Epilepsy and Seizure Disorders: A Review of Literature Relative to Chiropractic Care of Children
Pistolese RA
International Chiropractic Pediatric Association,
Research Department,
Stone Mountain, GA 30087-3414, USA
OBJECTIVE: To review the currently available literature regarding chiropractic care relative to patients with epilepsy, particular emphasis being placed on those who have epilepsy as children.
DATA SOURCES: The Index to Chiropractic Literature was searched for the years 1980 through 1998 through use of the keywords epilepsy and seizure. The MANTIS database was searched for the years 1970 through 2000 through use of the Medical Subject Heading (MeSH) keywords chiropractic, epilepsy, seizure, and child/children. In addition, a MEDLINE search of the literature was performed for the years 1966 through 2000 through use of the same subject headings.
RESULTS: The present study reviews 17 reports of pediatric epileptic patients receiving chiropractic care. Fourteen of the 17 patients were receiving anticonvulsive medications, which had proven unsuccessful in the management of the condition. Upper cervical care to correct vertebral subluxation was administered to 15 patients, and all reported positive outcomes as a result of chiropractic care.
CONCLUSIONS: Chiropractic care may represent a nonpharmaceutical health care approach for pediatric epileptic patients. Current anecdotal evidence suggests that correction of upper cervical vertebral subluxation complex might be most beneficial. It is suggested that chiropractic care be further investigated regarding its role in the overall health care management of pediatric epileptic patients.
From the Full-Text Article:
INTRODUCTION
The purpose of this report is to review the currently available literature regarding chiropractic care for patients with epilepsy, particular emphasis being placed on those who have epilepsy as children. The importance of evaluating the currently available literature relative to the pediatric population with epileptic seizure disorders is apparent when current statistics are considered. Approximately 2 million Americans have epilepsy; of the 125,000 new cases that develop each year, up to 50% are in children and adolescents. The prevalence of epilepsy in persons younger than 18 years is estimated to be as high as 4.7 per 1000.1 Affecting approximately 2% of the US population, epilepsy is a chronic neurologic condition characterized by sudden, brief attacks of altered consciousness, motor activity, sensory phenomena, or inappropriate behavior caused by abnormal electric discharges in the brain. However, any recurrent seizure pattern may be termed epilepsy. [1-4] Schimp [5] has provided a criterion by which seizure activity can be differentiated from other atypical sensory phenomena, and Duhameeuw [6] has recommended a means by which the chiropractor can minimize patient injury if a seizure occurs in the office.
Most people with epilepsy have only 1 type of seizure; approximately 30% have 2 or more types. Approximately 90% have generalized tonic-clonic (formerly called grand mal) seizures. Such a seizure typically begins with an outcry and continues with loss of consciousness and falling; this is followed by tonic, then clonic, contractions of the muscles of the extremities, trunk, and head. Urinary and fecal incontinence can occur. The seizure usually lasts 1 to 2 minutes. [7] Absence (formerly called petit mal) seizures consist of brief, primarily generalized attacks manifested by a 10- to 30-second loss of consciousness and eyelid flutterings at a rate of 3 per second, with or without loss of axial muscle tone. Affected patients do not fall or convulse; they abruptly stop activity and resume it just as abruptly after the seizure, with no postictal symptoms and no knowledge that an attack has occurred. Absence seizures are genetic and occur predominantly in children. Without treatment, seizures are likely to occur many times a day. Seizures often occur when the patient is sitting quietly, and they can be precipitated by hyperventilation. They rarely occur during exercise. [8] Frequently, epilepsy causes substantial disability, diminished quality of life, and impaired social, physical, and psychologic functioning. [9] Although effective treatment can prevent seizures in most people with epilepsy, some of those affected have frequent seizures, which can lead to brain damage. [10]
Several classification systems have been published. [11-14] The current system of classification categorizes these neurologic disorders into general epilepsies and localizationrelated epilepsies (local, focal, or partial). Each of these categories is then subdivided into symptomatic, idiopathic, and cryptogenic. The term symptomatic epilepsy indicates that a probable cause has been identified; at times, this permits a specific course of therapy to eliminate the identified cause. The term idiopathic epilepsy indicates that no obvious cause can be found, which is the case in approximately 75% of young adults and a smaller percentage of children under the age of 3 years. [15, 16] The term cryptogenic epilepsy implies a hidden or occult cause. Epilepsy beginning after the age of 25 years is usually secondary to cerebral trauma, tumors, or other organic brain disease.
Idiopathic epilepsy generally begins between the ages of 2 and 14 years. Seizures before 2 years of age are usually related to birth injuries, developmental defects, or a metabolic disease affecting the brain. Epilepsy due to birth trauma or other injury, resulting from a microscopic scar in the brain, might be misclassified during life as idiopathic but then show evidence of a causative lesion at autopsy or surgery for epilepsy. [17]
Although the treatment of seizure disorders with medication is common, the health complications associated with this approach are well documented. Many pharmaceutical agents commonly used to treat seizure disorders, [18] such as acetazolamide, carbamazepine (Tegretol), clonazepam, ethosuximide, fosphenytoin, gabapentin, lamotrigine, lorazepam (Ativan), phenobarbital, phenytoin (Dilantin), primidone (Mysoline), diazepam (Valium), divalproex sodium (Depakote), and topiramate can cause seizures as a side effect of their use. [19] In many cases it becomes necessary to use a combination of several of these agents in the management of the condition. This poses a challenge to the clinician prescribing the treatment, because in some cases it becomes unclear whether to increase or decrease particular dosages or discontinue the use of an agent or agents altogether. [20] Further complicating this challenge is the long list of other potentially serious adverse effects caused by these various pharmaceuticals.
DISCUSSION
The Index to Chiropractic Literature [21] was searched for the years 1980 through 1998 through use of the keywords epilepsy and seizure to find any reports involving chiropractic care for patients with epileptic seizure disorders. The MANTIS database (formerly Chirolars) was searched for the years 1970 through 2000 through use of the Medical Subject Heading (MeSH) keywords chiropractic, epilepsy, seizure, and child/children. In addition, a MEDLINE search of the literature was performed for the years 1966 through 2000 through use of the same subject headings. These date ranges represent the earliest searchable data available from each source. References provided in the articles found were also searched by citation index for other studies reporting pertinent information regarding chiropractic care of the pediatric epileptic patient. Articles reporting chiropractic care for patients with nonepileptic seizures were not considered for review. [22,23]
In a study performed by Vange, [24] 115 families with children (aged 0 to 7 years) with epilepsy, asthma, and/or diabetes are matched and compared with 317 families with healthy children. One third of the families with “sick” children had received alternative health care. Most of these families had consulted chiropractors, and 73% reported that the treatment had been of benefit. Because the correction of vertebral subluxation is noninvasive, the documentation of changes in the condition of epileptic patients that could reduce or eliminate the need for medication is a necessary step in developing the most efficacious care for the millions of children challenged by this condition. In the earliest noted anecdotal report of chiropractic care for epileptic patients,Young [25] describes 3 cases. Although 2 of these cases were in adults, careful reading of the report shows that all 3 patients experienced the onset of epilepsy during their childhood and adolescent years.
The first case is that of a 16-year-old girl whose epilepsy had begun at the age of 5 years. Before the onset of chiropractic care, the patient was experiencing 4 or 5 seizures a day. During chiropractic care, seizure activity was consistently reduced to a level of only 5 seizures per month. The second case involves a 34-year-old woman who reported that she had suffered from epilepsy since childhood. In this report, the patient provides testimony that chiropractic had been of help to her condition.
The third case involves a 66-year-old man who had suffered from epilepsy since the age of 14 years. Young reports that during 2 months of chiropractic care, the reduction obtained in epilepsy severity was encouraging enough for care to be continued.
Although Young has taken the initiative to report these cases, there is a failure to include further information that would serve the reader well. For each patient, Young fails to indicate the (1) type of epilepsy, (2) results of examination findings, (3) type of care provided, (4) segments adjusted, (5) chiropractic technique used, and (6) duration and frequency of care. In addition, it should be noted that this report appears in a non-refereed journal. However, Young does provide useful information about the pharmaceuticals used in the management of each condition, the patients’ subjective and objective complaints, and the results of care.
In a letter to the editor, Lorentz [26] discusses the case of a 22-year-old woman who had suffered from epilepsy since the age of 16 years and who sought care from a chiropractor. He admits that the patient’s seizures had not been well controlled through use of Dilantin, Tegretol, and Epilim. However, Lorentz alleges that in addition to manipulating the neck, the chiropractor recommended that the patient discontinue taking some medications and that the dosages of other medications be decreased. According to Lorentz, the patient experienced an increase in the frequency of her seizures, which occurred at least once a week in a series of 2 or 3 incidents. However, Lorentz presents no valid scientific evidence to support the claim of a complication arising as a result of chiropractic care. The report is speculative at best, lacking any sound scientific evidence to support the claim. Moreover,Webster [27] reports that although on rare occasions an increase in seizure activity will follow the onset of chiropractic care, after a period of time seizure activity often decreases with continued care.
Hospers et al [28, 29] report on several cases involving chiropractic care for children with seizures. In these reports, changes in condition (pre and post) were measured through use of electroencephalography (EEG) or computerized EEG (CEEG). It should be noted that appropriate studies for the diagnosis of epilepsy include EEG. [30] Hospers et al have successfully used EEG as an objective indicator of change in the conditions of patients receiving chiropractic care in other reports as well. [31]
In the first case, a 3-year-old epileptic girl experiencing generalized tonic-clonic seizures was examined twice weekly for 6 weeks and administered upper cervical specific adjustments. [32] Her “grand mal” seizures were reduced in frequency from 2 to 3 per week, each lasting an hour, to 1 every 7 to 10 days, each lasting only 5 to 10 minutes. In the second case, the patient, a 5-year-old girl, suffered absence seizures. Seizure activity had begun at the age of 4 years; there was no apparent history of trauma. [33] To correct vertebral subluxation, the child was administered upper cervical specific adjustments over a period of 3 months at a frequency of once a week. The incidence of seizures was reduced to 2 per day. However, the report does not indicate the pre–chiropractic care rate of seizure activity.
In the third case, a 12-year-old male patient with a history of multiple traumas who suffered generalized tonic-clonic seizures was administered chiropractic adjustments. After the initiation of chiropractic care, seizure activity was reduced to approximately 1 occurrence every 3 months unless the boy fell or suffered trauma during sporting activities.
In each of these well-documented case reports, Hospers et al indicate the following: (1) type of epilepsy, (2) the patient’s subjective and objective complaints, (3) results of examination findings, (4) objective test results, (5) type, duration, and frequency of care, (6) pharmaceutical agents used in the management of the condition, and (7) results of care. In a report by Goodman and Mosby, [34, 35] the case of a 5- year-old girl with a complicated birth who had begun to suffer generalized tonic-clonic seizures after experiencing head trauma at the age of 4 years 8 months was reviewed. At the time of initial chiropractic evaluation, the patient was experiencing 30 to 70 seizures per day. Examination and radiography revealed significant misalignment of the C0/C1/C2 junctures. Upper cervical specific adjustments were administered to correct subluxation at C1, initially on 3 consecutive days. After the first adjustment, seizure activity remained high. On the second and third visits, the patient had no more seizure activity during the day after the adjustment. This initial success was followed by a period of exacerbation on the 17th day of care (almost 100 seizures). However, on the 27th day of treatment all seizure activity abated for approximately 4 weeks. This pattern of an increase followed by a marked decrease in seizure activity seems to be consistent with a previously mentioned report by Webster. [36]
Goodman and Mosby do well to indicate the following for each case: (1) type of epilepsy, (2) subjective and objective complaints, (3) results of examination findings, (4) objective test results, (5) type, duration and frequency of care, (6) pharmaceutical agents used in the management of the condition, and (7) results of care.
Dubuc [37] details the case of a 6-year-old girl suffering from absence seizures. The child was experiencing 20 to 25 seizures per day, each with a duration of 35 to 50 seconds. Once every week the child was administered upper cervical specific adjustments to correct the atlas subluxation complex. There was an immediate reduction in the number of seizures experienced after administration of the adjustment. At the close of the report, the child was experiencing 0 to 1 seizures per week.
Converse et al [38] report a case of posttraumatic epilepsy that was treated with cervicocranial adjustments 3 times weekly. Although the report does not provide any information regarding the initial frequency of seizure activity, the authors do note that the chiropractic care was apparently effective in reducing the number of seizures associated with the patient’s posttraumatic neurologic disorder. The authors also discuss in detail the examination findings, the type of care provided, and the segmental level of care.
In a case spanning 8 years of chiropractic care, Golden and Van Egmond [39, 40] detail the clinical course of treatment for a 22-month-old multiply impaired boy suffering from nonfebrile seizures. According to this report, comprehensive care, in which chiropractic was coordinated with other health care approaches, was initiated after conventional medical treatment had produced a poor prognosis for any developmental or functional progress. Initially, chiropractic care was administered twice weekly for a period of 3 months through use of toggle recoil-type upper cervical adjustments and diversified full spine adjustments. Over the course of the study, the patient demonstrated significant objective improvement in both physical and psychologic functions. By the close of the study, pharmaceutical anticonvulsant therapy had been discontinued and the child was ambulatory, interactive, and mainstreamed into his age group for regular public school education.
Golden and Van Egmond well document the following: (1) subjective and objective complaints, (2) results of examination findings, (3) objective test results, (4) type, duration, and frequency of care, (5) spinal levels of care, (6) nutritional supplementation, (7) pharmaceutical agents used in the management of the condition, and (8) results of care. This report provides valuable information concerning a multidisciplinary approach to a severely challenged child.
In a nonscholarly journal, Anderson and Partridge [41] report the case of a 6-year-old boy suffering from absence seizures and attention deficit disorder with hyperactivity. This patient had a history of multiple traumas, and seizure activity had begun within 24 hours of his diphtheria-tetanus vaccination. Physical examination revealed what the authors considered “an above average number of vertebral subluxations.” The patient was given chiropractic adjustments 3 times per week for the first 18 months; subsequently, the frequency of visits was reduced to every other week. Approximately 1 year after the patient’s first visit, seizure activity ceased completely. However, seizure activity resumed several months later after the child fell from a tree.
Langley [42] reports the case of an 8-year-old girl whose epilepsy had begun shortly after a traumatic birth process. At the time that chiropractic care was initiated, the patient was taking 600 mg of Tegretol daily, and she still experienced 10 to 12 seizures per day. According to Langley, vertebral subluxations were located at C1 and C2. Chiropractic adjustments were given at a frequency of 3 times per week. After 1 year of chiropractic care, the number of seizures had diminished from 10 to 12 per day to 8 to 10 per week, and they are reported as mild when they do occur. Unfortunately, Langley fails to note the type of seizure activity.
Barnes [43] provides an anecdotal report of a female child with a history of seizures. The author reports that the girl “has had no seizures” after being a patient for approximately 1 year and receiving upper cervical adjustments. Barnes does not indicate the following: (1) type of epilepsy, (2) results of examination findings, (3) type of care provided, (4) segments adjusted, (5) chiropractic technique used, (6) duration or frequency of care, and (7) pharmaceuticals used. However, this report does well to illustrate the psychosocial stresses that this illness has on a family as well as noting the positive benefits that chiropractic care can have on the epileptic condition.
Hyman [44] reports the case of a 5-year-old boy with a primary complaint of absence seizures not controlled by medication. Physical examination findings indicated subluxations at multiple levels. Chiropractic care involving the use of toggle recoil-type upper cervical adjustments was used in the correction of subluxation at the C1 level. Other areas of the spine were adjusted through use of the Thompson technique. The patient was adjusted 2 times per week for a period of 2 months. Activity decreased from a pre–chiropractic care incidence of 4 to 6 seizures per hour, each lasting 4 to 5 seconds, to 0 to 1 seizure per day, each lasting 2 to 4 seconds.
A case report of a 21-year-old woman suffering from low back pain and generalized tonic-clonic epileptic seizures is detailed by Alcantara et al. [45] The patient in this report had suffered from epilepsy since childhood and was being treated with Dilantin and phenobarbital. Before chiropractic care, the patient suffered from seizures at 3-hour intervals, each seizure having a duration of 10 seconds to 30 minutes. Examination revealed vertebral subluxation complexes at the levels of C3-C4, C6-C7, and L5-S1. The patient received Gonstead technique “specific-contact, short lever arm, high velocity adjustments.” Activity had decreased in frequency to 1 seizure per day by the second visit. On the fifth visit there was a change of treatment whereby C2-C3 were adjusted. Subsequently, a marked increase in seizure activity ensued. During radiographic examination at the sixth visit, the patient suffered a seizure. While she was engaged in this seizure activity, she was positioned and adjusted at the C6-C7 level. On administration of this adjustment, the seizure activity stopped abruptly. This is the first published report of such a phenomenon. Subsequent examinations at 4, 7, and 13 days after the specific adjustment of C6 revealed no recurrence of subluxation complexes as well as no recurrence of seizure activity. At 1-year and 18-month follow-ups, the subject reported “intermittent seizures of short duration” every month; however, she further indicated that there had been periods of as long as 2 months during which she had had no seizures.
Amalu [46] details the case of a 5-year-old multiply impaired boy experiencing a combination of generalized tonicclonic and absence seizures. The child experienced approximately 30 seizures per day and was being treated with phenobarbital and Dilantin. On examination, the child was determined to have atlantooccipital subluxation. Two upper cervical specific adjustments were administered during the first week of care, at which time activity was reduced to 10 seizures per day. By the third week of care, all generalized tonic-clonic seizure activity had ceased. Some time between the 7th and 12th weeks of care, all seizure activity abated and the boy had only occasional staring episodes. Over the next 10 months of care, the child’s neurologist continued to reduce his medication levels, at which time his staring episodes stopped. After additional testing, the neurologist concluded that the child was no longer epileptic and withdrew all medication.
It has been suggested that if any area of scientific research should seriously be considered worthy of further investigation by the chiropractic profession, it is epilepsy. [47] To date, there have been relatively few studies regarding chiropractic care of epileptic patients. Moreover, many of the reports pertaining to care that do exist are anecdotal in nature, are printed in nonscholarly journals, and fail to propose any explanation by which the chiropractic care might have affected the epileptic condition.
Keating [48] has noted the importance of proposing hypotheses by which chiropractic care might affect the epileptic condition and has stressed the importance of critical consideration of rival explanations. To this end, Kibel et al [49] have advanced an experimental model according to which chiropractic adjustments promote the release of neurotransmitters, which might cause a decrease in convulsive activities. According to Haldeman, [50] evidence suggests that the autonomic nervous system does have an influence on cerebral blood flow. However, he points out the lack of literature reports to substantiate the effect of chiropractic adjustments on the epileptic condition through the influence of the autonomic nervous system on cerebral blood flow.
Hyman [51] has theorized that the mechanism of seizure reduction lies in the correlation of the structures of the upper cervical spine and their relationship with the central nervous system. She further theorizes that one result of correcting vertebral subluxation complexes in the upper cervical spine by chiropractic adjustment is a reduction of aberrant nerve impulses to the brain, leading to a decrease in or cessation of seizure activity.
Alcantara et al [52] have proposed a theoretical model according to which activation of various receptors in the spine results in neuronal impulses to the brain by way of the afferent pathways. The authors postulate that an adjustment to correct subluxation might activate these various receptors to send impulses to the appropriate pathways and sites in the brain, the result being a decrease in or cessation of seizure activity.
Amalu [53] has offered 2 theories to account for how chiropractic adjustments of the upper cervical spine could affect the epileptic condition. The first theory is that of central nervous system facilitation, [54-58] as a result of which an initial trauma causes the entrapment of meniscoids, articular hypomobility, and, finally, compensatory hypermobility. Consequently, hyperexcitation of periarticular mechanoreceptors and nocioceptors occurs and results in CNS facilitation . Amalu further suggests that this might cause a loss of central neural integration at the level of the chord, brainstem, and/or higher centers. Because of its poor biomechanical stability and high concentration of spinal mechanoreceptors, the upper cervical spine is particularly vulnerable to this condition.
The second theory offered by Amalu [53] is that of cerebral penumbra, or “neuronal hibernation.” [59-65] The state of neuronal hibernation occurs when a threshold of ischemia is reached; the cell remains alive but ceases to perform its designated function. Entire areas of the cerebral cortex can be affected. Also playing a role in the condition of neuronal hibernation is hyperafferancy, whereby hyperafferant activation of the central regulating center for sympathetic function can cause differing levels of cerebral ischemia. In addition, hyperafferant activation via the superior cervical sympathetic ganglia might also cause higher-center ischemia. However plausible, both of these theories remain largely untested.
CONCLUSION
At present, the chiropractic profession is woefully lacking in sound scientific data regarding its effect on the epileptic condition. In addition, in the literature that does exist, some studies have been insufficiently classified and thus hard to find and evaluate. Miller, [67] in a letter to the editor, stresses the importance of proper keyword classification to ensure that the community can readily find literature that documents chiropractic’s effect in the care of patients with epilepsy and other seizure disorders.
Because different published reports have unique reporting characteristics, results are not necessarily comparable. From the results of the present study, it is apparent that some concerted effort should be made to gather data in a reasonably uniform format or by common methods. Moreover, because of the relatively few reports that do currently exist, this review lacks the number of studies necessary to provide a basis from which to draw broad-based conclusions concerning chiropractic care for pediatric epileptic patients. Notwithstanding these limitations, the current study was undertaken as an effort to make observations about the literature that is available and to provoke more interest in this issue.
This paper reviews 17 reports of epileptic patients receiving chiropractic care. Fourteen of the 17 patients were receiving anticonvulsive medications, which had proven unsuccessful in the management of the condition. Upper cervical care to correct vertebral subluxation was administered to 15 patients, and all reported positive outcomes as a result of chiropractic care. In addition, a recent history of trauma was reported in 10 of 16 cases.
I do not suggest that chiropractic care is to be considered a substitute for prudent, proper medical attention for the pediatric epileptic patient. Furthermore, I do not practice, advocate, or condone a Doctor of Chiropractic’s recommending the reduction or discontinuation of any seizure medication; to this end, Partridge [68] has stated that “primarily, D.C.s are not licensed to do so and secondarily it is not necessary when the case is properly managed.” A pediatric neurologist should be consulted in assisting in the reduction and/or regulation of anticonvulsive medication.
When pharmaceutical agents are being considered for the management of epilepsy in the pediatric population, the expected benefit must be weighed against the inherent risks. To this end, chiropractic care might represent a nonpharmaceutical health care approach for pediatric epileptic patients; such an approach might also be associated with a decrease in seizure activity. Current anecdotal evidence suggests that correction of upper cervical vertebral subluxation complex might be most beneficial. In view of these observations, it is suggested that chiropractic care be further investigated regarding its role in the overall health care management of pediatric epileptic patients.
ACKNOWLEDGMENTS
The ICPA and Richard A. Pistolese thank the late Larry Webster, DC, for his love, guidance, and inspiration, and Christopher Kent, DC, Stephen Marini, DC, PhD, Bruce Pfleger, PhD, Travis E. Atherton, Renee D. Atherton, and Life University’s Resource Center Staff for their invaluable assistance.
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