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					Clinical Applications -                                                                                                                                  Updated August 10, 2010
                                    Click on the condition name to see the clinical application.
Conditions List




                                                                                                Pathology



                                                                                                                        Treatment
                                                                                                            Diagnosis




                                                                                                                                              Research
                                                                         Structure

                                                                                     Function




                                                                                                                                    Therapy
                                                                                                                                               Latest
             Course                               Condition                                                                                              X2



               640        1 Lumbar Disc Herniation                        Y          Y          Y           Y           Y           Y           N        722
               640        2 Piriformis Syndrome                           Y          Y          Y           Y           Y           Y           N        730
               640        3 Thoracic Outlet Syndrome                      Y          Y          Y           Y           Y           Y           N
               722        4 Burner/stinger                                Y          Y          Y           Y           Y           Y           N        750
               722        5 Canal stenosis                                Y          Y          Y           Y           Y           Y           N        740
               722        6 Cervical sprain/strain                        Y          Y          Y           Y           Y           Y           N
               722        7 Facet syndrome                                Y          Y          Y           Y           Y           Y           N        730
               722        8 Fibromyalgia                                  Y          Y          Y           Y           Y           Y           N        750
               722        9 Headache – Cervicogenic                       Y          Y          Y           Y           Y           Y           N
               722        10 Hypertension                                 Y          Y          Y           Y           Y           Y           N
               722        11 Lumbar Disc Herniation                       Y          Y          Y           Y           Y           Y           N        750
               722        12 Obesity                                      Y          Y          Y           Y           Y           Y           N
               722        13 Pernicious anemia                            Y          Y          Y           Y           Y           Y           N
               722        14 Plantar fascitis                             Y          Y          Y           Y           Y           Y           N
               722        15 Rotator cuff tear                            Y          Y          Y           Y           Y           Y           N        740
               722        16 Schizophrenia                                Y          Y          Y           Y           Y           Y           N
               730        17 Bell's Palsy                                 Y          Y          Y           Y           Y           Y           N
               730        18 Headache – Migraine/Cluster                  Y          Y          Y           Y           Y           Y           N
               730        19 Herniated Cervical Disc                      Y          Y          Y           Y           Y           Y           N        750
               730        20 Herniated Lumbar Disc                        Y          Y          Y           Y           Y           Y           N        750
               730        21 Lumbar Facet Syndrome                        Y          Y          Y           Y           Y           Y           N        750
               730        22 Multiple Sclerosis                           Y          Y          Y           Y           Y           Y           N


                                                                 1
Clinical Applications -                                                                              Updated August 10, 2010
Conditions List
               730        23 Muscular Dystrophy                          Y   Y   Y   Y   Y   Y   N
               730        24 Myasthenia Gravis                           Y   Y   Y   Y   Y   Y   N
               730        25 Parkinson's                                 Y   Y   Y   Y   Y   Y   N
               730        26 Piriformis Syndrome                         Y   Y   Y   Y   Y   Y   N   750
               730        27 Spondylolisthesis / Retrolisthesis          Y   Y   Y   Y   Y   Y   N   750
               730        28 Trigeminal Neuralgia                        Y   Y   Y   Y   Y   Y   N
               740        29 Brain Aneurysm                              Y   Y   Y   Y   Y   Y   N
               740        30 Canal Stenosis – Cervical                   Y   Y   Y   Y   Y   Y   N   722
               740        31 Carpel Tunnel Syndrome                      Y   Y   Y   Y   Y   Y   N
               740        32 Cholelithiasis, Cholecystitis               Y   Y   Y   Y   Y   Y   N
               740        33 Crohn's Disease                             Y   Y   Y   Y   Y   Y   N
               740        34 Diabetes                                    Y   Y   Y   Y   Y   Y   N
               740        35 Guillian-Barre Syndrome                     Y   Y   Y   Y   Y   Y   N
               740        36 Hyperthyroidism                             Y   Y   Y   Y   Y   Y   N
               740        37 Lateral Epicondylitis                       Y   Y   Y   Y   Y   Y   N
               740        38 Meniere's Disease                           Y   Y   Y   Y   Y   Y   N
               740        39 Osteoporosis                                Y   Y   Y   Y   Y   Y   N
               740        40 Otitis Media                                Y   Y   Y   Y   Y   Y   N
               740        41 Pelvic Inflammatory Disease                 Y   Y   Y   Y   Y   Y   N
               740        42 Pernicious Anemia                           Y   Y   Y   Y   Y   Y   N
               740        43 Reiter's Syndrome                           Y   Y   Y   Y   Y   Y   N
               740        44 Rheumatoid Arthritis                        Y   Y   Y   Y   Y   Y   N
               740        45 Rotator Cuff Tear                           Y   Y   Y   Y   Y   Y   N   722
               740        46 Schizophrenia                               Y   Y   Y   Y   Y   Y   N
               740        47 Scleroderma                                 Y   Y   Y   Y   Y   Y   N
               740        48 Temporal Mandibular Joint Dysfunction       Y   Y   Y   Y   Y   Y   N



                                                                     2
Clinical Applications -                                                                            Updated August 10, 2010
Conditions List
               740        49 Urinary Tract Infection                   Y   Y   Y   Y   Y   Y   N
               750        50 Abdominal Aortic Aneurysm                 Y   Y   Y   Y   Y   Y   N
               750        51 ADHD                                      Y       Y   Y   Y   Y   N
               750        52 Avascular Necrosis                        Y       Y   Y   Y   Y   N
               750        53 Burner/Stinger                            Y   Y       Y   Y   Y   N   722
               750        54 Canal Stenosis – Lumbar                   Y   Y       Y   Y   Y   N
               750        55 Cervical Disc Degeneration /Rupture       Y   Y       Y   Y   Y   N   730
               750        56 Depression                                Y       Y   Y   Y   Y   N
               750        57 DISH                                      Y   Y   Y   Y   Y   Y   N
               750        58 DJD                                       Y   Y   Y   Y   Y   Y   N
               750        59 Fibromyalgia                              Y   Y       Y   Y   Y   N   722
               750        60 Herpes Zoster                             Y       Y   Y   Y   Y   N
               750        61 Lumbar Disc Degeneration /Rupture         Y   Y       Y   Y   Y   N   730
               750        62 Lumbar Facet Syndrome                     Y   Y       Y   Y   Y   N   730
               750        63 Lumbar Strain                             Y   Y       Y   Y   Y   N
               750        64 Multiple Myeloma                          Y       Y   Y   Y   Y   N
               750        65 Myocardial Infarct                        Y   Y       Y   Y   Y   N
               750        66 Piriformis Syndrome                       Y   Y       Y   Y   Y   N   730
               750        67 Postural Syndrome                         Y   Y       Y   Y   Y   N
               750        68 Scoliosis                                 Y   Y       Y   Y   Y   N
               750        69 SI Sprain/Strain                          Y   Y       Y   Y   Y   N
               750        70 Spondylolisthesis                         Y   Y       Y   Y   Y   N   730
               750        71 Thoracic Compression Fracture             Y   Y   Y   Y   Y   Y   N




                                                                   3
                          CLINICAL APPLICATIONS
                         Faculty Case Study Preparation


CONDITION______Thoracic Outlet Syndrome

Prepared by:________Maria Michelin, DC.

RELEVANT PATHOPHYSIOLOGY:

Compression of the neurovascular bundle at the thoracic outlet. The neurovascular
bundle consists of the anterior primary rami of C5-T1, the subclavian artery and the
subclavian vein




CASE HISTORY:

PPW: Diffuse arm symptoms: primarily numbness and tingling, possible arm or
hand weakness, edema, pallor or discoloration of hands.
Onset-Initial        Trauma- 40 to 50 % of cases                         _____
       Palliative/Provocative denied/ reaching overhead (pec minor syndrome)
       Quality/Quantity     constant ache with paresthesia
       Referred/Radiating
       Site          most common medial aspect of arm
       Timing/Pattern       constant
       Other Pancost’s Tumor, large breasts, posture with rounded shoulders,
cervical ribs

Relevant History and Lifestyle
      Gender        females> males
      Age           20-60 years
      Occupation
      Traumas       40-50 % of cases
      Surgeries
      Medications
      Hospitalizations
      Immunizations
      Diseases or Conditions__________________________________ _
      Family History
      Diet
      Sleep Habits
      Sexual History
      Alcohol Usage
      Drug Usage

Maria Michelin, D.C.                 Page 1                            8/19/2010
Approved 07/14/04
         Smoking/Tobacco
         Other__________________________________________________


Review of Systems                                                     _____

     ______________________________________________________
___________________________________________________________



PHYSICAL EXAMINATION:

Height                             Weight

Vitals: BP             Pulse                    Respiration________ Temp.

Appearance, Motion, Gait

Orthopedic Tests

      Test Name                R        L                Test Name           R         L
Adsons                         x    +       -    Wright’s                    x     +     -
Halstead’s                     x    +       -    Costoclavicular             x     +     -
Roo’s                          x    +       -    Allen’s                + -        +     -
Eden’s                         x    +       -    Tinel’s                + -       +     -
Reverse Bakody                 x    +       -                            + -       +     -

Orthopedic Test Results Discussion:
        One or more of the TOS tests will be positive. Need to rule out vascular
insufficiency with Allen’s and CTS with Tinel’s




Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception
___________________________________________________________________
__Deep tendon reflexes –normal reduced grip strength possible with reduced arm
strength with shoulder abduction. Sensory – paresthesia at C7-T1 most common
can include C5 or C6.
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________



Maria Michelin, D.C.                 Page 2                                 8/19/2010
Approved 07/14/04
___________________________________________________________________
____________________________

LabValues__________________________________________________________
_____ ____________________________________________________________


Examination of Related Areas



Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




SPINAL EXAMINATION:

      Postural Analysis                       Postural Analysis   L       N       R
                                              Head Tilt
      Frequently with rounded shoulders       Head Rotation
                          _____               High Ear
                                              High Shoulder
                                              High Ilium
                                              Ext. Rotated Foot
                                              Int. Rotated Foot


ROM
             Cervical ROM                                 Lumbar ROM
               ROM      Pain     Level                     ROM     Pain       Level
Flexion        N  Y N                   Flexion          N     Y N
Extension      N  Y N                   Extension        N     Y N
R. Rotation    N  Y N                   R. Rotation      N     Y N
L. Rotation    N  Y N                   L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                   R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                   L. Lat. Flex.    N     Y N


Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion)




Maria Michelin, D.C.                 Page 3                           8/19/2010
Approved 07/14/04
List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

         X-rays       MRI          CT           Other

Views          A-P, lateral and oblique cervical spine

Findings       WNL




DIFFERENTIALS:

   1.   Vertebral subluxation
   2.   T4 syndrome
   3.   Cervical disc herniation
   4.   Carpal tunnel syndrome
   5.   Osteoarthritis
   6.   ulnar nerve entrapment
   7.   Orthopedic shoulder problems (strain, rotator cuff, tendonitis)
   8.   Angina or Myocardial infarction
   9.   Demyelinating cord disease

CASE MANAGEMENT:


Chiropractic Management:
      Adjust subluxations and first rib.


Maria Michelin, D.C.                   Page 4                             8/19/2010
Approved 07/14/04
Adjunctive Therapy:
      Proprioceptive training, possible taping or bracing for posture awareness.



PhysicalTherapy:__________________________________________________
_____Trigger point therapy, TENs, ice or pulsed ultrasound, PNFT, massage ,
positional release technique


Nutrition:
        Weight loss if caused by obesity (pendulous breasts) or axillary folds causing
the condition. Increase water intake to reduce swelling.



Exercise:
       Postural correction, stretch pecs, and scalenes, strengthen rhomboids and
mid to lower trapezius




Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education):
      ___________________________________________________________
________________________________________________________________

Further Evaluation:



Common Medical Management: ______________________________________
    Surgery for the minority whom do not respond to treatment.

Referral:


References:
Calliet; Neck and Arm Pain. 3rd edition
Souza; Differential Diagnosis and Management for the Chiropractor. 3rd edition
Vizniak and Carnes; Quick Reference Clinical Chiropractic Conditions Manual
Huff and Brady; Instant Access to Chiropractic Guidelines and Protocols.




Maria Michelin, D.C.                  Page 5                             8/19/2010
Approved 07/14/04
Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.


Condition Name         Baseline     Complicating/ Mitigating Factors    Revised
                       Complexity                                       Complexity
                                    Caused by-Pancost’s tumor-leads        10.0
  Thoracic Outlet         4.0       to bony compromise
    Syndrome                        Caused by –large breasts-               5.0
                                    modifications to adjustments




Maria Michelin, D.C.                Page 6                             8/19/2010
Approved 07/14/04
                           CLINICAL APPLICATIONS
                            Faculty Case Study Preparation


CONDITION Piriformis Syndrome

Prepared by: Janice Higgins-Fordree, D.C.
___________________________________________________________

RELEVANT PATHOPHYSIOLOGY:

Trauma to the sacroiliac joint produces a ligamentous sprain, leading to piriformis
syndrome. Biomechanical agents released from the inflamed piriformis muscle,
where two structures meet at the sciatic foramen, cause irritation of the sciatic nerve
sheath. Neurological injury to L5/S1 can result in denervation atrophy of the
piriformis. Facet injury can produce reflex syndrome of the muscle. Overuse can
produce fatigue or strain of the piriformis as can leg length asymmetry. Predisposing
factors include anomalous sciatic nerve, tight external rotators and neurological
insult to L5/S1. Differs from radiculitis in that there is no internal derangement of the
nerve – too protected by connective tissue.

CASE HISTORY:

PPW: Pain and/or parasthesia in the distribution of the sciatica nerve, Pain is either
deep boring or dull ache that radiates down the poster lateral thigh to the knee
occasionally extending to the foot. Burning sensation in the hips over the greater
trochanter, especially at night preventing the patient to lie on their side. Two most
common causes of piriformis syndrome are trauma to the sacroiliac joint producing a
ligamentous sprain and hormone changes that occur during menstrual cycle,
pregnancy, estrogen replacement therapy or oral contraceptives.

Onset-Initial
      Palliative/Provocative      Prolonged sitting, prolonged external rotation of
      leg (pressing an accelerator while driving), leg length discrepancy.
      Quality/Quantity     Deep boring pain in the buttock, burning sensation in hips
      over greater trochanter.
      Referred/Radiating Poster lateral thigh or calf, rarely to foot
      Site Buttock traveling down thigh and leg
      Timing/Pattern       After prolonged sitting, (watching TV, driving, class)
      Other

Relevant History and Lifestyle:
             Gender        6 Females to 1 male ratio
             Age                no specific age range ___
             Occupation truck driver, secretary, etc.
             Traumas

Janice Fordree, D.C.                   Page 1                              8/19/2010
Approved 04/08/04
             Surgeries
             Medications
             Hospitalizations
             Immunizations
             Diseases/Conditions   Pregnancy, menopause
             Family History
             Diet
             Sleep Habits
             Sexual History
             Alcohol Usage
             Drug Usage
             Smoking/Tobacco
             Other__________________________________________________


Review of Systems



PHYSICAL EXAMINATION:

Height                                 Weight

Vitals: BP             Pulse                        Respiration________ Temp.

Appearance, Motion, Gait               Antalgic

Orthopedic Tests

      Test Name                R            L              Test Name            R           L
SLR                        +       -    +       -                               +   -   +       -
Hibbs                      +       -    +       -                               +   -   +       -
Nafzinger                  +       -    +       -                               +   -   +       -
Valsalva                   +       -    +       -                               +   -   +       -
                           +       -    +       -                               +   -   +       -

Orthopedic Test Results Discussion:        (+) SLR – pain intensified by simultaneous
internal rotation of the leg and relieved by external rotation (piriformis test). (+)
Nafzingger/Valsalva indicators of disc herniation.


Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception - All WNLs




Janice Fordree, D.C.                      Page 2                                8/19/2010
Approved 04/08/04
Lab Values


Examination of Related Areas



Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.) Observations; foot flare, unilaterally of side of involvement,
overpronation




SPINAL EXAMINATION:

      Postural Analysis                        Postural Analysis      L      N        R
                                               Head Tilt
                                               Head Rotation
                                               High Ear
                                               High Shoulder
                                               High Ilium
                                               Ext. Rotated Foot
                                               Int. Rotated Foot


ROM
             Cervical ROM                                 Lumbar ROM
               ROM      Pain      Level                    ROM     Pain              Level
Flexion        N  Y N                   Flexion          N     Y N
Extension      N  Y N                   Extension        N     Y N
R. Rotation    N  Y N                   R. Rotation      N     Y N
L. Rotation    N  Y N                   L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                   R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                   L. Lat. Flex.    N     Y N



ROM Internal rotation of hip with knees flexed is painful / Sacroiliac asymmetry and
fixations are common.




Leg Length/Spinal Balance Normal to have leg discrepancy

Janice Fordree, D.C.                  Page 3                              8/19/2010
Approved 04/08/04
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion) Trigger points are palpable in the belly of the
muscle through the mass of the gluteus maximus muscle and the tendinous insertion
at the greater trochanter. Deep pressure of the muscle belly produces radiation
down course of sciatic nerve while pressure at the tendinous insertion produces
localized burning sensation. Tender at origin and insertion of piriformis

List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

       X-rays      MRI            CT        Other

Views A-P/Lateral Lumbopelvic


Findings    Unremarkable – may show possible increase in lordosis and the sacral
base angle.

NOTE – CT, MRI, x-ray, Myelography and EMG are of limited diagnostic value.




DIFFERENTIALS:

     Sciatica, Referred pain, Fracture, Myofascial pain syndrome, IVD syndrome,
Compression of nerve root lesions.

NOTE – Most unrecognized cause of sciatica.



DIAGNOSIS:
             Piriformis Syndrome

Janice Fordree, D.C.                 Page 4                          8/19/2010
Approved 04/08/04
Case Management:

Chiropractic Management:           Various techniques can be used to correct the
vertebral subluxation - Thompson, Pierce, and SOT are some of the more common
techniques to use for this condition.

Adjunctive Therapy:




Physical Therapy: Acute phase – ice, ultrasound (pulsed) and galvanism may be
used. Hip or contra lateral sacroiliac fixations should be adjusted. – caution is
advised against repeat non specific pelvic manipulation since this tends to
perpetuate the condition. Sub acute phase – moist hot packs, ultra-sound electrical
muscle stim combination, muscle work including trigger points and manipulation.

Nutrition:   Magnesium and calcium



Exercise:   Piriformis stretch, PIR stretch technique (Post isometric relaxation),
McKenzie extension exercises.


Health Promotion and Maintenance (i.e. ergonomics, spinal hygiene, psychosocial
concerns/education)      -get adequate rest on a firm mattress
                         -avoid heavy lifting or bending postures
                         -sleep supine with pillows under knees or on side with
pillow between legs
                         -perform piriformis stretch as instructed


Further Evaluation:        Indications that a referral may be need are true
anesthesia, loss/reduction of hamstring or Achilles tendon reflex,. Signs of
progressive atrophy or no improvement or increase in severity (failure to respond).
Referral would be to neurologist.

Common Medical Management: Include physical therapy, deep massage, ROM
exercises, NSAID’s (non-steroid inflammatory meds such as ibuprofen or naproxen),
a local anesthetic and corticosteroid injections. For persistent piriformis spasms an
injection of botulinum toxin (aka – “bo tox”) may be used.


Janice Fordree, D.C.                 Page 5                             8/19/2010
Approved 04/08/04
Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.




Condition Name      Baseline   Complicating/ Mitigating Factors         Revised
                    Complexity                                          Complexity
Piriformis Syndrome    3.0     Risk factor of prolonged overuse,           4.0
                               prolonged sitting, prolonged
                               external rotation of leg, leg length
                               discrepancy
                               Risk factor of hormone changes,              4.0
                               pregnancy and menopause
                               Risk factor of need for referral             6.0
                               include hamstring and Achilles
                               tendon reflex loss/reduction,
                               progressive atrophy and no
                               improvement and/or increase in
                               severity




Janice Fordree, D.C.                Page 6                            8/19/2010
Approved 04/08/04
                             CLINICAL APPLICATIONS
                            Faculty Case Study Preparation


CONDITION______Lumbar Disc Herniation____________________________

Prepared by: _Janice H. Fordree, D.C.__________________________________

RELEVANT PATHOPHYSIOLOGY:

Degenerative changes in disc and spine, sudden trauma, gradual micro traumas or a
combination of the last two. Also a chemical irritation from release of inflammatory
products.

 Most common cause is a series of rotational in juries that produce circumferential and
radial tears with one final traumatic event leading to herniation. May relate a
precipitating event such as lifting or twisting a heavy object but just a minimal
provocation incident. This is the patient that says, “I bent over to tie my shoes” or “I bent
over to pick up the soap”.

Severe compression injury with the spine in a flexed position may cause a sudden
rupture of the annulus.

Nuclear protrusion: localized protrusion of nuclear material into spinal canal resulting
from a thinned but not ruptured annulus fibers.

Nuclear Herniation: material has torn through the annulus fibrosis and is a free
segment.

Most common L4/L5 and L5/S1 = 95-98%.
Centrally located protrusion tends to produce LBP and leg pain.
Laterally located protrusion tends to produce leg pain.  _____________________

Approximately 75% of lumbar herniations resolve spontaneously within 6 months due to
reabsorption of herniated material. Larger herniations often resolve faster than small
ones.




Janice Fordree, D.C.                   Page 1                              8/19/2010
Approved 05/10/04
CASE HISTORY:

PPW: Back pain, leg pain or back and leg pain. Back pain often disappears with onset
of leg pain. Leg pain is often greater than back pain with herniations, however if there
are only annular tears with out herniation then back pain will be greater.

Pain may follow heavy lifting or twisting or heavy stress trauma and there may be a
history of intermittent LBP that usually resolves.
                                   __

Onset-Initial: Prior episodes of LBP and/or leg pain. Sudden onset of LBP with leg pain
past the knee.                                                                  _____
Palliative/Provocative
    Palliative: Rest with knees flexed in recumbent position.
    Provocative: Any movements that increase intradiscal pressure, weight bearing
        movements such as standing/walking for long periods of time and positional
        changes (lying to sitting, sitting to standing), forward bending, coughing,
        sneezing.

Quality/Quantity: Acute severe LBP with leg pain that can be shooting or electrical in the
dermatomal pattern.
Referred/Radiating Down leg
Site L4/L5, L5/S1 = 95-98%
Timing/Pattern          Standing/walking for long periods and positional changes (lying to
sitting, sitting to standing).
Other

Relevant History and Lifestyle
      Gender        Males> females
      Age 20-40 years old – due to nucleus pulposis is most hydrated - with
         highest incidence between 30-40 years of age.
      Occupation
      Traumas
      Surgeries
      Medications
      Hospitalizations
      Immunizations
      Diseases or Conditions__________________________________ _
      Family History
      Diet
      Sleep Habits
      Sexual History
      Alcohol Usage
      Drug Usage
      Smoking/Tobacco
      Other__________________________________________________

Janice Fordree, D.C.                 Page 2                             8/19/2010
Approved 05/10/04
Review of Systems                                                         _____

     ______________________________________________________
___________________________________________________________



PHYSICAL EXAMINATION:

Height                                 Weight

Vitals: BP             Pulse                        Respiration________ Temp.

Appearance, Motion, Gait

Orthopedic Tests

      Test Name                R            L              Test Name            R           L
SLR                        +       -    +       -    Valsalva’s                 +   -   +       -
Well Leg Raiser            +       -    +       -                               +   -   +       -
Bowstring                  +       -    +       -                               +   -   +       -
Kemp’s                     +       -    +       -                               +   -   +       -
Lasague                    +       -    +       -                               +   -   +       -

Orthopedic Test Results Discussion: Any test for SOL and/or nerve root irritation will be
positive and can be used.



Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception:

Decreased sensation over affected dermatome.
Muscle weakness of quadriceps, dorsiflexors of ankles and toes or plantar flexors may
be present, depending on the given spinal level. Weakness of great toe indicates L5
disc.
Diminished or absent DTRs.
In prolonged cases may have muscle atrophy.
______________________________________________________________________
________________________________________________________________




Janice Fordree, D.C.                     Page 3                                 8/19/2010
Approved 05/10/04
LabValues_____________________________________________________________
__    ____________________________________________________________


Examination of Related Areas



Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




SPINAL EXAMINATION:

      Postural Analysis                           Postural Analysis      L      N     R
                                                  Head Tilt
      Decreased lumbar lordosis                   Head Rotation
      *Antalgic posture with pain                 High Ear
       running down leg into foot.                High Shoulder
                                                  High Ilium
                                                  Ext. Rotated Foot
                                                  Int. Rotated Foot


       * Antalgic lean may be indicative of position of protrusion. If the disc protrudes
lateral to the nerve root, the patient assumes an antalgic lean away from side of
radicular symptoms. If the disc protrudes medial to the nerve root, patient may assume
an antalgic lean into side of radicular symptoms. Flexed antalgic with out lateral lean
may indicate a more central herniation.

ROM
             Cervical ROM                                  Lumbar ROM
               ROM      Pain       Level                    ROM     Pain         Level
Flexion        N      Y N                Flexion          N     Y N
Extension      N  Y N                    Extension        N     Y N
R. Rotation    N  Y N                    R. Rotation      N     Y N
L. Rotation    N  Y N                    L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                    R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                    L. Lat. Flex.    N     Y N


Leg Length/Spinal Balance
Instrumentation/Pattern Analysis


Janice Fordree, D.C.                  Page 4                             8/19/2010
Approved 05/10/04
Palpation (Muscle, Static, Motion) Myospasms may be present over lumbosacral para
spinals and gluteals.




List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

       X-rays       MRI          CT          Other

Views A-P /Lateral Lumbopelvic


Findings     Potential loss of disc height
             Lateral wedge sign

* MRI - best method to view herniation.

DIFFERENTIALS:

*Cauda equina syndrome
Facet syndrome with referred pain
Piriformis Syndrome
Lateral Stenosis / Central Stenosis




Janice Fordree, D.C.                  Page 5                        8/19/2010
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DIAGNOSIS:

Lumbar disc herniation


Case Management:


Chiropractic Management:
Cox flexion/distraction, low force techniques (Activator), listed references stated that
side posture is safe and effective – must keep lordotic curve maintained.
SOT – Category 3 – specific for herniation (especially L4/L5/S1)


* Contraindications to adjust:
    Peripheralization of symptoms
    If lesion is above L1/L2 disc space, possibility of UMN signs exist,
     signs include – saddle anesthesia
                      tonic bladder
                      (+) Babinski’s reflex
                       examine for sphincter incontenance and bowel/bladder
dysfunction.

RED FLAG – bowel/bladder dysfunction – refer immediately – may be CES



Adjunctive Therapy:
      Short term (2-3 days / 48-72 hours) – bed rest with knees flexed – prolonged
bed rest and inactivity are discouraged.
      Lumbosacral support – especially while sitting
      NSAIDs



Physical Therapy:
Acute phase: cold packs, ice massage and low volt galvanic for pain and edema.
TENS low frequency and high intensity of less than 10 HZ creates a analgesic affect
and increases endorphin production. Electrical stim increases levels of dopamine,
epinephrine and serotonin while diminishing nerve action potentials of A delta fibers
which are pain mediators.

Sub acute phase: other modalities and procedures that include trigger point therapy,
acupuncture and ultrasound. _***Do not place over spinal cord *** _
________________________________________________________________



Janice Fordree, D.C.                  Page 6                              8/19/2010
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Nutrition: * Note: The nutrition below is only a recommendation; there are no evidence-
based guidelines to the information listed below.

Acute pain and inflammation: Proteolytic enzymes (trypsin, chymitrypsin, bromelin),
Bioflavonoids (quercetin, hesperidin, rutin, etc) Herbals.

Tissue healing: Amino acids (glycine, L-cystine, L-proline and L-lysine) – supplies the
amino acid pool necessary for the structural production of collagen. Glucosamine
sulfate – nutrients for production of healthy ground substance,
Vitamin C, Iron, Alpha Ketoglutaric acid - all 3 needed for collagen production
Calcium, Vitamen E, Zinc, Copper, and Manganese – provide antioxidant effects and
serve as free radical scavengers to help remove cellular debris and promote
healing.


Exercise: McKenzie exercises and mild aerobic activity (swimming, walking, stationary
bike after patient can sit comfortably)
       Exercise ball for extension exercises.


Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education):
Instruction on back protection
Encourage life style modifications
Encourage weight loss if appropriate


Further Evaluation:
Week 6 – refer for surgical consult If profound muscle weakness has not responded
Week 12 – refer for surgical consult if poor response to conservative care


Common Medical Management: The treatment of a disc herniation is based on the
severity and duration of symptoms. Initial treatment is almost always non-surgical. Anti-
inflammatory medications, steroids and/or muscle relaxants with rest are initially used to
treat the sciatica. Physical therapy can also be very helpful. Most people have full
recovery from episodes of sciatica within the first few weeks. If the symptoms continue
past 6 weeks, however, one should consider undergoing an evaluation, which includes
MRI studies. If symptoms continue and conservative management has not been helpful,
surgical decompression of the disc (microdiscectomy) may be helpful in relieving the
symptoms. The only absolute indications for surgery, however, are progressive
neurological symptoms, bowel or bladder problems, and severe, unremitting.




Prognosis:
Janice Fordree, D.C.                  Page 7                             8/19/2010
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   Good for near complete recovery of functionality, although flare-ups may occur
   Surgery is rarely required
   First 6 weeks – 50% improvement based on functional rehab – manipulation can
  provide short-term improvement in pain and activity levels and higher patient
  satisfaction. The risks of manipulations are very low in skilled hands.


  References:
  Vizniak & Carnes: Quick Reference Clinical Chiropractic Conditions Manual
   Huff & Brady: Instant Access to Chiropractic Guidelines and Protocols
  Gatterman: Chiropractic Management of Spine Related Disorders, 2nd Edition
  ___________________________________________________________________


  Case Complexity:

  The category of complicating or mitigating factors should include the following
  considerations: Ancillary labs, diagnostic studies, co-management issues, early stage
  of condition, advanced stage of condition, psychosocial issues, etc. The complicating or
  mitigating factors can either increase or decrease the baseline complexity.

Condition Name    Baseline     Complicating/ Mitigating Factors             Revised
                  Complexity                                                Complexity
 Lumbar Disc         5.0       Risk factor of heavy lifting or twisting,       6.0
  Herniation                   heavy stress trauma or history of
                               intermittent LBP
                               Risk factor of movements that increase           6.0
                               intradiscal pressure, especially flexed
                               positions, weight bearing movements
                               and positional changes.
                               Risk factors of prolonged                        6.0
                               standing/walking, forward bending,
                               coughing and sneezing.
                               Risk factor of decreased sensation over          7.0
                               affected dermatome, weakness and/or
                               atrophy of involved muscles and
                               diminished or absent DTRs.
                               Chiropractic management –                        9.0
                               contraindications to adjust
                               Chiropractic management – modified               8.0
                               adjusting along with use of specific
                               techniques.
                               Chiropractic management – refer for              9.0
                               surgical consult if no response to
                               conservative care after ~ six weeks.


  Janice Fordree, D.C.                 Page 8                              8/19/2010
  Approved 05/10/04
                           CLINICAL APPLICATIONS
                          Faculty Case Study Preparation


CONDITION____Burner/stinger_AKA Cervical Brachial Syndrome/ Brachial
Plexus Syndrome

Prepared by:_________Kevin Power__

RELEVANT PATHOPHYSIOLOGY:

      Burner/stinger is usually associated with a lateral flexion injury of the
neck/head i.e.”lateral whiplash”. It can also occur with blunt force trauma.

CASE HISTORY:

PPW: Acute Episode: Sudden onset burning pain and/or numbness along the
lateral arm with associated weakness following trauma.

Chronic Episode: Burning pain/ and or numbness along the lateral arm following
activity that exacerbates original injury

Onset-Initial        Neck/head trauma
Palliative/Provocative     Minimising neck motion/Lateral flexion.
Quality/Quantity           Paresthesia; Burning pain and/or numbness.
Referred/Radiating         Usually located along the arm; however, it is most
        commonly located along dermatome distribution for the nerve roots.
Site                       Lower cervical spine.
Timing/Pattern             Several minutes
Other

Relevant History and Lifestyle
      Gender
      Age
      Occupation
      Traumas
      Surgeries
      Medications
      Hospitalizations
      Immunizations
      Diseases or Conditions__________________________________ _
      Family History
      Diet
      Sleep Habits
      Sexual History
      Alcohol Usage

Kevin Power, D.C.                      Page 1                             8/19/2010
Approved 5May05
         Drug Usage
         Smoking/Tobacco
         Other_______________Athletes.___________________________________


Review of Systems                                                     _____

     ______________________________________________________
___________________________________________________________



PHYSICAL EXAMINATION:

Height                             Weight

Vitals: BP            Pulse                 Respiration________ Temp.

Appearance, Motion, Gait

Orthopedic Tests

      Test Name               R       L            Test Name              R              L
Cervical compression          +       +      Jackson’s Compression           +           +
Cervical distraction          +       +                                  +       -   +       -
Shoulder depression           +       +                                  +       -   +       -
Brachial plexus stretch       +       +                                  +       -   +       -
Soto-Hall                     +       +                                  +       -   +       -

Orthopedic Test Results Discussion:              Cervical and Jackson’s compression
is usually applied with the patients head neutral, and then in all positions. Localized
pain indicates facet involvement, while radiating pain down the arm indicates nerve
root involvement. Cervical distraction is an attempt    to reduce local or radiating
complaints. Shoulder depression can cause nerve root compression and/or brachial
plexus stretching.

Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception
      When the brachial plexus is involved the upper trunk (C5,C6) is most often
             affected. C5 - motor supply to the deltoid (shoulder abduction) and
             biceps (elbow flexion/supination) biceps reflex, and sensory supply to
             outer shoulder (axillary nerve)
              C6 - motor supply to the biceps (elbow flexion/supination) and wrist
             extension, brachioradialis reflex, and sensory supply to the outer
             forearm.

Kevin Power, D.C.                     Page 2                             8/19/2010
Approved 5May05
LabValues__________________________________________________________
_____ ____________________________________________________________


Examination of Related Areas



Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




SPINAL EXAMINATION:

       Postural Analysis                         Postural Analysis    L       N       R
                                                 Head Tilt
       Head tilt may be affected the head        Head Rotation
would tilt away from the affected side with      High Ear
regards to IVF involvement and towards           High Shoulder
the side that had muscular involvement.          High Ilium
                                                 Ext. Rotated Foot
                                                 Int. Rotated Foot
ROM
              Cervical ROM                                    Lumbar ROM
                ROM      Pain     Level                        ROM     Pain       Level
Flexion         N  Y N                      Flexion          N     Y N
Extension       N  Y N                      Extension        N     Y N
R. Rotation     N  Y N                      R. Rotation      N     Y N
L. Rotation     N  Y N                      L. Rotation      N     Y N
R. Lat. Flex.            Y                   R. Lat. Flex.    N     Y N
L. Lat. Flex.            Y                   L. Lat. Flex.    N     Y N


Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion) Cervical myospasms and guarding may be
present.

List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




Kevin Power, D.C.                     Page 3                              8/19/2010
Approved 5May05
RADIOLOGICAL EXAMINATION:

         X-rays       MRI        CT           Other

Views        A-P,Lateral, Flexion, Extension and possibly oblique cervical

Findings: May include decreased or aberrant range of motion. May include
decreased cervical lordosis.

DIFFERENTIALS:

Disc herniation; Myelopathy; Thoracic outlet syndrome; Facet syndrome;
Torticollis.



Case Management:


Chiropractic Management: Manual adjusting is appropriate, however, it is
important to avoid reproduction of the injury with a lateral flexion-type of
adjustment. Alternatives would include : Activator Methods; Side-posture
toggle; Thompson technic; Pierce technic.

Common Medical Management: Pain medications; Muscle relaxers; Anti-
inflammatory medications.

Adjunctive Therapy:

PhysicalTherapy: Cryotherapy; Hot packs.

Nutrition:

Exercise: Given that re-occurrence of the injury is common in sports, athletes are
encouraged to strengthen neck muscles.

Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education): Athletes are encouraged to use protective gear when
appropriate, particularly football players.

Home care may include cervical pillows, supports, and stretches.
Recommendations would be made to avoid future “whiplash” type activities such as
roller coaster rides, etc.




Kevin Power, D.C.                    Page 4                             8/19/2010
Approved 5May05
Further Evaluation: Muscle weakness and sensory findings may be delayed,
therefore, it is important to re-examine approximately one week post-injury. Also, if
arm weakness is persistent after three weeks, an EMG study may be helpful.

References:

Differential Diagnosis and Management for the Chiropractor, by Souza



Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.


Condition Name         Baseline      Complicating/ Mitigating Factors      Revised
                       Complexity                                          Complexity
                                     Myospasms and Triggerpoints              5.0
                                     Avulsion of nerve root                   10.0
  Burner/ Stinger          4.0       Muscle strength decreases                6.0




Kevin Power, D.C.                     Page 5                             8/19/2010
Approved 5May05
                          CLINICAL APPLICATIONS
                  Case Study Preparation – Suggested Format


CONDITION: Lumbar Canal Stenosis
Prepared by: Dr. Renee Prenitzer

RELEVANT PATHOPHYSIOLOGY:

Lumbar canal stenosis is usually associated with the aging process which can
include normal wear and tear on the spine. Lumbar Canal Stenosis can also be
predisposed genetically. During normal development the canal reaches the adult
size around the age of four. If the canal does not reach adequate size by then, it
never will, This type of stenosis will usually be general and occur throughout the
spine. This type of stenosis may result in lack of symptoms until further
pathophysiology occurs, for example osteophtes, trauma, and IVD problems.
Lumbar canal stenosis can be acquired through trauma, degeneration of the spinal
segments, soft tissue pathology involving the ligamentum flavum and most
commonly spondylosis.

CASE HISTORY:

PPW: Dull to severe aching pain in the lower back or buttocks that develops with
walking or other activity. Pain radiates into one or both thighs and legs. Symptoms
are relieved by sitting or lying down, and/or by bending at the waist, such as when
walking behind a shopping cart. In rare cases, patients can lose motor functioning in
the legs, bowels, or bladder.

Onset-Initial
      Palliative: Bending forward at the waist helps, sitting or lying down helps.
                 Placing foot on stool while bending forward is also a palliative
                 position.
      Provocative: Walking or exercising vigorously.
      Quality/Quantity: Leg pain or numbness that occurs with exercise, especially
                 prolonged walking.
      Referred/Radiating: Possible radiation down thigh.
      Site: Located in Low Back and Buttock region, can travel down thigh and leg.
      Timing/Pattern: Activity related. Symptoms usually subside after cessation of
                 activity within 15 to 20 minutes or with the assumption of a flexed
                 position.
      Other

Relevant History and Lifestyle:
             Gender         No specific gender affinity.
             Age Usually a degenerative condition seen in patients 60 years of
             age and older.

Renee Prenitzer                      Page 1                            8/19/2010
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             Occupation
             Traumas
             Surgeries
             Medications
             Hospitalizations
             Immunizations
             Diseases/Conditions


             Family History
             Diet
             Sleep Habits
             Sexual History
             Alcohol Usage
             Drug Usage
             Smoking/Tobacco
             Other__________________________________________________


Review of Systems                                                       _____

           ______________________________________________________
___________________________________________________________


PHYSICAL EXAMINATION:

Height                               Weight
Vitals: BP          Pulse                         Respiration________ Temp.
Appearance, Motion, Gait

Orthopedic Tests

      Test Name              R             L              Test Name            R              L
Phalen Test                         +              Belt Test                    -                -
SLR                            -              -    Valsalva’s                   +involved side
Kemp’s                         +involved side      Hibb’s                       -              -
Well Leg Raiser                -              -    Braggard’s                   -                -
Minor’s Sign                   -              -    Milgram’s                    +involved side

Orthopedic Test Results Discussion: Phalen Test – Attempts to reproduce the
symptoms of leg pain, weakness, or numbness caused by neural ischemia. Patient
is upright and then bent into an extended position for 60 seconds. A positive test will
produce an progressive increase of the leg symptoms followed by rapid relief of
these symptoms when the patient flexes forward, places his hands on the
examination table, and places one foot on a stool.

Renee Prenitzer                           Page 2                              8/19/2010
Approved 04/15/04
Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception
Motor examination in both lower extremities is normal (however, mild weakness may
be present dependent on severity of stenosis and the length of involvement).
Sensory and reflex are normal as well.
NOTE: Motor/Sensory/Reflex findings may be inconsistent with symptom
experienced during exercise.


Lab Values


Examination of Related Areas


Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




SPINAL EXAMINATION:

      Postural Analysis                     Postural Analysis     L      N        R
                                            Head Tilt
                                            Head Rotation
                                            High Ear
                                            High Shoulder
                                            High Ilium
                                            Ext. Rotated Foot
                                            Int. Rotated Foot


ROM
             Cervical ROM                               Lumbar ROM
               ROM      Pain    Level                    ROM     Pain         Level
Flexion        N      Y N             Flexion          N     Y N
Extension      N  Y N                 Extension                Y          L4, L5, S1
R. Rotation    N  Y N                 R. Rotation      N     Y N
L. Rotation    N  Y N                 L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                 R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                 L. Lat. Flex.    N     Y N




Renee Prenitzer                    Page 3                             8/19/2010
Approved 04/15/04
ROM: Central Stenosis - May be limited in extension (with an increase in pain).
Flexion may decrease pain. Lateral Stenosis – May be limited in extension. Lateral
flexion and rotation to the involved side increases pain.

Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion)



List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




Renee Prenitzer                      Page 4                          8/19/2010
Approved 04/15/04
RADIOLOGICAL EXAMINATION:

         X-rays       MRI         CT              Other

Views: A-P Lumbar/ Lateral Lumbar, MRI, CT Scan, Myelogram can be used to
determine lumbar canal stenosis.

Myelogram: Involves injection of dye into the spinal sac where it mixes with CSF.
Any outward protrusion will block the flow of the dye. If this is done with the patient
in extension may offer the best information on location of stenotic areas

CT Scan: Most widely used test for evaluating the spine because it is noninvasive
and provides a three dimensional view. It is helpful for differentiating between hard
tissue and soft tissue. Used to evaluate for lateral stenosis and central stenosis

Findings: Einsensteins’s Method of analysis on Lateral Lumbar Film will indicate
possible canal stenosis if sagittal canal measurement is less than 15 mm.



Differentials:

Rule Out                          Rationale
                                  (defined: fixed claudication due to stenosis of the blood
                                  vessels) Differentiated by:
Vascular Claudication                                       -the bicycle test
                                                            -stoop test
                                  (defined: A condition of disk protrusion into and beyond the
                                  annulus fibrosus which may cause nerve root compression
, Disc Herniation                 and neurologic signs.
                                             Differentiated by:
                                                              MRI
                                  (defined: An anterior displacement of a vertebral body in
                                  relation to the segment immediately below. The displacement
                                  is a result of loss in continuity or elongation of the pars
, Spondylolisthesis               interarticularis.)
                                              Differentiated by:
                                                               -radiolographic findings


                                  (defined: A rotational compression injury of the richly
                                  innervated articular facets of the lumbar spine, characterized
                                  by local and/or referred pain arising from the zygapophyseal
                                  joints.
Facet Syndrome                               Differentiated by:
                                                             -radiographic findings of sclerosing
                                  of the facets:
                                                              -no osteophytes
                                                               -stress films may reveal abnormal


Renee Prenitzer                        Page 5                                     8/19/2010
Approved 04/15/04
                                 joint locking

                                 (defined: Rapidly progressing neurologic defecits,)
                                             Differentiated by:
, Cauda Equina Syndrome                                     Loss of bowel and/or bladder
                                 function.

                                 (defined: A low back pain condition described as a
                                 compression or irritation of the sciatic nerve by a contracted or
                                 stretched piriformis muscle.)
Piriformis Syndrome                           Differentiaed by:
                                                             Palpation of the piriformis muscle
                                 and by presence of trigger point tenderness of the muscle
                                 adjacent to the sacrum




Note:

DIAGNOSIS:

Lumbar Canal Stenosis


CASE MANAGEMENT:

Chiropractic Management: Manual adjustments may be contraindicated.
Conservative, low-force adjustments may be utilized. If improvement occurs and
continues, then management can continue; however, if the condition continues to
deteriorate or no progress is noted within two to three weeks then re-evaluation is in
order. Cox Flexion Distraction treatment may be utilized if compression of canal is
due to disc herniation or protrusion.

Adjunctive Therapy:




Physical Therapy: Used to restore flexibility and strengthen the back and abdominal
muscles in order to provide relief from symptoms.




Renee Prenitzer                        Page 6                                    8/19/2010
Approved 04/15/04
Nutrition:




Exercise: Abdominal exercise to strengthen and support the low back. Exercises to
restore flexibility.


Health Promotion and Maintenance (i.e. ergonomics, spinal hygiene, psychosocial
concerns/education): Important to be aware that pain may cause an increase in
psychosocial stress, physiological responses to pain may also occur.

Further Evaluation: Medical referral should be made if patient does not experience
significant improvement or if the symptoms reoccur quickly following the chiropractic
course of care. Referral: Orthopedist, Neurologist, Neurosurgeon.

Common Medical Management: Medication, Physical Therapy, Surgery
Medications: Anti-inflammatory medications such as ibuprofen and acetaminophen.
NSAIDs such as Motrin, Naprosyn, Celebrex, and Vioxx may also be prescribed.
Cortisone shots at the site of the low back pain. Lumbar Epidural Injection: 1. For
pain management the injection is into the epidural space. 2. For targeting the level
of the pain the injection is into the specific nerve root.


Surgery: Surgical treatment may include fusion, decompression (laminectomy,
lamina trimming, widening of lateral recess, removal medial rim of facets), postero-
lateral fusion.

       Laminectomy – involves removing the lamina from the vertebral body to allow
             the pressure to be removed from the dural sac or the nerve roots.
             When only a portion of the lamina needs to be removed the procedure
             is referred to as a laminotomy. The ligaments (ligamentum flavum)
             and soft tissue (facet capsules, herniated or bulging discs) in the
             affected area are also removed.

       Foraminotomy – are performed to enlarge the area where the nerve roots exit
             the spinal canal in order to decrease the amount of pressure on them.

       Spinal fusion – are performed when patients develop instability of the spine
              with the surgery. Spinal fusion involves grafting bone onto the spine
              and the use of rods and screws to provide support and stability.

       Micro-Endoscopic Laminotomy (MEL) – New treatment developed. A
             minimally-invasive technique that uses a surgical endoscope for

Renee Prenitzer                      Page 7                             8/19/2010
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             fluoroscopic x-ray a thin needle is inserted to the involved vertebral
             level. A small incision is then made around the needle and a hollow
             metal cylinder is passed over the needle to the area of stenosis and
             secured. Through this cylinder the surgical endoscope is inserted to
             allow the surgeons a close-up of the affected area. The surgeon then
             micro-surgically removes the bone compressing the nerve roots. Soft
             tissue can also be removed using this procedure. The level above and
             below can be decompressed as well. Additional benefits of MEL are:
             less disruption of normal tissue, faster surgical time, decreased post-
             operative discomfort, quicker recovery time, and more rapid return to
             normal activity.

References:
  •Wheeless’ Textbook of Orthopedics
  •www.merck.com
  •www.neurosurgery.org/health
  •www.spineuniverse.com
  •Differential Diagnosis and Management for the Chiropractor, by Souza



Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.


Condition Name        Baseline     Complicating/ Mitigating Factors       Revised
                      Complexity                                          Complexity
                                   Early Stage – light force/                5.0
                                   instrument adjustments, monitor
   Lumbar Canal           5.0      for changes in symptoms
     Stenosis                      Late Stage – symptomatic,                  6.0
                                   chiropractic management altered/
                                   no adjustments at level of stenosis
                                   Co-management with MD –                    5.0
                                   epidural injections
                                   Complicated by DDD/ DJD                    7.0
                                   Compression fracture                       8.0


Renee Prenitzer                     Page 8                               8/19/2010
Approved 04/15/04
                          CLINICAL APPLICATIONS
                             Case Study Preparation


CONDITION___Lumbar Facet
Syndrome______________________________________

Prepared by: Maria Michelin, DC__________________________________



RELEVANT PATHOPHYSIOLOGY:

Facet and the capsule are the source of the pain. One theory-synovial folds
(meniscoids) may be trapped or pinched and cause the pain. Theory two-
degeneration in older patients.



CASE HISTORY:

PPW: Well localized low back pain-usually at L4 to Sacrum that radiates into the
buttocks and can radiate into the thighs.
       Onset-Initial often sudden after arising from a flexed position or sudden odd
       movement.                                                              _____
       Palliative ice and lying down with legs elevated
       Provocative lifting weights, prolonged standing or sitting up straight
       Quality/Quantity constant dull ache, pain is sharp with lumbar extension
       Referred/Radiating some buttock or thigh pain with extension
       Site over spine L4 to sacrum
       Timing/Pattern        constant
       Other

Relevant History and Lifestyle
      Gender
      Age
      Occupation
      Traumas       can be related to microtraumas
      Surgeries
      Medications          OTC tends not to help
      Hospitalizations
      Immunizations
      Diseases or Conditions__________________________________ _
      Family History
      Diet
      Sleep Habits LBP interferes with sleep

Maria Michelin, D.C.                 Page 1                             8/19/2010
Approved 03/29/04
         Sexual History can aggravate LBP
         Alcohol Usage
         Drug Usage
         Smoking/Tobacco
         Other__can be aggravated by obesity________________________


Review of Systems                                                         _____

     ______________________________________________________
___________________________________________________________



PHYSICAL EXAMINATION:

Height                                 Weight

Vitals: BP             Pulse                        Respiration________ Temp.

Appearance, Motion, Gait

Orthopedic Tests

      Test Name                R            L              Test Name             R           L
SLR/WLR                    +       -    +       -                               +    -   +       -
Kemps                      +       -    +       -                               +    -   +       -
Nachlas                    +       -    +       -                               +    -   +       -
Yeomans                    +       -    +       -                               +    -   +       -
Belt                       +       -    +       -                               +    -   +       -

Orthopedic Test Results Discussion:     Kemps increases the pain from L4 to
sacrum and causes pain to radiate into the buttocks. Nachlas and Yeoman increase
to already present LBP.



Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception
The neurological examination is all with in normal limits there is no evidence of
reproducible sensory or motor involvement.________________________________
___________________________________________________________________
___________________________________________________________________




Maria Michelin, D.C.                     Page 2                                 8/19/2010
Approved 03/29/04
LabValues__________________________________________________________
_____ ____________________________________________________________


Examination of Related Areas



Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




SPINAL EXAMINATION:

       Postural Analysis                         Postural Analysis       L        N      R
                                                 Head Tilt
       Possible increase in lumbar               Head Rotation
       lordosis                                  High Ear
                                                 High Shoulder
                                                 High Ilium
                                                 Ext. Rotated Foot
                                                 Int. Rotated Foot


ROM
                Cervical ROM                                 Lumbar ROM
                  ROM      Pain      Level                    ROM     Pain            Level
Flexion           N  Y N                   Flexion          N     Y N
Extension         N  Y N                   Extension        N     Y N             L4-S1

R. Rotation         N      Y   N           R. Rotation        N      Y    N
L. Rotation         N      Y   N           L. Rotation        N      Y    N
R. Lat. Flex.       N      Y   N           R. Lat. Flex.      N      Y    N
L. Lat. Flex.       N      Y   N           L. Lat. Flex.      N      Y    N


Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion) Tenderness over the involved spinous processes




Maria Michelin, D.C.                    Page 3                               8/19/2010
Approved 03/29/04
List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

       X-rays       MRI          CT          Other

Views A-P, Lateral and Obliques

Findings     Possible L5 disc angle of greater than 15 degrees.    McNab’s line
and Hadley’s line may be positive for imbrication




DIFFERENTIALS:

Lumbar disc problems. Lumbar sprain/strains

DIAGNOSIS:

Lumbar facet Syndrome




Case Management:


Chiropractic Management:          Adjustments. Can use Cox flexion distraction.




Maria Michelin, D.C.                 Page 4                           8/19/2010
Approved 03/29/04
Physical Therapy: Axial distraction. Palliative care includes ice, pulsed
ultrasound, high volt galvanic and interferential__________________________

Nutrition:



Exercise: Williams flexion exercises



Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education):
       __Recommend avoid prolonged sitting or the positions that are specific to the
patient which encourage increased lumbar lordosis._______________________
________________________________________________________________

Further Evaluation:


Common Medical Management: Facet denervation and facet injections____

References:
Souza. Differential Diagnosis for the Chiropractor
Huff and Brady. Instant Access to Chiropractic Guidelines and Protocols

Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.


Condition Name         Baseline     Complicating/ Mitigating Factors      Revised
                       Complexity                                         Complexity
   Lumbar Facet            3        None really. It depends on if they         3
    Syndrome                        have to perform the activity that
                                    put them in this condition in the
                                    first place. Usually some twisting
                                    during extension.




Maria Michelin, D.C.                   Page 5                            8/19/2010
Approved 03/29/04
            Fibromyalgia




8/19/2010    Approved 05/17/04 Dr. Prenitzer
      Relevant Pathophysiology
• Fibromyalgia is a chronic pain syndrome of
  unknown etiology that is characterized by
  diffuse pain and tenderpoints (TeP), which
  are present for more than three months
• Fibromyalgia (FMS) Syndrome patients
  exhibit an increased sensativity to
  mechanical, thermal, and electrical stimuli,
  which suggests that central pain mechanisms
  may be dysfunctional and play a significant
  role in the pain FMS patients experience
8/19/2010      Approved 05/17/04 Dr. Prenitzer
  Relevant Pathophysiology -
 Pain Mechanisms of the CNS
• The CNS mechanisms for pain in FMS
  include: 1. Temporal summation of pain
  (wind-up) 2. Central sensitization




8/19/2010     Approved 05/17/04 Dr. Prenitzer
        Pathophysiology – Wind-up
                Explained
• Wind-up (WU) can result in short- and long-term
  changes of neuronal responsiveness, including
  central sensitization. WU occurs during repetitive
  nociceptive stimuli of sufficient intensity or
  frequency to remove the magnesium block of the
  NMDA receptor.
• This is followed by calcium influx into the cell
  and subsequent triggering of signaling cascades
  that can result in amplification of nociceptive
  input and long-term central sensitization.
8/19/2010         Approved 05/17/04 Dr. Prenitzer
            Pathophysiology – Central
                  Sensitization
• The mechanisms responsible for central
  sensitization depend on stimulus intensity
  and descending pain inhibition.
• Once central sensitization has occurred only
  minimal nociceptive input is required to
  maintain the sensitized state and clinical
  pain.

8/19/2010          Approved 05/17/04 Dr. Prenitzer
  Pathophysiology – Classic FMS
         vs Pseudo FMS
• The diagnosis of Classic FMS is for the patient
  who has significant symptoms of sleep disorder,
  anxiety syndrome, depression, alterations of brain
  and CNS chemistry, brain injury or trauma
• The category of Pseudo FMS encompasses a
  group of disorders that is misdiagnosed as FMS,
  such as, organic diseases, functional disorders, and
  musculoskeletal disorders

8/19/2010         Approved 05/17/04 Dr. Prenitzer
  Pathophysiology – Classic FMS
• Characteristics – patients do not sleep well at
  night, they wake and feel “crummy” constantly,
  they have an intolerance to heavy exercise, they
  have a lowered pain threshold to multiple areas of
  the body, they complain of low energy and brain
  fog, called “fibro-fog”.
• EEG of FMS patients revealed overall disruption
  in the deeper stages of sleep
• All lab tests come back negative for rheumatoid
  factor, sedimentation rate, and other serologic tests
  are negative
8/19/2010         Approved 05/17/04 Dr. Prenitzer
 Pathophysiology – Classic FMS

• Criteria for
  diagnosis of
  FMS – pain
  induced upon
  palpation of
  a minimum
  of 11 of 18
  predetermine
  d TeP sites
 8/19/2010       Approved 05/17/04 Dr. Prenitzer
            Pathophysiology – Pseudo
             FMS/Organic Disorders
• In patients with generalized pain and fatigue,
  patients must be assessed for underlying disorders
  such as, anemia, Lyme disease, hypothyroidism,
  inflammatory arthritides, auto-immune disorders,
  MS, and occult malginancies
• A diagnosis of FMS should not be made until all
  lab tests come back negative and fail to detect and
  “organic” reason for symptoms.

8/19/2010          Approved 05/17/04 Dr. Prenitzer
  Sign to look for Lyme Disease –
           Bull’s eye rash




8/19/2010   Approved 05/17/04 Dr. Prenitzer
 Pathophysiology – Psuedo FMS/
      Functional Disorders
• This category includes subclinical disease states
  and disorders involving dysfunction of internal
  organs
• These range from vitamin and mineral deficiencies
  to intestinal dysbiosis, gastric and pancreatic
  enzyme deficiencies, cellular dehydration, subtle
  endocrine imbalances, and post-viral immune
  suppression
• Common denominator – low energy, fatigue and
  widespread pain
8/19/2010        Approved 05/17/04 Dr. Prenitzer
 Pathophysiology – Psuedo FMS/
    Musculoskeletal Disorders
• There is a history of confusion with the use
  of the terms for myofascial pain syndrome
  and fibromyalgia syndrome.
• The terms fibrositis, myositis, myofascitis,
  fibromyalgia, and myofascial pain have
  been used interchangeably and incorrectly.
• There has also been the misuse of the terms
  trigger point (TrP) and tender point (TeP)

8/19/2010       Approved 05/17/04 Dr. Prenitzer
 Pathophysiology – Psuedo FMS/
    Musculoskeletal Disorders
• In a study of 252 patients referred to one
  clinic for treatment of FMS, 38% were
  misdiagnosed. They had a musculoskeletal
  cause for their symptoms
• The basic cause for these misdiagnoses is
  the fact that there is ignorance about the
  different types of referred pain phenomena

8/19/2010      Approved 05/17/04 Dr. Prenitzer
 Pathophysiology – Psuedo FMS/
   Musculoskeletal Disorders-
         Referred Pain
• A variety of deep somatic tissues, such as facet
  joints, spinal ligaments and muscles, intervertebral
  discs, meninges and dura mater, and joint
  capsules of the hip and shoulder can cause distal
  referred pain
• All of these tissues can be primary generators of
  noxious stimuli that causes the brain to perceive
  pain as arising from a different location from the
  tissues
8/19/2010         Approved 05/17/04 Dr. Prenitzer
        Pathophysiology – Psuedo FMS/
     Musculoskeletal Disorders- Referred Pain




8/19/2010        Approved 05/17/04 Dr. Prenitzer
       Pathophysiology – Psuedo FMS/
    Musculoskeletal Disorders- Referred Pain




8/19/2010       Approved 05/17/04 Dr. Prenitzer
       Pathophysiology – Psuedo FMS/
    Musculoskeletal Disorders- Referred Pain
• Most of the referred pain caused by irritated
  somatic tissues have a regional pattern
• According to the ACR guidelines, widespread
  pain is bilateral and affects the torso, upper and
  lower extremities
• DDX – need to be aware that more than one
  somatic tissue can be irritated at a time, this can
  cause overlapping regional pain patterns that can
  be misinterpreted as global or widespread pain
8/19/2010         Approved 05/17/04 Dr. Prenitzer
       Pathophysiology – Psuedo FMS/
    Musculoskeletal Disorders- Referred Pain




8/19/2010        Approved 05/17/04 Dr. Prenitzer
       Pathophysiology – Psuedo FMS/
    Musculoskeletal Disorders- Referred Pain

• Three types of referred pain phenomena –
  myofascial referred pain, scleratogenous
  referred pain, and dural referred pain.




8/19/2010       Approved 05/17/04 Dr. Prenitzer
       Pathophysiology – Psuedo FMS/
    Musculoskeletal Disorders- Referred Pain

• Myofascial referred pain stems from
  muscles that have been injured or have
  developed TrPs
• This type of pain is described as diffuse,
  deep, and achy
• Reproduced by digital pressure over the Trp


8/19/2010       Approved 05/17/04 Dr. Prenitzer
       Pathophysiology – Psuedo FMS/
    Musculoskeletal Disorders- Referred Pain
• Sclerotogenous referred pain arises from irritation
  of somatic tissues surrounding deep joint
• Most frequent generators of pain are spinal facets,
  hip and shoulder joints
• This pain is described as a “very deep, dull, achy,
  and vague.”
• May feel sharp stabbing pain upon certain motions
  or movements
• Reproduction of pain can be done by stressing the
  joints by full end range position
8/19/2010         Approved 05/17/04 Dr. Prenitzer
       Pathophysiology – Psuedo FMS/
    Musculoskeletal Disorders- Referred Pain
• Dural referred pain stems from irritation of the
  dura mater or meninges
• Frequently found with disc herniations
• This pain is described as “nauseating or
  sickening” and can be intense enough to cause
  syncope
• Cervical discs refer to the mid-thoracic/ posterior
  scapulae region
• Lumbar discs refer to the lumbosacral/ buttock
  area
8/19/2010         Approved 05/17/04 Dr. Prenitzer
       Pathophysiology – Psuedo FMS/
    Musculoskeletal Disorders- Referred Pain
• This category of musculoskeletal disorders mimics
  FMS
• This contributes to the category of patients that are
  “cured” of FMS by physical therapy, chiropractic,
  exercises, massage therapy, or any other manual
  therapy
• Clinically the patients responded to the “removal”
  of the specific pain generator via the manual or
  mechanical therapy
8/19/2010         Approved 05/17/04 Dr. Prenitzer
            Patient Presents With:
• Diffuse pain, insomnia, fatigue, and
  psychological distress
• There are 18 tenderpoints (TePs) that occur
  in specific areas bilaterally
• Patients may complain of morning stiffness,
  irritable bowel syndrome, anxiety


8/19/2010        Approved 05/17/04 Dr. Prenitzer
   Patient
  Presents
   With –
  Tender
Points, 11 or
 more spots
 to qualify
8/19/2010   Approved 05/17/04 Dr. Prenitzer
               OPQRSTs
• May be sudden following a traumatic event
• Pa – Pseudo FMS responds to chiropractic,
  massage, physical therapy, manual therapy
• Pr – emotional distress
• Q – diffuse pain, fatigue, tender points
• T – longer than three months in duration


8/19/2010      Approved 05/17/04 Dr. Prenitzer
    Relevant History and Lifestyle
•   Gender – 80% are female
•   Age – childbearing age
•   Occupation – not signficant
•   Traumas – History of trauma that affects the
    CNS. 50 % of all patients the start of the
    chronic pain after a traumatic event. Post-
    traumatic Stress Disorder is the
    precipitating factor 21% of the patients with
    FMS.
8/19/2010         Approved 05/17/04 Dr. Prenitzer
    Relevant History and Lifestyle
• Neck trauma increases the odds of FMS by
  10 times, within 1 year of the trauma
• Trauma Continued – Whiplash injuries that
  result in cervical strain cause FMS in about
  22% of the individuals



8/19/2010      Approved 05/17/04 Dr. Prenitzer
    Relevant History and Lifestyle
• Surgeries - not significant
• Medication – not significant




8/19/2010      Approved 05/17/04 Dr. Prenitzer
    Relevant History and Lifestyle
• Hospitalizations – not significant
• Immunizations – not significant
• Diseases – Hepatitis C, Lyme disease,
  coxsackie B infection, HIV, and parovirus
  infection have been described as trigger for
  fibromyalgia
• Family History – some evidence of familial
  aggregation for FMS
8/19/2010       Approved 05/17/04 Dr. Prenitzer
    Relevant History and Lifestyle
•   Diet – Not signficant
•   Sleep Habits – Insomnia is usually present
•   Sexual history - Not signficant
•   Alcohol usage - Not signficant
•   Drug usage - Not signficant
•   Smoking/ Tobacco - Not signficant

8/19/2010        Approved 05/17/04 Dr. Prenitzer
            Review of Systems
• EENT normal – May have headaches,
  bruxism
• Heart - normal
• Lungs - normal
• Digestive- IBS
• Reproductive- dysmenorrhea
• Genitourinary – irritable bladder
8/19/2010      Approved 05/17/04 Dr. Prenitzer
             Physical Exam
• Vitals – Normal
• Appearance – Normal to possible postural
  changes due to diffuse pain
• Orthopedic Tests – Possible false positives.
  Dependent of amount of pressure exerted
  during test and/ or the fact that 28% of
  patients with FMS experience BJHS
  (Benign Joint Hypermobility Syndrome)

8/19/2010       Approved 05/17/04 Dr. Prenitzer
                      BJHS
• Causes chronic pain in the joints, muscles,
  and ligaments.
• Abdominal pain and distress can result from
  laxity of connective tissue that provides
  support for the abdominal, thoracic, and
  pelvic organs.


8/19/2010      Approved 05/17/04 Dr. Prenitzer
    Physical Exam – Neurological
                Tests
• Shows increased sensitivity to mechanical
  stimuli
• This may alter findings during motor,
  reflex, and sensation tests.




8/19/2010      Approved 05/17/04 Dr. Prenitzer
              Lab Values
• Labs will be normal
• Labs for DDX – CBC, ESR, Thyroid
  Function tests, salivary tests
• Labs for DDX – standard blood chemistry
  panel: serum fasting glucose, liver
  enzymes, kidney function markers
• Elevated aluminum levels found in FMS
• EEG – altered with FMS
8/19/2010     Approved 05/17/04 Dr. Prenitzer
            Spinal Examination
• Diffuse areas of pain and tenderness upon
  palpation.
• At least 11 out of 18 TePs
• Postural exam may reflect pain level by
  affecting the attitude of the posture
• ROM may be affected, no real correlation to
  Classic FMS but Definitely to Pseudo FMS

8/19/2010       Approved 05/17/04 Dr. Prenitzer
            Spinal Examination
• Leg Length, Intrumentation, and Palpation –
  palpation may show increased levels of
  tenderness, TrP will show with pseudo
  FMS. Motion palpation may show positives
  with Pseudo FMS




8/19/2010       Approved 05/17/04 Dr. Prenitzer
            Radiological Examination
• Not Significant




8/19/2010          Approved 05/17/04 Dr. Prenitzer
               Differentials
•   Hypermobility (BJHS)
•   Regional musculoskeletal pain
•   Polymyalgia Rheumatica
•   Neuroendocrine Abnormalities
•   Acute or Chronic Infections
•   Hepatitis C Virus
•   HIV Syndrome
8/19/2010       Approved 05/17/04 Dr. Prenitzer
            Differentials Continued
• Exposure Syndromes – Sick building
  syndrome, Gulf War Syndrome, multiple
  chemical sensitivities
• Anemia
• Hypothyroidism
• Lyme disease
• Multiple Sclerosis
8/19/2010         Approved 05/17/04 Dr. Prenitzer
            Differentials Continued
•   Hypoadrenalism
•   Hyperadrenalism
•   Lupus
•   Dysglycemia
•   Malignancy



8/19/2010         Approved 05/17/04 Dr. Prenitzer
            Case Management
•   Chiropractic Care
•   Medical care
•   Physical Therapy
•   Adjuntive Therapy
•   Nutrition
•   Exercise
•   Health Promotion and Maintenance
8/19/2010       Approved 05/17/04 Dr. Prenitzer
            Chiropractic Management
• Manage as normal but special consideration
  needs to be paid towards patient comfort
  when adjusting
• Due to depression experienced, concerns
  about osteoporosis must be considered
• FMS may be linked to increased
  sympathetic nervous system activity

8/19/2010         Approved 05/17/04 Dr. Prenitzer
 Medical Management – focused
   on altering brain and CNS
         neurochemistry
• Low doses of antidepressant medications seem to
  have a positive affect on TePs ( a short-lived
  affect)
• Anxiolytic medications – counteracting anxiety
• Biofeedback
• Psychotherapy
• Desensitization Techniques

8/19/2010        Approved 05/17/04 Dr. Prenitzer
       Physical Therapy, Adjuntive
            Therapy, Exercise
• Studies show that aerobic exercise improves
  muscle fitness and reduces muscle pain and
  tenderness
• Heat and massage may also give temporary
  relief


8/19/2010      Approved 05/17/04 Dr. Prenitzer
                Nutrition
• Supplementation with magnesium, malate,
  and B-vitamins
• Malate and magnesium are competitive with
  aluminum, a substance shown to be high in
  patients with FMS



8/19/2010     Approved 05/17/04 Dr. Prenitzer
              References
• Fibromyalgia syndrome: A new paradigm
  for differential diagnosis and treatment.
  JMPT. October 2001. Volume 24. Number
  8
• www. Medscape.com/viewarticle/470556-
  Fibromyalgia Pain: Do We Know the
  Source
• www.medceu.com - Fibromyalgia

8/19/2010      Approved 05/17/04 Dr. Prenitzer
                                              Case Complexity:

 The category of complicating or mitigating factors should include the following considerations: Ancillary labs,
diagnostic studies, co-management issues, early stage of condition, advanced stage of condition, psychosocial
  issues, etc. The complicating or mitigating factors can either increase or decrease the baseline complexity.




     Condition Name             Baseline        Complicating/ Mitigating Factors             Revised
                                Complexit                                                    Complexit
                                y                                                            y


                                                Altered chiropractic adjustments                 6.0

            Fibromyalgia            5.0
                                                Complicated by depression                        6.0



                                                Co-management with counseling                    6.0



                                                Sequelae to MVA/ whiplash injury                 7.0




8/19/2010                            Approved 05/17/04 Dr. Prenitzer
                          CLINICAL APPLICATIONS
                         Faculty Case Study Preparation


CONDITION:__Cervicogenic Headaches____

Prepared by:_____Maria Michelin, DC

RELEVANT PATHOPHYSIOLOGY:

Pain referred from muscles, ligaments, joint capsules and vertebral discs. Suspect
sensory root involvement from C1 to C3.

CASE HISTORY:

PPW: Pain in the occipital region with associated neck pain and neck stiffness

Onset-Initial Gradual                                                        _____
      Palliative/Provocative       decreases with exercise or stress relief /
      increases with forward flexion
      Quality/Quantity     dull, non-pulsating pain, steady ache, mild to moderate
      Referred/Radiating neck stiffness and pain, travels around head
      Site occipital region
      Timing/Pattern       few times a week, typically begins in the late afternoon
      Other

Relevant History and Lifestyle –
      Gender        Females>Males
      Age
      Occupation
      Traumas       Precipitating factor
      Surgeries
      Medications
      Hospitalizations
      Immunizations
      Diseases or Conditions__________________________________ _
      Family History
      Diet
      Sleep Habits
      Sexual History
      Alcohol Usage
      Drug Usage
      Smoking/Tobacco
      Other__________________________________________________

Review of Systems:

Maria Michelin, D.C.                 Page 1                             8/19/2010
Approved 04/05/04
PHYSICAL EXAMINATION:

Height                                 Weight

Vitals: BP             Pulse                        Respiration________ Temp.

Appearance, Motion, Gait

Orthopedic Tests

      Test Name                R            L              Test Name             R           L
                           +       -    +       -                               +    -   +       -
                           +       -    +       -                               +    -   +       -
                           +       -    +       -                               +    -   +       -
                           +       -    +       -                               +    -   +       -
                           +       -    +       -                               +    -   +       -

Orthopedic Test Results Discussion:      Orthopedic tests are negative but some
upper cervical pain is produced with range of motion.


Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception
___________________________________________________________________
___All with in normal limits______________________________________________

LabValues__________________________________________________________
_____ ____________________________________________________________


Examination of Related Areas



Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




Maria Michelin, D.C.                     Page 2                                 8/19/2010
Approved 04/05/04
SPINAL EXAMINATION:

          Postural Analysis                       Postural Analysis       L            N      R
                                                  Head Tilt
                                                  Head Rotation
                                                  High Ear
                                                  High Shoulder
                                                  High Ilium
                                                  Ext. Rotated Foot
                                                  Int. Rotated Foot


ROM
                Cervical ROM                                  Lumbar ROM
                  ROM     Pain        Level                     ROM    Pain                Level
Flexion           N  Y N            Upper Flexion             N    Y N
                                     Cervical
Extension           N      Y   N            Extension          N          Y    N
R. Rotation         N      Y   N            R. Rotation        N          Y    N
L. Rotation         N      Y   N            L. Rotation        N          Y    N
R. Lat. Flex.       N      Y   N            R. Lat. Flex.      N          Y    N
L. Lat. Flex.       N      Y   N            L. Lat. Flex.      N          Y    N


Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion)           Tenderness in the upper cervical region.



List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




Maria Michelin, D.C.                     Page 3                                   8/19/2010
Approved 04/05/04
RADIOLOGICAL EXAMINATION:

         X-rays      MRI         CT           Other

Views A-P and Lateral Cervical

Findings   Some indication of arthrosis but this is not specific for cervicogenic
headaches.



DIFFERENTIALS:

   1.   Migraine Headaches
   2.   Cluster Headaches
   3.   Brain Tumors
   4.   Meningitis and Encephalitis
   5.   Aneurysms, hematomas and hemorrhages
   6.   Tension Headaches
   7.   Hypertensive Headaches


DIAGNOSIS:

        Cervicogenic headaches, headache with dysfunction of the cervical spine


Case Management:

Chiropractic Management:          Adjust the cervical and thoracic subluxations.



Common Medical Management: ____OTC medications and prescription muscle
relaxers

Adjunctive Therapy:

Physical Therapy: Deep tissue massage of occipital and paraspinal muscles,
trigger point therapy of SCM, supoccipital muscles and trapezius. Pulsed
ultrasound followed by moist heat. Ice for severe headaches.

Nutrition: Possibly has a food allergy component. Calcium and magnesium to
affect myospasm.



Maria Michelin, D.C.                 Page 4                             8/19/2010
Approved 04/05/04
Exercise:



Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene,
psychosocial concerns, education):

     ___________________________________________________________
________________________________________________________________

Further Evaluation:

References:


Vizniak, N., and Carnes, M. Quick Reference Clinical Chiropractic Conditions
Manual. DCPI. 2004. pages 8-13
Souza, T., Differential Diagnosis for the Chiropractor. Aspen. 2001, page 434



Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.


Condition Name         Baseline     Complicating/ Mitigating Factors     Revised
                       Complexity                                        Complexity
   Cervicogenic           2.0       Advanced DJD                            4.0
   Headaches




Maria Michelin, D.C.                 Page 5                            8/19/2010
Approved 04/05/04
                             CLINICAL APPLICATIONS
                            Faculty Case Study Preparation


CONDITION______Lumbar Disc Herniation____________________________

Prepared by: _Janice H. Fordree, D.C.__________________________________

RELEVANT PATHOPHYSIOLOGY:

Degenerative changes in disc and spine, sudden trauma, gradual micro traumas or a
combination of the last two. Also a chemical irritation from release of inflammatory
products.

 Most common cause is a series of rotational in juries that produce circumferential and
radial tears with one final traumatic event leading to herniation. May relate a
precipitating event such as lifting or twisting a heavy object but just a minimal
provocation incident. This is the patient that says, “I bent over to tie my shoes” or “I bent
over to pick up the soap”.

Severe compression injury with the spine in a flexed position may cause a sudden
rupture of the annulus.

Nuclear protrusion: localized protrusion of nuclear material into spinal canal resulting
from a thinned but not ruptured annulus fibers.

Nuclear Herniation: material has torn through the annulus fibrosis and is a free
segment.

Most common L4/L5 and L5/S1 = 95-98%.
Centrally located protrusion tends to produce LBP and leg pain.
Laterally located protrusion tends to produce leg pain.  _____________________

Approximately 75% of lumbar herniations resolve spontaneously within 6 months due to
reabsorption of herniated material. Larger herniations often resolve faster than small
ones.




Janice Fordree, D.C.                   Page 1                              8/19/2010
Approved 05/10/04
CASE HISTORY:

PPW: Back pain, leg pain or back and leg pain. Back pain often disappears with onset
of leg pain. Leg pain is often greater than back pain with herniations, however if there
are only annular tears with out herniation then back pain will be greater.

Pain may follow heavy lifting or twisting or heavy stress trauma and there may be a
history of intermittent LBP that usually resolves.
                                   __

Onset-Initial: Prior episodes of LBP and/or leg pain. Sudden onset of LBP with leg pain
past the knee.                                                                  _____
Palliative/Provocative
    Palliative: Rest with knees flexed in recumbent position.
    Provocative: Any movements that increase intradiscal pressure, weight bearing
        movements such as standing/walking for long periods of time and positional
        changes (lying to sitting, sitting to standing), forward bending, coughing,
        sneezing.

Quality/Quantity: Acute severe LBP with leg pain that can be shooting or electrical in the
dermatomal pattern.
Referred/Radiating Down leg
Site L4/L5, L5/S1 = 95-98%
Timing/Pattern          Standing/walking for long periods and positional changes (lying to
sitting, sitting to standing).
Other

Relevant History and Lifestyle
      Gender        Males> females
      Age 20-40 years old – due to nucleus pulposis is most hydrated - with
         highest incidence between 30-40 years of age.
      Occupation
      Traumas
      Surgeries
      Medications
      Hospitalizations
      Immunizations
      Diseases or Conditions__________________________________ _
      Family History
      Diet
      Sleep Habits
      Sexual History
      Alcohol Usage
      Drug Usage
      Smoking/Tobacco
      Other__________________________________________________

Janice Fordree, D.C.                 Page 2                             8/19/2010
Approved 05/10/04
Review of Systems                                                         _____

     ______________________________________________________
___________________________________________________________



PHYSICAL EXAMINATION:

Height                                 Weight

Vitals: BP             Pulse                        Respiration________ Temp.

Appearance, Motion, Gait

Orthopedic Tests

      Test Name                R            L              Test Name            R           L
SLR                        +       -    +       -    Valsalva’s                 +   -   +       -
Well Leg Raiser            +       -    +       -                               +   -   +       -
Bowstring                  +       -    +       -                               +   -   +       -
Kemp’s                     +       -    +       -                               +   -   +       -
Lasague                    +       -    +       -                               +   -   +       -

Orthopedic Test Results Discussion: Any test for SOL and/or nerve root irritation will be
positive and can be used.



Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception:

Decreased sensation over affected dermatome.
Muscle weakness of quadriceps, dorsiflexors of ankles and toes or plantar flexors may
be present, depending on the given spinal level. Weakness of great toe indicates L5
disc.
Diminished or absent DTRs.
In prolonged cases may have muscle atrophy.
______________________________________________________________________
________________________________________________________________




Janice Fordree, D.C.                     Page 3                                 8/19/2010
Approved 05/10/04
LabValues_____________________________________________________________
__    ____________________________________________________________


Examination of Related Areas



Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




SPINAL EXAMINATION:

      Postural Analysis                           Postural Analysis      L      N     R
                                                  Head Tilt
      Decreased lumbar lordosis                   Head Rotation
      *Antalgic posture with pain                 High Ear
       running down leg into foot.                High Shoulder
                                                  High Ilium
                                                  Ext. Rotated Foot
                                                  Int. Rotated Foot


       * Antalgic lean may be indicative of position of protrusion. If the disc protrudes
lateral to the nerve root, the patient assumes an antalgic lean away from side of
radicular symptoms. If the disc protrudes medial to the nerve root, patient may assume
an antalgic lean into side of radicular symptoms. Flexed antalgic with out lateral lean
may indicate a more central herniation.

ROM
             Cervical ROM                                  Lumbar ROM
               ROM      Pain       Level                    ROM     Pain         Level
Flexion        N      Y N                Flexion          N     Y N
Extension      N  Y N                    Extension        N     Y N
R. Rotation    N  Y N                    R. Rotation      N     Y N
L. Rotation    N  Y N                    L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                    R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                    L. Lat. Flex.    N     Y N


Leg Length/Spinal Balance
Instrumentation/Pattern Analysis


Janice Fordree, D.C.                  Page 4                             8/19/2010
Approved 05/10/04
Palpation (Muscle, Static, Motion) Myospasms may be present over lumbosacral para
spinals and gluteals.




List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

       X-rays       MRI          CT          Other

Views A-P /Lateral Lumbopelvic


Findings     Potential loss of disc height
             Lateral wedge sign

* MRI - best method to view herniation.

DIFFERENTIALS:

*Cauda equina syndrome
Facet syndrome with referred pain
Piriformis Syndrome
Lateral Stenosis / Central Stenosis




Janice Fordree, D.C.                  Page 5                        8/19/2010
Approved 05/10/04
DIAGNOSIS:

Lumbar disc herniation


Case Management:


Chiropractic Management:
Cox flexion/distraction, low force techniques (Activator), listed references stated that
side posture is safe and effective – must keep lordotic curve maintained.
SOT – Category 3 – specific for herniation (especially L4/L5/S1)


* Contraindications to adjust:
    Peripheralization of symptoms
    If lesion is above L1/L2 disc space, possibility of UMN signs exist,
     signs include – saddle anesthesia
                      tonic bladder
                      (+) Babinski’s reflex
                       examine for sphincter incontenance and bowel/bladder
dysfunction.

RED FLAG – bowel/bladder dysfunction – refer immediately – may be CES



Adjunctive Therapy:
      Short term (2-3 days / 48-72 hours) – bed rest with knees flexed – prolonged
bed rest and inactivity are discouraged.
      Lumbosacral support – especially while sitting
      NSAIDs



Physical Therapy:
Acute phase: cold packs, ice massage and low volt galvanic for pain and edema.
TENS low frequency and high intensity of less than 10 HZ creates a analgesic affect
and increases endorphin production. Electrical stim increases levels of dopamine,
epinephrine and serotonin while diminishing nerve action potentials of A delta fibers
which are pain mediators.

Sub acute phase: other modalities and procedures that include trigger point therapy,
acupuncture and ultrasound. _***Do not place over spinal cord *** _
________________________________________________________________



Janice Fordree, D.C.                  Page 6                              8/19/2010
Approved 05/10/04
Nutrition: * Note: The nutrition below is only a recommendation; there are no evidence-
based guidelines to the information listed below.

Acute pain and inflammation: Proteolytic enzymes (trypsin, chymitrypsin, bromelin),
Bioflavonoids (quercetin, hesperidin, rutin, etc) Herbals.

Tissue healing: Amino acids (glycine, L-cystine, L-proline and L-lysine) – supplies the
amino acid pool necessary for the structural production of collagen. Glucosamine
sulfate – nutrients for production of healthy ground substance,
Vitamin C, Iron, Alpha Ketoglutaric acid - all 3 needed for collagen production
Calcium, Vitamen E, Zinc, Copper, and Manganese – provide antioxidant effects and
serve as free radical scavengers to help remove cellular debris and promote
healing.


Exercise: McKenzie exercises and mild aerobic activity (swimming, walking, stationary
bike after patient can sit comfortably)
       Exercise ball for extension exercises.


Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education):
Instruction on back protection
Encourage life style modifications
Encourage weight loss if appropriate


Further Evaluation:
Week 6 – refer for surgical consult If profound muscle weakness has not responded
Week 12 – refer for surgical consult if poor response to conservative care


Common Medical Management: The treatment of a disc herniation is based on the
severity and duration of symptoms. Initial treatment is almost always non-surgical. Anti-
inflammatory medications, steroids and/or muscle relaxants with rest are initially used to
treat the sciatica. Physical therapy can also be very helpful. Most people have full
recovery from episodes of sciatica within the first few weeks. If the symptoms continue
past 6 weeks, however, one should consider undergoing an evaluation, which includes
MRI studies. If symptoms continue and conservative management has not been helpful,
surgical decompression of the disc (microdiscectomy) may be helpful in relieving the
symptoms. The only absolute indications for surgery, however, are progressive
neurological symptoms, bowel or bladder problems, and severe, unremitting.




Prognosis:
Janice Fordree, D.C.                  Page 7                             8/19/2010
Approved 05/10/04
   Good for near complete recovery of functionality, although flare-ups may occur
   Surgery is rarely required
   First 6 weeks – 50% improvement based on functional rehab – manipulation can
  provide short-term improvement in pain and activity levels and higher patient
  satisfaction. The risks of manipulations are very low in skilled hands.


  References:
  Vizniak & Carnes: Quick Reference Clinical Chiropractic Conditions Manual
   Huff & Brady: Instant Access to Chiropractic Guidelines and Protocols
  Gatterman: Chiropractic Management of Spine Related Disorders, 2nd Edition
  ___________________________________________________________________


  Case Complexity:

  The category of complicating or mitigating factors should include the following
  considerations: Ancillary labs, diagnostic studies, co-management issues, early stage
  of condition, advanced stage of condition, psychosocial issues, etc. The complicating or
  mitigating factors can either increase or decrease the baseline complexity.

Condition Name    Baseline     Complicating/ Mitigating Factors             Revised
                  Complexity                                                Complexity
 Lumbar Disc         5.0       Risk factor of heavy lifting or twisting,       6.0
  Herniation                   heavy stress trauma or history of
                               intermittent LBP
                               Risk factor of movements that increase           6.0
                               intradiscal pressure, especially flexed
                               positions, weight bearing movements
                               and positional changes.
                               Risk factors of prolonged                        6.0
                               standing/walking, forward bending,
                               coughing and sneezing.
                               Risk factor of decreased sensation over          7.0
                               affected dermatome, weakness and/or
                               atrophy of involved muscles and
                               diminished or absent DTRs.
                               Chiropractic management –                        9.0
                               contraindications to adjust
                               Chiropractic management – modified               8.0
                               adjusting along with use of specific
                               techniques.
                               Chiropractic management – refer for              9.0
                               surgical consult if no response to
                               conservative care after ~ six weeks.


  Janice Fordree, D.C.                 Page 8                              8/19/2010
  Approved 05/10/04
                             CLINICAL APPLICATIONS
                            Faculty Case Study Preparation


CONDITION: Obesity
Prepared by: Dr. Susan Boger-Wakeman

RELEVANT PATHOPHYSIOLOGY:

The medical definition of obesity is based on the amount of body fat a person has. It
is a reflection of increased fat stores, in both subcutaneous and visceral fat deposits.
A person can weigh more than is thought to be healthy without being obese. For
example:
        A person may weigh too much because his/her body retains too much water (edema).
        Though this is not a healthy situation, the person is not obese.

       Some athletes, such as football players and body builders, may weigh more
       than what is normally considered a healthy weight, but their excess weight is
       muscle, not fat.

Until recently, a person was thought to be obese if he/she weighed at least 20%
more than his/her ideal weight calculated from the Metropolitan Life height/weight
tables. However, these tables have been replaced by the body mass index (BMI)
which correlates significantly with body fat, morbidity and mortality.

The BMI is defined as:        Weight (kg)
                              Height (m2)

It can also be calculated: Weight (lbs) X 705 , then  height (inches)  height
(inches)

(The multiplier, 705 can vary depending on the organization. For example, the NIH
uses 704.5 and the American Dietetic Association recommends 700.

Definition of obesity using Body Mass Index

              Classification                  BMI (kg/m2__
              Underweight                     < 18.5
              Normal Weight                   19 – 24.9
              Overweight                      25 – 29.9
              Class I Obesity                 30 – 34.9
              Class II Obesity                35 – 39.9
              Class III Obesity               > 40

       NHLBI Clinical Guidelines on the Identification, Evaluation and
       Treatment of Overweight and Obesity in Adults-the Evidence Report.
       Obesity Research 1998(suppl.) 53S.

Susan Boger-Wakeman, Ph.D.               Page 1                             8/19/2010
Approved 04/05/04
In children and adolescents, overweight is defined as a gender and age-specific BMI
at or above the 95th percentile, based on revised growth charts by the Centers of
Disease Control and Prevention (CDC). There is no generally accepted definition of
obesity for children and adolescents.


Body fat distribution

People store body fat in two general ways; either above or below the waist. In both
men and women, excess intro-abdominal adipose tissue correlates strongly with
cardiovascular disease, dyslipidemia, hypertension, stroke and type 2 diabetes.
Documenting body fat distribution, in conjunction with BMI is important to assess
risk.

To determine the distribution of body fat using the waist circumference, measure at
the mid-point between the ileac crest and the lower rib. This measurement
correlates strongly with intra-abdominal adipose tissue assessed by CT and MRI.
Upper body obesity is defined as a waist circumference:
         35 inches (88 cm) for women
         40 inches (102 cm) for men




The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults
http://www.nhlbi.nih.gov/guidelines/obesity/practgde.htm

Susan Boger-Wakeman, Ph.D.                  Page 2                                   8/19/2010
Approved 04/05/04
Pathophysiology

Obesity occurs when a person consumes more calories than he/she expends. What
causes this imbalance between consumption of calories and caloric expenditure may
differ from one person to another. Genetic, environmental, psychological, and other
factors may play a role.

Research over the last twenty years has increased our knowledge about the
mechanisms of regulating body fat. We have a very complex system of regulating
energy balance and body weight. There are many “environmental” conditions that
can dramatically affect food intake. These factors can be “pregastric”, such as the
appearance of food, taste and odor of food, and psychological states such as
depression, and fear. Other factors important in regulating food intake are
gastrointestinal and postabsorptive in nature.

Factors that can impact the control of food intake can also be classified as “long-
term” control factors or “short-term” control factors.

Long-term control of food intake

Adult animals tend to maintain a relatively constant weight known as their “set
weight.” This appears to be regulated on a time scale of weeks or longer. If an
animal is starved over a period of time, its basal metabolic rate is decreased. When
an animal is force fed for a period of weeks and then is allowed access to food , it
will not eat very much. In both cases, its body weight returns back to its “set weight.”

Regulation of body weight is a complex integration of hormonal, metabolic and
neural signals.
Read the following articles:
Balasubramanyam, A. “The role of CNS signals controlling energy homeostasis in
obesity”
Available: http://medscape.com/viewarticle/419011.

Schwartz, M.W., Woods, S.C., Seeley, R.J., Barsh, G.S., Baskin, D.G, & Leibel, R.L.
“Is the energy homeostasis system inherently biased towards weight gain?”
Diabetes 52(2):232-238, 2003. Available:
http://www.medscape.com/viewarticle/448465.


Obesity-related Co-Morbidities:

Cardiovascular disease, hypertension, type 2 diabetes, dyslipidemia, respiratory
problems, gallbladder disease, degenerative joint disease, cancer, sleep apnea,
gynecological irregularities.




Susan Boger-Wakeman, Ph.D.            Page 3                              8/19/2010
Approved 04/05/04
Metabolic Syndrome (also known as Syndrome X, Insulin Resistance)

When chronic disorders of glucose intolerance, insulin resistance, hypertension,
hyperlipidemia, and abdominal obesity are linked together, they are known as
metabolic syndrome (also known as syndrome X).

Approximately 48 million Americans – 25% of adults – have metabolic syndrome.
This figure includes 10 million to 15 million individuals with type 2 diabetes. As the
U.S. population ages, the prevalence rate of metabolic syndrome will increase in
males and females of the older age groups. It is already approaching 50% in older
segments of the population. African American women have approximately a 57%
higher prevalence rate than men and Hispanic women have an approximately 26%
higher rate than men.

For most people, the primary factors of the metabolic syndrome are improper
nutrition and inadequate physical activity. The primary treatment is weight loss and
appropriate levels of physical activity.

Diagnostic Criteria for Metabolic Syndrome

       Abdominal obesity (waist circumference >35 “ in women and 40” in men)
       Hypertriglyceridemia       (>/= 150 mg/dL)
       Low HDL-C (<40 mg/dL in men, <50 mg/dL in women)
       High blood pressure (>/= 130/85 mm Hg)
       High fasting blood glucose (>/= 110 mg/dL)

Management of Obesity and Metabolic Syndrome

Weight loss is a key therapeutic objective. All components of the metabolic
syndrome are positively affected by weight loss. Even modest weight reductions
(5% - 10%) of initial body weight are associated with significant clinical
improvements in a wide range of co-morbid conditions.

   Energy balance and the control system incorporates three major components:
     - Resting energy expenditure (basal metabolic rate) – the energy expended
         in the activities necessary to sustain normal body functions such as
         respiration, circulation etc. Typically represents about 60% to 70% of total
         energy expended.
     - Thermic effect of food – increase in energy expenditure with the
         consumption of food. Accounts for approximately 10% of total energy
         expended.
     - Physical activity – Most variable component of total energy expended, It
         could be as little as 10% in a person who is confined to bed to as much as
         50% in an athlete. Includes energy expended in voluntary exercise.



Susan Boger-Wakeman, Ph.D.            Page 4                              8/19/2010
Approved 04/05/04
A goal to managing weight gain and obesity is to increase the resting energy
expenditure. This can be accomplished by increasing muscle mass and by
increasing physical activity resistance training.

Successful weight loss requires that more energy be expended than consumed on a
daily basis. Exercise is an extremely important part of a weight-management
program. By increasing lean body mass (LBM) in proportion to fat, exercise helps to
balance the loss of LBM and reduction of resting metabolic rate (RMR). A
combination of aerobic and resistance training is recommended.

CASE HISTORY:

PPW:


Onset-Initial                                                              _____
      Palliative/Provocative
      Quality/Quantity
      Referred/Radiating
      Site
      Timing/Pattern
      Other

Relevant History and Lifestyle
      Gender        No specific gender affinity
      Age                                              _______
      Occupation Tendency towards more sedentary occupations
      Traumas                                                       ______
      Surgeries                                               ________________
      Medications ________________________________________________
      Hospitalizations                                        ________________
      Immunizations                                                        _____
      Diseases or Conditions_________________________________________
      Family History       Increased risk in children with obese parents/siblings
      Sleep Habits _____                         ___________
      Sexual History                                                ___________
      Alcohol Usage        ____ _________________________________
      Drug Usage Certain drugs increase appetite. For example: coricosteroids,
      cyproheptadine, tricyclic antidepressants.
      Smoking/Tobacco             _________________

Review of Systems                                                  _____




Susan Boger-Wakeman, Ph.D.          Page 5                            8/19/2010
Approved 04/05/04
PHYSICAL EXAMINATION:

Height                    Weight

Vitals:          Pulse              Respiration__      Temp.

Appearance, Motion, Gait Excess adipose tissue around the waistline (central
obesity) Waist size larger than 35 inches in women and 40 inches I men indicator of
central obesity.

Orthopedic Tests

          Test Name         R           L           Test Name            R           L
                          +     -   +       -                        +       -   +       -
                          +     -   +       -                        +       -   +       -
                          +     -   +       -                        +       -   +       -
                          +     -   +       -                        +       -   +       -
                          +     -   +       -                        +       -   +       -

Orthopedic Test Results Discussion:




Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

Lab Values

Examination of Related Areas



Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




Susan Boger-Wakeman, Ph.D.            Page 6                          8/19/2010
Approved 04/05/04
SPINAL EXAMINATION:

      Postural Analysis                       Postural Analysis   L      N        R
                                              Head Tilt
                                              Head Rotation
                                              High Ear
                                              High Shoulder
                                              High Ilium
                                              Ext. Rotated Foot
                                              Int. Rotated Foot


ROM
             Cervical ROM                                Lumbar ROM
               ROM      Pain     Level                    ROM     Pain       Level
Flexion        N      Y N              Flexion          N     Y N
Extension      N  Y N                  Extension        N     Y N
R. Rotation    N  Y N                  R. Rotation      N     Y N
L. Rotation    N  Y N                  L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                  R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                  L. Lat. Flex.    N     Y N


Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion)




List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




Susan Boger-Wakeman, Ph.D.           Page 7                           8/19/2010
Approved 04/05/04
RADIOLOGICAL EXAMINATION:

         X-rays     MRI          CT          Other

Views

Findings




DIFFERENTIALS:

Body mass index (BMI) Note: that a person can have an elevated BMI if they have
increased muscle mass. Check the waist circumference.
Waist circumference >35 inches in females; >40 inches in males indicates central
obesity


DIAGNOSIS:

Body Mass Index                                              ________________

Case Management:


Chiropractic Management:          Locate, analyze and adjust all areas of
vertebral subluxations




Adjunctive Therapy:         Assess patient for other risk factors or comorbidities.
Some risk factors associated with obesity place patients at high risk for other
diseases such as metabolic syndrome. Also assess readiness to lose weight. If
patients do not want to lose weight but are overweight (BMI 25-29.9), without a high
waist circumference and with one or no cardiovascular risk factors, should be
counseled regarding the need to maintain their weight at or below its present level.


PhysicalTherapy:__________________________________________________
________________________________________________________________
________________________________________________________________


Susan Boger-Wakeman, Ph.D.           Page 8                            8/19/2010
Approved 04/05/04
Nutrition:     Caloric intake should be reduced by 500 calories per day from current
level will produce a recommended weight loss of 1 to 2 pounds per week.. For most
sedentary women, using the Daily Food Guide (Food Guide Pyramid) to guide their
food portions from various food groups may be an option. Emphasize whole grain
foods, fruits and vegetables, lean meats and lower-fat dairy choices. Refer to a
Registered Dietitian (RD) for more detailed diet counseling. Can contact the local
hospital or Public Health Department for an RD in you area.
Need to assess patient’s calcium intake. Her dietary assessment revealed
avoidance of dairy products.


Exercise:    Increasing physical activity is important because it increases energy
expenditure and reduces the risk for heart disease. Goal is to accumulate at least
30 minutes or more of moderate intensity physical activity on most, preferably all,
days of the week.




Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education):      Encourage engaging in some form of physical activity
each day. Use of a pedometer that tracts the number of steps walked each day is
an inexpensive and good motivational tool (<$20).
Provide patient with information on weight-loss programs being conducted in the
area of the patient’s home/work, preferably by a
Registered_Dietitian.______________


Further Evaluation: Periodically check weight, BMI and waist circumference (e.g.
every two months). Encourage/praise patient for trying/succeeding to losing weight
and increasing their physical activity.



Common Medical Management: Refer to MD for further assessment of other
diseases/conditions such as metabolic syndrome. _Pharmacotherapy may be
beneficial for eligible high-risk patients. Two medications commonly prescribed for
the morbidly obese are: Sibutramine which inhibits norepinephrine, epinephrine and
serotonin reuptake and Orlistat which inhibits pancreatic lipase and therefore
decreases fat absorption.
Several types of bariatric surgical procedures are performed also in the morbidly
obese individual. Common surgeries include Vertical banded gastroplasty or
“stomach stapling”, Roux-en Y gastric bypass, and Lap band.



Susan Boger-Wakeman, Ph.D.           Page 9                             8/19/2010
Approved 04/05/04
References:

US Department of Health and Human Services, Office of the Surgeon General. The
Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity.
Rockville, Md: US Department of Health and Human Services; 2001.

Executive Summary of the Third Report of the National Cholesterol Education
Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High
Blood Cholesterol in Adults (Adult Treatment Panel III). Journal of the American
Medical Association;285:2486-2497.

The Practical Guide: Identification, Evaluation, and Treatment of Overweight and
Obesity in Adults
http://www.nhlbi.nih.gov/guidelines/obesity/practgde.htm

Nutrition and Your Health: Dietary Guidelines for Americans – USDA
http://www.health.gov/dietaryguidelines/

Task Force Recommends Obesity Screening for Adults. The American Public
Health Association. The Nation’s Health 34(1), 2004

Rashid, MN, Fuentes, F, Touchon, RC, & Wehner, S. Obesity and the Risk for
Cardiovascular Disease. Prev Cardiol 6(1):42-47, 2003.

Bevoni, L. Management of Adult Obesity. Clinical Reviews 13(5):56-62, 2003.

Blackburn, Gl, & Bevis, LC. The Obesity Epidemic: Prevention and the Treatment of
the Metabolic Syndrome
http://medscape.com/viewprogram/2015_pnt

The Food and Nutrition Information Center (FNIC) at the National Agricultural Library
(NAL). Food Guide Pyramid
http://www.nal.usda.gov/fnic/Fpyr/pyramid.html

Bariatric Surgical Techniques
http://www.genesishealth.com/services/cbs_surgeries.aspx#
http://www.obesityhelp.com/morbidobesity/m-surgerytypes.phtml




Susan Boger-Wakeman, Ph.D.          Page 10                            8/19/2010
Approved 04/05/04
Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.


Condition Name        Baseline     Complicating/ Mitigating Factors         Revised
                      Complexity                                            Complexity
                                   Additional risk factors for other co-
      Obesity             2.0      morbidities, eg. Metabolic                   4.0
                                   syndrome, cardiovascular disease,
                                   hypertension
                                   Medications -                                3.0
                                   Psychosocial aspects -                       3.0
                                   Chiropractic management –                    3.0
                                   contraindications to adjustments,
                                   need for referral




Susan Boger-Wakeman, Ph.D.          Page 11                                8/19/2010
Approved 04/05/04
Pernicious Anemia
    Jason M. Abbott




      Approved 31 May 06,
       Implemented SU06
     Normal B12 Physiology
•Vitamin B12 is a vitamin found in meat
•It binds to proteins known as R binders in saliva
when meat is ingested
•R binders protect B12 from being broken down by
acid in the stomach
•Once the complex of B12 & R binder proteins reach
the ileum (the last section of the small intestine), it is
broken apart and B12 binds with intrinsic factor
   –Intrisic factor is a substance secreted by parietal cells in
                           stomach
   gastric mucosa of the Approved 31 May 06,
                          Implemented SU06
    Normal B12 Physiology
•Intrinsic factor allows B12 to cross the
intestinal mucosa
•Vitamin B12 exists in the plasma as MeCbl, 5’-
deoxyAdoCbl, and hydroxycobalamin
  –These forms are bound to either transcobalamin I
  or II
  –Transcobalamin I is the B12 storage protein
  –Transcobalamin II is the B12 transport protein
•0.1 % of the total B12 in the body is found in
                    ApprovedmL
                      pg/ 31 SU06
the plasma(200-750ImplementedMay)06,
   Normal B12 Physiology
• The remaining amount of the body’s B12 is
  stored in the liver
• There is enough B12 in the liver to supply
  the body for 3-5 years with no B12 uptake




                 Approved 31 May 06,
                  Implemented SU06
   B12 Pathophysiology
Because there are several stages in the
uptake and storage of the normal
physiology of vitamin B12, there are various
possibilities of how the process can be
interrupted. When anything goes wrong
with the process that takes up and stores
vitamin B12 in the body, and the previously
stored supply of B12 in the body is used up,
a person then experiences PERNICIOUS
ANEMIA.           Approved 31 May 06,
                Implemented SU06
    Patient Presents With
• Reflex loss
• Loss of position and vibratory sensation
• Loss of proprioceptive and vibratory
  sensation in the lower extremities
• Loss of tactile, pain and temperature
  sensation (uncommon)
• Optic atrophy
• Weakness
                  Approved 31 May 06,
                   Implemented SU06
    Patient Presents With
• Weight Loss Diffuse abdominal pain
• Parkinsonian symptoms may be seen in
  severe cases
• Glossitis
• Yellow / Blue color blindnessAlternating
  diarrhea and constipation
• Seizures
• Spasticity
                  Approved 31 May 06,
                   Implemented SU06
      Patient Presents With
•   Paranoia
•   Delirium
•   Confusion
•   Anorexia
•   Unsteady gait




                    Approved 31 May 06,
                     Implemented SU06
• ONSET – Gradual and insidous. Liver
 stores deplete slowly and may take years to
 drain completely.
• PALLIATIVE – Intramuscular or oral
 doses of B12. Fe therapy may be necessary
 prior to B12 therapy if Fe deficiency is
 found in bone marrow. If the
 pathophysiological mechanism cannot be
 corrected then B12 therapy must be
 continued throughout life.

                 Approved 31 May 06,
                  Implemented SU06
• PROVOCATIVE – Strict veganism, a diet
 consisting of no meat or animal proteins, will
 decrease or do away completely with the
 amount of B12 a person takes in, and this
 can cause pernicious anemia. Destruction of
 the gastric mucosa, where intrinsic factor is
 released, will decrease the uptake of B12.
 Certain disorders that compete for the
 uptake of B12 such as a fish tapeworm, and
 blind loop syndrome. Also, hyperthyroidism
 can increase the demand for B12. Removal
 of large portions of the small intestine where
 B12 is absorbed.
                  Approved 31 May 06,
                  Implemented SU06
• PREVIOUS CARE- None
• QUALITY- Anorexic conditions, GI
    problems, and neurological problems such
    as: weakness of muscles, decreased
    vibratory and position sensation, and
    tactile, pain, and temperature impairment.
•   QUANTITY- varies according to severity
•   RADIATING- None
•   SITE – Varies according to symptoms.
•   TIMING – Varies according to severity
                   Approved 31 May 06,
                    Implemented SU06
• TIMING – Varies according to severity

• GENDER- N/A
• AGE- Often in the elderly there is a decreased
  amount of food-bound B12 liberated and absorbed
  by the body.
• OCCUPATION- N/A
• TRAUMAS- N/A
• SUGERIES- Surgical resection of the small
  intestine can destroy portions of the ileum where
  B12 is absorbed.
• HOSPITILIZATIONS- N/A
                    Approved 31 May 06,
                     Implemented SU06
• IMMUNIZATIONS- N/A
• DISEASES or CONDITIONS-
  –   Loss of intrinsic factor due to gastritis
  –   Blind loop syndrome
  –   Fish tapeworm
  –   Inflammatory regional enteritis
  –   Chronic pancreatitis
  –   Chronic hyperthyroidism
  –   Celiac disease
  –   Sprue
  –   Malignancy in the ileal region
  –   Liver disease
  –   Kidney disease
                          Approved 31 May 06,
                           Implemented SU06
• FAMILY HISTORY- In some cases, the site
  for B12 absorption in the ileum is
  congenitally absent or decreased.
• MEDICATIONS-
  – Oral calcium-chelating drugs
  – Aminosalicylic drugs
  – Biguanides
• DIET- Normally B12 is acquired through
  the eating of meat. Vegans take in a diet
  absent of meat or animal proteins,
  therefore their intake of B12 is absent.
                   Approved 31 May 06,
                    Implemented SU06
• SLEEP HABITS- Pernicious anemis can
  cause a myriad of neurological problems
  which may lead to decreased sleep.
• SEXUAL HISTORY- N/A
• ALCOHOL USAGE- Chronic alcoholism
  can lead to pernicious anemia by disrupting
  the release of intrinsic factor from the
  mucosa or by reducing the absorption of
  B12 in the ileum.
• DRUG USAGE- N/A
• SMOKING/TOBACCO- N/A

                  Approved 31 May 06,
                   Implemented SU06
    Physical Examination
• HEIGHT-N/A
• WEIGHT- May be decreased due to
  anorexic symptoms
• BLOOD PRESSURE- N/A
• PULSE – N/A
• RESPIRATION- N/A
• TEMPERATURE- N/A
• ORTHOPEDIC TESTS – N/A

               Approved 31 May 06,
                Implemented SU06
       Neurological Tests
• Neurological symptoms are sometimes seen
  without hematological problems.
• The peripheral nerves are effected first,
  then the spinal cord.
• Loss of vibratory and position sensation of
  the extremities
• Weakness of musculature
• Loss of normal reflexes
                  Approved 31 May 06,
                   Implemented SU06
       Neurological Tests
• Spasticity of muscles is often seen in the
  later stages.
• The Babinski response is often seen as a
  pathological reflex
• Loss of position sensation in the lower
  extremities
• Loss of vibratory sensation in the lower
  extremities
                   Approved 31 May 06,
                    Implemented SU06
       Neurological Tests
• Spasticity of muscles is often seen in the
  later stages.
• The Babinski response is often seen as a
  pathological reflex
• Loss of position sensation in the lower
  extremities
• Loss of vibratory sensation in the lower
  extremities
                   Approved 31 May 06,
                    Implemented SU06
              Lab Values
•   MCV > 100 fL
•   Increased RDW
•   Macro-ovalocytosis
•   Anisocytosis
•   Poikilocytosis
•   Howell-Jolly bodies
•   Hypersegmentation of granulocytes
•   Neutropenia
                   Approved 31 May 06,
                    Implemented SU06
            Lab Values
• Thrombocytopenia found in 50% of severe
  cases
• Misshapen platelets
• Erythroid hyperplasia of bone marrow
• Increased indirect serum bilirubin
• Increased LDH
• Increased serum ferritin
• Decreased serum vitamin B12 (<150 pg/mL)

                Approved 31 May 06,
                 Implemented SU06
            Lab Values
• Decreased transcobalamin II-B12
  (<40pgmL)




                Approved 31 May 06,
                 Implemented SU06
Examination of Related Areas
• The only area where examination may
  indicate a problem is palpation of the
  abdomen. Diffuse tenderness may be found
  in this area.




                Approved 31 May 06,
                 Implemented SU06
          Other Findings
• The only findings not prevoiusly discussed is
  the presence of splenomegaly and
  hepatomegaly. Also the patient may
  complain of glossitis.




                  Approved 31 May 06,
                   Implemented SU06
      Spinal Examination
• No findings in the spinal exam would be
  diagnostic for pernicious anemia.




                 Approved 31 May 06,
                  Implemented SU06
 Radiological Examination
• No findings in the radiologcal exam would
  be diagnostic for pernicious anemia.




                 Approved 31 May 06,
                  Implemented SU06
              Differentials
•   Folic acid deficiency anemia
•   Achorhydria
•   Alcoholic fatty liver
•   Alcoholic hepatitis
•   Aplastic anemia
•   Bone marrow failure
•   Celiac Sprue
•   Cirrhosis
                    Approved 31 May 06,
                     Implemented SU06
            Differentials
•   Gastric cancer
•   Atrophic gastritis
•   Hemolytic anemia
•   Unconjugated hyperbilirubinemia
•   Hyerthyroidism
•   Hypothyroidism
•   Immune Thrombocytopenic Purpura
•   Iron deficiency anemia
                 Approved 31 May 06,
                  Implemented SU06
             Differentials
•   Macrocytosis
•   Malabsorption
•   Megaloblastic anemia
•   Myeloproliferative Disease
•   Neutropenia
•   Schizophrenia
•   Tropical Sprue
•   Zollinger-Ellison Syndrome
                   Approved 31 May 06,
                    Implemented SU06
           Differentials
• Blind loop syndrome
• Fish tapeworm
• Methymalonic acidemia




                Approved 31 May 06,
                 Implemented SU06
              Diagnosis
• Pernicious anemia due to B12 deficiency




                 Approved 31 May 06,
                  Implemented SU06
        Case Management
• Chiropractic Management: Adjust
  subluxations to allow the body to adapt to and
  correct deficiency.
• Medical Management: B12 supplements,
  either intramuscular or orally administered.
  Not only is there a need to supply the body
  with B12 immediately but also, the storage
  supply of B12 in the liver must be replenished.
  B12 supplementation must be maintained
  throughout life unless the cause of the
  deficiency is addressed. May 06,
                    Approved 31
                    Implemented SU06
        Case Management
• Surgical Management: N/A
• Adjunctive Therapy: In some cases of
  pernicious anemia, Fe amounts within the bone
  marrow are depleted, and in these cases, oral Fe
  therapy must be administered prior to the B12
  therapy.
• Physical Therapy & Exercise: In the case of
  long term neurological problems, physical
  therapy and exercise may be needed to
  strengthen atrophied muscles or improve
  coordination.    Approved 31 May 06,
                    Implemented SU06
    Case Management – Nutrition
• Increase protein in the diet (1-5 grams per kilogram of body weight)
  is desirable for both liver function and for blood regeneration.
• Increase green leafy vegetables because they contain both iron and
  folic acid.
• Liver is an excellent source of iron, vitamin B12, folic acid, and other
  important nutrients. Meats (especially beef and pork), eggs, milk
  and milk products are particularly good sources of vitamin B12.
• Vegans should consume plant-based foods fortified with vitamin B12
  or consume a supplement.

•   Reference: Mahan, L & Escott-Stump. S. (Eds.) (2003) Krause’s
    Food, Nutrition & Diet Therapy (11th ed.). Philadelphia: W. B.
    Saunders.

                             Approved 31 May 06,
                              Implemented SU06
        Case Management
• Further Evaluations: Lab results should be
  taken to evaluate the effect of treatments.
  There is increased risk of gastric and
  esophageal adenocarcinoma.




                   Approved 31 May 06,
                    Implemented SU06
            Resources Cited
• Conrad, Marcel E., MD; Pernicious Anemia;
       http://www.emedicine.com/med/topic1799.h0tm ;
       1/7/05.
•   Beers, Mark H., MD, & Berkow, Robert, MD; The
       Merck Manual of Diagnosis and Therapy (7th
       Edition); Merck Research Laboratories:
       Whitehouse Station, N.J.; 1999; pp.865-868.
•   Kumar S., Vitamin B12 Deficiency Presenting with an
       Acute Reversible Extrapyramidal Syndrome,
       Neurol India 2004; 52:507-509

                      Approved 31 May 06,
                       Implemented SU06
         Resources Cited
• Ye, W. and Nyren, O.; Risk of cancers of the
  oesophagus and stomach by histiology or
  subsite in patients hospitalized for pernicious
  anemia; Gut 2003;52:938-941
• Kumar S. Recurrent seizures: An unusual
  manifestation of vitamin B12 deficiency. Neurol
  India 2004;52:122-123


                   Approved 31 May 06,
                    Implemented SU06
                          CLINICAL APPLICATIONS
                          Faculty Case Study Preparation


CONDITION: Plantar Fascitis

Prepared by: Tim Guest DC

RELEVANT PATHOPHYSIOLOGY:

Strain or tear of the plantar fascia, sometimes involves micro tears at the calcaneal
insertion, inflammation of the Plantar Aponuerosis, Flexor Digitorum Brevis, other
contributors are metetarsalgia, calcaneal bursitis and Achilles tendonitis

CASE HISTORY:

PPW: Pain in the heel or arch when standing after short periods of rest, first few
       steps in a.m. but relieved as walking continues.
Onset-Initial Associated with over use such as running or prolonged standing on
       concrete floors
Palliative/Provocative: Rest/ Standing
Quality/Quantity: Sharp, intense pain, daily
Referred/Radiating:          None
Site: Arch of the foot (calcaneal to metatarsal phalangeal)
Timing/Pattern: Pain when standing after rest.
Other

Relevant History and Lifestyle

Gender       N/A
Age          N/A
Occupation None (tends to favor athletes)
Traumas      N/A
Surgeries N/A
Medications N/A
Hospitalizations N/A
Immunizations      N/A
Diseases or Conditions_N/A
Family History     N/A
Diet         N/A
Sleep Habits       N/A
Sexual History     N/A
Alcohol Usage      N/A
Drug Usage         N/A
Smoking/Tobacco N/A
Other

Tim Guest, D.C.                       Page 1                             8/19/2010
Approved 07/28/04
REVIEW OF SYSTEMS         N/A


PHYSICAL EXAMINATION:

Height N/A                            Weight           N/A

Vitals: BP            Pulse                        Respiration________ Temp.

Appearance, Motion, Gait During symptoms gait will be heel strike with limited or no
heel to toe motion.
Orthopedic Tests

      Test Name               R            L              Test Name            R           L
                           +      -    +       -                               +   -   +       -
                           +      -    +       -                               +   -   +       -
                           +      -    +       -                               +   -   +       -
                           +      -    +       -                               +   -   +       -
                           +      -    +       -                               +   -   +       -

Orthopedic Test Results Discussion: N/A


Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception: N/A

LabValues:______Arthritis panel to rule out RA, gout, AS, Reiters.___________

Examination of Related Areas: Increased pain with great toe extension,
     dorsiflexion of foot, initial weight bearing,

Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.): Palpatory pain under medial tubercle of calcaneus”trigger
      points” in flexor digitorum brevis tendon,

SPINAL EXAMINATION:

      Postural Analysis                              Postural Analysis   L         N       R
                                                     Head Tilt
      May observe pronation or                       Head Rotation
      supination of foot when                        High Ear
       standing, tendency to                         High Shoulder
      raise heel when standing                       High Ilium
      for duration.                                  Ext. Rotated Foot
                                                     Int. Rotated Foot

Tim Guest, D.C.                         Page 2                                 8/19/2010
Approved 07/28/04
ROM
             Cervical ROM                                 Lumbar ROM
               ROM      Pain     Level                     ROM     Pain          Level
Flexion        N  Y N                   Flexion          N     Y N
Extension      N  Y N                   Extension        N     Y N
R. Rotation    N  Y N                   R. Rotation      N     Y N
L. Rotation    N  Y N                   L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                   R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                   L. Lat. Flex.    N     Y N


Leg Length/Spinal Balance          N/A
Instrumentation/Pattern Analysis         N/A
Palpation (Muscle, Static, Motion)              N/A


List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion



RADIOLOGICAL EXAMINATION:

      X    X-rays   X   MRI        CT           Other

Views Medial to Lateral view of foot to identify osseous spur, MRI to identify
cartilaginous spur. Both media can be used to rule out other bone pathology.

Findings

DIFFERENTIALS:

Heel Spur
Achille’s Tendonitis
Diabetic Peripheral Neuropathy


Case Management:

Chiropractic Management: Adjustment of superior and / or medial calcaneus,
cuneiform (s), Navicular and first MTP


Tim Guest, D.C.                      Page 3                             8/19/2010
Approved 07/28/04
Adjunctive Therapy: “tear drop” taping procedure to approximate calcaneus to
arch of foot and “support” Pantar Fascia , Underwater ultrasound

PhysicalTherapy:____Manual massage of gastrocnemius and soleous muscles,
trigger point therapy of plantar fascia, ice massage of plantar fascia_______

Nutrition:   N/A


Exercise:    Stretching of the gastrocnemius and soleus, rolling a golf ball heel to
toe,

Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education):    Avoiding prolonged plantar flexion of feet, loose bed
sheets, ___________________________________________________________


Common Medical Management: Steroid injections, orthotics

References:
___________________________________________________________________
___________________________________________________________________
Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.

Condition Name        Baseline      Complicating/ Mitigating Factors       Revised
                      Complexity                                           Complexity
                                    Altered gait                              3.0
                                    Surgery                                   3.0
  Plantar Fascitis        1.0




Tim Guest, D.C.                      Page 4                             8/19/2010
Approved 07/28/04
                          CLINICAL APPLICATIONS
                         Student Case Study Preparation


CONDITION          Rotator Cuff Syndrome (Impingement Syndrome)

Prepared by: Tim Guest DC

RELEVANT PATHOPHYSIOLOGY:

Trauma or activity induced injury to the supraspinatus, infraspinatus, teres minor and
/or subscapularis muscles or tendons.

CASE HISTORY:

PPW: Immediate pain at injury, pain may subside with activity only to return later. A
popping or tearing sensation at moment of injury. Shoulder pain that is increased
with active shoulder movement. May also be insidious with age.      Complaint of
pain when sleeping on shoulder.

Relevant History and Lifestyle

Gender-None specific
Age- None specific
Occupation- None specific but favors athletes and persons who work
       overhead.
Traumas- Repetitive motion overhead, fall on outstretched arm, or sudden
       lifting of a heavy weight.
Surgeries- None specific
Medications- None specific
Hospitalizations- None specific
Immunizations- None specific
Diseases or Conditions-Often preceded by chronic tendonitis, occurs as an insidious
       onset with age.
Family History None specific
Diet- None specific
Sleep Habits- Painful shoulder when sleeping, restless.
Sexual History- None specific
Alcohol Usage- None specific
Drug Usage-None specific
Smoking/Tobacco - None specific
Other - None specific




Tim Guest, D.C.                      Page 1                             8/19/2010
Approved 11/24/04
Review of Systems                                                        _____

     ______________________________________________________
___________________________________________________________


PHYSICAL EXAMINATION:

Height                                Weight

Vitals: BP            Pulse                        Respiration________ Temp.

Appearance, Motion, Gait

Orthopedic Tests

     Test Name                R            L                Test Name          R           L
Codmans Drop Arm           +      -    +       -    Lift Off                   +   -   +       -
Empty Can                  +      -    +       -    Painful Arc                +   -   +       -
Apprehension               +      -    +       -                               +   -   +       -
Dugas                      +      -    +       -                               +   -   +       -
Yergason’s                 +      -    +       -                               +   -   +       -

Orthopedic Test Results Discussion: Empty can is indicative of supraspinatus
weakness, Lift off is indicative of subscapularis weakness, Drop arm indicative of
supraspinatus instability (tear).

Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception

None Specific

LabValues

None Specific

Examination of Related Areas

None Specific

Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.) Palpation reveals tenderness proximal humerus, Deltoid,
Supraspinatus and Infraspinatus may indicate atrophy.




Tim Guest, D.C.                         Page 2                                 8/19/2010
Approved 11/24/04
SPINAL EXAMINATION:

        Postural Analysis                       Postural Analysis      L      N        R
                                                Head Tilt
                                                Head Rotation
                                                High Ear
                                                High Shoulder
                                                High Ilium
                                                Ext. Rotated Foot
                                                Int. Rotated Foot


ROM
             Cervical ROM                                   Lumbar ROM
               ROM      Pain     Level                       ROM     Pain         Level
Flexion        N      Y N                 Flexion          N     Y N
Extension      N  Y N                     Extension        N     Y N
R. Rotation    N  Y N                     R. Rotation      N     Y N
L. Rotation    N  Y N                     L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                     R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                     L. Lat. Flex.    N     Y N


Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion)



List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion



RADIOLOGICAL EXAMINATION:

        X X-rays     X MRI           X CT          Other Arthrogram

Views

Findings


Tim Guest, D.C.                        Page 3                              8/19/2010
Approved 11/24/04
DIFFERENTIALS:

A/C seperation, DJD, Cervical Arthrosis, Cervico-brachial Syndrome, Myofascial
pain, Radiculopathy, Osteophytosis.


DIAGNOSIS:

Grade I Inflammation of the bursa and tendons
Grade II Thickening and scarring of the bursa
Grade III Rotator Cuff degeneration and tears are evident


Case Management:


Chiropractic Management

None Specific

Adjunctive Therapy:

None Specific

Physical Therapy:

Resisted abduction/adduction, wall walking.

Nutrition:

Proteolytic enzymes, Bioflavinoids, Vitamin C, Zinc, Vitamin E.

Exercise:

Shoulder shrug, Internal/external rotation, seated rows, forward punch, press-ups
(chair)


Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education):

Advise to change occupations, avoid overhead activities


Further Evaluation:



Tim Guest, D.C.                      Page 4                            8/19/2010
Approved 11/24/04
Common Medical Management:

Steroid injections, NSAIDS, Surgical repair.

References: _______

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity. ()

Condition Name        Baseline      Complicating/ Mitigating Factors    Revised
                      Complexity                                        Complexity
                                    Alter Shoulder Physics Affecting       2.0
                                    Cervical Spine
    Rotator Cuff            1
     Syndrome




Tim Guest, D.C.                      Page 5                            8/19/2010
Approved 11/24/04
                          CLINICAL APPLICATIONS
                        Faculty Case Study Preparation

CONDITION: Schizophrenia

Prepared by: McRae, Kenneth L. (July 25, 2005)

RELEVANT PATHOPHYSIOLOGY:
Schizophrenia is a multifaceted disorder characterized by profound disruption in
cognition and emotion that affect most fundamental human attributes. Currently
there are no physical or lab tests that are used to diagnose schizophrenia. A
referral to a psychiatrist for a complete mental evaluation and review clinical
symptoms helps determine a schizophrenic patient. People diagnosed with
schizophrenia have a combination of positive, negative, and cognitive symptoms.
Positive symptoms include hallucinations, delusions and racing thoughts.
Negative symptoms include apathy, lack of emotion, poor or nonexistent social
functioning. Cognitive symptoms include disorganized thoughts, difficulty
concentrating and/or remembering, difficulty following instructions, and difficulty
completing tasks. A complete diagnosis must include one month of symptoms
(positive, negative, or cognitive) persisting for six-months.

CASE HISTORY:

Patient Presents With: Upon further evaluation the patient appeared confused,
disoriented, and had a hard time remembering information regarding their family
history and initial complaint. The patient has a history of depression.

Onset-Initial: Birth for children with fathers over the age of 50. Malnutrition or
exposure
               to a viral infection during pregnancy. High blood pressure with
               diuretics during the third trimester of pregnancy. Genetic link
               increases the chance of schizophrenia 10 times.
Palliative: Prescribed medications such as Ziprasidone, Olanzapine,
Aripiprazole,
               Clozaril, Geodon, Risperdal, Seroquel, Zyprexa, Stelazine,
               Flupenthixol, Loxapine, Perphenazine, Chlorpromazine, Haldol, and
               Prolixin
Provocative: Stress, depression
Quality: Does not apply
Quantity: Does not apply
Referred: Does not apply
Radiating: Does not apply
Site: The brain- superior temporal gyrus (auditory processing) and planum
temporale
        (language processing).




                                         1
Timing: Schizophrenia is a psychological disorder. Attacks are unpredictable and
may
       vary in timing and quality depending on the stimulus. Continuous signs of
       the disturbance persist for about six months. The six-month period must
       include at least one month of symptoms that are positive, negative, or
       cognitive.
Other: Attacks occurs during high stress periods/ depression usually follows/ the
patient
       feels overwhelmed and like they can never get everything needed
accomplished.

Relevant History and Lifestyle:
Gender: Female
Age: 22.

Occupation: Student
Traumas: Does not apply
Surgeries: Does not apply
Medications: Prescribed medications such as Ziprasidone, Olanzapine,
Aripiprazole,
               Clozaril, Geodon, Risperdal, Seroquel, Zyprexa, Stelazine,
               Flupenthixol, Loxapine, Perphenazine, Chlorpromazine, Haldol, and
               Prolixin
Hospitalizations: Does not apply
Immunizations: Does not apply
Diseases or Conditions: Depression
Family History: Birth for children with fathers over the age of 50. Malnutrition or
       exposure to a viral infection during pregnancy. High blood pressure with
       diuretics during the third trimester of pregnancy. Genetic link increases
       the chance of schizophrenia 10 times.
Diet: Small appetite/ 1 meal per day sometimes forced
Sleep Habits: 2-3 continuous hours during a 10-hour sleep period, feelings of
       restlessness
Sexual History: Does not apply
Alcohol Usage: Does not apply
Drug Usage: Does not apply
Smoking/Tobacco: Does not apply
Other: Does not apply




                                        2
Review of Symptoms: (EENT, Respiratory, Cardiovascular,
Musculoskeletal, Gastrointestinal, Reproductive)

PHYSICAL EXAMINATION:

Height: 5’5         Weight: 100 lbs.

Vitals: BP- 110/70 Pulse- 88 bpm               Respiration- 20 bpm
       Temp.- 98.00F

Appearance, Motion, Gait:

Orthopedic Tests:
Test Name
Does not apply
Orthopedic Tests Results Discussion:
Does not apply

Neurological Tests: (Cranial Nerves/PNS/Equilibrium/motor/DTRs/Pathological
Reflexes/Light touch/proprioception)

Does Not Apply

Lab Values:

Does Not Apply

Other Findings: (Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)

Increased heart rate upon auscultation, Increased pulse rate upon palpation




                                       3
SPINAL EXAMINATION:
Postural Analysis Discussion:

Postural Analysis:    L      N       R
Head Tilt                            X
Head Rotation                        X
High Ear                             X
High Shoulder                            X
High Ilium            X
Ext. Rot. Foot                       X
Int. Rot. Foot        X

ROM
Cervical:       ROM   Pain   Level       Lumbar:      ROM    Pain   Level
Flexion         N     N      N                        N      N      N
Extension       N     N      N                        N      N      N
R. Rotation     N     N      N                        N      N      N
L. Rotation     N     N      N                        N      N      N
R. Lat. Flex.   N     N      N                        N      N      N
L. Lat Flex.    N     N      N                        N      N      N

Pattern Analysis: Leg Length/Spinal Balance/Instrumentation/Palpation
(Muscle, Static, Motion)

List the level for palpatory findings. Notate abnormal findings and motion
restrictions.
Level Muscle
Does not apply




                                         4
RADIOLOGICAL EXAMINATION:
         Views                           Findings
X-rays:        Does not apply

MRI          Brain                       21% unilateral (left-sided) gray matter
                                         volume difference in Hershel’s gyrus,
                                         with no volume differences in the
                                         planum temporale in either hemisphere
CT           None                        None
Other        None                        None

DIFFERENTIALS:

Schizophrenia is divided into five subtypes. In making a through diagnosis it is
                             important to evaluate the symptoms that the patient
                             presents with.
   1. Paranoid subtype- The distinguishing characteristics of this subtype are
      the presence of auditory hallucinations and prominent delusional thoughts.
      Patients falling under this subtype are believed to be more functional in
      their ability to work and engage in relationships with others.
   2. Disorganized subtype- The distinguishing characteristic of this subtype is
      disorganization of the thought process. The hallucinations and delusional
      thoughts present in the paranoid subtype are less pronounced, although
      there may be some evidence of these symptoms.
   3. Catatonic subtype- The predominant clinical feature in this subtype are
      disturbances in movement. Patients in this subtype exhibit a dramatic
      reduction in activity, to the point that voluntary movement stops (catatonic
      stupor). Activity can also dramatically increase, a state known as
      catatonic excitement.
   4. Undifferentiated subtype- This subtype includes patients whose symptoms
      don’t fit any particular category. The symptoms of patients in this subtype
      can fluctuate at different points in time, resulting in uncertainty as to the
      correct subtype classification.
   5. Residual subtype- Patients included in this subtype no longer display
      prominent symptoms. Hallucinations, delusions or idiosyncratic behaviors
      may still be present, but generally have lessened in severity.




                                         5
CASE MANAGEMENT:

Chiropractic Management: Treat subluxations refer out to a psychiatrist for
                       complete mental evaluation.
Common Medical Management: Treat schizophrenia with drugs Stelazine,
                       Flupenthixol, Loxapine, Perphenazine,
                       Chlorpromazine, Hadol, Prolixin and
                       psychotherapeutic activities such as stress
                       management and control, anger management and
                       control, support groups
Adjunctive Therapy: Psychiatrist
Physical Therapy: None
Nutrition: None

Exercise: None

Health Promotion and Maintenance (i.e. ergonomics, spinal hygiene,
psychosocial concerns, education):
Does not apply

Further Evaluation:
Refer to psychiatrist for further evaluation for potential schizophrenia/ co-manage
                              case and re-evaluate at an agreed time.

REFERENCES:

   1. The American Journal of Psychiatry 162:1535-1538, August 2005 c 2005
      American Psychiatric Association
   2. The American Journal of Psychiatry 159:1467-1469, September 2002 c
      2002 American Psychiatric Association
   3. http://www.schizophrenia.com/diag.html
   4. http://www.schizophrenia.com/newsletter/buckets/meds.html
   5. http://my.webmd.com/hw/schizophrenia/aa46916.asp?z=1835_00000_000
      0_rl_02


CASE COMPLEXITY:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.



                                         6
Condition Name   Baseline     Complicating/Mitigating Factors Revised
                 Complexity                                   Complexity
Schizophrenia           6           Schizophrenia related/depression 8




                                    7
                             CLINICAL APPLICATIONS
                             Faculty Case Study Preparation


CONDITION___Bell’s Palsy____________________________________________

Prepared by: __Fordree___________________________________________

RELEVANT PATHOPHYSIOLOGY:

Bells’ Palsy is a condition that causes the facial muscles to weaken or become
paralyzed as a result of trauma to the 7th cranial nerve and is not permanent. The more
common cause is believed to be a result of viral infection (herpes zoster lays dormant in
the facial nerve, mumps and rubella also) that may cause an inflammatory reaction in
the facial nerve near the stylomastoid foramen on the in the facial nerve path through
the temporal bone. The nerve increases in diameter becoming compressed as it passes
through the temporal bone. Other causes include stroke, cerebral tumor (mainly
involves lower face) mastoid infection, fracture, tumors (associated hearing loss),
Diabetes Mellitus and pregnancy. Diabetics are 4x’s more likely to develop BP and the
last trimester of pregnancy is 3x’s the increased risk for BP. Conditions that compromise
the immune system such as HIV or sarcoidosis increase the odds. It is possible to have
bilateral Bell’s Palsy but it is rare, less than 1%.

Recovery – normally start to improve within 3 weeks with 50 % complete recovery in a
short time (a few weeks and several months) with 35% recovering with in a year,
10% have re-occurrences with average time span being 10 years and women have
another attack when they get pregnant. Usually the second attack affects the other side
of the face.


CASE HISTORY:

PPW: Patient complains of facial weakness and distortion and is unable to close one
eye, along with a sagging eyebrow. May have associated ear pain. Other S&S include
numbness on the affected side of face, dry mouth, recent upper respiratory infection or
viral infection, drooling /dribbling after drinking or after brushing teeth, altered taste and
hearing and tearing eyes. Usually states, “Just got up with it”.

Onset-Initial Most people either wake up with BP or have symptoms such as a dry eye
or tingling around their lips that progress to BP during the same day. Occasionally
symptoms take several days to become recognizable as BP. The degree of paralysis
should peak within several days of onset – never longer than 2 weeks.
                                      _____


       Palliative/Provocative

Janice Fordree, D.C.                    Page 1                               8/20/2010
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         Quality/Quantity
         Referred/Radiating
         Site Face
         Timing/Pattern _______________________________________________
         Other


Relevant History and Lifestyle
      Gender        Equal occurrence between males and females.
      Age           any age, primarily middle age (30-40) and older
      Occupation
      Traumas
      Surgeries
      Medications
      Hospitalizations
      Immunizations
      Diseases or Conditions__Diabetics, _pregnancy, infections, compromised
      immune system_______________________________ _
      Family History
      Diet
      Sleep Habits
      Sexual History
      Alcohol Usage
      Drug Usage
      Smoking/Tobacco
      Other__________________________________________________


Review of Systems                                              _____

     ______________________________________________________
___________________________________________________________



PHYSICAL EXAMINATION:

Height                         Weight

Vitals: BP             Pulse            Respiration________ Temp.




Appearance, Motion, Gait

Janice Fordree, D.C.               Page 2                           8/20/2010
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      Expressionless face on involved side
      Patient can’t whistle, wink or close eye
      Possible loss of taste on anterior 2/3 of tongue
      Possible hyperacusis (stapedous muscle paralysis) – sensitivity to noises


Orthopedic Tests - WNL

       Test Name             R            L        Test Name              R           L
                            +     -   +       -                         +     -   +       -
                            +     -   +       -                         +     -   +       -
                            +     -   +       -                         +     -   +       -
                            +     -   +       -                         +     -   +       -
                            +     -   +       -                         +     -   +       -

Orthopedic Test Results Discussion:




Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception
___________________________________________________________________
Cranial Nerve VII (Facial Nerve) – has 2 parts:

      Motor: all voluntary and involuntary movements of the face – does not include
       jaw movements but does include elevation of the eyebrows, wrinkles the
       forehead, smile frown, grimace and puff out cheeks.

      Sensory: Taste for the anterior 2/3 of tongue

      Note: CN VII also innervates lacrimal glands, submandibular and submaxillary
       glands that are not routinely tested, but be aware of absence of saliva and tears.

All other CNs should be intact.

LabValues_____________________________________________________________
______________________________________________________________


Examination of Related Areas



Janice Fordree, D.C.                  Page 3                            8/20/2010
Approved 11/03/04
Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)



SPINAL EXAMINATION:

         Postural Analysis                       Postural Analysis      L     N      R
                                                 Head Tilt
                                                 Head Rotation
                                                 High Ear
                                                 High Shoulder
                                                 High Ilium
                                                 Ext. Rotated Foot
                                                 Int. Rotated Foot


ROM
             Cervical ROM                                 Lumbar ROM
               ROM      Pain     Level                     ROM     Pain        Level
Flexion        N  Y N                   Flexion          N     Y N
Extension      N  Y N                   Extension        N     Y N
R. Rotation    N  Y N                   R. Rotation      N     Y N
L. Rotation    N  Y N                   L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                   R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                   L. Lat. Flex.    N     Y N

Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion)

List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.

 Level     Muscle Motion       Level    Muscle Motion      Level     Muscle Motion




Janice Fordree, D.C.                   Page 4                          8/20/2010
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RADIOLOGICAL EXAMINATION:

        X-rays        MRI         CT          Other

Views         EMG – electromyography – measures the electrical activity of facial
muscles. If symptoms haven’t improved within 3 weeks patient may need x-ray or
referred for MRI.

Findings



DIFFERENTIALS:

      Ramsay Hunt Syndrome                            Myasthenia Gravis
      Stroke                                          Botox injections

DIAGNOSIS:

             Bell’s Palsy


Case Management:

Chiropractic Management:              There is debate over whether BP should be
treated initially. General belief is that because 50-60% of patients recover without
treatment, should monitor for 2-3 days. If the case appears to be on the more sever
side, then refer for limited steroid treatment.


Adjunctive Therapy:         Eye patch and eye drops until eye can be closed, taped shut
for sleeping,

PhysicalTherapy: __Consider modalities to prevent contracture of facial musculature
in long-term cases. Apply gentle heat to reduce pain, using a microwavable pad for
example. _______________________________

Nutrition:


Exercise:             Massage the face using a moisturizer, exercise the facial muscles.


Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education):
      ___________________________________________________________

Janice Fordree, D.C.                  Page 5                            8/20/2010
Approved 11/03/04
Further Evaluation:


Common Medical Management: ____Course of steroids within 24 hours or so of onset.
Acyclovir, an antiviral medication, may be prescribed.

Small number of people who have long term paralysis, there are several treatment
options:
    A form of physical therapy known as “facial retraining”
    A surgical technique called “tarsorrhaphy”, which narrows the space between
       the eyelids – this may improve eye closure
    Further use of steroid meds
    Hormone ACTH, which stimulates steroid production
    Surgery to relieve pressure on the facial nerve – rarely recommended
    Plastic surgery to improve permanent facial drooping

References:
The Bell’s Palsy Information Site
Vizniak and Carnes, Quick Reference Clinical Chiropractic Conditions Manual
Souza, Differential Diagnosis and Management for the Chiropractor

Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early stage
of condition, advanced stage of condition, psychosocial issues, etc. The complicating or
mitigating factors can either increase or decrease the baseline complexity.


Condition Name   Baseline   Complicating/ Mitigating Factors                 Revised
                 Complexity                                                  Complexity
  Bell’s Palsy      4.0     Risk factor include diabetes, pregnancy,             7.0
                            infections, compromised immune system
                            Risk factor of absence of saliva and tears.          5.0
                            Chiropractic management - eye patch and              5.0
                            eye drops until eye can close and tape shut
                            at night.
                            Medications- course of steroids or Acyclovir         5.0
                            Risk factor of drooling/dribbling after drinking     7.0
                            or brushing teeth, altered taste and hearing,
                            tearing eyes.
                            Risk factor of loss of taste on anterior 2/3 of      7.0
                            tongue.
                            Risk actor of hyperacusis resulting in               7.0
                            extreme sensitivity to noise.



Janice Fordree, D.C.                 Page 6                              8/20/2010
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                           CLINICAL APPLICATIONS
                          Faculty Case Study Preparation


CONDITION:         Migraine Headaches

Prepared by     Maria Michelin, DC

RELEVANT PATHOPHYSIOLOGY:

The most prevalent theory is that migraine headaches are caused by vasodilatation
of arteries in the brain. What triggers each migraine is up for discussion. The list is
almost endless..


CASE HISTORY:

PPW: Bilateral or unilateral head pain.

Onset-Initial May follow aura(20%), or may not.                            _____
      Palliative/Provocative      dark rooms, lying down/ strong odors, bright lights
      Quality/Quantity     pulsating, moderate to severe
      Referred/Radiating Possible nausea and vomiting, visual changes such as
      photophobia and scotoma, speech disturbances and sensory problems such
      as paresthesia and numbness, may demonstrate muscle weakness
      Site
      Timing/Pattern       4 to 72 hours each , 1 to 2 episodes a month typical
      Other

Relevant History and Lifestyle
      Gender        female most likely
      Age           10-30 most common
      Occupation           stress in general-a trigger-__
      Traumas
      Surgeries
      Medications
      Hospitalizations
      Immunizations
      Diseases or Conditions__________________________________ _
      Family History       tends to run in families
      Diet triggers-hunger, red wines, aged cheese, chocolate, nuts, alcohol
      Sleep Habits sleep disturbances and fatigue are triggers
      Sexual History       triggers-pregnancy and menstruation
      Alcohol Usage        a trigger
      Drug Usage
      Smoking/Tobacco             a trigger

Maria Michelin, D.C.                  Page 1                              8/20/2010
Approved 04/08/04
         Other___triggers-bright lights______________________________

Review of Systems                                                         _____

     ______________________________________________________
___________________________________________________________



PHYSICAL EXAMINATION:

Height                                 Weight

Vitals: BP             Pulse                        Respiration________ Temp.

Appearance, Motion, Gait

Orthopedic Tests

      Test Name                R            L              Test Name             R           L
                           +       -    +       -                               +    -   +       -
                           +       -    +       -                               +    -   +       -
                           +       -    +       -                               +    -   +       -
                           +       -    +       -                               +    -   +       -
                           +       -    +       -                               +    -   +       -

Orthopedic Test Results Discussion:
      Negative examination-there is not any specific findings for migraines


Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception
___________________________________________________________________
__Negative except during actual headache when findings vary with the symptoms
___________________________________________________________________
__________________________________________________________________

LabValues__________________________________________________________
_____ ____________________________________________________________


Examination of Related Areas
     Frequent spasm of the sub-occipital muscles

Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,

Maria Michelin, D.C.                     Page 2                                 8/20/2010
Approved 04/08/04
Auscultation, etc.)



SPINAL EXAMINATION:

       Postural Analysis                      Postural Analysis   L      N        R
                                              Head Tilt
                                              Head Rotation
                                              High Ear
                                              High Shoulder
                                              High Ilium
                                              Ext. Rotated Foot
                                              Int. Rotated Foot


ROM
             Cervical ROM                                Lumbar ROM
               ROM      Pain     Level                    ROM     Pain       Level
Flexion        N  Y N                  Flexion          N     Y N
Extension      N  Y N                  Extension        N     Y N
R. Rotation    N  Y N                  R. Rotation      N     Y N
L. Rotation    N  Y N                  L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                  R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                  L. Lat. Flex.    N     Y N

Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion)


List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




Maria Michelin, D.C.                 Page 3                           8/20/2010
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           RADIOLOGICAL EXAMINATION:

                    X-rays         MRI            CT             Other

           Views           All within normal limits

           Findings




           DIFFERENTIALS:

                   1. Cluster headaches
                   2. Cervicogenic headaches
                   3. Tension headaches
                   4. Hypertensive headaches
                   5. Stroke
                   6. Sinus headache
                   7. Glaucoma
                   8. Brain tumor
                   9. Meningitis
                   10. Temporal Arteritis
                   11. Aneurysm or hemorrhage


Rule Out                                         Rationale to differentiate from Migraine Headache
                                                 Warning signs that you should consider referring for a thorough
                                                 neurological evaluation:
                                                               -fainting
                                                               -abrupt onset of headache for first time
                                                               -neurologic abnormalities associated with
                                                                         headache (motor, sensory, reflex)
                                                               -increase body temperature
Serious possibly life threatening conditions
                                                               -onset over age of 50
such as neoplasm, infection, ocular disorders,
                                                               -headache with increase pressure (cough,
vascular
                                                                          valsalva, coitus)
                                                               -recent blood pressure elevation
                                                               -personality change with headache
                                                               -headache following head trauma
                                                               -disturbance in pulse rate/respiration
                                                               -constant sensory disturbance
                                                               -visual field defects
                                                        Differentiate by:
                                                               -usually bilateral, pressing, tight
                                                               -not throbbing, not aggravated by routine
Chronic and/or episodic Tension Headache
                                                                           physical activity
                                                               -mild to moderate, can perform activity
                                                               -no nausea, no vomit

           Maria Michelin, D.C.                       Page 4                                   8/20/2010
           Approved 04/08/04
                                                    -may have photophobia or phonophobia,
                                                                 but not both
                                                    -not associated with menstrual cycle
                                                    -usually stress, emotional, depression can
                                                                 precipitate
                                                    -no prodrome or aura
                                              Differentiate by:
                                                     -orbital, supraorbital, temporal
                                                     -stabbing, steady
                                                     -severe
                                                     -lacrimation, congestion, runny nose, ptosis,
                                                                   eyelid edema, face sweating
Cluster Headache (episodic or chronic)
                                                     -15 minutes to 3 hours
                                                     -frequency variable
                                                     -not associate with menstrual cycle
                                                     -alcohol, smoking, histamine, nitroglycerine
                                                                   precipitate
                                                     -males more 6:1
                                              Differentiate by:
                                                     -location variable
                                                      -mimic or combine features of tension
Post-traumatic Headache
                                                                    and migraine
                                                      -duration variable
                                                      -occurs less than 14 days after injury
                                              Differentiate by:
                                                      -neck/occipital region, may extend to
                                                                     forehead, temples, vertex,
                                                                     ears, orbits
                                                      -associated symptoms:
                                                          *resistance to passive neck motion and/or
                                                          *change in neck muscle tone, texture,
Cervicogenic (Headache with Neck symptoms)                           contract/relax and/or
                                                          *tenderness of neck muscles and/or
                                                          *x-ray evidence of movement
                                                                     abnormality, posture, fracture,
                                                                     RA, or other pathology
                                                       -precipitated by and aggravated by neck
                                                                    movements and/or sustained
                                                                    posture
                                               Differentiate by:
                                                       -between/behind eyes, frontal, teeth,
Sinus Headache
                                                                    may radiate to vertex
                                                       -purulent discharge, possible fever
                                               Differentiate by:
                                                       -location, in or radiating from TMJ
                                                       -mild to moderate
                                                       -at least two of the following:
TMJ Headache
                                                            *jaw pain with movement/clenching
                                                            *decreased range of motion
                                                            *noise with movement
                                                            *tenderness of capsule
                                                Differentiate by:
Post lumbar puncture Headache                         -worse with upright position
                                                      -disappears within 14 days of puncture



          Maria Michelin, D.C.               Page 5                                   8/20/2010
          Approved 04/08/04
DIAGNOSIS:

Eliminate the others. History is the primary method of diagnosis.

Case Management:
Chiropractic Management:
      Adjust the cervical and upper thoracic spine.


Adjunctive Therapy:
      Trigger point therapy or deep massage in sub-occipital region. Biofeedback
and acupuncture.

PhysicalTherapy:__________________________________________________
_____Ice packs over the sub-occipital region to induce vasoconstriction_
________________________________________________________________
Nutrition:    Avoid triggers. Cheese, wine , coffee, tea, colas, sugar, aspartame,
nitrites, MSG, and smoked meats



Exercise:
      Aerobic exercise reduces frequency of migraines


Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education):
      ___________________________________________________________
________________________________________________________________

Further Evaluation:


Common Medical Management: ______________________________________
Abortive-sumatriptan and ergotamine derivatives. Prophylactic- antidepressants and
antihypetensives.

References:
Vizniak and Carnes, Quick Reference Clinical Chiropractic Conditions Manual
Huff and Brady, Instant Access to Chiropractic Guidelines and Protocols
Souza, Differential Diagnosis and Management for the Chiropractor
Merck Manual, 17th edition

Case Complexity:




Maria Michelin, D.C.                 Page 6                            8/20/2010
Approved 04/08/04
The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.




Condition Name         Baseline     Complicating/ Mitigating Factors      Revised
                       Complexity                                         Complexity
   Migraine HAs           4.0       Pregnancy as cause-modify                7.0
                                    adjustments and lack of ability to
                                    X-ray
                                    Vomiting-messy can vomit after            5.0
                                    the adjustment
                                    Vertigo-symptom do not rotate C-          5.0
                                    spine or you can make it worse
                                    Visual disturbances-must modify           5.0
                                    light on patients face



Maria Michelin, D.C.                 Page 7                              8/20/2010
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                             CLINICAL APPLICATIONS
                           Faculty Case Study Preparation


CONDITION________Cervical Disc Herniation________________________

Prepared by: _Janice H. Fordree, D.C._______________________________

RELEVANT PATHOPHYSIOLOGY:

CDH is a result of rupture of the annulus fibrosis, which may allow the nucleus to
impinge on a cervical nerve root or thecal sac, causing pain and paresthesia. Is
usually unilateral but may be central herniation that compresses the spinal cord
which is more serious. Most common is poster lateral. May be a result of progressive
degenerative process or a trauma or whiplash may cause a sudden herniation.
Frequently found in individuals who lift heavy objects, cigarette smokers and in
deep-sea divers. Common to find in individuals who operate equipment that
continually vibrates or ride in cars for prolonged periods.

Most common @ C5/C6, followed by C6/C7, C4/C5 and C7/T1.

Complications include:
1) poster lateral herniation creates posterior ligament changes with impinging on
   the spinal cord or nerve root.
2) midline posterior hernation = acute surgery emergency that can cause
   paraplegia or inhibit breathing.
3) Cervical cord compression may lead to spastic paraparesis of the lower limbs.

The symptoms of a cervical disc herniation are always on the same side as the disc
herniation. In other words a right sided disc herniation between the fifth and sixth
cervical vertebrae will always cause pressure on the right sixth cervical nerve root.


CASE HISTORY:

PPW: Neck pain (usually lower) and shoulder pain with pain radiating down the arm
in the distribution of the involved nerve root. Can range from asymptomatic to mid
neck stiffness to severe pain. Radicular pain may be accompanied by pain into the
upper anterior/posterior chest and paresthesia in the form of numbness or tingling.
Onset-Initial Often gradual but can be acute especially with trauma         _____
       Palliative__Sleeping in upright position and walking
        Provocative Increased pain with coughing, sneezing, straining, neck flexion
       Quality/Quantity       Sudden/severe
       Referred/Radiating May radiate to extremities or chest, may follow C6, C7, C8
dermatome pattern.
       Site Cervicals


Janice Fordree, D.C.                 Page 1                             8/20/2010
Approved 06/03/04
        Timing/Pattern Exacerbations are common, severe pain at night that
interferes with sleep
        Other


Relevant History and Lifestyle
      Gender        Females more than males due to hormones/stress
      Age 20-40 Incidence decreases with age
      Occupation Movers, Divers, construction workers, etc.
      Traumas
      Surgeries
      Medications
      Hospitalizations
      Immunizations
      Diseases or Conditions__________________________________ _
      Family History
      Diet
      Sleep Habits
      Sexual History
      Alcohol Usage
      Drug Usage
      Smoking/Tobacco cigarette smoking
      Other__________________________________________________


Review of Systems                                                 _____



PHYSICAL EXAMINATION:

Height                           Weight

Vitals: BP             Pulse              Respiration________ Temp.

Appearance, Motion, Gait

Orthopedic Tests

       Test Name            R       L            Test Name             R      L
Valsalva                   + -     + -     Shoulder Abduction         + -    + -
Cervical Compression       + -     + -                                + -    + -
Bakody’s                   + -     + -                                + -    + -
Distraction                + -     + -                                + -    + -
Swallowing Sign            + -     + -                                + -    + -
(possible)

Janice Fordree, D.C.                Page 2                            8/20/2010
Approved 06/03/04
Orthopedic Test Results Discussion: Distraction of head/neck decrease pain due to
nerve root pressure being decreased. Foraminal compression increases nerve root
pressure – test is (+) when pain radiates into extremities. Radicular pain is
decreased by abduction of the affected shoulder with S.A.T.

Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception:
   - Decreased DTRs of biceps, triceps and or brachioradialis
   - Weakness of affected muscles, forearms and hands associated with muscle
      atrophy


LabValues_N/A______________________________________________________
      ____________________________________________________________


Examination of Related Areas



Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)



SPINAL EXAMINATION:

      Postural Analysis                       Postural Analysis   L      N        R
                                              Head Tilt
      Head – antalgic posture with            Head Rotation
      neutral flexion and deviated            High Ear
       away from side of pain.                High Shoulder
                                              High Ilium
                                              Ext. Rotated Foot
                                              Int. Rotated Foot


ROM
             Cervical ROM                               Lumbar ROM
               ROM      Pain    Level                    ROM     Pain        Level
Flexion        N  Y N                 Flexion          N     Y N
Extension      N  Y N                 Extension        N     Y N
R. Rotation    N  Y N                 R. Rotation      N     Y N
L. Rotation    N  Y N                 L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                 R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                 L. Lat. Flex.    N     Y N

Janice Fordree, D.C.                 Page 3                           8/20/2010
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Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion) Palpable tenderness over neck muscles with local
pain over site of herniation.



List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

         X-rays    xxx MRI        CT          Other

Views

Findings     Loss of cervical lordosis
              Narrowed IV disc space
              Disc material compressing nerve root

DIFFERENTIALS:

Subluxation complex
Trauma/fracture
Spinal stenosis/tumor
Facet trophism
TOS
Neoplasm
Myofascial pain syndrome
IVF encroachment
Hypertrophy of ligamentum flava

Janice Fordree, D.C.                Page 4                            8/20/2010
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DIAGNOSIS:

Cervical disc herniation


Case Management:


Chiropractic Management: Low force and gentle adjusting of cervical and
thoracic subluxations – do not adjust with acute pain – let subside. Do not adjust
in positions that reproduce pain.

Manipulation is a contraindication in the acute phase of CDH with neurological
deficits because of high risk of spinal cord compression. When neurological
deficits have recovered – may then start adjusting.


Adjunctive Therapy: Trigger point therapy (Nimmo/receptor tonus).
Wear soft/hard cervical collar for 10-14 days. Bed rest – no longer than 3 days to
decrease inflammation - each additional day may produce weeks of additional
rehab.


Physical Therapy: Ice packs – 15-20 minutes / chronic stages use moist heat
followed by slow ROM exercises to increase ROM and decrease scalene muscle
spasms. Ultrasound and EMS. Cervical traction.

Nutrition:   Re-enforce healthy diet.
             Omega 3 fatty acids
             Anti-inflammatories




Exercise: Program of progressive exercises


Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene,
psychosocial concerns, education): Administration and utilization of an ” Outcome
assessment questionnaire with neck disability index. _
Suggestive use of cervical pillow. _______________________________
Correct lifting procedures.
Suggest for smokers to quit smoking.



Janice Fordree, D.C.                 Page 5                             8/20/2010
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Further Evaluation: Check motor, sensory and reflexes each visit. If after 2-3
weeks of conservative care with no improvement or conditions worsen, an MRI or
referral to neurosurgeon may be needed.


Common Medical Management: The treatment of cervical disc herniation can be
divided into two categories, conservative (non-surgical) and surgical. In some rare
cases of very large disc herniation causing significant pressure on the spinal cord,
surgery may be considered the conservative option.
In general, conservative management consists of maneuvers to reduce pressure on
the nerve root. Immobilization with the neck in a flexed forward position may be
helpful. Straining should be avoided. Medication in the form of an anti-inflammatory
such as aspirin, ibuprofen, naproxen, celebrex or vioxx may be taken. As these
medications have side effects, patients should carefully read the package material or
consult their doctor if taking any medications for longer than a few days. Physical
therapy may be prescribed. This can consist of traction, mild stretching, exercise,
heat, massage and ultrasound. These can be using in various combinations
depending on the patient. A course of home cervical traction may be helpful. In
some cases, a referral may be made to a pain management specialist or a
physiatrist. These are doctors with special training in the diagnosis and treatment of
pain. Various injections in and around the cervical spine can be performed. The
particular type of injection depends on the individual patient. Up to 95 percent of
patients will get better without the need for surgery.
Surgical treatment is reserved for patients who exhibit the signs and symptoms that
require urgent decompression, patients who can not or do not wish to spend the time
to allow conservative approaches to work and patients who have failed conservative
management after a reasonable amount of time (six to eight weeks). Surgery for
cervical disc herniation is divided into two approaches, anterior (from the front) and
posterior (from the back). Since the disc is located in front of the spinal cord, the
anterior approach is the more direct approach. The most common anterior operation
is the anterior discectomy and fusion (ACDF). The disc is removed and usually
replaced with a small piece of bone (either from the patient's hip or from cadaver
donor). Sometimes, metal plates and screws may be used to assist the fusion.
Depending on the type of surgery performed, a cervical collar may need to be worn
for anywhere from a week to twelve weeks. The posterior approach is much less
commonly performed. In this operation, a small amount of bone is removed from the
back of the spine over the affected nerve root. Gentle retraction may allow removal
of a soft disc. Few surgeons perform this operation.




Janice Fordree, D.C.                  Page 6                             8/20/2010
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References: __Huff & Brady: Instant Access to Chiropractic Guidelines and
Protocols ___

Gatterman: Chiropractic Management of Spine Related Disorders, 2nd edition



Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.




Condition Name         Baseline     Complicating/ Mitigating Factors             Revised
                       Complexity                                                Complexity
   Cervical Disc           5.0      Risk factor of individuals who lift heavy        6.0
    Herniation                      objects, cigarette smokers and heavy
                                    equipment operators.
                                    Risk factor for prolonged car riding             6.0
                                    prolonged walking and upright
                                    sleeping.
                                    Risk factor of decreased DTRs,                   7.0
                                    weakness and/or atrophy of involved
                                    muscles.
                                    Risk factor of decreased motor,                  7.0
                                    sensory and reflexes.
                                    Chiropractic management –                        9.0
                                    contraindications to adjustments in the
                                    acute phase of CDH with neurological
                                    deficits.
                                    Chiropractic management – modified               8.0
                                    adjusting along with use of specific
                                    techniques.
                                    Chiropractic management – no                     9.0
                                    improvement/condition worsens after
                                    2-3 weeks refer to neurologists.




Janice Fordree, D.C.                 Page 7                                     8/20/2010
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                             CLINICAL APPLICATIONS
                            Faculty Case Study Preparation


CONDITION______Lumbar Disc Herniation____________________________

Prepared by: _Janice H. Fordree, D.C.__________________________________

RELEVANT PATHOPHYSIOLOGY:

Degenerative changes in disc and spine, sudden trauma, gradual micro traumas or a
combination of the last two. Also a chemical irritation from release of inflammatory
products.

 Most common cause is a series of rotational in juries that produce circumferential and
radial tears with one final traumatic event leading to herniation. May relate a
precipitating event such as lifting or twisting a heavy object but just a minimal
provocation incident. This is the patient that says, “I bent over to tie my shoes” or “I bent
over to pick up the soap”.

Severe compression injury with the spine in a flexed position may cause a sudden
rupture of the annulus.

Nuclear protrusion: localized protrusion of nuclear material into spinal canal resulting
from a thinned but not ruptured annulus fibers.

Nuclear Herniation: material has torn through the annulus fibrosis and is a free
segment.

Most common L4/L5 and L5/S1 = 95-98%.
Centrally located protrusion tends to produce LBP and leg pain.
Laterally located protrusion tends to produce leg pain.  _____________________

Approximately 75% of lumbar herniations resolve spontaneously within 6 months due to
reabsorption of herniated material. Larger herniations often resolve faster than small
ones.




Janice Fordree, D.C.                   Page 1                              8/19/2010
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CASE HISTORY:

PPW: Back pain, leg pain or back and leg pain. Back pain often disappears with onset
of leg pain. Leg pain is often greater than back pain with herniations, however if there
are only annular tears with out herniation then back pain will be greater.

Pain may follow heavy lifting or twisting or heavy stress trauma and there may be a
history of intermittent LBP that usually resolves.
                                   __

Onset-Initial: Prior episodes of LBP and/or leg pain. Sudden onset of LBP with leg pain
past the knee.                                                                  _____
Palliative/Provocative
    Palliative: Rest with knees flexed in recumbent position.
    Provocative: Any movements that increase intradiscal pressure, weight bearing
        movements such as standing/walking for long periods of time and positional
        changes (lying to sitting, sitting to standing), forward bending, coughing,
        sneezing.

Quality/Quantity: Acute severe LBP with leg pain that can be shooting or electrical in the
dermatomal pattern.
Referred/Radiating Down leg
Site L4/L5, L5/S1 = 95-98%
Timing/Pattern          Standing/walking for long periods and positional changes (lying to
sitting, sitting to standing).
Other

Relevant History and Lifestyle
      Gender        Males> females
      Age 20-40 years old – due to nucleus pulposis is most hydrated - with
         highest incidence between 30-40 years of age.
      Occupation
      Traumas
      Surgeries
      Medications
      Hospitalizations
      Immunizations
      Diseases or Conditions__________________________________ _
      Family History
      Diet
      Sleep Habits
      Sexual History
      Alcohol Usage
      Drug Usage
      Smoking/Tobacco
      Other__________________________________________________

Janice Fordree, D.C.                 Page 2                             8/19/2010
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Review of Systems                                                         _____

     ______________________________________________________
___________________________________________________________



PHYSICAL EXAMINATION:

Height                                 Weight

Vitals: BP             Pulse                        Respiration________ Temp.

Appearance, Motion, Gait

Orthopedic Tests

      Test Name                R            L              Test Name            R           L
SLR                        +       -    +       -    Valsalva’s                 +   -   +       -
Well Leg Raiser            +       -    +       -                               +   -   +       -
Bowstring                  +       -    +       -                               +   -   +       -
Kemp’s                     +       -    +       -                               +   -   +       -
Lasague                    +       -    +       -                               +   -   +       -

Orthopedic Test Results Discussion: Any test for SOL and/or nerve root irritation will be
positive and can be used.



Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception:

Decreased sensation over affected dermatome.
Muscle weakness of quadriceps, dorsiflexors of ankles and toes or plantar flexors may
be present, depending on the given spinal level. Weakness of great toe indicates L5
disc.
Diminished or absent DTRs.
In prolonged cases may have muscle atrophy.
______________________________________________________________________
________________________________________________________________




Janice Fordree, D.C.                     Page 3                                 8/19/2010
Approved 05/10/04
LabValues_____________________________________________________________
__    ____________________________________________________________


Examination of Related Areas



Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




SPINAL EXAMINATION:

      Postural Analysis                           Postural Analysis      L      N     R
                                                  Head Tilt
      Decreased lumbar lordosis                   Head Rotation
      *Antalgic posture with pain                 High Ear
       running down leg into foot.                High Shoulder
                                                  High Ilium
                                                  Ext. Rotated Foot
                                                  Int. Rotated Foot


       * Antalgic lean may be indicative of position of protrusion. If the disc protrudes
lateral to the nerve root, the patient assumes an antalgic lean away from side of
radicular symptoms. If the disc protrudes medial to the nerve root, patient may assume
an antalgic lean into side of radicular symptoms. Flexed antalgic with out lateral lean
may indicate a more central herniation.

ROM
             Cervical ROM                                  Lumbar ROM
               ROM      Pain       Level                    ROM     Pain         Level
Flexion        N      Y N                Flexion          N     Y N
Extension      N  Y N                    Extension        N     Y N
R. Rotation    N  Y N                    R. Rotation      N     Y N
L. Rotation    N  Y N                    L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                    R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                    L. Lat. Flex.    N     Y N


Leg Length/Spinal Balance
Instrumentation/Pattern Analysis


Janice Fordree, D.C.                  Page 4                             8/19/2010
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Palpation (Muscle, Static, Motion) Myospasms may be present over lumbosacral para
spinals and gluteals.




List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

       X-rays       MRI          CT          Other

Views A-P /Lateral Lumbopelvic


Findings     Potential loss of disc height
             Lateral wedge sign

* MRI - best method to view herniation.

DIFFERENTIALS:

*Cauda equina syndrome
Facet syndrome with referred pain
Piriformis Syndrome
Lateral Stenosis / Central Stenosis




Janice Fordree, D.C.                  Page 5                        8/19/2010
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DIAGNOSIS:

Lumbar disc herniation


Case Management:


Chiropractic Management:
Cox flexion/distraction, low force techniques (Activator), listed references stated that
side posture is safe and effective – must keep lordotic curve maintained.
SOT – Category 3 – specific for herniation (especially L4/L5/S1)


* Contraindications to adjust:
    Peripheralization of symptoms
    If lesion is above L1/L2 disc space, possibility of UMN signs exist,
     signs include – saddle anesthesia
                      tonic bladder
                      (+) Babinski’s reflex
                       examine for sphincter incontenance and bowel/bladder
dysfunction.

RED FLAG – bowel/bladder dysfunction – refer immediately – may be CES



Adjunctive Therapy:
      Short term (2-3 days / 48-72 hours) – bed rest with knees flexed – prolonged
bed rest and inactivity are discouraged.
      Lumbosacral support – especially while sitting
      NSAIDs



Physical Therapy:
Acute phase: cold packs, ice massage and low volt galvanic for pain and edema.
TENS low frequency and high intensity of less than 10 HZ creates a analgesic affect
and increases endorphin production. Electrical stim increases levels of dopamine,
epinephrine and serotonin while diminishing nerve action potentials of A delta fibers
which are pain mediators.

Sub acute phase: other modalities and procedures that include trigger point therapy,
acupuncture and ultrasound. _***Do not place over spinal cord *** _
________________________________________________________________



Janice Fordree, D.C.                  Page 6                              8/19/2010
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Nutrition: * Note: The nutrition below is only a recommendation; there are no evidence-
based guidelines to the information listed below.

Acute pain and inflammation: Proteolytic enzymes (trypsin, chymitrypsin, bromelin),
Bioflavonoids (quercetin, hesperidin, rutin, etc) Herbals.

Tissue healing: Amino acids (glycine, L-cystine, L-proline and L-lysine) – supplies the
amino acid pool necessary for the structural production of collagen. Glucosamine
sulfate – nutrients for production of healthy ground substance,
Vitamin C, Iron, Alpha Ketoglutaric acid - all 3 needed for collagen production
Calcium, Vitamen E, Zinc, Copper, and Manganese – provide antioxidant effects and
serve as free radical scavengers to help remove cellular debris and promote
healing.


Exercise: McKenzie exercises and mild aerobic activity (swimming, walking, stationary
bike after patient can sit comfortably)
       Exercise ball for extension exercises.


Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education):
Instruction on back protection
Encourage life style modifications
Encourage weight loss if appropriate


Further Evaluation:
Week 6 – refer for surgical consult If profound muscle weakness has not responded
Week 12 – refer for surgical consult if poor response to conservative care


Common Medical Management: The treatment of a disc herniation is based on the
severity and duration of symptoms. Initial treatment is almost always non-surgical. Anti-
inflammatory medications, steroids and/or muscle relaxants with rest are initially used to
treat the sciatica. Physical therapy can also be very helpful. Most people have full
recovery from episodes of sciatica within the first few weeks. If the symptoms continue
past 6 weeks, however, one should consider undergoing an evaluation, which includes
MRI studies. If symptoms continue and conservative management has not been helpful,
surgical decompression of the disc (microdiscectomy) may be helpful in relieving the
symptoms. The only absolute indications for surgery, however, are progressive
neurological symptoms, bowel or bladder problems, and severe, unremitting.




Prognosis:
Janice Fordree, D.C.                  Page 7                             8/19/2010
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   Good for near complete recovery of functionality, although flare-ups may occur
   Surgery is rarely required
   First 6 weeks – 50% improvement based on functional rehab – manipulation can
  provide short-term improvement in pain and activity levels and higher patient
  satisfaction. The risks of manipulations are very low in skilled hands.


  References:
  Vizniak & Carnes: Quick Reference Clinical Chiropractic Conditions Manual
   Huff & Brady: Instant Access to Chiropractic Guidelines and Protocols
  Gatterman: Chiropractic Management of Spine Related Disorders, 2nd Edition
  ___________________________________________________________________


  Case Complexity:

  The category of complicating or mitigating factors should include the following
  considerations: Ancillary labs, diagnostic studies, co-management issues, early stage
  of condition, advanced stage of condition, psychosocial issues, etc. The complicating or
  mitigating factors can either increase or decrease the baseline complexity.

Condition Name    Baseline     Complicating/ Mitigating Factors             Revised
                  Complexity                                                Complexity
 Lumbar Disc         5.0       Risk factor of heavy lifting or twisting,       6.0
  Herniation                   heavy stress trauma or history of
                               intermittent LBP
                               Risk factor of movements that increase           6.0
                               intradiscal pressure, especially flexed
                               positions, weight bearing movements
                               and positional changes.
                               Risk factors of prolonged                        6.0
                               standing/walking, forward bending,
                               coughing and sneezing.
                               Risk factor of decreased sensation over          7.0
                               affected dermatome, weakness and/or
                               atrophy of involved muscles and
                               diminished or absent DTRs.
                               Chiropractic management –                        9.0
                               contraindications to adjust
                               Chiropractic management – modified               8.0
                               adjusting along with use of specific
                               techniques.
                               Chiropractic management – refer for              9.0
                               surgical consult if no response to
                               conservative care after ~ six weeks.


  Janice Fordree, D.C.                 Page 8                              8/19/2010
  Approved 05/10/04
                          CLINICAL APPLICATIONS
                             Case Study Preparation


CONDITION___Lumbar Facet
Syndrome______________________________________

Prepared by: Maria Michelin, DC__________________________________



RELEVANT PATHOPHYSIOLOGY:

Facet and the capsule are the source of the pain. One theory-synovial folds
(meniscoids) may be trapped or pinched and cause the pain. Theory two-
degeneration in older patients.



CASE HISTORY:

PPW: Well localized low back pain-usually at L4 to Sacrum that radiates into the
buttocks and can radiate into the thighs.
       Onset-Initial often sudden after arising from a flexed position or sudden odd
       movement.                                                              _____
       Palliative ice and lying down with legs elevated
       Provocative lifting weights, prolonged standing or sitting up straight
       Quality/Quantity constant dull ache, pain is sharp with lumbar extension
       Referred/Radiating some buttock or thigh pain with extension
       Site over spine L4 to sacrum
       Timing/Pattern        constant
       Other

Relevant History and Lifestyle
      Gender
      Age
      Occupation
      Traumas       can be related to microtraumas
      Surgeries
      Medications          OTC tends not to help
      Hospitalizations
      Immunizations
      Diseases or Conditions__________________________________ _
      Family History
      Diet
      Sleep Habits LBP interferes with sleep

Maria Michelin, D.C.                 Page 1                             8/20/2010
Approved 03/29/04
         Sexual History can aggravate LBP
         Alcohol Usage
         Drug Usage
         Smoking/Tobacco
         Other__can be aggravated by obesity________________________


Review of Systems                                                         _____

     ______________________________________________________
___________________________________________________________



PHYSICAL EXAMINATION:

Height                                 Weight

Vitals: BP             Pulse                        Respiration________ Temp.

Appearance, Motion, Gait

Orthopedic Tests

      Test Name                R            L              Test Name             R           L
SLR/WLR                    +       -    +       -                               +    -   +       -
Kemps                      +       -    +       -                               +    -   +       -
Nachlas                    +       -    +       -                               +    -   +       -
Yeomans                    +       -    +       -                               +    -   +       -
Belt                       +       -    +       -                               +    -   +       -

Orthopedic Test Results Discussion:     Kemps increases the pain from L4 to
sacrum and causes pain to radiate into the buttocks. Nachlas and Yeoman increase
to already present LBP.



Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception
The neurological examination is all with in normal limits there is no evidence of
reproducible sensory or motor involvement.________________________________
___________________________________________________________________
___________________________________________________________________




Maria Michelin, D.C.                     Page 2                                 8/20/2010
Approved 03/29/04
LabValues__________________________________________________________
_____ ____________________________________________________________


Examination of Related Areas



Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




SPINAL EXAMINATION:

       Postural Analysis                         Postural Analysis       L        N      R
                                                 Head Tilt
       Possible increase in lumbar               Head Rotation
       lordosis                                  High Ear
                                                 High Shoulder
                                                 High Ilium
                                                 Ext. Rotated Foot
                                                 Int. Rotated Foot


ROM
                Cervical ROM                                 Lumbar ROM
                  ROM      Pain      Level                    ROM     Pain            Level
Flexion           N  Y N                   Flexion          N     Y N
Extension         N  Y N                   Extension        N     Y N             L4-S1

R. Rotation         N      Y   N           R. Rotation        N      Y    N
L. Rotation         N      Y   N           L. Rotation        N      Y    N
R. Lat. Flex.       N      Y   N           R. Lat. Flex.      N      Y    N
L. Lat. Flex.       N      Y   N           L. Lat. Flex.      N      Y    N


Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion) Tenderness over the involved spinous processes




Maria Michelin, D.C.                    Page 3                               8/20/2010
Approved 03/29/04
List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

       X-rays       MRI          CT          Other

Views A-P, Lateral and Obliques

Findings     Possible L5 disc angle of greater than 15 degrees.    McNab’s line
and Hadley’s line may be positive for imbrication




DIFFERENTIALS:

Lumbar disc problems. Lumbar sprain/strains

DIAGNOSIS:

Lumbar facet Syndrome




Case Management:


Chiropractic Management:          Adjustments. Can use Cox flexion distraction.




Maria Michelin, D.C.                 Page 4                           8/20/2010
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Physical Therapy: Axial distraction. Palliative care includes ice, pulsed
ultrasound, high volt galvanic and interferential__________________________

Nutrition:



Exercise: Williams flexion exercises



Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education):
       __Recommend avoid prolonged sitting or the positions that are specific to the
patient which encourage increased lumbar lordosis._______________________
________________________________________________________________

Further Evaluation:


Common Medical Management: Facet denervation and facet injections____

References:
Souza. Differential Diagnosis for the Chiropractor
Huff and Brady. Instant Access to Chiropractic Guidelines and Protocols

Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.


Condition Name         Baseline     Complicating/ Mitigating Factors      Revised
                       Complexity                                         Complexity
   Lumbar Facet            3        None really. It depends on if they         3
    Syndrome                        have to perform the activity that
                                    put them in this condition in the
                                    first place. Usually some twisting
                                    during extension.




Maria Michelin, D.C.                   Page 5                            8/20/2010
Approved 03/29/04
                                                              Approved : 05/31/06
                                                              Implemented: SU06
                                                              Reviewed:
                         CLINICAL APPLICATIONS
                        Faculty Case Study Preparation


CONDITION: Multiple Sclerosis

Prepared by: Intern Bradley Penrod

RELEVANT PATHOPHYSIOLOGY: The functional changes associated with or
resulting from Multiple Sclerosis are variable due to the fact that Multiple
Sclerosis is an autoimmune deficiency with no known cause and with many
neurological symptoms that mimic many other neuropathies. CNS
inflammation causes myelin sheath damage. The axons within the sheath are
also damaged. Some patients with MS will have a T cell mediated immune
response and some will have a toxin or virus induced demyelination that
causes a primary disorder within oligodendrocyte cells that produce myelin.
Although brain biopsies are the only way to determine the type of MS,
research is being done that suggests there may be CSF and MRI markers
associated with the disease. Lesions on the spinal cord cause sensory or
motor changes that usually affect one half of the body below the spinal level
of the lesion. Lesions on the brain stem will cause diplopia and abnormal
facial sensations. Lesions on the optic nerve cause blurred vision and painful
eye movements. The most common lesion is a cerebral lesion. However, the
cerebral lesion prevents with the least symptomatic problems. MS is a
progressive disease due to the fact that although there are times without
symptoms, lesions occur 10-20 times more often than remissions. When the
secondary progressive phase occurs, irreversible tissue damage has been
done.() At this time it is pointless to use immunotherapy. At the latter stages
of chronic MS inflammation slows or even stops. However, at this point there
has been significant chronic degeneration that will eventually lead to death.
Studies have shown that oligodendrocyte progenitor cells capable of axon
remyelination are seen even in patients with chronic MS. Therefore, there is
hope that research can find a way to use progenitor cells to remyelinate
axons. ()


CASE HISTORY:

Patient Presents With: Typically presents with numbness, weakness, and or
uncoordination in the extremities, ataxic or spastic gait, and or fatigue and
depression. Eye movements may be painful ()
      Onset-Initial: Not noticed in the preclinical phase. First noticed during
              relapse/remission phase
      Palliative: MS medications; times of remission; rest and relaxation
      Provocative: A stage of relapse; moving the eyes; trying to coordinate muscle


Brad Penrod                         Page 1                           8/20/2010
             movements; Not clear on what causes relapses
      Quality: Not painful except with extreme spasticity
      Quantity: Called the hopeful disease because between periods of relapse
             there can be long periods of remission
      Referred: There is no referred pain
      Radiating: The electric shock feeling found with cervical flexion will radiate
             from the cervical spine down the back and sometimes the extremities
             due to demyelination of the spinal cord ()
      Site: The brain, spinal cord, and optic nerve (CNS) are the typical sites for
             MS. However, the entire body is affected.
      Timing: Due to the uniqueness of MS, timing of relapse and remission is not
             known. The relapsing/remitting phase usually lasts 10-15 years and
             the secondary progressive phase usually lasts for 20 plus years to
             death. ()

Relevant History and Lifestyle
      Gender: Female to male ratio is 2:1
      Age: MS can be seen between the ages 10 and 60; Usually it is found
            between the ages of 20 and 40
      Occupation: Occupation has not yet been proven to be significant in
            correlation with MS
      Traumas: Although trauma occurs for some people near a relapse or the
            initial diagnosis, statistics show that there is no correlation between
            trauma and MS. ()
      Surgeries: Not significant in relapses, remission, or causing MS.
      Medications: Drugs controlling muscle spasticity – Diazepam, baclofen,
            tizanidin, and pyridinolmesilat work directly on the CNS while dantrolen
            targets the contractility of striated muscles (antispastic drugs should
            be managed very carefully due to the fact that during paresis of the
            extremities, some spasticity needs to be present to avoid atrophy, and
            sometimes the side effects out way its positive use) These antispastic
            drugs are also used to relax the detrusor muscle and help with
            incontinence (diazepam is used mainly for this) ()
            Drugs controlling pain – Most pain is caused by the spasticity of
            muscle causing incontinence and eventually urinary tract infections.
            The pain produced by MS alone is centrally located. Therefore, only
            antiepileptic and psychotropic drugs can be beneficial. These drugs
            also will help with the pain of trigeminal neuralgia, which is only seen in
            4 to 5 percent of MS patients. Using a low dose of each and
            combining the antiepileptic and psychotropic drugs will help minimize
            the side effects. ()
            Drugs that control MS during first acute relapse– Glucocorticoids
            have been shown to help reduce the time and severity of a
            relapse, as well as prolong the permanent effects. There are four
            types of therapy that target the immune system: Avonex-given
            intramuscularly; Rebif-given 3 times per week subcutaneous;


Brad Penrod                           Page 2                             8/20/2010
           Betaseron-given every other day subcutaneous; Copaxone-daily
           subcutaneous injections. The first three mimic interferons made by the
           human body. The last of the four is based on myelin protein. ()
           Drugs that control MS during the secondary progressive phase –
           Mitoxantrone is a type of chemotherapy that can only be used for the
           first two years due to the fact that its side effect is cardiac toxicity.()
           *** Note that there is no drug for primary progressive phase
     Hospitalizations: Although MS patients in the remission/relapse phase
           experience times of no symptoms and times of symptoms, it is
           important to be treated medically as well as observationally at the
           hospital. People with MS will be in and out of hospitals for the rest of
           their life.
     Immunizations: There is no substantial evidence that states that normal
           childhood vaccinations such as for tuberculosis, measles, mumps,
           rubella, pertussis, diphtheria, and tetanus could not be taken.
     Diseases or Conditions: There has not been any correlation with disease and
           the cause of MS. However, conditions such as incontinence,
           neuromuscular pain, and urinary tract infections are caused due to MS.

     Family History: There has not been a significant link genetically between
            family members of those with MS. Although twin studies are being
            done, the disadvantage is that only twins both diagnosed with MS were
            studied. Scientists believe that there may be a chromosomal trait
            responsible for MS, but the variable of the uniqueness of the immune
            system makes it hard to gain sufficient evidence for genetic correlation.
            It is hypothesized with some evidence that environmental factors play
            a role in MS prevalence. Populations farther from the equator are
            more prone to MS.()
     Diet: Due to the gastrointestinal problems created by MS, it is important to
            maintain a diet that will counteract constipation such as fiber and
            vegetables. Lean meat and other protein-enriched foods will maintain
            the protein balance. Bread and potatoes are good for carbohydrate
            balance. () Essential fatty acids should be taken due to their immune
            system benefits. They should be taken with Vitamin E due to the fact
            that antioxidants are needed with EFAs.
     Sleep Habits: Sleep habits normal for regular bodily function should be
            adhered to due to the fact that lack of sleep can lower the immune
            systems effectiveness.
     Sexual History: Sexual problems occur with men and women with MS
            Men-Impotence and loss of libido are common due to the fact that
                    bulbocavernous reflex is usually absent
            Women-Loss of sensation is common in the genital region as well as
                    spasticity of adductors.
            Psychologically-Because MS has remissions and relapses, the mental




Brad Penrod                         Page 3                               8/20/2010
                    problems that go along with the fear of not being able to please
                    their sexual partner causes many to abandon sexual relations
                    altogether. ()
       Alcohol Usage: Alcohol is not recommended due to the fact that it will cause
             problems with weight and extremity edema when combined with drugs
             taken for MS.
       Drug Usage: Not recommended due to the mixing of beneficial drugs and
             recreational drug effects
       Smoking/Tobacco: Smoking is not recommended for anyone

Review of Systems: (EENT, Respiratory, Cardiovascular, Musculoskeletal,
Gastrointestinal, Reproductive)


PHYSICAL EXAMINATION:

Height : Not significant              Weight: Obesity is not recommended

Vitals: BP:          Pulse:        Respiration:       Temp:
Appearance, Motion, Gait : During a relapse, an ataxic, spastic gait may be
       observed. For those with optic nerve lesions, nystagmus will be observed.
       Intention tremors may be a problem for those with progressive MS.


Orthopedic Tests

     Test Name                R            L        Test Name              R           L
Lhermitte’s sign            +     -    +       -                          +    -   +       -
                            +     -    +       -                          +    -   +       -
                            +     -    +       -                          +    -   +       -
                            +     -    +       -                          +    -   +       -
                            +     -    +       -                          +    -   +       -

Orthopedic Test Results Discussion: Lhermitte’s sign is seen when the patients
       cervical spine is taken into full flexion. A disturbing, electric shock sensation
       is felt down the spine and sometimes the arms and legs. However, the
       feeling is not necessarily painful. This happens due to the irritation of the
       demyelinated nerve. The only drawback is that this test is subjective and can
       be positive for other neural problems.()
Neurological Tests – (Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception) Due to spacticity and optic nerve problems
equilibrium can be thrown off as well as motor control. DTRs are minimized due to
the demyelinating effect of the CNS. Due to paresis of the extremities, light touch
and proprioception is diminished. During remission, neurological tests can be
negative.


Brad Penrod                             Page 4                            8/20/2010
LabValues: There are no significant laboratory values associated with Multiple
Sclerosis

Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.) Lesions on the optic nerve created by MS can cause painful and
uncontrolled eye movements.

SPINAL EXAMINATION:
Postural Analysis Discussion:

Postural Analysis     L         N     R
Head Tilt
Head Rotation
High Ear
High Shoulder
High Ilium
Ext. Rotated Foot
Int. Rotated Foot
ROM


             Cervical ROM                                   Lumbar ROM
               ROM      Pain        Level                    ROM     Pain        Level
Flexion        N  Y N                     Flexion          N     Y N
Extension      N  Y N                     Extension        N     Y N
R. Rotation    N  Y N                     R. Rotation      N     Y N
L. Rotation    N  Y N                     L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                     R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                     L. Lat. Flex.    N     Y N

Pattern Analysis: Leg Length/Spinal Balance/ Instrumentation/Palpation (Muscle,
Static, Motion)

List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




Brad Penrod                            Page 5                         8/20/2010
        RADIOLOGICAL EXAMINATION:

            Views                                   Findings
X-rays                                              No significant findings

MRI         Brain and Spinal Cord                   T2 lesions in brain and spinal cord that
                                                    correlate to MS are found, but more study
                                                    is needed on MRI evidence and MS
CT                                                  No significant findings

Other




        Multiple Sclerosis
        The advent of MRI has revolutionized the diagnosis and monitoring of MS.
        Typical findings and pulse sequences
        Because of the inflammation and breakdown of the blood-brain barrier in MS lesions,
        the presence of extravascular fluid leads to hyperintensity on T2-weighted images.
        Thus, in a patient with MS, MRIs typically demonstrate more than 1 hyperintense
        white matter lesion.
        Lesions may be observed anywhere in the CNS white matter, including the
        supratentorium, infratentorium, and spinal cord; however, more typical locations for
        MS lesions include the periventricular white matter, brainstem, cerebellum, and
        spinal cord.
        Ovoid lesions perpendicular to the ventricles are common in MS
        Perhaps the most specific lesions in MS are noted in the corpus callosum at the
        interface with the septum pellucidum
        Proton density (PD)–weighted MRI has an advantage over standard T2 imaging
        because, on PD series, MS lesions remain hyperintense while CSF signal is
        suppressed. Therefore, the lesions are easily identified. Depending on the PD
        technique, CSF signal is suppressed to a variable degree, rendering it isointense to
        hypointense relative to the brain parenchyma. This sequence results in substantial
        suppression of Virchow-Robin spaces, which are perivascular CSF spaces that may
        penetrate to the subcortical white matter. These spaces may appear as hyperintense
        spots on standard T2-weighted MRIs.
        Compared with other techniques, nonenhanced T1-weighted MRI is far less
        sensitive in detecting MS lesions. Acute lesions usually are not depicted at all. With
        T1-weighted MRI, the clinician can gain a general appreciation of the global cerebral
        atrophy that occurs with advanced chronic MS. Global atrophy has been suggested
        to have the strongest imaging correlation with disability.



        Brad Penrod                          Page 6                             8/20/2010
Chronic MS lesions usually result in localized leukomalacia, and they may
appear as hypointense lesions that represent loss of tissue.
Gadolinium-enhanced T1-weighted MRIs can depict acute active MS lesions.
These appear as enhancing white matter lesions, and the presence of an enhancing
lesion has been shown to increase the specificity for MS


DIFFERENTIALS:


Rule Out                              Rationale to differentiate from (condition name here)
Female younger than 40; loss of
hair; allergies to drugs; high
sedimentation rate; lymphopenia
and thrombopenia; antinuclear and
                                      Systemic Lupus Erythematosus
antimitochondrial antibodies in
serum; elevated serum IgM; cold
reactive lymphocyte antibodies;
elevated protein content in CSF()
Olfactory disturbances; facial
palsies; deafness; visual failure;
spontaneous remissions with
severe neurological deficits; signs   Sarcoidosis
of systemic disease;
hyperclacemia; hyperglobulinemia;
high protein in CSF()
MRI (1)                               Tumor
Old age; no oligoclonal bands in
CSF; VEPs show normal latencies       Cervical Spondylosis
()
****Note: These are a few of the main common differentials. There are many more
due to the fact that MS is such a broad disease that mimics many other
neuropathies.


CASE MANAGEMENT


Chiropractic Management: Not enough research has been done to prove the
effectiveness of chiropractic care. It is possible that chiropractic care increases
the remission and decreases the relapse time and severity based on testimony.
However, there is no way to prove that the patient would have or would not have
had similar occurrences without chiropractic care due to the fact that the timing of
relapse is unique to the individual.




Brad Penrod                                 Page 7                                   8/20/2010
Common Medical Management: Interferon drugs that control the relapse works
well. Also, it is important for the doctor to keep a close eye on the progression of the
disease.

Adjunctive Therapy:

Physical Therapy: It has been shown that increasing the range of motion and
stretching helps with the symptoms of MS.

Nutrition:
   Individuals with MS should be evaluated for Celiac disease. If serologic tests
       are positive for Celiac disease, then a gluten-free diet is required.
   Some data suggest increasing the diet with acids, particularly from fish
       sources; can improve the nutritional status of the individual.
   Diet consistency may have to be modified in individuals with dysphasia after
       being evaluated by a Registered Dietitian (RD) and Speech-Language
       Pathologist (SLP).

References: Mahan, L & Escott-Stump. S. (Eds.) (2003) Krause’s Food, Nutrition &
Diet Therapy (11th ed.). Philadelphia: W. B. Saunders.


Exercise: Useful only if the patient is experiencing minor symptoms. Cannot be
used as a replacement for physical therapy.

Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene,
psychosocial concerns, education): Ergo therapy is important for patients with
MS. Ergo therapists may change the entire household to benefit the patients so that
they may improve fine motor movements, sitting control, range of motion, and many
other aspects of daily life. Chiropractic care is extremely important due to the fact
that the immune system must work at its optimum level to prevent MS from reaching
the secondary chronic phase. Patients with family must also understand that there
must be communication concerning sexual relations due to the fact that MS causes
a loss of libido. ()

Further Evaluation:


REFERENCES:
1. Kesselring, Jurg. Multiple Sclerosis. Cambridge Press (1997)

2. Fox, Robert J. and Sweeny, Patrick J. “Multiple Sclerosis”. The Cleveland Clinic
      Foundation (2002)

3. Chang A, Tourtellotte WW, Rudick R, Trapp BD, Premyelinating oligodendrocytes
      in chronic lesions of multiple sclerosis. N Engl J Med 2002; 346: 165-173.


Brad Penrod                           Page 8                              8/20/2010
4. Mahan, L & Escott-Stump. S. (Eds.) (2003) Krause’s Food, Nutrition & Diet
Therapy (11th ed.). Philadelphia: W. B. Saunders.


CASE COMPLEXITY:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity. ()


Condition Name        Baseline     Complicating/ Mitigating Factors       Revised
                      Complexity                                          Complexity
 Multiple Sclerosis                Co-management with neurologist            8.0
                                   Advancing demyelination causing
                          6.0      loss of function with remission and         9.0
                                   relapsing cycles
                                   Relationship issues concerning
                                   sexual relations and daily activity         7.0
                                   MRI co-management                           6.0




Brad Penrod                         Page 9                               8/20/2010
                                                                       Approved : 05/31/06
                                                                       Implemented: SU06
                                                                       Reviewed:
                             CLINICAL APPLICATIONS
                            Faculty Case Study Preparation


CONDITION: Parkinson disease

Prepared by: Ryan Hiles
Contributions By: Dr. Susan Boger-Wakeman

RELEVANT PATHOPHYSIOLOGY: areas of the brain with high concentrations of
dopaminergic cell groups are destroyed particularly the substania nigra and its
associated areas including the caudate nucleus and putamen


CASE HISTORY:

Patient Presents With:
       Onset-Initial: usually insidious and starts with a pill rolling tremor in one hand but
becomes less noticeable as the disease progresses. The mean age of occurance is 57
years of age
       Palliative: tremor is absent with movement and during sleep. Levodopa is a
precursor to dopamine that is often used in treatment of disease
       Provocative: tremor occurance and intensity is increase under emotional stress
and fatigue.
       Quality: tremor is at 4-8 Hz.
       Quantity: N/A.
       Referred: N/A
       Radiating: N/A
       Site: N/A
       Timing: Tremors worse at rest but absent with sleep
       Other: NA

Relevant History and Lifestyle
      Gender: m=f
      Age: usually starts after 40 y.o. mean age is 57 y.o.
      Occupation: working with certain chemicals such as carbon monoxide and
manganese may increase chances
      Traumas: N/A
      Surgeries:N/A
      Medications: N/A
      Immunizations:N/A
      Diseases or Conditions:
      Family History: N/A
      Diet: N/A
      Sleep Habits: N/A
      Sexual History: N/A
          Alcohol Usage: N/A
          Drug Usage:
          Smoking/Tobacco: N/A
          Other: NA


Review of Systems: (EENT, Respiratory, Cardiovascular, Musculoskeletal,
Gastrointestinal, Reproductive) Upon examination, eyes,ears, nose and throat are
normal, except skin on face there is seborrhea. Respiration is normal and
cardiovascular system is normal. Musculoskeletal system presents areas of severe
rigidity throughout body. Muscle strength is good but slow to react. Gastrointestinal
exam may show signs of constipation 4 . Reproductive system has no significant
findings.


PHYSICAL EXAMINATION:

Height :N/A                       Weight: N/A
Vitals: BP         N/A   Pulse    N/A    Respiration: N/A      Temp: N/A

Appearance, Motion, Gait : classic presentation is pill rolling tremor, festinating gait,
mask like appearance, stooped posture and difficulty with movement.

Orthopedic Tests

             Test Name             R        L            Test Name              R           L

SLR                                 -       -     CERVICAL                       -          -
                                                  COMPRESSION
GOLDWAITES                          -       -     OBERS TEST                    +           +
TOE WALK                         + +      + + DISTRACTION                        -          -
HEEL WALK                        + +      + + ELY’S SIGN                        +           +
BECTEREWS                           -       -     THOMAS’ TEST                  +           +

Orthopedic Test Results Discussion: Toe and heel walk are both positive due to
already present difficulties with movement. Obers, ely’s and Thomas are positive due to
associated muscle rigidity
Neurological Tests – (Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception) +cranial nerve neurological test of the trigeminal
nerve(v).(corneal reflex is +) PNS has no significant findings. Motor strength is a 5, but
is slow. DTR’s are hyper reflexive. Pathological reflex has a +babinski's indicating uml.

4
    Merck Manual
+ myerson sign with a sustained blink response. Light touch and proprioception is
hypertonic.

LabValues: no significant findings


Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.) N/A


SPINAL EXAMINATION: No significant findings involving Parkinson’s Disease
Postural Analysis Discussion:

Postural Analysis        L      N      R

Head Tilt
Head Rotation
High Ear
High Shoulder
High Ilium
Ext. Rotated Foot
Int. Rotated Foot


ROM: ROM’s will both be normal in all ranges but will present with a cog wheel or rachet type
motion.
                Cervical ROM                                  Lumbar ROM

Flexion
Extension
R. Rotation
L. Rotation
R. Lat. Flex.
L. Lat. Flex.

Pattern Analysis: Pattern would be established on a case to case basis.
List the level for palpatory findings. There will be a global muscle tightness with other
palpatory findings existing on a case to case basis.
    Level         Muscle Motion   Level   Muscle Motion       Level    Muscle Motion




RADIOLOGICAL EXAMINATION:


                  Views                            Findings
X-rays            N/A                              N/A


MRI               brain                            heavily weighted T2 MRI shows decrease
                                                   size of substantia nigra para compacta 1 .

    CT            N/A                              N/A


Other




Parkinson's Disease
Magnetic resonance imaging and computed tomography scan are unremarkable in PD.
Positron emission tomography (PET) and single photon emission CT (SPECT) are
useful diagnostic imaging studies using radioactive [18F]dopa and single proton
emission tomography (SPECT) using the dopamine uptake ligand beta-CIT, are the
most sensitive biomarkers for the diagnosis of PD.




1
    Souza, 1997
DIFFERENTIALS:


Rule Out                         Rationale to differentiate from (condition name here)

Progressive Supranuclear Palsy   PPW loss of voluntary movements, muscle rigidity and
                                 bradykinesia but differs from parkinsons because of dysphagia
Cerebellar Disorders             PPW similar movement dysfunction specifically with equilibrium
                                 and coordination but differs b/c PD has mask like facies
Spinocerebellar Disorders        PPW progressive ataxia but differs b/c PD does not have
                                 decreased sensory




CASE MANAGEMENT


Chiropractic Management: Refer to neurologist immediately. Once condition is
under control. Adjust the spine with light drops and activator.

Common Medical Management: MD will usually prescribe Levodopa to improve
tremors and rigidity. Cabidopa helps reduce adverse affects of levodopa and increases
dopamine in brain. Surgery is an option, but some procedures are still under study and
should be discussed with patient 4 .

Adjunctive Therapy: electrical stimulation on musculature to decrease muscle spasms.
Avoid aspartame as some studies so a link of some degree.
Physical Therapy: PT to help increase muscle coordination, flexibility and decrease
falls. Speech therapy will help to increase voice volume and word pronunciation.
Occupational therapy can teach patients alternative methods of doing tasks 3 .

4
    Merck 1999
3
    JAMA
Nutrition:

         If patients are having refractory fluctuations of dipkinases, check drug-nutrient
          interactions, particularly between dietary protein and L-dopa.
         For some patients, restricting protein intake during breakfast and lunch only to 10
          grams and place the remainder of the protein in the evening meal to meet the
          RDA requirement for protein. This may improve mobility during the day, whereas
          rigidity occurs overnight. Patients should see some benefit of this altered timing
          of protein-intake within one week.
         Avoid any vitamin preparations and food fortified with pyridoxine (B6). The
          conversion of L-dopa to dopamine is dependent on pyridoxine and if excessive
          amounts of pyridoxine are present, L-dopa may be metabolized in the periphery,
          not n the central nervous system (CNS) where its therapeutic activity takes place.
         Medications for PD include anorexia, nausea, reduced sense of smell,
          constipation and dry mouth. To reduce the gastrointestinal effects of L-dopa, it
          should be taken with meals.
         PD medications can increase the risk for dehydration.
         Adequate fluids and fiber are important for reducing constipation.
         As PD progresses, rigidity interferes with the ability to control the position of the
          head and trunk necessary for eating. Eating is slowed; mealtimes may take up to
          one hour.
         Tremor in the arms and hands increases caloric needs.
         PD is a complicated disease that affects each person differently.
         The nutritional needs require the management of a Registered Dietitian (RD).


References for nutrition :
   4. Mahan, L & Escott-Stump. S. (Eds.) (2003) Krause’s Food, Nutrition & Diet
   Therapy (11th ed.). Philadelphia: W. B. Saunders.

      5. Parkinson’s Disease: Guidelines for Medical Nutrition Therapy. Kathrynne Holden,
      MS. RD. Five Star Living, Inc.


There is no evidence that a specific diet will help. A vegetable rich diet will help with
digestion and constipation. Take a balance approach to protein intake because protein
inhibits the absorption of levodopa in gut 2 .

Exercise: Exercise is just as important as taking medication. Exercise is essential for
maintaining and improving mobility, flexibility, balance and a range of motion and for
warding off many of the secondary symptoms 2 .


2
    PDF.ORG
2
    PDF.ORG
Health Promotion and Maintenance (I. e. ergonomics, spinal hygiene,
psychosocial concerns, education): For many people, groups play an important role
in the emotional well being of patients and families. They provide a caring environment
for asking questions about Parkinson, for laughing and crying 2 .

Further Evaluation: patient will need further evaluation by neurologist and physical
therapist.



REFERENCES:

1.SOUZA A. THOMAS, DIFFERENTIAL DIAGNOSIS AND MANAGEMENT FOR THE
CHIROPRACTOR. PG 433-434, 2005

2. PARKINSON DISEASE FOUNDATION INC. THE ROLE OF THE PATIENT. WWW.
PDF.ORG

3. JAMA, PARKINSON DISEASE, JANUARY 21, 2004, TORPY ET AL 291(3):390

4. The Merck Manual, 1999. PG.1466-1472.

5. Mahan, L & Escott-Stump. S. (Eds.) (2003) Krause’s Food, Nutrition & Diet Therapy
(11th ed.). Philadelphia: W. B. Saunders.

6. Parkinson’s Disease: Guidelines for Medical Nutrition Therapy. Kathrynne Holden,
MS. RD. Five Star Living, Inc.

CASE COMPLEXITY:
The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early stage
of condition, advanced stage of condition, psychosocial issues, etc. The complicating or
mitigating factors can either increase or decrease the baseline complexity.

Condition Name            Baseline     Complicating/ Mitigating Factors      Revised
                          Complexity                                         Complexity
    Parkinson’s Disease       4.0      As the disease progresses the             8.0
                                       patients will become very frail and
                                       weak to the point of being bed-
                                       ridden
                              4.0      Difficulty eating                         5.0




2
    PDF.ORG
                           CLINICAL APPLICATIONS
                            Faculty Case Study Preparation


CONDITION Piriformis Syndrome

Prepared by: Janice Higgins-Fordree, D.C.
___________________________________________________________

RELEVANT PATHOPHYSIOLOGY:

Trauma to the sacroiliac joint produces a ligamentous sprain, leading to piriformis
syndrome. Biomechanical agents released from the inflamed piriformis muscle,
where two structures meet at the sciatic foramen, cause irritation of the sciatic nerve
sheath. Neurological injury to L5/S1 can result in denervation atrophy of the
piriformis. Facet injury can produce reflex syndrome of the muscle. Overuse can
produce fatigue or strain of the piriformis as can leg length asymmetry. Predisposing
factors include anomalous sciatic nerve, tight external rotators and neurological
insult to L5/S1. Differs from radiculitis in that there is no internal derangement of the
nerve – too protected by connective tissue.

CASE HISTORY:

PPW: Pain and/or parasthesia in the distribution of the sciatica nerve, Pain is either
deep boring or dull ache that radiates down the poster lateral thigh to the knee
occasionally extending to the foot. Burning sensation in the hips over the greater
trochanter, especially at night preventing the patient to lie on their side. Two most
common causes of piriformis syndrome are trauma to the sacroiliac joint producing a
ligamentous sprain and hormone changes that occur during menstrual cycle,
pregnancy, estrogen replacement therapy or oral contraceptives.

Onset-Initial
      Palliative/Provocative      Prolonged sitting, prolonged external rotation of
      leg (pressing an accelerator while driving), leg length discrepancy.
      Quality/Quantity     Deep boring pain in the buttock, burning sensation in hips
      over greater trochanter.
      Referred/Radiating Poster lateral thigh or calf, rarely to foot
      Site Buttock traveling down thigh and leg
      Timing/Pattern       After prolonged sitting, (watching TV, driving, class)
      Other

Relevant History and Lifestyle:
             Gender        6 Females to 1 male ratio
             Age                no specific age range ___
             Occupation truck driver, secretary, etc.
             Traumas

Janice Fordree, D.C.                   Page 1                              8/19/2010
Approved 04/08/04
             Surgeries
             Medications
             Hospitalizations
             Immunizations
             Diseases/Conditions   Pregnancy, menopause
             Family History
             Diet
             Sleep Habits
             Sexual History
             Alcohol Usage
             Drug Usage
             Smoking/Tobacco
             Other__________________________________________________


Review of Systems



PHYSICAL EXAMINATION:

Height                                 Weight

Vitals: BP             Pulse                        Respiration________ Temp.

Appearance, Motion, Gait               Antalgic

Orthopedic Tests

      Test Name                R            L              Test Name            R           L
SLR                        +       -    +       -                               +   -   +       -
Hibbs                      +       -    +       -                               +   -   +       -
Nafzinger                  +       -    +       -                               +   -   +       -
Valsalva                   +       -    +       -                               +   -   +       -
                           +       -    +       -                               +   -   +       -

Orthopedic Test Results Discussion:        (+) SLR – pain intensified by simultaneous
internal rotation of the leg and relieved by external rotation (piriformis test). (+)
Nafzingger/Valsalva indicators of disc herniation.


Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception - All WNLs




Janice Fordree, D.C.                      Page 2                                8/19/2010
Approved 04/08/04
Lab Values


Examination of Related Areas



Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.) Observations; foot flare, unilaterally of side of involvement,
overpronation




SPINAL EXAMINATION:

      Postural Analysis                        Postural Analysis      L      N        R
                                               Head Tilt
                                               Head Rotation
                                               High Ear
                                               High Shoulder
                                               High Ilium
                                               Ext. Rotated Foot
                                               Int. Rotated Foot


ROM
             Cervical ROM                                 Lumbar ROM
               ROM      Pain      Level                    ROM     Pain              Level
Flexion        N  Y N                   Flexion          N     Y N
Extension      N  Y N                   Extension        N     Y N
R. Rotation    N  Y N                   R. Rotation      N     Y N
L. Rotation    N  Y N                   L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                   R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                   L. Lat. Flex.    N     Y N



ROM Internal rotation of hip with knees flexed is painful / Sacroiliac asymmetry and
fixations are common.




Leg Length/Spinal Balance Normal to have leg discrepancy

Janice Fordree, D.C.                  Page 3                              8/19/2010
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Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion) Trigger points are palpable in the belly of the
muscle through the mass of the gluteus maximus muscle and the tendinous insertion
at the greater trochanter. Deep pressure of the muscle belly produces radiation
down course of sciatic nerve while pressure at the tendinous insertion produces
localized burning sensation. Tender at origin and insertion of piriformis

List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

       X-rays      MRI            CT        Other

Views A-P/Lateral Lumbopelvic


Findings    Unremarkable – may show possible increase in lordosis and the sacral
base angle.

NOTE – CT, MRI, x-ray, Myelography and EMG are of limited diagnostic value.




DIFFERENTIALS:

     Sciatica, Referred pain, Fracture, Myofascial pain syndrome, IVD syndrome,
Compression of nerve root lesions.

NOTE – Most unrecognized cause of sciatica.



DIAGNOSIS:
             Piriformis Syndrome

Janice Fordree, D.C.                 Page 4                          8/19/2010
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Case Management:

Chiropractic Management:           Various techniques can be used to correct the
vertebral subluxation - Thompson, Pierce, and SOT are some of the more common
techniques to use for this condition.

Adjunctive Therapy:




Physical Therapy: Acute phase – ice, ultrasound (pulsed) and galvanism may be
used. Hip or contra lateral sacroiliac fixations should be adjusted. – caution is
advised against repeat non specific pelvic manipulation since this tends to
perpetuate the condition. Sub acute phase – moist hot packs, ultra-sound electrical
muscle stim combination, muscle work including trigger points and manipulation.

Nutrition:   Magnesium and calcium



Exercise:   Piriformis stretch, PIR stretch technique (Post isometric relaxation),
McKenzie extension exercises.


Health Promotion and Maintenance (i.e. ergonomics, spinal hygiene, psychosocial
concerns/education)      -get adequate rest on a firm mattress
                         -avoid heavy lifting or bending postures
                         -sleep supine with pillows under knees or on side with
pillow between legs
                         -perform piriformis stretch as instructed


Further Evaluation:        Indications that a referral may be need are true
anesthesia, loss/reduction of hamstring or Achilles tendon reflex,. Signs of
progressive atrophy or no improvement or increase in severity (failure to respond).
Referral would be to neurologist.

Common Medical Management: Include physical therapy, deep massage, ROM
exercises, NSAID’s (non-steroid inflammatory meds such as ibuprofen or naproxen),
a local anesthetic and corticosteroid injections. For persistent piriformis spasms an
injection of botulinum toxin (aka – “bo tox”) may be used.


Janice Fordree, D.C.                 Page 5                             8/19/2010
Approved 04/08/04
Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.




Condition Name      Baseline   Complicating/ Mitigating Factors         Revised
                    Complexity                                          Complexity
Piriformis Syndrome    3.0     Risk factor of prolonged overuse,           4.0
                               prolonged sitting, prolonged
                               external rotation of leg, leg length
                               discrepancy
                               Risk factor of hormone changes,              4.0
                               pregnancy and menopause
                               Risk factor of need for referral             6.0
                               include hamstring and Achilles
                               tendon reflex loss/reduction,
                               progressive atrophy and no
                               improvement and/or increase in
                               severity




Janice Fordree, D.C.                Page 6                            8/19/2010
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                            CLINICAL APPLICATIONS
                          Faculty Case Study Preparation


CONDITION___Spondylolisthesis__________________________________

Prepared by: _____Janice H. Fordree ______________________________

RELEVANT PATHOPHYSIOLOGY:

Spondylolisthesis is a medical term that refers to a slippage of one vertebral body
over another. This most commonly involves the fourth and fifth lumbar or the fifth
lumbar and first sacral vertebral bodies. There are a number of reasons for the slip,
one of, which is called spondylolysis. Spondylolysis is another name for isthmic
spondylolisthesis. In these cases, there is a defect in a portion of the spine called the
"pars interarticularis", on x-rays, it is seen as the neck of the "Scotty dog".
Spondylolisthesis is the most common cause of back pain in adolescents but most
cases are asymptomatic. Symptoms when they occur often begin with the growth
spurt. When symptoms occur, the course can be slow, progressive and severe. Long
asymptomatic periods are common.


Dysplastic/Congenital: inadequate development of the posterior elements without
slippage is spondylolysis. More common in women – usually occurs during growth
spurt. 14-21% of cases.
Isthmic: a break of the pars interarticularis as a result of a fatigue fracture (most
common), acute trauma (rare) or repeated micro trauma leading to elongation. More
common in men and in about half of the cases there is no slippage in 5-20% of
cases seen.
Degenerative: a break in the pars interarticularis as a result of erosive pressure
from the superior articular facet below and the inferior articular facet above. More
common in women and occurs after 40 years of age. Degenerative
spondylolisthesis is usually a result of long standing instability most common at the
junction of the 4th and 5th lumbar. The instability is a result of disc degeneration and
facet joint degeneration.
Traumatic: a break in the neural arch as a result of acute trauma to any area other
than the pars interarticularis.
Pathologic: destructive lesion to the pars interarticularis as a result of dysplasia,
carcinoma, metastasis, severe osteoporosis, Paget’s disease or others. This is the
least common cause.




CASE HISTORY:


Janice Fordree, D.C.                   Page 1                             8/20/2010
Approved 06/03/04
PPW: The most common symptom of spondylolisthesis is pain. The exceptions are
the degenerative, traumatic and pathologic types of spondylolisthesis. There are to
types of pain seen in cases of spondylolisthesis. One is a sciatic type of pain with
radiation (spread) to the buttock, back of the thigh and calf. This is due to stenosis of
the lateral recess (the area of the spine where the nerve exits). This type of pain
may be mistaken for a lumbar disc herniation. The second pain presentation in
spondylolisthesis is claudication type pain. While claudication means limping, the
pain is generally related to activity, walking or prolonged standing. The pain in these
cases is located in the back, buttocks, thighs or calves. It improves with rest, either
sitting or lying down.


Onset-Initial Findings often vary and are inconsistent – activities that require
extension/flexion movements increase incidence (rowing, gymnastics, etc.)
        Palliative/Provocative
Provocative: Increase LBP with hyperextension of the lumbar spine, activity or
upright posture.
Palliative: It improves with rest, either sitting or lying down.
      Quality/Quantity
      Referred/Radiating Back, buttocks, thighs or calves.
      Site L5 – 90%, L4 - 5%, L1-L3 – 3%, C5-C7 – 2%
      Timing/Pattern During activities that require repetitive extension/flexion,
walking or prolonged standing.
      Other

Relevant History and Lifestyle
      Gender       2:1 ratio males to females
      5-7% Caucasian 40% Eskimo population

      Age Toddlers - shortly after beginning to walk with repeated falls , especially if
premature walking occurs
       Ischemic occurs in 5-6 years old, Translations in 10-14 year olds,
degenerative occurs in the elderly.
      Occupation Activities or sports that require repetitive extension/flexion
movements, gymnastics, diving, pee wee football, weight lifters, pregnancy, etc.
      Traumas
      Surgeries
      Medications
      Hospitalizations
      Immunizations
      Diseases or Conditions__________________________________ _
      Family History
      Diet
      Sleep Habits
      Sexual History
      Alcohol Usage
Janice Fordree, D.C.                   Page 2                              8/20/2010
Approved 06/03/04
         Drug Usage
         Smoking/Tobacco
         Other__________________________________________________


Review of Systems                                                  _____

PHYSICAL EXAMINATION:

Height                           Weight

Vitals: BP             Pulse              Respiration________ Temp.

Appearance, Motion, Gait

Orthopedic Tests

      Test Name             R       L             Test Name             R       L
                           + -     + -                                 + -     + -
                           + -     + -                                 + -     + -
                           + -     + -                                 + -     + -
                           + -     + -                                 + -     + -
                           + -     + -                                 + -     + -

Orthopedic Test Results Discussion:      All negative unless acute trauma or
inflammation.



Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception ___Hypo/hyper DTRs possible, in rare cases
paresthesia over the lumbar nerve root dermatome pattern. __________________

LabValues__________________________________________________________
__

Examination of Related Areas



Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




Janice Fordree, D.C.                  Page 3                           8/20/2010
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SPINAL EXAMINATION:

      Postural Analysis                      Postural Analysis     L      N        R
                                             Head Tilt
      Hypolordosis in lumbars.               Head Rotation
                                             High Ear
                                             High Shoulder
                                             High Ilium
                                             Ext. Rotated Foot
                                             Int. Rotated Foot


ROM
             Cervical ROM                                Lumbar ROM
               ROM      Pain     Level                    ROM     Pain            Level
Flexion        N      Y N              Flexion          N     Y N
Extension      N  Y N                  Extension        N     Y N
R. Rotation    N  Y N                  R. Rotation      N     Y N
L. Rotation    N  Y N                  L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                  R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                  L. Lat. Flex.    N     Y N


Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion) Para spinal muscle spasms, tight hamstrings,
Chronic muscle spasms or myofascitis common, possible protrusion of spinous
process with depressed spinous at segment immediately above.


List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

       X-rays       MRI         CT           Other SPECT

Views A-P, Lateral, A-P spot shot, Flexion/extension and oblique views.


Findings A-P = L5 body over sacrum creates appearance of inverted “Napoleon Hat”
sign.
Janice Fordree, D.C.                Page 4                             8/20/2010
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         A-P spot shot = better view of L5/S1 disc space
               Flexion/extension = rule out instability
               Obliques = see “collar” on Scottie dog and “step ladder” sign which
indicates misalignment of zygapophyseal joints at involved level.
                      Lateral = Meyerding Grading scale – as follows

               Grade I = 1-25% slippage
              Grade II = 25-50% slippage
              Grade III = 50-75 % slippage
              Grade IV = 75-100 % slippage
              Grade V = complete slippage of vertebral body in relation to segment
below.

Spondylosis – will see lucent defect in pars
Spondylolisthesis – will see lucent defect in pars with forward slippage.

SPECT – single photon emission tomography – used to distinguish athletic patients
who require an antilordotic brace and rest from those who do not have an “active”
lesion. Nuclear medicine with computerized tomography.


DIFFERENTIALS:

N/A


DIAGNOSIS:

         Spondylolisthesis


CASE MANAGEMENT:


Chiropractic Management: Grade I or II:
- specific spinal manipulation at dysfunctional joints above and/or below
- adjust S/I joints
- flexion distraction technique
- sacral pull (bilateral knees to chest)
- Nimmo
- Cox Distraction
- Pierce PI (adjust PI supine)
- Thompson supine pelvic adjustments

Side posture ? – no prone adjustments @ site



Janice Fordree, D.C.                  Page 5                                8/20/2010
Approved 06/03/04
“Hot” SPECT bone scan – place in a brace for several weeks with follow up bone
scan.


Adjunctive Therapy:         Lumbar belt for bracing



Physical Therapy:_Acute = interferential , TENS ultrasound and cryotherapy
_______________Chronic = diathermy, ultrasound____________________
Lumbar traction, COLD laser therapy

Nutrition:


Exercise: Knee to chest stretches/ Pelvic tilt / Adductor stretch / hamstring stretch /
iliopsoas stretch / Bridging stabilization / Core strengthening exercises – especially
lower abdomen / massage / positional release therapy


Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education): Postural education / lifting education_______________
________________________________________________________________

Further Evaluation:


Common Medical Management: The treatment of spondylolisthesis is complex and
depends on the presentation (the signs and symptoms). In adolescent cases of
isthmic spondylolisthesis (spondylolysis), the x-ray and bone scan may help decide
the type of treatment. If the bone scan is positive ("lights up"), a trial of bracing may
be successful. Other forms of conservative treatment include rest and physical
therapy.
Surgical treatment is divided into two possible approaches, decompression and
decompression with fusion. Decompression without fusion is generally avoided as it
may lead to further slip and progressive problems. Most surgical procedures include
both decompression and fusion. Fusion may be done in situations where no attempt
is made to reduce (correct) the slip. In some cases, an attempt may be made to
reduce the slip to create a more "normal" appearance to the spine. Frequently, some
type of fusion instrumentation will be implanted along with bone graft. The surgeon
will decide on the specific type of surgery after taking into account the patients
symptoms and the appearance of the various imaging studies.
References: _Vizniak & Carnes : Quick Reference Clinical Chiropractic Conditions
Manual

Janice Fordree, D.C.                   Page 6                               8/20/2010
Approved 06/03/04
Huff & Brady: Instant Access to Chiropractic Guidelines and Protocols
___________________________________________________________________



Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.


Condition Name    Baseline      Complicating/ Mitigating Factors           Revised
                  Complexity                                               Complexity
Spondylolisthesis    3.0        Symptomatic                                   4.0
                                Dysplastic/Congenital                         5.0
(Asymptomatic)                  Isthmis/Traumatic (break due to               6.0
                                trauma)
                                Degenerative (results in disc                  7.0
                                degeneration and or facet joint
                                degeneration)
                                Pathologic (destructive lesion as a            7.0
                                result of carcinoma, metastasis,
                                severe osteoporosis, Paget’s disease
                                or others).
                                Risk factor for activities that require        6.0
                                repetitive extension/flexion, prolonged
                                walking and prolonged standing
                                (gymnastics, diving, pee wee football,
                                weight lifters, pregnancy).
                                Grade I (1-25% slippage)                       4.0
                                Grade II (26-50% slippage)                     5.0
                                Grade III (51-75%)                             6.0
                                Grade IV (76-100%)                             7.0
                                Grade V (complete slippage of                  8.0
                                vertebral body in relation to segment)
                                Chiropractic management –                      6.0
                                contraindications to adjustment and
                                use of specific techniques.




Janice Fordree, D.C.                Page 7                                8/20/2010
Approved 06/03/04
                           CLINICAL APPLICATIONS
                          Faculty Case Study Preparation


CONDITION Tigeminal Neuralgia AKA; Tic doulourex, Fothergill’s neuralgia, Trifacial
neuralgia
   1. Idiopathic
   2. Secondary-MS, Tumor, Vascular malformation

Prepared by: Robert Irwin, D.C.


RELEVANT PATHOPHYSIOLOGY:

Trigeminal neuralgia is a pain syndrome of the face due to a disorder involving the
trigeminal nerve. The incidence is 4/-5/ 100,000 and affects females’ 3:2 over males.
The patient is usually over fifty and rarely under thirty-five.

The mechanism of pain has many theories and is controversial, the three most
common are:
   1. compression of trigeminal nerve due to artery or vein in the posterior fossa
      (superior cerebral artery)
   2. Nerve root irritation near the pons from anurysms, tumors, chronic meningeal
      inflammation or other lesions
   3. Multiple Sclerosis(usually in younger patients)

Trigeminal Nerve :
      Sensory: V1 (Opthalmic), V2 (maxillary), V3(mandibular). Provides
             sensation to the anterior 2/3s of tongue
      Motor: V3 Branch provides innervation to the masseter, temporalis, lateral
             and medial pterygoid, anterior belly digastric, mylohyoid, and tensor
             tympani/veli palatine muscles.

The pain is severe and is usually on the right 5:1 and rarely bilateral . The chronic
patient is often distraught and may be considering suicide.

CASE HISTORY:

PPW:          Excruciating face pain,

Onset-Initial Sudden
Palliative/Provocative: Prov= touching the skin, brushing teeth, shaving, blowing
              nose, or cold air   Pall= nothing
Quality/Quantity:    Severe stabbing shock like electrical pain often progressive




Robert Irwin, D.C.                      Page 1                            8/20/2010
Approved 03/14/05
Referred/Radiating corner of the mouth to angle of jaw, ear,eye,or nose on same
               side
Site: side of face lips and cheek
Timing/Pattern: several times a day lasting for only a minute or two
Other: watery right eye at times and sometimes face flushes and facial muscle
               spasm (tic)

Relevant History and Lifestyle
      Gender: Female
      Age: 52 (usually over 50)
      Occupation: No Significant Findings
      Traumas: No Significant Findings
      Surgeries: No Significant Findings
      Medications : No Significant Findings
      Hospitalizations: No Significant Findings
      Immunizations: No Significant Findings
      Diseases or Conditions: No Significant Findings
      Family History : No Significant Findings
      Diet: No Significant Findings
      Sleep Habits: No Significant Findings
      Sexual History: No Significant Findings
      Alcohol Usage: No Significant Findings
      Drug Usage : No Significant Findings
      Smoking/Tobacco: No Significant Findings
      Other: No Significant Findings


REVIEW OF SYSTEMS                  All WNL

PHYSICAL EXAMINATION:

Height : No Significant Findings
Weight: No Significant Findings

Vitals:      BP : No Significant Findings
             Pulse: No Significant Findings
             Respiration: No Significant Findings
             Temperature : No Significant Findings


Appearance, Motion, Gait : Normal




Robert Irwin, D.C.                   Page 2                          8/20/2010
Approved 03/14/05
Orthopedic Tests

      Test Name              R             L               Test Name          R            L
                           +     -     +       -                             +     -   +       -
                           +     -     +       -                             +     -   +       -
                           +     -     +       -                             +     -   +       -
                           +     -     +       -                             +     -   +       -
                           +     -     +       -                             +     -   +       -

Orthopedic Test Results Discussion:                      no positives

Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception : Within Normal Limits
LabValues: WNL
Examination of Related Areas: WNL
Other Findings:     (Vascular, EENT, Cranial Nerves, Percussion, Palpation,
                    Auscultation, etc.):       WNL

SPINAL EXAMINATION:

Postural Analysis      L       N       R
Head Tilt
Head Rotation
High Ear
High Shoulder
High Ilium
Ext. Rotated Foot
Int. Rotated Foot

ROM
             Cervical ROM                                          Lumbar ROM
               ROM      Pain         Level                          ROM     Pain       Level
Flexion        N  Y N                            Flexion          N     Y N
Extension      N  Y N                            Extension        N     Y N
R. Rotation    N  Y N                            R. Rotation      N     Y N
L. Rotation    N  Y N                            L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                            R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                            L. Lat. Flex.    N     Y N


Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion)

Robert Irwin, D.C.                      Page 3                               8/20/2010
Approved 03/14/05
List the level for palpation findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

         X-rays      MRI           CT         Other

Views                      Not indicated but would be negative for pathologies

Findings: No Significant Findings

DIFFERENTIALS:

MS, usually suspect only in young payents.
TMJ Syndrome pain is less severe and uaually associated with dental issues
Atypical face pain, younger females (30-50) and pain is constant and burning,
Glossopharyngeal neuralgia, pain is inside the mouth (tounge, tonsils, throat or
sometimes ear)
 compression of trigeminal roots from tumors or aberrant vessels,
 Migraine,
 Chronic meningitis
 Herpes Zoster-prior to lesions


DIAGNOSIS:

350.1 Trigeminal Neuralgia


Robert Irwin, D.C.                    Page 4                            8/20/2010
Approved 03/14/05
Case Management:


Chiropractic Management:
These papers and presentation discuss the efficacy of chiropractic adjustments
in both the lower cervical spine as well as the upper cervical spine.
 SOT Cranial analysis should also be considered.

There is of course a lot of anecdotal evidence for chiropractic care through out the
profession. The author has had several cases over the years respond well to specific
adjustments. Certainly enough evidence exists to warrant further investigation and to
examine the patient presenting with TN and adjust the site of subluxation.


Adjunctive Therapy:        Acupuncture


PhysicalTherapy: TENS unit for pain. Microcurrent for healing

Nutrition:

Exercise:

Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene,
psychosocial concerns, education): Patient dependant

Further Evaluation:

Common Medical Management:
 Carbamazepine-for pain
Implant electric stim device

Surgery: 1. microvasular decompression
         2. Radiofrequency rhizotomy/denervation of facet joint nerve supply. Use is
reserved for those with limited life expectancy.




Robert Irwin, D.C.                   Page 5                            8/20/2010
Approved 03/14/05
REFERENCES:
Vizniak N, Carnes M, Quick Reference Clinical Chiropractic ConDC Publishing,
2004ditions Manual
Souza T, Differential Diagnosis and Management for the Chiropractor, 2nd ed. Aspen
Publishers Inc. 2001
Eriksen K, Upper Cervical Subluxation Complex, 1st ed. Lipincott Williams & Wilkins
2004
. JD Grostic, Dentate Ligament-Cord Distortion Hypothesis Chiropractic Res J,1988;
1(1):47-55.
R. Hinson Upper Cervical Neurology and TN presented at The 16th annual Upper
Cervical Spine conference 1999
R. Hinson, s Brown Chiropractic management of TN 130th annual Meeting of the
American Public Health Association 2002
G Weigel, KF Casey, Striking Back! The trigeminal Neuralgia Handbook 2000



Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.




Condition Name        Baseline     Complicating/ Mitigating Factors     Revised
                      Complexity                                        Complexity
                                   Suicidal thoughts and tendancies        7.0
                                   Pain regulated by E-Stim.               5.0
                                   Pain management/ Co-                    4.0
    Trigeminal            3.0      management
    Neuralgia




Robert Irwin, D.C.                  Page 6                            8/20/2010
Approved 03/14/05
Brain Aneurysm

By Utasha Watkins




   Author: Utasha Watkins
    Approved 31May06
                Definition
• A brain aneurysm is a localized dilation of
  an artery in the brain caused by a
  weakness in the arterial wall. It is also
  known as intracranial or cerebral
  aneurysm.




                 Author: Utasha Watkins
                  Approved 31May06
        Cerebral Aneurysms
• Involve the anterior and posterior
  circulation or vertebrobasilar circulation.
• Anterior circulation aneurysms arise from
  the internal carotid or its branches.
• Posterior circulation aneurysms come from
  the vertebral artery, basilar artery, or any
  of their branches.


                 Author: Utasha Watkins
                  Approved 31May06
         Intracranial Aneurysm

• These are named after the segment of origin.
• Examples include the following: anterior
  communicating aneurysms come from anterior
  communicating artery and posterior
  communicating aneurysms come from the
  internal carotid which is near the posterior
  communicating artery
• Intracranial aneurysms are either nonsaccular or
  saccular.

                   Author: Utasha Watkins
                    Approved 31May06
  Nonsaccular versus saccular
• Nonsaccular and saccular relate to size
  and shape of the aneurysm
• Nonsaccular types are atherosclerotic,
  fusiform, traumatic, and mycotic .
• Saccular types or berry types have other
  anatomical forms.
• They come from bifurcations of arteries or
  along a curve of an artery.
                 Author: Utasha Watkins
                  Approved 31May06
          Pathophysiology
• Many theories have been developed but
  only one is supported scientifically.
• Most pathogenic factor is mural
  degeneration in regions of hemodynamic
  stress.




                Author: Utasha Watkins
                 Approved 31May06
         Pertinent Findings
• Include history, physical examination,
  laboratory, spinal examination, x-
  ray/imaging studies, and other pertinent
  data




                 Author: Utasha Watkins
                  Approved 31May06
         History/Physical Exam of
          Unruptured Aneurysm
•   Patient presents with peripheral vision deficits
•   Thinking or processing problems
•   Speech complications
•   Perceptual problems
•   Sudden changes in behavior
•   Loss of balance and coordination
•   Decreased concentration
•   Short-term memory difficulty
•   Fatigue

                      Author: Utasha Watkins
                       Approved 31May06
    History/Physical Exam of ruptured
               aneurysm
•   Patient presents with worst headache of life
•   Nausea and vomiting
•   Stiff neck or neck pain
•   Blurred vision or double vision
•   Pain above and behind the eye
•   Dilated pupils
•   Sensitivity to light
•   Loss of sensation

                     Author: Utasha Watkins
                      Approved 31May06
                 History Continued
•   Onset- Patient may or may not know when aneurysm occurs. They
    will know when it ruptures due to severe headache.
•   Palliative- Nothing generally makes it better. Lack of movement of
    head and neck may help.
•   Provocative- Movement of the head and neck may make it worse.
•   Quality/Quantity- On a scale of 1 to 10, the headache will be a 10.
    The pain will be a throbbing one.
•   Radiates- pain will occur in the head and may radiate into the neck.
•   Site- head and neck
•   Timing- Pain will most likely occur continuously from onset.




                            Author: Utasha Watkins
                             Approved 31May06
              Laboratory
• If an aneurysm is suspected a lumbar
  puncture can be done.
• Blood should be found along with
  cerebrospinal fluid.
• Lumbar puncture is used as a screening
  test.



                Author: Utasha Watkins
                 Approved 31May06
             Spinal Exam
• Patient will have stiff neck or neck pain
• Positive orthopedic tests may include the
  following: Compression, Jackson’s
  Compression, Maximum Cervical
  Compression, George’s, Dekleyn’s, and
  Bikele’s sign.
• Any orthopedic test that places pressure
  on the skull and spine could elicit a
  positive response
                 Author: Utasha Watkins
                  Approved 31May06
        X-ray/Imaging Studies
• Plain radiography is not used.
• Computerized Tomography- works for 90% of
  the cases. Shows size and shape of aneurysm.
• Magnetic resonant imaging- shows size and
  shape of aneurysm
• Transcranial Doppler ultrasound- detects
  vasospasm of intracranial arteries
• Cerebral angiography- is a preoperative
  diagnostic instrument for intracranial aneurysms.
                   Author: Utasha Watkins
                    Approved 31May06
   Other Pertinent Data/Relevant
       History and Lifestyle
• These include-gender, age, occupation,
  traumas, surgeries, medications, family
  history, social history, alcohol and drug
  usage, smoking or tobacco usage, and
  other diseases.




                 Author: Utasha Watkins
                  Approved 31May06
          Gender and Age
• Women are more likely to get brain
  aneurysms than men 3:2.
• Brain aneurysms can occur at any age,
  but most of them occur between the ages
  of 35 to 60.




                Author: Utasha Watkins
                 Approved 31May06
     Occupation, Traumas, and
            Surgeries
• Occupation does not relate to this
  condition.
• Traumas- none mentioned at this time.
• Surgeries- none mentioned at this time.




                 Author: Utasha Watkins
                  Approved 31May06
Medications and Family History
• The use of analgesics is a risk factor.
• Genetics can predispose a person to this
  condition.
• Hypertension is a genetic risk factor for
  this condition.




                 Author: Utasha Watkins
                  Approved 31May06
   Social History, Diet, and Sleep
               Habits
• Social history was not discussed.
  However, exercise can reduce blood
  pressure.
• Diet- eating a healthy diet can reduce
  blood pressure.
• Sleep habits- were not mentioned.



                 Author: Utasha Watkins
                  Approved 31May06
  Sexual history, alcohol and drug
       usage, and smoking
• Sexual history has no relevance to brain
  aneurysm.
• Alcohol and drug usage do not have any
  affect.
• Smoking is a risk factor for a brain
  aneurysm.



                 Author: Utasha Watkins
                  Approved 31May06
           Other Diseases
• Patients with connective tissue disorders
  such as Marfan syndrome, Ehlers-Danlos
  syndrome, polycystic kidney disease,
  coarctation of the aorta, and intracranial
  arteriovenous malformations have an
  increased chance of brain aneurysms.



                 Author: Utasha Watkins
                  Approved 31May06
              Differentials
• The differentials could include stroke,
  transient ischemic attack, temporal
  arteritis, and subdural hematoma.




                  Author: Utasha Watkins
                   Approved 31May06
              Diagnosis
• Diagnosis could come from a lumbar
  puncture, CT scan, Cerebral angiography,
  or MRI. These were mentioned earlier in
  the x-ray and special imaging section.




                Author: Utasha Watkins
                 Approved 31May06
          Case Management
• As a chiropractor, you should refer out
  immediately. The patient should go to the
  emergency room. Time is of the essence.
• Patient will most likely die if left untreated.




                   Author: Utasha Watkins
                    Approved 31May06
                 Treatment
• Surgeons clamp off the artery before the
  unruptured aneurysm. If aneurysm is ruptured,
  surgeons restore respiration and reduce cranial
  pressure. Surgery is performed within three
  days and a clip is placed on the rupture to stop
  bleeding.
• Guglielmi Detachable Coils- Some patients can
  not undergo extensive surgery. These patients
  have a catheter placed in their femoral artery.
  The catheter is advanced until it reaches the
  internal carotid or vertebral artery. A coil is
  placed inside the aneurysm and closes it off.
                   Author: Utasha Watkins
                    Approved 31May06
          Other Treatments
• Bed rest, drug therapy, and hypertensive-
  hypervolemic therapy.




                 Author: Utasha Watkins
                  Approved 31May06
                  Prognosis

• The depends on the size and extent of
  aneurysm, person’s age, previous health, and
  neurologic condition.
• Brain aneurysms can lead to a stroke (#3 killer in
  America). There are placebo treatments for this
  condition now. A study was done by Richard
  Libman. Some patients were given
  antithrombolytic drugs and others were given
  nothing. 72% of the placebo group improved
  whereas 76% of the control group improved.
                   Author: Utasha Watkins
                    Approved 31May06
                   References
• 1 http://www.emedicine.com/radio/topic92.htm
• 2 http://www.brainaneurysm.com/aneurysm-
  treatment.html
• 3 http://www.wfubmc.edu/interneuro/aneurysmdes.html
• 4
  http://www.americanheart.org/presenter.jhtml?identifier=
  4457
• 5
  http://www.ninds.nih.gov/disorders/cerebral_aneurysm/c
  erebral_aneurysm.htm
• 6 http://stroke.ahajournals.org/cgi/content/full/31/2/355

                      Author: Utasha Watkins
                       Approved 31May06
Brain Aneurysm

              Created By Porche C. Gourdine
            Edited by Dr. Laura Greene-Orndorff




8/20/2010             Approved: 31May06
What is a Brain
Aneurysm?
• A brain aneurysm is a weak bulging
  spot on the wall of a brain artery very
  much like a thin balloon or weak spot on
  an inner tube. Aneurysms form silently
  from wear and tear on the arteries, and
  sometimes can form from injury,
  infection, or inherited tendency

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Two types of aneurysms
• Unruptured
• Ruptured (AKA subarachnoid
  hemorrhage)




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Pathophysiology
• When a brain aneurysm ruptures, it causes bleeding
  into the subarachnoid space around the brain. This
  causes a subarachnoid hemorrhage (SAH). Often the
  aneurysm heals over, bleeding stops, and the person
  survives. If bleeding continues, hemorrhage into the
  subarachnoid space causes immediate elevation of
  intracranial pressure, decreasing cerebral perfusion
  and often results in a transient loss of consciousness.
  Delayed effects of SAH include vasospasm, which
  can lead to brain infarctions and communicating
  hydrocephalus. In more serious cases, the bleeding
  may cause brain damage with paralysis or coma. In
  the most severe cases the bleeding leads to death.

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Symptoms

• Most brain aneurysms cause no
  symptoms and may only be discovered
  during tests for another, usually
  unrelated, condition.
• However, if there were…..



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Symptoms
Unruptured Aneurysm
• Peripheral vision deficits
• Thinking or processing problems
• Speech complications
• Perceptual problems
• Sudden changes in behavior
• Loss of balance and coordination
• Decreased concentration
• Short-term memory difficulty
• Fatigue
8/20/2010           Approved: 31May06
Symptoms
Ruptured brain aneurysm (subarachnoid hemorrhage)

•   Localized Headache- "the worst headache in my life“
•   Nausea & Vomiting
•   Stiff Neck
•   Blurred or Double Vision
•   Sensitivity to Light (photophobia)
•   Loss of Sensation
•   Seizures


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Patient Presents With…

A 42 years old African American
  Female presents with:
• “The worst headache in her life“
• Nausea & Vomiting
• Stiff Neck
• Blurred Vision
• Photophobia
• Loss of Sensation in arms
8/20/2010      Approved: 31May06
OPQRST

O- A couple of days before. “Never experienced
  headache this severe in lifetime”
Pall- keeping head still
Prov- lights
Q- severely achy headache, about a 10
R- stays generally in the head
S- frontal area of skull, behind eye
T- constant pain that seems to get worse
8/20/2010        Approved: 31May06
Contributing Factors

•   Smoking
•   Traumatic Head Injury
•   Use of Alcohol
•   Use of Oral Contraceptives
•   Family History
•   Other Inherited Disorders: Ehler's Syndrome,
    Polycystic Kidney Disease, and Marfan's
    Syndrome

8/20/2010          Approved: 31May06
Contributing Factors

• Infection
• Previous aneurysm.
• Gender. Women are twice likely as
  men.
• Race. African-Americans twice as likely
  as whites.
• Hypertension Atherosclerosis
• Age- most common in 35-60 year olds
8/20/2010      Approved: 31May06
Physical Exam

• High Blood Pressure
• Possible Dizziness or Decreased
  Consciousness




8/20/2010     Approved: 31May06
Orthopedic Test

No Positive Findings




8/20/2010      Approved: 31May06
Neurological Test

• Inability to perform all cardinal points of
  gaze
• Non-reactive pupil(s) during
  Direct/Consensual Test




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Examinations of Related
Areas
• There may be signs of increased
  pressure within the brain (raised
  intracranial pressure) including swelling
  of the optic nerve (papilledema) or tiny
  hemorrhages into the retina of the eye,
  which are evident on careful eye
  examination.

8/20/2010       Approved: 31May06
Lab Test

This disease may also alter the results of
 CPK isoenzymes.




8/20/2010       Approved: 31May06
Spinal Exam

Stiff cervicals and limited ROM due to
  discomfort




8/20/2010      Approved: 31May06
Detection Methods

• Lumbar puncture that shows blood.
• CTA (Computed Tomographic Angiography)
• MRI (Magnetic Resonance Imaging)
• MRA (Magnetic Resonance Angiography)
• Angiogram (Arteriogram)
*angiograms use contrast dye to view vessels



8/20/2010        Approved: 31May06
Detection Methods
•   CT Scan (Computed Tomography)
     • CT usually is the initial diagnostic procedure. A good-quality
       nonenhanced CT scan can depict SAH (Subarachnoid
       hemmorage) in more than 90% of patients, if they undergo
       scanning within 48 hours and depending on the location and
       extent of the subarachnoid blood and the time elapsed since
       ictus. The location of the subarachnoid blood identifies the
       presumed location of the ruptured aneurysm, a finding often
       supported by the demonstration of an aneurysm in the area
       of maximum clot localization or maximum amount of
       subarachnoid blood.




8/20/2010                 Approved: 31May06
Detection Methods
• CT Scan (Computed Tomography)
    • In particular, CT is useful when multiple aneurysms are present in
      one patient. In addition to indicating the location of the vascular
      lesion, the CT scan can show unsuspected anomalies, such as a
      related arteriovenous malformation, intraparenchymal hematoma,
      or hydrocephalus. Finally, by providing a quantitative measure of
      the amount of blood in the subarachnoid cisterns and ventricles, the
      initial CT scan provides a reliable predictive index that can be used
      to identify patients who are likely to have a vasospasm. Most often,
      the Fisher grading system is used to classify SAH; this system is
      based on the amount of blood visible on the CT scan. The Fisher
      grading system is as follows:
    • Grade 1 - No subarachnoid blood detected
    • Grade 2 - Diffuse vertical layers thicker than 1 mm
    • Grade 3 - Localized clot and/or vertical layer thicker than 1 mm
    • Grade 4 - Intracerebral or intraventricular clot with diffuse or no
      subarachnoid blood


8/20/2010                  Approved: 31May06
Detection Methods
•   MRI (Magnetic Resonance Imaging)
          MRI can provide additional details about the regional
    anatomy and the size, shape, and content of an aneurysm. Most
    intracranial aneurysms appear as an area of flow void larger
    than the healthy vessels in that region. Their interior usually
    enhances significantly after the intravenous administration of
    gadolinium–diethylenetriamine pentaacetic acid. Most giant
    aneurysms have calcifications and an intraluminal clot, but their
    residual lumen may be depicted as a region of flow void. The
    thrombosed areas may have variable signal intensity, which
    represents blood products at different stages. MRIs also can
    depict small amounts of parenchymal blood that can surround
    the aneurysms; this finding indicates which of the multiple
    aneurysms have bled.




8/20/2010                 Approved: 31May06
Detection Methods
• MRA (Magnetic Resonance Angiography)
    • MRA is useful in detecting intracranial aneurysms in both
      symptomatic patients and asymptomatic patients. In the
      former, MRA is noninvasive and sensitive in testing for an
      aneurysm in a high-risk population (ie, patients with
      polycystic renal disease, those with 1 or more first-order
      family members with documented cerebral aneurysms). In
      the symptomatic patient, MRA often reveals the site of
      aneurysmal dilation. Of the 2 main types of MRA, time-of-
      flight, or in-flow, techniques are used more often than
      phase-sensitive, or phase-contrast, techniques. For both
      types of sequences, a large set of axial source images are
      acquired; these are then reformatted into images that
      appear similar to conventional angiograms. The most
      common method used is the maximum intensity projection
      (MIP) method.

8/20/2010               Approved: 31May06
Detection Methods
• Angiogram (Arteriogram)
    • Cerebral angiography remains the definitive preoperative
      diagnostic tool in patients with intracranial aneurysms.
      Angiography also can be used to detect and evaluate
      aneurysmal multiplicity or other associated vascular
      diseases, to assess collateral circulation, to identify
      congenital anomalies, and to diagnose cerebral vasospasm
      and aid in their treatment.
    • A routine angiographic examination consists of a selective 4-
      vessel study, including both internal carotid and both
      vertebral arteries. This study enables the evaluation of the
      cerebral circulation to determine the source of SAH and to
      identify other concomitant lesions that may influence the
      surgical plan.



8/20/2010                Approved: 31May06
Differentials

•   Stroke
•   TIA
•   Brain Tumor
•   Subdural hematoma




8/20/2010      Approved: 31May06
Surgical Intervention
• Clipping-The aneurysm is blocked off with a tiny
  metal clip, which keeps blood from entering the
  aneurysm. This therefore prevents further bleeding
  and damage.
• Occlusion and Bypass – this is done by stopping
  the blood flow through the artery leading to the brain
  aneurysm and rerouting the blood to the part of the
  brain that had been fed by the damaged artery
• Endovascular Embolization or Coiling- the
  surgeon detects presence, size, and location of the
  aneurysm with an angiogram. After cutting and
  placing catheters inside the artery, a the coil system
  is introduced. This reduces or blocks the flow of
  blood into the aneurysm
8/20/2010            Approved: 31May06
Complications right
after surgery
• Blood Clots
• Swelling in the Brain
• Bleeding in the Brain
• Weakness
• Paralysis
• Loss of Sensation
• Loss of Vision
• Confusion
8/20/2010         Approved: 31May06
Complications right
after surgery
• Loss of Speech & Other Cognitive Functions
• Short-term Memory Problems
• Infections
• Vasospasm
• Seizures
• Hydrocephalus
• Stroke
• Death
8/20/2010        Approved: 31May06
Recovery

Post-Operative
 After treatment, most patients will spend a
 couple days in the Intensive Care Unit and
 will be monitored closely for complications.
 After a few days, the patient will be moved to
 a neurological floor within the hospital to
 determine how well the treatment worked and
 whether rehabilitation is needed.


8/20/2010        Approved: 31May06
Recovery
Evaluation
• Follow-up tests that may be done three to five
  days following the treatment.
• An angiogram may be performed to check
  the position of the coils or clips.
• A Doppler Test may be done daily to check
  for vasospasm.
• A CT Scan or an MRI will show if any
  bleeding or swelling in the brain has occurred
  after treatment.

8/20/2010         Approved: 31May06
Potential future
problems
•   Stroke
•   Partial or Complete Blindness
•   Peripheral Vision Deficits
•   Cognitive Processing Problems
•   Speech Complications

*Many of these problems decrease over time



8/20/2010         Approved: 31May06
Potential future
problems
• Perceptual Problems
• Behavioral Inconsistencies
• Loss of Balance & Coordination
• Decreased Concentration
• Short-term Memory Difficulties
• Fatigue
*Many of these problems decrease over time



8/20/2010       Approved: 31May06
Medications

• Pain killers/ anti-anxiety- headache relief
  and reduction intracranial pressure
• Antihypertensive medications- moderate
  reduction of blood pressure if it is very high.
• Phenytoin- prevention or treatment seizures.
• Nimodipine- prevents vasospasm




8/20/2010         Approved: 31May06
Chiropractic
Intervention
• There was no evidence to support
  chiropractic intervention of any kind.
• This condition is an emergency and the
  patient should be referred to an MD
  immediately.



8/20/2010      Approved: 31May06
Exercise/ Physical
Therapy
• Because of bed rest from the recovery of the
  surgery, patients are not as physically active
  as normal.
• Physical Activity in general is recommended
  to gain health and strength. However the
  patient should be careful while bending over
  and straining. A stool softener is given to
  prevent straining at stool.
• If there is damage to the motor parts of the
  brain, some physical therapy may be needed
8/20/2010         Approved: 31May06
Nutrition
• Potassium- decreases incidence of cerebrovascular
  disease. Also helps enzyme systems work efficiently
• Copper- for tensile strength of arteries
• Cut out food with high fats to prevent
  atherosclerosis, which could lead to an aneurysm




8/20/2010           Approved: 31May06
Prevention

• No known way to prevent the formation of a
  cerebral aneurysm.
• If discovered in time, unruptured aneurysms
  can be treated before causing problems. The
  decision to repair is based on the size and
  location of the aneurysm, and the patient's
  age and general health.
• Quit smoking and reduce alcohol intake

8/20/2010        Approved: 31May06
Prognosis
•   One in 15 people in the US will get one in their lifetime.
•   The annual incidence of aneurysmal subarachnoid hemorrhage
    in the U.S. exceeds 30,000 people. Ten to 15 percent of these
    patients will die before reaching the hospital and over 50
    percent will die within the first thirty days after rupture. Of those
    who survive, about half suffer some permanent neurological
    deficit
•   Statistics
    50% of those people die within minutes of a massive
    hemorrhage. Of the 50% who survive, half will suffer delayed
    death. The remaining survivors, depending upon the level of
    hemorrhage, usually live with severe long-term deficits.




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Resources

• http://www.nlm.nih.gov/medlineplus/ency/artic
  le/001122.htm
• http://www.bafound.org/info/detection.php
• http://www.diagnose-
  me.com/cond/C423942.html
• http://www.brainaneurysm.com/aneurysm-
  research.html
• Schievink WI. Intracranial aneurysms. New
  Engl J Med 1997; 336: 28-40
8/20/2010        Approved: 31May06
                          CLINICAL APPLICATIONS
                  Case Study Preparation – Suggested Format


CONDITION: Lumbar Canal Stenosis
Prepared by: Dr. Renee Prenitzer

RELEVANT PATHOPHYSIOLOGY:

Lumbar canal stenosis is usually associated with the aging process which can
include normal wear and tear on the spine. Lumbar Canal Stenosis can also be
predisposed genetically. During normal development the canal reaches the adult
size around the age of four. If the canal does not reach adequate size by then, it
never will, This type of stenosis will usually be general and occur throughout the
spine. This type of stenosis may result in lack of symptoms until further
pathophysiology occurs, for example osteophtes, trauma, and IVD problems.
Lumbar canal stenosis can be acquired through trauma, degeneration of the spinal
segments, soft tissue pathology involving the ligamentum flavum and most
commonly spondylosis.

CASE HISTORY:

PPW: Dull to severe aching pain in the lower back or buttocks that develops with
walking or other activity. Pain radiates into one or both thighs and legs. Symptoms
are relieved by sitting or lying down, and/or by bending at the waist, such as when
walking behind a shopping cart. In rare cases, patients can lose motor functioning in
the legs, bowels, or bladder.

Onset-Initial
      Palliative: Bending forward at the waist helps, sitting or lying down helps.
                 Placing foot on stool while bending forward is also a palliative
                 position.
      Provocative: Walking or exercising vigorously.
      Quality/Quantity: Leg pain or numbness that occurs with exercise, especially
                 prolonged walking.
      Referred/Radiating: Possible radiation down thigh.
      Site: Located in Low Back and Buttock region, can travel down thigh and leg.
      Timing/Pattern: Activity related. Symptoms usually subside after cessation of
                 activity within 15 to 20 minutes or with the assumption of a flexed
                 position.
      Other

Relevant History and Lifestyle:
             Gender         No specific gender affinity.
             Age Usually a degenerative condition seen in patients 60 years of
             age and older.

Renee Prenitzer                      Page 1                            8/19/2010
Approved 04/15/04
             Occupation
             Traumas
             Surgeries
             Medications
             Hospitalizations
             Immunizations
             Diseases/Conditions


             Family History
             Diet
             Sleep Habits
             Sexual History
             Alcohol Usage
             Drug Usage
             Smoking/Tobacco
             Other__________________________________________________


Review of Systems                                                       _____

           ______________________________________________________
___________________________________________________________


PHYSICAL EXAMINATION:

Height                               Weight
Vitals: BP          Pulse                         Respiration________ Temp.
Appearance, Motion, Gait

Orthopedic Tests

      Test Name              R             L              Test Name            R              L
Phalen Test                         +              Belt Test                    -                -
SLR                            -              -    Valsalva’s                   +involved side
Kemp’s                         +involved side      Hibb’s                       -              -
Well Leg Raiser                -              -    Braggard’s                   -                -
Minor’s Sign                   -              -    Milgram’s                    +involved side

Orthopedic Test Results Discussion: Phalen Test – Attempts to reproduce the
symptoms of leg pain, weakness, or numbness caused by neural ischemia. Patient
is upright and then bent into an extended position for 60 seconds. A positive test will
produce an progressive increase of the leg symptoms followed by rapid relief of
these symptoms when the patient flexes forward, places his hands on the
examination table, and places one foot on a stool.

Renee Prenitzer                           Page 2                              8/19/2010
Approved 04/15/04
Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception
Motor examination in both lower extremities is normal (however, mild weakness may
be present dependent on severity of stenosis and the length of involvement).
Sensory and reflex are normal as well.
NOTE: Motor/Sensory/Reflex findings may be inconsistent with symptom
experienced during exercise.


Lab Values


Examination of Related Areas


Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




SPINAL EXAMINATION:

      Postural Analysis                     Postural Analysis     L      N        R
                                            Head Tilt
                                            Head Rotation
                                            High Ear
                                            High Shoulder
                                            High Ilium
                                            Ext. Rotated Foot
                                            Int. Rotated Foot


ROM
             Cervical ROM                               Lumbar ROM
               ROM      Pain    Level                    ROM     Pain         Level
Flexion        N      Y N             Flexion          N     Y N
Extension      N  Y N                 Extension                Y          L4, L5, S1
R. Rotation    N  Y N                 R. Rotation      N     Y N
L. Rotation    N  Y N                 L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                 R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                 L. Lat. Flex.    N     Y N




Renee Prenitzer                    Page 3                             8/19/2010
Approved 04/15/04
ROM: Central Stenosis - May be limited in extension (with an increase in pain).
Flexion may decrease pain. Lateral Stenosis – May be limited in extension. Lateral
flexion and rotation to the involved side increases pain.

Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion)



List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




Renee Prenitzer                      Page 4                          8/19/2010
Approved 04/15/04
RADIOLOGICAL EXAMINATION:

         X-rays       MRI         CT              Other

Views: A-P Lumbar/ Lateral Lumbar, MRI, CT Scan, Myelogram can be used to
determine lumbar canal stenosis.

Myelogram: Involves injection of dye into the spinal sac where it mixes with CSF.
Any outward protrusion will block the flow of the dye. If this is done with the patient
in extension may offer the best information on location of stenotic areas

CT Scan: Most widely used test for evaluating the spine because it is noninvasive
and provides a three dimensional view. It is helpful for differentiating between hard
tissue and soft tissue. Used to evaluate for lateral stenosis and central stenosis

Findings: Einsensteins’s Method of analysis on Lateral Lumbar Film will indicate
possible canal stenosis if sagittal canal measurement is less than 15 mm.



Differentials:

Rule Out                          Rationale
                                  (defined: fixed claudication due to stenosis of the blood
                                  vessels) Differentiated by:
Vascular Claudication                                       -the bicycle test
                                                            -stoop test
                                  (defined: A condition of disk protrusion into and beyond the
                                  annulus fibrosus which may cause nerve root compression
, Disc Herniation                 and neurologic signs.
                                             Differentiated by:
                                                              MRI
                                  (defined: An anterior displacement of a vertebral body in
                                  relation to the segment immediately below. The displacement
                                  is a result of loss in continuity or elongation of the pars
, Spondylolisthesis               interarticularis.)
                                              Differentiated by:
                                                               -radiolographic findings


                                  (defined: A rotational compression injury of the richly
                                  innervated articular facets of the lumbar spine, characterized
                                  by local and/or referred pain arising from the zygapophyseal
                                  joints.
Facet Syndrome                               Differentiated by:
                                                             -radiographic findings of sclerosing
                                  of the facets:
                                                              -no osteophytes
                                                               -stress films may reveal abnormal


Renee Prenitzer                        Page 5                                     8/19/2010
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                                 joint locking

                                 (defined: Rapidly progressing neurologic defecits,)
                                             Differentiated by:
, Cauda Equina Syndrome                                     Loss of bowel and/or bladder
                                 function.

                                 (defined: A low back pain condition described as a
                                 compression or irritation of the sciatic nerve by a contracted or
                                 stretched piriformis muscle.)
Piriformis Syndrome                           Differentiaed by:
                                                             Palpation of the piriformis muscle
                                 and by presence of trigger point tenderness of the muscle
                                 adjacent to the sacrum




Note:

DIAGNOSIS:

Lumbar Canal Stenosis


CASE MANAGEMENT:

Chiropractic Management: Manual adjustments may be contraindicated.
Conservative, low-force adjustments may be utilized. If improvement occurs and
continues, then management can continue; however, if the condition continues to
deteriorate or no progress is noted within two to three weeks then re-evaluation is in
order. Cox Flexion Distraction treatment may be utilized if compression of canal is
due to disc herniation or protrusion.

Adjunctive Therapy:




Physical Therapy: Used to restore flexibility and strengthen the back and abdominal
muscles in order to provide relief from symptoms.




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Nutrition:




Exercise: Abdominal exercise to strengthen and support the low back. Exercises to
restore flexibility.


Health Promotion and Maintenance (i.e. ergonomics, spinal hygiene, psychosocial
concerns/education): Important to be aware that pain may cause an increase in
psychosocial stress, physiological responses to pain may also occur.

Further Evaluation: Medical referral should be made if patient does not experience
significant improvement or if the symptoms reoccur quickly following the chiropractic
course of care. Referral: Orthopedist, Neurologist, Neurosurgeon.

Common Medical Management: Medication, Physical Therapy, Surgery
Medications: Anti-inflammatory medications such as ibuprofen and acetaminophen.
NSAIDs such as Motrin, Naprosyn, Celebrex, and Vioxx may also be prescribed.
Cortisone shots at the site of the low back pain. Lumbar Epidural Injection: 1. For
pain management the injection is into the epidural space. 2. For targeting the level
of the pain the injection is into the specific nerve root.


Surgery: Surgical treatment may include fusion, decompression (laminectomy,
lamina trimming, widening of lateral recess, removal medial rim of facets), postero-
lateral fusion.

       Laminectomy – involves removing the lamina from the vertebral body to allow
             the pressure to be removed from the dural sac or the nerve roots.
             When only a portion of the lamina needs to be removed the procedure
             is referred to as a laminotomy. The ligaments (ligamentum flavum)
             and soft tissue (facet capsules, herniated or bulging discs) in the
             affected area are also removed.

       Foraminotomy – are performed to enlarge the area where the nerve roots exit
             the spinal canal in order to decrease the amount of pressure on them.

       Spinal fusion – are performed when patients develop instability of the spine
              with the surgery. Spinal fusion involves grafting bone onto the spine
              and the use of rods and screws to provide support and stability.

       Micro-Endoscopic Laminotomy (MEL) – New treatment developed. A
             minimally-invasive technique that uses a surgical endoscope for

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             fluoroscopic x-ray a thin needle is inserted to the involved vertebral
             level. A small incision is then made around the needle and a hollow
             metal cylinder is passed over the needle to the area of stenosis and
             secured. Through this cylinder the surgical endoscope is inserted to
             allow the surgeons a close-up of the affected area. The surgeon then
             micro-surgically removes the bone compressing the nerve roots. Soft
             tissue can also be removed using this procedure. The level above and
             below can be decompressed as well. Additional benefits of MEL are:
             less disruption of normal tissue, faster surgical time, decreased post-
             operative discomfort, quicker recovery time, and more rapid return to
             normal activity.

References:
  •Wheeless’ Textbook of Orthopedics
  •www.merck.com
  •www.neurosurgery.org/health
  •www.spineuniverse.com
  •Differential Diagnosis and Management for the Chiropractor, by Souza



Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.


Condition Name        Baseline     Complicating/ Mitigating Factors       Revised
                      Complexity                                          Complexity
                                   Early Stage – light force/                5.0
                                   instrument adjustments, monitor
   Lumbar Canal           5.0      for changes in symptoms
     Stenosis                      Late Stage – symptomatic,                  6.0
                                   chiropractic management altered/
                                   no adjustments at level of stenosis
                                   Co-management with MD –                    5.0
                                   epidural injections
                                   Complicated by DDD/ DJD                    7.0
                                   Compression fracture                       8.0


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                           CLINICAL APPLICATIONS
                          Faculty Case Study Preparation


CONDITION______Carpal Tunnel Syndrome

Prepared by:_______Maria Michelin, DC


RELEVANT PATHOPHYSIOLOGY:

External pressure on the carpal tunnel encroaches on the median nerve by
inflammation caused by overuse of flexors or extensors. Fluid retention as in RA,
pregnancy, diabetes, and connective tissue disorders can encroach on the median
nerve. Less likely is direct pressure on the median nerve at the carpal tunnel
caused by carpal fractures, ganglions and dislocations.


CASE HISTORY:

PPW: Numbness and tingling along palmer surface of thumb, middle and index
fingers.
Onset-Initial                                                                    _____
       Palliative/Provocative     rubbing or shaking the wrist/ manual activity or
       heat to wrist
       Quality/Quantity     Sharp burning with numbness and tingling
       Referred/Radiating possible up forearm and into shoulder joint
       Site palmer surface of thumb, index and middle fingers, thenar eminence
       Timing/Pattern       episodic, worse at night if related to fluid retention
       Other possibly related to menstrual cycle if caused by fluid retention

Relevant History and Lifestyle
      Gender        females>males
      Age
      Occupation
      Traumas       possibly caused poorly healed fracture, dislocations or
      ganglions
      Surgeries
      Medications
      Hospitalizations
      Immunizations
      Diseases or Conditions__________________________________ _
      Family History
      Diet
      Sleep Habits
      Sexual History

Maria Michelin, D.C.                   Page 1                             8/20/2010
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         Alcohol Usage
         Drug Usage
         Smoking/Tobacco
         Other__________________________________________________


Review of Systems          Possible signs and symptoms of diabetes, pregnancy or
connective tissue disorders if CTS is secondary to those conditions.
                                                                        _____


PHYSICAL EXAMINATION:

Height                             Weight

Vitals: BP             Pulse                    Respiration________ Temp.

Appearance, Motion, Gait

Orthopedic Tests

       Test Name               R        L               Test Name            R           L
Tinels                      X       +       -    Finklestein’s              +    -   +       -
Phalens                     X       +       -                               +    -   +       -
Prayer sign                 X       +       -                               +    -   +       -
Cozen’s                    + -      +       -                               +    -   +       -
Golfer’s elbow             + -      +       -                               +    -   +       -

Orthopedic Test Results Discussion:
       Tinel’s,Phalen’s and theprayer sign will all be positive on the side of
involvement. The other tests are to rule out lateral and medial epicondylitis and
Dequervain’s disease.

Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception ____Reduced grip strength on the side of
involvement and later stages atrophy of the thenar eminance. Nerve conduction
velocity may be delayed at the wrist (20%).

LabValues__________________________________________________________
_____ _____________________________________________________________


Examination of Related Areas

Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,

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Auscultation, etc.)




SPINAL EXAMINATION:

       Postural Analysis                      Postural Analysis   L      N        R
                                              Head Tilt
                                              Head Rotation
                                              High Ear
                                              High Shoulder
                                              High Ilium
                                              Ext. Rotated Foot
                                              Int. Rotated Foot


ROM
             Cervical ROM                                Lumbar ROM
               ROM      Pain     Level                    ROM     Pain       Level
Flexion        N  Y N                  Flexion          N     Y N
Extension      N  Y N                  Extension        N     Y N
R. Rotation    N  Y N                  R. Rotation      N     Y N
L. Rotation    N  Y N                  L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                  R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                  L. Lat. Flex.    N     Y N

Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion)


List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

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        X-rays        MRI          CT          Other

Views          Wrist series
Findings       usually unremarkable unless fracture or dislocation is the cause of the
CTS.



DIFFERENTIALS:

       1.   Thoracic outlet syndrome
       2.   C6 nerve root involvement
       3.   Tunnel of Guyon entrapment
       4.   Lateral and medial epicondylitis

DIAGNOSIS:

Carpal Tunnel Syndrome


Case Management:

Chiropractic Management: ____Adjust the spine and possibly adjust the lunate._
________________________________________________________________


Adjunctive Therapy:
      Trigger point therapy of wrist flexors and extensors__________________

Nutrition:
B-Complex vitamins, if diabetic special diet______________________________

Exercise:
       Stretching of forearm flexors and extensors. If weak finger extensors
strengthen the extensors to balance the musculature.___________________

Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education):
       Ergonomic advise if patient has desk work or repetitive motion occupation.
Splint wrist in neutral or slight extension if night pain is a problem. Cryotherapy to
reduce inflammation if applicable. Avoid activities such as typing if possible.
________________________________________________________________




Maria Michelin, D.C.                   Page 4                             8/20/2010
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Further Evaluation:



Common Medical Management: _____Anti-inflammatory medications and
analgesics. Surgery is rather common._________________________________


References:
Souza, Differential Diagnosis and Management for the Chiropractor
Merck Manual, 17th edition




Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.


Condition Name         Baseline     Complicating/ Mitigating Factors      Revised
                       Complexity                                         Complexity
   Carpal Tunnel          4.0       Secondary to pregnancy                   8.0
    Syndrome                        Secondary to fracture, ganglion or       4.0
                                    dislocation
                                    Secondary to Diabetes, Lupus,             7.0
                                    Scleraderma or other condition
                                    leading to systemic inflammation




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                          CLINICAL APPLICATIONS
                          Faculty Case Study Preparation


CONDITION______Crohn’s Disease___aka             Regional Enteritis_

Prepared by:____ _Arlene Welch, D.C._________________

RELEVANT PATHOPHYSIOLOGY:

      Crohn’s disease is a recurrent inflammatory bowel disease. The cause is
unknown. It may result from an abnormal response by the body’s immune system to
normal intestinal bacteria. It has an insidious onset and can be chronic or recurrent.
Acute attacks cause severe cramping in the lower abdomen, preceded by weeks or
months of milder cramping. Crohn’s is characterized by diarrhea or constipation,
abdominal tenderness with guarding and a palpable mass in the lower quadrant.
Crohn’s may mimic appendicitis. (2)



CASE HISTORY:

PPW: right lower quadrant pain, diarrhea, fever, weight loss, hyperactive bowel
sounds, nausea, abdominal tenderness with guarding. (2)

Onset-Initial Insidious onset__________________________________________
      Palliative/Provocative     NA                               ___________
      Quality/Quantity           severe cramping; colicky attacks____________
      Referred/Radiating         NA                               ___________
      Site                       right lower quadrant that mimics
         appendicitis_____________________
      Timing/Pattern cramping lower quad pain/diffuse with anorexia, fever, wt. loss
      Other perianal/perirectal abscesses or fistulas_______________________

Relevant History and Lifestyle
      Gender men/women equally (more common in Jewish people)
      Age young people, esp. late teens; also middle years
      Occupation NSF
      Traumas       NSF
      Surgeries     NSF
      Medications NSAIDS make worse
      Hospitalizations     NSF
      Immunizations        NSF
      Diseases or Conditions__possibly osteoporosis_(6)
      Family History       may run in families
      Diet weight loss, anorexia, loss of appetite

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         Sleep Habits       NSF
         Sexual History     NSF
         Alcohol Usage      NSF
         Drug Usage         NSF
         Smoking/Tobacco smokers at increased risk
         Other__higher socioeconomic group/ northern latitudes


Review of Systems abdomen – tenderness, guarding, diarrhea, constipation,
increased bowel sounds, stool may be dark and tarry_______________



PHYSICAL EXAMINATION:

Height                               Weight

Vitals: BP     NSF     Pulse         NSF          Respiration_____NSF___ Temp. low-
                                                                       grade fever

Appearance, Motion, Gait             abdominal guarding

Orthopedic Tests

     Test Name                 R          L              Test Name          R           L
McBurney’s Sign                 -     +       -                            +    -   +       -
                            +    -    +       -                            +    -   +       -
                            +    -    +       -                            +    -   +       -
                            +    -    +       -                            +    -   +       -
                            +    -    +       -                            +    -   +       -

Orthopedic Test Results Discussion:
              McBurney’s Sign indicates appendicitis. Palpate McBurney’s point with
patient supine, knees slightly flexed. Located 1/3 of the distance from the ASIS to
the umbilicus in right lower quadrant. Point tenderness is positive for appendicitis
                             (2)

Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception
___________________________________________________________________
________________________NSF_______________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

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LabValues___small, soft to loose or watery stools usually free of gross blood or less
blood than ulcerative colitis. Decreased RBC count (anemia), decreased B12 and
iron. WBC’s in stool.

Examination of Related Areas      Abdomen – tender, sausage shaped masses
palpable in right lower quadrant.


Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.) palpation of lower quadrant abdominal mass with tenderness.
                    Auscultation – increased bowel sounds_________________



SPINAL EXAMINATION:

      Postural Analysis                       Postural Analysis      L      N        R
                                              Head Tilt
                                              Head Rotation
                                              High Ear
             NSF____________                  High Shoulder
                                              High Ilium
                                              Ext. Rotated Foot
                                              Int. Rotated Foot


ROM
             Cervical ROM                                 Lumbar ROM
               ROM      Pain     Level                     ROM     Pain         Level
Flexion        N  Y N                   Flexion          N     Y N
Extension      N  Y N                   Extension        N     Y N
R. Rotation    N  Y N                   R. Rotation      N     Y N
L. Rotation    N  Y N                   L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                   R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                   L. Lat. Flex.    N     Y N


Leg Length/Spinal Balance                NSF              _______________
Instrumentation/Pattern Analysis         NSF              _______________
Palpation (Muscle, Static, Motion)       abdominal mass___________________




Arlene Welch, D.C.                   Page 3                              8/20/2010
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List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
     Level        Muscle Motion Level Muscle Motion Level Muscle Motion
Possible
lower
thoracic
restriction/
subluxations




RADIOLOGICAL EXAMINATION:

        X-rays        MRI           CT            Other         barium enema

Views         abdominal x-ray
Findings      Initial findings of loss of haustration. Later ulcerations called
“cobblestone” effect and strictures leading to what is called “skip” lesions form, both
of these are important diagnostic features of this disease.
              May show signs of bone loss indicative of osteoporosis.


DIFFERENTIALS:

      Appendicitis, diverticulitis, colitis, ulcer, polyps, intestinal obstruction, irritable
bowel syndrome, infection, cancer




DIAGNOSIS:

        Diagnosis is determined by case history, physical exam, lab values, and
imaging. Later ulcerations called “cobblestone” effect and strictures leading to what
is called “skip” lesions form, both of these are important diagnostic features of this
disease.


Arlene Welch, D.C.                       Page 4                                8/20/2010
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Case Management:


Chiropractic Management:
             If patient presents with osteoporosis or colostomy bag, consider
             low force chiropractic adjustments such as AK, SOT, Activator.
             Most people are able to resume normal activities following an
              ostomy.
             Sot management includes chiropractic manipulative reflex
technique (CMRT) and category one block placement. (9)

Medical Management           medication (aminosalicylates, corticosteroids) to maintain
remission. The severity and type of symptoms guide treatment. A few people have
persistent symptoms or complications that may require additional medications or
surgery. A high-calorie liquid diet may be recommended.        (5)




Surgical Management:        Surgery may be needed if no medication controls
symptoms; or complications such as fistulas, abscesses or bowel obstruction occur.
Surgery choices include ileostomy, proctocolectomy, resection or bypass of
intestinal transplant. When surgery is needed, as little of the intestines is removed as
possible to preserve normal function.    (7)



Adjunctive Therapy:         antidiarrheal medications



PhysicalTherapy:__________________________________________________
________________________________________________________________
____________________NA__________________________________________
________________________________________________________________
________________________________________________________________

Nutrition:             small frequent feedings may be better, increase omega 3 fatty
acids, low fiber diet.
              avoid milk, alcohol, spicy foods if necessary_____________
________________may be lactose intolerant____________________________
________________maintain a balanced diet_______(8)_____________




Arlene Welch, D.C.                    Page 5                              8/20/2010
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Exercise:             NA



Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education):       advise not to smoke
            _______________advise of _nutrition: vitamin E, omega 3 fatty acids;
homeopathy: cat’s claw, licorice may decrease inflammation; _____________
(homeopathy is not scientifically proven)
_____________________antidiarrheal medication_______(6)___________
_____________________stress reduction___________________________


Further Evaluation:         sigmoidoscopy, colonoscopy_____________________


Common Medical Management: _____see above______________________




References:

1. Manual of Laboratory and Diagnostic Tests, 4th Edition, Frances Fischbach
2. Professional Guide to Signs and Symptoms, 2nd Edition, Springhouse Corp.
3. Ambulatory Medicine, Mark Mengel, MD and Peter Schwiebert, MD
4. Mahan, L. & Escott-Stump, S. (Eds.) (2004). Krause’s Food, Nutrition & Diet
   Therapy (11th ed.) Philadelphia:W.B. Saunders.
5. Podolsky DK (2002). Inflammatory bowel disease. New England Journal of
   Medicine, 347(6): 417-429.
6. Trebble, T. American Journal of Clinical Nutrition. 11/2004; vol. 80: pp. 1137-
   1144.
7. Hanauer SB, Meyers S(1997). Management of Crohn’s disease in Adults.
   American Journal of Gastroenterology, 92(4): 559-566.
8. Botoman VA, et al.(1998). Management of Inflammatory Bowel Disease.
   American Family Physician, 57(1):57-68.
9. Blum, C. Journal Vertebral Subluxation Res.. 09/2003.




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Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.




Condition Name       Baseline        Complicating/Mitigating    Revised
                     Complexity      Factors                    Complexity
Crohn’s Disease      5.0             Decreased B12 –            7.0
                                     Pernicious anemia
                                     Chiropractic               6.0
                                     adjustments altered for
                                     patient comfort
                                     Co-management with         6.0
                                     other professionals
                                     Corticosteroid use         7.0
                                     increasing chance of
                                     osteoporosis
                                     Immunosuppressant          7.0
                                     usage
                                     Ileostomy, colostomy –     9.0
                                     chiro adj
                                     Osteoporosis               7-8.0




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                            CLINICAL APPLICATIONS
                          Faculty Case Study Preparation

CONDITION: Diabetes Mellitus
Prepared by:   Drs. Susan Boger-Wakeman and Cindy Gibbon

RELEVANT PATHOPHYSIOLOGY:

Diabetes Mellitus (DM) is a chronic disease that affects approximately 16 million
Americans – approximately 6 percent of the population. It results in an increase in
morbidity and mortality and is the fourth leading cause of death by disease.
Although early diagnosis and treatment can reduce the morbidity and mortality, 8
million Americans, which is 50% of the total population of clients with diabetes, are
undiagnosed.

DM is a clinically and genetically heterogeneous disorder characterized elevated
blood glucose levels. It occurs because insulin, produced by the beta calls of the
pancreas, is either absent, insufficient or not used properly by target tissues. As a
result, the body is unable to normally metabolize macronutrients (carbohydrate, fat,
and protein) in foods. When insulin is absent or ineffective, the body cannot convert
glucose into energy, and the level of glucose in the blood increases. Elevated blood
glucose levels can lead to short-term and long-term health-related complications.
There are several types of diabetes: type 1 diabetes, type 2 diabetes, maturity onset
diabetes of the young (MODY), impaired glucose intolerance (IGT), and gestational
diabetes (GDM).

Type 1: Characterized by an absolute deficiency of insulin caused by an
autoimmune attack on the  cells of the pancreas. In type 1 DM, the islets of
Langerhans become infiltrated with activated T lymphocytes, leading to a condition
called insulitis. Over a period of years, this autoimmune attack leads to gradual
depletion of  cell population. However, symptoms appear abruptly when 80-90% of
the  cells have been destroyed. At this point the pancreas fails to respond
adequately to ingestion of glucose, and insulin therapy is required to restore
metabolic control and prevent life-threatening ketoacidosis. This destruction
requires both a stimulus from the environment (such as a viral infection) and a
genetic determinant that allows the  cells to be recognized as “non-self.”

Type 2: Develops gradually without obvious symptoms and may be detected with
routine screening tests. Many individuals may have polyphagia and polydipsia that
lasts for several weeks. People with type 2 DM have a combination of insulin
resistance and dysfunctional  cells but do not require insulin to sustain life, although
insulin may be required to control hyperglycemia in some people. Insulin resistance
is the decreased ability of adipose tissue, muscle and liver to respond properly to
normal circulating concentrations of insulin. Obesity is the most common cause of
insulin resistance. The higher insulin concentration compensates for the diminished


Dr. Susan Boger-Wakeman                Page 1                               8/20/2010
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effect of the hormone that can eventually lead to decreased pancreatic secretion of
insulin causing the person to have to administer exogenous source of insulin.


Two basic types of Diabetes Mellitus with complicating factors being the same
for both types


                             Type 1 Diabetes             Type 2 Diabetes

Age of onset                 Usually during childhood    Frequently after age 35;
                             or puberty; symptoms        symptoms develop
                             develop rapidly             gradually
Nutritional status at time   Frequently malnourished     Obesity usually present
of disease onset
Prevalence                   900,000 = 10% of            10 million = 90% of
                             diagnosed DM                diagnosed DM
                             More common in northern     More common in African
                             European populations,       American, Native
                             less common among           American, Arizona Pima
                             African Americans,          Indians, Hispanic
                             Asians, Native Americans    populations
Genetic predisposition       Moderate                    Very strong
Defect or deficiency          cells of pancreas are     Insulin resistance
                             destroyed eliminating       combined with inability of
                             production of insulin        cells to produce
                                                         appropriate quantities of
                                                         insulin
Frequency of ketosis         Common                      Rare
Plasma insulin               Low to absent               High early in disease; low
                                                         in disease of long duration
Acute complications          Ketoacidosis                Hyperosmolar coma
Treatment with oral          Unresponsive                Responsive
hypoglycemic drugs
Treatment                    Insulin is always           Diet, exercise, oral
                             necessary                   hypoglycemic drugs, +/-
                                                         insulin

Gestational diabetes: from the 24th to the 28th week of pregnancy, the body’s need
for insulin increases (2-3 times as much insulin is needed during pregnancy to
maintain blood glucose homeostasis). The insulin resistance is a result of the
hormones produced for pregnancy (estrogen and progesterone). Another hormone,
human placental lactogen (HPL) is a potent insulin antagonist. HPL enhances fat
mobilization and reduces maternal glucose utilization and protein degradation so the
fetus has plenty supply of glucose and amino acids. Insulinase, produced by the
placenta, degrades insulin, reducing its supply even further.

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Secondary diabetes mellitus is caused by:
     chronic pancreatitis
     hormonal tumors (pheochromocytoma Pituitary )
     drugs: corticosterioids
     hemochromatosis
     genetic disorders(lipodystrophy)
     surgical (postpancreatectomy)

Maturity-onset of diabetes of the young (<25 y.o.) caused by: obesity and lack of
physical activity.

Complications:

Long-standing DM results in: microangiopathy, retinoapathy, nephropathy, and
neuropathy. Myocardial infarction is main cause of death in DM followed by renal
failure.

1. Microangiopathy: Diffuse thickening of basement membranes in all tissues.
Capillary become more leaky to plasma proteins.

2. Nephropathy: Kidneys are prime targets in DM and 3 lesions occur: glomerular,
renal vascular, and pyelonephritis.

3. Retinopathy: Changes in eye occur in long-standing DM: retinal changes include
thickening of the capillaries, microinfarcts( soft exudates) and deposits of lipids and
proteins(hard exudates), and neovascularization, also the lens can swell due to
increased intracellular osmolarity.

4. Neuropathy: CNS and PNS involvement. For specifics see Neuro exam. Most
common is peripheral, symmetric neuropathy of lower extremities affecting both
motor and sensory but more sensory usually. Brain also develops microangiopathy
leading to generalized neuronal degeneration. Can lead to cerebrovascular infarcts
and brain hemorrhages.

5. Accelerated atherosclerosis: Not well understood and many factors involved.
Lipoproteins change due to nonenzymatic glycosylation and effects lipid turnovers
and tissue deposition.

6. AGE= advanced glycosylation end products. Glucose chemically attaches to free
amino acid residues.




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CHIEF COMPLAINT: Polyruria, polydypsia. polyphagia with weight loss and
fatigue particulary in cases of Type 1 DM. Type 2 usually diagnosed during
routine screening tests and complaints concerning side effects of high blood
glucose levels. Visual changes and frequent urinary tract infections are the
most common complaints. Often seen are non-healing wounds in the
extremities.

Onset:          Usually fairly rapid with Type 1; insidious onset with Type 2

Palliative/Provocative:       Pall: diet/lack of physical activity/medications

Quality/Quantity:    Severity depends on the cause of diabetes. Type 1 more
       severe, requires exogenous source of insulin. Type 2 has wide variety of
       presentations

Referred/Radiating: Eyes, kidneys, nervous system, cardiovascular system

Site:    May also be prone to skin infections (puritis, boils, carbuncles, etc)

Other:     Ketone breath (present in uncontrolled Type 1DM)

PHYSICAL EXAMINATION:

Height :                             Weight : Type 1 usually underweight/normal
                                              weight. Type 2 usually obese (85-90%)

Vitals: BP                Pulse               Respiration________ Temp.

Appearance, Motion, Gait             NA

Orthopedic Tests

         Test Name              R       L             Test Name               R          L
                               + -     + -                                   + -        + -
                               + -     + -                                   + -        + -
                               + -     + -                                   + -        + -
                               + -     + -                                   + -        + -
                               + -     + -                                   + -        + -


Orthopedic Test Results Discussion:




Dr. Susan Boger-Wakeman                   Page 4                                 8/20/2010
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Neurological Tests - Motor/Sensory/Reflex

Varied depending on type of neuropathy/polyneuropathy
Symmetrical neuropathy: absent Achilles’s reflex
                         Loss of proprioception
                         Mainly sensory (numbness, tingling, burning, lancinating
Asymmetric: Cranial nn. III, IV, VI and peripheral nn.
             Painful dysesthesias and hyperesthesias
Amyotrophy: Unilateral weakness and atrophy of large muscle groups of upper
             leg and pelvic girdle
Autonomic: GI tract mainly: dysphagia, constipation, diarrhea
            Neurogenic bladder
            Impotence
            Orthostatic hypotension
Peripheral polyneuropathy


  Nerve Root Package             Motor (0-5)           Sensory          Reflex (0-4)
          C5                                             N    
          C6                                             N    
          C7                                             N    
          C8                                             N    
          T1                                             N    
          L4                                             N    
          L5                                             N    
          S1                                             N    


Lab Values:         Glucose testing: FBS > 126 mg/dl. = DM
                    GTT (Glucose tolerance test/ load) > 200 mg/dl. at 2 hours.
                    Glycosylated hemoglobin (HgbA1c) : monitor glucose control
                    Urinalysis: glycosuria, often proteinuria, ketonuria,budding yeast
                    Serum lipids: elevated, HDL decreased

Examination of Related Areas Eyes, Renal, Cardiovascular system, Neurological

Other Findings: (Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




Dr. Susan Boger-Wakeman              Page 5                               8/20/2010
Approved 11/24/04
         SPINAL XAMINATION:                     Postural Analysis       L      N        R
         Postural Analysis                      Head Tilt
                                                Head Rotation
              NA                                High Ear
                                                High Shoulder
                                                High Ilium
                                                Ext. Rotated Foot
                                                Int. Rotated Foot



ROM
             Cervical ROM                                      Lumbar ROM
               ROM      Pain      Level                         ROM     Pain       Level
Flexion        N  Y N                    Flexion              N     Y N
Extension      N  Y N                    Extension            N     Y N
R. Rotation    N  Y N                    R. Rotation          N     Y N
L. Rotation    N  Y N                    L. Rotation          N     Y N
R. Lat. Flex.  N  Y N                    R. Lat. Flex.        N     Y N
L. Lat. Flex.  N  Y N                    L. Lat. Flex.        N     Y N

Leg Length/Spinal Balance:        Any normal w/ subluxations

Instrumentation/Pattern Analysis:                          “

Palpation (Muscle, Static, Motion):                        “

List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.

 Level     Muscle Motion       Level   Muscle Motion            Level   Muscle Motion




RADIOLOGICAL EXAMINATION:

 X-rays       MRI         CT           X PEP Scan to view function of pancreas




Dr. Susan Boger-Wakeman                Page 6                               8/20/2010
Approved 11/24/04
Views:    NA

DIFFERENTIALS:

Primary DM versus secondary DM
Polyneuropathy: Evaluate B12 status, rule out pernicious anemia; MRI to evaluate
neuropathy and nerve conduction
Retinopathy: Rule out any other eye pathology
Neoplasms
Alcoholism
Vascular disease
Nephrogenic cause

DIAGNOSIS:

Diabetes Mellitus

CASE MANAGEMENT:

Chiropractic Management:
       Adjustment of misaligned/subluxated segments (when there are no
         contraindications) to restore neural integrity and improve mobility and
         range of motion.
       Work w/ MD for compliance w/ treatment and be aware of advancing
          signs and symptoms of other organ involvement.
       Instruction on importance of monitoring lower extremities for sores, ulcers,
         any discolorations, and keeping feet washed, dried, avoiding barefoot
         walking.

Adjunctive Therapy:         NO PT

Nutrition: Healthy diet
        Modification of total calories for achieving and maintaining healthy
          weight.
        Total fat intake should be <30% of total calories with the emphasis on
          choosing mono- and polyunsaturated fats over saturated/trans fats.
          Increase foods high in omega 3 fatty acids and plant stanols/sterols.
        Adequate total fiber (at least 25 grams per day) from both soluble and
          insoluble fiber sources.
        Limit simple sugar intake to no more than 10% of total calories.
        Limit sodium intake to <2300 mg/day
        Limit cholesterol intake to < 300 mg/day

Refer to a Registered Dietitian for nutrition assistance in individuals with all forms of
DM.


Dr. Susan Boger-Wakeman                 Page 7                               8/20/2010
Approved 11/24/04
Exercise:     Highly recommended
        Aerobic type of exercise 5-7 times/ week achieving THR(target heart rate).
          Important to monitor blood glucose levels before and during exercise for
          Type 1 DM.
Chiro. Guidelines recommend moderate exercise daily

Common Medical Management:
     Type 1: Insulin replacement
     Type 2: Oral agents to reduce hyperglycemia
                 Sulphonylureas – increase insulin excretion
                 Biguanides – suppress glucose synthesis in liver
                 Glucosidase Inhibitors – inhibit starch digestion to delay glucose
                 absorption
                 Thiazolidinediones – activate receptor to sensitize cell to insulin
                 Insulin and insulin analogs may be required later in the disease
                 process as Beta-cell/pancreatic function declines.
     Medications to reduce other risk factors:
       o Hypertension:          ACE Inhibitors; Alpha –blockers; ARBs, Calcium
         channel blockers,(low-dose diuretics, beta blockers in older adults)
       o Lipid-lowering therapy:       Statins (effective for lowering LDL);
         fibrates (effective for raising HDL, lowering TG)
       o Antiplatelet therapy in high risk patients with diabetes: Low-dose ASA
         (81-325 mg.day)

Further Evaluation:
       Self glucose monitoring
       Regular medical check ups
       Glycosylated hemoglobin levels every 3-6 months

Health Promotion and Maintenance:
       Educate about reducing risk factors for cardiovascular disease/stroke (e.g.
          no smoking)
Referral:
       MD immediately w/ any suspicions of DM or advancing signs & symptoms.

References:

   1. American Heart Association
      http://americanheart.org

   2. American Diabetes Association
      http://diabetes.org

   3. Holler, HJ & Pastors, JG. Diabetes Medical Nutrition Therapy. American
      Dietetic Association, 1997.

Dr. Susan Boger-Wakeman              Page 8                             8/20/2010
Approved 11/24/04
Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.




Condition Name        Baseline     Complicating/ Mitigating Factors     Revised
                      Complexity                                        Complexity
                                   Type 2 – No other co-morbidities,
     Diabetes              3       oral meds                                 4
                                   Type 1 – No other co-morbidities,
                                   insulin dependent                         5
                                   Presence of other co-morbidities,         6
                                   eg. DISH
                                   Microvascular complications –
                                   peripheral neuropathy                     9




Dr. Susan Boger-Wakeman              Page 9                             8/20/2010
Approved 11/24/04
Guillain-Barre Syndrome
     Shana L. Sullivan


       Shana Sullivan, Intern   Approved
                    05/11/05
    Relevant Pathophysiology
Guillain-Barre Syndrome (GBS), also called acute
inflammatory demyelinating polyneuropathy and
Landry’s ascending paralysis, is a disorder in which
the body’s immune system attacks the peripheral
nerves. When this occurs the antibodies the body
produces damage the myelin sheath that surrounds the
peripheral nerves. The myelin sheath increases the
transmission speed of nerve impulses so when damage
the rate at which nerve impulses travel is slowed
resulting in motor and sensory disturbances.

               Shana Sullivan, Intern   Approved
                            05/11/05
     Relevant Pathophysiology
GBS is referred to as a syndrome because the cause of the
disorder is unknown; it is not hereditary nor contagious.
Recent research has connected the onset of GBS with
previous bacterial or viral infections.

GBS typically starts as muscle weakness and abnormal
sensations such as tingling in the lower and upper limbs.
As the disorder progresses it may cause weakness of the
breathing muscles such as the diaphragm and intercostal
muscles. It may also cause heart arrhythmia and
fluctuation in blood pressure, which can be fatal if not
considered a medical emergency.
                 Shana Sullivan, Intern   Approved
                              05/11/05
             Relevant History
• Gender Profile: Equally males and females
• Age Profile: Any age

• Although GBS can attack any sex at any age, it is
  still a rare disorder, affecting only 1 out of
  100,000.


                 Shana Sullivan, Intern   Approved
                              05/11/05
           Relevant History
• Occupation, Traumas, Medications,
  Hospitalizations, Family History, Sleep
  Habits, Sexual History, Alcohol Usage,
  Drug Usage, and Tobacco Usage have
  NOT been connected with the onset on
  GBS.


              Shana Sullivan, Intern   Approved
                           05/11/05
                 Relevant History
• Most cases of GBS are connected with the
  following:
   – Gastrointestinal Infection
   – Campylobacter jejuni infection- usually from
     undercooked chicken
   – Respiratory infection
• Other connections with onset of GBS include:
   –   Pregnancy                    –Infectious mononucleosis
   –   Surgery                      –Viral hepatitis
   –   Vaccinations                 –Flu, common cold
   –   Blood Transfusions           –Porphyria
                    Shana Sullivan, Intern Approved
                              05/11/05
         Patient Presents With
• Flu-like Symptoms                 • Glove and Stocking
• Progressive Muscle                  Sensory Loss
  Weakness                          • Paralysis
• Upper body tingling               • Facial Paralysis
  Sensations
                                    • Loss of Reflexes
• Arm & Leg Weakness
• Arm & Leg Tingling                • Dyspnea
• Aching Shoulders                  • BP Changes
• Acute neuromuscular               • Arrhythmias
  Paralysis                         • Paresthesia

                Shana Sullivan, Intern   Approved
                             05/11/05
       Case History-Symptoms
• Onset: Hours to days after infection usually
• Palliative: Rest and aspirin
• Provocative: Exercise or physical activity
• Quality/Quantity: Achy weakness, tingling
  sensations
• Referred/Radiating: Does not apply
• Site: Entire muscle system most commonly
  bilateral legs and arms
• Timing: Constant (24 hours per day)
                 Shana Sullivan, Intern   Approved
                              05/11/05
        Physical Examination
• Fluctuating High or Low Blood Pressure
• Respiration: usually increased but shallow
  breaths due to weak respiratory muscles
• Pulse: may be increased or decreased
• Heart Sounds: arrhythmias present
• Appearance: Pale, exhausted, and weak

              Shana Sullivan, Intern   Approved
                           05/11/05
            Orthopedic Test
• No significant findings indicated by
  orthopedic testing




               Shana Sullivan, Intern   Approved
                            05/11/05
                Neurological Tests
• Cranial Nerves Testing
   – CN 5 lesion = muscles of mastication weakness
   – CN 7 lesion = facial weakness
   – CN 9 & 10 lesion = dysarthria
• Deep Tendon Reflexes (Wexler Scale)
   –   Biceps (C5)-1
   –   Brachioradialis (C6)-1
   –   Triceps (C7)- 1
   –   Patellar (L4)- 1
   –   Achilles (S1)-1 Sullivan, Intern
                     Shana                  Approved
                                 05/11/05
         Neurological Testing
• Muscle Testing
  – Upper Extremities
     • Trapezius weakness- Lesion of C3, C4 nerve roots
     • Bicep weakness- Lesion of C5, C6 nerve roots
     • Tricep weakness- Lesion of C6, C7, C8 nerve roots
  – Lower Extremities
     • Quadracep weakness- L2, L3, L4 nerve roots
     • Hamstring weakness- L4, L5, S1, S2 nerve roots
     • Gastrocnemius weakness- L5, S1, S2 nerve roots
                 Shana Sullivan, Intern   Approved
                              05/11/05
        Neurological Testing
• Dermatome Testing
  – Sensory disturbances may be found when
    testing dermatomes due to myelin sheath
    destruction of the nerves




               Shana Sullivan, Intern   Approved
                            05/11/05
          Spinal Examination

• Gait: Slow, careful steps-barely lifts feet off
  the ground
• Posture: Hunched
• Any Spinal Examination findings are most
  likely due to weak musculature

• No other significant spinal examination
  findings correlated specifically with GBS.
                Shana Sullivan, Intern   Approved
                             05/11/05
                Diagnostic Test
• Lumbar Puncture (spinal tap): First, the patient is
  given a local anesthetic. Then a needle is inserted
  between the L4 and L5 vertebrae and a sample of CSF
  is taken
   – An elevated level of protein in the fluid is characteristic
     of GBS
• Electromyogram (EMG): An EMG is used to record
  muscle activity and can indicate a loss of reflexes due
  to slowing of nerve responses
• Nerve Conduction Velocity (NCV): This test uses a
  EMG to record the speeds at which signals travel
  along the nerves. Sullivan, Intern Approved
                  Shana
                             05/11/05
     Other Tests Related to GBS
             Diagnosis
• Imaging Studies
   – Gadolinium-enhanced MRI of lumbosacral area may
     show irritation of cauda equina nerve roots
• Electrolyte screening
   – May show syndrome of inappropriate antidiuretic
     hormone
• Liver Function Tests
   – Elevated in 1/3 of patients with GBS
• Pregnancy Test
   – May be a trigger for GBS
• Antibody Screen Sullivan, Intern
               Shana                 Approved
                         05/11/05
   – Patient may have GQ1b antibodies present
                 Diagnosis
• In order the diagnose GBS, the diagnostic
  tests are used along with the patient’s case
  history and other objective and subjective
  findings.
• Due to the variety of symptoms, the sudden
  onset, and unknown cause of GBS, it is
  difficult to diagnose .

               Shana Sullivan, Intern   Approved
                            05/11/05
                 Differentials
•   Acute Poliomyelitis
•   Hexacarbon abuse- Glue sniffing (Huffing)
•   Diphtheria
•   Tick Infestation
•   Botulism
•   Toxic Neuropathy – impairment due to drugs
•   Symptoms purely sensory problems

                 Shana Sullivan, Intern   Approved
                              05/11/05
          Case Management
• Chiropractic Management
  – LACVS
  – Chiropractic care has been correlated to quicker
    recovery time due to keeping the nerve
    pathways unobstructed.




                Shana Sullivan, Intern   Approved
                             05/11/05
          Case Management
• Medical management
  – Plasmapheresis- a relatively safe treatment used
    to shorten the disease course, hospitalization,
    reduce mortality, and reduce the chance of
    permanent paralysis
  – Immune Globulin IV when given a
    400mg/kg/day is as effective and yields the
    same results as Plasmapheresis
  – After release from the hospital, patients may be
    given immunosuppressive drugs to stop a
    relapse of GBS.Sullivan, Intern Approved
                 Shana
                          05/11/05
              Case Management
• Physical Therapy and Exercise
   – Has been used to help patients regain motor control of
     muscles in order to walk and perform other daily
     activities
   – Also aids in rebuilding of the muscle tone and strength
     lost during the disease course
• Nutrition
   – A balanced diet will help regenerate muscle tone and
     strength by supplying proper vitamins and minerals
     needed to build muscles.
   – A balanced diet will also aid in restoring the energy of
     the patient lost while the disease ran its course.
                    Shana Sullivan, Intern Approved
                            05/11/05
            Case Management
• Nutrition Continued - Diet will be dependent on
  the patient. Some individuals will have
  involvement of the oropharyngeal muscles, which
  could lead to dysphagia and dysarthria. In this
  patient the diet is prescribed by a Registered
  Dietitian after the patient has been evaluated by a
  speech-language pathologist.
• If only a normal healthy diet is required, (absence
  of dysphagia), then follow the advise of the 2005
  Dietary Guidelines


                 Shana Sullivan, Intern   Approved
                              05/11/05
         Health Maintenance
• Diet- Balanced diet to aid in healing the
  body and restoring its natural balance
• Sleep- 8-10 hours per night especially until
  the body is fully recuperated
• Ergonomics- Avoid any stressful situations
  until body is fully recuperated
• Exercise- To build back muscle strength
• Attitude- Positive mental attitude
               Shana Sullivan, Intern   Approved
                            05/11/05
                       References
Beers, Mark, MD. and Robert Berkow, MD. The Merck Manual of
   Diagnosis and Therapy. 17th Edition. June 1999. pp. 1494-1495.
Fanion, David, MD. E-Medicine: Instant Access to the Minds of
   Medicine. Guillain-Barre Syndrome.
   http://www.emedicine.com/emerg/topic222.htm. March 2, 2005.
Neurology Channel. Guillain-Barre Syndrome.
   http://neurologychannel.com/guillain/. March 2, 2005
Pikula, John R. The Journal of the CCA. Guillain-Barre Syndrome: a
   case report. Volume 39 No.3. June 1995. pp 80-83.




                      Shana Sullivan, Intern   Approved
                                   05/11/05
Case Complexity:
The category of complicating or mitigating factors should include the
following considerations: Ancillary labs, diagnostic studies, co-
management issues, early stage of condition, advanced stage of
condition, psychosocial issues, etc. The complicating or mitigating factors
can either increase or decrease the baseline complexity.



  Condition Name     Baseline       Complicating/ Mitigating              Revised
                     Complexity     Factors                               Complexity

                                    Arrhythmias present, fluctuation of      9.0
                                    blood pressure
    Gullain-Barre       6.0         Pulmonary Complications                  8.0
     Syndrome
                                    Altered neurological findings            7.0




                           Shana Sullivan, Intern   Approved
                                        05/11/05
                          CLINICAL APPLICATIONS
                  Case Study Preparation – Suggested Format



CONDITION:           Hyperthyroidism

Prepared by:         Dr. Cindy Gibbon


RELEVANT PATHOPHYSIOLOGY:

Accumulation of mucopolysaccharides and fluids in retro-orbital tissues forcing
eyeball outward and overstimulationof levator palpebrae superioris (lid lag)

Excess thyroid hormone: produces hypermetabolic state

Overactivity of sympathetic nervous system: nervousness, tremors, tachycardia,
palpitations, irritability, hyperreflexia

Congestive heart failure may develop in an elderly patient


CASE HISTORY:

PPW: Nervousness, weight loss despite  appetite, heat intolerance, sweating,
diarrhea, tremors, insomnia, exopthalmia (not always), fatigue, smooth+velvet skin,
hyperphagia

      Onset-Initial
      Palliative/Provocative
      Quality/Quantity
      Referred/Radiating
      Site
      Timing/Pattern
      Other

Relevant History and Lifestyle
            Gender female (7-8x )
            Age           20-40 y.o
            Occupation
            Traumas
            Surgeries
            Medications
            Hospitalizations
            Immunizations

Cindy Gibbon, D.C.                   Page 1                            8/20/2010
Approved 05/11/05
             Family History strong family history of same or other auto-immune
                            pathology
             Social History
             Diet
             Sleep Habits insomnia
             Sexual History

             Alcohol Usage
             Drug Usage excess intake of thyroid hormone (thyrotoxicosis
                         factitia)
             Smoking/Tobacco
             Diseases/Conditions:    Watch for Thryoid Storm


PHYSICAL EXAMINATION:

Height                              Weight weight loss reported

Vitals: BP  pulse pressure Pulse slight  Respiration_slight  Temp.BMR

Appearance, Motion, Gait - Possibly enlarged goiter, exopthalmia, fine tremors in
                           hands
                          -Possible clumsiness walking

             Eyes: Exopthalmia, staring gaze, lid lag, tearing
Orthopedic Tests

      Test Name             R            L        Test Name             R           L
                           +    -    +       -                         +    -   +       -
                           +    -    +       -                         +    -   +       -
                           +    -    +       -                         +    -   +       -
                           +    -    +       -                         +    -   +       -
                           +    -    +       -                         +    -   +       -

Orthopedic Test Results Discussion:




Neurological Tests - Motor/Sensory/Reflex

Hyperreflexia




Cindy Gibbon, D.C.                    Page 2                           8/20/2010
Approved 05/11/05
  Nerve Root Package           Motor (0-5)          Sensory              Reflex (0-4)
          C5                                          N    
          C6                                          N    
          C7                                          N    
          C8                                          N    
          T1                                          N    
          L4                                          N    
          L5                                          N    
          S1                                          N    
Lab Values HLA-DR3
           T3,  T4,  (blood tests)
           LATS(long acting thryroid stimulators)
           TSI (thyroid stimulating immunoglobulin

Examination of Related Areas
     CNS: look for mood swings, occasional outbursts to overt psychosis
     Hair: fine, soft, premature graying,  hair loss in both sexes
     Nails: friable nails and onycholysis
     Skin: soft and velvet to thickened, accentuated hair follicles, raised red
           patches that may itch and painful


Review of Systems
      Cardiovascular: tachycardia, full bounding pulse, wide pulse pressure
                      increased cardiac output and blood volume
      Respiratory: dyspnea on exertion and at res
      GI: possible anorexia, N/V, defecation and soft stools, hypermobilitly,
          malabsorption, diarrhea
      Musculoskeletal: weakness, fatigue, muscle atrophy
      Reproductive: female: oligomenorrhea or amenorrhea, fertility
                     Male: gynecomastia
                    Both sexes: libido

Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)

THYROID STORM : abrupt onset of severe hyperthyroidism; acute elevation of
catecholamines, may give cardiac arrhythmias,: MEDICAL EMERGENCY




Cindy Gibbon, D.C.                    Page 3                             8/20/2010
Approved 05/11/05
SPINAL EXAMINATION:

      Postural Analysis                      Postural Analysis    L       N       R
                                             Head Tilt
                                             Head Rotation
                                             High Ear
                                             High Shoulder
                                             High Ilium
                                             Ext. Rotated Foot
                                             Int. Rotated Foot


ROM
             Cervical ROM                                 Lumbar ROM
               ROM      Pain   Level                       ROM     Pain       Level
Flexion        N  Y N                   Flexion          N     Y N
Extension      N  Y N                   Extension        N     Y N
R. Rotation    N  Y N                   R. Rotation      N     Y N
L. Rotation    N  Y N                   L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                   R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                   L. Lat. Flex.    N     Y N


Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion)
             Generalized muscle atrophy
             Enlarged thyroid


List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




Cindy Gibbon, D.C.                 Page 4                             8/20/2010
Approved 05/11/05
RADIOLOGICAL EXAMINATION:

        X-rays        MRI        CT           Other: Hyperthyroidism: Thyroid
function test which is a nuclear medicine study. Typically a thyroid scan with
uptake is performed to determine the etiology of the hyperthyroidism.

Views:
Findings:




DIFFERENTIALS:

Rule out thyroid storm
Primary hyperthyroidism; True Grave’s (overproduction of T4, enlarged thyroid,
multiple system changes.
Secondary hyperthyroidism: (usually TSH secreting pituitary tumors)
Ingestion of exogenous thyroid hormone for hypothyroidism treatment(thyrotoxicosis
factitia
Subacute thyroiditis (virus induced granulomatous inflammation of thyroid)
Multi-nodular goiter
Metastatic thyroid carcinoma


DIAGNOSIS:

Thyroid nodule fine needle aspiration
Thyroid US
Radioactive scanning
Stimulation/ suppression tests with hormones and monitor blood changes
Most common blood tests: T4, Antibody levels, TSH




Cindy Gibbon, D.C.                  Page 5                           8/20/2010
Approved 05/11/05
Case Management:
Chiropractic Management:           NA



Common Medical Management: ______________________________________




PhysicalTherapy:__________________________________________________
________________________________________________________________
________________________________________________________________

Adjunctive Therapy:          Drugs: Iodine, Proplthiouracil, methimazole,
                                   Beta-blockers
                             Surgery
                             Opthalmologist: corticosteroids for eye pruritis, NSAIDS,
                                              obribal radiation, surgery

Nutrition:      NA



Exercise:       NA


Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education):
      ___________________________________________________________
________________________________________________________________

Further Evaluation: Endocrinologist and opthamologist (exopthalmia)



Patient Care:


Referral:       Endocrinologist




Cindy Gibbon, D.C.                      Page 6                           8/20/2010
Approved 05/11/05
References:
Differential Diagnosis by Souza

Instant Access to Chiropractic Guidelines and Protocols by Huff and Brady

Professional Guide to Diseases, 6th ed., Springhouse, 1998

Basic Pathology, Kumar, Cotran, Robbins, 6th ed., 1997

Merck Manual, 17th ed.




Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.


Condition Name        Baseline     Complicating/ Mitigating Factors     Revised
                      Complexity                                        Complexity
                                   Irritability                            4.0
 Graves’s disease                  Hyperreflexia                           4.0
      AKA                 2.0      Tremors/nervousness                     4.0
 Hyperthyroidism




Cindy Gibbon, D.C.                  Page 7                            8/20/2010
Approved 05/11/05
                         CLINICAL APPLICATIONS
                         Faculty Case Study Preparation


CONDITION: ______Lateral Epicondylitis___________________________

Prepared by:_____Maria Michelin, DC_____________________________


RELEVANT PATHOPHYSIOLOGY:

Lateral elbow pain due to degeneration, tendonosis and periosititis at muscle bone
junction of the extensor tendon and lateral epicondyle of the humerous. Some
references say specifically tearing of the extensor digitorum communicans and
extensor carpi radialis longus and brevis.



CASE HISTORY:

PPW:         Lateral elbow pain

Onset-Initial        gradual                                                _____
      Palliative/Provocative       rest/tennis backhand, pronation to supination
      forced dorsiflexion with radial deviation and supination
      Quality/Quantity
      Referred/Radiating
      Site           lateral epicondyle
      Timing/Pattern
      Other

Relevant History and Lifestyle
      Gender
      Age
      Occupation novice tennis player, grocery scanner, using an non-motorized
      screwdriver, plumbers, meat cutters, weavers, excessive typing or writing
      Traumas
      Surgeries
      Medications
      Hospitalizations
      Immunizations
      Diseases or Conditions__________________________________ _
      Family History
      Diet
      Sleep Habits
      Sexual History

Maria Michelin, D.C.                Page 1                             8/20/2010
Approved 05/24/04
         Alcohol Usage
         Drug Usage
         Smoking/Tobacco
         Other__________________________________________________


Review of Systems                                                      _____

     ______________________________________________________
___________________________________________________________



PHYSICAL EXAMINATION:

Height                             Weight

Vitals: BP             Pulse                     Respiration________ Temp.

Appearance, Motion, Gait

Orthopedic Tests

       Test Name               R         L              Test Name             R           L
Mills                          X     +       -                               +    -   +       -
Cozens                         X     +       -                               +    -   +       -
Book                           x     +       -                               +    -   +       -
Golfer’s elbow                 -     +       -                               +    -   +       -
Valgus &Varus Stress           -     +       -                               +    -   +       -

Orthopedic Test Results Discussion:       Mills, Cozen and book all indicate lateral
epicondylitis if positive. Medial epicondylitis and collateral ligament damage is ruled
out by the golfer’s elbow and the valgus/varus stress tests.




Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception ___WNL except possibly elbow pain when
performing grip strength tests.__________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________




Maria Michelin, D.C.                  Page 2                                 8/20/2010
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LabValues__________________________________________________________
_____ ____________________________________________________________


Examination of Related Areas         Trigger points possible in wrist extensors.



Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




SPINAL EXAMINATION:

      Postural Analysis                          Postural Analysis      L      N        R
                                                 Head Tilt
                                                 Head Rotation
                                                 High Ear
                                                 High Shoulder
                                                 High Ilium
                                                 Ext. Rotated Foot
                                                 Int. Rotated Foot


ROM
             Cervical ROM                                    Lumbar ROM
               ROM      Pain     Level                        ROM     Pain         Level
Flexion        N  Y N                      Flexion          N     Y N
Extension      N  Y N                      Extension        N     Y N
R. Rotation    N  Y N                      R. Rotation      N     Y N
L. Rotation    N  Y N                      L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                      R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                      L. Lat. Flex.    N     Y N


Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion)




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List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

         X-rays       MRI         CT         Other

Views          All WNL


Findings




DIFFERENTIALS:

   1. Medial epicondylitis
   2. Radial head misalignment
   3. Lateral collateral ligament injury


DIAGNOSIS:

        Lateral epicondylitis



Case Management:

Chiropractic Management:         Adjust the spine, radial or olecranon if
necessary._________________________________________________
Adjunctive Therapy:       Active release technique, post acute-transverse friction
massage, positional release technique, trigger point therapy


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Physical Therapy: Rest and ice. Splint in 30 to 40 degrees extension if severe and
acute.__Elbow wrap to stabilize the radial head during activities which stress elbow.
__________________________________________________________________

Nutrition:          Omega-3 fatty acids




Exercise:           stretching of wrist flexors and extensors




Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education):                                                       Hammer
users-padded larger hammer, shock absorbing grip_____________________
Tennis players- larger sweet spot and better grip, avoid graphite rackets, play
on slower surfaces_______________________________________________
___________________________________________________________

Further Evaluation:        If no noticeable improvement after three weeks consider
MRI to rule out ligamentous tear.


Common Medical Management: ___Rest, ice and splint. Use NSAIDs




References:
Souza, Differential Diagnosis for the Chiropractor
Merck Manual, 17th edition
Calliet, Neck and Arm Pain




Case Complexity:



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The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.


Condition Name          Baseline     Complicating/ Mitigating Factors     Revised
                        Complexity                                        Complexity
Lateral Epicondylitis      1.0       Nothing that really affects
                                     management. Could consider this           3
                                     a 3 if we adjusted extremities at
                                     SCSC.




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                          CLINICAL APPLICATIONS
                          Faculty Case Study Preparation


CONDITION: Meniere’s disease

Prepared by: Rochelle J. Delain, D.C.

RELEVANT PATHOPHYSIOLOGY:
Meniere’s Disease is disorder caused by distension of the inner ear due to either
retention or overproduction of endolymph fluid in the labyrinth . The labyrinth
consists of 2 parts: the bony labyrinth and the membranous labyrinth. The
membranous labyrinth is encased in bone and filled with endolymph. An excess of
endolymph can cause the labyrinth to dilate. This condition is known as
endolymphatic hydrops. Some scientists believe that the rupture of the
membranous labyrinth allows endolymph to mingle with perilymph which is another
inner ear fluid found between the membranous labyrinth and the bony ear. It is
believed that the mixing of these two fluids may be the cause of the symptoms of
Meniere’s

CASE HISTORY:

PPW: Severe periodic attacks of rotatory vertigo that are often accompanied by
nausea vomiting, sweating, and nystagmus. These attacks are often preceded by a
sensation of fullness in the ear, tinnitus that sounds like a persistent roaring, and
difficulty hearing of low frequency sounds in particular.

Onset-Initial:
Palliative/Provocative: Lying very still in a quiet room/ loud “busy”
         atmospheres, stress, any movement
Quality/Quantity Patient states that it is “like drinking a lot of alcohol and riding a
        spinning amusement park ride”/ Severe
Referred/Radiating May cause headaches.
Site Tinnitus and hearing loss may occur in both ears at the same time or one ear at
        a time
Timing/Pattern No predictable frequency and duration may vary from hours to days
Other: No Significant Findings


Relevant History and Lifestyle
Gender Similar incidence of Meniere’s among males and females
Age: Most commonly afflicts people in their 40’s and 50’s, although people in their
      20’s and above may also be affected. Occasionally it is reported in children
Occupation: No Significant Findings
Traumas:     No Significant Findings
Surgeries: No Significant Findings

Rochelle Delain, D.C.                 Page 1                             8/20/2010
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Medications:         No Significant Findings
Hospitalizations: No Significant Findings
Immunizations:       No Significant Findings
Diseases or Conditions: No Significant Findings
Family History: No Significant Findings
Diet: No Significant Findings
Sleep Habits: No Significant Findings
Sexual History: No Significant Findings
Alcohol Usage: No Significant Findings
Drug Usage: No Significant Findings
Smoking/Tobacco: No Significant Findings
Other: No Significant Findings


Review of Systems:         Special emphasis is placed on the ears and other
structures of the head and neck to rule out inner ear infection, growths or other
abnormalities. Findings for Meniere’s patients, barring other disorders, are often
normal unless having an attack.

PHYSICAL EXAMINATION:

Vitals:      BP: No Significant Findings
             Pulse: No Significant Findings
             Respiration: No Significant Findings
             Temperature: No Significant Findings
             Height : No Significant Findings
             Weight: No Significant Findings

Appearance, Motion, Gait:            Staggering drunken gait when having an attack

Orthopedic Tests

      Test Name              R            L               Test Name      R           L
                           +     -    +       -                         +    -   +       -
                           +     -    +       -                         +    -   +       -
                           +     -    +       -                         +    -   +       -
                           +     -    +       -                         +    -   +       -
                           +     -    +       -                         +    -   +       -

Orthopedic Test Results Discussion:               Not Applicable




Rochelle Delain, D.C.                   Page 2                          8/20/2010
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Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception

Electroencephalogram (EEG)- This is a differential test that helps to diagnose
several disorders that might cause the same symptoms, e.g. confusion, head
injuries, brain tumors, infections, degenerative disease and metabolic disturbances.
Patient is asked to lie very still on her back while many electrodes are placed in
different positions on her scalp. The electrodes are attached to wires that are
connected to an amplifier and recording machine. Electrical impulses from the brain
are converted to wavy lines (similar to an ECG). This test helps to distinguish other
disorders that could affect the brain (e.g. seizure disorders, head injuries, brain
tumors etc.) from Meniere’s and is more of a ruling out test

Audiometry, This battery of tests measures different aspects of hearing ability
particularly sensory. The Speech discrimination audiometry test is the most helpful
in diagnosing Meniere’s. For example the ability to distinguish phonetically similar
words such as “fit” and sit” is diminished in the affected ear

Audiography, This test is more specific in testing hearing. It is measurement of air
conduction in which the patient wears earphones attached to the audiometer.
Several pure tones of varying intensity are delivered to one ear at a time and the
patient must indicate when they hear the sound and at what minimum intensity they
can still hear it. A graph attachment is also placed on the mastoid to test bone
conduction

 Transtympanic electrocochleography, (ECOG),
 This test assesses for cochlear involvement, and may indicate increase fluid
pressure in the inner ear pointing to a possible diagnosis of Meniere's

Electronystagmography, This is a test that may be performed to assess balance
function

Caloric stimulation: This test is performed to evaluate the acoustic nerve which
provides both hearing and balance . A teaspoon of cold water is place in each ear
one at a time. This should cause nystagmus of the eyes away from the side in
which the cold water is introduced and slowly back. Introduction of very warm water
will cause the eyes to go into nystagmus toward the side in which the warm water
was introduced. This test is not recommended if the patient has an ear infection,

Lab values: The following lab tests may be indicated: CBC to rule out possible
infections, urinalysis to rule out blood sugar problems and drug testing. Should be
normal in Meniere’s patients barring the presence of other disorders

Examination of Related Areas

Ear exam

Rochelle Delain, D.C.                Page 3                             8/20/2010
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Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
      Auscultation, etc.)

Mittlemeyers and Rhombergs should be performed to rule out disorders of the
posterior columns as well as inner ear problems not related to Meniere’s. These
tests are usually only positive in Meniere’s patients only when having an attack

SPINAL EXAMINATION:

      Postural Analysis                       Postural Analysis   L      N         R
                                              Head Tilt
                                              Head Rotation
                                              High Ear
                                              High Shoulder
                                              High ilium
                                              Ext. Rotated Foot
                                              Int. Rotated Foot

ROM
             Cervical ROM                                Lumbar ROM
               ROM      Pain     Level                    ROM     Pain        Level
Flexion        N  Y N                  Flexion          N     Y N
Extension      N  Y N                  Extension        N     Y N
R. Rotation    N  Y N                  R. Rotation      N     Y N
L. Rotation    N  Y N                  L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                  R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                  L. Lat. Flex.    N     Y N

Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion)


List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




Rochelle Delain, D.C.                Page 4                           8/20/2010
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RADIOLOGICAL EXAMINATION:

        X-rays      X MRI          CT           Other

Views:        Head and neck. This is normally the next course of action after the
detailed case history and physical examination to rule out other abnormal physical
conditions of the head and such as tumors or other lesions

Menieres: MRI of the head to r/o tumor, MRI of the Circle of Willis to rule out stenotic
blood vessels, MRI of the IAC (internal auditory canal) to rule out obstruction and
lesion.

Findings: Normal, no brain tumors.

DIFFERENTIALS:

Would include: Brain tumors, emotional illness, head or neck trauma, inner ear
infection, metabolic disturbances, alcohol or drug abuse, prescription drug side
effects, sinus infection (seasonal), TIAs.

DIAGNOSIS:

Meniere’s disease

CASE MANAGEMENT:
Chiropractic Management: Locate, analyze, and correct vertebral
subluxations. Pay particular attention to the upper cervical spine since there are
studies that show a connection between cervical spine (particularly upper
cervical) dysfunction and Meniere’s.
Common Medical Management: Diuretics, Anti-emetic, anti-nausea, and anti-
vertigo drugs, anti-anxiety drugs, steroids, anti-histamines, calcium channel
blockers, vasoactive drugs, osmotic drugs, ototoxic antibiotics. Physicians also
prescribe valium to the patients.
Adjunctive Therapy: Acupuncture has shown some benefit in both symptom and
stress relief in Meniere’s patients.

PhysicalTherapy:

Nutrition:

      Following a low sodium (salt) diet of ~ 2,000 mg per day of sodium
      A physician may prescribe a mild diuretic along with a low sodium diet to
       decrease the amount of fluid in the inner ear.
      Avoid foods high in sodium such as


Rochelle Delain, D.C.                 Page 5                              8/20/2010
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      1. Smoked, processed or cured meats and fish (e.g. bacon, ham, sausage,
         salt pork, chipped beef)
      2. Meat sauces, extracts and bouillon cubes
      3. Salted snacks (e.g. potato chips, pretzels, crackers)
      4. Condiments, pickles, soy sauce, ketchup, etc.
      5. Canned soups, cheeses and some frozen foods.

Reference: Mahan, L & Escott-Stump. S. (Eds.) (2003) Krause’s Food, Nutrition &
Diet Therapy (11th ed.). Philadelphia: W. B. Saunders.

General recommendations for a healthy diet using the 2005 Dietary Guidelines.
Some nutritional considerations may include: low salt diet, caffeine restriction,
chocolate restriction, alcohol restriction
Supplements: Ginkgo Biloba, Ginger, Lipoflavenoids

Some medical treatments are aimed at decreasing the amount of fluid in the inner
ear. Following a low sodium diet and taking a diuretic often accomplishes this.

Exercise:    No Specific Exercises

Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene,
psychosocial concerns, education): Since attacks may be provoked by stress,
effective stress management is very important.

Surgeries: If less invasive methods of treatment have not proven successful there
are several surgical options available. This include: Removal of part of the
emdolymphatic sac, Use of tympanostomy, endolymphatic decompression,
endolymphatic shunt, sacchulotmoy, cochleosacculotomy,, vestibular nerve section,
labyrinthectomy

Further Evaluation: None

REFERENCES:

“Symptoms and Incidence of Meniere’s Disease”
Washington University in St Louis School of Medicine Department of Otology
Web paged established in 1995 and maintained by Alec Salt, PhD
http://oto.wustl.edu/men/mn1.htm

“Meniere’s Disease”
National Institute on Deafness and Other Communication Disorders
http://www.nidcd.nih.gov/health/balance/meniere.asp

“How Meniere’s Disease is Diagnosed”
Information and Resources



Rochelle Delain, D.C.                Page 6                             8/20/2010
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Web page established and maintained by Karin and David Henderson citing the
American Academy of Otolaryngology –Head and Neck Surgery
http://www.menieres-disease.ca/diagnosis.htm

“Trends and Recent Development in Meniere’s Disease”
Washington University in St. Louis School of Medicine Department of Otology
Web page established in1995 and maintained by Alec Salt, PhD
http://oto.wustl.edu/men/recent.htm

“Compilation of Treatments for Meniere's Disease”
Washington University in St. Louis School of Medicine Department of Otology
Web page established in 1995 and maintained by Alec Salt, PhD
http://oto.wustl.edu/men/mntreat.htm

“Meniere’s disease: Alternative Medicine”
“Your Health”: Complimentary Medicine
University Health Systems of Eastern Carolina
www.uhseast.com/116498.cfm+Meni

“IUCCA Upper Cervical Chiropractic Care Corrects Dizziness/Vertigo”
www.erinelster.com/articles/vertigo_article_01_00.html

Mahan, L & Escott-Stump. S. (Eds.) (2003) Krause’s Food, Nutrition & Diet Therapy
(11th ed.). Philadelphia: W. B. Saunders.


Case Complexity

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.

Condition Name          Baseline     Complicating/ Mitigating Factors Revised
                        Complexity                                    Complexity
                                     Patient positioning for
                                     adjustment                          3.0
    Meniere’s              2.0       Knowledge of differential
                                     diagnosis for tumors, stroke,       4.0
                                     etc.
                                     Referral for co-management          3.0




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                          CLINICAL APPLICATIONS
                            Faculty Case Study Preparation


CONDITION_______Osteoporosis_________________________________________

Prepared by:_Dr Laura Greene-Orndorff___________________________________

RELEVANT PATHOPHYSIOLOGY:


Osteoporosis, or porous bone, is a disease characterized by low bone mass and
structural deterioration of bone tissue, leading to bone fragility and an increased
susceptibility to fractures, especially of the hip, spine and wrist, although any bone
can be affected.

When the bones lose their density, become more brittle because of the loss of
minerals (mostly calcium), and have an increasingly greater tendency to break, we
call the condition osteoporosis. Osteoporosis is the most common skeletal disorder
in the world, affecting nearly 20 million Americans - eight times as many women as
men-- and each year contributing to more than 80 percent of the two million fractures
of the elderly and nearly all of the 200,000 hip fractures of women over the age of
50(1) Contrary to popular belief, a fall is not the cause of all the fractures; in many
cases it's the fracture that causes the fall. The complications of hip fractures are one
of the primary causes of death in older women.

CASE HISTORY:


       Osteoporosis is often called the "silent disease" because bone loss occurs
without symptoms. People may not know that they have osteoporosis until their
bones become so weak that a sudden strain, bump or fall causes a fracture or a
vertebra to collapse. Collapsed vertebrae may initially be felt or seen in the form of
severe back pain, loss of height, or spinal deformities such as kyphosis or stooped
posture.

PPW: Severe mid back pain


Onset-Initial Two weeks ago__
      Palliative/Provocative     rest / lifting objects and standing
      Quality/Quantity     Sharp, nagging, deep pain
      Referred/Radiating radiate around the flank
      Site mid thoracic
      Timing/Pattern       constant
      Other

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Relevant History and Lifestyle
      Gender female
      Age 65
      Occupation retired elementary school teacher
      Traumas       none
      Surgeries     hysterectomy (age 45)
      Medications
      Hospitalizations     hysterectomy
      Immunizations        al childhood immunizations
      Diseases or Conditions___none__________________________ _
      Family History
      Diet
      Sleep Habits
      Sexual History
      Alcohol Usage        none
      Drug Usage none
      Smoking/Tobacco              1 pack a week for the past 45 years
      Other__________________________________________________


Review of Systems                                                        _____

     ______________________________________________________
___________________________________________________________



PHYSICAL EXAMINATION:

Height       5'4"                   Weight              155

Vitals: BP   130/90            Pulse               80    Respiration________ Temp.98.9


Appearance, Motion, Gait

Orthopedic Tests

      Test Name            R               L              Test Name          R           L
                           +    -      +       -                            +    -   +       -
                           +    -      +       -                            +    -   +       -
                           +    -      +       -                            +    -   +       -
                           +    -      +       -                            +    -   +       -
                           +    -      +       -                            +    -   +       -

Laura Greene-Orndorff                  Page 2                               8/20/2010
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Orthopedic Test Results Discussion:




Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

LabValues__________________________________________________________
_____ ____________________________________________________________


Examination of Related Areas



Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




SPINAL EXAMINATION:

      Postural Analysis                        Postural Analysis   L      N        R
      Rounded shoulders and increased          Head Tilt
      thoracic kyphosis                        Head Rotation
                                               High Ear
                                               High Shoulder
                                               High Ilium
                                               Ext. Rotated Foot
                                               Int. Rotated Foot



ROM
           Cervical ROM                                  Lumbar ROM
             ROM      Pain      Level                     ROM     Pain        Level

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Flexion            N      Y   N           Flexion               N      Y    N
Extension          N      Y   N           Extension             N      Y    N
R. Rotation        N      Y   N           R. Rotation           N      Y    N
L. Rotation        N      Y   N           L. Rotation           N      Y    N
R. Lat. Flex.      N      Y   N           R. Lat. Flex.         N      Y    N
L. Lat. Flex.      N      Y   N           L. Lat. Flex.         N      Y    N


Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion)          Tight muscles around T6-T10




List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

        X-rays          MRI         CT             Other       DEXA

Views A-P and Lateral X-rays of the thoracic spine

Findings       Loss of the horizontal trabecular pattern through out the thoracic spine,
compression fractures at T6, T7 and T8. A mark demineralization noted throughout the
thoracic spine. Increased density to the cortical outline    (Watch for neurological
complication) However, subjective impressions of bone density may be misleading because
osteoporosis cannot be diagnosed on x-ray (as radiolucency) until > 30% of bone has been
lost.


Laura Greene-Orndorff                  Page 4                                  8/20/2010
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DEXA                 Dual-Energy X-Ray Absorptiometry (DEXA) is the most
accurate and advanced test available for measuring bone mass with excellent
resolution and reproducible precision. Mineral radiation (less than 1/20 of a chest x-
ray) is used to determine the bone density of the spine, hip or wrist. A DEXA test
is more sensitive than ordinary x-rays, more accurate than radiograms (radiographic
absorptiometry) and can diagnose bone loss at an earlier stage.




DIFFERENTIALS:

Malnutrition
Hyperparathyroidism
Osteomalacia
Steroid usage
Calcium deficiency




DIAGNOSIS:

      Senile osteoporosis




Case Management:


Chiropractic Management:          correct subluxation(s) via low force technique




Adjunctive Therapy:



PhysicalTherapy: Resistance/strength exercise training



Laura Greene-Orndorff                 Page 5                             8/20/2010
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Nutrition:
Vitamins D, C, magnesium, zinc
Calcium; 1,000 mg/day for post-menopausal


Eat a healthy, balanced diet, including fresh vegetables (broccoli, kale, collard
greens, cabbage, and turnip greens), fruit, nuts and seeds.

Watch the animal protein intake try tofu, salmon, sardines, and grains. Low-fat milk
and/or yogurt are good sources of calcium. (A glass of low-fat milk and a cup of
yogurt add 600 mg of calcium to your daily diet).

* Drink eight 8-ounce glasses of water a day (herb teas, juices and coffee are not a
substitute for water.) Avoid caffeine, carbonated sodas, alcohol, and junk food.

Vegetarians have stronger, denser bones than meat eaters and lose less bone
density as they age. In one study the bone density of vegetarians in their seventies
was higher than that of meat eaters in their fifties. Red meat is rich in phosphorous,
and a diet that has more phosphorus than calcium can create a calcium loss.
Phosphorus is a major component of processed foods, including white bread and
cola drinks, and certain foods such as potatoes and meat. Excess salt in the diet
can also cause the loss of calcium.

Exercise:
Studies show that regular exercise, including walking (which also exposes the body
to sunlight for the production of vitamin D), increases bone mass or density.
Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education).
People suffering from osteoporosis should be careful when bending and
lifting heavy objects, including grandchildren. Bend from the knees,
not the waist, when lifting, and try to avoid hunching while sitting or standing.

Further Evaluation:
Risk Factors For Osteoporosis:
      1.  Being female-especially thin, Caucasian or Asian
      2.  Post- menopausal women
      3.  Having family history of osteoporosis
      4.  Being older than 40 years of age
      5.  Being physically inactive
      6.  Taking corticosteroids, thyroid medications, anticonvulsants,
         anticoagulants, Dilantin, diuretics, antacids with aluminum,
         and drugs that alter digestion, such as Ranitidine
      7. Smoking
      8. Heavy consumption of alcohol
      9. Heavy consumption of carbonated beverages, coffee

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     10.   Low intake of calcium and vitamin D
     11.   Chronic diseases of the kidney, lung, stomach, and intestines
     12.   Hormonal changes because of menopause or hysterectomy
     13.   Lactose intolerance, low stomach acid

Symptoms of Osteoporosis

Initially, osteoporosis has no symptoms. But after the condition has progressed, the
signs may include "dowager's hump," loss of height, abdominal protrusion, frequent
fractures, and sudden back pain (which is often caused by vertebral compression
fractures). Back pain is worse when the person afflicted with it is sitting or standing
and is relieved by lying down. Coughing, sneezing, and straining to move the
bowels can cause terrible pain.

Common Medical Management:

__Drug options for osteoporosis fall into five categories: estrogens, parathyroid
hormones (calcitonin) bisphosphonates (alendronate and risedronate sodium),
selective receptor molecules (raloxifene hydrochloride) and the newest category, the
bone formation agents (teriparatide). This group of drugs can slow bone loss,
promote bone growth, reduce the risk of fractures and even ease the pain of
fractures.


References:
 http://www.nlm.nih.gov/medlineplus/osteoporosis.html
http://www.nof.org/osteoporosis/diseasefacts.htm
http://www.arthritis.org/conditions/DrugGuide/about_osteoporosis.asp
http://www.merck.com/pubs/mmanual/section5/chapter57/57a.htm_


Condition Name         Baseline      Complicating/ Mitigating Factors       Revised
                       Complexity                                           Complexity
Osteoporosis               3         Loss of bone density on x-ray               5
                                     Vertebral body fracture.                    8
                                     Positive DEXA test                          5
                                     Steroid usage                               5
                                     Calcium deficiency                          5
                                     Smoker                                      4
                                     Heavy consumption of carbonated             5
                                     beverages, coffee and alcohol
                                     Hormonal changes because due                5
                                     to menopause or hysterectomy




Laura Greene-Orndorff                 Page 7                              8/20/2010
Approved 04/19/04
                            CLINICAL APPLICATIONS
                           Faculty Case Study Preparation


CONDITION: Otitis Media and Otitis Externa

Prepared by: Cindy Gibbon, DC


RELEVANT PATHOPHYSIOLOGY:

Otitis externa: usually bacterial cause or fungal; swimming predisposes,
                foreign objects in canal (bobby pins, Q tips), Ear phones/plugs, hair
                products or irritants causing itching and cellulitis

Acute serous otitis media: may come from upper respiratory tract infection,
              allergies,sinus. Develops from disruption of Eustachian tube patency,
               Barotrauma from air pressure (flying) scuba diving

Acute purulent otitis media: usu. From bacterial or viral infection secondary to URI.


CASE HISTORY:

PPW: Otitis externa: Ear is painful and itches

       Otitis media serous: Ear fullness for several weeks, barotraumas, past URTI
                   acute: deep ear pain, pressure, decreased hearing


CHIEF COMPLAINT: Earache and pain; both types may report hearing change
     OE: may have foul smelling discharge
     OM: may have discharge w/ rupture of tympanic membrane.(acute
         purulent)

Onset-Initial:     Sudden
Palliative/Provocative: Palliative would be pain meds, ear drops
Quality/Quantity: Usually severe.
                         OE: pain
                         OM: deep throbbing pain, possible signs of upper respiratory
                                  infection, fullness and popping in ear
Referred/Radiating:       OE: pain on auricle and tragus, chewing, yawnig,
                   OE: clenching teeth, regional cellulitis
                   OM: pain on mastoid;




Cindy Gibbon, D.C.                        Page 1                             8/20/2010
Approved 04/08/04
                   Acute purulent: Serous, Upper respiratory tract infection,
                   hearing loss, Fever, fullness, popping, Tinnitus/dizziness
                   click sounds w/ swallowing, Nausea/vomiting
Site: Ear, jaw, neck
Timing/Pattern:    continual
Other:

Gender: Not significant.
Age:    Acute OM: more common in children and infants
Occupation: OE: common w/ swimming and summer months
Traumas:     acute serous: barotrauma
Surgeries:          Not significant.
Medications: Not significant.
Hospitalizations: Not significant.
Immunizations:      Not significant.
Diseases/Conditions: Not significant.


Relevant History and Lifestyle:

Family History:      NA                        Sexual History:     NA
Social History:      NA                        Alcohol Usage:      NA
Diet:                NA                        Drug Usage:         NA
Sleep Habits:        NA                        Smoking/Tobacco:    NA

PHYSICAL EXAMINATION:

Vitals:      BP: Not significant.
             Pulse: Not significant.
             Respiration: Not significant.
             Temperature: Not significant.
             Height: Not significant.
             Weight: Not significant.

Appearance, Motion, Gait

Orthopedic Tests

      Test Name             R        L            Test Name             R        L
                           + -     + -                                + -       + -
                           + -     + -                                + -       + -

Orthopedic Test Results Discussion: No Relevant Orthopedic Tests




Cindy Gibbon, D.C.                       Page 2                             8/20/2010
Approved 04/08/04
Neurological Tests - Motor/Sensory/Reflex

WEBER Test might be positive. Rinne Test might be positive.
Audiometry testing may indicate a problem.

Lab Values: None unless bacterial cause. A culture and sensitivity can be performed
     to identify bacteria.

Examination of Related Areas
Check cervical spine for subluxations

Review of Systems: NA

Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.) Nothing significant.


SPINAL EXAMINATION:

      Postural Analysis                          Postural Analysis   L      N        R
                                                 Head Tilt
                                                 Head Rotation
                                                 High Ear
                                                 High Shoulder
                                                 High Ilium
                                                 Ext. Rotated Foot
                                                 Int. Rotated Foot


ROM
             Cervical ROM                                 Lumbar ROM
               ROM      Pain     Level                     ROM     Pain  Level
Flexion        N  Y N                     Flexion        N     Y N
Extension      N  Y N                     Extension      N     Y N
R. Rotation    N  Y N                     R. Rotation    N     Y N
L. Rotation    N      Y N                 L. Rotation    N     Y N
R. Lat. Flex.  N  Y N                     R. Lat. Flex.  N     Y N
L. Lat. Flex.  N  Y N                     L. Lat. Flex.  N     Y N
 Pattern Analysis including Leg Length/Spinal Balance/ Instrumentation/ Palpation
 (Muscle, Static, Motion): No significant findings.




Cindy Gibbon, D.C.                      Page 3                           8/20/2010
Approved 04/08/04
List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

          Views                                  Findings
X-rays    N/A

MRI       N/A

CT        N/A

Other     N/A


DIFFERENTIALS:

Acute otitis externa
Serous otitis media
Acute otitis media (usually purulent)
Mastoiditis
TMJ/ dental problems
Cervical sprain/ strain/ subluxation
Impacted cerumen


Case Management

Chiropractic Management:
      Journal of Clinical Chiro Pediatrics, 1997;2(2) “Role of chiropractic
                         adjustment in care and treatment of 332 children with
                        otitis media”
Adjunctive Therapy:
      Acute OE: heat therapy to periauricular area
                 Drugs: aspirin, acetaminophen, codeine
                Antibiotic ear drops
      Acute OM: Antibiotic therapy
                Possible myringotomy with continued bouts


Cindy Gibbon, D.C.                      Page 4                            8/20/2010
Approved 04/08/04
       Serous OM: several times a day: Valsalva’s maneuver, Nasopharyngeal
decongestant
Nutrition:

Exercise:
      OE: preventative drops of 50% each: white vinegar/ alcohol
      OM: recognition of early URI
            Perform Valsalva’s daily if able to comply
           Infants: do not feed infant in supine position or give bottle in bed
                    (avoid nasopharyngeal reflux)
          Identify allergies and treat accordingly

Referral:     EENT or GP

Further Evaluation:


REFERENCES:

Basic Pathology, 6th edition, Kumar, Cotran, Robbins, @1997
Instant Access to Chiropractic Guidelines and Protocols, Huff and Brady, 1999
Merck Manual, 17th edition
Differential Diagnosis for the Chiropractor, 1998; Souza
Manual of diagnostic and Laboratory Tests, 2nd ed; Panana, Mosby’s (2002)



Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early stage
of condition, advanced stage of condition, psychosocial issues, etc. The complicating or
mitigating factors can either increase or decrease the baseline complexity.



Condition Name          Baseline      Complicating/ Mitigating Factors            Revised
                        Complexity                                                Complexity
   Otitis Externa           2         Swimming; preventive instructions                1


                                      Myringotomy                                     1
                                      Repetative infx.                                1
    Otitis Media              3
                                      Loss of hearing/ learning                       2
                                      compromise


Cindy Gibbon, D.C.                        Page 5                              8/20/2010
Approved 04/08/04
Pelvic Inflammatory Disease
            (PID)
  Prepared by Michael Lee Minge II




          Approved: 31 May 06 Implemented
                        SU06
  Pelvic inflammatory disease
• an infection of the female reproductive organs
  uterus, fallopian tubes, cervix and ovaries.
  PID usually occurs when sexually transmitted
  bacteria spread from the vagina to the uterus
  and upper genital tract. PID may also develop
  when bacteria travel up a contraceptive
  device or when they're introduced during
  gynecologic procedures, such as insertion of
  an intrauterine device (IUD) or an abortion.
               Approved: 31 May 06 Implemented
                             SU06
        PID Pathophysiology
• Normally, the cervix prevents bacteria in the
  vagina from spreading up into the internal
  organs. If the cervix is exposed to a sexually
  transmitted disease. The cervix then
  becomes infected. If the disease travels up
  through the internal organs, they can also
  become inflamed and infected. It can damage
  the fallopian tubes and make it difficult to
  become pregnant.
               Approved: 31 May 06 Implemented
                             SU06
                     PPW
• “stomachache” with dull tenderness in
  the stomach and pelvic region during
  pelvic exam. A vaginal discharge that is
  green or yellow in color with an unusual
  odor.




             Approved: 31 May 06 Implemented
                           SU06
           Onset-Initial
• Each year more than 1 million women in
  the United States are diagnosed with
  PID, with the rate highest among
  teenagers. According to the National
  Institutes of Health (NIH), more than
  100,000 women become infertile as a
  result of PID, while others experience
  complications during pregnancy.
             Approved: 31 May 06 Implemented
                           SU06
    Site, Timing, and Pattern
• Site: Superior abdomen below rib cage
  to entire pelvic region.
• Timing/Pattern: lasting all day everyday
  gets worse during menstrual cycle can
  go into cramping.



             Approved: 31 May 06 Implemented
                           SU06
              Symptoms
Lower abdominal pain and abnormal vaginal
discharge. Other symptoms such as fever,
pain in the right upper abdomen, painful
intercourse, and irregular menstrual bleeding
can occur as well. PID, particularly when
cased by chlamydial infection, may produce
only minor symptoms or no symptoms at all,
even though it can seriously damage the
reproductive organs.

             Approved: 31 May 06 Implemented
                           SU06
            Lab Values
• A vaginal culture will be made and can
  result in a positives for STD, usually
  gonorrhea or chlamydia.




             Approved: 31 May 06 Implemented
                           SU06
         DIFFERENTIALS
•   Appendicitis
•   Heart Burn
•   Hernia
•   Upset Stomach




             Approved: 31 May 06 Implemented
                           SU06
              DIAGNOSIS
• Pelvic inflammatory disease can be difficult to
  diagnose. If symptoms such as lower
  abdominal pain are present, the doctor will
  perform a physical exam to determine the
  nature and location of the pain. The doctor
  also should check the patient for fever,
  abdominal, vaginal or cervical discharge, and
  evidence of cervical chlamydial infection or
  gonorrhea. If the findings of this exam
  suggest that PID is likely, current guidelines
  advise Doctors to begin treatment.
                Approved: 31 May 06 Implemented
                              SU06
      Medical Management
• Antibiotics are the standard treatment for PID.
• To prevent reinfection of PID, advise their
  sexual partner to be examined and treated.
• if seriously ill, pregnant or HIV-positive or
  have not responded to oral medications, you
  may need hospitalization. At the hospital, you
  may receive intravenous (IV) antibiotics,
  followed by oral antibiotics.

               Approved: 31 May 06 Implemented
                             SU06
    Surgical Management
• Rarely is surgery used but,PID may
  permanently scar the fallopian tubes or
  other pelvic scarring that may make the
  women infertile or have a tubal
  pregnancy. These conditions are hard
  to treat but are sometimes improved by
  surgery.

             Approved: 31 May 06 Implemented
                           SU06
  Chiropractic Management
• Analyze, locate and correct vertebral
  subluxations as necessary in cervical,
  thoracic, lumbar and pelvic regions.
  Lack of interference of the nervous
  system gives the patient’s body the
  ability to run at its peak performance
  and able let the body adapt faster to the
  stressors that are put on the body.
              Approved: 31 May 06 Implemented
                            SU06
             References
• http://www.mayoclinic.com/invoke.cfm
  “Pelvic Inflammatory Disease”.
• http://www.niaid.nih.gov/factsheets/stdpi
  d.htm “Pelvic Inflammatory Disease,
  NIAID Fact Sheet”.
• http://familydoctor.org/213.xml “Pelvic
  Inflammatory Disease (PID)”.

              Approved: 31 May 06 Implemented
                            SU06
Pernicious Anemia
    Jason M. Abbott




      Approved 31 May 06,
       Implemented SU06
     Normal B12 Physiology
•Vitamin B12 is a vitamin found in meat
•It binds to proteins known as R binders in saliva
when meat is ingested
•R binders protect B12 from being broken down by
acid in the stomach
•Once the complex of B12 & R binder proteins reach
the ileum (the last section of the small intestine), it is
broken apart and B12 binds with intrinsic factor
   –Intrisic factor is a substance secreted by parietal cells in
                           stomach
   gastric mucosa of the Approved 31 May 06,
                          Implemented SU06
    Normal B12 Physiology
•Intrinsic factor allows B12 to cross the
intestinal mucosa
•Vitamin B12 exists in the plasma as MeCbl, 5’-
deoxyAdoCbl, and hydroxycobalamin
  –These forms are bound to either transcobalamin I
  or II
  –Transcobalamin I is the B12 storage protein
  –Transcobalamin II is the B12 transport protein
•0.1 % of the total B12 in the body is found in
                    ApprovedmL
                      pg/ 31 SU06
the plasma(200-750ImplementedMay)06,
   Normal B12 Physiology
• The remaining amount of the body’s B12 is
  stored in the liver
• There is enough B12 in the liver to supply
  the body for 3-5 years with no B12 uptake




                 Approved 31 May 06,
                  Implemented SU06
   B12 Pathophysiology
Because there are several stages in the
uptake and storage of the normal
physiology of vitamin B12, there are various
possibilities of how the process can be
interrupted. When anything goes wrong
with the process that takes up and stores
vitamin B12 in the body, and the previously
stored supply of B12 in the body is used up,
a person then experiences PERNICIOUS
ANEMIA.           Approved 31 May 06,
                Implemented SU06
    Patient Presents With
• Reflex loss
• Loss of position and vibratory sensation
• Loss of proprioceptive and vibratory
  sensation in the lower extremities
• Loss of tactile, pain and temperature
  sensation (uncommon)
• Optic atrophy
• Weakness
                  Approved 31 May 06,
                   Implemented SU06
    Patient Presents With
• Weight Loss Diffuse abdominal pain
• Parkinsonian symptoms may be seen in
  severe cases
• Glossitis
• Yellow / Blue color blindnessAlternating
  diarrhea and constipation
• Seizures
• Spasticity
                  Approved 31 May 06,
                   Implemented SU06
      Patient Presents With
•   Paranoia
•   Delirium
•   Confusion
•   Anorexia
•   Unsteady gait




                    Approved 31 May 06,
                     Implemented SU06
• ONSET – Gradual and insidous. Liver
 stores deplete slowly and may take years to
 drain completely.
• PALLIATIVE – Intramuscular or oral
 doses of B12. Fe therapy may be necessary
 prior to B12 therapy if Fe deficiency is
 found in bone marrow. If the
 pathophysiological mechanism cannot be
 corrected then B12 therapy must be
 continued throughout life.

                 Approved 31 May 06,
                  Implemented SU06
• PROVOCATIVE – Strict veganism, a diet
 consisting of no meat or animal proteins, will
 decrease or do away completely with the
 amount of B12 a person takes in, and this
 can cause pernicious anemia. Destruction of
 the gastric mucosa, where intrinsic factor is
 released, will decrease the uptake of B12.
 Certain disorders that compete for the
 uptake of B12 such as a fish tapeworm, and
 blind loop syndrome. Also, hyperthyroidism
 can increase the demand for B12. Removal
 of large portions of the small intestine where
 B12 is absorbed.
                  Approved 31 May 06,
                  Implemented SU06
• PREVIOUS CARE- None
• QUALITY- Anorexic conditions, GI
    problems, and neurological problems such
    as: weakness of muscles, decreased
    vibratory and position sensation, and
    tactile, pain, and temperature impairment.
•   QUANTITY- varies according to severity
•   RADIATING- None
•   SITE – Varies according to symptoms.
•   TIMING – Varies according to severity
                   Approved 31 May 06,
                    Implemented SU06
• TIMING – Varies according to severity

• GENDER- N/A
• AGE- Often in the elderly there is a decreased
  amount of food-bound B12 liberated and absorbed
  by the body.
• OCCUPATION- N/A
• TRAUMAS- N/A
• SUGERIES- Surgical resection of the small
  intestine can destroy portions of the ileum where
  B12 is absorbed.
• HOSPITILIZATIONS- N/A
                    Approved 31 May 06,
                     Implemented SU06
• IMMUNIZATIONS- N/A
• DISEASES or CONDITIONS-
  –   Loss of intrinsic factor due to gastritis
  –   Blind loop syndrome
  –   Fish tapeworm
  –   Inflammatory regional enteritis
  –   Chronic pancreatitis
  –   Chronic hyperthyroidism
  –   Celiac disease
  –   Sprue
  –   Malignancy in the ileal region
  –   Liver disease
  –   Kidney disease
                          Approved 31 May 06,
                           Implemented SU06
• FAMILY HISTORY- In some cases, the site
  for B12 absorption in the ileum is
  congenitally absent or decreased.
• MEDICATIONS-
  – Oral calcium-chelating drugs
  – Aminosalicylic drugs
  – Biguanides
• DIET- Normally B12 is acquired through
  the eating of meat. Vegans take in a diet
  absent of meat or animal proteins,
  therefore their intake of B12 is absent.
                   Approved 31 May 06,
                    Implemented SU06
• SLEEP HABITS- Pernicious anemis can
  cause a myriad of neurological problems
  which may lead to decreased sleep.
• SEXUAL HISTORY- N/A
• ALCOHOL USAGE- Chronic alcoholism
  can lead to pernicious anemia by disrupting
  the release of intrinsic factor from the
  mucosa or by reducing the absorption of
  B12 in the ileum.
• DRUG USAGE- N/A
• SMOKING/TOBACCO- N/A

                  Approved 31 May 06,
                   Implemented SU06
    Physical Examination
• HEIGHT-N/A
• WEIGHT- May be decreased due to
  anorexic symptoms
• BLOOD PRESSURE- N/A
• PULSE – N/A
• RESPIRATION- N/A
• TEMPERATURE- N/A
• ORTHOPEDIC TESTS – N/A

               Approved 31 May 06,
                Implemented SU06
       Neurological Tests
• Neurological symptoms are sometimes seen
  without hematological problems.
• The peripheral nerves are effected first,
  then the spinal cord.
• Loss of vibratory and position sensation of
  the extremities
• Weakness of musculature
• Loss of normal reflexes
                  Approved 31 May 06,
                   Implemented SU06
       Neurological Tests
• Spasticity of muscles is often seen in the
  later stages.
• The Babinski response is often seen as a
  pathological reflex
• Loss of position sensation in the lower
  extremities
• Loss of vibratory sensation in the lower
  extremities
                   Approved 31 May 06,
                    Implemented SU06
       Neurological Tests
• Spasticity of muscles is often seen in the
  later stages.
• The Babinski response is often seen as a
  pathological reflex
• Loss of position sensation in the lower
  extremities
• Loss of vibratory sensation in the lower
  extremities
                   Approved 31 May 06,
                    Implemented SU06
              Lab Values
•   MCV > 100 fL
•   Increased RDW
•   Macro-ovalocytosis
•   Anisocytosis
•   Poikilocytosis
•   Howell-Jolly bodies
•   Hypersegmentation of granulocytes
•   Neutropenia
                   Approved 31 May 06,
                    Implemented SU06
            Lab Values
• Thrombocytopenia found in 50% of severe
  cases
• Misshapen platelets
• Erythroid hyperplasia of bone marrow
• Increased indirect serum bilirubin
• Increased LDH
• Increased serum ferritin
• Decreased serum vitamin B12 (<150 pg/mL)

                Approved 31 May 06,
                 Implemented SU06
            Lab Values
• Decreased transcobalamin II-B12
  (<40pgmL)




                Approved 31 May 06,
                 Implemented SU06
Examination of Related Areas
• The only area where examination may
  indicate a problem is palpation of the
  abdomen. Diffuse tenderness may be found
  in this area.




                Approved 31 May 06,
                 Implemented SU06
          Other Findings
• The only findings not prevoiusly discussed is
  the presence of splenomegaly and
  hepatomegaly. Also the patient may
  complain of glossitis.




                  Approved 31 May 06,
                   Implemented SU06
      Spinal Examination
• No findings in the spinal exam would be
  diagnostic for pernicious anemia.




                 Approved 31 May 06,
                  Implemented SU06
 Radiological Examination
• No findings in the radiologcal exam would
  be diagnostic for pernicious anemia.




                 Approved 31 May 06,
                  Implemented SU06
              Differentials
•   Folic acid deficiency anemia
•   Achorhydria
•   Alcoholic fatty liver
•   Alcoholic hepatitis
•   Aplastic anemia
•   Bone marrow failure
•   Celiac Sprue
•   Cirrhosis
                    Approved 31 May 06,
                     Implemented SU06
            Differentials
•   Gastric cancer
•   Atrophic gastritis
•   Hemolytic anemia
•   Unconjugated hyperbilirubinemia
•   Hyerthyroidism
•   Hypothyroidism
•   Immune Thrombocytopenic Purpura
•   Iron deficiency anemia
                 Approved 31 May 06,
                  Implemented SU06
             Differentials
•   Macrocytosis
•   Malabsorption
•   Megaloblastic anemia
•   Myeloproliferative Disease
•   Neutropenia
•   Schizophrenia
•   Tropical Sprue
•   Zollinger-Ellison Syndrome
                   Approved 31 May 06,
                    Implemented SU06
           Differentials
• Blind loop syndrome
• Fish tapeworm
• Methymalonic acidemia




                Approved 31 May 06,
                 Implemented SU06
              Diagnosis
• Pernicious anemia due to B12 deficiency




                 Approved 31 May 06,
                  Implemented SU06
        Case Management
• Chiropractic Management: Adjust
  subluxations to allow the body to adapt to and
  correct deficiency.
• Medical Management: B12 supplements,
  either intramuscular or orally administered.
  Not only is there a need to supply the body
  with B12 immediately but also, the storage
  supply of B12 in the liver must be replenished.
  B12 supplementation must be maintained
  throughout life unless the cause of the
  deficiency is addressed. May 06,
                    Approved 31
                    Implemented SU06
        Case Management
• Surgical Management: N/A
• Adjunctive Therapy: In some cases of
  pernicious anemia, Fe amounts within the bone
  marrow are depleted, and in these cases, oral Fe
  therapy must be administered prior to the B12
  therapy.
• Physical Therapy & Exercise: In the case of
  long term neurological problems, physical
  therapy and exercise may be needed to
  strengthen atrophied muscles or improve
  coordination.    Approved 31 May 06,
                    Implemented SU06
    Case Management – Nutrition
• Increase protein in the diet (1-5 grams per kilogram of body weight)
  is desirable for both liver function and for blood regeneration.
• Increase green leafy vegetables because they contain both iron and
  folic acid.
• Liver is an excellent source of iron, vitamin B12, folic acid, and other
  important nutrients. Meats (especially beef and pork), eggs, milk
  and milk products are particularly good sources of vitamin B12.
• Vegans should consume plant-based foods fortified with vitamin B12
  or consume a supplement.

•   Reference: Mahan, L & Escott-Stump. S. (Eds.) (2003) Krause’s
    Food, Nutrition & Diet Therapy (11th ed.). Philadelphia: W. B.
    Saunders.

                             Approved 31 May 06,
                              Implemented SU06
        Case Management
• Further Evaluations: Lab results should be
  taken to evaluate the effect of treatments.
  There is increased risk of gastric and
  esophageal adenocarcinoma.




                   Approved 31 May 06,
                    Implemented SU06
            Resources Cited
• Conrad, Marcel E., MD; Pernicious Anemia;
       http://www.emedicine.com/med/topic1799.h0tm ;
       1/7/05.
•   Beers, Mark H., MD, & Berkow, Robert, MD; The
       Merck Manual of Diagnosis and Therapy (7th
       Edition); Merck Research Laboratories:
       Whitehouse Station, N.J.; 1999; pp.865-868.
•   Kumar S., Vitamin B12 Deficiency Presenting with an
       Acute Reversible Extrapyramidal Syndrome,
       Neurol India 2004; 52:507-509

                      Approved 31 May 06,
                       Implemented SU06
         Resources Cited
• Ye, W. and Nyren, O.; Risk of cancers of the
  oesophagus and stomach by histiology or
  subsite in patients hospitalized for pernicious
  anemia; Gut 2003;52:938-941
• Kumar S. Recurrent seizures: An unusual
  manifestation of vitamin B12 deficiency. Neurol
  India 2004;52:122-123


                   Approved 31 May 06,
                    Implemented SU06
     Reiter’s Syndrome



      Created By: Lavetta Collins
Edited By: Laura Greene-Orndorff, D.C.



           Approved 31 May 06 ; Implemented
                        SU06
    Relevant Pathophysiology
   Reiter syndrome is triggered following
    enteric or urogenital infections. Reiter
    syndrome is associated with human
    leukocyte antigen (HLA)–B27, although
    HLA-B27 is not always present in an
    affected individual, particularly in the
    presence of HIV.
   Bacteria associated with Reiter syndrome
    are generally enteric or venereal and include
    the following:
                Approved 31 May 06 ; Implemented
                             SU06
       Relevant Physiology
 Shigella flexneri, Salmonella
 typhimurium, Salmonella enteritidis,
 Streptococcus viridans, Mycoplasma
 pneumonia, Cyclospora. These
 bacteria or been identified in synovial
 fluid cells, synovial biopsy specimens,
 and circulatory monocytes.

             Approved 31 May 06 ; Implemented
                          SU06
      What is Reiter’s Syndrome
It is an aseptic inflammatory arthritis that
produces pain, swelling, redness and heat in the
joints. It is one of a family of arthritic disorders,
called spondylarthropathies, affecting the spine
and commonly involving the joints of the spine and
sacroiliac joints. It can also affect many other parts
of the body such as arms and legs. Main
characteristic features are inflammation of the
joints, urinary tract, eyes and ulceration of skin and
mouth.

                  Approved 31 May 06 ; Implemented
                               SU06
    Patient Presents With

 Sore  muscles.
 Pain in the lower back, or on the heel or
  bottom of the foot
 Possible mild fever.
 Frequent or painful urination.
 Weight loss
 Skin rash
 Inflammation

             Approved 31 May 06 ; Implemented
                          SU06
              Onset/Etiology
   The exact cause is unknown, but the
    tendency to develop it can run in some
    families. About 75% of the people with the
    tendency to develop this disease have a
    special gene marker called HLA-B27.
   It can develop in certain people following an
    infection in intestines or genital or urinary
    tract. Reiter's usually occurs through
    inflammation of the intestinal tract followed by
    a bout of diarrhea caused by eating foods
                    with bacteria such
    contaminated Approved 31 May 06 ; Implemented as
    salmonella.               SU06
          Radiating Pain
 You may have pain in the lower
 back. The pain may reach to the
 buttocks and thighs and feel worse in
 the early morning.




            Approved 31 May 06 ; Implemented
                         SU06
        Gender /Age/ Race
Men between the ages of 20 and 40 are most
likely to develop Reiter's syndrome. It is the
most common type of arthritis affecting young
men. Among men under age 50, about 3.5 per
100,000 develop Reiter's syndrome each year.
Three percent of all men with a sexually
transmitted disease develop Reiter's syndrome.
Women can also develop the disorder, though
less often than men, with features that are often
milder and more subtle. Prevalence of the
disease is higher in white; people than in black
                Approved 31 May 06 Implemented
people, as in other spondyloarthropathies.
                             SU06
                Occupation
 Is   not relevant to condition




                Approved 31 May 06 ; Implemented
                             SU06
                Trauma


It   is not relevant to this condition




            Approved 31 May 06 ; Implemented
                         SU06
                Medications
   Non-steroidal anti-inflammatory drugs are
    often used to treat Reiter's syndrome. These
    are a type of medication that helps reduce
    pain and swelling of the joints and decrease
    stiffness. However, they do not prevent
    further joint damage.

   People with Reiter's syndrome that has gone
    on for more than a few months are often
    given disease modifying anti-rheumatic drugs
                                  try to stop
    (DMARDs). DMARDs06 ; Implemented the disease
                  Approved 31 May
    from getting worse. SU06
                 Medications
   They can take about two to six months before
    they make a difference in the pain and
    swelling.
   Occasionally a cortisone injection into an
    infected joint brings short-term relief and may
    prevent long-term stiffness. Cortisone is a
    steroid that reduces inflammation and
    swelling.
   If your eyes are affected, you may also be
    given cortisone eye drops.
                   Approved 31 may prescribe cortisone
    An ophthalmologist May 06 ; Implemented
    eye drops if you have iritis or uveitis.
                               SU06
              Hospitalization
 It   is not relevant to this condition




                 Approved 31 May 06 ; Implemented
                              SU06
                   Illnesses
   Sores in the mouth. These may be painful or
    painless.
   Thick, crusty red-purple sores on the palms of the
    hands or the soles of the feet.
   Sores on the genitals. These may be painful and
    can become infected.
   Dull pain in the pelvic area.
   Red, sore eyes. Sometimes the eyelids may stick
    together in the morning.
   Blurred vision.
                 Approved 31 May 06 ; Implemented
                              SU06
       Disease and Conditions
   Conjunctivitis
   Urethritis
   Iritis
   Uveitis
   Cystitis
   Cervicitis
   Prostatitis
   Enthesitis
                     Approved 31 May 06 ; Implemented
                                  SU06
         Family History


The  prevalence of the HLA-B27
tissue antigen is 63 to 96% in
Reiter's syndrome patients vs. 6 to
15% in healthy controls, thus
supporting the likelihood of a genetic
predisposition.

            Approved 31 May 06 ; Implemented
                         SU06
            Sexual History
Two  forms are recognized: sexually
transmitted and dysenteric Genital infections
with C. trachomatis are most often implicated
Men or women can usually acquire the
dysenteric form after enteric bacterial infections,
primarily caused by Shigella, Salmonella,
Yersinia, or Campylobacter as well as the
Chlamydia-associated disease. Persons with
HLA-B27 are at increased risk for developing
Reiter's syndrome after sexual contact or
exposure to certain enteric bacterial infections.
               Approved 31 May 06 ; Implemented
                            SU06
  Physical Examination
  Orthopedic Findings
Positive    Yeoman
Positive   Hibbs
Positive   Nachlas
Positive   Minor’s Sign
Lewin-Gaesnslen                Test
Laguerre’s      Sign
            Approved 31 May 06 ; Implemented

Goldthwaite’s          Test
                         SU06
Physical Exam-Neurological
         Findings


  Not relevant to this condition




          Approved 31 May 06 ; Implemented
                       SU06
                 LAB Values
   The erythrocyte sedimentation rate is
    elevated during the acute phase of the
    disease. Mild anemia may be present, and
    acute phase reactants tend to be increased.
    Synovial fluid is nonspecifically inflammatory,
    showing an elevated white cell count with a
    predominance of neutrophils. In most ethnic
    groups, three-fourths of the patients possess
    the HLA-B27 antigen.
                  Approved 31 May 06 ; Implemented
                               SU06
      Spinal Examination
 Decreased lumbar flexion. Patients with
 more chronic and severe axial disease
 may develop physical findings similar to
 ankylosing spondylitis




              Approved 31 May 06 ; Implemented
                           SU06
    Radiographic Examinations
   In early or mild disease, radiographic
    changes may be absent or confined to
    juxtaarticular osteoporosis. With long-
    standing persistent disease, marginal
    erosions and loss of joint space can be seen
    in affected joints. Periostitis with reactive new
    bone formation is characteristic of the
    disease, as it is with all of the
    spondyloarthropathies. Spurs at the insertion
    of the plantar fascia are common.
                  Approved 31 May 06 ; Implemented
                               SU06
         Radiographic Information
   In early stage, radiographs are normal. The synovial joint,
    symphyses, and entheses are affected. An asymmetric
    distribution with predominant involvement of lower
    extremities is seen.
   The general radiographic changes are similar to those of
    psoriatic arthritis, but the characteristic sites of abnormality
    are the small joints of the foot, the calcaneus, the ankle, the
    knee, and the sacroiliac joint. Nonspecific soft tissue swelling
    is frequently seen in the toes and fingers, resulting in
    sausage-shaped digits.
   Periarticular osteoporosis is seen with acute episode of
    arthritis. Diffuse loss of the articular space is characteristic
    and is frequently affects the small joints of the foot, hand,
    wrist, knee, and ankle. Bone erosions may also occur at these
    joints, resulting in sacroiliitis. Erosions initially occur at the
    joint margins and later progress to involve subchondral bone
    in the central portion.
                      Approved 31 May 06 ; Implemented
                                   SU06
      Radiographic Information
   Bone proliferation is characteristic of all seronegative
    spondyloarthropathies and is the most helpful radiographic
    feature in distinguishing these conditions from rheumatoid
    arthritis. Linear and fluffy periosteal bone proliferations
    are common in Reiter syndrome, especially in the
    calcaneus; knee; and metacarpal, metatarsal, and
    phalangeal shafts. A second variety of bone proliferation
    occurs at the sites of tendon and ligament attachments to
    the bone.
   MRI has extremely high sensitivity for active Reiter
    disease but low specify. Correlation with the clinical
    and radiographic findings is usually necessary to
    differentiate Reiter disease from other seronegative
    arthropathies.
                     Approved 31 May 06 ; Implemented
                                  SU06
Radiographic Examinations
Thesyndesmophytes may be coarse and
nonmarginal, arising from the middle of the
Lumbar vertebral body.
Common       findings on X rays of patients
with Reiter's syndrome include spondylitis,
sacroilitis, swelling of soft tissues, damage
to cartilage or bone margins of the joint, and
bone deposits where the tendon attaches to
the bone.
             Approved 31 May 06 ; Implemented
                          SU06
            Other Test
 An ECG should be performed in
 patients having a prolonged course of
 the disease to evaluate for conduction
 disturbances.




            Approved 31 May 06 ; Implemented
                         SU06
           Diagnosis
Diagnosing   Reiter's syndrome is often
difficult because there is no specific test to
confirm that a person has it. When a
patient reports symptoms, the doctor
must examine him or her carefully and
rule out other causes of arthritis.
The doctor will take the patient's
complete medical history, noting current
symptoms as well as any previous
diseases, problems, and infections

           Approved 31 May 06 ; Implemented
                        SU06
                 Prognosis
Most    people with Reiter's syndrome recover
fully from the initial flare of symptoms and are
able to return to regular activities within 2 to 6
months after the first symptoms appear
Only  20 percent of people with Reiter's
syndrome will have chronic arthritis, which is
usually mild
Studies    show that about 15 to 50 percent of
patients will develop symptoms sometime after
the initial flare has disappeared.
                 Approved 31 May 06 ; Implemented
                              SU06
               Differentials
Gonococcal       arthritis
Gouty     arthritis
Still's   disease
Rheumatic      fever
Psoriatic    arthritis
Rheumatoid        arthritis

                 Approved 31 May 06 ; Implemented
                              SU06
             Differentials

Anklosying    Spondylitis
Inflammatory        Bowel Disease
Septic   Arthritis




              Approved 31 May 06 ; Implemented
                           SU06
               Diagnosis
 The doctor may use various blood tests
to help rule out other conditions and
confirm a suspected diagnosis of
Reiter's syndrome
The   doctor is also likely to perform
tests for infections that might be
associated with Reiter's syndrome.
              Approved 31 May 06 ; Implemented
                           SU06
Diagnosis


                     Swollen "sausage"
                      toe and inflamed
                      ankle




Approved 31 May 06 ; Implemented
             SU06
Diagnosis

                   A patient with
                    postdysentery
                    reactive arthritis on
                    initial presentation.




Approved 31 May 06 ; Implemented
             SU06
    Chiropractic Management

For  the reason that there are
inflammatory condition of the joints
chiropractic adjusting could aggravate
this condition. One should only adjust
doing symptomatic basis which will result
in improved ROM and correct posture.


               Approved 31 May 06 ; Implemented
                            SU06
    Medical Management
The treatment for managing Reiter's
syndrome includes medications, rest, joint
protection and special exercises. Your
treatment program, which should be
developed by a rheumatologist, will be
designed to reduce pain and inflammation,
prevent or decrease the amount of joint
damage, and restore the function of damaged
joints. Your active involvement in developing
your prescribed treatment plan is essential.
             Approved 31 May 06 ; Implemented
                          SU06
      Medical Management
 Various symptoms are treated by
  healthcare specialists, including:
 A dermatologist for skin disorders
 An ophthalmologist for eye disorders
 A urologist for urinary tract disorders




              Approved 31 May 06 ; Implemented
                           SU06
     Surgical Management
No surgical treatment is recommended.




             Approved 31 May 06 ; Implemented
                          SU06
             Procedure
 Needle  aspiration of a joint may be
 necessary to rule out septic or
 crystalline arthritis




             Approved 31 May 06 ; Implemented
                          SU06
        Physical Therapy
 Physicaltherapy consists of
 different treatments to reduce
 inflammation as well as exercises
 to increase the mobility of joints
 and strengthen surrounding
 tissues.


             Approved 31 May 06 ; Implemented
                          SU06
     Occupational Therapy
 involves learning to perform
 activities of daily living in an
 efficient manner, placing less
 stress on joints, and thus making
 activities easier and joint damage
 less likely


             Approved 31 May 06 ; Implemented
                          SU06
           Nutrition

Not relevant to this condition




        Approved 31 May 06 ; Implemented
                     SU06
                   Exercise
   Exercise helps keep the muscles strong
    around a joint. Not using a sore joint will
    cause the muscles around it to become weak,
    resulting in pain.
   Exercise can also help you maintain a healthy
    weight, which puts less strain on your joints.
   Do stretching exercises every day to help
    keep your muscles and joints moving.
   If your muscles have become weak you may
    need to do strengthening exercises.
                 Approved 31 May 06 ; Implemented
                              SU06
                    Exercise
   Low impact exercises such as swimming,
    bicycling, water aerobics and walking will give
    you energy, strengthen your heart and help
    you control your weight.
   Exercises to help you maintain good posture
    and keep your back from getting stiff are also
    important if you have Reiter's syndrome.


                  Approved 31 May 06 ; Implemented
                               SU06
                   Bibliography
Reactive  Arthritis-Reiter’s Syndrome-Causes,
Diagnosis, & Treatment.Author unknown Available
Online: http://arthritis.about.com. March 11, 2005.
Prostatitis.
           Author Unknown Available Online:
www.prostatitis.org/reiters.html. March 11, 2005.
Reiter’s  Syndrome Available Online:
http://healthlink.mcw.edu/article/926056398html.
  March 11, 2005

                   Approved 31 May 06 ; Implemented
                                SU06
           Bibliography

Dr. Barth, F. Werner and
Dr.Segal Kinim Reactive Arthritis.
Online Available:
www.aafp.org/afp/990800ap/499.ht
ml March 11, 2005.



            Approved 31 May 06 ; Implemented
                         SU06
                           CLINICAL APPLICATIONS
                          Faculty Case Study Preparation


CONDITION       Rheumatoid Arthritis (RA)

Prepared by: Beth A. McDowell-Reizer, D.C.

RELEVANT PATHOPHYSIOLOGY:

Bilateral, symmetric joint inflammation resulting from the infiltration of the joint
synovial fluid by immune cells. Cytokinins are released that inhibit bone formation,
induce bone resorption, and stimulate the secretion of enzymes that destroy
cartilage and the joint. Articular surfaces are then remodeled by muscular
mechanical forces.

CASE HISTORY:

Patient Presents With: Insidious onset of progressive joint involvement with
simultaneous inflamm-ation in multiple joints (see site below). Tenderness in nearly
all inflamed joints. Synovial thickening; constitutional sx. may be present (e.g fever,
fatigue)
         Onset-Initial: Usually insidious but may be abrupt
         Palliative: Warm heat in chronic stage
         Provocative: Overuse of joints
         Quality: Aching pain in the joints
         Quantity: No Significant Findings
         Referred: No Significant Findings
         Radiating: No Significant Findings
         Site: Symmetric involvement of small hand jts. (PIP, MCP), foot (MTP),
             wrists, elbows and ankles
         Timing: Stiffness lasting > 30 min. in A.M. or after prolonged inactivity
         Other:

Relevant History and Lifestyle
      Gender: Women 2-3 times more often than men
      Age: Onset may be @ any age, most often 25-50 yo
      Occupation: No Significant Findings
      Traumas: No Significant Findings
      Surgeries: No Significant Findings
      Medications: No Significant Findings
      Hospitalizations: No Significant Findings
      Immunizations: No Significant Findings
      Diseases or Conditions: No Significant Findings
      Family History: No Significant Findings
      Diet: No Significant Findings

Beth McDowell-Reizer, D.C.            Page 1                              8/20/2010
Approved 04/13/05
         Sleep Habits: No Significant Findings
         Sexual History: No Significant Findings
         Alcohol Usage: No Significant Findings
         Drug Usage: No Significant Findings
         Smoking/Tobacco: No Significant Findings
         Other: No Significant Findings


REVIEW OF SYSTEMS

PHYSICAL EXAMINATION:

Height                                 Weight

Vitals: BP             Pulse                        Respiration________ Temp.

Appearance, Motion, Gait

Orthopedic Tests

      Test Name                R            L              Test Name            R           L
Not Applicable             +       -    +       -                               +   -   +       -
                           +       -    +       -                               +   -   +       -
                           +       -    +       -                               +   -   +       -
                           +       -    +       -                               +   -   +       -
                           +       -    +       -                               +   -   +       -

Orthopedic Test Results Discussion:


Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception

Lab Values: Normochromic (or slightly hypochromic) normocytic anemia – 80% of
cases; elevated ESR – 90% of cases; high rheumatoid factor – 70% of cases


Examination of Related Areas



Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




Beth McDowell-Reizer, D.C.               Page 2                                 8/20/2010
Approved 04/13/05
SPINAL EXAMINATION
Postural Analysis Discussion:


Postural Analysis     L         N     R
Head Tilt
Head Rotation
High Ear
High Shoulder
High Ilium
Ext. Rotated Foot
Int. Rotated Foot

ROM
             Cervical ROM                                   Lumbar ROM
               ROM      Pain        Level                    ROM     Pain    Level
Flexion        N      Y N                 Flexion          N     Y N
Extension      N  Y N                     Extension        N     Y N
R. Rotation    N  Y N                     R. Rotation      N     Y N
L. Rotation    N  Y N                     L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                     R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                     L. Lat. Flex.    N     Y N


Pattern Analysis: Leg Length/Spinal Balance/ Instrumentation/ Palpation (Muscle,
Static, Motion)


List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




Beth McDowell-Reizer, D.C.             Page 3                         8/20/2010
Approved 04/13/05
        RADIOLOGICAL EXAMINATION:

            Views                                  Findings
X-rays      X-Ray-- Hand, foot (earliest), knee,   Periarticular osteoporosis, uniform loss of
            wrist, hip, ankle, and spine           joint space, marginal erosions (“rat bite”),
            (including APOM and Nuetral            deformity (digital – boutonniere, swan-
            Lateral Cervical and Flexion/          neck and ulnar deviation, large
            Extension to assess AO/AA joints       pseudocysts, odontoid translocation,
                                                   atlas instability (ADI >3mm). Actetabular
                                                   protrusion may occur at the hip with
                                                   advanced cases of RA.
MRI

CT

Other       Nuclear medicine studies reveal
            bone destruction much earlier than
            plain film imaging (Lesions can take
            up to 6 months before they are
            noticed on plain film imaging) with
            nuclear medicine the destructive
            changes can be noticed with only 1-
            3 % change in bone density.




        DIFFERENTIALS:

        SLE, Lyme Disease, Sarcoidosis, Reiter’s Syndrome, Psoriatic Arthritis, Ankylosing
        Spondylitis, Osteoarthritis, Gout, Sjogren’s Syndrome


        CASE MANAGEMENT

        Chiropractic Management: Mercy Conference document has assigned cervical
        manipulation as an absolute contraindication in a patient with RA (Huff/Brady).
        Instability caused by RA of the upper cervical spine are contraindications to
        rotary high velocity thrust techniques.




        Beth McDowell-Reizer, D.C.          Page 4                              8/20/2010
        Approved 04/13/05
Common Medical Management: NSAIDS – Cox –1 or Cox-2 inhibitors;
corticosteroids, DMARDS (Disease modifying antirheumatic drugs); Biologic agents
which reduce the production of tissue necrosis factors (e.g. Embrel, Remicade)

Adjunctive Therapy: Treat with rest and relieve joint symptoms using wax baths,
ice packs, ultrasound and weak electrical current stimulation (interferential therapy)

PhysicalTherapy: Parafin baths are appropriate for pain management if the
patient in not in an acute phase of RA.

Nutrition:Pharmacologic therapy to control pain and inflammation is often a major
component of the treatment for RA. The choice of drug class and hype is based
upon the patient response to the medication, incidence and severity of adverse
reaction and, patient compliance. Drug-nutrient side effects can occur with any of
the drugs.

Salicylates are usually the first line of drug therapy. However, chronic aspirin
ingestion is associated with gastric mucosal injury and bleeding, increased bleeding
time, and increased urinary excretion of vitamin C. Taking aspirin with milk or food
often alleviates the GI symptoms. Vitamin C supplementation is prescribed when
serum and platelet levels of ascorbic acid are abnormally low.

Immunosuppressive agents such as methotrexate are commonly prescribed drugs
fro RA. Adverse effects of methotrexate include folate antagonism. Treatment with
methotrexate induces a significant rise in homocysteine, which is neutralized by folic
and supplementation.

Low doses of steroids such as prednisone are often prescribed to control the
inflammatory features of RA. Steroids have an extensive catabolic impact that can
result in negative nitrogen balance. Adequate consumption of high-biological
protein at 1gm/kg of body weight will assist in maintaining nitrogen balance.

Hypercalciuria and reduced calcium absorption can increase the risk of
osteoporosis. Calcium (1g) and Vitamin D (500 IU) supplementation along with
monitoring of bone status can minimize osteopenia. Care must be taken to avoid
serum calcium levels >11.00mg/dL. If edema is present, a sodium-restricted diet
and fluid restriction may be required.

Supplementation with omega 3 fatty acids from fish oil has an anti-inflammatory
effect and significant benefits have been reported. Flaxseed or flaxseed oil does not
contain eicosapentaenoic acid (EPA) or docosahexaenoic acid (DHA), therefore
flaxseed and fish oil are not interchangeable sources of omega 3 fatty acids. Avoid
prepackaged foods, coffee, tea, alcohol, fried foods, nightshade vegetables (e.g. gr.
Peppers, eggplant, tomato, white potato – contain solanine which can irritate jts)




Beth McDowell-Reizer, D.C.            Page 5                             8/20/2010
Approved 04/13/05
Exercise: Before acute inflammation is controlled, passive exercise to prevent
contracture is given carefully and within limits of pain. Active exercise, including
walking and specific exercises for involved joints, to restore mm mass and preserve
normal range of joint motion is important as inflammation subsides but should not be
fatiguing.

Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education: Because RA is an inflammatory condition, avoid moderate to
high impact aerobic activities which may exacerbate. Low impact activities such as
walking, stretching and yoga may be advised, but should not be fatiguing.


Further Evaluation:




REFERENCES:
Huff and Brady : Instant Access to Chiropractic Guidelines and Protocols, 1999
The Merck Manual, 17th Edition, 1999
Yochum and Rowe; Essentials of Skeletal Radiology, 3rd Edition, Volume 2, 2005
Souza, Differential Diagnosis and Management for the Chiropractor, 3rd Edition,
2005




Beth McDowell-Reizer, D.C.          Page 6                             8/20/2010
Approved 04/13/05
Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.

Condition Name         Baseline     Complicating/ Mitigating Factors    Revised
                       Complexity                                       Complexity
                                    Atlantoaxial instability               10.0
                                    Acetabular protrusion                   8.0
Rheumatoid Arthritis      6.0       Foot joint erosion                      7.0
                                    Deformity of extremities                7.0
                                    Osteoporosis secondary to               7.0
                                    medication usage




Beth McDowell-Reizer, D.C.          Page 7                             8/20/2010
Approved 04/13/05
                          CLINICAL APPLICATIONS
                         Student Case Study Preparation


CONDITION          Rotator Cuff Syndrome (Impingement Syndrome)

Prepared by: Tim Guest DC

RELEVANT PATHOPHYSIOLOGY:

Trauma or activity induced injury to the supraspinatus, infraspinatus, teres minor and
/or subscapularis muscles or tendons.

CASE HISTORY:

PPW: Immediate pain at injury, pain may subside with activity only to return later. A
popping or tearing sensation at moment of injury. Shoulder pain that is increased
with active shoulder movement. May also be insidious with age.      Complaint of
pain when sleeping on shoulder.

Relevant History and Lifestyle

Gender-None specific
Age- None specific
Occupation- None specific but favors athletes and persons who work
       overhead.
Traumas- Repetitive motion overhead, fall on outstretched arm, or sudden
       lifting of a heavy weight.
Surgeries- None specific
Medications- None specific
Hospitalizations- None specific
Immunizations- None specific
Diseases or Conditions-Often preceded by chronic tendonitis, occurs as an insidious
       onset with age.
Family History None specific
Diet- None specific
Sleep Habits- Painful shoulder when sleeping, restless.
Sexual History- None specific
Alcohol Usage- None specific
Drug Usage-None specific
Smoking/Tobacco - None specific
Other - None specific




Tim Guest, D.C.                      Page 1                             8/19/2010
Approved 11/24/04
Review of Systems                                                        _____

     ______________________________________________________
___________________________________________________________


PHYSICAL EXAMINATION:

Height                                Weight

Vitals: BP            Pulse                        Respiration________ Temp.

Appearance, Motion, Gait

Orthopedic Tests

     Test Name                R            L                Test Name          R           L
Codmans Drop Arm           +      -    +       -    Lift Off                   +   -   +       -
Empty Can                  +      -    +       -    Painful Arc                +   -   +       -
Apprehension               +      -    +       -                               +   -   +       -
Dugas                      +      -    +       -                               +   -   +       -
Yergason’s                 +      -    +       -                               +   -   +       -

Orthopedic Test Results Discussion: Empty can is indicative of supraspinatus
weakness, Lift off is indicative of subscapularis weakness, Drop arm indicative of
supraspinatus instability (tear).

Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception

None Specific

LabValues

None Specific

Examination of Related Areas

None Specific

Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.) Palpation reveals tenderness proximal humerus, Deltoid,
Supraspinatus and Infraspinatus may indicate atrophy.




Tim Guest, D.C.                         Page 2                                 8/19/2010
Approved 11/24/04
SPINAL EXAMINATION:

        Postural Analysis                       Postural Analysis      L      N        R
                                                Head Tilt
                                                Head Rotation
                                                High Ear
                                                High Shoulder
                                                High Ilium
                                                Ext. Rotated Foot
                                                Int. Rotated Foot


ROM
             Cervical ROM                                   Lumbar ROM
               ROM      Pain     Level                       ROM     Pain         Level
Flexion        N      Y N                 Flexion          N     Y N
Extension      N  Y N                     Extension        N     Y N
R. Rotation    N  Y N                     R. Rotation      N     Y N
L. Rotation    N  Y N                     L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                     R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                     L. Lat. Flex.    N     Y N


Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion)



List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion



RADIOLOGICAL EXAMINATION:

        X X-rays     X MRI           X CT          Other Arthrogram

Views

Findings


Tim Guest, D.C.                        Page 3                              8/19/2010
Approved 11/24/04
DIFFERENTIALS:

A/C seperation, DJD, Cervical Arthrosis, Cervico-brachial Syndrome, Myofascial
pain, Radiculopathy, Osteophytosis.


DIAGNOSIS:

Grade I Inflammation of the bursa and tendons
Grade II Thickening and scarring of the bursa
Grade III Rotator Cuff degeneration and tears are evident


Case Management:


Chiropractic Management

None Specific

Adjunctive Therapy:

None Specific

Physical Therapy:

Resisted abduction/adduction, wall walking.

Nutrition:

Proteolytic enzymes, Bioflavinoids, Vitamin C, Zinc, Vitamin E.

Exercise:

Shoulder shrug, Internal/external rotation, seated rows, forward punch, press-ups
(chair)


Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education):

Advise to change occupations, avoid overhead activities


Further Evaluation:



Tim Guest, D.C.                      Page 4                            8/19/2010
Approved 11/24/04
Common Medical Management:

Steroid injections, NSAIDS, Surgical repair.

References: _______

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity. ()

Condition Name        Baseline      Complicating/ Mitigating Factors    Revised
                      Complexity                                        Complexity
                                    Alter Shoulder Physics Affecting       2.0
                                    Cervical Spine
    Rotator Cuff            1
     Syndrome




Tim Guest, D.C.                      Page 5                            8/19/2010
Approved 11/24/04
                          CLINICAL APPLICATIONS
                        Faculty Case Study Preparation

CONDITION: Schizophrenia

Prepared by: McRae, Kenneth L. (July 25, 2005)

RELEVANT PATHOPHYSIOLOGY:
Schizophrenia is a multifaceted disorder characterized by profound disruption in
cognition and emotion that affect most fundamental human attributes. Currently
there are no physical or lab tests that are used to diagnose schizophrenia. A
referral to a psychiatrist for a complete mental evaluation and review clinical
symptoms helps determine a schizophrenic patient. People diagnosed with
schizophrenia have a combination of positive, negative, and cognitive symptoms.
Positive symptoms include hallucinations, delusions and racing thoughts.
Negative symptoms include apathy, lack of emotion, poor or nonexistent social
functioning. Cognitive symptoms include disorganized thoughts, difficulty
concentrating and/or remembering, difficulty following instructions, and difficulty
completing tasks. A complete diagnosis must include one month of symptoms
(positive, negative, or cognitive) persisting for six-months.

CASE HISTORY:

Patient Presents With: Upon further evaluation the patient appeared confused,
disoriented, and had a hard time remembering information regarding their family
history and initial complaint. The patient has a history of depression.

Onset-Initial: Birth for children with fathers over the age of 50. Malnutrition or
exposure
               to a viral infection during pregnancy. High blood pressure with
               diuretics during the third trimester of pregnancy. Genetic link
               increases the chance of schizophrenia 10 times.
Palliative: Prescribed medications such as Ziprasidone, Olanzapine,
Aripiprazole,
               Clozaril, Geodon, Risperdal, Seroquel, Zyprexa, Stelazine,
               Flupenthixol, Loxapine, Perphenazine, Chlorpromazine, Haldol, and
               Prolixin
Provocative: Stress, depression
Quality: Does not apply
Quantity: Does not apply
Referred: Does not apply
Radiating: Does not apply
Site: The brain- superior temporal gyrus (auditory processing) and planum
temporale
        (language processing).




                                         1
Timing: Schizophrenia is a psychological disorder. Attacks are unpredictable and
may
       vary in timing and quality depending on the stimulus. Continuous signs of
       the disturbance persist for about six months. The six-month period must
       include at least one month of symptoms that are positive, negative, or
       cognitive.
Other: Attacks occurs during high stress periods/ depression usually follows/ the
patient
       feels overwhelmed and like they can never get everything needed
accomplished.

Relevant History and Lifestyle:
Gender: Female
Age: 22.

Occupation: Student
Traumas: Does not apply
Surgeries: Does not apply
Medications: Prescribed medications such as Ziprasidone, Olanzapine,
Aripiprazole,
               Clozaril, Geodon, Risperdal, Seroquel, Zyprexa, Stelazine,
               Flupenthixol, Loxapine, Perphenazine, Chlorpromazine, Haldol, and
               Prolixin
Hospitalizations: Does not apply
Immunizations: Does not apply
Diseases or Conditions: Depression
Family History: Birth for children with fathers over the age of 50. Malnutrition or
       exposure to a viral infection during pregnancy. High blood pressure with
       diuretics during the third trimester of pregnancy. Genetic link increases
       the chance of schizophrenia 10 times.
Diet: Small appetite/ 1 meal per day sometimes forced
Sleep Habits: 2-3 continuous hours during a 10-hour sleep period, feelings of
       restlessness
Sexual History: Does not apply
Alcohol Usage: Does not apply
Drug Usage: Does not apply
Smoking/Tobacco: Does not apply
Other: Does not apply




                                        2
Review of Symptoms: (EENT, Respiratory, Cardiovascular,
Musculoskeletal, Gastrointestinal, Reproductive)

PHYSICAL EXAMINATION:

Height: 5’5         Weight: 100 lbs.

Vitals: BP- 110/70 Pulse- 88 bpm               Respiration- 20 bpm
       Temp.- 98.00F

Appearance, Motion, Gait:

Orthopedic Tests:
Test Name
Does not apply
Orthopedic Tests Results Discussion:
Does not apply

Neurological Tests: (Cranial Nerves/PNS/Equilibrium/motor/DTRs/Pathological
Reflexes/Light touch/proprioception)

Does Not Apply

Lab Values:

Does Not Apply

Other Findings: (Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)

Increased heart rate upon auscultation, Increased pulse rate upon palpation




                                       3
SPINAL EXAMINATION:
Postural Analysis Discussion:

Postural Analysis:    L      N       R
Head Tilt                            X
Head Rotation                        X
High Ear                             X
High Shoulder                            X
High Ilium            X
Ext. Rot. Foot                       X
Int. Rot. Foot        X

ROM
Cervical:       ROM   Pain   Level       Lumbar:      ROM    Pain   Level
Flexion         N     N      N                        N      N      N
Extension       N     N      N                        N      N      N
R. Rotation     N     N      N                        N      N      N
L. Rotation     N     N      N                        N      N      N
R. Lat. Flex.   N     N      N                        N      N      N
L. Lat Flex.    N     N      N                        N      N      N

Pattern Analysis: Leg Length/Spinal Balance/Instrumentation/Palpation
(Muscle, Static, Motion)

List the level for palpatory findings. Notate abnormal findings and motion
restrictions.
Level Muscle
Does not apply




                                         4
RADIOLOGICAL EXAMINATION:
         Views                           Findings
X-rays:        Does not apply

MRI          Brain                       21% unilateral (left-sided) gray matter
                                         volume difference in Hershel’s gyrus,
                                         with no volume differences in the
                                         planum temporale in either hemisphere
CT           None                        None
Other        None                        None

DIFFERENTIALS:

Schizophrenia is divided into five subtypes. In making a through diagnosis it is
                             important to evaluate the symptoms that the patient
                             presents with.
   1. Paranoid subtype- The distinguishing characteristics of this subtype are
      the presence of auditory hallucinations and prominent delusional thoughts.
      Patients falling under this subtype are believed to be more functional in
      their ability to work and engage in relationships with others.
   2. Disorganized subtype- The distinguishing characteristic of this subtype is
      disorganization of the thought process. The hallucinations and delusional
      thoughts present in the paranoid subtype are less pronounced, although
      there may be some evidence of these symptoms.
   3. Catatonic subtype- The predominant clinical feature in this subtype are
      disturbances in movement. Patients in this subtype exhibit a dramatic
      reduction in activity, to the point that voluntary movement stops (catatonic
      stupor). Activity can also dramatically increase, a state known as
      catatonic excitement.
   4. Undifferentiated subtype- This subtype includes patients whose symptoms
      don’t fit any particular category. The symptoms of patients in this subtype
      can fluctuate at different points in time, resulting in uncertainty as to the
      correct subtype classification.
   5. Residual subtype- Patients included in this subtype no longer display
      prominent symptoms. Hallucinations, delusions or idiosyncratic behaviors
      may still be present, but generally have lessened in severity.




                                         5
CASE MANAGEMENT:

Chiropractic Management: Treat subluxations refer out to a psychiatrist for
                       complete mental evaluation.
Common Medical Management: Treat schizophrenia with drugs Stelazine,
                       Flupenthixol, Loxapine, Perphenazine,
                       Chlorpromazine, Hadol, Prolixin and
                       psychotherapeutic activities such as stress
                       management and control, anger management and
                       control, support groups
Adjunctive Therapy: Psychiatrist
Physical Therapy: None
Nutrition: None

Exercise: None

Health Promotion and Maintenance (i.e. ergonomics, spinal hygiene,
psychosocial concerns, education):
Does not apply

Further Evaluation:
Refer to psychiatrist for further evaluation for potential schizophrenia/ co-manage
                              case and re-evaluate at an agreed time.

REFERENCES:

   1. The American Journal of Psychiatry 162:1535-1538, August 2005 c 2005
      American Psychiatric Association
   2. The American Journal of Psychiatry 159:1467-1469, September 2002 c
      2002 American Psychiatric Association
   3. http://www.schizophrenia.com/diag.html
   4. http://www.schizophrenia.com/newsletter/buckets/meds.html
   5. http://my.webmd.com/hw/schizophrenia/aa46916.asp?z=1835_00000_000
      0_rl_02


CASE COMPLEXITY:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.



                                         6
Condition Name   Baseline     Complicating/Mitigating Factors Revised
                 Complexity                                   Complexity
Schizophrenia           6           Schizophrenia related/depression 8




                                    7
                        CLINICAL APPLICATIONS
                        Faculty Case Study Preparation


CONDITION:          Scleroderma AKA: Systemic Sclerosis

Prepared by:               Steve Sinclair


RELEVANT PATHOPHYSIOLOGY: A chronic disease of unknown cause,
characterized by diffuse fibrosis; degenerative changes; and vascular
abnormalities in the skin, articular structures, and internal organs.2


CASE HISTORY:

PPW: Patient may present with Raynaud’s syndrome. The philtrum tends to be
smoothed, flattened out, or almost obliterated. The skin can be pinched and
shiny, and the small hairs in the moustache region, present in male and female,
tend to disappear. Sometimes the tightening progresses with only minor
evidence of atrophy from outward examination. The central incisors can be
visible, even with mouth at rest, due to tightening of the facial skin.1 There can
be insidious swelling of the acral portions of the extremities, with gradual
thickening of the skin of the fingers. Polyarthralgia is also prominent. GI
disturbances (eg. heartburn or dysphagia) or respiratory complaints (eg.
dyspnea) are occasionally the first manifestations of the disease.2

      Onset-Initial: It can be rapid progression which results in fatal visceral
                     involvement. It can be slow in progression, lasting several
                     decades, before full internal involvement. The disease can
                     be self-limiting.
      Palliative:    None
      Provocative: Cold weather, being around chemicals, pesticides, solvents,
                     or Silica
      Quality/Quantity:      Patient can have pains of joints, muscles and
                     tendons.
      Referred/Radiating: None
      Site:             Sclerosis of the skin-face and extremities
      Timing/Pattern: Can be rapid or insidious in progression

Relevant History and Lifestyle

      Gender:       Four times more common in women than men
      Age:          Usually 40-50 years old, but can appear in women from ages
                    30-39. It is rare in Children (less than 10% in younger than
                    20).

Steve Sinclair                        Page 1                             8/20/2010
Approved 04/13/05
      Occupation: Certain chemicals, solvents, pesticides, and minerals (eg.
                  Silica) can induce scleroderma-like disease.

      Traumas:      Trauma has been associated with linear scleroderma, which
                    often occurred in the same site as trauma within 6 months.
                    The most probable hypothesis is that physical trauma and/or
                    emotional stress may activate subclinical or aggravate
                    preexisting a disease.3
      Surgeries: No effect
      Medications: There are various medications that can be used to treat
                    conditions associated with scleroderma, such as vascular
                    disease, autoimmunity and tissue fibrosis.
      Hospitalizations: No effect
      Immunizations: Scleroderma can be associated with
      Diseases or Conditions: Raynaud’s phenomenon, vascular problems,
                         respiratory problems, autoimmune disfunction
      Family History:
      Diet:             No effect
      Sleep:            No effect
      Sexual History: No effect
      Alcohol Usage: No effect
      Drug Usage:       No effect
                           Smoking/Tobacco: Smoking will exacerbate the
                           condition, because of the vasoconstrictive action of
                           smoking and aggravation of dyspnea.

Review of Systems:

      Skin-Sclerodactyly, As the disease progresses, the skin becomes taut,
      shiny, and hyperpigmented; the face becomes mask like; and
      telangiectases appear on the fingers, chest, face, lips, and tongue. Biopsy
      of indurated skin shows an increase in compact collagen fibers in the
      reticular dermis, epidermal thinning, loss of rete pegs, and atrophy of
      dermal appendages. Rete pegs are the inwardly directed prolongations of
      the stratum germinativum of the epidermis that intermesh with the dermal
      papillae of the skin. Polyarthralgia is also prominent. GI disturbances (eg.
      heartburn or dysphagia) or respiratory complaints (eg. dyspnea) are
      occasionally the first manifestations of the disease.2


PHYSICAL EXAMINATION:

Height and Weight are not factors

Vitals: BP-Normal Pulse-Normal          Respiration-Can be decreased
       Temp.-Normal

Steve Sinclair                      Page 2                             8/20/2010
Approved 04/13/05
Appearance (see Case History) Motion and Gait-Normal

Orthopedic Tests: No Orthopedic test will be positive for condition
Neurological Tests: No Neurological test will be positive for condition

Lab Values: “Rheumatoid factor tests are positive in 33% of cases.
            Serum ANA is present in 90% or more.
            Anti-SCL-70 antibodies are present in diffuse scleroderma.
            HLA-DR5 is present with systemic sclerosis.
            HLA-DR1 is present with CREST syndrome.”2

SPINAL EXAMINATION:

Postural Analysis:                 No significance

Ranges of Motion:                  Can be decreased, due to muscle tightness,
                                   joint pain, or joint degeneration.

Leg Length/Spinal Balance:              No Significance
Instrumentation/Pattern Analysis: No Significance
Palpation:                        Skin and muscle may be hardened.

RADIOLOGICAL EXAMINATION:

X-ray of the extremities can show the degeneration of appendages due to
surrounding fibrosis. This especially is seen in the reabsorption of the distal tufts
of the fingers. There is also an overall calcification process of the soft tissues
observed. Honey comb lung as sign of lung fibrosis can be seen in high
resolution computer tomography.3


DIFFERENTIALS:

   “Morphea (generalized, linear): this a localized form of scleroderma, not
   affecting the entire body.

   Scleredema generalized Buschke: this condition involves the thickening of the
   skin of the neck, trunk, and upper arms; but, spares the hands. The hands
   are almost always involved with scleroderma.

   Scleromyxoedema:

   Mixed connective tissue disease: a syndrome characterized by symptoms of
   various rheumatic diseases (as systemic lupus erythematosus, scleroderma,



Steve Sinclair                         Page 3                              8/20/2010
Approved 04/13/05
   and polymyositis) and by high concentrations of antibodies to extractable
   nuclear antigens.

   Psoriatic arthritis: x-ray will reveal that it does not affect the distal tufts as
   scleroderma does.

   Shulman syndrome

   Shoulder-hand syndrome: reflex sympathetic dystrophy affecting the upper
   extremities and characterized by pain in and stiffening of the shoulder
   followed by swelling and stiffening of the hand and fingers.

   Pseudoscleroderma, eg:

          o   porphyria cutanea tarda
          o   polyvinyl chloride disease
          o   toxic oil syndrome
          o   drug induced pseudoscleroderma
          o   organic solvents syndrome

   Werner's syndrome: a rare hereditary disorder characterized by premature
aging”3



DIAGNOSIS:

See Case History, Examinations, and Differentials above.


Case Management:

Chiropractic Management: Monitor and correct vertebral subluxations

Medical Management:        No one drug has significantly influenced the condition,
            but various drugs are of value in treating specific symptoms or
            organ systems.2 Prescribe Calcium channel blockers, ACE-
            inhibitor (captopril), alpha-receptor blockers including reserpin,
            prazosin, phenoxybenzamin and methyldopa act by blocking
            sympathic vasoconstriction. Pentoxyphyllin is able to reduce the
            number of rat bite necroses and to improve the peripheral blood
            circulation. Stanozolol can be used to reduce fibrinolytic activity in
            serum. 3 Penicillamine may be prescribed to reduce skin thickening
            and to delay the rate of new visceral involvement.2

Surgical Management:         None

Steve Sinclair                          Page 4                                8/20/2010
Approved 04/13/05
Adjunctive Therapy: Advise patient to decrease exposure to environmental
noxious substances. Competent psychological guidance is important. Advise
patient to wear warm clothing to improve Raynaud’s phenomenon.3

Physical Therapy: Physiotherapeutic activities are recommended. The
application of warmth such as warm compresses, baths, hot paraffin or infrared
is advised. A whole body irradiation (800-1400 nm for 30 min.), appeared to be
very helpful. The same is true for lymph drainage, under water massages and
connective tissue massages. There are still some questions of when should the
Physiotherapeutic activities begin.3

Nutrition: Easily chewable and swallowable food of high protein and vitamin
content is recommendable. Nicotine must be omitted due to its vasoconstrictory
effect.3

Exercise: Exercise is important to slow or stop the stiffening progress.3



Health Promotion and Maintenance: Advise patient to decrease exposure to
environmental noxious substances. Competent psychological guidance is
important. Advise patient to wear warm clothing to improve Raynaud’s
phenomenon.3

Further Evaluation: Objective findings for Physical Therapy are difficult to obtain.

                                 REFERENCES:


   1.     Katz MD, Warren A. Rheumatic Diseases Diagnosis and
          Management. 1977

   2.     The Merck Manual. 17th edition. 1999.

   3.     Haustein MD, U.F. Systemic sclerosis-scleroderma. Dermatology
          Online Journal. June 2002. Volume 8. Number 1.




Steve Sinclair                        Page 5                                8/20/2010
Approved 04/13/05
Case Complexity

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.

Condition Name       Baseline      Complicating/ Mitigating Factors Revised
                     Complexity                                     Complexity
                                   Progressive skin changes            6.0
                                   affecting adjutstments
   Scleroderma            4.0      Joint pain altering spinal          6.0
                                   biomechanics
                                   Psychosocial issues such as         6.0
                                   depression, leading to
                                   increased cortisol levels
                                   (decreased bone density risk
                                   factor)




Steve Sinclair                      Page 6                            8/20/2010
Approved 04/13/05
Temporomandibular Joint (TMJ)
        Syndrome

             Luke Henry




                Approved 31 May 06 - Implemented
                                           SU06
What is TMJ?
   AKA Temporomandibular Disorders (TMD)
   Group of conditions affecting the temporomandibular
    joint and surrounding muscles
   Exact causes and symptoms are not yet fully
    understood
   Usually due to an anatomic problem with the joints and
    muscle tension; sometimes has a psychological
    constituent.
   Symptom complex includes pain, tenderness, and
    crepitus.

                   Approved 31 May 06 -
                    Implemented SU06
Anatomy of the TMJ




          Approved 31 May 06 -
           Implemented SU06
3 Types of Disorders of the TMJ

   Myofascial Pain Syndrome
   Internal Joint Derangement
   Arthritis




                Approved 31 May 06 -
                 Implemented SU06
Myofascial Pain Syndrome

   Muscle pain and tightness; TMJ is normal
   Spasm in the muscles of mastication
    (masseter, temporalis, internal & external
    pterygoid)
   Usually caused by nocturnal bruxism; bruxism
    may result from malocclusion or psychological
    stress

                 Approved 31 May 06 -
                  Implemented SU06
Internal Joint Derangement

   Anterior displacement of the articular disc due
    to pulling of the external pterygoid muscle
   2 Types:
    –   Derangement with reduction
    –   Derangement without reduction




                   Approved 31 May 06 -
                    Implemented SU06
Derangement with Reduction

   Disc returns to the head of the mandibular
    condyle during part of the motion of the TMJ
   Occurs in 1/3 of the general population; not a
    problem if asymptomatic
   Clicking or popping present when mouth is
    opened; this may be the only symptom
   Chewing hard foods may cause pain

                 Approved 31 May 06 -
                  Implemented SU06
Derangement without Reduction

   Without reduction: the disc remains anterior
    throughout the opening and closing of the
    mouth
   Clicking or popping sound is usually absent
   Maximum opening of the mouth is reduced
    from 40 to 45mm (normal) to 30mm or less



                 Approved 31 May 06 -
                  Implemented SU06
Arthritis

   Osteoarthritis
    –   Usually in patients over 50 years of age
    –   Bone grating due to a hole worn in the articular disc
    –   Usually bilateral
   Rheumatoid Arthritis
    –   TMJ affected in over half of RA patients
    –   Causes pain, swelling and decreased ROM
    –   May result in ankylosis

                     Approved 31 May 06 -
                      Implemented SU06
Patient Presents With

   Pain in the TMJ or muscles of mastication is the most
    common symptom; pain may radiate to face, neck or
    shoulders
   Restricted ROM or locking of the TMJ; deviation
   Joint crepitus accompanied by pain when opening or
    closing the mouth
   Sudden alteration in occlusion
   Nocturnal bruxism


                   Approved 31 May 06 -
                    Implemented SU06
Relevant History and Lifestyle
   Gender: Occurs twice as often in females
   Age: 20-50 years
   Occupation: N/A
   Traumas: Injury to the TMJ or jaw that causes fracture
    or disc damage can alter normal biomechanics leading
    to deviation, pain or locking and can also lead to
    arthritis.
   Surgeries: Artificial jaw joint replacement, intended to
    treat the condition, may worsen pain and damage bone
    surround the joint.

                   Approved 31 May 06 -
                    Implemented SU06
Relevant History and Lifestyle
(continued)

   Medications: N/A
   Hospitalizations: N/A
   Immunizations: N/A
   Diseases or Conditions: N/A
   Family History: There may be a genetic
    predisposition to TMJ
   Diet: N/A
   Sleep Habits: N/A
                Approved 31 May 06 -
                 Implemented SU06
Relevant History and Lifestyle
(continued)

   Sexual History: N/A
   Alcohol Usage : N/A
   Drug Usage : N/A
   Smoking/Tobacco : N/A
   Other: Physical or psychological stress may
    lead to nocturnal bruxism. It is unknown
    whether bruxism is a cause or effect of TMJ.

                 Approved 31 May 06 -
                  Implemented SU06
Review of Systems

   Associated Symptoms may be Present:
    –   Headaches, neck pain, whiplash trauma
    –   Tinnitus, earaches, dizziness, hearing problems




                    Approved 31 May 06 -
                     Implemented SU06
Physical Examination

   Height, Weight, Vitals: N/A
   Orthopedic: N/A
   Neurological: N/A
   Lab values: N/A
   The patient is asked to point to areas of pain.
   Palpation of the muscles of mastication and
    occipital muscles for tenderness and trigger
    points.
                 Approved 31 May 06 -
                  Implemented SU06
Physical Examination (continued)
   Instruct the patient to open the mouth as wide as
    possible and observe for deviation of the mandible. A
    vertical straight edge may be aligned with the maxillary
    and mandibular central incisors to better observe
    deviation. The mandible will usually deviate towards
    the painful side.
   Palpate and auscultate the joint while the patient opens
    and closes the mouth. Motion of the mandibular
    condyle may be palpated intrameatally with the fifth
    digit or by palpating just anterior to the tragus of the
    ear.
                   Approved 31 May 06 -
                    Implemented SU06
Spinal Examination

   May find evidence of cervical subluxation
    –   Misalignment, motion restriction of C1
    –   Postural analysis may reveal head tilt
   Other evidence of cervical subluxation (e.g.
    cervical syndrome, thermography) may be
    present but are not supported in the literature



                    Approved 31 May 06 -
                     Implemented SU06
Radiological Examination

   Dental x-rays and transcranial radiographs are usually
    not diagnostic
   Advanced imaging is only necessary when arthritis is
    suspected or treatment fails to improve the condition
   Arthrography is used to show internal disc derangement
   CT and MRI used rarely when patient is not responding
    to treatment
   TMJ may correlate with misalignments of the cervical
    spine, particularly atlas

                   Approved 31 May 06 -
                    Implemented SU06
X-ray




           X-ray of TMJ, labeled
            Approved 31 May 06 -
             Implemented SU06
X-ray (continued)




Panoramic dental x-rays generally are not useful in
                 diagnosing TMD.
              Approved 31 May 06 -
                 Implemented SU06
Radiological Examination
(continued)




   TMJ arthrogram 31 May 06
                Approved             -
                  Implemented SU06
CT




         Normal TMJ CT
     Approved 31 May 06 -
      Implemented SU06
CT (continued)




   TMJ CT showing anterior -displacement of disc
                Approved 31 May 06
                  Implemented SU06
MRI




       Normal06 -
      Approved 31 May
                      TMJ   MRI
       Implemented SU06
MRI (continued)




      TMJ MRI showing non-reducing disc
             Approved 31 May 06 -
                   displacement
              Implemented SU06
Differentials

   Headaches
    –   Due to sinusitis, temporal arteritis, tension,
        migraine, cluster headaches
   Pain
    –   Due to postherpetic neuralgia, reflex sympathetic
        dystrophy or traumatic neuroma following head or
        neck surgery



                     Approved 31 May 06 -
                      Implemented SU06
Differentials (continued)

   Pain accompanied by hearing problems
    –   Due to obstruction of the ear canals and Eustachian
        tube, otitis media
   Pain in the head, neck, and other areas of the
    body
    –   Due to fibromyalgia, generalized myofascial pain




                    Approved 31 May 06 -
                     Implemented SU06
Differentials (continued)
   Pain, numbness
    –   Due to intracranial aneurysm, metastatic neoplasms
   Pain that radiates to the TMJ region
    –   Whiplash injuries affecting muscles or cervical spine
   Pain that worsens when the patient swallows or turns
    the head
    –   Cervical spine or muscle disorders, Eagle syndrome (calcified
        styloid process)
   Trismus
    –   Depressed fracture of the zygomatic arch, infection,
        osteochondroma of the coronoid process
                       Approved 31 May 06 -
                        Implemented SU06
Diagnosis

   No widely accepted standard test
   Diagnosis is made from patient’s symptoms
    and physical exam in most cases




                Approved 31 May 06 -
                 Implemented SU06
Chiropractic Management

   Adjustment of the upper cervical spine
   Manipulation of the mandible
   Activator Methods TMJ protocol




                 Approved 31 May 06 -
                  Implemented SU06
Medical Management

   Oral appliance can be used temporarily to
    reduce muscle tension, clenching and bruxism
   NSAIDS or analgesics




                Approved 31 May 06 -
                 Implemented SU06
Surgical Management
   Arthrotomy is open joint surgery and includes
    discectomy, disc repositioning, modified condylectomy
   Arthroscopy is less invasive and includes lysis of
    adhesions and disc repositioning
   Surgical implantation of an artificial disc is rarely used
    and complications include increased pain and
    degeneration
   Occlusional adjustment by grinding down teeth
   Conservative and reversible treatment are
    recommended

                    Approved 31 May 06 -
                     Implemented SU06
Adjunctive Therapy

   Physical Therapy:
    –   Ultrasound
    –   Eletromyographic biofeedback
    –   Spray and stretch
    –   Friction massage
    –   TENS
    –   Trigger point therapy
   Exercise:
    –   Stretching and relaxation exercises
   Nutrition: N/AApproved 31 May 06      -
                       Implemented SU06
Self Management

   Eating soft foods
   Application of heat or ice
   Avoiding excessive opening of the mouth
   Relaxation and stress management
   Self care is often effective; TMJ usually
    resolves with conservative treatment


                 Approved 31 May 06 -
                  Implemented SU06
References
   Herbst RW. Gonstead Chiropractic Science and Art. Chicago:
    Sci-Chi Publications; 1968.
   DeVocht JW, Long CR, Zeitler DL, Schaeffer W. Chiropractic
    Treatment of Temporomandibular Disorders Using the Activator
    Adjusting Instrument: A Prospective Case Series. J
    Manipulative Physiol Ther 2003;26:421-5.
   Alcantara J, Plaugher G, Klemp D, Salem C. Chiropractic Care
    of a Patient With Temporomandibular Disorder and Atlas
    Subluxation. J Manipulative Physiol Ther 2002;25:63–70.
   Knutson G, Jacob M. Possible Manifestation of
    Temporomandibular Joint Dysfunction on Chiropractic Cervical
    X-ray Studies. J Manipulative Physiol Ther 1999;22:32-7.
                     Approved 31 May 06 -
                      Implemented SU06
References (continued)
   TMD: Temporomandibular Disorders. Available at:
    http://www.nidcr.nih.gov/HealthInformation/OralHealthInformationI
    ndex/TmdTmj/Tmd.htm. Accessed March 1, 2005.
   Beers M, Berkow, R. The Merck Manual, 17th Edition. Whitehouse
    Station, NJ: Merck; 1999.
   Gelb H. Clinical Management of Head, Neck and TMJ Pain and
    Dysfunction. Philadelphia: WB Saunders; 1977.




                      Approved 31 May 06 -
                       Implemented SU06
                             CLINICAL APPLICATIONS
                            Faculty Case Study Preparation


CONDITION: Urinary Tract Infection

Prepared by:Cindy Gibbon, D.C.


RELEVANT PATHOPHYSIOLOGY:

Females more prone to UTI’s due to shorter urethras than males.
UTI’s most commonly caused by bacteria of fecal origin.
Check for bladder stasis (immobilitly or dehydration) which may interfere with the frequent
passage of newly produced urine.
Males less prone to UTI’s : longer urethra and prostatic fluid has antibacterial action.
Monitor infants and young children for strictures and anatomical problems.
Common pathogens: E. coli (65-80%), proteus, Klebsiella, Enterobacter, Candida,
Enterococci, Staph. With abnormalities of the urinary tractA: Pseudomonas, Staph
epidermidis. UTI’s secondary to systemic disease: TB, salmonellosis . Adenovirus 2 and
11 in children. Recurrent or unrecognized UTI’s can cause permanent kidney damage and
even death in untreated cases.

CASE HISTORY:

PPW: Changes in urination, pain in abdomen and pelvis


             Gender Most commonly females (20- 50 y.o.)
                      Males > 50 y.o.
                      Occasionally children
             Age 20 – 50 y.o.
             Occupation          NA
             Traumas
             Surgeries
             Medications
             Hospitalizations    complication of a catheter
             Immunizations

Diseases/Conditions        3 main types of UTI’s: 1. Urethritis (urethra)
                                           2. Cystitis (bladder) most common
                                    3. Pyelonephritis (kidney)

Differential diagnosis: prostatitis, urethral syndrome, anatomical variations
                         Trichimonas, Yeast, Gonorrhea, underlying systemic illness such as
                        diabetes mellitus


Cindy Gibbon, D.C.                   Page 1                             8/20/2010
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Relevant History and Lifestyle:

Family History j some people have genetic predisposition
Social History      possible change in sexual activity
Diet
Sleep Habits
Sexual History      High correlation with sexual activity in females
Alcohol Usage       NA
Drug Usage          NA
Smoking/Tobacco NA


CHIEF COMPLAINT: Burning during urination.Frequency of urination and urgency.
Lower abdominal pain. Intense back pain with kidney involvement. High fever.
Chills. Nausea. Diarrhea

Acute pyelo: flank pain, high fever, severe chills, nausea, vomiting.
            Cystitis: pressure in low abdomen and strong-smelling urine
            Urethritis: may have pus in urine
            Males with urethritis: may have penile discharge

         Onset-Initial        Fairly suddenly
         Palliative/Provocative Sexual activity, foreign objects,
         Quality/Quantity     Fairly severe and uncomfiortable
         Referred/Radiating Low back
         Site Abdominal, suprapubic
         Timing/Pattern Continual and increased frequency; Nocturia also
         Other

PHYSICAL EXAMINATION:

Height                                Weight

Vitals: BP             Pulse  w/ fever    Respiration_ w/ fever_ Temp. slight fever
slight fever, and possible tenderness in abdomen and low back; suprapubic area

Appearance, Motion, Gait

Orthopedic Tests NA

      Test Name               R            L       Test Name               R           L
                            +     -    +       -                       +       -   +       -
                            +     -    +       -                       +       -   +       -
                            +     -    +       -                       +       -   +       -
                            +     -    +       -                       +       -   +       -
                            +     -    +       -                       +       -   +       -

Cindy Gibbon, D.C.                      Page 2                         8/20/2010
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Orthopedic Test Results Discussion:




Neurological Tests - Motor/Sensory/Reflex

  Nerve Root Package             Motor (0-5)         Sensory         Reflex (0-4)
           C5                                          N    
           C6                                          N    
           C7                                          N    
           C8                                          N    
           T1                                          N    
           L4                                          N    
           L5                                          N    
           S1                                          N    
Lab Values Urinalysis: Leukocytes
                         Bacteria
                         Hematuria
                  Positive nitrite possible
                         Possible proteinuria

                   Urine may be cloud or reddish if blood present
             Urine culture
             CBC: elevated WBC count
             Elevated ESR and c-reactive protein

             Blood test only needed if complications such as pyelonephritis
               or kidney failure is suspected.

Examination of Related Areas


Review of Systems


Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




Cindy Gibbon, D.C.                    Page 3                         8/20/2010
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SPINAL EXAMINATION:

      Postural Analysis                            Postural Analysis      L      N     R
                                                   Head Tilt
                                                   Head Rotation
                                                   High Ear
                                                   High Shoulder
                                                   High Ilium
                                                   Ext. Rotated Foot
                                                   Int. Rotated Foot



ROM
             Cervical ROM                                Lumbar ROM
               ROM      Pain     Level                    ROM     Pain         Level
Flexion        N  Y N                  Flexion          N     Y N
Extension      N  Y N                  Extension        N     Y N
R. Rotation    N  Y N                  R. Rotation      N     Y N
L. Rotation    N  Y N                  L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                  R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                  L. Lat. Flex.    N     Y N


Leg Length/Spinal Balance         possible short leg with posterior muscle guarding
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion) Rarely: enlarged kidney
T9- L2: possible tenderness with kidney involvement (viscerosomatic)



List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




Cindy Gibbon, D.C.                   Page 4                            8/20/2010
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RADIOLOGICAL EXAMINATION:

       Xx X-rays  MRI             CT           Other

Views Cystourethrogram
      VCUG (voiding cystorography)
      CT scans
      Cystoscopy
      Cystometry
      Fluoroscopy: shows physical problems that predispose children to UTI’s

Imaging needed especially: children, esp. boys with UTI”s
                        Adults with frequent or recurrent UTI’s


Findings


DIFFERENTIALS:

Prostatitis
Blockages BPH(benign prostatic hypertrophy), kidney stones
Sexually transmitted disease
Systemic illness: diabetes mellitus
Trauma/ spinal cord injury/ sprain/ strain
Recent strep infection, Anatomical variants/ blockages, stones


DIAGNOSIS:

URINARY TRACT INFECTION




Case Management:

Chiropractic Management:
      Adjust Area for subluxations

Adjunctive Therapy:
   1. Antiobiotics: usually a 3 day course/ sometimes low-grade long courses are
       given
   2. Natural treatments:
      A. Cranberrry juice: controversy on this but acidification of juice inhibits bacteria
          holding onto bladder wall (American Urological Assn, June 2001.


Cindy Gibbon, D.C.                    Page 5                              8/20/2010
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          Seems that the juice doesn’t treat infection but used more for prevention and
          control of number of infections.
       B. Uva Ursi: active ingredient is arbutin which is broken down in intestine to
          hydroquinone which is sent to kidney’s for excretion. Hydroquinone acts asan
          antiseptic in bladder but is fairly toxic!
       C. Estrogen therapy helps maintain normal lining of urinary tract
       D. Warm sitz baths / hot water bottle to ease pain
    3. Pain-relieving medications



Nutrition:      Not substantiated: goldenseal
                                   Lapacho and methionine
                                  Vitamin C and zinc help immunity

Patient education:                                                                        1.
Urination after sexual intercourse
       2. Diaphragms and certain spermicidal creams increase risk of UTI
       3. Drink plenty of fluids for proper hydration
       4. Do not delay in urination. Holding urine in bladder increases risk.
       5. Feminine hygiene: wipe from front to back to decrease bacterial
          contamination from anal area
       6. Frequent sexual intercourse and multiple partners increases risks.
       7.Elderly: ease to bathroom, hand rails, protective pads, semi-recumbent
          position
       8. Void urine at 2 – 3 hour intervals
       9. Avoid douches, hygiene sprays which may irritate urethra
       10. Avoid bubble baths and other chemicals in baths
       11. Avoid smoking: irritates bladder
       12. Avoid coffee, alcohol, spicy foods, which all irritate bladder
       13. Change soiled diapers infants and elderly promptly


Exercise: Cause dependent:
      1. Kegels, biofeedback, EMS: help in strengthening muscles
                    Good muscle tone is beneficial.


Further Evaluation:


Patient Care:


Referral: UROLOGIST




Cindy Gibbon, D.C.                    Page 6                           8/20/2010
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REFERENCES:


      Professional Guide to Diseases, 6th ed., Springhouse, 1998
      Basic Pathology, Kumar, Cotran, Robbins, 6th ed., 1997
      Instant Access to Chiropractic Guidelines and Protocols; Huff & Brady, 1999
      Merck Manual, 19th ed.
      American Family Physician, March 1, 1999, “Urinary Tract infections in Adults”
      UrologyHealth.org, American Urological Association, Education and Research, Inc.
      Urology Forum, Urology Channel


Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early stage of
condition, advanced stage of condition, psychosocial issues, etc. The complicating or
mitigating factors can either increase or decrease the baseline complexity.

Condition Name          Baseline     Complicating/ Mitigating Factors          Revised
                        Complexity                                             Complexity
                                     Structural problems                            1
                                     Neoplasms                                      1
    Urniary Tract           1.0      Repetitive UTI’s                               1
     Infections




Cindy Gibbon, D.C.                   Page 7                             8/20/2010
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                           CLINICAL APPLICATIONS
                          Faculty Case Study Preparation


CONDITION                Abdominal Aortic Aneurysm

Prepared by:             Ron Castellucci, DC

RELEVANT PATHOPHYSIOLOGY:

An abdominal aortic aneurysm is a dilatation of the wall of the descending aorta. The
chief signs of an arterial aneurysm are the formation of a pulsating tumor and often a
bruit is heard over the swelling. Sometimes there are symptoms from pressure on
contiguous parts. The aorta splits at L-4 into the common iliac arteries supplying the
lower extremities. The average diameter of aorta is 2.0-2.5 cm.

Aneurysms begin as micro tears and contain calcium and other blood coagulating
material, which seal the artery at the tear site. The greater number of arterial insults,
tears, and bleeds will create more calcium to be laid down. Since calcium is radio-
opaque, it can be visualized easily on AP and Lateral lumbar x -rays. The size of an
aneurysm is determined from the lateral lumbar film, measuring from the anterior of
the lumbar or thoracic vertebra to the front of the aorta at the greatest posterior to
anterior diameter. A measurement of 4.0 cm or greater, requires an evaluation by a
vascular physician prior to performing lumbar spine adjustments.

Aortic aneurysms develop slowly and over years however if they expand rapidly,
aortic dissection may occur. Aortic dissection involves bleeding into and along the
wall of the aorta most often because of a tear or damage to the inner wall of the
artery.


CASE HISTORY:

PPW: Most abdominal aortic aneurysms do not produce symptoms, but some
patients feel a pulsating sensation in the abdomen. These silent (asymptomatic)
aneurysms are often found on physical examination. Abdominal aortic aneurysm is
most likely to occur in people older than 60 years, and it affects men more often than
women. Most abdominal aneurysms are associated with arteriosclerosis and can
cause leg pain (claudication), numbness or fatigue. An artery may be sclerosed
(hardened) but if the lumenal diameter isn't altered, there is no aneurysm.


Onset-Initial: Pulsing abdominal mass, Hypertension; found on x-ray
      Palliative/Provocative: Hypertension; arteriosclerosis, age (50-70)
      Quality/Quantity: pain, however often asymptomatic
      Referred/Radiating: low back pain may be felt due to the aneurysm pressing

Ron Castellucci, D.C.                  Page 1                              8/20/2010
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                              on anterior structures, claudication, numbness and/or
                              fatigue in the legs due to altered blood flow,
          Site: midline Abdomen epigastric to umbilical region
          Timing/Pattern: N/A
          Other: patient may feel pulsing sensation in the abdomen

Relevant History and Lifestyle
      Gender: anyone but males most commonly
      Age: 50 - 70
      Occupation: not occupation specific however increased stress and
                     hypertension are associated with AAA
      Traumas: In children, abdominal aortic aneurysm can result from blunt
                  abdominal injury
      Surgeries N/A
      Medications N/A
      Hospitalizations N/A
      Immunizations N/A
      Diseases or Conditions: Arteriosclerosis, Hypertension
      Family History N/A
      Diet: a diet that contributes to hypertension
      Sleep Habits N/A
      Sexual History: N/A
      Alcohol Usage N/A
      Drug Usage N/A
      Smoking/Tobacco N/A
      Other: Marfan's syndrome

Marfan's syndrome is a disorder of connective tissue which causes skeletal defects
such as long limbs, spider-like fingers (arachnodactyly), chest abnormalities,
curvature of the spine and a particular set of facial features including a highly arched
palate, and crowded teeth. The most significant of the defects in the syndrome are
cardiovascular abnormalities, which may include enlargement or dilatation of the
base of the aorta. Abdominal aortic aneuryism is not uncommon in patients with
marfans syndrome.

Review of Systems

PHYSICAL EXAMINATION:

Height                              Weight
Vitals:         BP: elevated
                Pulse ** increased pulsations in the epigastric region upon inspection
                Respiration: No Significant Findings
                Temperature: No Significant Findings
                Appearance, Motion, Gait : No Significant Findings



Ron Castellucci, D.C.                   Page 2                            8/20/2010
Approved 04/13/05
Orthopedic Tests

      Test Name                  R           L         Test Name               R           L
No Significant Findings        +     -   +       -                           +     -   +       -
                               +     -   +       -                           +     -   +       -
                               +     -   +       -                           +     -   +       -
                               +     -   +       -                           +     -   +       -
                               +     -   +       -                           +     -   +       -

Orthopedic Test Results Discussion:


Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception : No Significant Findings


LabValues: No Significant Findings

Examination of Related Areas

An abdominal aortic aneurysm, there will be a "blowing" murmur or a "whooshing"
sound (bruit) over the aorta upon auscultation of the arteries of the abdomen.

If a rupture is suspected, signs of blood loss (hypovolemia) and an alteration in lower
extremity pulses and circulation may will be seen.

         Hypovolemia is a form of shock where the heart is unable to supply enough
          blood to the body because of blood loss, or inadequate blood volume and is
          known as hypovolemic shock. The loss can be from any cause, including
          external bleeding (from cuts or injury), bleeding from the gastrointestinal tract,
          other internal bleeding, or diminished blood volume resulting from excessive
          loss of other body fluids (such as can occur with diarrhea, vomiting, burns,
          and so on). In general, larger and more rapid blood volume losses result in
          more severe shock symptoms.

Symptoms of rupture include:

          Pulsating sensation in the abdomen
          Severe, sudden, persistent or constant pain in the abdomen
          Abdominal rigidity
***       Pain in the lower back
              Severe, sudden, persistent
              May radiate to groin, buttocks, or legs
              May radiate
          Paleness

Ron Castellucci, D.C.                     Page 3                              8/20/2010
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      Rapid pulse
      Dry skin/mouth, excessive thirst
      Anxiety, nausea and/or vomiting
      Light-headedness with upright posture
      Fainting with upright posture
      Fatigue (tiredness or weariness)
      Rapid heart rate (tachycardia) when rising to standing position
      Impaired ability to concentrate
      Shock
      Abdominal mass

Other Findings: (Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.) Auscultation may reveal turbulent blood flow. Palpation may
reveal abnormal pulsations.


SPINAL EXAMINATION:

      Postural Analysis                       Postural Analysis     L      N        R
                                              Head Tilt
                                              Head Rotation
                                              High Ear
                                              High Shoulder
                                              High Ilium
                                              Ext. Rotated Foot
                                              Int. Rotated Foot


ROM
             Cervical ROM                                Lumbar ROM
               ROM      Pain     Level                    ROM     Pain         Level
Flexion        N  Y N                  Flexion          N     Y N
Extension      N  Y N                  Extension        N     Y N
R. Rotation    N  Y N                  R. Rotation      N     Y N
L. Rotation    N  Y N                  L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                  R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                  L. Lat. Flex.    N     Y N



Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion)




Ron Castellucci, D.C.                Page 4                             8/20/2010
Approved 04/13/05
Palpation:
List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

XX X-rays  MRI            XX CT               XX Other CBC may detect blood
loss

Views:       A-P and Lateral Lumbar Plain Film views. A majority of AAA cannot be
seen on plain film; therefore, a CT scan is the preferred method of diagnosis. A
Doppler Ultrasound may also be used as a diagnostic method.

Findings      A ballooning or enlargement of the aorta may be visualized anterior to
the vertebral bodies in the thoraco-lumbar region. Often calcification will be seen
within the walls of the aorta. There may also be anterior vertebral body scalloping
seen on the lateral lumbar view.


DIFFERENTIALS:

Differential Diagnosis may include renal colic, GI hemorrhage, Low back pain (facet
syndrome/Disc herniation), SI involvement, Appendicitis, Cholelithiasis,
Diverticulosis/Diverticulitis, Gastric/Peptic ulcer, Myocardial Infarction, Bowel
obstruction, Pancreatitis, UTI (females).
If the aneurysm is visualized on x-ray, there are no differentials.


DIAGNOSIS:

       Abdominal Aortic Aneurysm




Ron Castellucci, D.C.                Page 5                            8/20/2010
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Case Management:


Chiropractic Management:         Modify adjustment procedures to exclude
extension and excessive rotation of the thoraco-lumbar spine. Referral to a
vascular specialist is recommended.




Adjunctive Therapy: none




PhysicalTherapy:_none_____________________________________________
________________________________________________________________
______________________________________________________________
________________________________________________________________
________________________________________________________________

Nutrition: Standard discussion of good dietary habits with the patient should be
followed.



Exercise:    Standard discussion of good exercise habits with the patient should be
followed.




Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education):
      ___________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________


Further Evaluation:       Referral to a vascular specialist is recommended for
those patients who are symptomatic. It is my opinion that all patients with abdominal
aortic aneurysm should be referred for further evaluation.



Ron Castellucci, D.C.                Page 6                             8/20/2010
Approved 04/13/05
Common Medical Management:

If the aneurysm is small and there are no symptoms, periodic ultrasound evaluation
is recommended to monitor for changes. Anti-hypertensive medications may be
prescribed.

Surgical repair or replacement of the section of aorta is recommended for patients
with symptoms, as they are at high risk of fatal rupture. Repair is also recommended
for patients with aneurysms greater than 5 cm in diameter. Stenting is also a
treatment option.

Stenting involves the use of a tube placed inside the vessel and can be performed
without an abdominal incision, with specialized catheters that are introduced through
arteries at the groin.

Prognosis:

The outcome is usually good when an aneurysm is monitored carefully and if
surgical repair is performed before the aorta ruptures.

Aortic rupture is life threatening. Less than 50% of people with a ruptured abdominal
aortic aneurysm survive.

   Complications include:
    Aortic rupture
    Bleeding from the aorta
    Hypovolemic shock
    Arterial embolism
    Insufficient circulation past the aneurysm
    Irreversible damage to the kidneys (kidney failure)
    Myocardial infarction
    Stroke
    Aortic dissection



REFERENCES:

      http://medlineplus.gov/
      http://www.avera.org/avera/
      http://www.chiroweb.com/archives/14/16/20.html (Abdominal Aortic Aneurysm
       and Low Back Pain Norman Engel, MS, DC, DABCO Dynamic Chiropractic
       July 29, 1996, Volume 14, Issue 16)
      http://www.xray2000.co.uk/


Ron Castellucci, D.C.                Page 7                             8/20/2010
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Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.

Condition Name          Baseline     Complicating/ Mitigating Factors    Revised
                        Complexity                                       Complexity
                                     Measures above 3.8 cm.                 5.0
                                     Measures above 5.0 cm.                 6.0
 Abdominal Aortic          4.0
    Aneurysm




Ron Castellucci, D.C.                Page 8                             8/20/2010
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                           CLINICAL APPLICATIONS
                                      Case Study

CONDITION – ADHD
Prepared By: Dr. Renee Prenitzer

RELEVANT PATHOPHYSIOLOGY:

ADHD can only be identified by looking for certain characteristics behaviors, these
behaviors vary from person to person. The most common behaviors fall into three
categories: inattention, hyperactivity, and impulsivity. Individuals who are
inattentive have a difficult focusing on one project and may easily get distracted.
Individuals who suffer from hyperactivity frequently find it hard to sit still. They roam
around, wiggle their feet, fidget, or leap from one activity to the next. Individuals who
are excessively impulsive have a difficult time controlling their immediate or thinking
before they react or speak. Specialists consider these characteristics and consider if
these behaviors are excessive, long-term, and pervasive.

According to the Diagnostic and Statistical Manual of Mental Disorders, signs of
inattention include: becoming easily distracted by irrelevant sights and sounds,
failing to pay attention to details and making careless mistakes, rarely following
instructions, losing or forgetting things like keys, toys, books. According to the
Diagnostic and Statistical Manual of Mental Disorders, signs of hyperactivity and
impulsivity are: feeling restless, fidgeting, or squirming, running or climbing in
situations where quiet behavior is expected, having difficulty waiting in line or for a
turn.

ADHD research has shown that in people with ADHD, the area of the brain that
controls attention uses less glucose, indicating that it was less active. It is
hypothesized from this research that lower levels of brain activity may cause
inattention. Toxins can also disrupt the brain function. Lead is a possible toxin, it is
found in dust, soil, flaking paint and in areas where leaded gasoline and paint were
used. There is also research to suggest that ADHD is familial and that there may
be genetic predisposition. At least 1/3 of the fathers who had ADHD also had
children with the condition.

CASE HISTORY:

PPW: Complaints of not being able to focus. Has difficulty sitting still, planning
ahead, finishing tasks or being aware of what is happening around them.

Onset-Initial
      Palliative/Provocative
      Quality/Quantity
      Referred/Radiating
      Site

Renee Prenitzer, D.C.                  Page 1                              8/20/2010
Approved 04/05/04
         Timing/Pattern
         Other

Relevant History and Lifestyle:
      Gender: This conditions affects boys two to three times more than girls.
      Age: It affects 3 to 5 percent of all children in the US. (Approximately 2
      million American children) Adults can be affected as well.
      Occupation:
      Traumas
      Surgeries
      Medications
      Hospitalizations
      Immunizations
      Diseases/Conditions


         Family History ; Children who have ADHD tend to have a least one relative
         who also has the disorder. One-third of all fathers who had ADHD in their
         youth bear children who have ADHD. Also a majority of twins share the trait.
         A family history of the mother using cocaine, alcohol, or subjecting fetus to
         certain environmental toxins may be connected to increased incidence of
         ADHD.
         Diet: In only about 5% of children wit ADHD was diet a factor. Refined
         sugar, artificial colorings, and preservatives were suspected.

         Sleep Habits
         Sexual History
         Alcohol Usage
         Drug Usage
         Smoking/Tobacco
         Other__________________________________________________

Review of Systems



PHYSICAL EXAMINATION:

Height                              Weight

Vitals: BP                Pulse              Respiration________ Temp.

Appearance, Motion, Gait

Orthopedic Tests



Renee Prenitzer, D.C.                  Page 2                            8/20/2010
Approved 04/05/04
      Test Name            R           L           Test Name             R           L
                          +    -   +       -                           +     -   +       -
                          +    -   +       -                           +     -   +       -
                          +    -   +       -                           +     -   +       -
                          +    -   +       -                           +     -   +       -
                          +    -   +       -                           +     -   +       -

Orthopedic Test Results Discussion:




Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

Lab Values


Examination of Related Areas



Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)



SPINAL EXAMINATION:

      Postural Analysis                        Postural Analysis   L         N       R
                                               Head Tilt
                                               Head Rotation
                                               High Ear
                                               High Shoulder
                                               High Ilium
                                               Ext. Rotated Foot
                                               Int. Rotated Foot


Renee Prenitzer, D.C.                 Page 3                           8/20/2010
Approved 04/05/04
ROM
             Cervical ROM                                   Lumbar ROM
               ROM      Pain     Level                       ROM     Pain        Level
Flexion        N      Y N                 Flexion          N     Y N
Extension      N  Y N                     Extension        N     Y N
R. Rotation    N  Y N                     R. Rotation      N     Y N
L. Rotation    N  Y N                     L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                     R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                     L. Lat. Flex.    N     Y N


Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion)




List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

        X-rays       MRI            CT          Other: PET Scan used to observe
the brain at work.

Views

Findings: Investigators found important differences between people who have
ADHD and those who don’t. In people with ADHD, the brain areas that control
attention used less glucose, indicating that they were less active. It appears from

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this research that a lower level of activity in some parts of the brain may cause
inattention.




DIFFERENTIALS:

A Chronic Ear Infection can make a child seem distracted or uncooperative. Living
with family members who are abusive or addicted to drugs or alcohol can also make
a child seem distracted or uncooperative. ADHD-like behavior can also be seen in
situations where the classroom condition leads to a defeated attitude (i.e. child is not
able to keep up with course-work due to learning disability). It also needs to be
noted that at during certain stages of development, children may exhibit
characteristics of inattention, hyperactivity, and impulsiveness. Another condition
known as petit mal seizures can look like ADHD.


DIAGNOSIS:

Diagnosis is usually made by a psychiatrist, psychologist, pediatrician, or
neurologist. Steps for diagnosing ADHD. 1. Gather information to rule-out a problem
other than ADHD. 2. Gather information on the individual’s ongoing behavior and
compare this to the symptoms and criteria listed in the DSM. 3.Poll the individual’s
teachers, parents, and other people who know the individual well about the behavior
expressed. 4. Tests for social adjustment and mental health may be performed.

Adults are diagnosed for ADHD based on their performance at home and at work.
When possible, their parents are asked to rate their behavior as a child. The adult is
also asked to rate their own experiences.



Case Management:


Chiropractic Management:           Many children with ADHD experience other
emotional disorders. With this in mind, it may be necessary to increase the amount
of spinal exams for subluxation due to the increased emotional stress that the
individual is under. Children with ADHD feel tremendous worry, tension, uneasiness
or fear. These feelings can affect the child’s thinking and behavior. These children
can also experience depression, which can lead to a lowered immune response. It
will be necessary to evaluate the individual with depression more frequently as well.




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Adjunctive Therapy: Educational professions try to accommodate children with
ADHD in several ways. They can seat the student in an area of the class where
there are few distractions, provide an area where the child can move around and
release excess energy, allow the student extra time on tests, reviewing instructions
and assignments on the board and listing the books and material needed for the
task. Teach techniques for monitoring and controlling their own attention and
behavior. Many children with ADHD or other disabilities are able to receive such
special education services under the Individuals with Disabilities Education Act.
Others may qualify under the National Rehabilitation Act (referred to as “504
eligibility”)

Physical Therapy:




Nutrition: ADHD has also been associated with a deficiency in essential fatty acids.
Deficiencies of certain fatty acids in the plasma were found in 44 children with ADHD
compared with age- and sex- matched controls. A randomized, double-blind
treatment trial in ADHD children with clinical signs of fatty-acid difficiency showed
that supplementation changed the blood profile of fatty acids and was associated
with reductions in ADHD symptoms.
Iron deficiency has been shown to effect energy metabolism and cognitive
performance. There has been significant research to indicate a link between iron
deficiency and brain function. EEG pattern abnormalities were found in men with
low serum ferritin levels. These EEG patterns were associated with processes
related to the attention span. Supplementation with zinc and iron showed
improvement in the attention span and short-term memory in young women who
were tested.

Exercise:




Health Promotion and Maintenance (i.e. ergonomics, spinal hygiene, psychosocial
concerns/education)          Other interventions available for ADHD co-management
with drugs are: psychotherapy, cognitive-behavioral therapy, social skills training,
support groups, parenting skills training. Some controversial treatments that have
not been scientifically validated but that do show anecdotal evidence of success are:
biofeedback, restricted diets, allergy treatments, medicines to correct problems with
the inner ear, megavitamins, chiropractic adjustments and bone re-alignment,
treatment for yeast infection, eye training and special colored glasses.



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Further Evaluation:


Common Medical Management: Three medications in the class of drugs known as
stimulants seem to be most effective in children and adults: Ritalin, Dexedrine or
Dextrostat, and Cylert. For lasting improvement, numerous clinicians recommend
that medications be used in concert with behavior therapy, emotional counseling,
and practical support. Other drugs may be used if the stimulants do not work, they
are antidepressants and in some cases antihistamines. Some cases respond to
Clonidine which is a drug used to treat hypertension.

References:

www.nimh.nih.gov/publicat/adhd.cfm     (National Institute of Mental Health) NIH
Publication No. 96-3572. Printed 1994, Reprinted 1996. Booklet. 44p.

Omega 3: Implications in human health and disease. By Bibus, Douglas PhD

Behavioral Health Matters: Omega-3 Fatty Acids and Mental Health, by Jay M.
Pomeranz, MD (www.medscape.com/viewarticle/409997_print)

Why Can’t I Concentrate? New Evidence on the Roles of Iron and Zinc in Adult
Cognition, by Mary J. Kretsch, Ph.D., R.D. (p. S70-S71)



Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.


Condition Name          Baseline     Complicating/ Mitigating Factors    Revised
                        Complexity                                       Complexity
                                     Medications with side-effects          4.0
                                     Altered stress levels                  4.0
      ADHD                 2.0       Referral for counseling                4.0




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            AVASCULAR NECROSIS

CASE PRESENTATION #1



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            What is Avascular Necrosis?

    AVN is a disease that results from temporary or
    permanent blood loss to the bone tissues.
    Without blood supply, the tissue of the bone dies
    and eventually the bone collapses
    AKA osteonecrosis, aseptic necrosis, and
    ischemic bone necrosis


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                   Patient Presents With…

    In the early stages, AVN is relatively symptom-less.
    As the AVN progresses, there may complaints of joint
    pain. Initially the pain may only occur when weight-
    bearing. Eventually as the disease increases in
    severity, the pain will occur when weight bearing and
    when resting.
    If the bone collapses the pain will become much more
    severe. (This may be of sudden onset)

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             Patient Presents With…

    Patients with AVN of the femoral head may
    present with groin pain that intermittently
    radiates down the anteromedial thigh.
    Other symptoms may include: antalgic gait,
    gluteus minimus limp, limit ROM



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                          Gender/ Age

    Avascular necrosis is an equal opportunity condition, it
    affects both men and women.
    Avascular necrosis is most common in the age group
    30-50 but can occur in younger and older individuals.
    The age of occurrence is dependent on risk factors
    such as injury, corticosteroid use, alcohol use, and
    certain disease conditions. (this will be introduced more
    in the pathophysiology section.

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                      Occupation

    There is no strong correlation between
    occupation and AVN
    The only thing that might correlate is a job where
    you would be in danger of dislocating the hip or
    incurring a hip fracture, either stress fracture or
    full break.


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                              Trauma

    Studies show that in about 20% of the people
    who have dislocated a hip, AVN develops. Of
    the hips that remain dislocated longer than 12
    hours, 52% develop AVN
    Fracture



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            Trauma – Dislocation and Fracture




               Radiograph of the pelvis with anterior
               dislocation of the left hip associated with
               a subcapital femoral neck fracture
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                          Surgeries

            There is not a correlation between
            surgeries and AVN. If surgery resulted
            in a fat embolism, blood embolism, or
            any other type of embolism, and that
            embolism, blocked the blood flow to the
            arteries in the bone, then it could be
            causative.

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                        Medications

    Relevant medications that might contribute to the
    incidence of AVN are:

              Corticosteroids – Prednisone
              Some studies show a 35% association
              between steroid use and AVN


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                    Hospitalizations

    Nothing really correlates to AVN
    If the individual had a recent hospitalization for
    treatment of the “Bends” aka decompression
    sickness, aka Caisson’s Disease, there might be
    a possibility that a nitrogen bubble caused
    intraluminal obliteration of the end vessels
    (Long-shot!!)

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                            Illnesses

    Individuals who have a history of conditions
    treated with corticosteroids: Systemic Lupus
    Erythematosus, Rheumatoid Arthritis,
    Inflammatory Bowel Disease, Vasculitis, Asthma




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             Diseases and Conditions

    There a some disease conditions that have a
    correlation to AVN, they are: Possibly Legg-
    Calve-Perthes, Blood Coagulation Disorders
    (Sickle Cell Anemia), Gaucher’s Disease,
    Pancreatitis, Gout




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             Diseases and Conditions

    Gaucher’s Disease – A familial autosomal
    recessive disorder of lipid metabolism resulting
    in an accumulation of abnormal
    glucocerebrosides in reticuloendothelial cells,
    and manifested clinically by
    hepatosplenomegaly, skin pigmentation,
    skeletal lesions, and pingueculae.

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            Relevant History and Lifestyle

    Family History – Sickle Cell Anemia
    Social History – Excessive use of alcohol is
    thought to be a contributing factor; in people who
    drink excessive amounts of alcohol, fatty
    substances may block blood vessels.
    Diet – No major relevant contributing factors
    although cholesterol might play a part in artery
    blockage

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            Relevant History and Lifestyle

    Sleep Habits – Nothing relevant
    Sexual History – Nothing relevant
    Alcohol Usage – Excessive usage is linked to
    occurrences of AVN, possibly due to fatty
    substances blocking vessels



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                       Drug Usage

    Recreational drugs do not contribute to AVN




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             Smoking or Tobacco Use

    No significant contributing factors.




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               Physical Examination

    Height – No significance
    Weight – May contribute to possible fracture in
    someone who is obese and on long-term
    corticosteroid use
    Vitals – No major significance
    Appearance – Gait will be altered in a person
    with AVN, either due to pain or structural
    deformity
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            Physical Exam – Orthopedic Tests

    Tests that will most likely have positive findings:
    Anvil, Patrick Faber, Hibbs, Laguerre’s, SLR
    may be uncomfortable (finding not a true
    positive)
    Test that may give findings or false positives:
    Minor’s sign, SLR, Nachlas, Yeoman's, Ely’s
    Heel to Buttock, Trendelenburg’s

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        Physical Exam – Neurological Tests

    Nerve Root Packages may have mixed findings
    for Muscle, Reflex, and Sensation.
    The femoral nerve may be positive for muscle,
    reflex, and sensation because of its proximity to
    the hip joint and the irritation and inflammation
    present in that area.


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            Physical Exam – Femoral Nerve

    Innervation to the Sartorius, Rectus Femoris,
    Vastus Medialis, Vastus Lateralis, Pectineus,
    Iliopsoas
    Sensory for the skin on the front and over the
    medial aspect of the thigh and the medial side of
    the leg and foot.


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            Physical Exam – Femoral Nerve

    Actions that may be interfered with due to
    Femoral Nerve damage or irritation: Adduction
    and external rotation, Knee Extension, Hip
    adduction, Hip flexion
    There may be a loss of or reduced patellar reflex
    There may be gait changes: circumductive gait
    aka steppage gait

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                          Lab Values

    This individual may test positive for Sickle Cell
    Anemia
    Biopsy – a bone biopsy which is considered a
    surgical procedure is a conclusive way to
    diagnose AVN. This is an option that is rarely
    used because of the invasive nature of the
    procedure.
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                        Lab Values

    Functional Evaluation of Bone – There are tests
    to measure the pressure inside a bone; however,
    they require surgery




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            Other Categories That Are Not
                Significant with AVN

    Examination of Related Areas
    Review of Systems
    Other Findings such as: EENT, Cranial Nerves,
    Percussion (except for Anvil Test)
    Palpation (Of other areas other than spine and
    pelvis)
    Auscultation
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            Spinal/ Extremity Examination

    May reveal paraspinal muscles spasms due to altered
    gait
    Postural Analysis may reveal unleveling of the pelvis
    due to compensation or pain
    ROM may reveal limited ROM, especially in flexion,
    abduction, and internal rotation. A finding seen with
    external rotation may be an audible click. This may
    especially be seen when changing from a seated
    position to a standing position
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              Normal Hip ROM Values

    Hip Abduction             45 °
    Hip Adduction             20 °
    Hip Flexion             135 °
    Hip Extension             30 °
    Hip Internal Rotation     35 °
    Hip External Rotation      45 °
    Flexion and Adduction
    Flexion, Abduction, and External Rotation
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                        Leg Length

    There have not been any studies to show leg
    length changes and a correlation to AVN;
    however, as the femoral head structure becomes
    deformed (flattened) there should be evidence
    of a permanent leg length change.
    Compensatory changes in leg length may occur
    due to muscle spasms in the pelvis.

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            Leg Length – Permanent Changes




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            Other Categories That Are Not
                Significant with AVN

    Instrumentation and Pattern Analysis Have not
    been shown to result in correlative changes
    Palpation may reveal spinal, pelvic, and lower
    extremity muscle spasms; however, there is
    nothing that directly correlates to AVN



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            Radiological Examination

    MRI is the most sensitive for diagnosing AVN
    X-Ray or CT scan can be used to determine the
    duration of AVN
    Bone Scanning is more sensitive than X-Ray but
    is non-specific



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            Radiological Examination - MRI

    MRI is the most sensitive noninvasive method
    for diagnosis AVN
    MRI detects chemical changes in the bone
    marrow and can show AVN in its earliest stages
    T1 image is used to detect marrow foci of
    decreased signals
    T1 images are diagnostic of AVN in 95% of the
    cases
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            MRI – Avascular Necrosis- T1/T2




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            Radiological Examination - MRI

    T2 image is used to detect the characteristic
    double line sign – the inner border of the
    peripheral band shows high signal in 80% of
    cases




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       Radiological Examination – CT Scan

    CT scans provides a three-dimensional picture
    of the bone
    It shows slices of the bone
    There are conflicting opinions of the usefulness
    of CT scans for diagnosing AVN; however, it
    may be useful for determining the extent of
    damage
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            Radiological Examination – CT Scan




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            Radiological Examination – Bone
                          Scan

    AKA Bone Scintigraphy
    Bone scans find all areas of the body that are
    affected
    Bone scans do not detect avascular necrosis in
    the earliest stages


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                     Radiological Examination –
                          Bone Scan
        Legg-Calve-Perthes: The child shown below was being evaluated for
        right hip pain. The bone scan demonstrated a focal area of photopenia
        in the lateral aspect of the right femoral head (black arrow) consistent
        with avascular necrosis. (Click the planar images to view selected
        SPECT images). T1-weighted MR images from the same patient
        demonstrate signal loss in the right femoral head epiphysis. A focal
        area of signal void can be seen in the lateral aspect of the epiphysis.
        (Click MR image to enlarge)




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            Radiological Examination – Bone
                          Scan




            Bone scan demonstrating focal increased uptake
            in right femoral neck (arrow).

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              Radiological Examination

    Crescent Sign – weakening of the subchondral bone
    may result in a fracture which separates the articular
    cortex form the underlying cancellous bone
    Epiphyseal infarction
    Collapse of the articular cortex
    Fragmentation
    Mottled trabecular pattern
    Subchondral cysts
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                                               Radiological
This 5-year old boy
presented with a limp                          Examination
and right hip
pain. Examination
showed a reduction in
abduction and internal
rotation. This plain x-
ray was obtained
which showed the
right femoral head to
be flattened and
fragmented. A bone
scan confirmed
avascular necrosis of
the capital femoral
epiphysis. The
appearances were
those of Perthe's
disease.
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    Radiological Examination – Ficat and
           Arlet Staging of AVN
    Stage 0 – Diagnosis by MRI or bone scan. No radiographic
    findings
    Stage 1 – Slight osteoporosis on plain films. No sclerosis
    Stage 2 – Diffuse osteoporosis and sclerosis on plain films. A
    reactive shell of bone delimits the infarct
    Stage 3 – Crescent sign under the subchondral bone
    representing a fracture. Joint space preserved
    Stage 4 – Femoral Head Collapse. Joint space narrowing
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            Radiological Examination – Ficat and
                Arlet Staging of AVN/ Stage 1




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            Radiological Examination – Ficat and
               Arlet Staging of AVN/ Stage 2




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            Radiological Examination – Ficat
            and Arlet Staging of AVN/ Stage 3




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            Radiological Examination – Ficat
            and Arlet Staging of AVN/ Stage 4




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            Radiological Examination – Ficat
            and Arlet Staging of AVN/ Stage 4




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            Relevant Pathophysiology
 A proposed mechanism for AVN is that the
 intraosseous bone marrow pressure increases.
 Elevation of the bone marrow pressure then effects
 the venules and capillaries within the bone, causing
 a decrease of blood flow to the bone
 Rapid, or uncompensated, increases in
 intraosseous pressure are thought to result in
 irreversible circulatory disturbances and subsequent
 tissue damage. Tissue damage causes edema,
 which then further elevates pressure.
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            Relevant Pathophysiology

    Early detection and decompression of the bone
    may stop the ischemia
    The decompression of the bone can be done by
    a process known as coring, this has a variable
    success rate from 40-90%



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              Differential Diagnosis

    Transient osteoporosis of the hip
    Transient bone marrow edema syndrome
    Septic Arthritis
    Stress Fracture




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                Differential Diagnosis –
              Transient Osteoporosis
    A self-limiting cause of hip pain which can effect
    middle aged men and women in their third
    trimester of pregnancy
    PPW hip pain and a limp without a history of
    trauma or infection
    Unknown etiology
    Resolves over a 4-10 month period of time
    Osteopenia is evident on X-ray
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            Transient Osteoporosis




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              Differential Diagnosis- Transient
            Bone Marrow Edema Syndrome

    Similar to transient osteoporosis in that it is self-
    limiting
    Diagnosis is made in those cases where there is
    no radiological evidence of osteopenia



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             Differential Diagnosis – Septic
                      Arthrosis
    Condition that may occur from a blood borne
    spread of an infectious agent or by contiguous
    spread
    If this is suspected, immediate joint aspiration
    must be performed to obtain a culture.
    Underlying bone changes are not typical

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                    Differential Diagnosis –
                    Stress Fracture
    Similar characteristics to AVN
    Usually occurs in young patients as a result of
    overuse and repeated stress with underlying
    normal bone
    May be seen in runners and military recruits
    May occur in osteoporitic women


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                     Diagnosis

     Avascular Necrosis
          of Hip




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            Chiropractic Management

    Avoid Hip Adjustments
    Adjust the lumbopelvic spine as necessary and
    take into consideration patient comfort
    Force should be limited: Light drop work,
    NUCCA, Logan Basic, Activator, Network
    According to patient comfort, circumduction
    exercises may be given to help with ROM

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                  Medical Management
    Medicines to reduce the amount of fatty substance that cause
    blockage to blood vessels
    NSAIDs to help reduce pain and inflammation
    Reduce weight bearing to help slow the damage caused by AVN
    and to allow for natural healing
    Range of Motion Exercises
    Electrical Stimulation to promote bone growth




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                   Surgical Management
     Bone decompression or coring – controversial with a variable
     success rate, 40-90%
     Osteotomy – Surgical reshaping of the bone to reduce stress on the
     affected area. There is a lengthy recovery period and the individual’s
     activities will be limited for up to 1 year following the procedure.
     Used most often in cases of advanced AVN.
     Bone Graft – May be used in conjunction with bone coring.
     Transplantation of healthy bone to the diseased area. Vascular
     grafts may also be done to increase the blood flow to the area. This
     too has a lengthy recovery period.
     Arthroplasty/ Total Hip Replacement – Treatment of choice for end
     stage AVN. This is recommended for people who are not good
     candidates for other types of treatments.
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            Physical Therapy Management
    ROM Exercises – Hip and Knee Flexion




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            Physical Therapy Management
    ROM Exercises- Hip Rotation with Hip Flexion




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            Physical Therapy Management
    ROM Exercise -




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            Physical Therapy Management

    ROM Exercise – Hip Abduction with Neutral Rotation




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            Physical Therapy Management
   ROM Exercise – Hip Abduction with Neutral
   Rotation/Another version




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                   Adjunctive Therapy
      Electrical Stimulation - bone growth stimulator which
      uses a very low-strength pulsed electromagnetic field
      (PEMF) to activate the body's natural healing process.
      Electrical currents have been used to heal bones since the
      mid-1800s. However, it wasn't until the 1950s that
      scientists made an important discovery. When human bone
      is bent or broken, it generates an electrical field. This low-
      level electrical field activates the body's internal repair
      mechanism, which in turn stimulates bone healing.
      Bone growth stimulation therapy was initially used to
      stimulate the natural healing process in long bone
      fractures.
8/20/2010                  Renee Prenitzer, D.C. Approved
                             05/10/04
                 Adjunctive Therapy

    Electrical Stimulation - produces a signal at the
    fusion site like the one your own body generates
    to induce normal bone healing.




8/20/2010           Renee Prenitzer, D.C. Approved
                              05/10/04
                             Nutrition

    Limit the amounts of fatty foods
    Increase the amount of fiber
    Decrease the amount of alcohol intake
    Non-substantiated information / Anecdotal-
    Glucosamine Chondroitin with MSM for joint
    support; Bromelian for natural anti-inflammatory;
    Garlic – for cholesterol

8/20/2010           Renee Prenitzer, D.C. Approved
                              05/10/04
                            Exercise

    Non-weight bearing exercise would be best
    during acute stages, I.e. swimming
    Passive exercises for the hip
    Upper trunk and extremity exercises to maintain
    aerobic ability, I.e. water aerobics



8/20/2010          Renee Prenitzer, D.C. Approved
                             05/10/04
        Health Promotion and Maintenance

    Education about stretches and exercises to
    maintain ROM
    Education about decreasing the amount of
    weight bearing
    Education about shoe-wear choices
    Education about dietary and supplemental
    choices
8/20/2010          Renee Prenitzer, D.C. Approved
                             05/10/04
                               References
    NIH Publication No. 00-4857
    www.niams.nih.gov/hi/topics/avascular_necrosis/index.htm
    Avascular Necrosis of Bone:MRI Evaluation –
    www.jhu.edu/~dbluemke/Avascular_necrosis.html
    www.merck.com/mrkshared/mmanual/section5/chapter53/53a.jsp
    Differential Diagnosis for the Chiropractor, Souza




8/20/2010                 Renee Prenitzer, D.C. Approved
                                    05/10/04
                 Real Life Case of AVN
    72 year old female initially begins care with wellness as
    the major health concern.
    Occupation is as a preschool teacher
    History of trauma includes: 3 month old fall, 1 year old
    fall
    The 3 month old fall resulted from slipping on an oil slick
    and falling on Left Hip and Leg. Patient sought MD
    evaluation and was told that she stretched her thigh
    muscles badly. Patient still has some pain if standing or
    walking too much

8/20/2010              Renee Prenitzer, D.C. Approved
                                 05/10/04
            Relevant History and Lifestyle

    History of slip and fall – resulted in fractured Left
    Acromion process
    History of Allergies – Medicates with Prednisone,
    Singular, Albuterol
    Patient also medicates with: Rhinocort Aqua and
    Flonase


8/20/2010            Renee Prenitzer, D.C. Approved
                               05/10/04
                Patient Examination

    Initial Spinal Exam Revealed: decreased LLF
    and decreased LR in the cervical spine
    Initial Physical Exam Revealed: Positive SLR
    from 30-60 degrees on the left, Patrick Faber
    was positive on the left, Achilles Tendon Reflex
    was diminished on the right
    Spinal Exam revealed altered gait on the left

8/20/2010           Renee Prenitzer, D.C. Approved
                              05/10/04
            Radiographic Examination

    Cervical x-rays revealed: Hypolordotic C-spine,
    DDD from C3-T1, DJD from C3-C7,posterior
    osteophytes at C4, C5, C6,and C7, and
    generalized decreased bone density
    Thoracic x-rays revealed: Hyperkyphotic T-
    spine, DDD of T11, DJD of T8-T9 and T11-T12,
    Calcific atherosclerosis of the aortic knob and
    decreased bone density
8/20/2010          Renee Prenitzer, D.C. Approved
                             05/10/04
            Radiographic Examination

    Lumbopelvic x-rays revealed: Hyperlordotic L-
    spine, Right rotatory scoliosis, DDD of L4-S1,
    DJD from L2- S1
    Calcific Atherosclerosis of the abdominal aorta,
    and decreased bone density



8/20/2010           Renee Prenitzer, D.C. Approved
                              05/10/04
                   Referrals Made

    Referral was made for MRI of the lumbar spine.
    MRI was taken within two weeks of beginning of
    care plan.
    MRI results: DDD at all levels. Central disc
    herniation at L4-L5. Moderate central canal
    narrowing at L3-L4, L4-L5, and L5-S1. Endplate
    changes at L4-L5. Rudimentary disc formation
    at S1-S2.
8/20/2010          Renee Prenitzer, D.C. Approved
                             05/10/04
                                     Radiographic
                                     Examination




8/20/2010   Renee Prenitzer, D.C. Approved
                      05/10/04
            Radiographic Examination




8/20/2010       Renee Prenitzer, D.C. Approved
                          05/10/04
                                             Radiographic
                                             Examination




8/20/2010   Renee Prenitzer, D.C. Approved
                      05/10/04
            Patient Management and Care

    For the initial first six weeks of care the patient
    experienced good results, her gait had improved
    and she had no new complaints. Adjustments
    included: C1, LIL (PIIN)
    About seven weeks into care, patient presents
    with new complaint of low back pain. It was
    decided to monitor her for changes and if
    needed re-assess.
8/20/2010           Renee Prenitzer, D.C. Approved
                              05/10/04
            Patient Management and Care

    Approximately three months from the start of her
    care, the patient visited her MD for possible
    referral for left hip pain. He gave her a cortisone
    injection into the left buttock. It was decided to
    leave the pelvis alone for about a week.
    For the next three weeks the patient fluctuated
    from doing better in the left hip and doing worse.

8/20/2010           Renee Prenitzer, D.C. Approved
                              05/10/04
            Patient Management and Care
    At the Review and Update, her major health concern
    was changed from wellness care to left hip pain with
    sporadic radiculopathy down the left lateral thigh to the
    knee.
    At three months and two weeks of care, with intermittent
    good results, it was decided to take a spot shot of L4-
    L5 (an area that did not show up as clear as preferred
    to make sure that nothing was missed. The cassette
    was turned lateral in order to make sure that both hips
    were visualized as well).
8/20/2010             Renee Prenitzer, D.C. Approved
                                05/10/04
            Radiographic Examination (2)




8/20/2010         Renee Prenitzer, D.C. Approved
                            05/10/04
            Patient Management and Care

    X-Ray revealed: blurring of the Left hip joint with
    possible effusion.
    Based on the new x-ray findings, an additional
    MRI referral was made.
    The MRI was completed three and half months
    after the start of care.


8/20/2010            Renee Prenitzer, D.C. Approved
                               05/10/04
                        MRI Results

    “Increased signal within the left femoral head,
    neck, and proximal femoral shaft, most
    consistent with underlying avascular necrosis.
    A septic joint would be a consideration also.
    Conceivably, there could be a pathological
    fracture at the level of the subcapital portion of
    the femur. This should be correlated with the
    clinical findings. Follow-up plain x-rays are also
    suggested.”
8/20/2010           Renee Prenitzer, D.C. Approved
                              05/10/04
                Patient Management

    Following the MRI results the patient was then
    referred to an Orthopedist for treatment.
    The treatment received was another plain film X-
    ray and instructions to stay off her feet as much
    as possible. Pain medications were also given.



8/20/2010           Renee Prenitzer, D.C. Approved
                              05/10/04
            Orthopedic X-Rays ( 4 months into chiropractic care)




8/20/2010           Renee Prenitzer, D.C. Approved
                              05/10/04
            Orthopedic X-Rays ( 4 months into chiropractic care)




8/20/2010      Renee Prenitzer, D.C. Approved
                         05/10/04
             Discussion and Prognosis
       Currently the patient is experiencing intermittent
       improvement of left hip symptoms. She has been
       educated about AVN and understands that
       chiropractically, all that can be managed are her
       subluxations.
       Medically, she has been told to wait until the pain is no
       longer bearable and she is not able to walk, before getting
       hip arthroplasty (hip replacement)
       The Prognosis is guarded. There is no evidence of
       marked improvement of the hip pain; however, the rest of
       her spine is reacting well to the adjustments.
8/20/2010                 Renee Prenitzer, D.C. Approved
                             05/10/04
                                  Case Complexity

            Condition Name         Baseline      Complicating/ Mitigating Factors        Revised
                                   Complexit                                             Complexit
                                   y                                                     y


                                                 Early Stage – no altered management        4.0

             Avascular Necrosis       4.0
                                                 Late Stage – altered gait present,         6.0
                                                 chiropractic management altered


                                                 Advanced stage resulting in hip joint      7.0
                                                 replacement- altered chiropractic
                                                 adjustments




8/20/2010                         Renee Prenitzer, D.C. Approved
                                            05/10/04
                           CLINICAL APPLICATIONS
                          Faculty Case Study Preparation


CONDITION____Burner/stinger_AKA Cervical Brachial Syndrome/ Brachial
Plexus Syndrome

Prepared by:_________Kevin Power__

RELEVANT PATHOPHYSIOLOGY:

      Burner/stinger is usually associated with a lateral flexion injury of the
neck/head i.e.”lateral whiplash”. It can also occur with blunt force trauma.

CASE HISTORY:

PPW: Acute Episode: Sudden onset burning pain and/or numbness along the
lateral arm with associated weakness following trauma.

Chronic Episode: Burning pain/ and or numbness along the lateral arm following
activity that exacerbates original injury

Onset-Initial        Neck/head trauma
Palliative/Provocative     Minimising neck motion/Lateral flexion.
Quality/Quantity           Paresthesia; Burning pain and/or numbness.
Referred/Radiating         Usually located along the arm; however, it is most
        commonly located along dermatome distribution for the nerve roots.
Site                       Lower cervical spine.
Timing/Pattern             Several minutes
Other

Relevant History and Lifestyle
      Gender
      Age
      Occupation
      Traumas
      Surgeries
      Medications
      Hospitalizations
      Immunizations
      Diseases or Conditions__________________________________ _
      Family History
      Diet
      Sleep Habits
      Sexual History
      Alcohol Usage

Kevin Power, D.C.                      Page 1                             8/19/2010
Approved 5May05
         Drug Usage
         Smoking/Tobacco
         Other_______________Athletes.___________________________________


Review of Systems                                                     _____

     ______________________________________________________
___________________________________________________________



PHYSICAL EXAMINATION:

Height                             Weight

Vitals: BP            Pulse                 Respiration________ Temp.

Appearance, Motion, Gait

Orthopedic Tests

      Test Name               R       L            Test Name              R              L
Cervical compression          +       +      Jackson’s Compression           +           +
Cervical distraction          +       +                                  +       -   +       -
Shoulder depression           +       +                                  +       -   +       -
Brachial plexus stretch       +       +                                  +       -   +       -
Soto-Hall                     +       +                                  +       -   +       -

Orthopedic Test Results Discussion:              Cervical and Jackson’s compression
is usually applied with the patients head neutral, and then in all positions. Localized
pain indicates facet involvement, while radiating pain down the arm indicates nerve
root involvement. Cervical distraction is an attempt    to reduce local or radiating
complaints. Shoulder depression can cause nerve root compression and/or brachial
plexus stretching.

Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception
      When the brachial plexus is involved the upper trunk (C5,C6) is most often
             affected. C5 - motor supply to the deltoid (shoulder abduction) and
             biceps (elbow flexion/supination) biceps reflex, and sensory supply to
             outer shoulder (axillary nerve)
              C6 - motor supply to the biceps (elbow flexion/supination) and wrist
             extension, brachioradialis reflex, and sensory supply to the outer
             forearm.

Kevin Power, D.C.                     Page 2                             8/19/2010
Approved 5May05
LabValues__________________________________________________________
_____ ____________________________________________________________


Examination of Related Areas



Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




SPINAL EXAMINATION:

       Postural Analysis                         Postural Analysis    L       N       R
                                                 Head Tilt
       Head tilt may be affected the head        Head Rotation
would tilt away from the affected side with      High Ear
regards to IVF involvement and towards           High Shoulder
the side that had muscular involvement.          High Ilium
                                                 Ext. Rotated Foot
                                                 Int. Rotated Foot
ROM
              Cervical ROM                                    Lumbar ROM
                ROM      Pain     Level                        ROM     Pain       Level
Flexion         N  Y N                      Flexion          N     Y N
Extension       N  Y N                      Extension        N     Y N
R. Rotation     N  Y N                      R. Rotation      N     Y N
L. Rotation     N  Y N                      L. Rotation      N     Y N
R. Lat. Flex.            Y                   R. Lat. Flex.    N     Y N
L. Lat. Flex.            Y                   L. Lat. Flex.    N     Y N


Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion) Cervical myospasms and guarding may be
present.

List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




Kevin Power, D.C.                     Page 3                              8/19/2010
Approved 5May05
RADIOLOGICAL EXAMINATION:

         X-rays       MRI        CT           Other

Views        A-P,Lateral, Flexion, Extension and possibly oblique cervical

Findings: May include decreased or aberrant range of motion. May include
decreased cervical lordosis.

DIFFERENTIALS:

Disc herniation; Myelopathy; Thoracic outlet syndrome; Facet syndrome;
Torticollis.



Case Management:


Chiropractic Management: Manual adjusting is appropriate, however, it is
important to avoid reproduction of the injury with a lateral flexion-type of
adjustment. Alternatives would include : Activator Methods; Side-posture
toggle; Thompson technic; Pierce technic.

Common Medical Management: Pain medications; Muscle relaxers; Anti-
inflammatory medications.

Adjunctive Therapy:

PhysicalTherapy: Cryotherapy; Hot packs.

Nutrition:

Exercise: Given that re-occurrence of the injury is common in sports, athletes are
encouraged to strengthen neck muscles.

Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education): Athletes are encouraged to use protective gear when
appropriate, particularly football players.

Home care may include cervical pillows, supports, and stretches.
Recommendations would be made to avoid future “whiplash” type activities such as
roller coaster rides, etc.




Kevin Power, D.C.                    Page 4                             8/19/2010
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Further Evaluation: Muscle weakness and sensory findings may be delayed,
therefore, it is important to re-examine approximately one week post-injury. Also, if
arm weakness is persistent after three weeks, an EMG study may be helpful.

References:

Differential Diagnosis and Management for the Chiropractor, by Souza



Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.


Condition Name         Baseline      Complicating/ Mitigating Factors      Revised
                       Complexity                                          Complexity
                                     Myospasms and Triggerpoints              5.0
                                     Avulsion of nerve root                   10.0
  Burner/ Stinger          4.0       Muscle strength decreases                6.0




Kevin Power, D.C.                     Page 5                             8/19/2010
Approved 5May05
                           CLINICAL APPLICATIONS
                                     Case Study

CONDITION: Depression
Prepared By: Dr. Renee Prenitzer

RELEVANT PATHOPHYSIOLOGY:

A diagnosis of major depressive disorder is made if an individual has five or more of
the following symptoms during the same two-week period: A persistant sad mood;
loss of interest or pleasure in activities that were once enjoyed; significant change in
appetite or body weight; difficulty sleeping or oversleeping; physical slowing or
agitation; loss of energy; feelings of worthlessness or inappropriate guilt; difficulty
thinking or concentrating; and recurrent thoughts of death or suicide.

Dysthymic disorder (or dysthymia) is a less severe yet typically more chronic form of
depression. It is diagnosed when the depressive mood persists for more than two
years in adults and more than one year in children or adolescents and is
accompanied by at least two other depressive symptoms.

In contrast to normal emotional experiences of sadness, loss, or passing mood
states, depression is and extreme and persistent state of these emotions and
interferes significantly with an individual’s ability to function.

The World Health Organization has found major depression to be the leading cause
of disability in the US and worldwide.

Psychosocial and environmental stressors are known risk factors for depression.
NIMH research has shown that stress in the form of loss can trigger depression in
vulnerable individuals. Environmental stressors interact with depression vulnerability
genes to increase the risk of developing depressive illness.

Other NIMH research indicates that stressors in the form of social isolation or eary-
life deprivation may lead to permanent changes in brain function that increases
susceptibility to depressive symptoms.

The hypothalamic-pituitary-adrenal axis is overactive in many patients with
depression. The hypothalamus increases the production of Corticotropin Releasing
Factor (CRF) when a threat to physical or psychological well-being is detected.
NIMH research suggests that persistent overactivation of the hormonal system may
lay the groundwork for depression. The elevated CRF levels detectable in
depressed patients are reduced by treatment with antidepressant drugs or ECT
(Electroconvulsive Therapy), and this reduction corresponds to improvement in
depressive symptoms.




Renee Prenitzer, D.C.                 Page 1                              8/20/2010
Approved 05/24/04
Co-occurrence of depression with other conditions: depression often co-exists with
anxiety disorders. It also frequently co-occurs with a variety of other physical
illnesses, including heart disease, stroke, cancer, and diabetes. A large scaled
survey revealed that individuals with a history of major depression were more than 4
times as likely to suffer a heart attack over a 12-13 year follow-up period, compared
to people without such a history. Even people with a history of two or more weeks of
mild depression were more than twice as likely to have a heart attack.

NIMH-funded scientists report a strong association between depression and
osteoporosis. The studies show that depression may be a significant risk factor for
osteoporosis. Major depression is associated with hormonal abnormalities that can
lead to changes in tissue, such as bone. Research suggests that higher cortisol
levels, often found in depressed patients, may contribute to bone loss and changes
in body composition. In one study, evidence showed that bone density in the lumbar
spine was 15% lower in 80 men and women older than 40 with major depression
compared to 57 men and women who were not depressed. The association
between depression, BMD, falls, and risk of fracture was examined in a study of
7,414 elderly women. Depression prevalence was 6%. Depressed women were
more likely to fall (70% versus 59%) and had more vertebral (11% versus 5%) and
non-vertebral fractures compared with controls.


CASE HISTORY:

PPW: A persistant sad mood; loss of interest or pleasure in activities that were once
enjoyed; significant change in appetite of body weight; difficulty sleeping or
oversleeping; physical slowing or agitation; loss of energy; feelings of worthlessness
or inappropriate guilt; difficulty thinking or concentrating; and recurrent thoughts of
death or suicide.

Onset-Initial                                                                _____
      Palliative/Provocative
      Quality/Quantity
      Referred/Radiating
      Site
      Timing/Pattern
      Other

Relevant History and Lifestyle:
      Gender: Nearly twice as many women as men are affected by depression
      each year.
      Age: Affects adults but research shows that up to 2.5% of children and 8.3%
      of adolescents in the US suffer from depression. Between 1 and 2% of
      people over the age of 65 living in the community suffer from depression.
      Occupation
      Traumas

Renee Prenitzer, D.C.                 Page 2                             8/20/2010
Approved 05/24/04
         Surgeries
         Medications
         Hospitalizations
         Immunizations
         Diseases/Conditions



         Family History: Risk factor, recent loss of close family member or friend.
         Diet
         Sleep Habits
         Sexual History
         Alcohol Usage
         Drug Usage
         Smoking/Tobacco
         Other__________________________________________________

Review of Systems                                                          _____

     ______________________________________________________
___________________________________________________________


PHYSICAL EXAMINATION:

Height                                  Weight

Vitals: BP              Pulse                        Respiration________ Temp.

Appearance, Motion, Gait

Orthopedic Tests

      Test Name                 R            L              Test Name             R           L
                              +     -    +       -                               +    -   +       -
                              +     -    +       -                               +    -   +       -
                              +     -    +       -                               +    -   +       -
                              +     -    +       -                               +    -   +       -
                              +     -    +       -                               +    -   +       -

Orthopedic Test Results Discussion:




Renee Prenitzer, D.C.                     Page 3                                 8/20/2010
Approved 05/24/04
Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Lab Values


Examination of Related Areas


Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




SPINAL EXAMINATION:

      Postural Analysis                        Postural Analysis   L       N       R
                                               Head Tilt
                                               Head Rotation
                                               High Ear
                                               High Shoulder
                                               High Ilium
                                               Ext. Rotated Foot
                                               Int. Rotated Foot


ROM
             Cervical ROM                                  Lumbar ROM
               ROM      Pain       Level                    ROM     Pain       Level
Flexion        N  Y N                    Flexion          N     Y N
Extension      N  Y N                    Extension        N     Y N
R. Rotation    N  Y N                    R. Rotation      N     Y N
L. Rotation    N  Y N                    L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                    R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                    L. Lat. Flex.    N     Y N


Leg Length/Spinal Balance
Instrumentation/Pattern Analysis

Renee Prenitzer, D.C.                 Page 4                           8/20/2010
Approved 05/24/04
Palpation (Muscle, Static, Motion)




List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

         X-rays     MRI             CT        Other Brain imaging technology

Views

Findings: Modern brain imaging technologies are revealing that in depression, neural
circuits responsible for the regulation of moods, thinking, sleep, appetite, and
behavior fail to function properly, and that critical neurotransmitters – chemicals
used by nerve cells to communicate- are out of balance.




DIFFERENTIALS:




DIAGNOSIS:



Renee Prenitzer, D.C.                  Page 5                         8/20/2010
Approved 05/24/04
Case Management:

Chiropractic Management: Upper cervical adjustments were shown to help in the
case of a 9 year old boy who had been diagnosed with Tourette’s syndrome, ADHD,
Depression, Asthma, Insomnia, and Headaches. (Journal of Vertebral Subluxation
Research, July 12, 2003)

             “At the patient’s initial evaluation, evidence of an
             upper cervical subluxations was found using
             paraspinal digital infrared imaging andn upper cervical
             radiographs. The upper cervical subluxations was
             corrected by performing a specific adjustment by
             hand to the first cervical vertebra according to
             radiographic findings. All six conditions were absent
             following six weeks of upper cervical chiropractic care
             and remained absent five months later at the
             conclusion of care.” Journal of Vertebral Subluxation
             Research, July 12, 2003)

Adjunctive Therapy: Herbal remedies that are currently popular with the public- St.
John’s wort. It is promoted as having antidepression effects. It is important to note
that St. John’s wort has been reported to have interactions with drugs used to treat
HIV and with those used to reduce the risk of organ transplant rejection.

Physical Therapy:




Nutrition: There has been research to show that omega 3 fatty acid deficits have a
correlation with major depression. There has been a link between the severity of
depression and the ratio of arachidonic acid to eicosapentaenoic acid in plasma
phospolipids. Supplementation with fish oil, which contains Omega-3
polyunsaturated fatty acids has been touted for its possible beneficial effect on
depression and other mental disorders. Epidemiologic studies show that
consumption of large amounts of fish appears to correlate to relatively low rates of
major depression.

Exercise: Regular exercise may reduce symptomatic depression and anxiety.
Meta-analysis of studies on the psychologic effects of exercise programs in coronary
patients shows a positive effect for both anxiety and depression.

Renee Prenitzer, D.C.                 Page 6                             8/20/2010
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Health Promotion and Maintenance (i.e. ergonomics, spinal hygiene, psychosocial
concerns/education) Physical and mental training can help to reduce anxiety.
Calming self-talk, which involves personal affirmations that one can cope is helpful.

Further Evaluation:


Common Medical Management:
Medication: Antidepressant Drugs- influence the function of certain
neurotransmitters of the brain, primarily serotonin and norepinephrine, (known as
monoamines). There also drugs called tricyclic antidepressant (TCAs) and
monoamine oxidase inhibitors (MAOIs) that affect the activity of both these
neurotransmitters. There are new medications known as Serotonin Reuptake
Inhibitors that also have less side effects than older drugs. Antidepressant
medications take several weeks to be clinically effective even though they begin to
alter brain chemistry within the first dose. Research now indicates that
antidepressant effects result from slow-onset adaptive changes within the brain
cells, or neurons.

Psychotherapy: Psychotherapy works by changing the way the brain functions.
NIMH research has shown that certain types of psychotherapy, particularly
cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT), can help relieve
depression. CBT helps patients change the negative styles of thinking and behaving
often associated with depression. IPT focuses on working through disturbed
personal relationships that may contribute to depression. Older adults with recurrent
major depression who received IPT in combination with an antidepressant
medication during a three-year period were much less likely to experience a
recurrence of illness than those who received medication only or therapy only.

Electroconvulsive Therapy (ECT): One of the most effective and most stigmatized
treatments for depression. 80-90% of people with severe depression improve
dramatically with ECT. ECT involves producing a seizure in the brain of a patient
under general anesthesia by applying electrical stimulation to the brain through
electrodes placed on the scalp. Repeated treatments are necessary to achieve the
most complete antidepressant response. Memory loss and other cognitive problems
are common, yet short-lived side effects of ECT.

Surgery:




Reference:

Renee Prenitzer, D.C.                 Page 7                             8/20/2010
Approved 05/24/04
Jamison, J. Chiropractic Management: Beyond Manual Care. JMPT June 2002;
Vol. 25, Number 5.

Jamison, J. Stress Management: An Exploratory Study of Chiropractic Patients.
JMPT Jan. 2000; Vol. 23, Number 1. 32-36

Elster, E. Upper Cervical Chiropractic Care For A Nine-Year-Old Male With Tourette
Syndrome, Attention Deficit Hyperactivity Disorder, Depression, Asthma, Insomnia,
and Headaches: A Case Report. Journal of Vertebral Subluxation Research. July
12, 2003.

http:// www.nimh.nih.gov
        - Depression, Bone Mass, and Osteoporosis
        - Depression Research at the National Institute of Mental Health

Omega 3: Implications in human health and disease. By Bibus, Douglas PhD

Behavioral Health Matters: Omega-3 Fatty Acids and Mental Health, by Jay M.
Pomeranz, MD (www.medscape.com/viewarticle/409997_print)


Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.


Condition Name          Baseline     Complicating/ Mitigating Factors      Revised
                        Complexity                                         Complexity
                                     Risk factor for osteoporosis,
                                     women and elderly                        6.0
                                     Chiropractic Management –                4.0
    Depression             2.0       Increased Frequency
                                     Chiropractic Management -
                                     Contraindications to adjustments         5.0
                                     Medications – affecting overall          3.0
                                     health
                                     Chiropractic Management –
                                     psychosocial aspects, need for           4.0
                                     referral




Renee Prenitzer, D.C.                 Page 8                            8/20/2010
Approved 05/24/04
                         CLINICAL APPLICATIONS
                           Faculty Case Study Preparation


CONDITION: Diffuse Idiopathic Skeletal Hyperostosis (DISH) AKA: Forrestier's
Disease

Prepared by:
Dr. Laura Greene-Orndorff

RELEVANT PATHOPHYSIOLOGY:


DISH is a phenomenon characterized by a tendency toward ossification of ligament,
tendon, and joint capsule (enthesial) insertions. DISH is a completely asymptomatic
phenomenon; no alterations are detectable based on history or physical
examination.

Causes are unknown. DISH is simply a tendency toward calcification of entheses.




CASE HISTORY:

PPW: DISH is an asymptomatic phenomenon. The condition is discovered
inadvertently.

Onset: Symptoms appear several years after the initial onset of the condition.

Palliative/Provocative

Quality/Quantity

Referred/Radiating: intermittent and non- radiating

Site

Timing/Pattern: Stiffness occurs most often in the morning upon arising and
dissipates within an hour of mild activity.




Laura Greene-Orndorff, D.C.          Page 1                            8/20/2010
Approved
Other: The discomfort can return in the late evening and become aggravated by
sitting or cold, wet weather.
Relevant History and Lifestyle
        Gender:
        DISH occurs more commonly in males (65%) than in females (35%).
        Age:
        Affects patients over the age of 55, but can begin as early at age 40.
        Occupation
        Traumas
        Surgeries
        Medications
        Hospitalizations
        Immunizations
        Diseases or Conditions_
        Tends to occur in people who are large-boned, muscular and
        overweight and have gout. It also affects people who have high blood
        pressure or diabetes 32% of the time.
        Family History
        Diet
        Sleep Habits
        Sexual History
        Alcohol Usage
        Drug Usage
        Smoking/Tobacco
        Other__________________________________________________


Review of Systems
Difficulty swallowing and reduced range of motion may be present depending on the
amount of ossification.


PHYSICAL EXAMINATION:

Height                             Weight

Vitals: BP             Pulse                Respiration________ Temp.

Appearance, Motion, Gait

Orthopedic Tests

       Test Name               R      L            Test Name             R      L
Swallowing Test            + -      + -                                 + -    + -
Forriester Bowstring       + -      + -                                 + -    + -


Laura Greene-Orndorff, D.C.          Page 2                             8/20/2010
Approved
Lewins Supine                 + -     + -                               + -    + -
                              + -     + -                               + -    + -
                              + -     + -                               + -    + -

Orthopedic Test Results Discussion:




Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception
___________________________________________________________________
__R/O neurological involvement due to the P.L.L. syndesmopytes.

Lab Values: No laboratory tests are indicated. An apparent association with
elevated glucose levels has not been substantiated as a relationship with diabetes
and HLA typing.

Examination of Related Areas




Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




SPINAL EXAMINATION:

          Postural Analysis                     Postural Analysis   L      N        R
                                                Head Tilt
                                                Head Rotation
                                                High Ear
                                                High Shoulder
                                                High Ilium
                                                Ext. Rotated Foot
                                                Int. Rotated Foot


ROM
               Cervical ROM                               Lumbar ROM
                 ROM      Pain      Level                  ROM     Pain        Level
Flexion          N  Y N                   Flexion        N     Y N

Laura Greene-Orndorff, D.C.            Page 3                           8/20/2010
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Extension          N      Y   N           Extension          N      Y    N
R. Rotation        N      Y   N           R. Rotation        N      Y    N
L. Rotation        N      Y   N           L. Rotation        N      Y    N
R. Lat. Flex.      N      Y   N           R. Lat. Flex.      N      Y    N
L. Lat. Flex.      N      Y   N           L. Lat. Flex.      N      Y    N


Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion)




List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

        X-rays          MRI         CT          Other

Views:
Radiography of the spine is the single most useful imaging modality in the diagnosis
of DISH. In addition, radiographs are inadequate in evaluating the extent of
compression caused by the large syndesmophytes on the trachea, bronchi, or
esophagus. In this case, CT scan of the spine is helpful and especially is aided by
coronal and sagittal reconstructions.
CT limited information about spinal cord involvement. In this situation, MRI is of
benefit, thus is primarily reserved for evaluating possible cord compression. This is
especially true if DISH is associated with PLL, which occurs in a minority of patients.



Laura Greene-Orndorff, D.C.            Page 4                               8/20/2010
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Findings: Radiographs of the spine typically demonstrate thoracic spine
involvement; however, DISH also can affect the lumbar and cervical spine. DISH is
distinguished by the presence of flowing syndesmophytes along, but separated from,
the anterior aspect of the vertebral bodies, involving at least 4 levels. The disease
begins as fine ossification, 1-to 2-mm thick, but ossification may thicken as much as
20 mm as the disease progresses.
Radiographic findings in DISH include the following extra-axial features:

      Skull - Ossification of the nuchal ligaments
      Pelvis
          o Enthesopathy at ischial tuberosities
          o Ossification of the sacrotuberous ligament
          o Ossification of the symphysis pubis
      Lower extremities
          o Ossification of the quadriceps and infrapatellar tendons
          o Ossification of Achilles tendon
      Upper extremities - Ossification of the triceps tendon

      Thoracic vertebrae are involved in 100%, lumbar in 68-90%, and cervical in
       65-78% of affected individuals.

False Positives/Negatives: The most common finding that mimics DISH is
degenerative osteophytes; however, the strict criteria of anterior location and
bridging involvement of 4 contiguous vertebral bodies (3 intervertebral disk spaces)
defines DISH.

DIFFERENTIALS:

Ankylosing Spondylitis
Neuropathic Arthropathy (Charcot Joint)
Osteoarthritis, Primary
Psoriatic Arthritis
Reiter Syndrome



DIAGNOSIS:




Case Management:



Laura Greene-Orndorff, D.C.          Page 5                             8/20/2010
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Chiropractic Management:
Patients generally respond well to chiropractic care it is important to keep motion
in the spine. An exception of patients with significant spinal stenosis should be
considered in advanced cases, the bony overgrowth can encroach upon
vertebral arteries and the spinal canal and should not be adjusted. Radiological
reassessment should be should be performed at least quarlty especially when
the P.L.L. is involved.

Adjunctive Therapy:




PhysicalTherapy:
Can help slow stiffening of the spine.

Nutrition:
Treatment may include weight loss, Omega 3 Fatty acids and fatty fish.

Exercise:
Exercise programs that include walking are the most common types of
treatment for DISH because areas of the spine and tendons can become
inflamed.
Range-of-motion and stretching exercises to help maintain mobility.
Conservative Yoga and water aerobics is also benefical.

Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education):

avoid postures that place a strain on your neck


Further Evaluation:
Conditions that may increase the risk of DISH: Greater body mass,
Higher serum level of uric acid and Diabetes Mellitus


Common Medical Management:
Because areas of the spine and tendons can become inflamed, anti-
inflammatory medications (NSAIDs), such as ibuprofen and Naproxen_are
recommended


References:
__emedicine.com_______________________________________________________

Laura Greene-Orndorff, D.C.           Page 6                             8/20/2010
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Hoffman LE; Taylor JA; Price D; Gertz G. Diffuse idiopathic skeletal hyperostosis
(DISH): a review of radiographic features and report of four cases. Manipulative
Physio Ther (UNITED STATES) Oct 1995, 18 (8) p547-53,

Clinical Imaging Dennis Marchorri




Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.



Condition Name        Baseline      Complicating/ Mitigating Factors     Revised
                      Complexity                                         Complexity
Dish                     1.0           Diabetes Mellitus                    4.0
                                    Chiropractic Management -               9.0
                                    Contraindications to adjustments
                                    (PLL involvement)
                                    Positive Swallowing Test (ALL            8.0
                                    involvement)




Laura Greene-Orndorff, D.C.          Page 7                            8/20/2010
Approved
                            CLINICAL APPLICATIONS
                            Faculty Case Study Preparation


CONDITION :         DJD (Degenerative Joint Disease) aka osteoarthritis

PREPARED BY:         Leslie M. Wise, D.C.

RELEVANT PATHOPHYSIOLOGY:

A chronic arthropathy characterized by progressive deterioration of the joint cartilage,
subchondral sclerosing, and the formation of osteophytes at the margins of the joint.
The American College of Rheumatology reports that more than 21 million Americans
are affected by the condition, which is the most common type of arthritis, and the
leading cause of disability in the United States. The CDC estimates that by the year
2020, sixty million Americans, or almost 20% of the population, will be affected by some
form of arthritis, and nearly 12 million will experience activity limitation. Total costs
associated with arthritis are estimated by the Centers for Disease Control and
Prevention (CDC) to be almost $65 billion annually.

Classification:

      Primary DJD - most common in the 60-80 age group as the result of wear and
       tear on articular cartilage over time.
      Secondary DJD - results from a previous process that damaged cartilage such as
       impact trauma, repeated microtrauma or inflammatory arthritis.


CASE HISTORY:

PPW: Joint pain, morning stiffness, limited range of motion, joint crepitus.

Onset-Initial: Soreness and aching in the joint and surrounding tissues generally
accompanies development of DJD. A grating sensation is frequently heard with
movement of the joint.
Palliative/Provocative: Frequently aggravated by exercise and strenuous activity.
Eased by rest, application of heat or topical analgesics.
Quality/Quantity: Pain can be mild soreness, but may magnify to sharp, piercing pain
on movement in advanced DJD.
Referred/Radiating: Not generally, but in advanced stages (especially in ilio-femoral
DJD) pain may radiate and refer. Cervical DJD may radiate pain along dermatomal
patterns on the upper extremities.
Site: The most commonly involved joints in primary DJD are: distal interphalangeal
joints, first carpo-metacarpal joint, and weight bearing joints of spine, hips, knees.



Lesie Wise, D.C.                      Page 1                              8/20/2010
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Relevant History and Lifestyle
      Gender: Before the age of 55 DJD occurs equally in both sexes. However,
               after 55 the incidence is higher in women.
       Age:    Symptoms may first appear without symptoms between 30 and 40
years of
               age and is present in almost everyone by the age of 70. Symptoms
generally
               appear in middle age.
 Occupation: DJD is prevalent in occupations that expose workers to impact injury
 and torsional loading.
 Trauma:Athletic Injury and DJD:
 It is not uncommon for athletes to injure joints. The non-healing of injuries causes
 the degenerative process to start in the joints. Additionally, repetitive low-grade
 impact from athletic events can be enough to damage the soft tissues and start the
 arthritic process. Certain participants in sports, for example, wrestlers, boxers,
 baseball pitchers, cyclists, cricket players, gymnasts, ballet dancers, soccer players,
 weight lifters, and football players have all been reported to have increased
 degenerative joint disease in articular sites subjected to sports-related stress.
 Participants in sports that subject joints to more intense impact and torsional
 loading than running may have an increased prevalence of DJD. Athletes in sports
 with a high degree of torsional loading and levels of impact must be extremely
 careful that all of their sports-related injuries heal completely, otherwise
 degenerative joint disease is likely to occur. The sports with the highest levels of
 impact and torsional loading, ( and thus the highest rates of injury) are
 baseball/softball, basketball/volleyball, football, handball/ racquetball, competitive
 running, squash, lacrosse, soccer, rugby, singles tennis, water skiing, and karate.
 Football players appear to have increased incidence of DJD in multiple joints
 because of the many injuries they sustain. One investigation reported that more
 than 30 percent of football players with a history of a knee injury had evidence of
 DJD 10 to 30 years after competing. Baseball pitchers appear to be at increased
 risk of DJD of the elbow and shoulder, because these are the areas that are injured
 with this game.
 Competitive soccer players also, because of lower extremity injuries, have been
 shown to get DJD in those areas at an increased rate.
Surgeries: Frequently performed surgeries directly related to DJD include:
    Total hip replacement
    Knee replacement
    Knee arthroscopy
    Disc decompression (lumbar and cervical)

Medications: OTC anti-inflammatories for mild DJD, NSAIDs and COX inhibitors
      frequently prescribed

Lesie Wise, D.C.                     Page 2                              8/20/2010
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Hospitalizations: N/A
Immunizations: N/A
Diseases or Conditions: N/A
Family History: A predisposition for DJD is thought to be inherited
Diet:
Sleep Habits: Stomach sleepers put postural stress on c-spine and lumbar spine,
possibly creating misalignments that lead to DJD
Sexual History: Some sexual postures may lead to misalignments and postural stress
that can contribute to DJD
Alcohol Usage: N/A
Drug Use: N/A
Smoking: N/A

Review of Systems: Musculoskeletal system review may demonstrate any or all of the
following:
     Limited ROM, painful at end range
     Point tenderness in region of affected joints
     Crepitus in affected joints
     Alterations in gait and carriage

PHYSICAL EXAMINATION:

Height                         Weight:        obesity tends to increase likelihood of
DJD, and when present exacerbates the condition

Vitals: BP: increased with pain              Pulse       Respiration________ Temp.


Appearance, Motion, Gait Posture, carriage, gait may all be antalgic. Ambulation is
frequently slow, the first few steps.

Orthopedic Tests

     Test Name               R           L           Test Name           R           L
Fabere-Patrick (hip)       +     -   +       -                         +     -   +       -
Compression/distraction    +     -   +       -                         +     -   +       -
                           +     -   +       -                         +     -   +       -
                           +     -   +       -                         +     -   +       -
                           +     -   +       -                         +     -   +       -

Orthopedic Test Results Discussion:
      Any provocative test which involves a joint may be positive if DJD is present.




Lesie Wise, D.C.                     Page 3                             8/20/2010
Approved 01/11/05
Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs /Pathological
Reflexes/Light touch/ Proprioception :

Equilibrium is often affected by forward head carriage, and resulting thoracic kyphosis.
Advanced DJD affects posture and ambulation which alters proprioception. Joint
erosion may lead to vertebrobasilar ischemia, ataxia and vertigo.

LabValues:

Examination of Related Areas:
Joints of fingers and toes may be enlarged due to bone overgrowth, and calcification of
ligamentous structures. Knee alignment is frequently affected as joint surfaces
deteriorate.

Other Findings:( Percussion, Palpation, Auscultation, etc.)
      Percussion of spinous processes may reveal tenderness.
      Deep palpation may elicit pain.
      Crepitus may be auscultated in affected joints.

SPINAL EXAMINATION:

       Postural Analysis                         Postural Analysis       L     N      R
                                                 Head Tilt
       Head forward posture is common.           Head Rotation
                                                 High Ear
  Hyperextension of knees occurs with joint      High Shoulder
erosion and ligamentous laxity.                  High Ilium
                                                 Ext. Rotated Foot
                                                 Int. Rotated Foot




 ROM Limited at affected area.
             Cervical ROM                                 Lumbar ROM
               ROM      Pain     Level                     ROM     Pain          Level
Flexion        N  Y N                   Flexion          N     Y N
Extension      N  Y N                   Extension        N     Y N
R. Rotation    N  Y N                   R. Rotation      N     Y N
L. Rotation    N  Y N                   L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                   R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                   L. Lat. Flex.    N     Y N

Lesie Wise, D.C.                     Page 4                             8/20/2010
Approved 01/11/05
Leg Length/Spinal Balance Hip joint erosion can affect leg checks, and give false
positive for pelvic misalignment.
Instrumentation/Pattern Analysis: NA
Palpation (Muscle, Static, Motion)See above




List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

        X-rays       MRI          CT           Other

Views Lateral spinal views best show evidence of DJD
       A-P views may reveal lateral listhesis and wedging misalignments associated
with DJD.      Special care should be taken to identify posteriorly directed osteophytes,in
the cervical views, which maybe involved in IVF encroachment and radicular
compression syndromes. Cord compression is possible if stenosis of the cervical canal
is present.

Findings:     Decrease of intervertebral disc space, with subchondral sclerosing, and
marginal osteophytic growth. Posterior vertebral joints (zygopophyseal joints) may
overlap and display roughened joint surfaces. The interspinous syndesmoses may show
signs of ligamentous calcium infiltration.


DIFFERENTIALS:

DISH, RA, AS, Osteoporosis, infectious arthritis, HNP, compression fx.,,Neurotrophic
arthropathy, dyskenesia, cerebellar dysfunction



Lesie Wise, D.C.                      Page 5                             8/20/2010
Approved 01/11/05
DIAGNOSIS:

ICDA Codes         722.4 Cervical DJD      722.10 Lumbar DJD



Case Management:

Chiropractic Management:
    Adjustments of misaligned/ subluxated segments (when there are no
      contraindications) to restore neural integrity and improve mobility and range
      of motion

Adjunctive Therapy:
    Trigger point therapy
    Cervical traction 10lbs increasing gradually to 40 lbs
    Ultrasound to break up fibrotic adhesions
    Cervical collar for short term joint separation (2 weeks max)
PhysicalTherapy:
           Parrafin bath for hands

Nutrition:
    Glucosamine sulfate may help with cartilage healing/ regeneration
    Vit C, Iron, Alpha ketoglucaric acid may helping production of collagen
    Ca, Vit E, Zinc, Copper and Manganese may provide antioxidant effect and serve
        as free radical scavengers

Exercise:
    Active and passive ROM ,
    Stretching in hot shower,
    Use of Posture Pump and exercise ball
    Avoid impact activities
    Swimming and walking as tolerated
    Yoga, Tai Chi
    Brugger’s Relief position
Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education:
    Educate about lifting, standing, sleep habits
    Consider cervical pillow
    Weight loss

Further Evaluation:
    MRI
    EMG if radicular symptoms are persistent
    Outcome assessment Index such as the Neck Disability Index

Lesie Wise, D.C.                     Page 6                            8/20/2010
Approved 01/11/05
Common Medical Management:
   NSAIDs, COX 2 Inhibitors, Cortisone injections into joints
   Physical Therapy
   Surgery (hip, knee replacement or disc decompression

References:
    Huff and Brady, Instant Access to Chiropractic Guidelines and Protocols,
      Mosby, 1999
    University of Iowa's Virtual Hospital, www.vh.org
    The National Quality Measures Clearinghouse™ (NQMC™), sponsored by the
      Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health
      and Human Services
    4/22/2003
      Benjamin Taragin, M.D., Department of Radiology, Columbia Presbyterian
      Medical Center, New York, NY. Review Provided by VeriMed Healthcare
      Network.
    The Merck Manual 16th ed. 1992


Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early stage
of condition, advanced stage of condition, psychosocial issues, etc. The complicating or
mitigating factors can either increase or decrease the baseline complexity.

Condition Name      Baseline     Complicating/ Mitigating Factors            Revised
                    Complexity                                               Complexity
                                 Early DJD (mild lipping, spurring, no
                                 appreciable loss of joint space)                3.0
      DJD               3.0      Mid-stage DJD (moderate lipping,
                                 spurring, loss of joint space up to 50%)
                                                                                 4.5
                                 Advanced DJD (severe lipping, spurring,
                                 loss of joint space more than 50%)              7.0
                                 DJD accompanied by osteoporosis,
                                 ankylosis, rheumatoid arthritis (or
                                 variant), compression fractures or              8.0
                                 artificial joint components.

The chiropractor may find it necessary to alter adjusting techniques as the DJD severity
increases. Most frequently, HVLA techniques are replaced by low force adjusting,
mobilization techniques, soft tissue techniques, and physiological therapeutics.



Lesie Wise, D.C.                     Page 7                             8/20/2010
Approved 01/11/05
            Fibromyalgia




8/19/2010    Approved 05/17/04 Dr. Prenitzer
      Relevant Pathophysiology
• Fibromyalgia is a chronic pain syndrome of
  unknown etiology that is characterized by
  diffuse pain and tenderpoints (TeP), which
  are present for more than three months
• Fibromyalgia (FMS) Syndrome patients
  exhibit an increased sensativity to
  mechanical, thermal, and electrical stimuli,
  which suggests that central pain mechanisms
  may be dysfunctional and play a significant
  role in the pain FMS patients experience
8/19/2010      Approved 05/17/04 Dr. Prenitzer
  Relevant Pathophysiology -
 Pain Mechanisms of the CNS
• The CNS mechanisms for pain in FMS
  include: 1. Temporal summation of pain
  (wind-up) 2. Central sensitization




8/19/2010     Approved 05/17/04 Dr. Prenitzer
        Pathophysiology – Wind-up
                Explained
• Wind-up (WU) can result in short- and long-term
  changes of neuronal responsiveness, including
  central sensitization. WU occurs during repetitive
  nociceptive stimuli of sufficient intensity or
  frequency to remove the magnesium block of the
  NMDA receptor.
• This is followed by calcium influx into the cell
  and subsequent triggering of signaling cascades
  that can result in amplification of nociceptive
  input and long-term central sensitization.
8/19/2010         Approved 05/17/04 Dr. Prenitzer
            Pathophysiology – Central
                  Sensitization
• The mechanisms responsible for central
  sensitization depend on stimulus intensity
  and descending pain inhibition.
• Once central sensitization has occurred only
  minimal nociceptive input is required to
  maintain the sensitized state and clinical
  pain.

8/19/2010          Approved 05/17/04 Dr. Prenitzer
  Pathophysiology – Classic FMS
         vs Pseudo FMS
• The diagnosis of Classic FMS is for the patient
  who has significant symptoms of sleep disorder,
  anxiety syndrome, depression, alterations of brain
  and CNS chemistry, brain injury or trauma
• The category of Pseudo FMS encompasses a
  group of disorders that is misdiagnosed as FMS,
  such as, organic diseases, functional disorders, and
  musculoskeletal disorders

8/19/2010         Approved 05/17/04 Dr. Prenitzer
  Pathophysiology – Classic FMS
• Characteristics – patients do not sleep well at
  night, they wake and feel “crummy” constantly,
  they have an intolerance to heavy exercise, they
  have a lowered pain threshold to multiple areas of
  the body, they complain of low energy and brain
  fog, called “fibro-fog”.
• EEG of FMS patients revealed overall disruption
  in the deeper stages of sleep
• All lab tests come back negative for rheumatoid
  factor, sedimentation rate, and other serologic tests
  are negative
8/19/2010         Approved 05/17/04 Dr. Prenitzer
 Pathophysiology – Classic FMS

• Criteria for
  diagnosis of
  FMS – pain
  induced upon
  palpation of
  a minimum
  of 11 of 18
  predetermine
  d TeP sites
 8/19/2010       Approved 05/17/04 Dr. Prenitzer
            Pathophysiology – Pseudo
             FMS/Organic Disorders
• In patients with generalized pain and fatigue,
  patients must be assessed for underlying disorders
  such as, anemia, Lyme disease, hypothyroidism,
  inflammatory arthritides, auto-immune disorders,
  MS, and occult malginancies
• A diagnosis of FMS should not be made until all
  lab tests come back negative and fail to detect and
  “organic” reason for symptoms.

8/19/2010          Approved 05/17/04 Dr. Prenitzer
  Sign to look for Lyme Disease –
           Bull’s eye rash




8/19/2010   Approved 05/17/04 Dr. Prenitzer
 Pathophysiology – Psuedo FMS/
      Functional Disorders
• This category includes subclinical disease states
  and disorders involving dysfunction of internal
  organs
• These range from vitamin and mineral deficiencies
  to intestinal dysbiosis, gastric and pancreatic
  enzyme deficiencies, cellular dehydration, subtle
  endocrine imbalances, and post-viral immune
  suppression
• Common denominator – low energy, fatigue and
  widespread pain
8/19/2010        Approved 05/17/04 Dr. Prenitzer
 Pathophysiology – Psuedo FMS/
    Musculoskeletal Disorders
• There is a history of confusion with the use
  of the terms for myofascial pain syndrome
  and fibromyalgia syndrome.
• The terms fibrositis, myositis, myofascitis,
  fibromyalgia, and myofascial pain have
  been used interchangeably and incorrectly.
• There has also been the misuse of the terms
  trigger point (TrP) and tender point (TeP)

8/19/2010       Approved 05/17/04 Dr. Prenitzer
 Pathophysiology – Psuedo FMS/
    Musculoskeletal Disorders
• In a study of 252 patients referred to one
  clinic for treatment of FMS, 38% were
  misdiagnosed. They had a musculoskeletal
  cause for their symptoms
• The basic cause for these misdiagnoses is
  the fact that there is ignorance about the
  different types of referred pain phenomena

8/19/2010      Approved 05/17/04 Dr. Prenitzer
 Pathophysiology – Psuedo FMS/
   Musculoskeletal Disorders-
         Referred Pain
• A variety of deep somatic tissues, such as facet
  joints, spinal ligaments and muscles, intervertebral
  discs, meninges and dura mater, and joint
  capsules of the hip and shoulder can cause distal
  referred pain
• All of these tissues can be primary generators of
  noxious stimuli that causes the brain to perceive
  pain as arising from a different location from the
  tissues
8/19/2010         Approved 05/17/04 Dr. Prenitzer
        Pathophysiology – Psuedo FMS/
     Musculoskeletal Disorders- Referred Pain




8/19/2010        Approved 05/17/04 Dr. Prenitzer
       Pathophysiology – Psuedo FMS/
    Musculoskeletal Disorders- Referred Pain




8/19/2010       Approved 05/17/04 Dr. Prenitzer
       Pathophysiology – Psuedo FMS/
    Musculoskeletal Disorders- Referred Pain
• Most of the referred pain caused by irritated
  somatic tissues have a regional pattern
• According to the ACR guidelines, widespread
  pain is bilateral and affects the torso, upper and
  lower extremities
• DDX – need to be aware that more than one
  somatic tissue can be irritated at a time, this can
  cause overlapping regional pain patterns that can
  be misinterpreted as global or widespread pain
8/19/2010         Approved 05/17/04 Dr. Prenitzer
       Pathophysiology – Psuedo FMS/
    Musculoskeletal Disorders- Referred Pain




8/19/2010        Approved 05/17/04 Dr. Prenitzer
       Pathophysiology – Psuedo FMS/
    Musculoskeletal Disorders- Referred Pain

• Three types of referred pain phenomena –
  myofascial referred pain, scleratogenous
  referred pain, and dural referred pain.




8/19/2010       Approved 05/17/04 Dr. Prenitzer
       Pathophysiology – Psuedo FMS/
    Musculoskeletal Disorders- Referred Pain

• Myofascial referred pain stems from
  muscles that have been injured or have
  developed TrPs
• This type of pain is described as diffuse,
  deep, and achy
• Reproduced by digital pressure over the Trp


8/19/2010       Approved 05/17/04 Dr. Prenitzer
       Pathophysiology – Psuedo FMS/
    Musculoskeletal Disorders- Referred Pain
• Sclerotogenous referred pain arises from irritation
  of somatic tissues surrounding deep joint
• Most frequent generators of pain are spinal facets,
  hip and shoulder joints
• This pain is described as a “very deep, dull, achy,
  and vague.”
• May feel sharp stabbing pain upon certain motions
  or movements
• Reproduction of pain can be done by stressing the
  joints by full end range position
8/19/2010         Approved 05/17/04 Dr. Prenitzer
       Pathophysiology – Psuedo FMS/
    Musculoskeletal Disorders- Referred Pain
• Dural referred pain stems from irritation of the
  dura mater or meninges
• Frequently found with disc herniations
• This pain is described as “nauseating or
  sickening” and can be intense enough to cause
  syncope
• Cervical discs refer to the mid-thoracic/ posterior
  scapulae region
• Lumbar discs refer to the lumbosacral/ buttock
  area
8/19/2010         Approved 05/17/04 Dr. Prenitzer
       Pathophysiology – Psuedo FMS/
    Musculoskeletal Disorders- Referred Pain
• This category of musculoskeletal disorders mimics
  FMS
• This contributes to the category of patients that are
  “cured” of FMS by physical therapy, chiropractic,
  exercises, massage therapy, or any other manual
  therapy
• Clinically the patients responded to the “removal”
  of the specific pain generator via the manual or
  mechanical therapy
8/19/2010         Approved 05/17/04 Dr. Prenitzer
            Patient Presents With:
• Diffuse pain, insomnia, fatigue, and
  psychological distress
• There are 18 tenderpoints (TePs) that occur
  in specific areas bilaterally
• Patients may complain of morning stiffness,
  irritable bowel syndrome, anxiety


8/19/2010        Approved 05/17/04 Dr. Prenitzer
   Patient
  Presents
   With –
  Tender
Points, 11 or
 more spots
 to qualify
8/19/2010   Approved 05/17/04 Dr. Prenitzer
               OPQRSTs
• May be sudden following a traumatic event
• Pa – Pseudo FMS responds to chiropractic,
  massage, physical therapy, manual therapy
• Pr – emotional distress
• Q – diffuse pain, fatigue, tender points
• T – longer than three months in duration


8/19/2010      Approved 05/17/04 Dr. Prenitzer
    Relevant History and Lifestyle
•   Gender – 80% are female
•   Age – childbearing age
•   Occupation – not signficant
•   Traumas – History of trauma that affects the
    CNS. 50 % of all patients the start of the
    chronic pain after a traumatic event. Post-
    traumatic Stress Disorder is the
    precipitating factor 21% of the patients with
    FMS.
8/19/2010         Approved 05/17/04 Dr. Prenitzer
    Relevant History and Lifestyle
• Neck trauma increases the odds of FMS by
  10 times, within 1 year of the trauma
• Trauma Continued – Whiplash injuries that
  result in cervical strain cause FMS in about
  22% of the individuals



8/19/2010      Approved 05/17/04 Dr. Prenitzer
    Relevant History and Lifestyle
• Surgeries - not significant
• Medication – not significant




8/19/2010      Approved 05/17/04 Dr. Prenitzer
    Relevant History and Lifestyle
• Hospitalizations – not significant
• Immunizations – not significant
• Diseases – Hepatitis C, Lyme disease,
  coxsackie B infection, HIV, and parovirus
  infection have been described as trigger for
  fibromyalgia
• Family History – some evidence of familial
  aggregation for FMS
8/19/2010       Approved 05/17/04 Dr. Prenitzer
    Relevant History and Lifestyle
•   Diet – Not signficant
•   Sleep Habits – Insomnia is usually present
•   Sexual history - Not signficant
•   Alcohol usage - Not signficant
•   Drug usage - Not signficant
•   Smoking/ Tobacco - Not signficant

8/19/2010        Approved 05/17/04 Dr. Prenitzer
            Review of Systems
• EENT normal – May have headaches,
  bruxism
• Heart - normal
• Lungs - normal
• Digestive- IBS
• Reproductive- dysmenorrhea
• Genitourinary – irritable bladder
8/19/2010      Approved 05/17/04 Dr. Prenitzer
             Physical Exam
• Vitals – Normal
• Appearance – Normal to possible postural
  changes due to diffuse pain
• Orthopedic Tests – Possible false positives.
  Dependent of amount of pressure exerted
  during test and/ or the fact that 28% of
  patients with FMS experience BJHS
  (Benign Joint Hypermobility Syndrome)

8/19/2010       Approved 05/17/04 Dr. Prenitzer
                      BJHS
• Causes chronic pain in the joints, muscles,
  and ligaments.
• Abdominal pain and distress can result from
  laxity of connective tissue that provides
  support for the abdominal, thoracic, and
  pelvic organs.


8/19/2010      Approved 05/17/04 Dr. Prenitzer
    Physical Exam – Neurological
                Tests
• Shows increased sensitivity to mechanical
  stimuli
• This may alter findings during motor,
  reflex, and sensation tests.




8/19/2010      Approved 05/17/04 Dr. Prenitzer
              Lab Values
• Labs will be normal
• Labs for DDX – CBC, ESR, Thyroid
  Function tests, salivary tests
• Labs for DDX – standard blood chemistry
  panel: serum fasting glucose, liver
  enzymes, kidney function markers
• Elevated aluminum levels found in FMS
• EEG – altered with FMS
8/19/2010     Approved 05/17/04 Dr. Prenitzer
            Spinal Examination
• Diffuse areas of pain and tenderness upon
  palpation.
• At least 11 out of 18 TePs
• Postural exam may reflect pain level by
  affecting the attitude of the posture
• ROM may be affected, no real correlation to
  Classic FMS but Definitely to Pseudo FMS

8/19/2010       Approved 05/17/04 Dr. Prenitzer
            Spinal Examination
• Leg Length, Intrumentation, and Palpation –
  palpation may show increased levels of
  tenderness, TrP will show with pseudo
  FMS. Motion palpation may show positives
  with Pseudo FMS




8/19/2010       Approved 05/17/04 Dr. Prenitzer
            Radiological Examination
• Not Significant




8/19/2010          Approved 05/17/04 Dr. Prenitzer
               Differentials
•   Hypermobility (BJHS)
•   Regional musculoskeletal pain
•   Polymyalgia Rheumatica
•   Neuroendocrine Abnormalities
•   Acute or Chronic Infections
•   Hepatitis C Virus
•   HIV Syndrome
8/19/2010       Approved 05/17/04 Dr. Prenitzer
            Differentials Continued
• Exposure Syndromes – Sick building
  syndrome, Gulf War Syndrome, multiple
  chemical sensitivities
• Anemia
• Hypothyroidism
• Lyme disease
• Multiple Sclerosis
8/19/2010         Approved 05/17/04 Dr. Prenitzer
            Differentials Continued
•   Hypoadrenalism
•   Hyperadrenalism
•   Lupus
•   Dysglycemia
•   Malignancy



8/19/2010         Approved 05/17/04 Dr. Prenitzer
            Case Management
•   Chiropractic Care
•   Medical care
•   Physical Therapy
•   Adjuntive Therapy
•   Nutrition
•   Exercise
•   Health Promotion and Maintenance
8/19/2010       Approved 05/17/04 Dr. Prenitzer
            Chiropractic Management
• Manage as normal but special consideration
  needs to be paid towards patient comfort
  when adjusting
• Due to depression experienced, concerns
  about osteoporosis must be considered
• FMS may be linked to increased
  sympathetic nervous system activity

8/19/2010         Approved 05/17/04 Dr. Prenitzer
 Medical Management – focused
   on altering brain and CNS
         neurochemistry
• Low doses of antidepressant medications seem to
  have a positive affect on TePs ( a short-lived
  affect)
• Anxiolytic medications – counteracting anxiety
• Biofeedback
• Psychotherapy
• Desensitization Techniques

8/19/2010        Approved 05/17/04 Dr. Prenitzer
       Physical Therapy, Adjuntive
            Therapy, Exercise
• Studies show that aerobic exercise improves
  muscle fitness and reduces muscle pain and
  tenderness
• Heat and massage may also give temporary
  relief


8/19/2010      Approved 05/17/04 Dr. Prenitzer
                Nutrition
• Supplementation with magnesium, malate,
  and B-vitamins
• Malate and magnesium are competitive with
  aluminum, a substance shown to be high in
  patients with FMS



8/19/2010     Approved 05/17/04 Dr. Prenitzer
              References
• Fibromyalgia syndrome: A new paradigm
  for differential diagnosis and treatment.
  JMPT. October 2001. Volume 24. Number
  8
• www. Medscape.com/viewarticle/470556-
  Fibromyalgia Pain: Do We Know the
  Source
• www.medceu.com - Fibromyalgia

8/19/2010      Approved 05/17/04 Dr. Prenitzer
                                              Case Complexity:

 The category of complicating or mitigating factors should include the following considerations: Ancillary labs,
diagnostic studies, co-management issues, early stage of condition, advanced stage of condition, psychosocial
  issues, etc. The complicating or mitigating factors can either increase or decrease the baseline complexity.




     Condition Name             Baseline        Complicating/ Mitigating Factors             Revised
                                Complexit                                                    Complexit
                                y                                                            y


                                                Altered chiropractic adjustments                 6.0

            Fibromyalgia            5.0
                                                Complicated by depression                        6.0



                                                Co-management with counseling                    6.0



                                                Sequelae to MVA/ whiplash injury                 7.0




8/19/2010                            Approved 05/17/04 Dr. Prenitzer
                           CLINICAL APPLICATIONS
                          Faculty Case Study Preparation


CONDITION: Herpes Zoster

Prepared by: Beth Roraback, DC

RELEVANT PATHOPHYSIOLOGY:

        Herpes Zoster, commonly known as shingles, is caused by a reactivation of
the varicella-zoster virus, the virus that initially causes chicken pox. The virus
remains in the body in a dormant form, residing in the cranial and spinal nerve
ganglia its reactivation is linked to a compromised or impaired immune system. It
is also associated with aging and stress.
        Often presents as a single attack, with no reoccurrence. Usually, a shingles
outbreak presents locally along the distribution of a single nerve root, or dermatome,
and not necessarily along its entire distribution. When the distribution is widespread,
it is known as Herpes Zoster Generalizata, or Disseminated Herpes Zoster. This
typically occurs in individuals with other systemic disorders, such as AIDS/HIV,
leukemia, Hodgkin’s disease, myeloma and other conditions causing weakening of
the immune system. Individuals undergoing radiation therapy, treatment for cancer,
treatment with transplant rejection drugs and t treated with immunosuppressant
drugs are at greater risk for developing disseminated zoster.
        Any age group may be affected, but much more commonly, people over the
age of 50. When chicken pox occurs before the age of one year, the likelihood of
herpes zoster occurring in childhood increases. Incidence in the USA is
approximately 600,000 to 1,000,000 per year.
        The virus is contagious by direct contact and can cause chicken pox in
individuals exposed with no prior history of infection.
The initial presentation is a superficial burning or hypersensitivity within a single
unilateral dermatomal area, followed within a few days by an outbreak of blistering
vesicles in a erythematous patch, typically in the trunk. Often the pattern is a
unilateral stripe or ribbon-like patch along the ribcage or wrapping around the
abdomen. Lesions may also similarly occur along the neck. The trigeminal nerve
may be involved, following one of the tree branches into the forehead, cheek area,
or mouth and jaw line. If the ophthalmic branch (Opthalmic Herpes Zoster) is
affected, and the globe is involved, blindness may result. Vesicles on the tip of the
nose indicate Nasociliary branch involvement and corneal ulcers and opacities may
occur.
        Auricular Herpes Zoster, Ramsay Hunt syndrome, may result from facial
nerve or geniculate ganglion involvement. There may be subsequent hearing loss,
facial paralysis, and loss of taste in the anterior tongue on the affected side. Lesions
may appear over the mastoid process, in the ear canal, on the tympanic membrane,
and into the oral mucosa and on the jaw, neck and scalp.
        Shingles occasionally presents in the limbs, or genitals.

Beth Roraback, D.C.                   Page 1                              8/20/2010
Approved 04/13/05
      Breakdown of Presentation with complicating and mitigating factors:

      1. Herpes Zoster in children and healthy adults under the age of 50 (patients
         who immuno-competent). Least complicated scenario: only one
         dermatome involved, one episode only, with no reoccurrence, resolves
         within 2-3 weeks. No residuals. No scarring.
      2. Immuno-compromised with Herpes Zoster. Greater likelihood of chronic /
         recurrent H.Z. 50% of patients with H.Z. over the age of 50 report some
         pain after resolution of cutaneous disease (Post-Herpetic Neuralgia -
         PHN). IV administration of Acyclovir decreases visceral complications, no
         effect on pain or lesions. CNS involvement more likely with fever,
         photophobia, headaches, meningitis, vomiting, transverse myelitis with
         possible motor paralysis. Multiple dermatomes involved, PHN more
         common In the elderly (> 60 y.o.) brief course of high dose corticosteroids
         may prevent PHN
      3. Patients with Hodgkin's Lymphoma or disease- Greatest risk for
         progressive H.Z.; Disseminated cutaneous distribution in 40% with 5 to
         10% increased risk for pneumonitis, hepatitis, and meningeo-encephalitis;
         Rarely fatal
      4. Bone Marrow Transplantation patients with H.Z.- Particularly high risk; 15
         % infected within 9 months; 30 % infected with one year; 45% of infected
         develop disseminated cutaneous or visceral H.Z., with 10% mortality of
         this group; If infected within 9 months of transplant, likelihood of PHN,
         scarring, and bacterial superinfections increased; Has Graft Vs. Host
         Disease, risk of infection and death is increased.
      5. Herpes Zoster Oticus aka Geniculate Herpes, Viral Neuronitis and
         Ganglionitis, Ramsay-Hunt Syndrome- Geniculate ganglion and CN8
         ganglia invasion. Other cranial nerves often involved, especially CN7.
         Possible symptoms: severe ear pain, hearing loss, vertigo, facial
         paralysis, loss of taste in anterior 2/3's of tongue. Vesicles on pinna,
         EAM, jaw line, neck, scalp possible. Meningeal irritation often involved.
         Any movement or orthopedic test involving forward flexion /curving of
         spine may cause shooting pain down spine. Mild generalized encephalitis
         in many. Hearing loss may be permanent, partial or resolve completely.
         Vertigo lasts days to weeks, effectively treated with Diazepam. Facial
         paralysis may resolve, may be permanent. Surgical decompression of the
         Fallopian Canal sometimes relieves facial paralysis.
      6. Opthalmic H.Z., Herpes Zoster Varicella Opthalmicus, Varicella-Zoster
         Virus Opthalmicus - Presents with lesions on forehead. 50% to 75%
         orbital globe will be involved. If lesions on tip of nose, nasociliary nerve is
         involved. Global involvement is 75%. If no lesion on tip of nose, 33%
         global involvement. Symptoms: marked lid edema, corneal edema,
         conjunctival, circumcorneal, episcleral hyperemia, epitheilial and stromal
         keratitis, uveitis, glaucoma, and pain may all be present in acute / active
         phase. Keratitis and uveitis may lead to corneal scarring with resultant

Beth Roraback, D.C.                   Page 2                              8/20/2010
Approved 04/13/05
          blindness. Treated with topical corticosteroids. Glaucoma, cataract,
          chronic/recurrent uveitis, neovascularization, hypesthesia, and corneal
          scarring are all common vision threatening treatable sequelae. Early
          treatment with Famcicyclovir decreases ocular complications. Intraocular
          pressure is monitored and Atropine and Scopoline are used to keep pupil
          dilated.



CASE HISTORY:

PPW: Initial presentation is a vague unilateral band or patch of skin pain, with
possible fever, chills, malaise, GI disturbances (prodomal phase –3 to 4 days prior
to vesicular outbreaks )
       Onset-Initial: 1 week ago. ( patient Age 60 )
       Palliative/Provocative: cold compress –some relief
       Quality/Quantity: severe tingling burningor itching pain
       Referred/Radiating: associated dermatome
       Site: Rectangular patch on lateral chest at level of 9th rib on right
       Timing/Pattern: 2 days ago, erythematous patch, with some vesicles in same
               area
       Other: ( burning is followed by an outbreak of blisters/vesicles and a
               reddened area of skin associated with dermatome, which typically
               begin to dry and scab over 5 days following eruption )

Relevant History and Lifestyle
      Gender: Males slightly more frequent
      Age: Most common affects 50 plus
      Occupation
      Traumas
      Surgeries
      Medications: immunosuppressive drugs, drug reaction ( i.e., arsenic         )

      Hospitalizations
      Immunizations: varicella zoster ( or infection)
      Diseases or Conditions: history of chicken pox or vaccination
      Family History
      Diet
      Sleep Habits
      Sexual History
      Alcohol Usage
      Drug Usage
      Smoking/Tobacco
      Other: immuno-suppressed state by drug, radiation or disorder




Beth Roraback, D.C.                 Page 3                            8/20/2010
Approved 04/13/05
Review of Systems

PHYSICAL EXAMINATION:

Height              Weight

Vitals: BP     Pulse         Respiration___ Temp: fever initially

Appearance, Motion, Gait



Orthopedic Tests: no positives associated

     Test Name               R        L           Test Name              R       L
Beevor's                       -       -    Forrestier's Bowstring        -         -
Schepelman's                   +       -

Orthopedic Test Results Discussion:
Beevor's rules out motor component association, this condition has no motor factors
involved.
Negative Forrestier's confirms normal motor and joint function of spinal segments to
rule out problems with spinal nerves.
Positive Schepelman's indicates intercostal neuritis. Pain is on same side as the
positive Schepelman's test. Neither intercostal myofascitis nor pleurisy is indicated
as they would present on the side opposite lateral flexion.


Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception: hyperesthesia and dysesthesia along affected
spinal ( or cranial ) nerve distribution. Entire distribution may not be involved.

LabValues: culture of vesicular material to reveal virus
            Tzanck prep with Wright or Giemsa stain reveal synctial ( protoplasm
            of one cell continuous with adjoining cells ) giant cells with
            Internuclear inclusions indicates herpesvirus, does not differentiate
            between herpes zoster and simplex-low sensitivity ( 60% )
            Direct detection of zoster antigens by immuno-cytochemistry or
            fluorescent microscopy of vesicular scrapings most sensitive
            FAMA and ELISA most sensitive in common use
            Polymerase Chain Reaction –not readily available

Examination of Related Areas

Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)

Beth Roraback, D.C.                  Page 4                             8/20/2010
Approved 04/13/05
SPINAL EXAMINATION:

         Postural Analysis                      Postural Analysis   L      N        R
                                                Head Tilt
                                                Head Rotation
                                                High Ear
                                                High Shoulder
                                                High Ilium
                                                Ext. Rotated Foot
                                                Int. Rotated Foot


ROM
             Cervical ROM                                 Lumbar ROM
               ROM      Pain     Level                     ROM     Pain        Level
Flexion        N  Y N                   Flexion          N     Y N
Extension      N  Y N                   Extension        N     Y N
R. Rotation    N  Y N                   R. Rotation      N     Y N
L. Rotation    N  Y N                   L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                   R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                   L. Lat. Flex.    N     Y N


Leg Length/Spinal Balance : NA
Instrumentation/Pattern Analysis may be compromised by hyperemia of involved
area
Palpation (Muscle, Static, Motion) dermal hypersensitivity over involved area


List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions: none

 Level     Muscle Motion       Level    Muscle Motion       Level   Muscle Motion




RADIOLOGICAL EXAMINATION:


MRI may be used in cases of myelopathy or encephalopathy to exclude other
etiologies.


DIFFERENTIALS:
Beth Roraback, D.C.                    Page 5                           8/20/2010
Approved 04/13/05
Pleurisy: Would have possible auscultory changes on chest exam, positive
       Schelepman's test.
Intercostal neuritis or myofascitis: positive Schelepman's, pain with lateral flexion
       Intercostal neuritis may also present with positive Beevor's test, and altered
       abdominal reflexes
Other Neuromuscular conditions- motor strength and neurological testing to rule out

DIAGNOSIS:

Differential diagnosis is difficult prior to vesicular eruptions. Easily made once
blistering is present.

Differentiate from pleurisy, Trigeminal Neuralgia, Bell’s Palsy and chicken pox (
primarily in children ) by subsequent blistering for the first three, and by pattern of
blistering for chicken pox ( as well as by known history of previous infection with
chicken pox ).


Case Management:


Chiropractic Management:

Adjunctive Therapy: Capsaicin ointments help with Post-herpetic Neuralgia.
Proteolytic Enzymes ( Bromelain, Trypsin, Chymotrysin ) may help in
initial attacks. AMP may help both initial symptoms as well as prevent
PHN. Cold Quartz UV decreases viral count superficially.

Physical Therapy: none

Nutrition:

Exercise:

Health Promotion and Maintenance (i.e. ergonomics, spinal hygiene, psychosocial
concerns, education):

B vitamins and vitamin E to support neural tissue repair.

Further Evaluation: subsequent evaluation of affected dermatomes for paresthesia,
hypoesthesia, and dysesthesia. Post-herpetic Neuralgia is uncommon in patients
without immuno-compromise, and when under the age of 50. Reoccurrence is
uncommon in this population.



Beth Roraback, D.C.                    Page 6                              8/20/2010
Approved 04/13/05
Common Medical Management: no specific therapy. Cold compresses may sooth,
aspirin ( 650 mg ) with codeine ( 5 to 60 mg ) every 4 to 6 hours for pain relief.
For immuno-suppressed patients,




In immuno-competent patients: Oral administration of:


   800 mg of Acyclovir 5x/day for 7 to 10 days,
Or 500 mg of Famciclovir for 7 days
Or 1000mg of Valacyclovir for 7 days
            To produce more rapid cutaneous lesion resolution and to decrease
            the duration of viral shedding if started within 3 days of onset of rash
     Helps to decrease the associated pain duration

      Antiviral drugs recommended with Trigeminal nerve presentation to diminish
      risk of keratitis and other ophthalmic complications ( decreases risk of
      blindness )

For immuno-suppressed patients: Intravenous administration of:

  Acyclovir 10 mg/kg TID for 10 to 14 days. If mild and limited to one dermatome,
  can be treated with oral adminstration initially and monitored for indications of
  progressive worsening. If present, should be switched to intravenous
  administration.

  If patient has renal insufficiency, dose reduction is required.



REFERENCES:

Merck’s Manual –16th edition
Harrison’s Principles of Internal Medicine –15th edition
Medline Plus ---National Institutes of Health, US National Library of Medicine
       ( www.nim.nih.gov/medlineplus/ency/article000858.htm )
Women and Infants Hospital of Rhode Island
       (http://www.womenandinfants.com/body.cfm?id=388&chunkiid=21722#P1)
Dynamic Chiropractic November 22, 1991, Volume 09, Issue 24 -- Cold Quartz UV




Beth Roraback, D.C.                   Page 7                            8/20/2010
Approved 04/13/05
Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.




Condition       Baseline     Complicating/ Mitigating Factors              Revised
Name            Complexity                                                 Complexity
                             Herpes Zoster in children and healthy
                             adults under the age of 50 ( patients who         3.0
                             immuno-competent ).
                    3.0      Mimic Musculoskeletal complaint                   4.0
                             Immuno-compromised with Herpes
                             Zoster.                                           5.0
                             CNS involvement.                                  7.0
Herpes                       Multiple dermatomes involved.
Zoster                                                                         5.0
                             Patients with Hodgkin's Lymphoma or
                             disease-                                          5.0
                             Bone Marrow Transplantation patients
                             with H.Z.-                                        5.0
                             Herpes Zoster Oticus aka Geniculate
                             Herpes, Viral Neuronitis and Ganglionitis,        8.0
                             Ramsay-Hunt Syndrome-
                             Opthalmic H.Z., Herpes Zoster Varicella
                             Opthalmicus, Varicella-Zoster Virus               8.0
                             Opthalmicus-




Beth Roraback, D.C.                 Page 8                                8/20/2010
Approved 04/13/05
                          CLINICAL APPLICATIONS
                  Case Study Preparation – Suggested Format


CONDITION: Lumbar Canal Stenosis
Prepared by: Dr. Renee Prenitzer

RELEVANT PATHOPHYSIOLOGY:

Lumbar canal stenosis is usually associated with the aging process which can
include normal wear and tear on the spine. Lumbar Canal Stenosis can also be
predisposed genetically. During normal development the canal reaches the adult
size around the age of four. If the canal does not reach adequate size by then, it
never will, This type of stenosis will usually be general and occur throughout the
spine. This type of stenosis may result in lack of symptoms until further
pathophysiology occurs, for example osteophtes, trauma, and IVD problems.
Lumbar canal stenosis can be acquired through trauma, degeneration of the spinal
segments, soft tissue pathology involving the ligamentum flavum and most
commonly spondylosis.

CASE HISTORY:

PPW: Dull to severe aching pain in the lower back or buttocks that develops with
walking or other activity. Pain radiates into one or both thighs and legs. Symptoms
are relieved by sitting or lying down, and/or by bending at the waist, such as when
walking behind a shopping cart. In rare cases, patients can lose motor functioning in
the legs, bowels, or bladder.

Onset-Initial
      Palliative: Bending forward at the waist helps, sitting or lying down helps.
                 Placing foot on stool while bending forward is also a palliative
                 position.
      Provocative: Walking or exercising vigorously.
      Quality/Quantity: Leg pain or numbness that occurs with exercise, especially
                 prolonged walking.
      Referred/Radiating: Possible radiation down thigh.
      Site: Located in Low Back and Buttock region, can travel down thigh and leg.
      Timing/Pattern: Activity related. Symptoms usually subside after cessation of
                 activity within 15 to 20 minutes or with the assumption of a flexed
                 position.
      Other

Relevant History and Lifestyle:
             Gender         No specific gender affinity.
             Age Usually a degenerative condition seen in patients 60 years of
             age and older.

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             Occupation
             Traumas
             Surgeries
             Medications
             Hospitalizations
             Immunizations
             Diseases/Conditions


             Family History
             Diet
             Sleep Habits
             Sexual History
             Alcohol Usage
             Drug Usage
             Smoking/Tobacco
             Other__________________________________________________


Review of Systems                                                       _____

           ______________________________________________________
___________________________________________________________


PHYSICAL EXAMINATION:

Height                               Weight
Vitals: BP          Pulse                         Respiration________ Temp.
Appearance, Motion, Gait

Orthopedic Tests

      Test Name              R             L              Test Name            R              L
Phalen Test                         +              Belt Test                    -                -
SLR                            -              -    Valsalva’s                   +involved side
Kemp’s                         +involved side      Hibb’s                       -              -
Well Leg Raiser                -              -    Braggard’s                   -                -
Minor’s Sign                   -              -    Milgram’s                    +involved side

Orthopedic Test Results Discussion: Phalen Test – Attempts to reproduce the
symptoms of leg pain, weakness, or numbness caused by neural ischemia. Patient
is upright and then bent into an extended position for 60 seconds. A positive test will
produce an progressive increase of the leg symptoms followed by rapid relief of
these symptoms when the patient flexes forward, places his hands on the
examination table, and places one foot on a stool.

Renee Prenitzer                           Page 2                              8/19/2010
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Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception
Motor examination in both lower extremities is normal (however, mild weakness may
be present dependent on severity of stenosis and the length of involvement).
Sensory and reflex are normal as well.
NOTE: Motor/Sensory/Reflex findings may be inconsistent with symptom
experienced during exercise.


Lab Values


Examination of Related Areas


Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




SPINAL EXAMINATION:

      Postural Analysis                     Postural Analysis     L      N        R
                                            Head Tilt
                                            Head Rotation
                                            High Ear
                                            High Shoulder
                                            High Ilium
                                            Ext. Rotated Foot
                                            Int. Rotated Foot


ROM
             Cervical ROM                               Lumbar ROM
               ROM      Pain    Level                    ROM     Pain         Level
Flexion        N      Y N             Flexion          N     Y N
Extension      N  Y N                 Extension                Y          L4, L5, S1
R. Rotation    N  Y N                 R. Rotation      N     Y N
L. Rotation    N  Y N                 L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                 R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                 L. Lat. Flex.    N     Y N




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ROM: Central Stenosis - May be limited in extension (with an increase in pain).
Flexion may decrease pain. Lateral Stenosis – May be limited in extension. Lateral
flexion and rotation to the involved side increases pain.

Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion)



List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




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RADIOLOGICAL EXAMINATION:

         X-rays       MRI         CT              Other

Views: A-P Lumbar/ Lateral Lumbar, MRI, CT Scan, Myelogram can be used to
determine lumbar canal stenosis.

Myelogram: Involves injection of dye into the spinal sac where it mixes with CSF.
Any outward protrusion will block the flow of the dye. If this is done with the patient
in extension may offer the best information on location of stenotic areas

CT Scan: Most widely used test for evaluating the spine because it is noninvasive
and provides a three dimensional view. It is helpful for differentiating between hard
tissue and soft tissue. Used to evaluate for lateral stenosis and central stenosis

Findings: Einsensteins’s Method of analysis on Lateral Lumbar Film will indicate
possible canal stenosis if sagittal canal measurement is less than 15 mm.



Differentials:

Rule Out                          Rationale
                                  (defined: fixed claudication due to stenosis of the blood
                                  vessels) Differentiated by:
Vascular Claudication                                       -the bicycle test
                                                            -stoop test
                                  (defined: A condition of disk protrusion into and beyond the
                                  annulus fibrosus which may cause nerve root compression
, Disc Herniation                 and neurologic signs.
                                             Differentiated by:
                                                              MRI
                                  (defined: An anterior displacement of a vertebral body in
                                  relation to the segment immediately below. The displacement
                                  is a result of loss in continuity or elongation of the pars
, Spondylolisthesis               interarticularis.)
                                              Differentiated by:
                                                               -radiolographic findings


                                  (defined: A rotational compression injury of the richly
                                  innervated articular facets of the lumbar spine, characterized
                                  by local and/or referred pain arising from the zygapophyseal
                                  joints.
Facet Syndrome                               Differentiated by:
                                                             -radiographic findings of sclerosing
                                  of the facets:
                                                              -no osteophytes
                                                               -stress films may reveal abnormal


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                                 joint locking

                                 (defined: Rapidly progressing neurologic defecits,)
                                             Differentiated by:
, Cauda Equina Syndrome                                     Loss of bowel and/or bladder
                                 function.

                                 (defined: A low back pain condition described as a
                                 compression or irritation of the sciatic nerve by a contracted or
                                 stretched piriformis muscle.)
Piriformis Syndrome                           Differentiaed by:
                                                             Palpation of the piriformis muscle
                                 and by presence of trigger point tenderness of the muscle
                                 adjacent to the sacrum




Note:

DIAGNOSIS:

Lumbar Canal Stenosis


CASE MANAGEMENT:

Chiropractic Management: Manual adjustments may be contraindicated.
Conservative, low-force adjustments may be utilized. If improvement occurs and
continues, then management can continue; however, if the condition continues to
deteriorate or no progress is noted within two to three weeks then re-evaluation is in
order. Cox Flexion Distraction treatment may be utilized if compression of canal is
due to disc herniation or protrusion.

Adjunctive Therapy:




Physical Therapy: Used to restore flexibility and strengthen the back and abdominal
muscles in order to provide relief from symptoms.




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Nutrition:




Exercise: Abdominal exercise to strengthen and support the low back. Exercises to
restore flexibility.


Health Promotion and Maintenance (i.e. ergonomics, spinal hygiene, psychosocial
concerns/education): Important to be aware that pain may cause an increase in
psychosocial stress, physiological responses to pain may also occur.

Further Evaluation: Medical referral should be made if patient does not experience
significant improvement or if the symptoms reoccur quickly following the chiropractic
course of care. Referral: Orthopedist, Neurologist, Neurosurgeon.

Common Medical Management: Medication, Physical Therapy, Surgery
Medications: Anti-inflammatory medications such as ibuprofen and acetaminophen.
NSAIDs such as Motrin, Naprosyn, Celebrex, and Vioxx may also be prescribed.
Cortisone shots at the site of the low back pain. Lumbar Epidural Injection: 1. For
pain management the injection is into the epidural space. 2. For targeting the level
of the pain the injection is into the specific nerve root.


Surgery: Surgical treatment may include fusion, decompression (laminectomy,
lamina trimming, widening of lateral recess, removal medial rim of facets), postero-
lateral fusion.

       Laminectomy – involves removing the lamina from the vertebral body to allow
             the pressure to be removed from the dural sac or the nerve roots.
             When only a portion of the lamina needs to be removed the procedure
             is referred to as a laminotomy. The ligaments (ligamentum flavum)
             and soft tissue (facet capsules, herniated or bulging discs) in the
             affected area are also removed.

       Foraminotomy – are performed to enlarge the area where the nerve roots exit
             the spinal canal in order to decrease the amount of pressure on them.

       Spinal fusion – are performed when patients develop instability of the spine
              with the surgery. Spinal fusion involves grafting bone onto the spine
              and the use of rods and screws to provide support and stability.

       Micro-Endoscopic Laminotomy (MEL) – New treatment developed. A
             minimally-invasive technique that uses a surgical endoscope for

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             fluoroscopic x-ray a thin needle is inserted to the involved vertebral
             level. A small incision is then made around the needle and a hollow
             metal cylinder is passed over the needle to the area of stenosis and
             secured. Through this cylinder the surgical endoscope is inserted to
             allow the surgeons a close-up of the affected area. The surgeon then
             micro-surgically removes the bone compressing the nerve roots. Soft
             tissue can also be removed using this procedure. The level above and
             below can be decompressed as well. Additional benefits of MEL are:
             less disruption of normal tissue, faster surgical time, decreased post-
             operative discomfort, quicker recovery time, and more rapid return to
             normal activity.

References:
  •Wheeless’ Textbook of Orthopedics
  •www.merck.com
  •www.neurosurgery.org/health
  •www.spineuniverse.com
  •Differential Diagnosis and Management for the Chiropractor, by Souza



Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.


Condition Name        Baseline     Complicating/ Mitigating Factors       Revised
                      Complexity                                          Complexity
                                   Early Stage – light force/                5.0
                                   instrument adjustments, monitor
   Lumbar Canal           5.0      for changes in symptoms
     Stenosis                      Late Stage – symptomatic,                  6.0
                                   chiropractic management altered/
                                   no adjustments at level of stenosis
                                   Co-management with MD –                    5.0
                                   epidural injections
                                   Complicated by DDD/ DJD                    7.0
                                   Compression fracture                       8.0


Renee Prenitzer                     Page 8                               8/19/2010
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                          CLINICAL APPLICATIONS
                             Case Study Preparation


CONDITION___Lumbar Facet
Syndrome______________________________________

Prepared by: Maria Michelin, DC__________________________________



RELEVANT PATHOPHYSIOLOGY:

Facet and the capsule are the source of the pain. One theory-synovial folds
(meniscoids) may be trapped or pinched and cause the pain. Theory two-
degeneration in older patients.



CASE HISTORY:

PPW: Well localized low back pain-usually at L4 to Sacrum that radiates into the
buttocks and can radiate into the thighs.
       Onset-Initial often sudden after arising from a flexed position or sudden odd
       movement.                                                              _____
       Palliative ice and lying down with legs elevated
       Provocative lifting weights, prolonged standing or sitting up straight
       Quality/Quantity constant dull ache, pain is sharp with lumbar extension
       Referred/Radiating some buttock or thigh pain with extension
       Site over spine L4 to sacrum
       Timing/Pattern        constant
       Other

Relevant History and Lifestyle
      Gender
      Age
      Occupation
      Traumas       can be related to microtraumas
      Surgeries
      Medications          OTC tends not to help
      Hospitalizations
      Immunizations
      Diseases or Conditions__________________________________ _
      Family History
      Diet
      Sleep Habits LBP interferes with sleep

Maria Michelin, D.C.                 Page 1                             8/20/2010
Approved 03/29/04
         Sexual History can aggravate LBP
         Alcohol Usage
         Drug Usage
         Smoking/Tobacco
         Other__can be aggravated by obesity________________________


Review of Systems                                                         _____

     ______________________________________________________
___________________________________________________________



PHYSICAL EXAMINATION:

Height                                 Weight

Vitals: BP             Pulse                        Respiration________ Temp.

Appearance, Motion, Gait

Orthopedic Tests

      Test Name                R            L              Test Name             R           L
SLR/WLR                    +       -    +       -                               +    -   +       -
Kemps                      +       -    +       -                               +    -   +       -
Nachlas                    +       -    +       -                               +    -   +       -
Yeomans                    +       -    +       -                               +    -   +       -
Belt                       +       -    +       -                               +    -   +       -

Orthopedic Test Results Discussion:     Kemps increases the pain from L4 to
sacrum and causes pain to radiate into the buttocks. Nachlas and Yeoman increase
to already present LBP.



Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception
The neurological examination is all with in normal limits there is no evidence of
reproducible sensory or motor involvement.________________________________
___________________________________________________________________
___________________________________________________________________




Maria Michelin, D.C.                     Page 2                                 8/20/2010
Approved 03/29/04
LabValues__________________________________________________________
_____ ____________________________________________________________


Examination of Related Areas



Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




SPINAL EXAMINATION:

       Postural Analysis                         Postural Analysis       L        N      R
                                                 Head Tilt
       Possible increase in lumbar               Head Rotation
       lordosis                                  High Ear
                                                 High Shoulder
                                                 High Ilium
                                                 Ext. Rotated Foot
                                                 Int. Rotated Foot


ROM
                Cervical ROM                                 Lumbar ROM
                  ROM      Pain      Level                    ROM     Pain            Level
Flexion           N  Y N                   Flexion          N     Y N
Extension         N  Y N                   Extension        N     Y N             L4-S1

R. Rotation         N      Y   N           R. Rotation        N      Y    N
L. Rotation         N      Y   N           L. Rotation        N      Y    N
R. Lat. Flex.       N      Y   N           R. Lat. Flex.      N      Y    N
L. Lat. Flex.       N      Y   N           L. Lat. Flex.      N      Y    N


Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion) Tenderness over the involved spinous processes




Maria Michelin, D.C.                    Page 3                               8/20/2010
Approved 03/29/04
List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

       X-rays       MRI          CT          Other

Views A-P, Lateral and Obliques

Findings     Possible L5 disc angle of greater than 15 degrees.    McNab’s line
and Hadley’s line may be positive for imbrication




DIFFERENTIALS:

Lumbar disc problems. Lumbar sprain/strains

DIAGNOSIS:

Lumbar facet Syndrome




Case Management:


Chiropractic Management:          Adjustments. Can use Cox flexion distraction.




Maria Michelin, D.C.                 Page 4                           8/20/2010
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Physical Therapy: Axial distraction. Palliative care includes ice, pulsed
ultrasound, high volt galvanic and interferential__________________________

Nutrition:



Exercise: Williams flexion exercises



Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education):
       __Recommend avoid prolonged sitting or the positions that are specific to the
patient which encourage increased lumbar lordosis._______________________
________________________________________________________________

Further Evaluation:


Common Medical Management: Facet denervation and facet injections____

References:
Souza. Differential Diagnosis for the Chiropractor
Huff and Brady. Instant Access to Chiropractic Guidelines and Protocols

Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.


Condition Name         Baseline     Complicating/ Mitigating Factors      Revised
                       Complexity                                         Complexity
   Lumbar Facet            3        None really. It depends on if they         3
    Syndrome                        have to perform the activity that
                                    put them in this condition in the
                                    first place. Usually some twisting
                                    during extension.




Maria Michelin, D.C.                   Page 5                            8/20/2010
Approved 03/29/04
                          CLINICAL APPLICATIONS
                         Faculty Case Study Preparation


CONDITION: Lumbosacral Sprain-Strain

Prepared by: Laura Green-Orndorff


RELEVANT PATHOPHYSIOLOGY:

       This can be a combination stretch, rupture, or separation injury of the
muscles and supporting ligaments of the lumbosacral spine. A stretching and
tearing of a spinal muscle and their attachments as result of uncontrolled
movements or direct trauma. Minor muscle stains may result from overuse or
repetitive tasks.


CASE HISTORY:

PPW: low back pain


             Gender        Male
             Age           35
             Occupation construction worker
             Traumas
             Surgeries
             Medications
             Hospitalizations
             Immunizations

Diseases/Conditions


Relevant History and Lifestyle:

             Family History
             Social History
             Diet
             Sleep Habits
             Sexual History

             Alcohol Usage
             Drug Usage
             Smoking/Tobacco

Laura Green-Orndorff, D.C.         Page 1                         8/20/2010
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CHIEF COMPLAINT: intense pain from lower lumbar region to the sacrum
     Onset-Initial two hours after water skiing
     Palliative/Provocative While resting/walking and moving about
     Quality/Quantity     sharp and intense to a dull ache
     Referred/Radiating to the buttocks
     Site localized to the lumbosacral region
     Timing/Pattern       pain when rising from bed or from a seated position
     Other




PHYSICAL EXAMINATION:

Height       6'                  Weight        180

Vitals: BP   128/85 Pulse        85       Respiration___normal_ Temp. 98.9

Appearance, Motion, Gait gait is slow and guarded, the posture is antalgic

Orthopedic Tests

       Test Name             R        L          Test Name          R            L
Bilateral straight leg       +        +                            + -       + -
raiser
+ O'Donahue's                +        +                            +    -    +       -
Well leg raiser              +        +                            +    -    +       -
Neri's bowing                +        +                            +    -    +       -
Kemps                        +        +                            +    -    +       -

Orthopedic Test Results Discussion: All test mentioned above are (+) in the
acute phase
      *Valsalva maneuver should be performed to r/o a disc




Neurological Tests - Motor/Sensory/Reflex

*All are within normal limits (No radiculopathy)




Laura Green-Orndorff, D.C.            Page 2                       8/20/2010
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  Nerve Root Package            Motor (0-5)           Sensory         Reflex (0-4)
           C5                                           N    
           C6                                           N    
           C7                                           N    
           C8                                           N    
           T1                                           N    
           L4                                           N    
           L5                                           N    
           S1                                           N    
Lab Values


Examination of Related Areas


Review of Systems


Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




SPINAL EXAMINATION:

      Postural Analysis                       Postural Analysis   L      N        R
                                              Head Tilt
      antalgic                                Head Rotation
                                              High Ear
                                              High Shoulder
                                              High Ilium
                                              Ext. Rotated Foot
                                              Int. Rotated Foot


 ROM (Restricted in all planes)
             Cervical ROM                               Lumbar ROM
               ROM      Pain   Level                     ROM     Pain        Level
Flexion        N  Y N                 Flexion          N     Y N
Extension      N  Y N                 Extension        N     Y N
R. Rotation    N  Y N                 R. Rotation      N     Y N
L. Rotation    N  Y N                 L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                 R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                 L. Lat. Flex.    N     Y N

Laura Green-Orndorff, D.C.         Page 3                             8/20/2010
Approved 04/08/04
Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion):     Tenderness over the involved muscles,
spinous tips and transverse process. Edema decreases with rest. Diffuse
tenderness over the paravertebral muscles and joint fixation. Increased skin
temperature due to the vasodilation. Strains are painful with active isometric
movement. Sprains are painful in active and passive range of motion

List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

       X-rays        MRI        CT          Other

Views A-P and Lateral lumbo-pelvic

Findings     Flattened lumbosacral curve (due to the muscle spasm)



DIFFERENTIALS:

Facet syndrome
Lumbar instability
Facet trophism
Metastatic lesions


DIAGNOSIS:
Lumbosacral Strain-Spain




Laura Green-Orndorff, D.C.          Page 4                           8/20/2010
Approved 04/08/04
Case Management:


Chiropractic Management: adjust subluxated area(s) . Low force adjustment to
the sprain strain region in the acute phase (1 week or until the patient has no
pain at rest). Low force adjustment or up to patient comfort in the sub-acute
phase. Mild strains may take 7-10 days to heal. Mild sprains may take 1-4
weeks to heal. Moderate strains 2-4 weeks to heal . Moderate sprains 1month-
1year to heal. Severe strains/sprains may need surgical repair. Lumbo-sacral
support belt can be recommended


Adjunctive Therapy: Acute phase: ice packs to promote vasoconstriction to
decrease inflammation, pain, edema and muscle spasm. Interferential for pain
and edema management. Chronic phase: moist hot packs, ultrasound,
galvanic and electrical stimulation. TENS unit can be used in the acute and
chronic stage

Nutrition: (weight related- weight reduction program),   Vitamin C and
glucosamine sulfate for soft tissue healing. Increase levels of protein for soft
tissue healing

Exercise: 1. proper lifting and bending biomechanics 2. Stretch the low back,
abdominals and hamstrings to recondition injured muscles and prevent
adhesions. 3.Abdominal exercises to strengthen



Further Evaluation:


Patient Care: avoid heavy lifting, avoid soft furniture, high heeled shoes, sleep
supine with a pillow under the knees, rest on a firm mattress



Referral:    G.P.

Meds: NSAIDS and muscle relaxers (scalactin, flexural)




Laura Green-Orndorff, D.C.          Page 5                           8/20/2010
Approved 04/08/04
REFERENCES:


Instant Access to Chiropractic Guidelines and Protocols; Huff and Brady


http://www.emedicine.com/sports/topic69.htm



Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.

Condition Name        Baseline     Complicating/ Mitigating Factors     Revised
                      Complexity                                        Complexity
   Lumbosacral            2        Rupture, or separation of the            10
   Strain-Spain                    muscles and or supporting
                                   ligaments of the lumbo-sacral
                                   spine
                                   Obesity                                   5




Laura Green-Orndorff, D.C.          Page 6                            8/20/2010
Approved 04/08/04
Multiple Myeloma
    Marcus Abbott




    Approved 31May06 Author: Abbott, Marcus
            Multiple Myeloma
 Multiple myeloma is a type of cancer that affects
    plasma cells.
   It is the most common type of primary cancerous
    bone tumor.
   Accounts for about 1% of all cancers
   About 12,500 cases are diagnosed per year.
   Plasma cells and other white blood cells are part
    of the immune system, which helps the body
    protect itself from infection and disease.
                   Approved 31May06 Author: Abbott, Marcus
              Multiple Myeloma
 Plasma cells are important to the immune
    system because they produce antibodies.
   Antibodies are proteins that move throughout
    the blood stream to fight foreign, harmful
    substances.
   Each type of plasma cell produces a specific
    antibody to fight a specific foreign substance.
   Since the body has many different types of
    plasma cells, it can respond to, or fight against,
    many different foreign substances.
                    Approved 31May06 Author: Abbott, Marcus
         Multiple Myeloma
 When plasma cells become cancerous,
  they reproduce uncontrollably.
 The tremendously increased number of
  plasma cells in multiple myleoma crowd
  out healthy red and white blood cells,
  preventing them from functioning as
  effectively as they should.


              Approved 31May06 Author: Abbott, Marcus
  Equal Opportunity Offender?
 Multiple myeloma can affect anyone.
 Men are at a higher risk than women
  having a 3:2 ratio.
 African-Americans are affected at a 2:1
  ratio over Caucasians.
 African-American females are at a higher
  risk than Caucasian females.

               Approved 31May06 Author: Abbott, Marcus
Why More Incidence in Blacks?
 There are a couple of explanations as to
 why multiple myeloma has a higher
 prevalence among African Americans:
   Blacks have higher levels of circulating
    immunoglobulin G (IgG) representing a greater
    opportunity for B-cell malignancy and transformation
   General increased exposure to pollutants (air, water,
    food) over time promoting chronic antigenic
    stimulation of the immune system.


                   Approved 31May06 Author: Abbott, Marcus
           Who’s At Risk?
 Elderly are at a higher risk.
 Peak occurrence of multiple myeloma
  happens between the 5th and 7th decades
  of life.
 Median age of the disease in the U.S. is
  65 years old, but 2% of cases occur before
  the age of 40.


               Approved 31May06 Author: Abbott, Marcus
   Etiology of Multiple Myeloma
 Exact etiology is unknown.
 1st degree relatives of a patient with multiple
  myeloma have higher risk so there is a genetic
  linkage.
 Some studies have shown a viral etiology, HHV-
  8 (human herpes virus 8) has been identified in
  the bone marrow of multiple myeloma patients.
 Some chromosomal abnormalities such as loss
  of chromosome 13 and the jumping
  translocation of chromosome 1q.

                  Approved 31May06 Author: Abbott, Marcus
              Risk Factors
 Chronic low level exposure to radiation is
  associated with a 2 – 6 fold increase in
  incidence. This may occur as late as 20
  years after exposure.
 Chronic antigenic stimulation such as
  recurrent infection and drug allergies are
  evident in patients with multiple myeloma.


               Approved 31May06 Author: Abbott, Marcus
     Risk Factors Continued
 Occupational exposure to low-dose
 ionizing radiation, wood, textile, rubber,
 metal, petroleum products, and chemicals
 used in herbicides has been associated
 with development of multiple myeloma.




              Approved 31May06 Author: Abbott, Marcus
       Clinical Manifestation
 The most frequent symptom associated
  with multiple myeloma is bone pain.
 Once symptoms are present, an untreated
  patient has a median life span of seven
  months, but can be extended to 2-3 years
  with traditional treatment.



              Approved 31May06 Author: Abbott, Marcus
      Clinical Manifestation (ctd.)
 Clinical course of the disease is complicated by:
     Pathological fractures
     Pain
     Hypercalcemia
     Spinal cord compression
     Anemia
     Fatigue
     Thrombocytopenia
     Recurrent bacterial infection
     Renal failure
                     Approved 31May06 Author: Abbott, Marcus
 Clinical Manifestations of Multiple
             Myeloma
 Multiple Myeloma may manifest in the
 following forms:
     Skeletal Involvement
     Infection
     Bone Marrow Involvement
     Renal insufficiency
     Metabolic syndrome
     Hyperviscosity syndrome
     Peripheral neuropathy
                 Approved 31May06 Author: Abbott, Marcus
        Skeletal Involvement
 68-80% of multiple myeloma patients
  present with painful osteolytic lesions at
  the time of diagnosis.
 Lesions can be:
   Solitary osteolytic lesions
   Diffuse osteoporosis
   Multiple discrete osteolytic ‘punched out’
    lesions

                 Approved 31May06 Author: Abbott, Marcus
      Skeletal Involvement (ctd.)
 Typically affect the pelvic bones, spine,
  ribs, and skull
 Symptoms that are associated with these
  lesions include:
     Hypercalcemia(20-40% of patients)
     Pathological fractures
     Acute and chronic pain
     Decreased mobility
     Inability to participate in daily life activities
                     Approved 31May06 Author: Abbott, Marcus
    Skeletal Involvement (ctd.)
 Pathophysiology of the bone destruction is
  thought to be associated with myeloma
  cell production of osteoclast activation
  factor (OAF).
 Myeloma associated lesions are more
  readily diagnosed by x-ray or bone scan,
  with MRI being the method of choice.


               Approved 31May06 Author: Abbott, Marcus
                  Infection
 Infection is the leading cause of death in
  multiple myeloma patients.
 As with most malignancies, 50-70% of
  multiple myeloma patients will die as a
  result of bacterial infection.
 2 most common sites of infection are the
  respiratory tract and the urinary tract.
 The bacterial agents are usually Staph
  aureus, Strep pneumonniae, E coli,
  Pseudomonas, and Klebsiella.
                Approved 31May06 Author: Abbott, Marcus
    Bone Marrow Involvement
 A normocytic, normochromic anemia clinically
  manifested by fatigue and weakness occur in
  over 60% of multiple myeloma patients.
 Anemia is initially caused by excessive
  replacement of erythrocyte precursors with
  plasma cells in bone marrow, and can also be
  caused by increased destruction of RBCs.
 ‘M’ protein coats erythroctytes causing rouleaux
  formation, leading to hemolysis.

                 Approved 31May06 Author: Abbott, Marcus
          Renal Insufficiency
 At initial diagnosis, renal insufficiency is
  present in 20-35% of multiple myeloma
  patients.
 During treatment, 50% will experience
  renal failure, 2-3% will be put on dialysis,
  15% will die as a result of renal
  insufficiency.


                 Approved 31May06 Author: Abbott, Marcus
     Renal Insufficiency (ctd.)
 Multiple myeloma can cause intrinsic renal
  lesions as well as cause renal failure
  precipitated by the sequelae of the
  disease.
 The most common type of renal lesion
  associated with renal failure is called
  ‘myeloma kidney’.


               Approved 31May06 Author: Abbott, Marcus
     Renal Insufficiency (ctd.)
 In ‘myeloma kidney’, renal tubules are
  filled with damaging, dense casts.
 The casts contain light chain
  immunoglobulins (Bence-Jones proteins)
  which are directly toxic to renal tubular
  epithelium.



               Approved 31May06 Author: Abbott, Marcus
        Metabolic Syndrome
 Hypercalcemia as a clinical sequelae of
 multiple myeloma if untreated can
 precipitate renal insufficiency by:
   Reducing GFR
   Altering renal blood flow
   Changing the kidney’s ability to concentrate
    urine
   Precipitating calcium in tubules

                 Approved 31May06 Author: Abbott, Marcus
        Hyperviscosity Syndrome
 Rare,(<5%) of multiple myeloma patients can
    present with hyperviscosity.
   Caused by high concentrations of proteins that
    increase serum viscosity and results in vascular
    sludging.
   Initial clinical signs of this:
       Blurred vision
       Irritability
       Headache
       Drowsiness
       Confusion

                         Approved 31May06 Author: Abbott, Marcus
      Peripheral Neuropathy
 Recognized as part of the clinical
 sequelae of multiple myeloma.




               Approved 31May06 Author: Abbott, Marcus
 Assessment of Multiple Myeloma
 Physical Exam findings:
   Bone pain (with or without decreased ROM)
   An inability to bear weight
   Signs or symptoms of spinal cord
    compression.
   May also present with:
      Change in mental status related to hypercalcemia
      Hyperviscosity syndrome
      Renal insufficiency
                  Approved 31May06 Author: Abbott, Marcus
         Diagnostic Imaging
 MRI is potentially useful in imaging
 multiple myeloma because of its superior
 soft tissue resolution. The typical
 appearance of a myeloma deposit is a
 round low signal intensity (relative to
 muscle) focus on T1-weighted images,
 which becomes high in signal intensity on
 T2-weighted sequences.

                Approved 31May06 Author: Abbott, Marcus
              Radiographic Findings
   Osteoporosis is most common skeletal abnormality in this disease

   Lesions are usually multiple and found in vertebrae, ribs, skull, pelvis, and femur

   Over 50% of solitary lesions are found in vertebrae

   Mandible involved in 1/3 of patients with diffuse involvement

   Widespread lucencies in bone

   Discrete, “punched-out” lesions

   Uniform in size

   Distinctive to MM are the lucent, elliptical, subcortical shadows, especially in long
    bones=endosteal scalloping

                                Approved 31May06 Author: Abbott, Marcus
             Radiographic Findings
Due to buttressing since MM is usually a slower process than lytic mets
In spine, MM destroys body and spares pedicle
DDX: lytic mets and disuse osteoporosis
MM is more widespread
More discrete holes in MM
Large foci of coalescence more often due to lytic mets
Severe disuse osteoporosis may simulate bone changes of MM
Sclerosis is usually seen only with treatment or fracture
Bone scans may typically be negative and many hot areas on scan may be healing
   fractures
Most believe that almost all patients with a solitary plasmacytoma will develop multiple
   myeloma
Solitary plasmacytoma produces “soap-bubbly” expansile, septated lesion, when
    characteristic
                               Approved 31May06 Author: Abbott, Marcus
                Lab Findings
 Lab findings for multiple myeloma may be
 any of the following:
     Increased levels of blood urea nitrogen (BUN)
     Increased levels of creatinine
     Increased levels of uric acid
     Increased levels of calcium




                  Approved 31May06 Author: Abbott, Marcus
         Lab Findings (ctd.)
 Diagnosis of multiple myeloma can be
  confirmed by a bone marrow biopsy
 Histological confirmation of increased
  numbers (>10%) of plasma cells.
 Presence of ‘M’ protein in the serum or
  urine (seen in 85% of patients).
 ‘M’ spike as shown by electrophoresis
 Inverse albumin to globulin ratios
               Approved 31May06 Author: Abbott, Marcus
         Diagnostic Work-up for Multiple
                    Myeloma

Diagnostic Exam                                         Purpose
   Bone marrow aspiration/biopsy                Check % of plasma cells
   Serum protein electrophoresis/               Check for presence of M protein
   Serum chemistry                              Check for:
                                                   Hypercalcemia
                                                   Renal dysfunction
 CBC                                            Check for anemia/thrombocytopenia
 Skeletal survey                                Check for osteolytic bone lesions



                            Approved 31May06 Author: Abbott, Marcus
           Medical Treatment
 Treatment is aimed at preventing
  symptoms and complications, destroying
  abnormal plasma cells, and slowing
  progression.
 Treatment types include:
     Chemotherapy drugs
     Radiation therapy
     Surgery

                 Approved 31May06 Author: Abbott, Marcus
        Additional Treatment
 Patients should drink lots of water to
  prevent dehydration and to help the renal
  system.
 Patients should stay active as possible,
  prolonged bed rest tends to accelerate
  osterperosis and make bones more
  susceptible to fracture.
 People with weakened bones should avoid
  running, lifting, or other strenuous activity.
                Approved 31May06 Author: Abbott, Marcus
     Medical Treatment (ctd.)
 There is currently no cure for multiple
  myeloma.
 Treatment of the disease is meant to
  prolong the life of the patient as long as
  possible, this may be up to 2-3 years after
  symptoms begin.



                Approved 31May06 Author: Abbott, Marcus
          Chiropractic Care
 Chiropractic care is important to help the
  patient function as optimally as possible
  during the disease and treatment.
 Because of the lytic nature of the disease
  on bones, any adjustments should be very
  low force.



                Approved 31May06 Author: Abbott, Marcus
                Conclusion
 Multiple myeloma is the most common primary
  cancerous tumor of bone, accounting for 1% of
  all cancers.
 Affects the plasma cell production within the
  bone marrow.
 Affects people over 40, men more than women,
  and African Americans more than Caucasians.
 Can manifest in several forms including skeletal
  involvement, infection, and renal insufficiency.

                 Approved 31May06 Author: Abbott, Marcus
          Conclusion (ctd.)
 Assessment of multiple myeloma is
  determined by use of lab findings, physical
  exam findings, radiological findings.
 No current cure for multiple myeloma
 Treatment is aimed at prevent spread and
  reducing symptoms as much as possible.
 With treatment a patient can extend their
  life from approximately 7 months after
  diagnosis, to 2-3 years.
               Approved 31May06 Author: Abbott, Marcus
                 Bibliography
 Beers, Mark H.,MD, & Berkow, Robert, MD; The Merck
  Manual of Diagnosis and Therapy. (7th edition); Merck
  Research Laboratories: Whitehouse Station, NJ; 1999;
  pp 855-857.

 Myeloma Institute for Research and Therapy. “What is
  Multiple Myeloma?” available at
  http://myeloma.uams.edu/whatismyeloma.asp

 Susan Groenwald, RN, MS, & Michelle Goodman, RN,
  MS, OCN; Cancer Nursing; Principles and Practice. (5th
  edition); available
  athttp://www.cancersourcern.com/search/getcontent.cfm
  ?DiseaseID=20&Contentid=16860
                   Approved 31May06 Author: Abbott, Marcus
                 Bibliography
 Itano, Joanne, Taoko, Karen N. & Taoko, Karen T.,
  Core Curriculum for Oncology Nursing; Saunders W.B.
  Co.; February 2005; pp 1363-1371.

 Melton III, Joseph, & Kyle, Robert, & Achenbach, Sara,
  & Oberg, Ann & Rajkumar, Vincent; “Fracture Risk With
  Multiple Myeloma: A Population-Based Study”, Journal
  of Bone and Mineral Research, 2005;20; pp 487-493




                    Approved 31May06 Author: Abbott, Marcus
                                CLINICAL APPLICATIONS
                                      Case Study

Condition : Myocardial Infarction
Prepared by: Maxim Ivanov

CASE HISTORY and CHIEF COMPLAINT:

This 49-year-old married white male school teacher was a 2 pack/day smoker with a history
of diabetes mellitus, hyperlipidemia and obesity, and a family history of coronary artery
disease. He was awakened from his sleep at 03:00 with crushing substernal chest pain
which radiated to his left arm and was accompanied by shortness of breath. When
paramedics arrived, they found the patient cool, clammy, bradycardic and hypotensive.
Intravenous fluids and atropine were given and he was transported to a suburban hospital.

PHYSICAL EXAMINATION:

When paramedics arrived, they found the patient cool, clammy, bradycardic and
hypotensive. Intravenous fluids and atropine were given and he was transported to a
suburban hospital.

ORTHOPEDIC AND NEUROLOGICAL TESTS: N/A.

SPINAL EXAMINATION:

N/A

RADIOLOGICAL EXAMINATION:

N/A

On arrival in the emergency department at the hospital:

The patient was in considerable distress. He was still bradycardic. He had no jugular venous
distention. He had decreased breath sounds with occasional expiratory wheezes. At 04:01
his white blood cell count was 7,900/cu mm, hematocrit 45.8%, platelets 246,000/cu mm,
creatine phosphokinase (CPK) 89 IU/L and troponin-I <0.4 ng/ml. Electrocardiogram showed
ST-segment elevation in leads II, III, AVF and V4-V6.

Chest x-ray showed borderline cardiomegaly without signs of pulmonary edema.

The patient was treated with morphine, atropine and aspirin, but he remained bradycardic
and hypotensive. He had decreasing pulse oximeter blood oxygen saturation despite
supplemental oxygen and he became cyanotic. He was intubated. A transcutaneous
pacemaker was placed. A dopamine drip was started, resulting in an increase in the patient's
blood pressure. He was started on heparin and emergency cardiac catheterization showed
non-critical disease of the left anterior descending and left circumflex arteries but a

Author: Maxim Ivanov                 Page 1                            8/20/2010
Approved: 28 July 2004
dominant right coronary artery which was totally occluded proximally. Percutaneous
transluminal coronary angioplasty (PTCA) was attempted but failed to re-open the right
coronary artery. An intra-aortic balloon pump was placed and the patient was transferred via
helicopter to the university hospital. At the university hospital, his total CK rose to 4422 IU/L
(MB isoenzyme 223.8 ng/ml 1). The evolving clinical data made it clear that his prognosis
was extremely grim. He was given comfort measures and he died peacefully.


RELEVANT PATHOPHYSIOLOGY:

The most common cause of AMI is narrowing of the epicardial blood vessels due to
atheromatous plaques. Plaque rupture with subsequent exposure of the basement
membrane results in platelet aggregation, thrombus formation, fibrin accumulation,
hemorrhage into the plaque, and varying degrees of vasospasm. This can result in partial or
complete occlusion of the vessel and subsequent myocardial ischemia. Total occlusion of
the vessel for more than 46 hours results in irreversible myocardial necrosis, but reperfusion
within this period can salvage the myocardium and reduce morbidity and mortality.

Frequency:
In the US: AMI is a leading cause of morbidity and mortality in the United States. There are
1.3 million reports of nonfatal AMI each year, for an annual incidence of approximately 600
per 100,000 people.

Mortality/Morbidity:

• Approximately 500,000-700,000 deaths caused by ischemic heart disease occur in the
  United States alone.
• More than one half of deaths occur in the prehospital setting.
• In-hospital fatalities account for 10% of all deaths. An additional 10% of deaths occur in
  the first year postinfarct.

Sex:

• Male predilection exists in persons aged 40-70 years.
• In persons older than 70 years, no sex predilection exists.

Age:

• AMI occurs most frequently in persons older than 45 years.
• Certain subpopulations younger than 45 years are at risk, particularly cocaine users,
   insulin-dependent diabetics, patients with hypercholesterolemia, and those with a positive
   family history for early coronary disease. A positive family history includes any first-degree
   male relative aged 45 years or younger or any first-degree female relative aged 55 years
   or younger who experienced a myocardial infarction.
• In younger patients, the diagnosis may be hampered if the physician does not maintain a
   high index of suspicion


Author: Maxim Ivanov                   Page 2                              8/20/2010
Approved: 28 July 2004
History:

• Chest pain, usually across the anterior precordium, is described as tightness, pressure, or
   squeezing.
• Pain may radiate to the jaw, neck, arms, back, and epigastrium. The left arm is affected
   more frequently than the right arm.
• Dyspnea, which may accompany chest pain or occur as an isolated complaint, indicates
   poor ventricular compliance in the setting of acute ischemia.
• Nausea and/or abdominal pain often are present in infarcts involving the inferior wall.
• Anxiety
• Lightheadedness and syncope
• Cough
• Nausea and vomiting
• Diaphoresis
• Wheezing
• Elderly patients and those with diabetes may have particularly subtle presentations and
   may complain of fatigue, syncope, or weakness

Physical:

• Frequently, physical examination findings are normal.
• Patients with ongoing symptoms usually will lie quietly in bed and appear pale and
diaphoretic.
• Hypertension may precipitate AMI, or it may reflect elevated catecholamines due to
anxiety, pain, or exogenous sympathomimetics.
• Hypotension indicates ventricular dysfunction due to ischemia. It usually indicates a large
infarct and may be observed with a right ventricular infarct.
• Acute valvular dysfunction may be present.
        o This dysfunction usually involves the papillary muscle.
        o Mitral regurgitation due to papillary muscle ischemia or necrosis may be present.
• Congestive heart failure (CHF) may occur.
        o Neck vein distention
        o Third heart sound (S3)
        o Rales on pulmonary examination
• New or worsening mitral regurgitant murmur may be noted.
• A fourth heart sound is a common finding in patients with poor ventricular compliance that
   is due to a preexisting heart disease or hypertension.
• Dysrhythmias may be present.
• With heart block or right ventricular failure, cannon jugular venous a waves may be noted.

Causes:

• The predominant cause is a rupture of an atherosclerotic plaque with subsequent spasm
   and clot formation.
• Ventricular hypertrophy (eg, left ventricular hypertrophy [LVH], idiopathic hypertrophic
   subaortic stenosis [IHSS], underlying valve disease)


Author: Maxim Ivanov                 Page 3                             8/20/2010
Approved: 28 July 2004
• Hypoxia due to carbon monoxide poisoning or acute pulmonary disorders (Infarcts in this
   setting usually occur when myocardial demands dramatically are increased relative to
   blood supply.)
• Emboli to coronary arteries, which may be due to cholesterol or infectious causes
• Coronary artery vasospasm
• Arteritis
• Coronary anomalies, including aneurysms of the coronary arteries
• Cocaine, amphetamines, and ephedrine
        o Increase afterload or inotropic effects, which increase myocardial demand
        o Primary vasospasm of the coronary artery
•Risk factors for atherosclerotic plaque formation include the following:
        o Age
        o Being male and younger than 70 years
        o Smoking
        o Hypercholesterolemia and hypertriglyceridemia
        o Diabetes mellitus
        o Poorly controlled hypertension
        o Type A personality
        o Family history
        o Sedentary lifestyle

Lab Studies:

• Creatine kinase–MB (CK-MB)
       o This is the criterion standard for detection of myocardial necrosis.
       o Levels begin to rise within 4 hours after injury, peak at 18-24 hours, and subside
           over 3-4 days.
       o Upper limit of reference range values for CK-MB is 3-6% of total CK.
       o A level within the reference range in the ED does not exclude the possibility of
           myocardial necrosis.
       o A single assay in the ED has a sensitivity of 34%.
       o Serial sampling over periods of 6-9 hours will increase the sensitivity to nearly 90%.
       o Over 24 hours, the sensitivity is near 100%.
• Myoglobin
       o This is a very sensitive early marker of acute myocardial necrosis, but it is not
         specific for myocardial cell necrosis.
       o The myoglobin/carbonic anhydrase III ratio increases specificity. Myocardial cells do
         not release carbonic anhydrase.
• Troponin I
       o This is a contractile protein that normally is not found in serum. It is released only
         when myonecrosis occurs.
       o For early detection of myocardial necrosis, sensitivity of this study is superior to that
         of the CKMB. Troponin I is detectable in serum 3-6 hours after an AMI, and its level
         remains elevated for 14 days.
       o Troponin T has similar release kinetics and specificity for myocardial necrosis, but it
         is slightly less sensitive than troponin I within the first 6 hours.


Author: Maxim Ivanov                   Page 4                              8/20/2010
Approved: 28 July 2004
DIFFERENTIALS:

Acute Coronary Syndrome
Anxiety
Aortic Stenosis
Asthma
Cholecystitis and Biliary Colic
Cholelithiasis
Chronic Obstructive Pulmonary Disease and Emphysema
Congestive Heart Failure and Pulmonary Edema
Dissection, Aortic
Endocarditis
Gastroenteritis
Mitral Regurgitation
Myocarditis
Pancreatitis
Pericarditis and Cardiac Tamponade
Pneumothorax, Iatrogenic, Spontaneous and Pneumomediastinum
Pulmonary Embolism
Shock, Cardiogenic

CASE MANAGEMENT:

Chiropractic Management: N/A

Medical Management:

Antithrombotic agents -- These agents prevent the formation of thrombus associated with
myocardial infarction and inhibit platelet function by blocking cyclooxygenase and
subsequent aggregation. Antiplatelet therapy has been shown to reduce mortality by
reducing the risk of fatal myocardial infarctions, fatal strokes, and vascular death. : Aspirin
(Anacin, Bayer Buffered Aspirin, Ecotrin)

Vasodilators -- Opposes coronary artery spasm, which augments coronary blood flow and
reduces cardiac work by decreasing preload and afterload. It is effective in the management
of symptoms in AMI but may reduce the mortality rate only slightly. Nitroglycerin can be
administered sublingually by tablet or spray, topically, or IV. In the setting of AMI, topical
administration is a less desirable route because of unpredictable absorption and onset of
clinical effects. : Nitroglycerin (Minitran, Nitrogard, Nitrol, Nitrolingual, Nitrostat)


Beta-adrenergic blockers -- Inhibit chronotropic, inotropic, and vasodilatory responses to
beta-adrenergic stimulation and reduce blood pressure, which decreases myocardial oxygen
demand. Short-term and long-term mortality rates are reduced in patients with AMI. Greatest
benefit is achieved when given within 8 hoursof symptom onset. Aim for a target heart rate
of 60-90 beats per minute (bpm).: Metoprolol (Lopressor)


Author: Maxim Ivanov                   Page 5                              8/20/2010
Approved: 28 July 2004
Thrombolytic agents -- These agents prevent recurrent thrombus formation and rapid
restoration of hemodynamic disturbances. In addition, they remove pathologic intraluminal
thrombus or embolus not yet dissolved by the endogenous fibrinolytic system. When given
within 12 h of symptom onset, they restore patency of occluded arteries, salvage
myocardium, and reduce morbidity and mortality of AMI. Thrombolytic treatment should be
started within 30 min of arrival (door-drug time). Maximum benefit occurs when administered
within 1-3 h of symptom onset: Alteplase (Activase) or Reteplase (Retavase)

Platelet aggregation inhibitors -- These agents inhibit platelet aggregation and reduce
mortality.¨ Clopidogrel (Plavix)

Analgesics -- Reduce pain, which decreases sympathetic stress. May provide some preload
reduction. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating
properties, which are beneficial for patients who experience chest discomfort resulting from
a myocardial infarction.: Morphine sulfate (Duramorph, Astramorph, MS Contin)




Author: Maxim Ivanov                 Page 6                             8/20/2010
Approved: 28 July 2004
                           CLINICAL APPLICATIONS
                            Faculty Case Study Preparation


CONDITION Piriformis Syndrome

Prepared by: Janice Higgins-Fordree, D.C.
___________________________________________________________

RELEVANT PATHOPHYSIOLOGY:

Trauma to the sacroiliac joint produces a ligamentous sprain, leading to piriformis
syndrome. Biomechanical agents released from the inflamed piriformis muscle,
where two structures meet at the sciatic foramen, cause irritation of the sciatic nerve
sheath. Neurological injury to L5/S1 can result in denervation atrophy of the
piriformis. Facet injury can produce reflex syndrome of the muscle. Overuse can
produce fatigue or strain of the piriformis as can leg length asymmetry. Predisposing
factors include anomalous sciatic nerve, tight external rotators and neurological
insult to L5/S1. Differs from radiculitis in that there is no internal derangement of the
nerve – too protected by connective tissue.

CASE HISTORY:

PPW: Pain and/or parasthesia in the distribution of the sciatica nerve, Pain is either
deep boring or dull ache that radiates down the poster lateral thigh to the knee
occasionally extending to the foot. Burning sensation in the hips over the greater
trochanter, especially at night preventing the patient to lie on their side. Two most
common causes of piriformis syndrome are trauma to the sacroiliac joint producing a
ligamentous sprain and hormone changes that occur during menstrual cycle,
pregnancy, estrogen replacement therapy or oral contraceptives.

Onset-Initial
      Palliative/Provocative      Prolonged sitting, prolonged external rotation of
      leg (pressing an accelerator while driving), leg length discrepancy.
      Quality/Quantity     Deep boring pain in the buttock, burning sensation in hips
      over greater trochanter.
      Referred/Radiating Poster lateral thigh or calf, rarely to foot
      Site Buttock traveling down thigh and leg
      Timing/Pattern       After prolonged sitting, (watching TV, driving, class)
      Other

Relevant History and Lifestyle:
             Gender        6 Females to 1 male ratio
             Age                no specific age range ___
             Occupation truck driver, secretary, etc.
             Traumas

Janice Fordree, D.C.                   Page 1                              8/19/2010
Approved 04/08/04
             Surgeries
             Medications
             Hospitalizations
             Immunizations
             Diseases/Conditions   Pregnancy, menopause
             Family History
             Diet
             Sleep Habits
             Sexual History
             Alcohol Usage
             Drug Usage
             Smoking/Tobacco
             Other__________________________________________________


Review of Systems



PHYSICAL EXAMINATION:

Height                                 Weight

Vitals: BP             Pulse                        Respiration________ Temp.

Appearance, Motion, Gait               Antalgic

Orthopedic Tests

      Test Name                R            L              Test Name            R           L
SLR                        +       -    +       -                               +   -   +       -
Hibbs                      +       -    +       -                               +   -   +       -
Nafzinger                  +       -    +       -                               +   -   +       -
Valsalva                   +       -    +       -                               +   -   +       -
                           +       -    +       -                               +   -   +       -

Orthopedic Test Results Discussion:        (+) SLR – pain intensified by simultaneous
internal rotation of the leg and relieved by external rotation (piriformis test). (+)
Nafzingger/Valsalva indicators of disc herniation.


Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception - All WNLs




Janice Fordree, D.C.                      Page 2                                8/19/2010
Approved 04/08/04
Lab Values


Examination of Related Areas



Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.) Observations; foot flare, unilaterally of side of involvement,
overpronation




SPINAL EXAMINATION:

      Postural Analysis                        Postural Analysis      L      N        R
                                               Head Tilt
                                               Head Rotation
                                               High Ear
                                               High Shoulder
                                               High Ilium
                                               Ext. Rotated Foot
                                               Int. Rotated Foot


ROM
             Cervical ROM                                 Lumbar ROM
               ROM      Pain      Level                    ROM     Pain              Level
Flexion        N  Y N                   Flexion          N     Y N
Extension      N  Y N                   Extension        N     Y N
R. Rotation    N  Y N                   R. Rotation      N     Y N
L. Rotation    N  Y N                   L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                   R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                   L. Lat. Flex.    N     Y N



ROM Internal rotation of hip with knees flexed is painful / Sacroiliac asymmetry and
fixations are common.




Leg Length/Spinal Balance Normal to have leg discrepancy

Janice Fordree, D.C.                  Page 3                              8/19/2010
Approved 04/08/04
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion) Trigger points are palpable in the belly of the
muscle through the mass of the gluteus maximus muscle and the tendinous insertion
at the greater trochanter. Deep pressure of the muscle belly produces radiation
down course of sciatic nerve while pressure at the tendinous insertion produces
localized burning sensation. Tender at origin and insertion of piriformis

List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

       X-rays      MRI            CT        Other

Views A-P/Lateral Lumbopelvic


Findings    Unremarkable – may show possible increase in lordosis and the sacral
base angle.

NOTE – CT, MRI, x-ray, Myelography and EMG are of limited diagnostic value.




DIFFERENTIALS:

     Sciatica, Referred pain, Fracture, Myofascial pain syndrome, IVD syndrome,
Compression of nerve root lesions.

NOTE – Most unrecognized cause of sciatica.



DIAGNOSIS:
             Piriformis Syndrome

Janice Fordree, D.C.                 Page 4                          8/19/2010
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Case Management:

Chiropractic Management:           Various techniques can be used to correct the
vertebral subluxation - Thompson, Pierce, and SOT are some of the more common
techniques to use for this condition.

Adjunctive Therapy:




Physical Therapy: Acute phase – ice, ultrasound (pulsed) and galvanism may be
used. Hip or contra lateral sacroiliac fixations should be adjusted. – caution is
advised against repeat non specific pelvic manipulation since this tends to
perpetuate the condition. Sub acute phase – moist hot packs, ultra-sound electrical
muscle stim combination, muscle work including trigger points and manipulation.

Nutrition:   Magnesium and calcium



Exercise:   Piriformis stretch, PIR stretch technique (Post isometric relaxation),
McKenzie extension exercises.


Health Promotion and Maintenance (i.e. ergonomics, spinal hygiene, psychosocial
concerns/education)      -get adequate rest on a firm mattress
                         -avoid heavy lifting or bending postures
                         -sleep supine with pillows under knees or on side with
pillow between legs
                         -perform piriformis stretch as instructed


Further Evaluation:        Indications that a referral may be need are true
anesthesia, loss/reduction of hamstring or Achilles tendon reflex,. Signs of
progressive atrophy or no improvement or increase in severity (failure to respond).
Referral would be to neurologist.

Common Medical Management: Include physical therapy, deep massage, ROM
exercises, NSAID’s (non-steroid inflammatory meds such as ibuprofen or naproxen),
a local anesthetic and corticosteroid injections. For persistent piriformis spasms an
injection of botulinum toxin (aka – “bo tox”) may be used.


Janice Fordree, D.C.                 Page 5                             8/19/2010
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Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.




Condition Name      Baseline   Complicating/ Mitigating Factors         Revised
                    Complexity                                          Complexity
Piriformis Syndrome    3.0     Risk factor of prolonged overuse,           4.0
                               prolonged sitting, prolonged
                               external rotation of leg, leg length
                               discrepancy
                               Risk factor of hormone changes,              4.0
                               pregnancy and menopause
                               Risk factor of need for referral             6.0
                               include hamstring and Achilles
                               tendon reflex loss/reduction,
                               progressive atrophy and no
                               improvement and/or increase in
                               severity




Janice Fordree, D.C.                Page 6                            8/19/2010
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                            CLINICAL APPLICATIONS
                           Faculty Case Study Preparation


CONDITION: Postural Syndrome

Prepared by: Dr. Renee Prenitzer

RELEVANT PATHOPHYSIOLOGY:

According to Dr. Craig Liebenson, D.C. dysfunction involving excessive T4-T8 kyphosis
is common and is usually the result of continued sitting with bad posture. The patient
most often works at a deskjob and has a tendency towards anterior head carriage and
forward rolled shoulders. The resulting muscular imbalance effects the anterior chest
and shoulder muscles as well as the posterior chest and shoulder muscles. Postural
syndrome is also referred to as sternosymphyseal syndrome. Muscle imbalances that
may be seen on the anterior chest and shoulder are the following: contractured or
shortened pectoralis muscles, scalene muscles. Muscle imbalances that may be seen
on the posterior chest and shoulder following: weakness and strain of the rhomboids,
the upper and middle trapezius and the levator scapulae. The slumping associated with
postural syndrome can be associated with inhibition of the diaphragm and
overactivation of the scalenes.

Posture can be affected by psychosocial issues such as shyness or abuse. Persons
with low self-esteem reflect their emotional well-being in the attitude of their posture.
This can be seen commonly in young women in the beginning stages of development of
sexual characteristics by an attempt to hide breast development by rounding shoulders
forward. Anatomically, heavy breasted women may have a higher tendency towards
rounded shoulders and anteriorly shifted weight due to the size and weight of breast
tissue. [ Chiropractic Management of Spine Related Disorders by Meridel Gatterman,
Lippincott, Williams, & Wilkins, 2nd edition.]

CASE HISTORY:

PPW: Chronic complaints of pain in the neck, upper, mid, or low back.

Onset-Initial: Usually of gradual onset
Palliative/Provocative: Relieved by activity and stretching, made worse by continued
        working at a desk.
Quality/Quantity: Aching nagging pain located at the back of the neck between the
        shoulder blades in the upper and mid-thoracic spine and in the low back.
Referred/Radiating :
Site: Problem area is generally between T4-T8; however, that may cause pain
        elsewhere in the spine
Timing/Pattern: Daily, worse during working hours (can last for entire working day
        dependent upon desk time

Renee Prenitzer, D.C.                Page 1                             8/20/2010
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Other: Nothing Sufficient

Relevant History and Lifestyle

      Gender: Not significant
      Age: Not significant
      Occupation: Is associate with desk jobs, i.e. office worker. Can be associated
             with athletic activities which accentuate specific muscle groups, i.e.,
             swimmers, weight lifters, body builders
      Traumas: Can be related to one or more compression fractures in the thoracic
             spine
      Surgeries: Not significant
      Medications: History of corticosteroid use can contribute to an increase of
                            compression fracture occurrence
      Hospitalizations: As to the differential, hospitalization for tuberculosis
      Immunizations
      Diseases or Conditions: Prolonged history of asthma/ allergies with corticosteroid
             use, history of tuberculosis (ddx)
      Family History: Not significant
      Diet : Not significant
      Sleep Habits: May be exacerbated by using a big pillow when sleeping on back
             or when sleeping on stomach
      Sexual History: Not significant
      Alcohol Usage: Not significant
      Drug Usage : Not significant
      Smoking/Tobacco: Not significant
      Other: Not significant


Review of Systems: May see differences in respiration, may see problems with
respiratory system if tuberculosis (ddx) is indicate.



PHYSICAL EXAMINATION:

Height : Tall patients with low self-esteem who slouch may be associated with this
syndrome

Weight: Non-sufficient findings

Vitals: BP: NSF Pulse: NSF        Respiration: NSF Temperature : NSF

Appearance, Motion, Gait: Slouched posture with anterior head carriage. Postural
changes may be seen in individuals with self-esteem issues.



Renee Prenitzer, D.C.                Page 2                            8/20/2010
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Orthopedic Tests

      Test Name               R          L            Test Name              R           L
Prone Extension Test          +          +                                  +    -   +       -
Adam’s Position’s Test         -          -                                 +    -   +       -
Chest Expansion            Finding Finding                                  +    -   +       -
                            + -         + -                                 +    -   +       -
                            + -         + -                                 +    -   +       -

Orthopedic Test Results Discussion: Prone Extension Test is performed by having the
patient lie prone and place hands on hips and try to extend thoracic spine. If the
hyperkyphosis diminishes or disappears, then it is functional, if it remains then the
hyperkyphosis is structural.

Chest Expansion Test may show a finding of decreased expansion if the patient has
multiple compression fractures in the thoracic spine or if the patient has constrained
posture that inhibits full inhalation and exhalation.

Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception : Neurological Tests will reveal that all areas are
within normal limits.

  Nerve Root Package               Motor (0-5)         Sensory           Reflex (0-4)
          C5                                             N    
          C6                                             N    
          C7                                             N    
          C8                                             N    
          T1                                             N    
          L4                                             N    
          L5                                             N    
          S1                                             N    


Lab Values: Labs work can be performed to rule-out tuberculosis

Examination of Related Areas: As part of the differential diagnosis, Thoracic Outlet
Syndrome needs to be ruled-out. Preferably using the orthopedic tests Wright’s
Hyperabduction Test and Eden’s Test. As part of the differential diagnosis, 1st Rib
dysfunction needs to be ruled out.

Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.) Non-sufficient findings




Renee Prenitzer, D.C.                 Page 3                             8/20/2010
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SPINAL EXAMINATION:

       Postural Analysis                             Postural Analysis         L      N       R
                                                     Head Tilt
Anterior Head Carriage, Rolled Shoulders,            Head Rotation
Hyperkyphotic Spine, Possible Flaring of the         High Ear
Scapulae                                             High Shoulder
                                                     High Ilium
                                                     Ext. Rotated Foot
                                                     Int. Rotated Foot
Normal Posture Examination
Lateral view: balance about a coronal line of reference or gravity line that passes
through the external auditory meatus, the odontoid process, a point just anterior to the
AC joint, slightly posterior to the center of the hip joint, slightly anterior to the center of
the knee and d slightly anterior to the lateral malleoli of the ankle

Anterior to Posterior View: division of the body into symmetrical halves by bisection of
the following points: glabella, fenulum, episternal notch xiphoid process,symphysis
pubis, and a point midway between the medial malleoli.

Anterior Head Carriage - “For every inch that the head moves forward, the compressive
forces on the lower cervical spine increase by the additional weight of the entire head.”
[Rehabilitation of the Spine: A Practitioner’s Manual by Editor, Liebenson, Craig.
Williams & Wilkins, 1996, p. 177]

Signs of Poor Posture: weight over the balls of the feet, hyperlordosis in lumbar spine,
hyperkyphosis in thoracic spine, rounded shoulders, anterior head position, and a chin
that juts forward. [Rehabilitation of the Spine: A Practitioner’s Manual by Editor,
Liebenson, Craig. Williams & Wilkins, 1996, p. 177]


 ROM – Possible global changes in ROM due to muscle strain and pain due to
 muscle strain
             Cervical ROM                         Lumbar ROM
               ROM      Pain Level                 ROM        Pain     Level
Flexion        N  Y N             Flexion        N        Y N
Extension      N  Y N             Extension      N        Y N
R. Rotation    N  Y N             R. Rotation    N        Y N
L. Rotation    N  Y N             L. Rotation    N        Y N
R. Lat. Flex.  N  Y N             R. Lat. Flex.  N        Y N
L. Lat. Flex.  N  Y N             L. Lat. Flex.  N        Y N


Leg Length/Spinal Balance


Renee Prenitzer, D.C.                    Page 4                               8/20/2010
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Instrumentation/Pattern Analysis: Possible increased heat readings over areas of
       overuse
Palpation (Muscle, Static, Motion) : Increased incidence of spasmed paraspinal
       muscles


List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

       X-rays       MRI          CT           Other

Views: Lateral and Anterior to Posterior Thoracic views
Findings: Lateral thoracic findings of anterior compression of vertebral body greater
than 50% of the height of the posterior vertebral body or a greater than or equal to 20
degree amount of wedging may indicate an unstable compression fracture. Loss of
posterior vertebral height may indicate pathological fracture due to metastasis. Anterior
to Posterior view may reveal missing pedicle (seen with metastasis of breast cancer).

DIFFERENTIALS:

Scheuermann’s disease (seen with radiographs), compression fracture, Gibbous
Deformity, Dowager’s Hump, Rib Misalignment or Dysfunction, Tuberculosis of the
Spine, T4 Syndrome ( reproduction of arm complaints may be seen upon exerting
pressure over the spinous or transverse process of T4), With associated chest pain –
Myocardio Infarction. Pulmonary Emphysema.




Renee Prenitzer, D.C.                Page 5                             8/20/2010
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Dowager’s Hump




                                                                  Gibbous Deformity
    Case Management:


    Chiropractic Management: Thoracic adjustments, stretches for the anterior
    musculature (scalenes, pectoralis muscles), strengthening exercises for the
    posterior musculature (rhomboids, upper and middle trapezius, levator scapulae),
    shoulder girdle adjustments. Thoracic Adjustments. Cervical Adjustments.

    Adjunctive Therapy: Massage Therapy, Biofeedback for posture changes, Heat, Trigger
    Point Therapy, Positional Release Therapy.

     Brugger’s Relief Position – works muscles that tend to be inhibited and eases muscles
    that tend to be shortened. The patient sits close to the edge of a chair with his arms
    hanging down. The feet are placed directly beneath the knees and then positioned
    slightly apart and turned outward. The patient should roll the pelvis slightly forward to
    increase the lordosis in the low back. The patient should project the sternum up and
    forward and then turn the arms outward, so that the fingers face forward. Have the
    patient separate the fingers until the thumbs face slightly backward. Have the patient
    tuck the chin slightly. Hold this posture for a cycle of 4 to 5 breaths. Repeat as needed.
    This “relief” posture helps keep the chest free and open and can reverse the effects of
    long periods of sitting.

    Renee Prenitzer, D.C.                Page 6                             8/20/2010
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PhysicalTherapy:_____________________________________________________
_____________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Nutrition:




Exercise: 1) Head Extension Isometric Exercise – Patient in a seated position. Have
patient clasp fingers behind head. Have patient extend head back as far as comfortably
possible and contact muscles against the resistance of their interlocked fingers. Have
the patient hold this for 10 seconds and repeat for 10 repetitions. (Can perform up to 10
sets per day). 2) Head Retraction Exercises – Have the patient sit in a chair that
supports the shoulder blades and slide the head and neck back as far as comfortably
possible. Hold this position for 10 seconds and repeat 10 times. (Can perform up to 10
sets per day).               [ Structural Rehabilitation of the Spine & Posture: A
Practical Approach by Stephan Troyanovich, D.C. MPAmedia, 2001]              3) Assume
the “military position”. Stand with back against wall and flatten shoulder blades against
the wall in a relaxed manner. Stack the cervical spine so that the back of the head is
flush against the wall with the chin slightly tucked. (Repeat throughout the day as
necessary)



Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education): Proper workstation ergonomics, Brugger’s Relief Position, Military
Posture, Counseling for Self-esteem issues.

Further Evaluation:



Common Medical Management:

Scheuermann’s Disease - When the kyphosis is more severe, recommendations include
casting, a spinal brace, or rest and recumbency on a rigid bed. Orthotic management of
Scheuermann kyphosis usually requires 12-24 months of treatment. Pain generally
responds to nonsteroidal anti-inflammatory drugs (NSAIDs), as well as to temporary
activity restriction
Surgery rarely is indicated in patients with Scheuermann disease. Probably the 2 most
common indications for surgery are spinal pain and unacceptable cosmetic appearance.

Renee Prenitzer, D.C.                Page 7                             8/20/2010
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References:

Structural Rehabilitation of the Spine & Posture: A Practical Approach by Stephan
Troyanovich, D.C. MPAmedia, 2001

Rehabilitation of the Spine: A Practitioner’s Manual by Editor, Liebenson, Craig.
Williams & Wilkins, 1996

Differential Diagnosis and Management for the Chiropractor, by Souza

Chiropractic Management of Spine Related Disorders by Meridel Gatterman, Lippincott,
Williams, & Wilkins, 2nd edition.



Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early stage
of condition, advanced stage of condition, psychosocial issues, etc. The complicating or
mitigating factors can either increase or decrease the baseline complexity.




Condition Name          Baseline     Complicating/ Mitigating Factors         Revised
                        Complexity                                            Complexity
                                     Compression fractures as cause              4.0
                                     Cause of TOS                                5.0
 Postural Syndrome          2.0      Degeneration of spinal structures           4.0
                                     due to altered biomechanics
                                     Consequence of esteem issues –                 5.0
                                     referral for counseling
                                     Due to breast size – referral for              3.0
                                     breast reduction




Renee Prenitzer, D.C.                Page 8                              8/20/2010
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                           CLINICAL APPLICATIONS
                          Faculty Case Study Preparation


CONDITION: Sacroiliac Sprain

Prepared by: Maria Michelin, DC


RELEVANT PATHOPHYSIOLOGY:

Sprain or mild separation of the sacroiliac joint. This is a strong ligament and actual
increases in joint space are minimal.


CASE HISTORY:

PPW: Pain over the sacroiliac joint
Onset-Initial Mode-lifting a heavy object or rising from a stooped position
      Palliative- not moving or lying down
      Provocative-moving, changing positions, lifting
      Quality/Quantity-sharp and stabbing, moderate to severe
      Referred/Radiating–possible low back or buttock radiation
      Site-sacroiliac joint
      Timing/Pattern-constant ache, recurrent sharp and stabbing
      Other- May be due to pregnancy

Relevant History and Lifestyle
      Gender
      Age
      Occupation
      Traumas
      Surgeries
      Medications
      Hospitalizations
      Immunizations
      Diseases or Conditions__________________________________ _
      Family History
      Diet
      Sleep Habits
      Sexual History
      Alcohol Usage
      Drug Usage
      Smoking/Tobacco
      Other- “Weekend Warrior” type injury or overuse


Maria Michelin, D.C.                  Page 1                              8/20/2010
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Review of Systems                                                      _____

     ______________________________________________________
___________________________________________________________



PHYSICAL EXAMINATION:

Height                             Weight

Vitals: BP             Pulse                Respiration________ Temp.

Appearance, Motion, Gait – antalgic posture and gait

Orthopedic Tests

      Test Name                R       L         Test Name                   R              L
Belt                           +       +     FABERE                             -           -
Gaenslen                       +       +                                    +       -   +       -
Hibbs                          +       +                                    +       -   +       -
Gillet                         +       +                                    +       -   +       -
Yeoman                         +       +                                    +       -   +       -

Orthopedic Test Results Discussion:
All of the tests should aggravate the pain the involved sacroiliac joint.


Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception
All within normal limits

LabValues__________________________________________________________
_____ ____________________________________________________________


Examination of Related Areas



Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




Maria Michelin, D.C.                   Page 2                               8/20/2010
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SPINAL EXAMINATION:

      Postural Analysis                        Postural Analysis   L      N        R
                                               Head Tilt
      Antalgic posture                         Head Rotation
                                               High Ear
                                               High Shoulder
                                               High Ilium
                                               Ext. Rotated Foot
                                               Int. Rotated Foot

ROM
             Cervical ROM                                 Lumbar ROM
               ROM      Pain      Level                    ROM     Pain       Level
Flexion        N      Y N               Flexion          N     Y N
Extension      N  Y N                   Extension        N     Y N
R. Rotation    N  Y N                   R. Rotation      N     Y N
L. Rotation    N  Y N                   L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                   R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                   L. Lat. Flex.    N     Y N

All lumbar ROM will cause pain in the involved sacroiliac joint

Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion)




List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




Maria Michelin, D.C.                  Page 3                           8/20/2010
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RADIOLOGICAL EXAMINATION:

         X-rays       MRI        CT            Other

Views           All WNL

Findings




DIFFERENTIALS:

        1.   Lumbar facet syndrome
        2.   Piriformis syndrome
        3.   Lumbar disc herniation
        4.   Sacroiliac subluxation


Case Management:


Chiropractic Management:
Do not adjust into an acute sprain if greater than a grade 1. Adjust subluxations
to stabilize the spine.

Adjunctive Therapy:
Trigger point therapy and soft tissue massage.

Physical Therapy:
Ice to reduce the edema. Rest in the acute phase. SI support braces are useful.

Nutrition:




Exercise:
Avoid stretching of ligaments into already sprained direction. When able,
recommend strengthening the muscles of the low back and pelvis in the non-acute
status.



Maria Michelin, D.C.                  Page 4                            8/20/2010
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Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education):
Avoid crossing legs while sitting, sitting on wallet, and sitting on worn-out furniture.

Further Evaluation:



Common Medical Management:
None that is really effective. NSAIDs.

References:
Vizniak and Carnes, Quick Reference Clinical Chiropractic Conditions Manual
Souza, Differential Diagnosis and Management for the Chiropractor
Huff and Brady, Instant Access to Chiropractic Guidelines and Protocols


Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.


Condition Name         Baseline   Complicating/ Mitigating Factors            Revised
                       Complexity                                             Complexity
SI Sprains/Strains        2.0     Grade 1-self resolves in less than a           2.0
                                  week.
                                  Grade 2-                                        6.0
                                  modifications/contraindications to
                                  adjustments. PT and home care
                                  recommendations
                                  Grade3-fracture of pelvis                      10.00
                                  Grade 3-gross instability requiring            10.00
                                  orthopedic-medical consult
                                  regarding surgical implications




Maria Michelin, D.C.                   Page 5                              8/20/2010
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                            CLINICAL APPLICATIONS
                          Faculty Case Study Preparation


CONDITION___Spondylolisthesis__________________________________

Prepared by: _____Janice H. Fordree ______________________________

RELEVANT PATHOPHYSIOLOGY:

Spondylolisthesis is a medical term that refers to a slippage of one vertebral body
over another. This most commonly involves the fourth and fifth lumbar or the fifth
lumbar and first sacral vertebral bodies. There are a number of reasons for the slip,
one of, which is called spondylolysis. Spondylolysis is another name for isthmic
spondylolisthesis. In these cases, there is a defect in a portion of the spine called the
"pars interarticularis", on x-rays, it is seen as the neck of the "Scotty dog".
Spondylolisthesis is the most common cause of back pain in adolescents but most
cases are asymptomatic. Symptoms when they occur often begin with the growth
spurt. When symptoms occur, the course can be slow, progressive and severe. Long
asymptomatic periods are common.


Dysplastic/Congenital: inadequate development of the posterior elements without
slippage is spondylolysis. More common in women – usually occurs during growth
spurt. 14-21% of cases.
Isthmic: a break of the pars interarticularis as a result of a fatigue fracture (most
common), acute trauma (rare) or repeated micro trauma leading to elongation. More
common in men and in about half of the cases there is no slippage in 5-20% of
cases seen.
Degenerative: a break in the pars interarticularis as a result of erosive pressure
from the superior articular facet below and the inferior articular facet above. More
common in women and occurs after 40 years of age. Degenerative
spondylolisthesis is usually a result of long standing instability most common at the
junction of the 4th and 5th lumbar. The instability is a result of disc degeneration and
facet joint degeneration.
Traumatic: a break in the neural arch as a result of acute trauma to any area other
than the pars interarticularis.
Pathologic: destructive lesion to the pars interarticularis as a result of dysplasia,
carcinoma, metastasis, severe osteoporosis, Paget’s disease or others. This is the
least common cause.




CASE HISTORY:


Janice Fordree, D.C.                   Page 1                             8/20/2010
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PPW: The most common symptom of spondylolisthesis is pain. The exceptions are
the degenerative, traumatic and pathologic types of spondylolisthesis. There are to
types of pain seen in cases of spondylolisthesis. One is a sciatic type of pain with
radiation (spread) to the buttock, back of the thigh and calf. This is due to stenosis of
the lateral recess (the area of the spine where the nerve exits). This type of pain
may be mistaken for a lumbar disc herniation. The second pain presentation in
spondylolisthesis is claudication type pain. While claudication means limping, the
pain is generally related to activity, walking or prolonged standing. The pain in these
cases is located in the back, buttocks, thighs or calves. It improves with rest, either
sitting or lying down.


Onset-Initial Findings often vary and are inconsistent – activities that require
extension/flexion movements increase incidence (rowing, gymnastics, etc.)
        Palliative/Provocative
Provocative: Increase LBP with hyperextension of the lumbar spine, activity or
upright posture.
Palliative: It improves with rest, either sitting or lying down.
      Quality/Quantity
      Referred/Radiating Back, buttocks, thighs or calves.
      Site L5 – 90%, L4 - 5%, L1-L3 – 3%, C5-C7 – 2%
      Timing/Pattern During activities that require repetitive extension/flexion,
walking or prolonged standing.
      Other

Relevant History and Lifestyle
      Gender       2:1 ratio males to females
      5-7% Caucasian 40% Eskimo population

      Age Toddlers - shortly after beginning to walk with repeated falls , especially if
premature walking occurs
       Ischemic occurs in 5-6 years old, Translations in 10-14 year olds,
degenerative occurs in the elderly.
      Occupation Activities or sports that require repetitive extension/flexion
movements, gymnastics, diving, pee wee football, weight lifters, pregnancy, etc.
      Traumas
      Surgeries
      Medications
      Hospitalizations
      Immunizations
      Diseases or Conditions__________________________________ _
      Family History
      Diet
      Sleep Habits
      Sexual History
      Alcohol Usage
Janice Fordree, D.C.                   Page 2                              8/20/2010
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         Drug Usage
         Smoking/Tobacco
         Other__________________________________________________


Review of Systems                                                  _____

PHYSICAL EXAMINATION:

Height                           Weight

Vitals: BP             Pulse              Respiration________ Temp.

Appearance, Motion, Gait

Orthopedic Tests

      Test Name             R       L             Test Name             R       L
                           + -     + -                                 + -     + -
                           + -     + -                                 + -     + -
                           + -     + -                                 + -     + -
                           + -     + -                                 + -     + -
                           + -     + -                                 + -     + -

Orthopedic Test Results Discussion:      All negative unless acute trauma or
inflammation.



Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception ___Hypo/hyper DTRs possible, in rare cases
paresthesia over the lumbar nerve root dermatome pattern. __________________

LabValues__________________________________________________________
__

Examination of Related Areas



Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)




Janice Fordree, D.C.                  Page 3                           8/20/2010
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SPINAL EXAMINATION:

      Postural Analysis                      Postural Analysis     L      N        R
                                             Head Tilt
      Hypolordosis in lumbars.               Head Rotation
                                             High Ear
                                             High Shoulder
                                             High Ilium
                                             Ext. Rotated Foot
                                             Int. Rotated Foot


ROM
             Cervical ROM                                Lumbar ROM
               ROM      Pain     Level                    ROM     Pain            Level
Flexion        N      Y N              Flexion          N     Y N
Extension      N  Y N                  Extension        N     Y N
R. Rotation    N  Y N                  R. Rotation      N     Y N
L. Rotation    N  Y N                  L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                  R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                  L. Lat. Flex.    N     Y N


Leg Length/Spinal Balance
Instrumentation/Pattern Analysis
Palpation (Muscle, Static, Motion) Para spinal muscle spasms, tight hamstrings,
Chronic muscle spasms or myofascitis common, possible protrusion of spinous
process with depressed spinous at segment immediately above.


List the level for palpatory findings. Notate abnormal muscle findings and motion
restrictions.
 Level Muscle Motion Level Muscle Motion Level Muscle Motion




RADIOLOGICAL EXAMINATION:

       X-rays       MRI         CT           Other SPECT

Views A-P, Lateral, A-P spot shot, Flexion/extension and oblique views.


Findings A-P = L5 body over sacrum creates appearance of inverted “Napoleon Hat”
sign.
Janice Fordree, D.C.                Page 4                             8/20/2010
Approved 06/03/04
         A-P spot shot = better view of L5/S1 disc space
               Flexion/extension = rule out instability
               Obliques = see “collar” on Scottie dog and “step ladder” sign which
indicates misalignment of zygapophyseal joints at involved level.
                      Lateral = Meyerding Grading scale – as follows

               Grade I = 1-25% slippage
              Grade II = 25-50% slippage
              Grade III = 50-75 % slippage
              Grade IV = 75-100 % slippage
              Grade V = complete slippage of vertebral body in relation to segment
below.

Spondylosis – will see lucent defect in pars
Spondylolisthesis – will see lucent defect in pars with forward slippage.

SPECT – single photon emission tomography – used to distinguish athletic patients
who require an antilordotic brace and rest from those who do not have an “active”
lesion. Nuclear medicine with computerized tomography.


DIFFERENTIALS:

N/A


DIAGNOSIS:

         Spondylolisthesis


CASE MANAGEMENT:


Chiropractic Management: Grade I or II:
- specific spinal manipulation at dysfunctional joints above and/or below
- adjust S/I joints
- flexion distraction technique
- sacral pull (bilateral knees to chest)
- Nimmo
- Cox Distraction
- Pierce PI (adjust PI supine)
- Thompson supine pelvic adjustments

Side posture ? – no prone adjustments @ site



Janice Fordree, D.C.                  Page 5                                8/20/2010
Approved 06/03/04
“Hot” SPECT bone scan – place in a brace for several weeks with follow up bone
scan.


Adjunctive Therapy:         Lumbar belt for bracing



Physical Therapy:_Acute = interferential , TENS ultrasound and cryotherapy
_______________Chronic = diathermy, ultrasound____________________
Lumbar traction, COLD laser therapy

Nutrition:


Exercise: Knee to chest stretches/ Pelvic tilt / Adductor stretch / hamstring stretch /
iliopsoas stretch / Bridging stabilization / Core strengthening exercises – especially
lower abdomen / massage / positional release therapy


Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education): Postural education / lifting education_______________
________________________________________________________________

Further Evaluation:


Common Medical Management: The treatment of spondylolisthesis is complex and
depends on the presentation (the signs and symptoms). In adolescent cases of
isthmic spondylolisthesis (spondylolysis), the x-ray and bone scan may help decide
the type of treatment. If the bone scan is positive ("lights up"), a trial of bracing may
be successful. Other forms of conservative treatment include rest and physical
therapy.
Surgical treatment is divided into two possible approaches, decompression and
decompression with fusion. Decompression without fusion is generally avoided as it
may lead to further slip and progressive problems. Most surgical procedures include
both decompression and fusion. Fusion may be done in situations where no attempt
is made to reduce (correct) the slip. In some cases, an attempt may be made to
reduce the slip to create a more "normal" appearance to the spine. Frequently, some
type of fusion instrumentation will be implanted along with bone graft. The surgeon
will decide on the specific type of surgery after taking into account the patients
symptoms and the appearance of the various imaging studies.
References: _Vizniak & Carnes : Quick Reference Clinical Chiropractic Conditions
Manual

Janice Fordree, D.C.                   Page 6                               8/20/2010
Approved 06/03/04
Huff & Brady: Instant Access to Chiropractic Guidelines and Protocols
___________________________________________________________________



Case Complexity:

The category of complicating or mitigating factors should include the following
considerations: Ancillary labs, diagnostic studies, co-management issues, early
stage of condition, advanced stage of condition, psychosocial issues, etc. The
complicating or mitigating factors can either increase or decrease the baseline
complexity.


Condition Name    Baseline      Complicating/ Mitigating Factors           Revised
                  Complexity                                               Complexity
Spondylolisthesis    3.0        Symptomatic                                   4.0
                                Dysplastic/Congenital                         5.0
(Asymptomatic)                  Isthmis/Traumatic (break due to               6.0
                                trauma)
                                Degenerative (results in disc                  7.0
                                degeneration and or facet joint
                                degeneration)
                                Pathologic (destructive lesion as a            7.0
                                result of carcinoma, metastasis,
                                severe osteoporosis, Paget’s disease
                                or others).
                                Risk factor for activities that require        6.0
                                repetitive extension/flexion, prolonged
                                walking and prolonged standing
                                (gymnastics, diving, pee wee football,
                                weight lifters, pregnancy).
                                Grade I (1-25% slippage)                       4.0
                                Grade II (26-50% slippage)                     5.0
                                Grade III (51-75%)                             6.0
                                Grade IV (76-100%)                             7.0
                                Grade V (complete slippage of                  8.0
                                vertebral body in relation to segment)
                                Chiropractic management –                      6.0
                                contraindications to adjustment and
                                use of specific techniques.




Janice Fordree, D.C.                Page 7                                8/20/2010
Approved 06/03/04
                          CLINICAL APPLICATIONS
                          Faculty Case Study Preparation


CONDITION________Thoracic Compression Fracture____________________

Prepared by:_______Dr. Joseph J. Donofrio__________________________

RELEVANT PATHOPHYSIOLOGY:

       Most commonly found at T11 and T12. Sometimes associated with injuries
from convulsive seizures (T4-T8) or electric shock due to violent contracture of
abdominal muscles. Often a result of osteoporosis in elderly patients and post
menopausal women. Most often a result of trauma & hyperflexion injuries when seen
in young patients. Most commonly a compression of the anterior half of the vertebral
body but may include the entire vertebral body and pedicle region in most severe
and pathological forms.

CASE HISTORY:

PPW:           Lower thoracic pain (but could be clinically silent), severe cases may
result in anterior abdominal pain and loss of abdominal sensation and even motor
losses

Onset-Initial Sudden/recent                                              _____
      Palliative/Provocative     worse with flexion movement and weight bearing
      Quality/Quantity     Thoracic pain dull to sharp
      Referred/Radiating         May radiate if IVF encroachment or neural canal
compromised
      Site Thoracic spine
      Timing/Pattern       worse with activity
      Other

Relevant History and Lifestyle
       Gender        in women over age 40, 35% due to menopausal changes, 30%
due to long term corticosteroid usage. 8% due to hyperthyroidism. Less than 2% due
to malignancy.
       Age Youth – trauma 40+ osteoporosis or pathological
       Occupation n/a
       Traumas       possibly
       Surgeries     n/a
       Medications may self medicate with otc pain relievers
       Hospitalizations     n/a
       Immunizations        n/a
       Diseases or Conditions ___possible history of cancer, if pathological__
       Family History       possibly related to above

Joe Donofrio, D.C.                    Page 1                             8/20/2010
Approved 03/14/05
         Diet         n/a
         Sleep Habits     n/a
         Sexual History   n/a
         Alcohol Usage    n/a
         Drug Usage       n/a
         Smoking/Tobacco n/a
         Other__________________________________________________


Review of Systems           n/a                                           _____

     ______________________________________________________
___________________________________________________________



PHYSICAL EXAMINATION:

Height                                 Weight

Vitals: BP             Pulse                        Respiration________ Temp.

Appearance, Motion, Gait May present with hyperkyphosis of thoracic spine.


Orthopedic Tests

      Test Name                R            L              Test Name            R           L
Beevor’s Sign               +      -    +       -                               +   -   +       -
Schepelmann’s Sign          +      -    +       -                               +   -   +       -
Soto-Hall Test              +      -    +       -                               +   -   +       -
                            +      -    +       -                               +   -   +       -
                            +      -    +       -                               +   -   +       -

Orthopedic Test Results Discussion:     Beevor’s may cause pain as well.
Schepelmann’s may be positive if there is attending intercostal neuritis. Soto-hall will
cause pain when involved segment if flexed. Healed anterior compressions may not
present any positive ortho/neuro signs.


Neurological Tests – Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception ___Under most typical conditions patient will not
have any neurological deficit unless vertebral fragments are ejected into neural
canal, in which case there may be signs of nerve root lesion, numbness and/or


Joe Donofrio, D.C.                       Page 2                                 8/20/2010
Approved 03/14/05
paresthesia. Collapse of all supportive spinal elements may result in motor loses as
well._________________________
LabValues_________n/a_______________________________________________
_______

Examination of Related Areas          local paraspinal muscle splinting may be evident



Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.)        n/a




SPINAL EXAMINATION:

          Postural Analysis                       Postural Analysis       L        N      R
                                                  Head Tilt
          Hyperkyphosis may be                    Head Rotation
          Present. (Dowagers Hump)                High Ear
                                                  High Shoulder
                                                  High Ilium
                                                  Ext. Rotated Foot
                                                  Int. Rotated Foot

ROM
              Thoracicl ROM                                   Lumbar ROM
                 ROM     Pain         Level                    ROM     Pain            Level
Flexion          N  Y N                     Flexion          N     Y N
Extension           N       Y   N           Extension          N      Y    N
R. Rotation         N       Y   N   maybe   R. Rotation        N      Y    N
L. Rotation         N       Y   N   maybe   L. Rotation        N      Y    N
R. Lat. Flex.       N       Y   N   maybe   R. Lat. Flex.      N      Y    N
L. Lat. Flex.       N       Y   N   maybe   L. Lat. Flex.      N      Y    N


Leg Length/Spinal Balance           n/a
Instrumentation/Pattern Analysis            possible thermographic imbalances
associated with nerve distribution and possible swelling at lesion level
Palpation (Muscle, Static, Motion)          paraspinal spasm in thoracic spine possible
ES activity with attending scoliosis, if present.




Joe Donofrio, D.C.                       Page 3                               8/20/2010
Approved 03/14/05
         List the level for palpatory findings. Notate abnormal muscle findings and motion
         restrictions.
          Level Muscle Motion Level Muscle Motion Level Muscle Motion




         RADIOLOGICAL EXAMINATION:

                  x X-rays     MRI             CT             Other

         Views        AP, Lateral
         Findings     Decreased anterior body height or wedge shape deformity of the
         vertebral body. Displaced endplates (step sign) may be observed on the lateral
         radiograph. Also observable may be a linear zone of condensation and paraspinal
         hematoma. Compression fracture will most likely effect superior endplates.
         May require CT or MRI for further diagnosis.

         DIFFERENTIALS:

                Pathological fractures are seen more at posterior vertebral bodies, pedicles
         and other paraspinal structures usually caused by postmenopausal osteopenia,
         multiple myeloma and metastatic carcinoma. MRI or CT may be necessary to better
         view posterior displacement of vertebral material into spinal cord and IVF.
         Schmorle’s nodes, Scheuerman’s disease, degenerative osteophytes and Hahn’s
         venous channels.

         Differentials:

Rule Out                      Rationale

                              (defined: pain that is unilateral extending in a band around the chest.)
Intercostal neuritis                Differentiated by:
                                                     X-rays would be negative for vertebral body compression.
                              (defined: a strain of the thoracic musculature.)
Thoracic strain                      Differentiated by: X-rays are negative for vertebral body compression



         Joe Donofrio, D.C.                        Page 4                                   8/20/2010
         Approved 03/14/05
DIAGNOSIS:

       Thoracic Compression Fracture


CASE MANAGEMENT:


Chiropractic Management:

With anterior compression fracture; proceed with caution. Several days to weeks
of bed rest will promote healing. As segment heals, may be adjusted with light
force techniques. Accommodate patient discomfort. Healed compression
fractures are considered stable and may be adjusted.

Posterior body fractures are more serious and unstable though may be adjusted
depending upon severity of fracture and necessity of correction. Fractures
involving pedicle region are unstable and should not be adjusted. These types of
fracture typically indicate underlying pathological process that needs to be co-
managed with and MD.

Adjunctive Therapy:        n/a




PhysicalTherapy:______n/a__________________________________________
________________________________________________________________
__
________________________________________________________________
________________________________________________________________
________________________________________________________________

Nutrition:   Be aware of medications that cause osteoporosis



Exercise:    Walking and swimming will discourage osteoporosis




Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education):    Exercise regularly, stay adjusted

Joe Donofrio, D.C.                  Page 5                            8/20/2010
Approved 03/14/05
     ______________________________________________________________
________________________________________________________________
________________________________________________________________


Further Evaluation:



Common Medical Management: _Medication for discomfort and kyphoplasty for
unstable fractures cases.




References:

Terry R. Yochum, Lindsay J. Rowe, Essentials of Skeletal Radiology, 3rd edition
(Williams & Wilkins 2005)
Thomas A. Souza, Differential Diagnosis and Management for the Chiropractor
(Aspen Inc. 2001, 2nd ed.) 82
Joseph J. Cipriano, Photographic Manual of Regional Orthopeadic and Neurological
Tests, 4th ed., (Lippincott Williams and Wilkins, 2003) 245-252.
Dos Winkel, Diagnosis and Treatment of the Spine, (Aspen Publishing, 1996) p450-
453



Condition Name        Baseline     Complicating/ Mitigating Factors       Revised
                      Complexity                                          Complexity
     Thoracic             4        Chiropractic Management –                   7
   Compression                     underlying pathology
     Fracture                      Chiropractic Management –                   6
                                   modification of adjusting technique
                                   due to instability
                                   Risk factor for osteoporosis,               5
                                   women and elderly
                                   Chiropractic Management –                   9
                                   neurological involvement




Joe Donofrio, D.C.                 Page 6                                8/20/2010
Approved 03/14/05
                                                                        Approved : 06/30/06
                                                                        Implemented: SU06
                                                                        Reviewed: 06/01/06
                                CLINICAL APPLICATIONS
                                Faculty Case Study Preparation


CONDITION:            Cervical Spinal Canal Stenosis

Prepared by:          Patricia Kuhta DC

RELEVANT PATHOPHYSIOLOGY:

Spinal stenosis is defined as narrowing of the spinal canal thereby reducing the space
available for the cord.

Compressive myelopathy resulting from spinal stenosis can effect the long tracts of
the cord including the corticospinal tract, spinothalamic tract, or dorsal columns.

This may result in central cord neuropraxia ( temporary burning pain, tingling,
numbness in arms and or legs), mild cord brusing (temporary paraylisis of arms and or
legs), or severe cord compression (permanent quadriplegia and loss of bowel, bladder
and sexual function)

Patients with cervical spinal canal stenosis are at greater risk of sustaining cord
damage from accidents or forces to the spine.

Spinal stenosis is known to be progressive in nature and worsens over time.


CASE HISTORY:

Patient Presents With:
      Onset-Initial: Can be sudden (as in post traumatic cases) or
                     gradual (as in degenerative cases).


      Palliative:       Resting with neck in neutral position.


      Provocative:      Usually neck extension, sometimes neck flexion, cervical kyphosis,
                        traumas of cervical hyperextension, cervical flexion/extension, or
                        cervical axial compression.


      Quality:          Burning pain.


      Quantity:       ( Highly variable )

                    Asymptomatic = until provoked by spinal degeneration or trauma.

Patricia Kuhta DC                       Page 1                         8/20/2010
                   Mild = headaches, neck pain, numbness/tingling in neck or arm (s)

                   Severe = muscle weakness of arm(s), and or leg(s), increased or
                   decreased DTRs, decreased manual dexterity, difficulty walking
                   ( gait disturbances, frequent stumbling or falls ), muscle spasticity, loss of
                   bowel and or bladder sphincter control (retention), sexual disfunction (loss
                   of sensation and function).


      Referred:       Pain may be localized to involved area of neck only.


      Radiating:      Pain may radiate into arm(s) or hand(s). Pain may also radiate down the
                      back or arm(s) when neck is flexed or extended.

      Site:           C5-C7 at central canal, lateral recesses, or IVFs.

                      Central canal stenosis is the most serious form of spinal stenosis.


      Timing:         NA


      Other:

Relevant History and Lifestyle
      Gender:            NA

      Age:                   Congenital type = usually under 30 yrs old.

                             Acquired type = usually over 50 yrs old but can occur younger.

      Occupation:            NA

      Traumas:        Hyper extension, flexion/extension, or segmental retropulsion from axial
                      compression.

      Surgeries:      Can be a result of post spinal surgical scar formation.

      Medications:           NA

      Hospitalizations:      NA

      Immunizations:         NA

      Diseases or Conditions:       Spinal stenosis can result from DJD, DDD, disc herniations,
                                    ligamentum flava hypertrophy, spinal cancers, Pagets,


Patricia Kuhta DC                      Page 2                               8/20/2010
                                       basilar impression/invagination, OPLL from DISH, RA, AS,
                                       Reiters, Downs, Psoriatic arthritis.

       Family History:      NA
       Diet:                NA
       Sleep Habits:        NA
       Sexual History:      NA
       Alcohol Usage:       NA
       Drug Usage:          NA
       Smoking/Tobacco:     NA
       Other:

Review of Systems: (EENT, Respiratory, Cardiovascular, Musculoskeletal,
Gastrointestinal, Reproductive)

PHYSICAL EXAMINATION:

Height :      NA                       Weight:          NA

Vitals: BP    NA       Pulse           NA           Respiration____NA____ Temp.       NA

Appearance, Motion, Gait :             Normal or altered depending on severity of stenosis

Orthopedic Tests

       Test Name               R            L              Test Name          R                L
Valsalva                    +      -    +       -    L’hermittes            +     -        +       -
Dejerine                    +      -    +       -                           +     -        +       -
Cervical compression        +      -    +       -                           +     -        +       -
Jackson                     +      -    +       -                           +     -        +       -
Spurling                    +      -    +       -                           +     -        +       -

Orthopedic Test Results Discussion:
Patient s with spinal stenosis may have no positive orthopedic findings.
Patients with spinal stenosis may test positive for any or all of those listed above

Neurological Tests – (Cranial Nerves/PNS/Equilibrium/Motor/DTRs/Pathological
Reflexes/Light touch/Proprioception)

Neurological tests may be normal.

Positive neurological findings may include decreased dermatomal sensation, Increased or
decreased DTRs in arm(s) and / or legs(s) due to compressive myelopathy effecting the long
tracts of the spinal cord (corticospinal tract, spinothalalmic tract, dorsal columns),

Motor strength may be normal or decreased in hand(s), arm(s) and or leg(s) in moderate to
severe cases of stenosis.

Patricia Kuhta DC                           Page 3                           8/20/2010
DTRs may be normal, increased or decreased.

LabValues:          NA

Other Findings:(Vascular, EENT, Cranial Nerves, Percussion, Palpation,
Auscultation, etc.) : NA


SPINAL EXAMINATION:                                   Postural Analysis      L      N     R
Postural Analysis Discussion:    NA                   Head Tilt
                                                      Head Rotation
                                                      High Ear
                                                      High Shoulder
                                                      High Ilium
                                                      Ext. Rotated Foot
                                                      Int. Rotated Foot


ROM:         May be normal without pain or may be decreased in flexion or extension
             with pain.

             Cervical ROM                                   Lumbar ROM
               ROM      Pain       Level                     ROM     Pain         Level
Flexion        N  Y N                     Flexion          N     Y N
Extension      N  Y N                     Extension        N     Y N
R. Rotation    N  Y N                     R. Rotation      N     Y N
L. Rotation    N  Y N                     L. Rotation      N     Y N
R. Lat. Flex.  N  Y N                     R. Lat. Flex.    N     Y N
L. Lat. Flex.  N  Y N                     L. Lat. Flex.    N     Y N


Pattern Analysis: Leg Length/Spinal Balance/ Instrumentation/Palpation (Muscle, Static,
Motion)
                       NA
List the level for palpatory findings. Notate abnormal muscle findings and motion restrictions.
                       NA

Level    Muscle Motion          Level    Muscle Motion      Level    Muscle Motion




Patricia Kuhta DC                       Page 4                          8/20/2010
RADIOLOGICAL EXAMINATION:
       Views              Findings
X-rays     Neutral Lateral Cervical   Decreased A-P spinal canal diameter from the clinically
                                      normal measurements.
                                      Normal = C1 16mm, C2 14mm, C3 12mm, C4-C7 12mm.

                                      Any measurement of 10mm or less is absolute for stenosis.

                                      Positive Torg Ratio may also be present . Torg ratio is the A-
                                      P canal diameter divided by the A-P vertebral body width. A
                                      ratio of .80 or less is positive for stenosis.

MRI        Sagittal and or Axial      Same as with x-ray in addition to a positive SAC value
           views                      confirming the presence of functional stenosis.

                                      SAC value is the space available for the cord. Determined
                                      by subtracting the A-P cord width from the A-P canal width.

                                      MRI is the most reliable way of determining spinal stenosis.

CT         Sagittal and or Axial      Same as with MRI
           veiws
Other




DIFFERENTIALS:         Cervical Disc Herniation, Subluxation, Cervicalgia,
Cervicogenic Headache, Burner/Stinger, Brachial Neuritis, Thoracic Outlet Syndrome,
Carpal Tunnel Syndrome, Cervical Radiculopathy

CASE MANAGEMENT:

Act on the side of caution. Perform the appropriate ortho-neuro tests. Take x-rays and
evaluate them for stenosis. Correlate symptoms, ortho-neuros and x-ray findings.
Recommend referral for cervical MRI & get radiology report. Adjust when safe with low force
non- rotary techniques. Refer when appropriate for medical evaluation/consultation.

Chiropractic Management:
Opinions differ greatly regarding the chiropractic treatment of patients with spinal canal
stenosis.

Yochum and Rowe states: “ Surgical treatment should be considered only after an adequate
trial of conservative therapy has been unproductive. This includes spinal manipulation.
Conservative therapy should be continued as long as the patient can tolerate it”.

Marchiori states “ The type of treatment for spinal stenosis is usually based on the type of
symptoms being experienced by the patient. Most patients with intermittent or mild
symptoms can be managed nonsurgically. If the patient doesn’t respond, surgical
decompression and possibly fusion is an option.”

Patricia Kuhta DC                      Page 5                                8/20/2010
Samuel Homola, D.C. author and chiropractic educator states: “Neck manipulation is
contraindicated in cases of spinal stenosis with herniated disc. Muscle weakness and loss of
reflexes is a big red flag for cervical adjustments. It is unwise to have neck adjustments
when there are neurological symptoms caused by spinal stenosis. Bony stenosis can’t be
improved by manipulating the spine and manipulation might injure the nearby spinal cord or
spinal nerves.


Common Medical Management:

Conservative =To relieve symptoms and improve function. Consists of rest, neck bracing,
epidural cortisone injections and NSAIDs to reduce pain.

Surgical = To remove the physical cause of cord compression. Surgical reair or complete
removal of herniated disc. Laminectomy may be performed with or without surgical fusion of
involved segments.

Adjunctive Therapy: NA
PhysicalTherapy:       Recommended post surgery to strengthen muscles, help
                       stabilize the spine, and help patient to resume activities of
                       daily living.

Nutrition: NA

Exercise: NA

Health Promotion and Maintenance (i. e. ergonomics, spinal hygiene, psychosocial
concerns, education): NA

Further Evaluation:       NA

REFERENCES:

   Yochum and Rowe, Essentials of Skeletal Radiology, second edition pg. 273-314,
    554,
   Marchiori, Clinical Imaging, pg. 78, 502, 504, 507.

   Homola (http://www.chirobase.org/17QA/stenosis2.html)

   American Chiropractic
    Association(http://www.amerchiro.org/record_css.cfm/CID=670)

   La Jolla Spine Institute (http://www.lajollaspine.com/sdds_cerv_treat.shtml)

   Spine-health.com
    (http://www.spinehealth.com/topics/cd/overview/cervical/crev03.html)


Patricia Kuhta DC                   Page 6                            8/20/2010
   Understand Spine Surgery .com
    (http://www.undersdtandspinesurgery.com/cervical_stenosis_article.asp)

   Hospital for Joint Diseases Spine Center
    (http://www.msnyuhealth.org/hospitals/hjd/hjdspine/cervicalstenosisandmyelopath
    y.htm)

   Texas Spine and Joint Hospital (http://www.tsjh.org/patient-education/spine-
    anterior-crevical-spinal-stenosis.html)

   Family Practice Notebook.com (http://www.fpnotebook.com/ORT41.htm)

   Dr. Dillin.com (http://www.drdillin.com/education/basics_csshtm)

 Spine Universe
(http://www.spineuniverse.com/displayarticle.php/article209.html)


   North American Spine Society (http://www.spine.org/articles/cervicalstenosis.cfm)




CASE COMPLEXITY:

The category of complicating or mitigating factors should include the following considerations:
Ancillary labs, diagnostic studies, co-management issues, early stage of condition, advanced
stage of condition, psychosocial issues, etc. The complicating or mitigating factors can either
increase or decrease the baseline complexity.

Condition Name        Baseline      Complicating/ Mitigating Factors      Revised
                      Complexity                                          Complexity
                                    Positive for neurological deficits       8.0
                                    Intermittent symptoms of                 6.0
    Cervical Canal         3.0      neurological deficits
      Stenosis                      Need for co-management with               6.0
                                    other medical professional




Patricia Kuhta DC                    Page 7                              8/20/2010

				
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