Chiropractic & Manual Therapies - Unravelling functional … · 2017. 8. 24. · Chiropractic...

REVIEW Open Access

Unravelling functional neurology: a scopingreview of theories and clinical applicationsin a context of chiropractic manual therapyAnne-Laure Meyer1,2,3* , Amanda Meyer4, Sarah Etherington5 and Charlotte Leboeuf-Yde1,2,3

Abstract

Background: Functional Neurology (FN), a seemingly attractive treatment approach used by some chiropractors,proposes to have an effect on a multitude of conditions but some of its concepts are controversial.

Objectives and design: A scoping review was performed to describe, in the context of chiropractic manualtherapy, 1) the FN theories, and 2) its clinical applications (i.e. its indications, examination procedures, treatmentmodalities, treatment plans, and clinical outcomes) using four sources: i) one key textbook, ii) the scientific peer-reviewed literature, iii) websites from chiropractors using FN, and iv) semi-structured interviews of chiropractorsusing FN.

Methods: The scientific literature was searched in PubMed, PsycINFO, and SPORTDiscus, completed by a handsearch in the journal Functional Neurology, Rehabilitation and Ergonomics (November 2016 and March 2017,respectively). The only textbook on the topic we found was included and articles were chosen if they had anelement of manual therapy. There was no restriction for study design but discussion papers were excluded.Websites were found in Google using the search term “Functional Neurology”. Chiropractors, known to use FN,were invited based on their geographical location. Theories were mainly uncovered in the textbook as were allaspects of the clinical applications except treatment plans. The other three sources were used for the five aspectsof clinical applications. Results were summarized and reported extensively in tables.

Results: Eleven articles were included, five websites scrutinized, and four semi-structured interviews performed. FNis based on the belief that reversible lesions in the nervous system are the cause of a multitude of conditions andthat specific clusters of neurons can be positively affected by manipulative therapy, but also by many other stimuli.Diagnostic procedures include both conventional and unusual tests, with an interpretation specific to FN. Initialtreatment is intense and clinical outcomes reported as positive.

Conclusion: FN gives the impression to be a complex alternative to the old variant of the chiropractic subluxationmodel, in which the vertebral subluxation is replaced by “physiological lesions” of the brain, and the treatment,spinal adjustments, are complemented by various neurological stimuli. Both models purport to treat not thesymptoms but the cause. We conclude there is a need for more scientific documentation on the validity of FN.

Keywords: Functional neurology, Chiropractic, Spinal manipulation, Scoping review

* Correspondence: [email protected]é, Innovation et Activités Motrices et Sportives, UniversitéParis-Saclay, 91405 Orsay Cedex, France2Complexité, Innovation et Activités Motrices et Sportives, Universitéd’Orléans, 45067 Orléans, FranceFull list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Meyer et al. Chiropractic & Manual Therapies (2017) 25:19 DOI 10.1186/s12998-017-0151-1

http://crossmark.crossref.org/dialog/?doi=10.1186/s12998-017-0151-1&domain=pdf

http://orcid.org/0000-0003-0840-4176

mailto:[email protected]

http://creativecommons.org/licenses/by/4.0/

http://creativecommons.org/publicdomain/zero/1.0/

BackgroundChiropractic is a health profession that is legally rec-ognized in several countries under a regulatoryframework to deal with neuromusculoskeletal condi-tions [1, 2]. Spinal manipulation is one of the keyaspects of chiropractic treatment, often combinedwith advice on life-style, physical activities, specificexercises, and ergonomics [3, 4]. Clinical experienceshows that manipulation of joints can have a pain-reducing effect, and this has also been confirmed inpurely experimental studies [5], providing at leastsome evidence for the approach.However, some chiropractors propose therapeutic solu-

tions outside the recognized scope of chiropractic practice.For as long as chiropractors have existed, some practi-tioners have also treated non-musculoskeletal conditionssuch as asthma, colic in children, and dysmenorrhea, al-though this part of clinical practice has been lesscommon than the treatment for musculoskeletal con-ditions [4, 6, 7]. The rationale for such treatment isthat spinal manipulation can have an effect also onthe autonomic nervous system [8].There are several currents within chiropractic that pur-

port to successfully treat various non-musculoskeletalconditions. One such approach is Functional Neurology(FN), which, at first glance has as its rationale the conceptthat disturbances of the physiology in the nervous system,especially those in the brain, can have many detrimentaleffects on the body. These disturbances are proposed tobe often reversible or at least to have the potential forimprovement. The list of conditions proposed to besuccessfully treated by FN is extensive, the diagnosticprocedures complex and the therapeutic approach oftenmulti-facetted.When attempting to review the origins of FN, the

earliest reference to FN found in the scientific litera-ture is an article from 1997 by a chiropractor, alsopresented as the founder of FN, FR Carrick [9]. Inthis article, he stated that spinal manipulation canalter the size of the physiological blind spot of theeye in certain cases, a phenomenon that he claimedwas a proof that spinal manipulation has an effect onbrain function. In that article, there is also a lengthypresentation of the presumed causative link betweenspinal manipulation and brain function. This workelicited several responses to the editor, with manyquestions and criticisms [10–16], but also generatedpositive comments [17–19].Despite the criticism that FN has encountered over

the last 20 years, both inside and outside the profession[10, 14–16, 20, 21], FN appears to have become anattractive discipline for many chiropractors [3, 22],promoted by some as a discipline at the cutting edge ofscience [22, 23]. For example, a recent survey of the

Australian chiropractic workforce reports that 13.3% ofthe respondents use FN [3]. Other health practitioners(e.g. medical doctors, physiotherapists) also seem to beinterested in this new discipline, having access to FNcourses [24].The main criticism leveled at FN concerns the lack

of scientific basis [10, 14–16, 20, 21]. In addition,published information seems to be sparse and, for theuninitiated, the subject is complex. An overview ofFN would therefore be of value to chiropractors, stu-dents and chiropractic educators, with an interest inFN to: 1) provide a basic description of its conceptsand their clinical applications and 2) to present thescientific evidence underlying these basic concepts.In this scoping review we will focus on the first point

by attempting to provide a basic description of FN con-cepts and their clinical applications, in the context ofchiropractic manual therapy. Our six research objectiveswere to describe: 1) the theories that constitute the basisof FN, 2) the conditions that functional neurologiststreat, 3) the diagnostic procedures, 4) the therapeuticmodalities, 5) the course of care, and 6) the clinical out-comes obtained or expected with this approach.The field of FN is large, composed of different sub-

specialties [25], some of which have developed some-what different directions than the original one. Thework of G Leisman and R Melillo in the area of FNapplied to childhood neurodevelopmental disorders isan example of such sub-specialties [26]. Nevertheless,it appears to be practiced primarily by chiropractors.In fact, FN is also known as “Chiropractic Neur-ology”. For these reasons, we have limited our reviewof the literature to the fundamental concepts of FNand/or with FN as a supplement to “traditional”chiropractic, i.e. which would typically include the useof manual therapy.

MethodDesign and brief description of studyIn order to obtain information on our six researchobjectives, we performed a scoping review using threewritten sources and one semi-structured interview, asbriefly described below. Scoping reviews are oftenused to obtain a preliminary understanding of apoorly understood topic, have a non-rigid but system-atic approach, allow for multiple methods, and do notnecessitate a critical element [27, 28]. Although thereare currently no strict methodological rules for con-ducting scoping reviews, we endeavored to follow thesix steps of the Arksey and O’Malley framework [27].Initially, the first author read the only comprehen-

sive textbook on the concepts of FN that was found[29]. We used this source as the basis or startingpoint for our future work in order to gain an

Meyer et al. Chiropractic & Manual Therapies (2017) 25:19 of 23

understanding of the FN theoretical background.Thereafter, we consulted the scientific literature tosee what information was available and searched theinternet to obtain an idea of how practitioners, whostate that they practice FN, describe their activities.Also, we interviewed a number of practitioners whouse FN in their daily practice, making it possible toask clarifying questions. To allow for ease of reading,several aspects of the various methods have been de-scribed in Additional files 1, 2 and 3.

Search strategy for informationWritten information

Textbook We had access to a textbook [29] that servedas our first source of information. This book,recommended by organizations such as the AmericanChiropractic Neurology Board and the FunctionalNeurology Society, is authored by a chiropractor, RWBeck, with the foreword written by FR Carrick.

Scientific literature It was difficult to find scientific lit-erature on FN using the usual search strategies, for whichreason alternative methods were employed. These havebeen described in Additional file 1. Briefly, a search byname of author on PubMed, PsycINFO, andSPORTDiscus was conducted. This was complemented bycontacting by email a number of practitioners and/or re-searchers known to be involved in FN to ask them fortheir updated publication list. Following this step, wesearched for articles in the journal Functional Neurology,Rehabilitation, and Ergonomics, which has FN among itsaims and scope. This journal was recommended by one ofthe researchers involved in FN.

Websites The internet was searched via Google using thekeyword “Functional Neurology” in order to capture anumber of professional websites of chiropractors presentingthemselves as functional neurologists.

InterviewsThrough our network of contacts, we identified European-based chiropractors who used FN in their daily practiceand who were likely to participate in a future interview. Aconvenience sample consisting of five of those, all living inFrance, where also the chief investigator was located, werefinally invited. The four who replied were interviewed.These four chiropractors were contacted by email, providedwith information about the survey and asked to provideinformed consent.

Inclusion and exclusion criteria of articles and websitesScientific articlesArticles were included if they described studies on aFN therapeutic approach to one or more specificcondition(s) or if they described studies on a FNtherapeutic approach on healthy or non-healthy sub-jects with positive clinical sign(s). Also, the articleshad to include the use of manual therapy. Articleswritten by functional neurologists dealing with issuessuch as medication use or modified states of con-sciousness were not included. Discussion papers, ab-stracts, poster presentations, conference papers, andletters to the editors were excluded.

WebsitesWebsites of chiropractors describing themselves asfunctional neurologists were included if they clearlymentioned that they were Diplomates of the Ameri-can Chiropractic Neurology Board (DACNB), as thisseems to indicate that the person has obtained a cer-tain level of proficiency on this topic. There were norestriction criteria regarding their nationality or theirnumber of years of experience in FN. However, thesearch was restricted to websites written in English.

Inclusion criteria for the interviewOur inclusion criteria were that the chiropractors wereDACNB or, at least, in active training. They also had tobe willing to clarify the basic concepts of FN and todescribe the applications of FN in their daily practiceduring a semi-structured interview. We selected the fourFrench chiropractors for geographical reasons, as theresearch team was located in Paris.

Collection of relevant informationWritten information

Textbook The chapters of interest of the textbook wereselected based on its table of contents. The whole bookwas read prior to this in order to attempt to gain a goodunderstanding of the topic.

Scientific articles The first investigator searched the da-tabases and publication lists forwarded by the authorson request (see Additional file 1) and selected the poten-tially relevant full texts from titles and abstracts. As theauthors were not familiar with FN, the selection of po-tentially relevant full texts was generous. ALM and CLYindependently made the search in the journal FunctionalNeurology, Rehabilitation, and Ergonomics and selectedthe potential relevant full texts from titles and abstracts.All full texts were independently assessed in relation tothe inclusion and exclusion criteria. In addition, the first


investigator searched reference lists for relevant articlesfrom the databases and the journal.

Websites Once the first author had found the men-tion that the chiropractors were DACNB, the corre-sponding websites were screened (except for theirblog section) sequentially, in the order by which theyappeared in a Google search conducted in September2016. This was performed by searching for terms inrelation to FN and our research objectives. When nonew information was found for one topic, search wasstopped for this topic but continued for the othersuntil no new information was found. Texts weredocumented with screenshots.

InterviewsThere are no strict rules for how to conduct or interpretinterviews in scoping reviews. Relevant information wascollected through a semi-structured interview designedby the first author and another PhD student. It wastested on one of the chiropractors, after which some im-provements were made, mainly to the wording of thequestions. The interview contained twenty-four ques-tions, eleven were used in this review and the others willbe used elsewhere (see Additional file 1). Clarifyingquestions were added as needed during the interviews.The interview instrument was constructed based on ourspecific questions related to FN and thus had not beenpreviously used, tested or validated.

Ethical considerationsAccording to French law [30, 31], no ethics permis-sion is required when interviewing consenting adultsin a non-interventional context. However, the writtenconsent of each interviewed chiropractor concerningthe recording of the interview and its use as researchmaterial was obtained. Furthermore, no personal in-formation was collected and all results were reportedanonymously. The transcribed versions were providedto the interviewees for comments.

Extraction of informationWritten informationThe information from the textbook by RW Beck [29] wasretrieved by the first author from specific chapters almostentirely dedicated to our topics of interest. Chapters 1, 4and 18 were used to extract the theories, which were com-plemented by information from chapters 3, 9, 19 and 20.Chapter 19 and, to a lesser extent chapter 20, were used toextract the indications. Chapter 4 and, to a lesser extentchapter 19, were used for examination procedures. Chapter20 and, to a lesser extent chapter 19, were used for treat-ment modalities. The information related to the outcomesof treatment were extracted from chapter 19. Despite a

chapter dedicated to clinical cases, there was no detailed in-formation on treatment plans. References in this text (sec-tion “Neurophysiological theories”) refer directly to thesechapters and relevant pages to assist the reader who mightwant to compare our information with that of the textbook.Descriptive checklists were created to collect

systematic information from the scientific articles andfrom the websites, in relation to the researchobjectives (available in Additional file 2a and b). Theformat and contents were somewhat different,depending on the data source. For example, thewebsites were expected to provide information onexpected outcome rather than reported outcomewhereas the reverse was expected from the scientificliterature. The search for relevant information in thescientific literature was done independently by twoauthors (ALM and CLY). The descriptive checklist forthe websites was completed by the first author whoblindly performed this procedure twice for eachwebsite.

InterviewsEach interview was taped and transcribed in a narrativeform and in a tabulated form to better visualize the infor-mation (tabulated form is available in Additional file 2c).They were conducted by the first author and another PhDstudent, one of whom was responsible for the narrativetranscript of two of the interviews and the other for thetranscript of the remaining two. After agreement betweenthe two interviewers on the content of each narrativetranscription (tapes were available in case of disagree-ment), the transcript was sent to the interviewed chiro-practor to obtain his/her agreement on its content.Absence of feedback was interpreted as an acceptance ofthe text (the interviewees were informed of this). There-after, based on each narrative transcript, the two inter-viewers independently extracted and collated informationby themes in a table, which was created in relation to theresearch objectives of the review. The content of their re-spective tabulated transcript was compared for agreement(final table is available in Additional file 2c).

Data analysis and synthesisInitially, the first author identified which of the foursources had dealt with the various research objectives(see Table 1). Thereafter, we concentrated on one itemat a time, collecting the relevant information either in atable or as narrative text. The multiple methods aredetailed in Additional file 3. A narrative synthesis wasdone for each research objective, based mainly on thetabulated overview of the information.


ResultsGeneral informationTextbookThe textbook provided information for five of our objec-tives (theories, indications, diagnostic procedures, treat-ment modalities and short-term outcomes). As shown in

Table 1, it was the only source that could clearly be usedto describe the theories of FN. We selected some of themajor concepts of FN, which we have attempted todescribe in the text below (“Detailed results”) in orderto capture the theoretical framework of FN, as pre-sented in this book.

Scientific articlesThe selection process is summarized in Fig. 1. Threecase reports, one controlled trial, and one randomizedcontrolled trial were found in our areas of inquiry in theselected databases. Six case reports were found throughhand searching, including three in the journal Func-tional Neurology, Rehabilitation, and Ergonomics. Listsof publications obtained from known FN researchersand/or practitioners did not provide any additionalrelevant material. Nevertheless, the scientific literatureprovided information on diagnostic procedures, treat-ment modalities, treatment plans and clinical outcomesfor various conditions. The controlled trial and therandomized controlled trial provided information onlyon diagnostic procedures and treatment modalities (seeAdditional file 3 for details). Moreover, two case studies

Table 1 Sources used in a scoping review on FunctionalNeurology to obtain information on six research objectives

Researchobjectives

Book(n = 1)

Scientific articles Websites(n = 5)

Interviews(n = 4)Randomized

controlled trialand controlledtrial (n = 2)

Casereports(n = 9)

Theories 1

Indications 1 9 5 4

Diagnosticprocedures

1 2 9 4 4

Therapeuticmodalities

1 2 9 5 4

Treatment plans 7 3 3

Clinicaloutcomes

1 9 5 4

Fig. 1 Description of the search for literature in a scoping review of Functional Neurology in a chiropractic context


did not report the treatment plan and, another casestudy did not report the brain areas targeted by thetreatment. There was no disagreement between the twoauthors who independently collected the informationfrom the scientific literature.

WebsitesThe search for information on the internet was saturatedfairly quickly. We did not find any new information afterreading the full content of the first five websites onGoogle. These all belonged to chiropractors practicingin the United States. The internet search providedparticular information on the indications, diagnosticprocedures, and treatment plans. Only one website pro-vided information on treatment in relation to a specific-ally targeted area in the brain. Furthermore, the websitesgenerally gave only general information about the ex-pected outcomes following FN treatment. One websitedid not provide information about the diagnostic testsused by the chiropractors and two websites did notprovide relevant information related to treatment plansexcept to say that they were individualized.

InterviewsThe first interview lacked somewhat in clarity and thusserved as a pilot interview. However, the following threeinterviews provided clear and extensive answers to ourquestions. All four interviews could be used in this studyas they provided fairly homogeneous information.Therefore it was deemed unnecessary to collect datafrom additional practitioners. The transcripts sent to theparticipants needed only few minor revisions on theirpart; three of them gave us feedback. The interviews in-formed us mainly about indications, diagnostic tests, andtreatment modalities. We were able to collect less infor-mation related to treatment plans (3/4 informants) andexpected outcomes, for which only general informationwas provided. The tabulated transcriptions (available inAdditional file 2c) made by the first author and the otherPhD student revealed no obvious difference in theircontent.In the section below, the theories of FN are reported

first in relation to the neurophysiology, thereafter interms of treatment implementations. This work aims toprovide a basic description of these theories and doesnot pretend to cover them in depth. Although weattempted to report these theories of FN faithfully, thetext below represents our understanding of FN derivedfrom this study, which does not necessarily depict theofficial view of FN. Finally, the five different aspects ofthe clinical applications of FN are discussed, based onour four sources of information.

Detailed resultsNeurophysiological theories: (information from textbook)The practice of FN includes the detection, evaluationand conservative treatment of functional aberrations ofthe neuraxis, especially of the brain [32]. Within FN,neurological aberrations are named “physiological le-sions” or “functional lesions”. They are stated to be thecause of a large number of unlabeled, poorly labeled ormisunderstood symptoms in the medical field (e.g. neu-rodevelopmental disorders, movement disorders) [33].By the same reasoning, FN proposes explanations alsofor musculoskeletal disorders.These “physiological lesions” are described as revers-

ible due to the neuroplastic properties of the nervoussystem and may affect any parts of the nervous system.“Physiological lesions” are different from “ablative le-sions” that are defined as only potentially and veryslowly reversible, as they have resulted from death ofneuronal tissues (e.g. post-stroke). These two types of le-sions would lead to very similar symptoms and could co-exist [34].The textbook information on the neurophysiological

rationale of FN can be broadly classified under threeheadings:

1. Cellular level,2. Related neurological pathways,3. The FN concept of “hemisphericity”.

For each of these, we found:

1. A description and interpretation of coreneurophysiological and/or neuroanatomicalinformation,

2. A description of consequences when theneurophysiology goes wrong (possible disorders andsymptoms), which, may or may not represent thegenerally acceptable view in the scientific world,

3. Methods to test the integrity of various groups ofneurons, most often indirectly, especially thoselocated in the brain.

Some of the major components of the theoreticalframework of FN will be reported following the aboveclassification.

Cellular level: (information from textbook)At a cellular level, the central tenet of FN is that symp-toms result from a dysfunctional “central integrativestate” (CIS) of one or several functional units of neuronswithin the nervous system (e.g. group of neurons of theright dentate nucleus). In other words, a “physiologicallesion” corresponds to a group of neurons with a dys-functional CIS. More precisely, such lesions would occur


following disturbances of neuronal physiology that inturn would affect communication within the central ner-vous system, leading to hyper and/or hypo-functionalarea(s) within certain areas of the brain. In response tothis altered function, the concerned area(s) would sendan abnormal quantity of outputs, i.e. too many or notenough, causing diverse motor, sensory, visceral orcognitive symptoms such as the ones listed in Table 2and discussed later in this text [34]. In general, a“physiological lesion” is said to affect only one side of abrain structure (e.g. one side of the cerebellum or onecortical hemisphere), leading to asymmetries of outputs

(aspect discussed later in section “The FN concept of“hemisphericity””).The CIS of a functional group of neurons appears to

be considered as the “state of health” of those neurons.This state is said to be determined by three parametersthat allow the survival and function of neurons: i) oxy-gen supply, ii) nutritional supply, and iii) stimulation, i.e.synaptic activation [34]. These three parameters have tobe in an adequate amount to ensure a “healthy” CIS.Many factors, mainly external, would negatively modifythe state of health of a functional group of neurons. Animmobilization in a cast, an acute anoxic episode after

Table 2 Indications for treatment using Functional Neurology according to four sources in a scoping review

Groups and/or subgroups of conditions Source of information

Book Articles Websites Interviews

Neuromusculoskeletaldisorders

Headaches NM NM X X

Others Low back pain withradiculopathyPeripheralneuropathies

Low back painNeck painAnkle pain

Low back painRadiculopathiesNeck painPeripheral neuropathiesSpinal stenosisUpper/lower extremityconditions

Low back painRadiculopathiesNeck pain

Traumatic brain injuries (symptom(s) relatedto such injuries)

X X X X

Neurological diseasesor disorders

Neurodegenerativedisease

Parkinson’s disease Parkinson’s disease Parkinson’s diseaseMultiple sclerosisAlzheimer’s disease

Parkinson’s diseaseMultiple sclerosis

Movement disorders Dystonias Cervical dystonia DystoniaTremor disorders

Dystonia

Post-strokesymptoms

X NM X X

Others MigrainesComplex regionalpain syndromeDysautonomia

MigrainesComplex regional painsyndromeLandau Kleffnersyndrome

MigrainesSeizure disordersSpinal cord lesionsFibromyalgiaRestless legs

Migraines

Psychiatric disorders Neurodevelopmentaldisorders

ADHD ADHD ADD/ADHDDyslexiaAutism

ADD/ADHD« dys » disorders,including dyslexia

Mood disorders Anxiety Depression NMa Anxiety disordersDepression

NM

Others OCD OCDTourette’s syndrome

OCDPTSD

PTSD

Various neurological and non-neurologicalsymptoms

TinnitusDeafnessMuscle spasmsPost manipulativetherapy symptoms

Paresthesia Balance disordersVertigoNumbnessSleeping difficulties

Balance disordersVertigo

Others Oral dysplasia Primary nocturnalenuresis

Physical, cognitive, academicand/or creativity enhancementLyme disease

NM

NM Condition(s) not mentionedX Condition(s) mentioned without specific example(s)ADD/ADHD Attention deficit disorder / attention deficit and hyperactivity disorderOCD Obsessive compulsive disorderPTSD Post-traumatic stress disorderaOne reviewed article deals with mood disorders in a context of multiple symptoms related to traumatic brain injury


attempting suicide, or an inappropriately performedspinal manipulation are examples of such proposedexternal factors [35, 36].Evaluating the CIS of the different units of neurons of

the central nervous system, especially those of the brain,is the central aim of the clinical examination within FN.As it cannot be performed directly, it is mainly evaluatedthrough a detailed analysis of the responses of differenteffectors tested during the patient’s examination. Theseresponses are proposed to be, to a large extent, deter-mined by the CIS of the presynaptic neuronal pool(s)projecting to the neurons ending at the tested effector.A major sign of a dysfunctional CIS is described as a“fatigability” of the tested neurons, which means that theresponse to a continued or repeated stimulus cannot besustained as it should [33]. An effector has to be testedbilaterally in order to find the faulty side, because of theconcept of asymmetrical function of two parts of a brainstructure. In addition, as a “physiological lesion” canresult in symptoms qualified as “subclinical”, functionalneurologists have to attempt to detect “minor” asymmet-ries. This concept, in FN that “minor” asymmetries areclinically relevant, makes up one of the big differencesbetween FN and classical neurology [33].

Related neurological pathways: (information from textbook)To assess the CIS of one or several neuronal units andto elaborate an individualized treatment plan, solidknowledge in neuroanatomy is needed, as a “physio-logical lesion” could occur at any point along a neuralpathway. Some pathways are identified as being ofparticular importance to a FN assessment, such as thecortico-reticulo-spinal tract that is described as begin-ning at a cortical hemisphere, passing mainly through theipsilateral pontomedullary reticular formation (PMRF)and terminating, for most of the fibers, in the ipsilateralspinal cord [34]. We will use this particular pathway as anexample to illustrate FN reasoning.For functional neurologists, the importance of this

pathway would relate to its following roles:

– Ipsilateral facilitation of muscle tone,– Ipsilateral inhibition of anterior muscles above the

spinal level of T6 and of posterior muscles below T6,– Ipsilateral inhibition of pain sensation,– Ipsilateral inhibition of sympathetic nervous system.

These functions are described as the result of the nor-mal activation of the PMRF by the ipsilateral cerebralcortex.In fact, this is a key pathway in FN, said to become

disturbed if a “physiological lesion” on one side of thebrain, in FN named “hemisphericity”, decreases thePMRF outputs. This decrease is described to be due to

the decrease of the cortical outputs to the PMRF. Clinic-ally, this would lead to:

– A global ipsilateral decrease of muscle tone,– A “flexor angulation” of the ipsilateral upper limb

and an “extensor angulation” of the ipsilateral lowerlimb, a posture known in FN as “pyramidal paresis”,

– One or more ipsilateral pain syndrome(s),– An ipsilateral increase of sympathetic activity

leading to a number of autonomic signs (e.g.increase of blood pressure, increased sweating, largepupil size) [34].

Combined, these clinical signs indicate that the patientwould suffer from a “hemisphericity”, further discussedbelow.

The FN concept of “hemisphericity”: (information fromtextbook)The concept of “hemisphericity” (also termed “corticallateralization” or “brain asymmetry”) appears to be spe-cific to FN, referring to a cerebral hemisphere sufferingfrom a dysfunctional CIS. Thus, this is a “physiologicallesion” that does not refer to a recognized pathologicallesion such as a brain lesion caused by a stroke. Usually,it describes the side where the cortical activity is statedto be decreased. Within the FN framework, this conceptrests on the assumptions that the two hemispheres: i)control different body functions, and ii) can function attwo different levels of activation without there being anobvious pathology [34].Widespread consequences are thought to result from

this one-sided “physiological lesion”, including: cognitive(e.g. attention deficit disorder / attention deficit andhyperactivity disorder), psychiatric (e.g. depression),motor (e.g. muscle weakness), immune (e.g. systematiclupus erythematosus), and autonomic manifestations[32] (e.g. asymmetry of blood pressure). It is alsoconsidered that “hemisphericity” may lead to spinalmanifestations and conditions such as: “subluxation”,modifications of the spinal curves, spondylosis, musclestiffness, and muscles weakness of the intrinsic spinalmuscles [34]. Such diagnoses, symptoms, or findingsorientate the functional neurologist to the side of thedysfunctional hemisphere.In addition to these clinical manifestations and to

signs evoked above in relation to disturbance of thecontrol of the PMRF outputs, other signs could besearched for and additional tests performed to diagnosea “hemisphericity”. Among them there are:

– Eye movement dysfunction(s),– Contralateral cerebellar sign(s),


– Contralateral enlargement of the physiological blindspot of the eye, an, apparently, original concept ofFN (see [9] or [33] for details about measurement ofthe physiological blind spot).

In fact, any neurological dysfunction that can be re-lated somehow to aberrant cortical outputs is consideredpotentially relevant [37].The concept of the physiological blind spot deserves

some explanation because it belongs to the history ofFN. In classical textbooks, the blind spot (optic disc) isdescribed as the area of the retina devoid of photorecep-tors, i.e. the area where converging retinal ganglion cellsexit the eyeball to form the optic nerve. The perimeterof the blind spot can be mapped out during the examin-ation of the visual field to detect some eye pathologiesand to follow their progress [38]. However, FR Carrick[9] presents the claim that, in the absence of an eyepathology, the size of the blind spot can be altered in re-sponse to the CIS of the visual cortex and, by extension,the CIS of one hemisphere, which in turn would dependto a large extent of the afferent inputs it receives fromthe thalamus through the thalamocortical radiations.Related to this concept, spinal manipulation occupies aprominent place in FN, principally because of its pro-posed supra-segmental effects. Indeed, it is stated thatspinal manipulation is able to generate changes in thesize of the blind spot because of the afferent stimulationit would provide to the thalamus, in this way affectingthe amount of afferent inputs to the cortex by the thal-amus. Thus, manipulation is stated to have a directeffect on the brain, a central tenet within FN [32, 34].This leads us to discuss the theories surrounding thetreatment in FN.

Treatment theories: (information from textbook)The aim of FN treatment is to restore the optimal me-tabolism within the targeted neurons, i.e. the neuronsconstituting the “physiological lesion(s)”, in order to pro-mote positive neuroplastic changes. By this process,normalization of their efferent outputs and thus aresolution (at least partial) of the patient’s symptoms isexpected. This treatment is often multi-facetted andcould include manual therapy but also the applicationof, for example, sensory, motor, or cognitive stimuli.Some such treatments were described in our foursources of information and were reported below in thesection “Treatment modalities”.Some rules are proposed to be followed for imple-

menting a treatment in FN, specifically that: 1) theintensity of the stimulus has to be progressive andadapted to the degree of “fatigability” of the targetedgroup(s) of neurons; 2) the type of the stimuli and theside of their application depend on the characteristics of

the stimulated pathways; 3) the stimuli have to be re-peated and a single “physiological lesion” can be affectedby several kinds of stimuli; and 4) the effects of treat-ment have to be assessed regularly by testing the positiveindicators found during the initial clinical examination(e.g. assessing the decrease or the increase of “fatigabil-ity”) [39].Concerning the intensity of the stimulus and the ne-

cessity of reassessing regularly the “fatigability” of thepatient’s nervous system, in FN it is considered that neu-rons suffering from a dysfunctional CIS may be not ableto support either an overly intense stimulation or toomany repetitions of stimuli. The risk would be to aggra-vate the “physiological lesion(s)” [34]. This implies thatparameters such as the “fatigability” of a group of neu-rons vary during treatment, appearing as a barometer ofthe treatment dose that the patient would be able tosupport.In regards to the type and side of stimulation, these

parameters refer to the fact that a variety of treatmentmodalities exist for acting on various parts of the ner-vous system. The choice of the type of stimuli dependson the targeted group(s) of neurons. The side on whichthey are delivered depends on whether the pathway thatgoes to the targeted neurons is crossed or uncrossed. Inother words, a treatment modality is chosen for its ex-pected ability to alter neuronal communication along apathway until it reaches the “physiological lesion” ofinterest. For example, to reverse a “physiological lesion”of the left parietal cortex, the application of a source ofvibration to joints of the right side of the body may bechosen [40]. Finally, the stimuli have to be repeated inthe perspective of re-training the nervous system inorder to cause lasting neuroplastic changes. The treat-ment is therefore dependent on the assumed area(s) ofthe defect nervous system and thus the same treatmentcan be provided for a multitude of diagnoses/symptoms.

Clinical application of FN: (information from all foursources)Indications: (information from all four sources)All the groups of indications we identified were found inat least three of our four sources of information. Indica-tions of FN are multiple with an emphasis on brain-related dysfunctions. Thus, according to our foursources, FN would be suitable to manage neuromuscu-loskeletal disorders, symptoms related to traumatic braininjuries, neurologic diseases or disorders, psychiatricdisorders, and various neurologic or non-neurologicisolated symptoms. In addition, three sources showedthat this approach would also be suitable for variousconditions which did not fit with any of these groups ofindications (see Table 2).


Among these indications, the following specific exam-ples were reported by at least two sources: low back pain,neck pain, radiculopathies, peripheral neuropathies, upperand lower extremity conditions, Parkinson’s disease,multiple sclerosis, dystonias, migraines, complex regionalpain syndrome, attention deficit disorder (ADD), attentiondeficit and hyperactivity disorder (ADHD), dyslexia,anxiety disorders, depression, post-traumatic stressdisorders, obsessive compulsive disorders (OCD), balancedisorders, and vertigo. Additional indications are listed inTable 2. In fact, several specific examples collected on thewebsites or through the interviews were apparently notreported in the literature.

Examination procedures: (information from all four sources)As in other health disciplines, a detailed medical historyis collected and the patient is observed, thus providingthe first clues about which areas of the nervous systemmay present a physiological dysfunction. In addition,vital signs may be assessed and a general physical exam-ination can be conducted. Complementary exams, e.g.magnetic resonance imaging and video-nystagmography,can also be recommended in order to detect/exclude asevere pathology and/or to supplement the functionalneurological diagnosis.However, the main aspect is the functional neurology

examination. Table 3 provides a summary of diagnosticprocedures used in FN according to our four sources. All ofthem reported the use of tests to assess the following:autonomic nervous system, sensory and motor componentsof spinal nerves, cranial nerves, reflexes, vestibulo-cerebellar system, cortical lobes and/or hemispheres, andcognition. The majority also reported assessing the basalganglia. Specific tests are also mentioned, some of whichare used to assess several structures or functions. Forexample, eye movements are used to assess the vestibulo-cerebellar system, the brainstem and/or the cerebral cortex,and finger-to-nose test is used for assessing the cerebellumand/or indirectly the cortical hemispheres.Importantly, while most of the tests reported in Table 3

are commonly used in conventional neurological examin-ation (e.g. myotomes and Romberg’s test) or in non-neurological examinations (e.g. vital signs), some of themare unusual or used differently in FN. The blind spot map-ping is an example of such an unusual diagnostic test. Themeasurement of the vital signs to assess the CIS of theautonomic nervous system, which in turn is said to be ableto reflect the CIS of cortical hemispheres, is an example ofusual tests used and interpreted differently to what wouldusually be the case. This relationship between vital signs,autonomic nervous system and the CIS of the corticalhemispheres is said to be mediated by the cortico-reticulo-spinal tract (described in the section “Relatedneurological pathways”).

Tests may be used also without any obvious clinicalindication and the interpretation of their results appearsto be specific to FN, i.e. identification of one or more“physiological lesions”. The assessment of the cerebellarfunctions in a context of mechanical low back pain withspinal root compression illustrates the apparent “gap”between the clinical condition and the tests selected bythe therapist [36]. In other words, to an “ordinary” clin-ician it would not be clear in which way tests of thecerebellar function would be relevant in mechanical lowback pain.It is our understanding that clinicians may take an

individual approach to their diagnostic tests; eitherchoosing specific tests based on the initial interview andobservation of the patient or performing tests in orderto screen for affected areas of the nervous system. It alsoappears that all tests are not used by all FN clinicians.

Treatment modalities: (information from all four sources)Treatment modalities mentioned by our sources of in-formation, as listed in Table 4, are coupled with theparts of the nervous system they are proposed to affect.As previously stated, treatment modalities appear to beprimarily selected for their expected abilities to stimulatebrain area(s) rather than in relation to the patient’s con-dition. The table shows how one brain area may be stim-ulated by several approaches and how one treatmentmodality may stimulate several areas. For example, eyemovement exercises and manual therapy may be used tostimulate both the cortical hemispheres and the cerebel-lum. Another example is vibration therapy that may beused for these same areas, i.e. the cortical hemispheresand the cerebellum, as well as for the basal ganglia. Infact, the therapeutic modalities appear to include almostanything that would stimulate the nervous system,making it difficult to describe a treatment pattern. Thistreatment often includes home exercises to regularlystimulate the nervous system and it is often comple-mented with nutritional counseling or supplements.All the sources described the content of the treatmentas individualized.

Treatment plans: (information from scientific literature,websites and interviews)Concerning the treatment plans, we analyzed informa-tion from three sources (the book was excluded). Onthis basis, it seems clear that treatment plans are individ-ualized. During the initial treatment period, regardlessthe conditions discussed, several appointments per weekor even per day were proposed to patients. The periodduring which these treatment sessions are planned isvariable but typically extended two weeks. Moreover, theuse of home exercises appears quite common in additionto treatment with the therapist. Very little information is


given in regard to the long-term strategies of care thatmight be established. This information and some detailsrelated to the course of care (e.g. duration of treatmentsessions or home exercises) are available in Table 5.

Clinical outcomes: (information from all four sources)Finally, we were interested in the factual or expectedclinical outcomes. This is reported in the order of thescientific “credibility” of the sources. In general, websitesand informants reported for various conditions, relief or

recovery, but most of the time without mentioning theusual time course of recovery/improvement (see Table 6).The textbook [36] reported on six different cases: i)

complex regional pain syndrome, ii) migraines associatedwith vertigo, iii) ADHD, iv) depression, v) low back painwith spinal root compression, and vi) symptoms related totreatment by spinal manipulation. For these patients, clin-ical outcomes were reported as positive in general aftertwelve weeks, whether partial or complete. No clinicaloutcomes were reported beyond this period of treatment.

Table 3 Diagnostic procedures used in Functional Neurology according to four sources in a scoping review

Structure(s) orfunction(s)

Sources of information

Book Scientific articles Websites Interviews

Spinalnerve

Sensory Spinothalamic tracta

Dorsal columnsbSpinothalamic tracta

Dorsal columnsbX X

Motor MyotomesMuscle tone

Myotomes Myotomes X

Reflexes OsteotendinousPlantarSuperficial abdominal

OsteotendinousPlantar

X Osteotendinous

Cranial nerves I to XII At least, II to VIII, X to XII At least, III, IV, VI,and VIII

I to XII

Vestibulo-cerebellar

Eye movementsCN II, III, V, VII and, VIII to XIIRomberg / Fukuda testsFinger-to-nose / Heel-to-shin testsRapid alternative movementsVestibulo-ocular reflexBalance assessmentTandem gaitWalking on toes / heels

Eye movementsFinger-to-nose / Heel-to-shintestsRapid alternative movementsVestibulo-ocular reflexBalance assessmentFunctional Romberg test

Eye movementsBalanceassessment

Eye movementsRomberg / Fukuda testsVestibulo-ocular reflexBalance assessment

Brain lobe(s) Eye movementsBlind spot mappingqEEG

Eye movementsBlind spot mappingGait assessmentFinger dexterityMuscle testingPrimitive reflexesDual mental tasking

Eye movementsBlind spotmapping

Eye movementsBlind spot mapping

Basal ganglia Looking for fascial tics Colored lenses NM X

Autonomic Observation (e.g. pupillary size, condition of theskin)Pupil light reflexBlood pressureForehead / tympanic temperaturesHeart rateRespiratory rate / ratioOximetryBowel auscultationDermographiaVein-to-artery ratio of the retinal vessel

Blood pressureHeart rateHeart auscultation“Respiratory excursion”Vein-to-artery ratio of theretinal vesselSearch for dermographia

X Pupillary size or pupillight reflexBlood pressureHeart rateOximetry

Cognitive Questions about patient’s orientation and fortesting memory

Wechsler intelligence scale forchildrenTest of variables of attentionFinger tapping testCognitive tasks (e.g. memorytasks)

X Test of variables ofattention

X Structure(s) or function(s) mentioned without specific example(s)NM Structure(s) or function(s) not mentioned in the sourceqEEG Quantitative electroencephalographyaThis includes nondiscriminative touch, temperature and pain sensationsbThis includes fine touch, and conscious proprioception


Table

4Treatm

entmod

alities

used

inFunctio

nalN

eurology

accordingto

four

sourcesin

ascop

ingreview

Sourcesof

inform

ation

Con

ditio

nsor

sign

sTissuesat

fault

Therapeutic

mod

alities

Specificcommen

tsGen

eralcommen

ts

Book

Chap.19

Migraines

andvertigo

Righ

tcerebralhe

misph

ere

SMT

Eyeexercises

Breathingexercises

Nutritionalthe

rapy

Mostof

thetreatm

entmod

alities

(e.g.SMT,soun

dtherapy,eye

exercises)areprovided

orpe

rform

edto

theop

posite

side

ofthetargeted

hemisph

ere.

Nutritionalthe

rapy

consistsmainly

ofvitamin

B,om

ega3andC0Q

10supp

lemen

tatio

n.

Com

plex

region

alpain

synd

rome

Cereb

ralh

emisph

ere(s)

Jointmanipulations

Cou

ntingbackwards

Breathingexercises

Nutritionalthe

rapy

Hot

andcold

compresses

Ortho

tics

Thetargeted

hemisph

ereis

prob

ablytheleftbe

cause

coun

tingbackwards

issaid

bytheauthor

tostim

ulate

theleftcerebralhe

misph

ere.

Atten

tionde

ficitand

hype

ractivity

disorder

Righ

tcerebralhe

misph

ere

andleftcerebe

llum

Jointmanipulations

Soun

dtherapy

Spatialrearrange

men

texercises

Breathingexercises

Nutritionalthe

rapy

Dep

ression

Cereb

ralcortex

Jointmanipulations

Soun

dtherapy

Spatialrearrange

men

texercises

Lookingat

oldph

otos

and

makingup

storiesabou

tthem

Breathingexercises

Nutritionalthe

rapy

Low

back

pain

with

spinalroot

compression

Righ

tcerebralhe

misph

ere

Jointmanipulations

Breathingexercises

Nutritionalthe

rapy

PostSM

Tsymptom

sRigh

tcerebralhe

misph

ere

andleftvestibulo-cerebe

llar

system

Jointmanipulations

Softtissueandtrigge

rpo

inttherapy

Breathingexercises

Nutritionalthe

rapy

Chap.20

NA

Cereb

ralh

emisph

ere

Activation:

Any

complex

chore

Manipulativetherapy

Eyeexercises

Cereb

ellaractivation

Sensorystim

uli:visual,

auditory,olfactory

Transcutaneo

uselectricalne

ural

stim

ulation

Inhibitio

n:Earplugs,b

linde

rsVisualizerather

than

perfo

rmactivities

Somespecificstim

ulito

stim

ulatetherig

htandthe

leftcerebralcortex

are

describ

ed.M

oreo

ver,some

specificstim

ulid

irected

for

thedifferent

lobe

sof

the

hemisph

eres

arealso

describ

ed[39].

Stim

ulid

irected

tothe

cerebe

llum

are

describ

edbe

low.

InChap.

20,the

author

does

not

dealwith

cond

ition

sbu

ton

lywith

targeted

neurolog

icalstructures.


Table

4Treatm

entmod

alities

used

inFunctio

nalN

eurology

accordingto

four

sourcesin

ascop

ingreview

(Con

tinued)

Evoked

potentialsat

redu

ced

amplitu

de

NA

Cereb

ellum

Manipulativetherapy

Warmingtheauditory

canal

Revolvingchair

Eyemovem

ents

Passivemusclestretch

Squeezingaball

Pointin

g

Specificexercisesto

stim

ulate

themed

ialp

artandthe

lateralp

artof

thecerebe

llum

arealso

prop

osed

[39].

NA

Vestibule

Caw

thorne

-Coo

ksey

exercises

Balanceexercises

Forde

tails

concerning

these

exercises,see[39].

NA

Brainstem

Smelland

/ortastefood

Exercisesand/or

stim

ulio

fmuscles

inne

rvated

bycranialn

erves

Rectaldilatio

n

Specificexercisesto

stim

ulate

themesen

ceph

alon

arealso

men

tione

d[39].

NA

Sympatheticactivity

Localapp

licationof

warm

Transcutaneo

uselectricalne

ural

stim

ulation

Thesemod

alities

are

describ

edto

inhibitthe

sympatheticactivity.

NA

Caudate

nucleus

Visualizingpleasant

stim

uli

Incontrast,amygdalaand/or

hipp

ocam

pusmay

bestim

ulated

byvisualizing

unpleasant

stim

uliand

“narrativerecall”

andlist

learning

.

Scientific

articles

Carrick

(1997)

[9]

Enlarged

physiological

blindspot

Cereb

ralh

emisph

ere

SMT

Inthearticleslistedhe

re,the

large

majority

ofthetherapeutic

mod

alities,i.e.m

anipulation,

vibrationtherapy,eyeexercises,

andmirror

therapy,areprovided

orpe

rform

edde

pend

ingon

the

targeted

structure(s)andits/the

irside

(s),

except

inthearticlesof

Pedro

(2005)

(whe

rethisisno

tmen

tione

d)andof

Hirsh(2013)

(whe

rethisison

lymen

tione

dfor

vibrationtherapy).

bThesestud

ieswerecond

ucted

onhe

althysubjectswho

were

foun

dwith

anen

larged

blindspot

ofon

eof

theireyes.

Pedro

(2005)

[41]

Land

au-Kleffn

ersynd

rome

Lefthe

misph

ereandrig

htcerebe

llum

Manipulation

Eyemovem

entexercises

Visual,olfactory,auditory,

vestibular

andsomatosen

sory

stim

uli

Interactivemetrono

me

Nutritiontherapy

Therewas

noprecisionof

which

mod

alities

wou

ldalter

oneof

thetw

otargeted

structurerather

than

theothe

r.

Daube

ny(2010)

[57]

Enlarged

physiological

blindspot

Cereb

ralh

emisph

ere

Upp

erextrem

itymanipulations

Bova

(2013)

[43]

Cervicald

ystonia

Leftcerebralcortex

(fron

tallob

e)Eyemovem

entexercises

Righ

tcerebe

llum

SMTVibrationtherapy

Righ

tvestibular

system

Eyemovem

entexercises

Leftbasalg

anglia

Eyemovem

entexercises

Vibrationtherapy

Blue-lensed

glasses

Kuhn

(2013)

[44]

Migraines,atten

tion

deficitandhype

ractivity

Righ

tcorticalhe

misph

ere

SMTCoo

rdinationactivities

associated

with

eyemovem

ents


Table

4Treatm

entmod

alities

used

inFunctio

nalN

eurology

accordingto

four

sourcesin

ascop

ingreview

(Con

tinued)

disorder,obsessive

compu

lsivedisorder,

andTourette’ssynd

rome

Interactivemetrono

me

Leftcerebe

llum

SMT

Coo

rdinationactivities

associated

with

eyemovem

ents

Interactivemetrono

me

Righ

tbasalg

anglia

SMTCoo

rdinationactivities

associated

with

eye

movem

ents

Interactivemetrono

me

Leftpo

nsSM

TCoo

rdinationactivities

associated

with

eyemovem

ents

Hirsh

(2013)

[46]

Atten

tionde

ficitand

hype

ractivity

disorder,

prim

aryno

cturnal

enuresisand

musculoskeletalpain

Righ

tcorticalhe

misph

ere

andleftcerebe

llum

SMTBlue-lensed

-glasses

Optokineticstim

ulation

Vibrationtherapy

Balanceexercises

Vestibular

stim

ulation

Timingexercises,includ

ing

interactivemetrono

me

Hom

eexercises:inhibitory

ofprim

itive

reflexes,muscles

streng

then

ing,

andbalance

exercises.

Dietary

change

s

Therewas

noprecisionof

which

mod

alities

wou

ldalter

oneof

thetw

otargeted

structurerather

than

theothe

r.

Espo

sito

(2013)

[48]

Symptom

srelatedto

traumaticbraininjury

Cortex(includ

ingfro

ntal

lobe

)Off-axisrotatio

nald

evice

Other

mod

alities

areused

(see

Add

ition

alfile2a)with

out

clearmen

tionof

which

neurolog

icalareasaretargeted

.Vestibule

Off-axisrotatio

nald

evice

Righ

tlower

brainstem

Off-axisrotatio

nald

evice

Leftup

perbrainstem

Off-axisrotatio

nald

evice

Supe

riorcolliculi

Red-blue-lenses

Bova

(2014)

[45]

Parkinson’sdisease

Cereb

ralcortex

SMT

Cross

craw

lexercises

Mirror

therapy

Cross

craw

lexercises

are

perfo

rmed

tostim

ulatethe

frontallobe

.Mesen

ceph

alon

was

also

targeted

with

outanymen

tion

ofwhatmod

alities

wereused

for.

Basalg

anglia

Vibrationtherapy

Blue-lensed

glasses

Mirror

therapy

Bova

(2014)

[40]

Idiopathic

hemiparesthesia

Leftcerebralcortex

(parietallob

e)Vibrationtherapy

SMTandcold

lasertherapy

werealso

used

.

Leftvestibular

system

Eyeexercises

Traster

(2014)

[47]

Symptom

srelatedto


Leftcerebralhe

misph

ere

Manipulativetherapy

Passivecomplex

movem

ents

oftheextrem

ities

Eyemovem

enttherapies

Earth-verticalaxisrotatio

ns

Breathingexerciseswerealso

givento

thepatient.


Table

4Treatm

entmod

alities

used

inFunctio

nalN

eurology

accordingto

four

sourcesin

ascop

ingreview

(Con

tinued)

Leftbrainstem

(includ

ing

theleftsupe

riorcolliculus)

Optokineticstim

ulations

Overallvestibule

Eyemovem

enttherapies

Earth-verticalaxisrotatio

ns

Web

sites

Web

site

4Symptom

srelatedto

traumaticbraininjuries

Vestibular

system

Off-axisrotatio

nald

evice

Theconten

tof

each

treatm

entis

individu

alized

,followingthe

statem

entsof

thefiveweb

sites.

Allof

thepractitione

rsresortto

eyeexercisesandto

home

exercisesand/or

lifestyle

coun

seling,

espe

ciallyconcerning

nutrition

(see

Add

ition

alfile2b

).

Interviews

Inform

ant

1NA

Tempo

rallob

e(s)

Riding

abike

Theconten

tof

each

treatm

entis

describ

edas

individu

alized

.Alltheinform

antsresortto

home

exercises.

Themajority

ofthem

use

manipulativetherapyandeye

exercises(see

Add

ition

alfile2c).

Inform

ant

2NA

Cereb

ralh

emisph

ere

Manipulativetherapy

Symptom

sfollowing

traumaticbraininjuries

Brainstem

Somatosen

sory

evoked

potential

Inform

ant

3NA

Cereb

ralh

emisph

ere

Manipulativetherapy

Coo

rdinationexercisesand

exercisesforfinemotor

skills

arepe

rform

edto

stim

ulatethe

lateralp

artof

thecerebe

llum.

NA

Cereb

ellum

Manipulativetherapy

Coo

rdinationexercises

Exercisesforfinemotor

skills

SMTSp

inal

man

ualthe

rapy

NANot

applicab

le


Table 5 Treatment plans used in Functional Neurology according to four sources in a scoping review

Sources of information Condition(s) Initial care Maintenance care

Articles Pedro(2005) [41]

Landau Kleffner syndrome Daily visits, 4.5 h per week, for12 weeks

Beck(2009) [42]

Complex regional painsyndrome

1 to 2 visits per week for 8 weeks, plus 1visit each 2 week for 1 month, plus homeexercises

Kuhn(2013) [44]

Migraines, ADHD, OCD and,Tourette’s syndrome

42 visits over 19 weeks

Hirsh(2013) [46]

ADHD, primary nocturnalenuresis, and musculoskeletalpain

36 visits over 18 weeks, plus daily homeexercises

Bova(2014) [45]

Parkinson’s disease 2 visits per week for 2 months, plus homeexercises

After the initial care (i.e. 2 months), thefrequency of 2 visits per week was maintained(for at least 8 months).

Bova(2014) [40]

Idiopathic hemiparesthesia 3 visits in 2 weeks

Traster(2014) [47]

Symptoms related to traumaticbrain injury

Approximately 2 to 3 visits per week for3 months

Websites Website 1 In general IndividualizedUsually, several times per day with anaverage of 3 times of 1.5 h each, for 1to 2 weeks

Website 4 In general IndividualizedUsually, 2 times per week for 6 weeks,plus home exercises

Complex conditions (type ofconditions was not specified)

3 to 5 times per day for up to 5consecutive days

Website 5 In general IndividualizedUsually, 1 to 3 times per week for fewweeks, plus home exercisesThis frequency is usually decreased over2 to 4 months

Patient is often requested to do homeexercises.

Complex conditions (e.g. severebrain injuries, and advanceddegenerative diseases)

Several visits per day for 1 to 2 weeks

Interviews Informant 1 In general IndividualizedUsually 2 to 3 visits close in time, plushome exercisesIf good results are obtained, treatmentis continued, more spaced in time.Daily visits or, 2 to 3 visits per week,may be needed, for 2 to 3 weeks.

Complex conditions(unspecified)

Informant 2 Moderate neurodevelopmentaldisorders

IndividualizedUsually, 1 to 2 visits per week for a fewweeks, plus daily home exercises for about10 min per dayThis frequency is usually progressivelydecreased

Severe neurodevelopmentaldisorders

Visits are more frequent than for themoderate form.

Informant 4 In general Individualized Usually, 3 to 4 times (about20 min each) per day for 2 to 3 weeks or2 times per week for 3 to 4 months

Parkinson’s disease Several visits per day for 3 consecutive daysfor 1 week

Patient is seen 3 to 4 times per year forthe same treatment plan.

ADHD Attention deficit and hyperactivity disorderOCD Obsessive compulsive disorder


Table

6Clinicalou

tcom

esrepo

rted

and/or

expe

cted

aftertreatm

entwith

Functio

nalN

eurologicalaccording

tofour

sourcesin

ascop

ingreview

Sourcesof

inform

ation

Con

ditio

nsEarly

clinicalou

tcom

esClinicalou

tcom

eswith

unspecified

timeframe

Long

-term

clinicalou

tcom

es

Book

Chapter

19p.332–341

Com

plex

region

alpain

synd

rome

At12

weeks,fullrecoveryof

functio

n,pe

rsistenceof

bouts

ofpain

Migraines

andvertigo

Less

frequ

entmigraines,resolution

ofvertigo

ADHD

At12

weeks,improvem

entof

concen

tration,readingability

and

othe

racadem

icabilities

Furtherimprovem

entisexpected.

Dep

ression

At12

weeks,improvem

entof

depressive

state

Furtherimprovem

entisexpected

with

continuedtreatm

ent.

Low

back

pain

with

spinalroot

compression

At12

weeks,p

ainfre

e,bu

tpe

rsistent

episod

esof

numbn

ess

Postmanipulativetherapysymptom

sAt12

weeks,resolutionof

imbalance

andhe

adache

s,redu

ctionof

the

othe

rsymptom

sinclud

ingconfusion

Furtherimprovem

entor

even

resolutionisexpected

with

continuedtreatm

ent.

Articles

Pedro(2005)

[41]

Land

au-Kleffn

ersynd

rome(caserepo

rt)

At12

weeks,improvem

entof

lang

uage

,aud

itory

andmotor

skills

Beck

(2009)

[42]

Com

plex

region

alpain

synd

rome(caserepo

rt)

At12

weeks,fullrecoveryof

functio

n,bu

tpe

rsistenceof

boutsof

pain

At1year,fun

ctionalrecoveryis

maintaine

d,ep

isod

esof

pain

are

repo

rted

.

Bova

(2013)

[43]

Cervicald

ystonia(caserepo

rt)

Functio

nalimprovem

ent,

decrease

ofspasmod

ictorticollis

Kuhn

(2013)

[44]

Migraines,A

DHD,O

CD,Tou

rette’s

synd

rome(caserepo

rt)

At19

weeks,m

igraines

werego

ne,

ticsand,

learning

andbe

havioral

capacitieswereim

proved

Hirsh(2013)

[46]

ADHD,p

rimaryno

cturnalenu

resis,and

musculoskeletalpain

(caserepo

rt)

At18

weeks,improvem

entof

behavior,con

fiden

ce,and

posture

Nomoredifficulty

indaytim

eurinary

control

At3mon

ths,occasion

albe

dwettin

gandim

provem

entsin

vario

usactivities

ofdaily

living

Espo

sito

(2013)

[48]

Symptom

srelatedto


(caserepo

rt)

At10

weeks,improvem

entof

balance,

cogn

itive

abilities,moo

d,andanxiety

Decreaseof

thenu

mbe

randseverity

ofph

ysicalcomplaints

Bova

(2014)

[45]

Parkinson’sdisease(caserepo

rt)

At2mon

ths,im

provem

entof

posture,

functio

nandwell-b

eing

At10

mon

ths,treatm

entiscontinued

twicepe

rweekformainten

ance

care

with

stableresults.

NB:Relapsewas

observed

whe

ntreatm

entwas

redu

cedto

once

perweek.

Bova

(2014)

[40]

Idiopathicparesthe

sia(caserepo

rt)

At2weeks,sym

ptom

freeafter2

visits

Traster(2014)

[47]

Symptom

srelatedto


(caserepo

rt)


Table

6Clinicalou

tcom

esrepo

rted

and/or

expe

cted

aftertreatm

entwith

Functio

nalN

eurologicalaccording

tofour

sourcesin

ascop

ingreview

(Con

tinued)

At3mon

ths,recovery

ofvibration

sense,fre

eof

dysesthe

sia,and

improvem

entof

balanceandgait

Web

sites

Web

site

1Unspe

cified

Reliefor

resolutionof

patient’s

symptom

(s)

Symptom

srelatedto


Resolution

Parkinson’sdisease,Alzhe

imer’s

disease,andADD/ADHD

Improvem

ent

Web

site

2Unspe

cified

Reliefof

patient’ssymptom

(s)

Web

site

3Unspe

cified

Sign

ificant

reliefor

resolutionof

patient’ssymptom

(s)

Migraines,and

Post-con

cussionsymptom

sResolution

Web

site

4Unspe

cified

Reliefor

resolutionof

patient’s

symptom

(s)

Web

site

5Unspe

cified

Profound

reliefo

rresolutionof

patient’ssymptom

(s)

Interviews

Inform

ant1

Mostof

thecond

ition

sImprovem

entsof

patient’s

symptom

(s),usually

after2to

3visits

Vertigo

“Good”,usuallyafter2to

3visits

Tinn

itus

Lessconstant,usuallyafter2to

3visits

Inform

ant2

Mostof

thecond

ition

s“Good”,usuallyafter2to

3weeks

oftreatm

ent

Neurode

gene

rativediseases,

trem

ordisorders,high

“fatig

ability”

ofthene

rvou

ssystem

Lessconstant

andlong

erto

observe

Inform

ant3

Reversibleor

“functio

nal”cond

ition

s(e.g.vertig

o,balanceissues,headaches)

“Goo

d”,and

potentially

stable,

after3to

4visits

Irreversiblecond

ition

sResults

concerning

someof

the

symptom

(s)of

thepatient’s

patholog

y,take

long

erto

achieve,

andstablewith

maintenan

cecare.

Inform

ant4

Mostof

thecond

ition

sImprovem

ent,usually

tran

sitory,of

someof

thepatient’ssymptom

(s)

Any

pediatric

cond

ition

s(e.g.A

DD,cereb

ral

palsy),and

post-stroke

symptom

s,andchronic

musculoskeletaldisorders

Results

arebe

tter

than

those

describ

edfortheothe

rcond

ition

sin

adults.For

children,results

are

also

morestable.

Expe

cted

clinical

outcom

esarerepo

rted

inita

licADD/ADHDAtten

tionde

ficitdisorder/Atten

tionde

ficitan

dhy

peractivity

disorder

OCD

Obsessive

compu

lsivedisorders


We found seven case studies in the literature reportingon: i) Landau-Kleffner syndrome [41], ii) complex regionalpain syndrome [42], iii) cervical dystonia [43], iv) mi-graines, ADHD, OCD and Tourette’s syndrome [44], v)Parkinson’s disease [45], vi) idiopathic hemi-paresthesia[40], and vii) ADHD, primary nocturnal enuresis andmusculoskeletal pain [46]. Two case studies were foundthat reported on symptoms post-traumatic brain injury[47, 48]. For these case reports, clinical outcomes were re-ported at various time intervals as positive, whether partial[41–48] or complete [40, 42, 44, 47]. Two case studies [42,45] reported long term clinical outcomes, both describingpatients as improved. One case study [46] reports the out-comes three months after cessation of care, describing thepatient as being improved. No randomized controlled tri-als were found that could confirm the therapeutic effect ofFN approach as a supplement to “traditional” chiropracticon any clinical outcome (for more information seeTable 6). In fact, to the authors’ knowledge, no studydesign other than case-reports currently exist that de-scribe therapeutic outcome in symptomatic patients.

DiscussionBrief summary of findingsTo our knowledge, this is the first article to providean overview of the theoretical framework and theclinical applications of FN, in the context of chiro-practic manual therapy. In short, FN is described as atherapeutic approach that could be used for a largearray of conditions, provided that the cause of suchconditions can be traced primarily to parts of thecentral nervous system. The diagnosis is performedthrough the use of many conventional, but also moreunusual tests, with a very “fine-tuned” interpretationof test results. In some cases, the fine tuning consistsof looking for minor asymmetry and “subclinicallesions”. Treatment consists of various activities ortherapies that are thought to affect clusters of neu-rons that have been diagnosed as dysfunctional. Theinitial treatment plan appears intense with severalsessions per week or even per day. After this initialintervention period, it seems that the clinicaloutcomes are generally reported as positive, whetherpartial or complete, regardless of the condition of thepatient (e.g. Parkinson’s disease, low back pain withradiculopathy).

Methodological considerationsThis information was obtained through a scoping re-view that included four sources: i) one textbook ofFN, ii) eleven articles from the scientific literature, iii)the websites of five chiropractors proficient in FN,and iv) a semi-structured interview of four chiroprac-tors who practice FN daily. As our research purpose

was broad and FN is not well documented in the sci-entific or academic literature, we performed a scopingreview rather than a number of rigorous systematicreviews, using for this multiple sources ofinformation.Our four sources helped us cover our six research

objectives. However, the book was the only materialthat we used for the theoretical background of FN asit extensively informed us on its fundamentalconcepts. Few scientific articles were found in relationto our areas of inquiry; most of them case studies.Thus, websites of FN practitioners and the interviewswere needed to collect enough information to make itpossible to provide a clear and consistent picture ofwhat constitutes FN. The latter two sources, i.e.websites and interviews, were also selected to fit therecommendations for conducting scoping studies [27, 28].The representativeness of our sources of information

and the validity of the extruded information seem to besatisfactory, as discussed below. Perhaps other re-searchers using alternative sources of information mayhave obtained varying results but it is our opinion thatthis review has reasonably captured the spirit and natureof FN, as there was good agreement between the varioussources.We decided to restrict the present review to FN

theories and their clinical applications in the chiro-practic context, i.e. we were interested only insources that included the use of manual therapy.Thus, the work presented here does not depict thewhole field of FN, which is wide and merits furtherexplorations. As reported in the introduction, FN iscurrently composed of different sub-specialties whichrepresent various forms of FN practice. These donot always include manual therapy but choose othertherapeutic strategies, for example eye movementtraining [49–51], “hemisphere specific remediationprograms” [52, 53], and music therapy [54].

i) TextbookOnly the first author read the entire book andcollected the relevant information for our work,which may be a methodological weakness.However, the understanding of the theoreticalframe of FN was corroborated by the semi-structured interviews that contained severalquestions about fundamental concepts of FN, thusaiding in understanding. Further, the FN theoriesreported here, seem to be in agreement with howFN is defined by statements produced by someFN associations [23, 55]. Concerning our researchobjectives relating to clinical applications of FN,the information was straightforward to findbecause the textbook is well structured with


specific chapters dedicated to those topics ofinterest to this work. Still, it is possible that someinformation may have been missed ormisinterpreted.

ii) Scientific literatureThe usual strategy of searching for relevant articlesby key words could not be used as it resulted in onlyone relevant article. The reason for this is that theterm “functional neurology” is not usually used insuch publications, maybe because FN covers manyfields of clinical applications. Therefore, relevantkeywords could not be predicted.Instead, we attempted a search by author, includingat first all authors that appeared to publish in thisarea. However, this produced many irrelevantauthors with the same surname and initials.Therefore, we stopped this strategy after the searchfor FR Carrick, RW Beck, G Leisman and R Melilloin the three selected databases. These four wereselected because they appeared to be central to theFN movement. Thereafter, on the advice of aspecialist librarian, we wrote directly to these fourauthors and authors known to have published withthem, asking them for their lists of publications. Inthis way, five publication lists were obtained whichresulted in no additional peer-reviewed articles beingfound. One of these authors recommended a searchof the journal Functional Neurology, Rehabilitation,and Ergonomics. Three additional articles were foundin this journal. Finally, our citation search did notresult in any additional publications. The obstaclesencountered in searching the literature made itdifficult to appreciate if all relevant peer-reviewedarticles were captured. However, all the acquiredliterature had the hallmarks of FN, as we hadinterpreted it from the other sources, so it is ourimpression that we managed to catch the essenceof FN.The selection of articles for this review was madeindependently by the first author and an experiencedresearcher in the team. There were nodisagreements between them. Further, the search forrelevant information was also blinded with totalagreement between the two.

iii)WebsitesThe first author read the websites and collected therelevant information. These were read twice andblinded to previous findings. Subsequent readingswould sometimes result in more information beingincluded but no obvious misunderstandingsappeared in the later readings.

iv) InterviewsEach interview was conducted by the first authorand another PhD student. Each tabulated

transcription was done independently by these twopeople, with the option to listen again to the tapedinterview. This was necessary only once to clarifythe content of the reply of one of the fourinformants to one of the 24 questions. No otherdifferences between the content of thesetranscriptions were found between the interviewers.

Synthesis of findingsAccording to our review, FN has a well described ra-tionale that, if correct, has the potential of improvingthe lives for many people with a wide variety of con-ditions which are most often chronic and difficult tomanage. The diagnosis of the neurological lesions inFN, i.e. the “physiological lesions”, certainly requires asolid background in central neurology. For chiroprac-tors who embrace this approach, clinical practicewould surely be both interesting and challenging.Further, the practice of FN demands an understand-

ing of how to test the various potential lesions. Theinterpretation of these tests seems to be very specificto FN, requiring them to be done bilaterally, attempt-ing to detect asymmetries which would indicate le-sions, also at a “subclinical” stage. In addition, thepatient examination appears time consuming giventhe numerous tests that are performed, even whenthere is no obvious indication for them to be per-formed. Since these tests are used not only to detectlesions but also to monitor progress, the whole treat-ment strategy seems to be based on these tests; theyhave great importance, perhaps more than the symp-toms. For these reasons, it would be relevant for FNusers to assure that all their diagnostic tools are reli-able and valid.Since the recommended treatments do not appear to

be noxious, even prolonged treatments are unlikely tocause any direct physical harm. Notwithstanding theapproach being low risk, there are two other importantaspects which need consideration. Firstly, the choice ofone type of therapy may keep patients away from apossibly more suitable treatment; hence the need forcomparative studies to determine relative efficacy. Sec-ondly, frequent treatments during a long period of timeare costly, potentially both to individuals and society,hence the need to show that they provide better resultsthan less costly alternatives.We noticed that the list of conditions amenable to

improvement with FN is large and the conditions varyin type. However, only few of these have beendescribed in the scientific literature and there seemsto be a lack of studies on the effectiveness of thetreatment. In relation to treatment effect, it may bedifficult to conduct randomized controlled clinicaltrials on a treatment that concentrates on the


underlying lesion(s) rather than on groups of patientswith similar symptoms, because it might be difficultto find enough patients with sufficiently similar le-sions to satisfy the methodological requirements forsuch studies. Obviously, case reports are not sufficientto “prove” the benefit of a treatment, unless the con-dition is truly irreversible and the observations abso-lutely objective and irrefutable, as many factors otherthan the treatment can make a patient feel or appearimproved.At early follow-up, the clinical outcomes in FN are

generally reported as complete or partial, without a spe-cific pattern related to the type of condition and/or theseverity of the underlying neurological abnormalities.However, we could not judge the long-term clinical out-comes or prognosis for various conditions or in relationto the diagnosed neurological status from a lack of infor-mation in our sources. Such outcomes require documen-tation, to ensure that early improvements endure wellpast the initial placebo (honeymoon) effect.Our final impression of FN is that it can be

described as a complex alternative to the old variantof the chiropractic subluxation model [56], in whichthe chiropractor does not consider symptoms, but in-stead claims to treat the underlying “cause”. Further-more, when this “cause” has been removed, symptomswill diminish or disappear. According to this trad-itional chiropractic concept, the “cause” is the verte-bral subluxation.Likewise with FN, the chiropractor does not deal

directly with the presenting complaint, but is claimingto treat the underlying “cause”. The main differencesare: i) that the “cause” is not as “simple” as the verte-bral subluxation but one or more complex dysfunc-tion(s) of the nervous system (often located in thebrain), and ii) that the treatment is not limited to thespine and can be quite complex. In sum, the old vari-ant of the chiropractic subluxation concept is spine-centered whereas FN embraces the whole nervoussystem, with an emphasis on the brain.Verification of the scientific rationale of the theories

of FN, evaluation of the validity of its treatment pro-cedures, and consideration of the effectiveness of itstreatments were beyond the remit of this scopingreview. However, given that FN has been subject tolively criticism [10, 14–16, 20, 21] and the apparentpaucity of scientific documentation within thedomains we searched, it would be appropriate toscrutinize these aspects in future studies. Thisrequirement would be the same for any therapeuticapproach that is not an accepted part of mainstreammedicine.The neurological concepts presented by functional

neurologists are varied and difficult to verify without

having access to experts within many fields, willing tosubmerge themselves in this topic. A study of the plausi-bility of the concepts used in FN therefore would appearto be very difficult and time-consuming. Nevertheless,such studies may be justified but only if the treatmentapproach was tested and found to be valid.A first step towards a validation of FN would therefore

be to study whether one or several of the therapeutictools suggested by the functional neurologists actuallyhas an objective effect on the nervous system. If so, itwould also be needed to investigate if this effect is clinic-ally relevant and sustainable. For example, one centralargument in FN is that joint manipulation has a power-ful effect on the brain [9, 39, 57]. As some research hasbeen conducted in this area [58–61], a review of the lit-erature seems timely.Another necessary, perhaps more simple, approach

would be to test the validity of the clinical tests.Obviously, the diagnostic procedure has to be reprodu-cible for the diagnosis to be valid. In turn, it is crucial toensure that the treatment effect (if there is one) can beattributed to the purported mechanisms.

ConclusionThe FN concept that reversible lesions in well-defined areasof the nervous system, especially of the brain, can be anidentifiable cause of a multitude of disorders, is difficult forclinicians untrained in FN to verify. Nevertheless, the po-tential ability to change the quality of life for people suffer-ing from poorly understood and/or chronic disordersmakes this concept attractive for both clinicians andpatients.However, there is a need for more transparent documen-

tation on the validity of the various steps normally consid-ered important in evidence-based practice. In other words,the scientific community is waiting with interest to learnmore about: i) the plausibility of the rationale of the variousmore unusual concepts of FN, ii) the reliability of its clinicaltests and neurological diagnoses, and iii) the effect oftreatment, particularly in relation to spinal manipulation,whether applied to musculoskeletal complaints or not.

Additional files

Additional file 1: Appendices 1 Search strategy for scientific literature.2. Questions at a semi-structured interview on the use of FunctionalNeurology. (ZIP 30 kb)

Additional file 2: Appendices 3a Description of 11 peer-reviewedarticles on Functional Neurology included in a scoping review. 3b.Clinical information from websites of chiropractors using FunctionalNeurology. 3c. Clinical information on the use of Functional Neurology(FN) from semi-structured interviews of chiropractors proficient in its use[62–66]. (ZIP 78 kb)

Additional file 3: Appendix 4. Data analysis and synthesis.(DOCX 109 kb)


dx.doi.org/10.1186/s12998-017-0151-1

dx.doi.org/10.1186/s12998-017-0151-1

dx.doi.org/10.1186/s12998-017-0151-1

AbbreviationsADD: Attention deficit disorder; ADHD: Attention deficit and hyperactivitydisorder; CIS: Central integrative state; DACNB: Diplomate of the AmericanChiropractic Neurology Board; FN:: Functional neurology; OCD: Obsessivecompulsive disorder; PMRF: Pontomedullary reticular formation

AcknowledgementsThe authors gratefully acknowledge Marine Demortier for her help with thesemi-structured interviews.

FundingApart from the authors being funded from their institutions, there were noexternal grants for this project.

Availability of data and materialsThe datasets used or analyzed during the current study are available fromthe corresponding author on reasonable request.

Authors’ contributionsALM and CLY performed the scoping review and interpreted the findings.ALM wrote the first draft. CLY, AM and SE provided comments for thesubsequent drafts. All the authors revised and approved the final manuscript.

Authors’ informationALM is a chiropractor and presently enrolled in a PhD program at the Universityof Paris-Saclay. AM, BSc (Hons), PhD, completed a double major inanatomy/physiology with first class honours and then a PhD at the University ofWestern Australia. She holds the Human Anatomy Practice Licence for MurdochUniversity and has taught gross anatomy and neuroanatomy/neurology tochiropractic and medical students since 2012. SJE has a PhD in neurophysiology,with a special interest in somatic and cortical electrophysiology. She is currentlyemployed as a Senior Lecturer in Physiology at Murdoch University, where sheteaches biomedical, chiropractic, medical and veterinary students. CLY is achiropractor and a Professor in Clinical Biomechanics at the University of SouthernDenmark. She has a background in epidemiology and systematic critical reviewsand is the main supervisor on this PhD project.

Ethics approval and consent to participateA written consent was obtained from each chiropractor who participated tothe semi-structured interview to record it and to use its content as searchmaterial.

Consent for publicationNot applicable.

Competing interestsThe authors declare that they have no competing interests.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims in publishedmaps and institutional affiliations.

Author details1Complexité, Innovation et Activités Motrices et Sportives, UniversitéParis-Saclay, 91405 Orsay Cedex, France. 2Complexité, Innovation et ActivitésMotrices et Sportives, Université d’Orléans, 45067 Orléans, France. 3InstitutFranco Européen de Chiropraxie, 24 Bld Paul Vaillant Couturier, 94200 Ivry surSeine, France. 4School of Health Professions, Murdoch University, 90 SouthStreet, Murdoch, W.A 6150, Australia. 5School of Veterinary and BiomedicalSciences, Murdoch University, 90 South Street, Murdoch, W.A 6150, Australia.

Received: 4 April 2017 Accepted: 12 July 2017

References1. Chang M. The chiropractic scope of practice in the United States: a cross-

sectional survey. J Manip Physiol Ther. 2014;37(6):363–76.2. Décret n°2011–32 du 7 janvier 2011 relatif aux actes et aux conditions

d’exercice de la chiropraxie. In. https://www.legifrance.gouv.fr/.3. Adams J, Lauche R, Peng W, Steel A, Moore C, Amorin-Woods LG, Sibbritt D.

A workforce survey of Australian chiropractic: the profile and practice

features of a nationally representative sample of 2,005 chiropractors.BMC Complement Altern Med. 2017;17(1):14.

4. French SD, Charity MJ, Forsdike K, Gunn JM, Polus BI, Walker BF, Chondros P,Britt HC. Chiropractic observation and analysis study (COAST): providingan understanding of current chiropractic practice. Med J Aust. 2013;199(10):687–91.

5. Millan M, Leboeuf-Yde C, Budgell B, Amorim MA. The effect of spinalmanipulative therapy on experimentally induced pain: a systematicliterature review. Chiropr Man Therap. 2012;20(1):26.

6. Pollentier A, Langworthy JM. The scope of chiropractic practice : a survey ofchiropractors in the UK. Clin Chiropr. 2007;10(3):147–55.

7. Hawk C, Long CR, Boulanger KT. Prevalence of nonmusculoskeletal complaintsin chiropractic practice: report from a practice-based research program. JManip Physiol Ther. 2001;24(3):157–69.

8. Bolton PS, Budgell B. Visceral responses to spinal manipulation. JElectromyogr Kinesiol. 2012;22(5):777–84.

9. Carrick FR. Changes in brain function after manipulation of the cervicalspine. J Manip Physiol Ther. 1997;20(8):529–45.

10. Meyer JJ, Anderson AV. Changes in brain function after manipulation of thecervical spine. J Manip Physiol Ther. 1998;21(7):498–9.

11. Turk DR. Changes in brain function after manipulation of the cervical spine.J Manip Physiol Ther. 1998;21(7):497.

12. Chea H. Changes in brain function after manipulation of the cervical spine. JManip Physiol Ther. 1998;21(7):495–6.

13. Ahadpour A. Changes in brain function after manipulation of the cervicalspine. J Manip Physiol Ther. 1998;21(7):495.

14. Lantz CA. Changes in brain function after manipulation of the cervical spine.J Manip Physiol Ther. 1998;21(6):426–8.

15. Troyanovich SJ, Roudebush M, Harrison D, Harrison D. Changes in brainfunction after manipulation of the cervical spine. J Manip Physiol Ther.1998;21(4):297–9. author reply 300-292

16. Seaman DR. Changes in brain function after manipulation of thecervical spine. J Manip Physiol Ther. 1998;21(4):295–6. authorreply 296-297

17. Lee SW. Changes in brain function after manipulation of the cervical spine.J Manip Physiol Ther. 1998;21(7):496–7.

18. Henry G. Changes in brain function after manipulation of the cervical spine.J Manip Physiol Ther. 1998;21(4):303–4.

19. Noone P. Changes in brain function after manipulation of the cervical spine.J Manip Physiol Ther. 1998;21(4):302–3.

20. Science-Based Medicine. Exploring issues & controversies in science &medicine. Chiropractic Neurology [https://sciencebasedmedicine.org/chiropractic-neurology/]. Accessed 21 March 2017.

21. Science-Based Medicine. Exploring issues & controversies in science &medicine. Blind-Spot Mapping, Cortical Function, and ChiropracticManipulation [https://sciencebasedmedicine.org/blind-spot-mapping-cortical-function-and-chiropractic-manipulation/]. Accessed 21 March 2017.

22. Carrick Institute. Institute of clinical neuroscience and rehabilitation. Aboutthe CI [https://carrickinstitute.com/about-the-ci/]. Accessed 21 March 2017.

23. Functional Neurology Society. What is Functional Neurology? [https://functionalneurology.ca/what-is-functional-neurology/]. Accessed 21March 2017.

24. Carrick Institute. Institute of clinical neuroscience and rehabilitation. FAQs[https://carrickinstitute.com/faqs/]. Accessed 21 March 2017.

25. Carrick Institute Institute of clinical neuroscience and rehabilitation.Programs [https://carrickinstitute.com/]. Accessed 23 May 2017.

26. Melillo R, Leisman G. Neurobehavioral disorders of childhood an evolutionaryperspective. Dordrecht Heidelberg London New York: Springer; 2009.

27. Arksey H, O’Malley L. Scoping studies : towards a methodologicalframework. Int J Soc Res Methodol. 2005;8(1):19–32.

28. Levac D, Colquhoun H, O'Brien KK. Scoping studies: advancing themethodology. Implement Sci. 2010;5:69.

29. Beck RW. Functional neurology for practitioners of manual medicine. 2nded. Churchill Livingstone. Edinburgh: Elsevier; 2011.

30. LOI n°2012–300 du 5 mars 2012 relative aux recheches implicant lapersonne humaine (1). In. https://www.legifrance.gouv.fr/.

31. Décret n°2016–1537 du 16 novembre 2016 relatif aux recherchesimpliquant la personne humaine. In. https://www.legifrance.gouv.fr/.

32. Beck RW. Fundamental evidence. In: Functional neurology for practitionersof manual medicine. 2nd ed. Churchill Livingstone. London: Elsevier;2011. p. 325–32.


https://www.legifrance.gouv.fr

https://sciencebasedmedicine.org/chiropractic-neurology/

https://sciencebasedmedicine.org/chiropractic-neurology/

https://sciencebasedmedicine.org/blind-spot-mapping-cortical-function-and-chiropractic-manipulation/

https://sciencebasedmedicine.org/blind-spot-mapping-cortical-function-and-chiropractic-manipulation/

https://carrickinstitute.com/about-the-ci/

https://functionalneurology.ca/what-is-functional-neurology

https://functionalneurology.ca/what-is-functional-neurology

https://carrickinstitute.com/faqs/

https://carrickinstitute.com/



33. Beck RW. History and examination. In: Functional neurology for practitionersof manual medicine. 2nd ed. Churchill Livingstone. New York: Elsevier; 2011.p. 53–86.

34. Beck RW. Fundamental concepts in functional neurology. In: Functionalneurology for practitioners of manual medicine. 2nd ed. ChurchillLivingstone. Oxford: Elsevier; 2011. p. 1–14.

35. Beck RW. Biochemistry and physiology of receptor activation. In: Functionalneurology for practitioners of manual medicine. 2nd ed. ChurchillLivingstone. Philadelphia: Elsevier; 2011. p. 29–49.

36. Beck RW. Approaches to patient management. In: Functional neurology forpractitioners of manual medicine. 2nd ed. Churchill Livingstone. St Louis:Elsevier; 2011. p. 336–8.

37. Beck RW. The cortex in: Functional neurology for practitioners ofmanual medicine. 2nd ed. Churchill Livingstone. Sydney: Elsevier; 2011.p. 179–82.

38. DeMyer WE. Examination of vision. In: Technique of the neurologicexamination: a programmed text. 4th ed. New-York: McGraw-Hill;1994. p. 86–108.

39. Beck RW. Approaches to treatment. In: Functional neurology forpractitioners of manual medicine. 2nd ed. Churchill Livingstone. Toronto:Elsevier; 2011. p. 343–79.

40. Bova J, Sergent A. Chiropractic management of a 24-year-old womanwith idiopathic, intermittent right-sided hemiparesthesia. J Chiropr Med.2014;13(4):282–6.

41. Pedro VM, Leisman G. Hemispheric integrative therapy in landau-Kleffnersyndrome: applications for rehabilitation sciences. Int J Neurosci.2005;115(8):1227–38.

42. Beck RW. Conservative therapy for complex regional pain syndrome type Iin a paediatric patient: a case study. J Can Chiropr Assoc. 2009;53(2):95–101.

43. Bova JA, Sergent AW. Chiropractic care using a functional neurologic approachfor idiopathic cervical dystonia in a 59-year-old woman. J Chiropr Med.2013;12(2):60–5.

44. Kuhn KW, Cambron J. Chiropractic management using a brain-based modelof care for a 15-year-old adolescent boy with migraine headaches andbehavioral and learning difficulties: a case report. J Chiropr Med.2013;12(4):274–80.

45. Bova J, Sergent A. Chiropractic management of an 81-year-old man withParkinson disease signs and symptoms. J Chiropr Med. 2014;13(2):116–20.

46. Hirsh O. Treatment of ADHD and enuresis by novel method. Funct NeurolRehab Ergon. 2013;3(1):85–91.

47. Traster D. 68-year-old female with apallesthesia improved through brain-based rehabilitation : a case study. Funct Neurol Rehab Ergon.2014;4(4):265–74.

48. Esposito SE, Mullin LE, Carrick FR. The treatment of persistent imbalance in apatient with traumatic brain injury using a functional neurologicalapproach. Funct Neurol Rehab Ergon. 2013;3(4):423–9.

49. Carrick FR, McLellan K, Brock JB, Randall C, Oggero E. Evaluation of theeffectiveness of a novel brain and vestibular rehabilitation treatmentmodality in PTSD patients who have suffered combat-related traumaticbrain injuries. Front Public Health. 2015;3:15.

50. Carrick FR, Oggero E, Pagnacco G, Wright CH, Machado C, Estrada G, Pando A,Cossio JC, Beltran C. Eye-movement training results in changes in qEEG andNIH stroke scale in subjects suffering from acute middle cerebral arteryischemic stroke: a randomized control trial. Front Neurol. 2016;7:3.

51. Carrick FR, Pagnacco G, McLellan K, Solis R, Shores J, Fredieu A, Brock JB,Randall C, Wright C, Oggero E. Short- and long-term effectiveness of aSubject's specific novel brain and vestibular rehabilitation treatment modalityin combat veterans suffering from PTSD. Front Public Health. 2015;3:151.

52. Leisman G, Melillo R, Thum S, Ransom MA, Orlando M, Tice C, Carrick FR.The effect of hemisphere specific remediation strategies on the academicperformance outcome of children with ADD/ADHD. Int J Adolesc Med Health.2010;22(2):275–83.

53. Leisman G, Mualem R, Machado C. The integration of the neurosciences,child public health, and education practice: hemisphere-specificremediation strategies as a discipline partnered rehabilitation tool in ADD/ADHD. Front Public Health. 2013;1:22.

54. Carrick FR, Oggero E, Pagnacco G. Posturographic changes associated withmusic listening. J Altern Complement Med. 2007;13(5):519–26.

55. Parker University Chiropractic Neurology Club. Discover. What is FunctionalNeurology? [https://www.parkerneurologyclub/what-is-functional-neurology.htlm]. Accessed 22 March 2017.

56. Rosner AL. Chiropractic identity: a neurological, professional, and politicalassessment. J Chiropr Humanit. 2016;23(1):35–45.

57. Daubeny N, Carrick FR, Melillo RJ, Leisman G. Effects of contralateralextremity manipulation on brain function. Int J Disabil Hum Dev. 2010;9(4):269–73.

58. Haavik H, Niazi IK, Holt K, Murphy B. Effects of 12 weeks of chiropractic careon central integration of dual Somatosensory input in chronic pain patients:a preliminary study. J Manip Physiol Ther. 2017;

59. Haavik H, Niazi IK, Jochumsen M, Sherwin D, Flavel S, Turker KS. Impact ofspinal manipulation on cortical drive to upper and lower limb muscles.Brain Sci. 2016:7(1).

60. Lelic D, Niazi IK, Holt K, Jochumsen M, Dremstrup K, Yielder P, Murphy B,Drewes AM, Haavik H. Manipulation of dysfunctional spinal joints affectsSensorimotor integration in the prefrontal cortex: a brain source localizationstudy. Neural Plast. 2016;2016:3704964.

61. Ogura T, Tashiro M, Masud M, Watanuki S, Shibuya K, Yamaguchi K, Itoh M,Fukuda H, Yanai K: Cerebral metabolic changes in men after chiropracticspinal manipulation for neck pain. Altern Ther Health Med 2011, 17(6):12-17.

62. APEX Brain Centers [https://apexbraincenter.com/]. Accessed 4 September 2016.63. Olympic Spine and Sports Therapy [https://www.olympicspine.com/].

Accessed 4 September 2016.64. ImagineX Functional Neurology [http://ixneuro.com/]. Accessed 6

September 2016.65. Minnesota Functional Neurology and Chiropractic [http://

mnfunctionalneurology.com/]. Accessed 4 September 2016.66. Northwest Functional Neurology [http://northwestfunctionalneurology.com/].

Accessed 6 September 2016.

• We accept pre-submission inquiries

• Our selector tool helps you to find the most relevant journal

• We provide round the clock customer support

• Convenient online submission

• Thorough peer review

• Inclusion in PubMed and all major indexing services

• Maximum visibility for your research

Submit your manuscript atwww.biomedcentral.com/submit

Submit your next manuscript to BioMed Central and we will help you at every step:


https://www.parkerneurologyclub/what-is-functional-neurology.htlm

https://www.parkerneurologyclub/what-is-functional-neurology.htlm

https://apexbraincenter.com/

https://www.olympicspine.com

http://ixneuro.com

http://mnfunctionalneurology.com

http://mnfunctionalneurology.com

http://northwestfunctionalneurology.com

Chiropractic & Manual Therapies - Unravelling functional … · 2017. 8. 24. · Chiropractic...

Documents

Transcript of Chiropractic & Manual Therapies - Unravelling functional … · 2017. 8. 24. · Chiropractic...