Cervicogenic Temporal Mandibular Disorder (CTMD)
Manuscript Preparation of Completed Research for Publication
Introduction & Perspective
Throughout the history of the chiropractic profession, the belief that a bone in the spine is fixed in an abnormal position (subluxated) and when the spine is adjusted, the bone is corrected to a normal position. This has been the nemesis of scientific investigation and research for years. Even to this day few chiropractors and researchers have been aware of the ability of upper cervical chiropractors to measure misalignments of the cervical spine using angular (rotatory) relationships. Fewer still are aware of the ability of upper cervical chiropractors to apply the correction principle and return a “subluxated bone (joint)” to a normal position.
During early chiropractic investigations and education, the focus of care was on the upper cervical spine. Over time, this focus shifted to the entire spine creating a shift in belief systems between upper cervical and “full-spine” or “segmental” chiropractors. Few resources have been dedicated to research to test the upper cervical proposition that spinal misalignments (abnormal position) create mechanical distress that has a global affect on the nervous system, body posture, and normal physiology.
Chiropractic research has been focused on the effectiveness of spinal manipulation therapy regarding the outcomes of a wide range of symptoms, pain relief, and increasing the mechanical range of motion. This has been practiced to the near exclusion of determining what is biomechanically and neurologically normal. This also includes identifying what forces should be used to correct spinal misalignments and what forces produce common spinal misalignments. There are no studies showing the negative health effects of chronic spinal misalignments.
Research Goals
The Spinal Model project specifically addresses what is biomechanically normal. Once a biomechanical normal is established, then measurements become less relative, more absolute and scientifically acceptable. After biomechanical normal is established, we will assess the effects of misalignments/mal-position of both cervical vertebra and head-neck relationships, as well as the effect of forces the head-cervical spine and forces producing malposition of both cervical vertebra and head–neck relationships.
Modeling Technique
The stress strain relationships, material behavior, geometry, loads and constraints on any structural component can be represented by a set of equations. However, as the complexity of the geometry (i.e., the shape of the component), loading conditions and the constraints in an engineering problem increase, it becomes impossible to find an exact solution to this set of equations. Finite element analysis is a numerical technique that is used to find an approximate solution to this set of equations.
The engineering-problem in finite element analysis is represented by what is called a finite element model. In a finite element model, the geometry of the structural component is divided into small parts/mesh. Each of these small parts is called an “element” and the points where these small parts connect to each other is called a “node”. Appropriate material properties are assigned to each element. Therefore, intuitively, as the size of the element becomes smaller, the model more closely represents the actual material continuity that exists. As the mesh is refined, the model shape will match more closely to the actual shape.
The University of Toledo Spine Research Laboratory’s ABAQUS software is used for finite element analysis. Previously, 3-D finite element models have been made of the lumbar, thoracic, and cervical spinal segments. These models incorporated all the details of the segment including the ligaments, facet joints, the intervertebral discs, vertebral bodies, etc. The material properties of various tissues have been adapted from the literature and from in-house data.
Principal Investigators/Credentials
The principal investigator of this project is Dr. Vijay K. Goel, McMaster-Gardner Professor of Orthopedic Bioengineering, Co-Director Engineering Center for Orthopaedic Research Excellence (E-CORE) at the University of Toledo. Dr. Goel holds appoints in the Departments of Bioengineering and Orthopaedic Surgery in the Colleges of Engineering and Medicine. His specialty is in orthopedic and dental biomechanics, especially spine biomechanics and spinal discs. Dr. Goel is a recipient of the University of Toledo’s 2005-2006 Outstanding Faculty Researcher Award and is internationally renowned for his work on spinal implants. In 2003 he received the H.R. Lissner Award from the American Society of Mechanical Engineers for his work on spinal implants. Between 2000 and 2006 he has published 56 peer-reviewed manuscripts, several book chapters, and more than 130 abstracts.
Chiropractic Liaison
The principle chiropractic liaison on this project is Jim Palmer, Professor of Physics at the University of Toledo, who is the UCRF Director of Research. He is also the editor of The Upper Cervical Monograph and a long-time contributor to this in-house publication. Chiropractors Dr. K. Denton and Dr. T. Palmer are also assisting as chiropractic liaisons.
The cost for the first two years of the Spinal Model study is $140,000 to support the development, testing, and documentation of the finite element model of the cervical spine, skull and jaw. After the first two years, we intend to facilitate the development of a more sophisticated model and ongoing testing of questions about the misalignment complex and it affects on the spine. We hope to continue the study for an additional five to six years by utilizing the expertise of PhD level researchers for an additional $60,000 annually.
Cervicogenic Temporal Mandibular Disorder (CTMD)
Introduction and Perspective
Chiropractic and dental literature suggest an association between Temporal Mandibular Disorders, commonly called TMJ or TMD, and cervical chiropractic. One study in Cranio (April 2005, Vol 23, No. 2 pp119-129) showed the production of scoliosis in rats as a result of experimentally-induced malocclusion. All of the rats with scoliosis exhibited a tilt of the atlas or what the Upper Cervical Research Foundation would call Atlas Laterality.
Dr. Marshall Dickholtz Sr. has conducted preliminary studies with Chicago area neuro-muscular dentists who are members of the International College of Cranio-mandibular Orthopaedics (ICCMO) on approximately 8 patients with TMD/TMJ in preparation for designing the protocol used in this project. This protocol has been submitted for approval to an institutional review board. All of the preliminary subjects with TMJ have responded to upper cervical misalignment correction. Earlier data from the office of Dr. Dickholtz Sr. supports the effects of chiropractic on pain associated with TMJ. There are a number of NUCCA doctors and UCRF board members who have been working with dentists and dental researchers for more than fifteen years.
Research Goals
This project is designed to provide an understanding of the interconnections between TMD and malposition of the atlas. In addition to providing an understanding between TMD and atlas malposition, this project is expected to determine the optimal way in which dentists and upper cervical chiropractors can work together for the benefit of the patient. The question to be answered is, “Does a malposition of the upper cervical spine change the dental occlusion or bite? For example, if the atlas is corrected and not malpositioned, does that decrease the number of adjustments needed on dental occlusion and appliances? Clinical observations to date support the view that increased spinal stability and dental function are seen with patients using an integrated approach to dental care. The cervical spine-jaw-head modeling at the University of Toledo will be used to interpret what is seen dentally and chiropractically and will provide a biomechanical model relating TMD and misaligned cervical vertebrae.
Principal Investigators/ Credentials
Dr. Marshall Dickholtz Sr. will be the lead chiropractor and the other investigators will be announced once an Institutional Review Board has approved the project. The involved University faculty has yet to be finalized.
Estimated Expenses
Dental organizations are providing $200,000 for their share in this joint project. UCRF is responsible for $185,000 of the projected cost. This covers $100,000 for chiropractic services, and $85,000 for data management, writing of research results, writing/organization of IRB (Institutional Review Board) proposal and additional involvement with University.
Manuscript Preparation of Completed Research for Publication
Introduction & Perspective
The NUCCA approach to atlas correction presents many opportunities to collect data and conduct scientific study. As part of this process, compelling findings must be documented and published to ensure validation and further research. Publication of research findings allows for scientific discussion and exchange of ideas which assist in the reduction of errors, improved methods of investigation, and interpretation of results. The potential value of such academic publication assures NUCCA a position to attract other science and health care professionals to assist in these investigations and to ultimately improve the quality of life and optimal health and well-being for the public at large. The vision of investigating the NUCCA correction using a large sample of diverse populations provides evidence that will help establish the successful demonstration of the positive impact on health the NUCCA correction may offer. The Upper Cervical Research Foundation is currently committed to the academic publication of the three research projects described as follows:
Mechanisms in Cerebrovascular Blood Flow Following Atlas Realignment
As a result of the Hypertension study published in Journal of Human Hypertension, May 2007, the investigation for a mechanism explaining how the NUCCA atlas correction exerts the effect on the autonomic nervous system is in progress. This involves an examination of changes in cerebral blood flow pre and post correction, and describes a case reporting the results of an imaging study of the vasculature of the brain stem region using cutting edge imaging tools that allow for the most accurate study of this phenomena to date. Professionals involved in the research include: Terry Lichtor, PhD; MD, Noam Alperin, PhD; Bruce Bell, MD; Charles Woodfield, RPh, DC.
Estimated Timeline and Expense
Publication of the Blood Flow study requires $6,000.00 for literature review and manuscript preparation to be completed by June, 2008.
Hypertension Study Data Report
Unpublished data from the hypertension study showing the effect of the NUCCA correction on blood pressure levels which was published May, 2007 in the Journal of Human Hypertension is described in this update. Quality of life results from the SF-36 quality of life survey, Pain Scales from the VAS, and the end of study questionnaire and quality of life measures are presented and discussed. Authors from the hypertension study include G. Bakris, MD; M. Dickholtz, Sr. DC; P.M. Meyer; G. Kravitz; E. Avery; M. Miller; J. Brown, DC; C. Woodfield, RPh; B. Bell, MD.
Estimated Timeline and Expense
The Hypertension paper requires $8,000.00 total: literature review and manuscript preparation, $6,000.00; Data entry, $500.00; Biostatistician consultation, $1,500.00. Completion scheduled for July, 2008.
Atlas Misalignment and Chronic Fatigue Syndrome
A case series of 19 subjects medically diagnosed with Chronic Fatigue Syndrome according to the Center for Disease Control’s differential diagnosis criteria, were studied pre and post NUCCA atlas adjustment. Multiple diagnostic tests and outcome measures were used including the SF-36 survey and Pittsburgh Sleep Quality Index. The study shows improvement in SF-36 quality of life descriptors indicating that the NUCCA correction may help ease the suffering of those diagnosed with Chronic Fatigue Syndrome. The final manuscript reports on a case series of patients suffering from chronic fatigue syndrome and how the correction improved their quality of life and several immune markers over a 6 month study period. Participating professionals include: Charles Woodfield, RPh, DC; Leo Jacobs, MD; Bruce Bell, MD; Marshall Dickholtz, Sr.
Estimated Timeline and Expense
The Chronic Fatigue manuscript requires $6,000.00 for literature review and manuscript preparation to be completed by August, 2008
Liaison
Dr. Charles Woodfield began his chiropractic research career at Palmer Center for Chiropractic Research and was the architect of the Chronic Fatigue Case Series using the SF-36 as the primary outcome to NUCCA care. The hypertension study was based on a protocol of his design with input from the other investigators.
