The sad reality about the burden of a serious illness is that it’s never just the illness itself. There are the side effects of treatments, the impaired quality of life, and the recovery that can extend further into the future than you anticipated. A recent case published in the Asia-Pacific Chiropractic Journal highlights a case where an individual has sought chiropractic care to combat ongoing medication-induced symptoms. The case details the 3-month chiropractic care of a 20-year-old female with a 5-year history of neurological difficulties following chemotherapy [1].
Frankly, it’s an eye-opener. We have seen prior research show that heart rate variability (HRV), a measure of nervous system health, can be impaired after cancer, as well as research that shows chiropractic care may increase HRV [2-7]. But this latest case report indicates that we may be prudent to pay attention to the wider benefits of chiropractic care after chemotherapy.
Most people are familiar with the common and various adverse effects experienced by individuals receiving chemotherapy. While some of these effects present themselves in a physical and observable way, and constitute what we typically imagine when considering the negative effects of the therapy, many are internal effects that only the individual receiving the treatment can have a full comprehension and appreciation of. One such ‘invisible’ side-effect is chemotherapy-induced neurological deficits. It can affect both the peripheral and central nervous system, with central neurotoxicity typically causing a difficulty in initiating or maintaining voluntary physical and cognitive activities.
Cognitive impairments following chemotherapy are far from rare, affecting approximately 75% of patients during chemotherapy, with an estimated 35% of patients continuing to experience cognitive difficulties in the months and years following treatment.
The patient in the current case had a form of cognitive impairment called chemotherapy-induced peripheral neuropathy (CIPN), beginning following a surgery performed to remove an osteosarcoma in her left femur in 2016 (5 years prior to presenting for care).
CIPN can present in a variety of ways, including more common sensory and motor deficits, and less common autonomic function deficits. Sensory symptoms typically affect the hands and feet, and include numbness, tingling, neuropathic pain, and a sensitivity to hot and cold temperatures. Motor deficits manifest as weakness, hyporeflexia (decreased or absent reflexes), gait and balance abnormalities. The rarer autonomic symptoms include orthostatic hypotension, and relevant to the case at hand; hearing loss.
The prevalence of CIPN is entirely drug-dependent, in that it only affects individuals who receive or have received medications used for chemotherapy, and ranges from 19-85%. The prevalence of CIPN decreases as time after the completion of therapy increases. As it stands currently, there are no effective and accepted treatment strategies for CIPN. In these situations, non-pharmacological and alternative approaches are able to shine, as a non-invasive and accessible option to combat symptoms. They are often preferentially ‘reached’ for when the classic medical approach has effectively treated the original illness but leaves individuals with ongoing effects that negatively impact their everyday lives. And this case is no exception.
The case:
In this recent case report a 20-year-old female presented for chiropractic care with a 5-year history of chemotherapy-induced neurological deficits following a surgery in 2016 to remove an osteosarcoma in the left leg. At the initial consultation a thorough health history was taken and the patient reported the following symptoms:
- Numbness and tingling in hands and feet beginning after 12 months of intravenous chemotherapy
- Decreased sensation in both hands and forearms throughout the day
- Cold sensation in the left arm along the C5-C7 dermatomes
- ‘Pins and needles’ feeling in the hands at night, which was more severe in the left arm
- Decreased sensation in the left leg from the middle of the femur to the foot, as well as in the right foot
- Chemotherapy-induced visual and hearing disturbances
It was also found that at the age of 16 the patient was diagnosed with depression and anxiety, receiving prescriptions for gabapentin and citalopram. The sensory examination performed revealed the following:
- Decreased sensation in all digits on both sides of the body
- Decreased sensation in lower limbs from L1-L5 on the left and L4-S1 on the right
- Slightly reduced upper limb strength on the left
- The patient was unable to perform a left knee extension against resistance, had a reduced hallux extension on both sides of the body, and all muscle stretch reflexes were absent in upper and lower limbs
- A left lean when standing (normal gait), a significant sway in part 2 of Romberg’s test, and was unable to perform either tandem gait or tandem Romberg’s
- Cranial nerves examination revealed a decreased sensation on the left cheek to pain, nystagmus on left gaze, superior gaze paralysis in both eyes, and left-sided hearing loss
The patient received regular chiropractic adjustments for a total of 9 weeks. The frequency of sessions was twice a week for the first 3 weeks, at which point a progress review was conducted. Following the progress review the frequency of sessions decreased to once a week for the remaining 6 weeks. A combination of diversified and upper cervical specific technique was utilised by the treating chiropractor, and for the majority of care the spinal segment C1 was the main focus of treatment. Other important vertebral subluxations identified at the initial consultation were the right ilium, T3, C6, and occiput, although it is not reported in the case that these were adjusted for. The only other spinal segment to be adjusted was the PL sacrum on the 9th visit. In addition to the patient history, sensory and cranial nerves examination, and the average assessment conducted during the initial consultation, the patient also completed a quality of life questionnaire (RAND-36). All of these measures were reassessed at the 6th visit during the third week of care.
What improved after 6 visits?
At the progress review the patient reported improvement in mobility, strength, mood, independence, sleep, and digestion. There was an increase in sensation in all fingers and toes, an increase in left arm strength, and increased sensation in the lower limbs. The patient was still unable to perform the left knee extension against resistance, but reflexes were improved. The left lean observed when standing originally was resolved, gait remained normal, and the patient was able to perfrom tandem gait. Upon re-examination of the cranial nerves there was a decreased sensation to pain on the left cheek, there was no nystagmus or superior gaze paralysis. Interestingly, the left-sided sensorineural deafness was also no longer present.
The patient’s cervical range of motion improved along with 7 of the 8 quality of life factors as assessed by the RAND-36 questionnaire (physical functioning, emotional wellbeing, social functioning, pain, role limitations caused by physical health, role limitations caused by emotional problems all increased, while overall general health perceptions decreased slightly).
Why did it work?
A well-functioning sensory and motor system are essential for a high quality of life. Subsequently, when our perception and integration of sensorimotor information is distorted or altered from the norm it can produce issues in the way we function in our everyday lives. It was assumed that the patient’s CIPN symptoms were being driven by an ongoing altered sensorimotor input, and thus after receiving regular chiropractic care the integration of this information may have improved, contributing to the improved function and quality of life. Another potential mechanism spinal manipulation may have utilised to resolve symptoms is affecting the patient’s balance and proprioception. This mechanism is essentially an expansion on the theory previously mentioned; improved sensorimotor integration and perception. We know adjusting the spine can lead to better proprioceptive processing, a more accurate understanding of where the limbs are in space. We also know it can improve muscle strength and activation, including activating muscles involved in maintaining posture. In respect to the improvement in the quality of life of the patient, this is consistent with the extensive reporting of musculoskeletal complaints and chiropractic care, in which measures of quality of life were consistently improved with regular adjustments.
While this case is exciting in supporting the possibility of providing relief for individuals with ongoing chemotherapy-induced neurological deficits, it has its limitations. As with any case study, its generalisability to anyone beyond the individual within the case report is greatly reduced. There was little control over other external factors aside from the chiropractic care, including the natural progression of healing. The patient also introduced dietary and lifestyle changes throughout the period she was receiving care, and these may have contributed to her symptomatic changes, improved function, and improved quality of life. Thus, it cannot definitively be said that chiropractic care, by itself, was driving these positive changes. But that isn’t really the aim of case reports. Case reports provide the basis for future studies, they show us where to look, and reflect the ‘real-life’ impact of chiropractic care. When viewed in this light, the current case opens a door to assisting an important group of people, who for the most part, are beyond the reach of the benefits of traditional medicine. All modes of care have a part to play, and this case report shows that it further research into the role of chiropractic care post-chemotherapy may just be what the doctor ordered.
REFERENCES:
- Cade A, Fisher-Van de Veen W, Te Wharau C. Changes in post-chemotherapy neurological deficits after chiropractic care: A case report. Asia-Pac Chiropr J. 2021;2.4. URL net/papers-issue-2-4/#CadePostchemocare
- da Silva F, Moreire G, Zomkowski K, de Noronha M, Sperandio F (2019), “Manual Therapy as Treatment for Chronic Musculoskeletal Pain in Female Breast Cancer Survivors: A Systematic Review and Meta-Analysis,” Journal of Manipulative and Physiological Therapeutics, Is. 7, Pp. 503-513, https://www.sciencedirect.com/science/article/pii/S0161475418302628retrieved 3 June 2020
- Staff Writer, (2019), “Interview with Dr Otto Janke – HRV Post-Cancer Case Study,” Australian Spinal Research Foundation, https://spinalresearch.com.au/interview-with-dr-otto-janke-hrv-post-cancer-case-study/retrieved 3 June 2020
- Caro-Moran E, Fernandez-Lao C, and Galiano-Castillo N (2015), “Heart Rate Variability in Breast Cancer Survivors After the First Year of Treatments: A Case-Controlled Study.” Biological Research for Nursing, https://journals.sagepub.com/doi/abs/10.1177/1099800414568100?journalCode=brnaretrieved 3 June 2020
- Kloter E, Barrueto K, Klein S, Scholkmann F and Wolf U (2018), “Heart Rate Variability as a Prognostic Factor for Cancer Survival – A Systematic Review,” Frontiers in Physiology, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5986915/retrieved 3 June 2020
- Staff Writer (2017), “Possibile clinical applications of heart rate variability,” Australian Spinal Research Foundation, https://spinalresearch.com.au/possible-clinical-applications-heart-rate-variability/retrieved 3 June 2020
- Staff Writer (2018),”Improvements in HRV under chiropractic care,” Australian Spinal Research Foundation, https://spinalresearch.com.au/improvements-in-hrv-under-chiropractic-care/retrieved 3 June 2020
