Chiropractic Care of a Patient with Chronic Muscle Spasms and Headaches with Complex Comorbidity: A Case Report

Skeletal muscle spasms are commonly due to overuse or
muscle fatigue, dehydration, electrolyte imbalances, or injury...


Introduction
Skeletal muscle spasms are commonly due to overuse or muscle fatigue, dehydration, electrolyte imbalances, or injury [1].
Chronic muscle spasms can occur intermittently for several months or years, characterized by involuntary short-lived, sudden, violent contractions of individual muscles or muscle groups [1]. Identifying the etiology can be a complex investigation that must consider patient history, past illnesses, and current symptomatology. This article describes a patient with a complex health history including cirrhosis, which may have contributed to her chronic muscle spasms. A 2014 American Journal of Medicine article stated that 67% of patients with cirrhosis reported having chronic muscle cramps [2]. It was noted that this may be due to the 66% of these patients who were deficient in Vitamin D [2]. The main function of vitamin D is to increase calcium absorption and promote normal bone formation and mineralization [3]. Vitamin D deficiency is known to cause muscle aches, weakness, and pain resulting in muscle spasms [3]. In addition to a complex health history, this case involves polypharmacy, which is defined as taking 5 or more concurrent prescription medications. Polypharmacy increases the risk for adverse drug-drug interactions, and malnutrition [4]. This report describes the chiropractic care of a patient with

Methods
The patient was a 26-year-old female with a height of 57" and weight of 79 lbs. She was a painter, sculptor, and college student.
Informed consent for this case report was provided. Her chief complaint was chronic muscle spasms along the mid back and up into the neck bilaterally. The purpose for seeking care was to engage a more conservative pain management treatment and reduce opioid use. The patient's medical history included being hospitalized for four months at age 3 years due to a chicken pox infection. Between the ages of 9-15 she had two occurrences of Non-Hodgkin's Lymphoma. Each occurrence was treated with chemotherapy drug mixtures of CHOP (cyclophosphamide, doxorubicin, and prednisone) [5] and ICE (ifosfamide, carboplatin, and etoposide) [5], total body irradiation, and Allogeneic stem cell transplant.
Patient small stature was likely influenced by the radiation and chemotherapy during critical growth stages. She had a history of hypothyroid disorder that started during the first round of cancer.
The cancer treatments caused mouth sores from frequent vomiting, which resulted in two gastronomy-tube placement surgeries and two bowel resection surgeries. In early adulthood, she was diagnosed with liver cirrhosis, Type II diabetes, high cholesterol, restless leg syndrome, depression and asthma. She suffered from recurrent chest and sinus infections as well as seasonal allergies.
She had frequent headaches, constant back and neck pain and muscle spasms occurring approximately 5-6 times a day. She reported having severe throbbing headaches upon awakening. The symptoms were worse in the morning and at night when trying to sleep. They were aggravated by sitting or standing for extended periods of time, looking down, typing, bending, exercise, stooping and twisting. The patient reported that she had received partial relief of her symptoms after periods of no movement, previous treatments of spinal manipulation, application of heat or ice, and performing certain stretches or exercises. The patient reported no symptoms that radiated out to her extremities. The patient reported regularly taking 29 different medications including diabetes medications, fenofibrate, pramipexole, levothyroxine, desvenlafaxine, promethazine, metaxalone, dicyclomine, albuterol, esomeprazole, and diphenhydramine. Due to the patient's long list of prescription medications, drug interaction causing adverse symptoms and reactions was a concern. Medscape's drug interaction checker [6] was used to identify possible drug interactions. There were 3 severe and 7 moderate interactions ranging from chemical interactions to patient sedation which were all communicated to the patient and the patient's primary care provider, which did result in a reduction in her medications. The patient rated the intensity of her symptoms with activity as a 7/10 on the Numeric Pain Scale (NPS), with zero being complete absence of symptoms and ten being very severe or unbearable. Pain at rest was rated at 3/10. The pain was

Results
After the patient's first treatment visit she reported some mild soreness in the lower cervical region and on the trapezius bilaterally.
She also reported having only a mild headache after waking. After the first four visits the frequency and severity of back spasms were reported by the patient to have decreased by 40%. By the eighth visit the patient resumed her hobbies without significant pain or restriction including painting and working for a local sculptor. The patient also reported improved sleep, less allergy symptoms, and better control of her blood glucose. After three months of care, the patient was scheduled on an as needed basis. She reported an improved quality of life overall. PROM scores were measured again ten weeks after care began. The NDI score decreased from 56 to 52.
The OBP score increased from 46 to 48. These outcome measures were not sensitive to this case, as the patient verbally reported having a significantly improved quality of life with a decrease in severity and frequency of symptoms and satisfaction with her care.

Discussion
Care for the patient in this case was consistent with current guidelines as described in "The Treatment of Neck Pain-Associated

Disorders and Whiplash-Associated Disorders: A Clinical Practice
Guideline" [8]. They recommend non-pharmacological treatments including spinal manipulation and exercise when possible.8 Guideline based care also suggests multidisciplinary management for chronic and medically complex cases.8 For this patient, there was a collaborative effort with her primary care physician (PCP) to address polypharmacy issues. A study published in the European Spine Journal in 2018 that looked at applying evidence-based guidelines to treat middle-low income communities suffering from back and neck pain was referred to in the papers title as the "Global Spine Care Initiative" [9]. This study recognized the need to treat these conditions without expensive or invasive treatments [9].
Treatment options that the researchers found to be effective for acute and chronic low back and neck pain included exercise and spinal manipulation.9 To increase patient success rates clinicians were instructed to provide education and reassurance, advise patients to remain active, and provide information about self-care options [9].
While this study was focused on creating guidelines for a model of care for medically underserved areas and low-and middle-income countries, it is consistent with the previously discussed guidelines and effective for all economic classes. In a literature review titled "Kinesiological research: the use of surface electromyography for assessing the effects of spinal manipulation", the author discussed the mechanisms involved that would allow for muscle relaxation after an adjustment as well as the reasons why certain studies may refute those mechanisms.10 The populations ranged from 18-65 years old suffering from muscle spasms. The researchers focused the adjustments on hypomobile segments in the cervical, thoracic, and pelvic regions [10]. Both manually delivered manipulations and manipulations delivered via a mechanical adjusting device (such as an Activator™) were associated with changes in muscle activation [10]. The state of muscle dysfunction (e.g. palpably tender or subjectively taut) may have been a factor in achieving a myoelectric response to spinal manipulation [10]. The review noted that spinal manipulation did cause short term changes in electromyographic amplitude and muscle function [10]. It is possible that the spinal manipulation treatment of this patient contributed to reduced short term axial muscle tone changes leading to a reduction of headaches and muscle spasms. In the study, "The mechanism of back pain relief by spinal manipulation relies on decreased temporal summation of pain", the authors aimed to determine whether thoracic spinal manipulation would decrease temporal summation of back pain.11 The study comprised two controlled experiments including 16 and 15 healthy participants, respectively. Each study included six Other methods of conservative chiropractic care have proven effective in treating neck pain in a non-pharmacological way.
In the case study, "Chiropractic treatment of postsurgical neck syndrome with mechanical force, manually assisted short-lever spinal adjustments", a 35-year-old woman with chronic neck pain for over 5 years after two separate surgeries of the cervical spine sought a chiropractic evaluation of her condition to avoid further surgical intervention.12 An Activator Adjusting Instrument (AAI) II was used and effectively treated her neck pain with resolution of all symptoms within 30 days.12 Longitudinal examination over the next 2 years showed that the patient experienced no residual effects or further recurrences of her previous chronic problem after her initial course of chiropractic care. 12 The patient in our study preferred manual adjusting to mechanically assisted adjustments.
The more medications a patient takes, the higher the risk of a drug-to-drug interaction (DDI). 13 The patient in this case was taking 29 medications and severe DDIs were exposed. The effects of DDIs are hard to quantify in a given patient, but they have the potential to cause additional side effects. By reducing the number of drugs that were taken to remove the DDIs, the patient may see an improvement of symptoms and/or functions. Although the DDI's did not impact the diagnosis or choice of treatment, it is possible that the actions taken to remove the severe DDIs found for this patient played a role in reduction of symptoms and the improvement of her activities of daily living.
Selecting PROM's that provide a meaningful representation of the patient's outcome is challenging.14 In this case study, the PROMs chosen did not match the improvements the patient reported. Pain and disability scores did not capture the entire patient experience.
A more accurate representation of the patient's improvement in this case were the activities of daily living and the patient's ability to perform the tasks, which were important to her. Choosing the appropriate PROM's that match the patient goals is important and needs more research. The National Institute of Health's Patient Reported Outcomes Measurement Information System (PROMIS) roadmap initiative is one example of an emerging tool that merits consideration for use with future patients.14 This patient represents just one case, however, based off her demographic information and health history, the patient relates to other studies concerning back or neck spasm with a history of cancer, liver cirrhosis, diabetes, or other chronic disease. Further case reports are needed to provide additional information on patients that suffer from chronic muscle spasms that have benefited from chiropractic care.

Conclusion
This case study showed that collaborative management for a patient with chronic muscle spasms and other comorbidities was possible and was a non-pharmacological option for a patient who was dealing with polypharmacy. PROM's used in this case study were not the most valid way of discerning patient improvement.
Despite the scores showing little to no improvement, the patient reported significant improvements in her activities of daily living and an overall improved quality of life.