Case Report

1
Case Report

• 55 year old Male with
• Multiple Sclerosis

2
History

• The patient presents as a 55 year old male who
  was first diagnosed with Multiple Sclerosis (MS)
  after having symptoms in 1996. Since then he has
  retired from his vice-principal position at a
  junior high school to lead a more sedentary
  lifestyle. He walks with a cane displays a
  limping gait, as well as dragging his left foot.
  He demonstrates major incoordination of movement
  in his left leg, as well as associated weakness
  in both legs..

3
History

• He entered the Palmer Rock Island Clinic with a
  chief complaint of Migraine Headaches. A
  detailed history was taken concerning his
  complaint. Frequency of his headaches was
  reported at 3 times per week with a sharp burning
  sensation in the frontal and occipital regions.

4
History

• He reports to have suffered with migraine
  headaches for the last 10 years.
• He has paresthesia in the left leg and foot, as
  well as in the left hand.
• The patient was noted to have an overall apathy
  toward the chiropractic care.

5
Provide your Differential Diagnosis

• Minimum of 2
• Examinations for DDx
• What examinations would you perform on your
  patient?

6
Exam

• What would You do?
• What should you look for?
• What would you expect to find?

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Cause

• Multiple sclerosis (MS) is a disease
  characterized by patchy demyelination with
  reactive gliosis in the spinal cord, optic nerve,
  and white matter of the brain. The cause is
  unknown, but MS is suspected to be an immune
  disorder.

Differential Diagnosis and Management for the
Chiropractor Soza
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Multiple Sclerosis

• MS occurs mainly in individuals who live in
  temperate zones and especially in individuals of
  western European ancestry. There is an apparent
  genetic relationship due to the association of MS
  and HLA-DR2.

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What to Know

• The patient is usually younger (less than age 55)
  presenting with a history of dizziness, numbness,
  tingling, or weakness that resolved over a few
  days. Other similar neurologic events have
  occurred in the past.

Differential Diagnosis and Management for the
Chiropractor Soza
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Evaluation

• MS is characterized by episodic attacks that
  initially resolve but eventually leave residual
  neurologic deficits.
• The initial episode often will resolve in days,
  and the patient may remain symptom free for
  months or years.
• Eventually, symptoms recur,
• Symptoms usually will involve a region and
  consist of numbness, tingling, weakness,
  diplopia, dizziness, or urinary sphincter
  dysfunction (urgency or hesitancy).

Differential Diagnosis and Management for the
Chiropractor Soza
11
Evaluation

• MRl will demonstrate multifocal areas of patchy
  demyelination in the brain or cervical spinal
  cord.
• Laboratory evaluation may reveal mild
  lymphocytosis or increased protein count in the
  cerebrospinal fluid (CSF more often in acute
  attacks).
• Immunoglobulin G and oligoclonal bands are more
  often seen in the CSF.

Differential Diagnosis and Management for the
Chiropractor Soza
12
Management

• There is no cure for MS. During acute
  exacerbations, corticosteroids are sometimes used
  to speed recovery.
• Nutritional approaches are unproven, yet some
  research" suggests that an increase in
  polyunsaturated fatty acids and metabolic enzyme
  supplements assist in providing an adequate lipid
  pool for oligodentrocytes.
• Also, antioxidants such as vitamins A,
  beta-carotene, E, C with bioflavinoids, and
  selenium may help with myelin membrane
  perioxidation.
• Immunosuppresive therapy looks promising for
  slowing the progression of MS."

Differential Diagnosis and Management for the
Chiropractor Soza
13
Examination

• Physical exam revealed numerous postural
  distortions, including a left lateral distortion
  of the thoracic spine.
• There was decreased Range of Motion in the
  cervical spine.
• The Vertebral Basilar Test produced dizziness
  when preformed with left rotation.

• The left carotid artery had reduced amplitude.
• He was unable to heal walk and has an overall
  weakness in the left leg.
• While lying supine he reported dizziness and
  stated that this position usually starts his
  migraine headaches.

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Chiropractic Examination

• After the physical exam, the patient had the
  first of 3 cervical infrared thermography scans
  with the TyTron C3000.
• The 3 graphs indicated a presence of a consistent
  pattern as defined by thermography
  presentation.
• Leg Length Inequality (LLI) indicators used where
  the prone leg check, cervical syndrome, Derefield
  Leg check and the Prill leg Checks. All LLI
  indicated the presence of spinal dysfunction.

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Spinographs

• A complete set of Blair Upper Cervical
  Chiropractic Spinographs were exposed (including
  a Base Posterior, APOM, AP, Lateral, Lateral
  Stereos and a right and left oblique nasium
  (Blair Protracto Views).

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Spinographs
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Spinographs
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Spinographs
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What We Found

• The leg checks and spinographs confirmed an atlas
  subluxation.
• The spinographs showed a misalignment at the C1
  vertebra in a Double Anterior Superior Position.
  (ASR/ASL) and Posterior C2 PLI.
• The LLI indicators showed interference of neural
  impulses at the upper cervical spinal segments
  with a Short right leg on the C1 and C2 Tests.

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What do the test results mean?

• Positive tests?
• Negative tests?
• What else should we test?

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Final Dx

• 784.0 Headache
• 346.1 Common migraine
• 340 Multiple sclerosis
• 782.0 Disturbance of skin sensation,
  Paresthesia
• 780.4 Dizziness
• 739.1 Cervical Segmental Dysfunction

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Patient Management Plan

• Patient will be seen for an estimated 18-20
  visits during a 3 month period of time.
• 3 x per week for 2 weeks
• 2 x per week for 4 weeks
• 1 x per week for 6 weeks
• Decrease the frequency, intensity and duration of
  the headaches

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1st Adjustment

• On 11/23/2005 he was given a chiropractic
  adjustment to his Atlas Vertebrae using the Blair
  Toggle Torque procedure to achieve the desired
  correction of Atlas.
• Immediately after the adjustment the patient
  reported that his upper neck felt red hot. He
  felt like we were pouring hot water down his
  neck.
• He was moved to an adjusting table to rest for 15
  minutes following the adjustment. Following the
  15 minutes rest, we rechecked the patient to see
  if we had achieved the desired affect from the
  adjustment.
• It was at this time when the patient reported a
  tingling feeling down his left leg during the
  rest period.

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2nd Visit

• On 11/28/2005 he returned for his follow up
  chiropractic visit.
• He was very excited on this visit.
• He had a list of changes he had noticed in his
  condition since we last saw him.

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2nd Visit

• Over the thanksgiving weekend, following his
  first adjustment, he reported
• Improvement in the migraine headaches, none since
  adjustment,
• Increased strength in his left leg,
• Less pain in his left rotator cuff,
• Increased sensation in his left leg and foot.
• He noticed an increase in urinary function which
  he used to have sensations to empty his bladder
  after 2 hours and if he didnt evacuate
  immediately, he would have an accident.

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2nd Visit

• Following his chiropractic spinal correction he
  can go up to 5 hours between bathroom breaks and
  when he does feel the sensation to go, he can
  take his time without worrying about an accident.
  
• He also noticed a reduction of pain in his low
  back, an increase in eyesight in which he had to
  remove his classes while watching TV in order to
  reduce his eye strain.
• He noticed an ability to stand without a cane for
  30 minutes and showed us he could walk without
  his cane for 10 feet down the hall in the clinic.

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2nd Visit

• He did show positive for spinal subluxation of
  the Atlas vertebra and was adjusted accordingly.
• When checking out at the front desk, he reached
  into his front pocket with a surprised look on
  his face. I asked him what was wrong, and he
  pulled out his keys.
• He explained that he usually can feel that he is
  touching something but has no idea what it is. He
  will pull out everything in his pocket and search
  for the keys.
• He reached back in his pocket and said here is a
  quarter, as he pulled it out of his pocket.

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3rd Visit

• On 11/29/2005 the patient returned with a
  continued feeling of improvements in his
  condition.
• He did report having a migraine type headache
  which started that morning after a bowel
  movement. He described the feeling as an intense
  sharp pain in the frontal and occipital areas of
  his head.
• On this visit however he did not show the need
  for a spinal correction and was released for the
  day with instructions to see us in 2 days.

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4th Visit

• On 12/2/2005 he reported feeling better since his
  last visit, his energy level has improved and he
  has an improvement in strength in his left leg.
  He was no longer dragging his foot to walk.
• No migraines have occurred since his last visit.
  He does report having some stiffness in his low
  back.

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• The patient was evaluated for the need of a
  spinal correction.
• He continued to be holding his spinal correction
  at this point.
• He was released from care at the Palmer
  Chiropractic Clinics on 12/2/2005 so he could
  return back home which was out of state.

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Since then

• A family member told us he parked over 100 yards
  away from his church and walked without trouble
  to and from service without incident.
• He has returned to the Quad cities to continue
  care at Palmer College.
• He is seen 1x/wk on average.
• He continues to improve and has used multiple CAM
  therapies to help with his improvement.

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What to leave With

• Dont throw all symptoms in one bucket.
• Maybe you should adjust your patient.
• The student on the case reminded me that his
  adjustment has held longer than mine.