Abstract
Objective
To describe the applied kinesiologic evaluation of Chapman's neurolymphatic (NL) reflexes in the management of a person with an unusual congenital bowel abnormality and its role in the manifestation of low back pain. The theoretical foundations of these reflexes will be elaborated on and practical applications discussed.
Clinical features
A 29-year-old man had chronic low back pain. Radiographs of the patient's lumbar spine and pelvis were normal. Magnetic resonance imaging (MRI) demonstrated a mild protrusion of the fifth lumbar disk. Oral anti-inflammatory agents, cortisone injections, and chiropractic manipulative therapy provided little relief. Though generally in robust health, the patient was aware of a congenital intestinal abnormality diagnosed when he was a child; it was thought to be of no consequence with regard to his current back condition.
Intervention and outcome
The patient's history, combined with applied kinesiology examination, indicated a need to direct treatment to the large bowel. The essential diagnostic indicators were the analysis of the Chapman's neurolymphatic reflexes themselves, coupled with an evaluation of the traditional acupuncture meridians. The primary prescribed therapy was the stimulation of these reflexes by the patient at home. This intervention resulted in the resolution of the patient's musculoskeletal symptomatology, as well as improved bowel function.
Conclusion
The rather remarkable outcome from the application of this relatively simple, yet valuable, diagnostic and therapeutic procedure represents a thought-provoking impetus for future study and clinical application.
Keywords
Introduction
Chapman's neurolymphatic (NL) reflexes
1
have been recognized and used in therapy by the osteopathic profession for approximately 70 years, the last 37 of which have seen their integral role in the application of applied kinesiology (AK). Since Goodheart2
introduced them to the budding AK community in 1965, the literature of the International College of Applied Kinesiology has been teeming with testimonials and anecdotal reports of their clinical effectiveness, though little academic research has been carried out.The NLs, discovered by Chapman,
1
were originally described as receptor organs, located primarily in the intercostal spaces. Similar in palpatory quality to trigger points, they are detected as irritable nodules. It was thought that their stimulation, with firm rotary massage, would not only affect local lymph drainage but also a related viscus, by way of the sympathetic nervous system connections of the intercostal nerves. A more advanced neurological model, described by Schmitt and Yanuck3
and discussed in greater detail below, states that the clinical responses from NL treatment may reflect “a relative increase in parasympathetic activity, due to a resolution of the pattern of ischemia and muscular spasm associated with the irritable NL area, and a subsequent reduction of over-stimulation of sympathetic activity at the intermediolateral cell column.”3
Seemingly unrelated to the work of Chapman is a system of manual muscle testing, developed in the 1950s by 2 physical therapists, Kendall and Kendall.
4
This body of knowledge has been integrated over the years into standard orthopedic examination,5
where muscles are graded on a scale of 0/5 to 5/5 according to their relative strength.Goodheart,
2
through a process of trial and error in the early 1960s, began connecting the work of Kendall et al4
with the disparate work of Chapman.1
By using manual muscle testing, Goodheart2
clinically correlated specific NLs to specific muscular inhibition patterns. This was accomplished by observing that rotary massage of certain NLs would facilitate certain inhibited muscles with a greater probability than other inhibited muscles. Similarly, stimulation of certain NLs would facilitate certain inhibited muscles with a greater probability than the stimulation of other NLs or unrelated sites on the body.Although the aforementioned muscle testing system of Kendall et al
4
is generally used in orthopedic examination to rate gross degrees of muscular strength,5
applied kinesiology manual muscle testing (AK MMT) interprets this integer of motor strength from a functional neurological perspective. As such, what would customarily be graded as a 4/5 nonpathological muscular “weakness” by standard orthopedic procedures would be the equivalent of a functional muscular “inhibition” pattern, as determined by AK MMT. This muscular inhibition is thought to reflect the central integrative state of the alpha motor neuronal pool. Furthermore, the introduction of sensory challenges or stimuli, such as treatment to a NL, would theoretically impact this central integrative state via central or peripheral neural mechanisms, yielding a change in the extent of facilitation or inhibition of motor pathways. Thus, a muscle that meets the demands of AK MMT, appearing strong, is termed conditionally facilitated. A muscle that fails in response to AK MMT, appearing weak, is termed conditionally inhibited. These terms will be used throughout, though the terms strong and weak, respectively, may be found in the relevant literature, in keeping with the habits of applied kinesiology practitioners.6
As stated above, Goodheart
2
used manual muscle testing to clinically correlate specific NLs to specific muscular inhibition patterns. In doing so, he began to extrapolate what has become known in AK as the muscle-organ/gland relationship, ie, a viscerosomatic relationship of specified viscera to specified muscles. Interest in these novel AK ideas was further piqued by the clinical evidence of acupuncture meridians and other reflex procedures sharing similar viscerosomatic relationships.3
, 7
This case report describes a patient whose primary therapy was the treatment of these NLs. The results were extremely rewarding, but what makes this case noteworthy is the definitive documentation, by way of barium enema, of a congenital intestinal abnormality. When therapy was directed at improving the function of the viscus in question by using the NLs purported to affect the digestive tract, not only did bowel function improve, but so too did the musculoskeletal concomitants.
Case report
A 29-year-old man had chronic low back pain of 6 months' duration. The patient described the pain as a relatively persistent “dull ache,” centrally located in the lower lumbar spine, though occasionally more accentuated in the area of the left erector spinae muscle group. No radiation or referral of pain was noted in the lower extremities. The condition appeared relatively unaffected by activity level, positioning, and temporal factors. Sporadically, less intense episodes of low back pain had occurred over the last several years.
In the past, this affliction had been addressed with oral anti-inflammatory agents and local cortisone injections. Presently, however, these measures were ineffective at penetrating the symptoms. As such, radiographs and, later, magnetic resonance imaging (MRI) were performed. The radiographs were unremarkable. MRI demonstrated a mild disk protrusion at the fifth lumbar (L5) level, posterolateral on the left; no other abnormalities were noted. In light of these imaging findings, the patient was referred to a chiropractor for treatment. After a clinical trial of 12 treatments involving chiropractic manipulative therapy in concert with the standards of motion palpation and diversified techniques, little progress was observed. The patient was then directed to my office for an applied kinesiology evaluation.
The patient stood 170 cm tall; weighed 165 lb; and had a respiratory rate of 16, a pulse rate of 76, and blood pressure of 120/80 mm Hg (seated). Postural analysis revealed a high left iliac crest. No other postural discrepancies were noted. Leg length evaluations, both prone and supine, were equivocal. Baseline neurological evaluation was unremarkable. Orthopedic evaluation revealed a positive Kemp's test bilaterally, though more severe on the left. Palpatory tenderness and tension were noted over the erector spine muscle groups bilaterally, though again more prominent on the left.
Before discussing the applied kinesiology findings, it is important to stress that the procedures performed with applied kinesiology manual muscle testing can be quite involved and require a great deal of study. Furthermore, the development of significant psychomotor skills necessary to meet the demands of accurate AK MMT is a prerequisite.
8
Even with a sound knowledge of these procedures, AK findings are meant to be correlated with other established diagnostic parameters.9
Moreover, because a discussion of the individual procedures is beyond the scope of this article, clinicians are encouraged to avail themselves of these theories.7
Acupuncture meridian analysis, as performed in applied kinesiology, was conducted. Pulse point diagnosis and alarm point analysis are familiar features of traditional Chinese medicine.
7
, 10
, 11
Goodheart12
has speculated that these points may be evaluated by AK MMT. The indication from this type of evaluation, in the present case, was an underactive large intestine meridian on the left. The tensor fascia lata, theorized by Goodheart12
to be associated with the large intestine acupuncture meridian, the large intestine Chapman's NL reflex, and the organ itself,2
, 7
, 12
was conditionally inhibited bilaterally.In light of these examination findings, the patient was further queried about the presence of any gastrointestinal issues that he did not initially disclose. Although he was in good physical condition and pursued a generally balanced diet, he reported that since infancy he had suffered from moderate to severe constipation, averaging 1 bowel movement per week. This was attributed to a congenital intestinal abnormality, identified by means of a barium enema.
On this first visit, the aforementioned large intestine meridian on the left was addressed by acupressure of its tonification point,
7
, 10
, 11
which is Large Intestine 4, located at the radial elbow crease with the elbow in full flexion. The acupressure employed basically consists of firm, digital pressure by the examiner on the acupuncture point in question for approximately 30 to 60 seconds. The stimulus resulted in conditional facilitation of both tensor fascia lata muscles. Chiropractic manipulative therapy was applied to the lumbopelvic region. No other therapy was instituted.On returning for the second visit several days later, the patient brought the results of the last barium enema, performed about 20 years earlier. The radiologist cited an “abnormally long sigmoid colon with an excessively tortuous and twisting course.” It was further noted that the “entire digestive tract presented with hypotonic dilatation.” It was concluded that the malady, which was not given a specific diagnosis, was innocuous. Although nothing could be done, it was suggested that he be seen occasionally by his gastroenterologist to monitor any change in his bowel habits.
The patient reported no change in his symptomatic picture on this second visit. At that time, he was tested for food sensitivities, using applied kinesiology methods. Essentially, this entails the stimulation of the lingual gustatory receptors with common foodstuffs, tested 1 at a time, and observation for changes in the conditional facilitation or inhibition of the muscles being manually tested. Through this process, it was determined that the patient was sensitive to dairy, specifically cow's milk. This procedure was discussed in an interesting pilot study
13
that had recently been published, indicating that AK MMT may be of value in determining food sensitivities. (The subject of food sensitivities, in and of itself, is controversial, although the indexed literature is replete with papers on the concept.) As a result, the patient was asked to temporarily eliminate all dairy products from his diet. In addition, he was asked to drink at least 2 liters (eight 8-oz glasses) of water per day and limit the consumption of diuretic liquids, such as coffee and alcohol, in an effort to improve tissue hydration. Dietary roughage was increased to speed bowel evacuation time. Chiropractic manipulative therapy in the lumbopelvic region was again performed.The patient's third visit, 1 week later, was met with a notable improvement in his overall health status. The pain and stiffness in his lower back had decreased by an estimated 50%, and for the first time in as long as he could recall, he had had 2 well-formed, voluminous bowel movements in a single week. He had also lost over 4 pounds with no other dietary changes than those hitherto described. Consequently, it was advised that he continue with a dairy-free diet and report for a follow-up 2 weeks later.
By the next and fourth visit, 2 weeks later, the patient's condition had leveled off. While it seemed encouraging that an additional weight loss of 4 pounds had taken place and the patient noted feeling “lighter” and “less bloated,” a plateau in his symptomatic complex had been reached. That is to say, abstaining from dairy products initially accounted for a striking change, but the patient still only perceived an estimated 50% decrease in low back pain and stiffness, with respect to the first visit, and was evacuating his bowels about twice a week. The tensor fascia lata muscles were again inhibited bilaterally, as determined by AK MMT. Based on this inhibitory pattern, the Chapman's neurolymphatic reflexes for the small and large intestines were evaluated. Chapman,
1
through clinical trial and error, proposed that the NLs for the colon lie along the anterolateral borders of the thighs, roughly along the lengths of the iliotibial bands. There were multiple small intestine NL loci described by Chapman1
and Goodheart,2
2 of which were linear centers along the anteromedial borders of the thighs, roughly along the lengths of the adductors longus and magnus muscles. When active, they present as focal, nodular areas of tenderness, described as a “gangliform contraction.”1
In this patient's case, these areas indeed had a boggy, nodular quality on palpatory inspection and were quite sore to the touch. They were stimulated with a firm, rotary massage along their entire lengths for approximately 30 to 60 seconds on each reflex, as advocated by Chapman1
and Goodheart.2
This resulted in the conditional facilitation of the tensor fascia lata muscles, bilaterally. As a result, the patient was shown the locations of these reflex centers and instructed to begin stimulating them twice daily at home. At home, he or an assistant (in this case, his wife) was to apply firm rotary massage for 2 minutes to each NL for a total of 8 minutes of therapy, twice daily. (It should be noted that although AK exam findings implicated the large intestine more directly, a clinical decision was made to undertake stimulation of the small intestine NLs as well, in light of the hypotonic dilatation of the entire digestive tract noted on barium enema.)Two weeks after NL stimulation at home was instituted, the patient returned to report remarkable improvements. A few days after faithfully initiating home therapy, he began evacuating his bowels nearly every day. Such a feat had never been accomplished in his lifetime, not even with laxative medication. In addition, the pain and stiffness in his low back had almost completely subsided. On examination, the Chapman's NL reflex areas were much less tender to palpation, as were the erector spinae muscles. AK MMT now yielded normal facilitation of the tensor fascia lata muscles, bilaterally. Kemp's test was now negative, whereas it had previously provoked pain and discomfort. Postural exam revealed a leveling of the iliac crests on visual inspection. Encouraged by the progress, he was asked to continue daily NL stimulation for 1 week and then slowly diminish the frequency, first to every other day, then twice a week, and so on. He was further told to continue with a dairy-free diet for approximately 2 weeks and then attempt to reintegrate dairy occasionally, about once per week.
Monthly follow-ups revealed no acute exacerbation of the problem. It was noted by the patient, however, that if he were to occasionally indulge in excessive dairy consumption, he would become constipated for several days and his low back pain and stiffness would return to some degree. Because the provoking factors had been identified, the patient could return to normal by immediately eliminating all dairy products from his diet and stimulating the NLs (which would become tender to palpation while he was constipated) at home for 1 or 2 days. Over the course of 1 year after initial treatment began, the patient learned how to regulate minimal amounts of dairy in his diet to keep his bowel habits regular, his low back pain at bay, and generally enjoy robust health.
Discussion
Viscerosomatic reflexes have long been a popular topic in the osteopathic arena, as debates have ensued with regard to their clinical detection, significance, cause, utility, and so forth.
14
, 15
Frank Chapman, DO, made the initial discovery in the 1930s of what he termed neurolymphatic reflexes, borne out through years of private clinical investigation. His life's work was subsequently presented to the osteopathic community after his death, through a compilation of his manuscripts.1
Goodheart2
brought Chapman's findings to the applied kinesiology community in 1965, after having carefully correlated them with predictable patterns of muscle inhibition, detected through applied kinesiology manual muscle testing.Just as viscerosomatic reflexes have been the subject of polemics in the healing arts over the years, so too has AK. Since the introduction of manual muscle testing as a diagnostic parameter for the application of AK principles by Goodheart
16
in 1964, innumerable practitioners and health-seeking lay people have employed unrelated muscle testing for variant purposes. Because many of their approaches also became known as diverse “kinesiologies” or were compared with AK by unenlightened observers, disorder and disputation ensued. Yet, the nomenclature is where the similarity between these various forms of kinesiology and AK comes to an end. AK, as described by the multidiscliplinary professional organization known as The International College of Applied Kinesiology,9
utilizes manual muscle testing as a part of and as an extension of functional neurologic examination.3
, 6
When considering the mechanism of the NLs, Chapman,
1
by following the known anatomy of the lymphatic system at the time, was led to base his findings largely on anatomical research. Originally, the stimulation of these reflex centers was thought to affect lymphatic drainage, in light of the clinical observation of edema reduction with their utilization. Most of the NLs lie in the intercostal spaces. Between the superficial and deep layers of the intercostal fascia, some lymphoid tissue can be found, and it is within this tissue that Chapman1
proposed the NL to reside. On becoming active, they would present as discrete areas of tenderness and vary somewhat in character and size, from a small “BB shot” to a “bean-sized nodule,” occasionally multiple in number. They were further described as “amorphous gangliform contractions” of the cutaneous fibers of the intercostal nerves.The lymph resembles blood plasma and is responsible for the recovery of proteins, among other functions. It is collected throughout the body and propelled through the lymphatic circulation via smooth muscle contractions of the larger lymphatic vessels in response to an increase in pressure.
17
In addition to this basic intrinsic propulsion, 6 extrinsic factors have been cited18
in the movement of lymph fluid: (1) muscular activity; (2) passive movement; (3) pulsation of blood vessels; (4) motility of the intestinal tract; (5) venous pressure; and (6) gravity. It is this muscular action in the pumping of lymphatic fluid which Goodheart2
thought crucial to the relationship of the NLs with specific muscles and, hence, the viscerosomatic connections. Theoretically, lymphatic fluid from the NLs would be pumped by the pectoral lymph nodes into the thoracic duct on the right, draining the right arm and right side of the head, and the jugular duct on the left draining the rest of the body. The lymphatic fluid would ultimately drain into the venous system.17
Although Chapman
1
and Goodheart2
have both contended that the observed effects from NL treatment occur as a result of lymph passage, modern neurological thought provides us with a more comprehensive interpretation of these phenomena. Indeed, if the actions of the NL are through the autonomic nervous system, as alluded to above, the viscerosomatic effects would be more far-reaching than simple lymph drainage. An abnormal stimulus of the visceral efferent neurons could result in cutaneous hyperesthesia, as well as sudomotor, pilomotor, and vasomotor changes, to name but a few autonomic concomitants.14
, 15
Animal studies19
, 20
also suggest that nociceptive visceral stimuli may result in localized contraction of skeletal muscle. Suprasegmental neural centers, acting on the muscle spindle cells via the extrapyramidal system, could account for the segmental reflex response clinically observed.14
Because muscle spindles have sympathetic fiber innervation,21
repetitive stimulation would augment the afferent receptor discharge, leading to an increase in the gamma activity. Thus, the tone of the extrafusal fibers of the muscle spindles would be heightened, leading to greater tonic muscle activity.14
These considerations may give insight into the nodular palpatory quality of the NLs.Recently, Schmitt
3
, 22
set forth the most complete neurological model, specific to the NL mechanism, known to date. Because the palpable nodules of the NL are thought to represent areas of ischemia and hyperirritability, increased afferent activity would be transmitted to the spinal cord during weight bearing and movement, including respiration. Since nociceptors and many other fibers have direct contact with the intermediolateral cell column's (IML) primary autonomic neurons,23
an involved NL would create a local focus of irritation, thus driving the IML to a heightened state of activity. From the first thoracic to the second lumbar vertebrae, an increase in IML firing will result in an increase of sympathetic outflow. By treating the NLs through rotary massage and normalizing sensory feedback from the NLs in the intercostal spaces (and possibly throughout the body), the bombardment, which is driving the local IML neurons to increased sympathetic activity, would be decreased. Increased sympathetic activity results in vasoconstriction to most viscera and decreased secretion of most organs. Consequently, correction would result in decreased sympathetic activity to those organs that are influenced by the local level of sympathetic outflow. If parasympathetic outflow to those organs remains unchanged, the net result of treating a NL would be a relative increase in the parasympathetic activity of the affected organs. Furthermore, because parasympathetic activity causes vasodilation to the viscera plus increased organ secretion and increased peristalsis, the effect of treating a NL would be to increase the functionality of the organ(s) treated. After treating a NL, the resultant changes in a muscle's conditional inhibition, as determined by AK MMT, can be attributed to the collateral connections from the IML axon that reach α-motor neurons. These are the same α-motor neuron connections utilized by all flexor reflex afferent pathways in the flexor withdrawal and crossed extensor reflexes. As a result, it is reasonable to expect changes in muscular facilitation, as well as the reflex inhibition of hypertonic antagonists, reflecting an altered central integrative state of the α-motor neuronal pool.22
In this case, a net increase in the parasympathetic activity of the digestive tract, resulting from NL treatment, would support Schmitt's
3
, 22
theory. The intestinal tract of this patient had hypotonic dilatation. Increasing local parasympathetic activity would have an effect of increased smooth muscle tone and a greater probability of peristaltic action, resulting in the increased frequency of bowel movements. Again, this would appear more plausible than lymphatic drainage of the intestinal mesentery via the stimulation of NLs.Beyond the various theoretical models presented, little academic research has been carried out thus far. One study worthy of note is that of Mannino,
24
investigating the possible use of NLs in the control of some types of hypertension. It was found that prolonged stimulation of a posterior NL, theorized to relate to the adrenal glands, resulted in the lowering of aldosterone in low-renin, high-aldosterone hypertension.In another study by Lines et al,
25
NLs were suggested to be of therapeutic value in the treatment of patients who exhibited below average respiratory function. Thirty asymptomatic subjects were treated on 4 separate occasions, employing stimulation of the NL theorized to relate to the diaphragm. Of the 30 subjects, 5 reported a past history of asthma or bronchitis. Spirometric assessment of respiratory function before and after each treatment was performed. Measurements of forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) over the whole sample showed no significant improvement following the treatment regimen. Eight of the 30 subjects had lower than predicted initial FVC and FEV1 values. When the results for the group of 8 subjects were analyzed separately, it was found that a significant improvement was attained from the first pretreatment FVC to last posttreatment FVC (paired t test significant at α = .02). Such research, combined with the observations of practitioners utilizing Chapman's NL reflexes, provide us with a glimpse of the clinical possibilities.Though some of the knowledge of the basic sciences may theoretically confirm the existence of these somatovisceral and viscerosomatic relationships, the specificities remained ill-defined. Chapman
1
reported that these NLs appear to be viscerosomatic windows. Goodheart2
expanded on these ideas by clinically correlating NLs to specific muscle inhibition patterns. Thus, the notion of a “muscle-organ/gland relationship” was born in AK nearly 4 decades ago. Though all the far-reaching implications of these and other AK procedures are beyond the scope of the current discussion, it is nonetheless logical to ask: Could the NLs provide some supporting evidence for such proposed viscerosomatic relationships? Furthermore, if these NLs are valid phenomena, what do they actually represent and can AK MMT serve as a means toward their diagnostic identification and the appropriate delivery of therapeutics? Indeed, these questions and numerous others could be asked, in light of the current findings. Because no case study on applied kinesiology or Chapman's NL reflexes has ever appeared in the indexed literature, these questions and related concepts are meant to serve as bases for further academic and clinical investigations.Conclusion
As clinical experience dictates, low back pain can have a multitude of causes. In this case, the role of a congenital intestinal anomaly was crucial. It should also serve to remind us that, oftentimes, even pathological conditions such as the one present in this case, may be changed from a functional standpoint. In this instance, not only was Chapman's neurolymphatic therapy instrumental in eliminating the patient's musculoskeletal manifestations, but it also ameliorated a lifelong struggle with constipation. This is highly significant when we consider that increased bowel evacuation time has been implicated in decreased oncogenesis and a slew of other health benefits.
26
It could be argued that 3 main variables were at play in the recovery of this patient, specifically, chiropractic manipulative therapy, dietary modification, and NL stimulation. However, while chiropractic manipulative therapy was indeed executed, a previous clinical trial of 12 visits with another chiropractor, utilizing similar manipulative techniques as the sole therapy, was ineffective. Second, the dietary modifications, most importantly the elimination of dairy (to which the patient appeared sensitive), only accounted for an initial and partial improvement in his condition. The patient improved during his first week on a dairy-free diet, after which his progress reached a plateau and his condition remained largely stationary for 2 weeks. It was only after employing daily stimulation, at home, of Chapman's NL reflexes were the following phenomena witnessed: (1) his bowel evacuation time became regular; (2) his back pain completely subsided; (3) applied kinesiology manual muscle testing revealed conditional facilitation of the tensor fascia lata muscles, bilaterally; (4) postural distortions were eliminated; and (5) orthopedic evaluation (Kemp's test) was normal.
One could further contend that progress resulting from dietary modification was simply stalled and that the patient may very well have made a recovery without NL stimulation, if given adequate time. In my opinion, it is certainly possible; however, it does not seem probable. By comparison, one could state that the clinical trial of 12 visits with another chiropractor had indeed made progress, but that it was only manifested by a decrease in symptoms after 3 visits with the author. Yet, few in clinical practice would think it reasonable to expect an almost complete recovery with 3 applications of lumbopelvic manipulation, when 12 nearly identical applications had previously failed. In other words, unless there are alterations in the treatment protocol, we would generally expect progress to be steady and predictable. When such stark changes occur while a patient is under care, the logical question becomes, what has been modified to effect this recovery? As such, the fact that the patient observed no change for 2 weeks on a dairy-free diet but then experienced an estimated 300% increase in the speed of bowel evacuation and a nearly complete abolition of musculoskeletal discomfort in a matter of a few days after initiating NL therapy is quite telling. Rather than the steady, predictable progress we would expect, there was a disproportionate improvement, which would appear to be the direct result of the addition to the treatment plan. Incidentally, it bears repeating that the degree of subjective tenderness noted by the patient, as well as the degree of palpatory nodularity of the NLs reported by the examiner, would closely parallel his bowel habits. Such an observation might not only give credence to the notion that the NLs are sensitive viscerosomatic windows of function but also that their stimulation in this case was essential in recovery.
This particular case report may lend support to one of the viscerosomatic relationships proposed by Goodheart,
2
, 12
that being the tensor fascia lata muscle, the large intestine, the large intestine Chapman's NL reflex, and perhaps the large intestine acupuncture meridian, which was used in this case as a diagnostic adjunct. Consequently, the diagnostic identification and subsequent utilization of NLs, through AK methods, might broaden our clinical possibilities and allow our applications to better the quality of life for our patients. Further clinical investigation and well-designed research of these complex phenomena are warranted.Acknowledgements
Many thanks to those who reviewed this manuscript and assisted in its preparation, namely Rita Azzam, DO, Richard Belli, DC, Scott Cuthbert, DC, Jan Hambrick, and Walter Schmitt, DC.
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Article info
Publication history
Received in revised form:
October 1,
2002
Received:
July 29,
2002
Identification
Copyright
© 2004 National University of Health Sciences. Published by Elsevier Inc. All rights reserved.
