ICPA 180 Hour Certification Examination

Yoshiaki Obata D.C.
3-7-18 Motoyama Kitamach Higashinada
Kobe, JAPAN 658-0003
011-81-78-451-1162
obaty@yahoo.co.jp
06/01/2007

Contemporary Pediatric Chiropractic
Joel Alcantara, DC

Jan 6-7, 2007 San Francisco

1. Describe the 7 unique biomechanical features of the pediatric spine and theirimplications to chiropractic care.
1. Active Process of Growth :The pediatric spine is going through highly active process of growth, even from in-utero andright after the birth. Because of this special feature of the pediatric spine, it is always important
to assure the safest and the healthiest growth of it, by avoiding the pathological processes suchas malformation, deformation, and disruption. The implications of chiropractic care to theseissues are, first the preventive characteristics which can be applied to the care for both themother and the baby. Webster In-Utero Constraint Technique is known as one of the mosteffective chiropractic approaches helps to avoid complications during pregnancy, according to
the article by Pistolese RA (1). This technique is designed to help preventing malposition of ababy caused by intrauterine constraint, with which the optimum growth of a fetus could be
affected. In addition, malposition of a baby will increase the risk of dystocia and surgicalintervention such as cesarean section, which could be a reason for birth trauma. Birth trauma isa major reason disrupting the optimum growth of a pediatric spine. The other implication is theactive care towards pediatric spine through chiropractic adjustments. This will help optimizing
each stage of the rapid growth of pediatric population, especially on the spinal growth andavoiding those pathological processes mentioned above.
2. Malleability
Malleability is one of the unique biomechanical features of a pediatric spine, and not only thespine, but the bone structure of a pediatric population is malleable in general as well.

Historically, Chinese foot binding, or molding of the skulls seen in North American tribe(Chinook) are some good example for its malleability (2). Because of this nature, when external
force is applied, pediatric spine may start to have problems even in their early stage of growth.
Furthermore in some cases, pediatric spine absorbs significant amount of external forces before
it starts to show signs of malfunction, making it harder for early detection of the problem.
Chiropractic care will be one of the best approaches to detect and correct the most subtle change
in the pediatric spine before seeing major problems, and also this malleability supports thesafety factor of the chiropractic adjustments, rendered precisely and with the most adequate
amount of the force.
3. Adaptability
The term “Adaptability” denotes one of the biomechanical features of the pediatric spine. The
pediatric spine has high ability to resist and hold out against the external forces and stresses, andadapt to it. Because of this feature, early detection of ongoing potential problems in a child’s
spine and body is hard. In some cases, sub-clinical entities may not be recognized by usual
medical approach examinations, because a child appears to be maintaining a good function level.
Long term hidden dysfunction of the spine can cause significant clinical outcome (i.e. earlyspinal degeneration and associated complications affecting the neural structures adjacent to thespine). Chiropractic examination and treatment is one good candidate for early detection of thechild’s spinal dysfunction, correction, and maintaining optimal spinal hygiene. It is thechiropractic concept of “Wellness Care” that supports and enables the best growth of a child’s
spine at any stage.
4. Hypermobility :Compared to the spine of the adult population, the spine of pediatric population has rather wider
Range of Motion, and it is described as “Hypermobility” of the pediatric spine. This nature isdue to the immature soft tissue component, such as muscles and ligaments, are not functioning
enough yet to prevent excessive, hypermobile motion in a spine. Other reason for this nature isthat the facet orientation between each vertebrae has lesser angle and flatter, and thus resulting
in wider Range of Motion. Some implications for chiropractic care are; when examining andrendering adjustments to cervical region (C0/C1/C2), because of its anatomical considerations(facet joint orientation, ligament composition), one should need to pay additional attention
towards normal variant such as C2 pseudo-subluxation seen on lateral cervical radiograph (2),and upon palpatory examination or adjusting this area, one should be aware of some variants onmotion palpation findings and/or the Line of Correction and Line of Drive of the adjustments
applied to this area. In addition, this hypermobile nature is linked closely to the greater
instability of pediatric spine, therefore special attention needs to be paid in case of major trauma
such as severe fall or in a Motor Vehicle Accident.
5. Changing Spinal Contours
The pediatric spine is in its active process of growth, and especially after the birth in accordancewith each developmental stage, it is susceptible to more and different types of forces. These
forces are the necessary stimulus to prompt its growth, but if any potential problems (i.e.
subluxations) are present, these forces can act more as stress factors which might cause bothrotational and coronal deformities (2), and prevent the optimal growth of it. The contour of thepediatric spine such as lordosis and kyphosis are developed as a child starts to follow thedevelopmental mile stones (i.e. holding the head and neck upright, rolling over and crawling,
standing upright and walking). This rapid change of the physical activities is the timing that thespine receives more and different types of forces, or stresses in cases as mentioned above. It issaid that the transitional regions in a spine are the regions of additional force/stressconcentration (2), therefore, special attention to those regions is paid when a chiropractor
performs the examinations and the adjustments.
Here are some good examples of implication to chiropractic care towards the rapid growing
pediatric spine. These are the general areas to observe during different developmental stages ofa child (3); the upper cervical region is examined in case of a newborn, since any birth trauma
can cause extra damage to the area. The upper to middle thoracic region is examined in addition,
if history of Cesarean section is reported. When a child is eight to ten weeks old, typically when
they start to hold the head and neck upright, it is important to examine the lower cervical region
with this timing. When a child is about five months old, and able to roll and lift up the torso inprone position, the lower thoracic region needs to be examined. The lumbar and the sacral
regions are especially examined when a child starts to sit, stand, and walk, normally after theage of eight months or later. All of these examples indicate that it is important to particularly
focus on the transitional regions of the spine, depending on each developmental stage.
6. Changing Applied Forces
When discussing the pediatric spine, it is necessary to review the forces applied to it in relation
with the level of physical development of a child. Needless to say, because the pediatric spine isvery fragile and immature, it is at higher risk of developing subluxation with lower forces. In
addition, as a child goes through each stage of physical development, both quality and quantityof the force applied to the spine changes. For example, when they start to stand and walk, thespine starts to experience different types and greater amount of forces. A child normallyexperiences repetitive fall on their buttock in the learning process, especially at the beginning.
This longitudinal application of the force increases the chances of subluxation formation,
particularly at their sacral area.
Another discussion is the relation between the cervical spine and the forces applied to it (i.e.
whiplash injuries or Shaken Baby Syndrome) (2). Due to the fact that a typical pediatric patient
has larger mass and weight of the head compared to their neck and the body, there is a tendency
to produce more impact and damage to the cervical spine. In case of Shaken Baby Syndrome,
this greater impact could cause serious damage to the head and brain as well. By putting thesefeatures into consideration, it is necessary to keep in mind that relative low forces for adults, as
in a low impact collision from a motor vehicle accident, could result in producing considerable
injury to the body of a child.
7. Immature Neuromuscular System
The immaturity of the pediatric neuromuscular system is one of the unique biomechanicalfeatures associated with the pediatric spine. One implication in chiropractic care of this featureis the risk of injury to both the skeletal system (i.e. spine) and the adjacent neuromuscularsystem. Needless to say, the immatureness of these systems increases the possibility of injuries
which causes damages and symptoms such as pain and decreased physical functions. Early andappropriate chiropractic care will contribute to maximize the healing process of the injury (i.e.
pain reduction and recovery of the damaged tissues), and restoring the functions of the systems.
However, if the injury is not treated properly and any damage was left, it could lead to further
complications and long-term effect.
Scoliosis, defined as a lateral curvature of the spine with rotation of the vertebrae about thevertical axis (4), is an example of the long-term effect and dysfunction. The cause of scoliosis is
not known. However, recent research indicates that genetic, hormonal, or environmental factors
contribute to the development of scoliosis (4). From the chiropractic point of view, any spinal
subluxation formation which could prevent the optimal development of the spine is considered
to be one causative factor of scoliosis. Another implication of scoliosis to chiropractic care is
the “Dinner Plate-Flagpole theory”. Based on the retraining theory of the brain, the theorysuggests that, for example, chiropractic care and concurrent use of braces is an effective
approach to treat scoliosis. The outline of the theory is as follows; any spinal subluxation istaken care by chiropractic adjustments to stimulate and activate the spinal joints, and to restore
the normal function. Concurrently, bracing is applied to help restoring the better alignment of
the spine, and sending the “retrained” information from the spinal joints and its surrounding
structures to the brain. Upon receiving the retrained information, the brain integrates it and start
to function towards further improvement of the spinal alignment.

References
1. Pistolese RA. The Webster Technique : a chiropractic technique with obstetric implications.
J Manipulative Physio Ther 2002 Jul-Aug ; 25 (6) : E1-9
2. Alcantara, Joel, D.C., Contemporary Pediatric Chiropractic; 26, 27, 28,
3. Rossi, Armand M. D.C., F.I.C.P.A., Introduction to Chiropractic for the Family Practice; 94. Massachusetts General Hospital Orthopaedic Surgery
http://www.mgh.harvard.edu/ortho/Scoliosis.htm

2.

Provide a critical appraisal of the Balon et.al. Asthma Clinical Trial and the Olafsdottir
et. al Colic Clinical Trial.

Critical Appraisal of the Balon et.al. Asthma Clinical Trial:
In the Asthma Clinical Trial of Balon et.al (1), there are three issues that need further
examination regarding the purpose and conclusion of the paper.
First, the paper was designed to measure the benefit of chiropractic spinal manipulation inchildhood asthma by a comparison of the benefits of active and simulated chiropractic
manipulation. With regard to the term “simulated chiropractic manipulation”, they need toclarify the distinction between “active” and “simulated” chiropractic manipulation to obtain aplausible result and conclusion in the study. In addition, the motivation for using simulatedchiropractic manipulation to determine the benefits of active chiropractic manipulation is
unclear since in general, studies become more acceptable when comparing two methods orinterventions which have clear distinctions and/or different qualities (i.e. an active chiropractic
manipulation to a medication or placebo) in each. By putting these points into consideration, thebasic purpose of the study seems uncertain, and hence the conclusion becomes questionable.

Second, the conclusion of the paper states that the addition of chiropractic spinal manipulation
to usual medical care provided no benefit in children with mild or moderate asthma (1). In the
study, “ninety one children who had continuing symptoms of asthma despite usual medical
therapy were randomly assigned to receive either active or simulated chiropractic manipulation
for four months (1).” The question arises from the statement that the group of children was
randomly assigned despite usual medical therapy. The method of a study should be instead
designed to clearly eliminate the effect from any other interventions when measuring thebenefits of one treatment towards a symptom. Therefore, the result of this study is questionable
since there is no clear verification indicating weather the outcome data was brought from theeffect of chiropractic manipulation or from the usual medical therapy. The conclusion isconsequently questionable as well, since it is not supported by the evidence of examining solely
the benefit of chiropractic manipulation (active or simulated) towards childhood asthma.
Lastly, the third issue is the failure of differentiation between two groups of patients (thirtyeight in the active-treatment group and forty two in the simulated-treatment group) based on theoutcome measurements, and the discrepancy associated with previous studies. This was pointed
out by Anthony Rosner, PhD., in the article of “Walking on the Wild Side of Allopathic
Medicine: Going Ballistic Instead of Holistic.” The article states that the conclusion of Balon et.
al is based upon the failure to differentiate two patient groups in both measurements of qualityof life (including nighttime symptoms) and airway function, although another study performedby Balon et. al seventeen months earlier concluded that there was a significant difference withnighttime symptoms within the same two patient groups (2). The article further states that thisdiscrepancy was not mentioned by Balon et.al, and thus leading to a suspicious conclusion of
the paper by Balon et. al (1).

References
1. Balon J, Aker PD, Crowther ER, Danielson C, Cox PG, O’Shaughnessy D, Walker C,
Goldsmith CH, Duku E, Sears MR. A comparison of active and simulated chiropractic
manipulation as adjunctive treatment for childhood asthma. N Engl J Med 1998 Oct
8;339(15):1013-20
2. Anthony Rosner, PhD. Walk on the Wild Side of Allopathic Medicine: Going Ballistic
Instead Holistic.

Critical Appraisal of the Olafsdottir et.al Colic Clinical Trial
The Randomized controlled trial of infantile colic treated with chiropractic spinal manipulation
by Olafsdottir et.al, concludes that chiropractic spinal manipulation is no more effective thanplacebo in the treatment of infantile colic (1). This statement needs to be examined further withthe comparison to a similar study formerly performed. The clinical trial by Wilberg JM et.al,investigating the short-term effect of spinal manipulation in the treatment of infantile colic (2),was performed in October, 1999. The objective, participants, and the intervention were similar
enough since both studies were investigating the effect of spinal manipulation in the treatment
of infantile colic. However, the results and the conclusions from those two studies revealed
significant contrast. This contrast brings the necessity for a closer examination of the studies toclarify the definition and the specific description regarding the spinal manipulation performed ineach study. It needs to include, for example, the name and features of each spinal manipulation(i.e. the effectiveness of the technique towards pediatric patients, typical force application), andthe detailed description of each manipulation (i.e. spinal examination protocol, manipulated
spinal segments). It is expected that the results of the same type of clinical trials as those above
will be more substantial if the interventions are selected with these differences in mind.

References
1. Olafsdottir E, Forshei S, Fluge G, Markestad T. Randomized controlled trial of infantile
colic treated with chiropractic spinal manipulation. Arch Dis Child 2001 Feb;84(2):138-41
2. Wilberg JM, Nordsteen J, Nilsson N. The short-term effect of spinal manipulation in thetreatment of infantile colic: a randomized controlled clinical trial with a blinded observer.
J Manipulative Physiol Ther 1999 Oct;22(8):517-22

ICPA 180 Hour Certification Examination

Yoshiaki Obata D.C.
3-7-18 Motoyama Kitamach Higashinada
Kobe, JAPAN 658-0003
011-81-78-451-1162
obaty@yahoo.co.jp
06/01/2007

Short Lever Adjusting
Claudia Anrig, DC

June 4-5, 2005 Los Angeles

Please answer the following questions in essay form:
1. Explain the difference of the AS condyle and PS condyle subluxation.
a. Specifically address for both of them the mechanisms of injury, possible
clinical symptoms related to this subluxation complex.
AS Condyle Subluxation
The mechanism of injury and some common causative factors of the Anterior-Superior
Occipital Condyle Subluxation (AS condyle subluxation) are: malposition of the fetus resulting
in in-utero constraint position such as brow or facial presentation, or transverse-lie presentation(1). When a fetus is in these presentations, typically the fetus is in prolonged extended positionof the head and neck, which chould result in AS condyle subluxation. In cases of older children,
accidental fall on the forehead or on the face resulting in an extension injury of the head andneck, is one of the common reasons to form AS condyle subluxation. In addition, forceful headbanging motion to back and forth as seen in motor vehicle accident, is another example ofpossible mechanism of injury.
Some of the possible clinical symptoms related to AS condyle subluxation are; low APGAR
score at birth (1), abnormalities in neurological reflexes, severe neurological symptoms such as
seizures, epileptic seizures, Cerebral Palsy, Autistic Spectrum Disorders (1), and Pervasive
Developmental Disorders. Various clinical manifestations especially a sudden change fromnormal is said to be related with AS condyle subluxation (2). Other signs seen in a pediatricpatient with this subluxation are; anterior translated posture with extension of the neck (2),regular choking (3), and babies prefers to lay down prone.

PS Condyle Subluxation
Some of the mechanisms of injury and the causative factors of the Posterior-Superior Occipital
Condyle Subluxation (PS condyle subluxation) are; malposition of the fetus resulting in in-utero
constraint position same as in AS condyle subluxation, especially the transverse-lie presentation(1). This presentation forces the fetus in prolonged flexed position of the head and neck.
Additionally, in-utero exposure to alcohol, drugs, and toxin from cigarette are said to cause
in-utero formation of PS condyle subluxation (3). Accidental fall causing flexion injury of thehead or whiplash injury could result in PS condyle subluxation formation as well.
Examples of the possible clinical symptoms related to this subluxation are; some of the similar
manifestations as seen in the AS condyle subluxation, but usually the severity of thosemanifestations are not as intense (1). Other example is the conditions commonly associated withthe upper cervical (C0/C1) subluxations and/or parasympathetic involvement such as asthma or
any other allergic symptoms (4). Noticeable flexion of the head and neck, or head tilt upon
visualization examination indicates possible PS condyle subluxation as well.
References
1. Anrig, Caludia D.C., Chiropractic Approaches to Pregnant and Pediatric Care; a Specific
Biomechanical Approach Adapting the Gonstead System; 38,39
2. Mullin, Linda D.C., The Challenged Child; 12,13
3. Rossi, Armand M. D.C., F.I.C.P.A., Introduction to Chiropractic for the Family Practice; 8
4. Thompson, James V. D.C., Examination, Analysis, and Spinal Correction of Children; 27

b. Discuss the set-up procedure for correction on the infant and child (include
patient and doctor set-up, patient contact point, the doctors hand contact and lineof correction).
AS Condyle Subluxation
Patient set-up; a condyle block is always used when correcting all AS condyle subluxations. It isnecessary to choose the condyle block with the correct size depending on each patient, andplaced along the cervical spine from C1 through C7 to support the region. In case of an infant,typically they are placed supine on a table, and the head should be at the edge of the table. The
condyle block is positioned behind the patient’s neck.
For a straight AS condyle subluxation without any laterality or rotatory component (AS), doctor
kneels or squats directly behind superior to the patient, and in case with any laterality (ASRS or
ASLS), the doctor positions slightly to the same side of the laterality. The patient’s contact point
and the doctor’s hand contact point for AS listing are as follows; the doctor contacts the glabellaof the patient with both right and left thenar eminences. The fingers are located around andunder the posterior occiput to create minimum lift. This is done also by using the second and thethird digits placed on the glabella, while the thumb is used to create the lift. For ASRS/ASLS,
doctor contacts patient’s glabella with the soft portion of the pisiform (fleshy pisiform) ofright/left hand, while the opposite hand cups the posterior occiput to create the lift. Doctor’s
elbow should stay close to the side of the body for both methods. The Line of Correction (LOC)for AS listing is; Anterior to Posterior (A to P), minimum Superior to Inferior (S to I), witharching type of motion. The LOC for ASRS/ASLS listing is same as in AS listing with somemodification in doctor’s contact to adjust for the lateralities.
For the listings with any rotatory component (ASRSRA, ASRSRP, ASLSLA, ASLSLP), thehead of the patient is rotated away from the rotatory component in the listing, prior to theadjustment (i.e. the head is slightly rotated anterior in case of RP or LP listings).
In case of an older child, typically they are placed upright (i.e. sitting on a chair). The condyle
block is positioned behind the patient’s cervical spine, while doctor’s abdomen is used forstabilization. For AS condyle listing, the doctor stands straight behind the patient, and for
ASRS/ASLS, the doctor positions slightly to the same side of laterality. The patient contact
point and the doctors hand contact for AS listing are; the doctor contacs the center of theglabella with typically with the third, fourth, or fifth digit, while the opposite hand overlappedfor stabilization. The doctor’s elbow should stay close to the side of the body always. When thepatient is positioned upright, slight flexion of the head is needed to obtain pre-tension at thejoint. The LOC for AS listing is A to P, S to I, with inferior arching type of motion. The LOC
for ASRS/ASLS is A to P, S to I, right to left/left to right (R to L/L to R) with the archingmotion across the lateral mass of C1. For the listings with ratatory component, the patient’s
head is rotated away from the rotatory component in the listing prior to the adjustment.

PS Condyle Subluxation
Infant is placed upright either on the lap of the parent, or between the thighs of the doctor, while
the parent supports the back and the chest of the child. The doctor is positioned behind thepatient, and contacting the supra-mastoid groove on the side of the listing either with the thumbor the thenar eminence, whichever fits better to the patient. Other fingers are placed on theposterior side of the cervical spine to provide support and stabilization, and to increase thespecificity of the segmental adjustment. The opposite hand is placed on the cervical spine andmusculature of the other side of involvement, especially at C1/C2 segments for additional
stabilization. The LOC of Posterior-Superior (PS) condyle listing is; Posterior to Anterior (P toA), S to I with an inferior arching type of motion across the lateral mass of C1. If there are any
lateralities in the listing (i.e. PSRS PSLS), R to L/L to R component is needed in addition.
In case of an older child, they should be in seated position (i.e. on a cervical chair). The doctor
stands behind the patient and slightly to the side if any literality is present in the listing. The
patient is stabilized by the parent or by use of the stabilization strap. The doctor contacts thesupra-mastoid groove of the patient on the side of listing, with the thenar eminence of theadjusting hand. The opposite hand is placed on the mastoid process and the cervical spine of theother side of involvement. The LOC for PS, PSLS, PSRS are same as in the adjustments ofinfants. As for the listings with any rotatory component, the component is compensated upon
the set up of the adjustment (i.e. the head of the patient is slightly rotated away from the rotatorycomponent).

ICPA 180 Hour Certification Examination

Yoshiaki Obata D.C.
3-7-18 Motoyama Kitamach Higashinada
Kobe, JAPAN 658-0003
011-81-78-451-1162
obaty@yahoo.co.jp
06/01/2007

Neurosensory Integration
Dr. Monika Buerger

Oct 28-29, 2006 Chicago

Please answer the following questions in essay form:
1. Case history:

A 7 y.o. boy comes into your office for an evaluation for possible

sensory issues. The mother states that her son has a hard time sitting still in class andpaying attention. She also states that during circle time, her son can not sit still andoften gets up and runs around. He also is very distractive when he sits in class as helikes to kick the desk of the kid that sits in front of him. Upon taking the history you
also find that the child often goes around touching things and people; sometimes
inappropriately, and he also has difficulty performing tasks that require multiple steps.
a. Describe how you would perform the following primitive reflex exams and,if retained, what you would see:
1. Palmer
Doctor asks the patient to stand so that the vestibular system is engaged. Also it is better to cut
all other sensory inputs such as sound and light, to obtain better findings. The doctor uses a lightbrush to stroke the patient’s both palms. Stroking is performed along the horizontal crease andthe vertical crease respectively. Positive findings are noted by slight flexion and abduction of
the thumb, or any finger movement.
2. Schilder’s (Asymmetrical Tonic Neck Reflex)
Doctor is positioned behind the patient, and the patient brings up both arms in front with theeyes closed. The doctor next turns patient’s head to one side then to the other side. The doctor
checks if the child’s arms shifts and drifts downward and apart while turning the head for few
times. If the child’s arm is shifted and/or drifted, it is the positive finding.

3. Spinal GalantPatient is positioned on floor on his/her knees and hands, while the doctor strokes the patient’s
back on their skin, downward from the shoulder to the base of the spine with a light brush.
Positive findings are noted by the patient shifting the hip to right/left side when stroking down
the right/left side of the spine.

b. In this particular case, what would you expect to see when performing the following tests?
1. Sequential finger touching
Patient is asked to make an “O” shape with his/her thumb and the index finger. This isperformed with the patient’s eyes opened and then closed, or watching the fingers then not
watching the fingers. The doctor notes any flat looking “O” shape made with their fingers.
2. Diadokokinesis
Patient is asked to touch his/her nose by their index finger. It is performed five times on one
side, and then five times on the other side. The doctor would expect to see the patient missing totouch the nose, or the child tilts their head as to tilt the nose into the finger. If the patient isseven years old or above, they should not miss to touch the nose more than once.
3. Prone extension
Patient is asked to lay down prone on a table or the floor, and next the patient is asked to lift up
his/her upper torso and legs. The patient is asked to hold the position for about twenty seconds.
The doctor notes that the child shows difficulty when lifting and holding up their torso and legs,
and also any flexion of their knees and/or extension of their head.

ICPA 180 Hour Certification Examination

Yoshiaki Obata D.C.
3-7-18 Motoyama Kitamach Higashinada
Kobe, JAPAN 658-0003
011-81-78-451-1162
obaty@yahoo.co.jp
06/01/2007

Transition to Wellness
Tony Carrino, DC

Jan 27-28, 2007 St. Louis

Please answer the following questions in essay form:
1. A 3-year-old pediatric patient presents at your office for consultation and examination.
Upon reviewing your office intake forms for this patient it is noted that the reason for thisconsultation is concerning chronic Otitis Media. The parent has disclosed that she islooking for an alternative treatment for the child’s condition. In a concise chronologicalorder please discuss how you would properly evaluate this patient beginning with yourinitial consultation.

One of the most important purposes of initial consultation is to demonstrate the difference
between chiropractic and medical concept toward the definition of health, and to initiate theshift of paradigms from symptom based allopathic model to function based non-allopathic
model. In this case, when considering the reason for the consultation was chronic Otitis Mediaand looking for an alternative treatment for the condition, the doctor should expect that theparent has misinterpretation with the need and reasons for the treatment, and understand themindset of the parent to prevent further misconceptions.
The initial consultation consists of two main components. First is the Chief Complaint Focused
Consultation which evaluates the history of the condition and the past medical history
associated with the condition including positive/negative clinical outcome. Second is theconsultation to review the patient’s present health challenges and the effect on overall healthwith relation to the chief complaint. This consultation is essential to educate the parent thestrong connection between symptoms and the physiological dysfunctions as the underlying
cause, and let the parent understand the need of the treatment even after the symptom hasrelieved. The definition and the concept of chiropractic care are then introduced to emphasizethat chiropractic is not a treatment of symptoms of diseases. It also reinforces theunderstandings of the role of chiropractic in overall health of the child, and provides the parent
with the best opportunity to make an informed decision. When considering the significance of
the initial consultation, it may be better to have the consultation only with the parent so that theparent would be able to focus on the consultation without any distraction. As the last part of theinitial consultation, it is necessary to create a form summarizing the terms of acceptance whenstarting the care of a child. The form not only prevents future misconceptions and negative legal
ramifications, but leads to the agreement and patient compliance towards the best chiropractic
care, and overall health and wellbeing.
Upon completing the initial consultation, general and case history of the patient is taken. In caseof this three-year-old pediatric patient, the history should include the pregnancy and birth since
intrauterine constraint during the pregnancy and/or birth trauma could be the major causative
factor of subluxation formation. In addition, nutritional status and history of any physicaltrauma should be assessed as well. General and chiropractic examinations are performed next.
General examinations are composed of physical examinations of the systems such as
musculoskeletal, cardiovascular, gastrointestinal, ears, nose, and throat, and if necessary,radiographic and/or diagnostic testing are included. Chiropractic examination assesses thepresence of vertebral subluxation, and it is composed of spinal palpation (static/motion),
postural and range of motion examinations, muscular testing, and orthopedic/neurologicalexaminations. Interpretation of the findings from the history and examination provides theclinical impression of the patient, and it is essential to determine the most appropriatechiropractic treatment and plan to the patient.
Report of Findings (ROF) is the second major step following the initial consultation. It is theopportunity for the doctor to integrate all the information and findings from the initialconsultation, talk over the clinical impression in relation with the chiropractic concept with thepatient and family, and inform them the course of treatment and how it will be monitored. The
first adjustment is performed after the ROF, and the care continues with the proper visit to visit
dialogue (i.e. reiteration of the chiropractic concept and explanation of the procedure), visit tovisit monitoring (i.e. subjective/objective responses, range of motion, postural improvement,
and soft tissue integrity), and visit to visit documentation (i.e. using the SOATP format).
Progressive re-evaluation will be scheduled every thirty days or every ten to twelve regular
visits. Besides the benefit of evaluating the progression of the patient’s status, re-evaluation isthe opportunity that sets and gives motivation for families to move away from symptom basedcare, and shift to lifetime functional based chiropractic care.
The concept and knowledge described in this essay was referred from the handout“Transitioning your patients to wellness” by Dr. Tony Carrino.

ICPA 180 Hour Certification Examination

Yoshiaki Obata D.C.
3-7-18 Motoyama Kitamach Higashinada
Kobe, JAPAN 658-0003
011-81-78-451-1162
obaty@yahoo.co.jp
06/01/2007

Technical Integration
Dr. Peter Kevorkian

March 3-4, 2007 Raleigh-Durham

Please answer the following questions in essay form:
1. Describe the technique protocol you would use for a newborn. Explain the rational foreach part of the spinal analysis and describe how you would select an appropriate force
application. You may use a specific subluxation pattern to be as specific as possible inyour description.

The technique protocol of choice for a case with a newborn is the Sacro Occipital Technique(SOT) analysis and the adjustments. With the SOT approach, spinal and cranial subluxation
patterns should be divided into two major groups, the meningeal subluxation complex and thestructural subluxation complex (1). This division helps the doctor to detect the major type ofneurological facilitation and the most effective corrective techniques (i.e. vector determinationand force application) to apply for each patient (1). The SOT technique emphasizes that ininfants up to six months of age, the meningeal subluxation complex is almost always the major
component. This is because the supporting structure of the central nervous system ispredominantly meningeal membranes at this stage of development, and any cranial and/or spinal
subluxation is detected and corrected better with the approach focusing on the meningeal
subluxation pattern.
Atlanto-occipital subluxation is one typical example seen in a newborn with meningeal
subluxation complex (1). It is analyzed by the Condylar System (i.e. atlanto-occipital restriction,high occiput) examinations and the Atlas Occipital Decompression examination, which is a partof standard SOT examination protocol. Detection of any unequal tension and/or restriction in
Range of Motion (ROM) of the area is the goal of these examinations, and the correction isdone by specific adjustments for each positive findings. Both the examinations and thecorrection in this method assures the doctor to select the appropriate force application since thetechnique is designed and modified to fit best to the features of newborn’s body. As an example,
the detailed description of the Condylar System (atlanto-occipital restriction) examination andthe adjustment is as follows: doctor places tip of the index and middle fingers bilaterally to thepatient’s occipital bowls, and checks the side of restriction (side of the subluxation) by gently
side-bending the area right to left about three to five degrees of angle. When one side shows
restriction on ROM than the other, the doctor applies sustained pressure into the restriction until
it is released, and the ROM is equal on both sides. It is important to note that the doctor should
feel the amount of the pressure matches the tone of the restriction, so that the most appropriatepressure is applied.

2. Please describe how the chiropractor can create rapport with a child (age 6) both withthe child’s conscious mind (i.e. having them do what you want them to do) and with
their subconscious patterns (i.e. stored data – programs – within the nerve system).

The rapport both with the child’s conscious mind and with their subconscious patterns isessential to attain the best chiropractic care, and reach deeper relationships with each other.
To create rapport with a child, the chiropractor must first move into the child’s space. The childmust then move into the chiropractor’s space.
The rapport with the child’s conscious mind can be created by matching the tone and resonatingwith them. For example, the chiropractor moves into the child’s place by setting a safe,
welcoming, kids-friendly environment. This includes smooth and comfortable procedures forboth initial and regular visits. The chiropractor should again move into the child’s place bylistening carefully and talking in an understandable manner, not only to the child, but to theparents as well. It is essential for the parents to be comfortable and confident with thechiropractor in order to gain the trust of the child. When this is accomplished and goodcommunication is established, we can expect that the child will start to move into our space andgetting closer to the rapport. In addition, breathing with the child, for example, will help us toharmonize the consciousness with the child to minimize the distance between each other.
The chiropractor can create rapport with the child’s subconscious pattern by utilizing the rightand the left brain evaluations, and integrating those results to determine the best chiropractic

technique. The left brain evaluations (i.e. physical and chiropractic examinations) enable thechiropractor to move into the child’s space by gathering information such as stored data andprograms within the nervous system, which is typically in an altered pattern due to the effect ofvertebral subluxations. The right brain evaluations are also important to let the child move into
the chiropractor’s space. The chiropractor uses the right brain to establish deeper connection
with the child so that he/she can talk and listen to their subconscious mind and patterns. The
connection is between eye to eye, mind to mind, spirit to spirit, and once connected closer toeach other, the chiropractor is able to create rapport to converse with, and embrace the child’s
whole body.
Altogether with the integration of these evaluations, and with the rapport, the best chiropractic
care can be given to the patients. This will lead to further development of the relationships not
only with each patient, but with ourselves and with every person involved, and let us reach to
the deeper stages of relationships.

References
1. Martin G. Rosen, D.C., SOT Pediatric Spinal Adjustment; 24, 25, 26, 27

ICPA 180 Hour Certification Examination

Yoshiaki Obata D.C.
3-7-18 Motoyama Kitamach Higashinada
Kobe, JAPAN 658-0003
011-81-78-451-1162
obaty@yahoo.co.jp
06/01/2007

Neuroimmunology
Dr. Stephen Marini

Feb 17-18, 2007 St. Louis

Please answer the following questions in essay form:
1. Immunostasis equates with the optimum levels of Th1 and Th2 cells for the individual
to maintain health and wellness.
a. Discuss when a high Th1/Th2 ratio is necessary and what psychological,
nutritional or physical factors have been shown to increase this ratio.
A high Th1/Th2 ratio is necessary to increase the function of Cell Mediated Immunity (CMI)
and the activities of Th1 cells. CMI system is described as the first line of immune response byprotecting the body against infections, cancer cells, some allergies, and reactions fromtransplantations. CMI performs this function by means of various immune cells such as
phagocytic cells (against bacteria, fungi, and parasites), T cells (against bacteria, viruses, fungi,
and cancer cells), and NK cells (against viruses, cancer cells). T cells and NK cells have someother functions additionally, which are the elimination of cancerous cells, virus infected cells,
and the process called immune surveillance. One of the psychological factors leads to highTh1/Th2 ratio is the Welfare Consciousness Patterns (1). It is obtained by shifting from
Emergency (stress) Consciousness Patterns which causes sympathetic activities to increase andstimulates Hypothalamic-pituitary adrenocortical (HPAC) axis (1). The results are low Th1/Th2
ratio and overall immunosuppressive conditions (1). Nutritional intake can act as a Th1 up
regulator as well, to support high Th1/Th2 ratio. Some examples are Glucans and Mushroom
extracts, Melatonin, plant sterols, and fish oils (1). Probiotic supplements will help to maintain
Th1/Th2 balance by supporting the normal flora of intestine and enhancing proper function of
the enteric immune system. Breast feeding is one of the most important factors for babies toestablish a good Th1/Th2 ratio. Physical factors such as viral and/or bacterial infections will

trigger the shift of Th1/Th2 ratio, and especially in children, these exposure is essential for thedevelopment of healthy immune system with a good balance between Th1/Th2 cells.

b. What factors contribute to generating a low Th1/Th2 ratio and what are some of
the consequences?

Factors contribute to generate a low Th1/Th2 ratio can be divided into three categories as
discussed in the previous part. Nutritional factors leading to low Th1/Th2 ratio are: excess
dietary intake of particular fats (i.e. TFAs, 6EFA), sugars, proteins, and food preservatives oradditives. Nicotine, caffeine, and heavy metal toxicity could be included as well. Some of thephysical factors are: vaccinations, use of antibiotics, infection in skin or respiratory systems,
exposure to allergens, exposure to environmental toxins (i.e. chemical fumes, pesticides, andhormones), and familial and/or genetic history. Psychological factors such as anger, anxiety,fear, and depression can also act as a Th2 up regulators. These emotions are connected to“Emergency Consciousness” (1) which stimulates the sympathetic activities and triggers the
HPAC axis, resulting in low Th1/Th2 ratio and overall depression of the immune function (1).
The consequence of a low Th1/Th2 ratio is the predominance of Th2 humoral immunity. Some
examples are allergies (i.e. asthma, atopic dermatitis, seasonal allergies, and rhinitis),autoimmune disorders (i.e. SLE, Rheumatoid Arthritis, and Graves’ Disease), inflammatory
bowel diseases (i.e. ulcerative colitis, Crohn’s Disease), and immunodeficiency disorders suchas AIDS.

c. How can a Th2 dominant child affect your chiropractic assessment andadjustment plan?

In case with a child who is thought to be in a Th2 dominant status, besides a thoroughchiropractic spinal examination, an assessment of the child’s immune system throughpsychoneuroimmunology model is considered to be an effective approach. The effect ofVertebral Subluxaxion Complex (VSC) towards neuroimmune modulation, endocrine system,and psychoneuroimmune modulation is considered first. The presense of vertebral subluxation
is linked to immune imbalance since it influences autonomic neuroimmunomodulatingpathways and neuroendocrine factors, and thus leading to Th2 dominant status (1). The
psychoneuroimmunology model with gastroenteric and musculoskeletal components consist the
PNEIGMs model (1), and in addition, it should be utilized to focus how a patient’s immune
responses are regulated in relation with the function of each system. Problems in each systemshould be assessed through patient’s general history, physical and neurological examinations,dietary history, and from any past medical records. The chiropractic assessment in this caseshould be based on the integration of all findings from the history and examinations, andmoreover, it is necessary to understand the impact of VSC towards immune imbalance, and thesignificance of chiropractic adjustment in modulating immune function. The adjustment plan ofa Th2 dominant child should, for example, take the effect of chiropractic adjustments toward theautonomic nervous system into consideration. The Gonstead Chiropractic Methodology
recommends dividing spinal segments into two groups in relation with sympathetic nervous
system and parasympathetic nervous system, and not to correct subluxations of both groups at
the same time. The priority of correction needs to be considered depending on each case, andalong with any changes seen in the course of the treatment.

Reference
1. Marini, Stephen C., M.S., D.C., PhD, Neuroimmunology: Patterns of interference; 19, 25,
26, 28, 46

ICPA 180 Hour Certification Examination

Yoshiaki Obata D.C.
3-7-18 Motoyama Kitamach Higashinada
Kobe, JAPAN 658-0003
011-81-78-451-1162
obaty@yahoo.co.jp
06/01/2007

Challenged Child
Dr. Linda Mullin

April 9-10, 2005 Dallas

Please answer the following question in essay form:
1. Using People First Language, describe specific, common physical complaints that achild with Autism commonly has and how chiropractic care can benefit them.

Common complaints that a child with Autism has are interpreted as both behavioral andphysical. Some of the behavioral complaints are; strong resistance to change in pattern or daily
routine, difficulties in establishing social relationship or communication with others, lack of orpoor expression such as smiling and/or laughing, lack of or poor eye contact, and spending a lotof time in odd play such as spinning, turning, or lining things.
Physical aspect associated with a child with Autism are as follows; tantrums, hypersensitivity toa specific sound and/or light, hypersensitivity to body contact, including body hugging/cuddling,
hypersensitivity/hyposensitivity to pain, apparent physical hyperactivity/hypoactivity,
self-injurious behavior, problems with gross/fine motor skills including toe/heel walk, problems
with equilibrium (sense of balance) and proprioception(sense of the body and joint location in
the air), and along with those mentioned above, headaches, stomachaches, and vowel irritation
are reported.
From the chiropractic point of view, one of the reasons for these common complaints of a childwith Autism is suspected to be the disruption of the proper function and development of thenervous system caused by vertebral misalignment called “Subluxation”.
One example of this disruption is the Sensory Integration Dysfunction. In our daily life, we are
surrounded by different kinds of sensory inputs; (i.e. vision, hearing, smell, sense of touch(tactile), and so on). When these inputs are not properly processed and integrated, we are notable to understand what is happening, and not able to take action or behave properly to it. Thisphenomenon is said to be one of the possible explanations for the autistic behavioral complaints
listed above.
Furthermore, sensory integration dysfunction has a strong connection to the dysfunction of thegeneral motor skills and functions of a child. Our motor skills are developed close together withthe development of the sensory system. For example, gross motor skills are developed inharmony with the sense of equilibrium. We learn how to use and control specific muscles tomaintain good balance of our bodies against gravity, or when the body is in motion. A child that
could not take advantage of this learning opportunity may develop problems maintaining
equilibrium later on, resulting in uncoordinated motor skills. Sensory Integration Dysfunction
can affect Fine motor skills as well, such as writing or putting on clothes and button, require
good development of proprioception and tactile sensation. Proprioception helps us to know
where the hand is, and where it should go, and tactile sense will help determine required amountof force for a task. With the combination of these senses, we are able to perform various
complex tasks successfully.
As mentioned before, the chiropractic approach considers that it is critical to attain proper
function and development of our nervous system, especially in the developmental aspect in thecase of pediatrics. Chiropractic care specializes in removing “Subluxation” with non-invasive,
non-surgical, and the safest method known as “Spinal Adjustment”. By removing subluxation,
we are able to minimize the disruption and expect maximum development of the nervous
system of the child.
It would be safe to say that the benefit of chiropractic care is considerable for any pediatricpopulation, especially for a child with Autism.

2.

Write a short article for your patients to educate them on some common play activities
that can result in Shaken Baby Syndrome.

The Shaken Baby Syndrome (SBS) is a type of serious traumatic brain injury that occurs when
violent, excessive shaking type of force is applied to a baby’s head and neck. This can result in
considerable damage to the baby’s eyes, bones of the head and neck, and the spinal cord. Severecases can result in swelling of the brain (Cerebral Edema), bleeding in the brain (Subdural
Hematoma), direct brain tissue damage, and even coma or death. Other signs and symptoms of

SBS are Dilated Pupils (most common and first sign of SBS), Retinal Hemmorage, difficult
breathing or sleeping, vomiting, seizures, convulsions, lethargy, feeding problems, etc.
The most common cause of Shaken Baby Syndrome is non-accidental trauma, such as childabuse. However, parents frequently ask if daily play activities with babies can cause it. The
answer is no. SBS is not typically caused when playing with a baby like bouncing the baby on
your knee or tossing the baby in the air gently. But inadvertent damage can occur. Recently, it
has been reported that when the baby’s head accidentally struck a surface, causing a whiplash
type of injury, resulting in signs and symptoms listed above. It is always safer to consult a
specialist to make sure if there is any damage or not. Other cases could cause SBS are, repeat
tossing a child in the air or bouncing /swinging motion strongly and vigorously.
Also SBS might be caused while jogging with carrying a baby in a backpack, causing the baby’s
head and neck to shake back and forth without any support.
To prevent SBS, it is necessary to keep in mind that child’s body is very fragile, and needs
special attention at all times.

ICPA 180 Hour Certification Examination

Yoshiaki Obata D.C.
3-7-18 Motoyama Kitamach Higashinada
Kobe, JAPAN 658-0003
011-81-78-451-1162
obaty@yahoo.co.jp
06/01/2007

Perinatal Care
Jeanne Ohm, DC

April 2-3, 2005 Los Angeles

Please answer the following question in essay form:
1.

Define the four obstetric reasons for dystocia: and relate each reason to thechiropractic adjustment.

a. Abnormalities of the expulsive forces
According to the Williams Obstetrics, abnormalities of the expulsive forces are due to either
insufficient or inappropriate coordination of the uterine forces (uterine dysfunction), or
inadequate voluntary muscle effort.
Implication in chiropractic adjustments of this problem is that the chiropractic adjustment
eliminates stresses in the spine and the pelvis due to the displacement and misalignment (known
as “Subluxation”) of those structures. Subluxation is considered to cause interference to thenervous system, resulting in decreased function of the uterus, and overall function of the body.
The chiropractic adjustment specifically focuses on removing the subluxation, allowing theuterus to function with the highest potential and the overall optumim function of the whole body.
These improvements will naturally lead to decrease the uterine dysfunction and the possibilityof dystocia, and thus lead to easier and safer birthing processes for both the mother and thebaby.

b. Abnormalities of the maternal bony pelvis – the pelvic contraction (Passage)
Williams Obstetrics notes that “Any contraction of the pelvic diameters that diminish thecapacity of the pelvis can create dystocia (difficulty) during labor.” They further state that thediameter of the woman’s pelvis is decreased when the sacrum is displaced.

One important reason to receive chiropractic adjustments during pregnancy is to improve andmaintain the optimum balance of the mother’s pelvis. When the pelvis of a mother is misaligned,
it will disturb the whole balance of both the bony structure of the pelvis and the ligaments andmuscles attached to it. This imbalance will directly affect the diameter of the pelvis to decrease,which is an obvious factor for dystocia. In addition, as mentioned before, especially the sacral
displacement decreases the pelvic diameter. The Webster Chiropractic Technique is a specificchiropractic adjustment for pregnant mothers which focus on the correction of sacral
subluxations, and balancing the whole pelvis alignment, including the pelvic muscles andligaments. The optimum balance of the mother’s pelvis is essential to not only assuring the mostfavorable passage for the baby, but to assure the most favorable birthing process.

c. Abnormalities of presentation, position, or development of the fetus
One of the main reasons of malpositioned fetus is said to be the Intrauterine Constraint. It isdefined as “any forces external to the developing fetus that obstructs the normal movement of
the fetus”. The intrauterine constraint is typically associated with uterine torsion which is
caused by torsion and uneven tension in the supporting structures of the uterus (i.e. roundligaments and uterosacral ligaments). These ligaments are attached directly to the uterus tomaintain the optimum position of it, however, the uterus could be malpositioned andconstrained when any torsion or uneven tension is transmitted through these ligaments.
Furthermore, the uterine malposition and constraint may lead to any malposition and/or
developmental abnormalities of the fetus, since the uterus is not maintaining its optimumfunction. It is said that posterior subluxation of the sacrum may result in creating both tension
and torsion of the surrounding ligaments, resulting in uterine dysfunction and further
intrauterine constraint of the fetus.
The Webster Chiropractic Technique will correct the sacral subluxation, and balances the
supporting ligaments of the uterus. This is necessary to remove the intrauterine constraint of the
fetus, allows the ideal development of the fetus, and prevents the fetal malposition so that the
fetus is able to move into the best position for delivery.
d. Abnormalities of the soft tissue of the reproductive tract that form an obstacle to fetal
descent
Williams Obstetrics notes “in general, these are considered as developmental anomalies
incurred during embryogenesis or they may be acquired and caused by events that usually occur

during adulthood”. Some examples such as uterine displacement, cervical mymomas, or cervicalstenosis are introduced in the text, however, the clear mechanism and the etiology of theseabnormalities are not known. Here is another example of maternal abnormality forming
obstruction to fetal descent. The Obstetrics Illustrated Sixth Edition by Hanretty, notes that“dysfunctional labour occurs when the cervix does not dilate with the presence of uterine
contraction to fetal descent”. They mention the causes of the dysfunctional labour as;
dysfunctional uterine activity, malposition/malpresentaion, and rare causes such as cervicalstenosis, however, the etiology was not mentioned either in this textbook.
From chiropractic point of view, it is thought that these conditions could result from themisalignment occurred in the spine and the pelvis called “Subluxation”. The subluxation puts
pressure on the spinal cord and nerves, causing disruption in the nervous system and thus the
optimum function of the body is not attained. Specific chiropractic adjustment is designed tocorrect the subluxation, not the symptom or complication itself. When the subluxation iscorrected and the pressure and the disruption in the nervous system is removed, it restores the
body’s function to its maximum potential, leading to prevent dysfunctions in pregnancy and toeasier and safer delivery for both the mother and baby.

2. For the next 25 patients who come into your office: analyze their sacrum for posteriority
as you would usually do. Write a step by step protocol of that analysis. Compare thatanalysis with the Webster analysis. Record your results.
Posterior rotation of the sacrum is analyzed typically by using the palpation and the X-Ray
analysis based on the Gonstead Technique. The distance from the sacral tubercles to the
Posterior Superior Iliac Spine (PSIS) is palpated, and measured visually. Occasionally, theposterior sacrum is obviously visualized, with the findings of edematous change and tenderness
over the involved Sacroiliac (SI) articulation. In addition, motion palpation checks for the SI
articulations are done such as knee raiser test, leg fanning test, or fluid motion test, to detect any
fixation in the SI articulation. The X-Ray analysis is done by using A to P lumbopelvic film,
and the procedure is as follows; The center of the first sacral tubercle is marked, then the
distance from the center to both right and left most lateral borders of the sacrum is measured. If
the measurement of one side is greater than the other, and the difference is more than four
millimeters, the greater side is considered as the side of posterior sacrum.

Patient

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ICPA 180 Hour Certification Examination

Yoshiaki Obata D.C.
3-7-18 Motoyama Kitamach Higashinada
Kobe, JAPAN 658-0003
011-81-78-451-1162
obaty@yahoo.co.jp
06/01/2007

Conventional & Holistic Pediatric Medical CareDr. Lawrence Palevsky

March 25-26, 2006 Los Angeles

Please answer the following question in essay form:
1. A mother has been bringing her 4 year old boy to you since birth. She rarely goes to thephysician for medical care. Recently she reports that her son suffered a benign febrile
seizure and was brought to the ER for observation. No tests were done. Her son’s
follow up appointment with her private physician one week later was normal. At youroffice, the boy is lying on the exam table and has another seizure while you are in theother room with another patient. Only his mother was with him. By the time you comeinto the room, the boy is lying still with his eyes closed. The mother had been told at
her doctor’s visit that she didn’t need to rush to the ER if another seizure occurred.
The boy appears to be sleeping. You assess the boy and he has an open airway, isbreathing on his own, has a good heart rate and has good color.
a. What findings in the history of this seizure in your office and from the exam ofthis boy would influence your decision to refer this family directly to their
physician?
First, the assessment of the boy indicated no sings of cessation of the breathing, which needs tobe confirmed before proceeding to any further assessment (i.e. presence of fever, post-ictal state,residual neurological findings, responsiveness). The doctor then need to ask the mother about
the detailed description of the seizure occurred in the office (i.e. duration of the seizure, type of
seizure) since the doctor was not present in the room when it occurred. The doctor should
further ask questions regarding any past history of seizures and clinical visits associated with it,
including the reason why the mother had been told at her doctor’s visit that she did not need tobring her son to the ER immediately with another seizure occurrence. In this case, the vital signof the boy was stable, and if the doctor’s further assessment in the office and the mother’s
description both followed the criteria of a benign febrile seizure, with no questionable pasthistory of the patient, it was safe enough to consider that the boy had another episode of benign
febrile seizure. Therefore, the doctor had no obvious reason to refer this family directly to their
physician based on the findings above. In addition, it is always necessary to keep a good recordof past history of any patients. In this case, it is essential to keep all the medical record from thebirth of the patient so that the doctor would be able to make the most appropriate clinicaldecision.
b. Demonstrate an understanding of benign and atypical febrile seizures inchildren and what criteria you would use to influence your decision to refer thefamily right away?
Benign Febrile Seizure is a condition characterized by generalized tonic-clonic seizures which isseen in children of six months to five years of age. The seizure typically occurs once withintwenty four hour period and lasts up to fifteen minutes with short or no post-ictal period. It is
not accompanied by signs of CNS infection or residual neurological findings. Atypical Febrile
Seizure is different from benign febrile seizures since it occurs more than once within twenty
four hour period and lasts longer than fifteen minutes, and may have focal or partial seizure
manifestations. Some of the criteria that indicate the needs to refer the family immediately are
as follows: a patient with the characteristics of atypical seizures mentioned above and may
accompanied by signs of focal or CNS infection, prolonged lost-ictal state, altered mental status
or unresponsiveness. It is also necessary to refer the patient immediately when a seizure is seen
in a child less than six months of age with/without fever manifestations.
2. A mother brings her 14 year old daughter to you for a routine visit. You see allmembers of the family for regular chiropractic care. The family rarely sees their family
physician. The girl tells you that she has had occasional vomiting on and off for amonth.
a. What questions do you ask to figure out what is contributing to this problem?
The question needs to be asked in this specific case should be covering the causes of vomiting
in wider range when considering the age, gender, and the manifestation with this patient.
General questions focused on the common causes of vomiting which lasts only a day or two
should be asked first. Common causes seen in both adults and children such as viral infection,
food poisoning, motion sickness, coughing, and illness with high fever should be considered.

Furthermore, causes of recurrent, persistent vomiting (lasting more than one week) should beconsidered as well since the patient complains occasional vomiting on and off for a month. The
questions are focused on the caused such as: side effects of certain medications (i.e. pain
relievers, antibiotics, gastrointestinal medications), abdominal and gastrointestinal disorders (i.e.
indigestion, constipation, regurgitation, peptic ulcer, gastroenteritis, appendicitis, pancreatitis),
hormonal and metabolic disorders (i.e. parathyroidism, hyperthyroidism, diabetes), pregnancy(morning sickness), and psychological conditions or eating disorders.
b. What findings on history and physical might lead you to refer the family to their
physician?
The family should be referred to their physician with findings on history and physicalexaminations such as: bloody vomit (coffee grounds appearance) or green color in the vomit,
projectile vomiting, history of head injury and/or severe headache, history of notable weight
loss, any possible signs of pregnancy, pain in the chest or lower abdominal pain, history and/or
signs of diabetes (i.e. fruity breath odor), previous history of abdominal or any other surgeries,
and change in mental status (i.e. confusion, decreased attention, drowsiness).
c. Demonstrate an understanding of the intra-intestinal and extra-intestinal causesof vomiting in children at this age.
Intra-intestinal causes of vomiting in children are such as viral infection, food poisoning, foodallergy, indigestions, reaction to medication or supplement (especially at the first day of use),which typically results in vomiting for only a day or two. Other intra-intestinal causes which
may lead to vomiting lasts longer that one week are: abdominal and gastrointestinal disorders(gastritis, gastroenteritis, appendicitis, pancreatitis, peptic ulcer), prolonged side effects frommedications, effect of anesthesia following surgery, and obstructive conditions such as blockageof the stomach or intestines. Extra-intestinal causes of vomiting in children are: infections seen
as in meningitis, hepatitis, urinary tract infection, sepsis, neurological conditions such as
headaches, motion sickness, head injury or brain tumors, or any vomiting induced by bad smells
or tastes. Hormonal and metabolic disorders (i.e. diabetes, thyroid disorders) may cause
vomiting as well. Pregnancy and the associated hormonal change could be the cause of vomiting
in case of adolescent female patients. Psychological disorders also need to be considered as
extra-intestinal causes of vomiting, for example, eating disorders such as bulimia and anorexia
nervosa.

ICPA 180 Hour Certification Examination

Yoshiaki Obata D.C.
3-7-18 Motoyama Kitamach Higashinada
Kobe, JAPAN 658-0003
011-81-78-451-1162
obaty@yahoo.co.jp
06/01/2007

The Fascial Link in Chiropractic
Dr. Carol J Phillips

Dec 2-3, 2006 San Francisco

Please answer the following questions in essay form:

1. If you were to explain to a new patient the concept of the fascial link in chiropractic,
how would you describe the following:a.

the fascial system

The definition of fascia is layers of fibrous tissue that covers and separates all the muscles in our
body. In fact, fascia is not divided into individual pieces, but it is one broad sheath wraps
around and encapsulates all muscles in our body from the top to the bottom. This means, inother words, every single muscle is connected together through the fascia, no matter how far themuscles are located. For example, the muscles of neck and ankle are literally connected becauseof the fascia, and those muscles are connected to any other muscles in our body as well. In
addition, every bone, joint, and organ has connection to some muscles to maintain the proper
position and function. Although those bones, joints, and organs look like located independently,
they are connected with each other by means of muscles, and as mentioned before, thosemuscles are connected altogether by means of the fascia. This means in summary, the fascia
connects all muscles, bones, joints, and organs as a whole body system.
b. the connection between the fascial system and energy conduction
The fascial system is the concept shows that every muscle, bone, joint, and organ is connected
through one broad sheath of fibrous tissue called fascia. By means of the fascia, our body is able
to function as a whole body system, and it is possible when the fascia is maintaining its balanceso that each component of the body is in balance and functioning properly. Additionally, thisbalance and function is maintained by uninterrupted energy conduction in every part of the body
via blood vessels, lymph vessels, and nerves. These tracts are seen in every single muscle, bone,
joint, and organ, literally throughout the body, and conducting essential energies such as blood,
immune cells, and nerve signals. However, because of this nature of the fascia, any imbalance in
one pare of the body could trigger an imbalance in any other parts of the body, and affecting thewhole balance and function of the body as well. For example, when a person had an ankle
sprain, besides the local damage to the structures and the fascia of the area, the damage can betransmitted through the fascial system and possibly causing imbalance in other parts of the body.
Furthermore, this local damage may cause an interruption of energy conduction (i.e. lack ofblood flow, decreased immune response, and interference in the nervous system), and thus
leading to alteration from the optimum balance and function of our body.
c. the concept of tissue memory
Tissue memory is a memory held in the body and tissue of a person, and it is independent fromthe person’s conscious memory. This memory can be associated with either favorable orunfavorable past events, but the greater significance is seen with the unfavorable memory
causing any adverse effect on the person. For example, a baby who has a history of difficult
birth and/or birth trauma, or a person who was involved in a motor vehicle accident, typicallyholds the tissue memory leading to various types of physical complications. These tissue
memories have close connection with the fascial system since any negative past histories (i.e.
physical injuries and/or emotional stresses) will cause both the fascial torsion and theaccumulation of tissue memories. Upon unwinding the fascial torsion, the release of the tissue
memory is triggered, and it is expressed by the person literally repeating the exact physicalmotion happened in the injury, and letting out the emotions. With a case of a baby, this is seen
in a baby repeating the position and the movement from the birth and crying to let out the fear
and anger from the birth, or a person repeating the whiplash motion and expressing the negative
emotions associated with the injury. The concept of tissue memory emphasizes the importanceof releasing the fascial torsion and the tissue memory, so that a person is out from the negative
subconscious pattern, and will be able to step to the next stage of healing with a new pattern to abetter memory.

ICPA 180 Hour Certification Examination

Yoshiaki Obata D.C.
3-7-18 Motoyama Kitamach Higashinada
Kobe, JAPAN 658-0003
011-81-78-451-1162
obaty@yahoo.co.jp
06/01/2007

Family Wellness
Dr Armand Rossi

March 5-6, 2005 Los Angeles

Please answer the following questions in essay form:
1. Describe, in detail, three different ways of adjusting an atlas on a newborn.

a. Toggle Adjustment of Atlas
Patient placement is in neutral side posture position with the side of atlas laterality in “up”
position. When placing the patient’s head on the headpiece (i.e. Webster Infant Adjusting
Headpiece), the mastoid process should be level to inferior tip of the headpiece. The patient canbe held upright by the parent, with the atlas laterality facing toward doctor. The doctor uses thestrap to hang the headpiece over his/her neck. The doctor stands anterior to the patient, andcontacting the atlas transverse process with the tip of the first, second, or fifth digit. The Line ofCorrection (LOC) is right to left or left to right to correct the laterality, with minimum thrust
just to cause the headpiece to drop. In case with a newborn, Toggle Set adjustment is done
instead of recoil adjustment, since the development of the cervical musculature is not ready forthe recoil component of the adjustment.
b. Sustained Contact Atlas Adjustment
Doctor examines and determines the atlas laterality. Patient placement is either supine or upright,
whichever the patient is in comfortable position. The doctor contacts the atlas transverse process
on the side of laterality, with any digit fits better depending on each patient. Sustained pressure
is applied in the LOC, with the adequate amount of pressure measured by feeling the tension
from the laterality and matching the pressure against it. The pressure is held until the doctor
feels the release of the tension, or approximately twelve to fifteen seconds.

c. SOT Upper Cervical Adjustment with Indirect Technique
Cervical stairstep examination is preformed to detect upper cervical subluxation formation in apatient. Any positive findings at the upper step (step four) indicates the possibility of atlas/axis
involvement, and the side of the involvement is determined by detecting swollen and tendermuscle nodulations and/or restricted Range of Motion on one side. The patient is positioned
supine, and the doctor places superior to the patient. The doctor uses the index finger to contact
the lateral mass or transverse process of the atlas, and the lamina pedicle junction or transverse
process of the axis at the involved side. The other hand supports the patient’s head with shifting
it laterally and slightly superior to the opposite side of the contact point. It is important not torotate or laterally flex the patient’s head and neck at this point. Next, the doctor gently puts
motion on the patient’s head and neck by rotating, side-bending, and extending the head while
applying moderate pressure through the contact point. The pressure is applied until the doctor
feels the release of the tension and restriction, and typically for about ten seconds to a minute.
Post-adjustment recheck is indicated and it is done by performing again the examinations
mentioned above.

2. Describe what you would do if you suspected that a child was a victim of abuse.

Reporting child abuse is the obligation for any doctor of chiropractic as a mandated reporter. All
doctors needs to be aware of the background knowledge and typical indicators of child abuse forearly detection, and the appropriate reporting action to prevent any further abuse whensuspected. The victim of child abuse is described as a single person under the age of eighteen,
who has been non-accidentally injured physically or mentally, treated negligently or sexually
abused, or who dies as a result of abuse or neglect (1). There are no tendencies in races,
religions, nationalities, and socio-economic status with people who was involved in child abuse.
However, it is said that the largest group of child abusers have drug and alcohol problems (1),and people tend to abuse children when they do not have knowledge of normal childdevelopment and parenting, or they have unrealistic expectations of the child’s ability regardlessof their growth or development (1).
Physical abuse denotes any non-accidental physical injury caused by the parents or othercaretakers. Possible indicators are: unexplained bruises and welts on different parts of a body invarious stages of healing, unexplained burns such as cigarette burns, immersion burns, patternedburns, and rope burns, unexplained fractures and dislocations such as multiple fractures in any

part of a body in various stages of healing, and unexplained lacerations to mouth, lips, gums,
eyes, genitalia, or any signs of human bite. Neglect denotes any negligent treatment or
maltreatment of a child causing actual or risk of harm to a child’s safety, life necessities,
medical and health care, education, and growth and development. Some of the indicators are:consistent hunger, begging or stealing food, poor hygiene and clothing, obvious lack ofsupervision, prolonged stays at nursery or school, and sings of unattended physical/emotional
problems or medical needs. Sexual abuse denotes the exploitation of a child for the sexual
gratification of a person typically older than the child, but not always a crime of adults toward
children (1). It includes not only the violent sexual behaviors and assault (i.e. rape, incest, andsodomy), but it may include variety of behaviors such as fondling, verbal assault, voyeurism,and sexual harassments. Possible signs and behavioral indicators are: self destructive behaviors(i.e. alcohol/drug abuse, eating disorders, and suicidal attempt), anxiety/panic attacks, dissociate
phenomena, sleeping disorders, withdrawal/fantasy or infantile behavior, unusual fear of aperson, unusual interest in or knowledge of sexual matters for a child of that age, and so on.
Occasionally, a child reports sexual abuse by themselves, but usually many abusers use threatsor other methods to force children not to tell, which makes it more difficult to detect theongoing abuse (1,2).
When a doctor suspects that a child was a victim of abuse, he/she immediately needs to report
the suspected case to, for example, state Department of Human Services, Juvenile Department,
Police Offices, or to hospitals with a SCAN team (1,2). The initial reporting is considered as arequest for an assessment of a suspected incident of abuse or neglect, and not as an establishedfact (1). The report should include the basic information of the child and the parents or the
caretaker, evidences of abuse, any given explanation of injuries, and doctor’s findings whichmight be helpful in the assessment of the abuse (1). The doctor also needs to tell the child thathe/she needs to contact people who will help them. The details of the suspected abuse is notnecessarily asked at this point, and the doctor should not display any shock, horror, or
disapproval of parents/caretakers, child, or the situation. The doctor only needs to suspect abuse
and initiate the report (1).
As a doctor practicing in Japan, I would like to mention one important issue regarding the Child
Abuse Prevention Law in Japan. This law was revised in 2004 to ensure the protection ofchildren and to offer more desirable consultation to parents. Each municipal Child Consultation
Centers are in charge of these services, however, they are still not able to conduct those
activities exclusively and independently from other legal authorities. This means due to the“bureaucratic” aspect of the involved processes, it may take unreasonable amount of time totake the actual actions for effective protection of the child and further preventions, althoughimmediate actions are essential for identification, stoppage, and prevention in any cases of childabuse.

References
1. Oregon Department of Human Services, Recognizing and reporting child abuse & neglect.
An explanation of Oregon’s Mandatory Reporting Law; 3, 4, 5, 6, 10, 11, 12
2. Rossi, Armand M. D.C., F.I.C.P.A., Introduction to Chiropractic for the Family Practice; 19,
20, 21, 22

ICPA 180 Hour Certification Examination

Yoshiaki Obata D.C.
3-7-18 Motoyama Kitamach Higashinada
Kobe, JAPAN 658-0003
011-81-78-451-1162
obaty@yahoo.co.jp
06/01/2007

Diagnostic Imaging
Dr. Robert Schlampp

Sep 23-24, 2006 Dallas

Please answer the following questions in essay form:
1. Discuss hip dysplasia. Include in that discussion:a. the difference between congenital and secondary hip dysplasia
Congenital hip dysplasia is a condition with abnormalities in the hip joint structures which arepresent at birth, or become evident soon after the birth. Recently, this condition has been termeddevelopmental dysplasia of the hip (DDH) since more literature suggests that it often has adevelopmental etiology (1). Congenital hip dysplasia or DDH may result in hip joint instability
and partial or complete dislocation of the hip with acetabular dysplasia (1), and may associatedwith leg length inequality and /or restricted range of motion. Studies have reported the increased
risk with family history and/or breech intrauterine presentations, and obvious female
predominance (2). Early postnatal diagnosis and treatment of DDH is highly suggested toreduce the potential of instability and dislocations (3). However, if DDH was not treatedproperly, it may result in hip dysplasia in later infancy or childhood, or further in adolescentsand adults (2, 3). These conditions may be considered as secondary hip dysplasia including any
abnormal structures of the hip joint. It may present as skeletal malformations (i.e. shallow
acetabulum, flat femoral head, pseudo-joint formation) (3), gait difficulties, osteoarthritis, andmay associate with prolonged pain.
b. Explain how would you evaluate hip dysplasia from radiographic findings.
Include a list of the lines of mesuration and explain these lines.
The classic radiographic findings of DDH are lateral displacement of the femur, an absent or
small femoral capital epiphysis, and increased acetabular angulation (Putti’s triad) (1). On ananteroposterior pelvic radiograph, a horizontal line is drawn through both right and left
triangulate cartilages (Hilgenreiner’s line or Y-Y line) (1). Acutabular Index is the angle
measured by drawing oblique line along the lateral and medial portions of both right and left
acetabuli to Hilgenreiner’s line (2). In newborns, the average angle is twenty eight degrees, andlimits up to thirty five degrees (2). In one-year-olds, the average is twenty degrees, and limits up
to twenty nine degrees (3). Shenton’s line is another way of mensuration to detect hip dysplasia
such as hip dislocation, femoral neck fracture, and slipped capital femoral epiphysis (3). The
same radiograph is used, and a line is drawn along the medial and superior surface of the
obturator foramen to the medial surfave of the femoral neck (1). The line should be smooth, andobvious interruption of the smooth line indicates hip dysplasia with any of the condition
mentioned above.

2. Discuss Legg-Perthes disease. Include in this discussion:a.

the average age of onset and sex predominanceLegg-Perthes disease is an avascular osteonecrosis of the femoral capital epiphysis seen inchildren (1). The clear etiology is not known, however, history of trauma, endocrine disorder,
and infections are indicated as possible causes (1). The average age of onset is between three totwelve years, and most commonly among three to seven years age group (1, 3). There is certain
predominance in male of 5:1 with this disorder (3).
b.

besides radiography, other studies may be beneficial in your diagnosis

Radiographies are commonly used for early detection of Legg-Perthes disease, and also assist in
the evaluation of following progression (3). The radiography will provide typical findings suchas soft tissue swelling, fragmentation of the epiphysis, osteosclerosis (snowcap sign), anddeformities of the femoral head and neck (1, 3). MRI and bone scan will assist the diagnosis inearly stage of disease, and in addition, MRI will exhibit the status of the articular cartilage andthe degree of replacement of normal marrow by necrosis (1, 3). CT is useful in detecting thedetail of the femoral head deformity (3).

c. If the deformity is present after healing, explain what secondary condition(s)is probable?
The most significant secondary condition associated with the prognosis of Legg-Perthes diseaseis osteoarthritis. This occurs due to inadequate revascularization and epiphysial remodeling,
resulting in incongruent articulation formation and overall biomechanical alterations of the hip
joint (1, 3). Some of the typical manifestations are: restriction and painful range of motion,
contracture and atrophy of the surrounding musculature, leg-length inequality, and painful limp
which is improved by walking (1, 3).

References
1. Marchiori, Dennis M. et al: Clinical imaging: with skeletal, chest, and abdomen patterndifferentials, St. Louis, 1999, Mosby.
2. Schlampp, Robert A. Diagnostic Imaging in Pediatric Healthcare; 27, 28, 29, 30
3. Yochum, Terry R. Rowe, Lindsay J.: Essentials of Skeletal Radiology, ed3, vol1,
Philadelphia, 2005, Lippincott Williams and Wilkins.

ICPA 180 Hour Certification Examination

Yoshiaki Obata D.C.
3-7-18 Motoyama Kitamach Higashinada
Kobe, JAPAN 658-0003
011-81-78-451-1162
obaty@yahoo.co.jp
06/01/2007

Neuro Physiology and Nutrition
Dr. David Seaman

Oct 14-15, 2006 Chicago

Please answer the following question in essay form.
1. Describe the neurogenic inflammatory process and how it drives chronic pain andsubluxation.

The neurogenic inflammatory process exhibits the inflammatory/healing mechanism seen in,for
example, a joint complex structure and through with the central nervous system (CNS). It is an
intricate process involving various components such as leukocytes, pro/anti-inflammatory
mediators, hormones, nociceptors, and nerve fibers influencing one another. This processexplains how chronic pain is produced in a human body, and the consequential formation of
spinal subluxations.
Injuries from macro/micro trauma and biomechanical stress to the body would trigger the
inflammatory reaction in a joint complex structure (1). From this point, there are different
processes which would lead to chronic pain manifestation. The inflammation triggers the releaseof bradykinin (a neuropeptide causes vasodilation) and the production of free radicals (hydrogenions), which will excite the group Ⅳmechanoreceptors (nociceptors) and nerve fibers (1). This
inflammation also activates the leukocytes to release substances such as pro-inflammatory
cytokines and prostaglandins (i.e. IL-1, IL-6, and PGE2), leukotriene B4, thromboxane A2(eicosanoid), serotonin (5-HT), and histamine. These substances again excites the groupⅣ
nociceptive components (1). These reactions then leads to the release of substance P (transmits
nociceptive impulses from peripheral receptors) and CGRP (Calcitonine Gene Related Peptide),which excites the nuclear factor-kappa B (1). Some of the leukocytes again starts the release of
inflammatory mediators in response, and repeats the excitation of the groupⅣ components (1).
The result of this neurogenic inflammatory process drives chronic pain due to the recurrent

excitation of the groupⅣ nociceptive components. In addition, the groupⅣ nociception isrelated to two more different processes leading to chronic pain. The groupⅣ nociception istransmitted to the Dorsal Lateral Funiculus and divided into two pathways. One is the pathway
via white rami, paravertebral ganglion, gray rami, then reach to the terminals which triggers thesynaptic transmission to the sympathetic nervous system, and activates the release of
norepinephrine and prostaglandins (1). The other pathway is via the anterolateral tract of the
spinal cord. The nociception is transmitted through Hypothalamus and Adrenal gland to
stimulate the release of epinephrine (1). These two pathways in common releases substances
which excites the groupⅣ components, and thus leading to the recurrent excitation and chronic
pain.
When these neurogenic inflammatory processes and resulting chronic pain patterns were seen ina spinal joint, it may cause abnormal spinal joint complex afferentation, and further spinal
dysfunctions/subluxations. Biedermann describes that the abnormality of afferentation occurs
when the sensory innervation to a joint complex is disturbed due to, for example, abnormal
increase and continuous nociceptive input and reduced input of other mechanoreceptions (2).
This abnormal afferentation alters the normal sensory-motor functions of a spinal joint, andleading to a painful neck associated with restricted range of movement of the region (2), which
can be interpreted as a typical manifestation of spinal dysfunction/subluxation. Anotherexample which indicates the relation between the neurogenic inflammatory process andsubluxaiton can be described based on the neuro-physiological model of Pickar (3). It exhibits
the neuro-physiological mechanism of how the mechanical overload to a spinal joint complex
leads to spinal dysfunctions such as tenderness, altered paraspinal muscle tone, altered vertebral
movement, and abnormal reflex responses (3). This model notes the adverse effect on paraspinal
sensory receptors and afferent nerve fibers, which may be linked to the abnormal afferentation,and resulting manifestations of spinal dysfunction/subluxation.

References
1. Seaman, David R., D.C., M.S., D.A.B.C.N., D.A.C.B.N., Neurology of Subluxation; 33
2. Biedermann H. Manual therapy in children: proposals for an etiologic model. JMPT 2005;
28: 211.e15
3. Pickar JG. Neurophysiological effects of spinal manipulation. Spine J. 2002; 2(5):357-71

2. Describe how the process of neurogenic inflammation is likely reduced by appropriate
nutrition.

The appropriate nutrition to reduce the neurogenic inflammatory process is labeled asanti-inflammatory diet or supplements, and it recommends taking specific amount of nutritional
substances per day either from foods or dietary supplements. The functions of those substances
are to reduce the inflammatory process by inhibiting the pro-inflammatory substances,enhancing the anti-inflammatory substances, preventing cell damages and ATP depletion, andleading to overall reduction of chronic inflammation and prompting healing process(1). The
basic anti-inflammatory nutrients/supplements are substances such as various vitamins andminerals, magnesium, eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), Coenzyme
Q10, and nutrients contained in ginger and turmeric (2). Deficiencies of these important
nutritional substances are reported to be linked with chronic inflammation and resulting various
pathologies (3).
Magnesium deficiency, for example, is reported to be linked with symptomatic forms of central
nervous system hyperexitability (CNSHE), and it is due to both direct cellular effects andlocal/systemic mediated effects of the deficiency (4). Those effects are such as increased
cellular susceptibility to free radicals (peroxidation), increased activity of excitatoryneuromidiators, increased production of inflammatory mediators, and decreased activity of
inhibitory neuromediators (4). When considering the association of these substances with theneurogenic inflammatory process, appropriate nutritional intake of magnesium is expected toinfluence the activities of both pro and anti-inflammatory substances, and therefore leading tooverall reduction of the inflammatory process. EPA and DHA are different examples which play
an important role in preventing inflammatory responses. Research by Watkins et al shows thatthese substances act as anti-inflammatory agents in case with joint pathology (i.e. osteoarthritis
or rheumatoid arthritis) (5). Pro-inflammatory prostaglandins and cytokines such as PGE2 andIL-1 play a major role in mediating inflammatory responses, inducing cartilage degradation, andthus results in exacerbating degenerative arthritis (5). The research further states thatincorporation of n3 fatty acids into articular cartilage resulted in reduction of the expression of
inflammatory cytokines and cartilage degradation (5). As shown in this research, the effect of n3
fatty acids toward pro-inflammatory substances is an example which provides a supporting
factor that the process of neurogenic inflammation is reduces by appropriate EPA/DHA intake.
Some other nutritional substances or food such as coenzyme Q10, ginger, and turmeric havebeen reported to function as anti-inflammatory factor as well (6, 7). Coenzyme Q10 mediates

ATP synthesis, and function as an antioxidant, while ginger and turmeric function as natural
inhibitors of pro-inflammatory substances and reduce pain with musculoskeletal inflammatory
pathologies (6, 7).
As seen in the examples mentioned above, the primary goal of proper anti-inflammatory dietand supplements are the reduction of inflammatory processes, and it is achieved by theinteraction between pro and anti-inflammatory mediators, function of antioxidant, and theprovision of the energy necessary for the healing process.

References
1. Cotran RS, Kumar V, Collins T. Robbins’ Pathologic Basis of Disease. 6th ed. Philadelphia:
WB Saunders; 1999: p.1-112
2. Seaman, David R., D.C., M.S., D.A.B.C.N., D.A.C.B.N., Biochemistry of Subluxation; 4
3. Nicklas BJ, You T, Pahor M. Behavioral treatments for chronic systemic inflammation:effects of dietary weight loss and exercise training. Can Med Assoc J 2005; 172: 1199-1209
4. Durlach J, Bac P, Bara M, Guiet-Bara A. Physiopathology of symptomatic and latent formsof central nervous hyperexcitability due to magnesium deficiency: a current general scheme.
Magnes Res 2000; 13 (4): 293-302
5. Watkins BA et al. Omega-3 polyunsaturated fatty acids and skeletal health. Exp Biol Med
2001; 226: 485-97
6. Linnane AW et al. Human aging and global function of coenzyme Q10. Ann N Y Acad Sci.
2002; 959: 396-411
7. Seaman DR. Nutritional considerations in the treatment of soft tissue injuries. In Hammer Wl.
Ed. Functional soft tissue examination and treatment by manual methods. 3rd ed. Boston:
Jones and Barlett; (in press for 2005)
Seaman DR. Nutritional considerations for rehabilitation and health promotion. In Liebenson
CL. Ed. Rehabilitation of the spine: a practitioner’s manual. Baltimore: Williams & Wilkins;(in press for 2005)

ICPA 180 Hour Certification Examination

Yoshiaki Obata D.C.
3-7-18 Motoyama Kitamach Higashinada
Kobe, JAPAN 658-0003
011-81-78-451-1162
obaty@yahoo.co.jp
06/01/2007

SOT
Dr. Marty Rosen

Feb 11-12, 2006 Los Angeles

Please answer the following questions in essay form regarding Sacro-Occipital Technique.
1. What are some of the indicators used to determine if the subluxation pattern is moremeningeal versus structural in the pediatric patient?

There are two major divisions of spinal and cranial subluxation patterns, the meningeal
subluxation complex and the structural subluxation complex (1). In pediatric patients, especially
up to age of six months, it is said that the meningeal subluxation complex is the major
component (1). Due to the fact that the cranium and its sutures, as well as the brain and otherneural tissues are extremely soft and fragile, it tends to get influenced easily by forces fromtorsion or traction. This is one of the major factors leading to the formation of meningeal
subluxation complex. In addition, when the skull starts to have more structural function after the
closure of the fontanels, this meningeal subluxation could remain if uncorrected on earlier
timing. The possibility of the meningeal involvement must be considered until a child is at six
or seven years of age, to decide the most effective techniques both in the evaluation and thecorrection of it.
Positive findings in Condylar System (atlanto-occipital restriction) examination is one
indication of meningeal subluxation pattern, since the atlas and atlas subluxations are always
involved (1). Atlas involvement is also detected in examinations such as Atlas Occipital
Decompression and Cervical Stairstep. Abnormal CSF rhythm is another indicator of meningeal
involvement. Movement of the CSF is accomplished by the dural and the osseous motion upon
exhalation (extension) and inhalation (flexion). The Reciprocal Motion (Sacro-Occipital
Motion) and the Rotational Motion (rotation of the occiput and the sacrum) examinations aregood examples to detect any abnormalities in CSF rhythms. Noticeable cranial distortions suchas flat occiput, depressed sphenoids, bulging of the frontal bones or the parietal sutures, and any
cranial asymmetries also indicate meningeal subluxation complex (1). Visual analysis andpalpation of the cranium needs to be performed with special caution since it indicates possible
severe meningeal stress and CSF flow restrictions.

2. Name three evaluation techniques you might use in an infant to determine the subluxation
pattern at the C1-Occipital level. What do these positive findings indicate about thedirection of the subluxation?

1. Condylar System (atlanto-occipital restriction)
Doctor contacts the occipital bowl bilaterally (the index and the middle fingers are positioned
medial to the mastoid processes of the temporal bone, and slightly lateral to the occilital
condyles). The thumbs are contacting both right and left frontal bones at approximately half aninch lateral to the metopic suture. While holding the skull lightly, laterally flex the skull to theright and left with the angle of three to five degrees approximately. Make sure the cervical spine
is not involved when side bending. Restriction in Range of Motion (ROM) in one side than theother indicates a positive finding of atlanto-occipital restriction and subluxation pattern either tothe right or left.
2. Condylar System (High Occiput)
Doctor palpates the difference of tensions at the atlanto-occipital condyles bilaterally. Uponfinding the increased tension on one side than the other, the ROM is checked to detect any
restriction. When restriction is felt with lateral flexion into the side of more tension, it indicatesthe High Occiput in the involved side (i.e. increased tension with restricted ROM on the rightside indicates High Occiput to the right). Visual analysis may also provide another indication ofHigh Occiput when the patient is in prone or seated position. The chin of the patient will
typically show deviation towards the High Occiput side in the prone position.

3. Atlas Occipital Decompression
Doctor holds the patient’s occiput by using four-finger contact, and the thumb is placed aroundat the anterior side of the ears bilaterally. Next, the patient’s head is extended then flexed with agentle rocking type of motion, to detect any restriction when the head is moving into flexed
position. If any restriction is noted, it indicates hyperextension of the condyles, which means theatlas condyles are posterior to the occipital condyles.

References
1. Martin G. Rosen, D.C., SOT Pediatric Spinal Adjustment; 24, 25, 26, 27

ICPA 180 Hour Certification Examination

Yoshiaki Obata D.C.
3-7-18 Motoyama Kitamach Higashinada
Kobe, JAPAN 658-0003
011-81-78-451-1162
obaty@yahoo.co.jp
06/01/2007

Techniques:
Dr James Thompson

May 7-8, 2005 Los Angeles

Please answer the following questions in essay form:
1. For each of the following five categories, give the method of finding the syndrome andthe detailed method of correction, including line of drive.
a. cervical syndromeb. bilateral cervical syndromec. Derefield positived. Derefield negativee. Derefield X

a. Cervical Syndrome
Patient lays down prone on the Thompson Terminal Point Table. One need to make sure thepatient is positioned straight by checking the alignment of the External Occipital Protuberance(EOP) and the gluteal cleft. Doctor examines the leg length inequalities, and noting one leg isshorter than the other in extended position. Upon flexing both legs, the short leg becomes either
longer, shorter, or stays the same. Upon rotating the patient’s head to the right, and noting theshort leg becomes even, this is the Right Cervical Syndrome (RCS). When the short leg
becomes even upon rotating to the left, it is the Left Cervical Syndrome (LCS). Next, the doctor
palpates the most cephalad tender mass and/or muscle knot on the opposite side of the cervicalsyndrome (i.e. the doctor palpates the left side in RCS, and the right side in LCS).
Detailed method of correction is as follows; patient is positioned prone, and doctor is positioned
inferior and in close on the palpated side. Both the cervical and thoracic sections are set to drop

with eight ounces of pressure approximately. Contact point of the doctor’s hand is the lateral
aspect of the second or third joint of the index finger of the superior hand. The doctor sets thehand at the lamina-pedicle junction of the involved segment with medial to lateral tissue pull.
The doctor stabilizes with the non-adjusting inferior hand contacting the segment above theinvolvement, and broadly the mandible and zygomatic arch of the patient. The Line of Drive(LOD) is posterior to anterior, inferior to superior and slight right to left of left to right, andperpendicularly to the facet plane of the involved segment. Recheck is done by checking the leg
length equalities with patient’s head turning.
b. Bilateral Cervical Syndrome
Doctor examines the leg length both in extension and flexion, and noting that the legs arestaying even. When the patient turns the head to the right, and the right leg shortens, or turning
the head to the left causes the left leg shortening, this is the Bilateral Cervical Syndrome (BCS).
Detailed method of the correction of BCS; patient position is prone, and doctor can stand either
on the right/left side of the patient, while placing doctor’s sternal notch over the patient’s T5level, or standing on a position that both the doctor’s and the patient’s shoulder becomesparallel. The doctor sets both hands with the thenar onto the occiput bilaterally medial to themastoid process, or slight lateral to the EOP. The LOD is inferior to superior, slightly posterior
to anterior, with the equal impulses right and left. While following the facet orientation, theadjustment is done about three times with the motion trying to open up between the occiput andthe atlas, since the lesion in BCS is said to be an AS (Anterior-Superior) Occiput misalignment.
Recheck is done by noting patient’s head turning does not cause leg length inequalities.
c. Derefield Positive Syndrome (D+)
Before the examination of D+ syndrome, the examination of the cervical syndromes is done tosee if there is any cervical involvement causing the leg length inequalities. If any cervicalinvolvement is seen, it is corrected and rechecked before proceeding to examine the pelvic
involvement. On D+ examination, doctor checks the leg length as follows; short leg in extension
becomes long upon flexion of the legs, or short leg becomes even upon flexion of the legs, oreven legs in extension becomes long upon flexion. Some findings associating the leg length
inequalities are; increased resistance during flexion of the legs due to possible muscle tension
and/or tenderness over the sacroiliac joint on the side of the involvement. Putting these findingstogether, when the right/left leg is involved, it is named Derefield Positive on the right or left
respectively (Rt D+, Lt D+).
Detailed method of the correction of D+; patient is positioned prone, with placing the anterior
superior iliac spines just above the superior edge of the pelvic piece. The pelvic piece is set todrop down and caudad, and the lumbar piece to straight down. The doctor stands inferior to thesacroiliac joint either on the same or opposite side of the involvement. The doctor sets the fleshy
pisiform of the contact hand on the patient’s posterior-superior iliac spine (PSIS), whilestabilizing the other side of the involvement by contacting on ischial tuberosity with the otherhand. The LOD is posterior to anterior, and following the angle of each pieces drops. The
adjustment is done usually three times. Recheck is done by noting any changes after the
adjustment.
d. Derefield Negative Syndrome (D-)
Same as in D+ syndrome, and cervical involvement is examined before proceeding to examine
the pelvic involvement. On D- examination, doctor checks the leg length as follows; short leg in
extension stays short upon flexion. Some associating findings with the leg length inequality are;the lightness of the leg lift (facilitation), tenderness over the sacroiliac joint, pubic bone, ischial
tuberosity, and the medial aspect of the knee of the involved side. On the other side of theinvolvement, tenderness is checked between T2 and T7 costo-vertebral junctions. Putting thesefindings together, when the right/left leg is involved with the additional findings, it is named
Derefield Negative on the right or left respectively (Rt D-, Lt D-).
Detailed method of the correction of D-; on part one, the patient is positioned supine, with the
involved leg flexed. The pelvic piece is set to drop down and cephalad, and the lumbar piece tostraight down. The doctor stands on the side of the involvement, with contacting patient’s
ischial tuberosity with the inferior hand, and the patient’s anterior-superior iliac spine with thesuperior hand. The LOD is inferior to superior with a “scooping arch” type of motion withfollowing the angle of each pieces drops. On part two, the patient is positioned supine, with theleg flexed opposite to the involved side. Both the pelvic and the lumbar pieces are set to drop
down. The doctor stands on the side of the involvement, with superior hand contacting thepatient’s middle and lateral portion of the inguinal ligament around the location of the tendermass. The inferior hand is placed in the flexed leg for stabilization. The LOD is anterior toposterior, with a torque action in clock-wise for Lt D-, and counter-clock-wise for Rt D-.
Recheck is done by noting any changes in the leg length.

e. Derefield X Syndrome (Dx)Same as in other Derefield Syndromes, and cervical involvement is examined before proceeding
to examine the pelvic involvement. Doctor checks the leg length as follows; legs are even when
extended, and upon flexion, one leg appears to be short. While the legs are in flexed position,
the patient turns the head. Upon turning the head to the right /left, and the legs appears even,this is listed as DxRCS /DxLCS respectively. When turning the head does not cause any change
in the leg length, suspect the possibility of Derefield Negative by checking the render spots seenin D-. If one of the five spots is found, it is listed as DxD-R or DxD-L depending on which is
the involved side. The method of correction and the recheck is the same as the description
written on each syndrome.

2. What is the meaning of “clear” in this method and how would you demonstrate it?
Here is one example describing the meaning of clear in this technique.
Before performing any procedure to detect the pelvic involvement in a patient, one needs to go
through the examinations of cervical syndromes, and if needed, correction is done. When therecheck does not show any inequality of the legs, the cervical is clear and proceeded to checkany pelvic misalignments. Upon examination, for example, D+ was detected and properly
adjusted. If the recheck shows equal leg length, the cervical is clear and the pelvis is clear as
well.
In Thompson Technique, first of all, the leg length is checked to see the balance of the spine.
When the legs are even, the hips are well balanced, and no major tension is found in the neck,the spine is in balance and the optimum functioning of the nervous system is expected in the
body. This indicates no necessity of an adjustment. Any indication of imbalance of the spine
and nerve interference needs to be corrected until the doctor sees all the criteria are met.
References
Thompson, James V. D.C., Examination, Analysis, and Spinal Correction of Children;
12,15,16,17,18,19,20