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spacer Case Discussions shared with permission spacer Best of Bristol Chiropractors
 
Below are listed just a few of my cases, in an informal report format. It is not my intention to construct a reproducible phenomenon, these are just simply reports - accounts of various patient's improvement in my office.
 
Or in the case of information compiled by others, I am passing this information on to you as education as a member of the public, for a description of a case or for your further education & research.
 
The names are omitted to protect the confidentiality of patient circumstances from any third party, but are completely verifiable and shared with the patient's express permission.
 
Contact me if you have further questions or would like to discuss how we may help you or a family member or friend or associate.
 
A Case of a Chiropractic Patient with Resting Tremor Concomitant with Low Back Pain.
Leah Remeika-Dugan, BSc, DC, MCC, IDE
 
This 68 year old man presented to our clinic in June 2009, complaining of low back pain when walking and general overall resting tremor.
 
I examined the gentleman to discover that he suffered from low back tenderness, a moderate to marked resting tremor on a scale of 3-4/5 where 5 is the worst. He had a postive Rhomberg's test along with several misalignments in his spine at L3-4-5, T8, C1-6
 
I adjusted his lumbar, thoracic, and cervical spine. Following his first three treatments, his resting tremor diminished to 1/5 and is now only mildly visible on examination and his low back pain diminished to 1/5. He has had one mild recurrence of tremor rated at 2/5, which again diminished to 1/5 after his adjustment where it has remained to this day.
 
He continues to come in for a series of corrective adjustments and reports that he can now walk much faster, lighter and pain free.
 
References:
1. J Can Chiropractic Assoc. 2008 August; 52(3): 185.192. Parkinson's disease without tremor masquerading as mechanical back pain; a case report. Robert R. Burton, BSc, DC, FCCRS(C)*
2. Jensen TW. Vertebrobasilar ischemia and spinal manipulation. J Manipulative Physiological Therapuetics 2003;26:443-7.
 
To repeat: It is not my intention to construct a reproducible phenomenon, these are just simply reports - accounts of various patient's improvement in my office.
 
A Case of a 42 Year Old Chiropractic Patient Suffering From Loss of Concentration, Neck Pain and Headache, and Low Back Pain, following a Head Injury.
Leah Remeika-Dugan, BSc, DC, MCC, IDE
 
This patient presented to us in Summer 2009, complaining of a loss of concentration, neck pain, seizures, Left temporal lobe numbness, bilateral hand tingling, frontal headache, and low back pain following a head injury he sustained in a fall from a step ladder, which resulted in a head injury such that his left frontal bone of his skull was openly fractured.
 
I examined the gentleman to discover that he suffered from diminished accommodation in extra ocular movements, and had a +5/5 jump response to palpation of his cervical spine (neck) on the left, as well as tenderness on the right cervical spine near the occiput. As well he suffered from palpatory tenderness in the lumbar spine on both sides. As well as the above, the gentleman also presented with a dull affect.
 
I adjusted his cervical, thoracic, and lumbar spine with modified Gonstead chiropractic technique on a regular basis, and monitored his condition and progress on a weekly basis.
 
The patient and his family reported after the first phase of treatment that "they have their husband and father back", in that his affect and disposition are returned to normal and that he has not suffered from any more seizures. The patient also reported that his low back pain has disappeared completely.
 
References:
1. J Manipulative Physiol Ther 1998 (Jul); 21 (6): 410-418. Alcantara J, Heschong R, Plaugher G, Alcantara J. Palmer Center for Chiropractic Research, Palmer College of Chiropractic-West, San Jose, CA 95134, USA.
2. Journal of Clinical Chiropractic Pediatrics Vol. 1 No. 1 Jan 1996 Chiropractic Adjustments and the reduction of petit mal seizures in a five-year-old make: a case study. Hyman CA.
 
To repeat: It is not my intention to construct a reproducible phenomenon, these are just simply reports - accounts of various patient's improvement in my office.
 
A Case of a 7 Year Old Chiropractic Patient Suffering From Abdominal Migraine.
Leah Remeika-Dugan, BSc, DC, MCC, IDE
 
This young patient presented to our clinic in February 2000, whose parents complained of constant, unexplained crying and pulling the bed sheets over her head, saying "I have a tummy ache". The child's stomach was protruding out slightly and she said it hurt.
 
I examined the child to discover that she suffered from mild to moderate abdominal tenderness of unknown aetiology. There were no bruits, no exquisite point tenderness, and she had normal bowel sounds.
 
Musculoskeletal examination revealed several misalignments in her cervical spine which I believed, after careful examination, may be causing her an unusual presentation of migraine headache as a stomachache.
 
I adjusted her cervical and lumbar spine with a gentle modified Gonstead Chiropractic Technique and I had her drink some water afterward. The next day she was no longer suffering from disturbed or painful sleep and her stomach pains disappeared.
 
She initially had been prescribed Amytriptyline, an antidepressant which is sometimes prescribed to patients as a last resort for Migraine, when no other solution can be found. After several treatments her mother spoke to her GP and she discontinued the medication as she no longer required it, and was symptom free.
 
She continued to come in for a series of corrective treatments and then periodically for wellness check-ups and adjustments and both the child and parents reported they were grateful that they no longer had to suffer through sleepless and painful nights.
 
References:
1. Nelson CF, Bronfort G, Evans R, Boline P, Goldsmith C, Anderson AV (1998). "The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for the prophylaxis of migraine headache.". Journal of Manipulative and Physiological Therapeutics 21(8) page=511-9.
2. Bronfort G, Nilsson N, Haas M, Evans R, Goldsmith CH, Assendelft WJ, Bouter LM (2004). Non-invasive physical treatments for chronic/recurrent headache. Cochrane Database Syst Rev. 3.
 
To repeat: It is not my intention to construct a reproducible phenomenon, these are just simply reports - accounts of various patient's improvement in my office.
 
A Case of a Newborn Infant with a lack of enthusiasm for feeding, and with concomitant vertebral chiropractic joint dysfunction, asymmetrical tonic neck reflex, poor reflex for suckling and rooting, and an absent Galant reflex.
Leah Remeika-Dugan, BSc, DC, MCC, IDE
 
This case involved the chiropractic management of a 10 day old infant female patient, who presented to our clinic in July of 2009. The parents complained of the lack of enthusiasm that the infant had for feeding.
 
The baby was tested for primitive reflexes including grasping reflex, stepping/walking reflex, Galant reflex, tonic neck reflex, plantar reflex, Babinski reflex, and morrow reflex. There was an absent Galant reflex at first exam, an asymmetrical tonic neck reflex, and absent suckling and rooting reflexes on the left. The infant also resisted left active rotation of the head and was rather lethargic.
 
Following the initial exam, the infant received gentle chiropractic activator adjustments to the right upper cervical spine, to the mid thoracic spine and the pelvis.
 
The tonic neck reflex and suckling and rooting reflexes were tested again at the first visit following the initial adjustment, and the reflexes were improved, additionally the baby would now actively rotate the head to the left which was induced with stroking of the left cheek for rooting reflex, which had also returned following the adjustment.
 
The parents reported improved feeding later that week, and at the two follow up visits in the same month the reflexes remained normal and intact and the infant showed improved thriving and alertness as well as weight gain.
 
References:
1. Resolution of suckling intolerance in 6 month old chiropractic patient. Holtrop DP. J Manipulative Physiol Ther 2000 Nov-Dec;23 ( 9):615-618
2. Chiropractic care for infants with dysfunctional nursing: a case series. Hewitt, EG, Journal of Clinical Chiropractic Pediatrics, Vol. 4, No. 1, 1999.
3. Case study: infant's inability to breast-feed. Krauss, L. Chiropractic Pediatrics Vol 1 No. 3 Dec. 1994.
 
To repeat: It is not my intention to construct a reproducible phenomenon, these are just simply reports - accounts of various patient's improvement in my office.
 
A Case of a Chiropractic Patient with Dizziness concomitant with chiropractic joint dysfunction.
Leah Remeika-Dugan, BSc, DC, MCC, IDE
(a further discussion of the dizzy patient as a topic is at the bottom of this section of the website)
 
"The role of the spinal column in the maintenance of balance is usually underrated. It is important to remember that under normal conditions the labyrinth is not necessary for the maintenance of equilibrium." K Lewit. Manipulative Therapy in Rehabilitation of the Locomotor System.
 
This case involved the chiropractic management of an adult male patient, who came to my office by self-referral in April 2000, complaining of unexplained dizziness following a negative MRI with no clinically significant findings. Further medical studies were carried out before and during the course of his chiropractic care in my office, which all were negative.
 
Upon presentation of this patient to my clinic he rated his dizziness at VAS = 5/5 (worst possible). His history revealed that he carried out a flip over an obstacle whilst on his push bicycle which resulted in him landing on his neck as a child. Radiological studies for his cervical spine (neck) were negative. My examination revealed multiple segmental joint restrictions in his cervical, thoracic, and lumbar spine. The patient was initially treated 12 times over a period of 5 weeks, resulting in a decrease of his dizzy symptoms both subjectively from an initial VAS=5/5 to a VAS=2-3/5, and objectively his performance on a Rhomberg's test was improved.
 
He continued to receive chiropractic care as needed to support his improved function and reported that his dizzy symptoms had resolved to only occasional 1-2 episodes at VAS= 1/5 monthly.
 
*For a further discussion of dizziness and the lack of attention focused in the cervical spine input into maintenance of balance, see the discussion at the bottom of this section.
 
To repeat: It is not my intention to construct a reproducible phenomenon, these are just simply reports - accounts of various patient's improvement in my office.
 
A Case of a Female Patient Complaining of Low Back Pain and the Inability to Conceive.
Leah Remeika-Dugan, BSc, DC, MCC, IDE
 
This patient presented to our clinic in August of 2001, complaining of low back pain, +4/5 and also incidentally mentioned an inability to conceive.
 
I examined the lady to discover that she suffered low back tenderness between L2 . L5 and associated spinal segmental dysfunction at those same levels, as well as chiropractic joint dysfunction in her upper cervical spine C0 to C2 and in her thoracic spine at T4.
 
She was adjusted once weekly for 4 weeks and then once a fortnight for the following 4 visits, then once per month. She continued with regular periodic adjustments, then coincidentally reported that she was finally able to conceive 23 months after beginning chiropractic care and later gave birth to a healthy daughter.
 
This report when combined with other reported chiropractic cases encourage further investigation of possible neurological sequalae from spinal dysfunction identified as vertebral joint dysfunction by chiropractors and treated by specific spinal adjustments as it relates to infertility.
 
References:
1. Resolution of Infertility in a Female Undergoing .Chiropractic. Based Chiropractic Care: Case Report & Review of Literature. Journal of VS Research 2008: Aug 6: 1-6.
Examination protocols of Diversified Technique were utilized to detect and adjust chiropractic joint dysfunction for the first 2 1/2 months of care and Toggle/Webster Technique protocols were used exclusively thereafter. Visits included thermography as an instrumentation procedure. The patient had her first natural menstrual cycle 3 1/2 months into care and discovered she was pregnant 4 1/2 months after initiation of chiropractic care. Ultrasound confirmed the pregnancy shortly after.
2. Female Infertility and Chiropractic Wellness Care: A Case Study on the Autonomic Nervous System Response while Under Chiropractic Care and Subsequent Fertility.Journal of VS Research 2003 (Nov 2): 1-10.
After receiving wellness chiropractic care for the detection and correction of chiropractic joint dysfunction, the practice member showed marked improvement in autonomic and motor system function as demonstrated on her sEMG and thermography scans. In additon, after having great difficulty conceiving, she became pregnant nine months after commencing chiropractic care. Further studies are needed to document the relationship between infertility, autonomic nervous system function, and the response to wellness chiropractic care, including subsequent fertility.
 
To repeat: It is not my intention to construct a reproducible phenomenon, these are just simply reports - accounts of various patient's improvement in my office.
 
Case of a Chiropractic Patient with Seizure Disorder following a Road Traffic Accident with Head Injury.
Leah Remeika-Dugan, BSc, DC, MCC, IDE
 
This case involves the chiropractic care of a single, 31 year old male patient, who came to my office suffering from recorded complaints of 6-10+ seizures per day, following an historical road traffic accident with head injury. The range of numbers is varied because his seizure diary varied from between six per day to well over 10+ from day to day. Upon presentation to the clinic in May 2001, the patient was taking Phenobarbital daily to control his seizures and was scheduled by his GP for an open MRI to determine the next course of action for treatment.
 
The patient had a dull affect and was spending most of his time exhausted from being in a postictal state for the most part of each day. On examination the patient was suffering from multiple spinal levels of chiropractic misalignments of the C0 to C5 levels of the spine, as well as several areas of misalignment in his lumbar spine, and thoracic spine. Earlier MRI analysis revealed ectopic areas of scarring in the left hemisphere near the temporal lobe and the studies were unable to determine anything else by way of the report.
 
Chiropractic adjustments were comprised of diversified thoracic and lumbar adjustments and modified Gonstead cervical adjustments, involving a specific-contact, short-lever arm, high-velocity, low-amplitude maneuver (i.e., Gonstead) were applied to the joint dysfunction at the cervical region. The patient's reported seizure frequency decreased from 10+ per day, to 1-3 per week. The patient continued care for another 18 months to maintain correction and the seizures remained under better control with between 1 to 3 seizures per week.
 
These results (and others) encourage further investigation of possible neurological sequalae, such as epileptic seizures, from spinal dysfunction identified as vertebral segmental joint dysfunction by chiropractors and treated by specific spinal adjustments.
 
References:
1. J Manipulative Physiol Ther 1998 (Jul); 21 (6): 410-418. Alcantara J, Heschong R, Plaugher G, Alcantara J. Palmer Center for Chiropractic Research, Palmer College of Chiropractic-West, San Jose, CA 95134, USA.
 
To repeat: It is not my intention to construct a reproducible phenomenon, these are just simply reports - accounts of various patient's improvement in my office.
 
A Case of a Chiropractic Patient with chiropractic segmental joint dysfunction with coexisting Migraine 3-6 times per week.
Leah Remeika-Dugan, BSc, DC, MCC, IDE
 
This 53-year-old female married patient presented to our clinic in October 2003, suffering from vertebral joint dysfunction in her cervical spine along with the clinical features of classic migraine with aura and nausea.
 
The patient complained of severely restricted activities of daily living in that she could not go to work or drive regularly because of the migraines, and spent most of her days medicated and at home. She also reported migraines of VAS intensity of VAS=7-9/10 3-6 times per week.
 
I examined her cervical and thoracic spine which revealed multiple cervical spine joint misalignment. Her cervical and upper thoracic spine was adjusted with modified Gonstead chiropractic adjusting 2 times per week for 3 weeks, once weekly for the following 2 weeks, and then bi-weekly for the following 3 visits, then once per month unless she felt she needed to come in before her next scheduled visit, which only happened twice in two years.
 
After the first 3 weeks, the patient reported a VAS (visual analog scale pain rating) rating of VAS=2-3/10 and after another 2 weeks, she reported a VAS=1-2/10 most days of the week. She had a couple of setbacks in which her headache returned to between VAS=3-5/10 which reduced to 1-2/10 following another chiropractic adjustment. The patient came in periodically for a chiropractic checkup and treatment, and remained between 1-2/10 during the period she remained under chiropractic care.
 
References:
1. Nelson CF, Bronfort G, Evans R, et al. The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for prophylaxis of migraine headache. Journal of Manipulative and Physiological Therapeutics, Oct. 1998;21(8), pp511-19.
 
To repeat: It is not my intention to construct a reproducible phenomenon, these are just simply reports - accounts of various patient's improvement in my office.
 
A Case of a Chiropractic Patient with chiropractic segmental joint dysfunction with coexisting Myasthenia Gravis, daytime fatigue and lack of restful sleep at night.
Leah Remeika-Dugan, BSc, DC, MCC, IDE
 
This 18 year-old female patient presented to our clinic in Oct 2002, suffering from vertebral joint dysfunction along with the clinical features of myasthenia gravis. The patient had an initial compliant of disturbed activities of daily living due to excessive need for sleep. She reported sleeping for 10 and up to 12 hours during the day and then sleeping for 6 hours at night.
 
The patient had a thymectomy in 1998 in hopes of remitting her condition, however she was still suffering following the surgery, and was unable to hold down any type of job or schooling due to her M.G. condition.
 
I examined her spine and discovered that she had several areas of misalignment in her thoracic spine, her pelvis, and her neck (cervical spine). She was treated with modified Gonstead chiropractic adjusting 3 times per week for 2 weeks, twice weekly for the following 2 weeks, and then weekly for the following 3 months. We then offered her to come in once per month, however she complained that after 2 weeks she would begin to feel tired again and missed her adjustments, so we changed her treatment plan, after which time she remained under maintenance care on a schedule of a full spinal adjustment every 3 weeks and she reported feeling more .normal. and able to cope with her daily activities of living.
 
During this period of time her symptoms of tiredness and spinal pain were recorded at each visit, and ranged (from the onset of treatment) from VAS = 5/5 with 5 being the worst, down to between a VAS =1-2/5 on a regular basis. At one instance she suffered from the flu and at that time her VAS = 3/5 but returned to her average rating of 1-2/5 in two weeks.
 
After the first 3 weeks of care she was able to secure part time employment, as she had regained a good part of her waking day. She made further arrangements to advance her higher education as her function continued to improve.
 
References:
1. J Manipulative Physiol Ther 1999 (Jun); 22 (5): 333-340. Joel Alcantara, DC, David M. Steiner, DC, Gregory Plaugher, DC, Joey Alcantara. This study was funded by Palmer College of Chiropractic West, San Jose, California and the Gonstead Clinical Studies Society, Mount Horeb, Wisconsin.
 
To repeat: It is not my intention to construct a reproducible phenomenon, these are just simply reports - accounts of various patient's improvement in my office.
 
Education Section:
 
Chiropractic Neurology (Opinion)
 
Mechanism for upper cervical neurologic function may be chiropractic upper cervical misalignments, which needs more research:
 
The first mechanism, central nervous system facilitation, can occur from an increase in afferent signals to the spinal cord and/or brain coming from articular mechanoreceptors after a spinal injury. 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.
 
Hyperexcitability or activation (through central nervous system 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.
 
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 the cell ceases to perform its designated purpose. The brain cell may remain in a hibernation state indefinitely, with the potential to resume 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 patients sustain an injury to his/her upper cervical spine during one or more traumas experienced. It is also likely that because of the injury, through the mechanisms described previously, sympathetic malfunction can occur (measured by paraspinal digital infrared imaging), possibly causing a decrease in cerebral blood flow.
 
If blood supply to the substantial nigra is compromised, it is possible that a certain percentage of those cells exist in a state of hibernation rather than cell death. Therefore the combination of theories suggests that when blood supply is restored to the hibernating substantial nigra cells (from chiropractic care), the cells resume their dopaminergic (dopamine-secreting nerve fibers) function. Further investigation into chiropractic joint fixation and resulting neuropathophysiology as a possible contributing factor to neuropathophysiology should be considered.
 
HYPOTHESIS FOR THE UNDERLYING NEUROLOGICAL MECHANISM OF REACTIONS FOR CHANGING THE RESPONSE TO TRIGGERS. COMPILED PERSONAL NOTES (AGAIN OPINION)
 
In much the same way, if you stroke the back of a cat, the muscles contract spontaneously because their action potentials are near threshold for firing, this is what occurs to the hyper-reactive nerve fibres which are too close to firing and therefore hyper-sensitive at the end organs (including muscle) if there are chiropractic joint dyxfunctions in the spine.
 
If there was adequate neuronal potentiation to pain sensation (nocioception) causing an action potential, stimulation to second and third order neurons (specifically the VPL and CNL of the thalamus) nocioception would take place,1 eventually signaling the post central gyrus as well as the association cortex.
 
Three major ascending pathways, would be the spinothalamic tract which originates from neurons in laminas I, V-VII and is comprised of axons of nocioceptive specific and wide dynamic range neurons.
 
A second pathway would send 2/3 or 66% of nocioception to the reticular formation in the medulla and pons and a third tract would send nocioceptive afferents to the mesencephalic periaqueductal gray.1
 
Chiropractically speaking an adjustment lowers the threshold for firing and increases this sensory perception and will cause a presynaptic inhibition at the dorsal horn, as well as enkephalons and endorphins release caudally and cephalad. This is what was referred to as suprasegmental and segmental modulation of nocioception.
 
Chiropractic vertebral adjustments will cause an increase in neuronal propagation of joint mechanoreceptors to the thalamus. Specifically with the upper neck and the duality of nerve function in this area via cranial nerve 5 and the upper cervical neurons at C1-C3, chiropractic adjustments in this area would cause a presynaptic inhibition to nocioceptors in this region. Once the chiropractic vertebral joint misalignment has been calculated and the proper line of correction applied in this part of the spine, alleviation of the nocioceptive input and an increase in the central integrated state of the neural axis would be achieved.
 
When dealing with altered nerve input, we are really encountering second autonomic concomitants such as increased sweating, heart rate, respiration, change of bowel time, pupil dilation and nausea, altered sympathetic response, just to name a few. Obviously, there are neuronal connections to the nuclei that cause these concomitants.
 
When dealing with pain these scenarios take on a different perception for the patient. People tend to tolerate more of the pain, so it is important to keep these joints functioning by maintaining joint function regularly as pain is only experienced when the threshold of firing is in a hyper-excitable state, and the symptoms are already present.
 
In the case of migraines, head and facial pain as with a classical migraine, localization appears to be shared by two different nerves. Sensorially, the face is innervated by the afferent portion of the trigeminal nerve2 and the head is supplied by C2 and C3 dermatones.3 To perceive these areas of pain simultaneously, both sensory nerves thus stated would be brought to the threshold.
 
With receptor potentiation that exceeds threshold causing an action potential to nocioception, the flexor-reflex afferent system is stimulated, thus causing reflexogenic myospasm of the related segmental musculature via stimulation of the alpha motor neuron.4,5 As pertaining to the head and facial pain, spasms of the suboccipital, posterior cervical and trapezius muscles occur.5,6
 
Joint fixation or aberrancy of movement of vertebral segments can also set up these pain patterns.
 
So how could chiropractic serve to reduce these scenarios? With lack of vertebral motion there co-exists a decrease in receptor potentiation from joint mechanoreceptor (Merkel, Meissner, and pacchionian corpuscles),7 and a reduction of peripheral receptor potentiations.
 
Since pain modulation could be segmental or suprasegmental, the correlation exists between a reduction in this modulation and reduction in sensory receptor potentials.
 
The knowledge of the neural axis is essential for the clinical care of the patient, and the verification of importance of the science, art and philosophy of that is chiropractic.
 
References:
    Paul F. Stefanelli, DC, DACNB
    Kandall, Schwarts, Tessel. Principles of Neural Science, Chapter 27.
    Wilson, Pauwels, Akesson, Stewart. Cranial Nerves Anatomy and Clinical Comments, Chapter 5.
    Kandall, Schwarts, Tessel. Principles of Neural Science, Chapter 25.
    Kandall, Schwartz, Tessel. Principles of Neural Science, Chapter 38.
    Guyton. Basic Neuronal Science, Chapter 16.
    Kendall, McCreary. Muscle Testing and Function.
    Kandall, Schwartz, Tessel. Principles of Neural Science. Chapter 5.
    Sensory Innervation of the Spinal Joint and Effects of Manipulation The Chiropractic Neurological Examination by Joseph S. Ferezy, DC; University Chiropractic Consultants; Minneapolis, Minnesota; 1992
Type I mechanoreceptors are located in the outer layers of the spinal joint capsule. When stimulated, they fire at a frequency proportional to the degree of any active or passive joint movement or traction. The firing rate is inhibited by joint end approximation. They have a low threshold and are therefore very sensitive to movement. They are termed dynamic receptors because they only fire with movement. Some will continuously fire at 10 to 15 Hz even with no joint movement; these are known as static receptors. Type I receptors are slow adapting, so movement effects on them are longer lasting.
 
Their functions include:
    perception of posture and movement
    reflex modulation of postural background and movement through constant monitoring of outer joint tension
    inhibition of centripetal flow from pain receptors via an enkephalinergic synaptic interneuron
    tonic effects on lower motor neuron pools involved in neck, limb, jaw, and eye muscles
This relationship between cervical joint innervation and musculature in the limbs, jaw and eye helps us better understand how Chiropractic adjustive therapy achieves results with complaints such as shoulder and temporomandibular joint pain and diplopia. Additionally, contributions of joint mechanoreceptors to pain perception, posture, and movement, as well as to reflex actions related to the above, would clarify the role of Chiropractic adjustments in treating pain, dystaxia (gait disorders), and postural conditions such as primary kyphosis, scoliosis, thoracic outlet syndrome, etc.
 
Type II Mechanoreceptors are found within the deeper layers of the joint capsule. They also have a low threshold (dynamic), sensing even minor changes in inner joint tension. But unlike type I mechanoreceptors, they are very rapidly adapting (accelerator); firing may cease within 0.5 second of joint movement. Type II mechanoreceptors are completely inactive in immobilized joints. Functions of type II mechanoreceptors appear to include monitoring of joint movement for reflex actions and perhaps perceptual sensations inhibition of centripetal flow from pain receptors via enkephalinergic synaptic interneuron phasic effects on lower motor neuron pools involved in neck, limbs, jaw, and eye movement
 
Type III Mechanoreceptors
These mechanoreceptors are, interestingly enough, completely absent from all spinal joints. They are slow adaptors with a very high threshold and appear to be the joint version of golgi tendon organs, which have an inhibitory effect on motor neurons.
 
Type IV receptors are associated with pain perception. They possess an intimate physical relationship with the type I and II mechanoreceptors and are omnipresent throughout the fibrous portion of the joint capsule and the ligaments of the spine but are absent from articular cartilage. They are very high threshold receptors and are, of course, completely inactive in the physiologically normal joint. Joint capsule pressure, narrowing of the intervertebral disc, fracture of the vertebral body, dislocation of the apophyseal joints, chemical irritation, and interstitial edema associated with acute and/or chronic inflammation may all activate the nociceptive system. The basic functions of these spinal nocioceptors include: evocation of pain, tonic effects on neck, limb, jaw and eye muscles, provision of central reflex connections for pain inhibition, provision of central reflex connections for myriad autonomic effects.
 
Discussion of The Topic of the Dizzy Patient
Credit: David Seaman, DC, MS, DABCN
Asheville, North Carolina
 
Lewit appears to take issue with the focus of attention on the vestibular labyrinth. "The role of the spinal column in the maintenance of balance is usually underrated. It is important to remember that under normal conditions the labyrinth is not necessary for the maintenance of equilibrium."11
 
However, Lewit states that upper cervical spine receptors are very important for equilibrium and thus, "it is no coincidence that vertigo and dizziness are very frequently of cervical origin."11 Basic scientists support this statement made Lewit who is a clinician researcher. For example, Guyton states that, "by far the most important proprioceptive information needed for the maintenance of equilibrium is that derived from the joint receptors of the neck."8
 
In the 1988 book, Control of Head Movement, published by Oxford University Press, there is a chapter devoted to sensory receptors in the neck. Richmond, et al. state: "For more than 100 years, we have known that sensory receptors in the neck play a special role in the control of posture and movement. As early as 1845, Longet reported that surgical damage of neck muscles in a wide range of species led to generalized but transient motor disturbances characterized by an ataxia similar to that which followed cerebellectomy."14 These authors cite 10 papers, written between 1939 and 1979, which extended the experimental observations of Longet.
 
In Hospital Practice in 1993, Caranasos and Israel discussed gait problems in the elderly and explained how cervical spine mechanoreceptors provide major input regarding the position of the head in relation to the body. "With aging, mild defects impair the function of these endings and their fibers."4 The result is decreased proprioception the patient becomes more dependent on visual input to maintain and monitor body position.4
 
In 1985, Hinoki published a paper which discussed a number of experiments which provided an explanation for how cervical and lumbar receptors can help to promote disequilibrium, dizziness and/or vertigo.10 The problem with this paper is that the terminology is inconsistent regarding receptors and vertiginous symptoms.
 
In 1991, Revel, et al. demonstrated that patients with neck pain have an alteration in neck proprioception. The authors developed a proprioceptive test which involved head and neck repositioning after an active head movement. Patients with neck pain consistently performed this test significantly worse than pain-free controls. The authors concluded: "The test may also permit a completion of post-trauma cervical pain investigation by studying the responsibility of neck proprioceptors in dizziness and unclear 'pseudovestibular' disorders."12
 
In 1994, Revel, et al. performed a study which sought, in part, to determine if an exercise program based on eye-head coordination can improve cervicocephalic kinesthesia. The results demonstrated that such a rehabilitation program was successful. The authors concluded: "The rehabilitation program of cervicocephalic kinesthesia could be particularly appropriate for patients with neck pain and dizziness after neck trauma, because it has been postulated that this syndrome sometimes called 'cervical vertigo,' could be the result of damage to cervical proprioceptors."13
 
Notice that Revel, et al. state that dizziness after trauma is sometimes called "cervical vertigo." If you are not a stickler for definitions, then this characterization will not bother you. However, if you are interested in detailed definitions you might be inclined to agree with Dr. Hain who states that "cervical vertigo is rare."9 Let's quickly examine the definitions of vertigo and dizziness so we can put Hain's statement into context. Vertigo is defined as "the illusion of motion or position, either of the patient or the environment."5 Dizziness is "a general term, implying only the sense of a disturbed relationship to the space outside oneself."5 "Dizziness, synonymous with lightheadedness, is the more common and less arresting floating feeling of instability, unsteadiness and depersonalization."5 With dizziness, sensations of movement or nausea are mild, if they exist at all.5
 
The following quote from Brandt supports Hain's statement that cervical vertigo is rare:
 
"Neck afferents not only assist the coordination of eye, head, and body but also affect spatial orientation and control of posture. This implies that stimulation of or lesions in these structures could produce cervical vertigo. In fact, unilateral local anesthesia of the upper cervical roots induces ataxia and nystagmus in animals, and ataxia without nystagmus in humans. Cervical vertigo, if it exists outside these experimental conditions, is obviously characterized by ataxia and unsteadiness of gait rather than by a clear rotational vertigo."3
 
Brandt appears to be quite sure cervical vertigo does not exist and that cervicogenic disequilibrium may only exist in the laboratory.
 
In 1991, Brandt wrote a detailed text, Vertigo: Its Multisensory Syndromes. In a chapter about somatosensory vertigo, five pages are devoted to the topic of cervical vertigo.2 The first paragraph is exactly the same as the one quoted above. Brandt goes on to state that there is a "fierce controversy between those who believe in cervical vertigo and the non-believers." Brandt then provides a table that describes clinical cervical vertigo and states that symptoms include "ataxia and unsteadiness of gait associated with some neck pain or limitation of neck movement."
 
It now appears that Brandt is convinced that cervicogenic disequilibrium is a real-life syndrome. Unfortunately, he does not mention how common dizziness or disequilibrium is compared to true vertigo, and also emphasizes that there is no reliable test to confirm the existence of true cervical vertigo. [It should be mentioned that none of the papers and chapters that I reviewed, attempted to quantify how many patients suffer with each of the different varieties of dizziness.]
 
Enter Fitz-Ritson in 1991. In the article, "Cervicogenic Vertigo," Fitz-Ritson presents a new method for assessing cervicogenic vertigo.7 A patient is seated on a stool or chair that rotates. The patient closes his eyes while the doctor holds the head still. The patient rotates the body by moving the chair with the legs and feet. "If the patient now experiences vertigo, it will originate from the tissues of the cervical spine."7 See the article for a detailed description of this test.
 
Fitz-Ritson found that 112 out of 235 patients experienced cervical vertigo by this test method. The definition of vertigo used in this study can be either "a subjective vertigo, i.e., the patient feels that he is rotating, or objective vertigo, i.e., the feeling that the room or environment is rotating." In this study, half of the patients had true "rotational" vertigo. "After 18 treatments, 101 of the 112 patients (90.2%) were symptom free."7 This finding is consistent with the findings of Lewit of states that manipulation is very effective for reducing vertigo and dizziness.11
 
It should be clear that more information about cervicogenic dizziness and vertigo is available than that which appears in the average medical textbook. Unfortunately, this fact is not well known.
 
References:
    Baloh R. The dizzy patient: treatment options. In: Hachinski V. editor. Challenges in Neurology. Philadelphia: F.A. Davis, 1992:15-27.
    Brandt T. Vertigo: Its Multisensory Syndromes. New York: Springer-Verlag, 1991:277-81.
    Brandt T. Vertigo and Dizziness. In: Ashbury A et al. Diseases of the Nervous System: Clinical Neurobiology. 2nd edition. Philadelphia: W.B. Saunders, 1992:451-68.
    Caranasos G, Israel R. Gait disorders in the elderly. Hosp Pract 6/15/91:67-94.
    Douglas F. The dizzy patient: strategic approach to history, examination, diagnosis, and treatment. Chiropr Tech 1993; 5(1):5-14.
    Echiverri H, Dizziness and Vertigo. Seminar, 3/95.
    Fitz-Ritson D. Cervicogenic vertigo. J Manipulative Physiol Ther 1991; 14(3):193-98.
    Guyton A. Basic Neuroscience. 2nd edition. Philadelphia: W.B. Saunders, 1991:221.
    Hain T, Zee D. The dizzy patient: diagnostic approaches. In: Hachinski V. editor. Challenges in Neurology. Philadelphia: F.A. Davis, 1992:3-14.
    Hinoki M. Vertigo due to whiplash injury: a neurotological approach. Act Otolaryngol (Stockh) 1985; (Suppl) 419:9-29.
    Lewit K. Manipulative Therapy in Rehabilitation of the Locomotor System. 2nd edition. Boston: Butterworth Heinemann, 1991:18.
    Revel M et al. Cervicocephalic kinesthetic sensibility in patients with cervical pain. Arch Phys Med Rehabil 1991;72:288-91.
    Revel M et al. Changes in cervicocephalic kinesthesia after a proprioceptive rehabilitation program of in patients with neck pain: A randomized controlled study. Arch Phys Med Rehabil 1994;75:895-99.
    Richmond F et al. The sensorium: Receptors of Neck Muscles and Joints. In: Peterson B, Richmond F. editors. Control of Head Movement. New York: Oxford University Press, 1988:49-62.
To repeat: It is not my intention to construct a reproducible phenomenon, these are just simply reports - accounts of various patient's improvement in my office.
 

 
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