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The Static Postural Pelvic Exam
I include a static postural analysis in my evaluation routine whether you are a patient in pain or an elite-sport athlete in training. In my day-to-day practice, I require patients to stand still while I "just look" at them.
Ringing in the Billing New Year
What are the new modifiers that replace modifier 59? Will they allow doctors of chiropractic to be paid for 97140, manual therapy, when done with chiropractic manipulation?
News in Brief
While indignation may be your immediate reaction to H.R. 5780, the Protecting the Integrity of Medicare Act of 2014, the American Chiropractic Association suggests the legislation is just what the chiropractic profession needs.
Helping to Create the Healthiest Generation
The imperative to create the "Healthiest Generation by 2030," envisioned by the American Public Health Association (APHA), was in full force at the APHA's 142nd Annual Meeting held in New Orleans from November 15-19, 2014.
Right Back Where We Started?
More than 25 years after Judge Susan Getzendanner issued her historic opinion in the Wilk v AMA anti-trust case, evidence suggests that despite increasing collaboration between doctors of chiropractic and their allopathic medical counterparts, when it comes to organized medicine, we may be right back where we started.
Movement Assessments: The DC's Sphygmomanometer
I think back to when I was going through chiropractic school outpatient clinic. I was embarrassed to have my family and friends come in for treatment because initial evaluations took three hours to complete.
Trouble Down Under: San Zhen Therapy for Lower Jiao Issues
In the last several columns, I have discussed many clinical options for utilizing San Zhen or Three Needle Therapy. In this installment, I will continue this trend and discuss several foundational patterns which can be found in several very common clinical presentations.
Happy New Year 2015 Gong Hoy Fat Choi
Welcome to the year of the sheep! We begin a new year guided by the sign of a quietly and creatively organized animal.
Two for One: The Cervical Distraction Test
In today's healthcare system, diagnoses and treatment plans follow a western medical model - especially if you work with attorneys or insurance companies.
Taking the Freeze Out of Adhesive Capsulitis
Adhesive capsulitis or "frozen shoulder" is a relatively common condition resulting in severe shoulder pain and global loss of glenohumeral joint range of motion. Incidence of the condition is approximately 3 percent in the general population.
Fight Colorectal Cancer With Folic Acid
CRC is the second most common cause of cancer mortality in the U.S. and Canada. Although genetic susceptibility plays a role in the etiology of CRC, dietary factors, including certain vitamins, have also been shown to influence the development of the disease in various studies.
AWB Makes a Difference in the Yucatan
We are in the sleepy town of Izamal, located about an hour from the Merida airport where our group arrived last night. Later that morning, on a bus winding through the dusty roads of the Yucatan, fourteen acupuncturists, two facilitators from AWB and two tour guides make their way to the small rustic town of Popola.
We Get Letters & Email
Rethinking Our Approach to Immunization; Coming Together for the Good of Our Patients.
The Way of Zen Performance Enhancement
Working with elite athletes and implementing various techniques to keep athletes focused and at their optimal performance for a sustained period of time includes incorporating various meditation techniques that counterbalance their sport-specific physical and mental demands, which is an important element of success throughout the years.
Age and Fertility: Why We Should Worry Less About Age and More About Overall Health
Recently, on one of the acupuncture alumni forums, the topic of age and fertility came up when a practitioner posted a question regarding a patient that was about to turn 40-years-old.
Environmental Toxins: Cause of Modern Illness, Part 2
In Part I of this article, we detailed the variety of environmental toxins assaulting our bodies. These include pesticides and herbicides; plastics; preservatives; cosmetics; gasoline additives, solvents and glues; and heavy metals.
The App Advantage: Get More for Less
You may have noticed the list of "app-exclusive" articles in the directory on the front page of the print issue and in the Table of Contents on page 4. You can't find these articles in print or even in our online archives.
The Conscious Evolution of Healing: Importance of Opening the Sensory Portals in Classical Chinese Medicine
The Chinese medical classics are not just clinical guides. They give advice; ways we can awaken more fully into conscious awareness.
Professionalism and Evidence-Based Health Care
Today's chiropractors are facing a conundrum with the Affordable Care Act and its health care reform requirements, including evidence-based practice and health technology assessment.
Chiropractic Research in Review
Occupational LBP in Primary- and High-School Teachers; Treating MVA Complications With Chiropractic Care; Neck Pain: Immediate Effects of Active Scapular Correction; Taping Benefits Stride, Step Length in Fatigued Runners.
Show Up and Show Respect
I was recently asked about my chiropractic philosophy. My answer surprised my questioner.
Three for One: The Cervical Distraction Test
Taking the time to do an exam is important, but it is time spent. The exam serves as a way to physically validate your clinical impression following a history and clinical consultation.
How to Use Online Video as a Tool to Market Your Practice
Health care practitioners, including chiropractors, should consider online videos as a key element of their Internet marketing strategy. In the next three years, videos are expected to account for nearly 70 percent of all consumer online traffic, according to Cisco.
Acupuncture and its Place in the Integrative Healthcare Practice: The Need to Move from Modality to Profession
Acupuncture and oriental medicine (AOM) has grown and flourished from its inception thousands of years ago in China. In surrounding regions of Asia, AOM developed as a response to differing cultural, pathological, health and wellness care needs.
I Felt it in My Fingers First
I'm not afraid to say it. Massage therapists make better acupuncturists. I'll tell you how I know, but first I have a question: What do a microcurrent device, a laser and a hippie massage therapist have in common?
Animal Acupuncture Gaining in Popularity
We have just finished the year of the fire hoarse and now it is time to spend some time alone, daydreaming and thinking outside the box in terms of where our profession is headed. The sheep person is well organized and creative so this should not be difficult to do.
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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