Case Study

Making a House Call
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Case Study
Written by Tedd Koren, D.C.   
Tuesday, 23 August 2011 20:58


got a call from someone who sounded terrible.

“Doctor Koren, I’m in agony.  A few days ago I was out golfing with my family and something went out in my back.  I’ve been in bed for days. Yesterday, I was literally carried to get an MRI and a neurosurgeon will be getting back to me soon.  A friend who saw you said you can help me.  Can you do anything for me?”

“Can you come over to my office?”

“I can’t get out of bed.  I haven’t shaved in days.  I can’t move.  Can you come here?”

“Of course.”

I got his address, picked up my arthrostim adjusting instrument and was off.

When I arrived at his house, his wife let me in.  “Please follow me, he’s upstairs in bed; he’s been counting the seconds until you arrived.”

I followed her upstairs.

It looked like he had not left his bed for many days.  He had a 5 or 6-day-old beard.

“Thank you so much for coming. Please excuse me for not getting up.”

“No problem, where’s an electrical outlet?”  I plugged in the instrument and, quite literally, in the most professional way possible, climbed into bed with him.

“I haven’t showered in a few days,” he said.

“That’s OK,”I told him.  “Neither have I.”

My getting into the bed moved the mattress and he grunted in pain.  “I’ll try to move around slowly,” I told him.

I checked and adjusted him as he lay there. I adjusted what I could and it was no surprise that his discs as well as his vertebrae were subluxated.  In addition, he was very dehydrated; disc problems and dehydration go together. He was playing golf on a very hot day and drinking margaritas.  That’ll dry you out and it may have precipitated his disc damage.

Actually I’ve found that, if you get people with disc problems to drink more water, a large number of them would, by that act alone, become pain free.  When discs are dehydrated, they become friable—the fibers crack and split.  That can occur especially when they are under stress (such as swinging a golf club.)

I adjusted the discs and vertebra.  He was still in a lot of pain.  “I’ll see you tomorrow, I told him.”

The next day, as I entered the bedroom, he sat up in bed. He was able to move a little without too much pain and had even showered and shaved.  He couldn’t stand very long and was still fairly immobile most of the time.  I climbed into bed and worked on him again; this time I was able to reach more areas.

The next day, he was driven to my office and, using crutches, walked into the adjusting room.  Because I was able to adjust him standing as well as sitting and in the position he was in as he swung his golf club, more subluxations were revealed and could be corrected.

The following day, he drove in by himself.  After a few more days, he was pain free.

Later in the week, he drove himself to the neurosurgeon.  As he walked into the doctor’s office, the MD’s jaw dropped.  “Your MRI was the second worst train wreck I had ever seen in my 30 year career.  I was going to recommend immediate surgery.  I can’t believe you’re pain free. Amazing.”

“Would you like to know what I did to get out of pain?” he asked.

“No, not really.”

Surprised?  I’m sure that if you’re a doctor of chiropractic reading this story you’ve got plenty of similar stories.

The number one rule in all healing is, “Listen to the patient; the patient is your teacher.”  Of course, that only works if one’s mind is open.

Another example

This medical phenomenon is not only related to chiropractic care.  For example, Harris Coulter, Ph.D., the world famous medical historian, cites a friend of his who was diagnosed with lung cancer and given six months to live.  Dr. Coulter recalled, “I told him that, in Alexandr Solzhenitsn’s book, The Gulag Archipeligo, Solzhenitsn mentioned that he had been diagnosed with lung cancer and cured it after taking extracts from a yew tree.”

So, his friend found a source of yew extract and began to take it under the direction of a naturopathic physician. Six months later, he returned to the MD who had given him six months to live.  After the examination, the doctor reported, “Your lungs are clear.  No cancer at all.”

“Would you like to know what I did?”

“No, not really.”

Medical mis-education

I’m shocked that the medical profession ever questioned the intelligence, ethics and morality of chiropractors and other alternative healthcare practitioners. Apparently, they were looking in a mirror, blinded by the prestige, money and power that society has given them.

What is it with the medical mind?  How can they be so clueless?  Coulter discusses this in his magnum opus Divided Legacy, Vol. 4 in chapter 26, “The Training of Physicians,” (P. 645), where he quotes MD’s, educators and students.  Coulter writes:  “The majority of students complain that they experience constant anxiety and stress.  A “dehumanizing experience” is their most frequent characterization of medical school….

From a sophomore: “I was not sure the day after I entered whether I was in a prison or a kindergarten, and I still haven’t made up my mind.” Daniel H. Funkenstein

The doctor-scientist orientation produces a nasty side effect; it takes incoming medical students who are interested in people and transforms them into doctors interested in diseases. Michael Crichton

Students entering medical school are a very healthy bunch of young people.  If they’re not when they leave, it’s because we did it to them. Pearl Rosenberg

Coulter continues:  “The clinical years of medical school thus perpetuate the confusion and alienation of the preclinical ones.  The first two years instill in the student just enough abstract information to inhibit precise observation, while the last two deaden the sensibilities which might have enabled him to overcome the legacy of the preclinical period.  He leaves medical school dehumanized.”

Worshiping an idol?

These are people who are worshipped by the general public who are unaware of what kind of people they are putting their trust in.  These are people who are caught in a machine that is as much political as it is professional.  Their education is increasingly overseen by pharmacological research and they graduate with a narrow view of life and health.  Perhaps they have no concept of health, since their focus is disease.

Is it any wonder that, when true healing is revealed, they recoil in shock and bewilderment?  Fearful of admitting their deficiencies, they quickly turn away and mumble, “No, not really.”

And they are right.  They don’t want real.  Real is a frightening place.  It is beyond the confines of their comfortable thoughts.  There is no reality in their education, outlook and practice.  They’re better off not going there; it would destroy their powerful, though brittle, world.

A bed call

That house call, or bed call, that I made was a microcosm of what many patients must deal with.  This patient was lucky to have looked outside the system.  Not everyone is lucky enough to have a chiropractor make a house call or open enough to invite one.


Tedd Koren, D.C., is the developer of Koren Specific Technique.  For information, go to Dr. Koren also writes patient education materials.  Go to Dr. Koren can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Unstable Arches in an Active Baby Boomer
Case Study
Written by John Danchik, D.C., F.I.C.C., F.A.C.C.   
Tuesday, 23 August 2011 19:13

History and Presenting Symptoms

A 61-year-old female presents with a recent history of occasionally moderate pain in her lower back.  Although the pain responds well to chiropractic adjustments, it invariably recurs within a couple of days.  While there are no specific triggering activities, being on her feet and engaged in physical activity does seem to bring on the pain more rapidly.  She describes her current level of low back pain as usually around 35mm to occasionally 45mm on a Visual Analog Scale.


Exam Findings

Vitals. This maturing, physically active woman (she performs water aerobics at least twice each week and walks 1.5 miles every day) weighs 143 lbs. which, at 5′ 6″, results in a BMI of 23; she is not overweight.  She reports that she has been a non-smoker for over 30 years, and limits her alcohol intake to one glass of wine per day.  Her blood pressure and pulse rate are at the lower end of the normal range.

Posture and gait. Standing postural evaluation finds a lower iliac crest on the left, and a low left greater trochanter.  The right shoulder is slightly lower than the left, with no history of fracture or surgery.  She has a mild bilateral knee valgus and moderate calcaneal eversion and hyperpronation on the left side, with a noticeable outward flare of her left foot.  Palpation of the left arch, when standing, finds it significantly lower than the right, but it is not tender to direct pressure.  The Navicular Drop test demonstrates greater excursion of the left navicular bone when moving from sitting to standing (non-weight bearing to weight bearing).

Chiropractic evaluation. Motion palpation identifies limitations in segmental motion at L4/L5 and L5/S1, with some local tenderness.  These segmental dysfunctions demonstrate loss of end-range mobility in all directions.  Additional fixations are noted at T9/T10, C5/6, and C2/3.  Lumbar ranges of motion are full and pain free and neurological testing is negative.



Upright, weight-bearing X-rays of the lumbar spine demonstrate moderate loss of intervertebral disc height at L4/L5 and L5/S1, with small osteophyte formation at those levels.  A discrepancy in femur head heights is seen, with a measured difference of 6mm (left side lower).  A moderate lumbar curvature (6°) is noted, convex to the left side, and both the sacral base and the iliac crest are lower on the left side.  The sacral base angle and measured lumbar lordosis are within normal limits.


Clinical Impression

Moderate lumbosacral osteoarthrosis and disc degeneration, with mechanical dysfunction associated with poor biomechanical support from the lower extremities.  There is a functional short leg on the left side.  The asymmetry in the lower extremities is clearly demonstrated by the loss of left arch stability seen on the Navicular Drop test.  There is noticeable hyperpronation, arch collapse, and foot flare consistent with left arch collapse, with the expected effects in the pelvis and spine.


Treatment Plan

Adjustments. Specific chiropractic adjustments for the lower extremities and the involved spinal regions were provided as needed.

Support. Individually designed, stabilizing orthotics were provided to support the left arch and calcaneus (pronation correction) and decrease the asymmetrical stress on the knees and back.

Rehabilitation. This patient was instructed to perform an at-home series of back exercises using elastic tubing to develop and maintain coordinated strength in her spinal stabilizers (paraspinal musculature) and core (trunk and pelvic) musculature.


Response to Care

She responded well to the adjustments and exercise, and reported a rapid decrease in symptoms.  Within two weeks of receiving her orthotics, she reported that she felt she had more energy, and no longer had the previous nagging low back pain.  She was released to a self-directed home stretching program after a total of eight treatment sessions over six weeks.



This patient had no foot or arch pain; however, she was undergoing plastic deformation of her arches, which for unknown reasons was accelerated in the left foot.  This produced a chronic, asymmetrical strain on her pelvis and spine.  Her condition was documented with a test for stability of the arches—the Navicular Drop test.  This highlighted the asymmetry in her lower extremities and provided for an easy discussion of the benefits of long-term orthotic support.

Obese Patient Benefits from Orthotic Support
Case Study
Written by John Danchik, D.C., F.I.C.C., F.A.C.C.   
Saturday, 25 June 2011 23:31

obesepeopleHistory and Presenting Symptoms

A 31-year-old male office worker reports a history of mild-to-moderate, intermittent lower back pain, along with an aching tightness in his neck.  His back pain comes on with no specific triggering activities, and the neck tension is worse during long, stressful workdays.  He is not involved in any recreational sports or exercise activities, and he doesn’t recall any back or neck injuries.  On a 100mm Visual Analog Scale, he rates the low back pain as usually 35-45mm, and his neck tightness as around 25-30mm.

Exam Findings

Vitals. This man weighs 224 lbs, and is 5’9’’ tall.  This calculates to a BMI of 33—he is obese.  His waist measures 49 inches at the largest point above the ASIS, confirming abdominal obesity.  His blood pressure is somewhat elevated at 144/90 mmHg, and his pulse rate is 80 bpm.

Posture and gait. Standing evaluation highlights the postural effects of abdominal obesity: a loss of lumbar curve, an accentuated thoracic kyphosis, and cervical anterior translation (forward head carriage).  There is no noticeable lateral pelvic listing or lateral spinal curvature.  He does have moderate bilateral knee valgus and bilateral calcaneal eversion, as well as collapsed medial arches.  During gait evaluation, both feet flare outwards and exhibit excessive pronation.

Chiropractic evaluation. Motion palpation identifies several limitations in intersegmental spinal motion: the left SI joint, L4/L5 on the right, L2/L3 on the left, T11/12 generally and several levels at the cervicothoracic junction.  There is no specific spinal tenderness or spasm of the paraspinal muscles, but adipose tissue is prevalent throughout.  All active thoracic and lumbar ranges of motion are limited slightly by general stiffness.  Neurological tests are negative for nerve root impingement, but straight leg raise is limited bilaterally by hamstring shortening and tightness.


Upright, weight-bearing X-rays of the lumbar spine demonstrate loss of intervertebral disc height at L4/L5 and L5/S1, with moderate osteophyte formation at those levels.  There is no discrepancy in femur head or iliac crest heights, and no lateral listing or lateral curvature.  The sacral base angle and lumbar lordosis are both decreased, which is consistent with the postural analysis.

Clinical Impression

Chronic spinal stress syndrome due to obesity.  This is emphasized by poor support from the lower extremities, with bilateral knee valgus, excessive pronation and calcaneal eversion.

Treatment Plan

Adjustments. Specific, corrective adjustments for the identified fixations were provided as needed, with good response.  Specific manipulation of both feet and knees was also performed.

Support. Custom-made, flexible stabilizing orthotics were provided, to support weaknesses in the pedal foundation and decrease stress to the knees and back during walking.  A custom-made cervical traction pillow was ordered, to provide proper alignment of the head, neck and shoulders during the night.

Rehabilitation. He was started on a localized spinal activation and strengthening program using elastic resistance tubing for the multifidus muscles—first in extension, then into rotation and lateral flexion.  In addition, he was counseled on building up to 60 minutes a day of moderate physical activity for weight loss.  He chose to walk for 15 minutes during lunchtime and another 15 minutes prior to his evening meal.  After three weeks he doubled his time at each session.  He used an exercise log as part of his motivation for sustaining his fitness activities, which included a healthy and balanced diet program. 

Response to Care

He tolerated adjustments well, and adapted to the orthotics and cervical support pillow without difficulty.  Low back symptoms resolved rapidly and, shortly thereafter, his neck tightness disappeared.  His brisk walking program did not irritate his back, even after he increased to a total of 60 minutes daily.  After six weeks of adjustments (8 visits), he was released to a self-directed home stretching program, with instructions to continue his exercise and healthy dieting.


Obesity is still on the rise in all industrialized countries, since so many of us—like this case study—now live primarily sedentary lives.  Additional, unhealthy pounds place increased stress on the lower extremities and spine, resulting in chronic symptoms and accelerating degenerative changes.  Specific spinal adjustments and custom, postural support need to be combined with individualized dietary and exercise instructions for best results.  An exercise/dietary log can improve patient adherence to recommended lifestyle changes.

Head Injury
Case Study
Written by Kirk Lee, D.C.   
Wednesday, 11 May 2011 18:17

or the past year, it seems anytime you open a magazine, newspaper or watch a television show, you see some reference to the raisingbraininjurymay awareness of the rate of traumatic brain injuries (TBI) or concussion in today’s youth. This information is mainly directed toward the adult population. Football has always been the sport of primary focus, but recent injuries to NHL star Sydney Crosby has made even more people sit up and take notice. For purposes of this article, our emphasis will be more on the adolescent.

Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include:

Concussion may be caused by either a direct blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head.

Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously.

Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury.

Concussion results in a set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course; however, it is important to note that, in a small percentage of cases, post concussive symptoms may be prolonged.

No abnormality on standard structural neuroimaging studies is seen in concussion.1

One of the most common mistakes in understanding concussion, at one time, was that it was believed you had to have been knocked unconscious to have suffered a concussion. Today, we know this is far from the truth. Actually, only 9 percent of all concussions result in loss of consciousness (LOC). As doctors of chiropractic, we understand how different stresses at one part of the neuromusculoskeletal chain can affect areas above and below the area of insult. Due to this understanding, we can biomechanically understand that an “impulsive” force to the body can be transmitted to the head. So, the damaging blow does not have to be a hit to the head, but can be anywhere within the neuromusculoskeletal chain and result in compromising the integrity of the brain, spinal cord and nerve roots.

Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.

You may say to yourself, “Concussions occur primarily in sports, and I do not treat many athletes and I’m not a team doctor.” This statement is about as false as the statement that you have to be knocked unconscious to have suffered a concussion. We all treat patients who—through falls, motor vehicle accidents, worker’s comp injuries—have entered our office with complaints of headaches, dizziness, nausea, balance issues, blurred vision, ringing in the ears, just to name a few. Are these signs and symptoms any different that those of a TBI, closed head injury, or concussion?

The reason for the increased awareness is the increase in two syndromes that are associated with concussion, the first being “post concussion syndrome.” Simply put, this is nothing more than continued symptoms that we mentioned above that last longer than 24 hours. The other is “second impact syndrome.” Second impact syndrome results from a patient or athlete who sustains a second head injury while the signs and symptoms of the first have not yet cleared. It has to be no more of a force that causes the brain to accelerate or quickly decelerate.

Diagnosing someone who is suffering from a traumatic brain injury can sometimes be difficult. Many times, it is simply listening to the patient (or someone who is close to the patient) tell you about changes they may be noticing. These symptoms include not sleeping in the same normal patterns, behavioral changes, and depression, speech or balance issues. They can all be clues that your patient maybe suffering from something more than just a vertebral subluxation complex.

In sports, there are three accepted guidelines for grading concussion and returning to play. Today, primarily the one developed by the American Academy of Neurology (AAN) is the preferred source.

Grade 1 or mild concussion is defined as no loss of consciousness, and post-concussive signs and symptoms that are lasting longer than 15 minutes.

Grade 2 or moderate is again no loss of consciousness but the post-concussive signs and symptoms last longer than 15 minutes.

Grade 3 or severe is defined as “any” loss of consciousness.

For the athlete to return to play, the considerations are based on several factors:

Patient must be “asymptomatic”

Patient must pass memory & neurological testing

NO signs and symptoms with exertional testing.

Additional assistance is used by many with the use of Sport Concussion Assessment Tools. These are tests that are given before an athlete participates and, again, once it is suspected that he/she may have received a head injury. The test involves a section the athlete fills out on post-concussion symptoms, grading them from 0 (none) to 6 (severe). The second part is filled out by a qualified healthcare professional. It involves scoring signs and symptoms, cognitive assessment and neurologic screening and, finally, a return-to-play recommendation. Examples of these tests can be found on the Internet.

These symptoms include not sleeping in the same normal patterns, behavioral changes, and depression, speech or balance issues.

So, why are adolescents having an increase in concussions? First and foremost is the increased level of competition. Today, most parents want their children to grow up healthy and happy. But, with the influence of increased pressure to participate and win, we have a tendency to overlook the environment in which we may be placing our children. Another consideration is the lack of properly trained healthcare professionals at adolescent events. Think of how many coaches there are for youth programs. Typically, they are moms and dads who want to be involved with their children, but who may know little to nothing about proper mechanics of the sport or have no training in first aid and CPR. Many youth organizations are starting to change this and make it mandatory for all coaches to have training in first aid and CPR, and it’s more common to have a defibrillator as part of the equipment mandated at events.

We mentioned that forces can be transmitted to the brain. We know that the heel-strike portion of the gait cycle produces transmitted forces that can travel the length of the neuromusculoskeletal system. To help improve these forces, you can: recommend the use of custom-made orthotics, make sure that the foot is going through a normal biomechanical heel-to-toe transition, and recommend the use of a good athletic shoe to help absorb and distribute shock. The use of mouth protectors has also been considered in helping reduce forces transmitted to the brain.

I recommend you do more research on traumatic brain injuries and concussion to help you better understand the signs and symptoms associated with it. Find a center that deals with traumatic brain injury patients. They often need additional occupation therapies to help them with activities of daily living that most doctors of chiropractic may or may not be able to provide. These types of injuries can be very scary, but having a good understanding of how and what is happening allows you to provide the best chiropractic care possible for your patients.


A 1980 graduate of Palmer College of Chiropractic, Dr. Kirk Lee is a member of the Palmer College of Chiropractic Post Graduate Faculty and Parker College of Chiropractic Post Graduate Faculty. He has lectured nationwide on sports injuries and the adolescent athlete, and currently practices in Albion, Michigan.



1. Consensus Statement on Concussion in Sport, 3rd International Conference on Concussion in Sport, Nov 2008, Clin J Sport Med 2009; 19:185-200

Hip Imbalance Leads to Tension and Pain
Case Study
Written by John Danchik, D.C., F.I.C.C., F.A.C.C.   
Monday, 25 April 2011 18:34

History and Presenting Symptoms


A 56-year-old male presents with recurring episodes of moderate pain and “tension” in his left hip. He denies injuring the hip, and cannot discern any specific precipitating activities or events. Mornings seem to be particularly problematic, but the pain is never disabling. On a 100mm Visual Analog Scale, he rates his left hip pain around 45mm. He takes over-the-counter NSAID’s, which provide sufficient relief. However, he desires to discontinue taking drugs for his hip pain.

Exam Findings

Vitals. This active male weighs 175 lbs., which, at 5’10’’, results in a BMI of 25—right on the borderline of overweight. He works out regularly on resistance machines at his local community recreation center, which indicates that some of his excess weight is possibly lean body mass. He doesn’t smoke, his blood pressure is 118/78mmHg, and his pulse rate is 76 bpm. These findings are within the normal range.

Posture and gait. Standing postural evaluation finds a lower iliac crest on the right and a low right greater trochanter. The left shoulder is somewhat lower than the right, with no history of fracture or surgery. His knees are well aligned, but there is obvious medial bowing of the right Achilles tendon, with a lower medial arch on the right foot.

Chiropractic evaluation. Motion palpation identifies several mild limitations in spinal motion: the left SI joint, the lumbosacral junction, T11/12, and at the cervicothoracic junction. Palpation finds no significant tenderness in these regions, and all active spinal ranges of motion are pain free. Hip ranges of motion are also pain-free. Provocative orthopedic and neurological tests for nerve root impingement and/or disc involvement are negative.

Lower extremities. Closer examination finds that the right medial foot arch is lower than the left when standing. His right calcaneus is everted when bearing weight. When he is seated and non-weightbearing, the right arch appears equal to the left, and when he performs a toe-raise while standing, the right arch returns. Manual testing finds no evidence of weakness in the peroneal or anterior tibial muscles.

Chronic hip pain must be evaluated fully, in order to identify any underlying problems and propose effective treatment.


A-P and lateral lumbopelvic X-rays are taken in the upright, weightbearing position. A discrepancy in femur head heights is noted, with a measured difference of 6 mm (right side lower). A moderate lumbar curvature (8°) is noted, convex to the right side, and both the sacral base and iliac crest are lower on the right. The sacral base angle and measured lumbar lordosis are increased, but not outside of normal limits. No loss of joint spacing or osteophyte formation is identified in the hip joints.

Clinical Impression

Moderate functional leg length discrepancy (right short leg), with associated pelvic tilt and slight lumbar curvature. There is an accompanying history of chronic left hip pain.

Treatment Plan

Adjustments. Specific, corrective adjustments for the SI joints and the lumbar, thoracic, and cervical regions were provided as needed, with goodresponse. Right-foot manipulation, including navicular, cuboid, and calcaneal bones, was also performed.

Support. Custom-made, flexible stabilizing orthotics were provided, with added pronation correction on the right side. The adaptation process posed no difficulties.

Rehabilitation. He was shown a series of standing hip strengthening exercises in all ranges, using elastic resistance tubing. His exercise log was reviewed at each visit to ensure adherence to the exercises.

Response to Care

All adjustments were well tolerated, and orthotics helped to improve his postural alignment. After four weeks of adjustments (eight visits), daily home exercises, and wearing the orthotics, he successfully completed his re-examination and was released to a self-directed maintenance program.


With no history of leg, hip or pelvic injury, this patient apparently had a functional right short leg that produced a chronic biomechanical stress on the left hip joint. Pronation and biomechanical asymmetry in the foot and ankle are seldom locally symptomatic. Chronic hip pain must be evaluated fully, in order to identify any underlying problems, rule out osteoarthritis and other important conditions, and propose effective treatment. The foot and spinal adjustments and the hip exercises were helpful, but the problem most in need of correction was the pronation asymmetry that caused a functional imbalance at the hips and pelvis.


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