A Case Report

1
A Case Report
2
History

• Chief Complaint Chronic Lyme Disease (088.81)
• 55 year old white female presents with whole body
  pain and fatigue including neck and back pain,
  headaches, chronic fatigue, depression.
• She states it is sometimes difficult to find the
  correct words to use, has short term memory loss
  and finds it difficult to focus.
• She complains of foot drop, tingling and pain in
  her upper extremities and weakness in the lower
  extremities with left leg numbness.
• Foot drop mostly comes on when she is not on
  antibiotic therapy.

3
History

• Headaches Start on the right and/or left side
  and wrap around her head like a band.
• Sometimes the pain starts at the base of her neck
  and comes up into her head.
• Her full body pain is worse in her cervical and
  thoracic spine and paraspinal tissue. And at her
  SI joints bilaterally.

4
Provide your Differential Diagnosis

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

5
History

• The pain is worse in the spring and fall.
• She states she has about 2 comfortable days per
  month.
• Her pain seems to cycle through the month and
  seem to be worse with a full moon.

6
History

• She believes she contracted Lyme Disease in 1969,
  however, was diagnosed by a DC with the disease
  in 1993.
• Confirmed by Darkfield microscopy.
• Borrelia burgdoferi spirochete confirmed as late
  as October 2006.
• She is currently on long term IV antibiotic
  therapy with a new treatment beginning every 2
  years.

7
History
Before the Diagnosis of Lyme Disease she has been
diagnosed with

• Chronic Fatigue Syndrome
• Alzheimer's
• MS
• Lupus
• Irritable Bowl Syndrome
• Fibromyalgia
• Depression

8
History

• Due to the Lyme Disease she now has
• Cytomegalovirus Human herpesvirus 5 (CMV)
  especially attacks salivary glands. CMV infection
  can also be life threatening for patients who are
  immunocompromised
• HHV6 A and B Human herpesvirus-6
  "Immunosuppressive effect... on T-cell functions"
  such as "suppression of interleukin-2 synthesis
  and cell proliferation."
• Coinfection of Bartonella Babiisiae common
  with chronic lyme disease
• Lipoprotein A deficiency Hypercoagulation
  Results of Chronic Lyme Disease

Flamand L et al. Blood 1995 Mar 185(5)1263-71.
9
History

• Stroke in 1992
• Head-on car accident in 1997
• Breast Cancer 2000 (lumpectomy)
• Broken leg and ankle (left)
• Currently seeing a DO and 3 DCs (weekly) who all
  adjust her spine, only one DC adjusts her
  extremities.
• Symptoms get worse whenever she experiences a
  trauma. (?)

10
DDX

• What would you do?
• How can You help?
• What else do you need to know?

11
Chronic Lyme Disease

• Chronic persistent Lyme disease is a late stage
  of the inflammatory disease.
• AKA Tertiary Lyme disease Stage 3 Lyme disease
  Late persistent Lyme disease Chronic Lyme
  disease
• Tertiary Lyme disease occurs months to years
  after the initial infection.

http//www.nlm.nih.gov/medlineplus/ency/article/00
0669.htm
12
Chronic Lyme Disease

• Lyme disease is caused by the bacterium Borrelia
  burgdorferi and is transmitted to humans by the
  bite of infected black-legged ticks.
• Typical symptoms include fever, headache,
  fatigue, and a characteristic skin rash called
  erythema migrans (may occur in less than 50 of
  infected patients).
• If left untreated, infection can spread to
  joints, the heart, and the nervous system.

http//www.dermatlas.org/derm/IndexDisplay.cfm?Ima
geID2125845465
13
Chronic Lyme Disease

• Lyme disease is diagnosed based on symptoms,
  physical findings (e.g., rash), and the
  possibility of exposure to infected ticks
  laboratory testing is helpful in the later stages
  of disease.
• 2 tier diagnostic criteria requiring both the
  ELISA and Western Blot. You should know these
  tests lack sensitivity, and can leave up to 90
  of infected patients with a false negative DX.
• Most cases of Lyme disease can be treated
  successfully with a few weeks of antibiotics if
  diagnosed early.
• However, there is no reliable test for Lyme
  Disease

14
Chronic Lyme Disease

• The Center for Disease Control and Prevention
  (CDC) considers Lyme Disease (LD) to be the
  fastest growing vector-born disease in the USA.
• Estimated to be 10 times higher than the 17,730
  cases reported to the CDC during 2000.
• The prevalence of chronic LD ranges from 34 to
  62 of those patients who contact LD.
• Physical findings are often normal and
  nonspecific but may indicate arthritis,
  meningitis and/or Bells palsy.

Expert Rev. Atni-infect. Ther. 2(1), 2004
15
Chronic Lyme Disease
Symptoms include skin, neurological, and
musculoskeletal problems.

• joint inflammation in large joints
• chronic arthritis
• memory loss
• mood changes
• sleep disorders
• numbness and tingling
• consciousness, decreased
• confusion
• abnormal sensitivity to light
• Headaches
• Diarrhea
• Swollen Glands

• Fatigue
• Low grade fever, hot flashes, chills
• Night Sweats
• Sore throat
• Stiff neck
• Back pain
• Jaw pain
• Blurred vision
• Tinnitus
• Vertigo
• Cranial nerve disturbance

16
Chronic Lyme Disease
Symptoms include skin, neurological, and
musculoskeletal problems.

• joint inflammation in large joints
• chronic arthritis
• memory loss
• mood changes
• sleep disorders
• numbness and tingling
• consciousness, decreased
• confusion
• abnormal sensitivity to light
• Headaches
• Diarrhea
• Swollen Glands

• Fatigue
• Low grade fever, hot flashes, chills
• Night Sweats
• Sore throat
• Stiff neck
• Back pain
• Jaw pain
• Blurred vision
• Tinnitus
• Vertigo
• Cranial nerve disturbance

17
Chronic Lyme Disease

• Treatment The objective of treatment is to
  eliminate the infection with antibiotic therapy.
  A high dose of penicillin or ceftriaxone is
  usually required in the late stages of the
  disease to treat the infection. (CDC)
• Expectations (prognosis) Symptoms of arthritis
  may fail to resolve with treatment. Other
  symptoms should improve with treatment.
• Complications continued arthritis

18
Chronic Lyme Disease

• B burgdorferi has been detected in every organ in
  the body, including the nervous system.
• Oral antibiotics have minimal effect through the
  blood brain barrier, therefore IV antibiotics are
  used for months at a time.

19
Examination

• Physical orthopedic and neurological findings not
  mentioned were within normal limits.
• Thyroid slightly enlarged
• Mild nystagmus in all directions
• Pain produced when testing Cervical flexion and
  extension motor units.
• 4\5 Left shoulder abduction, Elbow flexion, wrist
  ext., finger abduction/adduction.
• Decreased ROM Passive Cervical ROM in all
  directions with pain upon Flx/Ext/R.rot.

20
Examination

• Cervical Compression Sharp pain at C5
• Cervical Distraction Relieved pain
• Pain reported in the Cervical, thoracic and SI
  areas of the spine.
• Lyme Pain Scale (-4) (0 to -10)
• Support group affectionately calls themselves
  Lymies

21
Examination

• Chiropractic findings indicated
• Prone leg check with a short right leg
• Negative Right Cervical Syndrome
• Positive Cervical Pattern
• Fossa reading .92 to the left
• Tight muscles and tenderness at cervical,
  thoracic musculature and on the left SI.

22
What do the test results mean?

• Positive tests?
• Negative tests?

23
Evidence Based/Best Practice

• Bournemouth Questionnaire
• Neuromusculoskeletal questions
• Psychological Questions
• Instructions The following scales have been
  designed to find out about your neck pain and how
  it is affecting you. Please answer ALL the
  scales, and mark the ONE number on EACH scale
  that best describes how you feel.

24
Bournemouth Questionnaire

• No Pain Worst Pain
• Possible
• ________________________________________
• 0 1 2 3 4 5 6 7 8 9 10
• 1. Over the past week, on average, how would you
  rate your neck pain?

25
Bournemouth Questionnaire

• Over the past week, how much has your neck pain
  interfered with your daily activities (housework,
  washing, dressing, lifting, reading, driving)?
  9
• Over the past week, how much has your neck pain
  interfered with your ability to take part in
  recreational, social, and family activities? 9

26
Bournemouth Questionnaire

• Over the past week, how anxious (tense, uptight,
  irritable, difficulty in concentrating/relaxing)
  have you been feeling? 9
• Over the past week, how depressed
  (down-in-the-dumps, sad, in low spirits,
  pessimistic, unhappy) have you been feeling? 9

27
Bournemouth Questionnaire

• Over the past week, how have you felt your work
  (both inside and outside the home) has affected
  (or would affect) your neck pain? 9
• Over the past week, how much have you been able
  to control (reduce/help) your neck pain on your
  own? 7

28
Bournemouth Questionnaire

• Scoring a questionnaire
• 7 Questions
• 70 points possible
• Add up the score from the patient..61
• Divide by the total possible points..70
• .87
• Multiply by 100 87

29
Type of Treatment

• Should we accept the patient for care?
• Do we change treatment of other doctors?
• What complications of past chiropractic care
  might there be?
• What technique(s) do we use?

30
X-Rays

• Moderate degeneration at C4-5 with loss of disc
  height.
• Loss of cervical lordosis with hyperflexion at
  C4-5.

31
X-Rays

• Right convexity of the cervicothoracic junction.

32
X-Rays
33
X-Rays

• C1 ASL asr
• C2 ARS
• C3 ALS
• C4 ALS ARS
• C5 PRI PLI
• T1 PL
• T2 PR

34
Final Dx

• What is your final Dx?
• 088.81 Lyme Disease
• 722.4 Cervical Disc Disease
• 723.4 Radiculitis
• 723.1 Cervicalgia
• 724.1 Dorsalgia
• 736.81 Unequal leg length (acquired)
• 739.1 Cervical Subluxation
• 739.2 Thoracic Subluxation

35
Patient Management Plan
36
Patient Management Plan
2/6/2007
2/6/2007
Blair Upper cervical / Palmer package
To be determined as care progresses
Postural Exercises give as care progresses
37
Patient Management Plan
3 times per week for 2 weeks, 2 times per week
for 4 weeks, 1 time per week for 6 weeks
4/9/2007
Goal decrease bournemouth Questionnaire by 30
in 2 months (61). Increase stability of spine
allowing for decreased occurrence of subluxation
38
Daily Visits

• Visit 1 1st adjustment after chiropractic
  evaluation was for subluxation
• C1 and C4 Blair
• Visit 2 Patient noticed neck and mid-back relief
  after the first adjustment but was knocked down
  by her dog yesterday and had a return of her
  headache, neck pain and jaw pain. (-8 scale)
• Chiropractic evaluation was for subluxation
• C1, C4 and T1 Blair
• Postural exercises started today (Cat/Camel)

39
Daily Visits

• Visit 3 Patient reports her headache persisted
  since the last adjustment. She hasnt been
  sleeping and her right eye has been hurting. The
  base of her neck feels very sore. (-9)
• Adjusted C1, C2, C4, T1 and T2 (standing Tall
  exercises and coffea cruda)
• Visit 4 No headache, eye is better, The base of
  her neck is still on fire but better from the
  last visit. Her arms are painful and become worse
  with use. (She received 2g Rocephin today)
• Findings for subluxation at C2 only.
• Post adjustment patient noticed alternating
  throbbing in her temporal region.

40
Daily Visits

• Visit 5 Her sleep has improved, her headaches
  have not returned, she complained of SI pain on
  the left side which started today. Her left hand
  is tingling but is not painful.
• T1, T7, Left Ilium, T1 ribs bilateral.
• Visit 6 She reports having to take 800 mg of
  ibuprofen to help with her pain. The pain seems
  better now and she reports she feels the pain
  medication made the difference. She saw D.O.
  today who adjusted her SI T9 and ribs.
• Left Femur, Left Ilium, T1 and T1 ribs.

Protocols changed due to fill in doctor on visits
5-6
41
Daily Visits

• Visit 7 Patient returns with a headache on her
  right side (occiput to eye), with pressure behind
  her eye. The middle of her neck feels like there
  are spikes in it and T12 are hot again. Her SI
  was worse until yesterday. PT worked on T4 today.
  PT was instructed to massage in the reverse
  direction of the subluxation. Her right arm
  continues to tingle.
• C2, C4, C5
• Visit 8 No headache or neck pain after the last
  adjustment until she shoveled snow. Now the base
  of her neck is hot. She has had tingling in her
  hand over the weekend. Some discomfort in the
  right eye but no pain.
• C4

42
Daily Visits

• Visit 9 No headache since the last visit. Her
  C/T junction is tight, hot and painful. Occ-C2 is
  tight, her left SI hurts today, Her right hand is
  tingling. (She received 2g Rocephin today)
• C2 T1 (Pelvic unleveling cleared after C2 and
  T1 were adjusted with no fixation of the SI
  noted)
• Visit 10 Headache today (bilaterally), She has
  upper and mid thoracic pain, fingers are sore and
  numb, her upper cervical spine feels tight. She
  took 800mg IBP for headache. (-9)
• C2, T4 and T8 (on palpation)
• -D was noted before C2 adjustment but cleared
  afterward.

43
Daily Visits

• Visit 11 She has felt better overall since the
  last visit. She has no headache but does have
  some facial pain along the right maxilla. She
  states she had the same pain a few years back for
  a couple of months. The facial pain is a -9/10.
  She states she does have Lumbar pain is a -6/10
  that started a few days ago. (No mention of hand
  numbness or tingling).
• C1
• Visit 12 No headache, no facial pain, no eye
  pain, her right hand is better than it has been
  in a long time, her lower neck is sore, she
  didnt sleep well last night and her left hip
  hurts today.
• C1, T11 (upon palpation)

44
Daily Visits

• Visit 13 (10 days later) She had a good week
  over all. Right hand tingling, T12 area is sore
  (-2), her left SI is sore, Her eyes are good and
  she had 2 minor headaches that didnt go anywhere
  and she didnt have to take a pain reliever for
  them.
• C2 and T12

45
Follow-up Bournemouth (6 weeks post care)

• No Pain Worst Pain
• Possible
• ________________________________________
• 0 1 2 3 4 5 6 7 8 9 10
• 1. Over the past week, on average, how would you
  rate your neck pain?

46
Bournemouth Questionnaire

• Over the past week, how much has your neck pain
  interfered with your daily activities (housework,
  washing, dressing, lifting, reading, driving)?
• 9 2
• Over the past week, how much has your neck pain
  interfered with your ability to take part in
  recreational, social, and family activities? 9 2

47
Bournemouth Questionnaire

• Over the past week, how anxious (tense, uptight,
  irritable, difficulty in concentrating/relaxing)
  have you been feeling? 9 5
• Over the past week, how depressed
  (down-in-the-dumps, sad, in low spirits,
  pessimistic, unhappy) have you been feeling?
  9 6

48
Bournemouth Questionnaire

• Over the past week, how have you felt your work
  (both inside and outside the home) has affected
  (or would affect) your neck pain? 9 2
• Over the past week, how much have you been able
  to control (reduce/help) your neck pain on your
  own? 7 2

49
Bournemouth Questionnaire

• Scoring a questionnaire
• Add up the score from the patient..21
• Divide by the total possible points..70
• .30
• Multiply by 100 30
• Started at 87, Now 30, Goal was 61

50
Re-examination

• Will be this week
• Questions?