Thursday, March 15, 2012

Chiropractic Care of a Patient with Amyotrophic Lateral Sclerosis

CASE STUDY

Chiropractic Care of a Patient with Amyotrophic Lateral Sclerosis

Jennifer James Padrta, BS, Chiropractic Intern  .  June 2002


ABSTRACT

This study examined the effects of chiropractic adjustments in a patient with Amyotrophic Lateral Sclerosis (ALS).  The adjustments were performed manually in most cases, with the exception of the atlas adjustments performed by a mechanical spring loaded chiropractic adjusting device.  Further studies are needed to examine the long-term effects of chiropractic adjustments on patients with ALS.

BACKGROUND

Amyotrophic Lateral Sclerosis (ALS) is part of a group of motor neuron diseases with degeneration of the lower cranial nerves, corticospinal and corticobulbar tracts.  The onset is usually between 30-60 years of age and progresses at different rates.  Most cases are sporadic, even though there are some familial cases.  ALS is often referred to as “Lou Gerhig’s Disease.”  Lou Gerhig was a baseball player for the New York Yankee’s that died from the disease in 1941 at 38 years old. (1)  Lou Gerhig made the disease well known, although it was actually described by Charcot in 1874. (6)

 

ALS is usually characterized by a combination of upper and lower motor neuron lesion signs.  Fasciculations and muscle atrophy are noticeable, as well as brisk deep tendon reflexes are apparent with the upper motor lesion portion.  Sensory function is completely normal. (3) 


 Lower Motor Neuron and Upper Motor Neuron Signs in Four CNS Regions
PRIVATEPRIVATE "TYPE=PICT;ALT=Divider"

Brainstem
Cervical
Thoracic
Lumbosacral
Lower motor neuron signs
weakness,
atrophy,
fasciculations
jaw, face,
palate,
tongue,
larynx
neck, arm,
hand,
diaphragm
back,
abdomen
back, abdomen,
leg, foot
Upper motor neuron signs
pathologic spread of reflexes, clonus, etc.
clonic jaw
gag reflex
exaggerated snout reflex
pseudobulbar features
forced yawning
pathologic DTR's
spastic tone
clonic DTR's Hoffman reflex
pathologic DTR's
spastic tone

preserved reflex in weak wasted limb
loss of superficial abdominal reflexes
pathologic DTR's
spastic tone
clonic DTR's - extensor plantar response
pathologic DTR's
spastic tone

preserved reflex in weak wasted limb
*World Federation of Neurology
There is no single definitive diagnostic test for ALS. To diagnose ALS, it requires the presence of upper and lower motor neuron degeneration by clinical, electrophysiological or neuropathologic examination and the progression of the symptoms to other regions or within the same one.  To determine the diagnosis of ALS, there must be an absence of any other disease that might explain the upper and lower motor neuron degeneration. (10)

Recently, there has been interest in looking deeper into a phenomenon called “apoptosis” which means, programmed cell death.  Researchers are trying to uncover if apoptosis is responsible for the neurodegenerative processes in ALS, by checking for levels of certain oncoproteins and their possible link with a predisposition of apoptosis. (4)  No solid research has proven this theory, as of yet.

Research has recently shown an enterovirus in the motor neurons of the anterior horn cells of people with ALS. (5) There have been many studies theorizing the same point, but this is the first time it has been scientifically proven. Of course, not all ALS patients have an enterovirus in their brain tissue, so there is not one cause of ALS.  Some proposed underlying causes of ALS include genetic susceptibility, heavy metal exposure, environmental toxins (pesticides), head trauma, viral infections and autoimmunity. (6)

The prevailing cause of familial cases of ALS is a defective superoxide dismutase (SOD1) gene on chromosome 21. The normal function of SOD1 is to limit the production of intracellular free radicals. The mechanism of the defect is not known, but it is theorized the defective enzyme has an unwanted neurotoxic property. (11)

Excessive amounts of the amino acid glutamate (glutamic acid) along with MSG, may also play a role in the progression of ALS. Cyclooxygenase-2 (COX-2) produces prostaglandins that cause astrocytes in the CNS to release glutamate. In turn, glutamate may induce the formation of free radicals. (8)

Dr. Alf Breig’s work on skull traction and cervical cord injury is another approach to the possible treatment of ALS.  Dr. Breig has written about how surgically setting the cervical spine in slight extension, thereby allowing slack in the pons cord tract, could successfully treat ALS and number of other neurogenic problems. (2, 15)
           
According to most references, there is no cure or treatment for ALS, as it is considered a fatal disease.  Most ALS patients die within 2-2 ½ years of their diagnosis.  The 5-year survival rate is only 20%.  (3)

In the late 1970’s, the New England Journal of Medicine published an account by Norman Cousins, about how he used humor to recover from ALS.  Mr. Cousins stated that 10 minutes of belly laughter produced an anesthetic effect lasting at least two hours.

Right up the same alley, a study by Martin & Lefcourt showed that heavy laughter increased levels of enkephalins and endorphins in the brain.  And yet, another study by Dillon, Minchoff, and Baker reports that finding something funny results in a significant increase in IgA antibodies.

At this point science has no concrete answers of how to treat ALS, so one approach may work for one person, but not the next. 

INTRODUCTION


The patient is a 62 year-old male who, in 1992, began having muscle spasms in his left leg and left arm.  In 1994 he was diagnosed with Amyotrophic Lateral Sclerosis (ALS). Muscle atrophy continued and included all limbs beginning in the hands, then to the upper arms and into the shoulder region. He has been wheelchair bound for the past five years. Current symptoms include dysarthria and dysphagia, acid reflux, fasciculations, and periodic spells of gagging or coughing after having swallowed food or drink. Edema is present in his hands, legs, and feet.

It is necessary to note that the patient suffered trauma at the age of 19 years, when he fell 30+ feet off of a railroad trestle and landed on his head, breaking both wrists and right elbow. 

He wears a BI-PAP breathing apparatus at night to ensure continued respiration. His lower extremity muscle strength is intact and can shuffle out of his wheelchair with assistance for short distances. Most of his time is spent on a computer using a specialized program which is operated by one knee, allowing him to open programs, write letters, and surf the web. His mind is completely intact.

The following medications are taken daily and prescribed by a medical doctor at an ALS facility:

Neurontin manufactured by Parke-Davis Pharmaceuticals, also known as gabapentin, is an anti-epileptic seizure medication. Neurontin is a glutamate blocker, but it has no apparent affect on ALS.  According to Parke-Davis in a press release, “The results of this longer, larger, higher dose study of gabapentin in ALS provides no evidence of effectiveness of this drug for patients with this disease." (7)

The patient has been taking Neurontin for approximately 4 years and states that he feels “disconnected and doesn’t feel good” when he does not take it.  Oddly enough, another research journal finds that Neurontin is used successfully with patients with chronic neuropathic pain used with diabetics, but it seems that ALS patients are finding relief with the Neurontin as well. (12)

Rilutek (Riluzole) is also a glutamate blocker and has been proven to be able to slow the progression of ALS and extend the survival of ALS patients. It is the first medication to have an effect on the progression of ALS and approved by the FDA. There is the possibility of liver injury, and patients should have lab tests performed as a baseline before beginning Rilutek and during the drug treatment period.

Celebrex is a cyclooxygenase-2 (COX-2) inhibitor. Inhibition of the COX-2 mechanism provides protection for spinal motor neurons in SOD1 mouse models. GI problems, kidney, and liver problems are potential concerns. (8)

Quinine is used widely for muscle cramps.
Prilosec is commonly used for acid reflux disease or gastroesophageal reflux disease (GERD). Prilosec is indicated for short-term treatment of active duodenal ulcers. Most patients heal within four weeks, but an additional four weeks may be necessary. (13) The patient has been taking Prilosec for much longer than 8 weeks.

Prozac is a commonly used anti-depressant. The patient states that it is difficult to have a quick mind and a body that won't comply.  He has been taking Prozac for 4 years.

Amitriptyline HCL is used as an anti-depressant, but the patient states that he takes it as an anti-inflammatory drug.

Ambien is a hypnotic and allows the patient to sleep when he has difficulties.

The patient introduced approximately 900mg of calcium lactate chelated with magnesium and noticed an immediate decrease in fasciculations to the point of almost non-existence.  He also began taking d-alpha-tocopherol (vitamin E), betaine hydrochloride with pepsin, vitamin A, phenylalanine, glutamine, N-acetyl cysteine (NAC) to help the body produce glutathione, coQ-10, essential fatty acids, ginseng, gingko biloba and creatine.

The patient entered the Life Chiropractic College West Health Center with a complaint regarding his speech due to ALS, but after receiving some musculoskeletal relief, complained of "butt pain" from being unable to ambulate on his own and being confined to his wheelchair. 

He had upper motor neuron lesions of the lower extremities and lower motor neuron lesions of the upper extremities.  The fasciculations were so extreme that getting a pulse and blood pressure readings were nearly impossible.  His muscle strength in the lower extremities had complete range of motion against gravity, either with some or all resistance.  The lower extremity reflexes were either average of hyperactive.  There was no evidence of contractility or joint motion in the upper extremities and either had no response or an average response unilaterally when performing reflex exam.

All cranial nerves appeared to be intact.  Heart, lung and abdominal exams all appeared normal.

The only sensory exam that was abnormal was differentiation of dull from sharp on face.

Motion palpation revealed taut and tender fibers and/or fixations at the occipital and atlas region on the right, bilaterally at T2-T7 and bilaterally at T10.

Cervical range of motion was decreased overall without pain.

All other tests were either within normal limits or were unable to be performed.

Radiographic studies concluded spondylosis from C2-C6, lower thoracic spine and entire lumbar spine with a transitional segment at L5 with accessory articulation on the right.  Chest films were taken which demonstrated a chronic degenerative cyst and other findings suggest a chronic lung disease, which may be associated with the history of ALS.

METHODS


Conservative manual adjustments of the spine and its articulations were administered usually at one week interims and then extended to two week interims, as the patient had difficulty commuting such a distance when it was necessary to rely on others to drive him to the health center.

A persistent subluxation complex of the coccyx was apparent, possibly due to the time spent in the wheelchair.  Other subluxation complexes included T2, T8, T12/L1, sacrum and on occasion C1 was adjusted using a mechanical spring loaded chiropractic adjusting device.  Both shoulders were chronically subluxated anterior inferior, possibly due to the extreme muscle wasting in the upper extremities and chest.

RESULTS


The patient involved with this study did not follow all recommendations for home exercises and frequency of adjustments.  The distance between his home and the health center was excessive for is condition to be seen more than 1-2 times per month.

Upon a re-evaluation, the patient noticed that he has less pain when in a supine position.  Also noted was the cervical range of motion increased in all directions except for lateral flexion bilaterally.

Complaints changed, as he found relief for his left hip pain, low back pain and tail bone pain.  It appeared as though once a problematic area was relieved, he would notice another area that he hadn't noticed prior.

There were no other objective changes obtained, as many of the initial objective tests were unable to be performed during the physical exam.

Subjectively, the patient received some relief for periods of time.  Immediately after an adjustment, his speech was noticeably different to everyone in the room.  Musculoskeletal complaints varied due to multiple variables including sleep, activity, adjustment frequency and psychosocial attitude.

 

CONCLUSION


Recent  research findings suggest that a chiropractic adjustment  or SMT may produce hypoalgesic and sympathoexcitatory effects leading to the activation of the descending inhibitory pathways from the periaqueductal grey area of the midbrain. (14)  We know from basic neurology that the periaqueductal grey area has an analgesic effect when stimulated.

After reviewing some of Dr. Alf Breig's work, it is possible that chiropractic adjustments along with Chiropractic Biophysics care, could induce the amount of extension or cervical lordosis necessary to stop spinal cord tethering and allow some relief or even resolution of some of the symptoms that are common to ALS patients.

Chiropractors have long approached patients with a variety of conservative manual adjustments, dietary and lifestyle changes.  Since there are no absolute treatments for ALS that are efficient across the board, a large-scale study should be explored in regards to chiropractic care and the treatment of ALS patients.

ACKNOWLEDGEMENTS


I would like to thank Jerry Steele for his unrelenting support, both physically and mentally, by helping with movement of the patient on each visit.  Also, for bouncing ideas off me in regards to ALS and sharing ideas and research with me.  I would also like to thank Dr. Gregory Plaugher for showing me how to look for reliable research information, as well as the faculty at Life Chiropractic College West.

REFERENCES


1.      McGuire V, Longstreth WT Jr, Nelson LM, Koepsell TD, Checkoway H, Morgan MS, van Belle G. Occupational exposures and amyotrophic lateral sclerosis. A population-based case-control study. American Journal of Epidemiology 1997 Jun 15;145(12):1076-88.

2.      Breig A.Chapter 6. Pathological stress in the pons-cord tissue tract and its alleviation by neurosurgical means. Clinical Neurosurgery 1973;20:85-94.

3.      Souza.  Differential Diagnosis for the Chiropractor: Second Edition, pg 402-3

4.      Neuropathologies and Applied Neurobiology Aug:27 (4):257-74


5.      Giraud P, Beaulieux F, Ono S, Shimizu N, Chazot G, Lina B. Detection of enteroviral sequences from frozen spinal cord samples of Japanese ALS patients. Neurology. 2001 Jun 26;56(12):1777-8.


6.      Rowland LP, Shneider NA. Amyotrophic lateral sclerosis. New England Journal of Medicine. 2001 May 31;344(22):1688-700.

7.      Miller, Roger G. Phase III double-blind, placebo-controlled study of gabapentin (Neurontin) in patients. ALS Meeting of the American Neurological Association in Seattle, Washington on October 13, 1999.

8.      Drachman, DB. and Rothstein, JD. Inhibition of cyclooxygenase-2 protects motor neurons in an organotypic model of amyotrophic lateral sclerosis. Annals of Neurology. 2000 Nov, 48(5): p.792-795.

9.      Oey PL, Vos PE, Wieneke GH, Wokke JH, Blankestijn PJ, Karemaker JM. Subtle involvement of the sympathetic nervous system in amyotrophic lateral sclerosis. Muscle Nerve 2002 Mar;25(3):402-8

10.  Subcommittee on Motor Neuron Diseases/Amyotrophic Lateral Sclerosis of the World Federation of Neurology Research Group on Neuromuscular Diseases and the El Escorial "Clinical limits of amyotrophic lateral sclerosis" workshop contributors. El Escorial World Federation of Neurology criteria for the diagnosis of amyotrophic lateral sclerosis, Journal of the Neurological Sciences 1994 Jul;124: 96-107. 

11.  Mitsumoto, H. and Munsat, T, Amyotrophic Lateral Sclerosis: A Guide for Patients and Families: Second Edition. Pgs 37-45

12.  Backonja M, Beydoun A, Edwards KR, Schwartz SL, Fonseca V, Hes M, LaMoreaux L, Garofalo E. Gabapentin for the symptomatic treatment of painful neuropathy in patients with diabetes mellitus: a randomized controlled trial, JAMA 1998 Dec 2;280(21):1831-6

13.  National Committee for Clinical Laboratory Standards. Summary Minutes, Subcommittee   on Antimicrobial Susceptibility Testing, Tampa FL, January 11-13, 1998.

14.  Sterling M, Jull G, Wright A. Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity. Manual Therapy 2001 May;6(2):72-81

15.  Breig, A.  Overstretching of and circumscribed pathological tension in the spinal cord – a basic cause of symptoms in cord disorders. Journal of Biomechanics 1970 Vol 3, pg 7-9

8 comments:

  1. I just want to share my story so i can reach out to others. My mom was diagnosed with ALS (Lou gehrig's disease) in the summer of 2013. She is my best friend and all i have got in this world. And I was scared because when the doctor told me about how deadly this disease is i could not help but cry. She suffered all through the time, she could no longer walk as all her bones were weak, speak or even eat, this were years of torment as i have never seen anything like it or ever been so scared in my life and i wept as the days go by. We tried several drugs like Riluzole, and various therapy that was prescribed by the doctor but it came out even worse as she became very thin. She is 65 years old. I actually thought i was going to loose her after all i have spent. I was in church one day when a fellow in the christian faith told me about a doctor who has a cure and that this doctor had cured a colleague she knew suffered from ALS, i was in shock and recalled the doctor once told me there was no cure, she gave me the doctor's contact and i contacted him and told him all we have been through and he told me about his very effective herbal medicine that treats it permanently, though at that time i did not believe but i wanted my mom to be okay again so i decided to give a try and he sent me the medicine which i gave her as instructed by the doctor. In a month time i was amazed at the improvement and by the second month she was completely okay, during all these times she did not experience any side effects. To confirm all these we went back to the doctor to confirm, he ran all the tests and found no trace of ALS in her again. Today my mom can run, jog, eat and speak fine without any assistance currently she is baby sitting my daughter and till now she is still very strong. If you are suffering from ALS (Lou gehrig's disease) do not die in silence because there is still hope for you. Contact the doctor on (josephalberteo@gmail.com) i am very sure he can help you too.

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  2. MUST READ: HOW I GOT CURED FROM ALS DISEASE) I am from U.S.A and my name is Clara Wilson. I was diagnosed of ALS disease (Lou Gehrig’s disease) in 2013 and I have tried all I can to get cured but all to no avail, my life was gradually coming to an end, until i saw a post in a health forum about a herbal doctor from Africa who prepares herbal cure to cure HIV/AIDS and all kind of diseases including ALS, MND, Epilepsy, Leukemia, Asthma, Cancer, Gonorrhea etc, at first i doubted if it was real but decided to give it a try, when i contact this herbal doctor via his email,(dr.ezomorootandherbals@gmail.com), he prepared an ALS herbal portion and sent it to me via courier service, when i received this herbal portion, he gave me step by step instructions on how to apply it, when i applied it as instructed, i was cured of this deadly disease within 7 days, I could not walk or talk understandably before but after i took the herbal cure as he instructed i regained strength in my bones and i could talk properly unlike before, I am now free from the deadly disease, all thanks to Dr.ezomo Contact this great herbal doctor via his email dr.ezomorootandherbals@gmail.com

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  4. As a sign of gratitude for how my husband was saved from the dreaded ALS, i decided to reach out to those still suffering from this.
    My husband was diagnosed of ALS in 2013 and it was really tough and heartbreaking for me because he was my all and the symptoms were terrible, he had difficulty swallowing, all his joints were dead and that made him immobile to mention but a few. we tried various therapies prescribed by our neurologist but none could cure him. I searched for a cure and i saw a testimony by someone who was cured and he left the contact of the doctor who had the cure in 2015. I never imagined ALS has a cure not until i contacted him and he assured me my husband will be fine. I got the herbal medication he recommended and my husband used it and in three months he was fully okay even up till this moment he is so full of life. ALS has a cure and it is a herbal cure contact the doctor for more info on josephalberteo@gmail.com on how to get the medication. Thanks for reading my story.

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  5. Hello, I want to give a brief story on how i was cured from ALS with the help of Dr. OJENMEN, i was been diagnosed in October 2014 and since then I was told that there's no cure for the virus, so I wept badly, One day I saw a blog talking about Dr. OJENMEN and his marvelous work, he has helped a lot of people that are been passing through hardship and he has the cure to all manner of diseases, so i decided to contact him and I told him about my problems, he told me that I should be rest assured that everything will be fine, he prepared his herbal medicine and sent it to me and I took the medicine for 14 days after then he asked me to go for check-up and I was cured, I couldn't believe the marvelous work he did for me, I know many people are suffering from the same virus and diseases, so I decided to bring him out to the world, so that they can have their own problems solved with the help of Dr. OJENMEN, you can reach him on drojemenspellhome@hotmail.com, whatsapp or call his number +2348157027254, and so he can cure all types of diseases like HIV/AIDS,HEPATITIS B,DIABETICS,CANCER,HERPES,LOW SPERM CAM. Thank you Dr.OJEMEN, for saving my life, He's waiting to help you.

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  6. Thanks be to God for sending me a deliverer who cured my Amyotrophic lateral sclerosis (ALS) i lived with this virus for 3 years without a cure, i lost strength and i became weak i tried all possible means to get cured but they failed,all my hope was lost, i thought i would die soon, i searched for natural remedies and i found a lot of people who where cured by Dr Harrison so i contacted him and he gave me hope and prepare his herbal medicine which i took for 8 days as instructed and to my greatest surprise i was cured using his herbal product. am so happy, i can't believe i could be healed again. please contact him via email if you are having ALS diseases his email is SACREDSPELLTEMPLE@HOTMAIL.COM or add him on whats app +2348079540032. contact me for more information huffmike077@gmail.com or call me 1 954 327 8869

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  7. My mother had told the chiropractor about my accident, and he encouraged her to make sure I came in to see him as soon as possible. medical treatments

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  8. My ALS (amyotrophic lateral sclerosis) symptoms started out with a "foot drop" on my left foot. From there my left leg lost all muscle tone and then the entire left leg muscles were gone. Also my fingers and thumbs "contract" at times. Left arm was losing muscle tone too.I was given medications to slow down the progress of the disease,i resorted to a wheelchair (Perbombil C300).This was till my husband's sister introduced my husband to a herbal clinic in Johannesburg who sell herbal medicines to cure all kind of diseases including ALS, we contacted the herbal clinic via their email and purchased the ALS herbal remedy, we received the herbal medicine via courier within 7 days and commenced usage as prescribed, its totally unexplainable how all the symptoms gradually dissapeared, my speech has greatly improved and am able to walk a distance now with no help, contact this herbal clinic via their email healthherbalclinic@gmail.com Or website www.healthherbalclinic.weebly.com

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