UPPER CERVICAL TECHNIQUES

Orthospinology Upper Cervical

Reprinted with the permission of Dr. Kirk Eriksen, D.C.; President of the Society of Chiropractic
Orthospinology. www.orthospinology.org

In order to do justice to Dr. Eriksen’s work I provide herein the unedited paper
as provided to me by him. In this paper he summarises the orthogonal
approach to upper cervical analysis, correction, puts forward some theories as
to the casual mechanisms of ill health and provides a rich list of references for
further reading. The evidence that ‘specific’ upper cervical chiropractic is effective in promoting
wellness is compelling and widespread. You need only look for it.

POSITION PAPER FOR ORTHOGONALLY-BASED

UPPER CERVICAL CHIROPRACTIC CARE

By Kirk Eriksen, D.C.

Definition

First, I would like to provide a definition for orthogonally-based upper

cervical chiropractic care as follows: A method for analyzing and
correcting the occipito-atlanto-axial subluxation complex. It is actually a
series of steps in the total care of the patient and is therefore a
chiropractic procedure and not simply a spinal adjusting technique. The
procedure employs a method of X-ray analysis that quantifies the
lateral and rotational misalignments between atlas and axis as well as atlas and occiput. The
analytical procedure examines the spatial orientation of the atlas, the geometry of the
articulating surfaces, and the misalignment configuration to arrive at an effective correction
vector. In addition to the X-ray analysis, the system contains steps for ensuring the precision of
the X-ray analysis, adjusting procedures, and post-adjustment re-evaluation procedures. These
procedures allow the doctor to assess the effectiveness of the adjustment and, equally
important, to fine-tune the adjustment to the individual patient. The adjustment can be
administered manually or by using an adjusting instrument. The hand delivered adjustment
involves a light contact and a shallow thrust. The contact point, the pisiform, usually travels less
than 3/16" during the thrust. Many doctors utilize a hand-held solenoid-powered instrument to
deliver a very quick and shallow thrust, or various forms of table-mounted instruments.

Anatomy/Biomechanics

A thorough understanding of the anatomy, biomechanics and neurophysiology of the upper

cervical spine is a prerequisite to be able to appreciate the clinical manifestations of the occipito-
atlanto-axial subluxation complex. White and Panjabi describe the upper cervical articulations as
“…the most complex joints of the axial skeleton, both anatomically and kinematically.”1 The two
upper cervical vertebrae differ in shape and function from the remainder of the spine. The
configuration of the atlanto(C1) and axial(C2) joints, enables these structures to carry the
head and determine its movement. These articulations also provide protection for the intimate
neurologic and vascular structures. The atlas and axis are two of the nine atypical vertebrae.
The atlas articulation is diarthrodial and is the most freely movable segment in the spine, in
relation to C1-C2 rotation and C0-C1 flexion/extension. The occipito(C0)-C1 articulation consists
of reciprocally curved superior facets of the lateral masses of the atlas and the ellipsoid synovial
joints of the occipital condyles. This articulation allows for primarily flexion-extension motion,
with very little rotation or lateral flexion. The atlas vertebra has a condyloid articulation with the
axis that allows for 45-50% of rotation in the cervical spine, but the consensus of the studies
show that little motion occurs between the atlas and occiput. The small amount of movement
that does occur is found at the end point of the range of motion. This is a critical point when
discussion is made about the misalignment component of the subluxation.

Neurology

The neurological dysfunction related to the upper cervical subluxation can be explained by a few
different mechanisms. However, it is likely that these mechanisms manifest concurrently in
many patients. The two most plausible hypotheses have to do with spinal cord tension and
mechanoreceptive dysafferentation. The upper cervical spinal cord is directly attached to the
circumference of the foramen magnum, to the second and third cervical vertebrae and by
fibrous slips to the posterior longitudinal ligament.2 Hinson3, Grostic4 and others discuss
dissection evidence showing a dural attachment at the atlas level. The uppermost denticulate
ligaments are arranged almost horizontally, as compared to the inferiorly angled ligaments
found around the rest of spinal cord. The most cephalad ligaments are also thicker and stronger
to help anchor the spinal cord around the foramen magnum. These ligaments are so strong that
they have been found to sever the upper cervical spinal cord in some cases of hydrocephalus.5
Recent studies have also revealed a connective tissue bridge between the rectus capitis
posterior minor muscle and the dura mater of the upper cervical spinal cord.6 A similar
attachment has also been found to the spinal cord via the ligamentum nuchae.7 The spinal dura
mater has been found to be innervated and a possible source of pain and neurological
dysfunction.8,9 These anatomical facts, as well as the biomechanical descriptions covered
previously, reveal that the upper cervical spine is quite susceptible to injury and/or the entity
called subluxation. The upper cervical spine has sacrificed stability for mobility as evidenced by
~50% of cervical rotation occurring between the atlanto-axial articulation. Grostic’s paper, The
Dentate Ligament—Cord Distortion Hypothesis4, provides a compelling hypothesis for how
these anatomical connections can lead to spinal cord distortion, in the presence of upper
cervical misalignment. It is posited that the neurological dysfunction can occur via two
mechanisms: 1) direct mechanical irritation of the nerves of the spinal cord, and/or 2) collapse of
the small veins of the cord, producing venular congestion with a loss of nutrients necessary to
carry on the high energy reactions necessary for nerve conduction. Spinal cord tension can
affect the spinocerebellar tracts which can result in a functional short leg.

Afferent/efferent joint mechanoreceptive neurology also has interesting implications in this area
of the spine. Mechanoreceptive innervation has been found in the cervical facet joints,
ligaments, intervertebral discs.10-13 The muscle spindle may be the most important
proprioceptive receptor in the upper cervical spine. The spindles are intrafusal fibers that are
imbedded within all muscles of the body; however, they are extremely dense in the suboccipital
muscles.14-20 The human experience is governed by receptors of all types. Cerebral cortical
firing initiates efferent activity. However, the thalamus regulates the cerebral cortex through
summation and integration. Another key point is that all sensory information goes through the
thalamus (except aspects of olfaction).21 It is apparent how these two functions are vitally
important for neurological integrity and appropriate cortical representation. Mechanoreception is
the primary input into the cerebellum due to life in a gravity environment. The primary load to the
thalamus is via the cerebellum due to the vast amount of afferent input required to maintain
upright posture. It is plausible to theorize that stimulating or regulating mechanoreceptors can
have a significant impact on the neurological activity of the brain and many bodily functions.

It appears that the cervical spine has more mechanoreceptors per surface area than any other
region of the spinal column.22 It is thought that the upper cervical articulations have the greatest
amount or receptors in the cervical spine. This may give the region the greatest potential for
spinal mechanoreceptive afferentation into the neuraxis. There is also evidence suggesting that
the upper cervical afferents feed directly into the vestibular and other high order nuclei.23-32 This
enables a less modified input of information from the upper cervical articulations into the brain
stem nuclei, as opposed to the lower segments of the spine. Inappropriate afferentation (i.e.
subluxation) and appropriate input (subluxation correction) into the vestibular nuclei is yet
another plausible explanation for the functional short leg/pelvic distortion that is observed
clinically with patients under upper cervical chiropractic care. This can occur by way of upper
cervical mechanoreceptive functional integrity through the anterior and posterior spinal
cerebellar tracts, cerebellum, vestibular nuclei, descending medial longitudinal fasciculus
(medial and lateral vestibular spinal tracts), regulatory anterior horn cell pathway which affects
postural motor tone.

X-ray Assessment

The X-ray analysis is the real core of upper cervical procedures. Because the radiological
assessment is so important, early developers, such as Dr. John Francis Grostic, felt that
chiropractors should always lead the way in X-ray quality and patient safety. He was the first in
the profession to advocate and teach doctors the use of aligned X-ray equipment. He
collaborated with Travis Utterback to help develop self-centering head clamps, the X-ray turn-
table chair and "L-Frame" apparatus. Many X-ray equipment setups (such as my own) are
installed with the utilization of laser alignment to ensure precision. The issue of X-ray safety is
addressed with the utilization of lead filters, high film/screen speed combinations, shielding and
high kVp technique by many doctors who utilize upper cervical procedures. The use of lead
filters has been shown to reduce radiation to the patient by as much as 80-90%.33-34 Increasing
film screen speed from 250 to 800 can also reduce the milliamperage per second (mas) setting
by almost 70%, while not sacrificing image quality to any clinical significance.35

The radiological assessment provides a quantitative analysis as opposed to only qualitative

information. This makes it possible to determine if the care is actually reducing the subluxation,
or if it is just moving the structures around with no net correction. Thus, quantification of the
misalignment provides a means of evaluating the effectiveness of the adjustment. Orthogonally-
based procedures utilize several measurements from the X-rays to calculate the correction
vector used in the adjustment. The films are analyzed with manual template analysis and/or
computer-aided digitization. By using this information, the goal is to compute a correction vector
which will reduce all of the misalignment factors proportionately. In essence, the Procedure
enables the doctor to provide a "tailor-made" adjustment.

It should be noted that the upper cervical X-ray analysis involves angular measurements of the
atlas in the frontal (Z), sagittal (X) and transverse (Y) planes. Angular measurements in degrees
are utilized, as this analysis is less prone to magnification errors in comparison to linear
measurements. Inter- and intra-examiner reliability in the marking and reading of the films has
been demonstrated and reveals error of only <.6o and <.5o, respectively.36-39 Rochester and
Owens have studied the issue of patient placement and the potential distortion errors that can
take place in the measurement of upper cervical X-rays.40 Patient-to-film error can occur if head
rotation is present when the film is taken. According to their study, the distortion is insignificant
in most all cases seen in clinical practice. The study involved the development of a
computerized algorithm, with the utilization of a three-dimensional computerized model of the
cervical spine and head, as well as the measurement of X-rays from a clinical practice. Other
potential errors include human measurement that can occur when the doctor draws lines on the
X-rays and measures the deviations. He/she could either measure or record it incorrectly. This
potential error has been greatly decreased with the development of computerized digitization
programs. The previous reliability study by Rochester tested the DOC! program and revealed
that it was as good as, if not superior to, manual analysis.

Post X-ray Assessment

Two large studies (n=45841 and n=20042) found that in these orthogonally-based practices, the
more the subluxation was reduced, the better the patient outcome. The study by Eriksen and
Owens determined this by measuring patient rating of symptoms as well as number of visits and
adjustments necessary. This study concluded that post X-ray assessment was recommended to
ascertain that at least 50% correction was achieved after the initial adjustment. Post X-ray
assessment is also important to determine if an errant adjustment occurs; and provides
information for the doctor to make the appropriate correction(s) for future adjustments. A series
of case studies have been published which found that significant errors in upper cervical
adjusting caused temporary iatrogenic symptomatic reactions in unsuspecting patients.43 This is
an important finding since many believe that the upper cervical adjustment is innocuous since
very little force, if any, is actually felt by the patient. This type of adjustment is too gentle to
“injure” the patient, but osseous structure is realigned and the central nervous system is affected
in the process. The “seasoned” doctor understands that the true tragedy is not correcting the
subluxation so the patient can experience neurological integrity, as opposed to temporarily
increasing the misalignment. A single reported case revealed a patient’s upper cervical
subluxation being reduced significantly after a NUCCA upper cervical adjustment.44 The patient
was then sent to a practitioner who utilized diversified/ Maitland manipulation. The patient was
once again X-rayed, which revealed that the misalignments had increased more than the
original subluxation. Fortunately, the patient was re-adjusted by the NUCCA doctor and the
subluxation was reduced once again.

Studies have revealed that the radiographic measurement of misalignment between the occiput
and atlas is not affected when the head is placed, up to a certain degree, in off-centered
positions.45-47 However, this does not indicate that X-ray placement is not important, as it can
cause errors in other measurement parameters. A study by Jackson et al.48 involved 38 subjects
who had two sets of anterior to posterior nasium and lateral cervical radiographs. The second
set of X-rays was taken from one-half to four hours after the initial set. No chiropractic
adjustment was administered between radiographs, although a simulated adjustment was
conducted. The analyzed data revealed a reliability measurement of one-half degree for the
upper angle and two-thirds of a degree for the lower angle. This study helps to further establish
that the upper cervical misalignments that are measured on precision X-rays are static and that
post adjustment radiography is a valid outcome assessment. One study has shown that barring
trauma, an upper cervical misalignment pattern in a patient with signs of subluxation tends to be
static (although the magnitude of the misalignment tends to decrease over time when the patient
becomes subluxated).49 In other words, the upper cervical spine does not move around freely
finding a new position each time the patient is radiographed. It appears that the reduction of the
misalignment post adjustment is due to something other than patient placement. These reasons,
taken together, explain why upper cervical protocol calls for X-ray assessment of misalignment
factors in an occipito-atlanto-axial subluxation.

Postural Distortion

Upper cervical subluxations manifest clinically in various forms of postural distortion (i.e.
functional leg length inequality, pelvic distortion, head and shoulder tilt, head translation,
unequal weight distribution, etc.). The functional leg check is an outcome assessment utilized by
most all upper cervical doctors on a visit-by-visit basis. It is my opinion that functional pelvic
distortion (FPD) is a more accurate term; for what the doctor is actually measuring is muscle
tone and resultant pelvic imbalance, instead of only leg length. Functional pelvic distortion
contrasts with anisomelia, which is an anatomical short leg. Leg length inequality (LLI) often has
a different significance to various physicians. For some, this condition is thought to have no
importance until the inequality is ½” or greater.50 To the other extreme, many authors feel that a
difference of just a few millimeters is significant for various musculoskeletal complaints.51-59 LLI
has been related to lower back pain60-68, disc/joint degeneration54,60,65,69-75, an increased
susceptibility to sports injuries and potential improved performance71,76-84, an association with
scoliosis58,69,74,75,85-93, and its effect on bilateral weight deviation.94-99 Preliminary data have been
published showing very high intra- and inter-reliability for the supine leg check assessment.100
Moderate reliability has been assessed for the prone leg check.101-103 Pilot studies on pre- and
post-assessment of FPD after an upper cervical adjustment have been conducted104-106, with
larger validity studies planned for the future.
A blinded single case study did show a statistically significant correlation between an objective
measure and the FPD test for when an adjustment was indicated.107 Another case study
involved atlanto-occipital intra-articular injection that moderated postural distortion.108 Another
study also revealed postural changes occurring in subjects after undergoing upper cervical
care.109 Two studies have shown statistically significant changes in right and left weight bearing
pre- and post- upper cervical adjustment.95,96 In addition, there are reports of relief of low back
and leg pain110-127, knee pain128 and idiopathic scoliosis129,1130 with the utilization of upper
cervical specific care. This implies, but does not prove, a causal link between global postural
distortion and upper cervical chiropractic care.

Outcome Assessments

Other outcome assessments that have been studied in clinical and research settings with
specific upper cervical chiropractic care include the following: thermocouple scanning131-134,
surface electromyography105,106,135, somatosensory evoked potentials136-141, static palpation142-144
and range of motion.145 Palpatory and other methods of determining upper cervical
misalignments and asymmetry have not been shown to be reliable.143,144,146,147 There is also
research that reveals how non-radiographic methods of determining upper cervical subluxation
listings have poor concordance when compared to X-ray analysis.146,148 The motion of the upper
cervical spine is quite complicated, capable of excursion into the x, y and z planes. The X-ray
procedure provides the information for the appropriate direction or vector to adjust the patient.

Studies on Patient Efficacy

Orthogonally-based upper cervical care is not a treatment for conditions or diseases, however,
this subluxation-centered care has been shown to have an associative effect on various
conditions. The following is a review of the peer-reviewed literature that shows a documented
correlation between orthogonally-based care (Grostic/ Orthospinology, NUCCA and Atlas
Orthogonality) and the improvement of various patient complaints. Studies have been published
showing positive outcome for patients with cervical curve distortion153,154, neck pain155-1156,
cervicobrachialgia157,158, motor vehicle trauma159, headaches160-161, low back pain110-116,
scoliosis129, postural distortion95,96,108, knee pain128, general health enhancement158-160, cerebral
palsy161, autism162, Tourette’s syndrome163, seizure disorders164, mental dysfunction165, multiple
sclerosis166, Arnold-Chiari malformation167, HIV168, cystic hygroma169, asthma170, bowel
dysfunction171-172 and hypertension.173-174 The previous papers involve various levels of scientific
evidence which range from case studies to randomized controlled clinical trials.

Conclusion

This paper has provided a compelling and cogent argument for the clinical and scientific efficacy
of orthogonally-based upper cervical chiropractic care. There is a logical chain of arguments that
support specific upper cervical work. This chain is supported by some evidence at each link,
with the evidence for some aspects being stronger than others. Given the anatomical,
biomechanical and neurological complexity of the upper cervical spine, specific upper cervical
work is an appropriate approach to adjust the upper cervical subluxation.

References
1. White AA, Panjabi MM. Clinical Biomechanics of the Spine. Philadelphia: JB Lippincott, 1978.
th
2. Warwick R, Williams PL, editors. Gray’s Anatomy, 35 British Edition. W.B. Saunders Co., 1973.
th
3. Hinson R, Zeng ZB. Epidural Attachments in the Upper Cervical Spine. Abstracts From The 15
Annual Upper Cervical Spine Conference, November 21-22, 1998, Chiropr Res J, 1999; 6(1):31-32.
4. Grostic JD. Dentate Ligament — Cord Distortion Hypothesis. Chiropr Res J, 1988; 1(1):47-55.
5. Emery JL. Kinking of the Medulla in Children with Acute Cerebral Oedema and Hydrocephalus and its
Relationship to the Dentate Ligaments. J Neurol Neurosurg Psychiat, 1967; 30(3):267-275.
6. Hack GD, Koritzer RT, Robinson WL, Hallgren RC, Greenman PE. Anatomic Relation Between the
Rectus Capitis Posterior Minor Muscle and the Dura Mater. Spine, 1995; 20(23):2484-2486.
7. Mitchell BS, Humphreys BK, O’Sullivan E. Attachments of the Ligamentum Nuchae to Cervical
Posterior Spinal Dura and the Lateral Part of the Occipital Bone. J Manipulative Physiol Ther,
1998; 21(3): 145-148.
8. Groen GJ, Baljet Drukker J. The Innervation of the Spinal Dura Mater: Anatomy and Clinical
Implications. Acta Neurochir (Wien), 1988; 92(1-4):39-46.
9. Kumar R, Berger RJ, Dunsker SB, Keller JT. Innervation of the Spinal Dura, Myth or Reality? Spine,
1996; 21(1):18-26.
10. McLain RF. Mechanoreceptor Endings in Human Cervical Facet Joints. Spine, 1994; 19(5): 495-501.
11. Jiang H, Russell G, Raso J, Moreau MJ, Hill DI, Bagnall KM. The Nature and Distribution of the
Innervation of Human Supraspinal and Interspinal Ligaments. Spine, 1995; 20(8):869-876.
12. Roberts S, Eisenstein SM, Menage J, Evans EH, Ashton IK. Mechanoreceptors in Intervertebral
Discs, Morphology, Distribution, and Neuropeptides. Spine, 1995; 20(24): 2645-2651.
13. Mendel T, Wink CS, Zimny ML. Neural Elements in Human Cervical Intervertebral Discs. Spine,
1992; 17(2):132-135.
14. Cooper S, Daniel PM. Muscle Spindles in Man; Their Morphology in the Lumbricals and the Deep
Muscles of the Neck. Brain, 1963; 86:563-587.
15. Richmond FJ, Abrahams VC. Morphology and Distribution of Muscle Spindles in Dorsal Muscles of
the Cat Neck. J Neurophysiol, 1975; 38(6):1322-1339.
16. Richmond FJR, Abrahams VC. Physiological Properties of Muscle Spindles in Dorsal Neck Muscles
of the Cat. J Neurophysiol, 1979; 42(2):604-617.
17. Abrahams VC. Sensory and Motor Specialization in Some Muscles of the Neck. Trends Neuro Sci,
January 1981:22-27.
18. Richmond FJR, Bakker DA. Anatomical Organization and Sensory Receptor Content of Soft Tissues
Surrounding Upper Cervical Vertebrae in the Cat. J Neurophysiol, 1982; 48(1):49-61.
19. Bakker DA, Richmond FJR. Muscle Spindle Complexes in Muscles Around Upper Cervical Vertebrae
in the Cat. J Neurophysiol, 1982; 48(1):62-74.
20. Kulkarni V, Chandy MJ, Babu KS. Quantitative Study of Muscle Spindles in Suboccipital Muscles of
Human Foetuses. Neurol India, 2001; 49(4):355-359.
21. Guyton A. Basic Neuroscience. Saunders, 1991.
22. McLain RF, Pickar JG. Mechanoreceptor Endings in Human Thoracic and Lumbar Facet Joints.
Spine, 1998; 23(2):168-173.
23. Fitz-Ritson DE. The Direct Connections of the C2 Dorsal Ganglion in the Brain Stem of the Squirrel
Monkey: A Preliminary Investigation. J Can Chiropr Assoc, 1979; 23(4):131-138.
24. Brink EE, Hirai N, Wilson VJ. Influence of Neck Afferents on Vestibular Neurons. Exp Brain Res,
1980; 38:285-292.
25. Boyle R, Pompeiano O. Convergence and Interaction of Neck and Macular Vestibular Inputs on
Vestibulospinal Neurons. J Neurophysiol, 1981; 45(5):852-868.
26. Reker U. Function of Proprioceptors of the Cervical Spine in the Cervico-Ocular Reflex. HNO, 1985;
33(9):426-429.
27. Edney DP, Porter JD. Neck Muscle Afferent Projections to the Brainstem of the Monkey: Implications
for the Neural Control of Gaze. J Comp Neurol, 1986; 250(3):389-398.
28. Neuhuber WL, Zenker W. Central Distribution of Cervical Primary Afferents in the Rat, with Emphasis
on Proprioceptive Projections to Vestibular, Perihypoglossal, and Upper Thoracic Spinal Nuclei. J
Comp Neurol, 1989; 280(2):231-253.
29. Bankoul S, Neuhuber WL. A Cervical Primary Afferent Input to Vestibular Nuclei as Demonstrated by
Retrograde Transport of Wheat Germ Agglutinin-Horseradis Peroxidase in the Rat. Exp Brain Res,
1990; 79:405-411.
30. Bolton PS, Tracey DJ. Neurons in the Dorsal Column Nuclei of the Rat Respond to Stimulation of
Neck Mechanoreceptors and Project to the Thalamus. Brain Res, 1992; 595(1):175-179.
31. Boniver R. Whiplash Effects on the Hypothalamus and Sympathetic System. In: Cesarani. Whiplash
Injuries. Diagnosis and Treatment, Springer-Verlag, 1996:59-63.
32. Neuhuber WL. Characteristics of the Innervation of the Head and Neck. Orthopade, 1998;
27(12):794-801.
33. Dickholtz M. Comments and Concerns Re X-ray Radiation (A Guide For Upper Cervical X-ray).
Upper Cervical Monograph, 1989; 4(8):7-9.
34. Grostic JD. The Grostic Procedure. Today’s Chiropr, 1987; 16(3):51-52.
35. Hellstrom G, Irstam L, Nachemson A. Reduction of Radiation in Radiologic Examination of Patients
with Scoliosis. Spine, 1983; 8(1):28-30.
36. Rochester RP. Inter and Intra-Examiner Reliability of the Upper Cervical X-ray Marking System: A
Third and Expanded Look. Chiropr Res J, 1994; 3(1):23-31.
37. Jackson BL, Barker W, Bentz J, Gambale AG. Inter- and Intra-Examiner Reliability of the Upper
Cervical X-ray Marking System: A Second Look. J Manipulative Physiol Ther, 1987; 10(4): 157-163.
38. Jackson BL, Barker WF, Gambale AG. Reliability of the Upper Cervical X-ray Marking System: A
Replication Study. J Clin Invest Res, 1988; 1(1):10-13.
39. Seemann DC. A Reliability Study Using a Positive Nasium to Establish Laterality. Upper Cervical
Monograph, 1994; 5(4):7-8.
40. Rochester RP, Owens EF. Patient Placement Error in Rotation and Its Affect on the Upper Cervical
Measuring System. Chiropr Res J, 1996; 3(2):40-53.
41. Eriksen K, Owens EF. Upper Cervical Post X-ray Reduction and Its Relationship to Symptomatic
Improvement and Spinal Stability. Chiropr Res J, 1997; 4(1):10-17.
42. Gregory RR. Mechanical and Manual Adjusting: A Comparison. Upper Cervical Monograph, 1983;
3(6):1-2.
43. Knutson GA. Case Studies of Upper Cervical Adjusting Errors: The Possibility of Chiropractic
Iatrogenesis. Chiropr Res J, 1996; 3(3):20-24.
44. Kukurin GW. Chiropractic and Spinal Manipulative Therapy: A Critical Review of the Literature. Am
Chiropr Assoc J Chiropr, 1985; 22(6):41-49.
45. Seemann DC, Gregory RR. A Critique of a Critique of Vectored Adjusting. Upper Cervical
Monograph, 1981; 3(1):8-9.
46. Seemann DC, Dickholtz M. Range of Motion at the Atlanto-Occipital Joint: Lateral Flexion and Side
Slip. Eleventh Annual Upper Cervical Spine Conference, Life College, Marietta, Georgia, 1995.
47. Hart JF. Effect of Patient Positioning on an Upper Cervical X-ray Listing: A Case Study. J Chiropr
Res, 1988; 5(1):19-21.
48. Jackson BL, Barker WF, Pettibon BR, Woggon D, Bentz J, Hamilton D, Weigand M, Hester R.
Reliability of the Pettibon Patient Positioning System for Radiographic Production. J Vertebral
Subluxation Res, 2000; 4(1):3-11.
49. Palmer T, Denton K, Palmer J. A Clinical Investigation Into Upper-Cervical Biomechanical Stability:
Part I. Upper Cervical Monograph, 1990; 4(10):2-7.
50. Woerman AL, Binder-Macleod A. Leg Length Discrepancy Assessment: Accuracy and Precision in
Five Clinical Methods of Evaluation. J Orthop Sports Phys Ther, 1984; 5:230-239.
51. Nichols PJR. The Short Leg Syndrome. Br Med J, 1960; 1:1863.
52. Ingelmark BE, Lindstrom J. Asymmetries of the Lower Extremities and Pelvis and Their Relations to
Lumbar Scoliosis. Acta Morpho Neerl Scand, 1963; 5: 221-234.
53. Leading Article: Short Leg Syndrome. Br Med J, 1971; 1:245.
54. Gofton JP. Studies in Osteoarthrosis of Hip and Leg Length Disparity. Can Med Assoc, 1971;
104:791-799.
55. Beal MC. The Short-Leg Problem. J Am Osteopathic Assoc, 1977; 76(10):745-751.
56. Heilig D. Principle of Lift Therapy. J Am Osteopathic Assoc, 1978; 77(6):466-472.
57. Peter J. Short Leg and Sciatica. J Am Med Assoc, 1979; 42(11): 1257-1258.
58. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol I.
Baltimore, Williams Wilkins, 1983.
59. Kujala UM, Kvist M, Osterman K, Friberg O, Aalto T. Factors Predisposing Army Conscripts to Knee
Extension Injuries Incurred in a Physical Training Program. Clin Orthop, 1986; 210:203-212.
60. Friberg O. Clinical Symptoms and Biomechanics of Lumbar Spine and Hip Joint in Leg Length
Inequality. Spine, 1983; 8(6):643-650.
61. Sicuranza BJ, Richards J, Tisdall LH. The Short Leg Syndrome in Obstetrics and Gynecology. Am J
Obstet Gynecol, 1970; 107(2):217-219.
62. Giles LGF, Taylor JR. Low-Back Pain Associated with Leg Length Inequality. Spine, 1981; 6(5):510-
519.
63. Gofton P. Persistent Low Back Pain and Leg length Disparity. J Rheumatol, 1985; 12(4): 747-750.
64. Helliwell M. Leg Length Inequality and Low Back Pain. The Practitioner, 1985; 229(1403): 483-485.
65. Rothenberg RJ. Rheumatic Disease Aspects of Leg Length Inequality. Semin Arthritis Rheum,
1988; 17(3):196-205.
66. Steen H, Terjesen T, Bjerkreim I. Anisomelia. Clinical Consequences and Treatment. Tidsskr Nor
Laegeforen, 1997; 117(11):1595-1600.
67. Strait BW. Case History. Chief Complaint: Pain in the Left Hip, Leg, and Low Back. AAO J, 1998;
8(2):11-12.
68. Redler I. Clinical Significance of Minor Inequalities in Leg Length. New Orleans Med Surg J, 1952;
104:308-312.
69. Friberg O. The Statics of Postural Pelvic Tilt Scoliosis: A Radiographic Study on 288 Consecutive
Chronic LBP Patients. Clin Biomechanics, 1987; 2:211-219.
70. Beaudoin L, Zabjek KF, Leroux MA, Coillard C, Rivard CH. Acute Systematic and Variable Postural
Adaptations Induced by an Orthopaedic Shoe Lift in Control Subjects. Eur Spine J, 1999; 8(1):40-45.
71. McCaw ST, Bates BT. Biomechanical Implications of Mild Leg Length Inequality. Br J Sp Med, 1991;
25(1):10-13.
72. Cummings G, Scholz JP, Barnes K. The Effect of Imposed Leg Length Difference on Pelvic Bone
Symmetry. Spine, 1993; 18(3):368-373.
73. Hung SC, Kurokawa T, Nakamura K, Matsushita T, Shiro R, Okazaki H. Narrowing of the Joint Space
of the Hip After Traumatic Shortening of the Femur. J Bone Joint Surg[Br], 1996; 78(5):718-721.
74. Giles LGF, Taylor JR. The Effect of Postural Scoliosis on Lumbar Apophyseal Joints. Scand J
Rheumatology, 1984; 13(3):209-220.
75. Clarke GR. Unequal Leg Length: An Accurate Method of Detection and Some Clinical Results.
Rheum Phys Med, 1972; 11(8):385-390.
76. McCaw ST. Leg Length Inequality, Implications for Running Injury Prevention. Sports Med, 1992;
14(6):422-429.
77. Bailey HW. Theoretical Significance of Postural Imbalance, Especially the “Short Leg”. J Am
Ostopathic Assoc, 1978; 77(6):452-455.
78. Bolz S, Davies GJ. Leg Length Differences and Correlation with Total Leg Strength. J Orthop Sports
Physical Therapy, 1984; 6(2):123-130.
79. Bone T, Hammons RR. Acute Leg Length Discrepancy Causes Increased VO2. Gait & Posture,
1996; 4:108-111.
80. Shambaugh JP, Klein A, Herbert JH. Structural Measures as Predictors of Injury in Basketball
Players. Medicine and Science in Sports and Exercise, 1991; 23(5):522-527.
81. Glymph ID. Investigating the Effect of Upper Cervical Adjustment on Cycling Performance. Vector,
1999;2(4).
82. Kujala UM, Osterman K, Kvist M, Aalto T, Friberg O. Factors Predisposing to Patellar Chondropathy
and Patellar Apicitis in Athletes. Int Orthop, 1986; 10(3):195-200.
83. Kujala UM, Friberg O, Aalto T, Kvist M, Osterman K. Lower Limb Asymmetry and Patellofemoral Joint
Incongruence in the Etiology of Knee Exertion Injuries in Athletes. Int J Sports Med, 1987; 8(3):214-
220.
84. Friberg O, Kvist M. Factors Determining the Preference of Takeoff Leg in Jumping. Int J Sports Med,
1988; 9(5):349-352.
85. Papaioannou T, Stokes I, Kenwright J. Scoliosis Associated With Limb-Length Inequality. J Bone
Joint Surg[Am], 1982; 64(1):59-62.
86. Gibson PH, Papaioannou T, Kenwright J. The Influence on the Spine of Leg-Length Discrepancy
After Femoral Fracture. J Bone Joint Surg[Br], 1983; 65(5):584-587.
87. Walker AP, Dickson RA. School Screening and Pelvic Tilt Scoliosis. Lancet, 1984; 2(8395): 152-153.
88. Manganiello A. Radiologic findings in idiopathic scoliosis. Etiopathogenetic interpretation. Radiol Med
(Torino), 1987; 73(4):271-276.
89. Hoikka V, Ylikoski M, Tallroth K. Leg-Length Inequality has Poor Correlation with Lumbar Scoliosis, A
Radiological Study of 100 Patients with Chronic Low-Back Pain. Arch Orthop Trauma Surg, 1989;
108(3):173-175.
90. Specht DL, DeBoer KF. Anatomical Leg Length Inequality, Scoliosis and Lordotic Curve in
Unselected Clinic Patients. J Manipulative Physiol Ther, 1991; 14(6):368-375.
91. Potrafki B. Orthopadische Erkrankungren im Kindesalter und ihre Biologische Therapie. Biologische
Medizin, 1994; 23(6):335-340.
92. Borenstein DG, Wiesel SW, Boden SD. Low Back Pain, Medical Diagnosis and Comprehensive
Management, W.B. Saunders Co., 1995:216.
93. Morrissy RT, Weinstein SL, eds. Pediatric Orthopaedics, Volume II, Fourth Edition. Lippincott-
Raven Publishers, 1996:635.
94. Lawrence D. Lateralization of Weight in the Presence of Structural Short Leg: A Preliminary Report. J
Manipulative Physiol Ther, 1984; 7(2):105-108.
95. Seemann DC. Bilateral Weight Differential and Functional Short Leg: An Analysis of Pre and Post
Data after Reduction of an Atlas Subluxation. Chiropr Res J, 1993; 2(3):33-38.
96. Seemann DC. Anatometer Measurements: A Field Study Intra- and Inter-Examiner Reliability and Pre
to Post Changes Following an Atlas Adjustment. Chiropr Res J, 1999; 6(1):7-9.
97. Seemann D. A Comparison of Weight Differential Between a Group That Had a History of Spinal
Problems or Had Been Under Care and a Group That Had Neither a History of Spinal Problems nor
Been Under Care. Upper Cervical Monograph, 1991; 5(2):17-19.
98. Hoiriis KT, Hinson R, Elsangek O, Brown S, Verzosa GT, Burd D. Baseline Characteristics of
Chiropractic Patients, Correlation of Anatometer Readings with Supine Leg-Length Inequality. J
Chiropr Education, 2000; 14(1):8.
99. Mahar RK, MacLeod DA. Simulated Leg-Length Discrepancy: Its Effect on Mean Center-of-Pressure
Position and Postural Sway. Arch Phys Med Rehabil, 1985; 66(12):822-824.
100.Hinson R, Brown SH. Supine Leg Length Differential Estimation: An Inter- and Intra-
Examiner Reliability Study. Chiropr Res J, 1998; 5(1):17-22.
101.DeBoer KF, Harmon RO, Savoie S, Tuttle CD. Inter- and Intra-Examiner Reliability of Leg-
Length Differential Measurement: A Preliminary Study. J Manipulative Physiol Ther,
1983; 6(2): 61-66.
102.Fuhr AW, Osterbauer PJ. Interexaminer Reliability of Relative Leg-Length Evaluations in
the Prone, Extended Position. Chiropr Technique, 1989; 1(1):13-18.
103.Nguyen HT, Resnick DN, Caldwell SG, Elston EW, Bishop BB, Steinhouser JB, Gimmillaro
TJ, Keating JC. Interexaminer Reliability of Activator Methods’ Relative Leg-Length
Evaluation in the Prone Extended Position. J Manipulative Physiol Ther, 1999; 22(9):565-
569.
104.Hinson R, Pfleger B. Pre- and Postadjustment Supine Leg-Length Estimation. J Chiropr
Education, 2000; 14(1):37-38.
105.Eriksen K, James KA. Pilot Study: Electromyography, Temperature Differential Device,
Supine Leg Length Deficiency and Their Correlation with the Occipito-Atlanto-Axial
Subluxation Complex. Eleventh Annual Upper Cervical Spine Conference, Life College,
1994.
106.Eriksen K, James KA. A Randomized Controlled Double Blind Study of Specific Upper
Cervical Chiropractic Care. Twelfth Annual Upper Cervical Conference, Life College,
Marietta, GA, November 18-19, 1995.
107.Knutson GA. Thermal Asymmetry of the Upper Extremity in Scalenus Anticus Syndrome,
Leg-Length Inequality and Response to Chiropractic Adjustment. J Manipulative Physiol
Ther, 1997; 20(7):476-481.
108.Knutson GA. Moderation of Postural Distortion Following Upper Cervical Facet Joint Block
Injection: A Case Study. Chiropr Res J, 1998; 5(1):28-34.
109.Sherwood KR, Brickner DS, Jennings DJ, Mattern JC. Postural Changes After Reduction of
the Atlanto-Axial Subluxation. J Chiropr Res, Summer, 1989; 5(4):96-100.
110.Hoiriis KT. Case Report: Management of Post-Surgical Chronic Low Back Pain with Upper
Cervical Adjustment. Chiropr Res J, 1989; 1(3):37-42.
111.Vaillancourt PJ, Collins KF. CASE REPORT: Management of Post-Surgical Low Back
Syndrome with Upper Cervical Adjustment. Chiropr Res J, 1993; 2(3):1-16.
112.Robinson SS, Collins KF, Grostic JD. A Retrospective Study: Patients with Chronic Low
Back Pain Managed with Specific Upper Cervical Adjustments. Chiropr Res J, 1993; 2(4):
10-16.
113.Sweat R. Correction of Multiple Herniated Lumbar Disc by Chiropractic Intervention. J
Chiropr Case Reports, 1993; 1(1):14-17.
114.Oliverio AB. Review of the Literature Adjusting Only the Cervical Spine and its Effect on
Low Back Pain. Chiropr Res J, 1994; 3(1):3-6.
115.Hoiriis KT, Pfleger B, McDuffie FC, Alattar M, Owens EF. Design and Implementation of a
Randomized Controlled Clinical Trial of Chiropractic Care Versus Drug Therapy for Sub-
Acute Low Back Pain. Chiropr Res J, 1997; 4(2):50-63.
116.Knutson GA. Rapid Elimination of Chronic Back Pain and Suspected Long-Term Postural
Distortion with Upper Cervical Vectored Manipulation: A Novel Hypothesis for Chronic
Subluxation/Joint Dysfunction. Chiropr Res J, 1999; 6(2):57-64.
117.Kessinger RC, Boneva DV. A New Approach to the Upper Cervical Specific, Knee-Chest
Adjusting Procedure: Part I. Chiropr Res J, 2000; 7(1):14-32.
118.Dickholtz M, Woodfield C. Atlas Correction of Patients with Neck and Back Pain Using the
th
NUCCA Technique. (Abstracts from the 16 Annual Upper Cervical Spine Conference,
November 20-21, 1999), Chiropr Res J, 1999; 6(2):86-87.
119.Sweat RW. CASE STUDY. Today’s Chiropr, 1982; 11(4):50.
120.Robinson GK. CASE STUDIES. Today’s Chiropr, 1983; 12(2):54-55.
121.Robinson GK. CASE STUDIES. Today’s Chiropr, 1983; 12(5):34-35.
122.Van Putten G. CASE STUDIES. Today’s Chiropr, 1983; 12(6):46-47.
123.Zezula LR. CASE STUDIES. Today’s Chiropr, 1984; 13(2):9-10.
124.Vogel FM. Case Studies. Today’s Chiropr, 1985; 14(1):48-49.
125.Forlizzo J. Case Studies. Today’s Chiropr, 1985; 14(3):91.
126.Van Putten G. Case Studies. Today’s Chiropr, 1985; 14(4):42-43.
127.Sweat RW, Sweat MH, Cuthbert S, Welkis R. Chiropractic Atlas Orthogonal Technique for
the Care of Senior Citizens. Today’s Chiropr, 1998; 27(3):86-91.
128.Brown M, Vaillancourt P. Case Report: Upper Cervical Adjusting for Knee Pain. Chiropr
Res J, 1993; 2(3):6-9.
129.Eriksen K. Correction of Juvenile Idiopathic Scoliosis After Primary Upper Cervical Care: A
Case Study. Chiropr Res J, 1996; 3(3):25-33.
130.Basu KS, Blankenship NK. Chiropractic and Scoliosis: A Case Study. Chiropr Res J, 1999;
 6(2):71-76.
131.James KA. Thermocouple Scanning Device Intra-Examiner and Inter-Examiner Reliability
Study. 10th Annual Upper Cervical Spine Conference, Life College, 1993.
132.James KA. Correlation of Scanning Palpation and Grostic Cervical X-rays with a
Thermocouple Temperature Measuring Device. (Thirteenth Annual Upper Cervical Spine
Conference). Chiropr Res J, 1997; 4(1):28.
133.James KA. Inter- and Intra-Examiner Reliability in Interpretations of Readings from a
th
Thermocouple Temperature Measuring Device. Abstracts From The 14 Annual Upper
Cervical Spine Conference, November 22-23, 1997, Life University, Marietta, Georgia,
Chiropr Res J, 1998; 5(1):41.
134.Berti AA. Thermocouple Heat Differential Instrument Examination and Findings in
Correlation with the Supine Leg Check and X-ray Findings. Upper Cervical Monograph,
1993; 5(3):7-8.
135.Wiedemann RL. Case Studies of Surface EMG Tested at C1 & C3 Pre and Post Adjustment
Along with Correlated Pre and Post X-rays. Eleventh Annual Upper Cervical Spine
Conference, Life College, 1994.
136.Grostic JD. Somatosensory Evoked Potentials in Chiropractic Research. Today’s Chiropr,
1992; 21(3):56-58,90.
137.Collins KF, Pfleger B. The Neurophysiological Evaluation of the Subluxation Complex:
Documenting the Neurological Component with Somatosensory Evoked Potentials. Chiropr
Res J, 1994; 3(1):40-48.
138.Grostic J, Glick D, Burke E, Sheres B. Chiropractic Adjustment Reversal of Neurological
Insult. Proceedings of the Int’l Conference on Spinal Manipulation, May 1992:19.
139.Glick D, Lee F, Grostic J. Documenting the Efficacy of Chiropractic Care Utilizing
Somatosensory Evoked Potential (SEP) Testing: Post Spinal Adjustment Changes in SEP’s
Duplicating Those Observed. Proceedings of the Int’l Conference on Spinal Manipulation,
1993:82.
140.Collins KF, Pfleger B. Significance of Functional Leg Length Inequality Upon
Somatosensory Evoked Potential Findings. Eleventh Annual Upper Cervical Spine
Conference, Life College, 1994.
141.Glick DM. The Effective Utilization of Somatosensory Evoked Potentials in the Evaluation
and Management of Upper Cervical Subluxations: Two Case Examples. Eleventh Annual
Upper Cervical Spine Conference, Life College, 1994.
142.Sweat RW, Robinson GK, Lantz C, Weaver M. Scanning Palpation of the Cervical Spine
Interexaminer Reliability Study. Digest Chiropr Economics, 1988; 30(4):14-18.
143.Spano N. Static Palpation of Muscle Imbalance as Compared to Radiographic Evaluation of
C-1. J Straight Chiropr, 1995, 1(1):24-27.
144.Hart J. Comparison of X-ray Listings and Palpation Listing of the Upper Cervical Spine. J
Vertebral Subluxation Res, 2000; 4(1):
145.Kessinger RC, Boneva DV. The Influence of Upper Cervical Specific Chiropractic
th
Care on Lumbar Range of Motion. 17 Annual Upper Cervical Spine Conference, Life
University, Marietta, GA, February 3-4, 2001.
146.Eriksen K. Comparison Between Upper Cervical X-ray Listings and Technique Analyses
Utilizing a Computerized Database. Chiropr Res J, 1996; 3(2):13-24.
147.Jende A, Peterson CK. Validity of Static Palpation as an Indicator of Atlas Transverse
Process Asymmetry. European J Chiropr, 1997; 45:35-42.
148.Steinle L, Steinle N. Examination of Relationships Between Atlas Lateral Displacement,
Atlas Rotational Malposition and Supine Leg Length Disparities: A Correlation Study of
th
1,102 Cases. Abstracts From The 15 Annual Upper Cervical Spine Conference, November
21-22, 1998, Chiropr Res J, 1999; 6(1):25-26.
149.McAlpine JE. Subluxation Induced Cervical Myelopathy: A Pilot Study. Chiropr Res J,
1991; 2(1):7-22.
150.Reynolds C. Reduction of Hypolordosis of the Cervical Spine and Forward Head Posture
with Specific Upper Cervical Adjustment and the Use of a Home Therapy Cushion. Chiropr
Res J, 1998; 5(1):23-27.
151.Knutson GA. Chiropractic Correction of Atlantoaxial Rotatory Fixation. J Manipulative
Physiol Ther, 1996; 19(4):268-272.
152.Eriksen K. Management of Cervical Herniated Disc with Upper Cervical Chiropractic Care:
A Case Study. J Manipulative Physiol Ther, 1998; 21(1):51-56.
153.Glick DM. Conservative Chiropractic Care of Cervicobrachialgia. Chiropr Res J, 1989;
1(3): 49-52.
154.Feeley KM. Conservative Chiropractic Care of Frozen Shoulder Syndrome: A Case Study.
 Chiropr Res J, 1992; 2(2):31-37.
155.Knutson GA. Atlas Laterality/Laterality & Rotation and the Angular Acceleration of
the Head and Neck in Motor Vehicle Accident. Chiropr Res J, 1996; 3(3):11-19.
156.Mathis P. Specific Upper Cervical Adjusting in the Supine Position. Chiropr Res J, 1993;
2(4):1-5.
157.Knutson GA, Jacob M. Possible Manifestation of Temporo-Mandibular Joint Dysfunction on
Chiropractic Cervical X-ray Studies. J Manipulative Physiol Ther, 1999; 22(1): 32-37.
158.Hoiriis KT, Owens EF, Pfleger B. Changes in General Health Status During Upper Cervical
Chiropractic Care: A Practice-Based Research Project.Chiropr Res J, 1997; 4(1):18-26.
159.Owens EF, Hoiriis KT, Burd D. Changes in General Health Status During Upper Cervical
Chiropractic Care: PBR Progress Report. Chiropr Res J, 1998; 5(1):9-16.
160.Hoiriis KT, Burd D, Owens EF. Changes in General Health Status During Upper Cervical
Chiropractic Care: A Practice-Based Research Project Update. Chiropr Res J, 1999; 6(2):
65-70.
161.Collins KF, Barker C, Brantley J, Planas V, Roopnarine C, Thornton P. The Efficacy of
Upper Cervical Chiropractic Care on Children and Adults with Cerebral Palsy: A Preliminary
Report. Chiro Pediatrics, 1994; 1(1):13-15.
162.Aguilar AL, Grostic JD, Pfleger B. Chiropractic Care and Behavior in Autistic Children. J
Clin Chiropr Pediatr, 2000; 5(1):293-304.
163.Trotta N. The Response of an Adult Tourette Patient to Life Upper Cervical Adjustments.
Chiropr Res J, 1989; 1(3):43-48.
164.Goodman RJ, Mosby JS. Cessation of a Seizure Disorder: Correction of the Atlas
Subluxation Complex. J Chiropr Res Clin Invest, 1990; 6(2):43-46.
165.Thomas MD, Wood J. Upper Cervical Adjustments May Improve Mental Function. J Man
Med, 1992; 6:215-216.
166.Kirby SL. A Case Study: The Effects of Chiropractic On Multiple Sclerosis. Chiropr Res J,
1994; 3(1):7-12.
167.Smith JL. Effects of Upper Cervical Subluxation Concomitant with a Mild Arnold-Chiari
Malformation: A Case Study. Chiropr Res J, 1997; 4(2):77-81.
168.Selano JL, Hightower BC, Pfleger B, Collins KF, Grostic JD. The Effects of Specific Upper
Cervical Adjustments on the CD4 Counts of HIV Positive Patients. Chiropr Res J, 1994;
3(1):32-39.
169.Hunt JM. Upper Cervical Chiropractic Care and the Resolution of Cystic Hygroma in a
Twelve-Year-Old Female: A Case Study. J Clin Chiropr Pediatr, 2000; 5(1):315-317.
170.Hunt JM. Upper Cervical Chiropractic Care of a Pediatric Patient with Asthma: A Case
Study. J Clin Chiropr Pediatr, 2000; 5(1):318-321.
171.Hunt JM. Upper Cervical Chiropractic Care of an Infant with Irregular Bowel Function: A
Case Study. J Clin Chiropr Pediatr, 2000; 5(1):312-314.
172.Eriksen K. Effects of Upper Cervical Correction on Chronic Constipation. Chiropr Res J,
1994; 3(1):19-22.
173. Goodman R. Hypertension and The Atlas Subluxation Complex. J Chiropr Res Clin
Investigation, 1992; 8(2):30-32.
174.Knutson, G. Significant Changes in Systolic Blood Pressure Post Vectored Upper Cervical
Adjustment vs Resting Control Groups: A Possible Effect of the Cervicosympathetic and/or
Pressor Reflex. J Manipulative Physiol Ther, 2001; 24:101-109.