Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China

Take Home Message

  • 36.4% of patients with Covid-19 exhibit neurological symptoms.
  • Chiropractic neurologist should be vigilant when examining patients with headache, dizziness, impaired smell and taste, impaired vision, musculoskeletal pain and nerve pain.
  • When examining patients even without fever, consider Covid-19 as a possible cause of the patients problem.

Abstract

Importance  The outbreak of coronavirus disease 2019 (COVID-19) in Wuhan, China, is serious and has the potential to become an epidemic worldwide. Several studies have described typical clinical manifestations including fever, cough, diarrhea, and fatigue. However, to our knowledge, it has not been reported that patients with COVID-19 had any neurologic manifestations.

Objective  To study the neurologic manifestations of patients with COVID-19.

Design, Setting, and Participants  This is a retrospective, observational case series. Data were collected from January 16, 2020, to February 19, 2020, at 3 designated special care centers for COVID-19 (Main District, West Branch, and Tumor Center) of the Union Hospital of Huazhong University of Science and Technology in Wuhan, China. The study included 214 consecutive hospitalized patients with laboratory-confirmed diagnosis of severe acute respiratory syndrome coronavirus 2 infection.

Main Outcomes and Measures  Clinical data were extracted from electronic medical records, and data of all neurologic symptoms were checked by 2 trained neurologists. Neurologic manifestations fell into 3 categories: central nervous system manifestations (dizziness, headache, impaired consciousness, acute cerebrovascular disease, ataxia, and seizure), peripheral nervous system manifestations (taste impairment, smell impairment, vision impairment, and nerve pain), and skeletal muscular injury manifestations.

Results  Of 214 patients (mean [SD] age, 52.7 [15.5] years; 87 men [40.7%]) with COVID-19, 126 patients (58.9%) had nonsevere infection and 88 patients (41.1%) had severe infection according to their respiratory status. Overall, 78 patients (36.4%) had neurologic manifestations. Compared with patients with nonsevere infection, patients with severe infection were older, had more underlying disorders, especially hypertension, and showed fewer typical symptoms of COVID-19, such as fever and cough. Patients with more severe infection had neurologic manifestations, such as acute cerebrovascular diseases (5 [5.7%] vs 1 [0.8%]), impaired consciousness (13 [14.8%] vs 3 [2.4%]), and skeletal muscle injury (17 [19.3%] vs 6 [4.8%]).

Conclusions and Relevance  Patients with COVID-19 commonly have neurologic manifestations. During the epidemic period of COVID-19, when seeing patients with neurologic manifestations, clinicians should suspect severe acute respiratory syndrome coronavirus 2 infection as a differential diagnosis to avoid delayed diagnosis or misdiagnosis and lose the chance to treat and prevent further transmission.

Citation: Ling Mao; Huijuan Jin; Mengdie Wang; et al; Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol. Published online April 10, 2020. doi:10.1001/jamaneurol.2020.1127

ICCN Supports AAPM DCs

Featured

The ICCN is now offering credentialing support for chiropractors board certified by the American Academy of Pain Management (AAPM) also known by its newer name the Academy of Integrative Pain Management (AIPM). The AAPM/AIPM went bankrupt in January 2019 leaving all members hanging. Some AAPM members had recently paid their fees and provided credentialing CE hours only to see it all evaporate.

The bankruptcy of the AAPM was blamed on declining membership, loss of revenue support from pharmaceutical companies and a reduction in conference revenue. However, it was also was tied to opioid lawsuits that were filed that taxed academy resources.

AAPM

DAAPM MDs and nurses had a opportunity to join pain management organizations in their respective healthcare discipline but the chiropractors did not have a place to go. The Board of the ICCN decided to give our pain management brothers and sisters a hand and have formed a Pain Management (PM) committee functioning under the authority of the ICCN Board. The PM committee will support the pain management chiropractors board certified by the AAPM who wish for us to maintain their credentials.

The ICCN will recognize the DAAPM credential by endorsement. If we are legally blocked from supporting that credential, we are prepared to provide our own credential – the Diplomate of the International College of Pain Management (DICPM). However, since the AAPM is out of business, has no assets and no staff, we don’t believe there will be any reason why we cannot support the DAAPM credential. Similarly, we currently support the defunct American Chiropractic Academy of Neurology (DACAN) credential for some of our neurology diplomates.

There is no intention at present to provide a credential in pain management to non board certified chiropractors, but that remains a possibility. We are going slow at present, and take this step to support our credentialed PM brothers and sisters.

Neurologists boarded by the AAPM should contact the ICCN office if they are interested in maintaining their PM credential. If you know someone board certified by the AAPM, please let them know about this opportunity.

ICCN President Challenges UHC Policy on Headache

Dr. Richard Cole, President of the ICCN challenged United Healthcare’s new policy that prohibits reimbursement for spinal manipulation for the treatment of headache pain.  The challenge was in the form of a letter that Dr. Cole sent today to Mr. Dan Schumacher, president and CEO of United Healthcare.

Dr. Richard Cole

“At a time when everyone is looking for alternative pain treatment to fight the opioid addiction, this is a really stupid move.” stated Dr. Cole.   “This decision hurts United Healthcare insureds and will actually drive up the cost of headache treatment by removing a highly cost effective treatment option.”

Spinal manipulation, mainly performed by chiropractic physicians, has been proven to be  clinically effective and a highly cost effective method of treatment.  This proof is backed by a wide body of research.

Chiropractic neurologists are well versed in headache management and tend to attract as patients the worse headache cases.  “We tend to treat the tough cases,” stated Dr. Cole, referring to his fellow chiropractic neurologists.  “Patients who fail to respond to medication, acupuncture and other chiropractors find their way to our offices.  We are usually able to help them.”

Dr. Cole’s letter highlights the main research articles that proves that chiropractors are great at treating headaches.  Two articles demonstrate the cost effectiveness of chiropractic care.

“Insurance companies have a duty to their insureds,” stated Dr. Cole. “by enacting this policy, UHC is shirking its main responsibility of providing cost effective care to their insureds.”

Dr. Cole anticipates a response to his letter and hopes UHC will heed his suggestions.

Manipulation Does Not Cause Dissection

Manipulation Does Not Cause Dissection

TAKE-HOME MESSAGE

  • Early case reports suggested that cervical manipulation (CM) was the cause of cervical artery dissection (CAD) in patients and their resultant cerebrovascular accidents.
  • Cassidy published a 2008 report in Spine calling this assertion into question and found that the association of dissection following chiropractic physician exposure was similar to exposure to primary care physicians. Since that time, multiple papers have continued call into question whether CM was causative of CAD.
  • Based on the current research, it appears that CM does not place the cervical arteries in a strained position.
  • The current understanding of the literature is that patients with neck and headache pain from dissection seek chiropractic and medical care and eventually are found to have dissection, either by subsequent investigation of from the development of stroke.
  • This new paper concludes that no causal link has been established between CM and CAD and further suggests that this misunderstanding may be the genesis of inappropriate litigation against chiropractic physicians.   

Abstract

Background

Cervical ArteryCase reports and case control studies have suggested an association between chiropractic neck manipulation and cervical artery dissection (CAD), but a causal relationship has not been established. We evaluated the evidence related to this topic by performing a systematic review and meta-analysis of published data on chiropractic manipulation and CAD

Methods

Search terms were entered into standard search engines in a systematic fashion. The articles were reviewed by study authors, graded independently for class of evidence, and combined in a meta-analysis. The total body of evidence was evaluated according to GRADE criteria.

Results

Our search yielded 253 articles. We identified two class II and four class III studies. There were no discrepancies among article ratings (i.e., kappa=1). The meta-analysis revealed a small association between chiropractic care and dissection (OR 1.74, 95% CI 1.26-2.41). The quality of the body of evidence according to GRADE criteria was “very low.”

Conclusions

The quality of the published literature on the relationship between chiropractic manipulation and CAD is very low. Our analysis shows a small association between chiropractic neck manipulation and cervical artery dissection. This relationship may be explained by the high risk of bias and confounding in the available studies, and in particular by the known association of neck pain with CAD and with chiropractic manipulation. There is no convincing evidence to support a causal link between chiropractic manipulation and CAD. Belief in a causal link may have significant negative consequences such as numerous episodes of litigation.

Abstract

Ephraim W. Church1 , Emily P. Sieg1, Omar Zalatimo1, Namath S. Hussain1, Michael Glantz1, Robert E. Harbaugh1. Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus 8(2): e498. doi:10.7759/cureus.498

Dr. Taylor Published in JCM

Dr. Taylor Published in JCM

Our own Dr. David Taylor was published in the March 2017 edition of JCM in a pilot study on concussion.  It is fair to say that some of the best research being done in concussion is from the world of chiropractic medicine and we are thrilled to see Dr. Taylor as a part of the body of literature.

Here is the abstract for you to review.  https://www.ncbi.nlm.nih.gov/pubmed/28228694

David’s article can be viewed in print (from the JCM on your desk if you are a member) or online at http://www.journalchiromed.com/

Well done David.

Underrecognized Sleep Disorders Persist Following mTBI

Underrecognized Sleep Disorders Persist Following mTBI

TAKE-HOME MESSAGE

  • Increased sleep needs are likely part of the recovery process after traumatic brain injury (TBI). However, there is increasing recognition that many patients have long-term sleep–wake disturbances as a residual consequence of TBI.
  • In this comprehensive prospective study, patients with first-ever TBI were followed and a sleep assessment was performed 18 months after the trauma.
  • Findings included:
    • Sleep needs per 24 hours were persistently increased in TBI patients by one hour
    • Chronic excessive daytime sleepiness was present in 67% of TBI patients
  • The study confirms important sleep dysfunction persisting after TBI and suggests that subjective symptom reporting cannot be relied upon when evaluating this issue.

Abstract

Objective: This study is a prospective, controlled clinical and electrophysiologic trial examining the chronic course of posttraumatic sleep–wake disturbances (SWD).

Underrecognized Sleep Disorders Persist Following mTBIMethods: We screened 140 patients with acute, first-ever traumatic brain injury of any severity and included 60 patients for prospective follow-up examinations. Patients with prior brain trauma, other neurologic or systemic disease, drug abuse, or psychiatric comorbidities were excluded. Eighteen months after trauma, we performed detailed sleep assessment in 31 participants. As a control group, we enrolled healthy individuals without prior brain trauma matched for age, sex, and sleep satiation.

Results: In the chronic state after traumatic brain injury, sleep need per 24 hours was persistently increased in trauma patients (8.1 ± 0.5 hours) as compared to healthy controls (7.1 ± 0.7 hours). The prevalence of chronic objective excessive daytime sleepiness was 67% in patients with brain trauma compared to 19% in controls. Patients significantly underestimated excessive daytime sleepiness and sleep need, emphasizing the unreliability of self-assessments on SWD in trauma patients.

Conclusions: This study provides prospective, controlled, and objective evidence for chronic persistence of posttraumatic SWD, which remain underestimated by patients. These results have clinical and medicolegal implications given that SWD can exacerbate other outcomes of traumatic brain injury, impair quality of life, and are associated with public safety hazards.

Citation

Lukas L. Imbach, MD, Fabian Büchele, MD, Philipp O. Valko, MD, Tongzhou Li, Angelina Maric, MSc, John F. Stover, MD, Claudio L. Bassetti, MD, Ladislav Mica, MD, Esther Werth, PhD and Christian R. Baumann, MD.  Sleep–wake disorders persist 18 months after traumatic brain injury but remain Underrecognized. Neurology, May 24, 2016 vol. 86 no. 21 1945-1949

Dr. Ron Fudala Published in Dynamic Chiropractic

Dr. Ron Fudala Published in Dynamic Chiropractic

ICCN Newswire:  ICCN member Dr. Ron Fudala lectured on lumbar spinal stenosis at the Mid South Spine Symposium in Memphis, TN in February 2016.  His lecture was stimulating and greatly appreciated by those in attendance.

Ron Fudala 2

Dr. Ron Fudala

Since Dr. Fudala had done the research to prepare for his lectures, he decided to write up the info for publication in Dynamic Chiropractic (DC).  DC is a trade journal with a distribution to over 66,000 chiropractic professionals. The article was so good that it was featured on the front cover of DC in the June 1, 2016 edition.  The online version will be available in a few weeks.

We are very happy for Ron and hope his effort will encourage other members of the College to publish.

Well done Dr. Fudala!

Spinal Manipulation Changes Brain Processing

Spinal Manipulation Changes Brain Processing

TAKE-HOME Message

  • For the past 15 years, researchers have observed changes in brain processing following spinal manipulation (SM).
  • This article demonstrates that changes occur in the prefrontal cortex following cervical SM over areas of segmental dysfunction.
  • The prefrontal cortex plays a vital role in sensory motor integration and higher executive function.
  • This finding may answer why patients experience generalized pain improvement following SM and further supports the conclusion that SM has an effect on the central nerve system.

Abstract

Objectives. Studies have shown decreases in N30 somatosensory evoked potential (SEP) peak amplitudes following spinal manipulation (SM) of dysfunctional segments in subclinical pain (SCP) populations. This study sought to verify these findings and to investigate underlying brain sources that may be responsible for such changes.

prefrontal cortex

Methods. Nineteen SCP volunteers attended two experimental sessions, SM and control in random order. SEPs from 62-channel EEG cap were recorded following median nerve stimulation (1000 stimuli at 2.3 Hz) before and after either intervention. Peak-to-peak amplitude and latency analysis was completed for different SEPs peak. Dipolar models of underlying brain sources were built by using the brain electrical source analysis. Two-way repeated measures ANOVA was used to assessed differences in N30 amplitudes, dipole locations, and dipole strengths.

Results. SM decreased the N30 amplitude by 16.9 ± 31.3% (P = 0.02), while no differences were seen following the control intervention (P = 0.4). Brain source modeling revealed a 4-source model but only the prefrontal source showed reduced activity by 20.2 ± 12.2% (P = 0.03) following SM.

Conclusion. A single session of spinal manipulation of dysfunctional segments in subclinical pain patients alters somatosensory processing at the cortical level, particularly within the prefrontal cortex.

Citation

Lelic D, Niazi IK, Holt K, Jochumsen M, Dremstrup K, Yielder P, Murphy B, Drewes AM, Haavik H. Manipulation of Dysfunctional Spinal Joints Affects Sensorimotor Integration in the Prefrontal Cortex: A Brain Source Localization Study. Neural Plast. 2016.

Migraineurs Suffer Restless Legs

Migraineurs Suffer Restless Legs

TAKE-HOME MESSAGE

  • Poor sleep is a confounder in migraine recovery and tends to increase migraine incidence.
  • Restless leg syndrome (RLS) impairs high quality sleep.
  • In this large study, migraine patients were found to have a higher prevalence of RLS than normal controls and their RLS symptoms were much worse.
  • Efforts to control migraine that also address RLS may lead to better outcomes.

Abstract

BACKGROUND AND PURPOSE:

Our aim was to study not only the prevalence but more importantly the severity and the correlation between sleep quality and restless legs syndrome (RLS) in a large population of well-defined migraine patients as poor sleep presumably triggers migraine attacks.

cervicogenic headacheMETHODS:

In a large cross-sectional and observational study, data on migraine and RLS were collected from 2385 migraine patients (according to the International Classification of Headache Disorders ICHD-IIIb) and 332 non-headache controls. RLS severity (International RLS Study Group severity scale) and sleep quality (Pittsburgh Sleep Quality Index) were assessed. Risk factors for RLS and RLS severity were calculated using multivariable-adjusted regression models.

RESULTS:

Restless legs syndrome prevalence in migraine was higher than in controls (16.9% vs. 8.7%; multivariable-adjusted odds ratio 1.83; 95% confidence interval 1.18-2.86; P = 0.008) and more severe (adjusted severity score 14.5 ± 0.5 vs. 12.0 ± 1.1; P = 0.036). Poor sleepers were overrepresented amongst migraineurs (50.1% vs. 25.6%; P < 0.001). Poorer sleep quality was independently associated with RLS occurrence (odds ratio 1.08; P < 0.001) and RLS severity (P < 0.001) in migraine patients.

CONCLUSION:

Restless legs syndrome is not only twice as prevalent but also more severe in migraine patients, and associated with decreased sleep quality.

Citation

van Oosterhout WP, van Someren EJ, Louter MA, Schoonman GG, Lammers GJ, Rijsman RM, Ferrari MD, Terwindt GM. Restless legs syndrome in migraine patients: prevalence and severity. Eur J Neurol. 2016 Mar 21. doi: 10.1111/ene.12993

Coconut Oil in Prevention of Alzheimer’s Disease

Coconut Oil in Prevention of Alzheimer’s Disease

TAKE-HOME MESSAGE

  • Alzheimer’s disease (AD) is a complex  disease  that  progresses  over  many  years,  such  as diabetes,  heart  disease  and  other  chronic
  • A number of factors may increase or decrease an individual’s chances of developing the AD, including age, genetics, environment, lifestyle and metabolic diseases.
  • Coconut may be beneficial in the treatment of obesity, dyslipidemia, elevated LDL, insulin resistance and hypertension – these are the risk factors for CVD, type 2 diabetes and also for AD

Abstract

Coconut Oil in Prevention of Alzheimer’s DiseaseCoconut, Cocos nucifera L., is a tree that is cultivated to provide a large number of products, although it is mainly grown for its nutritional and medicinal values. Coconut oil, derived from the coconut fruit, has been recognised historically as containing high levels of saturated fat; however, closer scrutiny suggests that coconut should be regarded more favourably. Unlike most other dietary fats that are high in long-chain fatty acids, coconut oil comprises medium-chain fatty acids (MCFA). MCFA are unique in that they are easily absorbed and metabolised by the liver, and can be converted to ketones. Ketone bodies are an important alternative energy source in the brain, and may be beneficial to people developing or already with memory impairment, as in Alzheimer’s disease (AD). Coconut is classified as a highly  nutritious  ‘functional  food’.  It  is  rich  in  dietary  fibre,  vitamins  and  minerals;  however,  notably,  evidence  is  mounting  to support the concept that coconut may be beneficial in the treatment of obesity, dyslipidaemia, elevated LDL, insulin resistance and hypertension – these are the risk factors for CVD and type 2 diabetes, and also for AD. In addition, phenolic compounds and hormones (cytokinins) found in coconut may assist in preventing the aggregation of amyloid-b peptide, potentially inhibiting a key step in the pathogenesis of AD. The purpose of the present review was to explore the literature related to coconut, outlining the known mechanistic physiology, and to discuss the potential role of coconut supplementation as a therapeutic option in the prevention and management of AD.

Citation

WM Fernando, Ian Martins, KG Gooze, Charles Brennan, Vijay Jayasena, RN Martins.The role of dietary coconut for the prevention and treatment of Alzheimer’s disease: Potential mechanisms of action. The British journal of nutrition (Impact Factor: 3.45). 05/2015; Epub ahead of print(01):1-14. DOI: 10.1017/S0007114515001452