Chiropractic Care of an Infant with Erb’s Palsy: Another Worthless Case Report

At the risk of sounding like a bit of a broken record, chiropractic management of any infant is at best unhelpful. Unfortunately, it can expose these children to the indirect risk of delayed appropriate medical evaluation and treatment as well as their caregivers to anti-vaccine propaganda. At worst, there is the risk of direct injury. The case I am going to discuss today veers perilously close to a worst case scenario.

I was planning to write a post about the myriad ways in which the SARS-CoV-2 pandemic has harmed children, and perhaps even resulted in some benefits in a few unique (but still not worth it) ways. This is a fascinating issue and the more I looked into it the more I found to potentially discuss. I was just at the point of making the decision to put a pin in the topic in order to allow more time for reflection when some new “research” from the word of infant chiropractic was brought to my attention. As usual, I couldn’t resist.

A follower/followee of mine on twitter alerted me to an article from the Australian Spinal Research Foundation, a fundamentalist chiropractic organization devoted to the worship of the chiropractic subluxation:

At ASRF, we’re developing a clear understanding of vertebral subluxation and its effects, by funding scientifically testable research drawing on the philosophical tenets of chiropractic. We lead our profession by facilitating global research in the areas of vertebral subluxation science and the clinical benefits of chiropractic care for the human population.

The article in question is the press release for a case report published in the Asia-Pacific Chiropractic Journal, a new open access journal designed specifically for mobile platforms, and it is exactly what you would expect it to be. But before I get into it, here is an interesting video describing the journal that does not exactly inspire confidence.

In the ASRF press release, the author starts out with a comment on infant birth trauma and then briefly describes an anatomical region known as the brachial plexus. It quickly goes off course:

If you’ve ever suffered from pain in your arms and hands after a long day hunched over a computer, or suffered from chronic pain in your arms and hands at all, it could be due to this thing called the brachial plexus. Up in your neck, where the C5 and C6 Vertebra unite (at Erb’s point), a rich bunch of nerve fibres slip through a small gap and then out to your arms and hands. When we slump forward into a posture where our head is forward and our shoulders are rounded forward, we can make this gap even smaller causing pain.

The brachial plexus, a complex network of nerves which also contains branches originating at C7, C8, and T1, is unfortunately placed and injury with subsequent pain/weakness/loss of sensation are fairly common. But they don’t occur because of bad posture. Bad posture as a cause of pain or health problems is largely a myth propagated by chiropractors and other so-called “posturologists”. Friend of SBM Paul Ingraham did an excellent deep dive analysis of the role of posture in neck and back pain at his website that is worth checking out.

Brachial plexus injuries typically occur because of trauma, usually in the setting of participation in contact sports or involvement in a car or bicycle accident. The mechanism of injury is an impact that pushes the head away from the shoulder and stretches the neck forcefully. They can be mild and quickly resolve (stingers and burners) or cause long term weakness or even paralysis of the involved arm and hand (brachial plexus palsy).

Neonatal brachial plexus palsy (NBPP) is a form of brachial plexus injury diagnosed around the time of birth. And while a minority of cases can result from intrauterine injury, and some occur during easy deliveries, the biggest risk factor for NBPP is a difficult extraction requiring forceful lateral flexion of the neck when a baby’s shoulders are stuck in the pelvis during delivery, something called shoulder dystocia. It’s also not uncommon for NBPP to be accompanied by fracture of the clavicle or humerus on the involved side. As the author of the press release points out, the common term for most cases of NBPP is Erb palsy, although there are other types that go by different names.

A classic Erb’s palsy presentation occurs when the affected shoulder is held in internal rotation, with extension and pronation of the elbow and the wrist in flexion. It can result in some paralysis of some arm muscles, specifically biceps, deltoid, supraspinatus, and brachioradialis muscles which all sit around the upper arm and shoulder area. The degree of injury can vary, with mild cases resolving independently within a few weeks while severe cases may struggle to completely resolve. In more recent years it is understood that there may be residual defects, such as muscle weakness, shoulder and elbow contractures, bony deformity and shortening of the involved arm.

This explanation is good enough for our purposes, although it isn’t entirely accurate. Only about a third of infants with NBPP have a complete Erb palsy, known as Erb palsy plus, with injury to exiting spinal nerves at C5, C6, and C7 and a classic “waiter’s tip” phenomenon where the hand and fingers are flexed. The classic Erb palsy, where hand and finger extension is spared, is more common and is diagnosed in about half of cases. NBPP in its most severe form can involve the entirety of the arm and hand, and even present with paralysis of the diaphragm in rare cases.

But what does this have to do with chiropractic? Nothing, of course, but the press release claims that NBPP is a reason for having an infant checked after birth. Such a bold claim requires compelling evidence, however, and they’ve got just what the chiropractor ordered!

A recent case study looked at the instance of a 9-week-old girl that presented with right Erb’s palsy which had been diagnosed 2 days post-birth. Since birth, she had no movement in her right arm, and after consulting with a specialist it was decided they would wait and see if it resolved spontaneously (independent of treatment). It wasn’t expected this would happen and the infant’s mother sought chiropractic care as a final hope, but without much expectation.

That is unfortunate, but not terribly surprising. There is so much bogus chiropractic marketing to be found online, and I’ve written about a lot of it over the years. Of course some caregivers are going to fall for it. Claiming that the patient’s mother sought chiropractic care as a final hope is also unfortunate. It’s likely just manipulative language used by the author to promote chiropractic, but it could have been how the mother actually felt. If so, that’s potentially a failure of communication between her and the child’s pediatrician or neurosurgeon.

The gold standard approach to NBPP is to allow a considerable amount of time to pass, typically 3 to 9 months, before considering surgery. This is because the condition improves on its own in most cases and surgery is not at all guaranteed to benefit the patient. That doesn’t mean nothing is done to help the patient, of course. Physical and occupational therapies to prevent muscle contractures and promote muscle strengthening are standard components of care. Obviously we are relying on a biased interpretation of the facts of the case, so who knows what really went down, but the patient’s mother should not have felt hopeless at only 9 weeks out from the injury.

The press release goes on to give some unhelpful details on the patient’s injury and then reveals that the “Gonstead chiropractor” evaluating the child found a subluxation. Who saw that coming? Only the subluxation that they found was in the sacrum at the other end of the spine! But don’t worry, I just know that they will have a clever explanation for how that is supposed to be causing injury to nerves in the neck. And the child miraculously improved after only one treatment, which is, and trust me on this, quite literally impossible. The author points out that generalizations can’t be made based on one case report, but clearly believes that this specific child was cured with chiropractic and able to avoid an almost certain surgical fate.

It is possible that the child’s neurosurgeon had told the mother that surgery would likely be necessary. In order to hazard a guess regarding that possibility, however, we would need to know more details about just how severe the injury was. In other words, does “no movement in her right arm” really mean no movement at all in the entire arm, including the hand and fingers? I’m curious if there will be a more detailed explanation of the child’s diagnosis and prognosis in the case report, and we’ll get to it soon…I promise.

But first, a bit on the Gonstead system.

What makes the Gonstead System so special?

There are hundreds of chiropractic techniques, each with its own name and sometimes religious-like adherents. But there is a lot of overlap between them, and many have only very minor differences. They essentially boil down to a marketing scheme, with believers in specific techniques often promoting their preferred flavor of nonsense as the one true technique. It’s like Highlander without the beheadings, although not always for lack of trying.

The Gonstead System is very special, according to the people who practice it. It’s so special in fact that not just any chiropractor can handle its specialness. How special.

Gonstead procedures are the result of extensive clinical research by Clarence S. Gonstead, founder of the world famous Gonstead Clinic of Chiropractic in Mount Horeb, Wisconsin and his associates. Doctor Gonstead’s fifty-five years of continuous practice and over four million chiropractic adjustments resulted in the most complete method of biomechanical analysis available for use by today’s doctors of chiropractic. So why don’t all chiropractors use this technique? Because the analysis takes more time and mastering the art of delivering a specific adjustment takes a LOT of practice and dedication.

I always get a kick out of the absurd numbers of adjustments claimed to have been performed by some chiropractors in their marketing efforts. Let’s break this one down. Four million adjustments over 55 years comes out to almost 73 thousand every year. That’s about 200 adjustments every day if he didn’t take any days off. Even taking into account that he very likely “found” more than one subluxation to adjust in many if not most of his patients, that is still a ridiculous claim.

Gonstead’s extensive clinical research helped him establish 5 criteria to detect vertebral subluxations:

Finally…the case of the 9-week-old with the self-limited condition

Now for the case report itself. It’s bad. It’s read bad. It’s full of boilerplate Gonstead System scripture, it makes outlandish claims regarding the mechanism of action for chiropractic adjustments benefiting the patient, and it mentions but then completely disregards the significant limitations inherent in relying solely on an anecdote to support a conclusion that chiropractic helped this baby…(checks notes)…regenerate spinal nerves.

As described in the press release, the patient (Isabelle) was brought in for chiropractic evaluation at 9 weeks of age for NBPP diagnosed on the second day after delivery. Isabelle had apparently been evaluated by a surgeon who was unable to determine the severity of the nerve damage, but reportedly suspected an avulsion. This is when the spinal nerve is ripped out of the cord and it is the most severe cause of brachial plexus injuries.

An avulsion of a spinal nerve root will not heal without surgery. Even with surgery, many patients don’t regain full function of the involved arm. But, as the author even discusses at one point in the paper, it is impossible to reliably diagnose an avulsion clinically because mild to severe NBPP can present in the same way initially, with just a baby who isn’t moving an arm. MRI of the cervical spine isn’t even that helpful. Time is required to determine severity, with more significant injuries taking longer to improve or not improving at all.

Nine weeks is much too early to confidently determine that there has been an avulsion. It’s likely, however, that the surgeon discussed all the possible outcomes and management options with the child’s parents, but very unlikely that they would have said with any confidence that a nerve transplant would be required. As I mentioned earlier, surgeons typically allow several months to pass before going that route if there is no substantial improvement.

The patient’s mother, an occupational therapist, had learned of chiropractic as a potential treatment for NBPP from a Facebook group. The paper describes her as interested in seeing if chiropractic might help and feeling as if she had nothing to lose by trying, but it doesn’t paint the picture of hopelessness described in the press release. It reads more like she just got some bad information and perhaps didn’t run this by her daughter’s pediatrician and surgeon.

The author and Gonstead chiropractor, Karen Forsyth, describes the child’s neurological exam:

When observing Isabelle her right arm hung loosely by her side, she was unable to abduct or flex the right shoulder and there was no movement in the right elbow.

She does not mention anything about the hand or finger movement. It would be helpful to know if the entire arm, including the hand and fingers, was immobilized. The general rule in these cases is that the presence of any early improvement, particularly in the first 2-3 months, is a good sign that the patient will have meaningful recovery of function and will be very unlikely to ultimately require surgery. I’ll also point out here that Isabelle’s mother, an occupational therapist, was performing daily physical therapy exercises as instructed by the surgeon.

Forsyth’s chiropractic examination revealed a “sacral S1 segment posterior dyskinesia”, which is jargon for subluxation. And yes, that’s at the complete other end of the spine. She didn’t use a nervoscope to confirm her findings on visualization and palpation, however, because the patient was too small. So take her diagnosis with a grain of pink Himalayan sea salt.

During her exam ritual, she noted decreased lateral flexion in the cervical spine in both directions, which means that she stretched and could have further injured the involved nerves depending on how much force she used. I’m hopeful that she didn’t yank on the kid’s neck very hard, but would you trust your baby to an infant chiropractor in this situation? I wouldn’t.

After the first adjustment of the S1 vertebrae, Isabelle’s mother noted immediate and significant improvement in the movement of her arm. As I mentioned earlier, this is impossible. That’s just not how this works at all. Nerves don’t just up and start conducting like that. I mean, I realize that some chiropractors act like what they do is magic, but it’s not real magic. That would be impossible because they don’t have wands. Wait…never mind.

Her mother is an occupational therapist, so one might argue that she should be capable of assessing a patient’s ability to move their arm. But Isabelle is her daughter, not her patient, and the stress, fatigue, and worry of coping with a chronically ill infant can alter perception of reality. I’ve seen in many times. We are also only hearing one side of this story.

What happens next is portrayed in the paper as a miraculous and unexpected recovery. After several visits for adjustments of the S1 subluxation over many weeks, and then continued follow-up visits for many months, Isabelle’s arm improved dramatically. In fact, by her last visit prior to writing up this paper, when Isabelle was nearly 2 years old, her only noticeable deficit was some difficulty with bringing a spoon to her mouth. Forsyth noted that Isabelle’s surgeon has seen her several times during her course of chiropractic treatment and had declared that a procedure would not be necessary. Again, this is indistinguishable from the natural course of NBPP for the majority of patients.

In the discussion of the paper, Forsyth points out that spontaneous resolution has been observed in as many as 96% of patients in some studies and that the natural history of NBPP is hard to predict. She also notes correctly that a decent percentage, perhaps as many as a third, will have some degree of residual impairment. She leaves out that this residual impairment is usually not clinically meaningful.

She discusses the limitations of her report:

Limitations to this study include a possibility that this may have been the natural history of the Erb’s palsy. However, it would be very coincidental and rather ironic that movement would spontaneously begin the day following chiropractic treatment. Isabelle’s mum was near certain that she would require surgery at some point and when I was first consulted there was a high suspicion that the nerve was ruptured, and recovery would be minimal. Other biases and limitations include the lack of a control in this study, it is a small sample with only 1 case being presented and some may even argue the patient may have expected clinical resolution. This latter point is irrelevant as Isabelle was a baby when she received treatment and mum really had little expectations but more hope.

Ironic? Not really. I am sure that Isabelle’s mother believed that her improvement began suddenly and unexpectedly within hours of her first adjustment, but that just isn’t physiologically possible. Much more likely, despite Forsyth’s commentary on expectation and hope, is that she noticed minor changes that had been going on for some time and evaluated them in a more optimistic light, which is one of several possible placebo effects. I addressed the difficulty with determining nerve rupture and a need for surgery earlier. Also nobody would claim that a 9-week-old infant had expectation of benefit.

Before wrapping up, I wanted to briefly discuss Forsyth’s explanation for how adjusting a subluxation near the tailbone might improve function of nerves in the neck:

The proposed mechanism to describe how a subluxation as low as the sacrum can affect the 5th and 6th cervical nerve roots is, an S1 biomechanical misalignment may create a longitudinal tension in the dura and result in dural tension.

The dura is the covering that surrounds the brain and spinal cord, and it is continuous. She is essentially saying that if something tugs on the dura at any location, it can somehow pinch exiting spinal nerves at another location. This is silly. You are bending your neck and back, adding tension to the dura, nearly constantly without causing impingement of nerves. Simply bending over to pick something up off of the ground would result in significantly more tension than a so-called chiropractic subluxation that can only be appreciated with magic fingers and a bogus diagnostic device. Even if stretching the neck it takes significant force to actually stretch the nerves of the brachial plexus in a way that causes injury.

Okay, one last thing. You don’t often see an airing of grievances in the medical literature. That’s what blogs are for. I’m actually surprised that what I’m about to share made it through, but I’m not confident that the peer review process for this journal is all that robust. Forsyth, a subluxation-worshiping Gonstead devotee, does not take to kindly to those who would question the core tenets of her belief system:

This case provides interesting contrast to those in the Chiropractic profession who are ‘subluxation deniers’, such as Guillame Gonclaves, Christine Le Scanff and Charlotte Leboeuf-Yde, Chiropractic Researchers…They argue that vitalistic concepts such as ‘the body can heal itself and the nervous system controls and coordinates all body functions’ are false and chiropractic should be only for musculoskeletal problems…If we listened to people like Gonclaves, Le Scanff and Leboeuf-Yde, Isabelle may have been denied chiropractic care which would have been devastating for her and her family.

Conclusion: Chiropractic management of brachial plexus injury is a sham

No surprise there. I believe that I built my case effectively. With rock bottom plausibility as an intervention for injured spinal nerves, and nothing to support claims of benefit except for a few case reports, this is the only rational conclusion. Thankfully Isabelle did not suffer any apparent harm during her chiropractic evaluations, but unnecessary lateral stretching of her neck could have worsened her outcome. I’m happy that she did not end up requiring surgical intervention, and confident that chiropractic played no role whatsoever in her improvement.

Clay Jones, M.D. is a pediatrician and a regular contributor to the Science-Based Medicine blog. He primarily cares for healthy newborns and hospitalized children, and devotes his full time to educating pediatric residents and medical students. Dr. Jones first became aware of and interested in the incursion of pseudoscience into his chosen profession while completing his pediatric residency at Vanderbilt Children’s Hospital a decade ago. He has since focused his efforts on teaching the application of critical thinking and scientific skepticism to the practice of pediatric medicine. Dr. Jones has no conflicts of interest to disclose and no ties to the pharmaceutical industry. He can be found on Twitter as @SBMPediatrics and is the co-host of The Prism Podcast with fellow SBM contributor Grant Ritchey.

The comments expressed by Dr. Jones are his own and do not represent the views or opinions of Newton-Wellesley Hospital or its administration.

This content was originally published here.

Author: topline

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