A 41-year old female with 2 children, 5’ 7’’, 164 lbs. with complaint of mid back pain for a while. She is self-employed with a house cleaning business. She has no known allergies but is having many issues with eye drainage, itching along with redness, soreness and pain around the eyes.
She is on these prescription medications: Synthroid and steroids for eye irritation. She has had a thyroid panel check with a medical doctor and patient stated T4 Free levels are low.
With initial complaint of mid back pain and periodic headaches, a chiropractic and orthopedic exam reveals paraspinal tonicity with decrease active range of motion. Dermatomes, myotomes and reflexes are normal. Palpation reveals subluxation of the cervical and thoracic spine.
The patient received standard chiropractic care for her spinal issues and improvement was seen in active range of motion, decrease pain, improvement in ability to work. Headaches improved.
She continued to have eye irritation and was continuing steroids on a periodic basis. The eyes would clear up for a short term while taking the steroids then return when steroids were stopped. We discussed the allergies or irritation to her eyes. With her own business, hard to get away from cleaning house and avoid the dust, dirt and cleaning supplies. She was retaining fluid from the steroids and thyroid issues. Discussed the SHAPE Program with her and cleaning up her diet. She had many allergy tests with the medical doctor and nothing was revealed. She changed to hypo-allergic lotions, makeup, this has helped her eyes.
Patient was frustrated with thyroid issues and weight issues. We discussed the SHAPE Program to clean up her diet and improve immune function. We discussed that it would be very difficult to lose weight with the steroids for the eye issues. She presented her blood profile that was ordered by a medical doctor. TSH level 1.750 (normal range), T4 levels .57 (below normal), Platelets 389 high (inflammation), and alkaline phosphatase high at 112 (liver issues), all other labs were in normal limits. Initial urinalysis was taken on 09/09/13 with WNL with pH of 7 and trace blood in urine. Patient did not lose much weight for the first 2 months of the program – down about 12 lbs and couple of total inches at waist, bust, and hips. We have continued to follow up with biweekly UA’s. She will be in trace ketosis one test and not the other. We assume the steroids are the cause for no ketosis on regular basis. We started her on some prolamine iodine to help with the thyroid functions.
With the patient hitting a weight plateau for the last 6 weeks, we had her fill out the SHAPE questionnaires and results show that the estrogen and progesterone are issues in this case. We have recommended a couple of supplements either/or DIM or cruciferous vegetables to aid in the breaking down of the estrogen and liver detoxification. In follow-up with the patient, her protein intake has been low for the last month and recommendation to increase protein was also advised.
Conclusion:
This has been a difficult case with the steroids for the eye issues. We do have to give this patient a lot of credit for sticking with the program and getting continued results with total loss of 2 inches in the bust, 4 inches in waist, 5 inches in hips, and total loss of 20 lbs. She is much healthier but would like to lose another 10 lbs. Spinal issues are maintained with wellness visit regularly. She has not started DIM or cruciferous at this time.
Submitted by Dr. Troy Branson
Dr. Todd’s Teaching Assessment
There are so many factors to influence SHAPE’s effectiveness in this case:
- Note there is not a significant amount of weight to lose.
- She deals with toxic chemicals on a daily basis with her profession.
- She is dealing with hormonal imbalances for thyroid, estrogen and progesterone.
- She’s dealing with a significant amount of inflammation.
- She’s been using steroids, which is always a deal breaker with typical success during the SHAPE Program.
It’s always easier to lose weight for the patient that has a lot of weight to lose. For those who have 5 to 15 pounds they want to shed, it simply takes longer. As we always say to our patients, they have to do a lot right for a longer period of time.
It is so important to support each and every patient additionally with supplementation, HRT or whatever it takes to bring about biochemical balance. I put together a series of questionnaires to help the practitioner pinpoint what specific imbalance may be causing the patient to respond slower than normal. These can be found in Forms & Templates in the Practitioner Portal.
I would look at this patient as a tremendous success. Losing 20 pounds and inches is remarkable considering the steroid use. Hopefully the patient was pleased and will maintain a healthier lifestyle to decrease her inflammatory symptoms.
