Upper Cervical Chiropractic Management of a Patient with Parkinson's Disease: A Case Report
Journal of Manipulative and Physiological Therapeutics
By Erin L. Elster, D.C.
Objective: 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.
Clinical 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.
Intervention 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, thermography
A 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)
PD, 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.
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 become masked.
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.
Palmer 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.
A 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 treatment.
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 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.
The 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
This 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 found.
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.
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, the patient's paraspinal scan contained thermal asymmetries as high as 1.13 ºC. According to cervical thermographic guidelines, thermal asymmetries of 0.5 ºC 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.
Cervical 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 produced pain.
Because 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).
Then, 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 ºC, which was considered normal according to established cervical thermographic guidelines (compared to the pre-adjustment differential of 1.13 ºC). (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.
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 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 was underestimated.
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.
An 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 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 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.
It 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.
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.
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