"44.6% of PNES patients have a history of traumatic brain injury.(6) This information paired with observations from individual case studies could suggest a link between trauma and development of not only PNES but a variety of seizure disorders." 

Epilepsy is a spectrum of brain disorders which disturb the normal pattern of neuronal activity. A person is considered to have epilepsy if their history includes the occurrence of two or more seizures.(1) Disruption in the normal function of the brain can produce sensory deficits, mental disturbance, altered consciousness, abnormal bodily movements, and seizures. The spectrum of disorders characterized as epilepsy can range from benign to severely life threatening.(2) Causes of epilepsy can include head trauma, brain injury, stroke, cerebral infection, lead exposure, perinatal complications, neoplasm, and cerebral metabolic disorders. Individuals with epilepsy experience an overall lower quality of life due to challenges associated with co-morbidities, limited access to effective care, and social misunderstandings regarding epilepsy and seizure disorders.(3) The Centers for Disease Control and Prevention (CDC) cited the most recent National Health Interview Survey (NHIS) statistics indicating that around 1.0% of adults in the United States had active epilepsy in 2010. Only 52.8% of those adults reported seeing a neurologic specialist for epilepsy within the previous year and 33.4% with any epilepsy (active or inactive) had seen a neurologic specialist in the past year; these numbers were unchanged among differing sexes, ages, and ethnicity. Of adult individuals in families with an annual income below $34,999, 3.1% had any epilepsy and 1.9% had active epilepsy. 1.6% of adults in families with incomes greater than $35,000 had active epilepsy with 0.7% belonging to an unknown economic demographic. 86.4% of adults with active epilepsy and 76.6% with inactive epilepsy had seen a general doctor in the past year while only 66.1% of adults without epilepsy reported a doctor visit in the last year.(3,4)

The occurrence of multiple seizures is not always diagnosed as epilepsy. Psychogenic nonepileptic spells (PNES) are also known as "pseudoseizures" and present very similarly to epileptic seizures. Differentiating between PNES and epileptic seizures can be achieved by the use of electroencephalogram (EEG); however, there are often barriers to access and cost of monitoring.(5)  Most patients experience PNES an average of three to seven years before EEG monitoring. In 1998, the average length of stay for an inpatient study was 3.1 days with an average hospitalization charge of $6,832. Gender distribution for PNES displays a higher incidence in females.(6)

Asadi-Pooya et al. report an overall incidence of 1.4-4.9/100,000 and that 5-10% of outpatients and 20-40% of inpatients in epilepsy monitoring units have PNES.(7) Patients who experience pseudoseizures generally do not respond to anti-epileptic drugs and can develop paradoxical reactions or even toxicity in response to traditional medications prescribed for epilepsy.(8) Despite the fact that PNES is not usually life threatening, there is risk associated with aggressive treatment before identification and classification of a seizure-like event.(5)

Allopathic management of seizures entails the consideration of a variety of factors that may alter treatment choices in the seizure patient. Sarma et al. identified specific patient populations that provide a challenge in the treatment of epileptic and nonepileptic seizures.(5) The most common allopathic treatment for seizures are anti-epileptic drugs (AEDs) such as lamotrigine, ozcarbazepine, levetiracetam, phenytoin, phenobarbital, valproic acid, and zonisamide.(5) These AEDs pose a considerable threat to women with epilepsy who are at all stages of pregnancy as well as the developing infant.(5) Maintaining high blood levels of these drugs is associated with teratogenic effects such as congenital malformations; however, reducing blood levels in women who are pregnant also poses a considerable threat as seizure frequency may increase.(5) Maternal seizures pose a myriad of threats including physical trauma, accidents, placental abruption, and premature labor.5 Researchers at the Kerala Registry of Epilepsy and Pregnancy identified an association between AEDs and failure to conceive with a 20-times decreased conception rate in women taking three or more AEDs than that of a woman no taking AEDs.(5)

AED treatment is also complicated in patients with HIV/AIDS who experience seizures.(5) Due to potential adverse reactions between AEDs and highly active antiretroviral therapy the best choices for AED use in HIV/AIDS patients include levetiracetam, lacosamide, gabapentin, and pregabalin.(5) Enzyme-inducing AEDs such as phenytoin, primidone, phenobarbital, and carbamazepine should be avoided in this patient population.5Sarma et al. also identified challenges with AED application in the patient population identified as elderly or dementia patients who experience seizures.(5) A wide variety of differential diagnoses for seizure activity in the elderly confuses accurate diagnosis coupled with challenges of obtaining accurate health histories in the same population.(5) A Veterans Affairs study indicated that lamotrigine demonstrated the greatest bodily dose retention while the AED carbamazepine showed the worst retention.(10)

The use of EEG in clinical decision making regarding seizure activity is becoming increasingly significant. Continuous video EEG (cEEG) and quantitative EEG (qEEG) can help in the diagnosis and management of seizures; however, utilization of these has been shown to be variable.(5) Yigit et al. noted that EEG is not always necessary for the diagnosis of a seizure event but can provide information that most-appropriately guides a clinical treatment strategy.(11) One such situation is the aforementioned pseudoseizures or PNES which is easily diagnosed with cEEG.5 Since PNES may lack response or may respond adversely to AEDs prescribed for epilepsy, the information provided by cEEG would be vital to appropriate treatment.(5,8) Despite this fact, cost and access to cEEG are still highly variable and most PNES patients are managed with AED treatments before their seizures are realized as nonepileptic.(5)

PNES treatment varies. Cognitive behavioral therapy has demonstrated significant results by reducing seizure frequency in PNES patients confirmed by cEEG.(12,13) The drug known as venlafaxine is used to treat depression, generalized anxiety disorder, panic disorder, and social anxiety disorder. Though it is not an AED, venlafaxine has shown promising results in seizure reduction in PNES patients.(14) Sertraline is a selective serotonin reuptake inhibitor also used in treating a variety of mental disorders and has been shown to offer a significant frequency of seizure reduction when compared to a placebo.(15)

Case Report

A 32-year-old man reported for chiropractic care with a health concern of epilepsy. He reported tremors in his right arm, right leg, and head that began suddenly three months prior. The man identified a previous work injury where he fell off of a truck and hit his head on concrete. He described experiencing a sensory blurriness for a few days after.

A review of medical records revealed the man had a history of aneurysm, hypertension, hyperlipidemia, and GERD. He had experienced similar tremors ten years before the current report. The tremors were originally thought to be psychogenic; however, an investigation for the cause revealed an aneurysm of the left internal carotid artery. An angiogram was performed with coil placement and clipping. The tremors resolved following the operation. A follow-up two years later revealed that the aneurysm was stable with no residual change, no abnormalities, and normal venous drainage.

The patient's initiation of chiropractic care was preceded by a return of the tremors, two Emergency Department (ED) visits, and an electroencephalogram (EEG) study. The first ED visit resulted in treatment of symptoms associated with acute bronchitis. Three weeks prior the man received a round of anti-biotics and prednisone from his primary care provider. The bronchitis symptoms did not resolve and his primary care provider prescribed an inhaler and codeine cough syrup. The man experienced an exacerbation of symptoms including cough, dry mouth, and profuse sweating. A phone call with a local pharmacy suggested the man try Benadryl. Upon taking Benadryl he experienced the sensation that his throat was closing and reported to the ED immediately. He was administered fluids, valium, and discharged the same day upon stabilization.

Six days later his doctor suggested he continue use of the inhaler and within 30 minutes he began experiencing cough, dry mouth, and diaphoresis. He reported to the ED and was given intravenous steroids and shortly thereafter began to experience tremors. The tremors were qualified as moderate, located in the right upper extremity, and accompanied by shortness of breath. The patient also reported tightness in the right side of his neck at that time.

Three months later the patient was admitted for a 21 channel EEG study. Over the course of 24 hours a total of nine seizure-like events were recorded as well as a constant tremor in the right hand and shoulder. The events ranged in time from forty seconds to four and a half minutes. The patient's constant tremor would intensify to include bilateral arm shaking/beating his chest, side to side facial motions, hard facial grimace, back arching, and pelvic thrusting. Each episode would end abruptly followed by confusion and grogginess. Long and short term memory impairment was observed. Events were triggered by stress, flashing lights, and mental strain. EEG activity during and after the events displayed no electrographic correlate and were consistent with psychogenic non-epileptic spells (PNES).

The patient was noted to experience events while standing at which time he would fall; however, there was no report of severe injury. The patient had bitten the inside of his mouth before. There was no family history of seizures and no indication of childhood abuse or severe injury. The patient reported he finished high school on a regular track but was not academically inclined. At the time of the reoccurrence of his seizures he was taking college courses but had to discontinue his studies.

The chiropractic exam focused on the identification, location, and characterization of vertebral subluxation in the upper cervical region of the spine. Para-spinal thermography was used to demonstrate deviation from thermal symmetry which could indicate neurological compromise caused by a misaligned vertebral segment.(16) A cervical spine radiographic study consisting of a neutral lateral, anterior to posterior open mouth, and base posterior were taken to identify and measure the characteristics of segmental misalignment between the occiput, atlas, and axis vertebrae.

The origins of the use of thermography as an objective tool for vertebral subluxation analysis dates back to 1923 and the development of the neurocalometer instrument.(17) Dr. Lyle W. Sherman is credited for the "pattern" analysis of thermograph readings in conjunction with his research work as assistant director and chief of staff of the B.J. Palmer Chiropractic Clinic in Davenport, IA.(18,19) Pattern analysis is based upon static thermographic readings occurring persistently and indicating the presence of vertebral subluxation. Subsequent to the intervention of a precision adjustment the pattern in the thermograph readings will change in quality and dissipate over time coinciding with reduction of vertebral subluxation.(20)

The Tytron C-5000 unit was used to obtain comparative thermograph readings in this case and served as an analysis of the neurological component of the subluxation. The instrument is engaged and glided from the level of the vertebral prominence to the occiput per standard protocol originally described by Dr. B.J. Palmer.(21) Bilateral barrels housing infrared temperature sensors pick-up skin surface heat readings on each side of the mid-sagittal plane along the spine. When the instrument is disengaged a series of three graphs are displayed indicating the individual heat reading of each side and a central "delta-t" graph indicating the differential values between each side. Pattern analysis is based on the regulation of skin temperature by the autonomic nervous system. As such, readings which do not demonstrate adaptability and change can indicate sub-optimal nervous system function.(22)

Radiographs of the cervical spine were taken to visualize and measure misalignment of the atlas and axis vertebrae. The misalignment characteristics are used to determine the corrective vector of the adjustic movement applied to reposition the vertebra in question. The method used in this case study involved segmental position comparison by line-drawing methods.(23) Radiographs were also used to identify segmental attributes, relationships, soft tissue detail, hard tissue detail, and as a map for locating the most viable contact to be used in the application of the adjustment of the segment.(24) A lateral cervical, base posterior, and a-p open mouth view were taken to provide a complete 3-dimensional analysis of vertebral misalignment.

The physical movement applied by the chiropractor to affect the position of a misaligned vertebra is known as the toggle-recoil. This movement on the part of the chiropractor delivers a quick and light impulse to the specific segment. The toggle-recoil involves a rapid contraction and subsequent relaxation of the triceps muscles. The force produced is capable of cleavage necessary to shear adjacent articular surfaces of vertebral segments and when applied in the correct vector repositions the misaligned segment.(25,26) Adjustments were administered with the patient in the kneeling posture on a "knee-chest" solid headpiece upper cervical table.

After adjustment the patient was instructed to rest for 15 minutes and was checked again with the Tytron C-5000 instrument to monitor for the reduction or elimination of pattern reading.(27,28) At subsequent visits the patient was checked with the instrument and another adjustment was administered only if there was evidence of a return of the initial thermographic pattern.

Two days following the patient's first adjustment he reported that the tremors in his right hand had stopped. He was adjusted a total of 13 times during the course of care described in this report. At 11 weeks he reported only experiencing one seizure in the prior six weeks of care. The patient also reported feeling more relaxed, more alert, and less nervous.

Discussion

This case study serves to document the reduction of non-epileptic seizures in a patient undergoing chiropractic care for upper cervical vertebral subluxation. Upon initial consultation the patient reported a complaint of epilepsy; however, upon further review of medical history it was revealed that the man's seizures and tremors were of a non-epileptic etiology. It is interesting to note the adverse reactions that the patient had to a variety of medications which were prescribed for the treatment of a separate symptomatology. Alessi and Valente note the common reduction in PNES symptoms in association with placebo effect from anti-epileptic drugs.(29)  The idea that a chiropractic intervention is truly effective treatment for PNES symptoms is suspect due to the suggestibility of PNES patients.(29) Brockman performed a double-blind study on twenty asymptomatic individuals to address the question of chiropractic manipulation and psychological response.(30)  Results suggested that positive psychological markers following chiropractic manipulation were more likely due to viability of the treatment and less likely due to placebo. Common antiepileptic drugs may exacerbate nonepileptic seizures, represent substantial cost to the patient, and carry a high risk of teratogenicity in the pregnant female patient with seizures.(31) In light of the risk of AEDs in patients with PNES chiropractic care may present a viable adjunct to PNES treatment regardless of placebo effect.

Despite a paucity of information regarding the origin of PNES, some evidence suggests a connection to structural abnormalities which lead to changes in the central nervous system.(5) Lee et al. used diffusion tensor imaging to observe altered white matter structural connectivity primarily in the left hemispheres of EEG-confirmed PNES patients.(32) Xue et al. demonstrated similar connective abnormalities between the frontal lobe and other brain regions using non-invasive EEG-network analysis. This suggests an underlying pathophysiological mechanism in PNES patients.(33) Arthuis et al. describe the use of PET functional neuroimaging to observe PNES patients. They found anterior cingulate hypometabolism coupled with right parietal hypometabolism in their subjects.(34) Alterations in the central nervous system such as these have been associated with vertebral subluxation. Kent described the "dysafferentation model" for vertebral subluxation which leads to neurological dysfunction by disturbing the relationship between biomechanical properties of the spine and nociceptors/mechanoreceptors that surround vertebral segments and relay positional information to the brain. Kent used the word "dysponesis" to describe the end result of the dysafferentation process i.e. misdirected neurophysiologic reactions to stimuli.(35) It is plausible that seizures in PNES patients are an abnormal neurological response to stimuli in the presence of structural deviation of the structures encasing the nervous system as well as the central nervous system. Reinsberger et al. used heart rate variability to identify abnormal autonomic nervous system activity in PNES patients, lower parasympathetic activity was indicated.(36) Kent identifies autonomic dysfunction as a neurological consequence of spinal degeneration and vertebral subluxation. Barre'-Lieou syndrome and reflex sympathetic dystrophy are used as examples of autonomic dysfunction arising from the abnormal stimulation of sympathetic nerves via spinal insult.(35) It is plausible that PNES could represent an alternate manifestation of a similar cause i.e. vertebral subluxation[CK1] . Correction of vertebral subluxation with subsequent normalization of the mechanical properties of the spine is theorized to restore optimal functioning capacity of nerve tissues implicated in autonomic dysfunction.(35) In the case of PNES this may be evidenced by an immediate cessation of seizure activity or a gradual decrease in activity coinciding with clinical indicators that demonstrate progressive reduction or complete correction of vertebral subluxation.

[CK2] Brown and Swenson describe a case study of a 14-year-old female who experienced a resolution of pseudoseizures while receiving chiropractic care utilizing the Torque Release Technique (TRT) protocol.(37) It is notable that TRT addresses vertebral subluxations of all regions of the spine in contrast with the previously described upper cervical protocol. The patient was experiencing 30-40 seizures per month for three months when chiropractic care was sought out by the patient's mother. Definitive pathology was ruled out via multiple MRI's, CT, EEG, and blood work. Multiple emergency room visits for seizure events resulted in treatment with Valium but did not provide a resolution. There was a history of sports related trauma two years prior; however, the authors report that the trauma was unlikely to be the cause of the seizures. Over the course of five months of care the patient experienced a resolution of seizures.

Though not reported as pseudoseizures or PNES there are a number of case studies in the literature pertaining to upper cervical vertebral subluxation and seizures. Komarek et al. describe upper cervical chiropractic care of a 2-year-old male with seizures following a head trauma one year and four months prior.(38) The patient experienced a resolution of seizures over the course of five and a half months of care in which the patient was adjusted three times.

Hubbard et al. describe the care of a 25-year-old female with an 11 year history of juvenile myoclonic epilepsy.(39) The onset of the epilepsy coincided with menarche and a trauma where the girl hit her head falling out of bed. Over a 12-week period the patient was adjusted three times and experienced improvement in seizures.

Elster describes a 23-year-old male with rapid-cycling bipolar disorder, sleep disorder, seizure disorder, neck and back pain, and migraine headaches.(40) The man had experienced a head trauma at age 17 when he landed on his head while pole vaulting. Elster suggests a link between the trauma and development of symptoms due to resolution of all symptoms within 7 months of a single upper cervical chiropractic adjustment which corrected upper cervical vertebral subluxation.

44.6% of PNES patients have a history of traumatic brain injury.(6) This information paired with observations from individual case studies could suggest a link between trauma and development of not only PNES but a variety of seizure disorders. In addition to trauma there are numerous precipitating factors associated with PNES including but not limited to abuse, neglect, job loss, surgical procedures, separation, social, and legal psychosocial factors. Similar perpetuating factors have also been identified which can exacerbate the current PNES symptoms and hamper the patient's potential for recovery.6 In all cases described, the improvement or resolution of seizure disorders under chiropractic care for vertebral subluxation suggests a relationship between the two. A traumatic event in the patient's history further provides a plausible causative or exacerbating factor for vertebral misalignment and neurological interference indicative of vertebral subluxation.

There are limitations of this study that should be considered in investigating if chiropractic care is responsible for improvement in seizures. This case study represents the experience of a single patient without a control group. The observations gained cannot be applied to larger patient populations. The patient history also indicates a self-resolving seizure complaint from several years prior. It is unknown whether the patient sought any other treatment methods or made lifestyle changes that may have contributed to a decline in seizures. PNES patients may be more susceptible to suggestion or placebo.(29)

[CK3]

Conclusion

This case study records the care of a 32-year-old man who experienced a reduction of psychogenic nonepileptic spells while under chiropractic care for vertebral subluxation. After the first adjustment the man reported a reduction of constant tremor and between the fifth and eleventh week of care he reported only experiencing one seizure. At this time there is only one other case study in the chiropractic literature that describes a case of pseudoseizures. More research is needed to explore the relationship between vertebral subluxation and seizure disorders.

References

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• 34. Arthuis M, Micoulaud-Franchi JA, Bartolomei F, McGonigal A, Guedj E. Resting cortical PET metabolic changes in psychogenic non-epileptic seizures (PNES). J Neurol Neurosurg Psychiatry. 2014; 86(10):1106-1112.
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• 36. Reinsberger C, Sarkis R, Papadelis C, et al. Autonomic changes in psychogenic nonepileptic seizures: toward a potential diagnostic biomarker? Clin EEG Neurosci. 2015;46(1):16-25.
• 37. Brown C, Swenson A. Resolution of recurrent pseudoseizures in a 14‐year‐old female using torque release technique: a case study. Ann Vert Sublux Res. 2014 Spring;2014(2):Online access only p 49-54.
• 38. Komarek A, Tedder N, Tedder A. Cessation of seizures, behavioral disturbances and improvement in cognitive developmental delay following upper cervical chiropractic care in a 2 year old: a case report. J Upper Cervical Chiropr Res. 2015 Spring;2015(2):Online access only p 14-18.
• 39. Hubbard TA, Crisp CA, Vowles B. Upper cervical chiropractic care for a 25-year-old woman with myoclonic seizures. J Chiropr Med. 2010 Jun;9(2):90-94.
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More on epilepsy and chiropractic.

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