Bilateral Simultaneous Optic Nerve Dysfunction After
Periorbital Trauma: Recovery of Vision in Association
with Chiropractic Spinal Manipulation TherapyThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: J Manipulative Physiol Ther 1999 (Nov); 22 (9): 615–621 ~ FULL TEXT
OPEN ACCESS Danny Stephens, DC, DO, Henry Pollard, Don Bilton, DC,
Peter Thomson, DC, DO, Frank Gorman, DO
Dr R.F. Gorman, MBBS, DO,
PO Box 211, Marrickville 1475,
7/324 Marrickville Rd,
Marrickville, New South Wales 2204, AustraliaOBJECTIVE: To discuss the recovery of optic nerve function after chiropractic spinal manipulation in a patient with loss of vision as a result of facial fracture from a fall.
CLINICAL FEATURES: In a fall down a stairwell, a 53-year-old woman with migraines fractured her right zygomatic arch, which was later treated surgically. Approximately 3 weeks after the accident, vision in her contralateral eye became reduced to light perception. Electrophysiologic studies revealed that the function of both optic nerves was diminished, the right significantly more than the left. Single photon emission tomography showed pancerebral ischemic foci.
INTERVENTION AND OUTCOME: Chiropractic spinal manipulation was used to aid recovery of vision to normal over a course of 20 treatment sessions. At times, significant improvement in vision occurred immediately after spinal manipulation. Progressive recovery of vision was monitored by serial visual field tests and by electrophysiologic studies. Unfortunately, the patient refused a further single photon emission tomographic study when visual recovery was complete.
CONCLUSION: This case report adds to previous accounts of progressive and expeditious recovery of optic nerve function in association with spinal manipulation therapy.
From the Full-Text Article:
Discussion
The philosophy and practice of chiropractic and monocular visual loss
This patient's recovery of vision from an abnormality localized in the optic nerve is significant because each step in the recovery path was measured numerically by an independent observer, in this case, the static perimeter. We believe that in chiropractic practices around the world, similar recoveries occur every day but are not appreciated because they are difficult to measure. For instance, during the last century, anecdotes in which a patient remarks on a miraculous change in mental or physical performance after spinal manipulation have gained little credence outside the chiropractic profession. This account is the fifth in which optic nerve function has improved in association with spinal manipulation.
This patient's investigation and treatment reflect the benefits of spinal manipulation. The primary aim was not to correct a spinal derangement but to ameliorate a dysfunction occurring in the central nervous system. The nature of the spinal derangement was not paramount, other than that it was present and causing significant disability in the nervous system. For this reason, spinal radiographs were performed to elicit evidence of spinal pathology as a result of the recent traumatic incident (when she fell down the stairs). For instance, vertebral fractures could have been present that would have made spinal manipulation therapy more dangerous than in their absence.
In our opinion, the critical feature in the examination of the cervical spine was the presence of suboccipital tenderness, manifested by exerting pressure on the transverse processes of the atlas vertebra. These prominences can be easily palpated below the lobes of the ears in most patients. Patients with upper cervical spine derangement grimace when pressure is exerted and if standing, involuntarily rise on their toes.
SPECT is relatively inexpensive and easily accessible; most nuclear medicine facilities provide this service in Australia. The investigation is not sensitive because many patients with manifest cerebral hypoperfusion measured by the presence of visual field loss and significant symptoms suggesting vertebrobasilar insufficiency are noted to have normal scans. With this consideration in mind, the presence of cerebral vascular hypoperfusion designated by a SPECT scan would then logically indicate a significant degree of ischemia.
In our subject's case, the presence of multiple ischemic areas on the SPECT scan supports the hypothesis that explains the phenomenon of recovery of focal loss of vision with spinal manipulation therapy. We believe that the whole of her cerebral vascular system was stressed by a vasospastic influence. Fortuitously, from the point of view of recording her recovery with spinal manipulation therapy, the abnormality became manifestly obvious because of involvement of the optic nerves. As a result, the presence of the pathologic abnormality was amplified by the functional interference of vision; a similar-sized lesion elsewhere in the brain would have passed completely unnoticed.
Unfortunately the patient refused to have the projected SPECT scan after completion of the course of spinal treatment. Disappearance of the focal areas of ischemia, which were present before treatment, would support the accuracy of our hypothesis. Needless to say, the decision to undergo treatment must remain the prerogative of the patient; any coercion to do so, on philosophic or altruistic grounds, would be inappropriate.
The decision to accept spinal manipulation therapy
During questioning, the patient remarked that she received no indication from the medical practitioners initially consulted that her vision was likely to improve on medical therapy. However, she did not keep the appointment with the third ophthalmic consultant who might have boosted her confidence about the efficacy of traditional medical therapy. Overall, she did see orthodox ophthalmologists and the scientist who performed the neurophysiologic measurements, none of whom expressed confidence that return to normal vision was imminent.
In contradistinction, the chiropractic practitioners advised her that her illness might be an extension of her migraine condition, about which she was well informed. In addition, evidence was presented to her demonstrating the recovery of vision in similar circumstances in other patients who underwent spinal manipulation therapy.
The patient was not denied the opportunity to seek simultaneous treatment from both medical and chiropractic practitioners at any stage in the study. From a scientific viewpoint, it was fortunate that she did not use any treatment other than the spinal manipulation therapy; such additional treatment would have confounded the reasonably straight-forward treatment-response graph.
In addition, she was aware of the result of the SPECT scan, which showed sporadic areas of cerebral ischemia and supported our presumptive diagnosis of migrainous ischemic optic neuropathy, and knew that the electrophysiologic studies had shown the function of both optic nerves to be affected.
The pathogenesis of her condition
Considering the recovery of vision that occurred, the optic nerve dysfunction in this patient must have been recoverable from the outset. Two such pathologic conditions in which recovery is likely are optic nerve demyelination (optic neuritis) and optic nerve ischemia.
Demyelination processes have the propensity to recover spontaneously; most patients who have an episode of optic neuritis recover their vision to a great extent. [19]
Ischemic tissue can recover after long periods of inactivity provided that the level of oxygenation does not go below the lower level of the ischemic penumbra compartment. This concept has been advanced by Terrett [20, 21] and later by Stephens et al [6] in their account of the recovery of vision in 17 patients with bilateral constriction of the visual fields.
Optic nerve pathology is very complicated, and the discrimination among demyelinative optic neuropathy, ischemic optic neuropathy, and even glaucomatous optic neuropathy is by no means clearly defined.
From the point of view of the therapies that could be instituted, we believe that it is advantageous to consider that such patients have ischemic optic neuropathy rather than optic neuritis, which could be classed as an autoimmune process. Essentially, we argue that cerebral ischemia is more basic than autoimmunity and higher on the hierarchic ladder of pathogenesis relating to states of illness. For an autoimmune-type phenomenon to occur, cerebral computations pertinent to the process would have to be abnormal. Therefore we maintain that it is not logical to be satisfied with diagnosing that such a neurologic event was a demyelinative episode: we must ask why the demyelination has occurred.
We believe that migrainous cerebral ischemia produces abnormal cerebral computations that, in turn, produce brain failures of diverse kinds, including abnormal autoimmune responses. This concept is well-supported by the many varied, exquisitely complex bodily manifestations of the interictal migraine illness. [13, 18] To appreciate that interictal migraine has the potential to produce sophisticated pathologic conditions such as nerve demyelination, one only has to acknowledge the hematologic study by Gilman-Sachs et al, [17] which demonstrated that T8 lymphocytes were reduced in people with migraines compared with normal controls. [17]
In summary, we believe that the end diagnosis in this patient's case, which needed to be challenged by treatment, was migrainous spasm affecting the optic nerve. We considered that the patient's loss of vision could have occurred as a result of ischemia or demyelination, but that ischemia was more basic pathogenetically and so should be subjected to a trial of spinal manipulation treatment before a diagnosis of demyelination became paramount.
Further, there was a relation between her illness and spinal trauma, considering the fall and the zygomatic injury. The latent period between the injury and the onset of the neurologic symptoms for spinal trauma has been noted by Erichsen [22] in 1861 and reiterated by Gorman [23] in 1985. Erichsen [22] notes:The effects of the concussion of the spine that have just been described, whether arising from violence directly or indirectly applied, are occasionally slow in manifesting themselves to full intensity: so slow, indeed, that the patient may not connect their supervention with the injury which he had sustained some length of time previously.
The delay between the spinal injury (the fall down the stairs) and the onset of neurologic symptoms in this patient's case, is a postulated characteristic of what is now known as the cervical syndrome. [24]
Finally, in addition, the transverse processes of her atlas vertebra were tender to palpation, a feature noted in all of the 17 patients of Stephens' et al, [6] whose vision recovered in part after spinal manipulation therapy. We believe that this physical sign indicated that vasospastic irritation of the cerebral vasculature was likely in her case; this contention was significantly supported by the finding of multiple areas of brain hypoperfusion seen on her cerebral SPECT scan.
Did the spinal manipulation therapy play any part in the recovery of vision?
This problem has plagued chiropractic from its origin. The anecdotal accounts of improvement in various nonspinal functions after spinal manipulation raise the question of whether chiropractic spinal manipulation procedures are merely placebos.
This patient's graph of recovery may partially answer this question (Table 1). Note the steps of improvement that occurred at the treatments labeled A, B, and C in which there were significant increases in visual sensitivity immediate to the spinal treatments. Records made at the time of steps A, B, and C demonstrate the progressive return to normal values of the visual acuity and color vision. The improvement in color in vision was measured by the progressive reduction in the number of mistakes that she made during examination of the 17-plate Ishihara charts over the period of treatment. On 3 occasions (A, B, C), marked improvement in vision was recorded immediately after the spine was treated compared with measurements taken immediately before the treatment. Detractors from chiropractic practice might say that such improvements merely indicate that spinal manipulation therapy was a placebo of exceptional efficacy. The instantaneous recovery of vision with spinal manipulation therapy that has been noted in other patients under similar circumstances, the step phenomenon, [7, 8] counteracts this criticism. Although the step phenomenon does not rule out the possibility that spinal manipulation therapy is only an effective placebo, the multiple reported accounts of its occurrence should raise doubts about that contention in the minds of scientists.
The recovery occurred with great rapidity and began immediately after the institution of the spinal treatment and proceeded to complete normality within 7 weeks, after having been present for at least 3 weeks without significant change. We believe that the sudden improvement in vision that was proximate to the onset of spinal treatment is significant evidence that the manipulations did exert a beneficial, physical effect on the process.
Recently, Otte et al [25] at the University of Basel reported an instance in which verified cerebral ischemia that had been noted on SPECT disappeared after massage to the spine. [25] This is further evidence linking spinal manipulation to recovery from cerebral ischemia.
Conclusion
In this account, we report rapid recovery from monocular visual field loss in association with spinal manipulation therapy, adding to previous demonstrations of the same phenomenon. The significance to the chiropractic profession of recovery of monocular visual field loss with spinal manipulation should not be underestimated; it suggests that spinal derangement can be linked to sundry cerebral pathologic conditions, as was postulated by Palmer [26] more than a century ago.
The now well-authenticated recovery of concentric narrowing of the visual fields with spinal manipulation is detracted by the fact that the vision abnormality is generally considered a form of psychoneurosis. In this patient's case, it would be unreasonable to assign a psychologic pathogenesis to her condition in light of the clearly defined electro-physiologic abnormalities and the positive SPECT scan.
If spinal manipulation does influence the function of the nervous system anywhere in the brain, as the improvement in optic nerve function attests, then logically spinal manipulation therapy might have wide application in diseases of the nervous system. [27] Considering that the appropriate control of bodily functions depends on sound cerebration, the ultimate place of spinal manipulation therapy in health care needs urgent definition by further research.
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