by Anthony P. Calantoni, DC, CCEP, DAAMLP


Title: The Utilization of Long Term Care for Herniated Lumbar Discs with Chiropractic for the Management of Mechanical Spine Pain


Abstract: To explore the utilization of chiropractic treatment consisting of spinal adjusting, axial traction, electrical muscle stimulation, and core stabilization exercise for the management of mechanical spine pain. Diagnostic studies included physical examination, orthopedic and neurological examinations, and lumbar spine MRI.  The patient reports long-term success in reducing pain levels and increasing functionality by having the ability to perform activities of daily living (ADL’s) without frequent flare-ups which he reported of prior to undergoing chiropractic treatment.

Key Words: low back pain, sciatica, chiropractic adjustment, disc bulge, disc herniation, axial  traction, spinal manipulative therapy.

Introduction
On 2/6/2015, a 49 year old male certified nursing assistant, presented for consultation and examination due to a work injury which occurred on 11/12/2001.  The patient stated he sustained a lifting injury that resulted in severe low back pain.  He stated that he was under the care of a pain management interventionist receiving epidural injections in his lumbar spine on an ongoing basis since the injury occurred.  He added that the injections helped him to cope with the elevated pain levels he experienced on a frequent basis. The patient had previously received chiropractic and physical therapy for his injury and reported that the therapies did help him when he was actively treating.  He informed it had been over 3 years since he last treated with chiropractic or physical therapy.

The patient presented to my office on 2/6/2015 with a chief complaint of lumbar pain.  He rated the discomfort as a 7 on a visual analog scale of 10 with 10 being the worst and the pain was noted as being constant (76-100% of the time).  The onset of pain was a result of the work injury described above.  He reported that the pain would aggravate by activities which required excessive or repetitive bending, lifting, and pulling. He stated he experienced flare-up episodes 4-6 times a month depending on the type of activities he was involved with.  The quality of the discomfort was described as aching, gnawing, sharp, shooting, and painful and was noted as being the worst at the end of the day. He stated that when his pain levels were elevated, it would limit his ability of getting a good night sleep.  The patient further noted he was experiencing numbness and tingling in both legs and his right foot.

Prior History:

The patient denied any prior or subsequent low back injuries and/or traumas.

Clinical Findings:

The patient was 5 feet 10 inches and weighed 230 pounds. His sitting blood pressure was 132/86 and his radial pulse was 74 BPM.  The patient’s Review of Systems and Family History were unremarkable.

An evaluation and management exam was performed.  The exam consisted of visual assessment of range of motion, manual muscle tests, deep tendon reflexes, digital and motion palpation, and other neurological and orthopedic tests.  Palpation revealed areas of spasm, hypertonicity, asymmetry, and end point tenderness indicative of subluxation at T12, L2, and L4.  Palpation of the lumbar muscles revealed moderate to severe muscle spasms in the left piriformis, right piriformis, right sacrospinalis, right gluteus maximus, right erector spinae, right quadratus lumborum and right iliacus. He presented with postural deviations that were found using a plumb line assessment showing short right leg (pelvic deficiency), head tilted to the left, high left shoulder and high right hip.  Point tenderness was notably present along the midline of the spine at the L4 and L5 level.

Manual, subjectively rated strength tests were performed on some of the major muscle groups of the lower extremities, based on the AMA Guides to the Evaluation of Permanent Impairment, 4th Ed., 1993/5th ed., 2001. A rating scale of five to zero was used, with five representing normal muscle strength.  A muscle strength loss of the lower extremities indicates a neurological facilitation resulting from dysfunction in the lumbar spine.  Grade 4 muscle weakness was noted on the right extensor hallicus longus.

Dermatomal sensation was decreased at L4 on the right and decreased at L5 on the right.

Reflex testing was completed and was diminished: 0/+2 on the right patella and +1/+2 on the left patella. The following lumbar orthopedic examinations were performed and found to be positive: Ely's on the right, Hibb's on the right, Iliac compression test and Bragard's on the right.

Lumbar Range of Motion tested with Dual Inclinometers:

Range of Motion            Normal         Examination                       % Deficit

Flexion

90

40

 

56

Extension

25

10

 

60

Left Lateral Flexion

40

20

 

50

Right Lateral Flexion

40

15

 

62

Left Rotation

35

25

 

29

Right Rotation

35

20

 

43

Flexion and left lateral bending were painful at end range. The patient’s limitation to bend is corroborated by the persistent spasticity of lack of motion eliciting pain upon exertion in the lumbar spine.

MRI Results:

The MRI images were personally reviewed.  The lumbar MRI performed on 9/29/2014 revealed anterior positioning of the L4 vertebral body with respect to L5 with a right L4-L5 protrusion compromising the right neural foramen. There is a central herniation at the L5-S1 disc.

Fig. 1,  (A), (B), (C) shows in T2 MRI images (A) is Sagittal and (B) is Axial at L4-L5 and (C) is Axial at L5-S1

Fig. 1 (A)  Sagital

 

Fig. 1 (B) T2 Axial at L4-L5

Fig. 1 (C) T2 Axial at L5-S1




After reviewing the history, physical and neurological examination, and MRI’s it was determined that chiropractic treatment was medically indicated and warranted.  Frequency of treatment was determined 1 time a week.

The patient was placed on a treatment plan consisting of high velocity low amplitude chiropractic adjustments, axial traction, electrical muscle stimulation, and core stabilization exercise. The patient responded in favorable fashion to the chiropractic treatment over a 6 month period.  The patient demonstrated subjective and objective improvement and his care plan was reduced to one time every two weeks to manage and modulate pain levels associated with his permanent condition.

On follow-up re-evaluation approximately 9 months after starting supportive treatment the patient showed improvement in range of motion testing. 

Lumbar Range of Motion was tested with Dual Inclinometers:

Range of Motion            Normal         Examination                       % Deficit

Flexion

90

70

 

13

Extension

25

20

 

20

Left Lateral Flexion

40

35

 

12

Right Lateral Flexion

40

30

 

25

Left Rotation

35

30

 

15

Right Rotation

35

25

 

29

The patient also reported a reduction in pain levels rating the low back discomfort as a4 on a scale of 10 with 10 being the worst and the pain was noted as beingintermittent 25 to 50% of the time. Decreased muscle spasm in the lumbar paraspinal muscles was noted as well as better symmetry and tonicity.  The patient reported the ability of getting a better night sleep and waking up in the morning with less rigidity and achiness.  He stated he was able to perform his work duties and activities of daily living with less flare-ups and exacerbations occurring only 1-2 times a month.  The core training exercises we worked on have helped stabilize the patient’s spine and protected it from reinjuring the already injured tissues. 

Conclusion:

Chiropractic care has been shown to be both safe and effective in treating patients with disc herniation and accompanying radicular symptoms1-4. Spinal chiropractic adjustive therapy has been proven to modulate pain6. This patient presented with chronic low back pain sequela to an injury that occurred over 13 years ago.  The patient had prior success in reduction of pain when he was treating with chiropractic in the past then discontinued treatment.  The patient has been treating with pain management intervention since the injury occurred and it has helped him reduce his pain but has done minimal for him from a functional and mechanical standpoint. The history and exam indicated the presence of 2 herniated discs in the lumbar spine. Lumbar MRI’s were ordered prior to being evaluated and the images were viewed to establish an accurate diagnosis, prognosis, and treatment plan. Long term chiropractic treatment has been utilized successfully in this case study to reduce pain levels and restore the patient’s functional capacity of performing activities of daily living and work duties with less flare ups and exacerbations of low back pain.     

Competing Interests:  There are no competing interests in the writing of this case report.

De-Identification: All of the patient’s data has been removed from this case.

  1. Leeman S., Peterson C., Schmid C., Anklin B., Humphryes B., (2014) Outcomes of Acute and Chronic Patients with Magnetic Resonance Imaging-Confirmed Symptomatic Lumbar Disc Herniation Receiving High-Velocity, Low Amplitude, Spinal Manipulative Therapy: A Prospective Observational Cohort Study With One-Year Follow Up, Journal of Manipulative and Physiological Therapeutics, 37 (3) 155-163
  2. Hahne AJ, Ford JJ, McMeeken JM, "Conservative management of lumbar disc herniation with associated radiculopathy: a systematic review,"Spine35 (11): E488–504 (2010).
  3. Rubinstein SM, van Middelkoop M, et. al, "Spinal manipulative therapy for chronic low-back pain,"Cochrane Database Syst Rev(2): CD008112. doi:10.1002/14651858.CD008112.pub2. PMID 21328304.
  4. Hoiriis, K. T., Pfleger, B., McDuffie, F. C., Cotsonis, G., Elsangak, O., Hinson, R. & Verzosa, G. T. (2004). A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain. Journal of Manipulative and Physiological Therapeutics, 27(6), 388-398.
  5. Coronado, R. A., Gay, C. W., Bialosky, J. E., Carnaby, G. D., Bishop, M. D., & George, S. Z. (2012). Changes in pain sensitivity following spinal manipulation: A systematic review and meta-analysis.  Manuscript in preparation. 
  6. Whedon, J. M., Mackenzie, T.A., Phillips, R.B., & Lurie, J.D. (2014). Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66-69. Spine,  (Epub ahead of print) 1-33.

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Published in Case Reports

Case Report

 

By: Karen M. Callaghan, DC

Title: Spinal Adjustments are Safe in the Presence of Herniated disc with the Absence of Cord Compression

Abstract: The objective was to explore the use of MRI to increase the efficacy and safeness of adjusting the cervical spine in the presence of a disc herniation when there is no evidence of cord compression on MRI.

Key Words: Chiropractic, spinal adjustment, MRI, herniation

Introduction:  A 30 year old male patient presented to the office on 1/8/14 with injuries from a motor vehicle accident.  The motor vehicle accident had occurred 3 weeks prior to his first visit.  The patient was the restrained front seat passenger.  The car he was travelling in struck another car and the patient’s car was flipped over onto its roof.  While the car remained on its roof the patient was able to crawl out and awaited medical attention.  The patient was taken by ambulance to the hospital where he was examined and testing was ordered.  The patient had multiple CT scans of the head and X-rays of the cervical and lumbar.  The CT of the head revealed a nasal fracture and the patient underwent immediate surgery to repair his broken nose. 

The patient presented three weeks post-accident with persistent and progressive daily occipital headaches, neck pain into the shoulders bilaterally, upper back pain and lower back pain that radiates into the legs and down into the feet bilaterally. He has swelling at the left anterior knee and bandages around the right elbow and two black eyes. 

The patient states that he was having difficulty with regular activities of daily living including walking for more than 15-20 minutes, long periods of standing, more than an hour of sitting, any bending or lifting and any regular daily chores.  The patient also states he was having difficulty getting a restful night’s sleep due to the pain.  The patient’s visual analog scale rating was 10 out of 10.

History: The patient denied any prior history of neck or back pain.  No reported prior injuries or traumas.

Objective Findings:  An examination was performed and revealed the following:

            Range of Motion: 

Cervical Motion Studies:

Flexion: Normal=60                      Exam-   25 with pain  with spasm 

Extension: Normal=50                  Exam-   20 with pain  with spasm

Left Rotation: Normal=80             Exam-   35 with pain  with spasm

Right Rotation: Normal=80           Exam-   35 with pain  with spasm

Left Lat. Flex: Norma=-40             Exam-   15 with pain  with spasm

Right Lat. Flex: Normal=40           Exam-   15 with pain  with spasm

 

Dorsal-Lumbar Motion Studies:

Flexion: Normal=90                  Exam-   35 with pain   with spasm

Extension: Normal=30              Exam-   10 with pain  with spasm 

Left Rotation: Normal=30         Exam-   10 with pain  with spasm

Right Rotation: Normal=30       Exam-   5 with pain  with spasm 

Left Lat. Flex: Normal=20         Exam-   5 with pain  with spasm 

Right Lat. Flex: Normal=20       Exam-   5 with pain  with spasm 

 

               

Orthopedic Testing

The orthopedic testing revealed the following positive orthopedic tests in the cervical spine: Valsalva’s indicating the presence of a disc at L4-S1 and the lower cervical region, foraminal compression indicating radicular pain in the lower cervical region, Jackson’s compression , shoulder depressor and cervical distraction all indicating pain in the lower cervical region.  The lumbar testing revealed a positive Soto-Hall with pain at the L4-S1 level, Kemps positive with pain from L4-S1, Straight Leg raiser with pain at 60 degrees, Milgram’s with pain at the L5-S1 level, Lewin’s with pain at L5-S1, and Nachlas eliciting pain in the L5-S1 region.

 

Neurological Testing

The neurological exam revealed bilateral upper extremity tingling and numbness into the shoulder on the left and down the right arm into the hand. The lower extremity revealed tingling and numbness into the gluteal’s bilaterally with left sided radicular pain in to the leg into left foot.  The pinwheel revealed hypoesthesia at C7 bilaterally and L5 bilaterally dermatome level. The patient was unable to perform the heel-toe walk

The chiropractic motion palpation and static palpation exam revealed findings  at C 1,2 , 5, 6, 7 and T 2,3,4,9, 10  and L 3,4,5 as well as the sacrum.

X Ray  Studies:

The hospital had cervical x-rays and a CT of the head on the day of the accident. Thoracic and lumbar studies were needed as a result of the positive testing and the patients history and complaints The x-ray studies revealed a reversed cervical curve and misalignment of the C1,2,5,6,7 and the lumbar studies revealed a mild IVF encroachment at L5-S1 with rotations at L3,4,5.

The results of the exam were reviewed.  The patient’s positive orthopedic testing, neurological deficits coupled with the decreased range of motion and positive chiropractic motion and static palpation indicated the necessity to order both cervical[1]and lumbar[2]  MRI’s4.

 MRI results

The MRI images were personally reviewed.  The cervical MRI revealed a right paracentral disc herniation at the level of C5-6 with impingement on the anterior thecal sac.  There is also a C6-7 disc bulge impinging on the anterior thecal sac. The lumbar MRI revealed an L5-S1 disc herniation.  There are disc bulges at from L2-L4.

                  CERVICAL MRI STUDIES

LUMBAR MRI IMAGES

Treatment Plan:

After reviewing the history, examination, prior testing, x-rays, MRI’s and DOBI care paths3 it was determined that chiropractic adjustments6  wereclinically indicated

The patient was placed on a treatment plan of spinal manipulation with modalities including intersegmental traction, electric muscle stimulation and moist heat.  Diversified technique was used to adjust the subluxation diagnosed levels of C1,2,5,6,7 and L3,4,5.  Although there were herniated and bulging discs present in the cervical and lumbar spine there was no cord compression. Therefore; there was no contraindication to performing a spinal adjustment.  As long as there is enough space between the cord and the herniation or bulge then it is generally safe to adjust.5

The patient responded quite favorably to the spinal adjustments and therapies over the course of 6 months of treatments.  Initially, the patient was seen three times a week for the first 90 days.  The patient demonstrated subjective and objective improvement and his care plan was adjusted accordingly and reduced to two visits per week for the next 90 days of care.  His range of motion returned to 90% of normal:

Range of Motion: 

Cervical Motion Studies:

Flexion: Normal=60                      Exam-   55 with no pain 

Extension: Normal=50                  Exam-   40 with mild tenderness

Left Rotation: Normal=80             Exam-   75 with mild tenderness

Right Rotation: Normal=80           Exam-   75 with mild tenderness

Left Lat. Flex: Norma=-40             Exam-   35 with no pain 

Right Lat. Flex: Normal=40           Exam-   35 with no pain

 

Dorsal-Lumbar Motion Studies:

Flexion: Normal=90                  Exam-   80 with tenderness

Extension: Normal=30              Exam-   25 with tenderness 

Left Rotation: Normal=30         Exam-   25 with no pain

Right Rotation: Normal=30       Exam-   25 with no pain

Left Lat. Flex: Normal=20         Exam-   20 with no pain 

Right Lat. Flex: Normal=20       Exam-   20 with no pain

 

The patient had decreased spasm, decreased pain, increased ability to perform ADL’s and his sleep had returned to normal. The patient states that he was no longer having the same difficulties with regular activities of daily living.  He was now able to walk for 45 minutes to 1 hour before the lower back pain flared up, he is able to stand for 1-2 hours before the lower back pain begins, he is able to sit for an hour or more before the lower back pain flares up. When the patient bends or lifts he has learned to use his core and lifts less than 20-30 pounds to avoid exacerbating his low back.  The patient also states he was no longer having difficulty getting a restful night’s sleep.  The patient’s visual analog scale rating was 3 out of 10.

Conclusion:

The patient presented 3 weeks post trauma with cervical and lumbar pain as well as headaches.  The symptoms were progressing and the pain was radiating into the upper and lower extremities.  The history and exam indicated the presence of a herniated disc in the lower lumbar and cervical region.  Cervical and lumbar MRI’s were ordered to identify the presence of the herniated disc as well as to determine whether or not the patient should be adjusted.  The MRI results of both the cervical and lumbar MRI revealed herniated discs, however, because these discs were not causing cord compression it was safe to adjust the cervical and lumbar spine5.

Competing Interests:  There are no competing interests in the writing of this case report.

 

De-Identification: All of the patient’s data has been removed from this case.

 

References

  1. New England Journal of Medicine; Cervical MRI, July 28, 2005, Carette S. and Fehlings M.G.,N Engl J Med 2005; 353:392-399MRI for the lumbar disc, March 14  2013, el Barzouhi A., Vleggeert-Lankamp C.L.A.M., Lycklama à Nijeholt G.J., et al., N Engl J Med 2013; 368:999-1000 http://www.state.nj.us/dobi/pipinfo/carepat1.htm -16.7KB
  2. New England Journal of Medicine; Cervical-Disk HerniationN Engl J Med 1998; 339:852-853September 17, 1998DOI: 10.1056/NEJM199809173391219
  3. Is It Safe to Adjust the Cervical Spine in the Presence of a Herniated Disc? By Donald Murphy, DC, DACAN, Dynamic Chiropractic, June 12, 2000, Vol. 18, Issue 13
  4. Treatment Options for a Herniated Disc;  Spine-Health, Article written by:John P. Revord, MD

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Case Report


by Donald Capoferri DC, DAAMLP


Title: The Efficacy of Chiropractic Adjustments in the care of Migraine Headache with patients presenting with cervical disc bulge. 


Abstract: Objective: To explore the efficacy of chiropractic adjustments, and non-surgical spinal decompression in the treatment of cervical spine disc conditions presenting as neck pain, migraine headache, dizziness and visual disturbances. Diagnostic studies included physical examination, computer aided range of motion, orthopedic and neurological examinations, plain film x-ray studies, brain MRI, cervical spine MRI examinations.  Treatments included specific spinal adjustments, low level laser therapy and spinal decompression.  The patient’s outcome proved excellent in reduction of neck pain, headache severity and frequency as well as elimination of dizziness and visual disturbances.


Key Words: Migraine, chiropractic adjustment, disc bulge, spinal decompression.


Introduction: On 11/19/13 a 37-year-old female presented for examination and treatment of neck pain, migraine headaches with associated dizziness and visual disturbances.  The patient denies and recent injuries. 

Presenting Concerns: The patient reports neck pain in the cervical occipital region as a 4 on the Verbal Analog Scale of 0 meaning the complete absence of pain and 10 being unbearable pain.  The duration of the current symptom picture is 2 years and 1 month.  The patient further reports episodic migraine headaches starting at the upper cervical region and progressing into her occipital area.  These episodes are accompanied by dizziness and visual disturbances described as kaleidoscope vision.  At the time of the initial consultation these episodes were occurring 2-3 times per week.  The patient reports being afraid to drive her car due to concerns about headache onset.  The patient reports past consultations with her medical doctor who diagnosed her with vertigo and previous chiropractic care without results.  The records from both consultations were reviewed personally. 

Clinical Findings:  The patient presents with complaints of neck pain, headaches, dizziness and visual disturbances of 2 years duration.  The patient is a 37-year-old female who is a mother of 2.  The ages are 16 and 3.  

Her vital signs are:

Height - 5 ft. 0 inches

Weight - 130 lbs.

Handedness - R

Blood Pressure - L - 107 systolic and 78 diastolic 

Radial Pulse - 75 BPM

The patient’s Review of Systems and Family History were unremarkable.

Palpation/Spasm/Tissue changes:  The patient was evaluated by palpation and observation with the following findings: Bilateral cervical spine spasms rated at +2 in the cervical-occipital region.  Orthopedic testing was unremarkable.  Range of motion examination revealed mildly decreased left lateral flexion, moderately decreased flexion, right lateral flexion and extension. No pain was produced during range of motion examination.

Neurological Examination: Biceps, Triceps and Brachioradialis reflexes were rated at a +2 bilaterally.  Sensory examination revealed normal sensation bilaterally for dermatomes C-5 through T1.  Motor/Muscle testing revealed 5 out of 5 bilaterally for Deltoids, Biceps, and Triceps, Forearm and Intrinsic Hand muscles.



Radiographic findings: reversal of the cervical curve with altered C5/C6 disc space is noted. (Fig. 1, (A) (B) A small osteophyte is observed on the posterior inferior body of C5.  Flexion malposition of C5 is also noted.  (Fig. 1, (B).

Fig. 1,  (A), (B) show loss of the cervical lordosis, flexion malposition of C5, partial collapse of C5/6 anterior disc space.





Fig. 1. (B) shows upon magnification a small posterior-inferior osteophyte.





Fig. 2,  (A), (B) shows in T2 MRI images (A) is Sagittal and (B) is Axial a 

C5/6 central disc herniation contacting the ventral cord. 


Diagnostic Focus and Assessment: 
Diagnoses considered are: Brain Tumor, Cervical Disc Displacement, and Cervical-cranial     syndrome.  A brain MRI was ordered and produced normal findings.  Diagnostic reasoning included the C5/C6 disc/osteophyte complex and the encroachment into the ventral aspect of the central canal and contact with the cervical spinal cord. (1) Peter J. Tuchin, GradDipChiro, DipOHS, Henry Pollard, GradDipChiro, GradDipAppSc, Rod Bonillo, DC, DO.  Received 29 June 1999.  Another consideration was the treatment schedule because the patient lives 60 miles west of the clinic and 2 treatments was the ordered therapeutic schedule.

Therapeutic Focus and Assessment:  Assessment of the cervical spine MRI both sagittal and axial views of the C5/C6 and C6/C7 segmental levels revealed adequate space between the cervical cord and posterior vertebral elements.  It was determined that conservative management of this patient was appropriate.  Therapeutic focus was reducing the pressure of the C5/C6 disc/osteophyte complex on the ventral cord.  Promoting healing of damaged nerve tissue and restoring more favorable position and motion of vertebral segments C5/C6.  The modalities used to treat this patient were:

1.     Specific Spinal Adjustments: utilizing a Sigma Precision Adjusting Instrument to introduce a percussive force of 20 lbs. with a maximum of impact number of 50.

2.     Spinal Decompression: A Hill Spinal Decompression table was utilized with 8 lbs. of pull maximum and a cycle of 5 minute at maximum and 5 minutes at reduction to 50% over a 25 minutes treatment session.  The patient completed 18 sessions in total.  

3.     Low Level Laser Therapy was used to promote healing on a cellular level using a Dynatron Solaris system.  Treatments consisted of 30 seconds of exposure to an 860-nanometer beam at C5/C6 and C6/C7 levels.

Follow-up and Outcomes: The patient’s compliance to the treatment schedule as rated at 9 of 10.  Completion of the recommended 18 treatments required 1 week longer than anticipated.  For personal reasons the patient missed 2 treatment sessions but made them up by adding a week to the estimated completion date. Upon discharge examination the patient reports her neck pain on the Verbal Analog Scale a 2 of 10 with 0 being the complete absence of pain and 10 being the worst pain imaginable. She further reported her headaches as a 1 on the Verbal Analog Scale.  Both symptoms were constant since 10/01/11.  This is duration of 25 months prior to her first visit. Her symptoms of dizziness and visual disturbances have been absent since 12/13/13.

Discussion: Headaches and Migraine Headaches are a big health     problem. It has been estimated that 47% of the adult population have headache at least once within last year in general.  More than 90% of sufferers are unable to work or function normally during their migraine. American employers lose more than $13 billion each year as a result of 113 million lost workdays due to migraine. (2) Schwartz BS1, Stewart WF, Lipton RB.

              J Occup Environ Med. 1997 Apr; 39(4): 320-7.

 This case report is very limited because it represents the experience and clinical findings for just 1 patient. However a study of the references included with this report as well as reports by care providers as well as testimonials from patients indicates that more study should be invested in the relationship of the cervical spine, its structures and biomechanics during the diagnostic workup on headache and migraine patients.  

Informed Consent: The patient provided a signed informed consent.

Competing Interests: There are no competing interests writing of this case report.

De-Identification: All the patient’s related data has been removed from this case report.

References:

1. Schwartz BS1, Stewart WF, Lipton RB.

J Occup Environ Med. 1997 Apr; 39(4): 320-7.

Lost workdays and decreased work effectiveness associated with headache in the workplace.

Wikipedia, The Free Encyclopedia. (2010, July). Human musculoskeletal system. Retrieved from http://en.wikipedia.org/wiki/Musculoskeletal

2. Vernon, H., Humphreys, K., & Hagino, C. (2007). Chronic mechanical neck pain in adults treated by manual therapy: A systematic review of change scores in randomized clinical trials, Journal of Manipulative and Physiological Therapeutics, 30(3), 215-227.


3. Peter J. Tuchin, GradDipChiro, DipOHS, Henry Pollard, GradDipChiro, GradDipAppSc, Rod Bonillo, DC, DO.  Received 29 June 1999

A randomized controlled trial of chiropractic spinal manipulative therapy for migraine


4.Mark Studin DC, FASBE (C), DAAPM, DAAMLP, William J. Owens DC, DAAMLP Chronic Neck Pain and Chiropractic. A Comparative Study with Massage Therapy.

5. D’Antoni AV, Croft AC. Prevalence of Herniated Intervertebral Discs of the Cervical Spine in Asymptomatic Subjects Using MRI Scans: A Qualitative Systemic Review. Journal of Whiplash & Related Disorders 2006; 5(1):5-13.

6.  Murphy, D. R., Hurwitz, E. L., & McGovern, E. E. (2009). A nonsurgical approach to the management of patients with lumbar radiculopathy secondary to herniated disk: A prospective observational cohort study with follow-up. Journal of Manipulative and Physiological Therapeutics, 32(9), 723-733.

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