Here we are again with yet more chiropractic nonsense coated with a patina of science and published in a journal that was essentially created to serve the purpose of marketing bogus treatments for pediatric patients. Yes, I’ve taken you down this road before and I promise it’s as annoying to me as it likely is to you. And the sad truth is that I am confident this won’t be the last time.
The offending journal linked to above is the Journal of Pediatric, Maternal & Family Health – Chiropractic. Like the foundation that launched it, this particular waste of electrons and paper is dedicated to promoting the vertebral subluxation, a fictional entity often blamed for causing musculoskeletal complaints like neck and back pain as well as all manner of general health concerns. Barbara Loe Fisher, founder and president of the anti-vaccine National Vaccine Information Center, sits on the journal’s editorial board, as does my long time nemesis Joel Alcantara.
Alcantara is the research director for the International Pediatric Chiropractic Association. The ICPA is an organization that is similarly focused on the vertebral subluxation, believing that it is the nexus of the chiropractic multiverse. Alcantara has been promoting pediatric chiropractic care for decades by developing educational degree programs for chiropractors seeking ways to better fool parents through undeserved recognition as an expert in pediatric care. He has also done this by packing the chiropractic literature with scores of worthless case reports that are then used to promote pediatric chiropractic on practice websites around the world.
What’s the deal with case reports?
Case reports aren’t inherently bad things. At least they don’t have to be. They can serve a useful purpose despite their low rank on the hierarchy of scientific evidence used to support medical practice. They can challenge assumptions, generate hypotheses, and inform plans for future research. And when it comes to conditions that only effect a very small number of people, they might serve as the only available guide for clinical management.
Proper evaluation of any case report requires an understanding of their limitations. Even the most meticulously documented report is still an anecdote at heart, and thus can never be relied upon to establish whether an intervention truly is safe and effective. In the legitimate medical literature, case reports usually, but certainly not always, involve a treatment that has a reasonable degree of plausibility based on basic science. Still there are far too many variables that can’t be accounted for in this context, and over-reliance on case reports can result in false tracking.
When written to support a belief system, case reports are ultimately no more helpful than that time your mom told you that her friend from college treated her gout with a poultice of activated charcoal and ground flaxseed. Maybe she did. And maybe she thought it helped. Stories like that don’t tend to provide information such as what other medical treatments a person is using, what lifestyle factors might have changed, what the natural course of a condition looks like, and how symptoms might be impacted by the myriad non-specific factors we simplistically lump together as the “placebo effect”.
A high quality case report should discuss its own weaknesses. A high quality case report should make efforts to point out factors that might give the false impression that an intervention helped. And when a high quality case report is written up by a non-expert in the condition it focuses on, it would ideally include input from a relevant expert. Finally, a high quality case report should be built on a foundation of basic science and add something to our understanding of a particular condition or treatment approach.
A low quality case report: Resolution of Chronic Seizures in an Infant Undergoing Chiropractic Care for Vertebral Subluxation
The sole author of the case report I’m focusing on today is a fundamentalist private practice chiropractor in Missouri who epitomizes the manipulative use of a bogus ICPA certification for marketing purposes:
Dr. Nicole McCauley who is the only chiropractor within 250 miles of Springfield, MO who is a registered Pediatric Diplomate. This means she holds the highest level of education a chiropractor can receive in pediatric and perinatal care
Of even greater concern is how her practice website guides parents of acutely ill children to visit the website of a medical doctor in New York who promotes a wide variety of unscientific treatment modalities and is aggressively anti-vaccine, as discussed by Orac, who I believe is a sentient moisture vaporator from Tatooine, in this 2020 post. This is a prime example of two of the most serious concerns I have regarding pediatric chiropractic. Promoters are almost always vocally anti-vaccine and their patients face the risk of delays in appropriate care should they have a serious illness.
In the report, McCauley begins by briefly explaining seizures in the most simplistic and unhelpful way:
Seizures occur due to a disruption in the mechanisms responsible for balancing excitation and inhibition. Disrupting the mechanisms responsible for inhibition of firing or promotion of the mechanisms needed to facilitate excitation may both lead to seizures. Conversely, the opposite will usually bring about prevention of seizure activity.
This isn’t wrong, but it certainly leaves a lot out. I’m not arguing that the intro to a case report should be able to substitute for a review article on a condition, but she doesn’t even mention that it is an electrical disturbance or identify what these mechanisms might involve. It is in her best interest to keep it vague, however, because unscientific beliefs thrive in the gaps in our understanding. It doesn’t take much of an understanding of seizures and their numerous potential causes to grasp that there is zero plausibility behind claims that chiropractic subluxations or their treatment play a role.
The patient in this report is a 15-month-old child who supposedly began having seizures at the age of 6 months. McCauley claims that the child’s birth was traumatic, though the description of the delivery is rather benign:
The delivery was via C-Section at 37 weeks with an epidural administered. There was no fetal distress or meconium staining present. The infant cried strongly immediately, was pink all over, with arms and legs actively moving.
Not mentioned is why his mother had a c-section when she went into labor a bit early at 37 weeks. It is possible that the indication was some sign of fetal distress, which is perhaps why McCauley referred to the delivery as traumatic, but the baby clearly did fine. Meconium is the term used for the material built up in the fetal intestines while in the womb. Passage of meconium prior to delivery can be a sign that a baby is in distress, and its highly viscous nature makes it quite harmful if aspirated into the lungs. But again, nothing was stated that gives any impression of distress.
When fundamentalist chiropractors talk about birth trauma, they are typically referring to the forces applied to the head and neck during delivery that result in chiropractic subluxations. In their estimation, it doesn’t even have to be a forceps or vacuum-assisted delivery, or a particularly challenging extraction at all, to be traumatic. This is why many chiropractors promote chiropractic evaluation of all newborns, which always find subluxations, as a way to prevent a wide variety of future health problems.
Trauma is essentially meaningless as they define it, and there is no evidence whatsoever that pulling on the head during delivery can lead to seizures or any future health concern for that matter. Again, subluxations as imagined by chiropractors do not exist. This doesn’t mean that complications around delivery don’t sometimes result in injury to the brain and increase the risk of a child having seizures. But this occurs in the setting of decreased oxygen delivery to the brain, an entity know as hypoxic-ischemic encephalopathy.
After an uneventful newborn course, it is implied that the child had no problems until he had some number of “seizure-like episodes” six months later. These were not described in any way, and we aren’t told when they stopped occurring. Eight months later, however, he began to have additional concerning episodes:
The mother reported events of unresponsiveness with associated limpness occurring upon waking from naps when diaper is changed after patient has had a bowel movement. He would also sometimes experience episodes consistent with
bowel movements every other day. Each episode lasted approximately 1-2 minutes and happened 2-3x/week but there was no loss of consciousness.
He would suddenly become unreactive and unable to move parts of his body including all four limbs – though sometimes just the lower extremities or one side of the body. His otherwise strong neck muscle tone diminished, and he had a
difficult time keeping his head up during an episode. His lips would become cyanotic during some of the episodes, but he did not appear to have any difficulty breathing.
He did not have any tonic-clonic movements or any other involuntary movements of his body with these episodes. Mother reported having checked his heart during an episode with no noticeable abnormalities. She noted his lips would occasionally turn blue with episodes.
A brief tangent on scary and unexplained events in infants
One of the most frustrating clinical scenarios faced by pediatricians, particularly those working in hospitals, is something known as the Brief Resolved Unexplained Event (BRUE). In my roughly 20 years of practicing pediatric medicine, I have lost count of how many infants I’ve admitted to the hospital after a parent witnessed a concerning change in their child’s breathing, color, mental status, or muscle tone and then urgently sought medical care. Most came into the emergency department via ambulance, surrounded by tearful caregivers.
There are many reasons why these cases are so challenging. First off, they sometimes involve a truly dangerous condition with a list of potential offenders that is extremely long. Second, the child’s caregiver is almost always terrified because they have the perception that their child almost died. Many believe that some intervention done at home, such as blowing in a child’s face or even performing what they think was effective rescue breaths or chest compression, is what prevented death. They are often understandably worried that their child will die unexpectedly in the near future. Third, and the evidence is quite clear on this, these children are almost always completely fine, nothing dangerous actually happened, and their risk of unexpected death is no higher than in any other healthy child.
Here is where it gets really complicated. By definition, a BRUE doesn’t have any obvious red flags for serious pathology, such as when a child required (or is still requiring) high quality CPR performed by paramedics/emergency department personnel, or the description of the event by caregivers is classic for a generalized tonic-clonic seizure. Also by definition, the child has to look fine in the ED and can’t have any historical risk factors such as prematurity or known medical conditions that put them at risk for sudden death. So at a minimum, these kids all need a thorough physical exam and review of the child’s personal and family medical history. If something comes up, it isn’t a BRUE.
Sometimes if there is a very clear story from a caregiver that reveals a benign event, such as a bit of gagging during a feed, most of us feel comfortable providing reassurance, education, and discharge papers. But despite the fact that labs, imaging, and extended observation as an inpatient almost never end up revealing something to worry about, many babies still undergo a significant work up and get admitted to be watched on monitors for a day. As a hospitalist, this can be quite frustrating because in many cases this unnecessary evaluation doesn’t even provide reassurance for caregivers. Sometimes it has the opposite effect and increases the likelihood that a healthy child will be perceived as vulnerable. This increases anxiety in the home and the risk that the child will face more unnecessary medical interventions in the future.
So what is going on with these babies that scares their caregivers so much? Ultimately we don’t know, in part because we are relying on the observations of witnesses who were understandably not focused on taking meticulous notes. I’m confident that had I been at the bedside during the event, I probably wouldn’t have been concerned. But they happen at the child’s home, usually in the middle of the night and in a dark or dimly lit room. It is often the caregiver’s first baby. Essentially what I’m getting at is that most of these are probably misinterpretations of normal infant behaviors or a perception of reality altered by psychosocial factors.
When it comes to BRUE evaluations, we have to consider a host of frightening possibilities, like sepsis, meningitis, seizures, cardiac arrhythmias, metabolic diseases, ingestions, and even child abuse. But again, these are rarely to blame. We then have to communicate effectively with caregivers and hopefully guide them towards comfort with some amount of uncertainty while still counseling them on what red flags to watch out for. But we have avoid planting any seeds of anxiety or the believe that their child is at high risk of some bad outcome. We are also sometimes compelled to admit these babies after extensive evaluations that weren’t needed for observation that isn’t likely to be helpful. All of this adds to the moral fatigue that many of us experience on a daily basis.
But I digress.
What do BRUEs have to do with this case report?
The description of the events provided in the case report I was supposed to be focusing on in this post fits that of a BRUE quite perfectly, at least initially. The BRUE diagnosis doesn’t apply once multiple events have been witnessed or if a child is older than a year of age. In general, it’s just easier for parents to mistake normal behaviors for pathology in babies than it is in a toddler.
This doesn’t mean that toddlers always have a dangerous condition when a caregiver believes that they were about to die. If they look good in the emergency department, they also usually don’t have any serious pathology to worry about. And the same concerns regarding psychosocial influences on caregiver perception can still apply. But this is always a diagnosis of exclusion. Assumptions can lead to missed diagnoses and bad outcomes.
Though the case report assumes that the events in question are seizures, as described by McCauley they do not really fit well into any known seizure category. They are labelled as atonic seizures, which are also commonly referred to as “drop attacks”, but we don’t know by who. The diagnosis is likely based entirely on the caregiver’s understanding of the situation, which may not be accurate. It would be very helpful to know what the actual medical professionals involved in this child’s care thought about these recurrent events of clinical concern, particularly any neurologist that evaluated him.
The report is clear that there were no classic tonic-clonic episodes witnessed by caregivers. These seizures involve the stiffening and rhythmic jerking of muscles that most people are familiar with and used to be known as grand mal seizures. The description is also inconsistent with all other seizure types as well, though I get why someone at some point might have mentioned atonic seizures, as they involve loss of muscle tone and are the closest to what is described. This label could have been something that the patient’s caregivers, or perhaps even McCauley herself, applied after a clumsy internet search. Supporting this is the description of the child’s medical evaluation prior to being brought to see McCauley:
He had a number of medical tests performed including two EEG’s that were interpreted as normal. An MRI and ECG were also done and noted to be normal. He was examined for heart murmur, abnormal biventricular size and function,
abnormal valvular structure and function, and large intracardiac shunting due to an Aortic Arch Obstruction. All results were negative. There was no definitive medical diagnosis given.
A EEG that is obtained when there is no apparent seizure activity at the time is often normal. This is because EEGs are often ordered because of the suspicion that a seizure occurred and the movements of concern are often not true seizures. But even patients who ultimately end up being diagnosed with a seizure disorder can have a normal EEG between seizures. But it is unlikely that a child at that age and having events that frequently would have a normal EEG if they truly had epilepsy.
Atonic seizures do involve a sudden loss of muscle tone, so there is that, and they do typically start in childhood. But they represent less than 1% of seizures, almost always occur along with other types of seizures, and usually occur in the context of Lennox-Gastaut or Dravet syndrome, which are severe, very difficulty to treat, and associated with development delays and numerous other health problems. So while I can’t say with certainty that this never had any seizures, I would put it in the very unlikely category. The pediatric neurologist I consulted with, after reading the report, agreed.
When evaluated by McCauley, the child was found to have a few retained primitive reflexes (bogus but beyond the scope of this post) and, you’ll be shocked to learn, subluxations involving the “right S/I joint, T9, C1 and right Coronal Suture”. After eight months and 17 adjustments of his spine and skull, as well as parent driven home therapy involving stimulation of his feet and cheeks to fix those retained primitive reflexes, the supposed seizures gradually decreased in frequency until they were gone for good. His parents were also advised to restrict sugar, wheat, and dairy in his diet. This of course raises another concern with pediatric chiropractic, which is the potential for unproven or even harmful dietary recommendations, but also with case reports like this. When there are multiple interventions, how do we know what might have helped?
After a discussion including the description of a few earlier case reports involving chiropractic and seizures, each similarly worthless, McCauley does briefly get into potential limitations:
The author was unable to find cases in the scientific literature specifically describing the patient’s symptomatology. Further limitations included the use of a single case study design which cannot be generalized to the population, in addition to not having a control group to rule out maturation as a factor in improvement of chronic seizures. Moreover, further research is necessary to determine the effectiveness of chiropractic care in resolving chronic seizures in infants.
I would have added a bit to this section. But she does include what is most likely at play in this child’s apparent improvement. They got older. If I had to guess, there were a few scary, BRUE type events when he was an infant. This primed his caregiver to potentially perceive normal infant and then toddler behavior, such as breath holding spells for example, as seizure activity. He had an extensive evaluation out of an abundance of cation that was reassuring, but not reassuring enough. Enter the chiropractor and their nonsense. Over the next 8 months he outgrew the behaviors and chiropractic care had nothing at all to do with it. Just time.
McCauley came to a different conclusion:
The results of this case study and relevant research pertaining to chiropractic’s role in reduction and resolution of chronic seizures support the hypothesis that
subluxation reduction may have a positive impact on the symptoms associated with epilepsy.
Conclusion: This is why we can’t have nice things!
Case reports aren’t completely useless, unlike chiropractic care of pediatric patients. You just have to take them with a grain of pink Himalayan salt and understand their limitations. But if they involve an intervention so thoroughly lacking in basic science support and prior plausibility as adjusting subluxations to treat epilepsy, they are probably just trying to sell you something.