To discuss the use of IUCCA upper cervical
chiropractic care in managing a single patient
with Parkinson's disease and to describe
the clinical picture of the disease.
Features: A 60-year-old man was diagnosed
with Parkinson's disease at age 53 after
a twitch developed in his left fifth finger.
He later developed rigidity in his left
leg, body tremor, slurring of speech, and
memory loss among other findings.
and Outcome: This subject was managed with
IUCCA upper cervical chiropractic care for
nine months. Analysis of precision upper
cervical radiographs determined upper cervical
misalignment. Neurophysiology was monitored
with paraspinal digital infrared imaging.
This patient was placed on a specially designed
knee-chest table for adjustment, which was
delivered by hand to the first cervical
vertebrae according to radiographic findings.
Evaluation of Parkinson's symptoms occurred
by doctor's observation, the patient's subjective
description of symptoms, and use of the
Unified Parkinson's Disease Rating Scale.
Reevaluations demonstrated a marked improvement
in both subjective and objective findings.
Conclusion: IUCCA upper cervical chiropractic
care aided by cervical radiographs and thermal
imaging had a successful outcome for a patient
with Parkinson's disease. Further investigation
into upper cervical injury as a contributing
factor to Parkinson's disease should be
pursued. Key Words: upper cervical spine,
chiropractic, Parkinson's disease, trauma,
total of 1.5 million Americans have 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, 15
percent of patients are diagnosed before
age 50. (1)
a progressive disorder of the central nervous
system, results from destruction of the
substantia nigra. The substantia nigra signals
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, 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)
Diagnosis of PD occurs through patient history
and neurological exam and is best determined
by a physician specializing in movement
disorders. No definitive laboratory test
exists to diagnose or predict PD.
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. Because of 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
may lose volume and facial expressions may
The standard medical treatment for PD has
been the administration of a combination
of 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) Although
the medications and surgeries may temporarily
control symptoms, they neither stop nor
reverse the progressive degeneration of
the substantia nigra.
reported treatment of PD patients with upper
cervical chiropractic care 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 treatment
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 on a knee-chest table.
No other reference for the chiropractic
management of PD was found. To the author's
knowledge, this is the first report on this
topic in recent decades.
60-year-old man first experienced Parkinson's
disease symptoms at age 53 when his left
fifth finger began to twitch. His neurologist
diagnosed the patient with PD 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 patient's
left leg became rigid, causing difficulty
with walking. Most of the progression of
PD symptoms occurred in the last eighteen
months before upper cervical chiropractic
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 was
chosen over the Hoehn/Yahr and Schwab/England
scales because the latter two provided only
five and ten staging categories, respectively.
Conversely, the UPDRS classified 44 individual
Parkinson's symptoms on a scale of zero
to four, allowing for more detailed symptom
comparisons during treatment. 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.
UPDRS entrance symptoms of the patient,
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).
Table 1: United Parkinson's Disease Rating
Scale (UPDRS), Case 1
patient's initial UPDRS evaluation was 32
during on stages and 74 during off stages,
which is depicted as 32/74. (Table 1) 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
Paraspinal digital infrared imaging, which
measures cutaneous infrared heat emission,
was chosen as the diagnostic test for neurophysiology.
Thermography has been shown to be valid
as a neurophysiological diagnostic imaging
procedure with over 6000 peer-reviewed and
indexed papers over the past 20-year period.
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) This is
the first case reporting use of thermal
imaging with a patient with PD.
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, the patient'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
range of motion testing revealed pain on
left lateral bending and left rotation.
Left lateral flexion compression was positive.
In this patient's lumbar spine, flexion,
right rotation, and left lateral flexion
the two criteria determining subluxation
(thermal asymmetry and vertebral misalignment)
were met, a treatment plan was discussed
with the patient. After the subject consented,
treatment began with an adjustment to correct
the right laterality of atlas. To administer
the adjustment, the patient was placed on
a knee-chest table with his head turned
to the right. 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 right posterior arch of atlas as the
contact point, an adjusting force was introduced
by hand. (25) The adjustment's force (force
= mass X acceleration) was generated using
body drop (mass) and a toggle thrust (acceleration).
the patient was placed in a post-adjustment
recuperation suite for fifteen minutes as
per thermographic protocol. (17-19) The
adjustment's success was determined by reviewing
the post-adjustment thermal scan. The first
post-adjustment scan revealed a thermal
difference of only 0.1 ēC, which was considered
normal according to established cervical
thermographic guidelines (compared to the
pre-adjustment differential of 1.13 ēC).
(20-23) Therefore, resolution of the patient's
presenting thermal asymmetry was achieved.
All subsequent treatment 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 treatment 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.
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 2) 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 treatment
as well as his improvement after treatment.
As a result, this patient's overall percentage
improvement after three months of treatment
Because of 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 writing, he had undergone nine months
of upper cervical chiropractic care and
intended to continue his maintenance treatment
plan of one visit per month.
important aspect of this patient's medical
history was his recollection of head and/or
neck trauma(s) prior to the onset of PD.
He recalled six specific incidences of trauma
preceding the onset of Parkinson's symptoms.
Examples included two concussions while
playing football, twice hitting his head
against a windshield during a helicopter
crash and an auto accident, a sledding accident
in which his legs were paralyzed for 24
hours, and a riding accident in which he
was thrown from a horse. 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 but not
limited to Multiple Sclerosis (MS), epilepsy,
migraine headaches, vertigo, amyotrophic
lateral sclerosis (ALS), and attention deficit/
hyperactivity disorder (ADHD). (22-28) 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
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 this Parkinson's patient 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.
is likely that this Parkinson's patient
sustained an injury to his upper cervical
spine (visualized on cervical radiographs)
during one or more of the traumas he experienced.
It is also likely that due to the injury,
through the mechanisms described previously,
sympathetic malfunction occurred (measured
by paraspinal digital infrared imaging),
possibly causing a decrease in cerebral
blood flow. If blood supply to this patient's
substantial nigra 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 single case. Indeed, this patient was
treated with upper cervical chiropractic
along with nine other patients with PD during
a three-month period. Therefore, further
research is recommended to study the links
among trauma, the upper cervical spine,
and neurological disease.
This case study reveals a successful outcome
of a patient suffering from PD treated with
IUCCA upper cervical chiropractic care.
To the author's knowledge, this is the first
case reported on this topic since Palmer's
research seventy years ago. (2) No firm
conclusion can be obtained from the results
of one case, although it does suggest that
IUCCA upper cervical chiropractic care may
provide benefit for Parkinson's disease
patients when an upper cervical injury is
found. Further investigation into upper
cervical injury and resulting neuropathophysiology
as a possible etiology or contributing factor
to Parkinson's disease should be pursued.
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.
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