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Publications

Chiropractic as Part of an Interdisciplinary Team for the Care of a Patient with an Orbital Pseudotumor: A Case Report.

Introduction

Orbital pseudotumor is the third most common ophthalmologic disease of the orbit and accounts for 8 to 11% of all orbital tumors. A 47-year-old female woke up January 15, 2014 with darkness and limited vision in the right eye, which after two hours restored itself. After consulting an ophthalmologist she was diagnosed with swelling of the optic nerve in the right eye. An MRI and spinal tap were performed and was negative for pathology. She was diagnosed with orbital pseudotumor and was unresponsive to treatment with steroidal anti-inflammatories.

The patient presented at this office July 1, 2015 with a diagnosis of orbital pseudotumor and felt increased pressure in her head the past several days. She reported chronic intermittent headaches in the orbital region usually when awakening, which were characterized as mild migraines occurring 1 to 2 times a month and last for two hours. The headaches would include flashes of light in either her right or left eye affecting her whole vision at onset, then at the center, and then late would become a blind spots of the center of the eye. Following the headaches she would have a dull achy feeling in the frontal area that radiates to bilateral sphenoid wings. She also had a past history of tinnitus for years and began using hearing aids four-years-ago. The patient had a history of bruxism that was controlled with an upper mouthguard.

Methods

Examination noted obstructive airway compromise with maxillary deficiency, maxillary exostosis and mandibular tori. These findings were consistent with decreased oral cavity airway space and often found clinically with compensatory TMJ disorders.TMJ dysfunction was noted with evidence of clenching, malocclusion, decreased joint translation, and sensitivity and hypertonicity of the temporalis muscles.

Sensitivity to palpation was noted in the craniofacial bones and sutures as well as with hypertonicity of the sub-occipital muscles. She also presented with left SI joint instability associated with sensitivity and swelling in the upper aspect of that joint.

Orbital Pseudotumor

At the first office visit the patient was told to stop using the upper nightguard since this can further compromise her airway space due to limited tongue positioning. There was some consideration due to symptoms occurring when awakening that obstructive sleep apnea and reduced oxygenation might be contributing factors to her presentation. She was treated for eight visits from July 1 to August 24, 2015.

Results

After her fourth visit on July16, 2015 she reported her eyes were doing much better and was no longer waking up with the previous visual symptoms, which had persisted since January 2015. She was referred back to her ophthalmologist who determined there was a 65% improvement in her pseudotumor, which had previously been unresponsive to pharmaceutical interventions. She is currently scheduled for dental co-treatment to better maintain her reduced craniomandibular distortions with a mandibular appliance.

Conclusion

It is difficult to generalize from case reports, however the ongoing nature of the patient’s condition and the temporal relationship between the care received and his response warrants further study. Further research is indicated to help determine if the therapeutic applications and response can be generalized to a specific subset of patients presenting with orbital pseudotumors.

References

  1. Rootman J, Nugent R. The classification and management of acute orbital pseudotumors. Ophthalmology. 1982 Sep;89(9):1040-8.
  2. Clausen I, Eichhorst A, Röpke E, Bloching M, Frimmel H, Bilkenroth U, Duncker GI, Grünauer-Kloevekorn C. [Idiopathic orbital inflammatory syndrome (orbital pseudotumors): diagnosis and therapy]. [Article in German] Klin Monbl Augenheilkd. 2006 Mar;223(3):243-6.
  3. Flanders AE, Mafee MF, Rao VM, Choi KH. CT characteristics of orbital pseudotumors and other orbital inflammatory processes. J Comput Assist Tomogr. 1989 Jan-Feb;13(1):40-7.
  4. Fortson JK, Shapshay SM, Weiter JJ, Vaughan CW, Strong MS. Otolaryngologic manifestations of orbital pseudotumors. Otolaryngol Head Neck Surg. 1980 Jul-Aug;88(4):342-8.
  5. Kim RY. Orbital pseudotumors: histopathologic classifications and results of radiation therapy. Ala Med. 1987 Apr;56(10):43-8.
  6. Wirostko BM, Wirostko E, Wirostko RF. Orbital pseudotumors treated with systemic corticosteroids. Ophthalmology. 1996 Oct;103(10): 1519-20.
  7. Paris GL, Waltuch GF, Egbert PR. Treatment of refractory orbital pseudotumors with pulsed chemotherapy. Ophthal Plast Reconstr Surg. 1990;6(2):96-101.

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Chiropractic as Part of an Interdisciplinary Team for the Care of a Patient with Diplopia: A Case Report

Introduction

A 59-year-old male began to experience intermittent diplopia 50% of the time, which after three-days became constant. Over the previous 30 years it was not uncommon for him to initial awaken with “double vision” but after a few minutes it would go away. When his condition became constant he consulted with an ophthalmologist who diagnosed him with a fourth cranial nerve palsy causing a vertical displacement of his eye. He was given prism glasses to correct the displacement. He presented on February 17, 2015 for an assessment and treatment at this clinic.

Methods

A 56-year-old female patient presented for chiropractic and dental care with persistent symptoms of sleep apnea, excessive daytime sleepiness, short-term memory loss, foggy-headedness, TMJ pain, chronic myofascial neck and shoulder pain, fatigue, and vertigo.

Cranial palpatory pain was noted at the right zygomaticomaxillary joint, upper medial orbit, sphenoid wing, coronal and squamosal sutures, and an occipital extension cranial distortion pattern. Pelvic torsion with sacroiliac joint hypermobility was noted on the left (category two). Palpatory pain and hypertonicity of right sub occipital muscles was noted along with palpatory pain from C-1-6. He had cervical spine antalgia with decreased rotation range of motion to 25°.

The patient was treated for a total of six visits between February and April that was directed at stabilizing the sacroiliac instability SOT blocks and sacroiliac support belt. Spheno-maxillary cranial adjustments were administered to the maxilla and zygomatic bones along with intraoral cranial therapy for the occipital extension cranial distortion. Cranial dental co-treatment consisted of a lower occlusal splint, which involved one-visit per week three-weeks in a row, with the splint equilibrated immediately after cranial treatment.

Results

The patient was making consistent progress with reduced neck pain, antalgia, and significantly improved cervical ranges of motion so at that time was referred to have the splint dentally equilibrated after the third visit and noted at that time a 70% reduction in diplopia. By the fifth dental visit on April 2, 2015 he stopped needing prism glasses. Follow-up ophthalmology exam in May of 2015 found no evidence of diplopia.

Discussion

There is not much in the literature regarding chiropractic and optometric or ophthalmological co-treatment of patients. One study by Tymms discussed a 13-year-old male with intermittent diplopia referred for chiropractic care by his optometrist. In this case only one treatment achieved a full resolution of the patients symptoms with the optometrist finding on re-examination a correction of the overconvergence 1.

With cases that do not have a discrete relationship it is difficult to explain what were the specific mechanisms that affected improved ocular function following a chiropractic intervention. Many types of possibilities relating to chiropractic manipulative therapy and its affect on visual fields, vision, and optic nerve function have been discussed by Gorman et al in the literature 2-6.

Conclusion

It is difficult to generalize from case reports however the ongoing nature of the patient’s condition and the temporal relationship between the care received and his significant response warrants further study. Determining if there might be a subset of patients with visual or ocular disorders that might be helped with chiropractic and/or interdisciplinary care also deserved greater exploration.

References

  1. Tymms G. Visual recovery from diplopia in a 13-year-old following chiropractic intervention. J Clin Chiropr Pediatr. 2011 Jun;12(1): 876-878.
  2. Wingfield BR, Gorman RF. Treatment of severe glaucomatous visual field deficit by chiropractic spinal manipulative therapy: a prospective case study and discussion. J Manipulative Physiol Ther. 2000 Jul-Aug;23(6):428-34.
  3. Stephens D, Gorman RF. Does ‘normal’ vision improve with spinal manipulation? J Manipulative Physiol Ther. 1996 Jul-Aug;19(6): 415-8.
  4. Gorman RF. Monocular scotomata and spinal manipulation: the step phenomenon. J Manipulative Physiol Ther. 1996 Jun;19(5): 344-9.
  5. Gorman RF. Monocular visual loss after closed head trauma: immediate resolution associated with spinal manipulation. J Manipulative Physiol Ther. 1995 Jun;18(5):308-14.
  6. Gorman RF. The treatment of presumptive optic nerve ischemia by spinal manipulation. J Manipulative Physiol Ther. 1995 Mar- Apr;18(3):172-7.

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SOT Research Conference 2014

SOT Research Conference 2014 — TMD & Post Concussion Syndrome by Dr. Thomas E. Bloink, DC

Bloink TE, Charles L. Blum CL. Post concussion syndrome, temporomandibular joint disorders, and chiropractic dental co-treatment: A case report. 6th Annual SOT Research Conference. Redondo Beach, CA. May 15, 2014: 31-34.

Introduction

The awareness of sports-related concussions with post-concussion syndromes is gaining exposure in the chiropractic profession. The following case describes a 21-year-old female patient who had a concussion with subsequent post-concussion syndrome symptoms that persisted for five months.

Methods/Intervention

Along with reduced TMJ functioning the patient presented with some altered cranial nerve findings related to photophobia, contrast sensitivity, and convergence insufficiency. Sacro occipital technique category one and two findings relating to pelvic torsion and sacroiliac joint hypo/hypermobility was found and treated along with cranial and TMJ adjusting. A dentist equilibrated the patient’s mandibular occlusal splint over a 9-week period, which was immediately preceded by chiropractic care.

Results

As of March 18, 2014 the patient was completely pain free with no symptoms of lightheadedness, brain fog, or nausea. She has been able to exercise, and has been lifting light weights. She was also able to run five miles. This is a significant improvement given that her symptoms and lack of function were consistent since her accident of September 2013.

Conclusion

Further research is needed to determine whether a subset of post-concussion or head trauma patients may have TMD, which is limiting their ability to fully recover function and return to their activities of daily living. Collaborative efforts between emergency room doctors, chiropractors and dentists (with TMD care training) with post concussion patients may help ultimately lead to improved patient outcomes.

[This abbreviated abstract is from one of the 15 full text abstracts relating to topics such as SOT, cranial techniques, chiropractic manipulative reflex technique, occipital fiber diagnosis, dental chiropractic co-treatment of TMD, Alexander Technique, and Aqueous Ozone for Chiropractic Table Sanitization. Over 150 pages. http://www.sotousa.com/wp/?p=442]

SOT Cranial and TMJ therapy for unresolved BPPV: A case report.

Thomas Bloink, DC and Charles L. Blum, DC
Sacro Occipital Technique Organization – USA

Purpose and Background

Vertigo, also called dizziness, accounts for about 6 million clinic visits in the U.S. every year, and 17–42% of these patients eventually are diagnosed with benign paroxysmal positional vertigo (BPPV). Two treatments have been found helpful for BPPV: the canalith repositioning procedure (CRP) or Epley maneuver, and the liberatory or Semont maneuver 1. The following is a case study that discusses another possible treatment for BPPV.

A 37-year-old female with acute the front teeth. benign vertigo was referred to this office by her allopathic physician to determine the need for interdisciplinary care. The patient had 2-3 months of constant vertigo, diagnosed as BPPV. She had been treated with the Epley Maneuver and various medications, but her symptoms were unresponsive. Her vertigo would last the whole day, with peaks and valleys related to intensity. This affected her ability to function at home, drive her car and even walk “out of the door” of her home.

Methods

Patient presented with a sacro occipital technique category two (sacroiliac joint hypermobility syndrome)2, right temporal bone with external rotation, and significant malocclusion with clenching and anterior interferences. Her malocclusion was affected by the stress of the anterior interferences, particularly on the right side, and the repetitive stress on occlusion appeared to create right temporomandibular (TMJ) stress summating at the right temporal fossa. It was theorized this possibly contributed to the patient’s vertigo presentation 3.

Category two protocols for the pelvis were applied 2 and an intraoral cranial adjustment to the temporal bone, maxilla, sphenoid, and zygoma were performed 4. Reduction of palpatory pain in and around the TMJ along with joint translation was used to help guide treatment. Cotreatment with a dentist was used to help stabilize and maintain the chiropractic cranial and TMJ corrections.

Results

By the 7th-office visit (3-4 weeks of care) the patient’s vertigo had resolved. In addition her TMJ translation and opening had improved significantly with right TMJ and related tissue pain eliminated. The anterior interferences were treated with a nighttime dental appliance that allowed the patient to have bilateral posterior teeth contact and reduced contact to the front teeth.

Discussion

Occlusion and condylar position is purported to be affected by or affect cranial bone distortion patterns 5. When there is malocclusion affecting the cranial suture and local periosteal tissue, it is theorized that with some patients — possibly the internal periosteal dura, CSF circulation, and related cortical region might be affected 6-8.

On the other hand re-living the stressors of restricted cranial motion and malocclusion could lead to improved function just by reducing global stress to the CNS due to reduced pain and related myofascial tension 5.

Conclusion

In this case report the patient’s response to care was quite dramatic. She was unresponsive to prior care and her quality of life was profoundly affected. It is difficult to extrapolate from this one case and apply this to the general population however the patient’s rapid response to care suggests that further investigation into this method of care for patients presenting with vertigo be considered.

References

  1. Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, Chalian AA, Desmond AL, Earll JM, Fife TD, Fuller DC, Judge JO, Mann NR, Rosenfeld RM, Schurina LT, Steiner RW, Whitney SL, Haidan J, American Academy of Otolaryngology-Head and Neck Surgery Foundation. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008 Nov;139(5 Suppl 4):S47-81.
  2. Monk R. Sacro Occipital Technique retrospective evaluation Manual. Sacro Occipital Technique Organization – USA: Sparta, NC, USA. 2006: 91-126.
  3. Steigerwald DP, Verne SV, Young D. A of the impact of temporomandibular joint arthroscopy on the symptoms of headache, neck pain, shoulder pain, dizziness, and tinnitus. Cranio. 1996 Jan;14(1):46-54.
  4. Monk R, Blum CL. SOT Cranial Level Two Manual: TMJ Technique. Sacro Occipital Technique Organization – USA: Sparta, NC, USA. 2004.
  5. Chinappi AS, Getzoff H. The Dental-Chiropractic Cotreatment of Structural Disorders of the Jaw and Temporomandibular Joint Dysfunction. J Manip Physio Therap. Sep 1995; 18(7): 476-81.
  6. Retzlaff EW, Mitchell FL jr, Upledger J, Biggert T. Nerve fibers and endings in cranial sutures – research report. J Am Osteopath Assoc. 1978;77(6):474-5.
  7. Pick, MG. A Preliminary Single Case Magnetic Resonance Imaging Investigation into Maxillary Frontal-Parietal Manipulation and its Short-Term Effect upon the Intercranial Structures of an Adult Human Brain. J Manip Physio Therap. Mar-Apr 1994; 17(3): 168-73.
  8. Jones L, Retzlaff E, Mitchell FL Jr., Upledger J, Walsh J. Significance of nerve fibers interconnecting cranial suture vasculature, the superior sagittal sinus, and the third ventricle. J Am Osteopath Assoc. 1982;82:113.

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Integration of SOT cranial therapy with an occlusal splint for the treatment of obstructive sleep apnea: A case report.

Thomas Bloink, DC, Mamal Rahimi, DDS, and Charles L. Blum, DC
Sacro Occipital Technique Organization – USA

Purpose and Background

Obstructive sleep apnea (OSA) relates to an obstruction to the continuum of airway expressed as sleep-disordered breathing associated with multiple comorbidities and societal implications 1,2.

With untreated sleep apnea patient the risk of automobile accidents are approximately 8-times more likely than that of a normal sleeper and in the work arena likewise productivity and safety suffer1.

Common treatments for OSA usually start with a continuous positive airway pressure (CPAP) machine and can progress to surgery to facilitate airway expansion and/or increase function. Surgery is costly and invasive and patient compliance with CPAP machines is estimated at only 40%2.

A 56-year-old female patient presented for chiropractic and dental care with persistent symptoms of sleep apnea, excessive daytime sleepiness, short-term memory loss, foggy-headedness, temporomandibular joint (TMJ) pain, chronic myofascial neck and shoulder pain, fatigue, and vertigo.

Methods

Cranial-dental exam revealed a dental class II, narrow arches and premature anterior contacts with evidence of clenching and bruxism. The sleep study revealed a Respiratory Disturbance Index (RDI) of 17.1 and Apnea Hypopnea Index (AHI) of 16.3, with the lowest oxyhemoglobin saturation (SaO2) of 89% during sleep. Six-treatments over a 3-4 week period of time consisted of sacro-occipital technique (SOT) care3, cranial-dental treatments incorporating SOT intra-oral cranial adjustments4, and sphenomaxillary cranial care. Dental care was provided in conjunction utilizing occlusal balancing by a mandibular flat plane dental splint.

Results

Following the 6-office visits the patient reported significant reduction of all symptoms. Follow-up polysomnogram was performed one-month following prior study and with the dental appliance in her mouth. RDI and AHI were both reduced to 2.9 and lowest Sa02 was 92% during sleep. The patient had significantly reduced TMJ pain and the chronic myofascial neck and shoulder pain had gradually resolved over the 3-4 weeks of care. Due to her increased ability to sleep and increased oxygenation, she had less daytime fatigue and greater function.

Discussion

The combination of SOT cranial therapy with a flat plane mandibular occlusal splint appeared to help resolve this patient’s apnea and accompanied symptoms. This intervention was minimally invasive, less costly than a CPAP, and only required a 3-4 week treatment program. Splint type therapy has been found to be helpful for OSA patients and one prospective randomized study found “that a dental appliance could be an alternative treatment for some patients with severe OSA 5.”

Ascending and descending kinematic postural influences have been found between posture and occlusion, condylar position, and airway space — suggesting that the treatment of TMJ disorders and sleep apnea may be an opportunity for dental and chiropractic collaboration 6-8. Clinically, chiropractors and dentists are realizing a relationship between posture and the OSA, supporting the need for interdisciplinary efforts 8.

Conclusion

The persistent nature of the patient’s apnea, the pre and post-sleep study objective findings, and the patient’s significant reduction in pain and improved function are compelling features of this case. Greater study is needed to identify the subset of apnea patients that could benefit from this approach.

References

  1. Al Lawati NM, Patel SR, Ayas NT. Epidemiology, risk factors, and consequences of obstructive sleep apnea and short sleep duration. Prog Cardiovasc Dis. 2009 Jan-Feb;51(4):285-93.
  2. Kapur VK. Obstructive sleep apnea: diagnosis, epidemiology, and economics. Respir Care. 2010 Sep;55(9):1155-67.
  3. Monk R. Sacro Occipital Technique Manual. Sacro Occipital Technique Organization – USA: Sparta, NC, USA. 2006: 91-126.
  4. Monk R, Blum CL. SOT Cranial Level Two Manual: TMJ Technique. Sacro Occipital Technique Organization – USA: Sparta, NC, USA. 2004.
  5. Walker-Engström ML, Ringqvist I, Vestling O, Wilhelmsson B, Tegelberg A. A prospective randomized study comparing two different degrees of mandibular advancement with a dental appliance in treatment of severe obstructive sleep apnea. Sleep Breath. 2003 Sep;7(3):119-30.
  6. Sakaguchi K, Mehta NR, Abdallah EF, Forgione AG, Hirayama H, Kawasaki T, Yokoyama A. Examination of the relationship between mandibular position and body posture. Cranio. 2007 Oct;25(4):237-49.
  7. Maeda N, Sakaguchi K, Mehta NR, Abdallah EF, Forgione AG, Yokoyama A. Effects of experimental leg length discrepancies on body posture and dental occlusion. Cranio. 2011 Jul;29(3):194-203.
  8. Blum CL. TMD Functional Integrative Approach: Dental and Chiropractic Approach to Forward Head Posture. Journal of the American Academy of Craniofacial Pain. Fall 2009; 22(2):18,31,39.

 

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Autism and Language Delay, Integration of SOT Cranial Therapy, and Tomatis Auditory Therapy to Stimulate the Auditory Cortex: A Case Report

Thomas Bloink, DC • Private Practice, Los Gatos, California, USA
Charles L. Blum, DC • Sacro Occipital Technique Organization, USA

Introduction

Autism is a brain development disorder that impairs social interaction and communication, and causes restricted and repetitive behaviour, all starting before a child is three years old. Most recent reviews estimate prevalence of one to two cases per 1,000 people for autism, and about six per 1,000 for ASD, with ASD averaging a 4.3:1 male-to-female ratio. The number of people known to have autism has increased dramatically since the 1980s, at least partly due to changes in diagnostic practice; the question of whether actual prevalence has increased is unresolved. Autism is highly heritable, although the genetics of autism are complex and it is generally unclear which genes are responsible. However there are also non-hereditary possible etiologies or triggers that affect ASD presentations. Spontaneous structural events associated with ASD onset are also believed to be primarily deletions of a gene, leaving the individual with only one copy of a particular gene leading to disruption of that gene’s function and ASD. ASD has multifactorial presentations with one type involving language delay that obviously would affect social interaction and communication 1.

Case Report

Assessment: 19-year-old female diagnosed with autism spectrum disorder (ASD) characterized by pervasive language delay, presented for cranial treatment at Atlantis (Tomatis) Clinic, St Truiden, Belgium. The patient was unable to speak prior to 11 years of age at which time she had a series Tomatis Auditory Therapy (TAT) treatments 2. By age 19 she could speak coherently when her head would be in flexion with her eyes looking downward. With her head and eyes directed forward she was unable to speak in a coherent manner. Treatment/Intervention: Treatment consisted of sacro occipital techniques (SOT) and cranial care 3, specifically treatment for sacroiliac joint hypermobility syndrome (category two) 4 and for a significant craniomandibular dysfunction (CMD) 5. Typical blocking treatment was used for the pelvic component and the CMD was treated with cranial therapies including SOT related intraoral temporal and sphenomaxillary procedures.

Results

Immediately following care the patient stood up, held her head up and looked straight in the eyes of the doctor and said clearly, “Thank you very much, goodbye.” The patient’s ability to speak with the head and eyes in an upright position maintained for approximately 7 days, however due to her significant CMD, it appeared she would need concurrent dental orthopedic/orthodontic cotreatment to maintain a lasting positive outcome.

Discussion

Along with chiropractic SOT and cranial care, two main therapeutic interventions for autism spectrum language delay could be TAT and specific vestibular training exercises. Autism spectrum children commonly have hypersensitivity to touch, sound, and visual input. TAT has been found to improve the life of many autistic people by attenuating ASD symptoms. By stimulating the auditory system, and ultimately the brain, TAT, commonly used with other integrative therapies, has been able to help reduce the ASD symptoms. In this case study both chiropractic care and TAT were needed together to facilitate the best outcome, however for lasting effects dental interventions appears to be also necessary.

For ASD patients vestibular training is also essential and one vestibular type training exercise could involve using a “hula hoop” on one arm and while in motion moving the hoop from one arm to the other across the midline and back again, performing this 5-6 times per session, everyday.

Conclusion

Current theory on ASD believes that it is unreasonable to assume a “cure” will take place for this condition at this time, but rather acknowledging there are therapeutic interventions that will aid and raise the patient’s thresholds to cope and function. Treatments for some children may both have a physical component involving chiropractic or even dental chiropractic cotreatment and a neurological processing component, which can be helped with interventions such as auditory or vestibular training. It is important for future research to determine what subset of children may best respond to chiropractic therapy and neurological type exercises. While the case presented was quite dramatic, it illustrates the need for greater research into the study of interdisciplinary care of ASD and if these types of results can be duplicated in case controlled studies.

References

  1. Newschaffer CJ, Croen LA, Daniels J, Giarelli E, Grether JK, Levy SE, Mandell DS, Miller LA, Pinto-Martin J, Reaven J, Reynolds AM, Rice CE, Schendel D, Windham GC. The epidemiology of autism spectrum disorders. Annu Rev Public Health. 2007;28:235-58.
  2. Joan M. Neysmith-Roy, The Tomatis Method with severely autistic boys: Individual case studies of behavioral changes, S. Afr. J. Psychology, 2001, 31 (1).
  3. Blum CL, LETTER TO THE EDITOR: Sacroiliac Dysfunction and SOT – Response to the Nov. JACA Online Focus article on sacroiliac joint dysfunction. Journal of the American Chiropractic Association. Dec 2006: 20-1.
  4. Blum CL, Cuthbert S. Cranial Therapeutic Care: Is There any Evidence? Journal of Chiropractic and Osteopathy. 2006; 14(10).
  5. Fink M, Wahling K, Stiesch-Scholz M, Tschernitschek H. The functional relationship between the craniomandibular system, cervical spine, and the sacroiliac joint: a preliminary investigation. Cranio. 2003 Jul;21(3):202-8.

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