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GONSTEAD – 9/9/08

*** Slides are right out of the textbook ***

*** Midterm and Final will both be 1 hour each and 50% of course grade***

*** Midterm and Final material will be discussed in class…If not talked about in class, it won’t be on the exam ***

*** Everything in this class is on Part 2 of National Boards – especially the listings ***

General Info

1. Take Care of the patient…Treat them as they would want to be treated

2. Take care of yourself – If you do both things you will be successful in practice.

3. Informed patients are educated patients. Educated patients educate others. The best advertisement is someone talking about you and referring to you.

4. Believe in what you do and convey that to the patient.

5. Listings are short hand telling you what is going on. Put all those findings into 3-4 letters

6. Put the whole package together (static, motion, X-rays, and physical presentation).

Ex. – ASRA – Atlas (Anterior – seen on lateral X-ray), Superior (atlas goes superior on lateral film – nose and chin are up in the air), R (Right side the atlas goes right – restricted lateral flexion to the Right), A (rotation to the anterior)

9/16/08

Definition of Subluxation

A minor misalignment between 2 adjacent articular surfaces that causes a problem. Gonstead technique looks at every joint in the body. Any time you have a joint, you can have misalignment.

8 Signs of Inflammation

In Gonstead, any time your body sustains an injury anywhere, the site on injury responds with physiological mechanisms of inflammation. Specifically, there are 8 signs of inflammation:

1). Heat

2). Swelling/Edema

3). Decreased Motion

4). Tenderness

5). Hypertonicity

6). Redness

7). Perspiration/Sweat

8). Pain

All of these finding can be used to find the subluxation.

In Gonstead, look at the big 3: Heat, Edema, and Motion. Pain can be from local tissue or referred.

Just because an area is tender, just because it can be sweaty, doesn’t mean that the area is the source of the problem. In Gonstead, we use the big 3: heat, edema, motion to help find out the source of the problem.

Instrumentation

In Gonstead, we use instrumentation to measure heat. Ex. – Nervoscope, Temposcope,

Static Palpation

Palpate for heat, edema, and restricted bands. Puffy, swollen and edematous spots occur medial to these tight bands. The body puts the fluid to cushion and protect the area. The fluid accumulation puts pressure in the area creating discomfort.

Motion Palpation

6 Ranges of Motion – It is important to palpate through all 6 ranges.

How to Determine Subluxation

3 things to determine area of subluxation: 1), Instrumentation 2). Static Palpation 3). Motion Palpation

9/18/08

Patient Outcomes

3 Things: 1) get better 2) get worse 3) no change

Patient can get worse with chiropractic care due to wrong line of drive, wrong segment, wrong listing. Most of the time if you are on an incorrect vertebra, there will be no change; however, everyone is different and responds differently. Anything can cause anything.

Compensation-

A minor misalignment between 2 adjacent articulating surfaces that does not cause a problem; no heat, no edema/swelling, hypermobility; you will find the underlying main subluxation somewhere above/below this level.

Subluxation

You get heat, edema, and loss of mobility--- the most important of these 3 is loss of mobility. You can treat a patient until you restore optimum functional mobility

Objective of Adjustment

To restore optimum functional mobility

Importance of Motion Palpation

Orthopedics test are performed to reproduce the chief complaint. Motion palpation is a chiropractor’s orthopedic test/exam. Just because a segment looks bad on x-ray doesn’t mean that is causing the patient their particular problem.

It is very important to palpate the patient in order to find the problem.

Listen to the Patient

If you listen to the patient, most of the time they will tell you where the problem is.

If patient is having pain in the pelvic region, ask the patient the following questions:

Does walking exacerbate the problem? No; Going up stairs? No…If both of these are no, then it is not an SI issue.

Prolonged sitting? If yes, they are slouching—look at L4, L5

9/23/08

Subluxation

Compensations occur above and below the area of subluxation.

Gonstead Exam

1. History: Focus in on: 1). Drug History (a common drug given is for cholesterol – especially LIpitor….A common side effect of Lipitor is achy/sore muscles…The achy/sore muscles are due to the drug and be aware of this during treatment)…It is important to ask dosage, quantity, etc. 2). Occupation (Ex. – Construction Workers that are bent over in repetitive positions) 3). Detail (Detailed history of accidents, exactly as it happened…You’ll know what to do)

You cannot take someone off drugs. You can provide them information to take to the person that prescribed them the drug. As a chiropractor, you can give them a healthy alternative.

You can look at Lipid Panel, C-Reactive Proteins (CRP/Cardio – Looking at cardiovascular risk rates), Homocysteine Levels. CRP-Cardio and Homocysteine are important to check.

Ex. – Automobile Accident…Patient is broad sided into the passenger side. Body moves to passenger’s door with head going into the impact. The atlas goes lateral and superior when it subluxates. The atlas goes to the passenger side or into the impact.

2. Exam: 1). Observation of the Patient (Patient reaction to pain) 2). Heat Sensitive Instrument 3). Static Palpation 4). Motion Palpation…Of the 4, the most important is motion palpation. Motion palpation is a chiropractic orthopedic test. Motion palpation attempts to reproduce symptoms at a particular junction. See which range it is restricted and painful.

3. X-Rays: 1). 2 X-rays (Full Spine A-P and Full Spine Lateral – 18x36” shot…with additional views as necessary)…Make sure X-ray confirms your diagnosis. First thing to do when someone comes in with X-rays from other parties: 1). Make sure the X-rays are of the right patient

4. Fix It: Adjustments are to restore optimum functional mobility

5. Re-evaluate

6. Educate the Patient/Leave it alone when asymptomatic

Gonstead Philosophy --- The Major Saying of Gonstead

1. Find It 2. Accept it where you find it 3. Fix it 4. Leave it alone

Find it by observation, static, motion, and X-ray. Accept it, by recognition of the subluxation. Fix it by adjustment if necessary. Leave it alone by not over treating. The best thing you can do is not find a subluxation and no treatment. If you’ve done your job, you’ve corrected the problem and don’t need treatment. If you over treat, you may create another subluxation.

9/25/08

Some Features of Gonstead Technique

Gonstead incorporates motion, static, X-ray, Meric Chart, and case management.

Case Management

Sympathetic: C7-L5

Parasympathetic: Occiput to C6 and L5 through Pelvis

Parasympathetic Subluxation

Subluxation Stimulates: Diarrhea, Acid Reflux, Tachycardia (Arrow Up)…Adjustment of Parasympathetic will slow things down

Sympathetic Subluxation slows things down: Constipation, lack of energy, hypothyroidism, fatigue, depression, no energy, flaccid muscles. ((Arrow Down)…Adjustment of Sympathetic will speed things up.

In Gonstead, Do not mix the systems. This is like putting your foot on the accelerator and brake pedal at the same time, so nothing happens.

Sometimes you need to make an executive decision on adjustment and stick with it. For example, a person with parasympathetic problems (tachycardia, acid reflux) and sympathetic problems (constipation), fix the more serious of the 2 problems.

General Adjusting Rule

Another Rule: Allow 6-7 vertebrae between the levels you need to adjust. If you adjust T7 and T10, you run the risk of subluxating the one you fix, because they are too close together. You adjust 1 lumbar, 1 to 2 thoracics, and 1 cervical (so 4 total spinal levels as a maximum).

Importance of Specificity

Be Specific to get consistent results and then you know why you get consistent results.

X-RAY INFO

FS – Lat X-ray

1. Shows compression fracture (a compression fracture would look normal on AP)

2. ADI

3. Abdominal Aorta – You shouldn’t see this on the lateral film in a normal patient

4. Spondylolisthesis: Spondy looks normal on AP Film and that is why you take a lateral for spondylolisthesis

5. AP Curves: Tells you about curves (cannot see AP Curves on AP films)

6. Discs: Disc Degeneration (You have 6 classifications on Gonstead System)

7. Base Posterior/Sacral Base Angle/Spondylo

8. Fusion of Posterior Elements

FS – AP X-ray

1. Scoliosis

2. Listings: We confirm listings with AP X-ray (ex.: spinous laterality, wedging)

3. Transitional Segments

4. Sacrum, Pelvis and Femur Head Levels

5. Vertebral Count: Not everyone has 5 lumbars and 12 thoracics, so AP helps give the count.

9/30/08

Stages of Disc Degeneration – 6 Stages

D1-D6:

D1: 2-3 days…Acute, Disc Bulge

D2: 3-6 months…Decreasing Posterior Disc Space

D3: 3-5 Years…Decreasing Anterior and Posterior disc spaces

D4: 5-10 Years…Posterior Disc Space is gone, Anterior disc space is decreasing

D5: 10-15 Years…Paper thin, disc space between vertebral levels

D6: 15-30 Years…No disc is left between the vertebra

In Gonstead, the major portion of a subluxated vertebra from C2-L5 is posteriority. As the vertebra goes posterior, it also goes inferior. Your major thrust will relieve the posteriority.

4 Criteria of a Subluxated Motor Unit

1). Anterior disc space increases

2). Posterior disc space diminishes

3). Inferior Interspinous space diminishes

4). Superior Interspinous Space Increases

You can palpate 3 (decreased inferior interspinous space) and 4 (increased superior interspinous space) on the patient.

Ex. Josie comes into your office with LBP…She has antalgia and acute LBP. She never had any back pain before. You X-ray and you see a D6 at L5/S1. The problem has degenerated to D6 over time. The patient may deny this. The X-ray doesn’t lie. She eventually “remembers” the trauma years ago.

D5 and D6 occur with time. The problem has been there for a long time. The more chronic the condition the longer it’ll take for treatment. You can’t fix D5 and D6. Tell the patient you can’t fix D5 and D6, but you can keep the other areas from degenerating sooner. You can help to decrease pain. You can help to restore some minor degree of mobility in these patients

From D3 and down, these people when they sustain injury, it hurts and they get over it. Over time the injury comes back periodically. It comes and goes away. Each time it comes back, it is longer and more severe. The body compensates and the symptoms go away, but the problem does not.

Dr. Clarence Gonstead

Had Severe RA and studied at Wisconsin. He was bedridden and went to a chiropractor. The chiropractor helped Gonstead. He became a chiropractor at Palmer, graduating in 1923. He died in 1978. Gonstead put his knowledge of mechanics, background as an engineer, and passion for chiropractic into the Gonstead system. He looked at the pelvis and looked as the foundation of the spine. He was also interested in the sympathetic and parasympathetic systems.

Vertebral Subluxation Complex – ICA & ACA Definition

“Subluxation is an aberrant relationship between the 2 adjacent articular structures that may have functional of pathological sequelae, causing an alteration in the biomechanical and/or neurophysiological reflections of those articular structures, and/or body systems that may be directly or indirectly affected by them.”

Quote by Gonstead

“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 nervous system every chance you get. Our future will be the results.”

10/2/08

Ex. Patient Example: Chronic Fatigue Syndrome, Irritable Bowel, Fibromyalgia, patient is on 22 medications…Pt. doesn’t drink water. Pt. drinks a lot of Mountain Dew (10 cans per day). Pt is a smoker for 25 years. She is a frequent coffee drinker. You can see why the irritable bowel is occurring. She doesn’t sleep very well; she doesn’t have more than 1-2 bowel movements a week. She is toxic, with nutritional problems, toxins from medications. She has cold hands and cold feet. This all fits into a pattern. The pattern is hypothyroidism, hypo-adrenalism, hypoglycemia, chronic fatigue syndrome. All systems are linked.

One of the classic signs and symptoms of B12 loss/deficiency is memory loss.

Adjust - Synonyms

Convert, Improve, Right, Regulate, Mend, Straighten, Arrange, Position, Fix, Remedy, Harmonize, Correct, Restore

Manipulate

Exploit, Govern, Misuse, Handle, Sway, Take Advantage

Gonstead Clinic

Built in 1965 in Mt. Horab (Outside Madison, Wisconsin). The clinic has hotel, indoor pool, sauna, golf course, treating areas, etc. In the mid 1970’s, he sold to Doug and Alex Cox. Dr. Fred Barge was there for a while. Dr. Jack Rosser was also there in the late 1960’s. Dr. Nicholas Schultz bought the clinic later in time. He owned it for a couple years and sold it to Dr. Larry Trochsel. Dr. Trochsel started GMI. Dr. Trochsel passed away a couple years ago. It is owned by a group of doctors today.

Dr. Gonstead had a huge house. He had a practice at home as well as performing house calls. Gonstead also treated animals. He had an airfield in his backyard.

Parallel

This is an engineering tool for X-ray marking. You need a center scale, 0-80 on each side. The top scale is 0-260. Check the instrument before you purchase, so the rollers roll.

X-RAY MARKING

Look at the X-ray as if you are looking from posterior. The patient’s right is your right and the patient’s left is on your left. Place dots to mark.

Dot Placement – Stage 1

1. Dots are placed at the most superior portion of the femur head R and L (Dots 1 and 2).

2. Dots 3 and 4 are at the sacral grooves.

3. Dots 5 and 6 are at the superior portion of the iliac crest bilaterally.

4. Dots 7 and 8 are at the most inferior portion to the ischium.

5. Dot #9 is at the S1 tubercle.

6. Dot #10 is at the Vertical and Horizontal Center of the Symphysis Pubis.

*** Even #’s on the same side and Odd #’s on the same side ***

Stage #2 = Connect the Dots

1. Connect the Dots of the Femur forming the FEMUR HEAD BASE LINE.

Items Required for X-ray Marking

You need an X-ray, a view box, X-ray pencil and parallel.

10/7/08

MARKING – STAGE 2

2. Use the parallel, and roll it to the sacral groove dots on the superior sacral groove. Roll the parallel up to the superior groove and draw a straight line through the sacral grooves. As you roll the parallel up, you want to hit the bilateral dots at the same time. That is often not the case.

3. Continue a superior roll keeping the parallel even with the baseline of femur head heights. Continue to roll to iliac crest line.

4. Turn the parallel around and pull it from the femur line down to the ischial dots. Draw a line to the inferior portions of both ischiums adding more lines. The ischial lines should normally be parallel to the iliac crest lines.

5. Gridlines = Align the parallel in line with the gridline. If no grid line on the film, place the parallel at the bottom. Roll the parallel to the superior femur heads. Place a short line over the inferior femur head. Measure between the two lines.

*** If the 2 femur heads are parallel to one another, you won’t have the line ***

6. The parallel is now placed 90 degrees to the femur head. Place the center zero on the baseline (femur baseline). Roll the parallel to the dot closest to S1. Roll to S1 and draw a short line down through the center of the sacrum.

7. Draw a short line to/through symphysis pubis. The line is a continuation of center sacral line. In the ideal situation the line should go right through center of symphysis pubis.

*** Most lines are parallel or perpendicular to the femur head baseline in the Gonstead marking system ***

8. Draw a straight line at the lateral aspect of R innominate.

9. Continue the medial movement of parallel and put a straight line through most lateral aspect of R sacral ala.

10. Continue medial movement and line goes through most medial aspect or R innominate.

*** We have 3 lines on the R with lines that should be parallel and perpendicular to femur baseline ***

11. We do the same thing to the Left side. Draw a line to medial aspect of L innominate.

12. Line at the most lateral aspect of L sacral ala.

13. Line through the L ilia.

*** We have 3 lines on L, just like the 3 located on the R ***

14. Draw a line connecting the 2 sacral groove dots. The sacral line is called sacral base line. All we did was connect the sacral groove dots. In the ideal situation, we see the sacral baseline parallel to the femur head baseline. It is not in our example on the overhead.

*** We now have 6 total lines ***

15. Measure between iliac crests and ischium.

a). L innominate measurement = Measure L innominate bones from iliac crest to ischium.

b). Measure on R side: R Iliac crest to ischium = R innominate measurement

16. Take the center scale and put the zero line on the Femur head baseline, measuring the distance between the femur head and femur head line.

*** We have 1 mm of L femur head deficiency in this example ***

17. Measure center zero scale on parallel measuring the symphysis pubis lines on each side

*** We now have 4 mm of symphysis pubis (possibly indicating pelvic rotation) ***

18. Draw a straight line through sacrum. Measure the sacral ala’s bilaterally on each side. The center zero line goes on the center sacral line and we measure bilaterally to the sacral alas.

*** We have 60 mm of L sacral ala measurement and 55 of R sacral ala measurement in our example ***

19. L Ilium Measurement = Measure the width of L Ilium from L to R. Measure the width of the parallel lines (lines 11 and 12 on the slide) of the ilium (ex. 104 mm of L ilium measurement). Do not confuse the L Ilium measurement with L Innominate measurement (the L innominate measurement is top to bottom).

20. R Ilium Measurement (Line 13 and 14 on the slide). Measure between the 2 parallel lines (ex. 98 mm of R Ilium Measurement)

10/9/08

Gonstead Technique

We are not interested in straightening spines. Our goal in the technique is to restore mobility.

Abbreviations

A = Anterior

P = Posterior

IN = Internal (Rotation)….In regards to the pelvis (innominate)

EX = External (Rotation)…IN regards to the pelvis (innominate)

R = Right

L = Left

I = Inferior

S = Superior

T = Transverse (***) Process….12 Thoracic Vertebra utilize a transverse contact

LA = Lamina (***)…Process…Only utilized C2-C7 (NOT C1)

M = Mammillary (***)…Lumbars Only (L1-L5)

S = Spinous (***)…C2-L5 with the exception of C1

*** Denotes the contact pt for the adjustment ***

AP Malalignments

Our point of reference in Gonstead is the PSIS. The innominate tends to rotate on an arc around the sacrum. As the PSIS goes anterior it must also go superior. As the PSIS goes posterior, it must also go inferior.

PSIS – Anterior and Superior

The Anterior-Superior movement of the PSIS changes the innominate measurement from top to bottom (iliac crest to ischium). The innominate measurement that is smaller is the side of AS ilium. You will also see on an AS ilium, the obturator getting smaller. The AS obturator gets smaller in the vertical plane when compared to the opposite side (PI side). AS = Edema is at the inferior part of the joint.

PSIS – Posterior and Inferior

The R hand PSIS in our example (opposite side) now goes post and inferior. The obturator gets bigger in the vertical plane when compared to the opposite or AS side. The side of the larger innominate measurement is the PI side because as the innominate goes posterior and inferior the measurement increases. PI will show edema at the superior part of the joint.

Example of Innominate Measurements

Ex. 260 L innominate measurement vs. 265 R innominate measurement…The shorter measurement is AS and the larger measurement is PI.

*** JUST BECAUSE THERE IS A LISTING, DOES NOT MEAN IT IS SUBLUXATED! YOU MUST BASE THE ADJUSTMENT ON YOUR FINDINGS, PARTICULARLY MOTION! ***

We have 4 choices for subluxations in our example in class: 1). Left Ilium AS 2). Right Ilium PI 3). Neither 4). Both

SUMMARY OF AS & PI FINDINGS

AS Ilium

1. Is on the side of the shorter innominate measurement

2. Produces a smaller projected obturator foramen (vertical measurement)

3. Causes Decreased Lumbar Lordosis

4. Raises the Femur Head Level

5. Causes a spongy edema at the posterior-inferior margin of the SI joint

6. Leaves the sacrum posterior on the involved side (As the innominate goes AS it makes the sacrum appear as posterior…The sacrum does not move, but the presentation on the patient and X-ray would be such that the sacrum appears posterior)

PI Ilium

1. Is one the side of the longer/larger innominate measurement

2. Produces a larger projected obturator foramen

3. Increases Lordosis

4. Shortens the femur head level

5. Spongy edema at the superior part of SI joint

6. Leaves the sacrum anterior on involved side

INTERNAL AND EXTERNAL PELVIC ROTATION

To determine IN and EX, we use the PSIS as our reference point. EX and IN are found only in the innominates.

EX (External Rotation)

1. EX is listed when the PSIS (innominate) goes away from the center of the sacrum.

2. External rotation leaves the measurement of PSIS to sacrum larger

3. The obturator also presents as larger in the horizontal plane than that on the IN side.

4. The narrowed ilium shadow on the film is your EX side.

5. The EX causes the foot to go toe in.

6. EX causes the Gluteal musculature to tighten to support the body.

7. EX affects the medial knees

8. Greater chance for SI pain, hip pain and low back pain… The subluxation is the pelvis and the compensation is rotation of the lumbar spine creating LBP

9. Other general complaints: tight piriformis (but pain), hamstring pain, decreased lumbar motion, foot and ankle pain

10. Compensations: cervical spine (cervical pain), lumbar spine, thoracic spine (scoliosis)

IN (Internal Rotation)

1. IN is listed when the PSIS goes towards the center of the sacrum

2. The PSIS to sacrum measurement is smaller… Distance between PSIS and center of sacrum is smaller on the IN side

3. The obturator measurement is smaller in the horizontal plane

4. The IN side has the wider ilium shadow (compared to the opposite side)

5. The IN causes the foot to go toe out

6. IN causes the Gluteal musculature to go flaccid as the muscles move in and towards the center.

7. IN affects the lateral knees

10/14/08

9 INNOMINATE LISTINGS

1. AS

2. PI

3. IN

4. EX

5. ASEx

6. PIEx

7. ASIn

8. PIIn

9. ???

*** Know that there are 9 listings and what they are ***

ASEx, PIEx, ASIn, PIIn = are combined movements

The most common you’ll find is ASIn (up and in) and PIEx (down and out).

Pelvic Adjusting According to Gonstead

According to Gonstead, there is too much adjusting of the pelvis. Consider that trauma often induces pelvic subluxation. If walking irritates the patient, think SI or sacrum. If walking does not irritate the problem, it is usually not an SI or sacrum. If sitting really bothers them, it usually means the lumbar spine is the problem.

EX. L ASIn…PSIS goes anterior, superior and into the sacrum while the toes move outwards. The glut musculature is flaccid. The X-ray finds the L innominate is 270 mm and the R innominate is greater (PI shows greater measurement) or 275 mm. The ilium shadow measurement are 100 and 95 (on the EX side). The center sacral line goes through the R pubic bone. The innominate measurement, the shadow measurement, foot toed out, flaccid musculature as well as palpation gives us the label of L innominate as ASIn.

Adjusting Gonstead Style

1. 4 Separate Listings = For any one of the 4 separate listings utilize LOD to correct the situation (PI, AS, IN, EX) when they are by themselves. LOD is set up by forearm and body position.

2. Combinations = The LOD corrects the first part and torque corrects the second part of the listing. Torque is a twisting of the wrist to fix a combined listing. PIEx would show superior and anterior LOD for correction PI with twisting of the wrist counterclockwise for correction L PIEx. The contact is inferior to the PSIS and slightly lateral.

*** Torque consideration is given to the site/side of adjustment. IN our example, we used counterclockwise torque on the L PIEx. If the subluxation were R PIEx we would use clockwise torque. ***

10/16/08

Examples

PIEx: Walking makes pain worse, going up steps makes pain worse. Static palpation leads to pool of fluid in L SI joint. L motion palpation exacerbates the complaint due to lacking mobility. L innominate is the problem. Innominate measurement is larger (PI gives larger measurement). Ilium shadow will be narrow on PIEx. Obturator horizontally and vertically larger. LOD to correct PI and Torque corrects the Ex.

ASEx: Not that common…Innominate goes up and out. It causes the innominate measurement to get smaller because of AS than the other side. The ilium shadow will get narrower due to Ex. AS is corrected by LOD, EX is corrected by torque (twist of wrist).

PIIn: Edema in the L SI joint. L innominate measurement is larger (PI). The ilium shadow is larger (In) than the opposite side. The obturator is larger vertically (PI). The obturator horizontally is smaller (due to IN). L foot would be toed out (L PIIn) and the Gluteal tone would be flaccid.

Rule of 4 for Adjusting

The patient should be in a relaxed position. Side posture adjusting is best done on a flat bench. The inferior foot is off the edge of the table. No more than 3 inches from the end of the table is the proper patient position. No more than 45 degrees of roll. At 45 degrees, the patient must be up against your superior leg. The patient’s head must be extended. You don’t want them to look at you. You don’t want eye contact with the patient. The patient’s head should be flat on the pillow and slightly extended. Place the upper arm on the ribcage. Place the patient in a straight line head to toe.

1. Patient positioning: Relaxed position

2. Doctor Position: If the doctor is not comfortable, the patient is not comfortable. The bench should be no higher than mid patella. A lower table means you bend too much. A higher table means you are on the toes and unsteady. The table should also be against the wall, so it doesn’t move. Superior knee touches table top. Palpate the PSIS.

3. LOD & torque

4. Speed and Timing: Don’t back off. The patient may know the adjustment is coming. Also roll them into you slowly. As you slide down the thigh with your body, you pick up speed

EX. PIEx…Palpate the PSIS and lock it out. Take tissue slack out. Do not push the patient over as the patient pushes back. Roll the patient over with body weight. Superior hand is on the patients shoulder lightly.

Ex. PIIn: Contact is inferior and medial with the pisiform to the PSIS to lift (move the pelvis superior) and rotate the pelvis (external rotation with torque). LOD is up the spine for PI and In (torque externally to correct). L will have clockwise torque. R would show counterclockwise torque.

FEMUR HEIGHT CHANGES WITH ILIUM MISALIGNMENT

2 types of femur deficiencies: 1). Anatomical Leg Deficiency 2). Physiological Leg Deficiency

Anatomical Leg Deficiency

1 LE is shorter than the other because of anatomical reasons (congenital), trauma (fracture, surgery, dislocation, etc), and infection (polio, osteomyelitis, etc.). We can address the problem by heel lifts.

Physiological Leg Deficiency

This type occurs due to subluxation. It may be due subluxation of the pelvis, lumbar spine, other spinal levels, knee, foot or ankle.

Combined

The problem can be due to both (anatomical and physiological) reasons. Correct the physiological problem and restore mobility first. Then if they still have the anatomical problem, then correct it with a lift.

10/21/08

LISTING CAUSES OF SHORT LEG

PI Ilium, EX Ilium, PIEx Ilium = ALL CAUSE THE FEMUR HEAD TO BE LOW ON THE X-RAY (SHORT LEG)! As the innominate goes down and out (PIEx), the foot goes up and in and a short leg

LISTING CAUSES OF LONG LEG

AS, IN, ASIn WILL GIVE THE APPEARANCE OF HIGH FEMUR HEAD AND LONG LEG. As the innominate goes up and in, the foot goes down and out giving a long leg.

Ex. PI Ilium…1000 mm on both sides…On the PI ilium, you expect a short leg. On the opposite side, you suspect an AS and long leg. This is a physiological problem to correct the subluxation (either AS or PI).

Ex #2…NO AS and NO PI….The measurements are 1000 on L and 988 on the R for the femurs…The innominate measurements are the same, therefore we don’t have a PI and AS listing. We expect ilium shadow to be the same. The line through sacrum and symphysis pubis are equal. A low femur head occurs by anatomical leg problem in this example. The correction is by heel lift.

Ex #3…Combination of the two…R is shorter than L and you can have either PI, Ex, or PIEx. This is the most common situation. Eliminate the subluxation first. If the R side and it is PI, Ex or PIEx correct with either LOD, torque, or LOD and torque. After you address the subluxation, then correct with a heel lift.

SUBSCRIPT

Ex #1 = AS 5 (subscript)…The 5 comes from the difference in the innominate measurement from top to bottom AND gives the subscript for the AS and the PI. The L innominate measurement (ex) is 200 and the R measurement should be 195. (The AS is always the shorter measurement). The subscript and listings will be AS 5 subscript on R, and PI subscript 5 on L.

Example #2 = In 5 (subscript)…The other side is then Ex 5 (subscript). The subscript comes from the symphysis pubis measurement. Draw a line through the center of the sacrum and through symphysis pubis. If the line goes through the center of symphysis pubs, there will not be an In and Ex. If the line crosses the Ex pubic bone, the measurement is called the symphysis pubis measurement and the symphysis pubis measurement becomes our subscript.

RULES FOR CORRECTION OF SUBSCRIPT

1. For every 5 mm of subscript of AS or In correction, the femur head height will be lowered two millimeters. ---- 5-2 rule of correction…This came from decades of experience and tens of thousands of patients.

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

MD & AD

MD = Measured Deficiency

AD = Actual Deficiency

Ex. 10 mm of measured deficiency….270 innominate measurement on L side and 260 on the R side…10 is the difference. So AS is 10 and PI is 10. Straight line through sacrum goes through L pubic bone. We have In of 10 and Ex of 10….Start treating the patient and you Re-X-ray the patient. The AD would now be???....The subluxation is eliminated, and the AD would be what??? ---- Use the 5-2 Rule (for every 5 mm of PI correction we will have a 2 mm effect on the femur head). If the PI subluxation lowers the femur head, the PI correction will raise it 2 (5:2 ratio). So the femur head will be raised 4 because of the PI correction. So for the EX correction, we will also raise the femur head 4 (due to the 5:2 rule).

10/23/08

In and Ex measurements

Come from the symphysis pubis measurement.

Class Examples of MD and AD

Ex. #1 …. Femur head baseline = AS of 5 on R side with an MD = 0 because the baseline goes straight across. There is no femur head deficiency. As you correct the AS of 5 with LOD, you restore mobility to the R side. Re-exam of the patient and you notice the innominate measurement is equal and no AS or PI measurement. The AD will now be (based on the 5:2 law) 2. ON re-x-ray we expect the R femur to be down 2 mm. the MD was 0 and we dropped it down 2 mm with adjustment..

*** TEST QUESTION ***

Innominate subluxations will impact the femur height. We say that the patient had a previous femur deficiency of 2 mm on the R. Subluxation of the R innominate caused the heights to be even presenting as 0 mm of MD. Adjusting the AS, restores the femur to previous height. You find from this example that she previously had 2 mm of deficiency (found by correcting her). This means she always had 2 mm of deficiency and that the subluxation made the measurement appear even.

PI ilium causes a low femur height on X-ray with a short leg length on physical exam. It causes the LE to change its angle with regards to the midline. EX and PIEx will also do the same. An AS or IN or ASIn, causes the femur head to be high on X-ray and causes a long leg on physical exam as it draws the leg up and in. If the subluxation causes one thing, the adjustment should do the opposite.

Ex #2 = PI of 5…R innominate measurement is 250 and the L should be 245. The PI (R side in this example) should be larger and the AS (L side in this example) is shorter. We have 2 mm of femur head deficiency or MD on the first visit X-ray exam. We correct the PI by LOD. WE re-x-ray the patient and the new measurement is 245 and 245. There is no PI and AS. The AD should be 0 (MD was 2 and we correct the PI of 5 affecting the femur head by raising it 2 mm). 2-2 = 0 (0 is the new AD). The femur deficiency is due to physiological reasons corrected by adjusting.

EX #3…AS = 5 & In = 5….PI 5 and Ex 5…You adjust the R side because it is subluxated. The MD is 10 mm (5 + 5) on the R. You correct the R innominate subluxation and restore mobility. For every 5, we lower the femur head 2 for the AS and the same for the IN (lower 2 mm for every 5). Therefore, we lower it 4 mm and the new AD is 10mm + 4 mm= 14 mm (the measurement increases as we drop the femur further down). In this example, the initial X-ray shows the R femur is lower than the L and we have a 10 mm deficiency. The correction drops the femur head height lower. The patient may think the leg is made shorter and what we did was restore the R femur head back to where it had been before the accident that caused it to be ASIn. The subluxation drove the femur height up and in. We restored the femur head back to the original location. Now what we would want to do after the physiological correction, was to correct the anatomical problem with a heel lift.

*** Midterm Example ***

Ex. # 4 = MD is 10 on the R. The AD will be? AS of 5 comes from the difference in the innominate measurement. If the L is 200 the R should be 205. If AS is L, the R is PI. We know the AS has the shorter measurement so the other side R should be larger. The difference is represented in the subscript. AS of 5 correction will lower the femur height of 2.The IN 5 comes from the pubis symphysis measurement. The measurement becomes the subscript for In and Ex. Correct the In of 5 and the correction lowers the femur head 2. The new AD will be 6. 10-4 = 6. 10 (MD amount) – 4 (correction amount) = 6. The 6 is generated because the ASIn is on the L. The ASIn has a high femur head (L in our example). The leg deficiency is on the opposite side (R in our example). The R femur head is lower and the L femur head is higher to start with. We did not do anything to R innominate or R femur head. As we fix the L innominate, we lowered the femur head. We lowered 4 mm by adjustment. So, we start at 10 and lowered 4 mm to get a new AD of 6.

*** Test Question ***

Ex #5 = AS of 10 and Ex of 5. AS raises the femur head and Ex drops it down. We have a L MD of 6 mm. We are saying the L femur head is 6 mm lower than the R. What we be the AD after we correct the subluxated listing and restore mobility. AS correction lowers the femur head height. The AS will lower the femur height 4. The Ex correction raise the femur height 2 mm. The net of the change of AS and Ex will be 2 mm downwards. The new AD will be 6+ 2 = 8 mm on the L . The femur head deficiency appears worse on follow-up X-ray. We have restored the femur height back to where it was before the accident. The patient has both physiologic and anatomical problems.

Ex. #6 = AS of 5 and Ex of 10. MD is 0. There is no femur head height deficiency on initial X-ray as the baseline goes straight across and is parallel to the horizontal gridline. The L innominate is subluxated and is not moving upon physical exam. Motion palpation exacerbates the problem. She can’t go up the stairs due to L leg pain. The L innominate needs to be adjusted. 250 for the L and 255 on the R are the innominate measurements.. The difference is 5 (AS is the shorter #). The center sacral line crosses to the L innominate. Ilium shadow measurement is narrower than the other side giving Ex. We use LOD to correct AS and torque to correct Ex. We re-x-ray later and find the AD to be on the R. Correcting the AS we will lower 2. Correcting the Ex we raise the femur 4. We have 2 mm of AD on the R side. We have not touched the R innominate, we have touched the L and corrected the problem manifesting as a change on the R side. Initially the appearance is equal because of the trauma. We restore mobility to the pelvis and find out that all along she had 2 mm of AD that was changed by trauma and corrected by adjustment.

10/28/08

*** Test next Tuesday…True/False, Multiple Choice, Fill in the Blank ***

5:2 RULE EXAMPLES

Ex # 8 = AS of 10, Ex 5, 10 mm of L MD. The L femur is 10 mm lower than the R side. By correcting the AS of 10, we lower the femur head by 4 (5:2). WE raise the femur head by 2 for the Ex correction. The net is 2 mm of change. The new AD is 12. 10 + 2 = 12 mm.

POSTERIOR ROTATED SACRAL ALA

The sacral ala on one side goes posterior. The other side goes anterior. On Gonstead, we are interested in the posterior sacrum.

Ex. L Side Posterior Rotated Sacral Ala

1. L Wider sacral ala on AP film = Side rotated posteriorly

2. Symphysis pubis moves to the posterior side

3. Center sacral line crosses over the opposite pubic bone

2 Possibilities for Center Sacral Line Crossing a Pubic Bone

1. Ex Ilium

2. Posterior Rotated Sacral Ala (in our example this is the one we are concerned about)

4.

*** In the example, the innominates do nothing ***

*** As the sacrum goes, so goes the spine ***

Consequences of Posterior Rotated Sacral Ala on L

1. THE ENTIRE SPINE AND SPINOUSES TO ROTATE TO THE OPPOSITE SIDE (they go R in our example)…ALL THE SPINOUS FROM L5-C2 ALL GO TO THE RIGHT (opposite side)

2. WE SEE ON THE LEFT HIGH PROMINENT TP’S (same side as the posterior sacral rotation in our example)

3. TO OBSERVATION AND PALPATION, WE SEE PROMINENT MUSCULARTURE ON THE L SIDE (same side of posterior sacral rotation)

*** Sacral ala measurement will be at least 6-7 mm wider to be classified as rotation ***

4 Potential Sacral Malalignments

1. Posterior Rotated Sacral Ala on the R (P-R)…P-R refers to wider sacral ala because it goes posterior. It is at least 6-7 mm wider. For it to be truly listed, it must be 6-7 mm wider than the other side (L side). The center sacral line goes to the L side. We would expect the spinouses to go to the Left side. Prominent musculature and TP rotation on the R side.

2. Posterior Rotated Sacral Ala on the L (P-L)

*** P-R and P-L refer to the sacral ala only)

3. Posterior and Inferior Rotation on the R (PI-R) = The sacrum goes Posterior on R and Inferior on R.

*** In Gonstead, we are only concerned with sacral inferiority if it occurs on the side that is already rotated posteriorly. ***

4. Posterior and Inferior Rotation on the L (PI-L) = The sacrum goes Posterior on the L and Inferior on the L.

Implication of Sacral Foramina Lines

Ex. Sacrum appears inferior on the R side…IS THE SACRUM TRULY INFERIOR OR DUE TO MALFORMATION?

1. IF all the sacral foramina lines are parallel and parallel to sacral base line, then the discrepancy is actually due to inferiority of the sacrum on that side. We would use an I to denote this.

2. IF the same thing presents, but the sacral foramina are at different areas and the lines are not parallel to each other and the sacral base line = Malformation of the sacrum would present (ex. polio victims – it didn’t grow like the opposite side). If the sacral foramina lines are not parallel to each other and not parallel to sacral base line, then discrepancy between sacral baseline and femur head baseline is due to malformation and we leave it alone.

10/30/08

Example of Posterior Rotated Sacrum

Ex #1 = Sacral Ala on L goes posteriorly and center sacral line goes to opposite pubic bone in posterior rotated sacral ala.

The R side would be considered anterior. To be classified as posterior, the measurement must be wider by at least 6-7 mm. As the sacrum goes so goes the spine, all the spinous processes rotate to the R side (R is the side opposite the posterior sacrum) with the high TP’s and prominent mamillaries on the left (L is the side of posterior sacrum). In the Gonstead technique, we address the posteriority. In other techniques, like Basic we address the anteriority. In Basic, the objective is to move the sacrum posterior. In Gonstead, we take the posterior side and move it anterior. We have 2 techniques to address the same problem and get the same outcome, by emphasizing the opposite thing (either the posteriority – Gonstead or the anteriority – Basic).

Ex #2 = The sacral ala on the R in our example goes inferior. Ideally you want the sacral line and femur line parallel. True sacral inferiority occurs on the side of posteriority. PI-R is the listing, meaning the R sacral ala goes posterior and drops inferiorly. The listing tells us that all the spinouses go to the Left. PI-R tells us that the sacral ala on the R goes posterior and drops inferior on the R. It tells that the entire spine goes L and the high TP’s and mamillaries are on the R. Tight erectors on R, the center sacral line crosses over the L pubic bone (side opposite the posterior sacrum).

RULES FOR ADJUSTING THE SACRUM OR ILIUM

Adjusting Sacrum to Ilium

1. If the ilium is AS, or ASIn, adjust the sacrum to the ilium – Sacrum goes posterior on the that side

2. If the listing is ASEx (with the AS predominating) adjust the sacrum to the ilium…AS predominates, and has the larger subscript).

3. If the listing is PIIn, with the IN predominating, adjust the sacrum to the ilium….The IN subscript predominates.

The chart pertains to a situation with a posterior rotated sacrum on the same side as an innominate rotation./subluxation

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 --- The PI has the larger subscript

3. If the ilium listing is ASEx, with the EX predominating adjust the ilium to the sacrum…The EX has the larger subscript

The chart pertains to a situation with the posterior rotated sacrum on the same side as an innominate rotation/subluxation.

Adjusting one (either the ilium or sacrum) if you find both on the same side, will correct the other. So adjusting the ilium will correct the sacrum. Adjusting the sacrum will correct the ilium.

SACRUM AND RELATIONSHIP TO 5TH LUMBAR

Column #1 = Base Posterior (BP)

Do not confuse this with posterior rotated sacral ala (which is seen on AP film). Base posterior is seen on the lateral film. Both ala are now posterior with a base posterior. George’s line is broke at L5-S1. A break in George’s line at L5-S1 indicates base posterior. You also see base of sacrum posterior along with coccyx anterior. This is important with coccydynia (coccyx and rectal pain). Base posterior can occur from trauma (slipping and falling on the apex of the sacrum or coccyx causing the base to go posterior.) There is decreased anterior disc space and increased posterior disc space at L5-S1. The base of the sacrum is more horizontal in orientation. As it become more horizontal, posterior disc space increases and anterior disc space decreases.

Base posterior will affect the lumbar lordosis. The lumbar lordosis diminishes.

The entire sacrum goes posterior (both ala). There will be pain sitting and pain bilaterally. These are the patients with bilateral sciatica. Both sciatic nerves will be impacted. The innominates will be both go Ex. You’ll notice the patients walking in the door and see the foot turned in (bilateral toe in – pigeon-toed). This child may be one who wore braces to angulate their feet. The problem is the sacral base. The pain is not the underlying concern. Pain occurs because of other changes.

*** You’ll see base posterior only on the Lateral Lumbar films ***

Column #2 = Spondylolithesis

A break in George’s Line between L4-L5 and L5-S1 occurs. The 5th Lumbar goes anteriorly. The base of the sacrum is still contiguous with George’s line. A spondylolisthesis occurs with pars fracture (spondolytic spondylolisthesis). Spondylolisthesis will give Bilateral pain.

Anybody with the same bilateral symptoms (same dermatome), #1 – Rule out body chemistry (diabetes, RA, Tumor,), #2 – Low back = think base posterior or spondylolisthesis (rule it out with X-ray and MRI)

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