Establishing a Case for Cause and Effect
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《美国整骨期刊》
Department of Physical Medicine and Rehabilitation Hartford Medical Group Hartford, Conn
After reading the recent case report by David G. Lancaster, DO, and Thomas Crow, DO, "Osteopathic manipulative treatment of a 26-year-old woman with Bell's palsy," which appeared in the May 2006 issue of JAOA—The Journal of the American Osteopathic Association (2006;106:285–289), I find it necessary to address a few critical clinical points.
Although Bell's palsy can affect 0.02% of the population, most cases are mild to moderate, with an average recovery period of several days to a few weeks.1 Severe cases may take months to resolve, and in rare instances may result in permanent impairment. There seems to be an increased chance of Bell's palsy in patients with advanced age, autoimmune disorders, diabetes mellitus, and pregnancy. The most important clinical considerations are: (1) to protect the involved eye from desiccation and (2) to assess the patient for ear and mastoid process infections, intracranial mass, stroke, or other related pathologic conditions, such as autoimmune disorders, HIV (human immunodeficiency virus) infection, Lyme disease, and sarcoidosis.2
Lancaster and Crow, citing another study, state "osteopathic physicians commonly find restricted ipsilateral motion of the temporal bone and upper cervical restrictions in patients with Bell's palsy." I find this statement ludicrous. In my 12 years of clinical practice (including about 18 months of neurology as part of a physical medicine/ rehabilitation residency program of a large Baltimore hospital system), none of the 15 to 20 patients I have seen with Bell's palsy displayed these signs. It is also difficult to agree with the authors' conclusion that "...enhancement of lymphatic circulation resulted in the complete relief of the patient's unilateral facial nerve paralysis within 2 weeks...." How were the lymphatic circulation and the effects of "...osteopathy in the cranial field...to balance the tension membranes and to promote symmetry in the temporal bone and sacral motion" measured in this particular case
It seems much more likely that the patient described in the report had a mild case of Bell's palsy, which, like most, resolved within a few weeks. It is important to recognize that just because "B" follows "A," one cannot conclude that "B" is caused by (or is the result of) "A."
References
1. Martin JB, Beal MF. Disorders of the cranial nerves. In: Fauci AS, Braunwald E, Isselbacher KJ, Wilson JD, Martin JB, Kasper DL, et al, eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998:2378 .
2. Corse AM, Kuncl RW. Peripheral neuropathy. In: Barker LR, Burton JR, Zieve PD, eds. Principles of Ambulatory Medicine. 4th ed. Baltimore, Md: Lippincott Williams & Wilkins; 1995:1253 .(JOHN R. CARBON, DO)
After reading the recent case report by David G. Lancaster, DO, and Thomas Crow, DO, "Osteopathic manipulative treatment of a 26-year-old woman with Bell's palsy," which appeared in the May 2006 issue of JAOA—The Journal of the American Osteopathic Association (2006;106:285–289), I find it necessary to address a few critical clinical points.
Although Bell's palsy can affect 0.02% of the population, most cases are mild to moderate, with an average recovery period of several days to a few weeks.1 Severe cases may take months to resolve, and in rare instances may result in permanent impairment. There seems to be an increased chance of Bell's palsy in patients with advanced age, autoimmune disorders, diabetes mellitus, and pregnancy. The most important clinical considerations are: (1) to protect the involved eye from desiccation and (2) to assess the patient for ear and mastoid process infections, intracranial mass, stroke, or other related pathologic conditions, such as autoimmune disorders, HIV (human immunodeficiency virus) infection, Lyme disease, and sarcoidosis.2
Lancaster and Crow, citing another study, state "osteopathic physicians commonly find restricted ipsilateral motion of the temporal bone and upper cervical restrictions in patients with Bell's palsy." I find this statement ludicrous. In my 12 years of clinical practice (including about 18 months of neurology as part of a physical medicine/ rehabilitation residency program of a large Baltimore hospital system), none of the 15 to 20 patients I have seen with Bell's palsy displayed these signs. It is also difficult to agree with the authors' conclusion that "...enhancement of lymphatic circulation resulted in the complete relief of the patient's unilateral facial nerve paralysis within 2 weeks...." How were the lymphatic circulation and the effects of "...osteopathy in the cranial field...to balance the tension membranes and to promote symmetry in the temporal bone and sacral motion" measured in this particular case
It seems much more likely that the patient described in the report had a mild case of Bell's palsy, which, like most, resolved within a few weeks. It is important to recognize that just because "B" follows "A," one cannot conclude that "B" is caused by (or is the result of) "A."
References
1. Martin JB, Beal MF. Disorders of the cranial nerves. In: Fauci AS, Braunwald E, Isselbacher KJ, Wilson JD, Martin JB, Kasper DL, et al, eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998:2378 .
2. Corse AM, Kuncl RW. Peripheral neuropathy. In: Barker LR, Burton JR, Zieve PD, eds. Principles of Ambulatory Medicine. 4th ed. Baltimore, Md: Lippincott Williams & Wilkins; 1995:1253 .(JOHN R. CARBON, DO)