UPPER CERVICAL CHIROPRACTIC MANAGEMENT OF A MULTIPLE SCLEROSIS PATIENT: A CASE REPORT
 
   

Upper Cervical Chiropractic Management of a
Multiple Sclerosis Patient: A Case Report

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:
   Frankp@chiro.org
 
   

FROM:   J Vertebral Subluxation Research 2001 (May);   4 (2):   22-30 ~ FULL TEXT

Erin L. Elster, D.C.

Private Practice
Boulder, Colorado
erin@erinelster.com


This article reviews the upper cervical chiropractic care of a single patient with Multiple Sclerosis (MS). This 47-year-old female first experienced symptoms of Multiple Sclerosis (MS) at age 44, when she noticed cognitive problems and loss of bladder control. After viewing multiple lesions on MRI (MS plaques), her neurologist diagnosed her with MS. Two years later, she noticed additional symptoms of leg weakness and paresthesias in her arms and legs. Her symptoms progressively worsened without remission, so her neurologist categorized her as having chronic progressive MS and recommended drug therapy (Avonex). Upon initial examination of this patient, evidence of an upper cervical subluxation was found using precise upper cervical radiographs and paraspinal digital infrared imaging. The patient’s medical history included one possible mechanism (a fall approximately ten years prior), which could have caused her upper cervical subluxation. The patient was placed on a specially designed knee-chest table for adjustment, which was delivered by hand to the first cervical vertebra according to radiographic findings.

Monitoring of the patient’s progress was through doctor’s observation, patient’s subjective description of symptoms, thermographic scans, neurologist’s evaluation and MRI. The patient was managed with upper cervical chiropractic care for two years.

After four months of upper cervical chiropractic care, all Multiple Sclerosis ( MS) symptoms were absent. A follow-up MRI showed no new lesions as well as a reduction in intensity of the original lesions. After a year passed in which the patient remained asymptomatic, another follow-up MRI was performed. Once again, the MRI showed no new lesions and a continued reduction in intensity of the original lesions. Two years after upper cervical chiropractic care began, all MS symptoms remained absent.

This case report revealed that this specific upper cervical procedure (thermal imaging, cervical radiographs, and knee-chest adjustments) was associated with a successful outcome for a patient with Multiple Sclerosis. Post MRI’s, post thermographic scans, and the patient’s neurologist’s evaluation all suggested the intervention of upper cervical chiropractic care may have stimulated a reversal in the progression of Multiple Sclerosis.


From the Full-Text Article:

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. It strikes women twice as often as men and Caucasians more frequently than other ethnic groups.The occurrence of MS is greater in northern temperate zones. [1]

The pathological process involved in MS, a demyelinating disease, is the loss of myelin sheaths surrounding axons in the central nervous system (brain and spinal cord). 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]

Medical treatment for MS focuses upon 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 or reduce the frequency of exacerbations, 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 upper cervical misalignment, 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, only three references were found linking chiropractic and Multiple Sclerosis: two single case studies and one five-patient report. Of the two single cases, one patient was adjusted with an instrument, while the other was managed with thoracolumbar manual chiropractic adjusting procedures. [9, 10] Both cases responded favorably. Of the five patient report, five subjects were managed with upper cervical chiropractic care aided by cervical radiographs and thermal imaging. [11] In all five cases, upper cervical subluxations were discovered and all patients showed improvement and/or correction of MS symptoms after the intervention of upper cervical chiropractic care.

The rationale for the use of upper cervical chiropractic care in this case was to correct the patient’s upper cervical subluxation that was discovered during cervical radiographic and thermal imaging procedures. Similar upper cervical subluxations were found in other patients (with conditions such as Parkinson’s disease, asthma, epilepsy, and fibromyalgia) who responded favorably to upper cervical chiropractic care (aided by cervical radiographs and thermal imaging). [11-17] This case report reviews the patient’s symptoms and objective findings before and after the intervention of upper cervical chiropractic care.


Case Report

This 46-year-old female first experienced MS symptoms at age 44. She noticed inability to formulate words when talking to her two-year-old daughter and difficulty processing complex thoughts or tasks at work. In addition, she had trouble with muscular control to begin and end urination. Her neurologist told her that loss of bladder control and cognition were symptoms of MS and ordered an MRI. After viewing whitematter lesions on MRI (MS plaques), her neurologist rendered an MS diagnosis. A cerebrospinal fluid analysis was also performed, which appeared normal. Two years after her diagnosis, she noticed additional symptoms of leg weakness that she described as a “rubbery feeling” and continuous, painful paresthesias (tingling and loss of sensation) in both arms and legs often awakening her at night. In addition, the patient reported suffering from a stiff and achy neck for many years before noticing MS symptoms and demonstrated reduced and painful cervical extension.When questioned about her recollection of any past accidents, falls, head injuries, or whiplashes, the patient recalled a single fall over a decade prior to the onset of MS symptoms. Instead of the typical relapsing- remitting pattern, this patient’s neurologist considered her MS symptoms chronic and progressive, so he recommended drug therapy (Avonex) to slow the progression. Due to her concerns over long-term drug use, this subject chose to undergo upper cervical chiropractic care before beginning drug therapy.

The chiropractic care described below is based upon the original work performed by Palmer from the 1930’s through the 1950’s in the Palmer Research Clinic. [8] The care was administered as taught by the International Upper Cervical Chiropractic Association (IUCCA) through their Applied Upper Cervical Biomechanics (AUCB) program. [18]

After the patient’s medical history was recorded, a paraspinal thermal analysis was performed with the Tytron C-3000 (Figure 1 - Titronics Research and Development) from the level of C7 to the occiput according to thermographic protocol. [19-21] (Figure 2) Paraspinal digital infrared imaging measures cutaneous infrared heat emission and is a form of thermograpy. Thermography is a neurophysiological diagnostic imaging procedure with over 6000 peer-reviewed and indexed papers in the past 20 years. [22-24] Thermography has been established as a practical and sensitive test for spinal nerve root irritation, articular facet syndromes, peripheral nerve injuries, sympathetic pain syndromes, and the vertebral subluxation complex. [22-24] Since the amount of blood passing through the skin is directly controlled by the sympathetic nervous system (through control of dilation or constriction of blood vessels), the temperature of any one area of the skin reflects the neurological control of that area. Normal or abnormal skin temperature then becomes an indicator of normal or abnormal neurological function. In blind studies comparing thermographic results to that of CAT scan, 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. [25-27] 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. [28-37] Compared to established normal values for the cervical spine, the subject’s paraspinal scans contained thermal asymmetries of 0.5ºC (Figure 3). According to cervical thermographic guidelines, thermal asymmetries of 0.5ºC or higher indicate abnormal autonomic regulation or neuropathophysiology. [38-41] In addition to revealing thermal asymmetries, the subject’s scans displayed static thermal differences (Figure 4), thus, a thermal “pattern”was established.“Pattern analysis” of paraspinal temperatures was first developed by Palmer8 and paraspinal thermal analysis and pattern work are receiving increased attention in chiropractic research. [42-53] Pattern work has been used recently in conjunction with upper cervical chiropractic care with Parkinson’s disease, Multiple Sclerosis, fibromyalgia, epilepsy, and asthma. [11-17] Because upper cervical misalignments were suspected in this patient, a precision upper cervical radiographic series was performed. [54] The x-ray equipment included a laser-aligned frame (American X-ray Corporation) to eliminate image distortion.To maintain postural integrity, this subject was placed in a positioning chair using head clamps. In addition, the patient was aligned to the central ray using a laser (Titronics Research and Development) mounted on the x-ray tube.The four views (lateral, anterior-posterior, anterior-posterior open mouth, and base posterior) enabled examination of the upper cervical spine in three dimensions: sagittal, coronal, and transverse. 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 (Figure 5). [55] Right laterality of atlas and axis and right posterior rotation of atlas were found (Figure 6).

The two criteria used to determine subluxation in this case were thermal asymmetry (measured by thermal imaging) and vertebral misalignment (measured by cervical radiographs). Because both criteria (0.5ºC thermal asymmetry and right laterality and right posterior rotation of atlas) were met, a care plan was discussed with the patient. In addition, it was recommended that the subject continue consulting with her neurologist. After the patient consented, upper cervical chiropractic care began with an adjustment to correct the right laterality and posterior rotation of atlas. To administer the adjustment, the patient was placed on a knee-chest table with her head turned to the right (Figure 7).The knee-chest posture was chosen because of the accessibility of the anatomy to be corrected. Using the right posterior arch of atlas as the contact point, an adjusting force was introduced by hand. [55] The adjustment’s force (force = mass X acceleration) was generated using body drop (mass) and a toggle thrust (acceleration).

Then, the patient was placed in a post-adjustment recuperation suite for fifteen minutes as per thermographic protocol (Figure 2). [19-21] After the recuperation period, a post-adjustment thermal scan was performed. The post-adjustment scan revealed a thermal difference of only 0.1 ºC, which was considered normal normal according to established cervical thermographic guidelines (compared to the preadjustment differential of 0.5 ºC). Therefore, resolution of the patient’s presenting thermal asymmetry (elimination of the thermal “pattern”) was achieved (Figures 8 & 9).

All subsequent office visits began with a thermal scan. An adjustment was administered only when the patient’s presenting thermal asymmetry (“pattern”) 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.This subject’s office visits occurred two times per week for the first four weeks of care. After the initial adjustment, two other adjustments were administered during the first month. Visits were reduced to once per week for the second month of care. Adjustments were necessary on two of the four visits. By the third month of care, thermal asymmetry was rarely present, so visits were reduced to once per month.

Within the first week of upper cervical care, this subject reported improved bladder control (resumption of muscular control to begin and end urination) and a decrease in numbness, tingling, and pain in her left leg and right hand. One month later, her leg strength returned (“rubbery feeling” was absent) and numbness was noted only in her left hand. In addition, she reported experiencing normal cognitive ability in that she could formulate words and process complex thoughts. After two months of care, bladder control, sensation, 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 five months after the first showed no new lesions as well as a reduction in intensity of the original lesions.

During the subsequent year, this patient was examined once per month with paraspinal digital infrared imaging. During three of the twelve visits, thermal asymmetry (“pattern”) was present so an adjustment was administered. No MS symptoms reoccurred during the year. A third MRI performed ten months after the second once again showed no new lesions and continued reduction in intensity of the original lesions. The patient’s neurologist considered her case stable, no longer recommended drug treatment, and suggested she be reexamined once per year with MRI.Two years after the first adjustment was administered, the patient remained asymptomatic. During the two-years of upper cervical care, no other intervention was reported that could have provided an alternative explanation for the dramatic improvement of the patient’s condition.


Discussion

An important aspect of this patient’s medical history was her recollection of a fall, which could have caused her upper cervical subluxation. The body of medical literature detailing a possible trauma-induced etiology for MS, or at least a contribution, is substantial. [56-66] Trauma also has been implicated as a cause of other similar degenerative neurological disorders such as Parkinson’s disease and Amyotrophic Lateral Sclerosis. [62-64] When Parkinson’s disease patients were examined with thermal imaging and cervical radiographs, they too showed evidence of upper cervical subluxations and responded favorably to upper cervical chiropractic care. [16, 17]

Recent research has suggested that an alteration of the bloodbrain barrier (BBB) is an obligatory step in the pathogenesis of MS lesions. [58-60] Evidence supports that trauma (in particular mild concussive injury to the head, neck or upper back) impinges on the brain and spinal cord, and may result in an increase in BBB permeability. [58-60] While medical research shows that trauma may lead to MS, 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 this MS patient 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. [70-74] The upper cervical spine is uniquely at risk for this problem because it possesses inherently poor biomechanical stability (lacks intervertebral discs and vertical zygapophyseal joints) 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. [75-81] Because of the close association between the nervous and immune systems (the immune system is commonly classified as the neuroimmune system), [82, 83] upper cervical injuries affecting sympathetic function consequently may cause a cascade of non-favorable immune responses. [84-87] Among these are uncoordinated immune tissue responses (autoimmune responses) and the release of cortisol, which ultimately can result in decreased immune function.

It is possible that this MS patient sustained an injury to her upper cervical spine (visualized on cervical radiographs) during the spinal trauma she experienced. It is also possible that due to the injury, 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 or an increased permeability of the blood-brain barrier. According to the symptomatic improvement and the objective changes via MRI and thermography in the patient discussed in this report, it seems that adjustment of the upper cervical subluxation had a beneficial effect possibly stopping and perhaps even reversing the MS. Similar results occurred in five other MS patients whose upper cervical subluxations were corrected with upper cervical chiropractic care. [11]


Conclusion

This case report details the medical history and symptoms of a 46-year-old female suffering from Multiple Sclerosis; the two-year intervention of upper cervical chiropractic care; and the patient’s symptomatic response.At this patient’s initial evaluation, evidence of an upper cervical subluxation was found using paraspinal digital infrared imaging and upper cervical radiographs. The upper cervical subluxation was corrected by performing a specific adjustment by hand to the first cervical vertebra according to radiographic findings. The patient’s medical history included one possible mechanism (a fall) for her upper cervical subluxation. After four months of upper cervical chiropractic care, all previous symptoms of MS were absent.A follow-up MRI showed no new lesions as well as a reduction in intensity of the original lesions. After a year passed in which the patient remained asymptomatic, another follow-up MRI was performed. Once again, the MRI showed no new lesions and a continued reduction in intensity of the original lesions. Two years after upper cervical chiropractic care began, all MS symptoms remained absent. Further investigation into upper cervical trauma and resulting neuropathophysiology as a possible etiology or contributing factor to Multiple Sclerosis should be pursued.To confirm that this positive outcome could be replicated in additional patients, it is also recommended that a larger study be performed because few conclusions can be drawn from a small number of cases.


Acknowledgements

The author gratefully acknowledges Drs.William Amalu and Louis Tiscareno of the International Upper Cervical Chiropractic Association (IUCCA) for their Applied Upper Cervical Biomechanics (AUCB) Course and the Titronics Corporation for the Tytron C-3000 Paraspinal Digital Thermal scanner.


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