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ARTICLE

PARKINSON'S DISEASE: IUCCA UPPER CERVICAL CHIROPRACTIC MANAGEMENT OF TEN PARKINSON'S DISEASE PATIENTS

Today's Chiropractic, July-August 2000
By Erin L. Elster, D.C.

INTRODUCTION

One and one half million Americans suffer from Parkinson's disease (PD), more than are afflicted with Multiple Sclerosis and Muscular Dystrophy combined. (1) While PD is generally considered a disease that targets older adults, fifteen percent of patients are diagnosed before age 50. (1)

Parkinson's Disease, a progressive disorder of the central nervous system, results from destruction of the substantia nigra. The substantia nigra's purpose is to signal the basal ganglia (caudate nucleus and putamen) to secrete dopamine. Because dopamine is an inhibitory neurotransmitter, it is thought that the lack of dopamine allows the basal ganglia to send continuous excitatory signals to the corticospinal motor control system. Therefore, it is theorized that overexcitation of the motor cortex (due to lack of inhibition) creates typical Parkinson's symptoms such as rigidity (muscle tone increase) and tremors. (1) Current evidence suggests that PD symptoms appear after there has been an 80 percent loss of the dopamine producing cells in the substantia nigra and a similar loss of dopamine synapses with the basal ganglia. (1)

Parkinson's Disease symptoms often begin with an episodic tremor of the hand on one side of the body. Over time, resting tremors can be accompanied by slowness, stiffness, and lack of arm swing on the affected side. As symptoms progress, impairment may extend to the other side of the body. Due to fine motor deficits, finger and hand movements requiring skilled coordination, such as brushing teeth, buttoning clothes, and handwriting may become slow and difficult. Patients may notice a foot drag on the affected side, a slowed gait, shorter steps, or freezing (inability to start) when initiating movement. Voices can become softer in volume and facial expressions may become masked.

The standard medical treatment for PD has been the administration of the drug Sinemet, which combines Levodopa (a short-acting drug that enters the brain and is converted into dopamine) and Carbidopa (enhances levodopa's action in the brain). Several neurosurgical techniques also exist, including thalamotomy (destruction of ventral thalamus to control tremor), pallidotomy (destruction of posterior ventral globus pallidus to control hyperkinetic symptoms), and deep brain stimulation (electrode implantation for patient-controlled stimulation of thalamus to control tremor). (1) While the medications and surgeries may temporarily control symptoms, neither stops nor reverses the progressive degeneration of the substantia nigra.

B.J. Palmer reported the use of upper cervical chiropractic care with PD patients as early as 1934. (2) In his writings, he referred to patients with "shaking palsy" and listed improvement or correction of symptoms such as "tremor, shaking, muscle cramps, muscle contracture, joint stiffness, fatigue, incoordination, trouble walking, numbness, pain, inability to walk, and muscle weakness." His chiropractic care included paraspinal thermal scanning using a neurocalometer (NCM), a cervical radiographic series to analyze the upper cervical spine, and a specific upper cervical adjustment performed by hand. No other references for the chiropractic management of PD patients were found. To the author's knowledge, this is the first documented study of this topic since B.J. Palmer's research seventy years ago. This study was designed to investigate the effectiveness of modern upper cervical chiropractic aided by paraspinal digital infrared imaging and specific cervical radiographs in ten Parkinson's Disease cases. It was hypothesized that upper cervical care would normalize patients' neurophysiology as measured by thermal imaging and therefore would stimulate an improvement and/or reversal in their Parkinson's symptoms and an improvement overall in their health.

To locate the study participants, Parkinson's disease support groups were contacted. From the interested volunteers, ten subjects were chosen to achieve the largest range in age, severity, and duration of symptoms. The ten individuals selected suffered from Parkinson's disease for two to twenty years, ranged from 47 to 76 years of age, and had symptoms varying from mild to severe. All patients had been diagnosed with PD by their neurologist and were concurrently undergoing treatment with Parkinson's medications. All participants were asked not to change medication dosages or to undergo any other forms of treatment during the three-month chiropractic intervention period. The following report depicts one patient's case in detail. The nine other participants' results are summarized.

CASE 1

A 60-year-old male first experienced Parkinson's disease symptoms seven years earlier at age 53 when his left pinky finger began to twitch. His neurologist diagnosed Parkinson's disease and prescribed medications including Sinemet, Eldepryl, and Mirapex. Every six months, his neurologist monitored his condition and increased medication dosages as his condition worsened. Three years after the diagnosis, this subject's left leg became rigid, causing walking difficulty. Most of the progression of Parkinson's disease symptoms occurred in the last eighteen months prior to upper cervical chiropractic care.

Parkinson's symptoms were evaluated by doctor's observation, patient's subjective description of symptoms, and use of the Unified Parkinson's Disease Rating Scale (UPDRS). (3) The UPDRS classified 44 individual Parkinson's symptoms on a scale of zero to four. The 44 symptoms were rated during "on" and "off" stages of medication use, as directed by the scale's authors. An "on" stage occurred when medications temporarily decreased or masked Parkinson's symptoms. During an "off" stage, medications lost their effectiveness, so the true symptoms of the patient were exhibited.

This patient took multiple medication dosages per day in an attempt to reduce the frequency and severity of "off" periods. This patient's UPDRS entrance symptoms, such as tremor, rigidity, and depression are illustrated in Table 1. Each symptom was rated from zero to four according to disability level. A score of zero indicated absence of the symptom, whereas four represented complete disability. The authors of the scale developed specific rating criteria for each symptom. For example, when evaluating falling using the rating scale, zero indicated none, one denoted rare falls, two signified less than one fall per day, three represented one fall per day, and four indicated more than one fall per day. Thus, if a patient were completely disabled in all symptom categories, he/she would score a four in each of the 44 categories, producing a total of 176 (44 x 4).

This patient's initial UPDRS evaluation was 32 during on stages and 74 during off stages. This is depicted as 32/74. (Tables 1,4) His most severe symptoms included memory loss, depression, loss of motivation, slurred speech, illegible handwriting, tremor and rigidity in his left extremities, and difficulty arising from a chair. In addition to the symptoms rated by the UPDRS, this subject also complained of extreme fatigue, insomnia, and pain throughout his spine. The absence of such symptoms from the UPDRS reduced its effectiveness as a comparative tool but it was the most comprehensive scale found.

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 over the past 20 years. In many 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. (4-6) 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. (7-16)


At this 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. (17-19) Compared to established normal values for the cervical spine, this subject's paraspinal scan contained thermal asymmetries as high as 1.13 ēC. According to cervical thermographic guidelines, thermal asymmetries of 0.5 ēC or higher indicate abnormal autonomic regulation or neuropathophysiology. (20-23)
 

At this 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. (17-19) Compared to established normal values for the cervical spine, this subject's paraspinal scan contained thermal asymmetries as high as 1.13 ēC. According to cervical thermographic guidelines, thermal asymmetries of 0.5 ēC or higher indicate abnormal autonomic regulation or neuropathophysiology. (20-23)
   Because upper cervical misalignments were suspected, a precision upper cervical radiographic series, including Lateral, A-P, A-P Open Mouth, and Base Posterior views, was performed. (24) These four views enabled examination of the upper cervical spine in three dimensions: sagittal, coronal, and transverse. To maintain postural integrity, the 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. (24) Right laterality of atlas was found.

 

All subsequent office visits 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.

This participant's office visits occurred three times per week for the first two weeks of care. After the first adjustment, subsequent adjustments were administered on visits two, four, and six. By the end of the second week of care, the subject reported greater range of motion in his neck, improved sleep, better energy, and decreased stiffness in his body overall.

During weeks three and four of care, visits were reduced to twice per week and only one adjustment was administered during that time. A reevaluation occurred at the end of week four. Cervical and lumbar ranges of motion no longer produced pain. Cervical compression tests were negative. The UPDRS reevaluation revealed a reduction in symptoms to 20/56 during on/off stages. (Table 1) The patient reported that his most noticeable improvements included improved sleep and increased energy. He was more alert and no longer felt tired or depressed. He had improved range of motion in his neck, better balance, improved hand and leg agility, and less rigidity overall. His left leg no longer dragged and his walking improved. He routinely reported "feeling great." Mental clarity, handwriting, turning in bed, and arising from a chair also improved.

During the next eight weeks of care, the patient was seen once per week and received an adjustment on two out of the eight visits. At week twelve, a final UPDRS reevaluation occurred, which revealed another reduction in Parkinson's symptoms to 13/47 during on/off stages. (Table 1) During the third month of care, the subject reported that his greatest improvement was the return of his balance, which enabled him to resume riding a bike. He also noted that his wife, daughter, son, friends, and neighbors all noticed a marked improvement in his physical and mental health.

According to a comparison between beginning and final UPDRS evaluations, this patient showed an overall improvement of 43 percent after the third month of care. (Table 4) To calculate the percentage, the total of the final evaluation (13+47=60) was subtracted from the initial evaluation (32+74=106), producing a difference of 46. This reduction of 46 points was divided by the original total of 106, yielding a 43 percent improvement. While the UPDRS was helpful in evaluating specific Parkinson's symptoms, it did not take into consideration other associated symptoms, such as spinal pain, insomnia, and fatigue. Thus, the scale underestimated both the patient's severity of symptoms at the beginning of care as well as his improvement after care. As a result, this patient's overall percentage improvement after three months of chiropractic care was underestimated.

At the completion of the three-month study period, this patient chose to continue with chiropractic care. Due to his spine's stability after three months of care, this subject's treatment plan was reduced to one visit per month for the next six months. Adjustments were necessary on two visits. Over the six-month period, the patient reported maintenance of his previous improvements and no deterioration of his condition. He also reported a continued gradual increase in energy level and strength in his body, as well as a continued reduction in muscle and joint stiffness. Consequently, between months eight and nine, he enlisted a personal trainer's help and began an exercise program including cardiovascular and weight training three times per week. At the time of this paper's submission for publication, this patient had undergone nine months of upper cervical chiropractic care and intended to continue his maintenance treatment plan of one visit per month.

The nine remaining Parkinson's patients underwent the same chiropractic care described previously, including cervical radiographic analysis, paraspinal digital infrared imaging, and knee-chest adjustments. Computerized scans showed thermal asymmetries in all patients. In addition, cervical radiographs showed upper cervical misalignments in all subjects. Each patient's age, gender, x-ray listing, duration of symptoms, and initial symptoms are listed in Table 2. Atlas listings are depicted with laterality of left (L) or right (R) and rotation of anterior (A) or posterior (P). The lateral movement of axis is listed to the left (ESL) or right (ESR). All subjects underwent upper cervical chiropractic care for a minimum of three months. The nine patients' histories and outcomes are summarized below.

CASE 2

History: At age 43, this 63-year-old male noticed increasing stiffness in his neck, a head twitch, and a tremor in his right hand. At the start of upper cervical care, his most severe symptoms included rigidity in his neck, back, right arm, and right leg and tremor in his right hand and foot. He also had a stooped posture, a masked facial expression, decreased agility in his right hand, and illegible handwriting. Computerized thermal imaging showed thermal asymmetries up to 0.5ēC. Analysis of cervical radiographs revealed left laterality and left anterior rotation of atlas.

Outcome: After three months of chiropractic care, this patient's main areas of improvement were in spinal range of motion, flexibility, and posture. He reported improved motion, especially in his neck, and the ability to stand up straighter. He was able to take long walks without stooping over or feeling pain. In addition, he was able to stay on his feet and accomplish more during the day without spinal pain or feeling tired. He also reported improved facial expression, decreased rigidity, and improved ability to get up out of bed, to walk, and to arise from a chair.

CASE 3

History: This 47-year-old male first experienced neck and back pain in high school. At age 37, his right hand began to tremor. Before upper cervical care, his symptoms reported were intellectual impairment, depression, loss of motivation and facial expression, slurred speech, illegible handwriting, difficulty walking, dressing, arising from a chair, and turning in bed, frequent falling and freezing, tremor in his right hand and foot, rigidity in his neck, right hand, and foot, stooped posture, and bradykinesia. Computerized thermal imaging showed thermal asymmetries as high as 0.8ēC. Analysis of cervical radiographs revealed right laterality of atlas.

Outcome: After upper cervical care, this patient resumed playing eighteen holes of golf-walking and carrying his clubs the entire distance which he had not been able to do in seven years. He reported significantly improved neck range of motion and decreased neck and low back pain. His right arm improved overall due to decreased numbness, better arm swing, and reduction of severity and frequency of tremor in his right hand. He had fewer cramps in his right leg and foot and less "off" periods overall. He also reported improved mood, more motivation, more facial expression, improved turning in bed, no falling, better walking and arising from a chair, less rigidity in his legs, improved posture, and better movement overall.

CASE 4

History: This 61-year-old male first noticed a tremor in his left hand and foot at age 59. At the start of care, his symptoms included an increase in salivation, difficulty dressing, difficulty walking, tremor in his left hand and foot, and difficulty with his left hand and leg agility. He also described his neck and spine to be stiff and rigid ninety percent of the time over the past two years. Computerized thermal imaging showed thermal asymmetries up to 0.5ēC. Analysis of cervical radiographs revealed left laterality and left posterior rotation of atlas.

Outcome: After upper cervical care, this subject reported a dramatic increase in physical strength, energy level, agility, balance, and endurance. He was more mentally alert. He could ski an entire day where he previously had to stop by noon. He also noticed increased mobility in his spine because he could bend down to fasten his ski boots, which was previously impossible. Most importantly, he reported that the majority of his symptoms including tremor had been corrected and that he felt essentially "normal" other than slight weakness in his left arm and leg.

CASE 5

History: This 53-year-old female experienced her first Parkinson's disease symptoms at 33 years of age. She considered her Parkinson's progression to be slow because she still was able to function after twenty years of the condition but used high doses of medications to do so. She experienced frequent and severe "off" periods of dystonia (abnormal muscle tone) where her head seized to the left and her pelvis turned right. She often would remain frozen in that state, bedridden and in severe pain, for several hours. She rated her Parkinson's symptoms as "severe" rendering her bedridden and non-functional. Although the medications reduced her suffering, she still was plagued with dyskinesias (involuntary movements) 75 to 100 percent of the day. She also complained of neck pain, numbness in her left hand and arm, pressure at the base of her skull, and low back pain. Computerized thermal imaging showed up to 0.6ēC thermal asymmetries. Analysis of cervical radiographs revealed left laterality of atlas.

Outcome: After upper cervical care, this patient reported decreased numbness, spinal pain and head pressure, and increased energy. Her most marked improvement was in the decreased frequency and severity of "off" periods. Previously an episode of dystonia lasted for several hours, while after care it lasted for 30 minutes or less. She felt well enough to drive again and enjoyed her renewed independence. In addition, she rated her Parkinson's symptoms as "moderate and still functional," and the occurrence of dyskinesias dropped to 25 percent of the day.

CASE 6

History: This 66-year-old female noticed the onset of Parkinson's symptoms, including rigidity, jerky movements, and loss of hand coordination, at 58 years of age. Other health complaints included neck pain, hand numbness, low back pain, and sciatica. During her initial evaluation, her most severe Parkinson's symptoms included loss of motivation, poor handwriting, difficulty swallowing, slurred speech, difficulty turning in bed, loss of facial expression, rigidity in her neck, arms, and legs, and bradykinesia. Computerized thermal imaging showed thermal asymmetries as high as 0.9ēC. Analysis of cervical radiographs revealed left laterality of axis.

Outcome: After upper cervical care, this subject reported complete correction of neck pain, substantial reduction in rigidity, and a decrease in low back pain and sciatica. She also reported improved ability to turn in bed, improved flexibility in her neck, arms, and legs, and improved movement overall.

CASE 7

History: This 76-year-old male first noticed his left foot dragging at age 72. He also experienced pain in his left hip and underwent surgery on his lumbar spine one year later. He reported that the pain became more severe after surgery and consequently he had to take daily prescription pain medication. The combination of his dragging left leg and his right hip pain made walking and arising from a chair difficult. He also reported a stooped posture, neck pain, and difficulty with speech, handwriting, and swallowing. Computerized thermal imaging showed 0.7ēC thermal asymmetries. Analysis of cervical radiographs revealed right laterality of atlas.

Outcome: After upper cervical care, this patient had increased energy and accomplished more during the day. His hip pain decreased, substantially reducing his need for pain medication and he was better able to arise from a chair. He also reported improved neck range of motion, posture, and balance.

CASE 8

History: This 49-year-old male first noticed shaking of his right hand and loss of fine motor control while writing and buttoning his shirt at age 37. During the past two years, his Parkinson's symptoms progressed so that a marked difference existed between "on" and "off" periods of medication use. He also suffered from insomnia and low back pain. Computerized thermal imaging showed 0.5ēC thermal asymmetries. Analysis of cervical radiographs revealed right laterality of axis.

Outcome: After upper cervical care, he noticed improved sleep and a reduction in low back pain to almost none. In addition, he reported feeling better during "on" periods including fewer symptoms, better energy and better balance.

CASES 9 AND 10

Both of these patients were males over 65 with approximately eight-year histories of Parkinson's disease. Computerized thermal imaging showed thermal asymmetries up to 0.5ēC in both subjects. Analysis of cervical radiographs revealed left laterality of axis in one case and right laterality of axis in the other. Neither subject improved.

RESULTS

Three-month reevaluations revealed a substantial improvement in subjective and objective findings in six out of the total ten patients, and a mild improvement in two patients. (Tables 3-4) The final two patients, both over age 65, remained unchanged. Each of the eight improved patients noticed improvements within the first thirty days of chiropractic care, reported an increase in energy level and/or sleep, and showed a decrease in spinal pain and/or rigidity. Five patients had better balance, more upright posture, more fluid walking, improved hand agility, clearer speech, improved facial expression, better strength to arise from a chair, and improved ability to turn in bed. Three out of eight also reported more legible handwriting, decreased tremors, improved leg agility, and less frequent falling and freezing. According to the UPDRS, six out of ten patients showed overall improvement ranging from 21 to 43 percent after three months of upper cervical chiropractic care. (Table 4)

DISCUSSION

An important parallel in the Parkinson's patients' medical histories was their recollection of head and/or neck trauma(s) prior to the onset of Parkinson's disease. Nine out of ten patients recalled specific incidences of trauma preceding the onset of Parkinson's symptoms. Examples included a concussion from a football tackle, whiplash from an auto accident, and being rendered unconscious from a fall while skiing. The body of medical literature detailing a possible trauma-induced etiology for PD, or at least a contribution, is substantial. (26-31) In fact, medical research has established a connection between spinal trauma and numerous neurological conditions besides PD, including Multiple Sclerosis (MS), epilepsy, migraine headaches, vertigo, amyotrophic lateral sclerosis (ALS), and attention deficit/ hyperactivity disorder (ADHD), to name a few. (32-38) While medical research shows that trauma may lead to PD 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 two theories seems most likely to explain the profound changes seen in these Parkinson's patients due to upper cervical chiropractic care. The first mechanism, central nervous system (CNS) facilitation, can occur from an increase in afferent signals to the spinal cord and/or brain coming from articular mechanoreceptors after a spinal injury. (39-43) 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 the second mechanism, cerebral penumbra or brain hibernation. (44-50) According to this theory, a neuron can exist in a state of hibernation when a certain threshold of ischemia is reached. This ischemia level (not severe enough to cause cell death) allows the cell to remain alive, but it ceases to perform its designated purpose. The brain cell may remain in a hibernation state indefinitely with the potential for resuming function if normal blood flow is restored. If the degree of ischemia increases, the number of functioning cerebral cells decreases and the disability worsens. It is likely that these Parkinson's 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. If blood supply to these patients' substantial nigra cells was compromised, it is possible that a certain percentage of those cells were existing in a state of hibernation, rather than cell death.

Therefore, the combination of theories suggests that when blood supply was restored to the hibernating substantial nigra cells (from upper cervical chiropractic care), the cells resumed their dopaminergic (dopamine-secreting nerve fibers) function. 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 This study revealed the successful outcome of Parkinson's disease patients managed with upper cervical chiropractic care. Upon initial examination of the ten patients, computerized paraspinal thermal imaging revealed thermal asymmetries in all ten subjects. In addition, radiographs depicted upper cervical misalignments in all ten participants. Nine out of ten patients recalled experiencing head or neck trauma(s) prior to the onset of Parkinson's symptoms. After a minimum of three months of upper cervical chiropractic care, eight out of ten cases reviewed showed improvements in Parkinson's disease and associated symptoms. To the author's knowledge, these are the first cases reported on this topic since BJ Palmer's research seventy years ago. Further investigation into upper cervical injury and resulting neuropathophysiology as a possible etiology or contributing factor to Parkinson's disease should be pursued.

ACKNOWLEDGMENTS

The author gratefully acknowledges Drs. William Amalu and Louis Tiscareno for their Applied Upper Cervical Biomechanics Course and the Titronics Corporation for the Tytron C-3000 Paraspinal Digital Thermal scanner.

Table 1: United Parkinson's Disease Rating Scale (UPDRS), Case 1

Table 2: Age, Sex Duration of Parkinson's Symptoms, X-ray Listing, and Initial Symptoms for Ten Patients

Table 3: Improved Symptoms after Three Months of Chiropractic Care ˇ

Table 4: Unified Parkinson's Disease Rating Scale: Cases 1 through 10

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