The Vertebral Subluxation Complex Health And Social Care Essay

The word subluxation is made up of the Greek words sub and lux, which can be translated to "less than a dislocation". Originally, a subluxation was described as having the following characteristics; lessened range of motion, slight change in position of the articulating bones and the presence of pain (Gatterman, 1995).

There has been much controversy with regards to the use of the term in the realm of chiropractic. Chiropractors often refer to a motion segment in which alignment, movement integrity, and/or physiologic function are altered and the joint surfaces are in contact as a subluxation. This subluxation differs to its medical counterpart as it is not visible on radiographic studies as well as it may be corrected through chiropractic care through the use of manual thrust procedures i.e. manipulation (Gatterman, 2005).

Today, joint subluxation adopts a broader definition largely due to the work of Gillet, Illi, Mennell, Sandoz and Faye, who felt compelled to define the joint integrity in functional terms and not only structural terms. This meant that the dynamic characteristics played as much of a role in the subluxation than the positional characteristics. From this perspective, joints did not have to be malpositioned to be dysfunctional or conversely, minor malalignment did not necessarily predict the presence of dysfunction (Bergmann and Peterson, 2011).

Subluxation or joint dysfunction does not have any predilection for any age, gender, ethnicity or socio-economic class. The causes for joint dysfunction as described by Gatterman (2005) are acute trauma, repetitive overuse, abnormal posture and coordination, aging, congenital or developmental defects, or primary disease states. Causes of acute or chronic joint dysfunction manifest as meniscoid intrapment or extrapment, muscle spasm, displaced disc fragments and/or periarticular connective tissue adhesions. Although there may not be one specific mechanism implicated as the cause of subluxation, Gatterman believes that there may be a multitude of mechanisms contributing to the bigger picture of subluxation.

Subluxation is primarily a joint phenomenon that causes complex neurological, vascular, ligamentous and muscular effects and so, the term subluxation complex is more accurately used to describe the complex interaction of pathologic changes occurring within the soft tissue (Gatterman, 1995).

The vertebral subluxation complex is a model of spinal dysfunction that forms the cornerstone of the theory and practice of the chiropractic profession. In this text, the vertebral subluxation complex model encompasses multiple components which cannot be neglected when discussing this lesion (Lantz, 1989).

The tissue level components of the vertebral subluxation complex, namely the bones (providing structural rigidity), the fibrous connective tissue (allows formation of moveable joints), the vascular system (nourishes and cleanses tissues) and the nervous system (coordinates muscle movement), synergistically contribute to the overall picture of kinesiopathology existing at a motion segment. These components in addition to others, the inflammatory response, pathoanatomical and pathophysiological changes, and biochemical abnormalities to be exact, provide some explanation as to what the concept of subluxation entails (Lantz, 1989).

The vertebral subluxation complex is a concept and not an entity and therefore it need not require all the components to be present in order to classify it as a vertebral subluxation complex. The vertebral subluxation complex is regarded as a pathology which shows evidence of abnormal changes with respect to the mechanical, biochemical, physiological and/or anatomical properties of the cells and tissues of the human body. The changes that occur at cellular and tissue level tend to generate symptoms such as pain and other visceral or autonomic symptoms (Gatterman, 2005).

Below, each of the components is explained in brief detail except for the pathoanatomy and pathophysiology which is purely the pathological changes that occur to the structure and function of the spine. The biochemical component is also excluded as the depth in which it requires is beyond the scope of this text, however it is influential within each component from the chemokines and inflammatory cells in the inflammatory component to the hormones involved in pain modulation, to name a few.

Kinesiolopathology represents the abnormalities in the otherwise normal movement that should occur in daily life amongst human beings. It is fairly well known that immobility occurring at a joint is the initiator of loss of flexibility culminating in joint stiffness, with or without some degree of pain. This paves the way for degeneration of the joint to happen which undoubtedly concludes in fusion by osseous ankylosis (Lantz, 1989). The Kirkaldy-Willis’model illustrates the above mentioned process of spinal dysfunction and degeneration and suggests that the process is initiated by hypomobility of the spinal motion segment through altered segmental biomechanics (Bergmann and Peterson, 2011).

Lantz proposes that the degenerative effects of immobilization may be completely reversed if motion is restored within the joint. He explains that there is strong evidence to suggest that chiropractic procedures are effective in re-establishing a joint cleft, even when fibrofatty consolidation of the synovial fluid has set in. He claims that forced motion within the limit of anatomical integrity, causes disruption of the intermolecular cross-bridging of collagen and more importantly the gross structural adhesions that occur between the capsule and articular cartilage (Gatterman, 1995).

The spine is a complex structure which has a complicated kinesiology partly due to the fact that is comprised of several units that work in unison to afford the spine rigidity and flexibility (Kapandji, 1974) as an integral unit (Gatterman, 1995). The basic unit is known as an Integrated Segmental Unit which includes a motion segment that can be viewed as a three joint complex along with the associated spinal structures. These structures include segmental nerves, nerve roots, dorsal root ganglia, recurrent meningeal nerves, meningeal structures, muscles, ligaments and vascular structures. The Integrated Spinal Unit differs from spinal region to region, for example the cervical spine has vertebral arteries and uncovertebral joint, while the thoracic joint may not have the same but have costovertebral joints with the associated ribs, capsules and ligaments. It is clear that the kinesiology or kinesiopathology of the joints is far more complicated when the associated structures are factored, which lead Rothman & Simeone to state "that no disorder of a single major component of a segmental unit can exist without affecting first the functions of the other components of the same unit and then the functions of other levels of the spine" (Lantz, 1989).

As chiropractors, we are trained in the skill of motion palpation which offers the potential for a highly specific and extremely informative assessment of spinal segmental motion (Lantz, 1989). This technique is a tool to aid a chiropractor to locate aberrant motion and correct it through manipulative procedures before degenerative changes begins (Gatterman, 1995).

For many, the neurological component forms the cornerstone of chiropractic theory and currently, the concept is supported by scientific and medical research. Every aspect of the nervous system’s organization and function is applicable to the theory and practice of chiropractic, as it is in a chiropractor’s view that the nervous system is the mediator of vitality and health to the organs and tissues (Lantz, 1990). There are many levels of potential neurological involvement that exist in the vertebral subluxation and only a few that the author thought were relevant will be discussed.

Spinal nerves and dorsal root ganglia form part of the Integrated Spinal Unit and due to the interrelatedness of structures; we have already visited the idea of one structure adversely affecting another. Spinal nerve or dorsal root ganglion compression may occur as a result of spinal degeneration whether it is osteophytic outgrowths or disc herniation (Lantz, 1990).

Crelin disputed this fact in 1973, where he observed that the spinal nerves had enough room in the intervertebral foramen to expand and move without being compressed as a result of joint dysfunction and subluxation. Giles however, demonstrated that Crelin made this assumption by measuring the lateral borders of the intervertebral foramen and was indeed incorrect. He made measurements at the interpedicular zone and found that they were theoretically small enough to cause compression of the spinal nerve by joint dysfunction and subluxation. Compression of the spinal nerve need not be because of bony structures though. There is potential for the structures (arteries, veins, lymphatics, recurrent meningeal nerve, fat and areolar tissue) traversing the intervertebral foramen to mechanically effect the nervous tissue by being tensioned as a result of sustained misalignment or inflammation of the motion segment. This may in turn lead to disruption in blood supply and neuroischemia (Bergmann & Peterson, 2011) which can potentially cause radiculitis with the associated plethora of neurological manifestations (Lantz, 1990).

Pain is a significant aspect of spinal dysfunction and degeneration and is one of the most common neurological manifestations that patients present with when entering chiropractic offices (Gatterman, 1995). It is defined as a nociceptive-induced sensory and emotional experience that occurs in the limbic sectors of the cerebral cortex. These signals are carried via group III and IV afferent fibres or nociceptors, which responsible for detecting injury or tissue damage. Nociceptors along with group I and II afferent fibres or mechanoreceptors (responds to touch, vibration, joint position, and joint motion) are abundantly found in and around the spinal joint (Gatterman, 2005). Chiropractors use these connections with the central nervous system to influence the perception of pain through a widely discussed theory known as the Gate Theory of Pain. Simply, the manipulation stimulates mechanoreceptors providing large amounts of afferent input into the central nervous system, specifically on the internuncial neurons of the spinal cord. The numerous mechanoreceptive signals converging on the interneuron tends to render the interneuron unresponsive, therefore closing the gate of pain sensation (Lantz, 1990).

Gatterman (2005) maintains the fact that pain is perceived in the brain and so it is important to note that the key principle of the gate theory of pain is that the nociceptive signals fail to reach consciousness because they are blocked at the spinal cord.

Joint immobilization is largely accountable for the pathologic changes that arise in all connective tissue associated with the integrated spinal unit, each in their own unique pattern of change (Gatterman, 1995).

In the beginning of the immobilization process, synovial fluid undergoes fibrofatty consolidation, eventually progressing to more adherent fibrous tissue (Gatterman, 1995). Researchers noted that upon gross inspection of an immobilized synovial joint, excessive fibrous tissue depositions were present which developed into scar tissue, creating intraarticular adhesions (Gatterman, 2005). The fibrous tissue provides a matrix upon which bone salts are deposited terminating in bony ankylosis (Gatterman, 1995).

Meanwhile, the changes taking place in the synovial fluid contribute to the dehydration of the articular cartilage (Gatterman, 2005). Water and glycosaminoglycans is lost and the articular cartilage shrinks and softens, leaving it vulnerable to further damage with even trivial trauma (Gatterman, 1995).

In contrast, ligament act differently to the process of immobilization. Initially, they become more pliable and compliant in a condition referred to as ligamentous laxity. The intervertebral disc is fibrocartilaginous and these changes are similarly observed during immobilization. Eventually, the later stages of immobilization illustrate ligament contracture and stabilization via osteophytic growth (Gatterman, 1995).

2.4.4 Myologic component

Muscle degeneration triggered by immobilization invariably involves some degree of abnormal adaptation in the muscle tendon (Lantz, 1990). Gatterman (1995) believes that restricted mobility characteristic of early immobilization was primarily caused by alterations in the muscle/tendon unit.

It is proposed that muscle tension is instrumental in accelerating articular cartilage degeneration partly due to the high compressive forces applied across the joint. A viscious cycle is established where muscle spasticity causes joint contracture, which in turn causes muscle spasticity and so forth. This demonstrates the need to relieve hypertonicity in the muscles to restore and maintain full range of motion in the joints throughout the healing stages (Gatterman, 1995).

Hypertonicity and spasticity of muscle can be explained by the adverse effects occurring at the muscle spindles. The primary spindle endings show signs of degeneration in the form of swollen capsules and loss of cross striations which consequently modifies the physiological response pattern. Spindle afferents show an increased sensitivity to stretch with an elevated resting rate of discharge in the absence of muscular tension. Consequently, the increased spindle activity contributes excessive stimuli into the reflex pathways and hence an altered efferent response. The response lead to overstimulation of the muscle groups which further complicates the situation with muscle spasm and tender trigger point formation (Lantz, 1990).

2.4.5 Vascular component

Although the exact role that spinal dysfunction plays in the vascular congestion is unclear, it is speculated that integrated spinal unit dysfunction or associated inflammation is likely to impede blood flow through segmental venous structures (Lantz, 1990). This seems highly probable since the same scenario exists with the vertebral arteries in the proposed cerebral dysfunction theory. Lantz suggests that due to the susceptibility of the venous structures to be compressed by surrounding structures, it is highly probable that a state of venous stasis arises, which in turn promotes local ischemia, inflammation, and potential associated joint stiffness (Bergmann and Peterson, 2011).

Each motion segment and spinal canal is drained by a segmental vein. The segmental vein forms the exit ports for the Batson plexus which in turn receives blood from the basivertebral vein that drains the vertebral body (Bergmann and Peterson, 2011). The Batson plexus is void of valves and so opportunity for retrograde flow exists whereby toxins and/or inflammatory agents can be transported from more remote areas of the spine. An accumulation of these biochemical agents acts as a driving force in accelerating degenerative processes (Gatterman, 1995).

2.4.6 Inflammatory component

Inflammation is characterized traditionally as exhibiting the classic cardinal signs of calor (heat), rubor (redness), dolor (pain) and tumor (swelling). It has been declared however, that not all tissue respond this way. Fibrocartilage has a propensity to display signs of chronic inflammation in the form of fibroblast proliferation and macrophage recruitment when injured. Fibrosis is usually the end point for this situation through the alteration of collagen by prolonged macrophage activity (Gatterman, 1995).

Literature documents that inflammation regardless of the cause is able to initiate degeneration and is guilty of causing havoc in the surrounding tissues. Joint inflammation is marked by tender joints with decreased range of motion but what does occur, as explained above; inflammation is able to spillover and affects other tissue, especially nervous tissue. Nervous tissue such as the nerve roots, dorsal root ganglions are particularly at risk of inciting chemical insults, ending in radiculitis and neurological symptoms (Gatterman, 1995).

2.5 Manual Therapy

Manual therapy exists in multiple forms, including traction, massage, muscle energy techniques, mobilization and manipulation. These therapies are each unique in that they are all carried out in a specific manner and all affect different aspects of joint function and various tissues surrounding the joint. All these therapies essentially share a common characteristic which is the application of external forces to the body, resulting in movement of joint surfaces either actively or passively. This culminates in the restoration of normal articular relationships and function, neurologic integrity all the while influencing physiologic processes (Bergmann and Peterson, 2011).

2.5.1 Chiropractic manipulation

Chiropractic manipulation is a passive, manual, therapeutic procedure utilized by a chiropractor in order to influence the three-joint complex and neurophysiologic function. The manipulation employs controlled force, leverage, direction, amplitude and velocity directed towards specific joints and anatomic regions. Apart from neurophysiologic effects, the manipulation acts through various reflex mechanisms producing wide-spread effects (Gatterman, 2005).

Chiropractic manipulation is traditionally used when joints are misaligned and/or not moving correctly, meaning there is decreased range of motion. Originally, Sandoz claimed that manipulation was said to occur at the upper limits of passive range of motion but this was seen as incorrect and revised. The manipulation is to be delivered to a joint with clinically significantly less than normal mobility and not at the end of the normal range of motion. Manipulation is performed within a clinical physiological range at the end of which is a paraphysiological space. The joint will cavitate when the impulse of the thrust procedure is carried out and the joint will move into the desired position, regain lost range of motion and/or restore neurological flow. The clinically restricted joint now has improved range of motion, mobility and/or less pain through motion. Mechanisms that bring about this change are unclear although they may be mechanical or neurophysiological in nature or most likely a combination of the two (Vernon & Mrozek, 2005).

2.5.2 Effects of manipulation

As discussed earlier, manual therapy exists as multiple forms which have widespread effects that target different aspects of joint function. These effects may be mechanical, neurological, and psychological or those that affect soft tissue. These effects will be discussed in detail below but it is important to note that the effects of manual therapy may not be isolated, directed and limited. Instead, the results that occur at a joint following manual therapy are consequently due to a combination of effects.

When a manipulation occurs, it is thought to produce changes in the joint alignment, the dysfunctional joint motion and/or the dynamics of the spinal curvatures. In essence, whenever a mechanical dysfunction occurs, irrespective of how it is caused, selecting an appropriate manual therapy with its mechanical effects is sufficient to correct the dysfunction. Evidence of this is when entrapment or extrapment of a synovial fold transpires, causing pain and inflammation, is able to be released from the impinged position through the use of a manual thrust technique. This technique culminates in an intriguing joint phenomenon known as cavitation which can be explained as the sudden liberation of carbon dioxide bubbles from the synovial fold, followed by a rapid separation of the joint surfaces beyond the elastic barrier of resistance (Gatterman, 2005). Immediately, the collapse of the bubble produces an audible crack and a temporary radiolucent space that may in fact be enough for the impinged synovial fold to reduce to its normal position (Bergmann and Peterson, 2011).

Restoration of water imbibition followed by re-establishing normal joint motion is hypothesized to occur after manipulation. The aim of the therapy is to improve extensibility within the tissue by breaking fibrous cross-linkages as well as intracapsular fibroadipose adhesions. Manipulation, acting throught reflex arcs, is also able to bring about positive changes in the tone and strength of supporting musculature, effectively decreasing states of hypertonicity and improving states of muscle atrophy (Gatterman, 2005).

In a book compiled by Gatterman (2005), Wyke reported that stimulation of the mechanoreceptors through manipulative procedures provided reduction in pain by inhibiting the nociceptors from communicating with the central nervous system. Pain reduction is one of the neurological effects achieved when applying manipulative therapeutics to dysfunctional joints. In addition to this fact, manipulation has been shown to alter motor and sensory function as well as playing a role in influencing autonomic nervous system regulation. Manipulation has been implicated in affecting brain function by illustrating changes in one hemisphere and an increase or decrease in cortical activity is largely dependent on which side an enlarged cortical map exists (Carrick, 1997).Keeping with cortical activity, it has also been shown that cortical processing may be favorably affected by the use of upper cervical manipulation (Kelly et al., 2000). In a more relevant study compared to this one, neurocognitive function was assessed in a group of forty subjects. The authors showed that the group receiving upper cervical manipulative care showed significant improvements whereas the control group failed to demonstrate similar changes (Kessinger and Boneva, 1999).

Gatterman (2005) believes that the contact made by the therapist with the patient should not be overlooked or denied as it plays a significant role on the patient psycologically. Patients become convinced that there is a genuine interest, concern in the patients well-being when they receive skilled treatment from the therapist. Furthermore, manipulation that results in cavitation plays an irrefutably high placebo factor.

2.5.3 Contraindications and complications

Manipulative therapy is contraindicated when the therapy may cause injury to the patient, worsen an existing disorder, or delay appropriate curative or live-saving treatment. Danger of injury as a result of manipulation is relatively low, although there does exist a certain amount of risk when it comes to spinal manipulative therapy. In most cases, injury is avoidable provided that the chiropractor is able to utilize sound diagnostic assessment and possesses an awareness of the contraindications and complications of manipulative therapy (Bergmann, Peterson and Lawrence, 1993).

Certain conditions are absolutely or relatively contraindicated and each have specific complications that exist should the patient with any of the following conditions, receive manipulative therapy (Bergmann et al., 1993).

Cerebral dysfunction theory also known as brain hibernation theory was developed by a general practitioner, Eric Milne and an ophthalmologist named Frank Gorman in an attempt to explain some of the effects of spinal manipulation. They noted that patients receiving chiropractic treatment for unrelated conditions often observed that there were other health complaints such as visual disorders, dizziness, memory problems, attention span problems and concentration improved. This led to the postulation that there was decreased cerebral blood flow which resulted in irritation or hypofunction of parts of the nervous system (Terrett, 1993), which was correctable through the use of spinal manipulative therapy (Gatterman, 2005).

Traditionally, the thought of decreased cerebral blood flow would result in irreversible tissue ischemia and damage culminating in the death of the sensitive nervous tissue. Terrett wrote in a book by Gatterman (2005), stating that this is true although the picture was not as black and white as it seemed. He goes on to describe ischemic penumbra, a term coined in 1981 that describes a condition of decreased cerebral blood flow that was below normal but not low enough to cause cell death. The state of ischmeic penumbra brought about the hibernation of areas of the brain, whereby cells remained alive but their function ceased.This was evident in an experiments involving brain function in baboons where neurons stopped firing and cerebral conduction time slowed when blood flow decreased, illustrating that the decreased cerebral blood flow inititiated an electrical failure within the brain. This failure is progressive, illustrating that with increased severity of cerebral ischaemia there is considerably more disability due to the fewer and fewer functioning cerebral cells.

Injury to the cervical vertebrae or subluxations existing in the cervical spine, causing nerve interference is a suitable cause for decreased blood flow which in turn has an effect on blood presure (DeNoon, 2007). Gatterman (2005) corroborates this by stating that arterial insufficiency causing cerebral dysfunction is caused by the constriction of the lumen of the artery as a result of stress. Stress in the form of misaligned and/or malfunctioning vertebrae directly affects the arteries in the neck and is fairly common, occurring after seemingly trivial trauma or without any major trauma at all. He goes on to propose that the cause of this arterial constriction may be as a result of a sympathetic response or an eluding mechanism that is yet to be discovered.

The theory suggests that the core brain functions such as eating , walking, talking are not affected by decreased cerebral functioning however, the more sophisticated brain functions that are not required for basic existence such as; higher mathematical functioning, concentration, attention, peripheral vision, mood and emotion, are affected by the decreased cerebral blood flow (Gatterman, 2005). In essence, if the condition were present in an individual it would require significantly more "brain power" to function appropriately, to possess a good memory, to perform complicated mental and physical tasks as well as maintain a good emotional function. These requirements are extremely vital for a child when advancing through school and may be ridiculed due to poor performance, ability and intelligence when they in fact possess the potential but are unable to display it when they are affected by cerebral dysfunction (Terrett, 1993).

With a significant amount of anecdotal evidence, collected over the years, claims have been made that signs and symptoms of cerebral dysfunction as a result of decreased cerebral blood flow may be relieved through spinal manipulative therapy (Terrett, 1993). Spinal manipulation can therefore have hibernocerbrosomatic, hibernocerebrocognitive, and hibernocerebropsychologic effects (Gatterman, 2005). Chiropractic manipulation of the cranium, spine and ribs as well as the soft tissue therapeutics aimed at releasing muscle and fascial tension may also contribute to restoring a proper gradient in fluid pressures in the brain. In turn this may alleviate symptoms related to arterial pressures that are decreased (Pederick, 1994). Conversely, it is important to note that although there is little literature on the effects of manipulation on blood flow, it was found in one study that spinal manipulative therapy directed to the upper cervical spine did in fact cause a transient arterial spasm resulting in decreased blood flow to the cerebellum (Cagnie, Jacobs, Barbaix, Vinck, Dierckx and Cambier, 2005).

2.7 Edublox

The first Audiblox program consisted of three exercises and was invented in 1979 by Dr Jan Strydom as a school readiness program for his own daughter. Later, as an experiment, the program was used with a boy that had been diagnosed with a learning disability and the results were remarkable. The child went on to achieve the top achiever award with marks well over eighty percent and often above ninety percent. This led Dr Strydom to postulate that the Audiblox programme did in fact have greater possibilities as originally thought. He went on to use the programme amongst children with learning difficulties, often with resounding success (Strydom and Du Plessis, 2000). Dr De Wet found that the programme was superior to remedial education in a study conducted by him, not only because the IQ scores showed significant improvement, but the programme could be applied in a group setting (De Wet, 1989).

Edublox is a reading and learning clinic, which was established in 2009 where learners attend classes to develop and improve their reading and learning skills through the use of Audiblox. The Edublox Intensive Holiday Course is one of their products, comprised of a multitude of applications for reading and learning. The foundational skills that Edublox address are vital to allowing the child to read, spell and do mathematics effectively. These skills include concentration, visual and auditory discrimination, synthesis and analysis as well as addressing various types of memory and logical thinking. The course has been designed in such a way that the exercises do not address one cognitive skill at a time but in fact work in concert in addressing a multitude of cognitive skills, in much the same way we exercise multiple muscles to gain arm strength opposed to just working the biceps. The program is unique in that it is multi-sensory; this means that the child learns visual, auditory and kinaesthetic skills simultaneously (Edublox, 2013).

The programme came under scrutiny in a study when the programme was used on ten students and the results were astounding. After the two week programme, the verbal, non-verbal and full scale IQ results were significant in that they displayed increases on IQ scores of the learners. Initially, the mean verbal IQ score was 85.4, and after the programme had increased to a value of 91.0. The initial mean non-verbal score was 92.6 and increased to a value of 105.1 after the programme. Finally, the mean full scale IQ had risen from 87.0 to 97.1 after thirty to forty hours of tuition. The programme improves cognitive skills and therefore reading, learning and spelling ability (Edublox, 2012). It also formed part of an independent study in the U.S.A whereby 67 children with learning disabilities were examined before and after Audiblox training. It was found that there was a marked improvement by 52.45% amongst ADD/ADHD students, 46.76% amongst dyslexic students, 57.38% amongst students with dyscalculia and 64.14% amongst students with non specific learning disabilities (Edublox, 2013).

The Edublox Intensive Holiday Programme has a multitude of approaches to cognitive development and so the participants performed different exercises throughout the day. The exact details of each exercise are under copyright law and so at the request of Edublox, the details could not be discussed further although a basic breakdown is supplied below. The course was not altered in any way that would influence specific skills in favour of this study.

Both groups received the same cognitive development programme to maintain consistency and various exercises were carried out on a day and shuffled around between days. The course began with an exercise called Arrows, which intends firstly to automate position in space concepts and reading directionality. Secondly, the exercise intends to improve eye tracking and so the exercise aims at developing the foundation of skills for fluent and accurate reading. Pegs is the name of the next exercise to be discussed and is simply an exercise that addresses long term memory, visual memory and intends on developing memory as a technique. The ability to discriminate between foreground and background together with iconic memory determines ones eye-span. Eye span is one of the foundation skills that determines reading speed and is exercised through the implementation of a Flashing exercise. This exercise in conjunction with Pattern exercises and Sequencing exercises targets the visual memory and visual sequential. The Pattern exercises allow the child to distinguish between shape and form, enabling them to recognise letters and develop consistency when reading and writing these letters.

Although the relevance is questioned with regards to this study, Auditory exercises and Reading are included in the program, as they do in fact have their place when discussing cognitive skills. Susan Du Plessis, the owner of Edublox testifies that these auditory skills interact with other skills, contributing to the overall performance of the child with regards to reading, writing, spelling, learning and mathematics. Reading exercises make use of grouping phonemes, which are multiple words that share a similar sound. For instance the sound "f" is hear in; for, enough, phone, nephew. This exercise hopes to teach the child how to recognise, discriminate and effectively group sounds. When referring to sequential memory, recognising a telephone number or the arrangement of letters to form a word, and words to form a sentence, one assumes it is visual although Susan Du Plessis asserts that Auditory exercises play a large role in sequential memory.

Edublox maintains that their program is holistic and addresses all kinds of memory in an attempt to improve the skills, which has repercussive effects on reading, writing, learning, spelling and mathematics.