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January 2006, Vol. 16, No. 1
Table of Contents
CBP® Non-Profit Matches Dr. Bill Harris' $25,000 Research Grant • Counter Point Round III • Dr Deed Harrison is the Most Published Chiropractor in the Index Medicus • Flawed Thinking • It's Don's Opinion • JCCA Publishes CBP® Structural Rehab Protocol • More Studies to Confirm the Validity and Reliability of PosturePrint™ • Thriving in the New Health Care Marketplace • Organic Chiropractic • Patient Education • Point Round III • The Purpose Driven Practice • Radiation Hormesis • Research Corner • Subluxation Update • System Failure • Ten New Year's Resolutions for Your Practice • Chiropractic: A Useful Component of Traumatic Brain Injury Rehabiitation • Triano is a Chiropractic Pariah •
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Chiropractic: A Useful Component of Traumatic Brain Injury Rehabilitation
A Case Report
by Joshua Lander, DC
Dr. Lander received his Bachelor of Science degree in Health Science from Lock Haven University(PA) in 1996. He received his Doctor of Chiropractic degree in 2001, graduating cum laude from Life University (GA). As a student, he served as an instructor for the CBP® Club. He is a certified Fellow of CBP®. Dr. Lander is currently board-qualified for the Diplomate of the American Chiropractic Neurology Board. He operates a private practice in Westport, CT.
A general review of a chiropractic case report involving the rehabilitation of a patient with an acquired traumatic brain injury (TBI) is presented. A brief summary of the multi-modal therapeutic strategies, including the use of Clinical Biomechanics of Posture® (CBP®) methods is discussed.
TBI recovery is often unpredictable, physically and emotionally challenging, and most successful with a strategic plan that focuses on all facets of the patient’s condition. Although structural, functional, and neurophysiological aspects of rehabilitation were considered and utilized in this case, the vital principle of structural integrity governing systemic function was one of the basic tenets of the rehabilitative protocol implemented. The goals of this article are to encourage thought and illustrate the possibilities of an integrated approach to TBI recovery, specifically one that includes chiropractic applications and principles.
History
In May of 2002, a 28 year old male was involved in a motorcycle accident that caused a severe traumatic brain injury. Specifically, axonal shearing of the right cortex, contusion of the left pons, and infarct of the left cerebellum were diagnosed. The patient was in a comatose state for approximately six weeks. Other injuries sustained were fracture of the left clavicle, dislocated left shoulder, fractured left ilium and a torn posterior cruciate ligament of the left knee. Surgical procedures were needed to stabilize the fractured left ilium. Post-surgery, the patient was admitted to a rehabilitation hospital for nine months where speech, physical, and occupational therapies were administered. At the time of discharge, the patient displayed a left spastic hemi-paresis and was wheelchair bound. Concomitant conditions were classic TBI autonomic dysfunctions of unilateral hyperhydrosis, heterotrophic calcifications of the left elbow and knee, and abnormal extremity temperature regulation.1,2 In addition to the above-mentioned conditions, the patient also complained of headaches, dizziness, and neck pain. In July of 2003, the patient presented to a chiropractic clinic for consultation and evaluation.
Evaluation
A complete discussion of all examination findings and the physiological mechanisms that cause such findings would prove too lengthy for the purposes of this article. Therefore, only the examination findings that most influenced the assessment and treatment are included.
Vital Signs
BP 134/78 L, 128/78 R
Respiration 15/min with reversed inhale/exhale duration
Pulse 72
Height 5’8” Weight 205lb
Static Posture Evaluation
Left head translation(+TX) with coupled right flexion(+RZ)
Left thoracic rotation(+RY), Right pelvic rotation(-RY)
Active Posture Evaluation
(assisted half-squat)
Right thoracic translation(-TX), Left thoracic flexion(-RZ)
Increased magnitude of static postures +TX Head, +RY Thorax, and -RY Pelvis
Neurological
Characteristically, patients who have experienced anoxic cortical injury will present with contralateral anterior (flexor) hypertonus in the upper extremity and contralateral posterior (flexor) hypertonus in the lower extremity. The extensor muscles become reciprocally inhibited by the spasticity of the flexor musculature. This is an evolutionary neurological phenomenon of the bipedal human.
Flexed angulation and hyper-reflexive activity were revealed at the left elbow, hip, knee, and ankle. The extensor musculature of the left upper extremity tested weak (+2 on a +5 scale). The left ankle dorsiflexors also tested weak (+2 on a +5 scale). Pathological reflexes were present on the left, including Tromner, Babinski, and accessory myotactic movements in the upper extremity. Plantar-flexor myoclonus was activated by passive dorsiflexion of the left ankle. There was obvious dysmetria of the left extremities and disdiadocokinesia with any alternating repetitive movements. A right ocular ptosis and left lower facial paresis were present and made worse with exertion/fatigue. The left palate was paretic. Fast nystagmus was revealed upon right eccentric gaze. Opticokinetic (OPK) testing proved normal to the left and very poor to the right with gross ocular dysmetria. Joint position sense proved to be within normal limits. Pinwheel testing was hyperesthetic in the left lower extremity.
Orthopedic
The cervical spine musculature was severely spastic and rigid, in particular at the left splenii, and scalenes. The most notable range-of-motion deficiencies, as measured with dual inclinometers, were left lateral flexion (9 degrees/normal 45) and left rotation (39 degrees/normal 80). Heterotrophic calcifications were noted at the left elbow and medial left knee with hard end-feels upon flexion/extension. The patient’s left shoulder range of motion was markedly decreased with pain at 70 degrees of abduction. An abnormal scapular/glenohumeral rhythm was present. The bicep circumference measured 12-1/4”on the left and 15” on the right.
Radiographic Imaging
Radiographic mensuration of the lumbar spine was within normal limits of established values.5 No other significant radiographic findings were evident. Further evaluation of these findings will be reviewed in the Discussion section.
Methods/Results
The patient was given a strict multi-modal rehabilitative plan consisting of structural, functional, and neurological integrated methodology. The general goals of his treatment plan were based on the fundamental concepts of a) improving neurological plasticity, b) improving structural foundation, and c) improving dynamic function. The patient was prescribed care at a frequency of 3-4 days per week, for a duration of 1-1.5 hours each session. Formal update evaluations were performed monthly. Modalities included, but were not limited to, chiropractic applications (spinal and extremity mobilizations/ manipulations, CBP® methods, and myofascial therapy), neurological integrative exercises, gait training, and functional strength rehabilitation. Rather than administer these modalities exclusive to one another, they were integrated to create a unique rehabilitative plan resulting in both spatial and temporal affects.
At the time of this article’s conception, the patient had made remarkable advances in all facets of rehabilitation and surpassed any previous medical expectation of recovery. The patient had progressed from using a wheelchair to walking with a quad-cane within 3 months of beginning care. Within a year, he had the capability to walk with a standard cane, unassisted, approximately 150 feet in under two minutes. The patient gained the freedom to function in various planes of motion, including frontal, transverse, and vertical. There are numerous improvements in his activities of daily living, posture, including personal hygiene care, dressing, household chores, and the ability to drive an automobile.
Discussion
The success of brain injury rehabilitation is ultimately dependent on the ability of the brain to reorganize injured neuronal networks.6-9 Recently, there have been numerous studies proving the brain can accomplish this task.6-15 However, creating plastic change in the injured brain requires great effort, repetition, and above all, patience. In fact, research suggests the duration of a successful TBI rehabilitation program to be ongoing, lasting for many years with no definitive end-point.16 Although specific strength and range of motion improvements are clear goals of care, a problem arises if the focus of treatment is exclusively on the end-organs without regard to overall neurological function. Treatments were administered progressively and carefully not to cause excitatory damage to fragile neuronal pathways, a phenomenon that has been observed with neurological injury.17,18 Neurological metabolic threshold was monitored by autonomic signs such as blood pressure, pulse, sweating, skin color changes/temperature, and ocular ptosis. Other signs of surpassing threshold were worsening of posture, myoclonus, increased flexion spasticity of the left extremities, and slurred speech.
It is suggested that some TBI sequelae are due to transneurally degenerated neurological pathways which may undergo hyperexcitatory apoptosis.17-19 Therapeutic activity that does not account for transneural degenerative processes may, inadvertently, cause cellular apoptosis. Progressive models of neurological rehabilitation may be more appropriate to achieve the best healing possible.
Specific to chiropractic, the spinal column is thought to be a significant source of afferent potentiation throughout the neuroaxis.20-23 Chiropractic modalities, including CBP® methods, were an integral part of this patient’s rehabilitative plan and recovery. Keeping consistent with the proposed model of neurological threshold, certain areas of high afferency (i.e. upper cervical spine)21 were administered progressive mobilization (Grades 1,2,3, and so forth) until the patient displayed signs that his nervous system was healthy enough to accept the neurological potentials of Grade 5 manipulation. Again, signs of dysautonomia prevailed in the assessment of this threshold. Manipulations were utilized to increase range-of-motion, reset intrafusal fiber gain, improve joint mechanoreceptive balance, and promote specific CNS afferency. Oftentimes, the patient’s autonomic signs would change immediately after joint manipulations and/or posture adjustments. Examples include decreased sweating, decreased blood pressure, and improved skin color/temperature regulation.
One of the fundamental concepts of this patient’s treatment plan was that a normalized structural foundation would aid recovery of function and reduce dysponesis.24,25 Due to the patient’s obvious structural faults, CBP® methods (Mirror Image®) were integrated very early in this case. Mirror Image® adjustments were performed using both table and hand-held instrument techniques. Mirror Image® exercises were prescribed as simple isotonic movements but also actively integrated with eye exercises, strength training movements, and gait training. For example, the patient would perform a right thoracic rotation (-Ry) while also exercising the oscillatory BodyBlade® with the left hand or by holding a medicine ball. This simple movement accomplishes many goals including:
a) Mirror Image® structural exercise b) graviceptive vestibular reflex integration c) cortical control of affected extremity d) strong mechanoreceptive feedback from the spine and extremities and e) intrinsic core neuromuscular training.
Structurally, the patient’s most concerning spinal deformation was that of left head translation. Incidentally, this patient’s postural evaluation revealed gross leftward deviations. There are cerebellar theories about left head translation and other postural abnormalities.26,27 Simply, the right vestibular system would be functioning at a higher frequency than the left. This would potentially cause the patient to reflexively deviate away from the higher functioning side to compensate (toward the side of lesion). This scenario is seen in classic tests such as the Fukuda Stepping Test and labrynthine spinning tests in a Barany chair. These concepts are important to understand because they determine prognoses and treatment decisions. Mirror Image® corrective traction has proved to be effective in treating lateral deviation of the skull.28 However, Mirror Image® traction was initially delayed for two reasons. The first being the author’s opinion that the patient’s neuroaxis was not healthy enough to sustain the afferency from constant intrafusal neurological activation nor tolerate the duration necessary to achieve ligamentous deformation. The second being the hypothesis that correction would be most appropriate and efficacious in a standing graviceptive position and this, of course, was not possible in the beginning stages. Eventually, the patient completed 60 traction treatments in which he could subjectively tolerate 15-20 minutes each (Figure 1). Concentration was on the +Tx deviation of the skull. Due to the aforementioned neurological causation, this structural deformation proved difficult to improve. Ultimately, the patient did achieve measurable structural improvements (uncoupling of the “s” configuration29) and significant therapeutic benefit (Figure 2). During the corrective phases of Mirror Image® traction, the patient’s signs of unilateral hyperhydrosis reduced dramatically. Eventually, perspiration activity began to normalize in and out of traction — most importantly during other exertional activities of daily living.
Conclusion
Historically, TBI rehabilitation has consisted of a distinct role separation of physical therapists, occupational therapists, and others. The patient’s body was observed in parts, rather than as a whole, with each therapist responsible for a different region to rehabilitate. Slowly, this philosophy is changing to a more integrated, progressive, whole body approach with a focus on posture, stability, and sensory integration.30 Shumway-Cook and Olmscheid recognized the need for integration in the early 1990s stating, a progressive approach which utilized theories and treatments from all disciplines of rehabilitation was required for best results.31
The joints, muscles, and connective structures of the spine provide constant afferent feedback to the central nervous system.20-23,32,34-35 This is an important concept that is largely overlooked when deciding treatment options for TBI patients. Due to the neurophysiological effects of spinal manipulation33,36,37 and the need for posture and balance rehabilitation in this population of patients, it is proposed that chiropractic care, particularly CBP® methods, can be a valuable component in TBI rehabilitative protocols.
For References Contact Dr. Lander at lander@sbcglobal.net
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