Authored by Charles Blum*
Introduction
Evidence is emerging to support the theory that airway oxygenation, which is often associated with obstructive sleep apnea (OSA), is an important condition to include in a differential diagnosis. OSA is a condition that sometimes presents as a symptom of a more complex condition (e.g., cardiovascular, diabetes, cancer, inflammatory diseases, gastroesophageal reflux disorder, etc.) [1-10] without an apparent direct relationship to any airway compromise. One feature of OSA is the jaw-head position-hypoxia relationship that is associated with a persistent forward head posture [11-14] causing chronic skeletal pains that do not resolve with conventional therapies. As a means to sustain optimal airway space with OSA the head tends to move forward and while this improves oxygenation it adversely affects the cervical spine and body posture. Literature suggests there is a relationship between head posture and temporomandibular joint dysfunction (TMD) issues [15-20].
Case History
A 38-year-old patient presented for care at this office in November 2016 with an array of symptoms (autoimmune disorders, dizziness, obstructive sleep apnea-OSA, etc.). The onset of his condition reportedly began eight years ago following a surfing accident (fell on left shoulder) and removal of his wisdom teeth. After these events, he began experiencing syncope, brain fog, dizziness, and movement/vertigo, all of which worsen when sitting on soft seats or when hunching over or with his head tilted up or down. He noted that his condition was aggravated with computer work and when his head was in a forward posture. Brain fog prevented him from being able to concentrate at work, and he found his condition debilitating, relentless, and life-altering. He was primarily diagnosed with apnea (OSA), vestibular dysfunction, vascular headaches/migraines, and cervico/thoracic enthesopathy.
At eight years old, the patient reports that he fell off of a cliff and landed on his head. At age 10, he fell onto a skill saw blade and needed multiple stitches to the back of his head. The patient had an automobile accident at 14 years old, which resulted in head trauma and a fractured C7 spinous process. He had his adenoid and tonsils removed at the age of 21. Compounding his presentation, the patient had migraines and sleep disorders which were diagnosed as a form of sleep apnea in 2008. He has had a history of anemia with a low red blood cell count complicating his hypoxic condition. Of note he was temporarily disabled for 2 months in 2008 and during that time received chiropractic care over the course of a month. The patient reported that chiropractic helped him somewhat but did not affect the dizziness or brain fog. He was also on disability for 1 month in February 2017 due to his condition.
A 2010 ECG study showed probable left ventricular hypertrophy of heart, and ejection fraction at 67% of normal. EEG testing at that time showed some brief high voltage bursts of alpha activity followed by some decrease in the background activity. A recent MRI of the brain and head was described as normal. He was recently diagnosed with scleroderma but was not receiving care for that condition at the time of his presentation at this office. Since early 2012 he was using a continuous positive airway pressure (CPAP) machine for sleep and as a means to treat his OSA [21]. nose and throat specialist, allergy-immunologist, sleep specialist, internist, rheumatologist), cranial osteopaths, acupuncturists, physical therapists, and massage therapists. He has spent thousands of dollars on care and had been on short-term disability for the past year. For three years prior to beginning care at this office he had been unable to perform physical exercise. With regards to the other care he received, he reported that he felt somewhat better, though only temporarily, with upper cervical chiropractic treatment.
Methods/Interventions
The patient’s examination findings revealed reduced cervical rotation, and pain with lateral cervical flexion localizing to the occiput /C1 and C5 through C7. Lumbar vertebral flexion was limited with pain localizing to the L5 region. Sacro Occipital technique (SOT) cervical compaction test was positive for lumbopelvic involvement. Cervical stairstep was positive at the Occiput /C1 and C5-7 spinal levels. Forward head posture was noted with sensitivity on palpation at the right temporal bone styloid process (can be related to L5 [22,23] and the right 1st costotransverse junction. Body sway analysis noted both anterior/posterior and lateral sway patterns. He had sleep disorders/apnea with inability to reach deep sleep, stage 3-4, associated with frequent limb movements at the time he should enter deep sleep treated with a dental appliance and CPAP.
Treatment focused on SOT and SOT cranial chiropractic interventions, nasal balloon methods for craniofacial sinus expansion, and supplementation with B12/methylated folic acid (to facilitate red blood cell oxygen uptake) [24]. SOT interventions focused on releasing right psoas and bilateral piriformis muscles’ greater trochanteric attachments. The patient was treated for SB+ pattern, which relates to increased lumbosacral dural meningeal tensions [25]. His cervical spine was treated with cervical stairstep mobilization and adjusting. Osseous adjusting was applied to the thoracic and lumbar vertebra along with an anterior diaphragm pseudo-hiatal hernia release. Common cranial patterns included sphenobasilar right side-bending and vertical strain lesions [26]. Intraoral adjusting focused on releasing his right zygoma that was restricted in external rotation and bilaterally external pterygoid muscle release. The left sphenoidal greater wing was also corrected from an external rotation positioning. Initial use of nasal balloons focused on insertion into the lower right and middle left turbinates, followed with upper and middle turbinate releases [27] on alternate days.
Results
The patient was treated from November 15, 2016 through March 24, 2017. By early 2017 his eight-year bout with dizziness was reduced and he could function in most activities of daily living. By March 2017 he only noted mild neck pain (50% reduction) with significantly reduced tension and swelling. His lower back pain would only present on occasion and described by the patient to be 80% improved. Since he was using the CPAP and an oral dental appliance, he noted an improvement in his oxygenation characterized by a pulse oximeter reading of 98%, and a normal Epworth Sleepiness Scale scoring [28]. Initial pre-treatment (November 2016) Roland-Morris disability index scales [29] were scored at 28% for low back pain and disability and with a followup approximately six months later showing a minimal change or reduction to 24%, a reduction of 4%. His neck pain disability index scales [30] were initially measured at 52%, with follow-up testing (April 2017) showing a reduction of his neck disability index of 36%, a reduction of 16%. Beck’s motor testing [31-34] was normal for TMJ dysfunction and positive for his neck at the initial office visit and reported as normal after 2nd office visit.
The patient reported that the chiropractic care he received at this office, which consisted of sacro occipital technique (SOT) along with SOT extra cranial/intra oral and nasal balloons gave him at least 50% improvement of his symptoms, which had been unresponsive for eight years, along with giving him the ability to return to work. After approximately five months of care the patient has been able to maintain his improvements and continues to feel increasingly capable of doing his activities of daily living without restrictions. He still self-limits, particularly regarding heavy strenuous work, though for the first time in years he has been able to do rock climbing and other limited sports activities.
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