It has been observed clinically that changing the pattern of thermographic readings or balancing the paraspinal temperature correlates with a successful spinal Adjustment. Historically, upper cervical specific practitioners have used two methods of interpretation: pattern and break analysis. Dr. John F. Grostic preferred the break analysis for the assessment of the upper cervical Subluxation. A break is determined whenever the instrument’s graph line deviates laterally at an angle of approximately 45°, with a range of 30 to 60° (Fig. 10-2). The break must also exceed a certain threshold of deviation (Fig. 10-3). This may be a function of the particular instrument, rate of glide, ambient room temperature, and/or thermal state of the patient.

Various infrared temperature devices have been shown to have great value, but the dual-probe thermocouple instruments (e.g., Neurocalometer, Nervoscope) have the longest clinical track record in upper cervical practices. Thermocouple instruments consist of two thermal sensors composed of wires of two dissimilar metals. These wires are connected at two different junctions—one for temperature measurement and the other for a reference. The temperature difference between the two junctions is detected by measuring the change in voltage (electromotive force) across the dissimilar metals at the temperature measurement junction. The dual-probe
thermocouple instrument can be connected to a graphing device to help with interpreting the patient’s scan.

A disadvantage of thermocouple instruments is that they require skin contact. However, one advantage they have over infrared instruments is that they can obtain readings into the hairline with greater accuracy because of the instrument–patient contact. A thermocouple graph is obtained by first having the patient sit erect in a room with relatively even temperature and away from any heating and cooling vents. The glide can begin at the level of T1, although Grostic recommended starting the scan at the level of C5-C6. The paraspinal scan ends at the inferior nuchal line. Great care must be given to keeping the probes Perpendicular to the contour of the neck while maintaining firm but not excessive pressure (Fig. 10-4). The contact must be of equal pressure on both sides of the paraspinal region.

False breaks can result from improper technique (i.e., unequal pressure, losing contact unilaterally or bilaterally). Various skin lesions can also affect the readings, although the patient should be evaluated before the scan for this reason as well as sanitary reasons. Scar tissue, moles, wrinkles, and excessive hair can also affect the Reliability of the readings. A false-negative scan can result from the patient’s use of nicotine, caffeine, or certain medications within a few hours before the thermal scan. Grostic thought that an accurate thermal analysis should correlate with an imbalance of the Supine leg check of at least 3/16 inch if the patient was subluxated.

Pattern analysis is another system of interpretation used with dual-probe thermometry. It has been Hypothesized that an upper cervical Subluxation causes a patient’s paraspinal temperature readings to maintain a consistent pattern. This is established by obtaining three readings over separate time intervals before beginning care. This pattern analysis is used as a primary indicator for the need for an upper cervical Adjustment. The Hypothesis is that an optimum functioning autonomic nervous system is in a constant state of change as the body adapts to the environment to maintain homeostasis. Hart and Owens⁸ found that once a patient’s back is exposed to room temperature, the pattern of paraspinal skin temperature stabilized after an average of 16 minutes. The pattern analysis is more commonly used among doctors using Blair, knee chest, and Toggle recoil techniques.

Owens et al.⁹ tested the inter- and Intraexaminer Reliability of paraspinal, infrared thermal scans using the TyTron C-3000 and found intraclass correlation coefficient (ICC) values between 0.91 and 0.98. DeBoer et al.¹⁰ also found impressive inter- and Intraexaminer Reliability (0.639–0.998 ICC) for another type of infrared heat–measuring instrument. The Gonstead Nervoscope (a thermocouple device) was found to have fair to good Interexaminer Reliability as it is used to find segmental “breaks” on the graph. Moderate to excellent Intraexaminer Reliability was found as well.¹¹ James has presented research showing a high degree of inter- and Intraexaminer Reliability in both conducting dual-probe thermocouple scans of the posterior neck¹² and in the
interpretation of the results.¹³ He has also found a high degree of correlation between paraspinal Palpation and Thermocouple scanning in assessing patients for upper cervical Subluxations.¹⁴ These same tests showed improved changes after Orthospinology Adjustments were provided.

The rolling thermal scanner Works best in a stable environment with a temperature between 70 and 80°. Doors, entryways, and windows should be closed, and sunlight should not be directed on the thermal scanners. The exam area should not be in the immediate vicinity of heating or air-conditioning vents. If a full spine examination is conducted, women must be placed in a gown, and men must take off their shirts. This is not necessary if only a cervical scan is conducted and the patient is wearing clothing that leaves

the neck accessible. All necklaces and earrings must be removed before conducting the evaluation. Patients with long hair must have it pulled back and off the neck. At this point, allow at least 5 minutes for the patient’s skin to acclimate to the exam room’s ambient temperature. For obvious reasons, the patient’s spine must not be palpated or touched before starting the thermal scan.

The first step involves placing the thermal scanner at the base of the patient’s spine at the level of S1, while waiting at least 5 seconds for the initial temperature to stabilize. The scanner is then rolled slowly up the spine until reaching the top of the cervical spine. If only a cervical examination is conducted, then the instrument will be placed at the level of C7 to begin the scan. The doctor/technician will then place the scanner at like points on each side of the neck at C1, between the hairline and ear, after the rolling thermal scan is completed.

Under some circumstances, excess electrical noise can adversely affect the collection of sEMG data. Examples of some devices that may cause such interference include X-ray view boxes; additional computer monitors; television screens; fluorescent, halogen, or neon lights; stereo subwoofers; and autoclaves. If any of the above devices are present in the exam area, they should be turned off or removed before the sEMG scan is being performed. A bare tiled or wooden floor is recommended for the exam area, as carpet can produce static electrical buildup on the patient, the examiner, and the equipment. If the exam area is carpeted, an antistatic mat is recommended. Software incorporating digital signal processing may be used to filter out undesired signals.

A patient coming in for an sEMG scan should not be taking any medication that would affect muscular activity (i.e., muscle relaxants, steroids) and should refrain from any strenuous muscular activity in the hours before the sEMG scan. However, the patient should consult with his or her medical physician before discontinuing prescribed medication. To prepare for the examination, men must remove their shirt and women must get into a gown. Long hair must be pulled up and off the patient’s neck or back, and necklaces need to be removed. The patient’s spine is then wiped down with isopropyl alcohol and allowed to dry. The patient should be sitting with both feet flat on the floor and hands palms up resting on the lap, looking straight ahead, and remaining as stationary as possible. The patient should be reminded to relax during the examination to help obtain stable signals more rapidly.

When using the sEMG scanners, the doctor/technician should apply enough pressure to indent the patient’s skin somewhat, as this will help to assure that a good ground is established (Fig. 10-8). The doctor/technician should be sure to stay out of the hairline when scanning C1 and C3. The sEMG scanner tips should be lightly dipped onto a sponge that is soaked in alcohol. The sponge can be held in a small jar, and the dipping process should take place about every other scan level. The doctor monitors the blue and red polygraph lines on the computer screen as the handheld scanners are placed on the patient. The blue line represents the microvolts that are picked up from the right scanner, and the red line represents the sEMG signal from the left handheld scanner. The foot pedal should not be pressed to record a segmental reading until these lines on the monitor graph have stabilized.

The lines on the graph do not have to come together; in fact, if there is muscle asymmetry, the lines will never come together. A stable signal will show that both lines are close to being horizontal and have a relatively smooth configuration. However, if the patient’s muscles are severely Hypertonic, the lines may never stabilize because of increased spasm. In these cases, the foot pedal should be pressed at the center of the ranges. The following levels are assessed for sEMG activity: C1, C3, C5, C7, T1, T4, T6, T8, T10, T12, L1, L3, and L5. The patient’s microvolt readings are compared with a normative
database³² to determine if they are within the normal range or if the readings are 1, 2, or 3 SDs above normal and are represented as green, blue, or red, respectively. Levels that are found to be below normal, or microvolt readings found to be >3 SDs above normal, are represented on the report as yellow and black, respectively.

The software can also assess the patient’s muscle tone asymmetry by depicting the amount of muscle contraction from one side to another. This is important because one of the Orthospinology doctor’s primary visit-by-visit assessments is the Supine leg check. This evaluation provides a qualitative assessment of the imbalance in paraspinal postural muscle tone, whereas the sEMG can provide a quantitative assessment. The Insight™ sEMG report will reveal either white spikes or no spikes that denote normal symmetry; green, blue, and red represent mild, moderate, and severe levels of muscle asymmetry, respectively. The program produces a color graphical display to demonstrate the examination findings, and a copy can be provided to the patient and placed in the case file (Fig. 10-9).

The Insight™ also has the capability of conducting dynamic sEMG scans that can track up to four channels of muscle activity while the patient goes through various ROM activity. The electrodes can be affixed to the paraspinal region(s) being examined. The patient is typically asked to move the neck and/or low back through flexion and extension, as well as bilateral lateral flexion and rotation. The computer provides a graphical display that demonstrates the magnitude of paraspinal muscular contraction and relaxation that results. The flexion-relaxation phenomenon was previously explained; however, the doctor should be interested in determining the degree of left to right symmetry of the graphic display for lateral flexion and rotation.

The Norotrack Analyzer 360 system (Myotronics-Noromed, Inc.) is another option for assessing dynamic motion of the spine. This technology can provide valuable information regarding ROM, motion control (smoothness of recording data), consistency, coordination, and timing of the movement. The Norotrack 360 uses dynamic tracking technology, which simultaneously records the motion of two segments of the spine and displays it in a graphical representation on the computer screen. This system documents the active motion of the spine by providing quantity (static ROM) and quality (pattern) of movements. Each ROM can be measured three consecutive times to establish an average. If the mean measurement is <50°, then each of the three movements should fall within 5° of the average. If the mean ROM is >50°, then each of the three measurements should fall within 10% of the average.⁷⁶ This assessment can be referred to as the Validity test, which ensures that the doctor has accurate data, and as a secondary screening for possible malingering. Another Validity test for lumbosacral flexion and extension involves the use of the straight-leg-raising angle with the ROM.

Cervical ROM is measured by attaching lightweight inclinometers to a Velcro strap that is placed on the head. The examiner holds the inclinometer at the level of T1, although Velcro straps are available for this region as well. The inclinometer is held by the examiner so that it will move with the patient’s body as they move through the ROM (Fig. 10-10). The recording of the sensor at T1 is subtracted from the recording at the head to produce the differential recording graph, which
represents the true motion of the patient’s cervical spine during flexion, extension, and lateral flexion motions. Measuring cervical rotation involves the use of one inclinometer with the patient in the supine position. The Insight and Norotrack technologies are also capable of recording ROM of the thoracic and lumbar spine, as well as extremities. The software compares the patient’s readings with normative data retrieved from the Guides to the Evaluation of Permanent Impairment.⁷⁶

Cervical scanning Palpation is conducted by gently cradling the patient’s head with the doctor’s left hand (assuming the doctor is right-handed). The right side of the patient’s cervical spine is palpated with the distal end of the middle and/or index finger of the right hand, while the left side is examined with the distal end of the right thumb. The pressure applied to the cervical spine during the examination should be sufficient to produce moderate compaction of the soft tissue over the articular/neurological structures. Digital pressure is initially applied over the C1 spinal nerve area inferior to the occiput and superior to the posterior lateral aspect of the atlas posterior arch. Palpation is done one side at a time, and care should be made to use equal pressure on each side of the patient’s cervical spine. Next, digital pressure is applied over the region of the C2 spinal nerve ganglion, which is located inferior to the C2 posterior arch and superior to the axis lamina (Fig. 10-11). Palpation can continue down to the mid- or lower cervical spine and should be directed to the soft tissue over the cervical facet joints. Palpatory findings should be recorded in the patient’s office visit note as normal, mild, moderate, or severe (e.g., 0, +1, +2, +3). This is based on the subjective response of the patient as well as the results of the doctor’s own Palpation.

Deboer et al.⁸⁴ found statistically significant agreement for segmental fixation findings in the lower cervical spine, total lack of agreement in the middle cervical area, and intermediate Reliability for the upper cervical
region, as well as other Palpation parameters (e.g., muscle spasms, pain). Another study assessed passive intervertebral motion of three cervical segments and the mobility of the first rib. Sixty-one patients seeking care for cervical problems were evaluated by two physical therapists. The results demonstrated Interexaminer Reliability of between 70% and 87% and kappa coefficients ranging between 0.28 and 0.43, which is considered to be only fair to moderate.⁸⁵ A systematic review of the literature found that overall Interexaminer Reliability for motion Palpation in the cervical and lumbar spine was poor to fair.⁸⁶ However, assessment of motion segments C1-C2 and C2-C3 almost consistently reached at least fair Reliability. Indeed, the preponderance of evidence indicates that the Reliability of cervical motion Palpation is relatively poor.⁸⁷,⁸⁸,⁸⁹,⁹⁰,⁹¹,⁹²,⁹³ Orthospinology protocol does not typically include motion Palpation of the cervical spine because of the kinematic complexity of the upper cervical region and lack of Reliability of the evaluation from an evidence-based standpoint.