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Complementary Therapies in Clinical Practice 18 (2012) 89e93

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Complementary Therapies in Clinical Practice

journal homepage: www.elsevier .com/locate/ctcp

The chiropractic care of a child with extremity tremors concomitantwith a medical diagnosis of conversion disorder

Joel Alcantara a,b,*, Rebecca Adamek c

a International Chiropractic Pediatric Association, Media, PA, USAb Life Chiropractic College West, Hayward, CA, USAcMinneapolis, MN, USA

Keywords:Conversion disorderChiropracticPediatricsSubluxation

* Corresponding author. Life Chiropractic College WE-mail address: jalcantara@lifewest.edu (J. Alcanta

1744-3881/$ e see front matter � 2012 Elsevier Ltd.doi:10.1016/j.ctcp.2012.01.001

a b s t r a c t

Objective: To describe the care of a patient with spinal and cranial dysfunctions and medically diagnosedwith conversion disorder.Clinical features: The patient was an 11-yr-old girl presented by her parents with complaints of uncon-trollable tremors of both arms and right leg. Conversion disorder was diagnosed following negativeexamination findings for an organic etiology. Prior to institutionalization, her parents requesteda “second opinion” from a clinical psychologist that eventually led to chiropractic referral.Intervention and outcome: Care was provided using spinal manipulation to sites of spinal and cranialdysfunctions. With subsequent visit, the patient’s tremors improved. Following 12 chiropractic visits, thepatient’s symptoms resolved. Long-term follow-up revealed continued resolution of the symptoms oftremors.Conclusion: This case report provides supporting evidence that patients with ballistic tremors of possibleunknown organic etiology may benefit from chiropractic care. We support further research in this field.

� 2012 Elsevier Ltd. All rights reserved.

1. Introduction

Since Eisenberg et al.’s1 landmark study on the use of comple-mentary and alternative medicine (CAM) in the early 1990s, the useof CAM therapies in the United States have increased dramati-cally.2,3 This trend seems to hold true in other industrializedcountries.4e6 In a survey of Australians, 70% indicated using CAMand 40% visited a CAM practitioner in the preceding 12 months.4

Among British responders, 28% used CAM5 while 76% of Japa-nese6 and 60% of Canadian7 responders indicated using CAM. In theUnited States, Barnes et al.8 reported that children of parent CAMusers were twice as likely to use CAM when compared to childrenof parent non-CAM users. Of the practitioner-based non-allopathictherapies, chiropractic was the most popular and highly utilized forchildren.8 Concomitant with the general population, the use ofCAM therapies by individuals with psychiatric disorders continuesto rise.9 Of interest in this case report is the use of alternativetherapies by those diagnosed with conversion disorder. Conversiondisorders are a subset of the somatoform disorders that affectvoluntary motor and sensory function with presenting symptoms

est, Hayward, CA, USA.ra).

All rights reserved.

that are inconsistent with known neurological or musculoskeletalpathologies.10 Motor symptoms can include paralysis, aphonia,weakness, loss of balance and even urinary retention. Sensorysymptoms include paresthesias, blindness, deafness, hallucinationsand seizures.

In the interest of evidence-based practice, we provide thefollowing case report describing the successful care of an 11-yr-oldgirl with a medical diagnosis of conversion disorder. To the best ofour knowledge, this is the first reporting of its kind in the scientificliterature.

2. Case report

The patient was an 11-yr-old female with complaints ofuncontrollable tremors in both upper extremities and right lowerextremity. History examination revealed previous consultationswith a pediatrician, a neurologist and a psychiatrist. Thoroughphysical examination, magnetic resonance imaging (MRI),computer axial tomography (CAT) scanning, blood analysis andelectroencephalographic (EEG) studies were performed on thepatient with negative results for an organic cause. Consequently,she was diagnosed with conversion disorder. Institutionalization ina hospital in-patient facility was recommended to address hercomplaints. Prior to institutionalizing their daughter, the patient’s

J. Alcantara, R. Adamek / Complementary Therapies in Clinical Practice 18 (2012) 89e9390

parents decided to consult a clinical psychologist for a “secondopinion.” The psychologist concurred with the patient’s medicalproviders in the diagnosis of conversion disorder. As a last resort,the clinical psychologist recommended the chiropractor next door.

At the request of her parents, a chiropractic consultation wasmade for possible care. History examination revealed the following.Six months prior to the onset of her tremors, the patient experi-enced mechanical traumas to the head at the left temporal region.The patient recalled hitting her head on the ski slopes as an adultskier had “run her over.” She recalled “hitting” the left side of herhead with another student during play. One month prior to theonset of tremors, a violin case falling from the school bus overheadshelf struck her head. The location of impact was at the lefttemporal, parietal and sphenoid bones. The patient denied losingconsciousness but the following day, she began to experience fullbody tremors, headache and nausea. The tremors and nauseasubsided over the next “couple of days” but she continued toexperience headaches. Thereafter, the patient began to experiencegross tremor movements in both upper extremities and right leg.Twoweeks prior to the onset of these gross tremor movements, thepatient reported hitting her head (left temporal region) against thecorner of a paper towel machine and experienced a “tightening” ofher upper trapezius muscles, headaches and disturbances in hergait and characterized by internal rotation and flexion of the rightleg. The tremors continued to worsen from its onset to the extentthat the patient was having difficulties walking. At the time ofconsultation, the patient admitted to being severely hampered andchallenged in her activities of daily living. Not surprisingly, she haddifficulty putting on her shoes, playing the piano, reading a book orattending school. She was having problems falling asleep and whenshe did fall sleep, her sleep was disrupted throughout the night dueto the tremors. At the time of chiropractic consultation, the patientwas prescribed the anti-depressant medication Celexa (30 mgdose) as well as a number of other prescription medications.

The physical examination findings revealed the following. Onvisual inspection, the patient had difficulty walking withoutassistance and the tremors were so severe that she had difficultyputting on her shoes while sitting on the floor since the tremors inher right leg caused her to kick off her shoe. Digital palpationrevealed severe hypertonicity throughout the lumbar and thoracicparaspinal muscles (bilaterally). The upper trapezius muscles, thelevator scapula muscles, the scalenes and sternocleidomastoidmuscles and the pectorales major muscles, were also hypertonic,bilaterally. Additionally, palpation of the right lower extremitiesrevealed the psoas muscles, the quadriceps, and the gastrocnemiusand soleus muscles as hypertonic. Range of motion (ROM) exami-nation of the cervical spine revealed no restrictions or asymmetryand was interpreted to be within normal limits. Lumbar spine ROMcould not be performed by the patient due to the tremors. Cervicalcompression and distraction tests were unremarkable. Kemp’s Test,Straight Leg Test and Patrick’s Test were unremarkable but difficultto perform due to the constant tremors in the lower right leg.Neurological examinations of both upper and lower extremitieswere unremarkable except for a þ3 triceps reflex, bilaterally.

Examination of the cranium revealed cranial distortions.11 Apalpable ridge (due to overlap) as well as tenderness was present atthe left and right parietal bones as well as at the lefttemporalesphenoidefrontal junction. There was a reciprocal bulgeat the right occipitaleparietaletemporal junction. A lack of cranial-sacral (CS) pulse was noted at the sacrum, the frontal, parietal,sphenoid and temporal bones. Minimal CS pulse was also found atthe occipital bones but the rhythm was not synchronized. Spinalsegmental dysfunctions12 were detected at the following spinalsegments: anterior occiput, at the C1 and C4 vertebral body (VB), atthe T4 and T8 VB and no counternutation of the sacrum. Fascial

tensions were present at the pelvic and respiratory diaphragmswith the latter torsioned to the right with loss of left lateral flexion.

Chiropractic care began with cranial-sacral dural pull whereinone practitioner contacts the cranial bones while another contactsthe sacrum. Frontal lift, parietal lift, sphenoid lift, temporal release,and occipital lift were all performed in this order while constantsacral decompression was performed. Excessive head, neck, andtrunk motion were noted when the reciprocal tension membranesand diaphragms were released (i.e., described as full bodyunwinding). The above aspect of care lasted approximately 90 min.Chiropractic SMT to the occiput was performed using a “droppiece.” The doctor’s contact point was the right hand on thepatient’s frontal bone. A high-velocity low amplitude (HVLA) thrustin the anteroposterior direction was applied with concurrentdistraction by the doctor’s left hand contacting the patient’socciput. A segment of the chiropractic table built for this purposewas released downwards as a result of the HVLA thrust. Chiro-practic SMT to the C1 and C4 segmental dysfunctions were per-formed with the patient in the supine position. Using an indexfinger contact, an HVLA thrust in the posteroanterior andinferioresuperior direction was applied. SMT to the T4 and T8 VBswere performed with the patient prone. A hypothenar contact wasused and the HVLA thrust was simply posterior to anterior. The lossof sacral counternutation was addressed with the patient lying onher right side. The apex of the sacrumwas contacted with an HVLAthrust in the posteroanterior direction. Homecare instructions werealso provided to the parents to massage their daughter’s scalp andthe addition of an EPA/DHA supplement to her diet.

The patient did not attend care for another week due toa planned family vacation. As a follow-up to her last visit, thepatient indicated that she felt a mild “shift” in her tremors andthat her muscles felt more relaxed and with less pain, especiallyto the upper trapezius and levator scapula muscles. The flight totheir vacation destination was difficult and had increased hersymptoms.

Subsequent chiropractic care was similar to that described inthe first visit. Of interest was that during the dural pull, thepatient completely ceased to tremor for approximately 15 min. Atthe third visit, the patient indicated a noticeable decrease in hertremors with respect to its intensity and frequency. At the fourthvisit, the Logan Basic Technique13 was applied with the rightsacral tuberous ligament contact. During this procedure, thepatient’s tremors completely ceased for 15 min. A stretchingprogram was also instituted at this time (during chiropractic careand at home) to address her “tight” muscles. By the 6th visit, thepatient’s large tremor movements had disappeared and replacedwith mild “twitches.” Also at this time, the patient’s cranial-sacralsystem had balanced for the first time. The patient continued toimprove with subsequent chiropractic care. Her tremors hadceased to be constant and by the 9th visit, only a mild twitch wasnoticeable, if and when they occurred, which was rare as indi-cated by the patient. At this time, which was approximately 5weeks since initiation of care, the patient was able to attenda school field trip to a museum with her classmates and was ableto read a book. The patient continued to improve in her symp-toms and following 12 visits, the patient reported completeresolution of her symptoms.

3. Discussion

This case report brings to the forefront several issues fordiscussion. Salient to these discussions is the chiropractic care ofpatients with possible psychiatric disorders. Specifically, thechiropractic care of patients medically diagnosed with conversiondisorder involving a psychogenic movement disorder.

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3.1. Epidemiology

In children, approximately 20% report abdominal pain, limbpain, and headaches without any apparent organic cause.14 Thereported prevalence of conversion disorder in children varies from0.5% to 10% in childhood psychiatric clinics15 and 16.7% in pediatricin-patients who are referred to psychiatrists.16 The reportedsymptoms are usually central nervous system disorders in nature.This is not surprising when one considers the observation that 65%of children medically seen for conversion disorder are referred tothe psychiatric services in a hospital and the patient has been seenby a neurologist.15 Such was the clinical scenario for the patientpresented in this case report. About 2% of pediatric neurologicalreferrals are for conversion disorder. In children under 6 years ofage, conversion disorder is rare. Before the age of 10 years, thegender predisposition is equal. By adolescence, femalespredominate in a ratio of 3:1.16

In 2008, Schwingenschuh et al.17 reported on 15 cases of chil-dren with psychogenic movement disorder and a review of theliterature. The underlying diagnosis in the children reported wasconversion disorder. The most common types of movement disor-ders involved dystonia (47%), tremors (40%), and gait disorders(13%). Multiple hyperkinetic phenomenologies were observed inmany cases. As in the case described, the onset was abrupt andprecipitated by minor injuries accompanied with stressful lifeevents. The time from symptom onset until medical diagnosisvaried broadly between 2 weeks and 5 years. Prognosis improved iftreatment was instituted immediately following the onset ofsymptoms. According to Schwingenschuh et al.,17 treatment withcognitive and behavioral therapy and physical rehabilitation bya multidisciplinary team led to improvement in most cases.Recently, Sauerhoefer et al.18 described the successful care ofa 13-year-old girl with tremor in both wrists. The tremors were ofsuch severity that it prevented her from attending school. Thepatient was treated with a customized wrist brace and cognitiveand behavioral therapy to address her chronic and acute stressfactors which contributed to performance and examination anxietyin school.

Today, the symptoms leading to the diagnosis of conversiondisorder are thought to be due to early disruption of the functioningof the nervous system. The signs and symptoms exhibited by suchpatients are signs of an organic brain disorder in the early stagesthat is difficult to detect by known means such as MRI, CAT Scanand electrophysiological testing. Two prominent theories, thetheory of disturbed central nervous system (CNS) arousal and thetheory of cerebral asymmetry, provide a rationale for an organicdisorder. The theory of disturbed CNS arousal proposes thatpatients with conversion disorder have disturbed cortical arousalresulting in the activation of negative feedback loops between thecerebral cortex and the brainstem reticular formation. Messagesfrom the cerebral cortex may inhibit afferent sensorimotorimpulses resulting in manifested sensory deficits. The theory ofcerebral asymmetry is based on the notion that pseudoneurologicalmanifestations arise from environmental events acting on theaffective right hemisphere of the brain. This theory has gainedgreater popularity than the theory of disturbed CNS arousal since ithas been observed that patients with conversion disorder havesubtle cerebral impairments in verbal communication, memory,affect, incongruence and suggestibility.19 In the most recent updateon psychogenic movement disorders, Ellenstein et al.20 summa-rized the neuroimaging and neurophysiological basis of psycho-genic movement disorders. Positron emission tomographyscanning and single photon emission computed tomography(SPECT) studies have demonstrated abnormal activity in networksspanning motor and limbic areas, including the prefrontal and

anterior cingulate cortices. A SPECT study of psychogenic hemi-sensory loss measuring blood flow during tuning fork stimulationfound hypoactivation of the thalamus and basal ganglia contralat-eral to the affected limb. Various studies using EEG, event-relatedpotentials, magnetoencephalography, transcranial magnetic stim-ulation (TMS), action observation, and motor imaging suggestnormal activation of primary sensory and motor pathways butdisruptions in higher level cortical pathways, which may serve tointegrate perceptions about self and motivation.

3.2. Implications for chiropractic care

As introduced, CAM use among individuals with mental disor-ders or symptoms such as anxiety, depression, sleep disorders,attention-deficit/hyperactivity disorder, autism, bipolar disorders ison the rise.21 Data from a systematic review of studies on CAM useby mental health services users suggest that 50%e80% of peoplesuffering from psychiatric disorders use CAM.22 Sevilla-Dedieuet al.23 found that 20% of respondents (n ¼ 2928) from 6European countries reported lifetime seeking help for psycholog-ical problems with almost 9% turning to CAM providers, such aschiropractors and herbalists.

As a context to our discussion on the chiropractic care ofa pediatric patient with conversion disorder, we performeda systematic review of the literature on the subject. The databasesMANTIS [1965e2011]; ICL [1984e2011]; Pubmed [1966e2011];Medline [1965e2011] EMBASE [1974e2011], AMED [1975e2011],CINAHL Plus [1965e2011], Alt-Health Watch [1965e2011] andPsychINFO [1965e2011] were searched using the MeSH headings“conversion disorder” in Boolean combination with “chiropractic”alongwith relatedwordswhen appropriate. The searchwas limitedto publications in the English language and in peer-reviewedjournals. Additionally, chiropractic journals (i.e., Journal of Manip-ulative and Physiological Therapeutics, Journal of the CanadianChiropractic Association, Clinical Chiropractic, and The ChiropracticJournal of Australia) were hand-searched for the last five years forpossible relevant materials. One of the authors (JA) reviewed thetitle and abstracts of all articles generated from the electronicdatabase search as well as from the reference lists of relevantarticles. The full manuscripts of reports relevant to the chiropracticcare of children with growing pains were retrieved by applying thefollowing set of eligibility criteria: (1) themanuscript was a primaryinvestigation/report (i.e., case reports, case series, case control,randomized controlled trials and survey or surveillance studies)published in a peer-reviewed journal in the English language; (2)part or all of the study population involved children with hysteriaor conversion disorder. No articles were found according to ourselection criteria.

To the best of our knowledge, this is the first documentation inthe scientific literature on the successful chiropractic care ofa pediatric patient with tremors concomitant with the psychiatricdiagnosis of conversion disorder. The approach to patient care wasbased on the chiropractic theoretical and clinical framework thatchanges in the normal anatomical, physiological or biomechanicaldynamics of contiguous vertebrae can adversely affect function ofthe nervous system. We qualify here for the reader unfamiliar withcranial therapy that unlike the HVLA thrust type SMTapplied to thespine, a gentle and sustained manual pressure is applied to sites ofthe cranium to correct the distortions. The approach to patient carewas non-judgemental and one of empathy on the part of thechiropractor. To the patient and her parents, the patient’scomplaints were genuine, real and independent of her medicaldiagnosis. As such, mutual trust, acceptance and understandingwere established for all involved. Chiropractic has been describedas patient-centered with principles of vitalism, holism, humanism,

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conservatism, naturalism, and rationalism.24 This case reportexemplifies chiropractic’s possible role in the care of similarpatients under the paradigm of integrative medicine e thethoughtful incorporation of concepts, values, and practices fromalternative, complementary, and conventional medicines.25 AsTocchio26 commented in the care of patients with conversiondisorder; the approach should not be one of pre-determinedjudgments and concrete standards of care in conventional psychi-atry but rather beingmore open to alternative therapies andwillingto accept the strong connection between the mind and body. Therole of chiropractic care and other alternative therapies in patientswith conversion disorders and other psychiatric disorders remainto be characterized.

According to the medical diagnosis, the patient suffered frompsychogenic movement disorder characterized as uncontrollabletremors. Psychogenic movement disorders are generally thought ofas manifestations of dysfunctional motor control networks that canat times result in bizarre movements that cannot be mimicked. Aunified neuroanatomic basis for conversion disorder or psycho-genic movement disorders continues to be elusive. However,dysfunctional regions and networks initially related to sensori-motor control and emotion are being identified as associated withpsychogenic movement disorder.27,28

From a chiropractic perspective, the salutary effects of chiro-practic SMT are at best speculative. The decrease in tremorsfollowing chiropractic SMT in the case reported is reminiscent ofthe effects of SMT in patients with chronic low back pain. Severalstudies have noted that reduced paraspinal voluntary electromyo-graphic amplitude occurred following SMT.29e32 Additionally, wepostulate that the chiropractic SMT may produce an inhibitoryreflex response that is segmental in origin (i.e., as demonstrated bythe Hoffman reflex technique) and that this decrease of moto-neuron activity may lead not only in reduction of hypertonicity andthe pathogenesis of pain but also a decrease in tremors.33 Dishmanet al.37 demonstrated that basic neurophysiologic response tospinal manipulation is central motor facilitation. Based on theirstudy, it may be speculated that sensory discharges evoked by theSMT received by the patient may have provided the appropriateproprioceptive feedback signal to the central nervous system,which in turn may have stabilized the gain of the motoneuron pool.In fact, the data by Dishman et al.34 indicated that the central motorsystem, in its totality, is facilitated. Various clinical conditionsinvolving spasticity and hypertonicity such as that seen in tremordisorders have been attributed to pathophysiologic abnormalitiesin the modulation of motoneuron activity by presynaptic andpostsynaptic interneurons.

Perhaps, as speculated, chiropractic SMT leads to suppression ofmotoneuron excitability leading to the suppression of a patholog-ical condition like uncontrolled tremors. As described, the patient’stremors ceased during and 15 min after treatment and withcontinued care, the tremors abated with its eventual resolution.Conversion disorders are characterized by different cortical acti-vation patterns.35,36 Using somatosensory evoked potentials,Haavik-Taylor and Murphy37 were able to demonstrate that SMT ofdysfunctional cervical spinal joints can lead to transient corticalplastic changes. In a follow-up study, the investigators were able todemonstrate that SMT to the cervical spine leads to specific centralcorticomotor facilitatory and inhibitory neural processing andcortical motor control of 2 upper limb muscles in a muscle-specificmanner.38

4. Conclusion

This case report described the successful chiropractic care ofa pediatric patient with vertebral subluxations and tremors

concomitant with a medical diagnosis of conversion disorder. Wereviewed the neurophysiological basis of this disorder and dis-cussed the possible neurological mechanisms involved as a result ofchiropractic SMT. We support continued research in this field tofurther examine the role of chiropractic care in similar patients andothers with psychiatric disorders.

Conflict of interest statementThe authors declare no conflict of interest.

Role of funding source

This study was funded by the International Chiropractic Pedi-atric Association, Media, PA and Life Chiropractic College West,Hayward, CA.

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