Abstract: In this interesting case, the patient suffered injuries to the back and neck as a result of a MVC (motor vehicle crash). During routine radiological imaging, we noticed a number of pre-existsing issues including frank thoraco-lumbar scoliosis. The X-Rays tell the story. Note also the damage to the vehicle itself. *Pictures coming.

FIRST DAY REPORT - Patient: D T  S-2326    (DOB: 8/6/46)

HISTORY AND PRESENTING COMPLAINTS:
1/10/08: Mr. T presented to us seeking treatment for injuries received in a MVC (motor vehicle crash) on or about 1/1/08. He stated that he was the restrained driver in a 1990 Nissan Pick-up that was stopped at a stop sign when a mini-van slammed into the rear of his vehicle. The offending van was apparently going at a high rate of speed because the entire rear window of the Nissan exploded upon impact. Mr. T indicated that prior to impact he was facing forward, his head rest was set and the crash came as a surprise to him. He stated that the impact thrust him forward and backwards in his car seat and he furthermore slammed his chest against his own steering wheel. He denied any loss of consciousness, but did mention that he was dazed from the impact. He stated that there were no police or EMS called to the scene and that after exchanging papers, he opted to go home. Mr. T added that the pain became worse by the next day and that his wife drove him to Somerville hospital. He stated further that when he arrived at Somerville Hospital, he was attended by an ER doctor. He stated further than he was examined, received no X-Rays, was scripted for meds and told to go home and to rest. He stated that the reason he presented to our office (BSCs-Somerville) was because of continued chest, neck and back pain. He described the primary locus of pain as being in his L spine that was of a constant achy/sore pain in nature in which most activities such as bending, lifting, getting up aggravated his condition and was temporarily relieved with rest. He stated further that his neck and chest were not quite as painful as the LB but still extremely sensitive and sore. Mr. T stated that the entire region of his neck (like the entire region of his LB) was achy/sore/constant in nature where lifting and movement aggravated and rest offered slight relief. The same was true of his chest pain. All areas were sensitive and painful to touch. He stated that he did not smoke or drink. He informed us he did get yearly physical exams and that he was in otherwise in good condition. He added that he was feeling fine prior to the MVC without the abovementioned pain. Mr. T reminded us that he was a patient here in 2004 for injuries resulting from a MVC at that time. He was discharged at the time with few residuals. Upon further questioning, he could not recall any other significant past personal or family medical history including traumatic accidents. He further stated that the crash disrupted his ADLs; this included activities such as walking, going up/down stairs, getting in/out of the car, job activities, carrying groceries, lifting things, turning door knobs, getting dressed. *The patient was asked to obtain all of his relevant hospital records. He stated that he would attempt to do so.  

JOB DESCRIPTION:  Steward at the FOUR SEASONS Hotel in Boston. A Steward assists in the kitchen cleaning, washing, lifting etc.

VEHICLE PICTURE(S):  

Note tape holding right rear light assembly in place. Noted also here is the exploded rear window as well as the bumper damage.

*Pic Coming

We formatted this undercarriage picture larger to highlight the distorted rear Frame Rail. This shot was taken from the right ¼ panel looking to the left rear ¼ panel.

GENERAL PHYSICAL EXAMINATION:
Mr. T presented as an alert, cooperative, right handed, 61 year old, WDWNHaitianM standing 5’8” and weighing 131.6 lbs. Body fat was electronically measured at 4.8%. Appearance, mood, intelligence and thought process appeared appropriate. JOMAC and AMSIT were WNLs.  His blood pressure was 140/50 on the left.  Temperature was normal. His radial pulse was 62 bpm. Respiration’s were 17 pm. He was afebrile but in considerable discomfort. Gait appeared slow and guarded. A general query of the review of systems was performed and included constitutional symptoms, nervous system, muscular/skeletal system, skin/integument, ophthalmic, ear/nose/throat, respiratory, cardiovascular, gastrointestinal, genital/urinal, endocrine, immune/allergic, hemopoietic/lymphatic, and psychological.  Due to the age of this patient (39 yrs or  older), it is our recommendation that this patient have a PSA, SMAC-24, differential, CBC, Sed Rate, and Acid Phos to rule out possible prostate involvement.  The patient understood and will make an effort to do so.

We reviewed all 14 Systems. The only ROS (Review of Systems) that were pertinent to the patient’s chief complaints were as follows:

Cerebrovascular Craniocervical:
1. Subclavian/Carotid: No carotid or subclavian artery bruits were auscultated. If positive-vertigo, visual disturbances, nausea, syncope or nystagmus. Indicates vertebral, basilar, or carotid artery stenosis or compression. 
2. Vertebral Arteries: No ischemic reactions noted during rotation and hyperextension.
Vertebrobasilar Artery Tests:
1. Hallpike Maneuver: Dr. performs hyperextension and rotation holding for 15-45 seconds with the patient supine at the end of the exam table. Positive-if vertigo, blurred vision, nausea, syncope and/or nystagmus. Indicates vertebrobasilar vascular compromise. This is basically an exaggerated DeKleyn’s Test.
2. DeKleyn’s Test: Patient supine with his/her head extended off the end of the examination table. The patient rotates and hyperextends the neck to one side and holds that position for 15 to 45 seconds. The examiner may provide minimal support for the weight of the skull. The maneuver is repeated for the opposite side. The production of vertigo, visual disturbance, nausea, syncope, or nystagmus indicates vertebrobasilar circulation compromise. *Both were positive. I will endeavor to retest these two tests to differentiate between a rare but possible VA issue or a far more common mechanoreceptor issue.

Constitutional symptoms –The patient presented with fatigue/pain.
Nervous system – See below
Muscular/skeletal system – See below
Skin/integument – Scratches and cuts on the right shin.
Ophthalmic –Cardinal Fields of Gaze: (SO4LR6) SR-CN III, LR-CN VI, IR-CN III…IOblq.-CN III, MR-CN III, SO-CN IV. (Normal)
Ear/nose/throat -WNL
Respiratory –WNL- with no bruits noted.
 Cardiovascular –WNL.
Gastrointestinal –WNL based upon history
Genital/urinal – WNL based upon history
Abdomen- WNL
Endocrine –WNL based upon history
Immune/allergic -Hx
Lymphatic –Lymph nodes: Pre-Auricular, Post Auricular, Occipital, Tonsillar, Submaxillary, Submental, Superior Cervical, Posterior Cervical Chain, Deep Cervical Chain and  Supraclavicular: All appeared normal on investigation.
Psychological – Hx.

The ROS did not reveal any other significant findings pertinent to the patients’ chief complaints. 

Right shin.

TODAY’S OUTCOME FINDINGS: Tabulations for the C/L spine OSWESTRY Questionnaires are as follows:
C-Spine: (12 points ÷ 50) X 100 = 24% = Moderate Disability
L-Spine: (25 points ÷ 50) X 100 = 50% = Moderate Disability
Analog PAIN Scale C-spine: 8 of 10 (10 being the worst)
Analog PAIN Scale L-spine: 8 of 10 (10 being the worst)

OUTCOME INDICATORS: Note the back of the daily note sheets. There is a pain figurine and an Analog pain scale on each. We have the patient fill this out every visit or couple of visits.

HEAD-RESTRAINT GEOMETRY: An inquiry with the Insurance Institute for Highway Safety (www.iihs.com) on the efficacy or lack thereof on the patient’s particular vehicle tells us that a) the truck hasn’t been made by Nissan in years, b) the only year it was rated was 1997 and it received a mixed rating of A-M-P (acceptable, marginal, poor).  As one can see from the picture below, Mr. T’s back set is sizeable. As well, the head-restraint is situated low on his truck, at the “marginal” to “poor” zone. 

>Head restraint geometry explained: The necessary first attribute of an effective head restraint is good geometry. If a head restraint isn't behind and close to the back of an occupant's head, it can't prevent a "whiplash" injury in a rear-end collision. Institute researchers regularly evaluate the geometry of head restraints in passenger vehicles based on the height and backset relative to an average-size male. A restraint should be at least as high as the head's center of gravity, or about 9 centimeters (3.5 inches) below the top of the head. The backset, or distance behind the head, should be as small as possible. Backsets of more than 10 centimeters (about 4 inches) have been associated with increased symptoms of neck injury in crashes.

>Geometric ratings: Geometric ratings are good predictors of how well people will be protected in rear-end crashes — drivers with restraints rated good are less likely than those with poor restraints to claim neck injuries. Head restraint geometric ratings for hundreds of passenger vehicles are listed by vehicle make and series. Various head/seat combinations are rated (not every available seat option in every series has been measured). The restraints are measured with the angle of the torso at about 25 degrees, a typical seatback angle. Each restraint is classified according to its height and backset into one of four geometric zones — good, acceptable, marginal, or poor.

 
Note Back set of head restraint.

NEUROLOGICAL EXAMINATION:
Deep tendon reflexes were 2+ and equal bilaterally in both upper and lower extremities. Cranial nerves I-XII were intact and there was no evidence of pathological reflex. Sensation to pin and light touch was preserved in both upper and lower extremities. Motor strength testing was 5 in upper extremities and 5+ in the lower extremities. Position sense was intact.

PALPATORY AND ORTHOPEDIC EXAMINATION:
The cervical spine ranges of motion were found to be considerably decreased in all vectors and pathomechanical.  This was performed actively and passively and both elicited pain.  Myospasms muscles were noted in the anterior/posterior cervical/thoracic spine musculature. Noted also via motion palpation were pathomechanics of the C-T spine.

ROM: The “Dualer” inclinometer was used and the ROM is used here to simply monitor clinical progress. 

Cervical ROM 

Flexion 24  Normal 50 
Extension: 29 Normal 60  
RLF 18  Normal 45     LLF 10 Normal 25
LLF 26  Normal 45     RLF 13 Normal 25

Lumbar ROM 

Flexion 25    Normal 90
Extension 25 Normal 25
LR 32   Normal 80    
RR 20   Normal 80    

The lumbar spine ranges of motion were also found to be moderately decreased in two vectors and although flexion/extension was ostensibly normal, he was in much pain performing them and bent his knees to flex down. Pathomechanical were noted via motion palpation.  This was performed actively and passively and both elicited pain. The SI joint was notable for pathomechanics too; this ascertained via motion palpation. Hypertonic tone muscles were noted in the lumbar spine musculature. 
     
DYNAMOMETER: In Kgs.
L:  15, 15, 15
R:  15, 15, 15

Orthopedic Tests:
The following orthopedic tests were performed and are indicated as a positive or negative finding. The results of these orthopedic tests were used to DDX the patient’s presenting complaints and condition. The specific location of pain is also identified. WR=Whole Region.

The Neck: 
Bakody’s -
Brach. Plexus Tension -
Distraction - No reaction
Foraminal Compression +  L/R WR
Jackson’s +  R WR
Lhermitte’s Sign 
Max. Cerv. Compression  +  L/R WR
 
Shoulder Depression Test + L C5-7
Soto-Hall 

The Thoracic Spine:
Amoss +
Adam’s Position +
Schepelmann’s Sign + WR
Spinal Percussion + WR

The Low Back/Sacrum:
Bi-lat. Leg Lower 
Braggard’s 
Double Leg Raiser 
Ely’s 
Kemp’s + L/R L5
Minor + Walking very guarded
Nachlas 
SLR 
Erichsen’s + R SI
Hibb’s + L/R L5
Sacral Apex 
Squish Test 
Yeoman’s + R SI

DDX TESTS:

Cervical Spine:
Bakody’s Sign: While seated, the patient actively places the palm of the affected extremity on top of the head, raising the elbow to a height approximately level with the head. By elevating the supra-scapular nerve, traction of the lower trunk of the Brachial Plexus is relieved. The sign is present when radiating pain is relieved.
Brachial Plexus Tension Test: A positive test in this inventory strongly suggests a cervical root problem, most likely at C5.
Distraction test-local pain is increased on distraction then muscle strain, spasm, ligamentous sprain or facet capsulitis is suspect.  Relief of local or radicular pain is indicative of either foraminal encroachment or a disc defect.
Foraminal Compression-localized pain may indicate foraminal encroachment without nerve root pressure or apophyseal capsulitis, radicular pain may indicate nerve root involvement.
Jackson’s Compression Test: A positive sign suggests nerve involvement from a space-occupying lesion, subluxation, inflammatory swelling, exostosis or DJD, less so a tumor or disc herniation.
Maximum Cervical Compression: This test is performed bilaterally. Pain on the same side of testing suggests nerve root or facet involvement. Pain on the opposing side indicates muscular strain.
Shoulder Depression Test -local pain on the side being tested indicates shortening of the muscles, muscular adhesions, muscle spasm, or ligamentous injury.  Radicular pain may indicate compression of the neurovascular bundle, adhesion of the dural sleeve, or TOS.  If pain is elicited on the opposite side being tested it may indicate a decrease in the foraminal interval, facet pathology, or disc defect.

Thoracic Spine:
Adam’s Position: With the patient standing upright and the examiner standing behind the patient, the patient is asked to flex forward without bending the knees. Spinal curves such as scoliosis can be observed in this position. If the patient has an S or C scoliosis, the curvature may straighten out when the spine is flexed forward. If it does, it is a negative sign and evidence of functional scoliosis. A positive sign is noted when the scoliosis is not improved after flexion and suggests pathologic or structural scoliosis, trauma or subluxations.
Schepelmann’s Sign:  This sign identifies rib integrity and thoracic muscle tension. The patient raises his/her arms while seated and then bends laterally. If pain is created on the concave side, it is due to intercostals neuritis. Pain on the convex side suggests intercostals myofascitis.
Spinal Percussion Test: The examiner percusses the spinous processes and the associated musculature of each of the thoracic vertebrae with a neurologic reflex hammer. Evidence of localized pain indicates a possible fractured vertebrae. Evidence of radicular pain indicates a possible disc lesion.
Amoss Sign: The patient rises from a side posture position. If there is pain it is suggestive of severe sprain among other issues.

Lumbar Spine: 
Kemp’s test- localized lower back pain with no radicular component is indicative of lumbar muscle spasm or facet capsulitis. 
Minor Sign: The patient is seated and asked to stand. The examiner observes how the patient rises from the seated position. The sign is present if the patient supports weight on the uninvolved side by balancing on the healthy leg, placing one hand on the back, and flexing the knee and hip on the affected side. Present with SI lesions, L-S strain/sprains, fractures and disc lesions.
Nachlas test-stretching the quadriceps muscles causes the sacroiliac joint and the lumbosacral joints to move inferiorly, pain in the buttock may indicate a sacroiliac joint lesion, pain in the lumbosacral joint may indicate a lumbosacral lesion.  Radicular pain into the anterior thigh may indicate a compression or irritation of the L2, L3 and L4 nerve roots by a disc defect, spur, or mass.
Erichsen’s Test: This test suggests pain and problems in the SI complex.
Hibb’s Test: This test also suggests pathomechanics of the SI complex.
Sacral Apex Test: With the patient prone, the examiner places both hands at the sacral apex. Pressure is brought to bear causing the sacrum to shear in relation to the ilium. The test may indicate an SI lesion of there is pain reproduced over the joint.
Yeoman’s Test: This maneuver places extra stress on the SI joint and surround holding elements. Pain here suggests an SI lesion.

RADIOLOGICAL EXAMINATION:
A clinical decision was made to take the necessary X-rays today on this patient. This would normally include a cervical Davis Series as well as AP-Lat lumbar films. Findings are as follows:

C-spine: The AP shot reveals frank and profound scoliosis in the upper T spine as it blends into the lower C spine. The C-spine itself appears fairly straight, all things considered. There is moderately advanced DJD of the unco vertebral joints up and down the length the columns. The L lateral bending shot reveals practically no lateral bending with no theta Y coupling rotation. The right lateral bending shot is the same as the left. Not surprisingly, the remarkable Thoracic scoliosis is, in my opinion, a factor in these motion shots; most likely disrupting normal motion. The APOM appears WNLs in all respects. The lateral view reveals an anterior tilted C-spine relative to the shoulders. The spine is completely alordotic from C1 to C5. Noted is advanced DJD in the mid region such that there is a sizeable syndesmophyte anteriorly at C4 reaching caudally and apparently fusing with the anterior body of C5. I say apparently because in the flexion and extension views, this contact remains intact. That is to say, we don’t see a separation between the C4 syndesmophyte and the body of C5 in either of the motion views. Disc height is somewhat diminuated in the lower segments but considering the overall advanced state of degeneration of this individual, the disc integrity is surprisingly good. Looking further at the lateral view, we see a profound osteophyte jutting caudalward from the anterior/inferior body of C5. A smaller caudal jutting osteophyte can be seen at the ant/inf. body of C3. Noted further is a small ant/sup. body osteophyte at C6. *Incidentally, the patient doesn’t appear to have any teeth save a lone left frontal incisor. I presume he has been fitted with some kind of plastic amalgam dentures since he does appear to have “teeth” when interacting with this patient in person. I’ll ask him next time he comes in. Noted further is a pons posticus at C1. The forward flexion view is just the entire C spine tilting anteriorly. There is no flexion. The extension view shows some actual extension albeit limited. Generalized osteopenia is visualized as well here.

L-Spine: Notable in the AP view is the frank and profound dextro convex rotary scoliosis. The curve winds back levo into the thoracic spine. Although an AP T spine view was not taken, it is clear that the patient has a sizeable T-L “S” curve scoliotic spine. Although literature is somewhat divided, it has been my experience that with large “S” curves in the spine it is usually indicative of a more congenital scoliotic issue as opposed to the lesser and smaller “C” curves we more often see that are usually indicative of posturally induced scoliosis. I opted to measure the lower T/L spine curve utilizing the Cobb Method of mensuration. It came to 33°. There seems to be a sacralization of the left L5 TVP and the sacrum. Not surprisingly, the lateral view is obscured by the frank scoliosis and as such disc heights cannot be adequately viewed.  Schmorling is also seen throughout the region.

No evidence of fractures, dislocation or neoplastic activity was visualized in these films. *800 Rare Earth systems were used with lead collimation and shielding and the inclusion of the thick lead gonadal shield to absorb lower limb/abdomen scatter. Technique was good in this set. All views were weight bearing; sitting for the cervicals, standing for the thoraco-lumbars. **For some odd reason, the cervicals wound up sticking together during developing. This amounted to the edges showing stain patterns and some discoloration but no body parts were obscured. I retrieved the cervicals just as they came out of the processor so they didn’t wind up drying together while stuck together.

Extension view of DT’s cervical spine.

Neutral Lateral view of DT’s C spine.

 Lumbar AP view of DT’s low back. Left side is on left here, we are viewing this film from “behind.”

DIAGNOSIS (original):
Initial working diagnosis: Based on the patient's subjective comments, the case history, and the DDX analysis during the physical exam, it was opined that the patient sustained a Cervical-Lumbar/sacral strain/sprain Grade II with full spine pathomechanics and gross  myospasms, all as a result of the accident the patient suffered on or about 1/1/08. This all compounded by the patient’s pre-existing scoliosis. This is to a reasonable degree of medical certainty.

TREATMENT DISCUSSION & PLAN:
We have decided to accept the patient for care.  All findings will be explained to him.  This data will include all relevant physical, orthopedic, neurological and roentgenological findings.  We will also explain to him exactly what manipulative therapy is and how it will affect him.  As well, all risks inherent with manipulative therapy will be explained to the patient, although we do not foresee any complications with him. We will explicitly not guarantee results.  Our stated goals in this case are threefold: Primary/Short Term, Intermediate and Long Term.  The short-term goals are to reduce the strain/sprain incident of the musculoskeletal system dysfunction, to educate the patient on the crucial importance of maintaining proper posture, and strive towards intrinsic and global kinematic correction.  Our intermediate goals are to create strength and flexibility for kinematic function and initiate kinematic activity.  Finally, our long-term goals are to restore normal intrinsic, global and kinematic function, follow up on the patient’s efforts to rehab himself at home and continue with kinematic activity.  Our initial feeling is to initiate a clinical trial of 2 weeks of treatment on a 4-5x/week basis which will include CMT following Diversified protocols, and perhaps a form of therapy such as interferential current and low force intersegmental traction for pain relief. Manipulative reductions performed by me in the cervical spine consist of coupled reductions with a lateral thrust. There is never a rotational component in these moves. Lumbar reductions are more often than not, spinous pushes or pulls.  If the patient responds as anticipated, then we will continue for an additional 2 weeks. Re-examinations are performed regularly to asses progress of lack thereof. Targeted joints for this rationale will be the cervical, thoracic, lumbar, sacral spine. Spinal manipulation performed will consist of specific spinal adjustment and will be indicated in the patient’s daily treatment SOAP notes. The purpose of the manipulative procedures is for correction of the interoseous dis-relations, reduce fixations, improved range of motion and free articular anatomy for the reduction and/or removal of neurological dysfunction. The supportive therapeutics or procedures utilized will include: 1). electrical muscle stimulation for reduction of muscle spasms, edema and pain control; 2). mechanical traction of either the cervical or intersegmental full spine to help restore spinal curve, relax tense muscles, increase circulation, reduction of fixations and adhesions; 3) Ice to reduce inflammation. If the patient has not shown any signs of improving within the first 2 weeks, then we may opt to obtain a second opinion, physical therapy, and/or advanced imaging.  The patient appeared to understand everything that was explained to him thus far and made an informed decision to be treated with therapy today and plans to follow up as indicated. He understood that there will be further explanations when the X-Ray films are reviewed.

PROGNOSIS:
Based on the mechanism of injury, patient’s presenting complaints and the results of his objective initial examination, it is anticipated that the patient will respond favorably to our care. The patient’s final prognosis will be determined at a later date after he has responded to our care and a permanent and stationary status has been achieved. 

DISABILITY NOTIFICATION:
Pursuant to the M.G.L. Chapter 90, Subsection 34M; it was opined with clinical judgement and the patient’s testimony that he was totally disabled from 1/1/08 to 1/4/08 and partially disabled and ongoing, due to the beforementioned diagnosis.  This means that the patient has difficulty/had difficulty performing the activities of daily living /and his typical occupational demands are compromised due to his disability, which was a causal result of the motor vehicle crash on or about 1/1/08.

SUGGESTIONS: For showering, I suggested a quick wash-up for hygienic purposes and then get out but keep extra heat to a minimum for now. Use the supplements and keep the appointments.

HOME EXERCISES: The patient was given a set of home exercises to start doing in the comfort of his home.

HIPAA NOTIFICATION:
The patient was given a detailed PRIVACY notice. This was explained and understood by the patient. The patient signed an acknowledgment form indicating that they have received a copy of the PRIVACY notice.

I am a duly licensed chiropractic physician, licensed to practice in the Commonwealth of Massachusetts. This examination took over 80 minutes.  Subscribed and sworn to under the pains and penalties of perjury.

Sincerely,

John J Haberströh, DC
Chiropractic Physician   CV available upon request via E mail

JJH/

NB: The patient was put on pain inhibiting modalities today that included intersegmental traction(T-L spine, 20M), E-stim(L spine,9mA, 20M)  and ice (mid back, 20M). Also;

We discussed with the patient was the correct postural biomechanics involved with the proper use of the cervical spine support pillow and the recommended home application.

Also discussed with the patient was the correct application of cryotherapy, valerian root and other postural considerations at home and work. Also, we discussed how excess heat should NOT be applied post-injury. The patient stated an understanding of our lengthy discussion.

Analysis: The patient responded very well to care. Treatment parameters extended just over 30 visits. As you can see from the Narrative, he underwent rehabilitation methods as well as continued manipulative reductions of the spine. The patient is free to return on an as-needed basis henceforth.

Our first case study shows us a number of interesting things about this patient. It also points out that plain film X-Rays still have a place in the everyday practice and can reveal postural issues that may have been fomenting for years only to have "pain" appear years later. Let's see how this patient's history and findings came together:

 BOSTON SPINE CLINICS

FIRST DAY REPORT:  A H  S-24**  (DOB: 11-1-70)     

HISTORY AND PRESENTING COMPLAINTS:
4/22/09: The patient presented today seeking treatment for acute upper mid back pain, right arm radiculopathy and neck pain. Ms. H stated that although she has had discomfort in the back for a fairly long time, it was April 9, 2009 that the pain in her back and arm became so profound that she “felt like her arm was coming off.” Ms. H stated that she sought two massages and began taking Ibuprophin. As a result of that, she continued, her pain seemed to calm down. Ms. H presents today due to continual pain in the areas described. She stated that the worst of it is in her upper middle thoracic region, medial scapular area. She described the pain as being heretofore stabbing in nature but more of a noticeably achy sensation now as well as constant. She stated that stress issues as well as sitting at a desk all day aggravate as does sleeping. Ms. H added that movement relieved the pain somewhat. Ms. H further described the right arm pain along a specific C7 locus to the elbow. That is to say, a pure triceps pattern. She described this pain as achy/sore now, constant, where again, stress and sitting all day aggravate and movement offers some relief.  Ms. H further told us that the neck pain is right sided and more of a casual ache and least bothersome of her three big pain issues. It is also constant with the same aggravating and relieving factors.

Ms. H indicated that she gets medical checkups 1x/year and she is otherwise in good condition. She indicated that in 2001 and again in 2007 she experienced profound neck spasms. In fact, she continued, it was “excruciating.” She stated that she took Naproxen at the time for relief.  She added that her father has LBP and gets chiropractic care. Ms H also stated that her sister has RA and that her grandfather also had LBP issues. Apparently the rest of her family is in good physical condition. She stated that she does not smoke and enjoys a social drink. Upon further questioning, she admitted she sleeps on her left side and stomach, sometimes with her arms above her head. Upon further questioning, she could not recall any other significant personal or familial medical history including traumatic accidents.

JOB DESCRIPTION:  Marketing.

GENERAL PHYSICAL EXAMINATION:
The patient presented as a 38 yoa, alert, cooperative, right handed WDWNCF standing 5’4” and weighing 141 lbs. Body fat was not obtained today. AMSIT and JOMAC were normal. BP=100/60 on the left with a pulse of 70 bpm regular, steady and compliant bilaterally. Respiration's and temp were normal with no bruits noted. She was afebrile but in some discomfort. Auscultation of the heart and lung sounds was normal.

Allergies: NKDA

NEUROLOGICAL:
Neurological inventories were examined.  These included cranial nerve, cerebellar, sensory and reflex function. All inventories examined were clear at the time of the exam. 

PALPATORY, ROM AND ORTHOPEDIC EXAM:
The patient had extensive muscle spasm in the C-T spine and more of a moderate tension feel in the lumbar spine, along with global pathomechanics, especially about the upper mid back. Pathomechanics ascertained via motion palpation of the spine.  ROM was somewhat compromised in the Cervical, Lumbar spine region (s). 

>Cervical ROM:
 Flexion 24 Normal 50  -   Extension: 30 Normal 60  
 RLF 36 Normal 45  LLF 32 Normal 25
 LLF 34 Normal 45  RLF 24 Normal 25
 

>Lumbar ROM:
Flexion 25 Normal 90
Extension 22 Normal 25
LR 60 Normal 80    
RR 60 Normal 80    

ROM: Is used here to simply monitor clinical progress, as per the AMA Guides, 6th Ed.

   
DYNAMOMETER GRIP STRENGTH (Kgm):
L:  24, 24, 20
R:  20, 22, 22

Cerebrovascular Craniocervical:
1. Subclavian/Carotid: No carotid or subclavian artery bruits were auscultated. If positive-vertigo, visual disturbances, nausea, syncope or nystagmus. Indicates vertebral, basilar, or carotid artery stenosis or compression. 
2. Vertebral Arteries: No ischemic reactions noted during rotation and hyperextension.
Vertebrobasilar Artery Tests:
1. Hallpike Maneuver: Dr. performs hyperextension and rotation holding for 15-45 seconds with the patient supine at the end of the examination table. Positive-if vertigo, blurred vision, nausea, syncope and/or nystagmus. Indicates vertebrobasilar vascular compromise. This is basically an exaggerated DeKleyn’s Test.
2. DeKleyn’s Test: Patient supine with his/her head extended off the end of the examination table. The patient rotates and hyperextends the neck to one side and holds that position for 15 to 45 seconds. The examiner may provide minimal support for the weight of the skull. The maneuver is repeated for the opposite side. The production of vertigo, visual disturbance, nausea, syncope, or nystagmus indicates vertebrobasilar circulation compromise. *Both were negative.

Abdomen: WNL
Upper Extremities: WNL
Lower Extremities: WNL.
Lymph Glands: WNL
SI: Left superior SI pathomechanical
Thyroid: To the extent palpated WNL.
Respiration: Auscultation was all clear bilaterally.

ORTHOPEDIC TESTS:
The following orthopedic tests were performed and are indicated as a positive or negative finding. The results of these orthopedic tests were used to DDX the patient’s presenting complaints and condition. The specific location of pain is also identified. WR=Whole Region.

The Neck: 
Bakody’s + Right side
Brach. Plexus Tension + Right Side
Distraction - No Relief
Foraminal Compression +  Lower right side
Jackson’s +  Lower right side
Lhermitte’s Sign 
Max. Cerv. Compression  +  Lower right side
 
Shoulder Depression Test + right side
Soto-Hall 

The Thoracic Spine:
Spinal Percuss. -
Schepelmann’s Sign -

RADIOGRAPH DISCUSSION:
Due to the patient’s presenting complaints and objective findings, a clinical decision was made to perform AP/Lat/APOM views of the C-spine. Of note:

C-spine: The AP view reveals most prominently, a gentle dextro scoliosis reaching from the upper thoracics to the cephalad portion of the C spine. See documenting digital photos of the region in this view as well as the lateral view. The unco-vertebral joints were clear and well maintained. The lateral view is the other view that revealed much about Ms. H’s situation: noted was a frank kyphosis of the entire region. As well, her entire C spine is tilted slightly forward. Disc and body heights appear proportional and are well maintained. Finally, we have the APOM shot. Ms. H’s C1-2 segmental interface is intact and perfectly normal in relative body spacing. Due to the possible involvement of the thoracic spine in her scoliosis, we may opt to shoot an additional AP Thoracic X-Ray in the near future.

No evidence of fx, dislocation or neoplastic activity to the extent visualized on these films. *800 speed Rare Earth systems were used with full lead collimation and the inclusion of the thick lead gonadal shield to absorb lower limb/abdomen scatter. Ms. H was also given a lead apron for another layer of protection. Technique was good in this set. All views were weight bearing.

Ms. H’s AP cervical shot. Note the scoliosis that also leads into the upper Thoracic spine. We may opt to X-Ray her Thoracic spine shortly.

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  Ms. H’s lateral Cervical shot. Note the frank kyphosis (curve reversal, as opposed to a normal “lordosis”). Disc spacing is good and there is a minimum of any other indication of early DJD.

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Today’s OUTCOME Findings: Tabulations for the C/L spine OSWESTRY Questionnaires are as follows:
C-Spine: (12 points ÷ 50) X 100 = 24% = Moderate Disability
L-Spine: (0 points ÷ 50) X 100 = 0% = No Disability
Analog PAIN Scale C-spine: 6 of 10 (10 being the worst)
Analog PAIN Scale L-spine: 0 of 10 (10 being the worst)

OUTCOME INDICATORS: Note the back of the daily note sheets. There is a pain figurine and an Analog pain scale on each. We have the patient fill this out every visit or couple of visits.

CLINICAL DDX OF COMPLAINT: Casual back pain caused by pathomechanics, cervicogenic radiculopathy, cord compression, TMJ syndrome.

DIAGNOSIS:
Based on the patient's subjective comments, the case history, the DDX analysis and the physical exam, it was opined that the patient suffers from a chronic Cervico -Thoracic scoliosis that has finally begun to cause cognizant pain to this patient. Thus, a variant of the pathomechanical syndrome, the scoliosis is a long term issue. Noted also, pathomechanics in the entire spine with appreciable muscle spasm and cervicogenic radiculopathy. This to a reasonable degree of medical certainty.

TREATMENT DISCUSSION & PLAN:
We have decided to accept the patient for care. All findings were explained to her. This data included all relevant physical, orthopedic neurological and x-ray findings. We also explained to her exactly what manipulative therapy is and how it will affect her. As well, all risks inherent with manipulative therapy were explained to the patient, although we do not foresee any complications with this patient. We feel that home involvement will help this patient. To that end, she was instructed to sleep on her back, use an ortho pillow to start correcting any aberrant cervical curvature and to never sleep on her stomach.  That is to say, she needs to start rehabbing her C-spine on her own time nightly while sleeping. It is an efficient, gentle and inexpensive way to restore the normal lordosis to that region. This is crucial to her long term well being.

Our initial feeling is to initiate a preliminary clinical trial of 2 weeks of treatments which will include CMT following Diversified protocols. Manipulative reductions performed by me in the cervical spine consist of coupled reductions with a lateral thrust. There is never a rotational component in these moves. Lumbar reductions are more often than not, spinous pushes or pulls. At the end of this initial trial we will re-asses the patient and make a further decision as to continued care. Targeted joints for this rational will be the C/T/L/S spine. The operational end-point in this initial phase of care is some pain relief. We will explicitly not guarantee results. If the patient has not shown any signs of improving within the first 2 weeks, then we may opt to: alter our treatment plan, obtain a second opinion and/or order more advanced imaging. It was further explained to the patient that based on my experience, reactions vary with people after the first treatment; about 20% feel better, 20% feel worse and the remaining 60% feel no difference. The patient appeared to understand everything explained to her and made an informed decision to be treated today and plans to follow up as indicated.

SUGGESTIONS:  Use ortho pillow (she actually bought one today), stop jogging and start power walking instead to keep the joint pounding to a minimum, elevate all computer screens such that she is at least looking straight ahead if not in slight extension. Additionally, I stressed that any and all book reading should be elevated such that she doesn’t keep looking down all the time. 

HIPAA NOTIFICATION:
The patient was given a detailed PRIVACY notice. This was explained and understood by the patient. The patient signed an acknowledgment form indicating that they have received a copy of the PRIVACY notice.

I am a duly licensed chiropractor licensed to practice in the Commonwealth of Massachusetts. This exam took over 40 minutes. Subscribed and sworn to under the pains and penalties of perjury.

Sincerely,

John J. Haberströh, D.C.
JJH/

Analysis: The patient enjoyed her first two treatments and felt markedly better. She was admonished to use the ortho pillow regularly and sleep on her back henceforth. Patient involvement with care is crucial to ongoing success in treatment, especially in a "wholistic" approach to care in which a patient's lifestyle, postural and sleeping habits and exericise are taken into consideration.

Judicial used of X-Rays are indicated in many cases. When findings like we have here come up, they make for a compelling "Report of Findings" when explaining a diagnosis to a patient.

Remember, pain is NOT a reliable criteria with which to judge one's health. The deformation in this woman's spine took years to happen, yet she only felt serious pain more recently. Get checked by your chiropractor when there is the slightest suspicion of back/leg/arm pain and any of the other common issues we regularly treat such as headaches.

Yours in Good Health, Dr. Haberstroh

Dear Friends,

Please bear with me. This blog option literally just went up today, May 5, 2009. I will begin posting interesting chiropractic case studies and other issues as soon as possible.

Thank you for your patience.

Dr. Haberstroh