Alleviation of shoulder injury related to vaccine administration (SIRVA) pain and disability following COVID-19 vaccine with chiropractic biophysics^® (CBP^®) methods: a case report and long-term follow-up with global implications

Abstract

[Purpose] To present the dramatic improvement in posture, radiographic parameters and the alleviation of neck and severe shoulder pain related to shoulder injury associated with vaccine administration (SIRVA) after a COVID-19 injection with a shoulder mobility and posture rehabilitation program. [Participant and Methods] A middle-aged male presented complaining of severe left shoulder pain evolving since receiving a COVID-19 vaccination. The pain was severe and throbbed into the neck. Posture analysis showed a chronic stooped posture with forward head posture and thoracic hyperkyphosis. Treatment included 42 sessions of Chiropractic Biophysics^® technique and a shoulder rehabilitation program using three-dimensional vibration. [Results] At 4-months, the patient reported no neck or shoulder pain. There was a 60% decrease in neck disability. The forward head decreased 34 mm, thoracic hyperkyphosis decreased 13°, and T1–T12 forward lean decreased 73 mm, among other radiographic parameters. Re-assessment after 26-months showed maintenance of the treatment induced posture/x-ray corrections and shoulder pain relief. [Conclusion] This case demonstrates immediate and long-term improvement in a patient suffering from COVID-19 vaccine SIRVA, concomitant with neck pain and disability as well as significant radiographic postural/spinal deformity. These conditions all improved and were maintained at a 2 year follow-up without further treatment.

INTRODUCTION

Each year, billions of deltoid intramuscular (IM) injections are given to administer multiple vaccines globally^1,2,3,4,5,6). In some instances, this shoulder injection causes pain and dysfunction long after the normal soreness should persist. In many of those cases where the pain does not resolve, the patient will experience disability and reduction in quality of life^{4, 7)}. If the patient seeks treatment for the vaccine injury, the diagnosis of shoulder injury related to vaccine administration (SIRVA) is requisite. Prior to the global COVID-19 pandemic of 2020, SIRVA had been reported most frequently due to the Influenza vaccine inoculation^{3, 8)}. The introduction of the COVID-19 vaccine has produced some recent literature demonstrating SIRVA following administration^{2, 4, 8,9,10)}. This is important for global healthcare because billions of doses have been administered and it is likely that physicians, clinicians, therapists and nurses will attest to patients suffering from SIRVA^{1, 5, 8, 11)}. This case report offers a potential conservative treatment option.

The treatment of SIRVA following influenza and other deltoid-targeted IM vaccines has been discussed in the literature^{1,2,3,4, 7)}. Due to a dearth of literature, the treatment options are limited and range from over the counter (OTC) medications and prescription analgesics to physical therapy, ablations and surgery^{5, 8, 12)}. There are extremely few studies showing subjective and objective short and long-term positive measurable outcomes. Discussion of SIRVA treatment following COVID vaccine administration is even more rare. Shoulder pain is very common and differential diagnosis must be made^{6, 7, 13)}. Concomitant conditions can worsen the potential outcome of any treatment and must be correctly diagnosed to best treat the patient⁴⁾. Adult spine deformity (ASD: scoliosis >20°, sagittal vertical axis >5 cm, pelvic tilt >25° (reduced distal lumbar lordosis) or thoracic kyphosis >60°) can cause or complicate neck and shoulder pain and should be addressed by the astute clinician^{14, 15)}.

This case demonstrates the dramatic improvement in posture and radiographic measurements as well as the alleviation of mild to severe neck pain and severe shoulder pain after a COVID-19 injection with a shoulder mobility and posture rehabilitation program.

PARTICIPANT AND METHODS

On May 17, 2021 a 54-year-old male presented complaining of left shoulder pain. The pain was described as a dull ache, where the patient reported it felt like the shoulder was ‘ripping out’. The pain had escalated in severity over a three-week period following a Pfizer-BioNTech Comirnaty COVID-19 vaccination in the corresponding arm on April 28, 2021. The pain intensity was rated as an 8–9/10 (0=no pain; 10=worst pain ever). There was also a mild-to-severe pain in the neck described as an ‘odd pain’ that throbbed, where the patient scored a 70% on the neck pain disability questionnaire (NDI). The patient had never had these pains previously and reported that he had not slept at all for the last 4 nights due to the severity of pains.

Cervical range of motion (ROM) showed a severe loss of extension mobility, a significant limitation in bilateral side bending as well as a moderate restriction in bilateral rotation. Any pressure on the head in any position exacerbated the shoulder pain particularly backwards motions. There was severe restriction on left shoulder motion above the horizontal not due to restriction but due to severe pains, there was no restriction to right shoulder motion.

Radiographic assessment was performed and analyzed using the PostureRay^® EMR (Trinity, FL, USA) which uses the repeatable and reliable Harrison posterior tangent method to mensurate the lateral views^16,17,18,19). The radiographs (Fig. 1) showed a very hunched neutral standing alignment. In the cervical region, the patient had a 65.7 mm forward head posture, (FHP) (vs. normal <15mm^{20, 21)}), a flexed atlas plane line (APL: +2.6° vs. −24–29°^{20, 21)}) and reduced cervical lordosis (−14.2° vs. −31–42° normal^20,21,22)). The patient also had a T2-T11 thoracic hyperkyphosis (56.0° vs. 42° normal²³⁾) and a forward lean (horizontal distance between T1 and T12) of 62.1 mm (vs. 0 mm ideal²³⁾). On the lumbar view the patient demonstrated a 71.3 mm posterior thoracic translation (vs. 0 mm normal²⁴⁾), a loss of lumbar lordosis (−17.2° vs. −40° normal^{24, 25)}) and a reduced sacral base angle (SBA: 31.9° vs. 40° normal^{24, 25)}).

Fig. 1.

Lateral full-spine radiographs. Left: Pre-treatment; Middle: Post-treatment; Right: 2 year follow-up

Due to the excessive FHP, and because the patient’s main complaint involved the shoulder, it was decided to both work on shoulder mobility and improve FHP. A series of shoulder stretches were introduced that stretched the shoulder in 3 directions: horizontally across the body in both the anterior and posterior directions as well as posteriorly while the arms were straightened up overhead. All stretches were performed on the PowerPlate^® to intensify the stretch and create simultaneous co-contraction of primary and stabilization muscles of the shoulder and neck²⁶⁾.

Chiropractic BioPhysics^® (CBP^®) technique was used to improve the posture and abnormal sagittal spine balance^27,28,29); the primary purpose being to reduce the FHP and forward postural lean and thoracic hyperkyphosis. A mirror image^® exercise involved the patient standing with his back to the wall separated by a block. The head, pelvis and shoulders were simultaneously retracted backwards for a 3-count (Fig. 2). The patient progressed to performing 50 repetitions daily. Spinal manipulative therapy (SMT) was performed on the cervical, thoracic and lumbar spine bilaterally. Spinal mirror image traction (Fig. 3) began with a distraction traction to the head due to the patient initially not being able to tolerate backward bending of the neck as it aggravated the shoulder pain. As treatment progressed, the angle of pull onto the head was positioned increasingly posterior until the 23rd treatment where the traction was changed and the patient was able to fully hang his head off the end of an angled bench. As treatment progressed, weight was added to the chin and forehead to increase posterior head translation and extension of the spine. At the time of re-assessment the weight achieved was 5-pounds for 10-minutes. The patient gave informed consent to the publication of the treatment outcomes including any pictures and X-rays for the purpose of research.

Fig. 2.

Mirror image corrective exercise. The head and pelvis are simultaneously retracted towards the wall, held for 5-seconds and repeated for 50 repetitions.

Fig. 3.

Spinal traction set-ups. Top-left: Distraction traction; Top-right: Pope 2-way traction; Bottom-left: Hanging head traction; Bottom-right: Head traction with weight.

RESULTS

The patient experienced rapid pain relief with treatment and it is noted that after 1-month of treatments (13 sessions) the patient reported ‘feeling great’. The shoulder pain was rated a 0/10 after 33 treatments. A follow-up assessment after 42 treatments (over 4-months) was performed on September 13, 2021. The patient reported to be free of neck and shoulder pains and stated his posture felt improved; work colleagues had even noticed and commented on his upright posture. The pain was 0/10 and the NDI scored 10%. Repeat radiographs (Fig. 1) show a dramatic improvement in posture. X-ray analysis showed a 34.3 mm reduction of FHP (31.4 mm vs. 65.7 mm), a 17.6° increase on APL (−15.0° vs. +2.6°) and a 10° increase in cervical lordosis (−24.2° vs. −14.2°). The thoracic kyphosis reduced by 13.1° (42.9° vs. 56.0°) and the forward lean reduced 73.0 mm (−10.9 mm vs. 62.1 mm). The posterior thoracic translation was reduced 27.4 mm (43.9 mm vs. 71.3 mm), the lumbar lordosis increased 14.2° (31.4° vs. 17.2°) and the SBA increased 5.4° (37.3° vs. 31.9°).

An assessment performed on July 28, 2023, 22-months after the last treatment and 26-months after first starting care, demonstrated the patient remained well with no pain reported for the left shoulder or neck. There was only a little tightness in the left shoulder. The pain was a 0/10 and the NDI scored a 10%. The radiographic exam showed the maintenance of the postural correction; the FHP was further improved (25.7 mm vs. 31.4 mm), the APL was similar (−16.1° vs. −15.0°) and the lordosis was similar (−22.7° vs. −24.2°). The thoracic kyphosis was the same (43.4° vs. 42.9°) and the forward lean had regressed slightly (+8.3 mm vs. −10.9 mm). The posterior thoracic translation was similar (−45.5 mm vs. 43.9 mm), as was the lumbar lordosis (33.4° vs. 31.4°) and SBA (39.8° vs. 37.3°).

DISCUSSION

This case demonstrated the resolution of SIRVA and dramatic improvement in posture in a 54-year-old male who had suffered from debilitating shoulder pain 3 weeks following a COVID-19 vaccination. A 2 years’ follow-up showed the maintenance of the posture correction as well as the resolution of shoulder pain.

SIRVA is a common occurrence with multiple IM vaccines and the COVID-19 vaccine is no exception^{1, 2, 4, 5, 8)}. This shoulder pain can vary from very mild to very severe and has different levels of disability depending on the duration and severity of the condition^{2, 7, 9,10,11,12,13, 30, 45)}. Generally, this pain resolves with analgesics and conservative therapies and does not lead to further complications¹⁾; however, some patients require more invasive procedures. Some studies have shown that the shoulder pain can lead to severe conditions and can further worsen the patient’s subjective and objective assessments as well as increase disability and thus contribute to the global burden of disease (GBD). Chu et al. found that SIRVA patients seeking care in the chiropractic, orthopedic, and physiotherapy facilities in Hong Kong had a high prevalence of shoulder-related pain and he reported diagnoses possibly related to injection into the subdeltoid bursa instead of the deltoid muscle⁵⁾. Further, Chu et al. found that the literature and the vaccine adverse event reporting system (VAERS) documented 68 cases of SIRVA from the COVID vaccine and the conditions identified included bursitis, adhesive capsulitis, tendinopathy, nerve injuries and septic arthritis⁵⁾. Many patients can actually have more than one condition diagnosed^{5, 8)}. Most common injuries were found in females and the age ranged from 19–90⁵⁾. SIRVA has been most frequently found with the influenza virus vaccine; however, more authors are reporting a complex of shoulder conditions following the COVID-19 vaccine and these studies have demonstrated that capsulitis and bursitis are the most likely pain-causing sequalae^{1,2,3,4,5, 7, 9,10,11,12)}. Given the extremely large quantity of COVID vaccines administered, it is expected that more cases will be found in the literature over time⁸⁾.

Shoulder pain and related conditions are common in the medical literature and prevalence ranges widely across many counties with a median prevalence of 16% of the community globally and the burden on primary care is as much as 4.84%⁴⁾. Shoulder pain is more prevalent in women than men, greater in high income nations and is found in approximately 37.8 per 1000 people per year globally. Shoulder pain is reported daily, weekly, yearly and through life across many populations^{4, 6, 13)}. Our patient in this study was found to have a large FHP which Mahmoud et al.³¹⁾ in a systematic review reported to have a high correlation to shoulder pain and upper-extremity dysfunction. FHP has been found to be higher in patients with neck pain, and this complication was found in our patient. The patient herein had an initial 65.7 mm FHP and this needs to be clinically understood as a large / severe abnormal posture as the total range of motion of this posture has been reported to be approximately 75 mm in the average adult; thus, our patient’s neutral resting posture was 65.7 / 75=87.6% of maximum range of motion³²⁾. Such a large posture will increase muscle loads due to the increased lever arm from the center of mass of the skull relative to the upper thoracic spine and dramatically increase the stresses and strains on the cervical spine tissues including the discs, ligaments and vertebrae³³⁾.

CBP technique has extensive literature concerning the correction of abnormal coronal and sagittal balance^{29, 34, 35)}. These corrections have been shown to improve health related quality of life (HRQoL) measures, reduce pain, improve neuromuscular balance and coordination, and accelerate central nervous system conduction time^{29, 34, 35)}. These changes in the patient’s HRQoL as well as improvements in radiographic alignment have been shown to be repeatable, reliable, and stable over the long-term; that is, up to 1–2 years^{34, 35)}. These corrections reduce ASD and thus reduce the GBD. This is the first known study demonstrating the predictable results of the application of CBP techniques when used in a SIRVA patient following COVID-19 vaccine administration.

FHP is endemic³¹⁾ and is associated with a plethora of physical ailments and disturbances of function such as pain, ROM, abnormal respiration, reduced physical performance, and altered sensorimotor integration and HRQoL measures^36,37,38,39). FHP can be corrected using CBP methods and have been shown to improve short- and long-term pain and disability, improve HRQoL, as well as sensorimotor integration measures^{34, 35, 40, 41)}. Some of these findings are consistent with the improvements found for our patient. Further, as was found in our reported case, the correction of FHP and improvement in sagittal balance with CBP reduced the patient’s pain and improved disability measures, and were stable over long-term (22-month) follow-up. This case adds to the continually growing body of evidence demonstrating the wide variety of conditions that respond favorably both objectively and subjectively to CBP spine corrective care methods.

Radiography was critical in the proper diagnosis of the patient. Had the patient not received full spine films, the correct diagnosis and treatment approach could have been altered or missed and this would have likely contributed to worsening of his ASD and could have potentially led to results that likely would not have been as substantial both objectively and subjectively^{15, 42)}. Plain film and digital radiography to determine diagnosis and differential diagnosis is safe, despite the erroneous assumptions in the past that there are dangers^43,44,45). For example, the linear-no-threshold theory has been completely discredited as not realistic and any dangers caused by the radiation would be significantly less than the production of free-radicals via oxidation due to normal respiration⁴⁶⁾. This case further demonstrates how radiography continues to be the criterion standard in the proper diagnosis and treatment of pain and disability without which the patient would further contribute to the GBD⁴⁷⁾.

Limitations to this case includes this being a single case, the fact that cause and effect for SIRVA as described cannot be proven, and due to the multimodal treatment approach, it is not known what precise treatment modality led to either the posture correction or the shoulder pain relief. Regarding the posture improvement it has been demonstrated, however, that mirror image spinal traction procedures lead to improved spine alignment whereas physiotherapeutic procedures do not consistently produce such large results. More and larger studies and long-term research on effective treatments for SIRVA are necessary.

This case demonstrates significant improvement in a patient suffering from COVID vaccine SIRVA, concomitant with neck pain and disability as well as significant radiographic postural deformity. These conditions all improved when treated with CBP methods and a shoulder rehabilitation program. Vaccination with a COVID deltoid targeted vaccine and other upper extremity IM injections must follow standard and proper technique to prevent piercing the subdeltoid bursa and potentially setting in motion the process of concomitant conditions, pain, disability and worsening HRQoL measures. Knowing the population at highest risk of complications should be a part of informed consent when administering all vaccines and COVID is no exception. This paper gives the astute clinician a conservative treatment option for patients suffering from SIRVA and further adds to the growing body of evidence of the effective nature of CBP protocols. Further, larger studies are necessary to confirm the positive results reported herein.

Conflict of interest

Dr. Jason W. Haas (JWH) is an instructor for CBP Seminars. Dr. Paul A. Oakley (PAO) is a compensated consultant for CBP NonProfit, Inc. Dr. Deed Harrison (DEH) is the CEO of Chiropractic BioPhysics (CBP). This organization provides post-graduate education to health care providers / physicians. Spine rehabilitation devices are distributed through his company. DEH is the president of CBP NonProfit, Inc.—a not-for-profit spine research foundation.