AJCC October 2000

Normal Values in Anatomy, Physiology, Health, Disease and Chiropractic

By Deed Harrison, D.C. and Brian Paris, D.C.

Recently, one of us (DEH) received an interesting phone message for which a return call was needed. You know, the kind of message with a DC’s name at the bottom that you’ve never heard of before, the return phone number is something like 1-800-I’m An IME, and the DC is asking to speak with you regarding a specific patient of yours that you have not been paid on in months. In other words, you’re going to duke it out with an “Independent” Medical Evaluator or IME. Some of these calls can be quite simple and friendly, involving only minor clarification, while others are quite hostile where blood pressure medication, anger management counseling, a week’s vacation, and a thorough reference list of the appropriate index medicus literature are needed. Unfortunately, our call was the latter of the two.

     We would like to discuss one of several issues raised during our IME encounter in hopes that this information will aid you in support/defense of your long-term, structural rehabilitation patient treatment programs

     The foundation or major premise of this particular IME’s argument against insurance companies reimbursing for long-term, spinal corrective care was: “There is no such thing as a ‘Normal Spine,’ there are no normal values for the sagittal plane curves, and as such every patient’s spine is unique and different.”  The above is a common assertion by Chiropractic clinicians, academicians, and radiologists.1,2 At first glance, this seems a reasonable, rationale, and logical statement due to our innate human individuality. However, at second glance, with any sort of scrutiny, this is unreasonable, irrational, and illogical.

     Common sense would dictate that before any abnormal situation (spinal subluxation) can be identified, the normal situation or variables (Ideal Spine) must first be identified. However, it has been said, “Common sense is so truly rare, that it’s often mistaken for genius” (Andrew Sulyma, DC).3 

     Every Anatomy, Physiology, Chemistry, Math, Engineering, Biomechanics or other Health Science student realizes that Ideal and Average values form the backbones from which these disciplines are formed. We have compiled several tables of Ideal and Average values from the disciplines of Anatomy, Physiology/Biochemistry (Tables I-III), and Spinal biomechanics texts and journals (Table IV). These tables can be used to establish a standard in Health sciences. Everywhere in the Health Sciences Ideal and Average values are used to establish whether a given patient is healthy or has a disease process underway or has risk factors which may lead to a specific disease.

     Today, we now recognize that pain and spinal dysfunction are multi-factorial conditions. The process of spinal degeneration and abnormal biomechanics causing mechanical distortions of the peripheral nervous system (PNS) and central nervous system (CNS) is best characterized as a degenerative disease process. Accordingly, most symptoms appear after the disease process is well advanced (similar to heart disease, cancer, or hypertension). In such processes, the emphasis is placed on controlling risk factors. In Chiropractic Biophysics® (CBP®) we suggest that optimizing the spine’s position to resist the external compressive force of gravity and internal loads from muscle forces is a logical place to address an “optimal stress” risk factor. Of course, the entire oculo-vestibular, muscle spindle, and mechanoreceptor systems perform this function moment to moment in upright stance. To imply that this is an unimportant subject regarding spinal mechanics is to ignore a major function of our PNS and CNS. 

     Accordingly, in CBP®, we utilize ideal and average values for the upright static structure of the human spine. In the AP view, it is generally agreed upon that the Ideal spine is vertical alignment of the center masses of the skull, thorax, pelvis, and vertebra.12,13  In the lateral view of upright normal posture, it is generally accepted that there exists a cervical lordosis, thoracic kyphosis, and lumbar lordosis, however, neither the overall values for sagittal curvatures of the cervical, thoracic, and lumbar areas nor the segmental contributions are generally stated nor agreed upon. Therefore, when debating normal, only the overall geometric shape and segmental angulation of the cervical, thoracic, and lumbar sagittal curvatures are open to debate.

     This is where our Ideal and Average Harrison Spinal Model enters the literature (Table VIII-X). Both our average (400 subjects) and our ideal normal sagittal cervical spine models were published in Spine in 1996 and other technical conferences.14,15,16 Our average (derived from 552 subjects) normal lumbar model was published in the Journal of Spinal Disorders in 1997.17 Our ideal normal lumbar model was published in the Journal of Orthopaedic Research in 1998.18 Currently, we are revising our Ideal and Average model for the shape and magnitude of the thoracic kyphosis. However, we have reported values from the indexed medicus literature. (see Table IX).19-20

     At this point, it is important to point out that the Harrison Spinal Model is the normal path of the posterior longitudinal ligament along the posterior vertebral bodies. This ideal and statistical average model has a mean and a random error component (variation around the mean). It is not a model of the entire anatomy of the spine, only the curvature in the sagittal  plane. Models of the entire spine require huge computer codes utilizing Finite Elements Methods. However, this model with Ideal and Average values can be utilized to compare our patients’ spines to.

     We can decide with confidence when a patient’s cervical, thoracic, or lumbar spines are outside of the tolerance limits and thus require structural rehabilitation. This is true regardless of any IME’s opinion. We suggest that these Ideal and average values be utilized by the doctor of Chiropractic. Ideal and average values are utilized everywhere in the Health Sciences as standards of care to decipher health from disease. Shouldn’t these be utilized in Chiropractic Rehabilitative care too?? 

     One might wonder why we have gone to all the trouble to look up all these normal values and provide these in the following tables. It is because we have stated over-and-over that normal values are utilized everywhere in health care including spinal and postural alignment. However, DACBRs, IMEs, and Chiropractic faculty are ignoring these facts. We hope that you may be able to combat an IME with the following facts.  

Tables of Normal Values:

• Biochemical Indicators of Normal Nutritional Status Table 1

• Normal Physiological Paremeters Table IIa

• Normal Physiological Parameters Table IIb

• Normal Physiological Parameters Table IIc

• Normal Physiological Parameters Table IId

• Normal Physiological Parameters Table IIe

• Normal Physiological Parameters Table IIf

• Normal Physiological Parameters Table IIg

• Table III: Normal Measurments in Skeletal Radiology Lines and Angles of Skull (NORMALS)

• Table IV Lines and Angles of Cervical Spine

• Table V: Lines and Angles of Thoracic Spine

• Table VIa: Lines and Angles of the Lumbar Spine

• Table VIb: Lines and Angles of the Lumbar Spine

• Table VII: Lines and Angles of the Pelvis and Hip Joint

• Table VIII: Average and Ideal Normal Cervical Lordotic Values [Absolute Values from 400 Subjects]

• Table IX: Average and Ideal Normal Thoracic Kyphotic Values

• Table X: Average and Ideal Normal Lumbar Lordotic Values [Absolute Values from 552 Subjects:

References

1.    Haas M, Taylor JAM, Gillete RG. The routine use of radiographic spinal displacement analysis: A dissent. J Manipulative Physiol Ther 1999;22(4):254-259.

2.    Harrison DE, Harrison DD, Troyanovich SJ.   Reliability of Spinal Displacement Analysis on Plane X-rays: A Review of  Commonly Accepted Facts and Fallacies with Implications for Chiropractic Education and Technique. J Manipulative Physiol Ther 1998;21:252-66.

3.    Private communication with Andrew Sulyma, Spring Creek, Nv, 1999, Crown Royal convention room.

4.    Seidel HM, Ball JW, Dains JE, Benedict GW. Mosby’s Guide to Physical Examination. Mosby: St. Louis 1995, Appendix p. 882.

5.    Guyton AC, Hall JE. Textbook of Medical Physiology. W.B. Saunders; Philadelphia, 1996.

6.    Thomas CL. Taber’s Cyclopedic Medical Dictionary, Ed. 18. F.A. Davis Company: Philadelphia, 1997.

7.    Tortora GJ, Grabowski SR. Principles of Anatomy and Physiology. Harper Collins; New York, 1996, Appendix B, Pg A5-A11.

8.    Yochum TR, Rowe LJ. Essentials of Skeletal Radiology. Vol 1. Williams & Wilkins: Baltimore, 1996; 139-196.

9.    Torg JS, Pavlov H. Cervical spinal stenosis with cord neurapraxia and transient quadraplegia. Clincis in Sports Medicine 1987;6(1):115-133.

10.   Dickson RA. Spinal deformity- Adolescent idiopathic scoliosis. Nonoperative treatment. Spine 1999;24:2601-2606.

11.   Krismer M, et al. Motion in lumbar functional spine units during side bending and axial rotation moments depending on the degree of degeneration. Spine 2000;25:2020-27.

12.   Beck A, Killus J.  Analyse par computer de la statique du rachis (Computer analysis of spinal measurements). J Radiol Electrol Med Nucl 1975;56(suppl 2):402-403.

13.   Schultz AB, Miller JAA. Biomechanics of the human spine. In: Mow VC, Hayes WC, editors. Basic Orthopaedic Biomechanics. New York: Raven Press;1997,p.337-374.

14.   Harrison DD, Janik TJ, Troyanovich SJ, Holland B.  Comparisons of Lordotic Cervical Spine Curvatures to a Theoretical Ideal Model of the Static Sagittal Cervical Spine. Spine 1996;21:667-675.

15.   Harrison DD, Janik TJ.  Clinical validation of an ideal normal static cervical spine model.  In: Witten M, ed., Computational Medicine, Public Health, and Biotechnology.  Part 1.  Austin, TX: World Scientific Publishing, 1995: 1047-1055.

16.   Janik TJ, Harrison DD.  Prediction of 2-D static normal position of the cervical spine from mathematical modeling.  In: Witten M, ed.  Computational Medicine, Public Health, and Biotechnology. Part 2.  Austin, TX: World Scientific Publishing, 1995:1036-1046.

17.   Troyanovich SJ, Cailliet R, Janik TJ, Harrison DD, Harrison DE.   Radiographic Mensuration Characteristics of the Sagittal Lumbar Spine from A Normal Population with a Method to Synthesize Prior Studies of  Lordosis. J Spinal Disord 1997;10(5): 380-386.

18.  Janik TJ, Harrison DD, Cailliet R, Troyanovich SJ, Harrison DE.  Can the Sagittal Lumbar Curvature be Closely Approximated by an Ellipse?  J Orthop Res 1998; 16(6): 766-770.

19.   Stagnara P, De Mauroy JC, Dran G, Fonon GP, Costanzo G, Dimnet J, Pasquet A. Reciprocal angulation of vertebral bodies in a sagittal plane:  Approach to references for the evaluation of kyphosis and lordosis.  Spine  7:335-342, 1982.

20. Bernhardt M, Bridwell KH.  Segmental analysis of the sagittal plane alignment of the normal thoracic and lumbar spines and thoracolumbar junction.  Spine 1989;14:717-721.

21. Harrison DD. Chiropractic: The physics of spinal correction.  National Library of Medicine #WE 725 H318C, 1986, p 319.

Back to CBP® OnLine

CONTENTS

Attitude Adjustment

Biomechanical & Neuro responses to Adjustment

Communicating From the Inside Out

Normal Values in Anatomy, Physiology, Disease and Chiropractic

Thermography Mis-Education

2nd CBP® Seminar in Japan

Financial Repriortization

Ambulatory Translational Traction

If you havent read Palmer...?

Percutaneous Radiofrequency Neurotomy...