CASE STUDY – Severe arm and hand pain and numbness at 36 weeks gestation.


Case History  : 33 year old woman presents with severe arm and hand pain and numbness at 36 weeks gestation.

The patient is pregnant for the 5th time.  She had suffered a miscarriage during the 15th week of a previous pregnancy in July of 2004.  She was referred to our office for care by her midwife. Her previous 3 births were vaginal.  


She is currently complaining of water retention and severe arm and hand pain during this pregnancy.  She denies suffering from this complaint or any others prior to this pregnancy.     Although very painful and consistent, none of her current symptoms are interfering with her activities of daily living.  


Consultation:

She communicated the following automobile accident history:
At age 15, she was a passenger in the front seat of a car when it was impacted at 25 miles per hour on the driver’s side of the car.  She detailed that she hit her stomach but did not receive any medical treatment for her injuries


In the spring of 2005 she was involved in a more serious automobile accident in which the car she was in was totaled.  The patient was seated in the driver’s seat of the car in a parking lot.  Her car was struck in the rear at a high rate of speed by another car.  Her car then lurched forward and impacted a pole.  She sustained injuries to her face as a result of hitting the steering wheel.  She claims that she never received medical care for her injuries.


She is a nurse in a hospital setting and denies any on the job injuries.


Her current complaint of severe arm and hand pain and numbness started a few weeks prior to coming to the office for an evaluation.  She describes that it starts in her fingers and works it way up to her shoulder.  This pain and numbness is bilateral.  She reveals that the discomfort has become more constant in nature and is worse when talking on the phone for extended periods of time.  She also awakens frequently during the night due to the severe discomfort.  


This patient denies smoking.  She reportedly does not drink coffee or tea.  She reports that she eats a well-balanced diet.  She exercises on a regular basis; at least four to five times per week by way of walking on a treadmill.  She claims that she does not get at least eight hours of quality sleep per night due to her current complaint.  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.  She reported being unaware if her amniotic fluid levels were within normal limits.  

Physical Examination –


A thorough examination of her cervical spine was conducted due to her complaints of arm and hand pain and numbness.  Her lumbar spine was also thoroughly evaluated due to her advanced stage of pregnancy. Postural evaluation revealed a lumbar hyperlordosis most likely due to her advanced pregnancy, a high right shoulder and a high right ilium.  


Cervical active range of motion was within normal limits with the exception of right lateral flexion and left rotation which were both decreased with no noted pain or discomfort.  Lumbar active range of motion was within normal limits with no noted pain or discomfort.   

Palpatory tenderness was noted over the spinous of T10 and also over the right sacroiliac joint.  Spinous percussion was positive at the levels of L3 and C7  
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:
L5 posterior on the right (PR), T10 posterior on the right (PR), T5 Posterior, T1 posterior on the right (PR), C7 body right, C2 body left and a right anterior trochanter.


Prone leg checks uncovered a right short leg of ½ inch and a positive Derefield on the right as well as a right cervical syndrome.  Supine leg checks revealed no short leg.  Although George’s test was found to be negative, the patient complained of ringing in her left ear while performing the test.  


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 spine (specifically C1 and C7) which correlates and supports the initial exam findings.  


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 May 26, 2005.


C2 (BL) was adjusted on the left, manually, in the prone position as was C5 (BR) and T4(PL).  T10 was adjusted (PR) in the prone position using an instrument.  L5 (PR) was also adjusted on the prone position using an instrument.  A right anterior trochanter was adjusted using an instrument also in the prone position.  Due to her primary complaint or arm and hand pain and numbness, her upper extremities were mobilized as well.  It was also recommended that she increase her intake of Vitamin B6 to help with the carpal tunnel type symptoms she was experiencing.  


This patient received her second chiropractic adjustment on June 2, 2005.   She reported marked improvement of her primary complaint after the first adjustment. However, she still had considerable, asymptomatic swelling in both of her hands.   Again C2 (BL) was adjusted on the left, manually, in the prone position as was C5 (BR).  T1 and T10 were adjusted in the prone position, manually.  Manual traction was used in the cervical spine following her adjustment.  


This patient only received two adjustments as she delivered her baby the following week and wasn’t able to maintain her schedule care plan at that time.  


Discussion


Because of this patient’s primary complaint of arm and hand pain and numbness, it was vital that her cervical spine be evaluated thoroughly.  Oftentimes, supplementing one’s diet with foods high in Vitamin B6, symptomatic relief can be obtained.  


Food Sources of vitamin B6 include
  • sweet potatoes
  • avocados
  • brown rice
  • sunflower seeds
  • chick peas
  • salmon
  • pork
  • chicken
  • turkey
  • potatoes
  • bok choy
  • barley
  • bananas
  • Mangoes


Women who are more like to suffer from a vitamin B6 deficiency normally have a diet lacking in vitamin B6, a history of using oral contraceptives or hormone replacement therapy a diet of foods that contain yellow dye #5, such as some types of macaroni and cheese and pickles and/or have a history of stress.  A typical dose of vitamin B6 for carpal tunnel syndrome is 50 mg 2 to 3 times a day.   It can take up to 6 weeks to notice an improvement in symptoms.  Note:  The maximum intake of B6 from all sources (supplements and food sources) should be less than 200 mg a day

Enzyme supplements such as bromelain may help to reduce tissue swelling associated with carpal tunnel syndrome. It should be mentioned that it can take several weeks to notice results.



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Dr. Karen, just wanted to say wow…I’ve learned so much and I’m only into the 2nd module. This is the stuff we need to know in everyday practice! I could listen to you all day long!        ~ Dr. Katie Gelesko Stull

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