As most insurance professionals and litigators know, the hot new trend for plaintiffs’ attorneys is to turn whiplash cases with significant insurance limits into mild Traumatic Brain Injury (mTBI) cases. Such cases raise the stakes for insurers and litigators because they are expensive to defend and create more exposure for insureds and their indemnitors.
Because the symptoms for mTBI are subjective, and common in the general population, plaintiffs’ attorneys have turned to functional neurologists to litigate their mTBI claims. To fight back against these expensive, possibly exaggerated claims, we must understand what functional neurology (FN) is and how to defend against it.
FN, sometimes called chiropractic neurology or clinical neuroscience, has its roots in chiropractic care. In Washington state, for example, there are only a handful of certified functional neurologists, and all are trained chiropractors. It is important to understand that, although they master the jargon of neurology and have a chiropractic diploma in functional neurology—and perhaps several types of fellowships—none are board-certified neurologists.
This amorphous definition of FN frees up entrepreneurial chiropractors to create their own genre of medicine. FN offers to treat many and varied conditions by rehabilitating specific areas of the brain through various repeated exercises and even using spinal manipulation. Popular indications for treatment are mTBI and other brain-based conditions such as Alzheimer’s disease and autism.
A Brief History of FN
The scientific background of FN is not well-recognized. As its developer and main promoter, Frederick Robert Carrick is considered the father of FN. He is a chiropractor who graduated from a Canadian chiropractic college in 1979 and started teaching this approach soon after. Twenty years later, he obtained a Ph.D. degree, in education, from Walden University, an online college. Carrick created his own teaching institution, the Carrick Institute, which is very active, providing many courses both online and through seminars all over the world. An attendee can take online courses on FN to become a diplomate in neurology (DACNB), issued by the American Chiropractic Neurology Board, and can become a fellow in functional neurology. However, this neurology does not correspond to ordinary mainstream neurology.
It is difficult to obtain published information on FN, as it is taught in private seminars. However, an extensive scoping review revealed that one of the core elements is the concept of “disturbed clusters of neurons” said to be under- or overstimulated. Presently, there are no imaging procedures to prove or disprove this theory. Nevertheless, in FN, these hypothetically disturbed neurons are diagnosed through various neurological tests and questionnaires that may be interpreted differently in FN from how they are used in mainstream neurology.
Although FN consists of many known and promising novel elements from mainstream medicine and neurology, they are, as explained by Carrick in a 2014 article, put together in a different way. It is, however, difficult for non-experts to see when it crosses the line to become nonstandard because it is presented with complicated and confusing neuro jargon.
Strangely, despite Carrick having taught FN for more than 40 years, and FN’s assertive promises and (possibly) widespread occurrence, the clinical effects of this treatment have never been tested appropriately in clinical studies. The effect of treatment was, instead, mainly sought to be substantiated through simple case reports and in outcome studies without control groups. When control groups were included, the study methodology was found not to be appropriate, as revealed in two systematic reviews published in Chiropractic & Manual Therapies. Carrick has spent his time producing a fair number of publications, consisting mainly of topics irrelevant to testing the effect of FN, as can be seen by searching for his name in PubMed.
Scope of Practice and Therapeutic Approach
We have observed that FN treatments often are preceded by extensive neurological tests and questionnaires, and that they are assisted by an arsenal of machines, computers, movements, and cognitive exercises, which would be both daunting and tiring. Because functional neurologists are not bound by a restrictive standard of care, they may use unusual gadgetry that may impress their patients (e.g., sniffing sticks for smell, end-tidal carbon dioxide for respiratory rates, video nystagmography machine for gaze holding, treadmill for oxygen levels, light-up board for cognitive reaction time) to develop data to diagnose “functional deficits” and also to treat them.
Because functional neurologists search also for subtle signs, the examination procedure may be extensive, perhaps lasting several hours. These findings then govern the treatment, and so the same examination may be performed at each treatment session to direct the treatments. This explains why treatment sessions are time-consuming, and as they are also often frequent, the “disorder” and its treatment may turn into a time-consuming, all-encompassing experience. The data, which may amount to hundreds of pages of aggregated information, are not comprehensible to the patient (nor to certified medical experts in neurology), so the treatment is loosely based on a “trust me” agreement.
Because most people will test “positive” on at least some of the myriad questionnaires and physical tests that we have seen used in FN, patients consulting functional neurologists may emerge with a large set of diagnoses, such as dysregulated autonomic nervous system, hyperkinetic activity, and fatigable systems embedded within the original mTBI label. Further, in our experience, functional neurologists are even able to turn every detailed, seemingly irrelevant finding, such as loss of bowel control or scratchy throat, into an mTBI-related diagnosis.
Effect on Patients
Examination and treatment would most likely be very impressive and cause concern in the patient, and may even have a nocebo effect. Or, as a client who claimed compensation for mTBI stated in relation to her visits to a functional neurologist, “I did not know how ill I was.” This person even refrained from applying for a job because the experience with the functional neurologist made her think that she would be incapable of doing the job.
Even more scary would probably be if the functional neurologist claims to have detected future diseases and problems even before symptoms arise. This would be possible because these clinicians believe they can detect dysfunctional and not necessarily pathologically affected neurons, and are therefore able to “communicate” with a disturbed but not yet pathological brain.
Despite promises of miraculous outcomes, cases we have come across have not really improved and have continued receiving brain injury diagnoses. Plaintiffs’ lawyers should therefore consider the ethical aspects of subjecting a client to extensive tests and long, arduous, and expensive treatments only to risk the patient emerging convinced of being permanently brain injured from a minor injury that may or may not have had an impact on the brain.
Obvious Diagnostic Weaknesses
The whole encounter may appear very innovative, promising, and impressive. Nevertheless, there are three major problems with the interpretation of findings. First, if there is no baseline for these tests and questionnaires, it would not be possible to know what developed after the mTBI and what was already there before. Second, functional neurologists will often throw a wide net, examining a variety of functions to then take into account very subtle findings that other clinicians would consider irrelevant. Third, such subtle findings must be reproducible to assure that they are not mere signs of everyday fluctuations. This seems to be disregarded and is likely to explain the many and unusual diagnoses.
A fourth problem is that chiropractors are not educated to deal with non-musculoskeletal conditions, nor do they have a specialty in neurology. However, this is irrelevant in FN, as the diagnosis and subsequent treatment depend entirely on the many subtle tests used with this approach, making it largely irrelevant to understand the underlying pathophysiology. Thus, a person with Alzheimer’s disease may receive a treatment identical to somebody with Parkinson’s disease, and an autistic child may be treated in the same way as somebody with sciatica, whereas two persons with the same condition may receive completely different treatments.
Real or Pseudoscience?
Warning bells would ring for most educated people. But because anything to do with the brain is impressive and mysterious, it may be difficult to distinguish between real neurologists and those with a non-traditional approach, perhaps with elements of pseudoscience. A definition of pseudoscience is that it appears scientific but lacks substance. It is to be noted that not all aspects of a pseudoscientific treatment approach automatically lack clinical value, but rather that its claims greatly outstrip the evidence or even reality. Following are some warning signs for pseudoscience that may further underpin the intuitive feeling of alarm:
• The method of treatment was developed by a single person—a guru.
• The developer acts in a field outside his expertise.
• The indications of treatment are extensive—many different things can be treated.
• Claimed treatment outcomes appear to be too good to be true.
• Claims are often such that they cannot be tested scientifically (such as detecting clusters of dysfunctional neurons).
• The “proofs” are mainly reported verbally as successful clinical cases or, when published, as case reports or case series without comparing the results with those of proper control groups.
• Documentation is difficult to obtain, as it is typically taught in private seminars for a fee.
• Scientific publications on the topic are scarce and do not obey the rules for acceptable research practice.
In sum, a functional neurologist would:
• Claim to have a specialist education in neurology and possibly various specialist fellowships.
• Look for obvious but also minor signs and symptoms.
• Claim that these findings can be traced to specific neurological pathways and specific areas of the brain.
• Probably provide many diagnoses, based on both obvious and minor findings.
• Offer an extensive treatment program claiming to be able to reeducate the relevant areas of the brain.
• Report this in jargon that is difficult to understand, in a long and impressive-looking document.
• Strengthen the client’s impression of having a severely ill brain, making a multi-million-dollar claim feel reasonable, regardless of whether this is the case or not.
Further, it is possible that a functional neurologist may diagnose the event of a TBI based merely on the test results and not on the (confirmed) history of such injury.
Because there are relatively few functional neurologists, there are no obvious rebuttal experts in the field that are able and willing to discuss and possibly expose the FN business, making it difficult to identify the FN standard of care. To defend against these purported experts, we must understand how the FN practice differs from mainstream neurology, as this will be pivotal in our defense.
Our advice is to take the time to understand FN and its practitioners: Learn about their certification system. Make sure to retain an expert that understands the origins of FN and how it can be used to manipulate patients and others using non-standard, potentially pseudoscientific approaches. Also make sure to retain highly-trained and board-certified physicians to provide a stark contrast to the limited resumés and lack of supervised experience of chiropractors (and others) with a diploma in FN.
But do understand the risk: Functional neurologists can be extremely well-read on neurology, talk in impressively scientific jargon, and claim that they exclusively treat brain injuries. Therefore, they can easily be confused with board-certified neurologists, neurosurgeons, and neuropsychologists. It is important to not take them lightly and to formidably respond with a logical, medical/science-based defense.