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

2. Case Study
Actual case study from a Chiropractic College Clinic…

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

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

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

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

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

8. History
Pain with use of arms in forward elevation

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

10. Additional History
Reduced trunk ROM with back tenderness

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

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

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

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

15. 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?

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

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

18. Assessment
Do you agree with this assessment?
Why?

19. Your Opinion
Are you ready to treat the patient?

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

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

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

23. Clinical Question
What happened?

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

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

26. 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.

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

28. Working Diagnosis
What are your differential diagnoses?

29. Differential Diagnoses
Sprain/Separation
Costochondritis
Fracture
Coronary pain

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

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

32. Orthopedic Evaluation
Sternal compression
Rib cage compression

33. Imaging Study
Radiographic examination of the ribs is indicated…

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

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

36. Sternal Compression Test
Pronounces rib fractures
Produces pain with costochondritis

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

38. Vital Signs
Corroborate historical information with physical examination findings.

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

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

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

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