Introduction - Review of Course Syllabus and Course Outline, review of handout materials, discussion regarding class conduct and course objectives. Identification and assignment of individual student's filling out the General History Questionnaire and the History of neuromusculoskeletal Injuries and Disorders. Introduction to the structural model of clinical evaluation and case management, with emphasis on a whole-person, holistic approach to health care. Review of definition(s) of subluxation and the difference between adjustment and manipulation. Review of a case study which compares the outcome of care rendered to a 24-year-old female engineering student who had approximately 36 cervical "manipulations" over a course of three months (without the benefit of x-ray or a whole-person structural evaluation) in her effort to obtain relief and/or correction for her severe, disabling headaches with a gradual worsening of her symptoms; followed by x-ray evaluation and the application of a whole person, full-spine structural approach to her case management which yielded a total recovery within six weeks of care and remaining essentially asymptomatic through a documented six month period of follow-up monitoring.

Introduction of the AP and lateral, erect-posture, load bearing 14"x36" x-ray studies with discussion regarding advantages and disadvantages of using this specialized mode of radiographic assessment. Emphasis on appropriate filters, columation, gonadal shielding, speed of film and exacting calculation of body mass to assure optimal radiation exposure factors. Review of need to have x-ray equipment mounted properly to assure true vertical and true horizontal positioning of the film within the cassette. Affirmation of need for proper right angle tracking of the tube in relation to the bucky and appropriate positioning of the cassettes within the bucky to assure total visibility of the entire pelvis and all bony landmarks required to be able to do an accurate static) structural analysis of the patient's x-ray images. The reality of projectional error is also discussed with appreciation of the need to take this into consideration in evaluation of the findings. An actual exposed x-ray film of the image of a nineteen-year-old male subject is used for the above example and demonstration. A reminder is extended regarding the reading right and reading left of the film so that it is interpreted as if the patient's has his/her body facing away from the viewer. The need to do a critical assessment of the x-ray study regarding the presence or absence of bone, joint or soft tissue pathology; fracture, either recent or ancient; and/or congenital anomaly(ies) which may be present. Following this critically important initial assessment process, the study is then evaluated for evidence of structural stress, distortions, deformity(ies) and subluxations. Review of appropriate positioning of the patient in relation to the bucky to obtain optimal assessment is reviewed with suggestions to use the feet as the "base of support" and assess the body's mass in relation to the feet which are placed equidistantly from the midline of the bucky and with the heels perpendicular to the face of the bucky and the forefeet in a comfortable toe-in/toe-out position which approximates the patient's most natural, neutral posture.

Commencement of a 35 mm color slide program entitled, The Subluxation Complex. Slide demonstration of "normal" structure as depicted on line-drawing schematics of the skeletal framework in the antero-postero and lateral planes, using the feet as the body's base of support and reference point. This is followed by slides of a human adult male subject depicted in a plumb-line analysis in the AP and lateral planes demonstrating optimal axial loading and the ideal transfer of the body's mass over its base of support, thus representing the "normal" or non-subluxated state. Immediately following the above pair of slides, another adult male subject is depicted which clearly demonstrates a shift of the body's mass from optimal axial loading, demonstrated in both the AP and lateral planes, representing the "abnormal" or subluxated state. The next group of slides depict x-ray representations of the pelvis and spine, while in the neutral erect posture as well as in lateral bending and flexion and extension all of which demonstrate the "normal/non-subluxated" state.

The same 14"x36" x-ray studies as used the previous week are mounted on the view boxes in the lab and the hour is spent in demonstrating the actual physical marking of the pelvic image, based on the "Gonstead" system of x-ray analysis. A brief overview as to the rationale for choosing this particular system and its advantages over other systems in use within the profession. Students are shown how to systematically analyze the pelvis for tilt, twist and torque considerations as well as a side-sway distortion pattern. A discussion regarding limb-length discrepancies and the various factors which can cause the appearance of anatomical limb-length differences, including the variety of factors to consider in the determination of the presence of true anatomical limb-length differences.

Ten question quiz will be given

Class begins with a brief review of the normal depictions as shown during last week's slide presentation. After students have a clear appreciation of how structural "normal" appears on plumb-line and x-ray evaluation, they are then shown slides of examples of schematic, x-ray and plumb-line representations of structural faults, pelvic and spinal deformity, distortion and subluxation as represented by shifts from optimal axial loading, disturbances in the body framework and deviation from normal. A review of the three most common translations from normal found in spinal subluxations, including lateral flexion right or left, right or left rotation and extension or flexion is provided, with schematic and slide representations of radiographic manifestations of these malpositions. Discussion regarding the difference between spinal and skeletal joint "subluxation" and joint "fixation" and the need to critically assess the presence (or absence) of true subluxation as manifested by joint surface disrelationship and meeting all of the criterion to fulfill the "P.A.R.T.S." acronym, which refers to "pain or point tenderness"; "asymmetry" (malposition); "restriction of motion" (fixation) and changes in "tone, texture and turgor". In the evaluation for spinal subluxation, emphasis is placed on the integrity (or loss thereof) of the intervertebral disc. Deformation of healthy disc tissue is normally notably limited and when, through radiographic evaluation, combined with plumb-line, static and motion palpation, discal deformation is manifest, it is considered a significant sign of true spinal subluxation. Subluxation can only result from a breakdown of the holding elements of a joint, (ligaments, cartilage and capsules, i.e., sprain), and result from a wide variety of stresses the body is exposed to over a lifetime. True spinal subluxation, (as defined by traditional medical dictionaries) represents a (pathological) condition which meets the above criterion and results globally in a shift of the body's mass away from the midline in the AP plane or disturbs the normal, long, smooth uninterrupted arcs of the spinal curves in the lateral plane. On a local or regional level, subluxation results in a disturbance of optimal axial loading and loss of hydrostatic load transferring efficiency of the IVD resulting in a loss of efficient function of the three-joint complex of the spinal motor unit. This results in localized ischemia and neurological insult, pain and the potential for a wide variety of functional disturbances.

Using the same full-spine x-ray studies as during week one and week two, a brief review of pelvic evaluation and film marking is provided. After a basic understanding of the eight-joint pelvic mechanism and it potential subluxations has been achieved, students are taught how to identify the radiographic manifestations of spinal subluxation. A review of the engineering terms "load moment. bending moment and buckling point" is provided, which results from the presence of spinal subluxation. Load moments are considered the site of maximum stress in a loading system. Students are taught the means of reducing spinal subluxation for the purpose of reducing "load moments" and spinal stress, both locally/regionally as well as globally, with an end objective of restoring more optimal axial loading efficiency of the spine and balanced (or improved) distribution of the body's mass over its base of support.

Students will practice marking their own erect posture, load-bearing radiographic studies of the pelvis and spine.

Ten question quiz will be given

A continuation of review of slides representing actual patients, depicting a variety of subluxation/distortion patterns including the depiction and description of individual cases. Each case is presented from its unique perspective, including the patient's presenting symptoms and history, including mechanisms of onset/injury/pathology, physical, orthopedic, neurologic, clinical laboratory, radiographic assessment, diagnosis and evaluation and finally the chiropractic intervention case management and discussion regarding clinical outcomes whenever relevant.

By the fourth week, following a brief review of the basic fundamentals of structural assessment and clinical case management, a symptomatic student is selected as a volunteer for demonstration purposes. The student "patient" provides the class with relevant history, presenting/ongoing symptoms, previous care and current status. The student also permits and provides the use of his/her x-ray studies, which are evaluated and marked by the instructor, using the system described and taught during the previous three weeks. Students observe the x-ray evaluation process and questions and discussion is encouraged. The students all have the opportunity to participate in the history gathering process and an effort is made to correlate history findings, mechanisms of injury or insult to the body and x-ray findings when relevant. Students observe the x-ray marking process and have the opportunity to clarify questions they may have about the step-by-step process of accomplishing this task. To facilitate an expeditious overview of the physical, orthopedic, neurological, laboratory and related assessment components of the examination phase of the demonstration, reliance on the student patient to provide relevant data is extended. Only tests which may add to the base of awareness the student patient brings are conducted for demonstration purposes. Following an understanding of the probable nature and severity of the student patient's disorder a chiropractically oriented care plan is expressed and reviewed with the class participants as well as the student volunteer patient. Specific focus and emphasis is placed on the identification and reduction of the spinal, pelvic and extremity subluxations which may be present within the student patient.

A key component of the structural analysis of the student patient is through the use of a standard plumb-line apparatus, used primarily with the objective of correlating the erect-posture, load bearing x-ray studies with observations made of the student patient positioned within the plumb-line.

Students are also introduced to the application of the use of hand lotion as a means of facilitating more accurate spinal and pelvic palpation.

Permission is sought from the student patient to proceed with demonstration(s) of the specific manual adjustive procedures involved which are designed to reduce the subluxation complex and restore the body to a more optimal axial loading capability both at the individual motion segment (regional considerations) as well as from a global perspective as demonstrated by before and after plumb-line observations.

The student patient receives his/her first adjustment based on the structural analysis described above.

The discussion time for week eleven will devoted to the topic of Type II Round Back Deformity. Prevalence, gender distribution, radiographic considerations and potential clinical consequences of the disorder will be discussed along with chiropractic therapeutic interventions described.

A test for involvement of the piriformis muscle will be demonstrated for its potential role in the sciatic nerve syndromes.

Ten question quiz will be given

Continuation of slides representing patients with a variety of structurally related disorders and examples of specific subluxation patterns. Clinical history and assessment details are provided as part of each of these individual case study presentations.

The same volunteer student patient is interviewed regarding the outcomes/experiences regarding the specific adjustment he or she was given the previous week. The student is observed in the plumb-line and assessed from AP, P.A. and lateral dimensions as previously. The student/patient is adjusted once again based on the same diagnostic and therapeutic principles as before.

Students are invited to participate in the palpation process, having an opportunity to experience the unique sensation that is exhibited by the tissues surrounding a true subluxation. Changes in the tone, texture and turgor are expressed by these tissues, usually manifesting as dense, taught, granular fibers within the capsular ligament overlying the subluxated joint structures. These tissue changes within the joint capsules are particularly more evident when the doctor uses hand lotion to facilitate the accuracy as well as to provide additional patient comfort and tolerance for the depth of palpation required to actually feel the textural differences within the subluxated joint complex compared with normal. ESIL's nodes over-lying the sacroiliac joints are defined and explored for and demonstrated on volunteer student patients.

A combined Linder, Soto-Hall and VonBecterew's Sitting Test will be demonstrated to determine the potential of a space occupying lesion of the spinal cord, nerve root or dural sleeve entrapment disorders of the spine, especially the lumbo-sacral spinal region.
A test will be demonstrated and discussed which is used to identify the specific pain generating lesion in acute and/or semi-acute mechanical disorders of the lower spine. It is also useful as a means of determining the difference between mechanical back pain from visceral disorders of the gastrointestinal or genitourinary tract/reproductive system. The test is often call the "big four", and is useful in helping to differentiate subluxation of either innominate on the sacrum; the sacrum in subluxation between the innominates; the 5th lumbar in subluxation in relation to the sacrum; the 4th lumbar in subluxation in relation to the 5th lumbar; or the 3rd lumbar or any segment above the 3rd lumbar vertebral segment. In addition, the test, in combination with a variety of other signs and symptoms, can be helpful in judging when it is acceptable for persons recovering from lower spinal injuries and disorders to return to occupational or recreational activities.

Continuation of case studies with examples of disturbances of axial loading efficiency, shown by plumb-line deviations, shoe wear and shoe sole wear pattern differences and radiographic confirmation of these distortions from normal.

Another student volunteer is selected from the class with a different history, findings and symptoms. This subject is also adjusted and cared for using the structural analysis and subluxation reduction approach as previously. Students are given the opportunity to observe optimal table set up for optimal patient comfort and optimal patient positioning for optimal adjustive accuracy, ease of manual dexterity and preservation of the doctor's energy, balance and strength. Emphasis is placed on incorporating leverage, accurate line(s) of drive and careful and specific choice of bony contacts, rather than emphasizing speed and force to accomplish the adjustment. Students are instructed regarding the importance of introducing adjustive forces into the tissues gently and to obtain total end play, at which time a gradual, but firm application of the doctor's body weight into the patient's natural resistance is introduced prior to the delivery of the final impulse thrust. The specific adjustive procedures that are demonstrated are designed to initially cavitate the facet joints (in the case of a spinal subluxation) and then, with continuous, sustained, gentle and carefully chosen directional force, deliver the thrust with a purpose of changing (improving) the shape of the deformed disc. The theoretical basis for this adjustive approach to reducing/correcting spinal subluxation(s) is to restore (to the degree possible) the shape of the disc (elimination of, or at least reduction of the "load moment") to facilitate more optimal hydrostatic loading efficiency of the motion segment at a regional (segmental) level which will, when successful, contribute to a more efficient loading of the total body mass over its base of support from a global perspective.

Emphasis is also placed on the optimal position and stance of the doctor for adjusting the patient while in the side posture, prone, supine and sitting postures, proportionate to the unique nature, severity and type of subluxation(s) which may be presented.

Students will choose a partner they are comfortable with and proceed with the structural approach to thier partner's clinical case management as they observed with the two subjects who had serveed as patients for the observational portion of the class.

A discussion of a unique method of the clinical management of lumbar spondylolisthesis will be provided using slides and case studies.

A demonstration of the adjustive procedure involved in the clinical management of lumbar spondylolisthesis as discussed in the lecture period for week six.

Ten question quiz will be given

Continued demonstration of slides depicting the need for and application of radiographic evaluation of patients for determining the presence or absence of pathology, fracture, congenital anomaly and a wide variety of structural impediments the patient may demonstrate. Emphasis is placed on the conservative use of x-ray as a diagnostic tool, however with due consideration for the appropriate application for diagnostic imaging when the history, symptoms, and clinical presentation warrants this level of diagnostic intervention.

Discussion regarding the adjustive procedures and near term outcomes of the first two adjustments that were demonstrated is provided. These individuals are adjusted again as follow-up care so that their student classmates can once again observe the process of correlating all of the procedures accomplished during the previous lab sessions.

Ten question quiz will be given.