An Upper Cervical Chiropractic Approach to Chronic Fatigue Symptom 

Chronic Fatigue Syndrome (CFS) has an elusive etiology and baffling history. After extensive research diagnostic criteria finally were established by the Centers for Disease Control and Prevention (CDC). A differential diagnosis of CFS can be confirmed if a patient has a history of persistent or relapsing fatigue for six or more months, plus concurrent occurrence of four or more of the symptoms listed below.1 A careful evaluation of a patient's health is imperative to rule out other causes of ongoing or unexplained fatigue such as depression, obesity or thyroid disorders.

Through the efforts of a family practitioner, psychiatrist and chiropractor, a pilot study was designed and conducted to study the effects of chiropractic correction at the atlas level on patients diagnosed with CFS. A pool of twenty subjects was recruited and studied. One pilot- study subject's case history follows:

Subject #3 presented to her family practitioner a ten-year history of unexplained fatigue. She was 47 years old, married, mother of two children, and worked in sales. The initial screen, consisting of a list of the symptoms, revealed the presence of several of CFS's hallmark symptoms, including muscle- and multi-joint pain, headaches, and unrefreshing sleep. The physician ruled out medical conditions that rotund CF S in presentation as the cause of her ongoing fatigue. Subject #3 was referred for an evaluation to rule out psychiatric causes of her condition.

A Board-certified psychiatrist conducted a standard mental-status examination, including: assessment of orientation as to time, place, and person; cognition; mood and affect; impulse control; reality testing; and judgment. Personal and family histories were taken for the presence of psychiatric and/or mood disorders. Following special testing, Subject #3 began the chiropractic portion of the study. Upon arrival at the office of a chiropractic practitioner certified by the National Upper-Cervical Chiropractic Association (NUCCA), Subject #3 completed the study's informed-consent form, a symptoms survey, the SF-36, and the Pittsburgh Sleep Quality Index (PSQI). All testing was completed before introduction to the practitioner, to guarantee an unbiased baseline. Following NUCCA standards of care, a chiropractic evaluation was conducted to determine if the atlas were misaligned, the degree/orientation of atlas subluxation (spinal misalignment), and to form a visitation plan 2. It included the following:

1. Interview for history of present illness and presenting symptomatology;
2. Thermographic study using the Neurocalometer to determine differences in temperature in cervical musculature of the occipital area;
3. Comparison of leg-lengths, with subject in supine position, to screen for inequality due to spastic contracture;
4. With an Anatometer, a specialized posture-constant assessment tool, measurement of the distance between each iliac crest and the floor, when the subject was instructed to "stand normally," to gauge pre-adjustment degree of pelvic tilt (unequal ilium level in the frontal plane) and/or twist of the pelvis in the transverse plane;
5. A precise radiographic examination using a specialized grid and technique, (Lateral C-Spine, Vertex and Nasium views) to measure pre-adjustment atlas subluxation in degrees.

The radiographs were used to determine the subluxation type and placement position of the subject's head on the headpiece to deliver precise manual correction. Post adjustment radiographs confirmed subluxation-reduction of the atlas to within NUCCA's standards of tolerance.

Subject #3 was assessed regularly to confirm maintenance of atlas correction. After three consecutive months of alignment, the special testing-battery - including clinical laboratory tests, the SF-36 and PSQI-was repeated. After six months of continuous alignment, the SF-36 and PSQI were repeated and compared with baseline values.

The SF-36 was selected for this study because it evaluates multiple CFS-related aspects of health and quality of life. The outcome measure provided a beginning baseline to compare to this subject's response and has been used in other CFS projects with success 3,4. Chiropractic Research also has used the SF-36 effectively in several studies 5,6,7,8,9. The SF-36 is a recognized and accepted research standard.10 This self-administered pencil-and-paper instrument consists of 36 subjective and self-rated questions, measuring eight health categories, including physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional, and mental health. It has been used in several hundred research studies worldwide.

Since unrefreshing sleep is a major CFS symptom, the PSQI was employed to monitor changes in subjects' sleep quality. Sleep-disturbance has been studied in female populations diagnosed with CFS and fibromyalgia.11 PSQI's questions assess a wide variety of factors relating to sleep quality; including subjective reports of sleep duration, latency, frequency and severity of specific sleep-related problems 12. Grouped into seven component scores, questions are weighed equally on a 0-3 score. PSQI was administered to each study subject on two occasions, separated by at least one month, to discriminate between transient and persistent disturbances 13.

Radiographic films revealed demonstrable evidence of improvement following the NUCCA chiropractic process. The pre-adjustment nasal film showed atlas misalignment to be one degree to the right of the center of gravity of Subject #3's head. The head and neck were measurably to the right of her vertical axis. Post-treatment nasal film revealed the subluxation to have been corrected down to within one-quarter of a degree of atlas laterality, within "normal range," according to NUCCA standards. When supine, before adjustment, Subject #3's right leg was contracted 2.4 cm., compared to the left leg. When standing on the Anatometer, her right ilium was lower than the left by 2.3 cm. After correction, the legs were of equal lengths in the supine position. The illi were also level when Subject #3 stood on the Anatometer.

Subject #3's SF-36 results in eight categories are detailed in Figure One. Her improvement is clear over the monitoring period. By the seventh month, in fact, Subject #3's results had improved to almost 100% of by measures, with the exception of Physical Functioning, where she scored 95%. It is important to note that the SF-36 is geared toward assessing subject pools, not single individuals. Nevertheless, it is significant that that Subject #3's scores showed a substantially improving trend over the study period.

Lower PSQI Global Sleep Index scores reflect better sleep quality. Subject #3's scores moved from 17 out of 21 to 4 out of 21, signaling an improvement in sleep quality. Her reliance on sleep medication was eliminated, however, and her scores improved in sleep latency, sleep disturbances, and daytime dysfunction. Changes in Subject #3's individual component scores are detailed in Table Two below.

Unlike her pilot-study peers, who maintained atlas alignment after an average of only one adjustment intervention, it may be worth reporting that Subject #3 required several chiropractic corrections before she succeeded in holding atlas alignment for the requisite three months. Further research is required to study the significance of this, its impact on prognosis, and its implications for more intense and frequent monitoring protocols in post-correction phases for patients with histories of failure to hold alignment.

In conclusion, it was demonstrated that NUCCA chiropractic care improved Subject #3's perception of her quality of life and sleep, substantiated by her radiographic films. Further study is indicated on the effect of upper- cervical chiropractic care for patients diagnosed with IFS. A paper describing the overall results of the pilot study is forthcoming.

References:
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2. National Upper-Cervical Chiropractic Association Guidelines and Standards of Care. NUCCA. Monroe: 1997.
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Acknowledgements:
The authors are grateful: to the staff of the Chiropractic Health Offices, Chicago, IL for their efforts in assuring the subject's quality care; to Bruce Al. Bell, M.D, and Leo I. Jacobs, M.D., Barrington, IL, for providing medical and psychiatric examinations; to Advocate-Good Shepherd Hospital, Barrington, IL, for a grant that provided funding for special testing.
Dr. Charles Woodfield practices in Wilmington, NC and served as the project's advisor and coordinator. He can be reached at cwoodfield@worldnet.att.net

Dr. Marshall Dickholtz, Sr. was the adjusting chiropractor. He has practiced NUCCA for over 43 years and has been presented with several awards for his role in chiropractic research. In 1994 he received the David D. Palmer scientific Award Medal from Palmer College of Chiropractic. Dr. Dickholtz, Sr. can be seen on the Internet at www.nuccadickholtzsr.com. He can be reached at dmarshallsr@worldnet.att.net.