July 2002

Clinical Counter Point:

Chronic Antalgia vs. Posture - The CBP® Perspective

Dr. Heun is a 1983 graduate of Palmer College of Chiropractic - West.  He has extensive post-graduate training in sports chiropractic and chiropractic orthopedics and has been an instructor for CBP® for Life Chiropractic College-west as well as the CBP® Seminars.  Dr. Heun is currently in private practice in Pinole, CA and is new chairman of Research Fund Raising.
Joseph R. Ferrantelli, D.C. graduated with honors from Florida State University in 1995 with a B.S. in Biological Sciences and earned his Doctor of Chiropractic (D.C.) degree from Life University School of Chiropractic, graduating Magna Cum Laude in March 1999.  He is a distinguished Fellow of Clinical Biomechanics of Posture and a Certified Chiropractic Biophysics instructor for CBP®.  Dr. Ferrantelli is a contributing author for the newly released textbook entitled, CBP® Structural Rehabilitation of the Cervical Spine.  He is currently pursuing his advanced certification in Whiplash Traumatology and Accident Reconstruction through the Spine Research Institute of San Diego.  Dr. Ferrantelli currently is in private practice in New Port Richey, FL and may be contacted through this website or his clinic website www.normalspine.com or email at webmaster@idealspine.com

Introduction

In the April 2002 issue of the AJCC two cases were presented by Drs. Carb and Ueda.1 Apparently, these cases were presented to make the CBP® practitioner aware of the patient presenting with the condition of “Chronic Antalgia” due to canal stenosis and radiculopathy. We take exception to the article by Drs. Carb and Ueda. We believe that their discussion, as presented, indicates a lack of understanding of CBP® methodology, treatment methods, and protocols of care for rehabilitation of the cervical spine.2   Additionally, a general lack of knowledge of the scientific literature discussing natural history and treatment of cervical radiculopathy is apparent in their writing. We present a rebuttal in the form of a literature review and two case reports.

            Item #1: To begin, to us, the suggestion that if a movement provokes an increase in a patient’s symptoms then it is contraindicated, is indicative of a superficial understanding of pain and rehabilitation in general. It is well known that patients who work through their pain and discomfort are usually the ones that improve under aggressive rehabilitative care aimed at the prevention of cervical spine surgery.3

            Item #2: The “one-tool” style of care comment made by Carb and Ueda1 is definitely suggestive of an incomplete understanding of CBP® management of the cervical spine. In the new CBP® Cervical Spine Rehabilitation book,2 it is clearly stated that there are multiple types of exercises and traction procedures to be utilized in different cases. As an example, case #2 with excessive anterior head translation, presented by Carb and Ueda,1 could have been managed first by having the patient perform either posterior head translation traction or exercises before beginning any extension treatment. In fact, Abdulwahab et al.4 have reported that posterior translation head positioning was associated with an improved H-reflex and improvement of radicular discomfort in patients with confirmed radiculopathy.

            Item #3: Drs. Carb and Ueda1 suggested that we be fearful of malpractice issues in cases with cervical radiculopathy and surgery seems to be the more appropriate recourse in the long-term for these patients. However, the scientific literature on the topic of conservative vs. surgical management of cervical spondylotic radiculopathy is in total disagreement with Carb and Ueda’s assertion.

            For example, in a controlled randomized trial comparing conservative treatment of either physical therapy or cervical collar to that of surgical treatment for cervical radiculopathy, Persson et al.5-7 found no differences between the three groups at  one-year followup. Interestingly, several subjects in the surgical group had to undergo second operations. In a follow-up of more than one year on 26 patients with radiculopathy and confirmed disc herniation, Saal et al.8 found that 20/26 were appropriately managed with conservative care.                 Ellenberg et al.9 found that in patients with proven cervical radiculopathy, 80-90 percent can be managed appropriately with conservative methods. Most recently, the Cochrane review panel published a systematic meta-analysis on the role of surgery for cervical spondylotic radiculomyelopathy.10 They state, “Although more than 4000 operations are performed annually in the United Kingdom for conditions related to cervical spondylosis, no conclusive evidence was found to support surgical treatment for cervical spondylotic radiculomyelopathy.”10

            In light of the fact that the reported death from this surgical intervention is as high as 1.8 percent and the nonfatal complication rate is as high as eight percent,10 we suggest to Carb and Ueda that conservative management is much less a malpractice issue than they would have us believe.

Case Report #1

            This patient presented with acute lower back pain and related disability on 3/05/01. The patient chose to receive care limited to relief of his primary complaint of lower back pain, despite being made aware of the serious nature of his forward head posture and serious loss of cervical lordosis on x-ray. The patient did not list any complaints related to his neck nor his upper extremities at this time.

            On 12/2/01, the patient presented with acute severe neck pain, right shoulder and arm pain.  The patient was antalgic, holding his right arm across his body and with his biceps flexed and pronated.  He attributed the development of his symptoms to falling asleep in a chair (Apparently in flexion for an extended period of time.)  He had minimal lateral flexion bilaterally and noted numbness in his right hand. He was unable to sleep.  His only relief was with flexion of his head on his thorax while resting his head upon his forearm in a contorted position over an ottoman in his home.

Figure 1A-C

Initial examination findings 12/02/01:

            1. Postural Examination: Marked forward head posture (+TzH).

            2. Cervical range of motion.  Extension decreased 95 percent with an increase in radicular pain in the right arm and numbness into the right hand.  Right lateral flexion decreased 90 percent with an increase in right arm and shoulder pain with radiation past the elbow.                     

            Left lateral flexion was reduced, however with far less pain in the arm.  Forward flexion was unremarkable in the first ten degrees of motion, however beyond this range, increased arm and shoulder pain as well as mid-thoracic pain was produced. Rotation about gravity was reduced 30 percent and produced pain in the mid cervical spine, however no radicular symptoms were elicited.

            3. Orthopedic Tests: Distraction reduced the patient’s symptoms slightly but for only moments.  Shoulder depressor test was positive for pain on the right side with a corresponding increase in pain in the arm, forearm, and shoulder girdle.

            4. Neurologic Testing: The patient had no biceps or triceps deep tendon reflex on the right side despite reinforcement. He is right hand dominant but grip strength was severely reduced on the right with no reading elicited with Jaymar Dynamometer testing. The right triceps muscle was visibly flaccid. He was able to contract the muscle, however, not against resistance. See Figure 1A

Treatment

            The patient elected to begin chiropractic care after a detailed report of findings outlining his options for care (chapter 7 in the CBP® Cervical Rehab Book). He was informed that attempting to resolve or improve his particular problem was likely to be a challenging process necessitating daily office visits, and diligent effort.

            Initially, the patient was seen twice daily. Gradually, his head was brought back with gentle drop table Mirror Image Adjusting. The patient was given instructions to apply ice packs to his cervico-thoracic region twenty minutes out of each waking hour.

            Upright standing Mirror Image® Exercises were implemented in the second week.  This continued for the next two weeks. At this time, diversified manipulations were also employed, however, the patient noted increased pain in his arm and forearm as a result.  Ongoing communication with the patient kept his confidence and spirits up.

            In the sixth week of care, the patient began to traction. The patient was placed with his head over the end of the Regainer Traction Chair. Proprioceptive Neuromuscular Facilitation (PNF) technique was employed to allow for his initial intolerance to this position. The patient began with one minute of traction duration.

            By the end of the fourth week of traction, he could tolerate up to five minutes of traction time. This escalation of traction time and then force continued until the patient could sustain fifteen minutes of extension compression traction with a moderate amount of force applied to his forehead. A follow up lateral cervical x-ray was taken and demonstrated improvement in the Forward Head Posture and APL (Figure 1B).

            The patient was sleeping through the night at this point for the first time in over three months. His grip strength as well as the tone of his right upper extremity had improved dramatically.    The patient’s deep tendon reflexes in the upper right extremity normalized.               His overall posture was notably improved. At this time, a clinical decision was made to modify the patient’s traction position. The patient was placed in the Seated Compression 2-Way traction (Cervical Rehab Book Chapter 6). The load was gradually increased to 10 lbs. in the rear and 20 lbs. in the front.

            On 4/25/02 a second lateral cervical post x-ray was obtained to monitor the patient’s progress (see Figure 1C). The patient demonstrated marked improvement at this time. His head translation was reduced to 12mm, his lordosis increased to 25˚ and APL to 29˚.

Case Report #2

            A 40-year old male was rear ended at a velocity of approximately 40 mph on 9-15-2000.  After an initial three weeks of non-specific Chiropractic care at a separate clinic (not related to the authors), he was referred to an orthopedic surgeon who recommended he undergo an MRI scan and was referred for medical rehabilitation. 

            The MRI showed disc herniation at C5/6/7/T1 mild-moderate disc protrusions (Figure 2A).  The surgeon recommended a course of physical therapy including: functional rehabilitation in the form of ROM exercise, resistance training (non-specific), massage therapy (which did give some temporary relief), ultrasound (no lasting relief), and pain medication. He treated approximately six weeks at three times per week. The patient was given a 26 percent whole body impairment rating by an orthopedic surgeon and was told he would need eventual cervical fusion due to the permanency of his condition.

            His Chief Complaints upon entering (3-9-01) a CBP® practitioners (JF) office, was neck pain and right shoulder pain with intermittent arm pain. He always experienced neck pain with a VAS average of 5/10.  He states that it never resolved with previous care for more than approximately one day.      Sometimes the pain becomes a sharp stabbing pain between the shoulder blades and upper back, and he reported getting a “shooting jolt” with turning his head down the right extremity. At the initial examination from the CBP® practitioner’s office, the Subjective Questionnaire and VRS scores were:  46 percent N.D.I. and  5/10 VRS.

Imaging Results from the Prior providers (Initial):

            9-15-2000 (Not Shown): The lateral cervical radiograph revealed the following: +Tzh=74 mm, kyphosis C4/5 of 5 degrees; C5/6=10 degrees, compression of C6, ossification of anterior aspect of C5 disc.

            Initial posture (Figure 3A) and lateral cervical x-ray (Figure 3B) taken at the CBP® practitioner’s office: 3-12-2001:

            Large +Tzh=74mm persists, and Kyphosis Persists. The initial and follow up ROM is shown in the table I below.

TABLE I—ROM: inclinometer

            Treatment: Even though this patient had an initial inability to be moved into the Mirror Image® due to “Chronic Antalgia”, the patient was treated with Mirror Image® Drop table, Instrument, Traction (initially was posterior head translation), Mirror Image®  Exercise and PNF Stretching Prior to Traction. He was worked slowly up to 30 minutes of traction 4-5 days per week.

            Figure 3C and 3D depict the patient’s 10-week follow-up lateral cervical posture and x-ray. Note the improvement in anterior head translation and cervical alignment. The patient elected to continue care. The patient was switched to two-way extension compression after the 2nd exam.             

            Figure 3E and 3F show the 20-week postural and x-ray examination findings. Note the great correction in the structure of the cervical curve.

The patient’s pain was approximately 80 percent reduced at time of first exam; 100 percent by the end, NDI=0 percent from 46 percent at end of care, ROM was greatly improved. This case illustrates that the patient was obviously not at maximum medical improvement (MMI) when the case settled.

Figure 2: Pre MRI 10-18-00. Abnormal marrow signal with slight loss of vertebral height at C5 possible mild compression deformity.  Small Central disc protrusion at C4-5 and small buldging disc at C5-6.  No central canal stenosis or significant neuroforaminal narrowing identified.

a 40-year-old male with extreme pain impermanent disability rating.  In A initial lateral cervical posture shows a large head translation.  In B initial lateral x-ray shows 74 mm of forward head posture and no cervical lordosis.  In C the first post shows a great correction in lateral posture alignment.  In B the first post shows forward head posture has reduced remarkably.  In B the second reading shows continual postural improvement.  And after head translation is zeroed out in the cervical lordosis is notably improvement.  The patient's disability and pain improved after correction in spite of this "permanent disability rating" by the previous provider.  This case demonstrates that "chronic  antalgia"   is correctable giving the proper treatment in time.

Conclusion

            These two cases are presented to demonstrate that the presence of radiculopathy, due to disc herniation or spondylosis, need not deter the prudent chiropractor from applying CBP® principles judiciously in attempting to return a patient’s structure to normal or near normal while also improving the patients overall health. Whether the condition is acute or chronic, by working the patient through their initial pain and inability to move into the Mirror Image® position, successful outcomes can be achieved in the majority of cases. Too often, the patients who need us to take a stand for their health fall by the wayside because their doctors are not secure in their technical ability. Many chiropractors (including some CBP® practitioners) are not aware of the logical and sound clinical principles of CBP® that could be applied to make a difference in the lives of their patients. We encourage you to learn as much as possible about this work, for your patient’s sake.

References

            1. Carb GJ, Ueda A. Chronic Antalgia vs. Posture. AJCC April 2002, pgs. 10-11.

            2. Harrison DE, Harrison DD, Haas JW. CBP® Structural Rehabilitation of the Cervical Spine. Harrison CBP® Seminars, Inc., 2002, chapter 7.

            3. Nelson BW, Carpenter DM, Dreisinger TE, Mitchell M, Kelly CE, Wegner JA. Can spinal surgery be prevented by aggressive strengthening exercises? A prospective study of cervical and lumbar patients. Arch Phys Med Rehabil 1999;80:20-25.

            4. Abdulwahab SS, Sabbahi M. Neck retractions, cervical root decompression, and radicular pain. JOSPT 2000;30:4-9.

            5. Persson LC, Carlsson C-A, Carlsson J. Long-lasting cervical radicular pain treated with surgery, physiotherapy or a cervical collar: a prospective randomized study. Spine 1997;22:751-758.

            6. Persson L, Karlberg M, Magnusson M. Effects of different treatments on postural performance in patients with cervical root compression: a randomized prospective study assessing the importance of the neck in postural control. J Vestib Res 1996;6:439-453.

            7. Persson LC, Moritz U, Brandt L, et al. Cervical radiculopathy: pain, muscle weakness, and sensory loss in patients with cervical radiculopathy treated with surgery, physiotherapy or cervical collar. A prospective, controlled study. Eur Spine J 1997;6:256-266.

            8. Saal JS, Saal JA, Yurth EF. Nonoperative management of herniated cervical disc with radiculopathy. Spine 1996;21:1877-1883.

            9. Ellenberg MB. Hornet JC, Treanor WJ. Cervical radiculopathy. Arch Phys Med Rehabil 1994;75:342-352.

            10. Fouyas IP, Statham PFX, Sandercock PAG. Cochrane review on the role of surgery in cervical spondylotic radiculomyelopathy.