By Joseph S. Ferezy, D.C. UCERF 2009

 Defined in Dorland's Medical Dictionary  An incomplete or partial dislocation.  Defined By ACA  An alteration in the normal dynamics, anatomical or physiological relationships of contiguous osseous structures. Their positional characteristics should be described in standardized terms which depict the abnormal range or position of motion that they have manifested."  I am not even sure if there is a discrepancy.

SUBLUXATION AND THE THREE-LEGGED STOOL 1.Misalignments: May not be detectable by current technological methods. 2.Aberration of movement integrity [either deficient or excessive motion]: Reliable measurements of motion remain elusive. 3.Physiologic dysfunction: May be present with or without pain, may facilitate our understanding of [but must not be construed a priori to validate] chiropractic subluxations. 1 Rosner AL. The role of subluxation in chiropractic. Des Moines, IA: Foundation for Chiropractic Education and Research, 1997.

 Biomechanical Basis = Abnormal (Suboptimal) Joint Position/Movement  Chiropractor – Subluxation  Allopath – Somatic Dysfunction  Osteopath – Osteopathic Lesion  No Proof of Subluxation?  What Do You Call a Sore Back?

 A Clinical Neurologist’s Understanding - Ferezy  Acute Antalgia  Away From Pain  Recognized By All Who Treat/Suffer LBP ▪ Radiologist – “Loss of Normal Lordosis” ▪ Orthopedist – “Back Spasms” ▪ Patient – “Hey Doc, I Can’t Straighten up; I’m Crooked”

 Why? – When a joint tells the CNS that it hurts to move, the result is an intelligent “guarding” or “splinting” response designed to minimize painful movement of that joint (nociceptor activation).  Hilton’s law - a nerve trunks which supplies a joint also supplies the joint, the muscles which move the joint and the skin over the insertions of such muscles  Splinting reaction (Hilton’s law) – protects an “injured articulation”.

 This works to reduce/eliminate the pain.  Often the original sharp, violent, stabbing, etc. type pain (d/t instability) is replaced by a change in the character to a “tight” or “stiff” or “muscular” pain secondary to the sustained protective muscular contraction.  Patients need to be reminded that the muscle fiber is, for the most part, the slave of the neuron, controlling its every aspect.  Results in soft tissue treatment failures for secondary muscular complaints.

 Davis’ law – if the origin and insertion of a muscle are moved further apart for some time, the muscle looses tone and becomes relaxed. If they are approximated the muscle contracts or becomes contractured. Chronic de-conditioning and/or “chronic antalgia” yield bad posture.

 How? – Uses the muscles.  Para Spinal Musculature (From Superficial to Deep)  Semispinales  Multifidi  Rotatores Muscles

PARASPINAL MUSCLES

 Interspinalis  Intertransversarii

 Variations in the Pattern of Activity During Forward Flexion, Extension, and Axial Rotation Suggest That the Transversospinal Muscles Adjust the Motion Between Individual Vertebrae.  The Experimental Evidence Confirms the Anatomical Hypothesis That the Multifidi Are Stabilizers Rather Than Prime Movers of the Whole Vertebral Column  Donisch and Basmajian, 1972

All Results in Relation to the Mechanical Advantage, Center and Line of Gravity, and the Possible Axis of Movement Confirm the Idea That the Transversospinal Muscles Act As Dynamic Ligaments. These Adjust Small Movements Between Individual Vertebrae, While Movements of the Vertebral Column Probably Are Performed by Muscles With Better Leverage and Mechanical Advantage.

 A Clinical Neurologist’s Understanding - Ferezy  Antalgia  Away From Pain  Macro – Regional Subluxation ▪ Cervical & Lumbar Hypolordosis w/trauma  Mirco – Intersegmental Subluxation – Intertransversarii and deeper muscles = Dynamic Ligaments

 The International Classification of Headache Disorders (ICHD) is a detailed hierarchical classification of all headache- related disorders published by the International Headache Society. [1] It is considered the official classification of headaches by the World Health Organization, and, in 1992, was incorporated into the 10th edition of their International Classification of Diseases (ICD-10).  Each class of headache contains explicit diagnostic criteria— meaning that the criteria includes quantities rather than vague terms like several or usually—that are based on clinical and laboratory observations.  The ICHD was first published in 1988 (now known as the ICHD-1). The second and current version, the ICHD-2, was published in 2004.

 Hierarchy  1.1 The primary headaches ▪ ICHD 1, ICD10 G43: Migraine ▪ ICHD 2, ICD10 G44.2: Tension-type headache (TTH) ▪ ICHD 3, ICD10 G44.0: Cluster headache and other trigeminal autonomic cephalagias ▪ ICHD 4, ICD10 G44.80: Other primary headaches  1.2 The secondary headaches ▪ ICHD 5, ICD10 G44.88: Headache attributed to head and/or neck trauma ▪ ICHD 6, ICD10 G44.81: Headache attributed to cranial or cervical vascular disorder ▪ ICHD 7, ICD10 G44.82: Headache attributed to non-vascular intracranial disorder ▪ ICHD 8, ICD10 G44.4 or G44.83: Headache attributed to a substance or its withdrawal ▪ ICHD 9, ICD10 G or G44.881: Headache attributed to infection ▪ ICHD 10, ICD10 G44.882: Headache attributed to disorder of homeostasis ▪ ICHD 11, ICD10 G44.84: Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures ▪ ICHD 12, ICD10 R51: Headache attributed to psychiatric disorder  1.3 Cranial neuralgias, central and primary facial pain and other headaches ▪ ICHD 13, ICD10 G44.847, G44.848, or G44.85: Cranial neuralgias and central causes of facial pain ▪ ICHD 14, ICD10 R51: Other headache, cranial neuralgia, central or primary facial pain

 Muscle Tension Headaches, which were renamed tension-type headaches (TTH) by the International Headache Society in 1988, are the most common type of primary headaches. The pain can radiate from the neck, back, eyes, or other muscle groups in the body. Tension-type headaches account for nearly 90% of all headaches. Approximately 3% of the population has chronic tension-type headaches. [1] International Headache Societyheadaches [1]  1.Rasmussen BK, Jensen R, Schroll M, Olesen J. Epidemiology of headache in a general population--a prevalence study. J Clin Epidemiol. 1991;44(11):

 A tension headache is a condition involving pain or discomfort in the head, scalp, or neck, usually associated with muscle tightness in these areas.  Tension headaches are one of the most common forms of headaches. They may occur at any age, but are most common in adults and adolescents.headaches  If a headache occurs two or more times a week for several months or longer, the condition is considered chronic.chronic  Tension headaches can occur when the patient also has a migraine.

 Tension headaches occur when neck and scalp muscles become tense, or contract. The muscle contractions can be a response to stress, depression, a head injury, or anxiety.  Any activity that causes the head to be held in one position for a long time without moving can cause a headache. Such activities include typing or other computer work, fine work with the hands, and using a microscope. Sleeping in a cold room or sleeping with the neck in an abnormal position may also trigger a tension headache

 Hierarchy  1.1 The primary headaches ▪ ICHD 1, ICD10 G43: Migraine ▪ ICHD 2, ICD10 G44.2: Tension-type headache (TTH) ▪ ICHD 3, ICD10 G44.0: Cluster headache and other trigeminal autonomic cephalagias ▪ ICHD 4, ICD10 G44.80: Other primary headaches  1.2 The secondary headaches ▪ ICHD 5, ICD10 G44.88: Headache attributed to head and/or neck trauma ▪ ICHD 6, ICD10 G44.81: Headache attributed to cranial or cervical vascular disorder ▪ ICHD 7, ICD10 G44.82: Headache attributed to non-vascular intracranial disorder ▪ ICHD 8, ICD10 G44.4 or G44.83: Headache attributed to a substance or its withdrawal ▪ ICHD 9, ICD10 G or G44.881: Headache attributed to infection ▪ ICHD 10, ICD10 G44.882: Headache attributed to disorder of homeostasis ▪ ICHD 11, ICD10 G44.84: Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures ▪ ICHD 12, ICD10 R51: Headache attributed to psychiatric disorder  1.3 Cranial neuralgias, central and primary facial pain and other headaches ▪ ICHD 13, ICD10 G44.847, G44.848, or G44.85: Cranial neuralgias and central causes of facial pain ▪ ICHD 14, ICD10 R51: Other headache, cranial neuralgia, central or primary facial pain

A. Pain, referred from a source in the neck and perceived in one or more regions of the head and/or face, fulfilling criteria C–D B.Clinical, laboratory and/or imaging evidence of a disorder or lesion within the cervical spine or soft tissues of the neck known to be, or generally accepted as, a valid cause of headache C.Evidence that the pain can be attributed to the neck disorder or lesion based on at least 1 of the following: 1. demonstration of clinical signs that implicate a source of pain in the neck 2. abolition of headache following diagnostic blockade of a cervical structure or its nerve supply using placebo- or other adequate controls D. Pain resolves within 3 months after successful treatment of the causative disorder or lesion

 Muscle Contraction  Little Evidence of Importance in Majority of Sufferers  Cervico-genic  Mounting Evidence

 Common HA  Associated With  Fatigue  Stress  Prolonged Reading  Will Respond to a Simple Analgesic  Begins in an Episodic Form  Progresses Into a Chronic

 Almost Daily  Do Not Appear to Be Associated With Any Obvious Psychological Factors  About 90% of All Headaches  15% of Patients Are Likely to Experience Their First Attack Before Age 10  Intractable and Persist Throughout Life

 Headaches Almost Every Day for up to 30 Years  75% of Patients Are Women  No Genetic Explanation  40% of Sufferers Appear to Have a Family History of Some Form of Headache  Bilateral  Dull and Persistent, Variable

 Described As a Feeling of Pressure, Heaviness or Tightness  About 10% Sufferers Also Have Migraine  Symptoms May Become Superimposed to Give a Very Complex Headache Picture

 In Mild Cases, the Headache Develops During Recognizable Stress  May Appear in Anticipation of an Unpleasant Event  In Chronic Form Headache at the Start of the Day, Remains As Dull Ache Throughout the Course of the Day

 Last From 30 Minutes to 7 Days  By Definition, Occur Less Than 15 Times a Month = Episodic  Chronic Headache Diagnosed When Headache Is Present for More Than 15 Days Per Month

 Seriously Affected Patients Experience Headaches All Day Every Day  Not Normally Accompanied by Distinctive Characteristics of Migraine, Although Mild Photophobia or Phonophobia May Occur in Severe Attacks  Mild Nausea From Anxiety May Accompany HA

 Vomiting Is Not a Feature  Depression and Anxiety Are Common  Psychological Disorder?  Emotional Disturbances?  Headache Is Result of Physical Process  Now Outdated Term, Muscle Contraction Headache

 Greater Occipital Nerve  Anatomic Trespasses  Cervical Afferents and Cranial Nerve V Convergence  Connective Tissue Bridge Between Rectus Capitis Posterior Minor (RCPM) and Spinal Dura at C0-C1

Syndrome of the Greater Occipital Nerve

Reproduced Dozens of Times Since Discovery by Hack and Associates in Maryland

 Rarely Severe  Characteristic Pressing/tightening Quality  Bilateral  Does Not Worsen With Physical Activity  Lack of Associated Symptoms  General Physical and Neurological Are Normal

 Reassure  Bodily Relaxation  Chiropractic Approach  Pharmacological Approach

 Reduction of Cervicothoracic Subluxations  Active and Passive Stretching of Cervical and Shoulder Musculature  Reduce Cervicothoracic Trigger Points  Treat Emotional Problems  Diet  Rest  Exercise

 Relaxation Exercises  Biofeedback  Acupuncture/meridian Therapy

 Simple Analgesics (NSAID's)  Tranquilizers  Antidepressant  Barbiturates (Sleep)  Psychiatric Exam (May Require Referral)  Caffeine  Watch for Rebound HA's