In the Dutch Medical Journal, authors from the University Hospital St. Radboud in Nijmegen, Netherlands, report a tragic case history of an infant dying after being treated by a craniosacral therapist.
Deceased infant after “craniosacral manipulations” of neck and vertebral column
A formerly healthy, three-month-old girl died after manipulation of the neck and the vertebral column by a so called “craniosacral therapist.” During continued and deep bending of the neck, the patient developed incontinence of faeces, atonia and respiratory arrest followed by aystolia. Based on findings at the physical examination of the body, an additional MRI examination and the autopsy, it is likely that the cause of death was a local neurovascular or a mechanic respiratory-induced problem. This is the second report of infant death after forced manipulation of the neck. As long as there is no scientific evidence for the efficacy and safety of forced manipulation of the neck and the vertebral column, we advise against this treatment for newborns and infants.
Manipulations of the neck and the vertebral column are applied world-wide for very different symptoms. Although there is no conclusive evidence for the usefulness of this technique (1), it is also used with infants, to counteract excessive crying, motoric unrest and an asymmetrical positional preference of the head.
In this article, we describe the decease of an infant, following forced manipulations of the neck and the vertebral column. For this we made use of the hetero anamnesis of the parents who were present at this procedure.
Patient A was a three-month-old, healthy girl. Because their child exhibited mild motor unrest, the parents contacted a so-called “craniosacral” therapist who, after a short introductory interview, started administering the craniosacral therapy. He placed the child on her back on a changing mat, after which he palpated the neck and the skull. The patient cried vehemently at this. Then she was turned to her right side and a deep bending of the vertebral column was applied at which the chin touched the chest, as shown in figure 1. After the vertebral column was bent deeply in this manner during several minutes, the child lost faeces and several loud intakes of breath were clearly audible. The therapist interpreted this as a deep sleep, which he said was normal during the treatment. After about 10 minutes the girl was placed on her back and blue discolouration of the lips was apparent. The child was limp now and did not react to touching. The father started mouth-to-mouth resuscitation. Alerted ambulance personnel on arrival saw a deceased infant with asystolia. One hour after the reanimation had started, the patient showed a heart rate again with palpable pulsations. On arrival at the hospital, an intubated infant was seen with a body temperature of 32°C, a heart rate of 120 beats per minute and a bloodpressure of 60/30 mmHg. Physical examination of heart, lungs, abdomen and extremities showed no particularities. Without sedation the Glasgow Coma Score was E1M1Vtube. No abnormalities were seen in conventional radiology examination of the torso and the extremities. There was overall hypotonia, while tendon reflexes, cornea reflexes, oculocephalic reflexes and coughing reflexes were absent. A CT scan of the brain, the neck and the vertebral column showed no abnormalities, recent hemorrhages, fractures or dislocations. The MRI examination of the head, the neck and the vertebral column showed abnormalities within the pons and mesencephalon, corresponding with ischemia in the vertebrobasilar artery basin. Especially in the cervical part of the spinal cord and medulla oblongata signal abnormalities were seen (figure 2).
Radiological differential diagnosis of images of the cervical spine could point to direct trauma or overall asphyxia.
The cerebrum was oedematose, non-abnormal basal nuclei. No indications were found for dissection of the neck arteries, congenital anomalies, fractures, band injuries or haemorrhaging. Laboratory testing showed a metabolic acidosis with a pH of 6.62 and an elevated lactate concentration: 20 mmol / l (reference values: 0,5-1,7), and abnormal kidney and liver functions. Microbiological examination showed no indications of of a bacterial or viral infection. The ECG showed no abnormalities, the QT-time in particular was not extended. Ultrasound examination showed non-abnormal anatomical characteristics of the heart and a good left ventrical function. In fundoscopy, sharply defined papillae were seen on both sides, without bleeding in the retina.
While in the department of Pediatric Intensive Care, the infant developed further signs of progressive multi-organ failure and 12 hours after the manipulation, continued spontaneous breathing activity, brainstem reflexes and tendon reflexes remained absent. After multidisciplinary consultation we decided to stop the treatment. The girl died a few minutes later.
In the autopsy by the Dutch Forensic Institute, recent infarctions were seen in the spleen and the heart, corresponding with lack of oxygen and multi-organ failure. The brain showed signs of hypoxic encephalopathy. On a number of levels in the spinal cord, subtle axonal abnormalities were visible, which could have arisen because of hypoxia or stretching of the vertebral column. There were no indications of congenital deformities, organ abnormalities or infections.
In the death of this patient the following factors may have played a role.
During manipulation of the neck, the cervical spine may be wedged by the vertebral column. As the skeleton of infants consists mainly of cartilage, this may occur without radiologically visible abnormalities of the spine (2).
Temporary irritation or wedging of the myelum can result in a neurogenic bradycardia with apnoea.
Vegetative reactions, including apnoea and flushing of the face were seen earlier in 53% of infants during manipulations (3).
In another study, reduced heart rate after manipulation of the neck was observed in 40% of the infants. Children younger than 3 months developed more serious bradicardias; 12% of the children had apnoea (4).
During manipulation of the neck indirect neurogenic damage can arise because of injury or wedging of the A vertebralis (5). Ischemia of the myelum can generate symptoms of a high spinal cord injury (6).
A forced curved position of the neck may cause obstruction of the upper respiratory tract. Infants are more sensitive to airway obstruction than adults because of the relatively large tongue, narrower airways, weaker cartilage and the anterior position of the larynx (7). Also, thoracic breathing can be hampered by the curved posture.
On the basis of further investigation in our case, no signs of an infection, congenital abnormalities, cardiac or gastro-intestinal disorders were found. Given the relationship between spinal manipulation and the emergence of symptoms, a causal relationship seemed plausible.
Next to well-known risks of manipulation of the spine in adults (8), in 2005 the risks of spinal manipulation in infants were already pointed out. To this date, the decease of one other infant after manipulation of the vertebral column has been described (9). In that case the head of the infant had been rotated with some force. Our case demonstrates that also with a forced deep bending of the neck fatal complications may arise. As long as there is no scientific evidence for the efficacy and safety of forced manipulation of the spine, we advise against this treatment for infants.
The events of this case history prompted the public prosecution office to start an investigaton of the case.
- There is no scientific eviedence of the efficacy of forced manipulations of the vertebral column in children.
- Forced manipulation of the vertebral column in a child can lead to serious complications.
University Medical Centre St Radboud, Nijmegen.
Dept. of Orthopedic Surgery: Dr. M. Holla, orthopedic surgeon.
Dept. of Pediatric Intensive Care: Dr. M.M. Ijland, pediatrician, fellow pediatric intensive care; Dr. C.W.M. Verlaat, pediatric intensivist.
Dept. of Radiology: Dr. A.M. van der Vliet, neuroradiologist.
Dept. of Surgery: Dr. M. Edwards, surgeon.
||Brand PLP, Engelbert RHH, Helders PJM, Offringa M. Systematisch literatuuronderzoek naar de effecten van behandeling bij zuigelingen met ‘kopgewrichteninvloed bij storingen in de symmetrie’ (‘KISS-syndroom’). Ned Tijdschr Geneeskd. 2005;149:703-7.
||Pang D, Wilberger JE Jr. Spinal cord injury without radiographic abnormalities in children. J Neurosurg. 1982;57:114-29.
||Koch LE, Biedermann H, Saternus KS. High cervical stress and apnoea. Forensic Sci Int. 1998;97:1-9.
||Koch LE, Koch H, Graumann-Brunnt S, Stolle D, Ramirez JM, Saternus KS. Heart rate changes in response to mild mechanical irritation of the high cervical spinal cord region. Forensic Sci Int. 2002;128:168-76.
||Kuitwaard K, Flach HZ, van Kooten F. Dubbelzijdige A.-vertebralisdissectie tijdens chiropraxiebehandeling. Ned Tijdschr Geneeskd. 2008;152:2464-9.
||Brand MC. Part 1: recognizing neonatal spinal cord injury. Adv Neonatal Care. 2006;6:15-24.
||Turner NM, van Vught AJ. Advanced paediatric life support. 2e dr. Maarssen: Elsevier Gezondheidszorg; 2006.
||Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med. 2007;100:330-8.
||Jacobi G, Riepert Th, Kieslich M, Bohl J. Über einen Todesfall während der Physiotherapie nach Vojta bei einem drei Monate alten Säugling. Klin Padiatr. 2001;213:76-8.
Micha Holla, Marloes M. IJland et al. Ned Tijdschr Geneeskd, 2009
Members of the Dutch professional society of manual therapists:
May 8, 2009
Despite the fact that the authors have been very careful in their search for an explanation for the cause of death of the deceased infant, they do not succeed in establishing the likelihood of a causal relationship between this death and the therapy that was performed. Less careful is the way in which they have formulated their conclusion. On the basis of no more than an assumption, a negative advice is given on a therapy. Holla et al are neither qualified nor competent to do so. This seems inappropriate to us.
Should there appear to be a causal relationship however, then we can agree with the authors that possibly the therapist acted incompetently or negligently. This would be uncommon however and no reason to advice against or reject a therapy as such. In the medical world complications occur regularly in all disciplines and when negligence is established, measures are taken against individuals and institutions and not against an entire discipline.
Holle et al conclude that this is the second report of the decease of an infant after forced manipulation of the neck. If there has actually been a spinal manipulation as described in the nomenclatura of the manual therapist, then the acting craniosacral therapist has crossed the boundaries of his profession. The same applies to the other case which is referred to, where a children’s physiotherapist went outside the competence of her own field and applied manual therapy, for which she was neither authorized nor qualified, with disastrous consequences.
Holla et al had better call for the manipulation of infants by manual therapists only. Within the field of manual therapy, infants with asymmetrical head turning (excessive crying, KISS children) are treated. Training is done by the European Workgroup for Manual Medicine (EWMM). The EWMM manages a specialist register and initiates research. Treatment data have been registered since 2006 and on the basis of that we can report that (KISS) manual therapists have treated more than 21,000 infants in 66,239 treatment sessions without any complications. At the Faculty of Epidemiology of Maastricht University a cohort study with a control group is in preparation, in which the efficacy of manual treatment in asymmetrical infants will be studied.
Lastly, we would like to point out that a specialised manual therapist would never apply manipulations in the treatment of infants, let alone forced manipulations of which Holla et al speak. Rather, the description should read: targeted mobilizing impulse of very low intensity.
Practice for MT & FT, Boxmeer, the Netherlands
Eric Saedt & Bé van der Woude, manual therapists and members of the EWMM Nederland
Dutch craniosacral therapists:
The Nederlandse Cranio Sacraal Vereniging (Dutch CranioSacral Association) does not recognise this manipulation. According to a spokeswoman, craniosacral therapy tries to solve physical and psychological problems by “following the movement of the brain fluid with the hands, leading to a relaxation of the body.”
The therapist is not known at the professional association. The spokeswoman says that this could indicate that the practitioner isn’t certified.
Register CranioSacraal therapie Nederland (RCN), Velp; Verenigingen voor Upledger CranioSacraal therapie Nederland en Duitsland (Societies for Upledger CST Netherlands and Germany); Upledger Instituten Nederland, Duitsland en België (Upledger Institutes Netherlands, Gemany and Belgium)
Karin van Deelen-Wortman, secretaris RCN (Secretary RCN)
May 25, 2009
(1)The actual cause of death is unclear. Two possible causes are mentioned of which a direct link to the decease is not proven. The MRI images could be consistent with a “direct trauma or with overall asphyxia” and the autopsy report mentions “subtle axonal deviations which could have been caused by hypoxia or stretching of the spinal cord.”
In the article a causal relation is assumed between spinal manipulation and/or forced deep bending of the neck and the occurence of the symptoms. This is premature and wants further research and discussion, especially with regard to the following:
- the case history is based completely on the findings of the hospital and the heteroamnesis of the parents. The report of the therapist who treated the infant was not used to link actions and symptoms to a time line.
- A “direct trauma or stretching of the spinal cord” as the cause of death was not demonstrated. “Overall asphyxia with hypoxia” or other causes were not excluded.
- That the patient was healthy and without injuries before the treatment was not demonstrated.
- That the alleged mechanical force was applied during and because of the treatment was not demonstrated.
- The life saving and stabilizing measures may have contributed to the results of the MRI exam and the autopsy.
(2) It is unclear what is meant by “forced manipulation” and “forced deep bending.” It was not even shown that such actions were used during the treatment. The relation between such manipulations and CST is unjustly made.
The assumptions in this case history are premature. In our opinion, further research and discussion are necessary.
Reply from the MDs treating the infant:
May 26, 2009
The incidents during the treatment were described by both parents. At numerous moments they have given coherent and reproducible description of the incident. We see no reason to doubt their statements. Due to medical confidentiality we have not been in contact with the therapist. No public statement of the therapist is available and we have not received a reaction from the therapist.
Apart from mild motor unrest the parents described no symptoms indicating earlier illness or serious afflictions. The GP’s medical contained nothing remarkable either. Directly prior to the treatment, the child was awake, showed normal movements of arms and legs and reacted well to external stimuli. With the help of extended examinations and autopsy no indications were found that the child had been ill previously or had any congenital defects. Therefore we speak of a newborn being healthy before treatment.
Both parents have described that the therapist actively bent the girls head, neck and beck with both hands. This was done with such force that the chin touched the breast. Therefore we speak of a forced bending of the neck. All the time during the reanimation, the neck and the vertebral column were completely immobilized by the medical team. Because of the accident mechanism, in the hospital the neck and the vertebral column were not bent again. The axonal damage of the spinal cord consistent with stretching, which was observed during the autopsy, therefore cannot be explained by the life saving measures that were delivered. Also, the distinctive features of lack of oxygen of the brain and the organs cannot be reduced to the life saving and life stabilizing actions. On the contrary, these actions are specifically aimed to supply the patient with oxygen.
In our article we describe various pathophysiological mechanisms as the possible cause for the symptoms that were observed. Which of these is responsible for the fatal outcome remains unclear. The fact remains however that the serious symptoms which eventually led to the death of a newborn girl occurred during the deeply bent position of the neck and the vertebral column. The findings of the additional examination and the autopsy are consistent with previous over-stretching of the spinal cord, cardiac arrest and respiratory problems and confirm the causal relation between the forced position and the symptoms described.
We find it worrying that the people who perform these manipulations deny or do not recognize the relation between forced bending of the vertebras and the occurrence of serious symptoms. With this case report we hope to prevent another incident like this.
University Medical Centre St Radboud, Nijmegen.
Micha Holla, Marloes IJland, Michael Edwards, Ton van der Vliet & Carin Verlaat.