A Patient’s Perspective – Greg Buchanan
Well here it is my latest newsletter. I have chosen visual disturbances as the subject. I have found that it is extremely common for people to report improvements in vision immediately following a chiropractic adjustment, and there have also been some remarkable recoveries of loss of vision. I personally had visual disturbances which recovered following chiropractic intervention and even today if I have an upper cervical adjustment I can discern even the smallest improvements in visual acuity.

Some of the research papers I refer to in this newsletter are not specifically related to chiropractic; however what you will see again is the common thread of ‘cervical’ involvement in visual dysfunction.

The theories put forward by the various authors include irritation of the cervical sympathetic chain in the neck, incorrect proprioceptive feedback to the brain, irritation of the nerves affecting the vertebral and carotid arteries resulting in a reduced blood flow to the brain, referred to as hypoperfusion. One thing is certain, when you head is not on straight, interference could result to the various structures neurological and vasculature in the neck which could have the affect of diminishing visual functions.

 Researcher Dr. Allan Terrett[1] has observed in reference to chiropractic that “Many of the anecdotal claims that at first appear fanciful are being validated.”[2] The claims are no longer just anecdotal and certainly in my view have never been fanciful. These claims and positive results are appearing in chiropractic offices daily, in well constructed case studies and in scientific studies. The powerful healing powers of a well delivered upper cervical adjustment can no longer be ignored and can no longer remain hidden from us patients.

I hope you enjoy my newsletters and as always feel free to provide me with any feedback and suggestions to info@upcspine.com. Remember I am a patient and not a medical practitioner; however I am entitled to my own opinion. People are free to disagree with me. My newsletters are provided as an informational source only, and are not a medical opinion. Therefore you should do further research for yourself and make your own decisions.

CONDITION REPORT

Visual Disturbances

In a hunt for papers which discuss the correlation of changes in vision following chiropractic or spinal manipulative therapy you will find articles written by chiropractors, osteopaths, ophthalmologists and medical specialists. You will find papers in various chiropractic journals, the journal of Manipulative and Physiological Therapeutics, the journal of Chinese Medicine, optometry journals an so on. The point is that there are a diverse range of people who are smart enough to have recognized the obvious link between vision problems and the cervical spine.

Stephens and Gorman[3] discuss the case study of two girls aged 13, one with “headaches, blurred vision, motion sickness and peripheral pains and aches”. She had “concentric narrowing of the visual fields” and her “suboccipital joints were tender to palpation.” The other patient “complained of headaches, dizziness, blurred vision and peripheral pains and aches but no motion sickness”. She also had sub-occipital pain and decreased range of motion of the cervical spine. The authors indicate that treatment was by chiropractic manipulation of the cervical, thoracic and lumbar spines, so it wouldn’t be classed as ‘specific’ chiropractic, however, improvements in vision were immediate after spinal manipulation.

A further case by Gorman et al[4] is a single case of a patient with reduced visual field and retinal damage due to congenital glaucoma. The patient had her left eye removed at age 3 and glaucoma progression resulted in marked loss of vision in her remaining eye such that at age 16 she was “declared legally blind”. The patient apparently sought chiropractic care because of “long-term back pain, neck pain, headache, and frequent classic migraine.” I find in my research that in many cases people seek out chiropractic care for those conditions for which chiropractic treatment is pigeon-holed e.g. back pain. They are amazed to discover that when they are treated other symptoms and deficits seem to improve. This frequently occurs when upper cervical spine dysfunction is addressed. Previous chiropractic intervention to the lumbar and thoracic spine had not resulted in any visual field change. Confirmation of the patient’s visual field deficit was confirmed by ophthalmic examination. “Total area of vision …. was assessed as 2% of a normal field.” She indicated that her perception of vision was “shadows only.”  Chiropractic manipulation using diversified technique was applied (low amplitude, high velocity) with “joint cavitation sound.” Immediately after the first chiropractic treatment the patient reported that she “can now see a hand, not just a shadow”. Ophthalmic examination revealed visual field increase from 2% to 11%. Following the 2nd chiropractic session the field increased further. Many months after her treatment he visual field has increased to 20% and been maintained. Her headaches, migraines, neck and back pain responded well with migraines ceasing completely. In the discussion session of the paper there is a familiar theme, that is, “cervical pathology may irritate the sympathetic nerve fibres (vertebral nerve), which accompany the vertebral arteries which may lead to constriction of the vertebral-basilar arterial system.” The paper mentions a study by Bogduk[5] et al stimulating the cervical sympathetics resulting “in pronounced decrease in carotid artery flow (30% of control group)” and further said stimulation has been shown to “reduce blood supply to the retina in human subjects.” The treatment in this case was a good outcome for this patient, but one has to wonder if she could have achieved normal eyesight and not lost her left eye had she had the benefit of chiropractic evaluation and treatment very early on in her life.

Charlotte Leboeuf-Yde at al[6] initiated a study to investigate the frequency of different non-musculoskeletal symptoms reported by patients who had sought chiropractic care for musculoskeletal conditions e.g. back pain, sciatica etc. There have been reports throughout the literature and anecdotally that according to the authors “spectacular ‘cures’ have been reported, based solely on clinical observations.” 462 separate reactions were recorded by about 23% of the patients and these fell into the following categories; respiratory system “easier to breathe”; digestive system “improved function” and eyes/vision “clearer, sharper, better vision”, followed by circulatory system “improved circulation”; Urinary tract “easier to urinate”; hearing “less tinnitus, better hearing”; followed by other improvements. It is not clear from the paper what vertebrae were adjusted/manipulated or how the manipulation was achieved (what technique). In the 8 cases who reported improvements in hearing it is stated that the thoracic spine, in combination with some other spinal region was adjusted. The authors cite the Harvey Lillard experience and indicate that D.D. Palmer had adjusted the 4th thoracic vertebra or Lillard resulting in resumption of hearing. In fact my research shows this, adjustment to T4, to be incorrect, as according to the Chiropractic Green Books, Palmer actually adjusted axis (C2)-see my website
http://www.upcspine.com/news_vol1_1203.htm.

In yet another paper involving Gorman[7] a woman reported loss of vision in her left eye following a fracture of the left zygomatic arch. The left eye had reduced light perception and both optic nerves were diminished. Following chiropractic treatment over several sessions a significant improvement occurred in vision immediately following spinal manipulations.

Stephens and Gorman[8] in a paper discuss a patient who presented with neck pain, and a history of incidents of acute spastic torticollis. Examination revealed limited flexion, extension and rotation of the cervical spine and a slight scoliosis. The c-spine was adjusted by hand with a lateral thrust; each thoracic segment was adjusted and some “torsional lumbar manipulations” were performed. The graphs in this case study indicate “immediate improvement in visual field sensitivities and a decrease in defect levels measured after spinal adjustment.” The authors call for more research into how spinal manipulation can improve vision in so called ‘normal’ vision patients presenting with back pain. Bring on the research!

Stephens and Gorman in yet another paper[9] focus on visual deficit concerned with the narrowing of visual fields. They cite numerous studies which suggest a link between recoveries of vision following spinal manipulation. One of the hypotheses as to the cause of the vision loss they suggest is cerebral hypoperfusion (deficient or reduced blood flow) which “has been confirmed to be part of upper spinal derangement”.  In this case the patient presented with ongoing minor headaches which resulted in a more severe headache. The visual field results following the spinal manipulative therapy (SMT) revealed immediate full visual fields. In other words, the patient’s vision improved significantly. According to the authors “the patient was able to read the last line of the visual acuity chart.” A telephone follow up with the patient some 3 months later showed she no longer had headaches and her mother remarked on improvements in learning, sport and attitude. The authors conclude that SMT should be considered in the treatment of symptoms as a result of head trauma and whiplash and suggest that chiropractors utilize the various ophthalmic tests and equipment available to check for visual field loss before and after the application of SMT.

Gorman[10] presents a case of a 62-year-old male with presumptive optic nerve ischemia, who presented with a one week history of monocular visual defect, headaches and neck strain. Vision improved dramatically following spinal manipulation as measured using static perimetry. The author’s conclusion is that cervical spine derangement produces microvascular spasm in the cerebral vasculature, including that of the eye.

Gorman[11] again discusses a case of a 9 year-old with demonstrated spinal injuries which may have caused cortical and ocular vision loss which was ameliorated following spinal a manipulation under anaesthesia. Two separate incidents of head trauma and vision loss are discussed which resolved following spinal manipulation. Gorman refers to studies which discuss ‘cervical syndrome’ and personal experience with 6,000 manipulations under anaesthetic to support his theories that “spinal manipulation, by repositioning vertebrae, defuses the irritative focus, leading to relaxation of the cerebral vasculature.” Because the carotid artery supplies microcirculation to the optic nerve, he believes manipulation can affect this circulation by freeing up irritation to the arteries and restoring ‘normal’ flow.

Two chiropractors Kessinger and Boneva[12] carried out a study involving 67 subjects, which investigated the relationship between upper cervical ‘specific’ chiropractic care and changes in visual acuity. Results indicated statistically significant improvement in visual acuity in both right and left eyes. They noted that “considerable evidence attests an association between visual disorders and head/cervical neck trauma” although the body of study is not great with reported cases being only case reports or small studies. According to the authors it is also “not unreasonable to assume that ischemic changes in vasculature associated with the sympathetic and parasympathetic innervation, or pressure to the eyes per se could elicit changes in vision.” Of the 67 subjects in this case, 59 had a demonstrated C1 listing (subluxation) and the other 8 had a C2 listing.

Gorman[13] published a case of a patient who developed a scotoma in vision in the right eye. The scotoma resolved after spinal manipulation. The author found significant recovery in vision occurring with each spinal manipulation treatment. This case reinforces SMT as the recovery event, as Gorman discusses the reoccurrence of the scotoma on three separate occasions and on each case following SMT, vision returned to normal. According to the author this case suggests “SMT can affect blood supply of localized brain tissue and microvascular abnormality of the brain is caused by spinal derangement.” Interestingly Gorman cites a study by Otte which found that 6 of 7 patients with non-traumatic cervical pain had “parieto-occipital hypoperfusion” and “in 24 patients confirmed by independent observers to be suffering from cognitive disturbances after whiplash ALL had parieto-occipital hypoperfusion compared to control subjects.” Parieto-occipital hypoperfusion basically means reduced flow of blood to the cerebral cortex in the brain. For us laypersons it means the blood flow to part of your brain was not normal.

There are some other interesting studies worth following up as follows. A summary of a few of these can be found in Kirk Eriksen’s book[14].

Zhang et al[15] in this study provides information regarding improvement of visual disturbance in 83% of 111 cases treated over a period of seven years, including 9 cases out of 12 blind eyes which regained vision. The authors indicate a finding of a correlation between poor posture of the cervical spine and head and visual disturbances.

Briggs and Boone[16] show a relationship between upper cervical chiropractic adjustments and changes in nervous system response, sympathetic and parasympathetic.

Schutte et al[17] a study of 12 children with Esophoria, which is a muscle co-ordination problem in which an eye or eyes have a tendency to turn inward. The findings suggest that esophoria may respond to chiropractic cervical adjustment.

Terrett and Gorman[18] report a news article about a 4 year-old girl, blind since age 9 months who recovers sight after adjustment of the first cervical vertebra (C1-atlas) and discuss research with rabbits in which removal of superior cervical ganglion in the neck resulted in a disappearance of fluorescent fibers of the iris. In other words the sympathetic nerve fibers affecting the iris originate in the nerve ganglion in the neck! Thus visual disturbances may well be caused by irritation of the cervical sympathetic chain in the neck which may be corrected by cervical chiropractic adjustment to restore correct vertebral relationships.

Further information about the role of neck proprioception in visual competence can be gleaned from a study by Dichgans[19] et al in which they find that “compensatory eye movement is critically influenced by vestibular and neck afferents and is not initiated centrally” in the brain. The study discusses removal of labyrinth (labyrinthectomy) and neck input (rhizotomy) or both and finds a replacement compensatory mechanism between the two and not a central compensation. The authors state “these findings extend our previous conclusion that for the range of movements we tested, ocular stabilization is entirely achieved by afferents from the labyrinth and neck proprioceptors.” Following labyrinthectomy a recovery of ocular stabilization returned to 90% post 1-month and this is attributed to “an increase in gain of the neck-to-eye loop” and notably the tests were done in the dark so there was no visual feedback to the monkey during the test. This paper seems to lend weight to the argument that neck dysfunction can affect vision. The plasticity of the central nervous system is demonstrated in this case.

I also came across a study by Brown[20] in which it is suggested that accommodative disturbance has been cited as one of the causes of visual disturbance following whiplash injury. A whiplash group consisted of 19 subjects and the control group consisted of 43 subjects. The amplitude of accommodation of the right and left eyes of the whiplash and control group subjects was measured and the results of the two groups compared. The results indicate that whiplash was associated with defective visual accommodation in the present whiplash subjects.

Murphy[21] indicates that it is reasonable to conclude that the posture control system is affected in whiplash subjects due to misleading information from the cervical (neck) proprioceptors. This causes vertigo, disturbed eye movements and reading problems.

Ernst, Seidl and Todt[22] conclude “manual medicine should be an integrated part of modern clinical otolaryngology” and “joint disorders” in the c-spine are “characterized by a variety of symptoms” (e.g. headache, vertigo, dizziness, blurred vision)”.

Other useful references and comments on this subject can be found at http://www.chiropracticfirst.ca/healthtopics/BrainFunction.htm

Suggested Further Reading

1. Abraham M, Sakhuja N, Sinha S, Rastogi S.; Unilateral visual loss after cervical spine surgery; J Neurosurg Anesthesiol. 2003 Oct;15(4):319-22
2. Wong CW, Chen TY, Liao JJ, You DL; Serial regional blood flow and visual evoked responses in transient cortical blindness; Acta Neurochir (Wien). 1993;120(3-4):187-9
3. Awan KJ; Association of ocular, cervical, and cardiac malformations; Ann Ophthalmol. 1977 Aug;9(8):1001-11
4. Srinivasan K, Rajan N, Ramamurthi B; Craniovertebral anomaly with visual field defect; J Assoc Physicians India. 1970 Aug;18(8):697-8
5. Rohmer F, Brini A, Mengus M; Regression of visual disorders after reduction of a cervical spine dislocation; Rev Otoneuroophtalmol. 1954;26(1):31-4

Summary

The references, mainly by Gorman, which discuss recovery of vision following spinal manipulative therapy are compelling and cannot be ignored. Yes, of course more research is required and certainly some well constructed clinical studies would not go astray, but the immerging facts which point to the cervical spine being implicated in visual disorders and reversal following spinal manipulation should serve as a basis for that further research. Gorman it would appear uses non-specific manipulation with rotary techniques to the cervical spine. Specific ‘specialist’ upper cervical chiropractors do not use such techniques. Even though Gorman et al have achieved some successes I will insist that there is no need for the use of anaesthetic or any non-specific rotary techniques to adjust the cervical spine. Better results will most likely be obtained by a more scientific, precision approach to spinal adjusting. Specific ‘precision’ gentle upper cervical adjusting is available, does not involve rotary techniques and it’s mostly carried out by the various specific upper cervical chiropractors around the world. "Chiropractic is specific, or it is nothing," BJ Palmer.

References

[1] Faculty of Biomedical & Health Sciences, Royal Melbourne Institute of Technology, Australia

[2] The eye, the cervical spine, and spinal manipulative therapy: a review of the literature; Allan G.J. Terrett and R. Frank Gorman; Chiropractic Technique, Vol. 7, No. 2, May 1995

[3] Stephens D; Gorman F; Bilton D; The Step Phenomenon in the Recovery of Vision with Spinal Manipulation: A Report on Two 13-Yr-Olds Treated Together. Journal of Manipulative and Physiological Therapeutics; Volume 20, No9, 628-33; (November/December 1997)

[4] Benjamin R. Wingfield, BAppSc(Chiro), R. Frank Gorman, MBBS. DO, FRACO; Treatment of Severe Glaucomatous Visual Field Deficit by Chiropractic Spinal Manipulative Therapy. A Prospective Case Study and Discussion. Journal of Manipulative and Physiological Therapeutics; Volume 23, No6, 428-34; (Jul/Aug 2000)

[5] Bogduk N, Lambert G, Duckworth JW; The Anatomy and Physiology of the Vertebral Nerve in Relation to Cervical Migraine; Cephaalgia 1981; 1:1-14

[6] Charlotte Leboeuf-Yde, DC, PhD,  Iben Axén, DC, Gregers Ahlefeldt, DC,  Per Lidefelt, DC, Annika Rosenbaum, BAppSc (Chiro),  and Thomas Thumherr, DC ; The Types and Frequencies of improved Nonmuskuloskeletal Symptoms Reported After Chiropractic Spinal Manipulative Therapy. Journal of Manipulative and Physiological Therapeutics (JMPT); Volume 22, No9, 559-64; (Nov/Dec 1999)

[7] Danny Stephens, DC, DO, Henry Pollard,  Don Bilton, DC, Peter Thomson, DC, DO and Frank Gorman, DO; Bilateral Simultaneous Optic Nerve Dysfunction After Pariorbital Trauma: Recovery of Vision in Association with Chiropractic Spinal Manipulation Therapy. Journal of Manipulative and Physiological Therapeutics (JMPT); Volume 22, No9, 615-21; (Nov/Dec 1999)

[8] Danny Stephens, D.C., M.Chiro.Sc., R. Frank Gorman, M.B.B.S., D.O. Does ‘Normal’ Vision Improve with Spinal Manipulation? Journal of Manipulative and Physiological Therapeutics (JMPT); Volume 19, No6, 415-18; (Jul/Aug 1996)

[9] Danny Stephens, D.C., R. Frank Gorman, M.B.B.S., D.O. The Association between Visual Incompetence and Spinal derangement: An Instructive Case Study; Journal of Manipulative and Physiological Therapeutics (JMPT); Volume 20, No5, 343-50; (June 1997)

[10] R. Frank Gorman, M.B.B.S., D.O. The Treatment of Presumptive Optic Nerve Ischemia by Spinal Manipulation; Journal of Manipulative and Physiological Therapeutics (JMPT); Volume 18, No3, 172-77; (Mar/Apr 1995)

[11] R. Frank Gorman, M.B.B.S., D.O. Monocular Vision Loss After Closed Head Trauma: Resolution Associated with Spinal Manipulation; Journal of Manipulative and Physiological Therapeutics (JMPT); Volume 18, No5, 308-14; (June 1995)

[12] Robert Kessinger, D.C.; Dessy Boneva, D.C. Changes in visual Acuity in Patients Receiving Upper Cervical Specific Chiropractic Care; Journal of Vertebral Subluxation Research (JVSR); 2(1), Jan 1998

[13] R. Frank Gorman, M.B.B.S., D.O. Monocular Scotomata and Spinal Manipulation: the Step Phenomenon; Journal of Manipulative and Physiological Therapeutics (JMPT); Volume 19, No5, 344-49; (June 1996)

[14] Eriksen, Kirk Upper Cervical Subluxation Complex: A Review of the Chiropractic and Medical Literature. , pp339-344. Publisher: Lippincott Williams & Wilkins 2004 http://www.LWW.com.

[15] Zhang CJ, Wang Y, Lu WQ, Li YM, Shen ZX, Li JX, Liu XC, Zhou SD, Gao JS; Study on Cervical Visual Disturbance and its Manipulative Treatment; Journal of Traditional Chinese Medicine, 1984 Sep; 4(3):205-10

[16] Briggs L, Boone WR; Effects of a chiropractic adjustment on changes in pupillary diameter: a model for evaluating somatovisceral Response; Journal Manipulative Physiol Ther. 1988 Jun;11(3):181-9

[17] Schutte BL, Teese HM, Jamison JR; Chiropractic adjustments and Esophoria: A Retrospective Study and Theoretical Discussion; Journal Australian Chiropractic Association, 1989;19(4):126-128

[18] Terrett AGJ, R. Frank Gorman;The Eye, the Cervical Spine, and Spinal Manipulative Therapy: A Review of the Literature.; Chiropractic Technique, 1995;7(2):43-54

[19] J. Dichgans, E. Bizzi, P. Morasso, V. Tagliasco;The Role of Vestibular and Neck Afferents During Eye-Head Coordination in the Monkey.; Brain Research, 71 (1974) 225-232

[20] Shayne Brown; Effect of whiplash injury on accommodation; Clinical & Experimental Ophthalmology 31(5) 424 - Oct 2003

[21] Murphy DJ; Whiplash and Vision; American Journal Clinical Chiropractic 1999 9(2) 16-17

[22] A. Ernst, R.O. Seidl, I Todt;Mode-of-action of manual medicine in the cervical spine; HNO 2003 51:759-770 July 2003

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