The discoverer of chiropractic, D.D. Palmer, wrote extensively about the concept of tone. According to Palmer: “Life is the expression of tone. In that sentence is the basic principle of Chiropractic. Tone is the normal degree of nerve tension. Tone is expressed in functions by the normal elasticity, activity, strength and excitability of the various organs, as observed in a state of health. Consequently, the cause of disease is any variation of tone — nerves too tense or too slack.” (1)

Palmer’s tonal model is inherent in the modern concept of “tensegrity.” Tensegrity is maintained in “a system that stabilizes itself mechanically because of the way tensional and compressive forces are distributed and balanced within the structure.” (2) In living cells, tensegrity is maintained by contractile microfilaments which form a lattice that reorganizes locally into different forms.

The biological implications of tensegrity are described by a medical physician, Ingber: “Remarkably, tensegrity may even explain how all (these) phenomena are so perfectly coordinated in a living creature. At the Johns Hopkins School of Medicine, Donald S. Coffey and Kenneth J. Pienta found that tensegrity structures function as coupled harmonic oscillators. DNA, nuclei, cytoskeletal filaments, membrane ion channels and entire living cells and tissues exhibit characteristic resonant frequencies of vibration. Very simply, transmission of tension through a tensegrity array means to distribute forces to all interconnected elements and, at the same time, to couple, or ‘tune,’ the whole system mechanically as one.” (2) Tensegrity is not limited to the cellular level, but is operative on all anatomical levels.

Tone and tensegrity are elegant theoretical models with practical clinical implications. D.D. Palmer wrote: “Tone, in biology, is the normal tension or firmness of nerves, muscles or organs, the renitent, elastic force acting against an impulse. Any deviation from normal tone, that of being too tense or too slack, causes a condition of renitence, too much elastic force, too great resistance, a condition expressed in function as disease.” (3)

Functional consequences of changes in tone have been described. John H. Craven, professor of philosophy at the Palmer School of Chiropractic, wrote: “We have seen that the normal air pressure at sea level is fifteen pounds to the square inch. In order that the body will not be crushed by this weight it is necessary to have an internal resistance to equal this weight. This internal resistance is maintained in the body by the tone of all of its parts; it is maintained by the expression of mental impulses in the tissue cells.” (4)

In 1927, chiropractor Stephenson noted that cord tension and cord pressure may cause impingement upon the spinal cord. (5) Nearly four decades later, neurosurgeon Breig described how adverse mechanical tension on the spinal cord may result in abnormal neurological function and the development of pathology. (6,7,8)

Wall et al reported the results of experimental stretch neuropathy in an animal model. At only 6% strain, the amplitude of the action potential had decreased by 70% at one hour and returned to normal during the recovery period. However, at 12% strain, conduction was completely blocked by one hour, and showed minimal recovery. (9)

Health is dependent upon maintaining proper tone in the nervous system. As D.D. Palmer explained: “Life is action governed by intelligence. Intelligent life, the soul, depends upon the execution of functions. Functions performed by normal energy is health. Disease is the result of the performance of functions above or below a normal degree of activity. Impulses properly transmitted through nerves, result in functions being normally performed, a condition which results in health.” (10)

Recently, Lee described the theoretical role of the central nervous system (CNS) in all disease processes in the journal Medical Hypotheses: “Every malfunction in the periphery (in contrast to the CNS) must be sensed by the CNS in order that corrective measures be taken…the CNS is universally involved in all diseases, regardless of whether they originally arise from the periphery or are indigenous to the central nervous system; whether initiated by various infective agents, be it viral, bacterial, rickettsial or parasitical in nature or resulted from exposures to toxins, radiation, physical injuries, or emotional upheavals.” (11)

The ability to maintain tone requires a nervous system free of interference. Restoration of tone is dependent upon correction of vertebral subluxations. Alterations in the tone of the somatic system may be objectively evaluated using surface EMG. Altered autonomic tone may be evaluated using skin temperature measurements. Such objective assessments have the potential to make chiropractic the dominant strategy of 21st century health care, as modern research vindicates the discoverer’s vision.

References

1. Palmer DD: “Text-book of the Science, Art and Philosophy of Chiropractic for Students and Practitioners.” Portland Printing House Company. Portland, OR. 1910. Page 7.

2. Ingber DE: “The architecture of life.” Scientific American (January 1998) Vol 278 No 1 Pages 48-57.

3. Palmer 1910. Page 659.

4. Craven JH: “A Text-book on Hygiene and Pediatrics From A Chiropractic Standpoint.” Hammond Press. WB Conkey Company. Chicago, IL. 1924. Page 54.

5. Stephenson RW: “Chiropractic Textbook.” Palmer School of Chiropractic. Davenport, IA. 1927. Page 306.

6. Breig A: “The biomechanics of the spinal cord and its membranes in the spinal canal.” Verh Anat Ges (German) 1965,115:49-69.

7. Breig A, Turnbull I, Hassler O: “Effects of mechanical stresses on the spinal in cervical spondylosis. A study on fresh cadaver material.” J Neurosurg 1966 Jul, 25(1):45-56.

8. Breig A: “Overstretching of and circumscribed pathological tension in the spinal cord — a basic cause of symptoms in cord disorders.” J Biomech 1970 Jan, 3(1):7-9.

9. Wall EJ, Massie JB, Kwan MK, Rydevik BL, Myers RR, Garfin SR: “Experimental stretch neuropathy. Changes in nerve conduction tension.” J Bone Joint Surg (Br) 1992, 74(1):126-129.

10. Palmer 1910. Page 661.

11. Lee TN: “Thalamic neuron theory: theoretical basis for the role played by the central nervous system (CNS) in the causes and cures of all diseases.” Medical Hypotheses 1994, 43:285-302.

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Interest in the role stress plays with the dynamics of health has resulted in a proliferation of strategies designed to minimize or “manage” stress. To many people, the very term “stress” elicits a negative response. Yet, the notion that stress is an enemy we must resist or manage betrays a widespread misunderstanding of the nature of stress and how it affects our lives.

Hans Selye

Hans Selye pioneered investigations of the biological effects of stress in 1936 with the publication of his paper, “A syndrome produced by diverse noxious agents.” Since then, more than 100,000 articles and books have been written on the subject.

Selye describes stress as the nonspecific response to any demand. Experimental studies by Selye and other investigators revealed that when physical, chemical, or emotional demands were imposed on an animal, three stages could be identified which characterize the response:

1) Alarm reaction. The initial reaction to the stressor.

2) Stage of adaptation. The responses following the initial reaction.

3) Stage of exhaustion. When the limits of adaptation are exceeded, and the animal can no longer appropriately respond.

Dis-stress and eu-stress

Although many individuals have concluded that stress is inevitably destructive, this view is incorrect. As Selye noted, “Stress is not necessarily bad for you. It is also the spice of life, for any emotion, any activity causes stress…the same stress that makes one person sick is an invigorating experience for another…Complete absence of stress is incompatible with life since only a dead man makes no demand on his body or mind.”

Selye described two types of stress:

*** Dis-stress — from the Latin “bad,” as in dissonance.

*** Eu-stress — from the Greek “true” or “good,” as in eutonia.

Whether we experience a pleasant or unpleasant result from an event depends upon how our nervous system perceives, processes, and interprets that event. Selye wrote, “…the endocrine glands and the nervous system–help us both to adjust to the constant changes which occur in and around us, and to navigate a steady course toward whatever we consider a worthwhile goal.”

Stress and v.s.

More than 15 years before Selye’s historic publication, B.J. Palmer and J.H. Craven described a similar concept: concussion of forces. This term refers to the meeting of external invasive forces and internal resistive forces. Just as stress may be destructive or beneficial, concussion of forces may produce or reduce vertebral subluxation. The result is dis-ease or ease.

Craven wrote: “That which caused the normal cycle to become abnormal was a concussion of forces centering at some point in the spinal column causing a subluxation…tissues do not nor cannot express their normal function.”

Palmer stated that in the normal cycle, following Innate Intelligence is intellectual adaptation. Palmer quotes Webster’s definition of adaptation: “To make suitable; to fit; or suit; to adjust; alter so as to fit for a new use.” More than 60 years later, Selye wrote, “Every living being has a certain innate amount of adaptation energy or vitality.”

When a concussion of forces is corrective, Palmer noted the following changes: “Perversion changed to verification; abuse to proper natural use; abnormal interpretation to normal interpretation; distortion to healthful manifestation; corruption to correction.”

Although it is unlikely that Selye was familiar with the writings of Palmer and Craven, the similarities are striking: Stress and concussion of forces; eu-stress and ease; dis-stress and disease.

Health

The practical application of these concepts requires a working definition of health. The World Health Organization (WHO) defines health as “A state of complete physical, mental, and social well being and not merely the absence of disease or infirmity.”

In this context, Selye wrote, “The secret of health and happiness lies in successful adjustment to the ever-changing conditions on this globe; the penalties for failure in this great process of adaptation are disease and unhappiness.”

A key aspect of expressing our adaptive potential is keeping the nervous system free of interference by adjusting vertebral subluxations.

The realization of this objective is described in Palmer’s vision for the year 2000:

“Did you ever think what kind of a world this would be in a short time- -not later than 2000 A.D. — if the development of Chiropractic should continue until that time in proportion to the way it has developed during the last five years? By the time mentioned, we would see a race of giants, physically and mentally. There would be no chronic diseases of any kind; people would not know what tuberculosis is, except from history; no insane hospitals where men and women are confined as in a prison and made to suffer untold abuse…There would be no more penitentiaries because no crime would be committed by a sane man or woman; no poor houses because every man would be well and happy and have full possession of his faculties…”

“You are to prepare the way for future generations to follow. You are to blaze the way, blast the rocks, clear all rubbish of ignorance and prejudice, and open up the grand highway of truth.”

References

Selye, Hans: “The Stress of Life.” New York. McGraw Hill, Co. 1984.

Palmer, BJ; Craven, JH: “The Philosophy of Chiropractic.” Davenport, IA. Palmer School of Chiropractic. 1920.

World Health Organization. The first ten years of the World Health Organization. Geneva. 1958.

Palmer, BJ: History Repeats. Davenport, IA. Palmer School of Chiropractic. 1951.

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The term “mental impulse” was used by D.D. Palmer in his 1910 text. Palmer (1) wrote, “Chiropractors do not treat diseases, they adjust the wrong which creates disease; they have discovered the simple fact that the human body is a sensitive piece of machinery, run throughout all its parts by mental impulse…A mental impulse is an incitement of the mind by Innate or spirit, in the form of an abrupt and vivid suggestion, prompting some unpremeditated action or leading to unforeseen knowledge or insight.”

A popular misconception is that God, Innate Intelligence, and mental impulse are synonyms that may be used interchangeably. Milus (2) stated, “The concept of ‘Innate Intelligence’ is a fundamental component of chiropractic philosophy as developed by D.D. Palmer…B.J. Palmer modified the concept, popularizing a more materialistic notion of Innate that effectively equated it with ‘mental impulses.’”

Yet, B.J. Palmer clearly differentiated Innate Intelligence from mental impulse. According to B.J. Palmer (3), “Mental impulse is that accumulation of immaterial units of intellectual energy which, after having been absorbed, transformed and expelled thru the brain, Innate Intelligence deems of proper quantity and quality to personify specific characteristic functions.” B.J. Palmer (4) clearly stated that, “My Innate Intelligence is not God…”

Describing the nature of the mental impulse has been a formidable challenge to students of chiropractic. Early authors were limited by the basic science knowledge and technology of the time. For example, Stephenson (5) wrote, “We might conceive of this mental impulse as being composed of certain kinds of physical energies, in proper proportions, which will balance other such forces in the Tissue Cell; as electricity, valency, magnetism, cohesion, etc., etc.. Perhaps some of these energies are not known to us in physics. What right have we to assume that we have found them all? The writer presents this as a hypothesis or theory in order to get a working basis…It is no discredit to Chiropractic that it must also use theories concerning the transmission of mental forces.”

Furthermore, Stephenson (6) noted, “The mental impulse is not an energy at all. It is a message. A message is not a material, an energy, or a thing physical in any sense…Mentality makes it and sends it to an object of matter.”

In his last written text, B.J. Palmer (7) articulated the physical manifestation of the mental impulse, which he termed “nerve-force flow.” Although the action potential is one manifestation of the expression of the mental impulse, it seems that the developer had a broader concept in mind: “The brain-nerve-body, body-nerve-brain material system through which flowed an intangible, unseen, abstract, difficult to prove that there was a ‘something’ very powerful, dynamic, without which we would be dead matter. We, who proved existence of this continuity circular circulation call it the mental impulse nerve-force flow. This abstract circulation regulates, controls and directs the flow of arterial and venous blood.”

It is clear that the mental impulse, as described by the Palmers, is not synonymous with Innate Intelligence or the neurochemical action potential. It is a “thought” which may be expressed through a variety of neurobiological mechanisms. These mechanisms include synaptic and non-synaptic processes.

Boone and Dobson (8) described a model of vertebral subluxation which includes interference to action potential and interference to mental impulse. The non-synaptic mechanisms include axoplasmic flow, volume transmission, ephapsis, field effects, and peptide messengers. Future columns will discuss these mechanisms and their postulated relationship to vertebral subluxation.

References

1. Palmer DD: “Textbook of the Science, Art and Philosophy of Chiropractic.” Portland, OR. Portland Printing House Company, 1910. Pages 85 and 109.

2. Milus T: “The state of Innate.” Topics in Clinical Chiropractic 1995;2(2):45.

3. Palmer BJ: “The Science of Chiropractic.” Davenport, IA. The Palmer School of Chiropractic, 1920. Page 28.

4. Ibid. Page 45.

5. Stephenson RW: “Chiropractic Textbook.” Davenport, IA. The Palmer School of Chiropractic, 1948 edition. Pages 268, 269 and 292.

6. Ibid. Page 294.

7. Palmer BJ: “Our Masterpiece.” Davenport, IA. The Palmer School of Chiropractic, 1961. Page 6.

8. Boone WR, Dobson GJ: “A proposed vertebral subluxation model reflecting traditional concepts and recent advances in health and science.” Journal of Vertebral Subluxation Research 1996;1(1):19.

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Dr David is a renowned chiropractor who practiced for many years with his associates in a scan-centric thriving principled family-based practice in Toronto. He is a sought-after teacher mentor and keynote speaker who takes every opportunity to share the wisdom and the power of chiropractic as it is meant to be.

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Seeing RED: A Guide to Scan Interpretation and Communication

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In addition to techniques of skin temperature measurement, sweat gland activity is another indicator of sympathetic function. Sympathetic stimulation causes increased sweat gland activity. Increased sweat gland activity results in less resistance to the flow of an electrical current. Therefore, sweat gland activity may be assessed by passing a small electric current through the skin to measure resistance. Terms used to describe this procedure include ESR (electrical skin resistance), GSR (galvanic skin response), and electrodermatography. Korr, Thomas and Wright (1) summarized the physiologic rationale for evaluating patterns of electrical skin resistance in humans:

1. Electrical skin resistance is related to the activity of the sweat glands.

2. Interruption or retardation of the flow of impulses over sympathetic pathways to an area causes a marked elevation of resistance in that area.

3. Stimulation of sympathetic pathways either locally or systemically lowers the resistance.

Korr and Goldstein (2) observed that segmental differences in sweat gland activity are related to segments with reduced motor reflex thresholds. Areas of reduced skin resistance were often hyperesthetic. It was concluded that in segments with chronically reduced motor reflex thresholds, at least some of the preganglionic sympathetic neurons of the same segment are also maintained in a state of facilitation (lowered thresholds).

The results of investigations employing skin resistance methods to evaluate manifestations of visceral disease or segmental dysfunction have yielded equivocal results. This may be due, in part, to variations in technique and interpretation.

Korr (3) reported the results of a preliminary investigation to determine if paraspinal skin resistance patterns were related to visceral disease. Two classes of patients were evaluated. One group of patients had a history of myocardial infarction, and demonstrated low resistance areas over 2 or more of the upper 4 thoracic vertebrae. In one patient, such areas were observed three weeks prior to coronary occlusion. The second group of patients had duodenal cap ulcers. These individuals had low resistance areas at the T5 to T8 areas.

In a later work, Korr (4) stated that after examining hundreds of patients, “each had a rather characteristic pattern that remained fairly constant; the size of the areas might vary but the segmental distributions retained the individual’s characteristic pattern. We could identify the subject from his ESR — electrical skin resistance chart — almost as readily as one can from fingerprints. …Repeatedly it has been demonstrated that the distribution of low skin resistance — that is, areas of sympathetic nerve activity — correspond quite well to the actual nerve distribution of the lesioned segment in the spine.”

These conclusions are refuted by other investigators using skin resistance measurements. Bauch and Hartig (5) concluded that the electrodermatogram was unreliable as an independent or differential diagnostic method. It was concluded that due to nervous system overlap, segmental localization was imprecise and therefore not organ specific. The authors noted that the asymmetry of the conductivity between the two sides of the body was a phenomenon which could not be explained.

Plaugher et al (6) investigated the interexaminer reliability of a galvanic skin resistance device for the detection of low resistance areas along the spinal column in “relatively asymptomatic” subjects. Only modest levels of concordance were found. The authors suggest that the unevenness of data generated in certain spinal regions necessitates further investigation prior to reaching conclusions about the usefulness of this instrument in a clinical setting.

A possible explanation for these conclusions is offered by Korr (4). “You must not look for perfect correspondence between skin resistance and the distribution of the pathologic disturbance, because an area of skin which is segmentally related to a particular muscle does not necessarily overlap that muscle. With the latissimus dorsi, for example, the myofascial disturbance might be over the hip but the reflex manifestations would be in much higher dermatomes because this muscle has its innervation from the cervical part of the spinal cord.”

Ellestad et al (7) reported statistically significant changes in paraspinal skin resistance in back pain patients who received osteopathic manipulative treatment (OMT). Specifically, skin resistance decreased following OMT. The authors suggested that this may be due to a greater degree of relaxation. It was also reported that SEMG activity decreased following OMT.

In addition to assessing segmental autonomic function, skin resistance measurements may be used as indicators of general autonomic activity. Such measurements are often taken at the fingertips. This procedure is often used in biofeedback training to teach relaxation techniques.

A small study by Giesen, Center and Leach (8) used electrodermal measurements to assess autonomic nervous system activity in hyperactive children receiving chiropractic care. Behavioral assessments were also used to evaluate outcomes. The authors concluded that chiropractic care has the potential to become an important intervention for children with hyperactivity. Because of equivocal findings, and a paucity of published research in the chiropractic literature, the acceptance of skin resistance instrumentation in general clinical practice has been limited. Additional research to explore its potential value in assessing autonomic dysfunction associated with vertebral subluxation should be encouraged.

References

1. Korr IM, Thomas PE, Wright HM: “Patterns of electrical skin resistance in man.” J Neural Transmission 1958;17:77.

2. Korr IM, Goldstein MJ: “Abstract: dermatomal autonomic activity in relation to segmental motor reflex threshold.” Federation Proceedings 1948;7:67. In: The Collected Papers of Irvin M. Korr. American Academy of Osteopathy. Indianapolis, IN. 1979. P. 22.

3. Korr IM: “Abstract: skin resistance patterns associated with visceral disease.” Federation Proceedings 1949;8:87. In: The Collected Papers of Irvin M. Korr. American Academy of Osteopathy. Indianapolis, IN. 1979. P. 23.

4. Korr IM: “The segmental nervous system as a mediator and organizer of disease processes.” The Physiologic Basis of Osteopathic Medicine. The Postgraduate Institute of Osteopathic Medicine and Surgery. 1970:73.

5. Bauch K, Hartig W: “Electrodermatographic examination of segmental sweat secretion in the diagnosis and differential diagnosis of internal diseases.” Acta Neurovegetativa 1973;30:536.

6. Plaugher G, Haas M, Doble RW Jr et al: “The interexaminer reliability of a galvanic skin response instrument.” J Manipulative Physiol Ther 1993;16(7):453.

7. Ellestad S, Nagle R, Boesler D, Kilmore M: “Electromyographic and skin resistance responses to osteopathic manipulative treatment for low-back pain.” JAOA 1988;88(8):991.

8. Giesen J, Center D, Leach R: “An evaluation of chiropractic manipulation as a treatment of hyperactivity in children.” J Manipulative Physiol Ther 1989;12:353.

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Dr David is a renowned chiropractor who practiced for many years with his associates in a scan-centric thriving principled family-based practice in Toronto. He is a sought-after teacher mentor and keynote speaker who takes every opportunity to share the wisdom and the power of chiropractic as it is meant to be.

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Your Guide to Transformational Reporting

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Chiropractors and their attorneys sometimes contact me for help in legal entanglements. A typical query: “They have a well known orthopedic surgeon ready to testify against me. What can I do?”

The first question I ask is, “Was your diagnosis vertebral subluxation?” “Uh, no,” comes the sheepish reply. “It was lumbalgia with radiculitis.” “And on what did you base your diagnosis?” I ask. “Well, you know, X-rays and ortho/neuro tests,” comes the reply. “Were the X-rays to characterize vertebral subluxation? Is that reflected in your records?” “No. I just X-ray for pathology.” Uh huh.

It pains me to tell the poor soul on the other end of the line that the M.D. may well be allowed to testify concerning the diagnosis of lumbalgia and radiculitis, and the appropriateness of physical therapy and manipulation. When I ask, “Why didn’t you simply state that you analyzed and adjusted a vertebral subluxation?,” the reply is all too often, “Insurance companies won’t pay for that.”

At this point, I politely decline the request to review the records in the case. I sometimes don’t have the heart to tell the poor wretch what could happen in court. Imagine a judge or jury finding out that the D.C. was practicing something other than chiropractic as defined by statute in many states, and had fabricated a diagnosis because of a desire to facilitate reimbursement!

This need not be the case. The chiropractor who sticks to chiropractic examination procedures, employs chiropractic adjusting procedures, and uses a “terms of acceptance” document to clarify the nature of the doctor/patient relationship may be spared this unpleasant scenario.

It is not uncommon for chiropractors involved in litigation to be confronted by medical adversaries. These doctors are often orthopedic surgeons, neurologists, and radiologists. As professional expert witnesses, they may be articulate and confident. Some have impressive credentials, such as academic appointments at prestigious medical schools. As a consequence, many chiropractors feel intimidated when called upon to testify in such cases.

This column is not intended to serve as legal advice. D.C.s are encouraged to have the attorneys on their side review the strategy described. The objective is to demonstrate to the court that the M.D. adversary is not qualified in chiropractic.

Case law has held that chiropractic is a separate “school” of healing. In the appellant’s brief in the malpractice case of Sheppard vs Firth, it was stated, “Appellant was entitled to have his treatment tested by the rules and principles of the school to which he belonged…In malpractice cases the only expert who should be allowed to testify as to the propriety of the treatment complained of is one who belongs to the same branch of medicine or system to which the accused belongs.” The decision was in favor of the defendant-appellant, Firth.

Such protection, however, is only applicable if the chiropractor has not engaged in activities which constitute medical practice. This is true even if such medical practices are within the lawful scope of chiropractic in a given state. Such “common domain” procedures do not fall under the protection of the “separate school” argument, since they do not involve a unique theory of “cause” and “remedy.” As a consequence, medical practitioners may properly testify against chiropractors who employ such procedures.

The appellant’s brief in Sheppard vs Firth clarifies the issue: “It is only in those cases where members of two professions use methods recognized by each, or, as is sometimes said, work in a common field that the one can testify concerning the work of the other…for instance, had appellant used a diathermy machine, as chiropractic physicians sometimes do and as the medical profession does, then a member of the medical profession would have been competent to testify, as to the manner in which the machine was used.”

It may be argued that because a medical doctor holds a plenary license, such a person may testify concerning any aspect of the healing arts. The absurdity of this argument may be illustrated by an example. Although ophthalmology and proctology are both specialties within allopathic medicine, it is improbable that a court would permit a proctologist to offer expert testimony against an ophthalmologist concerning technical nuances of cataract surgery.

The following questions may be asked of an M.D. witness to establish that such an individual is not qualified to determine the safety of appropriateness of chiropractic care:

  • Doctor, are you an expert on chiropractic?
  • Was training in chiropractic principles and techniques included in your medical school education?
  • Was chiropractic included in your residency training?
  • Have you ever practiced chiropractic?
  • Are you a graduate of a CCE accredited chiropractic college?
  • Do you hold a certificate of attainment from the National Board of Chiropractic Examiners?
  • In which states are you licensed to practice chiropractic?
  • Have you published any papers on chiropractic in peer reviewed journals?
  • Would you please list for us the components of the vertebral subluxation complex?
  • What is spinal kinesiopathology, and how is it assessed?
  • What is myopathophysiology, and how is it assessed?
  • What is neuropathophysiology, and how is it assessed?
  • What examination procedures are used to assess vertebral subluxation?

Of course, this strategy is only applicable to the practice of subluxation-based chiropractic. D.C.s who dabble in medicine do so at the risk of facing testimony from allopathic adversaries.

References

Rutherford LW: “The Role of Chiropractic.” Clinton Press. Erie, PA. 1989.

Sheppard vs Firth 215 OR 268,334 P 2d 190(1959) at pages 32-26. Quoted in Rutherford.

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ABOUT THE AUTHOR

Dr. David Fletcher is actively involved in all aspects of innovation teaching and research connected to the INSiGHT™ scanning technologies. He is widely recognized for his ability to share his expertise in compelling and easy to understand ways.

Dr David is a renowned chiropractor who practiced for many years with his associates in a scan-centric thriving principled family-based practice in Toronto. He is a sought-after teacher mentor and keynote speaker who takes every opportunity to share the wisdom and the power of chiropractic as it is meant to be.

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Dr. David Fletcher
DC FRCCSS(C) – Founder & CEO CLA Inc.
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Variability in heart rate reflects the vagal and sympathetic function of the autonomic nervous system, and has been used as a monitoring tool in clinical conditions characterized by altered autonomic nervous system function (1). Spectral analysis of beat-to-beat variability is a simple, non-invasive technique to evaluate autonomic dysfunction (2).

Heart rate variability analysis has been used in the assessment of diabetic neuropathy and to predict the risk of arrhythmic events following myocardial infarction (3). The technique has also been used to investigate autonomic changes associated with neurotoxicity (4), physical exercise (5), anorexia nervosa (6), brain infarction (7), angina (8), and panic disorder (9).

Normative data on heart rate variability have been collected (10,11,12). This technology appears to hold promise for assessing overall fitness. Gallagher et al (13) compared age matched groups with different lifestyles. These were smokers, sedentary persons, and aerobically fit individuals. They found that smoking and a sedentary lifestyle reduces vagal tone, whereas enhanced aerobic fitness increases vagal tone. Dixon et al (14) reported that endurance training modifies heart rate control through neurocardiac mechanisms.

In occupational health, the effects of various stresses of the work environment of heart patients and asymptomatic workers may be evaluated using heart rate variability analysis (15).

Acquired dysautonomia is one of the three elements in the three dimensional model of vertebral subluxation (16). Skin temperature changes, reflecting alterations in vasomotor tone, are used clinically to assess autonomic changes associated with vertebral subluxations. Heart rate variability represents a promising, non-invasive technology to assess subluxation-related autonomic function.

References

1. van Ravenswaaij-Arts CM, Kollee LA, Hopman JC, Stoelinga GB: “Heart rate variability.” Ann Intern Med 1993;118(6):436.

2. DeDenedittis G, Cigada M, Bianchi A, et al: “Autonomic changes during hypnosis: a heart rate variability power spectrum analysis as a marker of sympatho-vagal balance.” Int J Clin Exp Hypn 1994;42(2):140.

3. Kautzner J, Camm AJ: “Clinical relevance of heart rate variability.” Clin Cardiol 1997;20(2):162.

4. Murata K, Landrigan PJ, Araki S: “Effects of age, gender, heart rate, tobacco and alcohol ingestion on R-R interval variability in human ECG.” J Autonomic Nervous System 1992;37:199.

5. Nakamura Y, Yamamoto Y, Muraoka I: “Autonomic control of heart rate during physical exercise and fractal dimension of heart rate variability.” J Appl Physiol 1993;74(2):875.

6. Petretta M, Bonaduce D, Scalfi L, et al: “Heart rate variability as a measure of autonomic nervous system function in anorexia nervosa.” Clin Cardiol 1997;20(3):219.

7. “Abnormal heart rate variability as a manifestation of autonomic dysfunction in hemispheric brain infarction.” Stroke 1996;27(11):2059.

8. Kamalesh M, Burger AJ, Kumar S, Nesto R: “Reproducibility of time and frequency domain analysis of heart rate variability in patients with chronic stable angina.” Pacing Clin Electrophysiol 1995;18(11):1991.

9. Yeragani VK, Pohl R, Berger R, et al: “Decreased heart rate variability in panic disorder patients: a study of power-spectral analysis of heart rate.” Psychiatry Res 1993;46(1):89.

10. O’Brien IA, O’Hare P, Corrall RJ: “Heart rate variability in healthy subjects: effect of age and the derivation of normal ranges for tests of autonomic function.” Br Heart J 1986;55(4):348.

11. Toyry J, Mantysaari M, Hartikainen J, Lansimies E: “Day-to-day variability of cardiac autonomic regulation parameters in normal subjects.” Clin Physiol 1995;15(1):39.

12. Sato N, Miyake S, Akatsu J, Kumashiro M: “Power spectral analysis of heart rate variability in healthy young women during the normal menstrual cycle.” Psychosom Med 1995;57(4):331.

13. Gallagher D, Terenzi T, de Meersman R: “Heart rate variability in smokers, sedentary, and aerobically fit individuals.” Clin Auton Res 1992;2(6):383.

14. Dixon EM, Kamath MV, McCartney N, Fallen EL: “Neural regulation of heart rate variability in endurance athletes and sedentary controls.” Cardiovasc Res 1992;26(7):713.

15. Kristal-Boneh E, Raifel M, Froom P, Ribak J: “Heart rate variability in health and disease.” Scand J Work Environ Health 1995;21(2):85.

16. Kent C: “A three-dimensional model of vertebral subluxation.” The Chiropractic Journal 1998;12(9):38,50.

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Dr David is a renowned chiropractor who practiced for many years with his associates in a scan-centric thriving principled family-based practice in Toronto. He is a sought-after teacher mentor and keynote speaker who takes every opportunity to share the wisdom and the power of chiropractic as it is meant to be.

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Thrival Guide

Want to change your narrative from survival to thrival? This guide introduces: RELEASE, REVITALIZE, and REOPRGANIZE concepts in order to create space to grow. When you make the Critical Shift you will flip how to be successful in your chiropractic office.

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Recently, a Calgary radiologist began a movement to restrict the availability of x-ray services for chiropractors. The absurdity of this position is apparent to any thoughtful clinician, medical or chiropractic. As a direct contact health care provider, the doctor of chiropractic is responsible for determining the safety and appropriateness of chiropractic care. (1) This responsibility includes the detection and characterization of vertebral subluxations.

Plain films and radiation safety

Plain film radiography has been the mainstay of imaging in most chiropractic practices. (2) Growing concern for the hazards of ionizing radiation and the availability of alternative imaging techniques may cause this to change. According to a National Research Council report, low doses of x-radiation pose a human cancer risk three to four times higher than previously reported. The report also noted that some fetuses exposed to radiation face a higher than expected risk of mental retardation. (3)

This does not mean that the chiropractor should abandon plain film radiography and dispatch all patients for an MRI study. It does mean developing increased awareness of the judicious use of ionizing radiation, and implementing radiographic procedures which minimize risk and maximize the amount of information obtained from the study.

Radiation protection is particularly important when x-raying infants, children, adolescents, and adults in their reproductive years. It has been stated that “For examination of the skeleton, there is no modality to match the time and cost effectiveness of the plain film radiograph.” (2)

The Bureau of Radiological Health emphasizes the importance of clinical judgement in selecting radiographic procedures. The Bureau also recognizes the right of the attending doctor to make benefits vs. risks determinations in selecting radiographic procedures. A Bureau publication states, in part:

In almost every medical situation, when the physician feels there is reasonable expectation of obtaining useful information from roentgenological examination that would affect the care of the individual, potential radiation hazard is not a primary consideration…The physician should retain complete freedom ofjudgement in the selection of roentgenologic procedures, and (the physician) should conform with good technical practices. (4)

The following are indications for pediatric radiologic examination:

1. History of trauma with clinical signs suggestive of fracture or dislocation.

2. Clinical suspicion of infection or neoplasm.

3. Clinical evidence of a congenital or developmental anomaly (e.g. Down’s syndrome) which could alter the nature of the chiropractic care rendered, or which may itself require treatment.

4. When clinical findings are equivocal, and the suspected condition can be detected or ruled out by plain film radiography.

5. When other examination procedures fail to disclose the nature of the condition, and the patient is not responding favorably to care.

6. To characterize the biomechanical component of the vertebral subluxation complex when such characterization would likely alter the chiropractic care (i.e. the direction and locations of adjustive intervention) and less hazardous or more accurate alternative examinations are not available.

7. To evaluate patient response to chiropractic care when such evaluation may alter the nature of the care being rendered, and less hazardous or more accurate alternative examinations are not available. (5)

Vertebral subluxation

Vertebral subluxations have been implicated as significant etiologic factors in a variety of conditions. (6,7,8,9,10) Subluxation can also be associated with congenital or developmental variation. (11) Many vertebral subluxations are asymptomatic, or produce symptoms quite distant from the anatomical site of involvement. (12) However, spinal subluxations may also associated with local tenderness. (13) Thus, it is important for the chiropractor to recognize the far reaching consequences of vertebral subluxation in the developing spine. The use of plain film spinography to characterize subluxations is indicated if the information to be gained cannot be obtained through clinical examination (14).

References

1. Gelardi T, Miller J, Drake M, Barge F, Healey J: “Questions and answers regarding SCASA memo.” Dynamic Chiropractic 8(5):37,1990.

2. Yochum T, Rowe L: “Essentials of Skeletal Radiology.” Williams & Wilkins. Baltimore, MD, 1987.

3. Ellett W: “Biological Effects of Ionizing Radiation (BEIR V).” National Research Council. Washington, DC, 1990.

4. “X-Ray Examinations — A Guide to Good Practice.” U.S. Department of Health, Education, and Welfare, Public Health Service. Washington, DC, 1971.

5. Kent C, Plaugher G, Borges D, et al: Chapter 8. “Diagnostic Imaging.” In: Anrig C, Plaugher G: “Pediatric Chiropractic.” Williams & Wilkins. Baltimore, MD. 1998.

6. Gutmann G: “Blocked atlantal nerve syndrome in infants and small children.” International Review of Chiropractic 46(4):37, 1990. (Reprinted from Manuelle Medizin Springer-Verlag, 1987).

7. Fysh P: “Upper respiratory infections in children: a chiropractic approach to management.” International Review of Chiropractic 46(3):29.

8. Klougart N, Nilsson N, Jacobsen J: “Infantile colic treated by chiropractors: a prospective study of 316 cases.” JMPT 12:281,1989.

9. Hart D, Libich E, Fischer S: “Chiropractic adjustments of the cervicothoracic spine for the treatment of bronchitis with complications of atelectasis.” International Review of Chiropractic 47(2):31.

10. Barge FH: “Wryneck.” Printed by Palmer Publications, Inc. Amherst, WI. 1998.

11. McMullen M: “Handicapped infants and chiropractic care: Down syndrome — Part I.” International Review of Chiropractic 46(4):32,1990.

12. Janse J, Houser R, Wells B: “Chiropractic Principles and Technic,” Chicago, IL. National College of Chiropractic, 1947. P. 235.

13. Ibid P. 312

14. Kent C: “An overview of pediatric radiology in the chiropractic practice.” International Review of Chiropractic 46(4):45, 1990.

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Dr. David Fletcher is actively involved in all aspects of innovation teaching and research connected to the INSiGHT™ scanning technologies. He is widely recognized for his ability to share his expertise in compelling and easy to understand ways.

Dr David is a renowned chiropractor who practiced for many years with his associates in a scan-centric thriving principled family-based practice in Toronto. He is a sought-after teacher mentor and keynote speaker who takes every opportunity to share the wisdom and the power of chiropractic as it is meant to be.

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Dr. David Fletcher
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Seeing RED: A Guide to Scan Interpretation and Communication

This RED E-Book summarizes the chiropractic paradigm while providing a concise and easily remembered protocol to use when both performing and sharing scan data. It has been designed to be used by staff members and doctors as a communication tip sheet.

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In traveling throughout the chiropractic world, I frequently encounter D.C.s who mindlessly regurgitate misinformation with the demeanor of one who has spoken directly with God. Examples are, “X-ray is useful only for pathology; line drawing is unreliable” or “14 x 36 full spine films expose the patient to more radiation than sectional studies” and the ever popular “there is no such thing as subluxation.”

Tracking down the primary source of this garbage poses a formidable challenge. But in many cases, it is easy to identify the messenger — a lazy chiropractic college faculty member who hasn’t bothered to check the facts, or, worse, is promoting a political agenda. Thankfully, these individuals are rare, but every college seems to have at least one. Students say these folks speak with such authority that they are rarely questioned. Some mention “recent studies” for which citations are rarely offered.

Let’s begin by examining the accuracy of lumbar spine film interpretation for pathology. A study was conducted where medical and chiropractic radiologists, medical and chiropractic clinicians, as well as medical and chiropractic students took a test on radiographic interpretation consisting of nineteen cases of clinically important findings. (1)

Here’s how they did (percent correct):

  • Chiropractic radiologists — 71%
  • Skeletal radiologists and fellows (medical) — 70.18%
  • General medical radiologists — 51.64%
  • Medical clinicians — 31.26%
  • Chiropractic clinicians — 28.8%
  • Chiropractic students — 20.45%
  • Medical students — 5.74%

While it is gratifying that the D.C.s in the study outperformed their medical counterparts, where I went to school 71% was failing — at best a low “D.” With general medical radiologists (board certified) the results are barely above 50%. It’s a good thing these folks aren’t taking chiropractic licensing exams.

The other results speak for themselves. Please realize I am not suggesting that radiography be abandoned, or that all films must be read by a radiologist. I am simply trying to demonstrate that radiographic assessment of pathology is a very imperfect art.

So much for pathology. What about line drawing? Is it reliable? Reliability studies investigating several systems of biomechanical analysis have been published. A sampling follows.

Plaugher and Hendricks evaluated the inter-examiner reliability of the Gonstead pelvic marking system. Agreement for categorizing listings was impressive. Inter-examiner concordance for listings of the ilia, sacrum, symphysis pubis, and femur head height was evaluated by calculating the kappa values for each. The resulting kappa values ranged from .4849 (moderate) to .8161 (excellent). (2)

In addition to Gonstead pelvic analysis, proponents of 14 x 36 full spine radiography also use the procedure to evaluate vertebral body rotation and lateral flexion malposition. Zengel and Davis investigated how projectional distortion affects such determinations. They concluded, “as long as a given osseous segment is compared to its adjacent segment (as in analysis for subluxation), the apparent vertebral rotation may be regarded as a sufficiently accurate representation of the actual rotation of the vertebra.” (3,4)

Studies have yielded results supporting the reliability of cervical spinographic techniques. The preponderance of evidence supports the reliability of these procedures when properly performed.

Grostic and DeBoer did a retrospective study of 523 patients evaluating roentgenographic measurements of atlas laterality and rotation pre and post adjustment. Statistically significant changes in the postulated direction of atlas positioning were reported. (5)

Jackson et al. studied the inter-and intra-examiner reliability of upper cervical x-ray marking. Six practitioners evaluated 30 radiographs. The study revealed very good intra- and inter-examiner reliability for the procedure employed. (6) Leach investigated the effect of chiropractic care on hypolordosis of the cervical spine. A significant improvement in the cervical curve was noted in patients receiving chiropractic care. (7)

The inter- and intra-examiner reliability of certain mensuration procedures in the lumbar spine ranged from .66 to .98 in a study by Troyanovich et al. (8) The inter- and intra-examiner reliability of cervical geometric line drawing procedures used in the Chiropractic Technique ranged from .72 to .98. (9)

One negative study is often cited by critics of upper cervical spinographic analysis. Sigler and Howe conducted an inter- and intra- examiner reliability study of a method for measuring atlas laterality. Twenty x-rays were marked by three different doctors. This study concluded that because of the ranges of error, differences produced using this system will be just as likely due to marking error as from actual atlas position change. (10) This study has several significant shortcomings. These include small sample size and a conclusion which cannot properly be drawn from the data presented.

What about the radiation levels of full spine vs. sectional radiography? Dosimetry studies using supplemental filtration and single-speed screens revealed that the 14 x 36 AP spinograph actually resulted in lower radiation levels than sectional AP films of like-sized subjects. As Hildebrandt observed, “It has been shown that it is possible to produce reasonably good diagnostic quality full-spine roentgenographs with less radiation exposure to the patient than when the same full-spine areas are exposed by smaller sectional views.” (11)

Phillips stated, “Anteroposterior views of the spine on a 14 x 36 inch exposure can be produced with acceptable quality.”(Ref #) Hildebrandt cites a comparative study conducted by the Bureau of Radiological Health stating, “In this study, it was shown that it was in fact possible to obtain diagnostic full-spine films with a skin dose exposure as low as 128.8 mR, while separate lumbar and thoracic films taken according to standard exposure practices delivered 166.1 and 184.5 mR respectively.” (12)

Buehler and Hrejsa evaluated lead-acrylic compensating filters in chiropractic full-spine radiography. The concluded that this system “is capable of producing full spine radiographs with good to above average imaging quality.” It was further noted that this filtration system was generally equivalent in radiation dose reduction to other systems. (13)

It’s time to stop perpetuating acquired ignorance. Challenge those making questionable claims to substantiate their pompous proclamations with references. Do your homework, and think for yourself.

References

1. Taylor JAM, Clopton P, Bosch E, et al: “Interpretation of abnormal lumbosacral spine radiographs. A test comparing students, clinicians, radiology residents, and radiologists in medicine and chiropractic.” Spine 1995;20(10):1147.

2. Plaugher G, Hendricks AH: “The interexaminer reliability of the Gonstead pelvic marking system.” Proceedings of the 1990 International Conference on Spinal Manipulation. Arlington, VA, 1990, pp 93-98.

3. Zengel F, Davis BP: “Biomechanical analysis by chiropractic radiography: Part II. Effects of x-ray projectional distortion on apparent vertebral rotation.” J Manipulative Physiol Ther (1988 Oct) 11(5):380-9.

4. Zengel F, Davis BP: “Biomechanical analysis by chiropractic radiography: Part III. Lack of effect of projectional distortion on Gonstead vertebral endplate lines.” J Manipulative Physiol Ther (1988 Dec) 11(6):469-73.

5. Grostic JD, DeBoer KF: “Roentgenographic measurement of atlas laterality and rotation: a retrospective pre- and post-manipulation study.” J Manipulative Physiol Ther (1982 Jun) 5(2):63-71.

6. 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 Aug) 10(4):157-63.

7. Leach RA: “An evaluation of the effect of chiropractic manipulative therapy on hypolordosis of the cervical spine.” J Manipulative Physiol Ther (1983 Mar) 6(1):17-23.

8. Troyanovich S, Robertson G, Harrison D, Holland B: “Intra- and interexaminer reliability of the Chiropractic Biophysics lateral lumbar radiographic mensuration procedure.” J Manipulative Physiol Ther (1995 Oct) 18(8):519-524.

9. Jackson B, Harrison D, Robertson G, Barker W: “Chiropractic Biophysics lateral cervical film analysis reliability.” J Manipulative Physiol Ther (1993 Jul) 16(6):384-391.

10. Sigler DC, Howe JW: “Inter- and intra-examiner reliability of the upper cervical x-ray marking system.” J Manipulative Physiol Ther (1985 Jun) 8(2):75-80.

11. Hildebrandt RW: “Chiropractic Spinography.” Des Plaines, IL. Hilmark Publications, 1977, p. 18.

12. Phillips RB: “The use of x-rays in spinal manipulative therapy.” In Haldeman S (ed) “Modern Developments in the Principles and Practice of Chiropractic.” Norwalk, CT. Appleton-Century-Crofts, 1980, p. 204.

13. Buehler MT, Hrejsa AF: “Application of lead-acrylic compensating filters in chiropractic full spine radiography: a technical report.” J Manipulative Physiol Ther (1985 Sep) 8(3):175-80.

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Dr. David Fletcher is actively involved in all aspects of innovation teaching and research connected to the INSiGHT™ scanning technologies. He is widely recognized for his ability to share his expertise in compelling and easy to understand ways.

Dr David is a renowned chiropractor who practiced for many years with his associates in a scan-centric thriving principled family-based practice in Toronto. He is a sought-after teacher mentor and keynote speaker who takes every opportunity to share the wisdom and the power of chiropractic as it is meant to be.

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Dr. David Fletcher
DC FRCCSS(C) – Founder & CEO CLA Inc.
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INSiGHT Communication Guide

This quick read covers the importance of communicating clearly and simply to your practice members.

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In my November 1998 column (“The Mental impulse,” page 32), I presented an historical overview of the mental impulse. I stated that the mental impulse, as described by the Palmers, is not synonymous with Innate Intelligence or the neurochemical action potential. It is a “thought” which may be expressed through a variety of neurobiological mechanisms. These mechanisms include synaptic and non-synaptic processes. Boone and Dobson (1) described a model of vertebral subluxation which includes interference to action potential and interference to mental impulse.

In 1969, the physiologist Hewitt (2) proposed a classification of physical mechanisms associated with signaling in the human body:

1. Diffusion of particles along concentration gradients.

2. Diffusion of quanta along electromagnetic gradients.

3. Circulation within structured channels.

4. Wave propagation.

Diffusion of particles along concentration gradients includes osmosis and diffusion. It also involves the exchange of water and solutes at physical interfaces, and between body compartments.

The second mechanism, diffusion of quanta along electromagnetic gradients, includes well-established processes such as temperature gradients and vision. However, it has the potential to explain field effects and other non-synaptic mechanisms of information exchange.

Circulation within structured channels describes the flow of blood, lymph, cerebrospinal fluid, and axoplasma. Biochemical mediators may be transmitted through these channels, as well as trophic factors, nutrients, hormones, and metabolic by-products.

Wave propagation refers to compression/rarefaction cycles, such as sound waves, and rectilinear displacements, such as arterial pulsation.

These physical mechanisms are operative in both linear, synaptic processes and non-linear, non-synaptic processes. As an example of a non-synaptic mechanism of neurologically mediated communications, consider the neuropeptide network.

Pert (3,4) and associates described a “psychosomatic network” composed of neuropeptides. It has been postulated that the neuropeptide-receptor system is a bidirectional communication system between the nervous system and immune system, as immunocytes produce neuropeptides and nerve cells produce immune-associated cytokines. Pert describes this system as “parasynaptic.” (5)

Neuropeptides are short chains of amino acids. The dorsal horn of the spinal cord is richly endowed with neuropeptide receptors. Since the dorsal horn is where sensory information from the periphery makes synaptic contact with the central nervous system, it is noteworthy that a non-synaptic or “parasynaptic” mechanism shares the same anatomical locus.

Neuropeptides have been described by Pert as “the biochemical substrates of emotion,” who noted that core limbic brain structures are infused with neuropeptide receptors (5).

The significance of this non-synaptic system is profound, and demonstrates that the concept of a “mental impulse” has a biological basis beyond the “hard wired” system of electrochemical nerve impulses.

As Pert wrote, “The bodymind can no longer be wholly characterized as a hierarchal system of hard-wired connections that descend down from a putative ruling station (the brain), but rather as an expansive network of free-flowing information transmitted by molecules that enter at any nodal point and move rapidly to any other point.” (6)

Pert’s insight is clearly compatible with the chiropractic concepts of innate intelligence and mental impulse. Pert wrote, “The integrity of the bodymind is protected and preserved by an internal healing system — a multidimensional entity guided by emotions and their biochemical substrates — vibrating with intelligence and purpose, without functional boundaries inside the human organism.” (5)

References

1. Boone WR, Dobson GJ: “A proposed vertebral subluxation model reflecting traditional concepts and recent advances in health and science.” Journal of Vertebral Subluxation Research 1996;1(1):19.

2. Hewitt WF: “Somatic aspects of applied physiology.” In Hoag JG (ed): “Osteopathic Medicine.” McGraw-Hill Book Company. New York. 1969.

3. Pert CB, Ruff MR, Weber RJ, Herkenham M: “Neuropeptides and their receptors: a psychosomatic network.” J Immunol 1985;35(2):820s.

4. Pert CB: “The wisdom of the receptors: neuropeptides, the emotions, and bodymind.” Advances 1986;3(3):8.

5. Pert CB, Dreher HE, Ruff MR: “The psychosomatic network: foundations of mind-body medicine.” Alternative Therapies 1998;4(4):30.

6. Pert CB: “The Molecules of Emotion: Why We Feel The Way We Feel.” Scribner. New York. 1997.

Get Started with INSiGHT Scanning

Take our Free Practice Strategy Assessment. A Personalized Guide and Expert Strategy Call to Help Determine How Scanning will Help you Grow
ABOUT THE AUTHOR

Dr. David Fletcher is actively involved in all aspects of innovation teaching and research connected to the INSiGHT™ scanning technologies. He is widely recognized for his ability to share his expertise in compelling and easy to understand ways.

Dr David is a renowned chiropractor who practiced for many years with his associates in a scan-centric thriving principled family-based practice in Toronto. He is a sought-after teacher mentor and keynote speaker who takes every opportunity to share the wisdom and the power of chiropractic as it is meant to be.

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Dr. David Fletcher
DC FRCCSS(C) – Founder & CEO CLA Inc.
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INSiGHT Communication Guide

This quick read covers the importance of communicating clearly and simply to your practice members.

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