CASE STUDY
Symptomatic Improvement of a Patient with Parkinson’s
disease subsequent to Upper Cervical Chiropractic care: A
Case Study
Robert Bello DC
ABSTRACT
Objective: The purpose of this case study is to report the symptomatic improvement of a Parkinson’s patient undergoing
specific upper cervical chiropractic care.
Clinical Features: A 66-year-old female that had been diagnosed with Parkinson’s disease (PD) one-and-a-half years
prior, entered a National Upper Cervical Chiropractic Association (NUCCA) clinic for chiropractic care, She had
symptomatic complaints since three years prior, following an unbraced fall in which she landed directly on her face while
doing the Cha-Cha during an evening of ballroom dancing. Her symptoms, which had been getting progressively worse,
included a resting tremor in her left hand, fatigue, depression and rigidity throughout her extremities, especially in the
third toe of both feet.
Interventions and Outcomes: The various analysis techniques employed by the NUCCA doctor will be discussed in
detail, including postural analysis, thermography, static surface electromyography, functional leg length analysis and a
series of precision pre and post orthogonal-based cervical x-rays. After receiving a specific, light force NUCCA
adjustment, the patient reported immediate symptomatic relief, which has persisted through the time this study was
written.
Conclusions: Although this case demonstrates the [far-reaching] possibilities of specific upper cervical care in nonmusculoskeletal cases, there is a serious need for additional research in order to make a multidisciplinary co-management
approach to clinical care more viable.
Key Words: chiropractic, NUCCA, Parkinson’s disease, upper cervical, subluxation, orthogonal
Introduction
respective countries are inflicted with this disease.2
Currently, there are thought to be over a million cases of
Parkinson’s disease (PD) in the US and 100,000 new cases
estimated annually.1 A European study comprising
participants from France, Italy, The Netherlands and Spain
deduced that an average of 1.6 people per 100 in their
In 1997, the annual costs related to PD in the US alone was
estimated to be $24 billion. Originally referred to as Shaking
Palsy, the disease received its current name in 1817 from the
British scientist James Parkinson. He was responsible for
recording a list of what are currently delineated as the
Private Practice of Chiropractic, White Plains, NY
symptoms of PD, such as resting tremor, stiffness/rigidity,
bradykinesia, depression, altered gait and dementia. 1
Parkinson’s disease, also called Paralysis Agitans, is a
progressive neurodegenerative disease characterized by
diminished dopamine producing cells within the basal ganglia.
Nigrostriatal axons from the pars compacta portion of the
substantia nigra connect within the striatum (globus pallidus
and caudate nucleus) portion of the basal ganglia and are
responsible for production of dopamine within the basal
ganglia complex. The overall affect of decreased dopamine
within this system will increase the activity of the globus
pallidus, cumulatively inhibiting output to the ventrolateral
thalamus, and hence the cortex, thus yielding a decrease in
motor output. 3
One of the primary functions of the basal ganglia is to provide
proper modulation of muscles by supplying an inhibitory
mechanism in motor actions. When functioning optimally,
this system ensures smooth motor patterns. However, with
Parkinson’s patients, there is a disconnect in this coordination
and dyskinesias as well as resting tremors are commonly
present.4 Upon presentation of a symptomatic Parkinson’s
patient, the dopaminergic cells are found to be 60-80% lifeless
or functionally impaired.4 Although there are many questions
unanswered regarding the origins of this crippling disease, a
mix of epigenetic (gene expression) and environmental factors
(toxins, trauma) have been demonstrated in the literature to be
associated with the onset of PD.5-6
which is a synthetic precursor to Dopamine and is permeable
to the blood brain barrier. Sinemet, the most common brand
name prescription used, is a mix of Levadopa and a
Carbidopa. Carbidopa is added to ensure that dopamine is not
converted too quickly in the brain, which can result in too
much dopamine produced and dyskinesias may occur.
The biggest downside to Levadopa treatment is that the body
tends to build tolerance and the effects have the tendency to
become mitigated after few years of treatment. There are a
host of other types of drugs whose effects range from
temporarily increasing dopamine levels to decreasing the
breakdown of dopamine within the synaptic junctions (ie.
dopamine agonists, MAO-B inhibitors and COMT
inhibitors).8-9
The two surgical interventions that are most currently
employed are deep brain stimulation (DBS) and
pallidotomy’s. DBS is a procedure where electrodes are
implanted into different locations in the brain and electric
signals theoretically stimulate the chosen areas to increase
activity. A Pallidotomy is a surgical procedure that attempts
to decrease activity in a portion of the Globus Pallidus by
either heating or cooling surgically implanted probes until the
surrounding tissue dies.
The goal is symptomatic
improvement of dyskinesias.8 Again, these procedures are not
meant to be a permanent solution to PD, but to provide
temporary symptomatic relief.
Case Report
Traditionally, when attempting to diagnose PD, a qualified
physician will perform a litany of general physical and
neurological examinations.
Upon completion of these
examinations, subjective clinical manifestations are recorded
in order to gather relevant information.
To categorize the progression of PD, the Unified Parkinson’s
Disease Rating Scale (UPDRS) and the Hoehn/Yahr and
Schwab/England scales are the most common surveys utilized.
These surveys record responses to subjective questioning and
ascertain levels of everyday functioning regarding movement
and behavior tasks. Although there are currently no widely
accepted gold standards for the definitive diagnosis of PD,
experimental use of both Single-Photon Emission Computed
Tomography (SPECT) and Positron Emission Tomography
(PET) scans have been utilized. These studies quantify the
remaining functional dopaminergic cells in the substantia
nigra.4, 7
Parkinson’s symptoms classically occur in adults 55 or older,
beginning unilaterally with a mild tremor and altered arm
swing. Most commonly these motor symptoms will manifest
bilaterally over time and are accompanied by other symptoms
such as depression, fatigue, anosmia (loss of smell),
constipation, diminishing facial expression, balance issues and
shuffling gait.8 As the disease progresses, the inflicted
individual may also experience pain, confusion, temperature
sensitivity, sleep problems, sexual dysfunction and dementia. 8
Current drug and surgical therapies are not curative, but
focused at temporary symptomatic relief to improve quality of
life for as long as possible until more permanent solutions are
uncovered. The most common drug treatment is Levadopa,
History
A 66-year-old female patient entered a NUCCA chiropractic
office. She was referred in by a relative who had been
researching health care practitioners that have demonstrated
positive outcomes with disorders of the central nervous
system. The patient had a family history of PD (her father and
uncle had been inflicted with PD) and she was diagnosed by a
neurologist when a PET test was performed using the nuclear
tracer F DOPA. The test demonstrated bilateral decreased F
DOPA uptake, with the largest deficit occurring in the right
posterior Putamen. This was concluded by the director of the
imaging facility to be consistent with early stage idiopathic
PD.
All of the symptoms started the day after a fall when the
patient was doing the Cha-Cha during a ballroom dancing
function. The heel of her shoe got caught in a gap in the floor
and she fell straight onto her face without any ability to brace
her fall. After it was ascertained that she did not need any
emergency medical attention, her husband brought her home
to rest.
The next day it was apparent that she did not escape this fall
without incident. After getting up and out of the house, she
and her husband immediately noticed that she was limping
with the left leg and she had an inability to swing her left arm.
This alarmed the couple and so began a two-year search that
led them to internists, neurologists, psychiatrists, holistic
practitioners and the like without any definitive diagnosis.
This seemingly endless process of attempting to determine the
cause of her symptoms finally came to a halt 8 months later
when the patient had PET study performed and it was
determined that she had a loss of dopaminergic cells that was
consistent with PD. In those two years of searching for a
diagnosis her arm became much worse and she could hardly
use it. A litany of other symptoms had emerged such as
depression, resting tremor in left hand, fatigue, rigidity in
upper and lower extremities, especially in the third toe of both
feet.
Traditionally, the NUCCA doctor will determine from the
postural evaluation and leg length assessment if the patient is a
candidate to move forward with further x-ray assessment.
Relying on the utmost precision, the NUCCA doctor will take
three x-rays from very distinct vantage points (frontal,
horizontal and sagittal) in order to obtain a three dimensional
study of where the atlas vertebra is exactly positioned in
relation to the skull above and the remainder of the cervical
spine below.
After being diagnosed with PD the patient was put on Sinemet
(Levidopa/Carbidopa), which did not provide the patient any
perceived symptomatic relief. When interviewed for this case
study the patient purported that she was told that she had been
on a time-released prescription of Sinemet, but just recently
found out she was not. At the time, the lack of symptomatic
fluctuations made sense to her because the dosage she was
taking was supposed to be released throughout the day and
maintain her symptoms at constant levels. The fact that she
did not have changes in her symptoms throughout the day,
when she should have normally because she was supposed to
be re-dosing, made her recognize that the administration of
this medication did not affect her symptomatically.
A very precise line drawing analysis will then be performed
that will determine the location and severity of the
misalignment. The measurements are converted into a listing,
which gives the doctor the specific side and degree of
misalignment as well as the exact direction of force needed for
the subsequent correction. The doctor grabs the backside of
his wrist and uses the skin around the pisiform bone on the
hand closest to the skin of the patient as the interface point
between the doctor and patient.
Examination
When the patient arrived in the NUCCA office, she filled out
an intake form listing all of her signs and symptoms and had a
brief consult with the doctor. The patient was then sent to an
examination room where several thorough tests were
conducted, namely a range of motion study, postural analysis,
functional leg length test, thermography and static surface
EMG (electromyography).
She demonstrated a left leg deficiency of a half an inch, high
right shoulder, high left ilium and right head tilt. The Insight
Millennium Subluxation Station was used to assess paraspinal
heat asymmetry and muscle imbalance. The thermography
exam demonstrated thermal asymmetry down the entire right
side of the spine with the greatest difference located at the C1
vertebra.
The static surface electromyography showed bilateral
hypertonic musculature in the C1 and C3 regions and
bilaterally in the area of the sacrum. The program then puts
all of the figures together and computes a total energy
expenditure value, which when equaling 100 means that the
nervous/musculoskeletal systems are running efficiently. The
patients total energy expenditure value was 273.85, which
exemplifies that her body was running very ineffectively. The
results of these studies demonstrated a pattern that is
consistent with interference to the nervous system (in
chiropractic referred to as a subluxation). These findings then
gave the doctor enough data to progress with the remainder of
traditional NUCCA protocol for analyzing the location and
severity of the suspected subluxation.
NUCCA chiropractic care
The NUCCA system is a chiropractic protocol that specializes
in finding misalignments in the first cervical vertebra.
The NUCCA practitioner always uses the x-rays to determine
where to precisely contact the patient on the side of the neck
so to be directly over the transverse process on the lateral
aspect of the atlas, which lays about an inch beneath the skin.
The objective of the NUCCA practitioner is to create just
enough force to overcome the resistance created by the
misaligned vertebra.
The doctor administers several light force maneuvers in the
direction of calculated line of necessary correction until the
atlas is back in place and the proper correction of the
misalignment has been accomplished. The NUCCA doctor
will then recheck functional leg length discrepancy as well as
posture.
If the doctor feels that the post adjustment
assessments have demonstrated that the subluxation has been
reduced or removed, a post x-ray study will be performed.
When comparing the results to the pre-adjustment x-ray study,
it can be determined if the correction of misalignment has
been objectively evidenced by bony alignment changes.
In this case the patient received the adjustment and was
allowed to rest on the NUCCA adjusting table while the
doctor left the room for several minutes. The patient stated
that she had felt a warm, flushing of her face. She also
described the feeling felt throughout her body as compared to
the sensation of muscular relaxation one experiences when
making and holding a very tight fist then opening it up and
feeling the release. After the doctor came back in the room,
he determined that her reaction to the adjustment (her leg
length inequality was now balanced and her postural
assessment had positively changed) warranted a post x-ray
study to be conducted.
Upon performing post x-ray line drawing analysis, there was a
correction in the alignment of her atlas to the skull and to her
cervical spine that was objectively measurable.
The
πhorizontal planes of the atlas, the skull and cervical spine
were all restored to parallel, in respect to each other, and
additionally created right angles with the central vertical
aspects of the skull and cervical spines, which is referred to as
“orthogonal” in various chiropractic techniques.
From the NUCCA doctor’s perspective, this is the ideal
position for theses structures to lie and is the final product of a
concise analysis and precisely implemented vector driven
NUCCA adjustment.
The patient stated from this point on that the vast majority of
her symptoms have completely gone away. The exception is
her third toes on both feet are still rigid on occasion. She
stated that her depression was totally gone and her energy
came back, her coping skills returned, her constant tremor was
gone, all the tightness in her muscles had ceased and she now
had regained all use of her left arm and leg. She simply put it,
“I have my life back.” She has been returning regularly to the
doctor’s office to be analyzed to make sure her body has been
holding her corrected alignment and receiving adjustments
only if determined that she is subluxated.
Objectives of Analysis
Functional Leg Length Assessment
Functional leg length assessment is an analysis procedure used
by many traditional chiropractic techniques to assess the
overall health of the nervous system. Through research efforts
this procedure has been evidenced to have high degrees of
inter and intra-examiner reliability as well as validity as an
analysis tool.10-12
The theory states that when there is an imbalance to the
nervous system this causes a subsequent hypertonicity of the
large muscles of the pelvis, which will potentially draw one
leg short.13 Due to the various connections of the spinal cord
via the dentate ligaments to the surrounding bony structures of
the upper cervical neural canal, it is hypothesized that during a
misalignment of the atlas vertebra, the spinal cord can become
tractioned.13
Thermography and Static Surface Electromyography
Thermography is a diagnostic tool used to read paraspinal skin
temperature to assess the functioning of the autonomic
nervous system. According to Uematsu et al, “The system is
governed by the autonomic nerve impulses generated from the
hypothalamus and the brain as a whole. The system is both
anatomically and physiologically symmetrical.”20
So upon running the thermal scan down the skin over the
spine, the Insight Millennium computer program outputs a
diagram of a human torso and uses colored bars on opposite
sides of the spine to depict location and degree of asymmetry.
The white represents within normal physiological limits, green
is one standard deviation from normal, blue is two standard
deviations from normal, red is three deviations from normal
and black is over three standard deviations from normal. As
long as proper protocol is followed, thermography has been
demonstrated to be reliable and valid in assessing the
autonomic nervous system within an office setting.20, 21
Static surface electromyography is an assessment of the
paraspinal musculature that is focused in determining possible
asymmetrical contracture, muscle splinting, abnormal muscle
recruitment patterns and severity of the particular condition. 22,
23
Demonstrated to have inter and intra-examiner reliability,
this technology is often used by chiropractors on the first visit
to measure the current state of a patient’s paraspinal
musculature and then again during ongoing assessment exams
to correlate with the care the doctor has rendered.22-24 With
myopathology being considered as one of the main
components of the subluxation, electromyography is an
essential tool for the chiropractor to assess the proper
functioning of the nervous system.14
Pre and Post X-ray Marking System and Analysis
Subsequently, the lateral structures of the cord become
compromised, namely the spinocerebellar tract. The most
lateral fibers of the dorsal spinocerebellar tract are responsible
for the larger muscles of the pelvic girdle so it is thought that
even the most minimal mechanical stress caused by a minor
bony misalignment of the upper cervical spine can cause the
legs to have a functional inequality.13-14
It has also been purported that dysfunctional muscle
physiology, such as chronic muscle contracture or shortening
as seen in subluxation, can cause the muscle spindles to relay
corrupt afferent messages to the central integrating centers
(referred to as dysafferentation), which can result in poor
efferent output and cause a vicious cycle not only in the
musculoskeletal system, but can involve the viscera as well.14-
NUCCA, along with the vast majority of upper cervical
chiropractic techniques, employs very precise x-ray analysis
procedures that allow for a change in objective criteria, the
juxtaposition of bones to one another, to be demonstrated post
adjustment
and
be
correlated
with
symptomatic
improvements.25-28 These films are a key, reliable foundation
which allow the practitioner to demonstrate postural changes
that result moments after the adjustment.27, 28 Once the doctor
knows that the correction performed results in the proper
orthogonal positioning, they can be confident that their x-ray
analysis has produced the precise information they were
searching for and that the symptomatic improvements are due
to the correction of the subluxation.
18
Discussion
This is particularly valid when considering atlas subluxations,
because the suboccipital muscles that attach the top vertebra to
the surrounding bony structures—oblique capitus inferior,
oblique capitus superior and rectus capitus posterior—are the
most richly concentrated per gram of tissue with muscle
spindles than any other muscles in the body (242/gram,
190/gram and 99/gram respectively).19
Due to the lack of known causes of PD, the abrupt
symptomatic changes that followed the NUCCA adjustment in
this case warrants discussion as to what possible mechanisms
could be responsible for such drastic relief. When addressing
PD and upper cervical chiropractic, reference must be made to
Elster’s work, in which she cites dysafferentation and cellular
hibernation as possible mechanisms affected by the upper
cervical adjustment.29-31
Chronic facilitation of the dorsal horn has been demonstrated
to spill over into the lateral horn, which increases sympathetic
tone, causing arterial constriction and ultimately cerebral
hypoperfusion.16-18, 32 This occurs by way of a chain reaction
of faulty mechanoreceptive afferent information, in this case
possibly resulting from proprioceptively-rich muscles held in a
sustained contracture due to the atlas misalignment. This
appears to be a plausible mechanism for cerebral
hypoperfusion seen in PD because the basal ganglia would be
affected as a result of reduced blood flow from the internal
carotid artery.
Consequentially, the internal carotid artery supplies the middle
cerebral artery, which divides into the lenticulostriate
branches—the direct blood supply to the basal ganglia. 33
Terrett’s cerebral hibernation theory, based on the research of
Milne and Gorman, does make a conceivable argument for the
idiopathic nature of particular cases of PD. The progressive
symptomatology is proposed to result from a cellular
dysfunction (hibernation) that precludes cell death when in the
presence of ischemic conditions.34
With the development of precision advanced imaging
technologies, there has been an abundance of research focused
on locating the presence of cerebral hypoperfusion in PD
patients. This research has linked exact locations of blood
supply deficit to specific symptoms associated with PD
including minor depression, tremors, memory loss, postural
instability, general motor deficits as well as the duration of the
disease.35-39
There is also mounting evidence one of the mechanisms of
efficacy of DBS (specifically in the pedunculopontine nucleus
[PPN] region) in attaining symptomatic relief is due to the
incremental increase in regional blood flow that results from
the procedure.40 The ability of the nigrostriatal axons to
become functional upon the restoration of proper blood flow
followed by the correction of the atlas subluxation is a
promising theory that requires more research to satisfy
requirements in becoming valid and widely accepted
throughout the scientific community.
Classically explained by using the common computer jargon,
“garbage in garbage out,” the second possible mechanism
responsible for the drastic symptomatic improvement seen in
this case is based on the theory of dysafferentation.
Mechanoreceptors and muscle spindles are continuously
giving feedback into the cerebellum and cerebral cortex to
appropriately modulate activities ranging from simple
movements to an intricate dance performed by a ballet dancer,
as well as cognition and emotion.14, 18, 43-44
With the patient in this case having a family history of PD,
this gives her an epigenetic predisposition to developing PD
after the age of fifty. This is especially true in the event of a
trauma like she experienced, which acts as an environmental
trigger. This theory contends that subsequent to the fall, a
maladaptive neurological cascade occurred, which resulted in
the start of a vicious cycle where the basal ganglia’s
dysfunction was caused and then perpetuated by faulty
mechanoreceptive input via the injured upper cervical spine.
The administration of the properly performed NUCCA
adjustment then stimulated a mechanoreceptive influx to both
the cerebellum and cortex simultaneously.3 This afferent input
then fired both the cerebellum and cortex directly into the
basal ganglia and had the effect of activating the neuronal
pools within the basal ganglia, which resulted in the
restoration of proper basal ganglia function.3
Although these scenarios are deduced using proven scientific
concepts, they are both theoretical until further research can be
conducted that contains greater levels of evidence and the
ensuing results are accepted throughout the research
communities at large.
Conclusion
In the search for mechanisms of etiology and effective
interventions for idiopathic neurodegenerative diseases such
as PD, it is encouraging to see chiropractic’s current potential
contribution, as well as the future implications it may continue
to have with evolving research. The fact that this is a case
study predetermines any results attained incapable of
surmounting the status of anecdotal evidence. Another
unfortunate weakness of this case study is that the patient did
not get a follow up PET study to determine if there was any
quantitative change in the properly functioning dopaminergic
cells post adjustment.
With current, exciting NUCCA research documenting whole
body physiological benefits (reduction of blood pressure equal
to that of two prescription drugs) resulting from the precise
correction of an atlas subluxation, it is apparent in the logical
mind that a systemic effect is rendered with this specific
chiropractic protocol.41 In the research world, there are
hierarchal levels of evidence.
Although a case study is considered Level 4 research (RCT is
Level 1A), it is likely that if the majority of Chiropractic cases
that had symptomatic improvements over the years were
documented, there would a database of information to
extrapolate useful data to further our efforts. It is also feasible
that in the future, explaining the global effects of
chiropractic—upper cervical work in particular—will lie
outside of current scientific paradigms, much like the cutting
edge research that is shaking the scientific communities
throughout the world by questioning the widely accepted,
basic understanding of nerve propagation.42
In conclusion, there must be efforts on both fronts. From
within the current scientific constructs as well as from
postulates that have not been revealed yet, to fully uncover the
potential of chiropractic as a health/disease intervention.
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Table 1 –
Figure 1 -- Pre and Post Imaging