TWB is a 17-year-old male who presented with learning disabilities and inability to concentrate.

When his mother was pregnant, she developed a pulmonary embolus and as a result the placenta received less blood. She was subsequently on heparin throughout the rest of the pregnancy. TWB was born 4 weeks premature, at a weight of 1645 g, via an emergency C-section because his heart had stopped, but his lungs were fully developed. TWB reports that he has experienced no trauma to the head nor taken any antibiotics or orthodox medicine. He has experienced no childhood viruses that were out of the ordinary. TWB was evaluated for ADHD when 4 years old by a homeopathic physician, who found him to be within normal limits for his age.

TWB complains of blurry vision to close objects. He reports that he has not had his eyes checked in the past year. No balance problems were present. His concentration is interrupted every few minutes. Coordination is not up to par. Spicy and junk food gives him stomach trouble. He reports no headaches. Dizziness is felt occasionally throughout the day. Shoulder and rib pain is occasionally bilateral. He complains of achy bones lately, and also reports he may have a tendency towards obsessive–compulsive activities. TWB was extremely affected when his parents broke up. He was afraid he would not see his father again. His father believes that he has lost respect for women because of the break-up. TWB’s stepfather is verbally abusive towards his mother but not to TWB. It bothered TWB when his mother and stepfather got married.

A diagnosis of attention deficit hyperactivity disorder (ADHD) secondary to right cortical hemisphericity was made. To confirm the diagnosis, follow-up qEEG analysis was undertaken, where a large increase in theta:beta power ratio supported by decrease in absolute beta and high beta power over frontal and central regions particularly the vertex (Cz) was found. However, there was no significant increase in absolute theta power. Typical ADHD has these signs, as well as an increase in absolute theta, which is also present. Therefore the results of this qEEG are consistent with previous history-based diagnosis of ADHD with an associated learning disability. These conclusions were made from linked ears analysis and Laplacian (looking at default report settings enabling determination of power ratios).

A follow-up qEEG is planned to document any changes since therapy was instituted. It is expected that TWB will continue to improve in all areas of concern until his full potential is reached.

The pattern of signs and symptoms revealed during TWB’s functional neurological consultation provide an insight into the possible levels of dysfunction in the longitudinal and horizontal planes of the neuraxis. Localisation of the lesion is assisted by a comprehensive knowledge of the afferent and efferent connections throughout the neuraxis and an ability to ascertain the frequency of firing (FOF) and integrity of fuel delivery in different regions and systems. History and examination directed at localising the symptoms to a specific level of the neuraxis, including the following well-defined functional levels, is necessary:

Asymmetry or dysfunction in each of these components of the nervous system can directly or indirectly affect various motor, sensory, visceral, and mental functions or indicate a dysfunction in any of these modalities.

Most importantly from a functional neurological perspective, asymmetry or dysfunction in the most influential components of the nervous system should be considered:

In the case of TWB, he showed signs and symptoms of left cerebellar and right cortical dysfunction. This was expressed in the physical exam by his relative lack of coordination on the left, his pupillary TND on the right, Romberg’s test falling to the left, his lack of ability to concentrate, and the hyperresponsiveness of his right-sided reflexes, which indicates increased tone due to decreased activation of the PMRF ipsilaterally.

ADHD is thought to occur as a result of an inability of the individual to maintain attention on a primary task because of an inability to inhibit or suppress motor responses to incoming sensory stimuli (Barkley 1997). Some consistency has been found in people with dysfunctions of the right frontal cortex in that they express great difficulty in suppressing motor responses to incoming sensory stimuli (Sergeant 2000). The right frontal cortex functions in some manner to inhibit inappropriate motor responses in a normally functioning brain. The activity of the right frontal cortex relies heavily on the dentato-ponto-cortical and dentato-rubral-thalamo-cortical pathways. Asymmetric reduction in afferent information to the cerebellum because of asymmetric dysfunctional peripheral afferent pathways may cause diaschisis in functional circuits downstream from the cerebellum, in this case the contralateral cortex. In this case, the application of manipulation to increase the afferent stimulus received by the cerebellum and other therapies aimed at increasing the activation of the right frontal cortex were successful in reducing the patient’s symptoms and ultimately his state of disability.

RS initially presented to another practitioner with a chief complaint of low back pain. The other practitioner manipulated RS’s neck and he immediately felt light-headed and developed a left-sided paraspinal muscle spasm in the cervical spine. RS left the practitioner’s office but felt unstable while walking and developed nausea within minutes of leaving. One to two hours following the manipulation RS reported an increase in the nausea and flashing sensations in his left eye. He also reports feeling a sense of mounting confusion. The neck pain and spasm intensified as the night progressed to the point that RS screamed out in pain. At this point he also developed a headache and notes that his body felt cold.

RS reports that the following day he had a persistent headache, nausea, confusion, and visual disturbances in his left eye. He also reports that he had developed a tremor in his left hand. RS returned to the initial practitioner and explained his symptoms. The initial practitioner palpated RS and proceeded to adjust the co/occipital region. RS reports no change in symptoms following the adjustment.

RS attended the initial practitioner again the following day and he manipulated C1 bilaterally. RS noted immediate worsening of his symptoms and became increasingly unstable while standing and walking. RS was referred to my clinic for evaluation.

A left occipital headache, which changed sides occasionally, had been present since the first adjustment. RS still reported light nausea which was exacerbated by walking. He reported his left eye felt dry and larger than the right. The visual field of the left eye remained blurred, with spotted blacked-out areas noted occasionally. He still had difficulty focusing. RS still felt confused and noticed difficulty forming sentences. He had a noticeable tremor of his left hand that had gradually worsened. He reported a feeling of unsteadiness on his feet and walked with a wide-based gait pattern. Pain was still present in the left cervical region.

RS presents with the clinical signs of a vestibular-cerebellar dysfunction on the left and right decreased cerebral hemispheric function. The cause of the dysfunction may be vascular or physiological in nature.

CT scan of the medulla–pons and cerebellar regions was conducted to rule out vascular damage. The results of these tests were inconclusive. Soft tissue and trigger point therapy was initiated to relieve the soft tissue trigger points. Left-sided manipulation was performed in a graded fashion to restore normal kinematics to his spinal motion segments and peripheral joints. The cervical spine was not manipulated until several weeks into therapy.

The patient was given breathing exercises to improve oxygenation levels. RS was also given omega 3 fish oils, CoQ₁₀ and B-complex supplementation to help in neuron repair processes.

RS experienced a rapid reduction in his symptoms over the first week of treatment. This was followed by a gradual improvement over the next 8–10 weeks. His gait has returned to normal, he has normal OPK testing results, and his headaches are gone. He still feels that he experiences periods of confusion but these are also becoming less frequent and less severe.

It is my hope that RS will continue to improve until he has returned to his previous state. In my experience, about 70% of these types of presentation will return to essentially normal function with continued treatment; however, about 30% of these patients will not return to their previous state despite further treatment.

I have included this case for a number of reasons. Firstly, it is important for manipulating practitioners to understand that the manipulations they give are, for the most part, helpful to the patient; however, they can also hurt the patient when delivered in an inappropriate fashion (Carrick 1997). Secondly, it is important for functional neurologists to know how to handle this type of case because these cases tend to be referred to us for an opinion at some point.

RH was in France where it was proposed she took some marijuana laced with some chemical, which resulted in some form of encephalitis developing. The resulting state of depression led to her attempting suicide by hanging herself. She was hypoxic for approximately 4–6 minutes before she was found and taken down. She has since received a variety of medications that have resulted in various forms of brain insults and has left her in a somewhat catatonic state. Her mother related that she is basically of the same temperament and personality as previously but now she exhibits the more negative emotional parts of her personality.

Depression and catatonic state.

RH responded in monosyllables (yes, no, fine) to most questions. She lacked the ability to sustain visual attention for more then 3–5 seconds in both right and left visual fields. Visual tracking was dyskinetic to the left. Her pupil responses were fast and fatiguing on the left. She exhibited anisocoria with the right pupil dilated. She showed good and accurate response to palmar dermatographia bilaterally. She showed no signs of extinction to touch in the C5–8 dermatomes but did to hearing on the left. Her reflexes (C5, C7, L4, S1) were diminished and fatiguing on the left. Heart rate was increased and stomach sounds decreased. No abdominal rigidity was noted. Both hands and feet were cold to touch. She stated her hands were always like this. Muscle strength was good in both hands. She could remember 5 of a 7-digit number immediately but no numbers 2–3 minutes later. RAM revealed a generalised lack of coordination in both hands but worse on the left. During Romberg’s test, RH fell to the left repeatedly with eyes closed.

MRI and EEG reports showed findings consistent with anoxia. qEEG results showed a significant increase in beta and high beta over the right hemisphere, particularly central regions and occipital regions. Also present were major but fairly localised right hemisphere dysfunction, in particular central to the mid-temporal region. The raw EEG data also revealed what appeared to be an asymmetric ‘spindle coma’ pattern, which is responsible largely for the significant increase in beta/high beta over the right hemisphere. These findings are consistent with anoxic injury or dysfunction, especially triggered by high doses of barbiturates.

Generalised cortical dysfunction, mainly involving the right hemisphere, secondary to an acute anoxic episode.

Sound therapy was utilised in this case. RH was advised to listen to Mozart or similar music from the left side for 10 minutes per day. Breathing exercises were also instituted to increase her oxygenation levels, initially for 2 minutes twice a day with expansion to four times per day after 2 weeks. Manipulation was performed to restore normal motion to the spinal motion segments and peripheral joints on the left side of her body. Supplementation with omega 3 fish oils, CoQ₁₀, vitamin B complex, and amino acids was also instituted. After 4 weeks of care, RH was instructed to look at old photo albums and make up stories about the pictures, then try to recall these stories at various times throughout the day. After 6 weeks of treatment, RH was also given the task of completing jigsaw puzzles with her left hand only.

RH has shown remarkable progress considering her presenting state. She now answers in simple sentences instead of one-word replies. Her mother reports that her ‘facial expressions look more human’. RH is now showing initiative in performing her daily chores. She does not fall on Romberg testing. qEEG follow-up showed significant changes, including a more normalised alpha pattern over the frontal lobes.

RH will continue to receive therapy employing novel stimuli, manipulation, and supplementation with the hope of further return of function.

I think this case demonstrates the incredible ability that the neuraxis has to restore function when given the appropriate conditions. This young woman, who was previously a Rhodes Scholar recipient, has undergone a series of traumatic cerebral events, exposing her brain to severe biochemical and physical stresses, but still the brain retains the amazing ability to maintain plasticity and recover.

A 47-year-old man, JS, presented with the chief complaint of left foot drop and low back pain centralised over the L5 region.

JS was involved in a serious skiing accident 2 years previous where he was paralysed from the waist down for several days. He eventually recovered and experienced no problems until last week when JS was lifting some packages from the boot of his car. He felt his back snap and immediately felt low back pain over the L5 region. Over the next 2 days he noticed that his left foot was numb and not functioning properly. He also noticed that his ability to concentrate had diminished and his short-term memory had been affected.

Lumbopelvic AP, lateral, and oblique radiographs were unremarkable with the exception of mild osteoarthritic degeneration at L5/S1. MRI showed a small disc protrusion at the L5/S1 disc.

Mild right hemisphericity secondary to spinal root compression at L5/S1.

JS received manipulation to address the altered spinal motion units and dysfunctional peripheral joint motion units discovered on examination. He received a natural anti-inflammatory supplement and multivitamins. He was given rib adjustments and breathing exercises to increase his oxygenation.

JS is now pain free. The numbness over his left foot still reoccurs from time to time but he feels very pleased with the outcome to date. He was originally scheduled for spinal fusion surgery, which he has now cancelled.

This case was included because it demonstrates that simple musculoskeletal problems also respond to functional neurological application. It was also included because it is a good case for illustrating the concept of localising the problem to the longitudinal level of the lesion. Some of my diagnostic considerations at each longitudinal level in this case included:

These considerations were systematically ruled in or out by physical examination findings or further imaging such as MRI.

Migraines and balance problems to the point that she falls over.

DC is a 57-year-old woman who initially noted the onset of dizziness and left-sided facial weakness 2 weeks prior to presentation. The facial weakness was noted only during migraine headaches, which she also had been getting for the past 2–3 years. She currently had a headache for the past 3 weeks straight. She experienced high stress in her profession and had been under extremely high stress for the last 6 weeks. She also reported that she fell and injured her neck quite badly 6–7 years previous. She had attended her general practitioner three times over the past 3 weeks with no improvement in symptomatology.

A number of diagnostic possibilities were considered in this case:

A final working diagnosis of migraine syndrome secondary to right hemisphericity was made and treatment instituted on that basis.

AV, an 8-year-old female, presented with unbearable left leg and foot pain without any sensation of touch or pressure, along with depression.

AV underwent surgery for the removal of ear grommets 9 months prior to presentation. Before administration of the anaesthesia, the nurse noted that AV had a rash on her arms and neck. The anaesthetist also noted the rash but thought that it was not an issue of concern. Following the surgery, AV developed pain and lost motor control of both her legs. She reported to the emergency department and was diagnosed with viral myalgia. Over the next several weeks, AV reported to the emergency room several times and was extensively evaluated with no explanation given for her pain other than viral myalgia. She was discharged to her mother’s care and sent home.

AV was still experiencing loss of motor control and chronic pain in both legs, but especially the left leg on presentation. Her mother had been carrying her everywhere and carried her into the office today.

Cervical spine AP, lateral, and oblique radiographs were unremarkable. MRI was also unremarkable.

Previous medical testing had ruled out meningitis and tumour as a differential. The diagnosis of complex regional pain syndrome secondary to asymmetric hemispheric function was made.

Manipulations were performed initially only on the legs. Eventually, manipulations of the entire spine were carried out. Supplementation including omega 3 fish oils, amino acids, and standard multivitamins were instituted. Orthotics were fitted to provide support for her feet, which were highly pronated due to the lack of use. Breathing exercises were introduced. When spasms of pain occurred she was instructed to count backwards from 100 by 7s to increase the activation level of her cortex and inhibit the pain somewhat. This technique appeared to be highly successful. Hot and cold compresses were applied to her legs on a daily basis.

AV showed a remarkable recovery with the return of full control of her legs and full weight bearing after 3 weeks of treatment. She still experiences bouts of pain that may last 2–3 hours in duration but has returned to a virtually normal life, attending school and playing soccer.

When asymmetry of function between hemispheres occurs, as appears to be happening in this case, quite commonly a decrease in the ability of the cortex to excite certain areas of the brainstem including the mesencephalon and other areas, namely the PMRF, ensues. A decreased excitation of the PMRF can result in a decrease in inhibition of the intermediolateral (IML) cell column, which results in increases in sympathetic activity. This can lead to dysautonomia and result in somewhat bizarre symptomatology, including the development of complex regional pain syndrome.