Thoracic Spine Lab Session DX 612 James J. Lehman, DC, MBA, DABCO University of Bridgeport College of Chiropractic

Case Study Actual case study from a Chiropractic College Clinic…

Clinical Presentation Chief Complaints Numbness both thighs Mild LBP Mild hand & foot pain Headaches Hypothyroidism Diabetes Left-sided chest pain

Secondary Symptoms Dizziness while getting out of bed Age-related fatigue Daily shoulder stiffness High blood pressure Gas and heartburn

Additional History Recent EKG normal Past Hx of MI Under financial stress Thigh numbness with standing & relieved with sitting (past 6 months)

High Risk Patient Is this guy a “walking time bomb?” Why?

Additional History Chronic thoracic and lumbar back pain for years Pain relief with mm relaxants & back support while sitting up straight

History Pain with use of arms in forward elevation

Additional History Infrequent headaches resembled those that he experienced as a child.

Additional History Reduced trunk ROM with back tenderness

Past Medical History Heart attack 1996, angioplasty? Fractured C-spine 3 y/o Controlled diabetes Hypertension Hypothyroidism & Synthroid Rx

Past Medical History Numerous meds for heart, high blood pressure, seizures, and acid reflux.

Past Medical History 20 year Hx of chiropractic care 2 years since chiro care Some manipulations helped but not the drop table treatments.

Physical Examination 59 y/o male 72” height 301# Hypesthesia anterior right leg and thigh Decreased LE DTR

Physical Examination Left shoulder pain with abduction with reduced arterial return Mild neck pain in all ROM and with lifting Can you name the test?

Additional Examination Would you prefer any other testing prior to assessment and treatment of this patient?

Intern/Clinician Assessment Working Diagnosis Myofascial thoracic and lumbar pain associated with subluxation.

Assessment Do you agree with this assessment? Why?

Your Opinion Are you ready to treat the patient?

Treatment Provided at Chiropractic College Clinic Prone T4 Carver Bridge adjustment Drop to the sacral base

Outcome of Thoracic Adjustment Immediate groaning and lifting up of torso off table with grasping and clutching of patient’s chest.

Post Manipulation Treatment Cryotherapy Supine posture with ice reduced patient’s pain.

Clinical Question What happened?

Patient Comments “I felt and heard several popping sounds from inside my chest. I know my ribs are broken”

Evaluation Positive finger pointing to anterior costal margins and exhibited signs of dyspnea

New Revelation… Patient fell off a building several years prior. He fractured several ribs at his sternum. He never went to a doctor for treatment… He forgot to mention this injury when asked in history x3.

Anatomy of Rib Cage Check margins Costal-cartilaginous junctures Sternal location

Working Diagnosis What are your differential diagnoses?

Differential Diagnoses Sprain/Separation Costochondritis Fracture Coronary pain

Evaluation Would you perform orthopedic testing? If yes, which tests?

Orthopedic Evaluation Positive finger point Palpation with positive jump sign Thoracic ROM testing

Orthopedic Evaluation Sternal compression Rib cage compression

Imaging Study Radiographic examination of the ribs is indicated…

Sternal Compression Test Contact sternum Apply AP force Compress rib cage gradually

Sternal Compression Test What is the value of the sternal compression test?

Sternal Compression Test Pronounces rib fractures Produces pain with costochondritis

Scheplemann's Test What is the value of Scheplemann’s test?

Vital Signs Corroborate historical information with physical examination findings.

Subjective and Objective Findings Are the Hoof Beats… Look for horses when you hear hoof beats,

Awareness Enhances Decision Making… not zebras, unless you are in Africa…

Two years later… Complaint Served with Allegations Medical negligence Failure to obtain informed consent Loss of consortium pled by spouse

Cardiac Emergencies Notice that cardiac pain is not only on the left side…