1. health and fitness
2. disease

10/30/2014
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Bhogal, DC, DABCI.
Chiropractic / Subluxation
VSC / PART
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© 2014 Bhogal
Chiropractic
© 2014 Bhogal
Chiropractic
Homewood
“A subluxation in the chiropractic sense is not a partial dislocation
(less than a luxation), but an alteration of the normal anatomical
or physiological relationships, or dynamics of contiguous
structures.”
Mercy Conference (1992)
“an aberration of normal spinal biomechanics, usually involving a
restriction or loss of normal movement of a motion segment, and
associated aberrations in the tissues which support articular
motion (e.g., nerve, muscle, connective, and vascular.”
Palmer College (circa 1980)
“A spinal subluxation is any alteration of the biomechanical and
physiological dynamics of contiguous spinal structures which can
cause neural disturbances.”
Palmer College (2002)
“A subluxation is a misalignment, malposition, or dyskinesia of any skeletal
articulation within its active or passive range of motion.”
“A vertebral subluxation is a subluxation of any weight-bearing spinal articulation
that compromises neural integrity and may influence organ system function and
general health.”
Haldeman (1992)
“Subluxation is an aberrant relationship between two adjacent articular
structures that may have functional or pathological sequelae, causing an
alteration in the biomechanical and/or neuro-physiological reflections of these
articular structures, their proximal structures, and/or body systems that may be
directly or indirectly affected by them.”
Stephenson (B.J. Palmer)
“a subluxation is the condition of a vertebra that has lost its proper juxtaposition
with the one above, or the one below, or both; to an extent less than a luxation;
and which impinges nerves and interferes with the transmission of mental
impulses.”
© 2014 Bhogal
Chiropractic
Strang (1984)
“a biomechanical disrelation or dysfunction anywhere in the body,
but particularly of the spinal column’s contiguous structures or
immediate articulations, resulting in aberrant neural function.”
ACA Council on Technique (1993)/Gatterman (1995)
Subluxation – “a motion segment, in which alignment, movement
integrity, and/or physiological functions are altered although contact
between joint surfaces remains intact”
Subluxation Complex- “a theoretical model of motion segment
dysfunction (subluxation) that incorporates the complex interaction
of pathological changes in nerve, muscle, ligamentous, vascular, and
connective tissues”
Subluxation Syndrome- “an aggregate of signs and symptoms that
relate to pathophysiology or dysfunction of spinal and pelvic motion
segments or to peripheral joints”
© 2014 Bhogal
© 2014 Bhogal
Chiropractic
ACC (Association of Chiropractic Colleges) (1996)
“A subluxation is a complex of functional and/or structural
and/or pathological articular alterations that compromise neural
integrity and may influence organ system function and general
health.”
WCA- Practice Guidelines for Straight Chiropractic (1993)
“a misalignment of one or more articulations of the spinal
column or its immediate weight-bearing articulations, to a
degree less than a luxation, which by inference causes alteration
of nerve function and interference to the transmission of mental
impulses, resulting in a lessening of the body’s innate ability to
express its maximum potential”
© 2014 Bhogal
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10/30/2014
Chiropractic Identity Document
Chiropractic is a philosophy, science and art.The philosophy ofchiropractic is built upon
the constructs of vitalism, holism, conservatism, naturalism and rationalism. It provides
context for the application of science and art.
Health is a state of optimal physical, emotional and social well-being. Central to the
philosophy of chiropractic is the principle that life is intelligent. This innate intelligence
strives to maintain a state of health through adaptation mechanisms. The nervous system
is recognized as an avenue for these self-regulating processes. Interference with
neurological function can impede these mechanisms, disrupt homeostatic balance and
adversely impact health. Chiropractic posits that subluxation of the spinal column and
other articulations can affect nervous system function and the expression of health,
which may result in symptoms, infirmity and disease.
Chiropractic
A conservative and conscientious
form of health care that concerns
itself (primarily) with the functional
integrity of the nervous system.
The understanding of the subluxation complex continues to progress from D.D. Palmer’s
early writings about misalignment of vertebrae and other articulating structures to
include additional anatomical, physiological, biomechanical, chemical and biopsychosocial
factors.
- Palmer College of Chiropractic, June 2012
© 2014 Bhogal
© 2014 Bhogal
Philosophy
Subluxation
An aberration in biomechanical
spinal anatomy, such that the
functional integrity of the nervous
system is compromised
(compromised capacity to adapt to
stimulus).
• The love of wisdom!
• What does chiropractic wisdom tell us:
– The body is intelligent
– It is self regulating – Innate Intelligence
– Created by a Universal Intelligence
– Love/hate relationship with Educated
Intelligence
– How well we utilize Educated facilitates
the expression of Innate
© 2014 Bhogal
The 33 Principles
© 2014 Bhogal
Principle Reminders
17. Cause and Effect
Every cause has an effect and vice versa
18. Evidence of life
We should live life to it’s potential
20. Innate Intelligence
Every living thing has it
21. The mission of Innate Intelligence
Active organization – homeostasis
Authored by Ralph W. Stephenson, DC
An amazing synopsis of the chiropractic
philosophy
w3.palmer.edu/bhogal
© 2014 Bhogal
© 2014 Bhogal
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10/30/2014
Vertebral Subluxation Complex
Principle Reminders
24. Limits of adaptation
Limitations of matter
30. The cause of dis-ease
Failure to adapt – transmission of Innate
31. Subluxations
Cause? or effect?
3 T’s (Should we consider a “4th T”)
“Adjusting” the cause or effect
Kinesiopathology
Position / Motion
Myopathology
Tonicity / Weakness / Asymmetry
Neuropathology
Compression / Stretch / Axoplasmic flow
Histopathology
Edema / Inflammation cascade
Pathophysiology – Name your disease!
© 2014 Bhogal
Vertebral Subluxation Complex
© 2014 Bhogal
Vertebral Subluxation Complex
Kinesiopathology (How to evaluate for it…)
Myopathology (How to evaluate for it..)
Atypical position or motion
Muscular dysfunction resulting in hypo/hyper tonicity
History
Palpation
Motor Exam
Posture
Specialized studies
History
Static/Motion Palpation
ROM
Posture
Imaging
EMG
Radiology / MR / CT
© 2014 Bhogal
Vertebral Subluxation Complex
Neuropathology
© 2014 Bhogal
Vertebral Subluxation Complex
Histopathology (How to evaluate for it..)
(How to evaluate for it..)
Dysfunction or disease of the nervous system
History
Instrumentation
DTR’s
Sensory / Motor Exam
Specialized studies
Imaging / NCV
Disease or dysfunction at a cytological level
History
Palpation
Imaging
Blood chemistry
© 2014 Bhogal
© 2014 Bhogal
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10/30/2014
Vertebral Subluxation Complex
The P.A.R.T System
A system devised by Centers for Medicare
and Medicaid Services (CMS)
Pathophysiology
Functional changes associated with disease or
injury
What are your named differential diagnoses?
What is your paradigm and scope?
How will you render care?
Patient education?
To validate the necessity of chiropractic care
and to document this necessity
X-ray can be used to document the
subluxation
Clinical documentation of the subluxation
utilizes the PART acronym if you are utilizing
physical examination
© 2014 Bhogal
The P.A.R.T System
© 2014 Bhogal
P - Pain and Tenderness
Observation: You can document, by personal observation, the
pain that the patient exhibits during the course of the
examination.
P – Pain and Tenderness
Percussion, Palpation, or Provocation: “Let me know if any of
this causes discomfort.”
A – Asymmetry or Misalignment
Visual Analog Type Scale: The patient is asked to grade the pain
on a visual analog type scale from 0-10.
R – Range of Motion Abnormality
Audio Confirmation: Like the visual analog scale, the patient is
asked to verbally grade their pain from 0-10.
T – Tissue / Tone Changes
Pain questionnaires: Patient questionnaires, such as the McGill
pain questionnaire or an in-office patient history form, can be
used for the patient to describe their pain.
American Chiropractic Association Centers for Medicare and Medicaid Services (CMS)/PART Clinical Documentation Guidelines
© 2014 Bhogal
© 2014 Bhogal
A – Asymmetry or Misalignment
R – Range of Motion Abnormality
Observation:
You can observe patient posture or analyze gait.
Observation: You can observe an increase or decrease
in the patient’s range of motion.
Static and Dynamic Palpation:
Describe the spinal misaligned vertebrae and
symmetry.
Diagnostic Imaging:
You can use x-ray, CAT scan and MRI to identify
misalignments.
© 2014 Bhogal
Motion Palpation: You can record your palpation
findings, including listing(s). Be sure to record the
various areas that are involved and related to the
regions manipulated.
Stress Diagnostic Imaging: You can x-ray the patient
using bending views.
Range of Motion Measuring Devices: Devices such as
goniometers or inclinometers can be used to record
specific measurements.
© 2014 Bhogal
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10/30/2014
T – Tissue Tone Changes
VSC / PART Relationship
Observation: Visible changes such as signs of spasm,
inflammation, swelling, rigidity, etc.
V.S.C.
P.A.R.T.
Palpation: Palpated changes in the tissue, such as
hypertonicity, hypotonicity, spasm, inflammation,
tautness, rigidity, flaccidity, etc. can be found on
palpation.
Kinesiopathology
Myopathology
Asymmetry or Misalignment
Neuropathology
Range of Motion Abnormality
Use of instrumentation: Document the instrument
used and findings.
Histopathology
Tissue Tone Changes
Tests for Length and Strength: Document leg length,
scoliosis contracture, and strength of muscles that
relate.
Pain and Tenderness
Is this a linear or intuitive
relationship?
© 2014 Bhogal
VSC / PART Relationship
© 2014 Bhogal
VSC / PART Relationship
Kinesiopathology
Asymmetry or Misalignment
Neuropathology
Pain and Tenderness
Palpation/Imaging/Posture
Provocation
Range of Motion Abnormality
Asymmetry or Misalignment
MRI
Myopathology
Pain and Tenderness
Asymmetry or Misalignment
Tissue Tone Changes
Tissue Tone Changes
Instrumentation
© 2014 Bhogal
VSC / PART Relationship
© 2014 Bhogal
VSC / PART Relationship
Histopathology
Pain and Tenderness
V.S.C.
Kinesiopathology
Observation of swelling / inflammation
Asymmetry or Misalignment
Imaging to see change at the tissue level
P.A.R.T.
AR
Myopathology
P A
T
Neuropathology
P A
T
Histopathology
P A
T
Tissue Tone Changes
They do correlate!
You just have to know how!
Instrumentation
Observing inflammation / swelling
© 2014 Bhogal
© 2014 Bhogal
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10/30/2014
VSC / PART Relationship
VSC / PART Relationship
Physical Findings
Physical Findings
VSC
VSC
PART
PART
This is the correct relationship!!
This is NOT a correct / linear
relationship!!!
© 2014 Bhogal
© 2014 Bhogal
References
Historical Overview and Update on Subluxation Theories
Journal of Chiropractic Humanities 2010 (Dec); 17 (1): 22–32
Exploring the Neuromodulatory Effects of the Vertebral Subluxation
and Chiropractic Care Chiropractic Journal of Australia 2010 (Mar); 40 (1): 37–44
Introducing the External Link Model for Studying Spine Fixation and Misalignment: Current
Procedures, Costs, and Failure Rates J Manipulative Physiol Ther 2009 (May); 32 (4): 294–302
Introducing the External Link Model for Studying Spine Fixation and Misalignment: Part 2,
Biomechanical Features J Manipulative Physiol Ther 2007 (May); 30 (4): 279–294
Chiropractic Subluxation Assessment: What the Research Tells Us
J Can Chiro Assoc 2002 (Dec); 46 (4): 215-220
The Subluxation Complex
Journal of Chiropractic Humanities 1999; 9 (1)
American Chiropractic Association Clinical Documentation Manual
Stephenson R W 1927 Chiropractic Textbook. Palmer School of Chiropractic, Davenport, IA
© 2014 Bhogal
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