At the end of each neurology seminar, Dr. Carrick customarily would show the class a video of an actual examination as it was being performed in real time. Our objective was to sit around with our friends and try to come up with a diagnosis and treatment plan based on what we had seen. Needless to say, most times (at my table at least) there were a myriad of confused looks, followed by out-and-out guessing. Slowly, as with all things, we started to understand more of what we were seeing, and the diagnosis and treatments did not seem so exotic. Little by little, our understanding of the nervous system and our effect on it as doctors started to flourish.
In that vein, I thought this month I would present a case history of a patient I recently treated. The diagnosis of this particular patient is one that I have written about in previous articles, so the signs and symptoms may seem familiar to you as the case is expanded upon. I hope this is the case with the majority of you, because it would mean to me that you have read and understood what I have written, and perhaps we are doing our part together to make the lives of our patients better and healthier.
A competitive cyclist, came in to the office quite distraught (and a little afraid of me). For the past five months, he had not been able to "generate any force" (his words) while riding, as well as having a pain in his lower right spine that would come on as soon as he got on the bike. He was currently under the care of a physical therapist who had been stretching him, as well as doing all the customary treatments related to low back pain. An orthopedist had referred the patient for the physical therapy, and the diagnosis had been the all-encompassing "bulged disc." An MRI had been performed of the lumbar spine, and there were indeed bulged discs at the L3-L4 and the L4-L5 levels.
The patient's condition had proceeded without much improvement; he stated he would feel better for a day or two following treatment, but all his symptoms would return immediately as soon as he got on the bike. He could not account for the etiology of his pain. He thought he may have injured it while doing some forceful pedaling in a road race, but the symptoms seemed to come on gradually and worsen over time. He denied ever having had something similar, and could not equate any one injury or trauma to his current state of weakness and pain.
The patient's presentation was as follows: Sensory examinations of the upper and lower extremity were unremarkable. Vital signs were exemplary. Cranial nerve examination was within normal limits. Evaluation of the vestibular system was unremarkable, though heel-to-shin evaluation revealed some signs of dysdiadokinesia of the lower extremities bilaterally. Cardiac and respiratory systems were within normal limits. Examination of the abdominal system was unremarkable for any masses or other pathology. Motor testing was as such: hamstrings and adductors tested normal, as did the tensor fascia lata bilaterally. Testing of the quadriceps group, however, revealed a pronounced weakness to resistance, with the left-side weakness greater than weakness of the right side. The weakness was such that, at best, I could grade the left side as a 4/5, and the right side as a 4.5/5.
Remember, this was a competitive cyclist with quads like tree trunks and calves that are better described as "steers." There were subluxations of the left sacroiliac joint, as well as L4-L5, T11-T12 and C5-C6, with tenderness to palpation. That's all folks. With this information, a diagnosis should be readily made, and a treatment protocol should present itself based on the patient's objective signs and symptoms.
To wit, I adjusted the patient once; then he went through a rebalancing process of nerve integration that took about six days, and responded as expected. He is now back on the bike without any pain or weakness, as evidenced by our ride on Wednesday when he attacked the group at 32 mph and put the hurting on all of us, yours truly included.(I have vowed to the group that I will never adjust him again.)
E-mail me with your suggested diagnosis and treatment approach.Just remember that I am a practice-management company's worst nightmare. If I can get a patient better in one visit, as I did with this patient, I will. The other side of that coin, of course, is that I now have a patient for life whenever the slightest thing will come up for him (as it will), and I have already received five referrals just three weeks after his treatment. He owns a bike shop, so the referrals will continue for years to come, I would imagine. Success breeds success, and as long as we do our jobs well, there will always be people knocking at our door.
Well, enough of that. E-mail me and I will e-mail back his actual diagnosis and treatment, with some neurological explanation to the case. Good luck, and keep on learning and pushing the chiropractic envelope.
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