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article on Dystonia

Cervical Dystonia and
Chiropractic Neurology

Chiropractic neurology is quite simply the marriage of hands-on chiropractic care with the most current knowledge of how the brain and nervous system work. It is not upper cervical or Kale technique. Chiropractic care has a long history of helping patients decrease pain and increase joint range-of-motion through manipulation or adjustments of joints either manually or mechanically.  Chiropractors also typically work with the muscles and soft tissues around a joint to decrease spasms and allow for quick healing.  Though most often thought of as “spine doctors,” chiropractors are educated in examination and diagnosis of the entire body (i.e.: cardiovascular system, gastrointestinal system, etc.) and trained in joint manipulation and rehabilitation of the majority of the joints and muscles in the body, not only the spine. In addition to addressing the immediate complaint, chiropractors are also trained in nutrition and supplementation and often advise patients on optimal healthy living. With this type of training and holistic approach, it is logical to see why so many dystonic patients seek out chiropractic care. It is an ideal initial choice for treating dystonia naturally.

Board Certified Chiropractic Neurologist

So what exactly is a chiropractic neurologist and how does one become board certified?  Chiropractic neurologists are specialists within the chiropractic community that focus their practice on neurologic cases such as dystonia and movement disorders, vertigo and balance problems, Attention Deficit and learning disorders and stroke rehabilitation just to name a few. The American Chiropractic Association Council on Neurology is accredited by the National Commission for Certifying Agencies (NCCA), the accrediting body of the National Organization for Competency Assurance (NOCA). Chiropractic neurologists are certified by the American Chiropractic Neurology Board and recognized by the ACA Council on Neurology insuring the highest quality practitioners. Upon successful completion of both written and practical portions of the examination, doctors are awarded a Diplomate degree in Neurology and thus become board certified chiropractic neurologists. There are currently 595 board certified chiropractic neurologists worldwide.  This post-doctorate training consists of a minimum of 300 classroom hours typically taken over three years. While these classroom hours focus on a different topic each module (i.e.: cerebellum, sensory system, motor system, etc.), many more hours are spent outside of the classroom studying the same neurology textbooks used by medical neurologists. And though both chiropractic neurologists and medical neurologists diagnose pathologic lesions (i.e.: tumors, strokes, neurodegenerative diseases, etc.) chiropractic neurologists have an intimate understanding of physiologic lesions (i.e.: complaints or symptoms that have no positive lab test results, MRIs, X-rays, etc. showing the problem). This additional training allows us to serve our patients at a higher level.

While it is frustrating to repeatedly receive negative test results, the good news is that physiologic problems quite often respond to brain based physical rehabilitation.

Pathology vs. Physiology

As most of you already know, dystonia is most often a neurophysiologic (or brain function) problem and not typically a pathology or disease. Consequently, it is not uncommon for dystonic patients to have many diagnostic tests return as negative and find themselves no closer to an answer. The reality of physiology versus pathology is of key importance to the treatment of dystonia. Though pathologic lesions need to be treated medically with surgery, radiation, etc., physiologic lesions typically do not necessitate such invasive treatment. The good news is that physiologic lesions can often be treated with physical interventions. Chiropractic neurology is a brain-based physical intervention. I often refer to this work as brain-based rehabilitation. In order for successful rehabilitation to be possible it is necessary for both the physical symptoms (muscle spasms, tremors, pain, decreased range of motion) and the neurologic mechanisms causing those physical problems to be examined and appropriately addressed.

To find a chiropractic neurologist in your area, visit www.acnb.org and search the referral listings by state. You can find more information about chiropractic neurology online at www.carrickinstitute.com , www.acnb.org and  www.dendrites.com

Treatment

Upper cervical or Kale technique is not a part of this approach. Treatment in a chiropractic neurologist’s office is different than in a physical therapist’s, occupational therapist’s, osteopath’s or traditional chiropractor’s office. While those practitioners focus on the immediate physical symptoms, the chiropractic neurologist’s goal is to identify the neurologic mechanisms causing the physical symptoms.  These areas are identified with a thorough history and examination including neurologic, orthopedic and chiropractic exams that clearly demonstrate what areas and brain pathways are functioning well and which are not. These findings are then applied to the model of brain hemisphericity to determine the appropriate side of the body to treat. Treatment is always gradual as it is crucial to never tire out these fragile pathways. Progress is re-evaluated every time the doctor sees you - changes are evident upon neurological exam. Treatment  may include balance and motor timing exercises, head tilts (both assisted and eventually independent), eye exercises, chiropractic adjustments, hemistim (color/light/eye tracking therapy), coordination rehabilitation, coloric stimulation, electric stimulation, TENS, and/or audio therapy. Treatment will never be exactly duplicated between two patients. Each patient's case is extremely specific and treatment is determined by the individual's exam findings. The doctor's job is to assess the patient, put the pieces of the puzzle together and come up with the most appropriate therapeutic intervention for the best possible outcome at each and every visit.

Brain Hemisphericity

The brain is divided into two halves or hemispheres.  Brain hemisphericity is the half of the brain that is decreased in function or it is the “weak” side. Remember that the side of the body adjusted, stretched, loosened, etc. will typically affect the opposite side of the brain. It is the chiropractic neurologist's job to then construct the best way to rehabilitate these weak brain pathways to increase brain function and decrease dystonic symptoms. Another difference is that much attention is paid to neurologic fatigue. Great care must be taken to stimulate that “fragile” pathway only to the point of fatigue and never beyond. After all, these sensory/motor pathways involved in dystonia cases have often been misfiring for months or years and it would be naïve to try to bring these pathways “up to speed” overnight. If home rehabilitation exercises are given, as they often are in order to continue exercising the “weak” areas, then you, the patient (or family member/caretaker) must be taught how to notice fatigue so that at that moment, you stop performing the exercises. The concept of “the more exercise, the stronger” does not typically work with dystonia and other brain based neurophysiologic disorders. Small amounts of very specific exercises focusing on your “weak” pathways will result in much greater improvement than many non-specific exercises that only take into account your physical symptoms. One last difference in a chiropractic neurologist’s treatment plan is that there may not be any therapies given to the area of pain or symptoms (for example,  the neck with spasmodic torticollis) in the beginning of your treatment plan. This is not due to an oversight but rather because all care is based on brain and nervous system function as these are the ultimate controllers of muscle tone and movement. In some cases, working on the cervical spine may not be the best approach to helping cervical dystonia. For example, if stretching or performing a technique to loosen the muscles of the affected area will increase stimulation to already over-active brain pathways, it would be unbeneficial to the bigger picture. The muscle may let down and feel better initially, but later may become much tighter, with increased tremors and more pain due to decreased brain integration. In other words, the therapy was not in concert with your specific neurologic weaknesses even though it was appropriate for your physical complaints and symptoms. This explains how physical intervention may make symptoms worse and clearly demonstrates the importance of examining the neurologic function prior to initiating any type of physical intervention. This example goes against the common notion that the tight muscle always needs to be worked on. Instead, any stimulus (i.e.: stretch, visual light stimulation, vestibular spinning stimulation, joint manipulation, etc.) needs to be used carefully to either excite pathways that are under active or to decrease firing of the overactive pathways.  The care needs to improve the function of the nervous system as well as the musculoskeletal system allowing for balanced function of both the brain and the body. This can then result in decreased muscle spasms and improvement in the dystonic symptoms. These “misfiring” or “weak” pathways are different in each individual case and consequently the treatment of two left-looking dystonia patients may be very different. Only after examination can a chiropractic neurologist determine the appropriate treatment for your specific case.

Research Study

Recent research by Frederick Carrick, DC, PhD, DACNB proved the tremendous effect spinal manipulation can have on cervical dystonia when performed in accordance to brain hemisphericity. The study included 111 subjects in a clinical setting. Patients were adjusted on the side opposite of decreased brain hemisphericity as determined by physiologic blind spot mapping of the eyes and muscle weakness. Each subject was adjusted an average of six times. Follow-ups two months later rated 67.6% had at least a 50% improvement in movement, 55.2% had at least a 50% reduction in tremors, 57.7% had at least a 50% decrease in muscle spasticity and 77.5% had at least a 50% decrease in pain. These results are outstanding and provide hope for dystonic patients looking for treatment options.

Reference:

Carrick, Frederick R.  The treatment of cervical dystonia by manipulation of the cervical spine: A study of brain hemisphericity, patient attributes and dystonia characteristics. International Journal of Applied Kinesiology and Kinesiological Medicine 2001; 10:20-36.

© Scott Theirl, DC, DACNB September 3, 2003