Hiccups (singultus) are a frequent occurrence during cancer treatment. The cause of the hiccups may be the chemotherapy drug itself, such as Cisplatin; or the prophylactic use of corticosteroids such as Decadron, which is used to prevent nausea and/or vomiting.
When cancer patients develop hiccups related to their course of treatment, therapeutic assistance in abating the hiccups can be challenging. The experience of intractable hiccups thus becomes a quality-of-life issue.
Numerous pharmacologic options have demonstrated a reduction and disappearance of symptoms. However, cancer patients who are receiving conventional cancer care are typically on more than one medication. Side effects of additional medications can detract from the attempt for a daily fulfilling life.
Instead of adding an additional pharmacological intervention to address hiccups as a front-line approach, recruitment of noninvasive, conservative, nonpharmacological pathways such as chiropractic care might be a strong consideration.
Case Presentation
The patient is a 39-year-old man who had been receiving treatment for stage IV adenocarcinoma of the appendix. After receiving his first dose of Xerili, he developed acute hiccups. At this time, he was also admitted to the hospital with a bowel obstruction and severe abdominal pain. The bowel obstruction led to the need for nutritional support.
Concurrently, the patient developed moderately severe neck pain, in addition to hiccups. His caregivers, the patient's parents, expressed deep concern for their son's comfort and requested whatever services may be available to minimize his neck pain and alleviate his hiccups. The hospitalist placed orders for chiropractic care to assist with cervical pain and hiccups.
Intervention: Assessment, Management and Outcome
Prior to the chiropractor visiting the patient, a complete and thorough review of the patient's chart was executed to determine if the patient was a candidate for chiropractic care. The chart presented no contraindications to care, such as a space-occupying lesion in or near the area of complaint, bone metastases or platelet counts below 30,000.
Chiropractic evaluation of the patient took place in the patient's hospital room, while the patient lay supine at a 45 degree angle to maximize his comfort.
Active range of motion was omitted, as the patient was feeling nauseous and week from the incessant hiccups and overall course of his disease. Passive range of motion revealed moderately severe restriction in lateral bending with 10 degrees to the right and 5 degrees to the left.
Extension was omitted to prevent discomfort to the patient. Right and left rotation were tolerated to approximately 35 degrees. Flexion caused discomfort at 15 degrees.
Moderate hypertonicity of cervical paraspinal and sternocleidomastoid (SCM) muscles was noted bilaterally. Moderate palpable tenderness was revealed along the left SCM and trapezius muscles. Mild abatement of hiccups was noted during palpation of the left SCM.
With patient consent, it was decided that chiropractic manipulation with soft-tissue manual therapy would be administered. Prior to the treatment, the patient gave an analog report on his neck pain from 0-10, 10 being the most severe. The patient rated his neck pain at an 8.
It was explained to the patient that he did not need to leave his bed. The chiropractor proceeded to perform manual manipulation of the SCM muscles and cervical paraspinal muscles bilaterally. This was followed by diversified cervical chiropractic adjusting at the C4-5 segmental region.
This led to an immediate abatement of the hiccups. The patient was asked to rate his neck pain after the adjustment. He rated the pain at a 5.
A follow-up visit occurred the next day. The hiccups had not returned. The patient did complain of the same neck pain he had reported on the first visit, but with some lasting improvement. He reported the neck pain remained at 5. The patient received a diversified cervical adjustment and reported additional relief, with an analog pain scale measurement rated at 4.
Due to unrelated oncological complications with the patient, no further chiropractic treatments were administered.
Discussion
It is not uncommon for some chemotherapeutic agents to induce hiccups in cancer patients. The literature notes there are physical maneuvers that can alleviate hiccups. And in the case of intractable hiccups, there appear to be several medicines, as well as aggressive medical approaches, such as nerve blocks and surgical interventions, that have been successfully used.
The concern with additional medicines and/or other medical procedures for cancer patients is that this patient population has many other challenges with treatment. Hence, another needle poke or pill pop may be less preferred as a front-line approach compared with a literal "hands-on" therapeutic application.
Note: A literature review revealed little significance when acupuncture was utilized. In an effort to be transparent (with reluctance), a case study published in the Journal of Internal Medicine suggests digital rectal massage may be a useful approach.
With the knowledge that the phrenic nerve is made up of fibers from chord levels C3-5, it might be reasonable to wonder if chiropractic manipulative therapy of any combination of these segments could positively impact a patient suffering from either acute or intractable hiccups. Furthermore, it is the belief of this author that cancer patients with chemo-induced hiccups would prefer a nonpharmacological approach to help alleviate hiccups when compared with other medical options.
Finally, a feasibility study may be warranted to determine if chiropractic care would make for a reliable first-line approach for cancer patients with chemotherapy- induced hiccups.
Resources
- Thompson DF, Brooks KG. Gabapentin therapy of hiccups. Annals Pharmacother, 2013 Jun;47(6):897-903.
- Una E, Alonso P. High dose of prokinetics for refractory hiccups after chemotherapy or the return to a simple drug. BMJ Case Reports, 2013 Oct 29 (epub ahead of print).
- Amara S. Oral glutamine for the prevention of chemotherapy-induced peripheral neuropathy. Annals Pharmacother, 2008 Oct;42(10):1481-5.
- Choi TY, Lee MS, Ernst E. Acupuncture for cancer patients suffering from hiccups: a systematic review and meta-analysis. Complementary Ther in Med, 2012 Dec;20(6):447-55.
- Odeh M, Bassan H, Oliven A. Termination of intractable hiccups with digital rectal massage. J Internal Med, 1990 Feb;227(2):145-6.
Dr. Jeff Sklar is the director of chiropractic services at Cancer Treatment Centers of America's (www.cancercenter.com) East Regional Medical Center in Philadelphia. He has been practicing chiropractic for more than 19 years and also serves as district director in Philadelphia for the Pennsylvania Chiropractic Association. He is a recent past recipient of the Cancer Treatment Centers of America Clinical Innovation Award; a nationally recognized public speaker on the topic of integrative oncology; and has been featured in numerous magazine articles and television interviews about chiropractic treatment and integrative care for cancer patients.