Well­ness Arti­cles

A Case Report of Improved Behav­iour and a Reduc­tion in Vio­lent Out­breaks in a 10-​year-​old Boy with Chi­ro­prac­tic Care

By Jonathan R Cook, MChiro, DC, LRCC

Pub­lished in Jour­nal of Clin­i­cal Chi­ro­prac­tic Pedi­atrics, Vol 14, No 3, Nov 2014

Abstract: Objec­tive: To present a sin­gle case study in which a reduc­tion in vio­lent behav­ior with a 10-​year old boy was achieved when the patient under­went chi­ro­prac­tic treat­ment. Design: A case report. Set­ting: Pri­vate chi­ro­prac­tic prac­tice. Sub­jects: This case involved a 10-​year-​old male who pre­sented with behav­ioral issues, includ­ing dra­matic changes from a calm man­ner, to sud­denly becom­ing vio­lent. He was also reported to have dif­fi­culty sleep­ing due to emo­tional detach­ment dis­or­der and fre­quently suf­fered from panic attacks. His mother also reported that he had dif­fi­culty notic­ing when he was suf­fi­ciently full fol­low­ing eat­ing. His behav­ioral changes caused him to be sus­pended from school. Upper cer­vi­cal, tho­racic and lum­bopelvic dys­func­tion were recorded in this case. Meth­ods: The patient received diver­si­fied low-​force chi­ro­prac­tic manip­u­la­tion to the spinal areas noted, includ­ing toggle-​recoil and drop piece tech­nique. His changes were recorded through the Mea­sure Your­self Med­ical Out­come Pro­file (MYMOP) ques­tion­naires over the course of his treat­ment. Treat­ment was pro­vided over a 4-​week, twice weekly period, with a MYMOP ques­tion­naire being filled out after his 3rd, 6th and 8th adjust­ment. Results: A reduc­tion in a MYMOP score of 66 to 1.6÷6 for behav­ior and vio­lent out­breaks after 8 chi­ro­prac­tic adjust­ments. Fur­ther improve­ments were noticed with sleep and anx­i­ety, as well as a dra­mat­i­cally improved aware­ness of feel­ing full after eat­ing. Dis­cus­sion: This case sug­gests a pos­si­ble asso­ci­a­tion between the devel­op­ment of spinal seg­men­tal dys­func­tion and con­se­quen­tial man­i­fes­ta­tion of behav­ioral dis­or­ders. It also high­lights the use of the MYMOP ques­tion­naire in cases out­side of mus­cu­loskele­tal pain syn­dromes, espe­cially where evi­dence may be lim­ited or where there may not be an exist­ing tool to mea­sure change.

Key words: chi­ro­prac­tic, pedi­atrics, behav­ior, vio­lence, spinal manipulation.

Intro­duc­tion
Pre­vi­ous research into the rela­tion­ship between behav­ioral prob­lems and chi­ro­prac­tic has focused on chil­dren diag­nosed with behav­ioral dis­or­ders such as autism and ADHD. There appears to be no pre­vi­ous research amongst the lit­er­a­ture that involves chil­dren that are yet to be diag­nosed, or who have been shown not to be suf­fer­ing from autism or ADHD, but still have behav­ioral prob­lems. A search of PubMed and Index to Chi­ro­prac­tic Lit­er­a­ture (ICL) was car­ried out using the key­words in var­i­ous com­bi­na­tions: chi­ro­prac­tic, pedi­atrics, behav­ior, vio­lence, adhd and autism. As of Sep­tem­ber 2014, there were no pre­vi­ous stud­ies of any evi­dence level that were sim­i­lar to this case.

In gen­eral, chi­ro­prac­tic research in pedi­atrics has been focused on the younger child, under 12 weeks of age, with most com­mon pre­sent­ing com­plaints being that of a mus­cu­loskele­tal ori­gin, and exces­sive crying1. Even in this demo­graphic, research was pre­vi­ously crit­i­cized as being weak, but fur­ther devel­op­ments includ­ing a sin­gle blind prag­matic RTC on exces­sive cry­ing helped bol­ster this evidence2. Fur­ther­more, there is an appar­ent dearth of clin­i­cal tri­als related to chi­ro­prac­tic and pedi­atrics, with many exist­ing stud­ies being of low evidence3.

Karpouzis4 sys­tem­atic review of chi­ro­prac­tic care for chil­dren with ADHD illus­trated the lack of evi­dence in sup­port of chi­ro­prac­tic care, with most of the stud­ies used being of low evi­dence. How­ever, the patient in this case report had not been diag­nosed with ADHD or other con­di­tions. It is there­fore pru­dent to report on this case, where behav­ior and vio­lent out­breaks improved, see­ing as there seems to be no prior pub­lished arti­cles that high­light this relationship.

Autism is char­ac­ter­ized by severe and per­va­sive impair­ment in rec­i­p­ro­cal social­iza­tion, qual­i­ta­tive impair­ment in com­mu­ni­ca­tion, and repet­i­tive or unusual behavior5. ADHD is then char­ac­ter­ized by inap­pro­pri­ate, chronic lev­els of inat­ten­tion, hyper­ac­tiv­ity and impulsivity6. There is also an asso­ci­a­tion with dif­fi­cul­ties in aca­d­e­mic achieve­ment, and behav­ioral con­trol, and as a con­se­quence, they have dif­fi­culty in estab­lish­ing pos­i­tive rela­tion­ships with fam­ily, author­ity fig­ures and their peers6.
Cur­rently phar­ma­ceu­ti­cal man­age­ment is the main­stay of care for many chil­dren with ADHD4. Med­ica­tion of youths has a com­mon side effect of weight gain7, as in the fol­low­ing case, and may be a rea­son behind poor adher­ence to med­ica­tion. There is grow­ing research with regards to the use of non-​pharmaceutical man­age­ment of symp­toms. 28.9% of youths with men­tal health dis­or­ders are reported to be using CAM ther­apy, com­pared to 11.6% of youths with­out men­tal health disorders8. Research also indi­cates that 10% of the US pop­u­la­tion use chi­ro­prac­tic care for non-​musculoskeletal con­di­tions and up to 14% of all vis­its is for pedi­atric care4.

It can be dif­fi­cult to effec­tively mea­sure change in patients pre­sent­ing symp­toms, espe­cially when there are no stan­dard­ised tests to mea­sure change. Due to this, in the UK, The Royal Col­lege of Chi­ro­prac­tors rec­om­mend the Mea­sure Your­self Med­ical Out­come Pro­file ques­tion­naire (MYMOP)9. MYMOP mea­sures patient-​perceived changes in symp­tom sever­ity, well­be­ing and abil­ity to under­take a key activ­ity. These mea­sures are com­bined to pro­vide a ‘pro­file’ that is quan­ti­fied before and at one or more inter­vals dur­ing a course of treatment.

A demon­stra­tion of pos­i­tive change among patients through use of such a tool does not unequiv­o­cally prove the clin­i­cal effec­tive­ness of the inter­ven­tion, but it does show that impor­tant aspects of a patient’s health sta­tus improve dur­ing the period they are receiv­ing care9. Patients are invited to choose one symp­tom which they are most con­cerned about on a scale of 06, where 0 is a good as it can be, and 6 being as bad as it could be. They then choose an optional sec­ond symp­tom. This is then fol­lowed by an optional activ­ity that the symp­tom affects, plus a rated gen­eral feel­ing of well­be­ing ques­tion, again rated 06.

Case report
A 10-​year old male patient pre­sented to a chi­ro­prac­tic clinic with behav­ioral issues, includ­ing a change from a calm relaxed man­ner, to sud­den out­breaks of vio­lence. His mother reported that he suf­fered from fre­quent panic attacks and peri­ods of anx­i­ety. These behav­ioral issues affected his school­ing, and he was sus­pended from sev­eral schools, and was only allowed to attend school for 50 min­utes a day. Due to being sus­pended from schools, he had not started the “state­ment­ing process” and was not diag­nosed with a spe­cific condition.

The Local Edu­ca­tion Author­ity car­ries out the State­ment­ing Process in the UK. The State­ment of Spe­cial Edu­ca­tional Needs is a legal doc­u­ment that sets out the learn­ing and edu­ca­tional needs of an indi­vid­ual child. These are usu­ally issued to chil­dren who find it sig­nif­i­cantly harder to learn than other chil­dren of the same age, through med­ical, com­mu­ni­ca­tion or behav­ioral prob­lems and where the school is unable to meet the needs of the child through its own resources10.

The patient was pre­vi­ously diag­nosed with Emo­tional Detach­ment Dis­or­der, and was unable to sleep alone, and reported poor, unre­fresh­ing sleep. His health his­tory revealed a dif­fi­cult birth, being born in an occiput pos­te­rior fetal posi­tion, which had to be cor­rected dur­ing labor. He suf­fered from sev­eral bouts of oti­tis media as a child, with three oper­a­tions to fit grom­mets. The mother did not recall whether or not he was pre­scribed antibi­otics for these bouts. His mother reported that he was often clumsy and had poor fine motor skills. His bowel habits were described as being vari­able, between bouts of con­sti­pa­tion and diar­rhea. His mother also explained that he had dif­fi­cult notic­ing when he was suf­fi­ciently full fol­low­ing eat­ing. He had been med­ically pre­scribed Arip­ipra­zole, which helped improve his behav­ior, but the side effects of increased weight gain caused him to stop tak­ing this medication.

The patient appeared above aver­age size for his age. Cer­vi­cal, tho­racic and lum­bar active and pas­sive ranges of motion were full, pain­less and unre­stricted. Pal­pa­tion of seg­men­tal motion revealed restric­tion of the upper cer­vi­cal, mid tho­racic and lum­bar spinal seg­ments, accom­pa­nied by sig­nif­i­cant ten­der­ness of the left sub occip­i­tal mus­cles. Sen­sory, motor and reflex (SMR) neu­ro­log­i­cal tests were unremarkable.

The patient’s mother com­pleted a MYMOP ques­tion­naire, which is a val­i­dated patient-​reported out­come mea­sure­ment tool. It is help­ful in iden­ti­fy­ing whether, from the patient’s per­spec­tive, cer­tain aspects of their health sta­tus change over time9.

On the ini­tial con­sul­ta­tion the mother high­lighted the patient’s vio­lent behav­ior as being the symp­tom that con­cerned her the most, rat­ing it as 66. Her sec­ond most impor­tant symp­tom was the patient’s poor sleep, which again she rated as 66. Over­all, she rated her son’s over­all health and sense of well­be­ing as being 66. This gave a MYMOP ‘pro­file’ score of 66.

The patient was rec­om­mended a course of chi­ro­prac­tic care. The sched­ule included a twice-​weekly sched­ule over a 4-​week period. Chi­ro­prac­tic care con­sisted of diver­si­fied, Thomp­son drop tech­nique and toggle-​recoil adjust­ments, with gen­tle soft tis­sue ther­apy. His mother also com­pleted a fol­low up MYMOP ques­tion­naire after his 3rd, 6th and 8th adjustment.

The patient responded pos­i­tively to his chi­ro­prac­tic adjust­ments, and by the 4th adjust­ment his MYMOP pro­file score dropped to 4.6÷6, then to 3.3÷6 by the 7th adjust­ment and finally to 1.6÷6 by the review stage of his care on the 9th visit. His mother reported that his vio­lent behav­ior had decreased. Fur­ther­more, when his out­bursts did occur, it was eas­ier and quicker to ease him out of the vio­lent episodes. She also noted that his behav­ior was more set­tled, and noted that he was becom­ing gen­er­ally more pos­i­tive with his out­look. At this review stage she also men­tioned that he was sleep­ing bet­ter and was able to sleep in his own bed, by him­self. She also reported that since start­ing care, he had no panic attacks. In addi­tion, she reported that he was more aware of when he was full fol­low­ing eating.

No adverse events were reported or noted as a result of chi­ro­prac­tic care. The patient was not receiv­ing any other care at the time of the study.

Dis­cus­sion
This was a unique case pre­sen­ta­tion of an improve­ment in vio­lent behav­ior in a male child with chi­ro­prac­tic care. Pre­vi­ous stud­ies have focused on chil­dren with med­ical diag­noses of con­di­tions such as ADHD and autism. The search of the lit­er­a­ture indi­cated no pre­vi­ous stud­ies that have shown a sim­i­lar link.

As stated in the intro­duc­tion, chil­dren with men­tal health prob­lems are using com­ple­men­tary med­i­cine, includ­ing chi­ro­prac­tic care as a tool to improve their over­all health. Stud­ies have shown that 28.9% of chil­dren with men­tal health are using CAM8.

It is impor­tant that patients and fam­i­lies of those affected by men­tal health are aware of the alter­na­tive and com­ple­men­tary forms of treat­ment, which may improve their health and well­be­ing. How­ever, as this case indi­cated, the research that is being pro­duced by chi­ro­prac­tors is either not being reported or not being pub­lished. Although case stud­ies are low-​level evi­dence they are use­ful in indi­cat­ing pos­si­ble responses to chi­ro­prac­tic care and pro­vide details regard­ing many dif­fer­ent aspects of a patient’s med­ical sit­u­a­tion, which is missed or unde­tected by clin­i­cal studies11.

Tra­di­tional phar­ma­ceu­ti­cal treat­ment of behav­ioral prob­lems may include pre­scrip­tion for Arip­ipra­zole, such as in this case. Arip­ipra­zole is an anti-​psychotic med­ica­tion, which com­monly pro­duces side effects, includ­ing weight gain in children7. Side effects such as these may result in a high non-​compliance rate12. Owing to this, chi­ro­prac­tic care may be an attrac­tive alter­na­tive to fam­ily and patients con­cerned with side effects of med­ica­tion, espe­cially as chi­ro­prac­tic care with chil­dren has shown to be safe and effective13.

There is a large amount of research that rep­re­sents patients’ responses to mus­cu­loskele­tal con­di­tions. This is likely to be due to the plethora of stan­dard­ised out­come mea­sures such as the Bournemouth Ques­tion­naire. How­ever, many con­di­tions are hard to mea­sure and quan­tify. The MYMOP ques­tion­naire has been shown to be prac­ti­cal, reli­able and sen­si­tive to change14-​30. It is evi­dent that ques­tion­naires such as MYMOP allow us to quan­tify, in the patient’s expe­ri­ence, the change that may have occurred through chi­ro­prac­tic care. This will then hope­fully gen­er­ate inter­est in the rela­tion­ship between chi­ro­prac­tic care and behav­ioral changes, and then lead to future high-​level studies.

Con­clu­sion
This case report demon­strates that chi­ro­prac­tic spinal adjust­ments, the only treat­ment being ren­dered, were effec­tive in improv­ing the child’s behav­ior. This study sug­gests that chi­ro­prac­tic care helped to reduce vio­lent out­breaks as well as to improve the patient’s sleep, with addi­tional improve­ments to sati­ety and fre­quency of panic attacks. Chi­ro­prac­tic care may be an effec­tive tool that chil­dren with behav­ioral and other men­tal health prob­lems may be able to use to improve their health and well­be­ing. This study has illus­trated a dra­matic improve­ment with chi­ro­prac­tic care, with­out any adverse reac­tions or side effects to care. In chil­dren who have reac­tions or side effects to med­ica­tion for their behav­ior, chi­ro­prac­tic care can be a safe and effec­tive alternative.

Cur­rent research high­lights pos­si­ble hypothe­ses that may explain the improve­ments noted in this study. One poten­tial mech­a­nism is that “altered affer­ent feed­back from a ver­te­bral sub­lux­a­tion alters the affer­ent milieu into which sub­se­quent affer­ent feed­back from the spine and limbs is received and processed, thus lead­ing to altered sen­so­ri­mo­tor inte­gra­tion of the affer­ent input, which is then nor­malised by high-​velocity, low-​amplitude adjustments“31,32. It is thought that if a ver­te­bral sub­lux­a­tion cre­ates neu­ro­plas­tic changes in the cen­tral ner­vous sys­tem due to altered affer­ent input, its impact on the sen­so­ri­mo­tor inte­gra­tive sys­tem may have neu­ro­log­i­cal man­i­fes­ta­tions far beyond the mechan­i­cal local site of the ver­te­bral subluxation32.

A sec­ond hypoth­e­sis sug­gests that chi­ro­prac­tic care may improve brain func­tion by increas­ing cere­bral blood flow, result­ing in a restora­tion of nor­mal cere­bral function33,34.

It is clear that fur­ther research needs to be car­ried out in order to assess the ben­e­fits of chi­ro­prac­tic care for chil­dren with behav­ioral prob­lems. In addi­tion, more research into the neu­ro­phys­i­ol­ogy of spinal adjust­ments may help our under­stand­ing of why these changes occur.

Writ­ten informed con­sent was obtained from the patient for pub­li­ca­tion of this case report and any accom­pa­ny­ing images. A copy of the writ­ten con­sent is avail­able for review by the Edi­tor of this journal.

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34. Gor­man RF. Monoc­u­lar vision loss after closed head trauma: imme­di­ate res­o­lu­tion asso­ci­ated with spinal manip­u­la­tion. J Manip­u­la­tive Phys­iol Ther 1993; 16:138.

Ran­dom Article

The above state­ment sums up the head­lines of a Reuters arti­cle by Mag­gie Fox appear­ing Jan­u­ary 30, 2006. The arti­cle is based on a

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