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Download Thursday, September 05, 1996
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Thursday, September 05, 1996 - Syllabus - You must get an actual copy of the book. - The book was written 20 years ago and there are mistakes in it. Dr. Gonstead never got to review the book. - The first exam will be on the 14th hour, when ever that falls. There will be a one week notice. Tuesday, September 10, 1996 - subluxation - a minor misalignment between 2 adjacent articulating surfaces that causes a problem - what do we mean by a problem : 1. irritation - inflamation - gives off heat 2. edema - swelling can be felt, spoongy 3. some decreased mobilty - hypomobilty or fixation 4. motion palpate 5. pain - the instrument that we use is called a temposcope - which used to be called a neurocalometer and then nervoscope and then the temposcope - a lot of techniques have instruments - static palpation - Pain in left shoulder could be due to a referral like from the gallbladder - adjusting would prob. only give symptomatic relief - What would happen if chronic inflammation at the T7-8 was left, atropy of the nerve, cold be cold - keep in mind acute versus chronic - When you treat a patient - can get better, remainded unchanged, or get worse - if he gets worse could be on the wrong vertebrae - or could have adjusted it the wrong way - atlas can subluxate lateral and superior - no change usually on the wrong bone - if the patient gets better and then worse - patient is prob doing something - could be a dental occlussion problem, or could be coming from the lower cervical - with every subluxation you have compensation - hypermobility - can be due to compensation from a subluxation - patient comes in with low back pain - laminectomy at L5 and L4 - surgery was a success for a number of years, the problem here is L3 because it was compensating for so many years - for every subluxation there is a compensation - does the compensation have to be above the subluxation, no - where do we find the subluxation on the patient Thursday, September 19, 1996 - Subluxation ----> Compensation - both of these things are a minor misalignment btw two atriculating sufaces - X problem - heat - found by instrumentation; edema - found by static palpation; diminished motion - found on palpation - compensation for every subluxation, the compensation usually being above but it doesn’t have to be - We find the problem on the patient - X-RAY - full spine A-P and Lateral - the most important of the two as a chiropractor - AP is most important because you can see the spinal curves and the disc spaces - The possiblity of getting C3 in postion with the spine being ramrod is not very good - AP curves are very important, so are the disc spaces - something else that is important on the lateral film that you would not see anywhere else kdkdkd In Summary: Reasons Why Lateral Films are Important 1. * AP curves - includes weight bearing 2. Disc condition 3. L/S Angle Spondylo./ BP - base posterior 4. fractures ---> - Gonstead always said the lateral film will be most advantageous to you as a chiropractor. - Gonstead system takes full spine radiographs in 2 exposures to minimize distortion - Full spine AP 1. Accurate vertebral count 2. Scoliosis - or lateral curvature 3. Leg Deficiency 4. Listings 5. Weight Bearing - we use the Radiograph to confirm what we have already found on the patient - We find the problem on the patient, we confirm this with radiographs Tuesday, September 24, 1996 - 6 stages of disc Tuesday, October 01, 1996 - Gonstead Clinic is 27,000 square feet - now owned by a Logan Graduate - Marking X-Rays - Put some dots, draw some lines, and then measure btw lines Dot 1 and 2 at the most superior head of the femur - Dot 3 and 4 at the sacral grooves 3 left 4 right - Dot 5 and 6 at the most superior portion of the iliac crest - Dot 7 and 8 at the most inferior portion of the ischium - Dot 9 at the first or second sacral tubercle - Dot 10 vertical center btw the symphysis pubes Marking instrument - is called a parallel, before you buy one - looking for a straight edge scale up to 250 and 0 scale in the middle, make sure the rollers bilaterally move before you buy it - First stage dots, second stage drawing lines - btw. dot one and two - we label this the femur head base line, next with our parallel we place it on the femur head base line and roll it up to the superior iliac crest, do this bilaterally - Turn parallel upside down and roll it on down until we reach the ischium - left and right - Total of 5 lines parallel to one another - Roll it down until we get to the most superior femur head - and the draw a short line over the inferior femur head if you have one - If both femur head is not short then you will not have a short line - Next - take the zero center scale kdkdk and roll over until you get to the center scarum line - continue line to the symphasis pubis line - in the ideal situation all of the lines will be parallel to the femur head ?????? suspect typing - This is based on the film being taken properly - most lateral aspect of the right ilium and draw a line - Roll over and draw a line through the most medial aspect of the ilium - What we did on the right is center on the left. - superior sacral groove dot - ideally as we roll it up - we would want the parallel to reach both of the grooves at the same time - sacral base line and our femur head base line we would like to see them parallel - all of the lines on our pelvic line we would like to see them parallel or perpendicular to the femoral head base line - 199 mm of left inonimate measurement - this will come back to haunt you - on over head it was 195 on the left and 197 on the right - 1mm of femur head deficiency - under ideal circumstances there would be none - take the zero center line and place on the symphysis line - 0-4 on the central scale - this was a symphysis pubes measurement Thursday, October 03, 1996 - Contin - cress day Tuesday, October 08, 1996 - Just because one ilium seems anterior and the obturator appears smaller the opposite PI ilium - this does not mean that either one is subluxated - On the X-ray and in the marking system we list the one we find subluxated on the patient - another thing we look at is where the edema is - the book says something different - don’t bet on it - We only list on the patient record card what we have found to be subluxated - What have we ruled out if they are having trouble walking up stairs? SI - If problems with getting up from a chair of standing - prob an lumbar problem - AS is on the side of the shorter innominate measurement - the innominate bone isn’t longer or shorter it just appears that way - PI - produces a larger - if the vertical plain - Edema can be found throughout - Number 6 - leaves the sacrum anterior on the left side - Number 1,2,5,6 - need to add the word vertical to the 1 and 2 - Ilium shadow measurement - PSIS is out reference point - the center sacral line is perpendicaulr to the femur head line - A and B should be equal - the obturator should also be equal - The ilium shadow would be smaller on the external side and the foot on that side would appear to have rotated internally. - Toe out on the internal side and the shadow measurement would be larger and the musculature would be flaccid - In a female this will effect her ability to get pregnant because it affects the uterus - Bed wetting and cryptochordism in young males. Can be helped with adjusting. - Subluxation Compensation - the larger obturator is the side of the ER PI innominate - The smaller is the side of the IR and - We have 9 innominate listings. Tuesday, October 15, 1996 - Talked about IN and EX - Line of drives corrects the pelvic distortions - PIEX - counterclockwise correction - The shorter innominate measurement is the AS side - AS is corrected by line of drive and In is corrected by torque - PIEx - Ex - side will see more on the X-ray - 4 Rules - doctor positioning so that the doctor is relaxed, Table is always designed for being mid tibia 2. Patient postitioning, keep the inferior toes off the end of table to prevent toes from hitting, Give the patient a pillow - this relaxes the muscularture, the upper arm along the side of the rib cage 3. Line of drive - if it has gone PIEx - the PI line of drive is AS, IN - pisiform inferior and lateral to the PSIS, torque with the wrist and not the body 4. Speed and timing - don’t stop - for testing purposes - counterclockwise and clockwise - not in the book - The ilium will affect the femur height on X-ray - The second category of short leg is a physiological short leg - such as a subluxation Thursday, October 17, 1996 - one ilium is listed in relation to the other, but it subluxates in relation to the sacrum - The ilium as it subluxates can and will effect the ?????? - take a look at the side of 5th lumbar rotation - this is the situation when they are both stuck, this is all int he action notes - subscripts - the AS measurement will be the the shortrt side, so the other side is PI - the difference in the innominate measurement is the subcript, if one side is IN the other one is EX Tuesday, October 22, 1996 - Rules for correction - taken from the book - 1. For every five millimeters of AS of In correction, the femur head height will be lowered two millimeters 2. For every five millimeters of PI or Ex correction, the femur head height will be raised ddkdkdk - look up the rest in the book - for every 5 millimeters of subscript you have a 2 millimeter change in the femur - MD - stands for measured deficeny, example of 5 mm of MD in Josey when she walks into the office - AD - 3 mm MD - 10 mm of measured defic before you adjust them - after eliminate PI we expect the AD to be 8 Thursday, October 24, 1996 - Will normal adjustment correct the person - in one adjustment , answer no - chronicity - longer it has been there the more conpensation that has occurred, so therefore the longer it will take to fix, age is also a factor , general overall health - get a lot quicker results with younger people - You do not continue to re- x ray until a new trauma has taken place - REMEMBER THE PROBLEM IS FOUND ON THE PATIENT - Listen to the patient Chapter 4 - the sacrum can sublxate in 2 areas with the sacrum or with the lumbar - one sacral alae rotates posterior and then the other one goes anterior - posterior rotated sacral alae - which means the sacrum can rotate in the opposite direction, basic is concerned with the anterior side and gonstead says push the posterior side anterior - the left sacral ala has gone posterior - as it appears on x ray will increase in reference to the other side - this can also cause the subluxation to be over to the other side on the center pubic line Thursday, October 31, 1996 - Last class before the test - Next Tuesday he midterm - everything until day 1 until today, if we did not cover it we don’t have to know it - We talked about the sacrum - as sacral ala rotates posterior it will appear wider on the X-ray - As the sacrum goes so goes the spine, we will expect to see rotations in the lumbars and thoracics - So there are a number of criteria - Four sacral potential sacral misalignments involving the sacroiliac articulation are as follows: 1. Posterior rotated sacral ala on the right P-R - this means the sacral ala on the right has rotated posterior, so we expect to see the spinouses above rotated to the left, up to and including C2 2. Posterior Sacrum on the left P-L 3. A posterior rotated sacral ala and an inferior sacral ala on the right PI-R 4. Posterior rotatd sacral ala on the left that has also rotated inferior on the left, this would say that it has gone anterior superior on the left side - Dr. Gonstead felt the posteriority that caused the problem Three criteria to be able to list a P-R or P-L *****1. SP of vertebrae of L5 ro C2 rotate to the opposite side 2. 6-7 mm difference in the sacral ala measurement 3. No scoliosis - begin to develop addtional problems - We would like to see the femoral and sacral base line parallel - inferiority of the sacral ala - if before we decide on inferiority we need to rule malformation - in order to rule out, if all parallel - all sacral foraminal lines - if all parallel to one another we feel we can in effect rule out malformation - for example, PI -R - the sacrum rotated posterior on the left and the went inferior, if we drew lines through the sacral formamina and sacral base line are parallel we can infact call it PI-R - in Gonstead listing - you say it is due to malformation of the sacrum ???? - if there is a problem at the SI joint we feel the posteriority causes the problem and thats how we get the listings - There is a posteriority recognizing our importance - This chart is only to be used if have a sacral ala and inominate are subluxated on the same side - look at page 12 of the action notes 1. If the ilium listing is AS, In, or ASIn, adjust the sacrum to the ilium 2. If the listing Thursday, November 07, 1996 - Now we are going to talk about the lumbars in relation to the lumbars - One of the things we are going to look at is the broken line - George’s Line - Base posterior - BP - how would we know this without a lateral film - answer you would not know - The fifth lumbar disc increased anteriorly decreased posteriorly - the base of the sacrum becomes more horizontal - If the base of the sacrum goes posterior - decreased AP curve - this could also be due to an AS ilium - We look for break in George’s Line only at L5-S1 - Base Posterior - both sacral alas would have gone posterior - Sacral Base Posterior - the apex of the sacrum goes anterior - symptoms of this would be - Decreased AP curves all the way up, patient is stiff, energy level - muscles are having to work harder and the patient is always tired and malaise - Both nerves right and left - bilateral sciatica - the same symptom bilaterally - Dr. Gonstead use to say - any time patient comes in with bilateral symptoms - same symptoms and dermatomes - what do you think - do you usually get this with the same subluxation - blown disc - one of the situations this will occur in is with a bilateral posterior sacrum - spondyolisthesis - George’s Line is broken at L4-5 and L5 and S1 - the sacrum is still in line but the fifth lumbar has gone anterior - spondylolysis - now we use percentages - can you imagine if you did not have a lateral film of this - on the back of the fifth lumbar - as the vertebra slides more anterior - the posterior portion of the disc gets smaller on the X-ray, anterior appears larger on X-ray - lumbar lordosis - will increase with a spondylolisthesis - what kinds of symptoms will a spondylo give you - Base posterior - might this affect foot flair - bilateral EX listing - with bilateral toe in - May have coccydema or coccyx pain - Two different entities which you need to correct - you will only know this by looking at the lateral film - if the patient is pain free - spondylolisthesis - if symptom free this patient you should leave alone - Misalignment of the coccyx - showed a written overhead - straight out of the book - The apex of the coccyx has gone straight into the pelvis bowel - there must be trauma to cause this - A-L and A-R - in out senario the coccyx went anterior and lateral to the right - if this is not taken care of within 6 months of the occurrence - leave it alone - this can be a problem during pregnancy - A-R and A-L - we will see this in reference to the atlas also - hint, hint, hint - If the patient is prone to constipation - have them take them vitamin C - high enough dose will cause him to go potty - 6 or 7 grams a day for a 150 pound person Tuesday, November 12, 1996 - The most important view in Gonstead is the Lateral - The most important portion of the subluxation is the posteriority - as vert goes post it also drops inferior - look for increased anterior disc space - he rampled off 4 things relating to this - Compensation - First letter of the listing would be a capital P - rotation or laterality - it is a spinous laterality system - We list in relation to the vertebrae below, we will list L5 in relation to the sacrum - In which direction has it misaligned and become subluxated - We will list the wedging on the side of spinous laterality - Our third letter is a capital I - PRS - PLI - P came from the lateral film - for posteriority - LI - came from the AP - You have to have a P Scoliosis - is determined in Gonstead by the side that is conxex 1. Right/Lateral Convexity 2. Simple - spinous to the convex, Rotatory - spinous to the convex - In the Gonstead Technique we always stand on the open wedge side - rather than standing on the concave side - Stand on the open wedge or the convex side, contact the spinous process versus - showed PLI - Anytime the third letter is an I - we are looking at a rotatory scoliosis - Anyitme the third letter is an I we must contact the - Anytime the third letter is an S - we will contact the spinous on that side and we do not need to contact that point - Figure 125 directly form the book 1. IF thepsinous process is rotated to the open side of the wedhe, the cmplete listings are PLS or PRS. It is not necessary to specify the contact point since it is always the spinous process. 2. If the spinous process is rotated to the closed side of the wedge, it is listed PLI-M or PRI -M, and the point of contact, which is the mamillary, is designated by the letter “M”. - He showed 4 examples on the overhead - PRS, PLI - M, PLS, PRI - M - When ever you have an open wedge on the left you will always use counterclockwise torque. Thursday, November 14, 1996 - Went over the letters more - Wedging on the side of spinous laterality - if no third letter you must list the contact points - When there is no wedging you must list the contact point - Rotary - occurs when the spinous goes to the concavity - Always want the contact on the convex side as not to make the scoliosis worse - With simple scoliosis the line of drive is P-A and Lateral to Medial - Rotary - straight posterior - P-A and L-M, by the book - no scolioisis, then contact the spinous Tuesday, November 19, 1996 - If no third letter - need to list the contact point - Always stand thrust on the convex side - What do you utilize to correct wedging - torque - L5 PRS - anytime third letter is an S - the contact is the spinous - L5 is subluxated - PRS - M - get on the high mammillary in the chronic situation - this is only true of L5 for now - If see an L5 PRS - doesn’t tell you enough, acute - PRS - sp, chronic PRS - M 1. PR-SP 2. PRI - When the 3rd letter is an I - you must list the contact point 3. L-5 Special situations for the lumbar spine 4 peculiar L5 listings - you will not see these listing anywhere else - 4 listings you will find only at the 5 lumbar - won’t be used with any other vertebrae other than L5 PRS - M PLS - M PLI - sp PRI - sp The chart in the book on this subject we do not have to memorize - Two suggestions - do not learn the chart, 3 by 5 cards - put the drawing on the front and the listing on the back Thursday, November 21, 1996 - Continued going over the chart - put on cards - ACA journal of chiropractics 1988 - Comparision - overhead of traditional listing versus his listings - Chapter 7 - Spinous rotate into the side of the concavity - We see AP curves on the lateral film - Why should we all have AP curves - shock absorption - Next time we will take about the lower cervicals Tuesday, November 26, 1996 Tuesday, December 03, 1996 - C1 and C2 - have an articular capsule - if irritated get inflammation, edema, The lateral mass will go superior and also a bit lateral - C1 and occiput - the occiput goes superior - major component form c1 on down is posterior, it is not the major component here, for atlas it is laterality - superiority - Chiropractic is an art; an artist develops, expands, and unfolds. It doesn’t just happen. It takes time, commitment, and practice. Practice requires desire and determination. Practice requires a conscious effort, repetition, and a structural approach. - Practice makes perfect!!! - An atlas subluxation occurs from the atlas misaligning with axis - this is in the book - 1st thing we do with atlas is look at lateral film - dot at tip and base of the odontoid - draw 90 degree angle to it - put a dot in the center of the anterior and posterior tubercle of the atlas - draw a line the full length of the parallel - read chapter 9 - 2 vertebrae and two lines - the lines are very important - line 1 - Odontoid line - line 2 - odontoid perpedi line - line 3 - through atlas - AP Atlas Plane Line - must be on the lateral film - the above are the three lines we will draw on out lateral film - Behavioral Optometry - visual recovery following Chiropractic intervention - Written by and OD and DC - Palpatory - taught muscles in the suboccipital region - restricted range of motion - adjustmetn - atlas vertebrae - The cervial cerve - hypo and hyper lordosis - look for changes in discs - the 6 stages - remember these - anterior superior corner, anterio and inferior corner, after years the concavity that develops - 5 as lines converge we get compensation - More than likely you will find go down to thelowest cervical vert wiht hypomob - get behind it and set it back up on the vertebrae it came off of - behind the spinous of 7 is a big white dot - BP - where the base of the sacrum goes posterior - not that uncommon in a young child where the sacrum has not become one - the second sacral segment can go posterior - what common symptom - euresis - A second sacral segment having gone posterior - Axis plane line - we can put a dot in the grooves or bottom of the odontoid - just must be the same bilateral, can do the same with the axis - draw 2 straight lines - 2 lines - Transverse Atlas Plane Line, Axis Plane Line - All of the other vertebrae from C2 on down - major concern is the posterior - Capital P - With the atlas the first thing it must do is go anterior - capital A - the entire vertebrae has moved anterior - 1 moves anterior, the anterior tubercle - it has gone inferior label it with a capital I - the labels of the lines AP atlas plane line, and the Odontoid Perpendicular line - when the 2 lines converge you have an AI listing, the patient presents usually within a nose and chin that are pointed downward - The anterior tubercle - can also go superior - AS - the will converge posteriorly - this will be an AS atlas - this patient may present with nose and chin up in the air - on the lateral film - first two letters of the listing - the third is an A- this means it just went straight anterior, the two lines would be parallel to one another - so far there are only 3 choices - AI, AS and A- AS is the most common one you will see in your office - Which one do you list - C1 or C2 - just because you list a vertebrae in relation to its adjacent it doesn’t mean that it is subluxated - Which is the subluxation if both are - C1 anterior and C2 posterior - if both are equally stuck - Gonstead goes to the most inferior one - Just because it is listed does not mean that it is subluxated - The most common you will see in your office is AS - AP film - as the vertebrae goes superior - the lateral mass will go superior and lateral - list the side of superiority - third letter could either be an R or an L - this is the most important letter of the atlas listing !!!!!!!!!!. this is the side of restricted lateral flexion, this is the side that has gone superior, 3 it is the side that has gone lateral, 4 the side that the 2 lines will diverge on - Transverse atlas plan line - the 2 lines will diverge on the right - or they will diverge on the side of 3 letter - If the 2 lines are parallel to one another the Gonstead adjusting technique - you do not have an atlas problem - The patient will have equal lateral flexion - The 4 step is rotation - number one - is anteriority, number 2 is anterior tublercle, number 3 side of superior laterality, 4 rotation on the side of laterality - now on the involved side is there any rotation - choice of 3 things - either rotated anterior or posterior or no rotation what so ever - The atlas x-ray - the widths of the lateral mass bilaterally - The next one rotation - the 2 lateral masses - as atlas - as lateral mass rotates anterior it will appear wider on the AP film - will appear as more of a light shadow - it becomes wider, that is compared to the opposite one Thursday, December 05, 1996 - If transverse atlas line and the axis line are parallel then you need no third letter - tells us side of laterality, side of involvement, - there are five things told to us by the fifth letter - How would the patient present - AS - nose and chin, ASR - laterally bent to the left with resticted rotation to the right - ASRA - forth letter so rotational component - it is wider on the right, as mass rotates toward the anterior, we see more of one lateral mass - the wider lateral mass - has rotated anterior - this person would have restricted rotation and lateral flexion to the right - review the disc degeneration - We still have restricted right lateral flexion, more narrow than the opposite one - ASRP - restricted rotation to the left bc it is the side that has gone anterior and has gotten stuck - AI - we could have had an AIRP - would look like this , could have A-RP - on the lateral film ARIP - the AP atlas line and the odontoid perpencilar line would converge anteriorly - On the lateral film they converge posteriorly - Three things - look at patient as they present, head bent to one side or the other, motion palpation - motion paplation is the third letter - you can have superiority on one side without rotation - A-R- the lateral masses would be the same, the third letter has to be there it gives you the laterality and the superiority - A-L this exact listing has been seen in the coccyx - A-L - can be occiput or the coccyx - With an A-R - It has to go superior and lateral on one side - if you have an atlas problem, so we have to have a third letter - The atlas versus the axis - how do you determine which is subluxated - do palpation on the patient - The listing would have to be a dash - can’t have an atlas listing if the Transverse Atlas plane line and the Axis plane line are parallel - If we have a transverse condyle line - connect dot btw dots in the mastoid - is not level talking about a condyle line - In the atlas - main thing is anteriority and laterality - condyle concerned with - PS or AS - entire condyle has gone posterior and superior, or anterior and superior - AS - condyle - number 1 the 2 lines - the formamen magnum line and the atlas line will converge - number 1 - under AS - lines converge posterior, decrease or increase OA space, if lines converge anteriorly the will have an increased OA space, common problems birth trauma - Chiropractors and dentists should work together - nerve irritation - at atlas occiput will irritae the parasympathetic nervous system - the second letter and the forth letter is an S - We will determine occiput rotation by looking at the widths of the lateral mass - Final Monday morning at 7:30 at Monday morning
