A 48-year-old electrician presented to my office on 4/6/96. He complained of left arm pain, which was acute in the morning, but would improve during the day. Later in the evening the pain would worsen.
The pain interfered with sleep and activities of daily living. There was no dyspnea, no constitutional symptoms, or other joint pain. There was some left sided neck pain one day prior to presentation. There were no sensory complaints. The patient reported some left elbow weakness associated with pain.
The onset of the arm pain was in December of 1995, perhaps associated with stress, or possibly from carrying a bucket down the hall. That same December the patient had three weeks of chiropractic care, but with little relief.
Subsequently the pain eased up on its own, but worsened under stressful conditions.
Other History
Family History
Father deceased in from cancer in the '70s. Patient does not know what type of cancer. Mother is alive.
Examination
Cervical range-of-motion elicited left neck pain, except right and left lateral flexion.
Right and left flexion restricted 30/40 with crepitus, but no pain.
Compression/distraction: negative.
Adam's position: right dorsal convexity.
No motor, reflex, or sensory deficits.
Left internal shoulder rotation painful.
X-ray report from prior chiropractor, 2/12/96: C5,7 degenerative changes.
Diagnosis: Left cervical brachial neuralgia
Recommendations: Diversified chiropractic adjustments, moist heat, therapeutic exercise, and patient education regarding activities of daily living.
Response to Treatment: On 4/16 the patient reported numbness of the left arm and leg after a rotary cervical adjustment performed by a covering chiropractor on 4/8/96.
Patient also reported a drunken gait and dragging of the right foot. Prior cervical adjustments did not elicit this response.
Upon questioning, the patient stated he had a similar episode years ago, was "worked up" by a neurologist and "everything" came back negative. Upon examination, no objective signs were noted. He was "feeling better."
Cervical adjustments were discontinued. Cervical manual traction and soft tissue work were performed.
Response to Treatment: Based on the absence of objective findings for VBAI, spinal tumors, and MS, I suspected a psychogenic etiology. We treated the patient through 5/3/96, and his response ranged from transient significant improvement to right and left arm pain and numbness, more so right-sided now, right chest tingling, and transient staggering gait reported, but not observed.
After nine visits (4/6 to 5/1/96), I referred the patient to a neurologist.
The neurologist performed an MRI performed on 5/13/96 which revealed:
However, having not seen the actual MRI, he wants to rule out a spinal cord tumor or demyelinating disease such as MS. He recommended an MRI of the brain and a spinal tap.
Conclusion
The results of any further testing are not available yet. What is important to learn is that a patient who is not responding to care the way you would expect needs to be investigated further.
Although some patients present with symptoms that may appear to be psychogenic based upon your exam and the patient's demeanor, organic disease must be ruled out.
Michael Horney, DC
East Setauket, New York
Many relevant diagnostic signs are not performed deliberately by the examiner or by the patient at the examiner’s direction. They are observed as the patient reacts to their condition. Fortin’s finger sign, Minor’s sign, and Vanzetti’s sign are three examples of this principle.
Spearheaded by burgeoning scientific and clinical research literature, psychedelics have reached a level of media coverage and popular interest that has not been seen for over half a century. By “psychedelics,” we are referring to the unique class of substances that includes psilocybin (the active compound found in so-called “magic mushrooms”), LSD, dimethyltryptamine (DMT), ayahuasca, 5-MeO-DMT, and mescaline – each of which occurs in the natural world (except for LSD, which is a semi-synthetic compound).
While working at the Lovelace Medical Center in Albuquerque, N.M., one of the primary care physicians stated that imaging every patient prior to receiving chiropractic was not medically necessary. It was at that point I reconsidered the need for the imaging of every patient to avoid malpractice.
