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 1;85(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 DC’s (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/000669.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?ImageID=2125845465

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 Bell’s palsy. Expert Rev. Atni-infect. Ther. 2(1), 2004

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

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

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 hasn’t 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 T1&2 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 didn’t 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, T1&2 area is sore (-2), her left SI is sore, Her eyes are good and she had 2 minor headaches that didn’t go anywhere and she didn’t 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?