CASE STUDY - Backache of Pregnancy with headaches at 18 weeks

Case History: 30 year old woman presents on January 31, 2007 with backache of pregnancy and headaches.  She is 18 weeks gestation.

The patient is currently pregnant with her second child.  

She is currently complaining of low back pain, tension headaches, digestive troubles with nausea and sinus trouble with this pregnancy.  She also reported suffering from headaches, and back pain prior to this pregnancy.   None of her current symptoms are interfering with her activities of daily living.  

She is currently under the care of a midwife for this pregnancy.  She delivered her first baby in a birthing center.  She hopes to have another birthing center birth with this pregnancy.  Her first baby was delivered vaginally.  

Consultation:
She communicated no automobile accident history:

This patient communicated the following accident history:

She has been an avid tennis player and has had numerous ankle injuries as a result of performing this activity.  She stated that she has had surgery to her right ankle due to the repetitive injuries she has sustained while playing tennis.  Approximately ten years ago she fell on a subway train and sustained a severe bruise to her tailbone.  She did not receive any medical attention for the injury, however.  This patient admits to sustaining an injury to her lower back about 18 years ago while lifting a heavy object at work.  She denies obtaining medical treatment for this injury.  

Her current complaint of low back pain started gradually during her second month of pregnancy.  She describes the pain as being intermittent and as shooting in nature.  She reports her low back pain is worse when walking and is exacerbated when climbing up a flight of stairs.  She explains that the low back pain is primarily at the L5-S1 and that it radiates into her left hip.  She has tried various stretching exercises and pelvic tilting exercises to try and get some relief, but to no avail.  

This patient denies smoking and drinking coffee.  She reportedly drinks one to two cups of tea per day.  She reports that she eats a well-balanced diet.  She does not exercise on a regular basis; at least four to five times per week.  She claims to get at least eight hours of quality sleep per night.  She is taking pre-natal vitamins as directed by her midwife.  She is also taking Zofran for her symptoms of morning sickness.  She reports that although this medication is giving her some mild relief, she is still quite uncomfortable with nausea.    

Physical Examination –

A thorough examination of her lumbar and cervical spines was conducted due to her chief complaint lower back pain and secondary complaints of tension headaches and sinus trouble.  Postural evaluation was within normal limits with the exception of a mild lumbar hyperlordosis most likely due to her advanced pregnancy.  

Cervical active range of motion was within normal limits with no noted pain or discomfort.  Lumbar active range of motion was also within normal limits.  However pain was noted at the L4-S1 region and left ilium during lumbar extension.  

Palpation revealed taut and tender fibers in the trapezius at the cervical, and mid-thoracic regions.  Trigger points and muscle spasms were noted upon palpation of the paraspinal musculature of the lumbar area.  Palpatory tenderness and spasm were also noted bilaterally at the L5-S1 region.      

Deep Tendon Reflexes:  Biceps (C5\C6):  left: normal;  right: normal. Brachioradialis (C5\C6):  left: normal; right: normal. Triceps (C7\C8):  left: normal;  right: normal. Patellar (L2\L4):  left: normal; right: normal. Hamstrings (L4\L5):  left: normal;  right: normal. Achilles (S1\S2):  left: normal; right: normal. Cranial Nerve Exam:  Myotome evaluation revealed no weakness in the upper or lower extremity. Dermatome evaluation revealed no altered sensation to pin prick in the upper and lower extremity.

Spinal analysis using muscle testing uncovered the following misalignments:

Posterior L4 on the right (P-R), Left Sacral Apex Rotation (SAL),  Right PI Ilium, posterior T4 and T6, C5 posterior, ASLP Atlas, and posterior coccyx  on the left (C-PL).  

Prone leg checks uncovered a left short leg of ¼ inch and a positive Derefield.  Supine leg checks also uncovered a left short leg of ¼ inch.  

Using Basic Sacral Occipital analysis, the patient was not found to be a Category.  

Spinous percussion was positive in the cervical and thoracic spine.  Cervical distraction was positive bilaterally, however all other cervical orthopedic tests were found to be within normal limits.  Minor’s sign was positive with radicular pain being noted on the right.  Ely’s test was positive bilaterally.  Kemp’s test was also positive bilaterally with pain being noted in the thoracic spine.  The remaining lumbar orthopedic tests that are not contraindicated during pregnancy were found to be within normal limits.  

A thermal spinal scan showed areas of severe thermal asymmetries in the cervical spine (specifically C6-C7), in the thoracic spine (specifically T7, T8, and T9) and in the lower lumbar sacral areas (specifically L5 and S1) which correlates and supports the initial exam findings and the patient’s presenting history and chief and secondary complaints.  

Care Plan
Based upon the patient’s history of traumas, previous pregnancies, weeks gestation of current pregnancy and presenting symptoms, the following care plan has be recommended:

Due to the acute level of this patient’s presenting symptom Specific Prenatal Chiropractic spinal adjustments are recommended two to three times weekly for at least three weeks for symptomatic relief.  Once relief is obtained, one to two weekly adjustments is recommended until the birth of the baby.  A 6 week post-partum check up is also recommended to evaluate a continued need for care.  

Treatments

This patient received her first chiropractic adjustment on January 31, 2007

Atlas (ASLP) was adjusted using an instrument, in the prone position as was C5 and T6. L4 (PR) was adjusted in the prone position using an instrument.  A Sacral Apex Left, a PL Coccyx and a Right PI ilium were also adjusted in the prone position using an instrument.  

She received her second chiropractic adjustment one day later on February 1, 2007.   She reported a tremendous improvement in both of her chief complaints of low back pain and headaches. She also stated that shortly after her first adjustment she vomited.  The same listings that appeared prior to her first adjustment were present again and adjusted.  In addition, a left anterior trochanter appeared and was adjusted in the prone position using an instrument.  

Re-evaluation , discussion and follow up

This patient’s next adjustment was 5 days later on February 6, 2007.  The exact same listings as her second visit were noted and adjusted on this third visit.  She hadn’t had any headaches since her first adjustment.  Her low back pain was starting to “flare up” again, however and was what brought her back for another adjustment.  Since her first adjustment and the vomiting episode that resulted, she has not had any further nausea complaints and has since discontinued taking the Zofran.  

This patient remained an active member of the practice throughout her entire pregnancy.  On each and every visit, she required adjustments to her trochanters; some visits on the left and some on the right.  In either case the trochanter almost always rotated anteriorly.  Regardless of the misalignment, it was always adjusted using an instrument as before.  Since the hormones relaxin and estrogen soften and relax ligaments, we have found that by using an instrument, we get much better results.  In my experience, low back pain of pregnancy will present many times, with a trochanter rotation.  When it does appear it’s almost always anterior.  However, when a pregnant patient presents with Meralgia Paresthetica as in this case, there will definitely be an anterior trochanter rotation in nearly every instance.  Most usually it will appear on the same side of symptomatology initially and may change sides once changes to the pelvis occur.  

Even though she was able to adhere to the recommended care plan, she and many other pregnant patients, aren’t always  able to obtain substantial, long lasting  symptomatic relief using pre-natal chiropractic care because of the inherent instability of the pregnant spine and pelvis and the pregnancy hormones that lead to said instability.   

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