It's Monday morning and your first new patient of the day, a 35-year-old female, presents with chronic headaches and neck pain. The patient was referred by her primary care provider for evaluation and management without the use of cervical manipulation.
She claims that prolonged sitting with her head turned to the left causes her to experience neck pain and headaches, which is a common posture because of her work station.
The aching in the neck is located in the posterior cervical spine paravertebral muscles, the upper trapezii, sternocleidomastoideus, and levator scapulae muscles. She denies any shooting pain into the arms or head. The headaches are usually on the left in the occipital, temporal and orbital areas.
On an 11-point numerical rating scale, she rates the pain at 7/10 at its worst toward the end of her work day and 0/10 on weekends with exercise. She normally wakes with a stiff neck. The pain in the neck and head seems to be worse this year. In spite of increasing her pain medications, the pain persists.
She denies receiving chiropractic care in the past and expresses fear of neck cracking. In fact, she states that she absolutely does not want her neck cracked or popped.
The Examination: All the Signs Call for Chiropractic
Your physical exam reveals the patient's vital signs to be acceptable and her appearance is that of a young, healthy female. She is alert, cooperative, well-nourished and an excellent historian. Palpation at the level of C1-3 on the left produces the chief concern of neck pain. Palpation of the left upper trapezius muscle reproduces the headache in the area of the left occipital area. Palpation of the left occipital nerves produces discomfort, but does not reproduce the chief pain concern. Palpation of the left upper trapezius, sternocleidomastoideus, and levator scapular muscles demonstrates localized, painful nodules and referred pain into the left occipital region.
She presents with forward head posture and slight rotation of the head to the left with a superior shoulder compared to the contralateral shoulder. Active cervical range of motion is within normal except for left lateral flexion and rotation, which is limited and painful at the level of C2-3 on the left. Motion palpation reveals restrictions and pain at C2-3 left.
The three-part, peripheral, neurological examination of the upper extremities demonstrates motor function 5/5 bilaterally, deep tendon reflexes 2+ bilaterally and sensory distribution intact for the upper extremities. There are no signs of pathological reflexes and the cranial nerve examination does not reveal any sensory or motor defects.
The differential diagnosis process generates a working diagnosis of chronic pain syndrome (G89.4). Both myofascial pain syndrome and cervicogenic headache syndrome are likely causes of this painful condition. As you know, chiropractic care is usually extremely successful for these causes of neck pain and headaches.1
How does your report of findings address both the treatment of the chronic pain and the patient's preference to not receive a chiropractic adjustment or cervical manipulation in an ethical manner?
What Do You Do Next?
Today, chiropractic students are taught to be ethical, evidence-based and patient-centered clinicians. Numerous peer-reviewed journals offer contemporary guidelines that assist the modern, ethical DC. The standard of care in 2018 is much different than when I started my chiropractic education at Logan in 1968.
During the '70s and '80s, I would have tried to convince this patient that chiropractic adjustments, myofascial treatments, and change in work posture would resolve her condition. Today, I would not advise manual manipulation with cavitation because of her request to not have her neck cracked or popped.
For a chiropractor with almost 50 years of clinical experience, one who appreciates the value of a chiropractic adjustment, it has been difficult to change from a doctor-centered behavior to a patient-centered behavior, but I am learning.
Rather than attempt to convince this patient – with a fear of cervical manipulation and a recommendation from the referring clinician not to manipulate her neck – to permit you to take her life into your hands and perform a chiropractic, cervical manipulation, what are your options? Let's search the literature and seek some evidence-based information.
Respecting Patient-Centered Care Over Evidence-Based Guidelines
A chiropractic clinical practice guideline from the Canadian Chiropractic Association recommends manipulation, mobilization and ischemic pressure for chronic neck pain.2 However, in this case, the referring primary care provider recommended that cervical manipulation not be provided and the patient stated that she absolutely did not want her neck cracked or popped.
Other than fear of the procedure, neither the referring clinician nor the patient was able to express a physical contraindication that explains why cervical manipulation should not be performed. Although it is your clinical opinion that cervical manipulation would benefit this patient with cervicogenic headaches, would you honor the patient and provider requests? I suggest the ethical answer to this conundrum is addressed with a patient-centered behavior, rather than an evidence-based, doctor-centric behavior.
Patient-centered care is the practice of caring for patients (and their families) in ways that are meaningful and valuable to the individual patient. It includes listening to, informing and involving patients in their care. The IOM (Institute of Medicine) defines patient-centered care as: "Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions."3
In spite of the evidence in the literature and our clinical expertise, we must respect the individual patient preference and not perform cervical manipulation or a chiropractic adjustment. Do you agree? If not, please contact me and explain why not.
Of course, we can recommend changes in the work station to address the repetitive strain of the cervical spine, postural exercises to strengthen weak muscles and stretches for tight muscles. Myofascial trigger points can be treated without cracking the neck. What if the chronicity prevents correction of the spinal joint dysfunction? Is there anything else we can recommend?
Exploring Other Options: An Example
Can chiropractors perform a cervical manipulation, mobilization or chiropractic adjustment that does not cause a cavitation? In other words, perform a therapeutic procedure to address the cervical joint dysfunction without a high-velocity, low-amplitude manipulation? Are there such procedures that would enable an evidence-based and patient-centered intervention for chronic neck pain and cervicogenic headaches?
I recall that one of my colleagues discontinued the use of HVLA spinal manipulation in favor of a technology that measured for joint restrictions and then treated them with a multiple impulse therapy. His rationale made sense to me. He believed that many people avoid chiropractic care because the cracking noise frightens them. It is his opinion that one of the reasons only 8-11 percent of the population receive chiropractic care is related to the fear factor!
I asked him to show me how he treats with this multiple impulse device. The examination for restrictions in the cervical spine was similar to motion palpation, but measured by the instrument. He then treated the joint restrictions with the device, which was painless and without cavitation. The treatment was followed up with retesting for restrictions.
Although I found the treatment comfortable, I wanted to see some evidence, which he provided for my investigation. One of the studies concluded that the response of patients experiencing low back and neck pain actually appeared to be considerably faster than that obtained in three recent studies which utilized hands-on spinal manipulation.4
So, perhaps it is time to consider integrating new technologies and adopting both evidence-based practice and patient-centered care. What would you do next?
References
- Bryans R, et al. Evidence based guidelines for the chiropractic treatment of adults with neck pain. JMPT, 2014;37:42-63.
- Canadian Chiropractic Association. Chiropractic clinical practice guideline: evidence-based treatment of adult neck pain not due to whiplash. J Can Chiropr Assoc, 2005;49(3).
- Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academies Press, 2001.
- Collins DL, et al. The efficiency of multiple impulse therapy for musculoskeletal complaints. JMPT, 2006;29(2):162.
Click here for previous articles by James Lehman, DC, MBA, DIANM.