In 2020, 27,428 Australians experience stroke for the first time in their lives. This equates to about one stroke every 19 minutes. [1] It is one of the biggest killers of the Australian population and there are hundreds of thousands of individuals living with the ongoing effects of stroke right now. While the majority of strokes are said to be preventable, their incidence is on the rise and is predicted that by 2050, without intervention, new stroke cases will continue to increase by approximately 50,000 annually. [1] While the rumour that chiropractic may cause strokes has been largely put to rest via research that revealed “no evidence for causation for cervical artery dissection”, and research is increasingly revealing that chiropractic may play a positive role in rehabilitation, there is always room for more chiropractic evidence surrounding stroke [2].
When a stroke hits, it attacks up to 1.9 million brain cells per minute, and time is of the essence when it comes to receiving treatment. [1] We know that the most effective treatments are the ones that can be administered as soon as possible, and facilitate the reoxygenation of the affected areas of the brain. But what can we do for those who have received treatment during the acute period of their illness, and are now preparing to re-engage with their life?
Some of the ongoing effects of stroke that may be with individuals for the rest of their lives include impaired speech, limited mobility, muscle weakness or paralysis, and emotional and personality changes. [3] Stroke complications are dependent on the regions of the brain that sustained the most damage, and how extensive the damage was. Sadly, stroke survivor’s chances of sustaining a second stroke at fifteen times that of the larger population. [4] Thus, affected abilities and recovery will be different from patient to patient and requires a personalised approach to care.
While prevention is key in mitigating the national effects of stroke, for survivor’s, effective rehabilitation is vitally important. We know that chiropractic care is a highly personalised approach to care, and we now have evidence that it may assist in stroke recovery along with traditional care. The case report at hand is more confirmation that this may indeed be true.
The Case at Hand
In the recent case report, published in the Asia Pacific Chiropractic Journal, a 72-year-old male presented for care. He had suffered a left middle cerebral artery infarct (the area of damage in a stroke causing issue death due to lack of oxygen in the brain). The cause of the blood clot was believed to be heart atrium thickening due to mitral valve prolapse from rheumatic fever as a child. His heart went into fibrillation which released a clot from the heart atrium wall.
Immediately Post-stroke, he was admitted to hospital and placed on Coumadin before being placed in rehab for approximately four months. His hospital rehab included physical therapy, occupational therapy, and speech therapy. When discharged, he still didn’t have full strength back in his right leg. His right arm and hand were still very weak and unstable.
He still felt like he had room to improve, and this is why he presented for chiropractic care.
Method
While larger studies have focused on intervention immediately post-stroke, this particular patient presented for chiropractic care months after the stroke occurred. He had already benefited from all that hospital-based stroke care offered him and the early-intervention window had long closed. This makes his response to care noteworthy.
Chiropractic care was in addition to his treatment plan and began with a thorough examination and evaluation. This included:
- Traditional orthopedic and neurological tests such as evaluation of range of motion in the spine and all limbs, cranial nerve testing, gait patterns, strength testing.
- A Sacro-Occipital Technique-specific (SOT) exam was also undertaken
- Videos of the patient walking, writing, speaking (etc) were taken. These videos were retaken throughout treatment and also at the 5-month follow up.
- Supportive care continued beyond the 5-month mark for the following 18 years
- CT scans compared from the initial hospital admittance and over the 18 years showed no increase in the size of the infarct.
The patient was also given neurorehabilitation exercises and homework. These included:
- Limb exercises of flexion and extension, starting with the normal limb and proceeding to the injured/paralysed limb work immediately afterward.
- Cross crawl exercises in their standing, or crawling positions, or aided while in a supine position.
- Activities that would target weakness in function to help increase stability. These exercises would be performed simultaneously during SOT chiropractic and cranial treatments as well as to help monitor and guide the patient for their home rehabilitative activities.
SOT care included orthopedic blocking and SOT cranial manipulations in the supine, prone, and sitting position as well as standing via a tilt table. The goals were to strengthen sacroiliac biomechanical and neurological stability in all positions.
Nutritional supplementation was also recommended to stimulate circulation to brain tissue and help support pituitary and adrenal gland function via Chinese herbology and vitamin therapy. Patient was analysed (urine, saliva, blood) for clinical deficiencies of pituitary and adrenal function. Brain neurotransmitter function was also tested (urine) and all deficiencies or imbalances were appropriately treated.
The patient continued chiropractic care biweekly up until the present day with the goal of sustaining his functional health as he enters his ninth decade of life.
Main findings
Encouragingly, following his engagement with chiropractic care, the patient’s recovery progressed to the point that he could return to work. He was fully stable and functional without any limitations. Prior to chiropractic care his condition was determined to have stabilised with no further improvement anticipated. Thus, the return to work marks a significant improvement above expectations.
It is especially significant given his line of work: he was an architect. This particular line of work places demands on many parts of the brain, therefore, his return to work nine months after stroke and five months after chiropractic care is an impressive feat indeed. He eventually retired at 86 years old – some 14 years after the stroke that should have ended his career.
CT scans at 72 y/o and 90 y/o showed no change in size or quality of the infarct. This is noteworthy given the percentage of stroke sufferers who stroke again after the initial infarct.
The case at hand seems to indicate that chiropractic care (in this case combining SOT, cranial care and specific neuro-rehabilitation exercises) may have supported the patients recovery and even helped him to develop motor skill learning – potentially an example of neuroplasticity in action.
Neuroplasticity refers to
- The ability of the brain to rewire itself which is involved in processing function in undamaged areas like speech or body movements(functional)
- The ability of the brain to alter its physical structure in response to learning new information, skills, or habits (structural)
- This can be further subdivided into neuromechanical and neurochemical. The neuromechanical form of treatment used in this case had its focus on biomechanical stimulation by balancing the spine and cranium. Improve structural neuroplasticity may facilitate local functional neuroplasticity.
In his case, motor skill learning with repeated sequences may have facilitated altered cortical activation and neuroplasticity in the brain. We cannot be sure of this, as the case study is retrospective and several therapies contributed to his improvement. However, the fact that improvement was seen after the crucial rehabilitation window immediately post-stroke is significant.
The big point here is that with chiropractic care added to the treatment plan, neuroplasticity was supported and facilitated the full recovery of motor function.
There are limitations with every case study. We can’t rule out whether there was a placebo effect, or whether the patient would have recovered regardless (although doctors advice seemed to indicate low expectations as to the latter). We also don’t know what effect chiropractic care would have for different age groups or stroke types. So, there is definitely more work to be done.
This case report contributes to the body of evidence supporting the effect chiropractic has on neuroplasticity andstroke rehabilitation. This can reach into many areas of care where a supported neuroplasticity would be beneficial. This line of investigation is also a significant contribution regarding the broader healthcare system, as the healthier people are and the further they can recover, the less pressure there is on the health system.
We still have a responsibility to promote healthy lifestyles, encourage patients toward reducing the risk factors (smoking, high blood pressure, diabetes, high blood cholesterol, sedentary lifestyle, etc), and engage in further research to ascertain the mechanisms behind some of the positive outcomes witnessed in this case report, but this is a positive contribution indeed.
References:
The case
- Remeta E, Blum C. Chiropractic cranial treatment model and neuroplasticity in a post stroke 72-year-old male: [Case Report]. Asia-Pac Chiropr J. 2021;2.2. URL www.apcj.net/papers-issue-2-2/#RemataNeuroplasticity
In-text
- Stroke Foundation – Australia. 2020. Available from: https://strokefoundation.org.au/About-Stroke/Learn/facts-and-figures
- Church E, Sieg E, Zalatimo O, Hussain N, Glantz M, Harbaugh R (2016) “Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation,” Penn State Neurosurgery Channel, http://www.cureus.com/articles/4155-systematic-review-and-meta-analysis-of-chiropractic-care-and-cervical-artery-dissection-no-evidence-for-causationretrieved 29 March 2017
- Effects of stroke – Better Health Channel. Vic.gov.au. 2013. Available from: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/effects-of-stroke
- Burn J, Dennis M, Bamford J, Sandercock P, Wade D, Warlow C. Long-term risk of recurrent stroke after a first-ever stroke. The Oxfordshire Community Stroke Project. Stroke. 1994;25(2):333–7.
- Holt, K.; Niazi, I.K.; Nedergaard, R.W.; Duehr, J.; Amjad, I.; Shafique, M.; Anwar, M.N.; Ndetan, H.; Turker, K.S.; Haavik, H. The effects of a single session of chiropractic care on strength, cortical drive, and spinal excitability in stroke patients. Sci. Rep. 2019. 9;2673.
- Christiansen, T.L. Niazi, I.K. Holt, K. Nedergaard, R.W. Duehr, J. Allen, K. Marshall, P. Türker, K.S. Hartvigsen, J. Haavik, H. The effects of a single session of spinal manipulation on strength and cortical drive in athletes. Eur. J. Appl. Physiol. 2018. 118;737–749
