April 2002

Chronic Antalgia vs. Posture

by Gregg Carb, D.C. and Al Ueda, D.C.

Introduction

             During our lifetimes, our bodies are exposed to a variety of physical forces. These forces may act on the body by way of a sudden event or gradually over time. Gravity is one constant force compressing the body. The skeletal frame and supporting soft-tissues resist the compression of gravity and hold the body upright. The spine is the central structure connecting the head, the thoracic cage and upper extremity, and the pelvis and lower extremity.

            The spine is shaped efficiently to perform its necessary functions of primary support, axis of motion, and protector of the spinal cord. In its most efficient shape, the spine appears as a vertical column from the anterior and contoured from the lateral perspectives. These contours represent the cervical lordosis, the thoracic kyphosis and the lumbar lordosis.

            Acute traumatic andor chronic cumulative forces acting on the body may overcome the resistance of the soft-tissues supporting the spine, thus altering their tension/length/elasticity/tonus. This results in a change in the normal resting shape of the spine. The articular and soft-tissue connections between the vertebrae (if intact) will dictate the coupling pattern of misalignment.

            As the spine connects the head, thoracic cage and pelvis, many changes in the shape of the spine can be observed externally by way of postural observation, as well as internally by way of radiological examination. Categorization of postural patterns, spinal adjustment by way of reversing those postural patterns (pre-stressing), traction to restore normal spinal contours, and postural exercises form the basis of CBP® technique applied.

            In some instances, when a patient presents with altered posture, the cause may be a conscious or unconscious response to acute or chronic pain, as opposed to a structural misalignment from sudden or cumulative forces acting on the spine, as described above. In such cases, pre-stressing posture may provoke further symptomatic expression. All useful therapeutic procedures have certain contraindications. By identifying the best (and worse) candidates for any particular procedure, the success rate of that procedure increases greatly and iatrogenic injury is avoided.

Case Presentations

            The following patients presented for chiropractic care, and illustrate cases where abnormal posture was antalgic-based. The increase of symptoms with postural pre-stressing indicated underlying pathology that required additional follow-up prior to undertaking corrective spinal care.

            Patient A is a 46 year-old male with a history of neck and right shoulder pain dating back to 1992. He suffered a wrestling injury that compressed his lower neck. He had prior physiotherapy, traction, chiropractic, manipulation under anesthesia, and neurological consultation. Present complaints included pain in the right shoulder with numbness and tingling into the right arm radiating to the thumb. He was taking anti-depressive medication.

            Cervical spine ROM examination showed normal flexion, tingling into the right arm on extension (not neck pain), 50% loss of right side-bending (with right arm tingling), 20% loss of left side-bending, 30% loss of right rotation and 20% loss of left rotation. Pain and radiating symptoms were present lying flat on his back with head recumbent. The bicep circumference in the dominant right upper extremity was 10.5” and the left non-dominant was 11”. There was a diminished brachioradialis reflex and decreased strength in the deltoid on the right.

            MRI of the cervical spine (Figure 1 & 2) demonstrated:

            C3-4 mild broad-based disc bulge causing mild spinal stenosis, with mild neural foraminal stenosis secondary to uncovertebral changes.

            C4-5 mild to moderate broad-based disc bulge and spondylosis resulting in mild to moderate spinal stenosis, and mild to moderate neural foraminal stenosis secondary to uncovertebral changes.

            C5-6 and C6-7 mild to moderate broad-based disc bulge and spondylosis resulting in mild to moderate spinal stenosis, and moderate neural foraminal stenosis secondary to uncovertebral changes.

            Cervical spine x-ray (Figure 3 & 4) demonstrated:

            Mild reversal of the cervical lordosis, moderate to severe mid-lower cervical degenerative changes with foraminal narrowing at C4-5 and C6-7 on the right.

            Postural findings (Figure 5) predominantly included left head translation and slight left tilt relative to the ribcage.

            Summary: This patient’s symptoms, exam findings, and diagnostics indicated a right-sided cervical radiculopathy, aggravated by pre-stressing him out of his antalgic posture.

            Patient B is a 41 year-old male with a history of progressive onset neck and arm pain since 1996. He complained of numbness, with achy and sharp/stabbing sensations, into both arms with certain activities. His hands would often go numb when chopping, mixing, stirring, cleaning, polishing furniture, and washing windows. When driving, he had to switch back and forth between hands because the side using a cell phone would go numb. The movement of bringing the shoulders up and back was helpful, while going down and forward was bad.

            On cervical ROM, head extension combined with right tilting caused the whole arm to feel numb. Tinels tap at the wrist and Phalen’s Test was negative. Maximal cervical compression caused numbness at the shoulder going down the arm within 15 sec to the hand on the right. Wright’s test caused slight tingling, slight diminished pulse on the right. Adson’s Test was negative on the right for a diminished pulse but increased tingling in arm due to rotating and extending the head. Cutaneous sensation and gross motor strength to the upper extremity dermatomes was intact.

            MRI of the cervical spine (Figure 6) demonstrated:

            C4-5 small, broad-based, central disc protrusion, leading to mild effacement of the anterior thecal sac.

            C5-6 mild disc bulge.

            C6-7 moderate-severe left and mild-moderate right foraminal narrowing due to incinate spurring and facet hypertrophic changes. Mild, diffuse broad-based disc bulge leading to mild central canal stenosis.

            Cervical spine x-ray (Figure 7 & 8) demonstrated:

            Mild reversal of the lower cervical lordosis, C6-7 spondylotic and osteoarthritic degenerative changes with narrowing of the intervertebral foramen.

            Postural findings (Figure 9) predominantly included anterior head translation relative to the ribcage.

            Summary: This patient’s symptoms, exam findings, and diagnostics indicated a cervical central canal and foraminal neuropathy, aggravated by pre-stressing him out of his antalgic posture.

Discussion

            Both of these patients complained of neck and upper extremity symptoms commonly encountered in chiropractic practice. Lest we be accused of a “one-tool” style of care, whereby we have the hammer and every patient presents as a nail, we need to determine which cases to select or defer for spinal correction. As a general rule, caution must be taken when posturally pre-stressing any patient who reports a worsening of symptoms. Both Patient A and B had neural compromise secondary to disc and bone pathology of the spine. Pre-stressing each patient’s respective antalgic head translation, which served as a means of neural decompression, quickly re-aggravated the associated nerve symptoms.

            These cases can and do get some relief from a modified chiropractic approach (such as treating the entire length of the nerve pathway from the neck to the hand). However, they are caught in a “Catch-22” situation where the standard procedures for correcting the spine/posture provoke their pain, but not correcting the spine/posture will ultimately further deteriorate their condition. For professional liability reasons, proper diagnostic and medical consultation follow-up is well-advised at the initiation of care in these situations. You don’t want to get blamed for causing or aggravating pathology that was already present, or failing to identify the full extent of the condition you are treating. Should the patient elect more aggressive intervention down the road, once they have recovered from the procedure, they usually become good candidates for the corrective care they should have had many years ago.

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