As Published in the Journal Today’s Chiropractic; Vol 23, No 6: 28-34

     Many of our colleges and field doctors are taking the exclusive path of musculoskeletal management, focusing their research efforts on low back pain and other forms of musculoskeletal conditions. Some say that we should maintain this focus and adhere to this realm of care alone. Some of our colleges are currently working towards modifying the chiropractic curriculum to produce a new practitioner, the Doctor of Chiropractic Medicine. Whether in ignorance or for medical acceptance, the decision to take our profession down this musculoskeletal path will inevitably lead to the most limited of practices.

     Some of us have decided to travel down another road, focusing on our profession's original premise -- to deliver a unique and different form of health care with the ability to affect global body function through the nervous system. Many doctors care for patients on a daily basis who recognize these effects and look to the profession to guard our rights with research in this area. Some studies are being done, but they are few and much more is needed.

     We all can appreciate the intrinsic potential of chiropractic care. Many doctors and technique founders have claimed miraculous results on countless cases. But where is the proof? Where is the objective data to substantiate such claims? Needless to say that when asked to produce such data none is forthcoming. Some field doctors have published case studies to share their findings with the profession. This may be important as a means of communicating possible results, but more is necessary if we are to demonstrate the actual scope of chiropractic care and gain a permanent foothold as a distinct health care delivery system. What would make the difference is the use of valid objective physiological testing along with these case studies and "miraculous results". Objective physiological data would demonstrate measurable internal changes which would be indisputable. If only half of the chiropractors in the world were to collect this type of objective data on a daily basis, we might be able to change the face of world wide health care!

     The question now becomes, what type of physiological data should be collected? Chiropractic already possesses an underlying tenant that stands on the firm foundation of substantial research -- the nervous system's dominant role in the control and coordination of all body functions. There is no further dispute over the nervous system's functional capacities (recent research has even demonstrated how the brain may communicate with every cell in the body). Since its inception, our profession has claimed to care for our patients through restoration of normal neurophysiology. Medical and chiropractic research has thoroughly documented the relationship between spinal biomechanics and neurological function. It would only seem logical to choose the nervous system as the target for objective physiological measurement.

     If we agree that the foundation of our profession is clearly grounded in neurology, then two fundamental questions remain to be answered. How can we produce the greatest impact on the nervous system itself?, and How can we directly monitor these effects on a daily basis? The answers to these questions could allow us to provide consistently high quality care for our patients while substantiating our results with evidence beyond reproach. The International Upper Cervical Chiropractic Association (IUCCA) offers the following information in an attempt to answer these questions and present an objective model for chiropractic care.

     Of the voluminous research compiled in the literature on spinal arthrokinematics and neuropathophysiology, the most neurologically intensive is on the upper cervical spine. The current literature is replete with information on aberrant upper cervical biomechanics and its possible ramifications on brain stem and higher order functions. Neurological pathways have been traced with radioisotopes from the upper cervical spine to brain stem centers. Dysfunctioning and non-functioning areas of the brain have been mapped, the cause found, and the solution traced to possible causes in the upper cervical spine. The amount of supporting research is staggering and exciting.

     No other site in the human body has so much data on the possible effects of an adjustment on global body function than the upper cervical spine. Although lower spinal dysfunction has been shown to potentially cause local neurological disturbances, the magnitude of these disturbances are significantly less than in the upper cervical spine. This junction between the brain control centers and the body below deserves critical attention if one is intent on consistently affecting the body as a whole.

     There are many types of diagnostic instruments being used in chiropractic today. Some of these instruments include inclinometers, surface EMG, SEP, SSEP, and dynamometers to name a few. Many of these and other instruments are objective in themselves, but when interfaced with humans the objectivity of the test can be seriously affected. Quite a few of these instrument procedures depend on patient compliance for measurable results. If a patient must move, remain motionless, or contract their muscles for any test, the test depends on compliance and thus becomes more subjective. If the patient does not wish to comply, the test will be in error. For this reason alone some of these tests are in error 50-60% of the time. There is also one remaining question, if a subluxation is defined by nervous system malfunction then why use instruments which attempt to measure the effects of the subluxation (muscle spasm with SEMG, altered range of motion with inclinometers, etc.)? If we are able to correct the subluxation via monitoring the nervous system will not all the component effects resolve?

     Since we are concerned with the objective measurement of nervous system function, most of these and other instruments will not be adequate. Our needs are even more specific than this. We want an instrument that can monitor the nervous system as it directs internal function, without the patient having any control over the outcome of the test. The only way to achieve both of these objectives is to monitor the autonomic nervous system.

     Digital Infrared Imaging (DII) is the only adequate testing procedure at this time which can objectively monitor the autonomic neurophysiology of the body on a pre and post adjustment basis. With nearly 9,000 peer reviewed studies, 30 years of research, and a high degree of sensitivity (99.2%) and specificity (98%), DII has demonstrated itself as a valid neurophysiological diagnostic imaging tool. Instrument standards and imaging protocols have been well established by both the chiropractic and medical fields. Extensive research has established both abnormal and normal thermographic values which can be used to determine the need for care and the outcome of the adjustment.

     Precision radiology allows for the imaging of the upper cervical complex in the three cardinal coordinate planes without disturbing the patient’s presenting posture. It also seeks to minimize anatomical distortion. Malpositioning of the patient to the central ray, and/or malalignment of the central ray to the film, can create sufficient distortion of the image to produce an erroneous biomechanical analysis. Precision radiology minimizes this effect by (1) accurate alignment of the radiological unit; and (2) proper patient placement in regards to the central ray.

     In the past, precision radiological units were out of the financial reach of most clinics. However, current technological manufacturing advancements have made these units available to every office. Simple modifications can also be made to a doctor’s existing radiological unit at a very reasonable expense. Advancements in laser technology have also lead the IUCCA to pioneer the first precision laser-optic patient alignment system for the chiropractic profession. Through the use of this system the patient can be aligned, for the first time, from the central ray itself; thus, yielding the most precise alignment system in the world.

     Precision radiographic imaging has now become a problem of the past. However, an accurate biomechanical analysis of the radiographs still presents us with many problems. Many different types of upper cervical roentgenometric procedures have been introduced over the last few decades. Almost all of these procedures have relied totally on osseous landmarks and line drawing to determine a proper adjustive procedure. Unfortunately, many of these landmarks have undergone remodeling due to Wolf's Law while others may be congenitally malformed. Research into the articular and general osseous structures of the upper cervical spine has determined that asymmetry is the rule rather than the exception. With this in mind, the total reliance on osseous landmarks and line drawing may produce significant analytical errors.

     In light of these findings, an accurate radiographic analysis of the upper cervical spine should incorporate more than just a line drawing evaluation. Recent studies have shown that careful analysis of overall cervical spine dynamics often yields information which allows the doctor to interpret through the inherent errors of radiographic line drawing. In order to maximize the doctor's ability to accurately evaluate the upper cervical spine, the IUCCA has developed a comprehensive method of radiographic analysis which incorporates these principles; thus, overcoming many of the flaws inherent in previous analytical procedures.

     For any adjustive procedure to be effective it must be able to access the vertebral segments both consistently and accurately. However, as previously mentioned, the anatomy of the upper cervical spine does not afford easy access to the osseous structures. A thorough study into the extensive functional anatomy of the upper cervical spine will demonstrate the difficult accessibility of the atlas vertebra in particular.

     For every increase in mobility there is a consequence of decreased stability. At the level of the atlanto-occipital and atlanto-axial articulations there is a decrease of structural integrity through a lack of pre and post-zygapophyseal joints and an intervertebral disc. This arrangement has resulted in the most mobile area of the spinal column. Although a good design for the immediate survival of the organism, decreased stability leaves this area susceptible to injury. This is partially compensated for by an extensive ligamentous network and a protective recessing of atlas in particular. In consideration of the importance of this area to the existence of the organism, it becomes apparent that extreme wisdom was used in this design.

     The protective recessing of atlas makes the accessibility of this segment very difficult to most adjustive procedures. Through extensive anatomical and radiographic studies it has become apparent that the traditional lateral transverse process contact of atlas is questionable in the majority of cases. However, through the unique use of specific biomechanical patient positioning, the adjustment of atlas can be secured on a regular basis as proven by objective thermographic evidence of consistent normalization of neurophysiology. If our care claims to effect the most important system in the body, it must be able to withstand objective scrutiny.

     As our profession is pulled externally by issues such as managed care and socialized medicine, it is also being pulled internally as we struggle for direction and identity. The results of our internal struggle will inevitably set the stage for the outcome externally. The need for a clear definition of chiropractic care is apparent. The collection of objective evidence to substantiate our identity is critical.

     If we are going to stand on the firm foundation of the nervous system's control over all systemic functions, we must be able to quantify our care both before and after it is rendered. The time has now come. Current technology gives us the ability to demonstrate the effects of our care objectively. If we are to maintain our autonomy as a distinct health care delivery system, our claims must be able to withstand objective scrutiny.

     We as chiropractors must shed any practice of mediocrity and strive for excellence if we are to enjoy a "broad scope of practice". Our quest should be for more precision, objectivity, thoroughness, and consistent outstanding results. We can no longer afford the lax attitude of "adjust anything and they will get better," because they don't always get better! We cannot afford the naive attitude of "everything works", because everything doesn't work -- at least not with the same degree of success. There is nothing wrong with treating patients with musculoskeletal conditions. There is also nothing wrong with treating the spine and hoping a gastrointestinal, respiratory, or cardiac condition will resolve. What is wrong, however, is achieving results by accident and being unable to duplicate them again for someone else who presents with a similar condition. It is wrong to claim to have a "broad scope of practice" and yet be unable to help patients with internal disorders.

     Our colleges, researchers, and leaders may be talking about the "glowing future" of chiropractic, but what future do we really have? What can we look forward to? If we are to change our education to include medical practices, what will distinguish us from a medical doctor? If we become "DCM's", embracing the use of limited pharmacology and ambulatory surgery, are we any different from a general practitioner who manipulates? Moving in this direction has significant historical meaning. It caused the absorption of an entire profession. What will prevent this from happening again?

     Our profession needs to wake up and start solidifying its foundations. An objective model for chiropractic care needs to be developed. The IUCCA is offering the Applied Upper Cervical Biomechanics Certification Program as a starting point for this venture. Regardless as to whether or not you "believe" in any particular technique, we as doctors must insist on the highest standards possible in objective neurophysiological outcome measurements. Only then will we truly discover what works and what doesn't.

     Our profession's selective scientific research is currently being used to pigeon-hole chiropractic into a musculoskeletal specialty. It is time we let pure science demonstrate exactly how far-reaching the practice of chiropractic really is. It may become the responsibility of doctors in the field to reclaim our profession. An objective model for chiropractic care is necessary if we are to undertake this challenge. Through the collection of objective neurophysiological data, along with consistent results in patient care, the field doctors of our profession could very possibly change the face of world wide health care. This is a truly exciting time in our history. The crossroads is before you, the path is yours to choose.