A 39-year-old female patient, and coauthor of this report, presented for care. She was previously diagnosed in 2000 with ET by her general medical practitioner. Before chiropractic care, the patient had received computed tomography and magnetic resonance imaging in 2002 as well as neurological evaluation and rheumatologist evaluation to rule out brain lesion, Arnold Chiari malformation, fibromyalgia, multiple sclerosis, anxiety disorder, systemic lupus erythematosus, and other like symptom disorders. Previous treatment included gabapentin (Pfizer Pharmaceuticals LLC, New York, NY), sertraline hydrochloride (Roerig-Pfizer, Belmont, WA), and bupropion (Biovail Corporation, Mississauga, Ontario). Although she could not recall dosage amounts, she reported not having a reduction in the frequency or duration in her tremor activity. She reported that the tremors were constant, bilaterally in the upper extremities, which were progressively becoming more severe. The patient was diagnosed at age 10 with migraine headaches with aura by her general medical practitioner. Previous treatments for migraine included propranolol oral, isometheptene/dichloralphenazone/acetaminophen, sumatriptan, and over-the-counter pain relievers. She could not recall dosage amounts and had intermittent reduction of her symptoms.
At the time of her first office visit, she reported experiencing 2 to 3 migraine headaches per week for the past 20 years. She stated that her previous chiropractic treatments, which included full-spine diversified manipulation as well as the National Upper Cervical Chiropractic Association technique, reduced the frequency of the migraine to 1 to 2 per week on an infrequent basis; however, she did not experience a reduction in the duration or frequency of her tremors.
Physical examination showed normal function in orthopedic and neurologic tests, with the exception of her upper extremity tremors. All cranial nerve test results were found to be normal. Increased muscle tone was found in the upper cervical spine bilaterally. There was a decrease in segmental passive range of motion from occiput through the second cervical vertebra bilaterally, and third cervical vertebra through seventh cervical vertebra on the left. Paraspinal musculature was hypertonic bilaterally from the occiput to the upper thoracic regions. Radiographic analysis showed an anterior misalignment of both the left and right occipitoatlantal articulations, as well as an anterior misalignment of the right C2-C3 articulation and a posterior misalignment of the left C2-C3 articulation using Blair measurement methods.
The patient received chiropractic treatment using the protocols of the Blair Upper Cervical chiropractic technique.10
At the time of the patient's first treatment, she was experiencing bilateral tremor as well as migraine. The treatment included cervical spinal adjustment to the first and second cervical vertebrae, after which the tremors ceased. An overall reduction of migraine headache intensity and frequency was reported at the next follow-up visit. The patient was seen 2 to 3 times per week for 4 months. She received 20 spinal adjustments to her upper cervical spine over that period. The patient was not receiving any other concurrent medical or pharmacological treatment at this time.
Upon follow-up evaluation after 4 months of chiropractic treatment using Blair Upper Cervical protocols, the patient reported that her tremors were no longer constant, that is, 1 to 2 intermittent episodes per week, and were often resolved with spinal postural stretching. The spinal posture stretching was a modification of the muscle energy technique described by Murphy,11
without using eye movement and deep breathing by the patient. Those episodes, which were not resolved with stretching, would cease after a spinal adjustment to her upper cervical spine. She reported that the frequency of her migraine headaches had diminished from 2 to 3 per week to 1 per month. On the patient's initial neutral lateral cervical radiograph, the Ruth-Jackson lines12
showed a cervical curve of 17° (). After 4 months of treatment, a follow-up neutral lateral radiograph showed a 30° angle () with the Ruth-Jackson lines indicating a restoration of her cervical curve. Both radiographs had her hard palate measuring at 8° from horizontal.
Lateral cervical radiograph taken at the beginning of care. The hard palate measured 8°. The cervical curve measured from the posterior bodies of C2 and T1 equals 17°.
Lateral cervical radiograph taken after 4 months of care. The hard palate is measured at 8°. The cervical curve measured from the posterior bodies of C2 and T1 equals 30°.
The outcome measures used to monitor the health progression of our patient showed improvement over 4 months of care. At the beginning, the tremor assessment13
(0-4 scale) was rated as 3 for resting right arm tremor and 2 to 3 for the areas of writing, fine movements, embarrassment, depression, and anxiety due to tremor. At 4 months of care, the same indicators were rated at 0 to 1 for all categories. The headache disability index14
at the onset of treatment was rated at 68/100, E = 28/52, F = 32/48; and after 4 months of care, her scores were 14/100, E = 4/52, F = 10/48. The headache disability index rates patient's answers to 25 questions regarding emotional (E) and functional (F) effects of headache.14
After 4 months, physical examination showed normal cervical spine paraspinal muscle tone and normal range of motion.