36yo M s/p moderate damage 2 vehicle auto accident acute complaint in the back of left neck, back of center of the neck and back of right neck region due to the accident on 5/17/2023. Also acute complaints in the back of lower left back and back of lower right back region.
Reported no significant medical history, but retrospectively, he was taking anabolic steroids. Does not appear he told his provider about this.
Below you will find the initial findings, diagnosis and the therapy treatments from his chiropractor. Attached as a photo is his initial neurological assessment. He had 17 therapy appointments between June 2 and Aug 2nd.
In early December, the PC had an episode of syncope and went to the ER for eval. Was found to have a vertebral artery dissection. There was speculation from neurology that the chiropractic manipulation could have contributed to the injury.
We seek an active practitioner and/or educator to determine if any of the therapy listed below falls below the standard of care. Also would like input on the steroid use factor.
If you need any further information, please reach out.
May of 2023:
Objective findings: - Spinal Restriction(s)/Subluxation(s): C3, C6, T1, T5, T8, T10, L2, L5, right pelvis and left sacrum
- Extraspinal Restrictions/Subluxations: left shoulder and right shoulder.
- Pain/Tenderness: cervico-thoracic, thoraco-lumbar, lumbo-sacral and hip
- Postural Analysis: internally rotated bilateral shoulders.
- Muscle Spasm(s): 8 out of 10 (10 being most severe) left splenius capitis and semispinalis capitis, right splenius capitis and semispinalis capitis, left posterior trapezius, right posterior trapezius, left Rhomboid major, minor, infraspinatus, right Rhomboid major minor, infraspinatus, left latissimus dorsi, right latissimus dorsi, left thoracolumbar fascia , right thoracolumbar fascia , left quadratus lumborum, right quadratus lumborum, right piriformis, left piriformis, left Gluteus maximus medius and minimus, left semitendinousus, biceps femoris, semimembrano, left popliteus and left gastrocnemius and soleus.
Diagnosis:
Cervicobrachial syndrome, (S16.1XXA) Strain of muscle, fascia and tendon at neck level, init, (S13.4XXA) Sprain of Cervical Ligts, Intial, (S23.3XXA) Sprain of ligts of thoracic spine, (S29.012A) Strain of back wall of thorax, (M54.16) Radiculopathy, lumbar reg, (S39.012A) Strain of lower back, (S33.5XXA) Sprain of lumbar ligts, initial, (M62.830) Muscle spasm of back, (M99.01) Seg and somatic dysf of cervical reg, (M99.02) Seg and somatic dysf of thoracic reg, (M99.03) Seg and somatic dysf of lumbar reg, (M99.04) Seg and somatic dysf of sacral reg, (M99.05) Seg and somatic dysf of pelvic reg, (M99.06) Seg and somatic dysf of lower extremity, (M99.07) Seg and somatic dysf of upper extremity
Treatments:
Same treatments for May 31, June 2 and 5:
Primary Treatment: Arthrostim (Impulse Gun)- Chiropractic Manipulative Therapy (CMT) to the spinal levels as listed in objective findings spinal level(s). Extraspinal region(s) adjustment: Arthrostim (Impulse Gun)- Chiropractic Manipulative Therapy to the extremity joint(s) as listed in objective findings.
Manual Therapy: Myofascial release and Trigger point performed on the following muscle: left splenius capitis and semispinalis capitis, left posterior trapezius, right posterior trapezius, right splenius capitis and semispinalis capitis, left Rhomboid major, minor, infraspinatus, left latissimus dorsi, right Rhomboid major minor, infraspinatus and right latissimus dorsi for 30 minutes.
Rapid Release Therapy Rapid Release Passive and Rapid Release Active performed on the following muscle: left thoracolumbar fascia , left quadratus lumborum, right
quadratus lumborum, right thoracolumbar fascia, left piriformis, left Gluteus maximus medius and minimus, right Gluteus maximus medius and minimus, right piriformis, left psoas and right psoas for 8 minutes.
Intersegmental Mechanical Traction applied to full spine for 15 minutes.
June 6, 7, 14 and 15:
Primary Treatment: Arthrostim (Impulse Gun)- Chiropractic Manipulative Therapy (CMT) to the spinal levels as listed in objective findings spinal level(s). Extraspinal region(s) adjustment: Arthrostim (Impulse Gun)- Chiropractic Manipulative Therapy to the extremity joint(s) as listed in objective findings.
Manual Therapy: Myofascial release and Trigger point performed on the
following muscle: right thoracolumbar fascia , left thoracolumbar fascia , right quadratus lumborum, left quadratus lumborum, right piriformis, left piriformis, left Gluteus maximus medius and minimus, right Gluteus maximus medius and minimus, left semitendinousus, biceps femoris, semimembrano and left popliteus for 30 minutes.
Rapid Release Therapy Rapid Release Passive and Rapid Release Active performed on the following muscle: left thoracolumbar fascia , right thoracolumbar fascia, left
latissimus dorsi, right latissimus dorsi, right Rhomboid major minor, infraspinatus, left posterior trapezius, right posterior trapezius, left Rhomboid major, minor, infraspinatus, left splenius capitis and semispinalis capitis and right splenius capitis and semispinalis capitis for 8 minutes.
Intersegmental Mechanical Traction applied to full spine for 15 minutes.
June 16:
Primary Treatment: Arthrostim (Impulse Gun) and Diversified- Chiropractic Manipulative Therapy (CMT) to the spinal levels as listed in objective findings spinal level(s).
Extraspinal region(s) adjustment: Arthrostim (Impulse Gun)- Chiropractic Manipulative Therapy to the extremity joint(s) as listed in objective findings.
Manual Therapy: Myofascial release and Trigger point performed on the following muscle: right thoracolumbar fascia , left thoracolumbar fascia , right quadratus lumborum, left quadratus lumborum, right piriformis, left piriformis, left Gluteus maximus medius and minimus, left semitendinousus, biceps femoris, semimembrano, right Gluteus maximus medius and minimus, right semitendinousus, biceps femoris, semimembran, left latissimus dorsi and right latissimus dorsi for 30 minutes.
Rapid Release Therapy Rapid Release Passive and Rapid Release Active performed on the following muscle: right Rhomboid major minor, infraspinatus, left posterior
trapezius, right posterior trapezius, left Rhomboid major, minor, infraspinatus, left splenius capitis and semispinalis capitis, right splenius capitis and semispinalis capitis, left anterior trapezius, right anterior trapezius, left posterior deltoid and right posterior deltoid for 8 minutes.
Intersegmental Mechanical Traction applied to full spine for 15 minutes.
June 22 Same as above but added:
Therapeutic Exercise - Patient consented: |ntervertebral Differential DynamicsTherapy® (IDD) - Therapeutic Exercises performed as detailed in the treatment plan for 30 minutes. - Number of units: See device specific notes 6/22/2023. Tension set at 62lb locked.
June 25 Same as above butlocked at 70lbs
June 29:
No IDD
- Primary Treatment: Diversified- Chiropractic Manipulative Therapy (CMT) to the spinal levels as listed in objective findings spinal level(s). Extraspinal region(s) adjustment: Manual- Chiropractic Manipulative Therapy to the extremity joint(s) as listed in objective findings.
- Supportive Therapy to optimize treatment effectiveness the following therapy(s) were performed: - As per treatment plan - Manual Therapy: Myofascial release and Trigger point performed on the following muscle: right thoracolumbar fascia , left thoracolumbar fascia , right quadratus lumborum, left quadratus lumborum, right piriformis, left piriformis, left Gluteus maximus medius and minimus, left semitendinousus, biceps femoris, semimembrano, right Gluteus maximus medius and minimus, right
semitendinousus, biceps femoris, semimembran, left latissimus dorsi and right latissimus dorsi for 30 minutes.
- Neuromuscular Re-education: Rapid Release Therapy Rapid Release Passive and Rapid Release Active performed on the following muscle: right Rhomboid major minor, infraspinatus, left posterior trapezius, right posterior trapezius, left Rhomboid major, minor, infraspinatus, left splenius capitis and semispinalis capitis, right splenius capitis and semispinalis capitis, left anterior trapezius, right anterior trapezius, left posterior deltoid, right posterior deltoid, right anterior deltoid and left anterior deltoid for 8
minutes.
Intersegmental Mechanical Traction applied to full spine for 15 minutes.
July 7:
- Primary Treatment: Diversified- Chiropractic Manipulative Therapy (CMT) to the spinal levels as listed in objective findings spinal level(s).
Extraspinal region(s) adjustment: Manual- Chiropractic Manipulative Therapy to the extremity joint(s) as listed in objective findings.
- Supportive Therapy to optimize treatment effectiveness the following therapy(s) were performed:
Therapeutic Activities (97530)- Dynamic activities were performed under constant supervision to improve functional performance for 30 minutes. the following movements/exercises were performed:
1. Levator 2x30sec hold BIL.
2. Upper trap stretch 2x30sec hold BIL.
3. Upper trunk rotation 2x10 BIL.
4.Piriformis stretch 2x30sec hold.
5. Figure 4 stretch 1x30sec hold.
Pt reported pain and dizziness when activities were performed.
Neuromuscular Re-education: Rapid Release Therapy Rapid Release Passive and Rapid Release Active performed on the following muscle: right Rhomboid major minor, infraspinatus, left posterior trapezius, right posterior trapezius, left Rhomboid major, minor, infraspinatus, left splenius capitis and semispinalis capitis, right splenius capitis and semispinalis capitis, left anterior trapezius, right anterior trapezius, left posterior deltoid, right posterior deltoid, right anterior deltoid and left anterior deltoid for 8
minutes.
Therapeutic Exercise - Patient consented: |ntervertebral Differential DynamicsTherapy® (IDD) - Therapeutic Exercises performed as detailed in the treatment plan for 30 minutes. - Number of units: See device specific notes 7/7/2023.
Intersegmental Mechanical Traction applied to full spine for 15 minutes.
July 12 and 13:
Primary Treatment: Diversified- Chiropractic Manipulative Therapy (CMT) to the spinal levels as listed in objective findings spinal level(s).
Extraspinal region(s) adjustment: Manual- Chiropractic Manipulative Therapy to the extremity joint(s) as listed in objective findings.
- Supportive Therapy to optimize treatment effectiveness the following therapy(s) were performed:
Therapeutic Activities (97530)- Dynamic activities were performed under constant supervision to improve functional performance for 30 minutes. the following movements/exercises were performed:
SKTC. 3X30sec hold BIL.
Knee fall out 3x30sec hold BIL.
Dead bug 3x8 BIL.
Lumbar stretch w/ball 3x30sec hold
Cervical extension isometric 3x10 .
Cervical flexion isometric 3x10
Cervical side bend isometric 3x10 BIL.
Activities were performed with minimal cuing and without incident.
- Neuromuscular Re-education: Rapid Release Therapy Rapid Release Passive and Rapid Release Active performed on the following muscle: right Rhomboid major minor, infraspinatus, left posterior trapezius, right posterior trapezius, left Rnomboid major, minor, infraspinatus, left splenius capitis and semispinalis capitis, right splenius capitis and semispinalis capitis, left anterior trapezius, right anterior trapezius, left latissimus dorsi, right latissimus dorsi, left thoracolumbar fascia , right thoracolumbar fascia,
quadratus lumborum and right quadratus lumborum for 8 minutes.
Therapeutic Exercise - Patient consented: |ntervertebral Differential DynamicsTherapy® (IDD) - Therapeutic Exercises performed as detailed in the treatment plan for 30 minutes. - Number of units: 2 units
Intersegmental Mechanical Traction applied to full spine for 15 minutes
July 17:
- Primary Treatment: Diversified- Chiropractic Manipulative Therapy (CMT) to the spinal levels as listed in objective findings spinal level(s).
Extraspinal region(s) adjustment: Manual- Chiropractic Manipulative Therapy to the extremity joint(s) as listed in objective findings.
- Supportive Therapy to optimize treatment effectiveness the following therapy(s) were performed:
- Neuromuscular Re-education: Rapid Release Therapy Rapid Release Passive and Rapid Release Active performed on the following muscle: right Rhomboid major minor, infraspinatus, left posterior trapezius, right posterior trapezius, left Rhomboid major, minor, infraspinatus, left splenius capitis and semispinalis capitis, right splenius capitis and semispinalis capitis, left anterior trapezius, right anterior trapezius, left latissimus dorsi, right latissims dorsi, left thoracolumbar fascia , right thoracolumbar fascia, left
quadratus lumborum and right quadratus lumborum for 8 minutes.
- Therapeutic Exercise - Patient consented: |ntervertebral Differential DynamicsTherapy® (IDD) - Therapeutic Exercises performed as detailed in the treatment plan for 30 minutes. - Number ofunits: 2 unitsSee device specific notes 7/17/2023
7/24
Primary Treatment: Diversified- Chiropractic Manipulative Therapy (CMT) to the spinal levels as listed in objective findings spinal level(s).
Extraspinal region(s) adjustment: Manual- Chiropractic Manipulative Therapy to the extremity joint(s) as listed
in objective findings.
- Supportive Therapy to optimize treatment effectiveness the following therapy(s) were performed:
- As per treatment plan - Manual Therapy: Myofascial release and Trigger point performed on the following muscle: left thoracolumbar fascia , left quadratus lumborum, left piriformis, left Gluteus maximus medius and minimus, left semitendinousus, biceps femoris, semimembrano, right thoracolumbar fascia , right quadratus lumborum, right piriformis, right Gluteus maximus medius and minimus and right semitendinousus,
biceps femoris, semimembran for 15 minutes.
- Neuromuscular Re-education: Rapid Release Therapy Rapid Release Passive and Rapid Release Active performed on the following muscle: right Rhomboid major minor, infraspinatus, left posterior trapezius, right posterior trapezius, left Rhomboid major, minor, infraspinatus, left splenius capitis and semispinalis capitis, right splenius capitis and semispinalis capitis, left anterior trapezius, right anterior trapezius, left latissimus dorsi, right latissimus dorsi, left thoracolumbar fascia , right thoracolumbar fascia, left
quadratus lumborum and right quadratus lumborum for 8 minutes.
- Therapeutic Exercise - Patient consented: |ntervertebral Differential DynamicsTherapy® (IDD) - Therapeutic Exercises performed as detailed in the treatment plan for 30 minutes. - Number of units: 2 units See device specific notes 7/24/2023. Tension set at 100 locked
8/2 Same as above, NO idd, but added Therapeutic Exercise: Whole Body Vibration - Therapeutic Exercises performed as detailed in the treatment plan for 15 minutes.
- Number of units: 1 unit
Files:
No questions yet!
Do you believe there might have been medical error?
Not possible to determine definitively from the limited records provided. Need more information on subjective complaints. Defendant may have failed to diagnose an existing dissection, but did not likely cause the dissection or stroke based on this information.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Not possible to determine definitively from the limited records provided. Need more information on subjective complaints. Defendant may have failed to diagnose an existing dissection, but did not likely cause the dissection or stroke based on this information.
What makes you a good expert for this case?
I do more of these types of cases than other any chiropractic expert witness in the country. Have published research in this area, also.
How often do you encounter cases similar to this one in your practice?
Approximately every two weeks.
Do you believe there might have been medical error?
Proximate cause hard to establish but possible lack of written informed consent, possible aggressive manipulation causing patient to end treatment on 8/2/23, no notes regarding any adverse reaction, if any, and no full initial examination or re-examination. No notes regarding diagnostic testing, or lack thereof. Use neuro to bolster case, depending on medical treatment after syncope and VAD.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
See above; VAD from chiropractic manipulation (CMT) common, and more likely if poor intake, lack of thorough examination and lack of diagnostic testing to rule-out contra-indications for CMT.
What makes you a good expert for this case?
At least a dozen prior VAD cases as an expert witness, with over 30 years in this field and over 100 hearings/depositions/trials- civil suits, malpractice, Workers Compensation and No Fault, along with third party actions. Many affidavits of merit and medical narratives in this history.
How often do you encounter cases similar to this one in your practice?
Most of my expert witness cases have been VAD.
Want to open a case or submit response?
Comments are accepted only from Chiropractor experts.