings … long innonimate & obturator but short leg

EX ilium … rotated externally on sacrum away from sacral line

DC contact … palmar

Pax contact …. Lateral ilium

LOD … medial / internal to restore SIJ to normal position

X-ray findings … narrow but poached out innonimate

IN ilium … rotated internally toward sacral line

DC contact … pisiform

Pax contact … medial border of PSIS

LOD … lateral / external to restore normal position of SIJ

X-ray findings …. Fatter & elongated ilium, stretched gluteus muscles

|Listing |DC contact to adjust |

|PI-IN |Medial PSIS |

|PI-EX |Lateral PSIS |

|AS-IN |Gonstead tubercle / medial ischial spine |

|AS-EX |Gonstead tubercle / lateral ischial spine |

On X-ray, every 5 mm defect is actually only 2 mm

Heel lifts …. help hold adjustments but they are permaneant b/c once you start, you do not stop

using them. They are to help the pax hold the adjustment not level the pelvis. Do not recommend high heels or sandals

IVD’s … this segment allows for the greatest amount of mobility of the spine

Contraindication to heel lifts scoliosis b/c it will make the scoliosis worse SP or body rotation

to side of Short leg is a No-No b/c => over-rotated vertebrae

Rule 1 .. if you have predominant AS or IN listing on the side of posterior sacrum adjust the

sacrum first b/c AS or IN crowds the sacrum in subluxation you create space first and

then reassess the AS and IN

If you find a hypermobile and a stuck ilium, which do you adjust ? the one that’s stuck and make it mobile

Movements of the sacrum …...PR or PL .. posterior on right or left

PI-R or PI-L ..posterior-inferior right or left

Base posterior

Spondylolisthesis

Rule 2 …if you have a predominant PI or EX on the side of posterior sacrum, adjust

the PI or EX first to approximate the two bones to reduce the ligamental

stretch

Ie. PI 5 EX 2 …. So adjust the PI more than the EX

ie. AS 6 IN 2 … adjust both simultaneously since they are ipsilateral

PI 2 IN 5 ….. adjust the IN b/c it predominates

PI 5 EX 2 …. Adjust the predominant PI

AS 3 EX 6 …. Adjust ilium EX component

AS 2 IN 3 … adjust IN component

61 69

33 39

39

Adjust S2 or S1 ….. segment closest to problem area and push it Inferior => Superior

Youths may still have mobile S1, S2, S3 & S4 segments so be careful

if it is L4 - L5 level …. Adjust L5

Base Posterior Sacrum … purely a L5-S1 IVD problem

If it is even or swollen posteriorly => base posterior is Dx

You cannot go backwards b/c there is nothing underneath it

to compare it to.

IVD usually wider anteriorly and narrow posteriorly but if

it swells up, you will find the reverse happening =>

"hockey puck" appearance of the IVD

The disc bulges w/ fluid to protect itself from stresses =>

1. symptomatic …. 94% trauma related

2. transient swelling will leave the IVD

Adjusting the base posterior …….. before adjusting, verify that there is no PARS

Fracture on X-ray

Lateral L5-S1 film should look normal

Usually, it is not difficult to adjust L5 when there is

an existing base posterority

Pt position ….. side lying on either side

DC contact … pisiform

Pax contact …. S2 tubercle

LOD …. PA from Superior-Inferior w/ a "swoop"

Finding the "major" subluxations ……... from C2 - L5, vertebrae move posteriorly

SP's rotate Rt or Lt

Disk spaces => wedge Ant/Post

Wedge … open side of the vertebra b/t 2 segments that are misaligned

Gonstead adjusts "over the rainbow" from the side of the open wedge or the

convexity of the scoliosis

Spondylolisthesis … aka. Anteriolisthesis … anterior slippage of a bone from it

Base …. Use Meyerding's grading technique … I - IV

Grade V is a spondyloptosis

L3 & L4 may not move anterior w/ L5

90 - 95 % all cases are asymptomatic

usually caused by pathology … pars fracture or elongation

Gonstead listings of L5 …. Separately b/c sacrum need not be level

P = posteriority

RT or LT = Verterbral rotation of SP to either Right or Left

S … Superior if the body rotation is on the side of the open wedge

I … Inferior if the body rotation is on the side if approximated TP's

L5 …. PRS-SP Normal PRS PRI

Functional motor unit ..aka trijoint complex .. 2 VB & assoc. IVD & all articulat'ns

In Gonstead, you move the whole unit

IVD is the biggest joint so Gonstead concerns itself w/ the

Disc … which we can normalize … stabilize the unstable

thus restoring proper function

Goal as a DC ….. restoration of Function

What happens if a joint is fixated …. No nutrition => degeneration => will happen before

sense of pain that's what you need a DC wellness to

prevent S/S before the pain

Between C2 - L5 … vertebral bodies move posteriorly before anything else b/c of the angle of

the facets

SP's & pedicles …. Check for rotation of the individual segment not relative to the one above

& below it

Rotation …. On X-ray …. Shortest distance b/t SP & TP is toward the side of rotat'n

Longest distance b/t SP & TP is away from the rotation

Gonstead contact points ….... SP's except C1

M…. Mamillary bodies (L-sp)

TP's (T-sp)

La ….. Lamina (C-sp)

Always try to contact the SP unless it is across from you

Use the Mamillary bodies next, then the LA and lastly, use the TP's

What do you do when there is a scoliosis ? You must always adjust from the side of the

convexity so as not to hurt the ligaments that are

already stretched adjust to close the wedge and use

a torque to help.

IVD is not seen on an X-ray …. Only an MRI can see it

AP X-ray PRI Lateral X-ray PI

Whether we take an SP or M contact, we are driving through the VB to rotate the TP

Making the adjustment …. Explore the passive end range of motion

Take the segment into tension @ end-range

Thrust into the paraphysiological joint space to restore Fx

L5 has more degrees of freedom of motion vs all other L-sp. Only @ L5 b/c sacrum

Conventional listings …. Occurs if the open wedge & scoliosis are in synch

PRS-SP PLS-SP PLI-M PRI-M

Always contact the SP's unless the SP is across from you and you are force to switch to M, La or TP

Gonstead always adjusts over the rainbow or from the of the convexity of a scoliosis

DC makes the contact w/ torque to close the wedge

Unconventional listings … if wedge & L-sp scoliosis are not in synch

PRS-M PLS-M PLI-SP PRI-SP

DC makes the contact on the M and torque it to close the wedge on the opposite side

Keys to Gonstead adjusting .…… Determine the convexity of scoliosis

Analyze the listing of L5

Decide the lever to use …. SP or M

Determine the direction of torque

X-rays …. Why …. Well, we get paid for them and you can find ……

Pathology …. Body is a whole unit & the effects can be global

Function …. DJD

Anomalies …. Tumours

Structure …. Affects the function

As you develop X-rays, evaluate …. Fractures, Dz, pathology or normal variants

Labelling X-rays …… label each vertebral body on the Full Spine X-ray

C-sp 1 – 7, T-sp 1 – 12 and L-sp 1 -5

Marking X-rays … keep the convention alive

All marks are to be inside the VB not along the perimeter

Mark the inside tops of femoral heads

Mark L5 inferior aspects where it joins the sacrum

Mark the top of the iliac crests

Mark the pubic symphysis

Mark the sacral ala, PSIS & ASIS

Mark the S2 tubercle

Now draw some lines …. Gridlines help you see if you are level to the floor / bottom of the film

which is supposed to be parallel to the floor

Femoral head line is parallel to the floor … measure any differences

Calculate using the 5:2 ratio to correct any distortion before recommending heel lifts to

your pax

Use the femoral head line as the level for the pelvis as you draw the iliac crest line and

the ischial tuberosity line

Draw the sacral centre line … which is a perpendicular line from femoral head line

crossing the S2 tubercle

Draw the lateral innominate, sacral ala & PSIS lines all parallel to the sacral centre line

Same diagram as page 4

Based upon your markings and your lines, write down the measurements and then

determine ……. AS, PI, IN or EX listings of the pelvis

Now include the listing for the sacrum as a separate entry

L5 … mark the TP-VB jx’n and evaluate the level w/ the sacral base line

When you find an unlevel VB, there will be others that will compensate

Approx 90% of Lower Back Pain (LBP) is b/c L5 => true subluxation and all other

findings are just compensatory.

Identify the next uneven segment by an eyeball perspective and draw lines through the

VB nuclear endplates along the inferior aspects

In Gonstead, mark the inferior aspects of the VB endplates …..

Find the level one first and draw a level line PRI-T

Find the unlevel one next and draw a line

Now you can determine the subluxation and the angulation

Repeat by looking for the next level segment and draw the base PRS-M

When you encounter an unlevel segment …. The first one beyond the level segment, draw another line along the inferior aspect of the VB

We adjust the subluxation onto a level base ie. C1 upon C2 or L5 upon S1

Scoliosis in the neck does not exist …. It is usually compensating for a subluxation somewhere lower down in the spine.

Torticolis is not scoliosis …. It is an antalgic response to a subluxation. So, if we level the base, the SCM’s will not be in spasms, and the Torticolis will be resolved.

Therefore, make a very careful assessment of the pax for the true subluxation

* *

L5 and C2 do not require a level base for adjusting …. The head almost always will level itself b/c of the righting reflex by the time the compensatory segments reach the C2 level so don’t be too overly concerned b/c this segment is not weightbearing but you need a lot of rotation in this segment.

Place 2 dots on the superior ½ of the JVL b/w C2 and C3

C2

* * C3

Place a dot on the odontoid process and the SP of C2 and draw the odontoid line Now we can evaluate C2 listing in relation to the rest of the spine

Place dots along the inferior occiput and along the inferior aspects of C1 and C2 to evaluate the VB level from horizontal.

Theoretically, it should look like this ….. C0 -------------------

C1 -------------------

C2 -------------------

Odontoid line

L5 retrolisthesis or anterolisthesis is not part of the protocol

C0 ___________

On a lateral X-ray of C-sp C1 C1 has gone Anterior & Superior (AS)

C2 ___________ SP is superior on the back

On an A-P X-ray, we look for wedging, laterality and VB rotation

Odontoid line

C0 ------------------------- C1 has gone lateral to the Left

C1 Open wedge is on the Left

Left Right C1 rotated posterior on the Left

C2 ------------------------- posteriorly rotated lateral mass

A-P X-ray Is smaller on X-ray

Anteriorly rotated lateral mass is larger on X-ray

If we combine the AP and Lateral X-rays, we get an ASL-P listing for C1

General evaluation of lateral X-rays will show only 2 possible listings

C0 -------------------- C0 ---------------------

POST C1 ANT POST C1 ANT C2 -------------------- C2 ---------------------

AI listing AS listing

When C1 moves laterally, it has a tendency to wedge itself

C0

C1 treat the finding as a C1 listing

C2 -------------------

Lateral X-rays … systematic marking for listings

Mark the C1 anterior tubercle and centre of the posterior ring …… draw a line

There should not be any abnormalities except diving or axial compression

injuries … normal variants like a posterior ponticle does not matter.

Mark the C2 odontoid process and VB …. Draw a perpendicular line to the odontoid

Evaluate the ADI to confirm suspicions of AS or AI

AI AS

Distance of C0 to the posterior ring of C1 should be = posterior ring of C1 to C2 SP

This is a quick check to determine any axial compression injuries

Occiput

C1

C2

Mark the endplates of all the C-sp from C3 all the way down to T1 and remember to mark inside the VB on the Anterior and Posterior aspects.

Line up the dots but not through the endplates so that you don’t obscure the details on the X-ray and make sure the line is in the VB not through the endplate

Lateral X-ray

C 1

C 2

C 3 Lordosis will show approximation of

C 4 SP’s posteriorly.

C-sp subluxations may move PI so we need to evaluate curve changes by simply following George’s line contour

Lateral X-ray film …… evaluate Anteriority & Posteriority

Superiority & Inferiority

Very fast approximation IVD spaces

Posture ….. lordosis, head carriage

Evaluate the hyperlordosis b/c the extrapolated lines cross posterior to the VB very quickly instead of further behind.

C-sp listings are usually … PRI, PLI, PRS-I & PLS-I ….. so we adjust superiorly

Gonstead does not have many listings for rotation in the C-sp b/c there are JVL’s which limits the rotation of the C-sp.

Gonstead uses an SP contact --- not the lamina

Primary adjustment is P A and Inf Sup b/c there is not much laterality Rt or Lt

The X-ray listing of Gonstead and the markings thereof are your standard of care

Atlas listings ….. C1 only ….. ASRA, ASRP, ASLA & ASLP

Thoracic spine …….. very similar to Lumbar spine adjusting except TP contact

Conventional listings ….. PRS-SP, PRI-TP, PLS-SP and PLI-TP

Unconventional listings ….. PRS-TP, PRI-SP, PLS-TP and PLI-SP

Gonstead Technique II Alan Pan

Gonstead Formula …. Find the subluxation

Accept it where you find it

Adjust it

Leave it alone

Fix the problem & then dismiss them for that condition

If another problem arises, then that is a new case !

Whenever you see a patient in your office, document everything & keep it for 7 years

Date of Hx and Patient Sign-In logsheets

Demographics data …. Name, Age, Sex, Occupation & Marital Status

Document any emancipation or else you need a legal guardian

SSN, CA D/L & a photocopy of a photo ID

Case Hx … HIPPIRONEL

History

Inspection

Palpation

Percussion

Instruments … reflex hammer & stethoscope but not the nervoscope

ROM

Orthopaedic tests

Neurologic test

EX-rays

Lab tests

Hx of Chief complaint (C/C) .. let the patient describe in their own words

Don’t put words in patient’s mouth

Location …. Ask them to point to the pain

Mechanism … how did this happen

Narrative … use quotations to document the patient’s own words

Onset … when did this happen

Provocation / Palliation …. What makes the pain worse or makes it better

Quality …. Descriptive words

Radiation / Referral … where does the pain go

Severity …. VAS or 0 – 10 scale to quantify the pain

Timing … how frequent do you feel the pain, time of day, month, year etc

Past Hx (PHx) …. Determine if this is an acute or chronic condition for the patient

Hospitalizations Genetic Dz Allergies

Surgeries Trauma Cancer

DM Childhood Dz Immunizations

Family Hx (FHx) ….Assess the general health of patient’s family

A thru I and S

Arthritis … OA, RA or DJD

Blood …… CVA or CVS

Cancer …

DM …. Multitude of problems assoc. w/ this Dz

Everything …. That patient says that may be pertinent to his condition

Fatalities ….. cause of death if any family members are deceased

Genetics ….. any inherited Dz that are present in the family

Hospitalizations ….

Immunizations ….

Surgeries ……

Trauma ……

Occupational Hx ….. how much time have they taken off from work

Social Hx ……Smoking … may reflect patient’s care for self & culture

Alcohol …. Social vs alcoholic …. Document frequency & quantity

Drugs …. Prescription (#1) or … recreational or therapeutic

Hobbies …. Stress relief or more stress

DC cannot recommend or discontinue any Rx that a patient is taking.

It is best to call the MD to review Rx regimen and work together for the patient

Military Hx …. Branch of service & duties

Diet Hx ….. evaluate nutritional status

Review of Systems …. Be systematic & thorough in a head to toe examination

Indications for adjusting …. ……………….. PI & SIJ dysFx

Paraspinal spasms Disk hernia

Joint dysFx lateral / central stenosis Joint dysFx in spondylolisthesis

SIJ syndrome post-Sx

Any sprain of an IVD is a herniation so don’t be afraid of it b/c you’re their only hope

Sx is not a sol’n b/c it shaves off the extra IVD sticking out

DC adjustments are intended to bring the nucleus back into the IVD

Waddell 1988 The Back Revolution …….. A subluxated segment that is not corrected

will persist and cause a cascade of events ie.

Joint degeneration & dysFx etc

Contraindications to adjusting ……..

Relative … this is a grey zone that could be or could not be just depends

Osteopenia / osteoporosis spondyloarthropathies

Patient w/ bleeding Dz psychiatric patient / mentally unstable

Malingerer Fussy patient that just might sue you !

Absolute …. No way in the world … do not adjust this person

Tumours of spine, ribs or pelvis healing fractures are present

Dislocated / unstable joint cauda equina syndrome => ER

AAA Visceral referred pain

Anticoagulant Tx alters the biochemistry of blood affecting Oxygen and RBC’s

If you thrust too hard => bleeding into joint cavity so make sure your patient is

being checked regularly for Protime and Prothrombin levels

A typical case of LBP ….. so how do you address it ?

Hx …. 58 y/o BM c/o severe LBP X 6 months

Onset while removing a lawnmover from the trunk of the car

Pain goes to his legs. PHx is –‘ve. Pain is constant.

DDx …. Prostate ca or DM …. Consider all possible diseases

Prostate cancer …. Often mets to L-sp and follows micturitional problems

DJD or spondylolisthesis …… need to adjust sacrum to correct L5 preferable in

AM.

L5 S1 disks get blown out by flexion & rotation &

compression movements to such a point that older

patients may not have an IVD left.

This requires longterm treatment but don’t overTx

Disk herniation ……. Possible but not likely b/c no complaints of Sciatica

Any tearing of fibres automatically puts the condition @

a grade III hernia

Strain / sprain ….. SIJ, ms, ligaments or L-sp …. Should not persist beyond 10

Weeks.

Subluxation .. be aware of compression & flexion movement injuries => sblx’n

Compression fracture …. Complete healing w/in 3 months

Instructions to the acute patient on the 1st office visit

Avoid heavy physical activity but stay active to keep the joints in motion

Avoid a soft mattress so lay on something firm

Do not sit > 30 minutes at any time ….. walk around to relieve the pressure

Avoid XS housework and any XS bending

If the patient is using heel lifts, don’t change them until there are improvements

Use a pillow under the knees or use a body pillow

Avoid crossing the legs while sitting b/c it stress the muscles & ligaments

If using a waterbed, keep the temperature < 85’F or else it is a dry hotpack

Furthermore ……

Make sure the office furniture / equipment is easily accessible by the patients

Educate the patient how to properly use biomechanical apparatus

Make house calls if the patient is too acute to go to the office

Use all modalities to make a proper Dx …. X-rays etc and treat accordingly

Accept acute LBP patients

Watch out for the L5 segment b/c 90% of the body weight is supported here

If you ever find a segment that is too hot to handle, go below it and start the motion and in doing so, restore the function of the joint.

Never go above the segment or else => you are in big trouble

If you cannot get a segment to go, ice it down & try again later

Torticollis ….. bending or twisting of the neck --- not just stiff.

Either spasmodic or non-spasmodic torticollis

Spasmodic torticollis …. Pain b/c of stretching of spastic muscles

S/S …...Antalgic lean towards the same side of the spasmed side

Etiol … spasms of the C-sp muscles

SCM’s (#1)

Suboccipital muscles (#2)

Scalene muscles (#3)

Path … irritation of cranial nerve XI (Spinal Accessory) which causes a reflex

contraction as a result

Brainstem problem can usually be corrected by adjusting C2 and above

Tx ….. adjust the upper C-sp C1 & C2 should resolve any problems w/in 3 wks

Adjustment done in PRONE position is designed to break the reflex

spasm cycle

Use a Hi-Lo table or side posture prone C-sp adjustment … don’t be

afraid to adjust this segment

nerve irritation spasms

Non-spasmodic Torticollis aka positional / postural torticollis b/c chronic condition

S/S …. Antalgic lean away from the painful lesion

Usually affects the lower C-sp or upper to mid T-sp

No spasms of the neck muscles

Tx ….. follow the Gonstead formula

This is a chronic condition and requires a long time to treat

Patient is usually older & may be complicated w/ DJD => long Tx time

Children …. Congenital condition b/c of trauma during birth

Easily infected by pathogens but respond very quickly too

P/T …. Ice is good as soon as possible w/in days not weeks

L5 IVD swollen => adjust the sacrum & use ice & encourage motion of the joint

The pain & swelling will subside and as it does, there may be

signs of sciatica & radicular pain b/c L5 slides posterior upon

the sacrum & needs to be reset upon the sacrum.

Disk bulge @ L5 L5 slides posteriorly

Treatment involves adjustments and then release the patient after 1 month

Determine when they return by how the adjustment progresses

If they are feeling good, perhaps you don’t want to adjust it

Sometimes, the best adjustment you can give is the one that you don’t make

Whiplash injuries …. Sprain / Strain problem

Occurs following acceleration/deceleration ie. Car accidents whereby the head undergoes Hyperflexion & Hyperextension.

Anytime a patient tells you that there is trauma involved, it changes everything

About MVA’s …. Whole body reacts to acceleration & deceleration motion

T-sp … often overlooked b/c insurance company do not want to pay $$$

L-sp … often a delayed onset of symptoms b/c the paraspinal muscles contract as a self

protective mechanism to prevent tearing.

Contracted erector spinae muscles put XS stress on the IVD’s

Once paraspinal ms relax => dull achy pain symptoms

Very difficult to treat successfully b/c soft tissue injury

C-sp … usually involves the lower C-sp unless the patient hit the steering wheel or the

windshield during impact …. Most often @ C6

Treatment plan ……. MD’s … muscle relaxants & NSAID’s

DC’s … adjustments & P/T … condition aggravated by pre-existing

conditions ie. DJD or chronic LBP

Chart patient’s progress in chart and perform all orthopaedic &

neurological tests then discharge the case

Re-evaluate every 3 weeks and chart the progress

Re-examine every 6 months

Repeat full Physical Exam every 2 years

Flowchart of Treatment plan for a patient

Acute trauma c/o neck injury whiplash type injury

Dx of subluxations & myospasms

Hx & consultation perform a complete Hx enough to reach 80 %

of the Dx ….. LMNOPQRST etc.

Findings to refer patient out ? Flexion injuries => posterior neck injury

Extension injuries => pain symptoms

Lower Back injuries b/c of seated position

Limited focussed examination

Diagnostic radiology APFS or Lateral FS series and spot films

Any condition that warrants referral Patients may be aware of their old injuries

Any pre-existing conditions ? X-rays are always required in trauma cases.

Is ROM < 50 % of normals ? 1st … Stress X-ray series

2nd … Obliques

3rd … Flexion / Extension views

You can shoot any X-ray that you feel is necessary

Instability ?

Comprehensive Physical Exam Find the subluxation and adjust it b/c any

injury will not spontaneously heal itself. That’s

why we have recurrent subluxations b/c old

injuries that never healed properly.

Abnormalities found ?

Additional Diagnostic exams orthopaedic test are not specific enough to

identify subluxations. Neurological tests are

good for nerve roots and determining the

severity of injury or progression of Dz

Gonstead principle :

Treat the condition Find the subluxation

Accept it where you find it

Adjust it where you find it

Leave it alone to heal

Osteoporosis … absorption of bone => bone loss w/ remaining bone is normal

Shiny trabeculae b/c stress & sclerosis

Pencil thin cortices @ endplates b/c the

medulla is gone

X-ray … check the opacities against the appearance of the soft tissues not the

adjacent bone

degree of “whiteness” of bone is usually diagnostic of the condition

pearl white => osteoblastic metastases especially if patient > 45 yr

Paget’s Dz that expands the size of bones

Growth plates => infex’n or child patient

Spine .. #1 Fx is to protect the spinal cord

#2 Fx is for weight bearing

any collapse of the anterior elements => compression Fx => incr’d kyphosis

bone is maintained @ posterior arch to enclose & protect the spinal cord

Epidemiol of osteoporosis … Females >> Males until 80 y/o

Risk factors for osteoporosis … …. Female low weight & petite build

NW European Red or Blonde

Freckles FHx

Scoliosis Sedentary lifestyle

No menses early onset menopause

In males, Etoh & Rx are the risk factors for osteoporosis

Etoh turns Males into Females and Females into Males

Lab Dx … blood test … [Ca2+] is normal b/c senile osteo shows no deficiency

Ca2+ absorption requires acidic conditions but ingest’n of Ca2+ will neutralize

stomach acid

Ideally, do not drink fluids w/ food …. Just drink H2O only

S/S … asymptomatic until there is a fracture of bone

These will be the patients that hear a “pop” when they strain to lift

They may even sneeze and hear a “pop” b/c that’s all it takes

DDx … sprain / strain

In osteoporosis, fractures of bone may be single or multiple

If you have a 45 y/o Female w/ advanced DJD w/ a Hx of Rx abuse

Too young for osteoporosis but the IVD’s are degenerated

L5-S1 => no IVD so adjust L4

Infex’n in the IVD b/c of decr’d blood supply/WBC’s but there

are plenty of GAG’s => proliferation of Dz or septicemia

Among Rx abusers, they have decr’d immunity

Degenerative Joint Dz (DJD)

Etiol … starts approx. 35 y/o … possibly related to trauma during youth

Patho … takes 20 yrs to manifest the b/d of joint articular cartilage

Px …. IVD collapse, osteophytes, crepidis, decr’d ROM of joints ie. Knees

S/S … numerous osteophytes = non-marginal desmophytes

Scheuermann’s Dz looks a lot like DJD

Lab Dx … loss of weight bearing joint space ie. Hip, low back & knee

Does not affect the ankle or C1-C2 b/c there is no cartilage !!!

Subchondral sclerosis as radio-opacity under the endplate

Osteophyte or desmophyte formation

Headaches … < 1 % are actually caused by intracranial defects

Important considerations … Time of day … work, school, meals, allergies etc.

Chemical cause in mornings b/c deplet’n

Region of head … tension H/A are diffuse

Tumour H/A are localized

Quality of pain … throbbing, vice-like, vortex etc

Migraine H/A Etiol … vasodilation or XS parasympathetic tonia

Emotional stress & menstruation

vasoactive foods Wine, cheese, chocolates, peanuts, Trp Tyr

Epidemiol …. affects 10 % of population … only 2/3 have a FHx

Starts in childhood or young adult

16 % of all Females during menopause

Patho … oral BCP’s aggravates condition … non-aura => aura

S/S …. Nausea & photophobia are common to both types of H/A

Classic Migraine … has an aura … usual course is 24 – 48 hours

Prodromal … patient is aware that something is coming on

Aura …. Beginning to experience the 1st symptoms of H/A

H/A …. Beginning of pain

Termination … pain fades

Post dromal … fatigue, irritability & sleepiness

Common migraine … no aura

Tx … pregnancy alleves the symptoms

Adjust C6 or C7 down to T3 …. Sometimes as far down as T9 or T12

Do not adjust the upper C-sp b/c you do not want a bigger

parasympathetic response since this is caused by XS parasympathetonia

Dx …. 2 or more must be present …. Pulsatile (vasodilation)

Moderate to severe intensity

Exacerbated by physical activity

1 or more must be present … Nausea, photophobia & phonophobia

Px … risk of CVA during migraine increases b/c incr’d intracranial pressure

via vasodilation .. XS sympathetonia => adjust lower C-sp & upper T-sp

adjust C6 – T3 for “chemical” H/A

adjust T12 – L3 for hormonal caused H/A

adjust lower L-sp if the cause is menstrual

Post Concussion H/A … Etiol … Hx of head trauma

S/S …. Neck pain ……. Sharp & localized pain if trauma directly on the skull

Diffuse & dull pain if the patient was wearing a helmet

Nervousness & irritability

Emotional neutral (blause) or crying spells

Decr’d mentation & memory loss “spaced out” but not “blacked out”

Altered speech patterns … sloppy & slurred

May have Nausea & vomitting

Dx … 1st check the pupils for anisocoria then check speech & memory

Tx …. Do not give them a cold beer !!!

HTN H/A … not common but patient will have BP = 220 / 120 and blurred vision

If the BP is lower that this, it would be a tension H/A

S/S … mild to moderate throbbing pain @ occiput or vertex region

Usually unilateral associated w/ muscular contractions in the shoulders

Dizziness when moving the head alleviated w/ rest or Rx

Exacerbated by smoking, stress & caffeine

Diastolic HTN …. 140 / 100 => parasympathetic problem

Tx .. adjust upper C-sp and CranioSacral segments

Systolic HTN …. 190 / 90 => sympathetic problem

Tx … adjust the C7 – T3 and T10 – L2 segments

Combination HTN … 190 / 150 => mostly a sympathetic problem

Tx .. adjust T10 – T12 first and then see what happens .. don’t mix Tx

Tension H/A … muscular contraction H/A b/c strained muscles @ neck & shoulders

#1 most common extracranial H/A exacerbated by stress

relieved by rest, Rx & massage

S/S … dull, achy mild to moderate pain @ upper C-sp muscles @ end of day

Risk factors … anterior head carriage & rounded shoulders

Sblx’ns @ upper to mid T-sp, ASIN Ilium => decr’d lordosis

Tx …. Treat the H/A first and the LBP second …. Gradually resolve symptoms

Take care of the major complaint and then dismiss the case

Additional complaints are treated as a new case

Coumadin …. Warfarin SO4 … rat poison which is an anticoagulant

PTT is normally 2.5 – 3.5

If PTT is > 5.0 => you will coagulate to death

If PTT is < 1.0 => you will bleed to death

Sinus H/A …. Inflam’n, congestion or infex’n of the sinuses … danger is meningitis

Frontal sinus is very close the CNS so it is very dangerous

Etiol …. Parasympathetic problem

Risk factors … Rx abuse causes vasoconstriction

Deviated septum

S/S … mild to moderate dull, gnawing diffuse sinus pain related to weather

Requires high humidity conditions to relieve sinus congestion

Tx …. Adjust condyle to C5 but the problem is usually @ C1 & C2

Cause a vasodilation to drain the sinuses & relieve the pain

Eyestrain H/A … mild to moderate sharp & radiating pain from the orbit to the

occiput

S/S … bilateral … follows the optic nerve from the front to the back

Tx …. Check the eyes for optic nerve function

Check the eyeglasses for fit and proper prescription & workmanship

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