Vertigo, tinnitus, and hearing loss in the geriatric patient

OBJECTIVE: To document clinical changes after a course of chiropractic care in a geriatric patient with vertigo, tinnitus, and hearing loss. Clinical Features: A 75-year-old woman with a longstanding history of vertigo, tinnitus, and hearing loss experienced an intensified progression of these symptoms 5 weeks before seeking chiropractic care. Radiographs revealed a C3 retrolisthesis with moderate degenerative changes C4-C7. Significant decreases in audiologic function were evident, and the RAND 36 Health Survey revealed subjective distress. Intervention and Outcome: The patient received upper cervical-specific chiropractic care. Paraspinal bilateral skin temperature differential analysis was used to determine when an upper cervical adjustment was to be administered. Radiographic analysis was used to determine the specific characteristics of the misalignment in the upper cervical spine. Through the course of care, the patient's symptoms were alleviated, structural and functional improvements were evident through radiographic examination, and audiologic function improved. CONCLUSION: The clinical progress documented in this report suggests that upper cervical manipulation may benefit patients who have tinnitus and hearing loss.     

Chiropractic care of a patient with vertebral subluxations and unsuccessful surgery of the cervical spine

OBJECTIVE: The chiropractic care of a patient with vertebral subluxations, neck pain, and cervical radiculopathy after a cervical diskectomy is described. CLINICAL FEATURES: A 55-year-old man had neck pain and left upper extremity radiculopathy after unsuccessful cervical spine surgery. INTERVENTION AND OUTCOME: Contact-specific, high-velocity, low-amplitude adjustments (i.e., Gonstead technique) were applied to sites of vertebral subluxations. Rehabilitation exercises were also used as adjunct to care. The patient reported a decrease in neck pain and left arm pain after chiropractic intervention. The patient also demonstrated a marked increase in range of motion (ROM) of the left glenohumeral articulation. CONCLUSION: The chiropractic care of a patient with neck pain and left upper extremity radiculopathy after cervical diskectomy is presented. Marked resolution of the patient's symptoms was obtained concomitant with a reduction in subluxation findings at multiple levels despite the complicating history of an unsuccessful cervical spine surgery. This is the first report in the indexed literature of chiropractic care after an unsuccessful cervical spine surgery.     

Chiropractic treatment of postsurgical neck syndrome with mechanical force, manually assisted short-lever spinal adjustments

OBJECTIVE: To describe a case of postsurgical neck pain, after multiple spinal surgeries, that was successfully treated by chiropractic intervention with instrumental adjustment of the cervical spine. CLINICAL FEATURES: A 35-year-old woman had chronic neck pain for over 5 years after two separate surgeries of the cervical spine: a diskectomy at C3/4 and a fusion at C5/6. Surgeries were performed 6 months apart in an attempt to resolve persistent neck pain and spasm of the cervical musculature. Neither surgery was effective in relieving the patient's pain. Five years after the second surgery, a third surgery was recommended by the patient's physicians to alleviate the chronic pain. The patient sought chiropractic evaluation of her condition to avoid further surgical intervention. INTERVENTION AND OUTCOME: The patient was treated with conservative instrumental chiropractic manipulation, consisting of mechanical force, manually assisted short-lever spinal adjustments rendered with an Activator Adjusting Instrument (AAI) II. She comfortably tolerated the treatment and responded favorably to this therapy. All chronic symptoms had resolved within 30 days of instituting the chiropractic instrumental adjustments with an AAI. More interestingly, longitudinal examination over the next 2 years showed that the patient experienced no residual effects or further recurrences of her previous chronic problem after her initial course of chiropractic care. CONCLUSION: Chiropractic treatment of postsurgical neck syndrome may be effectively treated, in certain cases, by mechanical force, manually assisted adjusting procedures with an AAI. The use of instrumental adjustment methodology may provide chiropractic physicians with an effective alternative to manual manipulation in those cases in which the patient's surgical history or presenting symptoms make forceful manipulation of the spine, particularly performed at end range, inappropriate. This approach may be contemplated by physicians faced with managing this type of condition. Further study should be made in this regard, in an academic research setting, to determine the safest and most effective approaches to managing postsurgical patients in a chiropractic setting.     

A suspected case of ulnar tunnel syndrome relieved by chiropractic extremity adjustment methods

BACKGROUND: There has been little published about ulnar tunnel syndrome (UTS) as it relates to the practice of chiropractic, despite chiropractors' apparent interest in nerve compression syndromes and a growing trend toward providing chiropractic extremity care. This syndrome is not very common and could be mistaken for carpal tunnel syndrome by practitioners who are not aware of the differences. OBJECTIVE: To discuss the case of a patient with ulnar tunnel syndrome whose symptoms were resolved by chiropractic extremity adjustment.Clinical features A 45-year-old female patient complained of numbness in her little finger. Standard orthopedic testing procedures for the wrist and hand reproduced the symptom, but tests for the cervical spine and thoracic outlet region were negative.Intervention and outcome Care for this patient consisted of adjustment procedures directed to the wrist, primarily the hamate and pisiform articulations with the triquetrum. Her symptoms were resolved in 4 office visits, with corresponding improvement in examination findings. CONCLUSIONS: This case report represents what a patient could expect during a typical chiropractic treatment. The examination and the care given were simple and cost-effective but might not be sufficient for a more complicated or persistent case. The costs for the care in this case were borne solely by the patient and were affordable. Hard conclusions cannot be reached without more sophisticated diagnostic procedures, additional similar cases, and controlled research conditions.     

Missed cervical spine fracture: chiropractic implications

OBJECTIVE: To discuss the case of a patient with an anterior compression fracture of the cervical spine, which had been overlooked on initial examination. CLINICAL FEATURES: A 36-year-old man was seen at a chiropractic clinic 1 month after diving into the ocean and hitting his head on the ocean floor. He chipped a tooth but denied loss of consciousness. Initial medical examination in the emergency department did not include radiography, but an anti-inflammatory medication was prescribed. Radiographs taken at the chiropractic clinic 1 month later revealed an anterior compression fracture of the C7 vertebra, with migration of the fragment noted on flexion and extension views. INTERVENTION AND OUTCOME: The patient was referred back to his medical doctor for further evaluation and management.He was instructed to wear a Philadelphia collar for 4 weeks. During this time period, he reported "shooting" pain and tingling from his neck into his arms. The patient reported resolution of his neck and arm symptoms at 2.5 months after injury. Follow-up radiographs at 6 months after injury revealed fusion of the fracture fragment with mild residual deformity. At that time, the patient began a course of chiropractic treatment. CONCLUSION: After head trauma, it is essential to obtain a radiograph of the cervical spine to rule out fracture. Chiropractors should proceed with caution, regardless of any prior medical or ancillary evaluation, before commencing cervical spine manipulation after head and neck trauma.     

Chiropractic care of a pediatric patient with myasthenia gravis

OBJECTIVE: To describe the chiropractic care of a pediatric patient with complaints associated with myasthenia gravis.Clinical features A 2-year-old girl was provided chiropractic care at the request and consent of her parents for complaints of ptosis and generalized muscle weakness (ie, lethargy), particularly in the lower extremities. Prior to entry into chiropractic management, magnetic resonance imaging of the brain and acetylcholine receptor antibody tests were performed with negative results. However, the Tensilon test was positive and the diagnosis of myasthenia gravis was made by a pediatrician and seconded by a medical neurologist.Intervention and outcome The patient was cared for with contact-specific, high-velocity, low-amplitude adjustments to sites of vertebral subluxation complexes in the upper cervical and sacral spine. The patient's response to care was positive and after 5 months of regular chiropractic treatment her symptoms abated completely. CONCLUSION: There are indications that patients suffering from disorders "beyond low back pain" as presented in this case report may derive benefits from chiropractic intervention/management.     

Use of cervical spine manipulation under anesthesia for management of cervical disk herniation, cervical radiculopathy, and associated cervicogenic headache syndrome

OBJECTIVE: To demonstrate the benefits of cervical spine manipulation with the patient under anesthesia as an approach to treating a patient with chronic cervical disk herniation, associated cervical radiculopathy, and cervicogenic headache syndrome. CLINICAL FEATURES: The patient had neck pain with radiating paresthesia into the right upper extremity and incapacitating headaches and had no response to 6 months of conservative therapy. Treatment included spinal manipulative therapy, physical therapy, anti-inflammatory medication, and acupuncture. Magnetic resonance imaging, electromyography, and somatosensory evoked potential examination all revealed positive diagnostic findings. INTERVENTION AND OUTCOME: Treatment included 3 successive days of cervical spine manipulation with the patient under anesthesia. The patient had immediate relief after the first procedure. Her neck and arm pain were reported to be 50% better after the first trial, and her headaches were better by 80% after the third trial. Four months after the last procedure the patient reported a 95% improvement in her overall condition. CONCLUSION: Cervical spine manipulation with the patient under anesthesia has a place in the chiropractic arena. It is a useful tool for treating chronic discopathic disease complicated by cervical radiculopathy and cervicogenic headache syndrome. The beneficial results of this procedure are contingent on careful patient selection and proper training of qualified chiropractic physicians.     

Missed cervical spine fracture-dislocations: the importance of clinical and radiographic assessment

OBJECTIVE: To review the case of a patient who suffered a cervical spine fracture-dislocation missed at a hospital emergency department. CLINICAL FEATURES: A 77-year-old man involved in a motor vehicle accident was transported to a local emergency hospital where cervical spine x-ray films taken were reported as demonstrating no evidence of acute injury. The patient visited a chiropractic clinic 6 days later, where x-ray films were again obtained, finding that the patient sustained fractures of C5 and C6, as well as a bilateral facet dislocation at C5/C6. Computed tomography confirmed the fractures, and magnetic resonance imaging findings demonstrated cervical spinal cord compression and posterior spinal cord displacement. INTERVENTION AND OUTCOME: The patient was referred for preoperative medical evaluation. He underwent C5-6 closed reduction and anterior/posterior fusion surgery and was released without complication. Patient follow-up indicated full recovery with minimal neurologic symptoms. CONCLUSION: Cervical spine fracture-dislocations are often missed during standard radiographic examinations in emergency department settings. Chiropractors are encouraged to perform a comprehensive evaluation of patients presenting with cervical trauma even if they have had prior x-ray films reported as normal. Standard x-ray films taken at emergency department facilities are not entirely reliable for detecting or revealing cervical spine fracture-dislocations. This case stresses the importance of careful clinical assessment and imaging procedures on patients who have encountered cervical spine trauma.     

Long-standing axis odontoid fracture in patient presenting with acute low back pain

Objective:To present the case of a patient affending for chiropractic care with acute low back pain. Incidentally, a previously unknown long-standing axis odontoid fracture was diagnosed, which resulted in a referral for neurosurgical management.Clinical features:A 63-year-old man presented for chiropractic care with a chief complaint of severe acute low back pain. His examination revealed evidence of lumbar and upper cervical subluxations. Subsequent X-rays revealed a double rotatory lumbar scoliosis and an axis odontoid fracture at its base. A cervical flexion X-ray revealed instability and a later computed tomography confirmed the fracture.Intervention and outcome:Due to poor patient compliance, a neurosurgical consultation and subsequent upper cervical arthrodesis did not take place until over 4 months after the initial diagnosis. A Brooks C1-C2 posterior fusion using Songer cables and an iliac crest bone graft resulted in a successful outcome. Prior to surgery, the patient's low back pain was managed by the chiropractor with a successful outcome.Conclusion:This case presents a rare, yet precarious situation with the chiropractic management of a patient with a potentially catastrophic condition. This clinical example also stresses the importance of careful clinical assessment and imaging procedures for patients before providing spinal adjustments in order to avoid a potential iatrogenic incident. This case report also demonstrates the successful outcome of specific chiropractic care in the amelioration of acute low back pain.     

Chiropractic management using Cox cervical flexion-distraction technique for a disk herniation with left foraminal narrowing in a 64-year-old man

OBJECTIVE: The purpose of this case report is to describe chiropractic management of a patient with a C6/C7 left posteromedial disk herniation with foraminal narrowing and concomitant neurological compromise in the form of left upper extremity radiating pain and hypoesthesia/anesthesia using Cox flexion-distraction technique. CLINICAL FEATURES: A 64-year-old man presented to a chiropractic clinic with complaints of neck/left shoulder pain and hypoesthesia/anesthesia into the palmar side of his left hand. Magnetic resonance images of the cervical spine revealed a left posteromedial C6/C7 disk herniation along with foraminal narrowing. In addition, there were other levels of degeneration, most noted at the C3/C4 spinal level, which also had significant left-sided foraminal narrowing. INTERVENTION AND OUTCOME: Treatment included Cox flexion-distraction protocols aimed to reduce nerve root compression along with supportive physiological therapeutic interventions to aid with pain reduction and functional improvement. The patient was treated a total of 10 times over a course of 4 weeks. The patient reported being pain-free and fully functional 8 months following the conclusion of care. CONCLUSION: This case study demonstrated the use of Cox flexion-distraction for treatment of a patient with a cervical disk herniation, foraminal narrowing, and associated radiating pain and radiculopathy in the left upper extremity.     

Lateral cervical curve changes in patients receiving chiropractic care after a motor vehicle collision: a retrospective case series

OBJECTIVE: To examine radiological changes of the lateral cervical curve in patients who received chiropractic care after motor vehicle collisions. DESIGN: A retrospective case series. Thirteen patients who had received chiropractic care after motor vehicle collisions were selected from a northeastern Washington chiropractic office. Patients had a lateral cervical radiograph taken prior to the initiation of chiropractic treatment and a comparative lateral cervical radiograph subsequent to a period of care. Cases were included if they met the previously stated criteria and if the radiographs were of sufficient quality to determine the lateral cervical curve from C2-C7. RESULTS: Adjustments rendered using an Activator Adjusting Instrument. Eleven of the subjects were also instructed to perform stretching exercises. Compared to the initial lateral cervical radiograph, the comparative radiographs demonstrated a mean increase in cervical lordosis between C2 and C7 of 6.4 degrees (SD = 8.2). The standard error estimate of the population was 2.3 degrees, with a 95% confidence interval of 1.4 degrees to 11.4 degrees. CONCLUSION: There was a mean increase in the cervical lordosis of 6.4 degrees (SD = 8.2). The standard error estimate of the population was 2.3 degrees, with a 95% confidence interval of 1.4 degrees to 11.4 degrees. We were not able to determine the individual effects of adjustment, stretching, and natural progression of the condition. The results suggest that further study of this phenomenon should be undertaken.     

Chiropractic care of a 47-year-old woman with chronic Bell's palsy: a case study

OBJECTIVE: The purpose of this case study is to describe the effect of chiropractic care on a patient with chronic Bell's palsy. CLINICAL FEATURES: A 47-year-old woman with medically diagnosed Bell's palsy presented for chiropractic care. She had experienced right sinus pressure and congestion, lack of facial tone on the right, and intermittent tingling of the right side of her face. INTERVENTIONS AND OUTCOMES: The patient received high-velocity, low-amplitude chiropractic manipulation (adjustments) to the cervical and thoracic spine, interferential muscle stimulation, and hydroculation on the trapezius muscles bilaterally. Reduction in symptoms occurred following the initial visit and continued over the next 9 weeks of care. After the course of a year of chiropractic care, the patient reached 90% improvement. CONCLUSIONS: For this patient, chiropractic care reduced Bell's palsy symptoms.     

Resolution of suckling intolerance in a 6-month-old chiropractic patient

OBJECTIVE: To discuss the management and resolution of suckling intolerance in a 6-month-old infant. CLINICAL FEATURES: A 6-month-old boy with a 4(1/2)-month history of aversion to suckling was evaluated in a chiropractic office. Static and motion palpation and observation detected an abnormal inward dishing at the occipitoparietal junction, as well as upper cervical (C1-C2) asymmetry and fixation. These indicated the presence of cranial and upper cervical subluxations. INTERVENTION AND OUTCOME: The patient was treated 5 times through use of cranial adjusting; 4 of these visits included atlas (C1) adjustment. The suckling intolerance resolved immediately after the first office visit and did not return. CONCLUSION: It is possible that in the infant, a relationship between mechanical abnormalities of the cervicocranial junction and suckling dysfunction exists; further research in this area could be beneficial. Possible physiological etiologies of painful suckling are presented.     

Missed lumbar transverse process fractures in a high school football player

OBJECTIVE: To discuss the case of a football player who had suffered a transverse process fracture of the lumbar spine that was overlooked on initial chiropractic and medical examination. CLINICAL FEATURES: A 17-year-old male football player had been speared in the back by another player. He reported severe initial pain that caused him to fall to the ground, and there was a moderate degree of pain at the time of his chiropractic examination 1 week after injury. INTERVENTION AND OUTCOME: Initial chiropractic treatment consisted of spinal manipulation to the lumbar spine. Follow-up care consisted of lumbar spine radiographs that showed evidence of a lumbar transverse process fracture at 2 levels. The boy was referred to his medical doctor, who was not convinced of the presence of a fracture and returned him to play. A computed tomography scan was subsequently performed; this confirmed fractures of the transverse processes of L2 and L3. The patient was precluded from contact sports for 4 weeks. Chiropractic care 3 weeks after injury included physiotherapy and drop table mobilization to the sacroiliac joints. The patient returned to play 4 weeks after the injury. CONCLUSION: Transverse process fractures commonly occur secondary to blunt trauma in contact sports such as football. With high-force direct trauma, radiographs should be performed to rule out fracture before returning the athlete to play or commencing spinal manipulation.     

Line drawing analyses of static cervical X ray used in chiropractic.

OBJECTIVE: This review article identifies the chiropractic techniques used to assess the structure of the cervical spine as seen on the static cervical radiograph. DATA SOURCES: On-line search of MEDLINE, key words, radiograph and X ray in combination with cervical spine (vertebrae); the Chiropractic Research Archives Collection (CRAC); indexes published in the Journal of Chiropractic Research; conference proceedings from Annual Biomechanics Conference of the Spine, FCER sponsored conferences and Annual Upper Cervical Spine Conference; references identified from bibliographies of pertinent articles; a telephone poll of radiography/technique instructors at chiropractic colleges. STUDY SELECTION: Techniques that quantitatively assess relative alignment of skeletal structures or distortion of the spinal column. DATA EXTRACTION: Techniques were grouped according to the structures analyzed and the views used. DATA SYNTHESIS: Variables and artifacts that limit the reliability or validity of static cervical X ray line drawing analysis were identified and the techniques assessed for their reported reliability and validity. CONCLUSIONS: Reliability studies exist showing that inter- and intraexaminer reliability are sufficient to measure lateral and rotational displacements of C1 to within +/- 1 degree. This amount of error allows objective analysis of upper cervical X rays to detect changes in the angular positional relationships of radiographic images on the order of those already seen clinically. Methods of cervical analysis that use relative angular measures of skeletal positioning are best able to control the effects of radiographic distortion. The accuracy of the analysis methods has not been ascertained to establish the extent to which angular measurement of vertebral relationships actually reflect three-dimensional movement. It is not known how much of the changes that are seen in pre/post-radiograph sets are due to positioning changes of the patient between radiographic procedure, and how much are due to actual changes of skeletal relationships brought about by adjustment.     

Occipitalization of the atlas

This paper discusses occipitalization of the atlas and its relationship to the chiropractic practitioner. Patients commonly consult a chiropractor with complaint of headache, suboccipital stiffness, restricted motion, dizziness and other symptoms related to the upper cervical region. Differential diagnosis of the exact etiological factor of these symptoms must be made via a thorough history, physical examination, and roentgenological examination. If occipitalization of the atlas is detected on the initial roentgenological examination, then follow-up magnetic resonance imaging, computerized tomography or linear tomographic studies may be warranted to rule out concomitant diverse osseous and/or neural anomalous conditions of the cervical spine which may easily mimic symptoms of disorders commonly treated by the chiropractic practitioner. The chiropractic practitioner must obtain appropriate roentgenological and other diagnostic imaging studies to ensure proper evaluation of the structural integrity of the cervical spine before appropriate treatment can be rendered.     

Clinical considerations in the chiropractic management of the patient with Marfan syndrome

OBJECTIVE: To describe the chiropractic management of a patient with whiplash-associated disorder and a covert, concomitant dissecting aneurysm of the thoracic aorta caused by Marfan syndrome or a related variant. CLINICAL FEATURES: A 25-year-old man was referred by his family physician for chiropractic assessment and treatment of neck injuries received in a motor vehicle accident. After history, physical examination, and plain film radiographic investigation, a diagnosis of whiplash-associated disorder grade I was generated. INTERVENTION AND OUTCOME: The whiplash-associated disorder grade I was treated conservatively. Therapeutic management involved soft-tissue therapy to the suspensory and paraspinal musculature of the upper back and neck. Rotary, manual-style manipulative therapy of the cervical and compressive manipulative therapy of the thoracic spinal column were implemented to maintain range of motion and decrease pain. The patient achieved full recovery within a 3-week treatment period and was discharged from care. One week after discharge, he underwent a routine evaluation by his family physician, where an aortic murmur was identified. Diagnostic ultrasound revealed a dissecting aneurysm measuring 78 mm at the aortic root. Immediate surgical correction was initiated with a polyethylene terephthalate fiber graft. The pathologic report indicated that aortic features were consistent with an old (healed) aortic dissection. There was no evidence of acute dissection. Six month follow-up revealed that surgical repair was successful in arresting further aortic dissection. CONCLUSION: The patient had an old aortic dissection that pre-dated the chiropractic treatment (which included manipulative therapy) for the whiplash-associated disorder. Manipulative therapy, long considered an absolute contraindication for abdominal and aortic aneurysms, did not provoke the progression of the aortic dissection or other negative sequelae. The cause, histology, clinical features, and management considerations in the treatment of this patient's condition(s) are discussed.     

Criteria to Screen for Traumatic Cervical Spine Instability: A Consensus of Chiropractic Radiologists

Objective

The purpose of this study was to establish consensus on a radiographic definition for cervical instability for routine use in chiropractic patients who sustain trauma to the cervical spine.

Recognition of prodromal cervical spondylotic myelopathy presenting in a U.S. Veteran referred to chiropractic for acute thoracic pain: A case report

ObjectiveTo highlight a patient who was referred to a VA chiropractic clinic for thoracic pain and upon physical exam was found to be myelopathic, subsequently requiring surgery.Clinical featuresA 58-year-old male attended a telephone interview with the VA chiropractic clinic for thoracic pain of 4 months duration; he denied neck pain, upper extremity symptoms or clumsiness of the feet or hands. At his in-person visit, he acknowledged frequently dropping items. The physical examination revealed signs of myelopathy including positive Hoffman's bilaterally, 3+ brisk patellar reflexes, and 5+ beats of ankle clonus bilaterally. He also had difficulty walking heel/toe.Intervention and outcomeCervical and thoracic radiographs were ordered and a referral was placed to the Physical Medicine and Rehabilitation (PM&R) Clinic for evaluation of the abnormal neurologic exam and suspicion of cervical spondylotic myelopathy (CSM). He was treated for 2 visits in the chiropractic clinic for his thoracic pain, with resolution of thoracic symptoms. No treatment was rendered to the cervical spine.The PM&R physician ordered a cervical MRI which demonstrated severe central canal stenosis and increased T2 signal within the cord at C5–C6, representing myelopathic changes. The PM&R specialist referred him to Neurosurgery which resulted in a C5-6, C6-7 anterior cervical discectomy and fusion.ConclusionThe importance of physical examination competency and routine thoroughness cannot be overstated. Swift identification of pathologic signs by the treating chiropractor resulted in timely imaging and surgical intervention.