Successful chiropractic management of a centenarian presenting with bilateral shoulder pain subsequent to a fall

Clinical Chiropractic (2005) 8, 66—74

intl.elsevierhealth.com/journals/clch

CASE REPORT

Successful chiropractic management of a centenarian presenting with bilateral shoulder pain subsequent to a fall B. Gleberzon Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario, Canada M2H 3J1 Received 1 April 2004; accepted 23 November 2004

KEYWORDS Chiropractic; Geriatric male human; Glenohumeral impingement syndrome; Preventive care; Shoulder pain

Abstract This report describes the chiropractic management of a 100-year-old patient who presented with bilateral shoulder pain subsequent to a fall. This case report brings to the surface several features especially germane to the successful management of older patients. These include: strategies to enhance both the history and physical examination procedures of an older person; an eclectic approach to care planning, coupled with a willingness to appropriately modify therapy as clinical circumstances dictate; monitoring outcome measures of importance to the patient; avoidance of ageist attitudes and the role of a chiropractor for health promotion and prevention. # 2005 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved.

Introduction The ‘Baby Boomers’ represent the largest demographic cohort group in Canada, the United States, Australia and the United Kingdom.1,2 As they age, coupled with their increase in life expectancy,3 it is more and more likely that a field practitioner will encounter patients of advanced age, including centenarians. Although the chiropractic care of an older person is, for the most part, indistinguishable from the chiropractic care provided for a younger person, clinical circumstances may dictate important modifications to diagnosis and management.4 There are differences with regards to incidence of presenting chief complaints; possible co-morbidity or complications; methods of enhancing both the interview E-mail address: [email protected].

and physical examination; etiology of pain and other symptoms; choice of diagnostic procedures; therapeutic options; monitoring of appropriate outcome measures and strategies to promote health and improve quality of life. For example, with reference to health maintenance, falls and subsequent injuries are a major concern to older persons.4—7 This necessitates appropriate care planning that often includes an eclectic combination of therapeutic procedures in-office (soft tissue therapies, modalities, mobilization, spinal adjustments) and athome (exercises and safety-promoting suggestions). In cases of trauma, whilst the first goal of care typically focuses on the restoration of a person’s health and functional capabilities to a pre-accident status,8 many practitioners also attempt to optimize a patient’s health as well, a concept embraced by a ‘wellness paradigm’.9,10 This may be achieved by

1479-2354/$30.00 # 2005 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.clch.2004.11.002

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offering patients strategies to augment and fortify their health while simultaneously monitoring outcome measures that are important to them. The purpose of this case report is to chronicle the successful management of a centenarian under chiropractic care subsequent to a fall.

Case history A 100-year-old man presented to the author’s office with a chief complaint of bilateral shoulder pain following a fall. When he presented to the office, the patient was appropriately dressed, and he had no difficulties responding promptly to questions asked of him during the patient interview. He did not require any assistance to complete the patient intake or consent forms. Several strategies were used to enhance this step in the clinical encounter.4,11 For example, the patient’s appointment had been scheduled for mid-morning, a time when the author could devote more time to the patient in case it was needed during either the interview or physical examination. He was escorted to the author’s office and asked to take a seat in a chair with armrests to help aid his ability to position himself into and out of the chair. To enhance the history taking procedure, the author sat facing the patient, with no obstacles between the doctor and patient. The room was quiet, warm, well lit and uncluttered (electrical cords from modalities were kept out of the way). The patient was asked to keep wearing his glasses, hearing aids and dentures, as some patients mistakenly believe these items should be removed, even during the interview. The patient revealed that he lived by himself, in the same home he had been born in, having suffered the death of his wife to Alzheimer’s disease several years before. He received some assistance from this 70-year-old daughter who lived 30 min out of town. The patient reported that he had been moving some furniture in the morning and fell onto his right shoulder 6 weeks prior to presentation and was still experiencing bilateral shoulder pain, worse on the right. The author asked him the ‘‘SPLAT’’ questions (Table 1)4—6 to better ascertain the details surrounding the fall. He did not recall being dizzy or lightheaded prior to falling, and had never fallen before. Table 1 The ‘SPLAT’ questions.4—6 Symptoms associated with the fall (vertigo, disequilibrium, nausea, headache) Prior falls Location of the fall Activity during the fall Time of day the fall occurred

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Initially, he sought out the care of his medical physician. The patient’s medical doctor had referred the patient for physiotherapy, which the patient attended for 1 week without experiencing any benefit. At that time, X-rays of both shoulders were ordered and were found to be unremarkable. When asked to point to the site of pain, the patient indicated the pain was principally in the region of the right anterior arm, in the area of the biceps tendon and muscle belly. He reported a sharp sensation of pain triggered by certain arm movements, particularly abduction above 908 and forward flexion. He also that reported the shoulder pain was worse when he was making left or right turns while driving his car (!). The intensity of the pain was reported to be mild to moderate (3 on a scale of 10, with 10 being worst pain). While at rest, the patient did not experience any pain in either shoulder. The left shoulder pain was more generalized, described as a general ache in the region of the left middle deltoid muscle. No radiations of the pain were reported. The most significant detriment to the patient’s lifestyle attributed to the shoulder pain was a difficulty in sleeping. The patient denied having had any shoulder pain or limitations of movement in the past. He had never been to a chiropractor before. The patient exercised by walking, fixing things around his home and playing the violin at social gatherings of his war-time peers (he often joked that he and his friends were veterans of the American Civil War rather than the Second World War). He reported that he had never been hospitalized, and had had no major surgery, falls or accidents prior to this incident. He had had some normal childhood illnesses (measles, mumps) and he was a non-drinker and non-smoker. Both his parents had lived into their 90s. He was not taking any medication, nor was he taking any vitamins, minerals, botanicals or other supplements. Author’s note It is important to pause here and emphasize the importance of inquiring about a patient’s pharmaceutical and nutriceutical use. Since many supplements are obtained from ‘Health Food Stores’ and can be self-prescribed, and since many patients often share or self-medicate themselves,12 patients may not associate these products with any potential adverse effects, and they may not realize the possibility of drug—herb interactions. The widespread use of pharmaceutical and nutriceutical products is of acute importance among older persons, who

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are the most likely to be prescribed drugs or other supplements but are paradoxically the least able to physiologically handle their sideeffects (a situation referred by as ‘the geriatric paradox’).13—15 A prudent clinician must therefore not only obtain a complete drug and nondrug consumption profile of his or her patients, a clinician should also suspect that any presenting chief complaint from an older patient may have a pharmaceutical or nutriceutical origin.16 The patient’s system review was generally unremarkable, with the patient being in excellent overhealth. The only aids he required were a hearing aid in his left ear and corrective eyeglasses. He was scheduled for cataract surgery in three months time. He was a retired administrator of a sheet metal factory.

Physical examination The patient was 160 cm in height, and weighted approximately 60 kg. His posture was generally good, with no obvious spinal asymmetries or aberrant curves. The patient displayed mild anterior head-carriage and a slight ‘rounding’ of both shoulders. There were no visible signs of trauma on either shoulder. Indeed, observation of the skin in the chest, abdomen and back revealed no unusual or suspicious moles or lesions. Upper limb sensations and reflexes were unremarkable. The patient reported pain on palpation in the region of the right biceps muscle, towards its long head origin into the humerus. The right pectoral major muscle was also painful on palpation towards its insertion. The deltoid muscles of the left shoulder were mildly painful to touch. Active ranges of motion testing of the right shoulder reproduced the patient’s chief complaint during arm abduction beyond 908 and during forward flexion. During right arm abduction beyond 908, the patient shifted his weight to the left in an apparent attempt to recruit thoracic trunk muscles to enhance this motion. There was a disruption of the normal scapulothoracic rhythm, with early rotation of the scapula. The patient was not able to circumduct either shoulders to their full extent. There was relatively little discomfort reported by the patient during passive ranges of shoulder motion testing (performed with the patient supine), although abduction was somewhat limited. With reference to the patient’s right shoulder, Speed’s test (resisted forward flexion of the arm) was painful and mildly weak but Yergason’s test (resisted forearm supination with elbow flexed to 908) was unremarkable (both of these procedures

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principally test the biceps muscle). Hawkins—Kennedy test (arm positioned into 908 of forward flexion while the shoulder is brought into medial rotation at the elbow), a test for shoulder impingement, was mildly positive, although Neer impingement test (arm elevated through forward flexion with internal rotation) was not. Codman’s or Drop-Arm test (which requires the patient to slowly lower their arm from a position of 908 of abduction in order to test for tears in the rotator cuff muscles) was normal. The Empty-Can test (arm positioned into forward flexion of 308, thumb pointing downwards, and patient asked to resist arm depression), a test for suprapinatus muscle strength was unremarkable (see McGee17 for more detailed description of orthopedic tests). The Lift Arm test (arm brought off patient’s back, a test for subscapularis muscle) and Horizontal Adduction test (a test for acromioclavicular sprain) were both negative, as where tests for anterior or posterior instability (apprehension tests). Joint play of the right shoulder provoked some pain in the patient, especially anterior-toposterior motion and posterior shear. Joint play of the acromioclavicular (AC) and sternoclavicular (SC) joints was judged to be within normal limits. The same tests performed on the left shoulder were generally unremarkable, except for limited abduction (see Table 2). Cervical ranges of active, passive and resisted motion were bilaterally symmetrical and did not reproduce the chief complaint. Compressive tests of the cervical spine (Kemp’s test, Spurling’s test and Jackson’s test) were all unremarkable. Motion and static palpation of the thoracic and cervical spine were performed. Although some regions of the patient’s spine were bilaterally asymmetric upon palpation, no area was pain producing, nor did palpation of the region reproduce the chief complaint. It should be mentioned that, during the examination (and later during each appointment), the author stayed close to the patient, especially during changes in body position from a supine to a seated position and from seated to standing. The concern here was that such changes in body position could result in the patient becoming dizzy or lightheaded and possibly fall off the table.16 Other strategies were used to enhance the physical examination process. For example, a blanket was used to cover the vinyl table, and another blanket was offered to the patient if he felt cold at any time. A pillow was positioned under the patient’s head and knees for patient comfort. Of particular importance, the physical examination was plotted out in such a way as to avoid unnecessary positional changes by the patient that might otherwise result in undue discomfort or instability.4,18 It should also be mentioned that, if a

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Table 2 Orthopedic findings in this case report (adapted from McGee17). Test

Structure examined

Response

Sensory and reflex testing Ranges of motion

Neurological Ligaments, tendons, capsule

Joint play Static palpation

Ligament integrity, joint function Various

Speed test Yerguson’s test Hawkins—Kennedy test Neer Impingement test Codman’s (Drop-Arm) test Empty-Can test Lift-Off test Horizontal Adduction test Apprehension test Cervical Compression tests (Jackson’s, Spurling’s, Kemp’s test) Cervical and thoracic motion palpation

Biceps tendon Biceps tendon Impingement (supraspinatus, biceps) Impingement (supraspinatus, biceps) Rotator cuff muscles Supraspinatus tendon Subscapularis tendon A/C joint Anterior and posterior instability Brachial plexus, vertebral artery, cervical discs, nerve root or facet joints Intersegmental vertebral motion

Unremarkable Reproduction of chief complaint with abduction beyond 908 and forward flexion. Limited circumduction Unremarkable Pain on palpation of 1 biceps muscle and (L) deltoid. Mildly positive Unremarkable Mildly positive Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable

practitioner plots out the physical examination beforehand, he or she is less likely to forget to perform any particular test; conversely, a disorganized examination is more likely to be incomplete and fail to instill confidence to the patient.

Diagnosis The patient was diagnosed with sub-acute moderate traumatic impingement syndrome of the right glenohumeral joint subsequent to a strain of the right biceps muscles and mild strain of the left deltoid muscle (some clinicians favor the terms tendonosis or tendonopathy to strain). Differential diagnosis was adhesive capsulitis of the right shoulder.

Plan of management The patient was started on a course of chiropractic care consisting of 2 treatments a week for 6 weeks. Initially, treatment consisted of ultrasound and soft tissue therapy to the affected muscles with the goal of reducing inflammation and promoting tissue healing. Home care consisted of cryotherapy using a gel pack (it was suggested that the gel pack be wrapped with a towel and applied to the area of pain for 10 min at a time only, once an hour, throughout the day). Suggestions to safety-proof his home were offered (Table 3); advice to avoid heavy lifting and light stretching exercises were all discussed and demonstrated to the patient. The stretching

Unremarkable

exercise given to the patient was to have the patient, while facing the wall, gently ‘crawl’ up the wall with his hand to the point of pain, and then to ‘crawl’ down the wall again. At the 6th appointment, mobilization procedures were added to the patient’s plan of management, primarily a ‘shoulder shake’ (Figs. 1 and 2). For this procedure, the patient was positioned supine and gentle traction applied to the arm above the elbow. Beginning with the patient’s arm at his side (08 of abduction), the arm was gradually brought into abduction to the point of pain or resistance. During this motion, a gently oscillating movement was imparted to the arm. The arm was then brought down from the point of maximum abduction to 08. The process was repeated with the shoulder positioned in external rotation, neutral position and internal rotation. The procedure was also repeated in the frontal plane. In addition to being well tolTable 3 Examples of home safety-proofing strategies.4,16,48 i. Replace 60 W bulbs with 100 W bulbs ii. Ensure non-slip mats are in places with water and soap (bathroom, kitchen) iii. Outside steps and railing in good working order iv. Unobstructed pathway from bed to bathroom (especially at night) v. Remove area or throw rugs; replace with wall-to-wall broadloom vi. Remove low tables (ottomans)

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Figure 1 Patient is positioned supine and a gentle traction is applied to the arm above the elbow. Beginning with the patient’s arm at his or her side (08 of adduction) the arm is gradually brought into abduction to the point of pain or resistance. During this motion, a gentle oscillating/circular movement is imparted to the arm. The arm is brought back down from the point of maximum abduction to the patient’s side.

erated by the patient, this procedure also permits a convenient method to monitor the patient’s progress from one appointment to the next. It was decided not to provide spinal manipulative therapy in this case. This decision was based not on the patient’s age but rather on the lack of diagnostic indicators used by the clinician (static and motion palpation and orthopedic tests). In essence, the author felt that, since the patient was not, and had not, experienced any significant spinal pain over

Figure 2 The process is repeated with the shoulder positioned in external rotation, neutral and internal rotation. The procedure is also repeated in the frontal plane. In addition to being well tolerated by the patient, this procedure allows for a convenient method to monitor the patient’s progress from one appointment to the next.

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the past century, it would be prudent not to disrupt the patient’s biomechanical adaptations. Outcome measures included diminished subjective pain, diminished pain on palpation, lack of pain during orthopedic testing, increase in both active and passive shoulder ranges of motion and improvement in the quality of the patient’s sleep. Using these factors as outcome measures, the patient demonstrated very slow progress, which, at times frustrated him. At such times, the clinician suggested the patient be encouraged by his improvements in shoulder ranges of motion and sleep patterns and that his recovery was slower because of this advanced age. By the 10th appointment, additional stretches were included, as well as a simple strength-training program, and the use of ultrasound was discontinued. The additional stretch consisted of the patient holding a soup can and swinging his shoulder in a gentle, slow, circular or pendular manner with the intent of increasing the range of motion of the shoulder joint. The strength training exercise consisted of the patient using the same object and performing five sets of three repetitions of biceps curls. The clinician judged this to be important because muscle strength is the most physiologically limiting factor of a patient’s ability to perform Activities of Daily Living (ADLs).19 Were the patient’s upper limb strength to decline due to disuse, it is possible that simple ADLs (getting out of chair or off the toilet, opening a can, cleaning and so on) would be severely impaired.19 The patient attended a scheduled appointment with his medical doctor at this point in time. The medical doctor was satisfied with the patient’s progress and he encouraged the patient to continue with chiropractic care. Between the 15th and 20th treatment, the patient demonstrated considerable improvement in his shoulder motions, with active abduction approaching 1208. As the impingement tests became unremarkable and his sleep quality was greatly improved, the frequency of treatments was dropped to once a week. By the end of the next month, the patient demonstrated an almost complete recovery from his injuries. The patient was unable to attend any appointments for a 4-week span as he had underwent cataract surgery. After the procedure, he was experienced a great deal of blurring and was having difficulty obtaining a correct eyeglass prescription. Due to a period of inactivity, his right shoulder pain reoccurred, and he required an additional month of care, at a frequency of twice a week. The patient was still unable to obtain a proper prescription and sustained a fall in his home 4 months post-surgery. Fortunately, his injuries were

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relatively mild and resolved within 6 weeks of conservative manual care. The patient was placed on a monthly maintenance program of appointments and experienced no reoccurrence of his chief complaint for the next 4 months. At no time during the entire course of chiropractic care did the patient report any adverse effects from his treatment. Unfortunately, the author was informed by a mutual acquaintance that the patient had fallen yet again, had been hospitalized, and subsequently died of injuries sustained. At the time of his death, he was 101 years old.

Discussion There are several examples in the chiropractic literature of authors describing the screening, examination and management of patients as young as newborns presenting to chiropractor’s offices with commonly seen childhood illnesses such as colic, enuresis, ear ache, asthma, epilepsy and autism.20 However, the state of affairs is much different with respect to the geriatric chiropractic literature, as reported by the author in a review of the literature conducted a few years ago.21 The author reported that, whilst there were 25 case reports published, the vast majority of these chronicled patients with metastatic cancer, fractures and other serious pathologies or relatively unusual cases. Thus, there appears to be paucity of articles chronicling the case management of older patients presenting with commonly seen conditions such as osteoarthritis, stenosis, spinal pain and sprains and strains. Another factor contributing to the relative scarcity of reference material to which a field practitioner can refer for guidance is the fact that older persons tend to be excluded, by design, from clinical trials.22 This is unfortunate because of the confluence of two identifiable demographic trends. As previously mentioned, the largest demographic group in many countries including Canada, the United States, Australia and the UK are the ‘Baby Boomers’. As they age and, as their life expectancy increases, it seems increasingly likely that a chiropractor will encounter patients of an advance age, including centenarians. This is particularly likely in light of the fact that centenarians in particular represent the fastest growing segment of all cohort groups in the ‘Baby Boomer’ countries.23

The shoulder Shoulder pain and dysfunction is a common chief complaint prompting a patient to seek chiropractic

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care, with the Job Analysis of Chiropractors 2000 reporting that upper extremity pain and injury accounts for 8.6% of all office visits.24 McDermott25 reports that, next to low back pain, shoulder pain is the most common cause of occupational injury claims. The high incidence of shoulder injuries is not surprising when one considers that the glenohumeral joint is a multiaxial synovial joint capable of complex movements and is prone to a vast number of pathologies ranging from arthritides, several inflammatory conditions and impingement syndromes of different etiological sites.17 Moreover, unique among all joints in the body, the shoulder joint’s support, stability and integrity are derived from the muscles that surround it, rather than from bones or ligaments.17 Proper shoulder biomechanics rely on the interactions of the ball and socket shaped GH joint, the planar AC and SC joints, and the scapulothoracic pseudo-joint. In addition, proper shoulder motions are governed by several important muscles that transverse these joints, including the biceps, pectoralis, trapezius, deltoid and the muscles of the rotator cuff, or ‘SITS’ muscles.17 During abduction, for example, it is the rotator cuff muscles that pull the humerus from its resting position from the upper part to the lower part of the glenoid permitting abduction.17 According to Kalb,26 95% of all cases of shoulder pain are attributed to tendons of the rotator cuff becoming impinged under the acromial hood. However, Neer27 recently reported that one-third of patients reporting impingement syndromes demonstrated anomalies of the biceps tendon as well. Hains,28 in a recent review of the literature of chiropractic management of shoulder pain, reported that it was his clinical experience that biceps tendonitis is a common finding in his clinical practice and often the culprit in impingement syndromes. Green recently carried out a systematic review of the literature characterizing the various medical methods of therapy for shoulder pain.29 His review found 31 clinical trials investigating approaches including anti-inflammatory medications, intraarticular cortisone injections, physiotherapy, manipulation under anesthesia and surgery. His review only found weak evidence to support the use of cortisone injections, although he ultimately concluded that there was little scientific evidence to support the effectiveness of many of the most commonly used medical therapies for shoulder pain. There are a few published papers describing the chiropractic management of patients with shoulder pain. Hains28 and Hanten et al.30 described protocols using trigger point therapy and ischemic com-

72 pression. Leahy and Mock31 described their softtissue approach, known as active release therapy (ART). Kazemi32 described a case of adhesive capsulitis, successfully managed using electrical modalities, ice, stretches and mobilizations and Polkington33,34 described two cases of AC sprain, successfully managed using instrument adjusting (an Activator). A common feature seen throughout these articles is that patients experiencing shoulder pain can be successfully managed by conservative care.

Issues of chiropractic care of older persons Maintenance care can be defined as a type of care provided to patients even in the absence of presenting symptoms.35 Notwithstanding putative evidence of the benefits of maintenance care (see, however, Descarreaux et al. 36), Rupert et al.37 have reported that both chiropractors,35 and their older patients, believe it is an important component of wellness care (optimization of a person’s health, amelioration of symptoms, prevention of recurrence and identification of emergent new problems). In fact, Rupert and his colleagues reported that, in a survey conducted of chiropractic patients aged 65 years and older, over 95% of them felt that maintenance chiropractic care was either considerably or very beneficial to their health.35 With respect to the management of older patients, Killinger38 reminded her readers that the time an older person requires to heal from trauma is usually much longer than the if the same injury occurred in a younger person. Gleberzon21,39 reached a similar conclusion and opined that the clinical decision making process in delivering chiropractic care is more a function of assessing the patient’s health status rather than his or her chronological age. Unfortunately, ageist attitudes are often inculcated into a clinician’s belief system as early as their first year of training,40 even in the field of manual medicine.41 It therefore behooves academic institutions to develop strategies to combat ageism among its students during their undergraduate educational program.39,40 A chiropractor must always be vigilant to the special needs of a patient, regardless of their age. Depending on the clinical circumstances, a practitioner may have to either modify or abandon their preferred method of care.42,43 In a comprehensive review of the literature of manual care for the elderly, Cooperstein and Killinger43 wrote that a clinician needs to possess a working knowledge of alternate therapeutic methods that may be needed as clinical circumstances dictate. Fortunately, there is no shortage of therapeutic options in chiropractic

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Table 4 Examples of chiropractic techniques that may be used instead of spinal manipulative therapy.41,43 Blocking techniques (i.e. Sacro-Occipital Technique) Distraction techniques (i.e. Cox Flexion Technique) Instrumented adjusting techniques (i.e. Activator) Upper cervical techniques (i.e. Palmer HIO) Low force techniques (Logan Basic, Network Spinal Analysis, BEST) Mobilizations and myofascial techniques (Nimmo, Active Release Technique)

practice, including a long list of technique systems that a practitioner may judge to be more clinically prudent according to cirumstance (Table 4).43,44 Finally, a recent study by Hawk et al.,45 which characterized patients aged 55 years and older who sought out chiropractic care, reported that, in addition to spinal adjustments, chiropractors most frequently recommend exercise, heat or ice application, and foot orthotics.

Safety-proofing This case underscores the dangers of falling injuries to older persons. Death due to falls is the 6th leading cause of death among older persons, the leading cause of death due to injury and the leading cause of injury in general.4—6 One-third of the communitydwelling elderly fall once a year, and this number exceeds 50% in those over the age of 80 years. The most debilitating injury attributed to falling is fracture, with 250,000 hip fractures occurring each year.46 Overall, falls account for 14,000 deaths and 22 million hospital visits a year in the United States.47 These alarming statistics highlights the importance of providing older patients with useful information to allow them to safety proof their homes, and the importance of a patient maintaining proper gait-related functions. A practitioner can take an active role in fall prevention. As previously mentioned, there are many safety-proofing suggestions that can be provided to patients16,48 and, for those patients prone to falling, a practitioner can suggest use of external hip protectors, which have been shown to be very effective in preventing serious injuries subsequent to a fall.49

Evidence-based care: the importance of the case report The importance of evidence-based care has emerged as an area of vital concern in all areas of health care and chiropractic has not been (nor

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should be) immune to the motivating forces giving impetus to this movement. This was recently evident during the 2004 inter-professional proceedings of the Association of Chiropractic Colleges and Research Agenda Conference (ACC/RAC) that had as its theme ‘Best Practices’. Many experts in this area spoke to the importance of constructing a firmer evidence-based edifice for chiropractic, constructed from well-designed clinical trials. However, most of the invited panelists were quick to add that the world of ‘Best Practice’ ought not to be solely populated by randomized, placebo or shamcontrolled clinical trials (or meta-analyses of these trials), which are fraught with limitations and areas of potential abuse (see Rosner50). Rather, evidencebased (or, perhaps, evidence-informed) care should also include the results from practice-based trials, experimental studies, case series and case reports, drawing on both qualitative and quantitative outcome measures.51—55 This has been emphasized in recent commentaries that suggest the ‘evidence based practice’ pendulum has swung too far towards RCTs and too far away from acknowledging the importance of a practitioner’s experience.55 There is considerable tension at the research-clinician interface, wherein researchers tend to focus on what is not known, while clinicians prefer to know what is known. Looked at from a different perspective, and turning a common axiom on its head, practitioners seem to fear that researchers posit that ‘something may work in practice, but it would never work in theory’. The sentiment behind this issue may have been captured best by Haynes and his colleagues when they wrote ‘‘evidence does not make decisions–—people do’’56. This article, as any other case report, can only serve to chronicle the events surrounding a particular patient who presented to a particular practitioner and was managed in a particular manner, it does not objectively prove anything (see Gleberzon and Killinger57). Case reports cannot differentiate between the efficacy of an implemented plan of management independent of a placebo effect or natural history. However, recent articles by JonesHarris,58 Young59 and Bolton60 in this journal reminded readers of the potential value of case reports such as the one provided herein, especially if they are combined with similar observations from the field.

Conclusion The particular case report illustrates several important features germane to the care of an older patient. Chiropractic care can be successfully deliv-

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ered to an older patient, even a centenarian, without adverse effects. There are important strategies that a clinician can use in order to enhance the history and physical examination process. A number of different therapeutic choices exist from which to choose, and many can be used for patients, even those of advanced age, without undue concern. Health promotion and prevention are areas that ought to comprise a significant component of practice activities. Following each treatment, pain, function and other outcomes measures important to the patient should all be simultaneously monitored. Lastly, home safety-proofing, stretches, strength training and other simple exercises are important for patient recovery and aid in maintaining an older person’s ability to live independently, which is often of primarily importance to them.

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