Category: Case Study

Abstract:

:dropcap_open:V:dropcap_close:itamin D insufficiency has been associated with increased risk of CVD, various cancers, autoimmune disease and type 2 diabetes. Despite adequate sun exposure, individuals inhabiting metropolitan areas display a high prevalence of vitamin D insufficiency as determined by serum levels of 25(OH) vitamin D less than 32 ng/mL. The purpose of this study was twofold: 1) to assess the serum levels of 25(OH) vitamin D and prevalence of vitamin D deficiency in a cohort of 20 firefighters that work and reside in the Denver metro region and 2) to perform follow-up lab work after eight weeks supplementation with a microemulsified liquid vitamin D-3 preparation. The initial baseline blood levels of 25(OH) vitamin D were assessed and the study subjects were advised to take 4,000 IU/daily (2 drops) of the vitamin D-3 preparation for eight weeks. After the eight week supplemental period serum levels were retested to establish the percent increase in the 25(OH) vitamin D blood levels. The average initial 25(OH) vitamin D blood level and eight week post test blood levels was 27.02 ng/mL and 54.01 ng/mL respectively. Pretest 75% of the study subjects were defined as deficient (below 32 ng/mL) and only 25% were deficient after 8 weeks of supplementation with the liquid emulsified vitamin D-3.  The average percent increase in serum 25(OH) vitamin D levels was 106%.

Conclusion: Suboptimal vitamin D status is prevalent in Denver firefighters and 8 weeks of 4,000 IU/daily supplementation with a microemulsified liquid vitamin D-3 preparation increased blood levels on average 106%.

Introduction

Vitamin D deficiency is a serious medical condition that has been associated with an increased risk of developing cardiovascular disease, type 2 diabetes, hypertension, various cancers and autoimmune diseases. Vitamin D insufficiency occurs at epidemic levels in many industrialized countries, where exposure to sunlight tends to be limited and diets tend not to include sufficient amounts of foods naturally rich in vitamin D. During 2009, Dr. Guillory tested more than 1,200 of his patients and found that roughly 90 percent had sub-optimal vitamin D levels, as determined by serum 25(OH) vitamin D levels below 32 ng/mL.  Dr. Guillory achieved great success in treating this with Bio-D- Mulsion Forte®, a microemulsified preparation made by Biotics Research Corporation.

The purpose of this study was twofold; firstly to increase public and physician awareness of the scope and seriousness of vitamin D deficiency and secondly to assess the effectiveness of the microemulsified vitamin D preparation. Several preparations have been recommended to patients by physicians for the treatment of vitamin D insufficiency. The availability of vitamin D preparations ranges from high potency tablets and capsules to liquid forms. Vitamin D is a fat soluble hormone and thus requires biliary secretions to properly saponify the fats for proper intestinal absorption. To maximize the efficacy and bioavailability of fat soluble nutrients, enhanced delivery methods have been developed. One such method is an oil in water microemulsification, a closely-held process that enables a fat soluble (water-insoluble) vitamin to be placed into a uniformly micrometer-sized, fat-soluble particle that is dispersible in water and capable of intestinal transport independent of bile acid-saponification. The aim was to ascertain how efficacious 2 drops, yielding 4,000 IU of microemulsified vitamin D-3, would be in raising low serum levels of 25(OH) vitamin D in a group of 20 firefighters residing in the Denver metro area.

Materials and Methods

20 full-time firefighters of the Aurora Fire Department were selected on a volunteer basis to participate in an eight-week study during the winter/spring months of 2009. Upon initiation of the study, the 20 subjects were advised to stop consuming multivitamins, cod liver oil and other supplements containing vitamin D. The subjects filled out a medical symptom questionnaire aimed to assess subjective indications of mood, energy level and digestive complaints. All subjects had blood drawn (at the Care Group, PC, office of Gerard Guillory MD in Aurora, Colorado ) and serum levels of 25- hydroxyvitamin D (25(OH)) vitamin D tested through Laboratory Corporation of America (Lab. Corp) via an assay developed by DiaSorin. The subjects were advised to take 4,000 IU/day (2 drops) daily of the liquid emulsified preparation produced by Biotics Research Corporation. After eight weeks of daily supplementation the study subjects 25(OH) vitamin D levels were retested by Laboratory Corporation of America. The subjects also filled out the same medical symptom questionnaire and the data was compiled.

Results

At the beginning of the study, the average baseline 25(OH) vitamin D blood level was 27.02 ng/mL. Current medical guidelines suggest that vitamin D insufficiency begins when blood levels are below 32 ng/mL and optimal disease prevention occurs when blood levels are above 60 ng/mL (REF). Only five study subjects had serum levels above the 32 ng/mL level and two subjects had blood levels less than 11 ng/mL. The majority of subjects had levels in the low to mid 20s (See Table 1). Prior to supplementation 75% of the subjects were deficient in vitamin D and 10% of the subjects were severely deficient (as defined by blood levels below 10 ng/mL).

After the eight week supplemental period the average 25(OH) vitamin D blood level was 54 ng/mL, a 106% average increase. Post supplementation 15 study subjects, or 75%, had serum levels above the deficiency blood level of 32 ng/mL (pre-supplementation 75% were deficient). Only 5 study subjects, or 25%, had serum levels below the 32 ng/mL level. Seven subjects had blood levels above 50 ng/mL, the highest being 114 ng/mL (See Table 1).

Discussion

The prevalence of vitamin D insufficiency in a group of 20 firefighters not taking any vitamin D supplements was found to be 75%. Studies show that individuals with vitamin D levels below 32 ng/mL have an increased risk for developing heart disease, cancers, and autoimmune diseases. Due to high prevalence of vitamin D insufficiency in firefighters residing in a sunny part of the country, physicians should increase their 25(OH) vitamin D blood testing on a more routine basis among firefighters and lay people alike. Increased screening would likely have a huge health and financial impact, leading to increased work productivity and decreased medical costs through disease prevention.

The form of vitamin D supplementation in deficient individuals should be inexpensive, highly bio-available and easy to use for optimal compliance. In this study the microemulsified Bio-D-Mulsion Forte® from Biotics Research Corporation was used and can be attributable to an average increase of 106% in blood levels of the study subjects. It’s likely that the microemulsification process in a liquid delivery form facilitates maximal absorption and bio-availability of the vitamin D supplement. This is evidenced by the consistent increases in blood levels after eight weeks of 4,000 IU/daily use, bringing 75% of the study subjects out of the deficiency reference range.

History and Presenting Symptoms

The patient is a 15-year-old female soccer player, who reports frequent pain for the past several months in her left hip and posterior thigh region.  The pain is most noticeable the day following a highly physical soccer competition or scrimmage, when she experiences tightness and tension in the back of her upper left thigh.  She denies any specific injury, but admits that she has been playing especially hard since getting caught up in the excitement of following the U.S. team in the 2011 FIFA Women’s World Cup this past summer.  She finds that lying down and putting warm towels around her hip helps the most. 

Exam Findings

Vitals.  This athletic girl weighs 129 lbs, which at 5’6’’ results in a BMI of 21 – she is very active and fit.  She is a non-smoker, and her blood pressure and pulse rate are well within the normal range.

Posture and gait.  Standing postural evaluation finds generally good alignment, with intact spinal curves and no evidence of scoliosis.  Closer inspection identifies a higher right iliac crest, mild bilateral knee valgus, and static pronation of the left foot (calcaneal eversion with low medial arch).  Brody’s navicular drop test finds 6mm of excursion of the left navicular prominence between sitting and standing, compared to 3mm of drop on the right.  Gait screening is negative for limp or noticeable asymmetry.

Chiropractic evaluation.  Motion palpation identifies a left sacroiliac fixation, with moderate tenderness and loss of endrange mobility.  Straight leg raise is limited to 78° on the left by pain at the hamstring origin.

Primary complaint.  The left hamstring is weaker than the right on manual muscle testing, and palpation finds tenderness at the left ischial tuberosity and slightly increased tension in the proximal hamstring muscle.  All knee and ankle ranges of motion are full and pain free.

Imaging

Standing AP lumbopelvic view shows a leg length discrepancy, with the left femur head 5mm lower.  Frog-leg views of both hips are negative for ischemic necrosis (Legg-Calve-Perthes) and slipped femoral capital epiphysis.

Clinical Impression

Chronic hamstring strain, with leg length discrepancy (left short leg) and asymmetric foot pronation.

Treatment

Adjustments.  Adjustments of the left SI joint and left foot and ankle were provided as needed.  The adjustments were supplemented by contract-relax stretches for the left hamstring muscle.

Stabilization.  Individually designed, stabilizing orthotics were fitted into her soccer shoes, and another pair was provided for daily wear.  Both were custom made for her postural needs.

Rehabilitation.  Daily strengthening exercises for the left hamstring were gradually progressed from light to strenuous resistance using elastic exercise tubing in a standing position.

Response to Care

This focused young athlete responded rapidly to the adjustments and strengthening exercises.  She adapted to the individually designed stabilizing orthotics with little difficulty, and reported that her ankles and knees felt more secure when on the field.  Within two-and-a-half weeks of receiving the orthotics, she had no post-exercise pain or tenderness.  She was released to a self-directed home stretching program after a total of eight visits over six weeks.

:dropcap_open:Knee, upper leg and hip pains in a young person with a still-maturing skeleton always raise concerns of ischemic necrosis.:quoteleft_close:

Discussion

Knee, upper leg and hip pains in a young person with a still-maturing skeleton always raise concerns of ischemic necrosis (Legg-Calve-Perthes) and slipped femoral capital epiphysis.  This teenaged athlete had no x-ray evidence of either condition, but did have a biomechanical asymmetry in the lower extremities, which caused a functional short leg.  Appropriate, focused treatment consisting of adjustments and stabilizing orthotics, along with stretching and strengthening exercises, brought about a rapid response.

This patient found wearing individually designed stabilizing orthotics in her soccer shoes to be effective in helping reduce her hip symptoms and enhancing her athletic performance.  Studies have found a significant decrease in electromyographic activity of the hamstring muscles during running while wearing orthotics.  This is thought to be due to the increased stability of the ankles and knee joints, which allows greater relaxation of the hamstrings during gait, especially when running.

History in Chief Complaint

Patient DH entered our office with a 45-year history of lower back pain.   2 Years prior, the patient travelled to Germany and underwent a lumbar spine operation, whereby he had artificial disks surgically implanted at L3, L4, and L5.  The procedure was highly successful at decreasing pain and increasing ambulation.  In June of 2004, the patient was seen for difficulties with balance and proprioception secondary to a marked scoliosis related to spasmotic antalgia.  On his initial visit the patient related that there was some post-surgical improvement in balance, and a reduction in the angle of his scoliosis. However, he was now experiencing intractable pain, 8 on a scale of 0 to 10 with 10 being unbearable pain, in the left lateral ankle region, inferior to the lateral malleolus.  The pain had started 2 days prior to his initial visit.  The patient related that the pain increased upon eversion of the foot, and was felt when walking and standing.  His foot was in constant inversion with the first ray off the floor.  The patient had no prior history of foot or ankle ailments.

Examination

There was obvious swelling to the lateral ankle without erythema.  Left ankle plantar flexion was limited at 25/85  degrees (normal active range of motion for plantar flexion is 50 degrees).  Left ankle dorsiflexion was also limited at 5/15 degrees (normal is 20).  Mid Tarsal joints were slightly rigid in motion bilaterally.  Hallux dorsiflexion was normal bilaterally.  The first ray had normal range of motion in a neutral bias and position.  The dorsal pedal pulse was normal bilaterally; however, the tibialis pulse was absent bilaterally. When standing, the patient demonstrated a posture with first ray dorsi flexion whereby the first ray was elevated at proximally 1 cm off the floor.  There was dorsiflexion of the first through fifth metatarsophalangeal joints bilaterally.  Muscle testing of the tibialis anterior extensor pollicis longus was graded 5/5.  Muscle testing of the fibularis (peroneus) brevis and fibularis longus demonstrated 3+ strength on the left.  The eversion stress test was positive and produced pain in the ankle.  The inversion and side-to-side tests were negative.  Patient DH demonstrated moderate tenderness throughout the lateral compartment.  There was pinpoint tenderness at the anterior talofibular ligament with exquisite pain at the calcaneal fibular ligament.  The patient’s left shoe demonstrated disproportionately marked wear on the sole at the lateral aspect of the heel and forefoot. 

Diagnosis

Based on the examination it was apparent that patient DH had S1 inhibition, which was being expressed by a marked fibularis longus and brevis weakness.  Patient DH was compensating for this by distributing more weight on the anterior talofibular ligament and calcaneofibular ligament to check ankle inversion.  As such, there was no antagonist control of the stirrup effect created by the tibialis anterior and the fibularis longus. Without this being controlled the tibialis anterior, along with the extensor hallux longus, were overly dorsiflexing the first ray in relationship to the foot upon stance.  The excessive lateral wear pattern on the patient’s shoe was associated with a lack of antagonist control of the deep posterior compartment maintaining the foot in an inverted position throughout the gait cycle and stance.

It was hypothesized that this effect could be the result of a marked aberrant gait pattern.  Prior to the disc replacement surgery, the patient was required to ambulate via crutches or a walker.  There may also be nerve root inflammation due to the surgical procedure.  Peripheral entrapment of the fibular nerve can also occur at the proximal fibular head.  This condition could also be maintained by a supinated gait pattern at the fibular musculature which is activated during the gait cycle.  In this case, the fibularis longus may entrap the common fibular nerve at the proximal fibular head.  However, usually symptomatology and pain in the distribution of the nerve into the lower leg, foot and ankle would precede localized compartmental weakness.

Diagnosis was that of S1 neural inhibition causing fibularis longus and brevis weakness with aberrant biomechanics and pain.

Treatment

Initial treatment consisted of functional application of Trigenics multimodal treatment procedures, incorporating resistive exercise neurology, mechanoreceptor manipulation and cerebropulmonary biofeedback. With Trigenics, the patient is essentially performing concentrative breathing with resisted load exercise movements while simultaneous treatment is applied to the muscle mechanoreceptors to create a cumulative afferent spinocerebellar overload. Correction of sensorimotor dysfunction is targeted by applying neuro-stimulative soft tissue treatment while the patient performs proprioceptive resisted exercises.* According to Dr. Frederick Carrick, “Trigenics is consistent with the principles of neuroplasticity and corticoneural reorganization of the sensorimotor and somatosensory systems.”

Trigenics was applied to the lateral compartment of the left lower leg.  A Trigenics myoneural strengthening procedure was performed and involved physical mechanoreceptor distortion at various points throughout the lateral compartment along with resisted antagonist manual muscle contraction at approximately 20% effort.  Concomitantly, this procedure utilized a pressurized concentrative abdominal breathing maneuver for additional neural input by way of global parasympathetic response. As a result of the application of Trigenics myoneural procedures as noted, there was an immediate, significant increase in muscle strength which improved to 4+/5.  Localized inflammation of the anterior talofibular and calcaneal fibular ligaments were treated with 1.0 W/m squared 20% pulsed ultrasound for 4 minutes and interferential with ice at 10 to 100 Hz for 10 minutes.  Post Trigenics kinetic taping was applied along the course of the fibularis longus in a facilitative pattern with tape applied at approximately 50 to 75% tension with the ankle and foot inverted and dorsiflexed.

Upon examination 5 days post treatment, the pain had reduced to a one on a scale of 0 to 10, and the frequency of the pain had reduced from constant to infrequent.  Muscle strength testing of the lateral compartment demonstrated 5-/5.  However, there was still 2-/3, moderate, pinpoint tenderness over the calcaneal fibular ligament, whereas the anterior talofibular ligament was negative.

This case demonstrated the marked effectiveness of using the multimodal Trigenics® Applied Functional Neurology® procedures in concert with kinetic facilitative taping in the treatment of pre- or post-surgical disc herniation and neuromusculoskeletal conditions or pain syndromes.

*Historically Trigenics is cited by its founder, Dr. Allan Oolo Austin, to be the first treatment of its kind to use a multimodal cumulative neural stimulation approach for enhanced outcome by combining soft tissue manipulation techniques with resisted exercise movements.

Dr. Ted Forcum is a Diplomate of the American Chiropractic Board of Sports Physicians (DACBSP). He is also a member of the ACA Council on Sports and Physical Fitness, the United States Sports Chiropractic Federation and the National Strength and Conditioning Association. Dr. Forcum is certified in KinesioTaping (CKTP), Graston Technique, NASM Certified Exercise Specialist (CES), NASM Performance Exercise Specialist (PES), and is a Registered Trigenics Practitioner (RTP). The American Chiropractic Association Council on Sports and Physical Fitness voted Dr. Forcum the 1994-95 & 2004 Sports Chiropractor of the Year and he was also awarded the 2000 ACA Sports Council Achievement Award. Dr. Forcum has worked as an event physician for such events as the Winter Olympics, U.S. Olympic Trials, U.S. Track and Field Championships and the NCAA National Championships as well as many others. Dr. Forcum has also worked extensively as a staff chiropractor for the PGA Tour.  In 2004, Dr. Forcum was voted in as the 2nd Vice President of the American Chiropractic Association Council on Sports and Physical Fitness. He has taught postdoctoral programs for Southern California Health Sciences University, Western States Chiropractic College, Logan Chiropractic College and Northwestern Health Sciences University. He is currently on the teaching faculty of FAKTR-PM and lectures nationally and internationally on the topics of sports injuries and biomechanics.

:dropcap_open:I:dropcap_close:got a call from someone who sounded terrible.

“Doctor Koren, I’m in agony.  A few days ago I was out golfing with my family and something went out in my back.  I’ve been in bed for days. Yesterday, I was literally carried to get an MRI and a neurosurgeon will be getting back to me soon.  A friend who saw you said you can help me.  Can you do anything for me?”

“Can you come over to my office?”

“I can’t get out of bed.  I haven’t shaved in days.  I can’t move.  Can you come here?”

“Of course.”

I got his address, picked up my arthrostim adjusting instrument and was off.

When I arrived at his house, his wife let me in.  “Please follow me, he’s upstairs in bed; he’s been counting the seconds until you arrived.”

I followed her upstairs.

It looked like he had not left his bed for many days.  He had a 5 or 6-day-old beard.

“Thank you so much for coming. Please excuse me for not getting up.”

“No problem, where’s an electrical outlet?”  I plugged in the instrument and, quite literally, in the most professional way possible, climbed into bed with him.

“I haven’t showered in a few days,” he said.

“That’s OK,”I told him.  “Neither have I.”

My getting into the bed moved the mattress and he grunted in pain.  “I’ll try to move around slowly,” I told him.

I checked and adjusted him as he lay there. I adjusted what I could and it was no surprise that his discs as well as his vertebrae were subluxated.  In addition, he was very dehydrated; disc problems and dehydration go together. He was playing golf on a very hot day and drinking margaritas.  That’ll dry you out and it may have precipitated his disc damage.

Actually I’ve found that, if you get people with disc problems to drink more water, a large number of them would, by that act alone, become pain free.  When discs are dehydrated, they become friable—the fibers crack and split.  That can occur especially when they are under stress (such as swinging a golf club.)

I adjusted the discs and vertebra.  He was still in a lot of pain.  “I’ll see you tomorrow, I told him.”

The next day, as I entered the bedroom, he sat up in bed. He was able to move a little without too much pain and had even showered and shaved.  He couldn’t stand very long and was still fairly immobile most of the time.  I climbed into bed and worked on him again; this time I was able to reach more areas.

The next day, he was driven to my office and, using crutches, walked into the adjusting room.  Because I was able to adjust him standing as well as sitting and in the position he was in as he swung his golf club, more subluxations were revealed and could be corrected.

The following day, he drove in by himself.  After a few more days, he was pain free.

Later in the week, he drove himself to the neurosurgeon.  As he walked into the doctor’s office, the MD’s jaw dropped.  “Your MRI was the second worst train wreck I had ever seen in my 30 year career.  I was going to recommend immediate surgery.  I can’t believe you’re pain free. Amazing.”

“Would you like to know what I did to get out of pain?” he asked.

“No, not really.”

Surprised?  I’m sure that if you’re a doctor of chiropractic reading this story you’ve got plenty of similar stories.

The number one rule in all healing is, “Listen to the patient; the patient is your teacher.”  Of course, that only works if one’s mind is open.

Another example

This medical phenomenon is not only related to chiropractic care.  For example, Harris Coulter, Ph.D., the world famous medical historian, cites a friend of his who was diagnosed with lung cancer and given six months to live.  Dr. Coulter recalled, “I told him that, in Alexandr Solzhenitsn’s book, The Gulag Archipeligo, Solzhenitsn mentioned that he had been diagnosed with lung cancer and cured it after taking extracts from a yew tree.”

So, his friend found a source of yew extract and began to take it under the direction of a naturopathic physician. Six months later, he returned to the MD who had given him six months to live.  After the examination, the doctor reported, “Your lungs are clear.  No cancer at all.”

“Would you like to know what I did?”

“No, not really.”

Medical mis-education

I’m shocked that the medical profession ever questioned the intelligence, ethics and morality of chiropractors and other alternative healthcare practitioners. Apparently, they were looking in a mirror, blinded by the prestige, money and power that society has given them.

What is it with the medical mind?  How can they be so clueless?  Coulter discusses this in his magnum opus Divided Legacy, Vol. 4 in chapter 26, “The Training of Physicians,” (P. 645), where he quotes MD’s, educators and students.  Coulter writes:  “The majority of students complain that they experience constant anxiety and stress.  A “dehumanizing experience” is their most frequent characterization of medical school….

:dropcap_open:From a sophomore: “I was not sure the day after I entered whether I was in a prison or a kindergarten, and I still haven’t made up my mind.” Daniel H. Funkenstein

The doctor-scientist orientation produces a nasty side effect; it takes incoming medical students who are interested in people and transforms them into doctors interested in diseases. Michael Crichton

Students entering medical school are a very healthy bunch of young people.  If they’re not when they leave, it’s because we did it to them. Pearl Rosenberg:quoteleft_close:

Coulter continues:  “The clinical years of medical school thus perpetuate the confusion and alienation of the preclinical ones.  The first two years instill in the student just enough abstract information to inhibit precise observation, while the last two deaden the sensibilities which might have enabled him to overcome the legacy of the preclinical period.  He leaves medical school dehumanized.”

Worshiping an idol?

These are people who are worshipped by the general public who are unaware of what kind of people they are putting their trust in.  These are people who are caught in a machine that is as much political as it is professional.  Their education is increasingly overseen by pharmacological research and they graduate with a narrow view of life and health.  Perhaps they have no concept of health, since their focus is disease.

Is it any wonder that, when true healing is revealed, they recoil in shock and bewilderment?  Fearful of admitting their deficiencies, they quickly turn away and mumble, “No, not really.”

And they are right.  They don’t want real.  Real is a frightening place.  It is beyond the confines of their comfortable thoughts.  There is no reality in their education, outlook and practice.  They’re better off not going there; it would destroy their powerful, though brittle, world.

A bed call

That house call, or bed call, that I made was a microcosm of what many patients must deal with.  This patient was lucky to have looked outside the system.  Not everyone is lucky enough to have a chiropractor make a house call or open enough to invite one.

Tedd Koren, D.C., is the developer of Koren Specific Technique.  For information, go to www.korenspecifictechnique.com. Dr. Koren also writes patient education materials.  Go to www.korenpublications.com. Dr. Koren can be reached at [email protected].

History and Presenting Symptoms

A 61-year-old female presents with a recent history of occasionally moderate pain in her lower back.  Although the pain responds well to chiropractic adjustments, it invariably recurs within a couple of days.  While there are no specific triggering activities, being on her feet and engaged in physical activity does seem to bring on the pain more rapidly.  She describes her current level of low back pain as usually around 35mm to occasionally 45mm on a Visual Analog Scale.

Exam Findings

Vitals. This maturing, physically active woman (she performs water aerobics at least twice each week and walks 1.5 miles every day) weighs 143 lbs. which, at 5′ 6″, results in a BMI of 23; she is not overweight.  She reports that she has been a non-smoker for over 30 years, and limits her alcohol intake to one glass of wine per day.  Her blood pressure and pulse rate are at the lower end of the normal range.

Posture and gait. Standing postural evaluation finds a lower iliac crest on the left, and a low left greater trochanter.  The right shoulder is slightly lower than the left, with no history of fracture or surgery.  She has a mild bilateral knee valgus and moderate calcaneal eversion and hyperpronation on the left side, with a noticeable outward flare of her left foot.  Palpation of the left arch, when standing, finds it significantly lower than the right, but it is not tender to direct pressure.  The Navicular Drop test demonstrates greater excursion of the left navicular bone when moving from sitting to standing (non-weight bearing to weight bearing).

Chiropractic evaluation. Motion palpation identifies limitations in segmental motion at L4/L5 and L5/S1, with some local tenderness.  These segmental dysfunctions demonstrate loss of end-range mobility in all directions.  Additional fixations are noted at T9/T10, C5/6, and C2/3.  Lumbar ranges of motion are full and pain free and neurological testing is negative.

Imaging

Upright, weight-bearing X-rays of the lumbar spine demonstrate moderate loss of intervertebral disc height at L4/L5 and L5/S1, with small osteophyte formation at those levels.  A discrepancy in femur head heights is seen, with a measured difference of 6mm (left side lower).  A moderate lumbar curvature (6°) is noted, convex to the left side, and both the sacral base and the iliac crest are lower on the left side.  The sacral base angle and measured lumbar lordosis are within normal limits.

Clinical Impression

Moderate lumbosacral osteoarthrosis and disc degeneration, with mechanical dysfunction associated with poor biomechanical support from the lower extremities.  There is a functional short leg on the left side.  The asymmetry in the lower extremities is clearly demonstrated by the loss of left arch stability seen on the Navicular Drop test.  There is noticeable hyperpronation, arch collapse, and foot flare consistent with left arch collapse, with the expected effects in the pelvis and spine.

Treatment Plan

Adjustments. Specific chiropractic adjustments for the lower extremities and the involved spinal regions were provided as needed.

Support. Individually designed, stabilizing orthotics were provided to support the left arch and calcaneus (pronation correction) and decrease the asymmetrical stress on the knees and back.

Rehabilitation. This patient was instructed to perform an at-home series of back exercises using elastic tubing to develop and maintain coordinated strength in her spinal stabilizers (paraspinal musculature) and core (trunk and pelvic) musculature.

Response to Care

She responded well to the adjustments and exercise, and reported a rapid decrease in symptoms.  Within two weeks of receiving her orthotics, she reported that she felt she had more energy, and no longer had the previous nagging low back pain.  She was released to a self-directed home stretching program after a total of eight treatment sessions over six weeks.

Discussion

This patient had no foot or arch pain; however, she was undergoing plastic deformation of her arches, which for unknown reasons was accelerated in the left foot.  This produced a chronic, asymmetrical strain on her pelvis and spine.  Her condition was documented with a test for stability of the arches—the Navicular Drop test.  This highlighted the asymmetry in her lower extremities and provided for an easy discussion of the benefits of long-term orthotic support.

History and Presenting Symptoms

A 31-year-old male office worker reports a history of mild-to-moderate, intermittent lower back pain, along with an aching tightness in his neck.  His back pain comes on with no specific triggering activities, and the neck tension is worse during long, stressful workdays.  He is not involved in any recreational sports or exercise activities, and he doesn’t recall any back or neck injuries.  On a 100mm Visual Analog Scale, he rates the low back pain as usually 35-45mm, and his neck tightness as around 25-30mm.

Exam Findings

Vitals. This man weighs 224 lbs, and is 5’9’’ tall.  This calculates to a BMI of 33—he is obese.  His waist measures 49 inches at the largest point above the ASIS, confirming abdominal obesity.  His blood pressure is somewhat elevated at 144/90 mmHg, and his pulse rate is 80 bpm.

Posture and gait. Standing evaluation highlights the postural effects of abdominal obesity: a loss of lumbar curve, an accentuated thoracic kyphosis, and cervical anterior translation (forward head carriage).  There is no noticeable lateral pelvic listing or lateral spinal curvature.  He does have moderate bilateral knee valgus and bilateral calcaneal eversion, as well as collapsed medial arches.  During gait evaluation, both feet flare outwards and exhibit excessive pronation.

Chiropractic evaluation. Motion palpation identifies several limitations in intersegmental spinal motion: the left SI joint, L4/L5 on the right, L2/L3 on the left, T11/12 generally and several levels at the cervicothoracic junction.  There is no specific spinal tenderness or spasm of the paraspinal muscles, but adipose tissue is prevalent throughout.  All active thoracic and lumbar ranges of motion are limited slightly by general stiffness.  Neurological tests are negative for nerve root impingement, but straight leg raise is limited bilaterally by hamstring shortening and tightness.

Imaging

Upright, weight-bearing X-rays of the lumbar spine demonstrate loss of intervertebral disc height at L4/L5 and L5/S1, with moderate osteophyte formation at those levels.  There is no discrepancy in femur head or iliac crest heights, and no lateral listing or lateral curvature.  The sacral base angle and lumbar lordosis are both decreased, which is consistent with the postural analysis.

Clinical Impression

Chronic spinal stress syndrome due to obesity.  This is emphasized by poor support from the lower extremities, with bilateral knee valgus, excessive pronation and calcaneal eversion.

Treatment Plan

Adjustments. Specific, corrective adjustments for the identified fixations were provided as needed, with good response.  Specific manipulation of both feet and knees was also performed.

Support. Custom-made, flexible stabilizing orthotics were provided, to support weaknesses in the pedal foundation and decrease stress to the knees and back during walking.  A custom-made cervical traction pillow was ordered, to provide proper alignment of the head, neck and shoulders during the night.

Rehabilitation. He was started on a localized spinal activation and strengthening program using elastic resistance tubing for the multifidus muscles—first in extension, then into rotation and lateral flexion.  In addition, he was counseled on building up to 60 minutes a day of moderate physical activity for weight loss.  He chose to walk for 15 minutes during lunchtime and another 15 minutes prior to his evening meal.  After three weeks he doubled his time at each session.  He used an exercise log as part of his motivation for sustaining his fitness activities, which included a healthy and balanced diet program. 

Response to Care

He tolerated adjustments well, and adapted to the orthotics and cervical support pillow without difficulty.  Low back symptoms resolved rapidly and, shortly thereafter, his neck tightness disappeared.  His brisk walking program did not irritate his back, even after he increased to a total of 60 minutes daily.  After six weeks of adjustments (8 visits), he was released to a self-directed home stretching program, with instructions to continue his exercise and healthy dieting.

Discussion

Obesity is still on the rise in all industrialized countries, since so many of us—like this case study—now live primarily sedentary lives.  Additional, unhealthy pounds place increased stress on the lower extremities and spine, resulting in chronic symptoms and accelerating degenerative changes.  Specific spinal adjustments and custom, postural support need to be combined with individualized dietary and exercise instructions for best results.  An exercise/dietary log can improve patient adherence to recommended lifestyle changes.

:dropcap_open:F:dropcap_close:or the past year, it seems anytime you open a magazine, newspaper or watch a television show, you see some reference to the raising awareness of the rate of traumatic brain injuries (TBI) or concussion in today’s youth. This information is mainly directed toward the adult population. Football has always been the sport of primary focus, but recent injuries to NHL star Sydney Crosby has made even more people sit up and take notice. For purposes of this article, our emphasis will be more on the adolescent.

Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include:

Concussion may be caused by either a direct blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head.

Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously.

Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury.

Concussion results in a set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course; however, it is important to note that, in a small percentage of cases, post concussive symptoms may be prolonged.

No abnormality on standard structural neuroimaging studies is seen in concussion.¹

One of the most common mistakes in understanding concussion, at one time, was that it was believed you had to have been knocked unconscious to have suffered a concussion. Today, we know this is far from the truth. Actually, only 9 percent of all concussions result in loss of consciousness (LOC). As doctors of chiropractic, we understand how different stresses at one part of the neuromusculoskeletal chain can affect areas above and below the area of insult. Due to this understanding, we can biomechanically understand that an “impulsive” force to the body can be transmitted to the head. So, the damaging blow does not have to be a hit to the head, but can be anywhere within the neuromusculoskeletal chain and result in compromising the integrity of the brain, spinal cord and nerve roots.

:quoteleft_open:Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.:quoteleft_close:

You may say to yourself, “Concussions occur primarily in sports, and I do not treat many athletes and I’m not a team doctor.” This statement is about as false as the statement that you have to be knocked unconscious to have suffered a concussion. We all treat patients who—through falls, motor vehicle accidents, worker’s comp injuries—have entered our office with complaints of headaches, dizziness, nausea, balance issues, blurred vision, ringing in the ears, just to name a few. Are these signs and symptoms any different that those of a TBI, closed head injury, or concussion?

The reason for the increased awareness is the increase in two syndromes that are associated with concussion, the first being “post concussion syndrome.” Simply put, this is nothing more than continued symptoms that we mentioned above that last longer than 24 hours. The other is “second impact syndrome.” Second impact syndrome results from a patient or athlete who sustains a second head injury while the signs and symptoms of the first have not yet cleared. It has to be no more of a force that causes the brain to accelerate or quickly decelerate.

Diagnosing someone who is suffering from a traumatic brain injury can sometimes be difficult. Many times, it is simply listening to the patient (or someone who is close to the patient) tell you about changes they may be noticing. These symptoms include not sleeping in the same normal patterns, behavioral changes, and depression, speech or balance issues. They can all be clues that your patient maybe suffering from something more than just a vertebral subluxation complex.

In sports, there are three accepted guidelines for grading concussion and returning to play. Today, primarily the one developed by the American Academy of Neurology (AAN) is the preferred source.

Grade 1 or mild concussion is defined as no loss of consciousness, and post-concussive signs and symptoms that are lasting longer than 15 minutes.

Grade 2 or moderate is again no loss of consciousness but the post-concussive signs and symptoms last longer than 15 minutes.

Grade 3 or severe is defined as “any” loss of consciousness.

For the athlete to return to play, the considerations are based on several factors:

Patient must be “asymptomatic”

Patient must pass memory & neurological testing

NO signs and symptoms with exertional testing.

Additional assistance is used by many with the use of Sport Concussion Assessment Tools. These are tests that are given before an athlete participates and, again, once it is suspected that he/she may have received a head injury. The test involves a section the athlete fills out on post-concussion symptoms, grading them from 0 (none) to 6 (severe). The second part is filled out by a qualified healthcare professional. It involves scoring signs and symptoms, cognitive assessment and neurologic screening and, finally, a return-to-play recommendation. Examples of these tests can be found on the Internet.

:quoteright_open:These symptoms include not sleeping in the same normal patterns, behavioral changes, and depression, speech or balance issues.:quoteright_close:

So, why are adolescents having an increase in concussions? First and foremost is the increased level of competition. Today, most parents want their children to grow up healthy and happy. But, with the influence of increased pressure to participate and win, we have a tendency to overlook the environment in which we may be placing our children. Another consideration is the lack of properly trained healthcare professionals at adolescent events. Think of how many coaches there are for youth programs. Typically, they are moms and dads who want to be involved with their children, but who may know little to nothing about proper mechanics of the sport or have no training in first aid and CPR. Many youth organizations are starting to change this and make it mandatory for all coaches to have training in first aid and CPR, and it’s more common to have a defibrillator as part of the equipment mandated at events.

We mentioned that forces can be transmitted to the brain. We know that the heel-strike portion of the gait cycle produces transmitted forces that can travel the length of the neuromusculoskeletal system. To help improve these forces, you can: recommend the use of custom-made orthotics, make sure that the foot is going through a normal biomechanical heel-to-toe transition, and recommend the use of a good athletic shoe to help absorb and distribute shock. The use of mouth protectors has also been considered in helping reduce forces transmitted to the brain.

I recommend you do more research on traumatic brain injuries and concussion to help you better understand the signs and symptoms associated with it. Find a center that deals with traumatic brain injury patients. They often need additional occupation therapies to help them with activities of daily living that most doctors of chiropractic may or may not be able to provide. These types of injuries can be very scary, but having a good understanding of how and what is happening allows you to provide the best chiropractic care possible for your patients.

A 1980 graduate of Palmer College of Chiropractic, Dr. Kirk Lee is a member of the Palmer College of Chiropractic Post Graduate Faculty and Parker College of Chiropractic Post Graduate Faculty. He has lectured nationwide on sports injuries and the adolescent athlete, and currently practices in Albion, Michigan.

Reference

1. Consensus Statement on Concussion in Sport, 3rd International Conference on Concussion in Sport, Nov 2008, Clin J Sport Med 2009; 19:185-200

History and Presenting Symptoms

A 56-year-old male presents with recurring episodes of moderate pain and “tension” in his left hip. He denies injuring the hip, and cannot discern any specific precipitating activities or events. Mornings seem to be particularly problematic, but the pain is never disabling. On a 100mm Visual Analog Scale, he rates his left hip pain around 45mm. He takes over-the-counter NSAID’s, which provide sufficient relief. However, he desires to discontinue taking drugs for his hip pain.

Exam Findings

Vitals. This active male weighs 175 lbs., which, at 5’10’’, results in a BMI of 25—right on the borderline of overweight. He works out regularly on resistance machines at his local community recreation center, which indicates that some of his excess weight is possibly lean body mass. He doesn’t smoke, his blood pressure is 118/78mmHg, and his pulse rate is 76 bpm. These findings are within the normal range.

Posture and gait. Standing postural evaluation finds a lower iliac crest on the right and a low right greater trochanter. The left shoulder is somewhat lower than the right, with no history of fracture or surgery. His knees are well aligned, but there is obvious medial bowing of the right Achilles tendon, with a lower medial arch on the right foot.

Chiropractic evaluation. Motion palpation identifies several mild limitations in spinal motion: the left SI joint, the lumbosacral junction, T11/12, and at the cervicothoracic junction. Palpation finds no significant tenderness in these regions, and all active spinal ranges of motion are pain free. Hip ranges of motion are also pain-free. Provocative orthopedic and neurological tests for nerve root impingement and/or disc involvement are negative.

Lower extremities. Closer examination finds that the right medial foot arch is lower than the left when standing. His right calcaneus is everted when bearing weight. When he is seated and non-weightbearing, the right arch appears equal to the left, and when he performs a toe-raise while standing, the right arch returns. Manual testing finds no evidence of weakness in the peroneal or anterior tibial muscles.

:dropcap_open:Chronic hip pain must be evaluated fully, in order to identify any underlying problems and propose effective treatment.:quoteleft_close:

Imaging

A-P and lateral lumbopelvic X-rays are taken in the upright, weightbearing position. A discrepancy in femur head heights is noted, with a measured difference of 6 mm (right side lower). A moderate lumbar curvature (8°) is noted, convex to the right side, and both the sacral base and iliac crest are lower on the right. The sacral base angle and measured lumbar lordosis are increased, but not outside of normal limits. No loss of joint spacing or osteophyte formation is identified in the hip joints.

Clinical Impression

Moderate functional leg length discrepancy (right short leg), with associated pelvic tilt and slight lumbar curvature. There is an accompanying history of chronic left hip pain.

Treatment Plan

Adjustments. Specific, corrective adjustments for the SI joints and the lumbar, thoracic, and cervical regions were provided as needed, with goodresponse. Right-foot manipulation, including navicular, cuboid, and calcaneal bones, was also performed.

Support. Custom-made, flexible stabilizing orthotics were provided, with added pronation correction on the right side. The adaptation process posed no difficulties.

Rehabilitation. He was shown a series of standing hip strengthening exercises in all ranges, using elastic resistance tubing. His exercise log was reviewed at each visit to ensure adherence to the exercises.

Response to Care

All adjustments were well tolerated, and orthotics helped to improve his postural alignment. After four weeks of adjustments (eight visits), daily home exercises, and wearing the orthotics, he successfully completed his re-examination and was released to a self-directed maintenance program.

Discussion

With no history of leg, hip or pelvic injury, this patient apparently had a functional right short leg that produced a chronic biomechanical stress on the left hip joint. Pronation and biomechanical asymmetry in the foot and ankle are seldom locally symptomatic. Chronic hip pain must be evaluated fully, in order to identify any underlying problems, rule out osteoarthritis and other important conditions, and propose effective treatment. The foot and spinal adjustments and the hip exercises were helpful, but the problem most in need of correction was the pronation asymmetry that caused a functional imbalance at the hips and pelvis.