TODAY'S CHIROPRACTIC , November 2000
by Erin Elster, DC.
by Erin Elster, DC.
INTRODUCTION
Multiple Sclerosis (MS) is the foremost
disabling neurological disease among adults between 20 and 50 years of
age, afflicting 250,000 people in the United States. (1) It strikes
women twice as often as men and Caucasians more frequently than other
ethnic groups. (1) The occurrence of MS is greater in northern temperate
zones. (1)
The pathological process involved in MS,
a demyelinating disease, is the loss of the myelin sheaths surrounding
axons in the central nervous system. Demyelination is thought to result
either from damage to the oligodendrocytes (white matter cells) that
produce the myelin or from a direct, immunologic (auto-immune) assault
on the myelin itself. (2)
Common early manifestations of MS
include paresthesias (numbness/tingling in extremities), optic neuritis
(vision loss), mild sensory or motor symptoms in a limb, and cerebellar
incoordination (balance loss). Although the most common course of the
condition is a relapsing and remitting pattern over many years, the
manifestation in each patient varies. In most cases, as the disease
progresses, remissions become less complete. Some patients have only a
few brief episodes of disability, whereas others have a relentless
downhill course over months or weeks. Although not all patients become
disabled, the end stage often can include ataxia (inability to
coordinate voluntary movement), incontinence, paraplegia, and mental
dysfunction due to widespread cerebral and spinal cord demyelination.
(2)
The MS diagnosis, primarily a clinical
one, is usually rendered based on neurological history and examination.
The diagnosis can be confirmed by specialized evaluation techniques
including magnetic resonance imaging (MRI), evoked potentials, and
cerebrospinal fluid (CSF) analysis, although none show findings
pathognomonic for MS. (3-5) Traditional medical treatment for MS focuses
on the use of medications to regulate the severity of symptoms such as
depression, pain, bladder impairment, and sexual dysfunction. Other
drugs may accelerate recovery from acute exacerbations of MS, but they
neither alter the long-term course of the condition nor reverse any
existing MS symptoms. (6)
B.J. Palmer, D.C., reported management
of Multiple Sclerosis patients with upper cervical chiropractic care as
early as 1934. (7-8) In his writings, Palmer listed improvement or
correction of symptoms such as "spasticity, muscle cramps, muscle
contracture, joint stiffness, fatigue, neuralgia, neuritis, loss of
bladder control, paralysis, incoordination, trouble walking, numbness,
pain, foot drop, inability to walk, and muscle weakness." His
chiropractic care included paraspinal thermal scanning using a
neurocalometer (NCM), a cervical radiographic series to analyze injury
to the upper cervical spine, and a specific upper cervical adjustment
performed by hand.
While few of Palmer's Research Clinic
cases were published, Palmer described one case of Multiple Sclerosis in
detail. (8) The patient, a 38-year-old male, went to the Palmer
Research Clinic in Davenport, Iowa, in 1943, after a diagnosis of MS by
the Mayo Clinic. At the time of admission into the Palmer Clinic, this
subject was "…helpless; he could not feed nor take care of himself." His
medical history included a head/neck trauma at age 16 in which "…he
fell ten feet off a building, landing on his head." The fall rendered
him unconscious for thirty minutes and he reported having a sore neck
for several days. At the Palmer Clinic, upper cervical radiographs
showed a misalignment of the atlas to the right. After upper cervical
chiropractic care, the patient remarked, "I am happy to say that through
chiropractic, I have been made almost well. Today, I have just a little
numbness left in my hands. I have the full use of my hands, feet, and
my whole body."
During the past several decades,
research linking chiropractic and MS has been virtually nonexistent. A
literature search produced only two single case reports. One patient was
adjusted with an instrument, while the other was managed with
thoracolumbar manual chiropractic adjusting procedures. (9-10) No other
references for the chiropractic management of MS patients were found. To
the author's knowledge, the MS cases discussed in this report are the
first documented using specific upper cervical care (cervical
radiographs, thermal imaging, and knee-chest adjustments) since Palmer's
research seventy years ago.
The following five individuals suffered
from Multiple Sclerosis for one to ten years, ranged from 33 to 55 years
of age, and had symptoms varying from mild to severe. All patients
showed lesions on MRI (MS plaques) and were diagnosed with MS by their
neurologist. Some concurrently were undergoing treatment with
medications. The following report discusses the upper cervical
chiropractic intervention in detail and summarizes the five cases'
results.
IUCCA UPPER CERVICAL CHIROPRACTIC INTERVENTION
At each subject's first upper cervical
chiropractic office visit, her/his medical history was discussed. In
Case 1, a nine-year history of the typical relapsing-remitting pattern
of MS symptoms was established. In Cases 2 through 5, MS symptoms were
constant and progressively worsening without remission
Paraspinal digital infrared imaging,
which measures cutaneous infrared heat emission, was chosen as the
diagnostic test for neurophysiology. Thermography has been proven valid
as a neurophysiological diagnostic imaging procedure with over 6000
peer-reviewed and indexed papers in the past 20 years. In blind studies
comparing thermographic results to that of CAT scans, MRI, EMG,
myelography, and surgery, thermography was shown to have a high degree
of sensitivity (99.2%), specificity (up to 98%), predictive value, and
reliability. (11-13) Thermal imaging has been effective as a diagnostic
tool for breast cancer, repetitive strain injuries, headaches, spinal
problems, TMJ conditions, pain syndromes, arthritis, and vascular
disorders, to name a few. (14-23)
At each patient's first upper cervical
chiropractic office visit, a paraspinal thermal analysis was performed
from the level of C7 to the occiput according to thermographic protocol.
(24-26) Compared to established normal values for the cervical spine,
each of the five subject's paraspinal scans contained thermal
asymmetries higher than 0.5 ºC. According to cervical thermographic
guidelines, thermal asymmetries of 0.5ºC or higher indicate abnormal
autonomic regulation or neuropathophysiology. (27-30) Because upper
cervical misalignments were suspected in all five patients, a precision
upp
er cervical radiographic series,
including Lateral, A-P, A-P Open Mouth, and Base Posterior views, was
performed at each patient's initial chiropractic office visit. (31)
These four views enabled examination of the upper cervical spine in
three dimensions: sagittal, coronal, and transverse. To maintain
postural integrity, each subject was placed in a positioning chair using
head clamps. Analysis of the four views was directed towards the
osseous structures (foramen magnum, occipital condyles, atlas, and axis)
that are intimately associated with the neural axis. Laterality and
rotation of atlas and axis were measured according to each vertebra's
deviation from the neural axis. (31) All five patients showed upper
cervical misalignments.
Because the two criteria determining
subluxation (thermal asymmetry and vertebral misalignment) were met in
each case, a treatment plan was discussed with each patient. After each
subject consented, chiropractic care began with an adjustment to correct
the atlas/axis misalignment. To administer the adjustment, the patient
was placed on a knee-chest table with his/her head turned to the
direction of misalignment (left for left misalignments and right for
right misalignments). The knee-chest posture was chosen because of the
accessibility of the anatomy to be corrected. In addition, this posture
retained spinal curvatures, thus preventing compression of the spine.
Using the posterior arch of atlas as the contact point, an adjusting
force was introduced by hand. (32) The adjustment's force (force = mass X
acceleration) was generated using body drop (mass) and a toggle thrust
(acceleration).
Then, each patient was placed in a
post-adjustment recuperation suite for fifteen minutes as per
thermographic protocol. (24-26) The adjustment's success was determined
by reviewing the post-adjustment thermal scan. The first post-adjustment
scans of all five patients revealed thermal differences of 0.1 ºC to
0.2ºC, which were considered normal according to established cervical
thermographic guidelines (compared to the pre-adjustment differential of
0.5 ºC or greater). Therefore, resolution of each patient's presenting
thermal asymmetry was achieved.
All subsequent office visits for each
patient began with a thermal scan. An adjustment was administered only
when the patient's presenting thermal asymmetry returned. If an
adjustment was given, a second scan was performed after a fifteen-minute
recuperation period to determine whether restoration of normal thermal
symmetry had occurred. On average, each subject's office visits occurred
three times per week for the first two weeks of care, two times per
week for the following two weeks, and once per week for the subsequent
month. After spinal stability was achieved (thermal asymmetry was rarely
present), visits were reduced to once per month.
CASE 1
History: This 54-year-old female was
diagnosed with Multiple Sclerosis at age 44 after a bout of optic
neuritis, which prompted an MRI (MS plaques were visible). Over the next
nine years, she experienced a minimum of one exacerbation per year
lasting an average of one month. She recovered completely each time
except for partial vision loss resulting from optic neuritis. The most
recent flare-up occurred at age 53 when she experienced numbness that
switched from side-to-side in her body. With this exacerbation, no
remission occurred. Symptoms included tingling in her arms, hands, legs,
and feet as well as a positive L'hermitte's Sign (pain, numbness,
tingling down extremities upon cervical flexion). After these symptoms
were present for three months, this subject's neurologist surmised her
condition was worsening and recommended drug therapy. Due to her
concerns over long-term drug use, this patient chose to undergo upper
cervical chiropractic care first.
Exam: During her initial chiropractic
examination, this subject showed reduced sensitivity bilaterally in her
arms, hands, legs, and feet. L'hermitte's Sign was present during
cervical flexion and right lateral flexion compression was positive. The
subject reported experiencing these symptoms constantly for the three
months prior to her chiropractic exam. Cervical ranges of motion were
reduced during left lateral bending and left rotation. She reported
visual loss from previous optic neuritis episodes. Computerized thermal
imaging showed thermal asymmetries as high as 1.0 ºC. Analysis of
cervical radiographs revealed left laterality and left anterior rotation
of atlas.
Outcome: Immediately following this
subject's first upper cervical adjustment, Lhermitte's Sign was no
longer present. During the following week, normal sensation returned to
her extremities. After two weeks of upper cervical care, cervical ranges
of motion no longer produced pain and cervical compression tests were
negative. At the end of week four, this patient reported improved vision
in her left eye (which had been damaged by the episode of optic
neuritis ten years earlier). After four weeks of upper cervical care,
this subject's neurologist reexamined her and no longer recommended drug
therapy. Two years after beginning upper cervical care, this subject
remained symptom-free.
Summary: This patient experienced a
minimum of one relapse per year for the ten years prior to upper
cervical care. After upper cervical intervention, two years passed
without reoccurrence of symptoms.
CASE 2
History: After this 33-year-old male
noticed visual changes at age 30, he was examined by a
neuro-opthalmologist and showed 20/30 vision in the right eye (according
to the Snellen eye chart examination). After an MRI showed three brain
lesions (MS plaques), he was diagnosed with MS. The year following his
diagnosis, this subject showed minimal deterioration in his condition.
However, during the subsequent two years, he experienced chronic
progression of MS symptoms. In addition to vision loss, he suffered from
loss of bladder control, constipation, loss of balance, sensory
deficits in his extremities, and L'hermitte's sign. Three years after
the MS diagnosis, he was reexamined by his neuro-opthalmologist who
noted his optic nerves appeared pale and his vision had deteriorated to
20/400 in the right eye and 20/200 in the left eye. He was declared
legally blind. A follow-up MRI showed ten lesions, one active. This
subject began upper cervical care soon after the second MRI.
Exam: During this patient's initial
examination, he reported wearing sunglasses at all times, even indoors,
due to light sensitivity. L'hermitte's Sign was present. Sensitivity was
reduced in his hands and feet. Heat aggravated his symptoms. He showed
inability to balance on one foot bilaterally and to walk heel-to-toe in a
straight line. As a result, he reported frequent falls on hiking
trails. He reported difficulty with bladder control (he urinated six
times per night) and constipation (averaging four to five days without a
bowel movement). He also suffered with memory loss (he carried a tape
recorder to remind himself of errands, etc.), insomnia, and fatigue.
Most of his MS symptoms had progressively worsened during the second and
third years following his diagnosis and had been constant for at least
one year. Analysis of cervical radiographs revealed left laterality of
atlas. Computerized thermal imaging showed thermal asymmetries as high
as 0.8ºC.
Outcome: After the first upper cervical
adjustment, L'hermitte's Sign was absent and balancing on his left leg
improved (both symptoms had been present for one year or greater). One
week later, he reported that due to less light sensitivity, he was able
to leave his sunglasses off, even outdoors. Upon visual reexamination
one month later, he tested 20/160 bilaterally. Six months later,
balancing on both left and right legs improved, so he was able to resume
hiking while carrying a heavy backpack. He also was able to take hot
showers and sit in jacuzzis because heat no longer aggravated his
symptoms. In addition, normal sensation returned to his extremities,
bladder control improved (urination occurred once per night), and
constipation improved (one bowel movement per day).
Summary: During the two years prior to
chiropractic care, this patient experienced a progressive worsening of
MS symptoms. Most symptoms had been present constantly for at least one
year prior to the start of upper cervical care. After the intervention
of chiropractic care, this subject reported immediate correction of some
symptoms as well as gradual improvement of other symptoms over several
months. One year after beginning care, this patient reported an overall
correction and/or improvement in MS symptoms.
CASE 3
History: This 46-year-old female first
experienced symptoms of MS at age 44, when she noticed memory and
cognitive problems (inability to formulate thoughts or words), frequent
urination and loss of bladder control (loss of muscular control to begin
and end urination). She was diagnosed with MS after an MRI showed
active brain lesions. Her symptoms remained constant without worsening
until the addition of sensory deficits (painful tingling) in her arms
and legs, two years after her diagnosis.
Exam: At her initial chiropractic
examination, this subject reported feeling continuous, painful tingling
and loss of sensation in both arms and legs during the previous month.
She complained of a weakness in her legs that she described as "a
rubbery feeling." She also had difficulty with cognition and bladder
control for the previous two years. She complained of generalized
stiffness and aching in her neck. Cervical extension was reduced and
painful. Analysis of cervical radiographs revealed right laterality and
right posterior rotation of atlas. Computerized thermal imaging showed
0.5ºC thermal asymmetries.
Outcome: Within the first week of upper
cervical care, this subject reported improved bladder control
(resumption of muscular control during urination) and a decrease in
numbing, tingling, and pain in her left leg and right hand. One month
later, her leg strength returned and numbness was noted only in her left
hand. In addition, memory and cognitive ability returned to normal.
After two months of care, bladder control, sensitivity, and strength in
her extremities returned to normal. After four months of upper cervical
care, this subject reported the absence of all MS symptoms. A follow-up
MRI showed no new lesions as well as a reduction in intensity of the
original lesions. During the subsequent six months, this patient was
examined once per month with digital infrared imaging. An adjustment was
necessary on three visits. At each of those three occasions, a minor
reoccurrence of symptoms also existed, which was corrected following
each adjustment. No other flare-ups occurred.
Summary: Most of this patient's MS
symptoms (except one month of sensory deficits) had been present for two
years prior to the start of upper cervical care. After the intervention
of upper cervical chiropractic care, the patient's MS symptoms
gradually improved over several months. After one year of care, this
individual primarily remained asymptomatic.
CASE 4
History: This 55-year-old female was
diagnosed with MS nine years ago at age 46 after an MRI confirmed active
brain lesions. Her symptoms included painful paresthesia of her left
arm, fatigue, mental confusion, insomnia, and lack of coordination of
her right arm and leg. All symptoms progressively worsened over the
nine-year period. Seven years after her diagnosis, a follow-up MRI
confirmed the addition of new active lesions. Due to the fatigue,
confusion, and pain, she had been on disability leave from work for
several years.
Exam: During this patient's initial
exam, she complained of extreme pain in her left arm, requiring multiple
doses per day of pain medication (neurontin). She also took daily
medication for sleeping (klonopin) and energy level (amantadine) due to
her insomnia and fatigue. Her handwriting coordination (right-handed)
was poor so she preferred using a computer. Cervical radiographs
depicted a misalignment of her atlas to the right and posterior.
Computerized thermal imaging revealed thermal asymmetries of 0.5ºC.
Outcome: During the first week of upper
cervical care, this subject noticed an increase in energy level. One
month later, she no longer noticed arm pain. Consequently, she consulted
with her neurologist to reduce her pain medication. Her pain medication
was reduced by two-thirds and she had no occurrences of arm pain. This
patient also reported a continued increase in energy level and a renewed
sense of mental clarity, so she considered looking for a part-time job.
She felt "more alert and energized" and her "mind was clear." Four
months after the start of upper cervical care her condition continued to
improve without any relapses.
Summary: For the nine years prior to
upper cervical care, this patient suffered from a chronic, progressive
worsening of MS symptoms. Since the intervention of upper cervical care,
this individual experienced improvements in MS symptoms and required
less medication.
CASE 5
History: This 43-year-old female first
experienced symptoms of MS seven years ago. The symptoms included
numbness in her legs, hands, and face, and lasted for two weeks. No
further symptoms occurred until six years later with the onset of
L'hermitte's Sign. Soon after L'hermitte's Sign began, this patient
noticed loss of grip strength and a spasmodic curling of her left hand.
After an MRI, she was diagnosed with MS. Because Lhermitte's Sign was
present every time she nodded her head causing her pain, she began daily
pain medications (neurontin). After the symptoms were constantly
present for six months, she began upper cervical care.
Exam: During her initial chiropractic
exam, cervical flexion produced L'hermitte's Sign. Cervical extension
and left rotation were reduced and painful. She reported constant
tingling in her left arm, grip strength loss in her left hand, and
weakness and pain in both forearms. She experienced aggravation of
forearm pain while taking notes in class. As an avid martial arts
participant, she expressed concern over her inability to perform
push-ups in class due to exacerbation of L'hermitte's Sign. She also
reported experiencing dizzy spells several times per day for many years.
Cervical radiographs depicted right laterality of atlas. Computerized
thermal imaging revealed thermal asymmetries of 0.5ºC.
Outcome: After the first upper cervical
adjustment, this patient noted reduction in intensity of L'hermitte's
Sign. By the end of two weeks of care, L'hermitte's Sign was noticeable
only occasionally and no dizzy spells had occurred. After four weeks of
care, this patient no longer reported experiencing any dizzy spells, arm
pain, tingling, forearm weakness, or L'hermitte's Sign. Consequently,
she reduced her pain medication dosage. In addition, she resumed taking
notes in class and performing pushups in her martial arts class without
pain or tingling.
Summary: This subject's symptoms were
present constantly for six months prior to upper cervical care. With the
intervention of chiropractic care, symptoms were reversed either
immediately or over one month's time.
RESULTS
At their first upper cervical
chiropractic office visits, computerized thermal scans showed thermal
asymmetries and cervical radiographs showed upper cervical misalignments
in all five subjects. Because these exam findings indicated upper
cervical injuries, all five patients consented to upper cervical
chiropractic care. The five subjects underwent upper cervical care for a
minimum of four months and a maximum of two years at the time of this
paper's submission for publication. Before the intervention of upper
cervical chiropractic care, four out of the five patients (Cases 2
through 5) showed patterns of constant, progressive MS symptoms for a
minimum of six months. After upper cervical care, MS symptoms were
improved or corrected, including L'hermitte's Sign, paresthesias, pain,
balance, muscle weakness, bladder control, bowel control, cognitive
ability, vision loss, insomnia, dizziness, and fatigue. The only case
that followed the typical MS relapse-remit pattern, Case 1, had a
history of MS relapses once per year for nine years. After the
intervention of upper cervical care, this subject had no further
relapses and remained symptom-free for two years. Therefore, results of
the five cases indicated that upper cervical chiropractic care prevented
the progression of MS, stopped the MS relapse pattern, and improved
and/or reversed symptoms of
DISCUSSION
An important parallel in the MS
patients' medical histories was their recollection of head and/or neck
trauma(s) prior to the onset of MS (also mentioned in the Palmer case
described in the Introduction). All five patients remembered specific
incidences of trauma preceding the onset of MS symptoms such as a fall
on an icy sidewalk, an auto accident, and a ski accident. In addition,
all five individuals showed evidence of upper cervical injury during
exams (digital infrared imaging and cervical radiographs). The body of
medical literature detailing a possible trauma-induced etiology for MS,
or at least a contribution, is substantial. (33-35) In fact, medical
research has established a connection between spinal trauma and numerous
neurological conditions besides Multiple Sclerosis, including
Parkinson's Disease, Amyotrophic Lateral Sclerosis (ALS), epilepsy,
migraine headaches, Attention Deficit Hyperactivity Disorder (ADHD),
vertigo, and bipolar disorder, to name a few. (36-43)
While medical research has shown that
trauma may lead to MS and the other neurological conditions mentioned
above, no mechanism has been defined. It is the author's hypothesis that
the missing link may be the injury to the upper cervical spine. While
various theories have been proposed to explain the effects of
chiropractic adjustments, a combination of several theories seems most
likely to explain the profound changes seen in these MS patients due to
upper cervical chiropractic care. After a spinal injury, central nervous
system (CNS) facilitation can occur from an increase in afferent
signals to the spinal cord and/or brain coming from articular
mechanoreceptors. (44-48) The upper cervical spine is uniquely suited to
this condition because it possesses inherently poor biomechanical
stability along with the greatest concentration of spinal
mechanoreceptors.
Hyperafferent activation (through CNS
facilitation) of the sympathetic vasomotor center in the brainstem
and/or the superior cervical ganglion may lead to changes in cerebral
blood flow, including ischemia. (49-55) Because of the close association
between the nervous and immune systems (the immune system recently has
been reclassified as the neuroimmune system), upper cervical injuries
affecting sympathetic function consequently may cause a cascade of
non-favorable immune responses. (56-58) Among these are uncoordinated
immune tissue responses (auto-immune responses) and the release of
cortisol, which ultimately can result in decreased immune function.
It is likely that the five MS patients
sustained injuries to their upper cervical spines (visualized on
cervical radiographs) during spinal traumas they experienced. It is also
likely that due to the injuries, through the mechanisms described
previously, sympathetic malfunction occurred (measured by paraspinal
digital infrared imaging), possibly causing decreases in cerebral blood
flow. Consequently, because the nervous and immune systems are so
closely intertwined, it is possible that CNS facilitation and cerebral
ischemia could have stimulated an auto-immune response such as myelin
destruction. According to the results of each of the five patients
discussed in this report, it seems correction of the upper cervical
injury not only stopped but also reversed the pathological processes
involved in MS. However, few conclusions can be drawn from a small
number of cases. Therefore, further research is recommended to study the
link between trauma, the upper cervical spine, and neurological
disease.
CONCLUSION
All five patients discussed in this
report recalled experiencing head or neck trauma(s) prior to the onset
of Multiple Sclerosis symptoms. In all five cases, evidence of upper
cervical injury was found using paraspinal digital infrared imaging and
upper cervical radiographs. After IUCCA upper cervical chiropractic
care, all five cases reviewed revealed improvements in Multiple
Sclerosis symptoms. In fact, correction of the five patients' upper
cervical injuries appeared to stimulate a reversal in the progression of
MS symptoms. To the author's knowledge, these are the first cases
reported on this topic using thermal imaging and knee-chest adjustments
since Palmer's research seventy years ago. Further investigation into
upper cervical injury and resulting neuropathophysiology as a possible
etiology or contributing factor to Multiple Sclerosis should be pursued.
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