Case Report

Handicapped Patients

History

On 2-11-06 a 25 year old black male presented to the Palmer Clinics with a chief complaint of neck discomfort. His mother is being seen in the Clinic for neuromusculoskeletal conditions and would like to have her son seen as well.

Complicating Factors:

Patient suffers from mental retardation and doesn’t speak.

History • Parents first noticed a developmental problem

when he was 2 years old. Prior to this he had been on penicillin for almost one year for treatment of otitis media. At this time they were told his brain was growing slower than normal.

• He doesn’t speak but does understand words and can locate the source of sound.

• His mother would like to see if we can help him. He had received chiropractic care in the past and had some improvement in his demeanor. They stopped going however, because he didn’t like the HiLo table and was afraid of the doctor.

• He has been complaining of “neck pain lately”.

Initial Differential Diagnosis

• Please list at least 2 Differential Diagnoses

• Neck Pain

• Mental Retardation

Not speaking

Examination

• Pronating Gait• Head Circumference is

observed to be smaller than normal

• Right Head tilt • Left Shoulder and hip tilt• BP: 130/80• Brachioradialis Reflex

+4/2• Could not preform

orthopedic exam or cervical ROM due to patient comfort

• Fasciculations increase with left sided sensory stimulation

• Hypertonic trapezium cervical musculature on the left

• Patient can Follow basic instructions

• Can recognize source of sound

Examination

What does this mean?

• Cause of cervical pain?

• Mental Retardation?

• Fasciculations?

• Not speaking?

Patient Management Plan

As of 2-17-2006 patient is seen for Cervical subluxation (739.1) with associated cervicalgia (723.1), Complicating factors include Microcephaly (742.1) and Motor Aphasia (784.5); at 1 time per week for 4 weeks, followed by 2 times per month for 6 weeks to decrease neck discomfort intensity, frequency and duration.

Microcephaly

• Definition: describes a head size (measured as the distance around the top of the head) significantly below normal for a person's age and sex, based on standardized charts.

• Considerations: Microcephaly most often occurs because of failure of the brain to grow at a normal rate.

• Conditions affecting brain growth that can cause microcephaly include; infections, genetic disorders, and severe malnutrition.

Dorland's Illustrated Medical Dictionary

• Microcephaly can be present at birth or it may develop in the first few years of life.  It is most often caused by genetic abnormalities that interfere with the growth of the cerebral cortex during the early months of fetal development. 

• It is associated with Down’s syndrome, chromosomal syndromes, and neurometabolic syndromes.  Babies may also be born with microcephaly if, during pregnancy, their mother abused drugs or alcohol, became infected with a cytomegalovirus, rubella (German measles), or varicella (chicken pox) virus, or was exposed to certain toxic chemicals. 

National Institute of Neurological disorders and Stroke

• Depending on the severity of the accompanying syndrome, children with microcephaly may have mental retardation, delayed motor functions and speech, facial distortions, dwarfism or short stature, hyperactivity, seizures, difficulties with coordination and balance, and other brain or neurological abnormalities. 

• Some children with microcephaly will have normal intelligence and a head that will grow bigger, but they will track below the normal growth curves for head circumference. 

National Institute of Neurological disorders and Stroke

• There is no treatment for microcephaly that can return a child’s head to a normal size or shape.

• Treatment focuses on ways to decrease the impact of the associated deformities and neurological disabilities. Children with microcephaly and developmental delays are usually evaluated by a pediatric neurologist and followed by a medical management team.

• Early childhood intervention programs that involve physical, speech, and occupational therapists help to maximize abilities and minimize dysfunction.

• Medications are often used to control seizures, hyperactivity, and neuromuscular symptoms. Genetic counseling may help families understand the risk for microcephaly in subsequent pregnancies

National Institute of Neurological disorders and Stroke

What is the prognosis?

Some children will only have mild disability.  Others, especially if they are otherwise growing and developing normally, will have normal intelligence and continue to develop and meet regular age-appropriate milestones. 

National Institute of Neurological disorders and Stroke

History with our Patient

• Diagnosed at the age of 2 with Microcephaly

• Prior to his diagnosis he was prescribed penicillin for over a year to treat chronic otitis media.

Motor Aphasia

• aphasia (apha·sia) (ə-fa´zhə) [a-1 + Gr. phasis speech]  any of a large group of speech disorders involving defect or loss of the power of expression by speech, writing, or signs, or of comprehending spoken or written language, due to injury or disease of the brain or to psychogenic causes. Less severe forms are known as dysphasia. See also agrammatism, dysphasia, and paraphasia.

Dorland's Illustrated Medical Dictionary

Motor Aphasia

• motor a.  aphasia in which there is impairment of the ability to speak and write, owing to a lesion in the insula and surrounding operculum, including Broca's motor speech area. The patient understands many written and spoken words but has difficulty uttering the words. Cf. receptive a. Called also Broca's a., expressive a., frontocortical a., nonfluent a., and logaphasia.

Dorland's Illustrated Medical Dictionary

Fasciculations

• An upper motor neuron lesion indicates pathology in the cerebral hemispheres, brain stem, or spinal cord. Interruption of the inhibitory influences eventually leads to increased reflexes and an increase in muscle tone and spastic paralysis; pathologic reflexes appear.

Differential Diagnosis and Management for the Chiropractor

Tomas A. Souza

Office Visits

Visit 1: Patient showed interest in the HiLo but wouldn’t ride on it and wouldn’t lie down on it.

He didn’t like to have his neck touched and wouldn’t sit still.

He did lie on the toggle table but didn’t like the nose of the table

Office Visits

• Visit 2: Patient didn’t want to have is neck touched and wouldn’t lie still long enough for an adjustment.

• Visit 3: Positive palpation findings for Atlas fixation. Patient has difficulty in trusting doctors. We moved to a padded side posture table and used a speeder board for the adjustment. After the adjustment was given the room would applaud in order to give positive reinforcement to the patient for getting adjusted.

Office Visits

• Visit 4: He missed an appointment due to scheduling difficulties but his parents report he has been more mischievous lately and more active. He is watching a lot of basketball (March Madness). He is allowing it to be easier to palpate his neck but continues to get confused easily and doesn’t completely trust the doctors.

Points of consideration

• We have noticed it easier to approach the patient when we don’t wear the white coats.

• First and foremost…patient comfort!

• Don’t rush things, hurry with the adjustment.