Case presentation

A 25-year-old female college student has been experiencing frequent headaches along with chronic neck and shoulder pain for the past five years. The pain typically lasts for hours, radiating from the sides of her neck to the occiput and extending down toward her shoulders. She described it as a dull ache with a moderate intensity, scoring 5-6 out of 10 on a numeric pain assessment scale. Occasionally, she experiences nausea during episodes where the headache becomes particularly severe. The patient noted that her symptoms worsened during the COVID-19 pandemic in Hong Kong, which forced her to rely extensively on laptops for online learning and messaging for an estimated 8-10 hours/day. The treatments provided by her family physician, which included prescribed analgesics, failed to relieve her discomfort. The persistent pain resulted in problems with sleep deprivation and hindered her ability to focus on her studies. In her quest for relief, she opted to seek chiropractic care to address her issues.

She denied any history of injuries or a family history of neurological disorders. She denied any prior history of physical neck trauma, head injuries, or a family history of neurological disorders. Further clinical inquiry confirmed no history of drug allergies, current or past hormonal therapy, or use of medications affecting calcium metabolism (such as long-term corticosteroids or anticonvulsants). Screening for red flags was negative, with no evidence, personal history, or systemic symptoms indicative of cervical tumors, neoplastic disease, or Pott's disease (spinal tuberculosis).

Upon initial examination, the patient presented with forward head posture, and her neck was straight with restricted extension, flexion, and rotation. Spurling's maneuver was negative, and the patient's nervous system was intact. Palpation demonstrated spasms and soreness in the bilateral cervical paraspinal, suboccipital, and upper trapezius muscles, as well as joint restriction in segments C3-C7. The laboratory results showed a normal blood count, creatinine, and electrolytes. A radiographic examination (Figure 1) revealed cloudiness of the facet joints (red arrows), narrowing of intervertebral spaces (white arrows), and reverse lordosis (Cobb C2-C7 6°). The results are in line with cervical spine osteoarthritis affecting the facet joints. Based on cervical radiographs and clinical symptoms, the patient was diagnosed with spondylitis of the cervical spine (ICD-10-CM M46.92).

Figure 1: Cervical radiographs taken at the time of initial presentationAnteroposterior (A) and lateral neutral (B) views show cloudiness of the facet joints (red arrows), narrowing of intervertebral spaces (orange arrows), and reverse lordosis (Cobb C2-C7 6°). The red line highlights the posterior vertebral body margins. The radiographic findings are consistent with cervical spine osteoarthritis of the facet joint.

Chiropractic treatment used thermal ultrasound therapy and a massage machine (G5® Massage Machine, General Physiotherapy, Inc., St. Charles, Missouri, United States) to improve blood flow and circulation in the neck and shoulders. Spinal manipulation was performed using the high-velocity, low-amplitude (HVLA) diversified technique. With the patient positioned in the supine position, the clinician applied precise, short-lever, posterior-to-anterior (P-A) and lateral-to-medial manipulative thrusts directed at the hypomobile C4-C6 segmental levels to restore normal facet joint motion and alleviate periarticular mechanical tension. Thermal ultrasound (1.0 MHz at 1.2 W/cm² for eight minutes) and percussive mechanical vibration massage were applied to the suboccipital and upper trapezius musculature prior to manipulation to achieve muscle relaxation. Mechanical traction (iTrac® Spine Remodeling System, Pivotal Health Solutions, Watertown, South Dakota, United States) was done to help restore movement in stiff neck and upper back areas. The patient had three chiropractic sessions per week for the first month. Following four weeks of consistent care, the patient demonstrated a 50% reduction in headache frequency and intensity, along with marked improvement in cervical range of motion. Her neck also moved much better. Then, she went weekly for three additional months. Four months following starting treatment, the patient reported no more headaches, neck, or shoulder pain. She could move her neck fully again. The patient continued chiropractic care twice a month for six months. The patient was given a home exercise program to strengthen her shoulder and neck. She was also given advice on how to improve her workspace, lifestyle tips, and a recommendation to limit her laptop and smartphone use to three hours.

In the follow-up radiograph (Figure 2) taken after 10 months of treatment, there was a restoration of cervical lordosis along with an increase in intervertebral spaces. The evaluation of pain intensity decreased from 6/10 to 1/10 on the rating scale. Subsequently, she continued to receive monthly maintenance therapy. No pathological or treatment-related adverse effects were noted.

Figure 2: Repeat cervical radiographs taken 10 months after treatment initiationIn comparison to the initial findings shown in Figure 1, there is noticeable improvement in the intervertebral spaces (white arrows) and facet joints (red arrows) in both anteroposterior (A) and lateral neutral (B) views, which display increased spacing. Additionally, the cervical curve shows restored lordosis with the C2-C7 Cobb angle measuring -12°.