CASE STUDY AND QUESTIONS: To be completed by the 16 th August

Case 5 Joe is a 35-year-old male.

Presenting Complaint:
Neck pain and occasional headaches. The neck pain was intermittent and aching in
nature. This began over the last 10-15 years. Since this time, he had adjustments
every week at least twice a week by a chiropractor in Tasmania. Now in Sydney, he
wants to have an adjustment which involves a position of rotation and then a strong
twist into further rotation and traction. The patient was insistent that the adjustment
be performed.
Physical Examination
Palpation: Hypermobility throughout the cervical spine. There was marked
hypertonicity throughout the cervical spine and shoulders bilaterally. There was
normal neurology, orthopaedic tests and physical examination findings.
1) What is the likely diagnosis? Give reasons for your answer.

Hypermobility is defined as a condition of generalized ligamentous

laxity affecting both spinal and peripheral joints. Early Spinal Instability:
This is defined as a functional condition in which excessive, abnormal
segmental motion and positive instability tests with no neurological
deficits. Deformation under load exceeds the capacity for the tissues to
recover. There may be early signs of incipient disc degeneration that
occurs before classic disc involvement.

2) Does this sort of adjustment described have dangers? Please explain the
mechanisms involved.

Deformation under load exceeds the capacity for the tissues to recover.
There may be early signs of incipient disc degeneration that occurs before
classic disc involvement. Symptomatic instability may be induced by a
single severe combined compression and torsion force. It is usually
brought about by repeated torsional injury and gradual loss of nuclear
integrity. Adjustments at end range may increase torsional strain of the 3
joint complex and would be not be advised unless necessary.
Case 5b Alison 70-year-old female

Presenting Complaint:
Alison presents to you with recurrent headaches. She has suffered from various
types of headaches since adolescence. She admits that stress appears to bring the
headaches on, and that they are sometimes accompanied by feelings of dizziness
and nausea.
Previous investigations over the years never revealed any pathology, and she was
regularly reassured by her medical practitioner that ‘they were nothing to worry
about’.

History of Presenting Complaint:

She smoked 10 cigarettes per day from the age of 16 to 60 years of age but has not
smoked since. She drinks occasionally but she says that it is not to excess.
She also complains of recent a 2-month history of occasional pain between the
scapulae, which seem to occur when she goes shopping, or after a large meal. The
pain is mild and does not seem too troublesome.
She denies any other health problems or past trauma and has not had any
operations. She did suffer a whiplash injury after a heavy rear end motor vehicle
collision some 20 years ago which caused pain for a couple of months. She takes
no medications apart from Nurofen (ibuprofen) and Nurofen Plus (ibuprofen plus
codeine), which she uses to control here headaches.

1. What other further pertinent questions would you ask Alison.

Any trauma, location and intensity of HA, any triggers, questions around
eating,what kinds of foods, any red flag questions, signs and symptoms
of flu, medications ,drugs, eyeglasses.

2. Using ONLY the information in the above case history, give 3 likely differential
diagnoses for;
Her headaches-

tension type cervico genic headache induced by stress

3.Her interscapular pain-

GERD or ulcer. Back pain after eating is likely caused by referred pain. Pay
attention to other symptoms that may help your doctor diagnose your
condition. These most commonly occur in the stomach or oesophagus.
 This open sore will often be irritated by spicy food, sugary foods, alcohol
or stress, and will also cause stomach pain that is often described as a
gnawing or burning pain.

If your back pain is caused by GERD or ulcers, you may need to make lifestyle
adjustments. Those can include changes to your diet, reducing your weight,
exercise, or medications. 

Posture
Slouching, bending over your food or bringing your mouth to the fork rather
than the other way around can all contribute to digestive issues and back pain.
If you eat at a desk or on the couch with your body hunched over, this will also
cause problems.
Explain your answer in each case.
3. What do you need to examine?

Vital signs: temp, throat, lymphatics, abdominal examination

Cardiovascular exam

Physical Examination.
Alison is tall and slightly overweight and walks with slightly hunched shoulders.
Vitals: Pulse rate/min = 62, Respiratory rate/min =10, Blood pressure/mm Hg =
150/95,
Height (cm) = 175, Weight (kg) = 85, BMI 27.7, Temperature (degrees) = 36.1

Her neck ROM is limited to left rotation by about 35% with minimal pain. Cervical
extension is uncomfortable at the extreme of range limited by 50%. Orthopaedic,
UMN and LMN tests are negative.
Interscapular region: tightness of rhomboids and trapezius.
Abdomen: Soft, non-tender, no masses.
4. Using ONLY the information above do you think Alison is suffering from:

 1 Cervicogenic headaches
 2 Classic migraine
 3 Cluster headaches
 4 Common Migraine
 5 Subdural hematoma
(6 Not likely or more likely)

5. What are possible causes of her interscapular pain? Why?

Posture
Possibly because of slouching as in the exam Alison has rounded
shoulders but this may also be due to her having osteoporosis at this
age either way bending over your food or bringing your mouth to the
 fork rather than the other way around can all contribute to digestive
issues and back pain. If you eat at a desk or on the couch with your
body hunched over, this will also cause problems.

6. Do you think it was necessary to take vital signs? Are the vital signs
normal/abnormal?

Vitals: Pulse rate/min = 62, Respiratory rate/min =10, Blood pressure/mm

Hg = 150/95, hypertensive headache

7. Do you think an abdominal exam is necessary or do you think this is

‘over examining the patient’?

Yes it is necessary to investigate digestive conditions- could be an ulcer,

gall stones or appendicis.

 An ulcer. These most commonly occur in the stomach or oesophagus. This open sore
will often be irritated by spicy food, sugary foods, alcohol or stress, and will also cause
stomach pain that is often described as a gnawing or burning pain.

 Gallstones. The gallbladder sits just underneath the liver and releases a

substance called bile that helps digest food. Small stones can develop in the gall
bladder and this can cause severe pain which can often extend into the back,
often towards the right shoulder blade.

 Pancreatitis. This is when the pancreas, an organ that sits just behind the
stomach, becomes inflamed. This causes stomach pain that can extend into the
back and left shoulder blade. You may also experience nausea and indigestion.
This condition can be acute or chronic and requires urgent medical attention.

 Appendicitis. This is when the appendix becomes inflamed and, if left

untreated, it can rupture, causing serious problems. Common symptoms are pain
in the middle of the abdomen which travels to the lower right and side, nausea,
diarrhoea and fever. In some cases, you may experience pain in your lower
back. Symptoms are often sudden and severe, and you should seek immediate
medical help if you think you have appendicitis.

I do not believe the patient was over examined based on history

8. If this patient was diagnosed with common migraines, what is your

proposed treatment/plan of management?

Correct postural imbalances, ergonomics, myofascial trigger points. Then

exercises, stretches, physiotherapy or acupuncture
 9. How would you manage her interscapular pain?

Investigate and treat accordingly with gentle chiropractic care, postural

correction exercises. If unresolved pain then refer to GP for MRI and full
blood tests to rule out malignancy due to history of smoking.

General Questions

1. Give the 2 categories for headaches and give examples for each.

one: the primary headaches

1. Migraine
2. Tension-type headache (TTH)
two: the secondary headaches
1. Headache attributed to trauma or injury to the head and/or neck
2. Headache attributed to cranial or cervical vascular disorder

2. List the ‘red flags’ for headaches.

Red flags” indicators:

• Recent onset. Less than 6 months especially in adult/elderly
• Position headache – worsens from lying to sitting. May indicate raised
ICP – often associated with positive Valsalva and cough.
• Focal neurological signs eg. motor or sensory deficits, cranial nerve
palsy, visual loss, cerebellar signs. (These may occur in classic
migraine aura but are transient only)
• Cognitive changes – confusion/memory loss can indicate SOL or
increased ICP. May ask spouse or relative about personality changes.
• Progressive headache – suspect-increasing ICP
• Raised temperature/fever – eg meningitis.

3. Give a list of the differential diagnoses of non-primary causes of headaches.

Headache attributed to trauma or injury to the head and/or neck

Headache attributed to cranial or cervical vascular disorder
Headache attributed to non-vascular intracranial disorder
Headache attributed to disorder of the cranium, neck, eyes,ears, nose,
sinuses, teeth, mouth or other facial or cervical structure
Headache attributed to a substance or its withdrawal
Headache attributed to infection
Headache attributed to disorder of homoeostasis
Headache or to psychiatric disorder
 4. Differential between tension headaches and classic migraine headaches.
Classic Migraine
headaches preceded by temporary focal neurological deficits (Prodrome)
headaches accompanied by nausea, vomiting ± photophobia
headaches triggered by certain foods or alcohol (red wine, chocolate, oranges,
cheeses)
headaches made worse by bright light or noises
Tension Type Headaches
headache relieved by massage
headache described as a tight band

5. Give a list of triggers that could lead to classic migraines?

Wine, cheese, alcohol, bright lights, noise levels, smoking, cured meats,
chocolate, oranges and the list goes on

6. How would you manage a patient with classic migraine headaches?

Reduce triggers, modify patient behavior, chiropractic management,

Quiet darkened room, adjunctive therapy eg massage, accupuncture,
Nutritional support advice (magnesium, fever few, 5-HTP, Omega 3)

7. Describe the clinical presentation for cervicogenic headaches?

• Intersegmental hypomobility (primarily in the upper cervical area)

•   Specific tender points
•   Dysfunctional motion of the cervical spine
•   Postural imbalance (forward head position and round-shoulder
appearance)
8. Describe the clinical presentation for cluster headaches?

Pain around the eye with tearing

Often wakes with a headache at night
Can occur a number of times per day in clusters of 1- 2 hours

9. Describe the clinical presentation of hypertension headaches?

Headache associated with a diastolic blood pressure greater than 115 mm

Hg (possible hypertensive headache)
Pulsatile in nature

10. Describe the clinical presentation for temporal arteritis?

A new headache in the elderly
Painful torturous temporal arties on palpation
Deep throbbing in their temples and upper trunk 9neck and shoulder
area)
Assoc with vision loss
Types of Headaches
Write an illness script for each headache including those demonstrated in the
diagram below.

For you to do

https://www.youtube.com/watch?v=3mF1hvIAcoo
 Study Guide Questions: 5.4

The questions for this week will focus on components of cranial

nerves I, II, III IV and VI.

1. What kind of information is found in the ventral root of a spinal nerve?

Motor or glandular function

2. Which of the following cranial nerves carries SSA information?

a. CN II
b. CN III
c. CN V
d. CN VII

3. Which procedure is NOT typically done in the clinical evaluation

of cranial nerve III?
a. Observe eyelid position
b. Pupillary response to light
c. Accommodation
d. Testing visual fields

4. A patient complains of light sensitivity. He will most

likely have a problem with which cranial nerve?
a. Optic
b. Oculomotor
c. Trochlear
d. Abducens