10th Annual Vertebral Subluxation Research Conference
December 7-8, 2002
Saturday, December 7
Time Speaker Name Presentation Title 8:30 - 9:30 am John Hart, DC Upper Cervical Specific: An Overview 9:30 - 10:15 Susan Brown, PhD, DC The Blair Technique: Biomechanics and Radiographc Analysis 10:15 - 10:30 Break _ 10:30 - 11:30 Robert Kessinger, DC Movements of the Atlas and Axis in subluxation correlated with X-ray findings 11:30 - 12:30 Chung Ha Suh, PhD Recollections of the Biomechanics Research Project at the University of Colorado and Recommendations for Future Research 12:30 - 2:00 pm Lunch Break Lunch provided by Precision Biometrics, Inc. with a special presentation honoring Dr. Suh. 2:00 - 2:45 Kirk Eriksen, DC Chiropractic Orthospinology X-ray Analysis and Biomechanics 2:45 - 3:30 David Amundsen, DC for Roy Sweat, DC Atlas Orthogonal Misalignment Patterns and X-ray Analysis 3:30 - 4:15 Michael Zabelin, DC The four basic types of NUCCA 4:15 - 4:30 Break _ 4:30 - 5:15 Lisa K. Bloom, DC The Scientific Basis for Maintenance Care in Chiropractic 5:15 - 6:00 Edward Owens, MS, DC X-ray Analysis Accuracy Testing using Computer Simulated Radiographs - An Interactive Research Presentation - Part 1
Sunday, December 8
8:30 - 9:30 am Ed Owens, MS, DC X-ray Analysis Accuracy Testing using Computer Simulated Radiographs - An Interactive Research Presentation - Part II, Results 9:30 - 10:15 Robert Cooperstein, MA, DC Interdisciplinary Assay of Literature Pertaining to Leg Length Inequality 10:15 - 10:30 Break _ 10:30 - 11:30 Robert Klingensmith, DC The Relationship Between Pelvic Block Placement and Radiographic Pelvic Analysis 11:30 - 12:30 Panel Discussion, Ed Owens, Moderator Panel Discussion - How can upper cervical technique practitioners and developers present their progressive side?
Contact information: Sherman College Continuing Education Department
Phone 800-849-8771 ext 1229
This conference is offered in association with the Academy of Upper Cervical Chiropractic Organizations (AUCCO) as a module in the Upper Cervical Diplomate Program. It will provide 6 hours of credit toward the biomechanics requirement and 6 hours toward x-ray analysis.
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Upper Cervical Specific: An Overview
John Hart, DC
Sherman College of Straight Chiropractic
Introduction In 1930 B.J. Palmer introduced an upper cervical technique known as hole-in-one (HIO), and in 1946 the technique was re-named upper cervical specific (1). The idea that the upper cervical region is the major area for subluxation did not initially belong to B. J. Palmer but he is known for promoting the concept. Palmer's early ideas about HIO biomechanics and its x-ray analysis can be found in the 1934 text Subluxation Specific, Adjustment Specific (2). The analysis was later refined and published in various texts such as the 1957 edition of Modern X-ray Practice and Spinography (3) and in Answers (4), as well as in various magazine articles from the International Review of Chiropractic (5-6). The technique has been discussed in more recent publications (7-10) and continues to be taught at a number of chiropractic colleges today. The typical upper cervical specific chiropractor analyzes his or her patients with a pattern analysis of: 1) paraspinal heat temperatures, and 2) leg length inequality. The radiographic set for upper cervical specific technique is comprised of three x-ray views: AP open mouth, base posterior and lateral neutral (11). The adjusting method consists of the toggle-recoil, with the patient in either the side-posture or knee-chest position.
Atlas In the upper cervical specific technique, the atlas is compared to the occipital condyles and can misalign in the following directions:
There may be exceptions to the different rules for the x-ray analysis. For example an exception to the point wedge rule on the AP open mouth view could be caused by an anomalous occipital condyle (13). As another exception, an overlap or underlap also may be due to malformation, since opposing articular surfaces may not be exactly the same size or surface area (14). Knowing whether some checks demonstrate greater inter-examiner reliability will help the chiropractor to know whether more weight should be given to some checks (that have been shown to be more reliable) and less weight on others (that have been shown to be less reliable). Also, a preponderance of evidence would be sought in the case of conflicting indicators. For example, three checks that indicate a right atlas while another two indicate that the atlas is left, would suggest that there is more evidence for a right atlas than a left atlas.
- Tilt, either superior or inferior, is assesed on the lateral view. The reference point is the anterior tubercle. The atlas normally “sits” on a superior tilt (anterior tubercle positioned superior to the posterior tubercle). Tilt is represented in the second letter of the atlas listing (i.e. ASR). So in an ASR, the atlas anterior tubercle is more superior than it normally is. There are a number of different criteria on the lateral view for determining whether tilt is present.
- Laterality, either left or right, is assessed on the AP open mouth and base posterior radiographs. There are also a number of different checks for laterality on the AP open mouth view, as well as a check on the base posterior view. Among the various checks on the AP open mouth view is the comparison of the distances from a vertical median line out to the lateral masses (the greater distance = the side of laterality). The vertical median line represents the vertical center of the foramen magnum, halfway between the medial inferior tips of the occipital condyles. Another check for atlas laterality on the AP open mouth view is noting if a point wedge is present. A point wedge is formed by the covergence of an atlas line and an occiput line. The occiput line is constructed simply by connecting two dots, one placed on each of the medial inferior tips of the occiput condyles. The atlas usually rides up on the condyle on the side of laterality, forming the point wedge on the side of laterality. Another check for atlas laterality consists of noting any overlap or under-lap when comparison is made to the corresponding superior articulating surface of atlas to the inferior articulating surface of the occipital condyle. The side of the overlap would represent the side of the lateral side-slip. Laterality is noted in the third letter of the atlas listing (i.e., ASR).
- Rotation: anterior or posterior, is assessed on the base posterior radiograph, as well as on the AP open mouth radiograph. On the base posterior, an atlas line (constructed via the dotted centers of the atlas transverse foramina) is compared to a Duff’s “V” line (12). The “V” line represents the spatial orientation of the occipital condyles, and is constructed by placing dots on structures (ossification centers) on the condyles that happen to be V-shaped. One of the advantages for the Duff analysis is that it helps to prevent erroneous analysis due to occipital condyle malformations. Rotation is listed on the side of atlas laterality. One of the criteria on the AP open mouth view for atlas rotation is determining whether the lateral masses are the same size. Assuming there is no head rotation during the x-ray, and assuming there is no congenitally large lateral mass present, the rule is that the side of the smaller lateral mass would represent the side where the atlas has rotated posterior (= the side closer to the film). Consequently, an ASRP atlas would be one that is misaligned on a superior tilt, and is side-slipped to the right, and is also rotated posteriorly on the side of laterality.
In the upper cervical specific technique, there are 12 basic listings for the atlas:Axis The axis (C2) vertebra is also compared to the occiput condyles, and can misalign in the following directions:
ASL ASLA ASLP ASR ASRA ASRP AIL AILA AILP AIR AIRA AIRP
In upper cervical specific technique there are 14 basic listings for the axis:
- Laterality (also referred to as rotation) of the body and/or spinous process, either left or right, is assessed on the AP open mouth radiograph. The vertical median line remains the reference point. Axis is analyzed according to pivot points. If for example the dens is in the center of the neural canal (derived from vertical median line) but the spinous process is lateral to the right of this line, then the x-ray listing would be body pivot, spinous right (BPSR). As another example, if C2 as a whole (dens and spinous) is misaligned to the right of the VML, then the listing would be entire segment right (ESR).
- Anteriority/posteriority is also taken into consideration for the adjustment line-of-drive by assessing whether or not the axis is in juxtaposition relative to C3, as seen on the lateral neutral radiograph. For example, if C2’s posterior body line (George’s line) on the lateral radiograph is in juxtaposition or anterior to C3’s posterior body line, then a P-A line-of-drive would be contraindicated in the adjustic thrust.
The PLI and PRI listing are the same as the BPSL and BPSR respectively except that the spinous process (in PLI and PRI) is more inferior as designated by the “I”. Furthermore, there also exists in the PRI and PLI listings the component of posteriority as noted in the letter “P” as determined on the lateral neutral radiograph.
ESL ESR BPSL BPSR SPBL SPBR ESL-SL ESR-SR ESL-BL ESR-BR CPBL CPBR PLI PRI
- Anonymous. A new era for PSC. International Review of Chiropractic. February 1956, p. 4.
- Palmer BJ. Subluxation Specific, Adjustment Specific. The Palmer School of Chiropractic. Davenport, IA. 1934.
- Remier PA. Modern X-ray Practice and Spinography. The Palmer School of Chiropractic. Davenport, IA, 1957, pp. 312-378.
- Remier PA. System of spinographic analysis. In: Palmer BJ. Answers. W.B. Conkey Co. Hammond, Indiana. 1952, pp. 1-25.
- Remier PA. Spinographic analysis. International Review of Chiropractic (ICA). February 1955, pp. 7-8, 32.
- Remier PA. Analysing the axis and atlas. International Review of Chiropractic (ICA). August 1955, pp. 6-10, 29.
- Bolton PS, Bolton SP. Acute cervical torticollis and Palmer upper cervical specific technique: a report of three cases. Chiropractic Journal of Australia 1996;26(3):89-93. and
- Amalu W, Tiscareno LH. HIO: old problems, new solutions. Today's Chiropractic 1997;26(6):24-34).
- Hyman C. The Upper Cervical Technique. Enchantment Publishing. 1996.
- Strazewski J. The Essentials of Toggle Recoil. 1998.
- Remier PA. Modern X-ray Practice and Spinography. The Palmer School of Chiropractic. Davenport, IA, 1957, p. 378.
- Forest TJ. Upper cervical chiropractic in a full spine practice. Digest of Chiropractic Economics. January/February 1980, p. 89.
- Remier PA. System of spinographic analysis. In: Palmer BJ. Answers. W.B. Conkey Co. Hammond, Indiana. 1952, p. 5.
- Panjabi MM et al. Articular facets of the human spine. Spine 1993;18(10):1298-1310.
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Blair Technique: Biomechanics and Radiographc Analysis
Susan H. Brown, PhD, DC
Private Practice, Atlanta, GA
William G. Blair studied thousands of radiographs and osseous specimens to give rise to his biomechanical model for the upper cervical spine. He quantified the prevalence of structural asymmetries and proposed models based on the assumption that misalignments take place at the articulations between bones. Anatomical relationships determine the possible misalignments of atlas relative to occiput and axis relative to third cervical. The specialized Blair radiographs, including proctractoviews and lateral stereo views, allow for direct visualization of misalignments.
This presentation will describe the Blair models for atlas and axis misalignment, using diagrams, computer animations and radiographs to demonstrate them. The radiographic positioning for Blair protractoviews and lateral stereo films will be outlined, and listings for atlas and axis will be illustrated.
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Movements of Atlas and Axis in subluxation correlated with X-ray findings
Robert Kessinger, DC
Private Practice, Cape Girardeau, MO
PURPOSE: Due to the anatomical shape and supporting soft tissue, the upper cervical spine is unique to all other areas of the spinal column. Other authors have adequately discussed normal biomechanics of the occipito-atlantal-axial region. The purpose of this presentation is to define biomechanics of the upper cervical spine in subluxation. These biomechanical definitions will be supported by known factors such as anatomical structure and function of supporting soft tissue along with plain view and stereo X-ray analysis.
BACKGROUND AND OBJECTIVES: The anatomical structure of the atlas, axis and occiput are known factors although there are unique differences from any one person to the next. The muscles and ligaments supporting the upper cervical spine are known and their functions have been described. These universally known factors are put together with knowledge gained through Blair Protracto views and lateral stereo analysis to arrive at a new way of looking at the biomechanics of the upper cervical region in subluxation.
CONCLUSION: The fundamental basis for upper cervical chiropractic adjusting techniques is to correct the upper cervical subluxation. Varied upper cervical techniques attempt this through methods specific to their own procedure. Facilitating the upper cervical spine into juxtaposition, thus removing neurological impediment, through an adjusting procedure is the goal. A common ground for all techniques is in the above defined fundamental basis and goal. Understanding the biomechanics of the upper cervical spine in subluxation is a foundation upon which to build further insight into what we do, why we do it, ultimately bringing us to greater application, regardless of specific upper cervical chiropractic technique utilized.
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Recollections of the Biomechanics Research Project at the University of Colorado and Recommendations for Future Research.
Chung-Ha Suh, PhD
Professor Mechanical Engineering(retired)
When the chiropractic research project began at the University of Colorado, Boulder in 1969, very little was known about human biomechanics. We very much had to start at the ground floor, making basic measurements of bony geometry and ligament and disc material properties using crude equipment that was designed for engineering of heavier materials. All of that is documented in the proceedings of the Biomechanics Conference of the Spine, which was held annually from 1970 until 1985.
Our early work involved a large group of faculty and graduate students. That work was presented at the first government sponsored conference on spinal manipulative therapies. We had an impressive enough program to be able to attract grant money from the NIH, the first federal grant that went to support research into chiropractic.
There were two main areas in which I was involved, the development of a computerized kinematic model of the spine, and the three-dimensional distortion-free x-ray analysis. A string of graduate students worked on these projects, getting their PhD's from me. After the NIH money ran out, we continued to receive funding from the ICA and particularly Life College in the most recent decade. In this talk, I will provide my perspective on how chiropractic biomechanics research should best proceed in the coming decade.
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Chiropractic Orthospinology X-ray Analysis and Biomechanics
Kirk Eriksen, DC
President, Chiropractic Orthospinolgy Association
Course objective: To introduce the doctor/student to the X-ray portion of the Grostic Procedure of adjusting the atlas subluxation.
Upper Cervical Subluxation Biomechanics
X-ray Analysis Lecture-showing properly taken lateral, nasium and vertex
- "Normal" alignment and motion
- How the atlas misaligns and creates various subluxation patterns
- How to locate structures and measure subluxation
- Research behind the validity of Grostic Procedure X-ray analysis
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Atlas Orthogonal Misalignment Patterns and X-ray Analysis
Roy W. Sweat, DC, BCAO
David Amundsen DC, BCAO
- Standard pre cervical x-rays
- a-p open mouth
- Standard post cervical x-rays
- sagittal(if positive on the pre)
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The Four Basic Types of NUCCA Misalignent
Michael Sven Zabelin, D.C.
Chairman, NUCCA Education Committee
COURSE OBJECTIVE: To familiarize the doctor/student to the Four Basic Types, from the analytical perspective to the biomechanical model. This will include force pathways dependent on Type, headpiece placement and line of drive.
- Review of anatomy. Upper Cervical anatomy as it relates to projectional geometry.
- Central Skull Line, Atlas Plane Line, Angular Rotation, reference Horizontal and Vertical Planes.
- Condylar and Axial arc segments
- Description of the four basic types. Reduction pathways for each type.
- Headpiece placement for each basic type.
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The Scientific Basis for Maintenance Care in Chiropractic
Lisa K. Bloom, D.C.
Diplomate of the International Board of Chiropractic Neurology
Diplomate in Applied Chiropractic Sciences
Associate Professor, Department of Diagnosis and Practice
New York Chiropractic College
The well-debated topic of maintenance or preventative care in chiropractic is generally understood to be the chiropractic management of a patient who presents without a chief complaint for the purpose of optimizing the function of the body through the adjustment of vertebral subluxations. Understanding the rationale for maintenance care mandates an understanding of two major well-documented concepts: 1) immobilization degeneration (ID); and 2) the neurology of pain processing.
If we can agree that a primary component of the chiropractic vertebral subluxation is hypomobility in a spinal joint complex, there is an immense body of research to support the ensuing degenerative process and the logical conclusion of restoring movement. Immobilization degeneration is supported by over 40 years of research. The literature notes a joint that has lost a degree of its normal movement will begin degenerating at a rate measurable within one week of onset. Notable is that this degenerative process is histologically distinct from osteoarthritis and will continue, often painlessly, until significant degeneration has occurred or sudden a significant biomechanical stress creates an acute injury.
ID alone is substantial enough to argue for the chiropractic care of a patient without back pain, but it is also important to understand why a vertebral subluxation may be present and the patient may remain asymptomatic. Nociceptors are peripheral receptors that depolarize with noxious stimuli. The impulse is carried into the spinal cord and ascends through the lateral spinothalamic tract to the thalamus. Once the signal reaches the thalamus the impulse is sent to three major cortical areas involved in the perception of pain: the postcentral gyrus, the anterior cingulated, and the insula. It is well understood that pain is perceived in the cortex. Three factors influence the perception of pain: 1) the intensity of the stimulus; 2) the duration of the stimulus; and 3) descending inhibition. It is also understood that most nociception never reaches the cortex allowing tissue damage to occur without symptoms. The spinothalamic tract sends impulses into the hypothalamus and reticular formation (spinoreticular tract) in the brain stem which accounts for more systemic autonomic changes secondary to nociceptor activity which, again, may occur without the perception of pain. This is the same neural mechanism that allows serious disease processes to progress subclinically. Additionally, nociceptors synapse on excitatory interneurons in the dorsal horn, which fire directly into the intermediolateral cell column resulting in increased firing in postganglionic sympathetic efferents. This is the connection between the musculoskeletal and non-musculoskeletal systems.
Immobilization Degeneration and the Fixation Hypothesis of Chiropractic Subluxation
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Dubner R. Neuronal plasticity in the spinal and medullary dorsal horns: A possible role in central pain mechanisms, In: Pain and Central Nervous System Disease: The Central Pain Syndromes; New York, Raven Press; 1991;pp143-155.
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Sato A, Sato Y, Schmidt RF. The Impact of Somatosensory Input on Autonomic Functions. Reviews of Physiology, Biochemistry and Pharmacology 1997; vol 130; Springer-Verlag, Berlin and New York, as reviewed in Chapman-Smith D. The Chiropractic Report. May 1997; v11 no3.
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X-ray Analysis Accuracy Tested using Computer Simulated Radiographs - An Interactive Research Presentation
Edward Owens, MS, DC
Director of Research
Sherman College of Straight Chiropractic
Introduction The major upper cervical techniques differ on the biomechanical models of Atlas misalignment they adhere to and on the methods they use to assess the misalignments. While HIO and Grostic style techniques consider the Atlas to be capable of lateral flexion malposition and rotational malposition with respect to the occiput, the Blair misalignment model is composed of a translation along the axis of one occipital condyle.
Likewise, each of the three techniques has its own particular x-ray views and analysis to determine the extent of misalignment in the different directions. The Blair technique and HIO use particular landmarks on the occipital condyles and Atlas articulations to assess alignment, while the Grostic Procedure uses landmarks on the skull edges and posterior arch/lateral mass intersection. It would be interesting to determine which of these methods provides the most accurate assessment of Atlanto-occipital relationship.
A computer model of the base of the occiput and the Atlas vertebra has been used to generate simulated x-ray views of just those two bones. The bones can be accurately positioned with respect to each other and simulated misalignments imposed with known displacements or rotations in 3 dimensions. Next, camera views were staged to represent the viewing positions for the HIO A/P open mouth, the Base Posterior view, the Nasium view and bilateral Blair Protractoviews. Finally, high quality images are rendered with semitransparent materials applied to the bones, producing a fair likeness of a radiograph.
For purposes of this study, printed copies of renderings of a mixture of misalignment patterns, from all 5 views, will be presented blindly to practitioners for analysis. The practitioners will be provided with pencils, rulers and protractors and asked to analyze the images with their preferred technique. Analyzers will not know what misalignments are shown on each image.
Data analysis will be carried out after the session and the results will be presented for discussion at a later session during the weekend. The main parameter will be the accuracy of each technique in determining the actual displacement shown on the images. If at least two assessors of each technique are present, then interexaminer reliability can be assessed as well.
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Interdisciplinary Assay of Literature Pertaining to Leg Length Inequality
Robert Cooperstein, MA, DC
Palmer College of Chiropractic - West
At least five different professions are concerned with leg length inequality: chiropractic, podiatry, medicine, physical therapy, and osteopathy. We gathered literature from each profession concerning the following pertaining to leg length inequality:
Our literature assay confirms that there are significant differences both within and between these professions in how they distinguish functional from anatomic short leg. Pronation, for example, may be considered by some a cause of functional LLI, in that it results from a correctable internal tibial torsion, whereas others may consider pronation a structural alteration by definition. Among the five professions, medicine is the least likely to address the functional short leg, and chiropractic the least likely to address the anatomic short leg. Chiropractors, despite their awareness of the ample literature on the prevalence of anatomical LLI, seem wont to simply ignore that evidence when performing prone and supine leg checks.
Whether it supports a conceptual distinction between a functional and anatomical short leg
Clinical significance: analytic/diagnostic findings, treatable entites, outcome measures
Patient position in assessing LLI: sittting, standing, supine, prone
Measuring technology: visual, instrumented, advanced imaging
How it addresses signs and symptoms thought related to leg length inequality.
The results of our interdisciplinary survey of LLI concepts and clinical implemation facillitate communication between practitioners from different professions, allowing more cross-fertilization of patient assessment and treatment parameters.
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The Relationship between Pelvic Block Placement and Radiographic Pelvic Analysis
Robert D. Klingensmith, DC, DAAPM
Sacro Occipital Technique Organization - USA
Winston-Salem, North Carolina
From a study by Lisi, Cooperstein and Morschhauser entitled “A Pilot Study of Provacation Testing with Pelvic Wedges: Can Prone Blocking Demonstrate a Directional Preference?” a relationship between block placement and pain was determined. The study found, “It appears that low back tenderness can change in response to various position of pelvic wedges, and that a preferred blocking pattern can be determined. “ Preliminary results of the study suggest that tenderness decreases on increases in response to various blocking positions. Also, the blocking positions that increase or decrease tenderness are typically diametrically opposed, that is, directional preference can be shown.”
In another study, Cooperstein found that padded wedges or SOT pelvic blocks could be used for lumbopelvic mechanical analysis.  Unger noted that pelvic block placement could be shown to affect muscle strength. 
In the Lisi et al study  they determined a pain pressure threshold of patients in a neutral position, and then with a pair of padded wedges placed under the subject in each of four different positions: (Right Short Leg - Category One) left iliac crest, right greater trochanter; (Left short Leg - Category One) right iliac crest, left greater trochanter; (SB+) left and right iliac crests; and (SB-) left and right greater trochanters.
In this current study, radiographs were taken to determine whether pelvic distortions could be demonstrated on x-ray when pelvic blocks were placed under the patient in the prone position. One patient was placed prone in a neutral position and radiographs were taken in a neutral position, and then with a pair of pelvic blocks placed under the subject in each of four different positions: (Right Short Leg - Category One) left iliac crest, right greater trochanter; (Left short Leg - Category One) right iliac crest, left greater trochanter; (SB+) left and right iliac crests; and (SB-) left and right greater trochanters. Findings indicated that pelvic block placement could create or affect distortions of the pelvis. Further studies are indicated correlating radiographic analysis, pain provocation, and muscle strength to determine if a clear pelvic block preference can be determined definitively.
Lisi AJ, Coopertein R, "A pilot study of provocation testing with pelvic wedges: Can prone blocking demonstrate a directional preference?" Proceedings of the ACC Conference IX, Journal of Chiropractic Education Spr 2002; 16(1): 30-1.
Coopertein R, "Padded Wedges for Lumbopelvic Mechanical Analysis" Journal of the American Chiropractic Association, Oct 2000: 24-6.
Unger JF, Jr, The Effects of a Pelvic Blocking Procedure upon Muscle Strength: a Pilot Study Chiropractic Technique Nov 1998; 10(4): 50-5.
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Panel Discussion - How can upper cervical technique practitioners and developers present their progressive side?
Edward Owens, Moderator
Upper cervical specific chiropractic techniques derive from traditional Hole-in-One (HIO) technique, which dates to the 1930s and B.J. Palmer. Sometimes these techniques are labeled as cultist or backward, perhaps reflecting Palmer's fascination with mysticism and philosophy. This perception may help account for the failure of upper cervical techniques to attract more than 5% of chiropractors.
On the other hand, upper cervical techniques have an element of progressiveness as well. Most are continually being modified and improved to reflect new discoveries and methods. There exists published research in the form of case and case series studies, reliability studies and some cohort studies that support the claims of upper cervical chiropractic's effectiveness. The fact that leaders of technique organizations are willing to come together at conferences such as this in an air of openness and curiosity to discuss their similarities and differences also points to their progressive nature.
This one-hour panel discussion will provide a forum for technique representatives to give their views on these questions: Is your technique open to progress and change? If not, why is it important to adhere to old notions? How can we best overcome the negative perception that the public seems to hold toward us?
It is expected that representatives from at least five techniques will be available for the panel. There will be time for questions and comments from the audience as well.
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