04/11/2016

Upper Cervical Chiropractic Care: Case Study of a Patient with Loss of Ambulation and Debilitating Pain

Julie Mayer Hunt, DC, DICCP | MAC Spring Convention Speaker

The author of this article, 2014 ICA Chiropractor of the Year Dr. Julie Mayer Hunt, will be speaking at the MAC Spring Convention & Exhibition, April 29-May 1, 2016. Her presentation, “The Atlas to Brain Health: Advanced Imaging of the Cervicocranial Junction,” will be on Saturday from 8-11a, for a total of 3 continuing education hours, including one hour in pain and symptom management and two hours in the performance and ordering of tests.  

Objective: To present a case study of a 31-year-old female with a diagnosis of fibromyalgia, possible Multiple Sclerosis (MS) and Lupus, discussing how chiropractic subluxation of the cervico-cranial junction (CCJ) may contribute to these conditions.  Design: A clinical case study. Lori, a 31-year-old Caucasian female was referred for chiropractic evaluation. She had been diagnosed with fibromyalgia, possible MS and Lupus which manifested as extreme fatigue, weakness, generalized pain throughout her body, balance problems, clumsiness, unsteadiness, and dizziness. Patient was not able to walk unassisted and was expected to require a wheelchair within two months. An MRI of her brain, with and without contrast, performed in July 2010 suggested signal intensity consistent with demyelinating disease. She was co-treating with a Neurologist, a Rheumatologist and a general practice MD. Results: Following six months of upper cervical chiropractic care, Lori demonstrated marked improvement in her gait, regaining her ability to walk unassisted, with balance being restored and significant reduction in her fatigue and pain.  Conclusion: Fibromyalgia complaints and ambulation capacity improved significantly following upper cervical chiropractic care.

INTRODUCTION

Fibromyalgia is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues. Researchers believe that fibromyalgia amplifies painful sensations by affecting the way your brain processes pain signals. 

Multiple sclerosis (MS) is an autoimmune disease that affects the brain and spinal cord (central nervous system). In the United States, the number of people with MS is estimated to be about 400,000, with approximately 10,000 new cases diagnosed every year (1). Recognized and described over 150 years ago by a French neurologist Charcot, the exact cause of the disease remains unknown.  

Lupus is an autoimmune disease where the body’s immune system becomes hyperactive and attacks normal, healthy tissue. The symptoms associated with Lupus include inflammation and swelling along with damage to joints, skin, kidneys, blood, heart, and lungs. 

All of these conditions can have a devastating effect on a patient’s ability to perform activities of daily living. This patient was also evaluated for rheumatoid arthritis, which was ruled out with blood chemistries. 

HISTORY

Lori, a 31-year-old Caucasian female, was referred for upper cervical chiropractic evaluation by an established patient who had experienced marked improvement in her myasthenia gravis symptoms. Lori was diagnosed with fibromyalgia, possible MS and lupus. She complained of extreme fatigue, even after 7 or 8 hours of sleep, as well as fatigue and weakness during or after normal activity. She had generalized pain throughout the body and localized pain, particularly in the hands, hips and legs, as well as the chest. Her skin was sensitive and extremely tender. She described her hips as “stiff.” There was difficulty with memory, concentration and recalling words. Low grade fevers between 99.2 and 99.8 were accompanied by temperature sensitivity. She had 2 to 4 headaches a month as well as loss of strength. There was tingling and numbness in the hands and feet, along with balance problems, clumsiness, unsteadiness and dizziness. She had nodules under the skin and periods of increased hair loss. There was also diarrhea, constipation and excessive stomach gas. 

Her complaints had developed over the previous two years. Her history of trauma included three motor vehicle accidents at ages 12, 18 and 19 with the last accident being a head-on collision. Her headaches and neck / back complaints developed following the first accident (age 12). She underwent extensive allergy testing with all negative findings. 

Lori’s presentation was extremely guarded in all movements and her husband assisted her to ambulate throughout the office.  

EXAMINATION

Lori presented with marked para-cervical muscle spasms, predominately left C2 through C4, with loss of vertebral motoricity particularly in left cervical rotation. Application of digital pressure produced irritation into the left brachial plexus. Right thoracic and lumbar muscle spasms were noted and she was unable to perform dorsolumbar range of motion. When supine on the examination table, Lori was unable to lift either leg up off the table. Postural evaluation revealed an elevated left shoulder with right head tilt.  

DIAGNOSTIC STUDIES

Chiropractic upper cervical spine x-rays were exposed revealing a loss of normal cervical lordoisis with disc heights appearing intact. A type 4 upper cervical chiropractic subluxation was analyzed revealing atlas measuring right 2.5° lateral with posterior rotation of 0.5°. Axis measured right 2.5° with spinous rotation left 3.5°. The lower cervical angle measured right 0.5°.  A resultant vector of correction was calculated using Orthospinology protocols based on the Grostic alignment model (2). 

Extensive laboratory studies which had been previously performed were provided by the patient. These studies were reviewed and appreciated. Rheumatoid tests were negative. Her Erythrocyte Sedimentation Rate was 61 (elevated, normal range 0 – 30).  

A brain MRI from July 2010 was reviewed. Multiple deep white matter and subcortical relatively small hyperintense lesions were identified on flair and T2 projections. These are nonspecific, but can be seen with demyelinating disease. Chronic small vessel ischemia could present similar findings, but the patient is 30 years old and therefore typically too young for this finding. 

During the first month of upper cervical chiropractic care, Lori was checked three times weekly. During the second month, she was checked twice weekly and then checked once per week for the next four weeks. Her ability to hold her upper cervical chiropractic correction improved as she gained strength and regained her ability to walk. Further office checkups were on a reduction frequency basis. Treatment consisted of upper cervical chiropractic specific atlas adjustments based on the Orthospinology procedure (2) and only performed when examination indicated an adjustment was necessary.      

Following her upper cervical chiropractic treatment, a comparison brain MRI study was performed in August 2012. Dr. David L. Harshfield, Jr. (radiologist) performed a comparative read of the two brain MRIs (July 2010, August 2012). The findings included: Interval decrease in the conspicuity of the moderate to high grade periventricular T2 and FLAIR hyperintensities (so called Dawson fingers) noted, accompanied by decreasing number and conspicuity of the deep and subcortical white matter lesions.  

July 2010	August 2012

Interval decreased distention of the CSF spaces surrounding the optic nerves (dural ectasia of the optic nerve sheaths), a finding having been directly correlated with intracranial pressure (thus indirect evidence of interval decrease in intracranial pressure).

 

July 2010	August 2012

RESULTS

Immediately following her first upper cervical chiropractic adjustment, Lori was able to lift her legs (one at a time) up off the table from a supine position. Initially, she achieved 5° to 10° of leg lift capability. As treatment proceeded over the next months, her leg lift capability increased to 90° with full strength. Six months after beginning treatment, she was able to walk unassisted throughout the office and at home. Lori’s cervical range of motion was measurably improved following her first adjustment. Muscle spasms throughout the cervical, thoracic and lumbar regions diminished considerably throughout her upper cervical chiropractic care treatment period. She was also able to walk for exercise and was therefore able to lose weight which she had gained in the preceding two years due to inactivity caused by her pain and weakness.  

METHODS

For the upper cervical chiropractic adjustment, the patient was placed on her left side with her left mastoid resting on a solid mastoid support headpiece. Upper cervical chiropractic adjustments were delivered with a solenoid-driven stylus, hand-held instrument (Laney instrument) with minimal excursion. The thrusts were administered along a lateral to medial vector as determined by the Orthospinology procedure x-ray analysis. The thrusts were high-velocity in nature, with little depth and are estimated at 4 pounds-force plus the pre-load against the skin and 2 – 3 milliseconds in duration (2,3). 

DISCUSSION

Although chronic pain and auto immune disorders may result from a myriad of causes, trauma can cause spinal misalignment and thereby interruption of the central nervous system function, as well as alteration of intracranial pressure dynamics. Lori had significant postural distortion in conjunction with muscle spasm, subluxation, and loss of vertebral motoricity. Lori’s trauma history included three motor vehicle accidents, two of which resulted in substantial injuries.  

A review of literature (4) reveals several studies which demonstrate positive clinical changes associated with MS symptomology for patients under upper cervical chiropractic care. These studies are listed in the bibliography (1,5,6,7,8). 

Recent research from the University of Rochester (9) reveals that the newly “discovered” Glymphatic system (lymphatic system of the brain) is driven by the CSF flow dynamic. It is postulated that the Glymphatic system can be affected by the aging process, trauma or possibly infection. Scientists have known that cerebrospinal fluid or CSF plays an important role cleansing brain tissue, carrying away waste products and carrying nutrients to brain tissue through a process known as diffusion. The Glymphatic system circulates CSF to every corner of the brain much more efficiently, through what scientists call bulk flow or convection (10). 

In conjunction with trauma related biomechanical misalignment of spinal segments possibly affecting nerve pathways, the referenced studies suggest that blood flow and cerebral spinal fluid flow can potentially also be altered by these chiropractic misalignments, particularly at the cervicocrainal junction.

Research published by Mandolesi, et. al. (1), in September 2013 suggests that extracranial venous compression is linked to severe misalignment of C1 resulting in a Mechanical Posture Vascular Compressive Block (MPVB). This blockage affects venous blood outflow from the brain. Chronic cerebrospinal venous insufficiency (CCSVI) was described in this publication as a condition that may possibly contribute to the symptoms often experienced by patients with MS. CCSVI was further called a vascular condition characterized by anomalies of the main extra-cranial cerebrospinal venous routes that interfere with normal venous flow (11). 

The origin of CCSVI related venous anomalies has not been determined. It has been hypothesized that cerebrospinal venous anomalies may cause alterations to blood flow that result in iron deposition, decreased brain parenchyma metabolism, degeneration of neurons and characteristic brain injury patterns found in MS (12).  

There are proposed relationships between MS and upper cervical chiropractic subluxation. Elster (6) conducted a study on upper cervical chiropractic subluxation and its connection to MS and Parkinson’s disease. Elster’s study focused on trauma as a possible cause of MS, whereas the previously referenced Mandolesi (1) study is focused on upper cervical misalignment and CCVSI in patients with MS. 

The goal of upper cervical chiropractic adjustments is to optimize neural integrity between the brain and the body. The Mandolesi study revealed increased venous drainage following upper cervical chiropractic care. The Glymphatic system research postulates removal of brain waste can be improved by increasing the CSF flow. The positive signal intensity changes observed in Lori’s August 2012 brain MRI suggest that fluid flow dynamics may have been improved by accurate upper cervical chiropractic care. Lori’s response to upper cervical chiropractic care resulted in her “getting her life back” (quote from Lori). Lori sent an email in the summer of 2012 stating that her latest brain (August 2012) MRI showed no signs of MS in her central nervous system. The current signal intensities noted in the 2012 MRI were consistent with someone with a history of migraines. 

CONCLUSION

A reduction of signal characteristics of demyelination in the brain white matter as well as clinical improvement of Lori’s prognosis and her general state of health occurred following upper cervical chiropractic care. It may be that by detecting the upper cervical chiropractic subluxation, intervening and providing treatment, we may have reduced impedance to nervous system communication and possibly fluid flow (blood and cerebral spinal) dynamics. Lori now has her life back, but observationally there were changes at the brain level that correlate clinically. This warrants further research to better understand fluid flow dynamics to and from the brain and the resulting effects on brain and nervous system health. 

Bibliography

1. Mandolesi, S., MD, Marceca, G., MD, Conicello, S., DC, and Harris, E., DC; Upper Cervical Vertebral Subluxation in Multiple Sclerosis Subjects with Chronic Cerebrospinal Venous Insufficiency: A Pilot Study; Journal of Upper Cervical Chiropractic Research; September 23, 2013; pg. 65 – 70
2. Eriksen, K., Rochester, R.; Orthospinology Procedures: An Evidence-Based Approach to Spinal Care; Lippincott, Williams & Wilkins; March 2007
3. Rochester, R; Neck pain and disability outcomes following chiropractic upper cervical care: a retrospective case series; Journal Canadian Chiropractic Association; 2009, 53(3), pp. 173 – 185
4. Eriksen, K.; Upper Cervical Subluxation Complex: A Review of the Chiropractic and Medical Literature; Lippincott Williams & Wilkins, 2004
5. Killinger, L.Z., Azad, A.; Multiple Sclerosis Patients Under Chiropractic Care: A Retrospective Study; Palmer Journal of Research; 1997, 2(4):96 – 100
6. Elster, E.L.; Upper Cervical Chiropractic Management of a Multiple Sclerosis Patient: A Case Report; Journal of Vertebral Subluxation Research; 2001; 4(2): 22 – 30
7. Kirby, S.L.; A Case Study: The Effects of Chiropractic on Multiple Sclerosis; Chiropractic Research Journal; 1994; 3(1): 7 – 12
8. Elster E.; Eighty-One Patients with Multiple Sclerosis and Parkinson’s Disease Undergoing Upper Cervical Chiropractic Care to Correct Vertebral Subluxation: A Retrospective Analysis; Journal of Vertebral Subluxation Research; August 2, 2004, pp. 1 - 9
9. Iliff, J., Nedergaard, M., et. al.; A Paravascular Pathway Facilitates CSF Flow Through the Brain Parenchyma and the Clearance of Interstitial Solutes, Including Amyloid β;  Science Translational Medicine, 15 August 2012, Vol. 4, Issue 147
10. University of Rochester Medical Center; "Previously unknown cleaning system in brain: Newer imaging technique brings 'glymphatic system' to light;" ScienceDaily, 15 August 2012. <www.sciencedaily.com/releases/2012/08/120815142042.htm>.
11. Weinstock-Guttman, B., Ramanathan M., Marr K., et al.; Clinical correlates of chronic cerebrospinal venous insufficiency in multiple sclerosis; BMC Neurology, 2012, 12(26), pp. 1-6
12. Williams, et al.; Iron deposition is independent of cellular inflammation in a cerebral model of multiple sclerosis; BMC Neuroscience, 2011, 12(59), pp. 1-10

Dr. Julie Mayer Hunt is the President of the Society of Chiropractic Orthospinology, a gentle form of chiropractic that aligns the upper cervical spine to enhance health, reduce pain, and ease chronic health problems. A graduate of Life, she currently also serves as a member of the Florida Board of Chiropractic Medicine. A Distinguished Fellow of the ICA, Dr. Mayer Hunt is a sought-after speaker who has taught classes and seminars concerning upper cervical chiropractic and upper cervical pediatrics to groups throughout North America. She is Board certified in Chiropractic Pediatrics and Chiropractic Orthospinology. Her numerous awards include the ICA President’s Award, BJ Palmer Award from the Upper Cervical Health Centers, and the Florida Chiropractic Society’s Outstanding Service Award.