CASE STUDY - Backache of Pregnancy, Headaches and Dizziness

Case History: 32 year old woman presents on December 5, 2006 with backache of pregnancy and headaches.  She is 34 weeks gestation.

The patient is pregnant for the 3rd time.  

She is currently complaining of low back pain, water retention, dizziness and headaches 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 hospital setting and the second in a birthing center.  She hopes to have another birthing center birth with this pregnancy.  Both previous babies were delivered vaginally.  

Consultation:
She communicated the following automobile accident history:

At age 16, she was a driver and was impacted at a 45 miles per hour on the driver’s side of the vehicle.  She reported she was wearing her seatbelt and that she sought no medical treatment as she had no immediate symptoms immediately following the accident.   

She communicated the following accident history:

She has been an avid water skier since childhood and has had many falls while performing this activity.  She reports to have at least one major fall each year that leaves her sore and achy.  The remainder of her history is unremarkable.

Her current complaint of low back pain started gradually.  She describes the pain as being intermittent and as a dull ache.  She reports her low back pain is worse in the morning and seems to be localized at the L5-S1 area.  She details that the pain is worse with lifting and bending.  Since she  is the mother of 2 small children who require her to bend and lift them, this pain is impacting her activities of daily living.  She further explains that she sometimes has pain in her feet and ankles although she denies it is radiating from her low back.  She reports that her feet and ankle pain are independent from her low back pain.

In addition to her headaches, she has intermittent shoulder pain on the left side.  The shoulder pain is concomitant with her headaches.  

She denies smoking. She reportedly drinks one to two cups of coffee per day as well as one to two cups of tea per day.  She reports that she eats a well-balanced diet.  She exercises 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.  This supplement is not causing digestive distress that is sometimes common with this particular supplement.  

Physical Examination –

A thorough examination of her lumbar and cervical spines was conducted due to her chief complaint lower back pain and headaches.   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 with no noted pain or discomfort.  

Palpation revealed taut and tender fibers in the left trapezius and in the lumbo sacral region bilaterally from L5 through Sacrum.  Palpatory tenderness and spasm was 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 and 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 L5, Posterior L3  (PL)on the left, Posterior Sacrum on the right (P-R), Right PI Ilium, posterior T4 and T6 on the left, C7 body left, C2 body right, Posterior right occiput, and superior pubic bone on the left.  

Prone leg checks uncovered a left short leg of ½ inch and a positive Derefield.  Supine leg checks also uncovered a left short leg of ½ inch.  

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

All cervical orthopedic tests were found to be within normal limits.  The lumbar orthopedic tests that are not contraindicated during pregnancy were also found to be within normal limits.  

A thermal spinal scan showed areas of severe thermal asymmetries in the cervical (specifically C2) and upper lumbar (specifically L1) regions which correlates and supports the initial exam findings and the patient’s presenting history and chief complaint.  

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 December 5, 2006.

Left occiput was adjusted using an occipital lift.  C2 (BL) was adjusted on the left, manually, in the prone position as was C7 and T6. L3 (PL) was adjusted in the prone position using an instrument.  A P-R sacrum and a Right PI ilium were also adjusted in the prone position using an instrument.  

A posterior right trochanter was adjusted in the prone position with an instrument as well.  A superior left pubic bone was found and adjusted in the supine position, also with an instrument.  

Due to the 60 minute commute to our office from her home, this patient was not able to maintain our recommended care plan.  Therefore she received her second chiropractic adjustment one week later on December 12, 2006.   She reported a tremendous improvement in both of her chief complaints of low back pain and headaches. T1 was adjusted manually, in the prone position.  L3 (PL) was adjusted in the prone position using an instrument.  A posterior right trochanter was adjusted in the prone position with an instrument as well.  A superior left pubic bone was found and adjusted in the supine position, also with an instrument.  

Re-evaluation , discussion and follow up

This patient’s next adjustment was nearly two weeks later on December 28, 2006.  The exact same listings as her previous visit were noted and adjusted on this subsequent 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.  

On each of her three visits in our office, this patient required adjustments to her right trochanter and her left pubic bone.   Both were done 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 almost always presents with pubic bone superiority.  Many times, but not always, there will also be a trochanter rotation.  When it appears it’s almost always anterior.  However, when a pregnant patient presents with Meralgia Paresthetica, there will definitely be an anterior trochanter rotation in nearly every instance.  

Even though she wasn’t able to adhere to the recommended care plan, she and many other pregnant patients, are able to obtain substantial symptomatic relief using pre-natal chiropractic care.  

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