resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
A Different Way of Looking at It
The way you and your chiropractic colleagues access information has changed over the past decade. According to a recent survey conducted by Dynamic Chiropractic, almost half (48 percent) of DCs read online articles on their personal computer or laptop daily.
With Low-Back Pain, Sometimes Little Things Matter
Typical treatments for low back pain involve large muscles like the quadratus lumborum, iliopsoas, and piriformis. However, there are situations when a very small muscle, the multifidus, can play a significant role in the diagnosis and treatment of low back muscular or spinal injury.
Billing Timed Services
Q: I do not always use physical medicine services but in my state I do have a scope of practice that allows me to provide many of these services. I am trying to understand what "direct one-on-one patient contact" means in relation to physical medicine services.
Billing One-on-One, Direct Patient Contact
This is often misunderstood and leads to trepidation when documenting and subsequently billing timed services.
Streamline Your Front Desk
Your front office can be your greatest source of efficiency or it can be a constant bottleneck. Increasing the productivity of this area, while not sacrificing the quality of patient interaction, can be a little tricky. However, with some focused effort and intention, your front desk can keep your practice running smoothly.
Sleepless nights, anxiety, mood swings, euphoric energy bursts, obsessive thinking, and a strange feeling in his chest. That is what Matt was experiencing when he first entered my practice. Rather than being concerned, he was loving every minute of it.
A Whole-Body Approach to Chronic Tension Headaches
Nearly every day in our practices, we see patients with chronic headaches that have not responded to traditional treatment. They present in our offices with a feeble hope that "maybe" a chiropractor can help.
In This Current Age of Anxiety
Anxiety, also referred to angst or hysteria, goes by many names. One, popularized by the sagacious Zhang Zhong Jing, who many practitioners of Chinese Medicine may be familiar with, is known as Restless Zang/Fu disorder.
Understanding Levels of Evidence
The concept of levels of evidence is a cornerstone of research literacy and a great starting point for understanding basic principles of how research works.
Keeping Malpractice Allegations at Bay
It has been suggested that in the litigious environment in which we live, the practice of chiropractic should be defensive and practitioners should constantly be watching their backs. An element of defensive practice is a good idea.
Living Well: Lessons From Our Oldest Old
Aging is a significant public health problem, important to chiropractors in practice and important to DCs who teach students training to become chiropractors.
The Need for Standards
ISO-TC-249: You may look at these letters and numbers and wonder what they are and what they might mean. They turn into: International Standards Organization- Technical Committee – 249. There is a global organization called The International Organization for Standardization.
Discovery: Finding Insights and Each Other in Different Disciplines
Recently I've been thinking about all sorts of things which are hidden from our daily direct experience. That general category is what links nearly everything that catches my attention and then demands some kind of investigation.
One of the most common trends to see in clinical medical practice and public health is the cycles of health "buzzwords." These come and go depending upon the current cultural zeitgeist. One year, "parasites" are causing all the issues, and the next year it's "candida."
Hip Flexor Contractures & LBP in Above-the-Knee Amputations
Patients with above-the-knee amputations (AK or AKA) are particularly prone to developing hip flexor contractures. Not to be confused with muscle tightness, contractures are a permanent shortening of tissues which cause deformity or distortion.
Constructing Our Reality, Part 2
My last article discussed perception and its relationship to the primary channels. Before we get to the channels most commonly used to treat sensory disturbances, the small intestine and triple heater, we should first talk about the bladder channel.
Holistic Skin Care and Modern Technology
Anti-aging is a concept that we hear in reference to skin rejuvenation and growing older on a daily basis. Aging begins as soon as we are born; therefore "pro-aging" is embracing all stages of life gracefully, with vitality, wisdom, joy, and gratitude as the goal.
Low Fat vs. Low Carb & the Power of Protein
A science-based website recently posted a nice summary of 23 randomized, controlled trials from peer-reviewed journals pitting low-carb diets against low-fat diets.
How to Reach Your World With the Chiropractic Message
My latest effort to share chiropractic occurred in mid-May while I was sitting at an introductory parent information night for high schoolers. The IT instructor informed us that each student would be receiving a computer for all their studies.
Distal Style Treatment of Neurogenic Pain
Treat locally or distally? This question has frequented my thoughts for the treatment of pain throughout my acupuncture career. Each style has strengths and weaknesses, thus the versatile practitioner would do well to forgo dogmatic adherence to any one style in deference to the needs of the individual patient.
Transforming Las Vegas
On a warm spring day in Las Vegas, Sonia Kim, clinic front desk staff, is busy preparing for a full day of intern shifts at Wongu Health Center. She greets patients, makes sure documents are properly signed, and lets the interns know that their patients have arrived.
News in Brief
NYCC Aggregates Degree Programs in New School; Palmer Chancellor Receives Education Award From ICA; Oklahaven Announces "Have a Heart" Winners.
Parker University Embraces New Era
Change is in the air at Parker University, which recently announced the selection of both a new president and a new consultant for its seminar program.
Prostate Cancer Risk
A large study published in January 2016 in the American Journal of Clinical Nutrition showed that men who are vegans had a 35% lower risk of developing prostate cancer compared to non-vegan men. The study followed more than 26,346 men who are part of the Adventists Health Study-2.
Building Bridges with Discipline
As practitioners of traditional Chinese herbal medicine, our role is to educate patients and medical practitioners about the various safety aspects of our medicine. Medical doctors that embrace Chinese medicine want to collaborate and include Chinese herbal medicine in more aspects of clinical care to support their patients.
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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