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Case Study

Case submitted by

Dr. David Clark
Chiropractic Neurologist

Northlake Chiropractic & Wellness Center
10233 E. NW Hwy #508
Dallas , TX 75238

214-341-3737

www.northlakechiropractor.com


04/05/04

Sterling H.
This 19 month old boy has never slept through the night since he was born.
He awakens 12 to 13 times per night, every night, screaming. He is very
small for his age. He has horrible digestive problems and cannot tolerate
cow˙s milk or soy milk. He has been able to tolerate goats milk. Since he
was born he has had at least 10 rounds of antibiotics. He has seen
gastroenterologists, internal medicine specialists and pediatric specialists.
Thus far he has been diagnosed as failing to thrive.


Findings:
Sterling likes to make linear patterns with objects, likes to organize
things. His parents report that he is fascinated by trains, and especially
enthralled by moving wheels. He likes flickering Christmas lights and will
stare at them and other similar visual stimuli for as long as he is allowed.
He does not like loud sounds.


Examination shows non tender abdomen. Optokinetic nystagmus is
not able to be elicited. During the examination spends a considerable
amount of time one the floor with toy trains and toy bugs. He does have
some language capabilities and can say mama, dada, bug, train. He
does interact during the examination and appears to be able to respond
to directions and questions. Cranial nerve examination reveals a right
pupil that is larger at rest than the left. The right pupil reacts very quickly to
light stimulation directed at the left nasal retina and also fatigues quickly.
Muscle tone examination does not reveal any spasticity nor rigidity in the
upper and lower extremities. Instead, his muscle tone is slightly hypotonic
and floppy. He is slightly pigeon-toed. Subluxations are noted on the
left side of C5/C6 articulations showing decreased lateral bending and
tenderness on palpation.


Diagnosis:
Segmental: subluxations at left C5/C6.
Suprasegmental: decreased right hemisphere function producing
concomitant REM sleep abnormalities and poor digestive tract function as
a result of diaschisis with the PMRF centers.

Treatment plan: Melatonin 1mg nightly, I capsule of Therbiotic from Klaire
laboratories; improve right neocortical brain function through passive
stimulation, initially, of right temporal lobe and right occipital lobe with
specific low-frequency environmental sounds provided by the

BrainBalance Music CD With Wolves and Whales for 10 minutes twice per day as well as left superior hemifield visual stimulation with red light for 5 minutes twice per day.

Outcomes: the afternoon of beginning treatment Sterling slept for 4 hours
straight. That night, he slept from 11:00 pm to 6:00 am. The next night he
slept from 11:00 pm to 8:00 am awaking twice for approximately 10
seconds each time. Two weeks later, we have discontinued the
melatonin only and he is continuing to sleep through the night. Needless
to say the parents are thrilled with his progress thus far.



 

 

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