Clinical Case Report
Dr. Danny McLane D.C., CHTI
Initial patient contact Aug. 7, 2012
A 33 y/o female reported to the clinic with a CC of hormone imbalances. Height 5’4”, current weight 180 lbs. In her history she cited weight fluctuation, extended and irregular menstrual cycles, sleep irregularities and chronic illness as evidence of hormone imbalances. Prior to entering our care she had blood work done for thyroid function. She did not produce the report for our review, but did mention that it had been viewed by the group that had run the panel and her General Practitioner M.D. and was told that conclusively it was “unremarkable”. Despite several requests for her to provide us this information, she declined. We proceeded with treatment. Also noted during her history were digestive disturbances such as heartburn ongoing for one month prior to her visit, food sensitivities, and sluggish digestion with frequent constipation with one bowel movement per two days on average. Additionally noted was abnormal anatomy of an additional kidney on the right side with accompanying proteinuria.
Weight fluctuation: patient states fluctuating almost 100 pounds over the course of a few months (variable between 3-6 months) in the range of 120-220 pounds. She reports that this weight loss/gain is without any alteration in her diet or exercise routine. Exercise consists of 30 min/day by 3x/ week and an additional 2 day of weights or cross training. Diet consists of 1700-2000 calories daily of meats, fruits vegetables and starches moderate amounts of sugars, and alcohol 1-3 drinks /week. Also self-reported occasional binge drinking once every 8-12 months of 1-2 days of bingeing. Patient states that when gaining weight above her ideal range, she would restrict calories and increase exercise. Conversely when losing weight below her ideal range, she would reduce activity and increase caloric intake. Ideal body weight range was 135-145. Anecdotally noted was her comment of having a closet full of extra clothes sizes ranging from 2-16 in order to be prepared for a change in size overnight such that she could not wear the same size clothes from the day before.
Irregular menstrual cycle: patient states that her menstrual cycle was irregular for two-three years, starting around age 29 and through age 32. Most recently in the past eight months has been regular with 14 days of menstrual flow out of a 28 day cycle.
Sleep irregularities: Patient states that she has trouble falling asleep, staying asleep and oversleeping. Depending on what period of time she was referencing she described both hyposomnia and hypersomnia, as she had difficulties with each. These episodes were regular and 6-7 nights/week. She also stated the regular use of common stimulants, such as coffee, to maintain alertness during her work day.
Chronic illness: patient states that she is “always sick”. Defined as some sort of sinusitis, cough, chest cold, sore throat etc. for at least 2-5 days and usually 3 episodes monthly.
The multi-symptom, multi-system nature if her condition suggested a blood related problem. Her metabolic fluctuations, sleep irregularities, menstrual irregularities, and chronic illness were the main focus of her CC and suggested the endocrine system. Due to the report of “normal” blood work and the lack of proper function, the working diagnosis was systemic inflammation. This working diagnosis also explains the food sensitivities. Other findings were right sided temporal bulge cranial fault, Hypohydrochloria, Ileocecal valve spasms, functionally inhibited muscles and some areas of spinal subluxation.
The course of care we decided on was the SHAPE ReClaimed process as described in The Complete Patient Guidebook. A weekly urinalysis was performed using Rapid Response brand, 10 parameters reagent strips. The baseline UA showed 15+ for protein, all other parameters were within normal limits (WNL). Also Applied Kinesiology techniques were used to address right-sided temporal bulge cranial fault, hypohydrochloria, Ileocecal valve spasms, functionally inhibited muscles and areas of spinal subluxation.
The first report of change in symptoms was at the weekly check in. the patient noticed an increase in energy overall and a decrease in digestive complications, more regularity. Also noted was a drop in body weight of 8 pounds. The UA showed KET 15+ and PRO 15+ (normal). The next change in symptoms was increase in restful sleep with less sleep disturbances with a total of three or less nights of disturbed sleep. This report was made at the week two visit. At the week two visit she also reported a weight loss of 7 pounds and that she was down a size in her clothing. Also noted was a headache, that the patient described as “normal”, but failed to mention in the history because it was “always there”. The UA showed KET 15+ and PRO 15+. Week three report a decrease in frequency of illness since the onset of the program, increased quality of sleep, reduction in body weight of 5 pounds, increased energy levels and decreased fatigue during the work day. The UA showed PRO 15+ and KET 160+. We added one extra fruit to her food plan per day. Week four report showed a delay in onset of her menstrual cycle. For the first 9 days on the program she was mid cycle. That cycle ended during week two. According to her history she expected to have started another cycle during week four. She also reported a decrease in body weight of another 6 lbs, no headache since last visit, also no illness, still sleeping better. The UA showed KET 40+ and PRO 15+. Week five report included the onset of her menstrual flow, 19 days since the end of the last cycle. Also noted was one minor headache that occurred after skipping lunch one day and having a busier than normal day. She has been more diligent with timing of meals and since then no recurrences. Also still feeling well, sleeping well, no illness since last visit. also reports a weight loss of 4.5 lbs. (Week six there was no visit, due to scheduling issues) Week seven report showed that her menstrual flow of last cycle lasted only 4 days, for the first time in eight months. Also reported was a decrease in body weight of 9 lbs. All of her previous complaints were no longer a concern for her at this time. the report for week eight showed that her weight had achieved a desirable level at 134.3 lbs and a resolution of all other complaints.
At that time we decided to transition her to Phase II of the SHAPE ReClaimed program but continue to use the SHAPE Drops. This decision was based on the patient value of the drops and concern to maintain her new normal for her menstrual cycle of four days of flow out of every 28 days. We also provided her a calorie calculation of 1900 cal/day along with 30 min 3x/ week of exercise. We set up a follow up consult for 4 weeks, unless she had concerns, then she was instructed to call in sooner. At the 4 week consult, she reported feeling great with no complaints. Her weight had increased to 141.6 and held steady there for more than 2 weeks.
In this case, where no assistance or solution was offered by standard western allopathic approach, a change in diet and use of the SHAPE ReClaimed drops along with chiropractic and Applied Kinesiology techniques created an environment that the body was able to heal previously chronic conditions. Further studies are needed to validate results in a more diverse population.
Dr. Todd Frisch: Teaching Assessment
Excellent case study!
Significant to realize what really occurred if our theory regarding hypothalamic function is correct, and we think it is:
This patient truly “reset” the hypothalamus (though the FDA warns using language stating the hypothalamus can be “reset” – we are seeing this clinically every day in our practices regardless of what the FDA believes.) She now experiences improved sleep, weight loss, and normalization of her menstrual cycle. Remember, the hypothalamus must be “satisfied” daily. The four things that “satisfy” the hypothalamus are: sleep, exercise, sex and food.
It is important to note the value of the baseline UA. She presented with protein at +15 and continuously showed protein at +15. This is obviously her norm as she has an additional kidney. Therefore, we would not increase protein in her case. Had a baseline not been performed, the practitioner would think it appropriate to increase the patient’s protein intake. In this case, that would have been detrimental to weight loss success. You will note Dr. McLane correctly altered her diet when she was spilling large ketones by increasing her fruit consumption.
We believe the rebound weight gain is tied to her kidney disorder. If a patient can gain a full dress size in 24 hours, the most logical explanation of this would be water retention. Her history dictates such. It is our hope that with her cycles normalizing and her hypothalamus function improved, she will stabilize.
Note the patients desire to stay on the drops. This is very acceptable and we would recommend .50 ml 2x daily. Since we have no hCG in our drops, we no longer have to restrict long term use.
Should the patient decide to return to Phase I, we recommend taking a minimum of seven days off the drops before restarting the program along with the two glutton days. It is our recommendation glutton days consist of healthier increased fats, such as: eggs, nuts, avocadoes to train the drops to go after and break down excess fat. Of course indulging in a fried chicken dinner or fettuccini and enjoying an ice cream treat is acceptable during glutton days. Once you shut down excess fat intake, the drops then go after stored, toxic fat. As soon as a patient cheats, the drops go after the most readily available fat, thus stalling the patient’s weight loss. We have observed clinically, it can take three to seven days for the body to revert back to stored fat burning mode.