Burning mouth syndrome (BMS) is a rare but potentially debilitating condition. So far, individualised homeopathy (iHOM) has not been evaluated or reported in any peer-reviewed journal as a treatment option. Here is a recently published case-report of iHOM for BMS.
At the Centre of Complementary Medicine in Bern, Switzerland, a 38-year-old patient with BMS and various co-morbidities was treated with iHOM between July 2014 and August 2018. The treatment involved prescription of individually selected homeopathic single remedies. During follow-up visits, outcome was assessed with two validated questionnaires concerning patient-reported outcomes. To assess whether the documented changes were likely to be associated with the homeopathic intervention, an assessment using the modified Naranjo criteria was performed.
Over an observation period of 4 years, an increasingly beneficial result from iHOM was noted for oral dysaesthesia and pains as well as for the concomitant symptoms.
The authors concluded that considering the multi-factorial aetiology of BMS, a therapeutic approach such as iHOM that integrates the totality of symptoms and complaints of a patient might be of value in cases where an association of psychological factors and the neuralgic complaints is likely.
BMS can have many causes. Some of the possible underlying conditions that can cause BMS include:
- hormonal imbalances
- acid reflux
- infections in the mouth
- various medications
- nutritional deficiencies in iron or zinc
Threatemnt of BMS consists of identifying and eliminating the underlying cause. If no cause of BMS can be found, we speak of primary BMS. This condition can be difficult to treat; the following approaches to reduce the severity of the symptoms are being recommended:
- avoiding acidic or spicy foods
- reducing stress
- avoiding any other known food triggers
- exercising regularly
- changing toothpaste
- avoiding mouthwashes containing alcohol
- sucking on ice chips
- avoiding alcohol if it triggers symptoms
- drinking cool liquids throughout the day
- smoking cessation
- eating a balanced diet
- checking medications for potential triggers
The authors of the above case-report state that no efficient treatment of BMS is known. This does not seem to be entirely true. They also seem to think that iHOM benefitted their patient (the post hoc ergo propter hoc fallacy!). This too is more than doubtful. The natural history of BMS is such that, even if no effective therapy can be found, the condition often disappears after weeks or months.
The authors of the above case-report treated their patient for about 4 years. The devil’s advocate might assume that not only did iHOM contribute nothing to the patient’s improvement, but that it had a detrimental effect on BMS. The data provided are in full agreement with the notion that, without iHOM, the patient would have been symptom-free much quicker.
Once upon a time, arsenic has been used widely for medicinal and other purposes. Now that we know how toxic it is, few people would voluntarily take it – except of course fans of homeopathy. In homeopathy, arsenic is an important and popular remedy.
Here is what HOMEOPATHY PLUS tell us about its therapeutic potential:
Arsenic is a toxic chemical element, historically used as a poison. It is safe to use with infants through to the elderly when prepared in homeopathic potencies. Those who need Arsenicum are prone to hypochondriasis and are intolerant of untidiness and disorder. They are anxious, critical, and restless, and dislike being alone but may be irritable with company. Restlessness may be followed by exhaustion which is out of proportion to their illness. They fear illness and disease, death, and being alone. Discharges tend to be acrid and burning. Burning pains paradoxically feel better for heat (except the headache which is better for cold applications). Thirst is for sips of warm drinks but cold drinks worsen. Symptoms worsen between midnight and 2 AM.
Colds and Hayfever
- Red, puffy, burning eyes that feel better for hot compresses.
- Watery, nasal discharge that burns and reddens the nostrils and lip.
- Frequent sneezing with no relief.
- Worsened by cold air or cold drinks.
- Rapid, difficult breathing, with wheezing (asthma).
- Coughs or wheezing worse for lying down and better for sitting upright.
- Burning, throbbing pain.
- Worsened by heat and relieved by cold applications or cool air (though rest of body will be chilly and rugged up).
- Eczema with burning, itching, dry skin.
- Thirst for frequent small sips of water.
- Burning stomach pains eased by drinking milk.
- Offensive, burning, scalding diarrhoea.
- A key remedy for food poisoning or gastroenteritis.
- Hot head and cold body.
- Chilly and want to be rugged up.
- Restless and anxious – insomnia between midnight and 2 AM
- Dreams of robbers
- Chilly, anxious pets.
- Itchy, dry skin eruptions in chilly, anxious animals.
Where do I find it?
Arsenicum album (Ars.) is available from our online store as a single remedy and is also included in the following Complexes (combination remedies): Anxiety; Common Cold – Watery; Hay Fever; Insomnia; Mouth Ulcer; Panic Stop; Sinus Pain; Winter Defence.
While above self-limiting or acute complaints are suitable for home treatment, see your healthcare provider if symptoms worsen or fail to improve. Chronic or persistent complaints, which may or may not be mentioned above, require a different treatment and dosage protocol so are best managed by a qualified homeopath for good results.
For acute and self-limiting complaints, take one pill or five drops of the remedy every 30 minutes to 4 hours (30 minutes for intense symptoms, 4 hours for milder ones). Once an improvement is noticed, stop dosing and repeat the remedy only if symptoms return. If there is no improvement at all by three doses, choose a different remedy or seek professional guidance. Chronic symptoms or complaints require a course of professional treatment to manage the changes in potencies and remedies that will be required.
So, arsenic is safe to use with infants through to the elderly when prepared in homeopathic potencies!
True of false?
We recently discussed a case of homeopathic arsenic poisoning from India. Now a similar one has been reported from Switzerland. A Swiss doctor published a case report of chronic arsenic poisoning associated with the intake of a homeopathic remedy.
For about 4 years the patient had taken globules of a freely purchasable homeopathic remedy containing inorganic arsenic (iAs) diluted to D6 (average arsenic content per single globule: 0.85 ± 0.08 ng). She took the remedy because it was advertised for gastrointestinal confort. In the previous 7 months, she had taken 20 to 50 globules daily (average 30 ng arsenic daily).
She complained of nausea, stomach and abdominal cramps, diarrhoea and flatulence, headache, dizziness, anxiety, difficulty concentrating, insomnia, snoring, leg cramps and fatigue, loss of appetite, increased thirst and sweating, reduced diuresis, weight gain, paleness and coolness of both hands with a furry feeling of the hands, eczema of the hands, arms and legs, conjunctivitis and irregular menstruation.
The physical and laboratory examinations showed a body mass index of 30 kg/m2, acne vulgaris, bilateral spotted leukonychia, eczema of hands, arms and legs, non-pitting oedema of the legs, elevated plasma alkaline phosphatase activity, folate deficiency and severe vitamin D3 insufficiency. The arsenic concentration in her blood was <0.013 µmol/l, and arsenic was undetectable in her scalp hair. The total iAs concentration was 116 nmol/l in the morning urine and 47 nmol/l in the afternoon urine.
The urinary arsenic concentration decreased and the patient’s complaints improved upon interruption of the arsenic globules, vitamin D3, thiamine and folic acid supplementation, and symptomatic therapy.
The author concluded that an avoidable toxicant such as inorganic arsenic, for which no scientific safe dose threshold exists, should be avoided and not be found in over-the-counter medications.
The author rightly states that causality of this association cannot be proven. However, he also stresses that a causal link between chronic iAs exposure and the patient’s nonspecific systemic symptoms is nevertheless suggested by circumstantial evidence pointing to the disappearance of CAsI signs and symptoms after therapy including interruption of the exposure. In his (and my) view, this renders causality most likely.
A systematic review of the evidence for effectiveness and harms of specific spinal manipulation therapy (SMT) techniques for infants, children and adolescents has been published by Dutch researchers. I find it important to stress from the outset that the authors are not affiliated with chiropractic institutions and thus free from such conflicts of interest.
They searched electronic databases up to December 2017. Controlled studies, describing primary SMT treatment in infants (<1 year) and children/adolescents (1–18 years), were included to determine effectiveness. Controlled and observational studies and case reports were included to examine harms. One author screened titles and abstracts and two authors independently screened the full text of potentially eligible studies for inclusion. Two authors assessed risk of bias of included studies and quality of the body of evidence using the GRADE methodology. Data were described according to PRISMA guidelines and CONSORT and TIDieR checklists. If appropriate, random-effects meta-analysis was performed.
Of the 1,236 identified studies, 26 studies were eligible. In all but 3 studies, the therapists were chiropractors. Infants and children/adolescents were treated for various (non-)musculoskeletal indications, hypothesized to be related to spinal joint dysfunction. Studies examining the same population, indication and treatment comparison were scarce. Due to very low quality evidence, it is uncertain whether gentle, low-velocity mobilizations reduce complaints in infants with colic or torticollis, and whether high-velocity, low-amplitude manipulations reduce complaints in children/adolescents with autism, asthma, nocturnal enuresis, headache or idiopathic scoliosis. Five case reports described severe harms after HVLA manipulations in 4 infants and one child. Mild, transient harms were reported after gentle spinal mobilizations in infants and children, and could be interpreted as side effect of treatment.
The authors concluded that, based on GRADE methodology, we found the evidence was of very low quality; this prevented us from drawing conclusions about the effectiveness of specific SMT techniques in infants, children and adolescents. Outcomes in the included studies were mostly parent or patient-reported; studies did not report on intermediate outcomes to assess the effectiveness of SMT techniques in relation to the hypothesized spinal dysfunction. Severe harms were relatively scarce, poorly described and likely to be associated with underlying missed pathology. Gentle, low-velocity spinal mobilizations seem to be a safe treatment technique in infants, children and adolescents. We encourage future research to describe effectiveness and safety of specific SMT techniques instead of SMT as a general treatment approach.
We have often noted that, in chiropractic trials, harms are often not mentioned (a fact that constitutes a violation of research ethics). This was again confirmed in the present review; only 4 of the controlled clinical trials reported such information. This means harms cannot be evaluated by reviewing such studies. One important strength of this review is that the authors realised this problem and thus included other research papers for assessing the risks of SMT. Consequently, they found considerable potential for harm and stress that under-reporting remains a serious issue.
Another problem with SMT papers is their often very poor methodological quality. The authors of the new review make this point very clearly and call for more rigorous research. On this blog, I have repeatedly shown that research by chiropractors resembles more a promotional exercise than science. If this field wants to ever go anywhere, if needs to adopt rigorous science and forget about its determination to advance the business of chiropractors.
I feel it is important to point out that all of this has been known for at least one decade (even though it has never been documented so scholarly as in this new review). In fact, when in 2008, my friend and co-author Simon Singh, published that chiropractors ‘happily promote bogus treatments’ for children, he was sued for libel. Since then, I have been legally challenged twice by chiropractors for my continued critical stance on chiropractic. So, essentially nothing has changed; I certainly do not see the will of leading chiropractic bodies to bring their house in order.
May I therefore once again suggest that chiropractors (and other spinal manipulators) across the world, instead of aggressing their critics, finally get their act together. Until we have conclusive data showing that SMT does more good than harm to kids, the right thing to do is this: BEHAVE LIKE ETHICAL HEALTHCARE PROFESSIONALS: BE HONEST ABOUT THE EVIDENCE, STOP MISLEADING PARENTS AND STOP TREATING THEIR CHILDREN!
Myelopathy is defined as any neurologic deficit related to the spinal cord. When due to trauma, it is known as (acute) spinal cord injury. When caused by inflammatory, it is known as myelitis. Disease that is vascular in nature is known as vascular myelopathy.
The symptoms of myelopathy include:
- Pain in the neck, arm, leg or lower back
- Muscle weakness
- Difficulty with fine motor skills, such as writing or buttoning a shirt
- Difficulty walking
- Loss of urinary or bowel control
- Issues with balance and coordination
The causes of myelopathy include:
- Tumours that put pressure on the spinal cord
- Bone spurs
- A dislocation fracture
- Autoimmune diseases like multiple sclerosis
- Congenital abnormality
- A traumatic injury
This review presents a series of cases with cervical spine injury and myelopathy following therapeutic manipulation of the neck, and examines their clinical course and neurological outcome.
Its authors conducted a search for patients who developed neurological symptoms due to cervical spinal cord injury following neck SMT in the database of a spinal unit in a tertiary hospital between the years 2008 and 2018. Patients with vertebral artery dissections were excluded. Patients were assessed for the clinical course and deterioration, type of manipulation used and subsequent management.
A total of four patients were identified, two men and two women, aged between 32 and 66 years. In three patients neurological deterioration appeared after chiropractic adjustment and in one patient after tuina therapy. The patients had experienced symptoms within one day to one week after neck manipulation. The four patients had signs of:
- central cord syndrome,
- spastic quadriparesis,
- spastic quadriparesis,
- radiculopathy and myelomalacia.
Three patients were managed with anterior cervical discectomy and fusion while one patient declined surgical treatment.
The authors note that their data cannot determine whether the spinal cord dysfunction was caused my the spinal manipulations or were pre-existing problems which were aggravated by the treatments. They recommend that assessment for subjective and objective evidence of cervical myelopathy should be performed prior to cervical manipulation, and suspected myelopathic patients should be sent for further workup by a specialist familiar with cervical myelopathy, such as a neurologist, a neurosurgeon or orthopaedic surgeon who specializes in spinal surgery. They also state that manipulation therapy remains an important and generally safe treatment modality for a variety of cervical complaints. Their review, the authors stress, does not intend to discard the role of spinal manipulation as a significant part in the management of patients with neck related symptoms, rather it is meant to draw attention to the need for careful clinical and imaging investigation before treatment. This recommendation might be medically justified, yet one could argue that it is less than practical.
This paper from Israel is interesting in that it discloses possible complications of cervical manipulation. It confirms that chiropractors are most frequently implicated and that – as in our survey – under-reporting is exactly 100% (none of the cases identified by the retrospective chart review had been previously reported).
In light of this, some of the affirmations of the authors are bizarre. In particular, I ask myself how they can claim that cervical manipulation is a ‘generally safe’ treatment. With under-reporting at such high levels, the only thing one can say with certainty is that serious complications do happen and nobody can be sure how frequently they occur.
It is hardly surprising that Gwyneth Paltrow’s obsession with so-called alternative medicine (SCAM) for the vagina is motivating women to try some of it. The consequences can be dramatic; not only for the wallet but also for the vagina!
Vaginal steaming made global headlines in 2015 after its promotion by celebrity Gwyneth Paltrow. One of many female genital modification practices currently on offer in Anglo-Western nations – practices both heavily promoted and critiqued – vaginal steaming is claimed to offer benefits for fertility and overall reproductive, sexual or even general health and wellbeing. We analysed a selection of online accounts of vaginal steaming to determine the sociocultural assumptions and logics within such discourse, including ideas about women, women’s bodies and women’s engagement with such ‘modificatory’ practices. Ninety items were carefully selected from the main types of website discussing vaginal steaming: news/magazines; health/lifestyle; spa/service providers; and personal blogs. Data were analysed using thematic analysis, within a constructionist framework that saw us focus on the constructions and rationalities that underpin the explicit content of the texts. Within an overarching theme of ‘the self-improving woman’ we identified four themes: (1) the naturally deteriorating, dirty female body; (2) contemporary life as harmful; (3) physical optimisation and the enhancement of health; and (4) vaginal steaming for life optimisation. Online accounts of vaginal steaming appear both to fit within historico-contemporary constructions of women’s bodies as deficient and disgusting, and contemporary neoliberal and healthist discourse around the constantly improving subject.
A recent case-report tells a cautionary tale. Here is its abstract:
Vaginal steaming has gained increased popularity as a method to achieve empowerment by providing vaginal tightening and to “freshen” the vagina.
A 62-year-old woman sustained second-degree burns following vaginal steaming in an attempt to reduce vaginal prolapse.
Clinicians need to be aware of alternative treatments available to women so that counselling may mitigate any potential harm.
As the full paper is not available to me, I had to rely on another report for further information.
The woman had been suffering from a prolapsed vagina and had been led to believe the vaginal steaming could help avoid surgery. Spas advertising “v-steaming” claim it has been used throughout history in countries in Asia and Africa. They claim the practice, which is sometimes called Yoni steaming, acts to “detox” the vagina, can ease period pains, help with fertility and much more. Experts, however, warn that it can be dangerous and point out that there is no good evidence for the health claims being made.
Dr Vanessa Mackay, a consultant and spokeswoman for the Royal College of Obstetricians and Gynaecologists, says it is a “myth” that the vagina requires extensive cleaning or treatment. She recommends using plain, unperformed soaps on the external vulva area only. “The vagina contains good bacteria, which are there to protect it,” she said in a statement. “Steaming the vagina could affect this healthy balance of bacteria and pH levels and cause irritation, infection (such as bacterial vaginosis or thrush) and inflammation. It could also burn the delicate skin around the vagina (the vulva).”
Dr Magali Robert, who authored the case-report, said the injured woman attempted to steam her vagina on the advice of a traditional Chinese doctor. The woman, who gave permission for her case to be shared, sat over the boiling water for 20 minutes on two consecutive days before presenting at an emergency department with injuries. She sustained second-degree burns and had to delay reconstructive surgery while she healed.
Dr Robert, who works in pelvic medicine and reconstructive surgery in Calgary, said word of unconventional therapies like steaming can spread through channels like the internet and word-of-mouth. “Health care providers need to be aware of alternative therapies so that they can help women make informed choices and avoid potential harm,” she says in the article.
Japanese neurosurgeons reported the case of A 55-year-old man who presented with progressive pain and expanding swelling in his right neck. He had no history of trauma or infectious disease. The patient had undergone chiropractic manipulations once in a month and the last manipulation was done one day before the admission to hospital.
On examination by laryngeal endoscopy, a swelling was found on the posterior wall of the pharynx on the right side. The right piriform fossa was invisible. CT revealed hematoma in the posterior wall of the right oropharynx compressing the airway tract. Aneurysm-like enhanced lesion was also seen near the right common carotid artery. Ultrasound imaging revealed a fistula of approximately 1.2 mm at the posterior wall of the external carotid artery and inflow image of blood to the aneurysm of a diameter of approximately 12 mm. No dissection or stenosis of the artery was found. Jet inflow of blood into the aneurysm was confirmed by angiography. T1-weighted MR imaging revealed presence of hematoma on the posterior wall of the pharynx and the aneurysm was recognized by gadolinium-enhancement.
The neurosurgeons performed an emergency operation to remove the aneurysm while preserving the patency of the external carotid artery. The pin-hole fistula was sutured and the wall of the aneurysm was removed. Histopathological assessment of the tissue revealed a pseudoaneurysm (also called a false aneurism), a collection of blood that forms between the two outer layers of an artery.
The patient was discharged after 12 days without a neurological deficit. Progressively growing aneurysm of the external carotid artery is caused by various factors and early intervention is recommended. Although, currently, intravascular surgery is commonly indicated, direct surgery is also feasible and has advantages with regard to pathological diagnosis and complete repair of the parent artery.
The relationship between the pseudoaneurysm and the chiropractic manipulations seems unclear. The way I see it, there are the following three possibilities:
- The manipulations have causally contributed to the pseudo-aneurysm.
- They have exacerbated the condition and/or its symptoms.
- They are unrelated to the condition.
If someone is able to read the Japanese full text of this paper, please let us know what the neurosurgeons thought about this.
Indian doctors have just published the case of a 38-year old man with cirrhosis of the liver due to compensated non-alcoholic fatty-liver-disease. He presented with acute worsening of his chronic liver disease. The acute event was not discernible even after extensive work up. Eventually, a transjugular liver biopsy revealed features suggestive of severe alcoholic hepatitis.
The patient and the family denied occult alcohol use when questioned over multiple times. According to the authors, the culprit ‘alcohol’ was found to be the homoeopathy medicines: the patient had been consuming a homeopathic remedy over a month for treatment of Gilbert’s syndrome. The researchers retrieved and tested the homoeopathy drug for alcohol content and found it contained 18% of ethanol. This, they felt, confirmed their diagnosis of alcoholic liver disease caused by the regular consumption of a homeopathic remedy.
Why did the patient help from a homeopath? Gilbert’s syndrome doesn’t usually require any treatment at all. Two weeks into his new treatment, the patient claimed he was feeling drowsy and slurring his speech, as if intoxicated. The liquid homeopathic formulation was therefore reduced at this stage. A further two weeks passed when his eyes yellowed, his urine darkened, and his legs began to swell. A liver tests confirmed a spike in his bilirubin 10 times above normal, with liver enzymes also elevated. All signs were thus pointing to an acute form of hepatitis commonly associated with alcohol binges. With the patient adamant he hadn’t touched alcohol, the doctors looked for other causes of hepatitis. None were found. When the patient admitted using homeopathy, his doctors thought to have found an explanation for the problem.
Despite starting the patient on a range of treatments and referring him to a liver transplant centre for further management, the damage to the patient’s liver proved to be irreversible. One month and 12 days later, the patient developed multiple organ failure and passed away. The authors of this case report point out “at risk patients and the general population need to be educated regarding the fact that complementary and alternative medications are not without side-effects.”
I do agree with their comment, but I very much doubt that their diagnosis of homeopathy-induced liver disease was correct. If the alcohol in the homeopathic remedy truly had been the cause, the patient would have needed to consume well in excess of one litre of it per day. The authors do not tell us about the volume of consumption, but I doubt that a patient would be able to afford such an orgy in homeopathy.
Highly diluted homeopathic remedies contain nothing, it is often said. This is not entirely true. In the case of solid preparations (globuli), they do contain sugar, and in the case of liquid remedies, they contain alcohol. Yet, as a source of either ingredient, they are neither practical nor economical. I fear therefore that the medical team of the diseased man are mistaken when accusing homeopathy of being the cause of their patient’s death.
Kampo, the traditional Japanese herbal medicine, developed out of traditional Chinese herbal medicine after it was introduced into Japan in the 7th century. In the early 20th century, Kampo was further influenced by modern Western medicine and science. The Kampo system is a pragmatic and simplified version of Chinese herbal medicine. Kampo medicines are standardised and not normally individualised as in Chinese herbal medicine. They are based on the symptoms of the patient, interpreted in the tradition of Kampo. Kampo diagnostic criteria consider hypofunction and hyperfunction, heat and cold, superficies and interior, and yin and yang.
Today, Kampō is fully integrated into the Japanese national health care system, and numerous Kampo preparations are registered in Japan and reimbursable from public funds. In Japan, Kampo is thus not a so-called alternative medicine (SCAM), but outside this country it clearly is.
Standardised Kampo formulas contain mixtures of herbal ingredients. They are manufactured under proper quality control. The most commonly used plants include liquorice, ginger and Chinese peony root. Most Japanese doctors routinely prescribe Kampo medicines, and most patients combine Kampo with Western medicine. Since 2002, the teaching of Kampo has been included in Japanese curricula of medical and pharmacy education. The efficacy of Kampo medicines is often less solidly documented than one would hope or expect. There is a remarkable shortage of high-quality clinical trials.
As Kampo medicines contain pharmacologically active ingredients, they can also cause adverse effects and might interact with synthetic drugs. Yet, the risks of Kampo are currently woefully under-investigated. And this is why an analysis of adverse events associated with Kampo formulations that was just published is particularly important.
The researchers obtained reports of adverse events associated with ethical Kampo formulations from the domestic adverse-event data from July 30, 2003, to March 31, 2018. Adverse events were then categorized, and the relationships between categories of adverse events and crude drugs were analysed.
There were 4,232 reported adverse events associated with Kampo. They related to liver injury, 1,193; lung injury, 1,177; pseudoaldosteronism, 889; mesenteric phlebosclerosis, 223; drug eruption, 185; and others, 565. Among events related to both liver injury and lung injury, approximately 70% were suspected to be induced by Kampo formulations containing Scutellariae Radix.
The pseudoaldosteronism-related events, which are induced by Glycyrrhizae Radix, included several events related to muscle injury, heart failure, and arrhythmia. Events related to mesenteric phlebosclerosis, believed to be induced by long-term use of Kampo formulas containing Gardeniae Fructus, increased remarkably during the study period. Among the events related to drug eruption, approximately 35% were suspected to be induced by Kampo formulations containing Ephedrae Herba.
The authors concluded that Kampo medicines may cause various adverse events. The present results provide valuable information regarding adverse events associated with Kampo medicines from the viewpoint of patient safety.
While this paper presents invaluable data, its authors offer little by way of critical discussion. There is hardly any good evidence to show that any of the Kampo formulas are effective. Thus a discussion needs to be had about the question whether they generate more good than harm. The authors are completely silent on this important issue, and I suspect the reason might be that Kampo is a bit of a ‘holy cow’ in Japan that must not be questioned.
The numbers of adverse events are impressively high, but we do not know how they compare to adverse events in other areas of healthcare. For instance, it would be valuable to have comparative data indicating how many adverse events occurred with Kampo compared to synthetic drugs per 1 000 patients using them.
Thus we are left with the conclusion that, once proper post-marketing methods are employed to monitor SCAM, we are likely to realise that adverse events do occur more frequently than SCAM enthusiasts might have predicted. In my view, it is high time that we have effective adverse event monitoring in all areas of SCAM.
Spinal manipulation has been associated with a wide range of serious complications. Usually, they occur after neck manipulations. Neurologists from Morocco just published a case-report of a patient suffering a subdural haematoma after lumbar spinal manipulation.
A previously healthy 23 years-old man was receiving spinal manipulation for chronic back pain by a physiotherapist when he experienced a knife-like low back pain and lower limbs radiculalgia. The manipulation consisted on high velocity pression in the lumbar region while the patient was in prone position. He woke up the next morning with a weakness of both lower limbs and sensation of bladder fullness.
On presentation to the emergency department, 24 hours after the manipulation, the neurological examination found a cauda equina syndrome with motor strength between 2/5 and 3/5 in the left lower limb, 4/5 in the right lower limb, an abolition of the patellar and Achilles reflexes, a saddle hypoesthesia and a tender bladder. The general examination was normal. Magnetic resonance imaging (MRI) of the lumbar spine was performed promptly and showed intradural collection extending from L2 to L3 level with signal intensity consistent with blood. There were no adjacent fractures, disc or ligament injuries. Routine blood investigations were normal.
The patient underwent an emergency operation via L2-L3 laminectomy. The epidural space had no obvious abnormalities but the dura mater was tense and bluish. After opening the dura, a compressive blood clot was removed completely. The origin of the bleeding could not be determined. At the end of the intervention, nerve roots appeared free with normal courses. Subsequently, the patient’s the motor function of lower limbs gradually returned. He was discharged without neurological deficits 6 days postoperatively. At 6-months’ follow-up, the neurological examination was totally normal.
Subdural haematoma is a rare occurrence. As a complication after spinal manipulation, it seems to be ever rarer. Our case-series of serious adverse effects after chiropractic manipulation did include such a case, albeit not at the lumbar level (as far as I remember):
To obtain preliminary data on neurological complications of spinal manipulation in the UK all members of the Association of British Neurologists were asked to report cases referred to them of neurological complications occurring within 24 hours of cervical spine manipulation over a 12-month period. The response rate was 74%. 24 respondents reported at least one case each, contributing to a total of about 35 cases. These included 7 cases of stroke in brainstem territory (4 with confirmation of vertebral artery dissection), 2 cases of stroke in carotid territory and 1 case of acute subdural haematoma. There were 3 cases of myelopathy and 3 of cervical radiculopathy. Concern about neurological complications following cervical spine manipulation appears to be justified. A large long-term prospective study is required to determine the scale of the hazard.
The big problem with adverse events of this nature is that their true incidence is essentially unknown. The two cases of subdural haematoma mentioned above seem to be the only two reported in the medical literature. But, as there is no monitoring system, the true figure is anybody’s guess.
The three-year old Noah was diagnosed with acute lymphoblastic leukaemia, a blood cancer with a very good prognosis when treated (~85% of all children affected can be completely cured and expect to live a normal life). The child was admitted to hospital and, initially, chemotherapy was started. But the treatment was not finished, because the parents took their child home prematurely. The mother, a 22-year-old ‘holistic birth attendant’, had been against conventional treatments from the start. She nevertheless agreed to the first two rounds of chemotherapy — “because they can get a medical court order to force you to do it anyways for a child with his diagnosis”.
Noah’s parent treated their sons with a number of home remedies:
- colloidal silver,
- Reishi mushroom tea,
- Apricot seeds,
- and other forms of SCAM.
After the child had gone missing, the police issued an alert:
“On April 22, 2019 the parents failed to bring in the child to a medically necessary hospital procedure. The parents have further refused to follow up with the life saving medical care the child needs.”
In a matter of hours, the parents and their child were found. Noah was then taken from his parents and was “now being medically treated,” the sheriff’s office stated. The parents, meanwhile, were being investigated on suspicion of child neglect.
They insist that they were merely trying to give their son alternative medical care, accusing the police and medical officials of stripping them of the right to choose their own treatment plan for their son. Their supporters call the state’s decision to take custody of Noah a “medical kidnapping”. Medical kidnapping is defined as the State taking away children from their parents so that the children can receive medical or surgical care which the parents would otherwise not allow to be administered.
“We’re not trying to refuse any kind of treatment,” the parents told reporters. “They think we’re refusing treatment all around, putting him in danger, trying to kill him. But not at all. We’re trying to save him.” An organization fighting on behalf of the parents, the Florida Freedom Alliance, which also supports “vaccine freedom,” argues that the couple should be entitled to “medical freedom” and freedom from “medical kidnappings.”
Who is right and who is wrong?
Are medical kidnappings legal?
I am, of course, not sure about the legalities. But I am fairly certain about the evidence in the above case:
- Noah’s condition is treatable, and in all likelihood he would be cured, if treated according to current oncological standards. This view was also confirmed by the oncologist who is in charge of treating him in hospital.
- None of the treatments mentioned by the parents are effective. In fact, alternative cancer cures are a myth; they do not exist and they will never exist. Once a treatment shows promise, it would be scientifically investigated. And, if the results are positive, it would become mainstream quicker than I can climb a tree.
Ethically Noah’s case could not be clearer: the child’s life must be saved, whether with the support of his parents or not. However strongly parents might feel about their under-age kids’ care, they do not own their children and must not be allowed to cause them significant harm.