Laser Articles and Research
Case Studies for the Treatment of
Cervicogenic or Vertebrogenic Headaches
Headaches that rapidly resolve following chiropractic treatment should empirically be classified as vertebrogenic or cervicogenic. One would think that headaches originating from the cervical spine would all be termed a "cervicogenic headache" however, cervicogenic headaches have criteria that limits its use for diagnosis. (This criteria really should be changed to reflect current scientific understanding and variability of the cervicogenic category). The classic definition of cervicogenic headache was originally proposed by Sjaastad in 1983. It has 3 criteria (1) unilateral headache triggered by head/neck movements or posture; (2) unilateral headache triggered by pressure on the neck; (3) unilateral headache spreading to the neck and the homolateral shoulder/arm. This classification of headache is still not accepted by The International Headache Society (IHC). Rather than recognizing this obvious form of headache, the IHC labels these headaches as a subset etiology of the tension-type headache or a variant of chronic daily headaches (CDH). The post traumatic patient may be diagnosed with new daily persistent headache (NDPH) a recent classification for headaches having multiple etiologies such as headache from post-concussion, subarachnoid hemorrhage, recent infection or other relatively rare disorders. The cervicogenic headache is one of the few types of headache where the source of pain originating from the reflexive pain generators in the spine can clearly and convincingly be identified based on segmental localization. Although the provocative cause of many headaches may be evident such as lumbar puncture headache, meningitis headache, toxic triggers or post concussion headache, the mechanism of pain production in most headaches is still incompletely understood or completely unknown. An alternative name for headaches originating from the spine is "vertebrogenic headache". This term was proposed by Howard Vernon, D.C. a researcher and professor from Canadian Memorial Chiropractic College to avoid the limitation created by the overly narrow definition created by Sjaastad for cervicogenic headache. Case study 1 Post traumatic 33 year old male patient with intensifying HA and nausea, disc herniations present at C3-4, C6-7 and T1-2. Normal brain MRI. Increased HA on cervical flexion. HA behind eyes, base of skull and vertex. Unrelenting HA for 3 months since MVA, unresponsive to Vicoden or Lortab. Multiple physicians consulted before referral to my office. Confirmation of spinal generators using manual axial traction applied to C6-7 on the left. Simultaneous axial decompression of C3-4 and suboccipital C1 level. HA reduction for 20-30 seconds with this maneuver. Treatment: Class IV K- laser to capsular region and intrinsic trigger points in the cervical spine. Results: Near complete resolution on first visit. Case study 2 Post traumatic 57 year old female patient with significant cervical DJD and multiple broad based HNPs. HA for 6 months duration since MVA, patient was taking aspirin or Tylenol on a daily basis. A mild C7 radiculopathy was also present with variable intensity reported between visits. Her HA was the primary complaint. She had regular chiropractic care for 6 months without any reduction in HA intensity. Class IV K-laser was used in the suboccipital and posterior cervical intrinsic musculature as well as scapular elevator musculature. There was no change in the patient's symptoms following the first two treatments. Following the third laser treatment the patient had complete resolution of HA symptoms. On a follow-up visit five months later, there were no episodes of HA reported.
CASE STUDY 2
Neck Pain: Dynamically Induced Chronic Cord
Compression and Radiculopathy
Confirming the source neurological compression in the patient with intermittent dynamically induced symptoms may be a diagnostic challenge. This diagnostic challenge is compounded when the doctor relies on a static x-ray or MRI report that discounts small structural intrusions in the spinal canal as being clinically insignificant. Symptoms that manifest during movement may be difficult to image if the mass-effect is small or provoked at end range motion. The following case is interesting because of the obvious change in pathologic interpretation between flexion and neutral positioning. The neutral lateral MRI (read by another radiologist) was considered to only have disc bulges. However, the purpose of this case study review is not to urge doctors to order flexion MRIs as standard practice it is a reminder that the spine is a dynamic structure and intermittent symptomatic compression of the neural elements may not be apparent on a static film. Thus, treatment may be delayed and the potential for chronicity may be underestimated. Greater deviation of neural elements or larger deformation has a greater potential to produce symptoms. Deformation of the spinal cord or square area of the spinal cord can be clinically graded however most radiologists do not use a measurable scale. Nagata et al (1) described a useful four-level scale based on T1 weighted sagittal images of the cervical spine. The spinal cord may also be deviated without obvious compression, causing excessive traction on the cord or roots. The degree of compression and intensity of symptoms may not be in direct proportion in cases of mild compression with extensive inflammation. Case Study: Clinical History: 43 y/o male with history of neck and upper quarter repetitive injury during full contact martial arts sparring. His pain was described as intense in the supraclavicular fossa and suprascapular region on the right. He had multiple epidural injections and a C6 sensory root rhizotomy. The patient had short-term benefits from these invasive procedures without complete resolution of his pain. He was unable to work in full capacity and upper extremity exercises intensified his radicular symptoms. Scalene and omohyoid muscular injury was suspected in addition to disk herniations observed on MRI. Chiropractic treatment over the three years after injury provided reduction in pain however periods of severe break-through pain occurred with activity. Laser Treatment Protocol: Class IV laser was used in the following regions and protocol: The posterior and lateral articular pillars C4-C7 and paravertebral muscles were treated in the cervical spine. The upper thoracic spine T1-T4 and right paravertebrals were treated predominantly in the thoracic spine. Trigger points in the ascending trapezius, omohyoid, scalene groups on the right were treated in conjunction with stretching. The treatment protocol used a dual infrared beam laser in the 800 nm and 970 nm ranges set at 3W of power for a duration of 15 minutes in the areas listed above. The initial treatment program was 1-2 visits per week over two months. There were three treatment phases during each session consisting of the frequencies 2 Hz, 10 Hz and 500 Hz. The probe was moved from point to point with direct contact technique in a grid pattern approximately 4-6 seconds per point. Results of Treatment: The patient had significant relief of pain after the first visit. By the third visit, his pain had dramatically reduced to a tolerable level. His need for pain medication also was reduced. At the end of the second month, he was no longer needing narcotic pain meds and was sleeping much better. He was still unable to return to pre-injury sports activities or work level, however he reported days without radicular pain and only mild pain on light activity. This improvement status has continued for six months with the patient only requiring treatment on a weekly basis. The intractable pain returned on a few occasions following physical activity. The treatment was considered highly successful because prior to the intervention with Class IV laser, the patient was taking Vicoden on a daily basis and had constant nagging intractable pain shooting into his supraclavicular fossa. His quality of life had improved and the patient was making it through the day without the need for narcotic pain relievers. Spinal cord compression noted at the C5-6 level and the T2-3 level with cervical flexion. These disk herniations were only part of the mechanisms responsible for pain production in this patient. Injury to the scalenes and omohyoid muscles was clinically suspected. Reference 1. Nagata, K et al. Clinical use of magnetic resonance imaging for cervical myelopathy. Spine. 15(1):1088-1096,1990.
CASE STUDY 3
Shoulder Pain: Subacromial Impingement
Clinical History: A 53 year old male presented with obvious signs of shoulder impingement. Symptoms gradually developed over a two-month period. The patient was unable to extend his arm forward without a jolt of pain. Abduction was cautious and slow from 0-90 degrees. He was unable to elevate or abduct beyond 90 degrees. External rotation was cautious without resistance and moderately to severely painful with any resistance. The patient was unable to move or resist his shoulder in any plane away from the body when pressure exceeded 5-10 lbs. X-rays were unremarkable for degeneration. The working diagnosis was subacromial bursitis and bicipital tendonitis. Treatment Protocol: The treatment program included Class IV dual beam laser for the shoulder joint and shoulder girdle musculature for six visits and one axial decompression adjustment on the second visit to the T2-6 region of the spine. The KLaser 4D model laser was used in the treatment of this patient, using a total of 9 minutes laser therapy for the upper quarter. Technique followed a direct contact method of delivery in grid pattern. Trigger points in the shoulder girdle, rotator cuff, and posterior lower cervical intrinsics were treated on each visit. Contact was approximately 4-6 seconds per grid point in the symptomatic upper quarter areas. The estimated dose was 4-6 Joules of laser delivered at the skin surface per point. Results of Treatment: The patient experienced dramatic reduction of pain on the first visit and was almost symptom free in three visits. On his sixth visit, the patient reported he only had very little pain but he had returned to full capacity manual labor. He has returned to normal activities without any signs of impingement. His only residual symptom at three months post treatment was a very mild tenderness in the lateral subacromial region on deep palpation. He has remained symptom free at this point for over a year. Discussion: The healing mechanism of laser therapy is termed photobiostimulation. There are four categories of biological effects demonstrated to occur. The first is Thermal; class IV laser has a warming effect on tissues improving flexibility of joints. The second is Biochemical; this is seen on a cellular basis with increased nitric oxide production and increases in enzyme activity. The third effect is Bioelectric; this occurs with membrane electrical gradient shifts and generation reactive oxygen species. The four effect is Bioenergetic; with influence on acupuncture meridians and system-wide clinical effects such as increased or decreased fatigue. There are many studies in animals and cell cultures, which demonstrate physiological effects such as increasing ATP production, increasing vasodilatation, relaxing spasm, and reduction of pain. The mechanism of pain relief and return of shoulder function in this patient appears to be the result of thermal and biochemical effects. Lasers are classified by their output strength and wavelength of light. Class I lasers are not regulated because their output is not strong enough to cause any tissue damage. Class II lasers operate at 1mw or less. These are commonly used in laser pointers and electronic equipment such as CD players. Class III lasers have an output below 500mw they are used in many low level lasers. Class IV lasers have an output above 500mw. An example is the KLaser an infrared dual-beam Class IV laser. This device has an output power ranging from 100mw-6000mw.
These 3 case studies were submitted by Dr. Jerome True who is a Board Certified Chiropractic Neurologist practicing in Stuart, FL. He is the Coauthor of the textbook "Myelopathy, Radiculopathy, and Peripheral Entrapment Syndromes".