A few articles back I authored a piece titled "The Weak Cyclist," presented as a "who-done-it," with the readers submitting their best-guess diagnoses. I received a lot of good feedback from that piece and a number of requests for another article in the same vein, so here is another real case for you to solve. In this instance, I'll provide the "answer" in the next issue [June 17 DC].
Case Presentation
Mrs. C presented to the office with severe, debilitating pain that she described as "all over" and lasting the better part of four years. She stated that she had constant pain of unknown origin that started in her back, but had made its way to her arms, legs and eventually her head. She stated that any activity made it worse, and that she had not even been able to wash dishes for the past four years due to the level of excruciating pain she would suffer just from trying to stand over the sink for 5-10 minutes at a time.
Mrs. C said that nothing really helped her pain, although she had tried all manner of medications, therapy and had even been to two chiropractors with little relief. She presented to the office with MRIs of the brain, full spinal exams, nerve conductions, needle EMGs of the upper and lower extremities, and numerous blood tests - all negative except for what most of us would consider "normal" findings for a 55-year-old female (some spinal degeneration, some bulging discs, with all other tests being inconclusive). In addition to the two chiropractors, she had seen two orthopedists, three neurologists, and a physiatrist who had performed two epidurals, and had already undergone three four-week sessions of physical therapy for her pain, with little to any results.
These symptoms had come on gradually, with no accident or trauma, but progressed over a period of months to the state she was now in and had been in for the past four years. Her prevailing complaint, in addition to the severe pain, was severe weakness of her right side, both the arm and leg, such that she could not even raise her arm to put a dish away or brush her hair. In her own words, "My brain tells my muscles to move, but they do not do it!" She came to the office with her husband, who helped her fill out her paperwork, get her changed, and then completed some of her history when Mrs. C was too upset to discuss her case further. Mrs. C had, as you can imagine at this point, been referred for psychiatric evaluation.
My Findings
Examination findings were as follows: Mrs. C was first asked to stand, which she could do quite well, although she was in obvious distress. When asked to put her feet together, she had much more trouble maintaining her balance, but she was able to maintain the position. When asked to close her eyes, however, she immediately started to fall to her right side, and if not for my being there, may have fallen. (This is a good thing to remember; always be ready for a patient to fall when examining them, since the power of visual afferentation may very well mask an otherwise severely compromised neurological state.)
When asked to raise her right leg and balance, it was all but impossible for her to do, even with some assistance from her husband and myself. Finger-to-nose tests were slightly off on the left, but she missed consistently with the right hand. Eye tests were normal on this patient, though there was some pursuit lag to the left with OPK testing. All other cranial nerves were essentially normal, and no facial asymmetry was noted.
Sensory exam of the upper and lower extremity to both pinprick and vibration was normal for dermatomes and peripheral nerve pathways. Muscle testing of the upper and lower extremity revealed major weakness to both the anterior and posterior muscles, and I could only describe the level as possibly a 3/5. I could literally push against her triceps with one finger and she could not meet the resistance, although she had some slight contractions, more so of the anterior musculature of the upper extremity and the posterior musculature of the lower extremity. Autonomic activity was essentially normal, but blood pressure and pulse rate were slightly lower on the right side.
That's it. At this point in the examination, I was pretty confident as to the diagnosis, and the approach in the end proved the diagnosis and treatment correct. I will say that one treatment was all it took to see vast improvements, and this should play into your thought process. She had about six treatments until she was "cured" and returned to all her previous normal activities, including finding a new job. Needless to say, she and her family were quite the happy campers.
So, what would you do? E-mail your diagnosis and treatment to me at romerochiro@yahoo.com, and I will e-mail back my approach and thought process. And remember, in the next issue of DC, I'll provide the "answer" to this case in a follow-up article. Have fun figuring this one out, and I look forward to hearing from you!
