Back To Chiropractic CE Seminars

Chiropractic Technique ~ 4 Hours

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This course counts toward your California Board of Chiropractic Examiners CE. (also accepted in other states, check our website or with your Chiropractic State Board)

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7. Upon passing exam (70%), you’ll be able to immediately download your certificate,

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Please retain the certificate for 5 years. DON’T send it to the state board.

If you get audited and lose your records, I’ll have a copy.

I’m always a phone call away... 707.972.0047 or email: marcusstrutzdc@gmail.com

Marcus Strutz, DC

Back To Chiropractic CE Seminars

33000 North Highway 1

Ft Bragg CA 95437

Chiropractic Technique Online Course

Presented by:

Dr. Lauren Ragazzo, D.C. For Back to Chiropractic

Dr. Lauren Ragazzo, D.C. Why I became a chiropractor instead of a pediatrician: I had Migraine Headaches for seven years- unresolved with multiple neurologists and medications; a doctor of chiropractic resolved this for me in three months. • I worked as the Patient Care Coordinator for the

University of Utah Hospital. • I then obtained my Associate of science degree from

Salt Lake Community College, as a part of their pre-med track

• I then attended Life University, where I completed my Bachelor's of Science Degree in Biology.

• I was quickly accepted into the nationally ranked Life University College of Chiropractic in Atlanta, where I then received my Doctor of Chiropractic Degree four years later.

• I did my internship with Dr. Jessica Gold in Encinitas California, where I began to work with UFC and MMA fighters, in addition to family practice for wellness care.

• I began the chiropractic department for several FQHC facilities which include: Neighborhood Healthcare, the San Marcos chiro branch for North County Health Services, and Family Health Centers of San Diego.

My focus in private practice:

• Postural correction via: gravity based traction• Wellness care• Treating the injuries of professional athletes

How might my experience differ, by working in a FQHC?

• I’m working with the underserved communities, therefore:

I typically see patients who have not had consistent health care.

• I am often their first doctor of chiropractic

• I typically see extreme cases every day in practice which include: severe disc herniation, failed surgeries, a history of severe physical trauma, multiple co-morbidities, dependent on pain medication and injections, patients who should be sent to the E.R. for their current condition

This course will utilize the following format:

• We’re going to look at specific case studies:– Patient history– Examination – Imaging– Diagnosis

• All of this information will be integrated:– So that the information we’re learning has real world

application– We can connect the technique with the history,

imaging an exam findings….– (As opposed to individual subjects)

Case #1

• A 49 year old male returns to your office for a follow up appointment, after receiving one chiropractic adjustment

• During the initial appointment his chief complaint was: lower back pain

– Which was a 7/10 pain scale

– Site L3-S1

I was fortunate enough to have imaging on file for this patient:

• 1)thoracic x-ray: s-shaped scoliosis (thoracic dextro, lumbar levo)

2) lumbar x-ray: L4 anterolisthesis

3) lumbar mri: six lumbar vertebrae: L1: disc bulge, L2: disc bulge contacting the thecal sac, L3 disc bulge at thecal sac, L5 anterolisthesis,L6-S1 disc bulge

What was the diagnosis for this patient so far based on the imaging?

• DX: lumbar disc displacement,

• lumbar djd

• anterolisthesis of the lumbar vertebrae

• six lumbar vertebrae

• dextroscoliosis of thoracic spine

• levoscoliosis of the lumbar spine

*Break down the imaging into the spinal levels we are avoiding first.*Then notate levels that may be

treated with gentle chiropractic care(activator typically)

• Which spinal levels should we avoid?

• The vertebrae are subluxated anterior

– Adjusting them P-A would make them worse

• It may be hard to isolate the other vertebrae in side posture, with a scoliosis curvature

• This patient has multiple levels of herniated discs!

• Side posture/ diversified may irritate a disc bulge or make it worse if we’re using a shearing motion to adjust

What else stood out about his imaging reports?

*He has six lumbar vertebrae!

– What a weirdo

– You should always palpate and count your spinal levels before adjusting (be specific!)

*What else might be important?

-He has two disc bulges which are touching the thecal sac!

-Which levels were those?

L2-L3 @ the thecal sac• What does that mean again?

– The disc is touching the outer covering of the spinal cord

– That’s bad.

– We should probably be careful here

What would this condition look like on an MRI?

(not the MRI of this case study)

How would we adjust this patient?

• (note: I can only see these patients 2x per month as per medi-cal)

• Adjustment: thoracic spine: gentle diversified/drop

• Lumbar spine: low force activator device with the avoidance of L4-L5 (anterolisthesis)

• Supine SOT blocks at L6

What was the outcome?

• Outcome: lbp decreased from 7/10 to intermittent 4/10 within one adjustment

Case #2

• 53 year old male, with chronic lower back pain thirty years in duration

• Has a history of multiple gunshot wounds (Injury occurred approximately Thirty years ago)

His Lumbar radiology report:

• FINDINGS:• BONES: Normal. No significant spondylosis, scoliosis, fracture, or

visible bony lesion.• DISC SPACES: There is moderate degenerative disc disease at the

L4-5 level. Mild degenerative disc disease at the L1-2, L2-3, L3-4 and L5-S1 levels.

• PARASPINOUS: There are two bullets within the central posterior tissues and the right paramedian posterior tissues.

• OTHER: There appears to be a small bullet fragment within the left side of the sacral canal.

• CONCLUSION:• Small bullet fragment within left side of the sacral canal. Bullet

fragments within the posterior soft tissues. Moderate degenerative changes

Initial adjustment approach

• The patient was laying PRONE

• With SOT blocks under the superior pelvis bilaterally (to increase disc spaces)

• The Activator device was utilized to adjust all lumbar subluxations

• The sacrum was avoided

How did the patient respond?

• He didn’t.

• No change for three visits (did I mention that I only get six visits with a referral?)

• So I looked at his x-rays myself to see if I could do more

What did I notice?

• The bullet fragments were very far from the spine itself and they were adjacent to T10 and T12 (I documented this on every visit so I was aware)

• The Sacral bullet fragment was not in the sacral canal. It was lodged in the left sacral base and was not in an area where nerves would be compromised

In case you were wondering…

• I’ve treated a lot of patients who have been shot

• The first patient was a surprise

• Five patients later, my eyes don’t get as big during the patient history

So how did I change this patients care?

• The drop table was utilized for three visits.

• The thoracic and lumbar spine were adjusted as well as the sacrum

• With the activator utilized for: T10 and T12 when necessary

How did the patient respond?

• He was feeling much better!• Pain reduced from 7/10 to 0/10, after 30 years of

chronic pain

However, he had a two month lapse in care after this

• Following a 2 month lapse in care, pain had returned to 7/10

• He needed to remain on a wellness are program

• Patient education regarding maintenance is very important

• He is currently feeling well again, and I see him every two weeks!

Anatomical review of: the lumbar spine, pelvis and sacrum

Assessment Protocol: Radiographic and Manual Examination Procedures

• BP or Base Posterior sacrum:– The definitive assessment for a posterior sacral base

or posterior sacral apex is based on a lateral lumbopelvic or sacral spot-shot radiograph. On X-ray, a posterior sacral base is indicated by the following on the lateral view: 1) A decrease in the sacral base angle to less than 36 degrees; 2) Hypolordosis of the lumbar spine; 3) Posteriority of the sacral base George‘s line relative to L5; 4) A posterior open wedge at the L5-S1 disc space.1-2

Text provided by Dynamic Chiropractic

Physical examination assessment of BP Sacrum:

• Motion palpation may reveal extension fixation at L5-S1.2 Patients with a base posterior sacrum usually can stand erect with no significant forward antalgia, but they may demonstrate a positive Minor's sign when rising from a seated position.

Text provided by Dynamic Chiropractic

Review of Sacral adjusting:

• Can be adjusted several ways:

– prone with a drop table

– Posture

– Activator technique

Prone drop adjustment

Image courtesy of Dynamic Chiropractic

Manual Adjustment of BP Sacrum

– Contact: second sacral segment

– LOD: inferior-to-superior (I-S) and posterior-to-anterior (P-A)

Nutation and Counternutation:

Nutation - occurs as the sacrum moves anteriorly and inferiorly while the coccyx moves posteriorly relative to the Ilium.[3]

Counternutation - occurs as the sacrum moves posteriorly and superiorly while the coccyx moves anteriorly relative to the Ilium.[3] This motion is opposed by the posterior sacroiliac ligament that is supported by the multifidus.

https://www.physio-pedia.com/Sacroiliac_joint

Case #3

• 58 year old male presents with chronic lower back pain (at the sacral area) approximately one year in duration, and right “trochanter” pain that is sharp approximately three months in duration. The patient has an abnormal gait where he is favoring the right leg. He also has an anterior antalgic lean at the waist.

RELEVANT HISTORY:

• approximately one year ago: the patient had fallen out of a hospital bed onto the floor. He landed flat on his back.

What do we think is wrong with this patient?(AKA: DIAGNOSIS)

IMAGING RESULTS:

• lumbar x-ray: djd, loss of lumbar lordosis, levoscoliosis

• lumbar mri: mild disc bulge at L3, retrolisthesis of L4

At this point what is our working diagnosis?

PHYSICAL EXAM FINDINGS:

• Valsavas: positive for the lumbar spine area• Lumbar ROM: restricted with flexion (could reach to the

tibias and pain began), lumbar rotation 5 degrees only in either direction elicited pain

• palpation: edema and joint fixation at the right sacral base, joint fixation L2-5;

• kemps test: positive with right rotation, PAIN ON THE RIGHT• SLR: negative• Belts test: positive for decreased pain with pelvic/SACRAL

stabilization• LE Sensation and muscle testing: all muscle testing wnl;

hyperesthesia on the RLE all dermatomes

What does the patient have so far?

• lumbar disc displacement (positive Valsavas and bulge noted on MRI at L3)

• lumbar radiculopathy (hyperesthesia in the RLE)

• lumbar djd (as noted on x-ray and MRI and positive Kemps)

• lumbopelvic sprain strain (positive belts test for sacral involvement)

• right hip pain (the patient complains of pain and he is favoring this leg with his gait)

The Adjustment:

• prone drop table

• 1) right base posterior sacrum

• 2) L2, L3, L5- body right/spinous left drop adjustment

• 3) (right apparent short leg of 3”)= PI Ilium on the right, AS Ilium on the left.

The result following this adjustment:

• LBP decreased from 7/10 to 1/10

• right greater trochanter pain resolved (90% of my patients with hip pain improve with the adjustment of the sacrum and pelvis. I rarely adjust the hip)

• (Side note: please stop pulling on patient’s legs! )

• gait WNL

• anterior antalgia resolved.

Joint fixations that are often missed:

• T1 Rib

• Lunate/capitate for carpal tunnel (A-P adjustment)

• Sacral adjustment

• Pelvis adjustments (most often PI; however assess for PI, AS, IN and EX)

• Lateral tracking of the patella

• Posterior fibula head

T1 Rib Subluxation: symptoms, palpation and adjustment of

T1 Rib Subluxation symptoms:

• Neck Pain

• Shoulder Pain

• Discoloration of the extremity

• Decreased temperature of the extremity

• Arm and Hand Numbness (abnormal dermatomes also/hypoesthesia)

• Limited cervical rotation

Lunate/capitate for carpal tunnel (A-P adjustment)

• Symptoms? (numbness tingling and weakness in the median nerve distribution)

• orthopedic tests for carpal tunnel: (tinels wrist, phalens and reverse phalens)

• palpation and adjustment of the Carpal bones

Sacral subluxationThe first thing I check!!!

BP sacrum; Right base posterior/ left sacral apex; Left Base posterior/right sacral apex; BA sacrum

Pelvic misalignments:

• Pelvis adjustments (most often PI)

• however assess for PI, AS, IN and EX)

Review of Knee Joint anatomy:

Lateral tracking of the patella

Patella Subluxation:

• A subluxating patella is a temporary partial dislocation of the kneecap from it’s original position

Contacts for superior lateral patella subluxation:

https://www.canadianchiropractor.ca/techniques/technique-toolbox-knee-dysfunction-2416

Posterior fibula head

https://www.orthobullets.com/knee-and-sports/3014/proximal-tib-fib-dislocation

Case #4

• 63 year old female presents with severe CS pain and anterior shoulder pain at a 9/10 pain scale; 5 months in duration; no history of trauma.

• Severe limitation in ROM of the right shoulder, and she is unable to abduct the arm. She also reports additional neck and shoulder pain with sleeping, lifting/carrying things, and overhead reaching. The pain is described as constant and sharp.

Examination:

• Postural assessment: anterior head translation approx. 40 degrees; left high shoulder; right shoulder five inches lower and right humerus appears to be partially dislocated.

• Cervical ROM: Restricted to 20 degrees of right rotation, and is painful.

• Right shoulder ROM: cannot abduct the arm beyond 10 degrees

• Palpation: multiple CS joint fixations, T1-4 joint fixation, T1 rib, and point tenderness of the right AI humerus

• **what is our working diagnosis at this time?• Would this be considered Thoracic outlet syndrome?

Is this TOS?

• **no discoloration of the extremity, dermatomes are intact, biceps reflex wnl, no numbness or tingling in the right hand.

Thoracic Outlet Syndrome:

https://www.howtorelief.com/cervical-rib-thoracic-outlet-syndrome-overview-diagnosis-treatment/

More exam findings….

• Orthopedic testing: cervical compression-positive on the right; shoulder depressor-positive for same side pain; cervical distraction- positive for less pain in the CS; Valsalva’s-negative for disc involvement.

Cervical X-Ray series:

Radiology report for Cervical x-ray

• **CS x-ray: cervical djd, anterolisthesis at C5

Shoulder X-Ray:

Shoulder x-ray: “negative”

• **meaning: no fractures, no tumor

• …however would a radiologist be able to see joint motion on film? Would a partial dislocation be recognized on film?

https://myphysiciansnow.com/4-signs-you-might-have-a-broken-collar-bone-injuries/

• Anterolisthesis at C5- would this case be considered cervical radiculopathy?

• If so, does this explain everything? Would this explain why she is unable to abduct the arm, however biceps testing and dermatomes are wnl?

• **Right shoulder x-ray: negative; no acute findings

My diagnosis for this patient:

• cervical djd; cervical anterolisthesis, cervical radiculopathy; right shoulder subluxation

**my adjustment of this patient 1)Seated activator adjustment of T1-4 (to relax the traps and create joint motion)

2)Seated activator adjustment of the CS avoiding C5 which is anterolisthesis (be sure that we are palpating and counting)

3)T1 Rib adjustment on the right **at this point the patient felt a decrease in neck and shoulder pain, however she still

could not use her right arm. What else should be done?4)Active release technique of the right shoulder muscles: very painful, yet restored

some motion**what more is needed at this time?

5)AI vs. Posterior humeral head subluxation testing (demonstration)Positive for AI humerus on the right

6)Seated AI humerus adjustment (demonstration)

Result: this adjustment was very painful and the patient became teary eyed, however the pain quickly subsided and she was able to abduct her arm to 45 degrees.

Pain decreased in the CS to 5/10 and a 7/10 in the right shoulder. Ice was applied in the office, and the patient was instructed to ice three times a day for the next four days.

After that time she is to continue icing the Cs however she may alternate heat and ice for the right shoulder.

Chiropractic manipulation A-I humerus

Photo courtesy of: https://www.crawfordsvillechiropractor.com/services-provided/

Patient response:

• Visit #1:

• CS pain reduced to 6/10

• Increased shoulder pain, however the patient could finally abduct her arm

• Visit #2:

• Less pain with palpation

• CS pain reduced to 4/10

• Right shoulder pain reduced to 7/10

• Right shoulder ROM improved by 50%

Case #5

• 59 year old male returns for follow up appointment for lower back pain, and evaluation of Cervical spine pain

Radiology report:

• FINDINGS:• BONES: Moderate degenerative changes are present at C6-

7 with milder degenerative changes at C5-6.• There is straightening of cervical lordosis. Multilevel facet

arthropathy is present. Bilateral C6-7• foraminal stenosis with milder foraminal narrowing on the

right at C5-6. Left C3-4 and C4-5 foraminal• narrowing.• DISC SPACES: Disc space narrowing C6-7• PARASPINOUS: Negative. No paraspinous abnormality is

seen.• OTHER: Negative.

• CONCLUSION:

• 1. Moderate degenerative disc disease C6-7 with bilateral C6-7 foraminal narrowing

• 2. Left C3-4 and C4-5 foraminal narrowing

• 3. Multilevel facet arthropathy

**you notice that the patient is slurring his words

• Pertinent history:

• Hyperlipidemia

• Iron deficiency anemia

• Essential hypertension

• Chronic alcoholism

• Vitamin B12 Deficiency

• ** Would you adjust this patient?

• **the patient is also having trouble with his memory you notice, and is having trouble finding the right words

• **What else might you ask?

The conversation:• ****I mentioned to the patient that it appeared that he was having trouble speaking.• the patient was asked if anything had happened recently?• He said ‘yes a lot has happened.”• I asked what he meant.• He said “my friends think I had a stroke.”• I asked what he meant by that. • The patient said that “His friends noticed that he was having trouble talking.”• ** I asked how long this has been going on?• He said it started three days after I last saw you (two weeks ago, where his lower back was

treated.)• I said, did anything happen two weeks ago when these symptoms started?• “Yes a lot.”• What happened?• “I fell and hit my head.” • Have you had a headache or blurred vision since that happened?• “no I don’t have headaches.”• Are you having trouble with memory since this happened?

“yes a lot.” • Have you seen another doctor for this since your last visit with me?• “no”• “the top of my head feels numb and so do my teeth”

• The patient denies Headache, dizziness, vertigo or blurred vision

• The patient is having: numbness in the top of his head, and teeth, difficulty with speech and memory.

• **How would you manage this patients care?

• ** would you adjust this patient?

DDX:

• CVA or subdural hematoma• Aren’t you glad we didn’t adjust this

guy?!

https://neuro4students.wordpress.com/pathophysiology/

https://neuro4students.wordpress.com/pathophysiology/

https://neuro4students.wordpress.com/pathophysiology/

https://neuro4students.wordpress.com/pathophysiology/

Hemorrhagic Stroke

https://neuro4students.wordpress.com/pathophysiology/

Common symptoms of stroke:

• Sudden severe headache

• Vision changes

• Loss of balance or coordination

• Numbness in an arm or leg

• Inability to move

• Seizure

• Abnormal speech, slurred speech, inability to speak

• Nausea and vomiting

• Loss of Consciousness

How was this managed:

• **I called 911

• an ambulance was sent

• Paramedics: did vitals and EKG (which showed inverted T wave)

• the patient was taken to the ER

How is he doing now?

• He’s been released from the ER

• Hospital records are pending

• He called today to try and have his neck adjusted (I’m not kidding)

• The patient will be evaluated by his primary and chiropractic care in the future is likely to be via the activator only (without cervical rotation)

Doing our Due Diligence:

• Take a proper history regarding any new symptoms with current patients

• Perform a proper examination and avoid any tests which may cause more harm (i.e.: Jackson’s compression)

• Refer when necessary

• Don’t be afraid to say no, if that’s what is safer for the patient

• Call 911 when necessary

When should certain cervical orthopedic tests be avoided:

• Any time a patient has a hx of severe trauma to the CS (may have a fracture, acute disc herniation, or vascular compromise)

• If the patient is having any of or a combination of the following: – Severe headache with nausea

– Slurred speech

– Facial drooping

– Sudden weakness on one side of the body

– Memory loss or confusion

If a patient has had severe, head or neck trauma avoid the following

tests:

Shoulder depressor:

Maximal Cervical Compression Test:

Alternatives to determine severity of CS injury:

• Valsvas test

• Spinal percussion

– GENTLE tapping of spinous processes with a reflex hammer

• If you suspect a fracture or cva you may want to avoid performing a physical examination entirely and decide to call 911 instead

Chiropractic in the news: how could this have been avoided?

Always ask further questions! (Did this doctor ask HOW she “pinched a nerve” during the photo shoot?)

• “If a person has neck pain due to some form of trauma like a slip and fall, and their head goes into extension and rotation, this can contribute to a vascular issue,” says Pomahac. “The only way to determine if the neck pain is coming from a vascular issue is to have every person get a CT angiogram.” –Dr.Robert Pohmahac, D.C

As doctors of chiropractic we must always keep this phrase in mind:

“First, do no harm.”

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Marcus Strutz DC

Back To Chiropractic CE Seminars

33000 North Highway 1

Ft Bragg CA 95437

707.972.0047