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?

7. 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

8. 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.

9. 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

10. 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. 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. Examination

14. 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.

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

16. Spinographs

17. Spinographs

18. Spinographs

19. 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.

20. What do the test results mean? • Positive tests? • Negative tests? • What else should we test?

21. 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

22. 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

23. 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.

24. 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.

25. 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 didn’t evacuate immediately, he would have an accident.

26. 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.

27. 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.

28. 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.

29. 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.

30. 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.

31. 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.

32. What to leave With • Don’t 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.