At a recent state board meeting, relicensing seminar on the upper cervical spine, vertebral artery injuries were discussed. The presentation, given at LACC, was excellent. The lectures were superb and a real credit to the profession. During a presentation by one of the presenters, a conclusion for causes of vascular accidents after all was said and done, was that when an accident occurs with a DC, the "DC was in the wrong place at the wrong time." There were no sure conclusions to be drawn regarding vascular accidents. After the presentation, I spoke to the presenting doctor about inappropriate adjusting predisposing to accidents; specifically, adjusting hypermobile upper cervical joints. The response was that this had been examined as a causative factor and was shown to be not a credible factor.
Neither of these statements felt comfortable to me because they defied common sense. This is the one thing the practitioner must rely upon when everything else fails to direct or inform properly. Common sense was with us since we were created and will continue to be with us whether we acknowledge it or not. My common sense tells me that there are two valid responses to the above statements. Being in the wrong place at the wrong time is an appropriate answer and valid when we do not know exactly what we are doing and when we do not know all the answers. The comment on joint dysfunction being invalid as a contribution depends upon who did the testing, and the skill of the tester.
I offer just a few ideas to consider as alternatives to the previous points of view. There have to be many other points of view to consider, but I will offer the two points referred to as follows:
1) Vascular accidents could occur as a result simply from weakness of connective tissues. This is a big subject and is presently being addressed by credible authorities as a major or single major cause of disease. The issue involves strengthening connective tissues.
2) The second point involves my own little world and my own observation. Common sense tells me that the vertebral arteries are more vulnerable to damage and reaction if they are over-stretched. Common sense and logic would tell a practitioner that it is dangerous to over-stress a vulnerable area or structure. It is simply illogical to assume that adjusting a hypermobile C-1/C-2 joint is not more risky than adjusting a hypomobile C-1/C-2 joint complex. From a standpoint of common sense, logic, and experience from adjusting hypermobile regions, I have taken the position that it is dangerous to adjust hypermobile cervical joints, especially upper cervical levels; so, I would like to relate some of my experiences which would reveal some vulnerable and dangerous situations for any technique system. I would not point towards any system as being safe or dangerous because I have seen Activator, specific upper cervical, higher force and rotation techniques having created acute episodes of pain, discomfort, and disorder.
My position is to look for the most significant hypomobile joint restriction. I perform my motion palpation in the supine position, rather than seated. I can feel a lot more and can position joints at different angles for analysis more easily than sitting. Also, there is more relaxation for the patient. Next, I have found that there are some patterns associated with the population I treat. Just as I stated in my articles on SI dynamics, there appears to be a sidedness issue which is evident upon supine examination. The next point is that anterior fixations can masquerade as post fixations and open the door to danger. These are the big points, but it is easier for me to just list point by point the issues, observations, and thoughts regarding my experiences for your consideration, using supine relaxed examination:
1) There is sidedness pattern to most cases. Most lateral flexion restrictions (fixations) occur on the left side. Most posterior (LP) type fixations occur on the left, and most anterior fixations occur on the right. The C-6/C-7, C-7/T-1 fixations are almost totally left posterior and lateral flexion fixations. The right side may also palpate with lateral flexion fixations, but will be almost predominantly anterior. The C-5 through C-4 levels are usually not as involved in fixation patterns, being more hypermobile. The upper cervical levels of O/C-1, C-1/C-2 and C-2/C-3 are most frequently involved in heavy fixation patterns. Again, the left side is most often involved in lateral flexion fixations of C-1/C-2 and C-2/C-3. There are posterior (LP) type fixations on the left, usually at C-1/C-2 and C-2/C-3 levels, being anteriorly positioned or fixated on the right.
2) The next is a crucial one. Anterior fixations cause joint approximation (compression) and can be accompanied by intense pain, soreness, swelling, and reactive spasm. It can surely lead a static palpator to conclude that a posterior listing is present and requires adjusting. It can also lead a motion palpator to conclude that a fixation is present and requires adjustive correction. This is a danger to connective and vascular tissues.
I have fallen victim to this trap very often and still do when I get careless. When I fail, it is because I missed with my evaluation of this mechanism. The classical case is where the patient comes in with intense neck pain, left or right shoulder pain, headaches (especially over the eyes, above the eyes), suboccipital pain/spasm. Supine palpation reveals an atlas with a left posterior and lateral flexion restriction, and a right anterior listing. However, the right C-1 side can be most sore and resistant to left rotation. There is a muscular element preventing C-1 left rotation, even though a right anterior fix is present. The muscular reaction is covering a hypermobile right anterior C-1. The body is preventing further anterior C-1 movement by creating a muscular fixation. If you break it by adjusting anteriorly on the right, you stress the connective joints and vertebral arteries. The key is adjusting the left sided C-1/2 fixation, which will be much easier and usually less painful. Hooking the 2nd or 3rd finger on the anterior tissue of C-1 on the right will pull C-1 posteriorly on the right. Mild manual traction and ST work on the right will also ease the pain.
3) The C-1/C-2 left posterior and left lateral flexion restriction accompanied by right cervical pain, headaches (possible), C-2/C-3 swelling, pain, left rotation restriction, right C-1 anterior to posterior restriction: The clear, safe, and least painful way to go is to adjust C-1/C-2 properly on the left. The C-2/C-3 will be less of a restriction on the right. There is a C-2/C-3 anterior fixation and the corresponding posterior to anterior restriction. Sometimes a right sided rotation correction will do the trick and be the appropriate choice, because there will be an element of posterior to anterior restriction also. However, too often this right C-2/C-3 fixation is a muscular fixation and inflamed. It is truly hypermobile in rotation from right to left, but the muscular reaction is preventing movement. It gives the impression of being truly restricted in its rotation right to left, i.e., it appears to be "posterior." Adjustive intervention can be dangerous and embarrassing. It will not help your self-esteem to fail with these right masquerading posterior fixations.
4) The left C-1/C-2 anterior and left lateral flexion fixation with possible right side occipital swelling and soreness: Left rotation may or may not be blocked, but often C-1 left rotation is restricted. Palpation can reveal rotation and lateral flexion restriction left and right. The left side will most often be the most affected in lateral flexion restriction. There can be immense headaches. There is a masquerade present! The left anterior and lateral flexion restriction creates reflex muscle contraction. Also, the left anterior fix can look like a posterior fix on the left, especially if anterior fixations are not tested for. If not tested, this left anterior segment can be forced even farther anteriorly, stretching ligaments and vessels, if adjusted for left posterior rotation. What is needed is a left lateral flexion correction, followed by a rotation correction with the contact on the right C-1 TP or joint level. A tissue pull with the tip of your second or third finger anterior to the left C-1 simultaneously is also helpful. In some cases, the left anterior and lateral flexion restriction may not be what it appears to be, for another reason. If there is a severe left anterior position, left lateral flexion may be a protective mechanism. A left lateral flexion correction could aggravate the anterior compression and the body sets up a reactive lateral flexion guarding to prevent further left C-1/2 facet joint compression and tension. I occasionally experience failure in trying to first correct a left lateral flexion fix in the presence of an anterior fix.
These are just a few examples of situations which are misleading. They can make one create errors which negatively impact the patient and create adverse reactions. The possible exaggeration of anterior fixations is present, with the great possibility of stressing vertebral arteries. Anterior fixations seek anterior more easily and resist posterior motion. There is already too much stress to safely accommodate an adjustment. This is food for though and careful consideration. I do not believe I am isolated and the only practitioner to make careless or ill-informed decisions regarding adjusting. It leads me to conclude that our procedures for analysis must be more cautiously and meticulously performed to avoid unnecessary stress to connective tissues and specifically those associated with vascular tissues. Too much force during adjusting is one caution, exaggerating anterior fixation is another caution application to all technique systems.
5) Miscellaneous. I examine in all positions while testing the cervical spine. For example, I rotate, laterally bend, flex, and combine positions for examination of the cervical spine. Checking intersegment motion of the cervical spine is not a routine practice by most chiropractors. Some fixations will not show until flexion is utilized. Everything is done supine. A lot of hidden problems may show up during flexion testing. Also, I never adjust the neck in extension.
For the young and inexperienced practitioner, I have to relate what experienced doctors know. While in clinical studies in college, you are taught that radicular or radiating pain into the shoulders, arms and back must be from a brachial plexus disorder. You can so easily be well-educated and well-intentioned yet make the serious mistake of adjusting C-4, C-5, and C-6 levels, often hypermobile, yet neurologically related to symptoms. This can too often get you nowhere except to create confusion and stress to ligaments and vertebral arteries. Too often you would miss the upper cervical fixation patterns. When I was in school I could never understand why Dr. Gonstead spoke about the upper cervical subluxations and their effects of creating shoulder, arm, and wrist pain. What did that have to do with the branchial plexus? If you properly motion palpate, you will find C-1/C-2, C-2/C-3 hypomobile fixations leading to all varieties of radicular patterns. But, you do not get locked into believing that all radiating patterns are upper cervical patterns either. Just examine meticulously and consistently.
To the inexperienced and experienced practitioner, I can offer some advice based on my experiences with regard to reduced adjusting, right-sided symptoms, and soft tissue work. I have found it unnecessary to adjust both sides of the neck, as we are often taught in order to balance the work. Most of my adjustments are on the left. Sometimes however, I do nothing on the left and only adjust the right side. Sometimes both sides are adjusted. One level on one side and another level on the other side may be done. In a case of left C-1 adjusting and no right sided adjusting, with right sided pain, I will incorporate manual distraction supine at the level of distraction fixation, often contacting C-2 level. This is followed by soft tissue treatment. I may use mild myofascial massage, electrotherapy, and/or ultrasound (pulsed on continuous). If the patient wants to be adjusted on both sides, but does not need it, you may have to do some soft tissue work to get needed relief.
Unrelated to the previous discussion is the issue of soft tissue evaluation and treatment. Cervical chronicity can be related to irregularities in muscle function, especially the upper trapezius and levator scapula. Radicular patterns which appear to be cervical in origin may be created by (often are) the infraspinatus, teres major and minor, and arm extensors. Inflammation in these muscles or dysfunction of some types can lead to radicular patterns. I complete my spinal exams with DSR soft tissue exams to locate contributors to symptoms and tissue inflammation.
I hope my perceptions, opinions, and suggestions are meaningful and helpful.
Joseph Kurnik, DC
2275 W. Torrance Blvd.
Torrance, California
Dr. Joseph Kurnik practices in Torrance, Calif. He is a former columnist and longtime contributor to DC; previous articles are available online at www.dynamicchiropractic.com.