Today’s Chiropractic 1998 (May/June); 27 (3): 16—25
ABSTRACT
The role
of chiropractic in the management of visceral disorders remains clouded
with regards to possible benefits. Observations of one patient presenting
with cortical blindness, cerebral palsy, epilepsy, and recurrent otitis
media are reported. Relief of symptoms is noted subsequent to correction
of biomechanical aberrations of the occipito-atlanto-axial complex. The
author suggests a relationship between biomechanical faults in the upper
cervical spine and the manifestation of abnormal central neurophysiological
processing.
Key Indexing Terms: Upper Cervical
Spine, Epilepsy, Cerebral Palsy, Blindness, Otitis Media, Imaging, Infrared.
INTRODUCTION
The role
of the upper cervical spine in the etiology of visceral conditions remains
controversial. The standard medical etiological paradigm of cortical blindness,
cerebral palsy, and epilepsy is accepted as permanent damage to the cerebral
cortex and/or cerebellum secondary to either anoxia, trauma, perinatal
injuries, disorders of metabolism, space occupying lesions, degenerative
disorders, infectious diseases, or entities unknown (1,2). In the case
of otitis media it is accepted that a bacterial or viral infection is
secondary to prolonged effusion or immune suppression (1,2). Thus, it
can be understood that the contribution of aberrant upper cervical arthrokinematics
has largely been ignored by most, considered to be of no significance
by many, and emphasized by only a few. Even so, the body of literature
detailing a possible upper cervical etiology, or at least contribution,
is substantial; and the case made for greater recognition of the involvement
of the upper cervical spine is compelling.
This article
has three main objectives. The first is to present the clinical picture
of a patient, with a constellation of medically diagnosed conditions,
that has been given almost no hope of improvement. Secondly, the presentation
of a chiropractic evaluation method focusing upon the detection of abnormal
upper cervical biomechanics and neuropathophysiology. And lastly, to detail
the management and outcome of the patient via correction of occipito-atlanto-axial
biomechanics using a specific upper cervical approach which combines specialized
adjusting procedures with objective neurophysiological monitoring.
CASE REPORT
A 5 year
old male was referred to the author with the chief complaint of recurring
middle ear infections at one month intervals. His parents advised that
the patient had also been diagnosed with cortical blindness, cerebral
palsy, epilepsy, and severe brain damage secondary to possible abort SIDS
or viral encephalitis. The patient’s medical records noted an extensive
work up from a team consisting of pediatric neurologists, orthopedists,
ophthalmologists, and internists.
His mother
reported that he had been very healthy with good visual contact, social
interaction, and normal development until an acute illness at three months
of age. Two days following a well-child checkup with an inoculation, the
patient became "colicky" and developed a mild upper respiratory
infection with fever. His mother recalls that he was a little fussy, not
eating, but alert when she put him down for a nap before leaving for work.
About fifteen minutes later, the baby-sitter found him cyanotic, gasping
for air, and nonresponsive. She called 911 and paramedics responded to
the home. In the emergency room he was found to be cyanotic, shocky, and
unresponsive with grunting respirations. He was immediately resuscitated
and given IV antibiotics.
A septic
workup was performed with no evidence of infection. A cranial CT scan
was obtained and found to be grossly abnormal along with cerebral edema.
The results of the scan were noted as compatible with either an ischemic
insult or sepsis. The child was treated and seemed fairly stable until
24 hours later when he began to have seizures. He remained hospitalized
for over 1 1/2 weeks during which time multiple medication combinations
were tried to finally control the seizures. Upon release, he was given
a diagnosis of severe hypoxemic encephalopathy secondary to a possible
near SIDS or viral encephalitis.
Due to the
severity of the seizures, he remained on phenobarbitol for over 1 1/2
years. When finally placed on dylantin, his personality noticeably improved,
but the seizures increased in frequency. Over the next 2 years, examinations
from multiple specialists formed the conclusion that he would never walk,
speak, regain his vision, or progress in school.
At the time
of consultation, the patient had been experiencing otitis media once per
month over the last 9 months with administration of amoxicillin every
month. Myringotomy with tube placement was to be scheduled if the infections
continued to occur. The patient was also having 30 seizures per day in
combinations of grand mal and complex partials. At the time the patient
was seen in our clinic he had been receiving OT and PT three times a week
for over 3 years. He was also enrolled in a special school where he was
taken daily for behavioral therapy.
Upon examination,
the patient presented as non-ambulatory, uncommunicative, and non-responsive
with a constant loud vocal drone and almost constant writhing torsocephalic
motions. His gross motor coordination included reaching out with his hands
and rolling over onto all fours. If held, the patient could support his
weight on both feet and stand momentarily. He kept his thumbs cortically
tucked with occasional fisting and showed no signs of fine motor skills.
Ear, nose, and throat examinations were unremarkable with the exception
of bilateral pretympanic serous effusion noted along with a normal light
reflex.
Orthopedic
examination revealed significant palpatory hypertonicity of the paraspinal
musculature from the occiput to C3 bilaterally. A combination of crying
and arched extension of the spine suggested tenderness in the same areas.
The patient demonstrated a reduction in passive cervical flexion, right
lateral flexion, and right rotation. Overall muscular spasticity was noted
in all extremities. Lumbosacral evaluation was unremarkable.
Figure 1 |
Neurologic evaluation revealed markedly increased DTRs at 4+ along with a
bilateral Babinski’s and 6-8 beats of ankle clonus bilaterally.
Cranial nerves were of note in that he showed no bright light
avoidance, did not visually fixate or follow, and a significant
decrease in direct and consentual pupillary reflexes. A paraspinal
digital infrared imaging analysis was performed from the level of S1
to the occiput in accordance to thermographic protocol (3-5) (Fig.1).
|
A continuous
paraspinal scan consisting of approximately 300 infrared samples was taken
and the data analyzed against established normal values (6-9). The paraspinal
scan was found to contain wide thermal asymmetries indicating abnormal
autonomic regulation or neuropathophysiology (Fig.2 & 3).
Figure 2
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Figure 3
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The
above information lead to suspected abnormal upper cervical arthrokinematics.
A precision upper cervical radiographic series was performed for an accurate
analysis of specific segmental biomechanics (10). Since positioning chairs
and head clamps cannot be used with infants or uncooperative children,
precision alignment of the patient to the central ray was facilitated
with an on-patient laser-optic alignment system (Fig.4 & 5). With
this system any patient can be accurately aligned from the source of the
X-ray beam rather than the bucky.
Figure 4
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Figure 5
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An
analytical radiographic method consisting of mensuration combined with
arthrokinematics was performed (10). Biomechanical abnormalities were
noted at the atlanto-occipital and atlanto-axial articulations.
CHIROPRACTIC MANAGEMENT
Correction
of the atlanto-occipital subluxation was chosen as the first to be adjusted
from the accumulated degree of aberrant biomechanics noted at this level.
Before treatment was rendered, the parents were counseled that they may
expect exacerbations in symptomatology as part of the normal response
to care. Even though a remote possibility, Goodman reported a case in
which seizures had increased to almost 100 per day before subsiding (11).
To correct
the subluxation, the patient was placed on a specially designed knee-chest
table with the posterior arch of atlas as the contact point. An adjusting
force was introduced using a specialized upper cervical adjusting procedure
(12). The patient was then placed in a post-adjustment recuperation suite
for 15 minutes as per thermographic protocol (3-5). The success of the
adjustment was determined from the post-adjustment infrared scan noting
resolution of the patient’s presenting neuropathophysiology (Fig.6
& 7). All subsequent office visits included an initial infrared scan,
and if care was rendered another scan was performed to determine if normal
neurophysiology was restored.
Figure 6
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Figure 7
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The
patient was adjusted twice during the first week of care. After the first
adjustment, the patient’s mother noted that he had his first good
night sleep in weeks. After the second adjustment, the patient’s
seizures reduced dramatically to only 10 per day, his vocal drone became
a quiet intermittent moan, and he began to clap his hands. During the
next week the patient was adjusted only once. His mother noted that he
had become more alert, continued to sleep more soundly, began sitting
up and looking around, responded to sounds by looking toward the source,
and continued with a decrease in seizures to only 5 per day. His consentual
pupillary reflexes returned to normal with some improvement on direct.
He also responded to bright light with closure and appeared to follow.
Almost all of his writhing motions had ceased. An examination of his ears
found them to be clear of effusion.
During the
third and fourth week of care the patient was adjusted three times. The
seizures continued to occur at 5 per day, but all grand mals had ceased.
He was sleeping completely through the nights now. For the first time
in his life he vocalized "dada" and began engaging in echolalia
with vowel sounds. By the end of the fourth week, his therapists suspected
that his vision was suddenly improving. His mother was told that he had
unexpectedly and repeatedly mimicked the answering of a phone by copying
the therapist and holding the receiver to his ear.
A re-examination
of the patient was also performed at this time. There were no signs of
any: vocal drone, writhing motions, occipital myohypertonicity or tenderness,
restricted cervical ranges of motion, or pretympanic effusion. Overall
muscular spasticity was markedly decreased in all extremities. He was
now capable of sitting up on his own and his mother reported that for
the first time he pulled himself up and stood for over one minute. He
began showing fine motor skills this week by grabbing his own pacifier
and placing it in his mouth. The patient’s DTRs had also improved
to 3 along with a decreased bilateral Babinski’s and only 4 beats
of right ankle clonus. The patient now showed avoidance to bright light,
visual fixation and following, and normal direct and consentual pupillary
reflexes. His mother noted that this was his first month free from otitis
media in 9 months. In light of these findings, it was determined that
an objective visual evaluation should be made as soon as possible.
The fifth
week of care was marked by a change in the patient’s response to
treatment. He was adjusted twice, but did not exhibit the resolution of
neuropathophysiology previously demonstrated. He was still having 5 seizures
per day, but only petit-mals. From the information gained in his paraspinal
infrared scans, it was decided to change the adjustment to axis. The post-adjustment
scan noted a resolution of the abnormal thermal emissions and a return
of normal neurophysiology as seen before (Fig.6 &
7). By the end of the fifth week of care the patient was seen by his
neurologist and ophthalmologist. His ophthalmologist noted a drastic improvement
with a recovery of central field vision. The patient’s neurologist
reported that his CP had greatly improved and that he would be requesting
further tests to evaluate his seizure condition.
With a
change in the adjustments to axis, the patient’s response to care
was immediate. His seizures reduced to only 3 per day during the sixth
week of care. Only one adjustment was given during this time. He continued
to improve with increased alertness, vocalization with the addition of
the word "eat", and fine motor coordination with handling toys.
His mother advised that he was now responding to verbal commands with
placing the phone receiver to his ear by saying "hello". The
patient’s follow-up examination with his pediatrician noted that
his ears were normal and that tubes would not be necessary.
Figure 8
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During the time period between the seventh and twelfth week, the patient’s
seizures steadily reduced to the point of staring episodes (Fig.8).
His mother noted
that the patient could be brought out of these episodes by calling
out his name. A re-examination was performed at eight weeks with
noted continued improvement in all his signs of upper motor neuron
dysfunction. There were no outward signs of seizures by the
end of the twelfth week.
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Over the next
10 months, the patient continued to improve. His neurologist slowly reduced
his medication causing his staring episodes to ebade. With further testing,
the patient was eventually classified as non-epileptic and final withdrawal
of all medication was made. He never experienced another episode of otitis
media. His vision improved to the point where he was prescribed glasses.
The patient continued to learn simple words with clear pronunciation of
"dada, mama, eat, and food". His fine motor coordination improved
such that he was learning to feed himself. The patient’s mother noted
that he was also potty training. His gross motor coordination continually
progressed to the point that he was able to walk slowly with the assistance
of holding one hand.
NEUROBIOLOGICAL MECHANISMS
Many theories
have been propounded to explain the effects seen in chiropractic patients.
However, there are two extensively studied neurophysiological mechanisms
which may explain the profound changes in this patient. The first is CNS
facilitation resulting from hyperafferency (13-17). This arises from an
initial trauma causing entrapment of meniscoids, articular hypomobility,
and finally compensatory hypermobility. Consequently, hyperexcitation
of periarticular mechanoreceptors and nociceptors occurs. Over time, this
bombardment of the central nervous system can cause facilitation. Facilitation
results in an exponential rise in the afferent signals to the cord and/or
brain. This may cause a loss of central neural integration at the level
of the cord, brainstem, and/or higher centers. The upper cervical spine
is uniquely suited to this condition as it possesses poor biomechanical
stability and the greatest concentration of spinal mechanoreceptors.
Cerebral
penumbra, or brain cell hibernation, is proposed as the second mechanism
(18-24). It was previously thought that the neuron had two basic states
of existence, function and dysfunction. However, a third state was discovered
which may explain the rapid and profound changes seen in patients. The
neuronal state of hibernation occurs when a certain threshold of ischemia
is reached; the cell remains alive, but ceases to perform its designated
purpose. Entire functional areas of the cerebral cortex or cerebellum
may be affected. The mechanism of hyperafferancy, as mentioned above,
plays an initiating role. Hyperafferant activation of the central regulating
center for sympathetic function in the brain may cause differing levels
of cerebral ischemia. A second route via the superior cervical sympathetic
ganglia, may also cause higher center ischemia.
CONCLUSION
The most
important factor in this case was our ability to objectively monitor the
adjustment’s affects on the patient’s neurophysiology. Many
different types of tests have been used in our profession such as leg
length, cervical challenge, motion and static palpation, and others. However,
these tests lack objectivity, posses inherent errors, and have no literature
confirmation of their ability to monitor neurophysiology (25-28). Infrared
imaging, however, has been researched for over 30 years compiling almost
9,000 peer-reviewed and indexed articles confirming its use as an objective
measure of neurophysiology. This method of nervous system monitoring was
responsible for the adjustment changes seen in this case and the resulting
positive impact on the patient’s physiology. By using this technology,
our clinic has been able to consistently determine the correct adjustive
procedures that produce positive neurophysiological improvements. If the
foundation of our profession stands on the principle that homeostasis
is dependent upon coordinated neurophysiology, then we must strive to
directly monitor this system as an outcome measure to our care.
The role
of the upper cervical spine in the etiology of visceral conditions remains
controversial. In a climate where much of the public see chiropractic
as only a treatment for neck and back pain, patients with complex visceral
disorders are left unaware of the possible benefits of care. The body
of literature detailing a possible upper cervical etiology, or at least
contribution, to visceral disorders is substantial. Further research into
this area of the spine, combined with objective monitoring of the nervous
system, may reveal that chiropractic does indeed offer consistent conservative
management of visceral disorders.
ACKNOWLEDGMENTS
The author would like to gratefully acknowledge the Titronics Corporation for their design of the TyTron C-3000 Paraspinal Digital Infrared Imaging Scanner.
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