Group 3William Tyson Austin

Janna CottingameJohn GriffithsElaine HollandRachel MooreCagan RandallDaniel Stasiak

Yevgeniya Yanayeva

Patient Presents• A female, 16 years of age, presents with right shoulder

pain that has been bothering her for a couple of weeks. But within the past couple of days it has become very painful.

• On a scale of 1-10 she says it’s a 6. She says pain is really achy and dull and she didn’t do anything out of the ordinary to cause the pain (no trauma).

• She is a competitive swimmer for Southlake Carroll Swim team. Her event is the freestyle or crawl and she knows her right shoulder pain is affecting her time because she is starting to loose races and that is why she is here.

• She comes in with her mother and is annoyed when the mother answers the questions for her. She has Blue Cross Blue Shield from her father’s employer.

Questions1. Where does it hurt?

1. Right Shoulder (pt points to trap area)

2. Have you had any previous treatment/imaging?

1. No treatment-onset was 2 weeks ago

3. Pain Freq and description?1. Dull ache, constant but varies in degree.

4. Provocative/Palliative?1. Pain with swimming(Ext rotation & Abduction). It hurts

worse when I am swimming and more when I wake up on my right side. Nothing makes it better.

5. Home life activity?1. Home work(She is right handed), talking on the phone,

“texting is a must”, typical teenager stuff. She lives her life anterior to her spine with her cervical spine flexed reducing any cervical lordosis.

Thoughts??

Provisional DDX• Supraspinatus Strain 840.6

• Shoulder Impingement 762.2

• Acquired Postural Kyphosis 737.10

• Postural Imbalance 729.90

• Muscle weakness 728.87

• Shoulder Pain = Missed the BOAT!!

Exams

• Posture• Myotomes• Ortho Test and Physical Diagnosis

– Cervical compression– Cervical Distraction – Apley’s Scratch– O2 sat– Chest Expansion

• Soft Tissue Mobilization/Palpation• ROM

– Cervical– Lumbar – Shoulder

• Balance & Coordination: – Mittlemeyer’s turn test– Tandem Gait

Exam

• Posture– Left head rotation– Anterior head carriage– AS occiput– Bilateral internal rotated shoulders– High rightshoulder– Hyperlordotic lumbar spine– Anterior translation of the pelvis– Bilateral external foot flare

Exam

• Myotomes:– C5 posterior deltoid weakness bilaterally

(4/5)– Supraspinatus 4/5

Exam

• Orthopedic Tests– Cervical compression

• referred pain to the upper right trapezius area.

– Cervical Distraction • makes her pain feel better

– Apley’s Scratch • She could not perform either side well. Pain when

right shoulder internally rotated.

Exam

– O2 sat 96%, Pulse 62 BPM

– Chest Expansion 1.0”• want at least 1 ½” for women 2” for men

Exam: Soft Tissue

• Soft Tissue Mobilization/Palpation– Pt has taut and tender right cervical paraspinals, as well as

tender right upper trap/lev scap area.

– The following muscles were restricted: • Pectoralis Major• Pectoralis Minor• Anterior Deltoid• Sternocleidomastoids• Scalenes• Levator Scapulae• Teres Major• Upper Trapezius• Sub-occipitals

Exam: Soft Tissue

• Soft Tissue Mobilization/Palpation– These muscles were inhibited:

• C-spine posterior lateral extensors• Rhomboids• Lower trapezium

Exam ROM

• Cervical– +1 pain response with extension

• Lumbar– The Lumbar ROMs are below normal in all directions

• Shoulder – Right shoulder ROM elicited pain in extension, abduction and

external rotation . Anterior head translation noted with shoulder abduction

Exam: Cervical ROM  Cervical Normal notes with initial condition

Flexion 55o 50o

Extension 35 o 60o Pain +1, cervical collapse

L Lat Flexion 25o 45o

 

R Lat Flexion 30o 45o

 

L Rotation 80o 80o  

R Rotation 70o 80o  

Exam: Lumbar ROM

Lumbar Normal Notes

Flexion 50 o 60o ratcheting ataxic motion throughout full range on bilateral lumbar para-spinals

Extension 15 o 25 o  

R Lateral 15 o 25 o  

L Lateral 15 o 25 o  

Exam : Shoulder ROM 

R Shoulder

L Shoulder

Normal notes with initial condition

Flexion 175 o 180 o 180 o  

Extension 15 o 20 o 50 o +2 pain

Abduction 120 o 180 o 180 o +2 pain

Adduction 25 o 45 o 50 o  

Internal Rotation

90 o 90 o 90 o  

External Rotation

60 o 80 o 90 o +2 pain

Exam: Balance & Coordination

• Mittlemeyer’s Turn Test– Rotates Right with eyes closed

• Tandem Gait: – No sway with eyes open– Right deviation with eyes closed, wide

stance

Imaging

• C-Spine– LCN– APLC– APOM – A-P Bilateral Lateral Flexion

Cervical Stress Lines

• Ruth Jackson's Angle is also known as Cervical Stress Lines, which is measured by constructing lines of mensuration from the posterior bodies of C-2 and C-7. These lines will form an angle which ordinarily intersect at the C4-C5 disc interspace in the neutral and extension view and C5-C6 disc interspace in flexion. The intersection point represents the focus of stress when the cervical spine is placed in the respective position. Muscle spasms, joint fixation, and disc degeneration may alter the stress point.

X-ray Neck

• DDD was noted from the LCN: C4/5 disc space was increased or is a type D1 inflamed disc

X-ray Neck

• APLC shows lower c-spine list to the left from C4-C7. This represents Coronal Displacement which only occurs after sagittal displacement.

• Bilateral lateral flexion c-spine films.

• To evaluate any abnormal biomechanics in relation to spinous deviation.

• Normal spinous deviation in the c-spine, the spinous will deviate into the convexity.

• When spinous deviation is into the concavity then the neck flexors (SCM’s) are mobilizing the c-spine in lateral flexion and not the lateral flexors (scalenes).

• These are static x-rays that give the chiropractor an insight into muscular activation and it’s relation to spinous deviation.

X-ray Neck

Other Imaging

• Shoulder X-ray– for supraspinatus Outlet– later if treatment doesn’t show

improvement

• MRI shoulder– later if treatment doesn’t show

improvement

Diagnosis• Acquired postural kyphosis 737.10

– Bony postural component– Treatment is 98940/97112– Rib adjustments 98943– Shoulder adjustment 98943

• Postural imbalance 729.90– Muscular component– Restricted anterior muscles above T6, Inhibited posterior muscle

below T6– Treatment is 97112/98940

• DDD 722.4 – inflammation of disc D1 type– IFC 97014– Boswellia A9150 Nonprescription

• Muscle weakness 728.87 – (para-spinals and the posterior muscles above T6)– 97110 (Strength, ROM, endurance)– Ant Head -> tension Spinal cord -> Large Diameter nerves affected

1st, Ischemia, Silent C5 radiculopathy (our patient doesn’t have this but…)

– Diagnosed with Needle EMG, NCV, Not ortho

Prognosis• Prognosis is Good. Condition is

expected to fully resolve with functional improvement. Patient recovery could take longer due to postural abnormalities.

Treatment

• Divided into 3 phases of care:

• Phase I: Symptom reduction

• Phase II: Corrective care

• Phase III: Stabilization

Treatment• Phase I: Symptom reduction of chief

complaint

• Frequency: 5x/week for 2 weeks

1.Adjustments• Cervical curve correction: P-A adj• Rib adj• Shoulder adj

Treatment

2. Interferential Current (3-5days)

3. Myofacial release of shoulder girdle

4. Neck extension exercises with arm abduction

• Activate supraspinatus and posterior deltoid muscles

5. Boswellia complex for inflammation• Initial dosage: 2g every 4hrs for 3 days

Treatment

• Phase II: Corrective care

• Frequency: 3x/week for 8 weeks

1.Continuation of adjustments

2.Denneroll orthotic exercises • 2x/ day up to 20 min per session• With or without graston and PIR on flexors

3.C-spine lateral flexion exercises

Treatment

“THERAPEUTIC VACATION”• Following the end of Phase II treatment

– See how the patient feels after 2 weeks without an office treatment

This will allow the DC to determine frequency of visits as the pt. enters the 3rd phase of care

– Home exercises should be performed as previously scheduled

Treatment

• Phase III: Stabilization

• Frequency: dependent on patient

1.Balance and co-ordination assessed

2.Core stabilization

3.Continue with full spine adjusting

Outcome Assessment

• After 1st 2 weeks– QVAs– SPADI– DASH – ROM (w or w/out pain)– Posture

• After 8 additional weeks– lateral flexion x-rays repeated after baseline study – LCN to verify DDD changes

Results-outcome assessment Phase 1

• QVAs: pre-Tx: 6/10; post-Tx: 0/10

• SPADI: pre-Tx: 60%; mid-Tx: 30%; post-Tx: 0%

• DASH

• ROM

• Posture

Results-outcome assessment Phase 2

• lateral flexion x-rays repeated after baseline study

• LCN to verify DDD changes

Outcome: Cervical

ROM values        

  Cervical Normal Outcome 1 Outcome 2

Flexion 55o 50o 55o 55o

Extension 35 o pain 1 60o 45 o 60o

L Lat Flexion 25o 45o 30o 45o

R Lat Flexion

30o 45o 35o 45o

L Rotation 80o 80o 80o 80o

R Rotation 70o 80o 80o 80o

Outcome: Lumbar

ROM values

       

Lumbar Normal Outcome 1 Outcome 2

Flexion 50 o 60o 55 o 60o

Extension 15 o 25 o 20 o 25 o

R Lateral 15 o 25 o 20 o 25 o

L Lateral 15 o 25 o 20 o 25 o

Outcome: Right ShoulderROM values        

  R Shoulder Outcome 1 Outcome 2 Normal

Flexion 175 o 180 o 180 o 180 o

Extension 15 o pain 2 35 o 50 o 50 o

Abduction 120 o pain 2 160 o 180 o 180 o

Adduction 25 o 40 o 50 o 50 o

Internal Rotation

90 o 90 o 90 o 90 o

External Rotation

60 o pain 2 90 o 90 o 90 o

Outcome: Left ShoulderROM values        

  L Shoulder Outcome 1 Outcome 2 Normal

Flexion 180 o 180 o 180 o 180 o

Extension 20 o 35 o 50 o 50 o

Abduction 180 o 180 o 180 o 180 o

Adduction 45 o 50 o 50 o 50 o

Internal Rotation

90 o 90 o 90 o 90 o

External Rotation

80 o 90 o 90 o 90 o

Estimated Cost of Care Plan1st Phase:

Spinal Adjustments 98940 $47.00X10 $470.00Extraspinal Adjustments 98943 $37.00X10 $370.00Interferential Current 97014 $20.00X4 $ 80.00Myofascial Release (each 15m) 97140 $15.00X10 $150.00Exercises (neck ext.) 97110 $50.00X10 $500.00

Total $1570.00

2nd Phase:Spinal Adjustments 98940 $47.00X24 $1128.00Extraspinal Adjustments 98943 $37.00X24 $ 888.00NMR (Denneroll) 97112 $30.00X24 $ 720.00Myofascial Release (each 15m) 97140 $15.00X12 $ 180.00Exercises (lateral Flex) 97110 $50.00X12 $ 600.00

Total $3516.00

Total for 1st and 2nd phase $5086.00

** This does not include initial exam, X-rays or Boswelia**

Figuring Insurance ReimbursementTotal Cost of first 24 visits:

Code Cost Allowable Paid-80% PPO Disc Total Cost Ins PPO98940 47.00 45.10 36.08 1.90 1082.40 870.72 45.6098943 37.00 29.15 23.32 7.85 699.60 559.68 188.4097112 30.00 21.05 16.84 8.95 505.20 404.16 214.8097140 20.00 18.95 15.16 1.04 416.90 333.52 22.8897110 50.00 36.30 29.04 13.70 798.60 638.88 301.4097014 20.00 16.40 13.12 3.60 65.60 52.48 14.40

Totals for first 24 visits: 3568.30 2859.44787.48

Additional care not covered by insurance:

98940 47.00X10 470.0098943 37.00X10 370.00

Total Not covered by Ins: 840.00

Summary:

Total Charges 4408.30Total Insurance 2859.44Total Patient Resp 1548.86

You Decide: INS: Total Paid for case 4408.30 Total PPO Disc 787.48 CASH: 5086.00

References

1. Seaman D. Dysafferentation: A Novel Term to Describe the Neuropathophysiological Effects of Joint Complex Dysfunction. A look at likely mechanisms of symptom generation. Journal of Manipulative and Physiological Therapeutics. Vol 21, Number 4. May 1998 pp 267-280

2. Reinold M. Electromyographic Anaylsis of Supraspinatus and Deltoid Muscles During 3 Common Rehabilitation Exercises. Journal of Athletic Training 2007:42(4):464-469

3. Ferrantelli J. Denneroll Combined with Pope 2-Way Aids Patient Suffering from Chronic Whiplash Associated Disorders & Advanced SADD. Chiropractic BioPhysics, American Journal of Clinical Chiropractic 2010 Oct pp 10-15.

4. Banno N. Anti-inflammatory activities of the triterpene acids from the resin of Boswellia carteri. Journal of Ethno-pharmacology 107 (2006) pp. 249-253.

5. Groen D. Innervation of Painful Lumbar Discs. SPINE, Vol 22 No. 20 1997 Oct 15. pp 37-46

backup

Test: Upper Cross• Anteriorly tightening/shortening

– Pectoralis Major, Pectoralis Minor, Anterior Deltoid fibers, Sternocleidomastoids, and Scalenes.

• Posteriorly tightening/shortening– Levator Scapulae, Teres Major, Upper

Trapezius, and Suboccipitals.

• Posterior stretch of the Scapular muscles– Rhomboids, Lower Trapezius, and Serratus

Anterior.

• Anterior Stretch of Deep neck flexors– the Longus Coli and Capitus muscles