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Chiropractic Journal of Australia : CJA June 2013
78 Chiropractic Journal of Australia Volume 43 Number 2 June 2013 chiropractic care. It was the marked deviation of SPs seen on the radiographs, the painful cervical range of motion, the tender left trapezius which led the investigators to the identifcation of OCS, and to consider the Thompson treatment protocol. It was at this time that a right frst rib subluxation was also identifed by palpation. Treatment consisted only of Thompson Technique chiropractic adjustments primarily of the right frst rib, but also of spinal segments as indicated on the day. For OCS cases, the Thompson adjustment for the 1st rib (right in this case) is performed by turning the prone patient's head to the side of spinous deviation (left in this case), thus pushing the spinous processes in the direction of correction (restoring proper biomechanics).2 The 1st rib is adjusted using a spring-loaded drop mechanism, with the contact made on the superiolateral aspect of the frst rib and with a line of drive superior-to-inferior and slight posterior to anterior. See Figure 3 for pictorial views of the adjustment setup. It is believed that this action will traction the contralateral trapezius and by default pull the spinous processes in the proper direction. Treatment frequency was 6 adjustments over an 8-week period. The patient reported signifcant immediate relief after the frst adjustment, and continued to improve until discharge following the 6th adjustment. Case#2 In the second case, a 36-year-old woman presented for chiropractic care for neck/mid-back pain and migraine headaches. The neck/mid-back pain was intermittent and of 4 years' duration. For this complaint, she reported having had previous chiropractic care, osteopathic care, acupuncture and massage, all giving her a degree of temporary relief. The patient also reported having had migraine headaches with photo- and phonophobia for the previous 15 years. Nothing gave her lasting relief, although Aleve (Naproxen, Bayer Healthcare LLC, Morristown, NJ), a nonsteroidal anti- infammatory drug (NSAID), gave her temporary relief. In addition, she reported having had three MVAs, all head on collisions, over the previous 15 years, with the last one being 5 years before presentation. This patient also completed a QVAS for the neck pain, mid- back pain and migraine headaches, an NDI, and a Revised Oswestry Back Pain Disability Questionnaire (ROBPDQ) for the mid-back pain. On the NDI, the patient scored a 9/50 (or 18%), and initially reported that she had moderate neck pain, moderate infrequent headaches, and her sleep has been slightly disturbed since the accident. During the physical exam, right and left cervical lateral fexions were marginally reduced (38o right and 40o left), however all other cervical ranges of motion were within normal limits. During the postural exam, a high left shoulder and forward head posture were also found. Also, palpation revealed hypomobility and tenderness on the right from C2 to T3, tautness of both trapezius muscles (worse on the right) and pain on palpation of the left 1st rib. In addition, testing of the upper extremity dermatomes revealed loss of pain sensation in the T1 dermatome on the right, while all other dermatomal testing were unremarkable. All other physical exam fndings were within normal limits, including: upper extremity motor testing revealed scores of 5/5 bilaterally for shoulder abductors, elbow fexors, wrist extensors and fexors, fnger extensors and fexors, and hand intrinsic; deep tendon refexes were +2 bilaterally for the biceps, brachioradialis and triceps refexes; Maximal Foraminal Compression, Jackson’s Compression, Shoulder Depression and Cervical Distraction Tests revealed no signifcant fndings. In addition, vital signs were recorded and found to be within normal limits: height 1.55 meters, 49.0 kg, BMI 20.4, heart rate 60 beats/ minute, respiratory rate 16/minute, normotensive, and body temperature 98.0oF. A radiographic examination of the cervical spine which included these views: anterioposterior (AP), AP open-mouth (APOM), and neutral lateral. On the AP radiograph, marked axis SP deviation to the right was noted, with the remaining cervical SPs also displaying moderate deviation to the right. In addition, mild arthritic changes were found on C4-C7 endplates and C5-C7 facet and uncinate joints. The cervical AP and APOM radiographs for this patient are shown in Figure 4. The presentation of right-sided neck pain, the taut and tender right trapezius muscle, the tender 1st ribs bilaterally and the cervical SPs deviation to the right pointed to the fnding of OCS. This case was also reviewed, diagnoses made and a treatment plan recommended. The ICD-9 diagnostic codes for this case are also outlined in Table 2. Treatment consisted of Thompson Technique chiropractic adjustments to left 1st rib (see Figure 3) and cervicothoracic junction, and manual myofascial triggerpoint therapy to both trapezius muscles. Treatment frequency was 11 weekly adjustments over a 12- week period at a chiropractic teaching facility. The patient responded well to care, reporting immediate reduction of neck pain and improved mobility after the frst adjustment. Her neck pain NPRS scores for each visit are outlined in Table 2. DISCUSSION This case series illustrates two patients presenting with the specifc signs and symptoms which have collectively been described as OCS by Dr. Thompson. Despite its frst description occurring nearly 30 years ago,1 no other account of OCS has yet been reported in any peer-reviewed literature. Perhaps this case series will stimulate interest in future research. Practical experience has shown that OCS often follows a traumatic injury to the neck, such as an MVA. Whether the subluxation of the 1st rib is the result of the injury or a risk factor for developing OCS remains to be seen. In either case, the resultant neck pain and dysfunction is oftentimes diagnosed as torticollis22 or cervical dystonia (CD),23 considered by some to be the same condition.24 Popular invasive treatments for CD include surgery,25,26 injection with botulism toxin,27, 28 antiparkinsonian drugs such as Trihexyphenidyl29 and other oral medications.30 While there have been a number of case series published describing non-invasive interventions (such as chiropractic) for CD,31,32 to date none have been verifed to be effective using scientifc methods.30 It is our speculation that trauma can cause an increased hypertonicity of the trapezius and scalene muscles, which in turn may result in cervical nerve dysfunction, and ultimately subluxations of the 1st rib and cervical or upper thoracic OVERCOMPENSATED CERVICAL SYNDROME (OCS) WELLS • BRINKLEY • JENSEN
CJA March 2013
CJA September 2013