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Giving Vets the Care They Deserve
The Department of Veterans Affairs (VA) administers the largest integrated health care system in the United States.
A Poor Choice for Pain Relief
Acetaminophen is the most popular pain reliever in the U.S., accounting for an estimated 27 billion annual doses as of 2009. With 100,000-plus hospital visits a year by users, it's also the most likely to be taken inappropriately.
Marijuana, Apathy and Chinese Medicine, Part 1
This article was written in response to the unheeded acceptance of marijuana as a harmless substance that potentially does good when used for the medical relief of pain.
The Tide is Rising in the Acupuncture Profession
Former President Ronald Regan said, "When the tide rises all boats float." The tide is rising for the acupuncture profession. Many forces outside the profession are helping the tides to rise.
5 Tips for Using Pinterest to Market Your Practice
Pinterest is a very popular, but often under-utilized, social media platform where people can bookmark, or "pin," fun and interesting things from all across the internet.
First Do No Harm?
There's no questioning the frightening nature of breast cancer, which strikes one in eight women in the U.S. – eclipsed only by skin cancer in terms of prevalence.
Spieth Thanks His Chiropractor After Historic Masters Win
Jordan Spieth didn't just capture the hearts of golf enthusiasts worldwide with his record-setting, wire-to-wire victory at the 79th Masters Tournament.
ACA or ICA: Which Best Represents You?
Last June, I was honored to represent Texas ICA members as their representative assemblyman at the ICA Annual Meeting in Kansas City.
5 Simple Steps to Create an Effective Marketing Calendar
In the educational experience of most healthcare practitioners, business and marketing are overlooked topics.
Leg-Length Inequality and Pelvic Fixation: A New Approach to the Negative Derifield (Part 2)
As we noted in our previous article, with a positive Derifield (+D), the doctor observes the reactive (shorter) leg in the prone position that becomes longer or "crosses over" in the flexed position.
Our Biggest Challenges to Compete in Wellness Care
In the first article in this four-article series [May 1 DC], I made the case that chiropractors should either embrace offering lifestyle wellness in their practices or face the possibility of losing their place in the wellness care marketplace.
Professional Credentialing and Board Certification: An Ethical Faux Pas
Because of the Affordable Care Act, health care systems are coordinating care through accountable care organizations (ACOs) in order to reduce the cost of care and improve quality of care.
Rethinking Musculoskeletal Pain – A Public Health Perspective
The American Public Health Association (APHA) is the world's oldest and largest association of its kind, founded more than 140 years ago and boasting over 25,000 members.
Integrating Art with Clinical Practice for Patients with PTSD: The Artemis Project
Are you restricted by those one-on-one clinic dynamics? Why not join colleagues and clients in experimental group settings? Three of us volunteered to do just that in Austin on behalf of women veteranss from all branches of the service.
The Acupuncturist's Problem
I want share with you some observations and insights into what seems to be the most common problem my colleagues in the acupuncture profession struggles with. If you also struggle with this problem, I hope you get a valuable "aha" moment from reading this.
The Challenges of Integrating Eastern and Western Medicine
My Masters thesis was titled, "The Challenges of Integrating Eastern and Western Medicine," which highlighted several reasons why it is hard for these two worlds to mix.
Animal Acupuncture: A Case Study in the Treatment of Traumatic Injury in the Equine
The rise of animal acupuncture in the U.S. began in the early 1970's as a result of the work by members of the National Acupuncture Association in Westwood, Calif.
Green Tea Improves Cognitive Function in Elderly Subjects
Publishing their results in the journal Nutrients in May 2014, researchers showed that drinking the equivalent of 2-4 cups of brewed green tea (or bottled tea) daily improved cognitive function or reduced the progression of cognitive dysfunction in elderly subjects.
We Get Letters & Email
A House Divided? (May 1 issue) provoked significant response from readers. Here are several of the surprisingly similar comments we received.
PCOM Granted Regional Accreditation
Pacific College of Oriental Medicine (PCOM) recently announce it has received regional accreditation from the Western Association of Schools and Colleges (WASC). This achievement reflects five years of hard work on the part of faculty, staff, and students.
How Much Do You Know About the Benefits of Birds Nest?
Edible bird's nest is the nest made by the Swiftlet bird of Southeast Asia that is usually prepared as a soup and prized in Chinese culture as a healthful delicacy.
Medicine is Clumsy, Don't You Be
All medical systems have clumsiness in them. If the technique isn't, the practitioner is. Everyone in every form of medicine is striving to improve. That is why we call it practice.
April, 2008, Vol. 08, Issue 04
The Progression of Cervical Stenosis Toward Cervical Spondylotic Myelopathy
By Dale G. Alexander, LMT, MA, PhD
Have you ever wondered whether there might be a neurological connection between chronic upper and lower extremity difficulties? There is one neural tract that has received little attention, yet clearly tends to be part of a long sine wave of progression toward reducing the quality of our lives. It is the neural reflex arc related to C5-6 outlined in the illustration.1 This relationship can be a co-conspirator in sciatic syndromes along with the same-sided upper extremity, shoulder and cervical difficulties. In addition to the progression of gallbladder dysfunction described in my previous article series, I have observed that the progression of cervical stenosis is implicated in many of the chronic problems our clients present to us.
The problem begins with a narrowing of the central cervical canal where, most commonly, the vertebral bodies of C4, 5, 6 or 7 may compress the canal, encroaching upon one or both of the foraminal openings for the exiting spinal nerves and eventually pressing on the spinal cord itself. This progressive compression is called stenosis.
The simple picture is to visualize the bony spine pinching the spinal cord more and more tightly over a period of years.2 Congenital predisposition (a narrow central canal at birth), accreted trauma or a major trauma often advances this progression to show itself earlier in life or in the severity of its expression.
Stenosis can occur anywhere along the length of the spinal cord but is most frequently identified in the cervical region.3 The segmental levels of L4-5, L1-2 and T8-9 are other areas where my clients report medically identified stenosis. An MRI scan can show the degree of central canal or foraminal compression and any spinal cord pinching. A CT scan often is used to determine the extent of bone remodeling, disc deterioration/herniation or the presence and types of osteophytes and spurs. Together these two tests usually are considered definitive in making a medical diagnosis, although additional testing sometimes is used for surgical planning.4
I distinctly remember a female client in her early 50s who came to me some 20 years ago and announced she had been diagnosed with cervical stenosis. Initially I freaked, as my understanding of this problem was minimal and is part of my motivation to write this article.
Yet, as I opened my awareness and began working with the layers of connective tissue and muscles of her neck and shoulders, I felt guided by her body's innate sense of what to draw from my library of skills at the time. She felt better and I learned a lot. And during the past decade, I have experienced an increasing number of clients whose chronic problems lead back to this C4-5-6-7 neurological relationship as a significant slice of the body's homeostatic pie.
Each of you has developed your own library of skills. Trust that your clients will evoke from you the best you have to offer. It is not technique but "intention" that opens the door to using your perception and kinesthetic instincts as therapeutic aides. Extend your awareness to the inside of their body. Centering yourself with them in embodiment, occupancy, congruence and presence invites their body to guide you.5
What I hope you will hold in your awareness at the end of this article, and any that follow, is the prevalence of progressive cervical stenosis and your consideration of it as a likely contributor to your clients' chronic somatic complaints. I also hope you will consider its possible contribution to diminished sensory and motor function of either the upper or lower extremities, and that you will develop a sense of when to refer clients on to physicians.
As in previous articles, I will make some speculative leaps into the underlying functional physiology of this degenerative progression. The distillation of information I wish to share will be broad brushstrokes because this diamond has so many facets and thus will be incomplete. But it will be a beginning.
The progression of cervical stenosis is quite similar to the gradual onset of gallbladder dysfunction in its progression toward disease, as it tends to fly under the radar of medical detection until more classic symptoms begin to point in its direction. Multiple sources suggest that in the early stages of cervical stenosis, it most often is asymptomatic.3,4 One reference suggested "symptoms are believed to develop when the spinal cord has been reduced by at least 30 percent."4
One of the principal factors to the narrowing of the central canal is spondylosis or osteoarthritis, with its accompanying disc thinning, bone remodeling, osteophyte and/or spur formation. This progression, coupled with the effects of congenital and/or accreted traumatic influences such as whiplash episodes or events involving cranial compression upon the neck, eventually can converge to further narrow the central canal and one or both of the foraminal openings for the exiting spinal nerves. Once sensory or motor function is affected, the term myelopathy is used. So, cervical stenosis progresses to cervical spondylotic myelopathy (CSM).
Myelopathy is distinguished from radiculopathy in that the pain or numbness patterns do not necessarily follow the commonly accepted map of the sensory nerve dermatomes. The pain and numbness of myelopathy tend to be more general. For example, broad areas of the neck, shoulder, arm, hip or leg are affected. And radiculopathy can coexist with myelopathy.3,4 For a quick review of the body's sensory dermatomes, please refer to Netter's Plates, pp. 150, 455 and 511.6
Quite often, the sensory or motor symptoms that do emerge during the progression from mild to moderate myelopathy do so insidiously. Among these may include:
The insidious part of these clinical indicators is that they come and go. Clients and their physicians often dismiss them as insignificant because they do go away. Instead of ignoring or denying these signs, we need to be part of our clients' early detection team.
Often, this collection of somatic complaints is filed away under the general heading of the aging process. The assumption that if something goes away on its own, there is no underlying pathological progression is one of my least favorite notions equaled only by the "oft-repeated saw" that children eventually will "grow out of" their somatic aches and pains and functional difficulties. And sometimes, a cigar is just a cigar. Either and both can be accurate given the mathematical curve of our genetic diversity. The important flag for our consideration is that when clients of ages 50 and older seek us out for assistance with their chronic problems, the progression of cervical stenosis is a possible and more probable part of the symptomatic puzzle.
When CMS is full blown, all of the above symptoms become exaggerated, more persistent and may include muscular atrophy of one shoulder, arm and/or hand and/or the emergence of an ataxic gait pattern. An ataxic gait pattern can have many expressions, yet typically is characterized by taking a step by lifting the advancing leg too high and then slapping it down to the ground. There often is an uneven spacing of steps and tottering or swaying also may occur. I personally observed one of my clients demonstrate the following: The affected leg is rigid and is swung from the hip in a semi-circle by the movements of the trunk. Then the patient leans to the affected side, and the arm on that side is held in a rigid, semi-flexed position.7 With obvious haste, I encouraged the client to seek a referral to a neurosurgeon even though they were able to walk out of my office with an improved gait pattern following our session. It is crucial that we recognize our role in referring clients.
It is estimated that approximately 80 percent of our aging population has some degree of clinical progression toward cervical spondylotic myelopathy.8 Mutiple sources note that "it is the most prevalent spinal cord dysfunction of people over 55 in North America."3,4 I find it interesting that in a parallel fashion, it has been speculated that 70 percent of the U.S. population over the age of 70 will experience gallstones and that these stones are estimated to take, on average, 11 to 25 years to become clinically obvious.9,10
Thus, my first speculative leap into functional physiology is to propose that gallbladder dysfunction and cervical stenosis may have an overlapping progression, as they share a common neurological junction at C5-6 related to the phrenic nerves, the brachial plexuses and C5-6 reflex arc's relationship to the same-sided sciatic nerve distribution.1,11 My clinical experiences do not imply any cause-and-effect relationship in a predictable sequence, but simply reflect the repetitive nature of what I have observed in my client population.
A female client who came to me following surgery for cervical myelopathy reported that most of her pre-surgical symptoms, principally left neck, right shoulder/scapular and same-sided hip pain, still bothered her, with the exception that her right shoulder and arm muscles had ceased their progressive atrophy and that she had been able to rebuild some of her strength and the general use of her right shoulder, arm and hand.
Over the next year, she committed to an extended series of treatment sessions. Her somatic complaints reduced considerably and her fine motor control improved. However, digestive complaints began to emerge. I encouraged her to return to her physician, requesting that they explore these symptoms. Long story short, her gallbladder was removed.
Her cervical myelopathy surgery was successful, as it did stop the progressive atrophy of her shoulder, arm and hand muscles. However, her cervical and shoulder pain, radicular arm and hand dysfunction and same-sided hip tightness continued unabated until she began treatment with me. Following the removal of her gallbladder, all of the above symptoms have diminished to more tolerable levels and she continues to receive periodic care.
Let us reprise: My intention in this first article is first, to highlight that there exists a little-recognized neurological relationship between the cervical reflex arc of C5-6 and lower extremity difficulties; second, to theorize that cervical stenosis progressing toward cervical spondylotic myelopathy may underlie many of the chronic somatic complaints that our clients bring to us either as a singular symptomatic etiology or in combination with other subtle progressions such as gallbladder dysfunction/disease; and third, to offer a listing of early indications of this progression so we may refer our clients for appropriate medical testing.
Additionally, I would speculate that as the population over the age of 50 continues to rise dramatically in our country over the next decade, we will have ample opportunity to be of assistance with clients experiencing this progression. I believe our profession will not only make a significant difference to improving the quality of life for our clients, but also can serve to educate our clients about the prevalence of this progression and encourage them to seek early detection through appropriate medical testing.
A caveat of perspective: Twenty years ago an MRI scan cost approximately $10,000, whereas today it runs approximately $1,600-$2,400 via insurance policies and can be done for $400-$700 in certain centers when direct personal payment is made. Encouraging our clients to seek such a diagnostic test may assist them in making important lifestyle choices and/or medical decisions.
In my next article, we will delve further into the many facets associated with cervical stenosis and its potential progression toward cervical spondylitic myelopathy.
Click here for more information about Dale G. Alexander, LMT, MA, PhD.
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