Whether or not you’ve ever been to a chiropractor, you probably know or have heard one thing about us… and that’s that we crack backs. 

Being a chiropractor has become synonymous with being a “back cracker” to many people over the years. 

Despite this phrase being crude and giving a very inaccurate description of what we do, perhaps the worst part is that for many it is a SCARY thought to have ones back “cracked”. This fear has lead to many being apprehensive of chiropractic care and in many cases missing out of what may have helped them tremendously. 

Crack (Definition, verb) – break or cause to break without a complete separation of parts. Frequently referring to a fracture or discontinuation in a body.

So the first problem is that when we hear the word crack we instantly think of something being broken. With a chiropractic adjustment, nothing (ligaments, tendons, bones, etc..) is being broken or fractured. This is just an unfortunate thought based on the term “crack” and hours of watching our favorite action heroes on TV like our good friend John Rambo. 

Correct Term = Cavitation

Simply put, a cavitation is a phenomenon in which changes in pressure in a liquid lead to the formation of bubbles which then collapse under pressure creating a popping or “cracking” sound. Your joints have a small amount of fluid inside them to help lubricate your movements. The fluid is called synovial fluid.

The sound heard occurs when we cause a brief tiny gap in the small joints in the spine called facet joints. The movement during a spinal manipulation along with the resulting sound sometimes lead people to feel like something very BIG just happened when in reality the movement in these joints is very small.  A recent study in 2018 measured the amount of joint movement or gapping in the facet joints that occurred during a chiropractic treatment. The average gapping was only 0.5 to 1.3 millimeters! 

It’s important to understand that the cavitation is the result of treatment NOT the treatment itself.

The movement is what we as Chiropractors are after! Restoring this motion back into a spinal joint or whole spinal segment can work wonders for your spinal complaints and help aid in keeping your spine moving properly. The sound is simply a result of us doing this. Occasionally the treatment won’t even cause a sound but this does not mean proper movement to the segment was not restored.  

About the Author

Dr. Kody Semrow  has a B.S. in Nutrition and a doctorate in Chiropractic. He has a passion for helping people improve their lives through Chiropractic care and lifestyle changes.

Reference:

1. Anderst WJ, Gale T, LeVasseur C, Raj S, Gongaware K, Schneider M Intervertebral Kinematics of the Cervical Spine Before, During and After High Velocity Low Amplitude Manipulation. Spine J. 2018 Aug 21. pii: S1529-9430(18)31085-4. doi: 10.1016/j.spinee.2018.07.026.

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Evidence based medicine (EMB) is composed of three main components, the best available evidence, patient preferences and values, and clinical experience and expertise. These three elements must be used concurrently in order to successfully implement the concept of EBM into clinical practice.⁽¹⁾ Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. ⁽²⁾

So, how does this translate into the evidence based Chiropractor? Here are some practical tips.

7 signs of an evidence based Chiropractor:

1. Does not hesitate to admit “I don’t know”

Let me just say this…

2. Does not rely on X-ray to diagnose the source of your symptoms

Routine x-ray is a common practice extremely overused in the chiropractic profession. The idea that “x-rays will give my doctor the most important information he/she needs to properly treat me” is a misleading one. Lots of research has CLEARLY indicated that routine x-ray for neck or back pain does NOT associate with benefits, exposes patients to unnecessary harm (radiation), and increases cost. ^(3-10) Take low back pain as an example. The American College of Physicians and the American Pain Society strongly recommend doctors to not routinely order x-rays or MRI for low back pain. ⁽¹¹⁾ The American College of Radiology recommends no imaging for low back pain within the first 6 weeks unless warning signs are present. ⁽¹²⁾

3. Performs a neurologic exam

Since x-ray is not needed in most cases, the diagnosis is mostly made on clinical grounds alone.⁽⁷⁾ Is the chiropractor doing the right tests to check out the integrity of your nervous system? And to rule out warning signs? Palpating the spine and a few orthopedic tests are often not enough. We need to focus less on orthopedic testing, but more on neurologic testing. The bottom line is that the chiropractor should at least test for sensation, muscles strength, reflexes, and balance and coordination to uncover neurological changes.

4. Answers­­ the question “what is the pain generator” ⁽¹³⁾

There are many structures that can cause chronic pain. The cause of pain may be related to nerve, muscle, fascia, bone, joint, disc, abnormal pain processing, or a combination of the above. Misdiagnosis means that you may get the wrong therapy. The clinical decision to identify a pain source is a complicated one. The diagnosis cannot be based simply on x-ray findings, because most of the time, what you see on the x-rays is NOT THE CAUSE OF YOUR PAIN.⁽¹³⁾ To reiterate point #2, routine x-ray is not supported by the evidence. X-ray does not replace a thorough physical examination. And this takes us back to point #3, you really need someone to perform a thorough physical exam to determine where your issue is coming from.

5. Adopts a multimodal and multi-disciplinary approach ⁽¹³⁾

This means that the chiropractor uses several different strategies to manage the problem, and does not hesitate to refer patients to other professionals for co-management.

6. Listen to the patient

Remember that patient’s preference is one of the components of EBM. In the chiropractic world, there are many different ways to adjust a patient. Insisting that one method is superior to the others and disregarding patient’s preference are not evidence-based practices. The fact is that when the patient likes one method better than the others, chances are he/she is going to respond better to his/her preferred treatment, regardless of what the doctor prefers.

7. Make reasonable outcome predictions based on experience

I like to let my patients know what they are in for. Of course, I understand that each patient is unique and the responses to treatment may vary. However, an experienced doctor should be able to give you an idea what to expect, the progression of your recovery, and adjust the plan accordingly during the process.

References:

1. Kowalski E, Chung KC. The outcomes movement and evidence based medicine in plastic surgery. Clin Plast Surg. 2013 Apr;40(2):241-247.
2. Sackett DL. Evidence-based medicine. Semin Perinatol. 1997 Feb;21(!):3-5.
3. Allan GM. X-ray scans for nonspecific low back pain. Can Fam Physician. 2012 Mar;58(3):275.
4. Chou R, Deyo RA, Jarvik JG. Appropriate use of lumbar imaging for evaluation of low back pain. Radiolo Clin North Am. 2012 Jul;50(4):569-85.
5. Srinivas SV, Deyo RA, Berger ZD. Application of “less is more” to low back pain. Arch Intern Med. 2012 Jul 9;172(13):1016-20.
6. Ersoy G, Karciogiu O, Enginbas Y, Eray O, Ayrik C. Are cervical spine s-rays mandatory in all blunt trauma patients? Eur J Emerg Med. 1995 Dec;2(4):191-5.
7. Binder AI. Cervical spondylosis and neck pain. BMJ. 2007 Mar 10;334(7592):527-531.
8. Yadla S, Ratliff JK, Harrop JS. Whiplash: diagnosis, treatment, and associated injuries. Curr Rev Musculoskelet Med. 2008 Mar;1(1):65-68.
9. Taylor JAM, Bussieres A. Diagnostic imaging for spinal disorders in the elderly: a narrative review. Chiropr Man Therap. 2012;20:16.
10. Andersen JC. Is immediate imaging important in managing low back pain? J Athl Train. 2011 Jan-Feb;46(1):99-102.
11. Chou R, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007 Oct 2;147(7):478-91.
12. Davis PC, Wippold FJ, 2^nd, Brunberg JA, et al. ACR appropriateness criteria on low back pain. J Am Coll Radiol. 2009;6(6):401-7.
13. Allegri M, et al. Mechanisms of low back pain: a guide for diagnosis and therapy. F1000Res. 2016 Jun 28;5.

About the Author

Dr. Lily Semrow is a Board Certified Chiropractic Neurologist who focuses on Neuro-Structural Correction. She has a B.S. in Nutrition and a doctorate in Chiropractic. She has a passion for serving families, and helping people who could not get better through traditional and alternative means.

Want to keep up with future posts?

The post How to find an evidence based chiropractor appeared first on Holland, MI Chiropractors | Brain and Body Chiropractic.

Case Study: Concussion

Patient: 15 year-old girl

Chief complaint: Constant headache, neck pain and dizziness after a concussion 2+ months ago

Back Story: The high school athlete sustained a concussion in Feb during a soccer game. At the ER, she was diagnosed concussion and was prescribed Ibuprofen. Her mom was proactive, and quickly got her involved in several rehab programs and therapies. By the time she saw me, she had gone through about 10 weeks of physical therapy, vestibular training, vision therapy, massage and chiropractic care. At that time, her neurocognitive testing (ImPACT test) had improved, but she continued to have constant headache on the top of her head, average 2-4/10 pain, and 6/10 at its worst. She also continued to have dizziness and neck pain.

Results

After 2 visits, her headache was gone for the first time in 11 weeks, and because of that, her emotional irritability also improved.

During the first month of specific Neuro-Structural Chiropractic Care, she was also undergoing speed and agility training prescribed by her MD a couple times a week. The problem was the jolting movements in this training always left her dizzy for quite some time after.

After we tweaked her vestibular exercises and gave her only a couple very specific eye exercises to do at home, she had no dizziness for the first time in weeks, and continued to be headache-free.

After 1.5 months of treatment (12 visits), she had no headache, dizziness or neck pain, and was cleared by her MD to return to play.

Discussion

1. Realistic expectation of recovery timeline

This is somewhat counterintuitive, but research has shown that young athletes recover from concussion more slowly than older athletes. ⁽¹⁾ If your child sustains a concussion, this is what you can expect. It is unlikely for the child to return to play within a couple days (2.5% probability). Most adolescent athletes make their way back to the sports within about a week (71.3% chance). ⁽²⁾ However, if your child is not able to return to play within 10 days, there is a good chance that he/she will have a prolonged recovery, which is the case for the girl in our case study. In this case, seek professional help as soon as possible.

2. Not all vestibular rehabs are the same.

Many of my post-concussive patients are slightly apprehensive when they hear vestibular rehab, because in their experience, the exercises often make them dizzy and they feel awful afterwards. But then they thought to themselves, I have to feel worse before I feel better, right? WRONG. When your rehab makes you feel worse afterward, this is a good indicator that the intensity and/or duration of the exercises are too much for your brain to handle. Less is more. Again. Less. Is. More.

Conclusion

1. If your child had a concussion, and was cleared by his/her physician to go home. Rest him/her for the first week. If he/she is not able to return to play after the first 7-9 days, seek professional help.

2. Although research suggests that the chance of return to play beyond 21 days post concussion does not increase, we beg the differ by what we see clinically. With the right therapies, the child can still make a relatively smooth recovery.

References:

1. Nesmith JD. Sports concussion in the child and adolescent athlete. J Ark Med Soc. 2010 Nov;107(6):111-4. [PubMed]
2. McKeon JMM, et al. Trends in concussion return-to-play timelines amon ghighscholl athletes from 2007 through 2009. J Athl train. 2013 Nov-Dec;48(6):836-843. [PubMed]

About the Author

Dr. Lily Semrow is a Board Certified Chiropractic Neurologist who focuses on Neuro-Structural Correction. She has a B.S. in Nutrition and a doctorate in Chiropractic. She has a passion for serving families, and helping people who could not get better through traditional and alternative means.

Want to keep up with future posts?

The post Case Study: Post-Concussion Headache, Neck Pain And Dizziness – Chiropractor In Holland appeared first on Holland, MI Chiropractors | Brain and Body Chiropractic.

First Things First, To Rest Or Not To Rest?

For those who don’t get better in 7-10 days, the universal recommendation used to be “continue to rest in a dark room”, and I still hear this from time to time.

Unlike the acute care immediately after concussion, as of 2016, there is still no consensus for treating chronic post-concussive symptoms. ⁽³⁾ Although conventionally, doctors tend to tell their patients to rest as long as symptoms still exist, new research suggests that it’s not a good idea to simply rest beyond the first few days after concussion. ⁽⁴⁾

This makes a lot of sense from a neurological perspective. Our brain is an ever-changing organ that constantly remodels itself based on the stimulations it receives from the environment. Deprivation of sensory stimulation, albeit temporarily necessary, hinders rather than aid recovery in the long run.

While uncontrolled activity will most likely exacerbate the symptoms ⁽⁴⁾, emerging evidence suggests that controlled physical and cognitive exercises can aid recovery ⁽⁵⁾.

Is Post-Concussive Headaches Driving You Crazy?

As I mentioned before, headache is the most commonly reported symptom after concussion. Ironically, there is a serious lack of research and very little evidence supporting any particular treatment for post-traumatic headache. ⁽⁶⁾

So meanwhile, the researchers basically say until we know more about it, forget about the label “post-traumatic headache” for a second, simply categorize these headaches, just like we do other headaches, and treat accordingly. ⁽⁷⁾ And that’s what we do in our practice, and we find success with many cases.

Most of the headaches from concussion are migraine or tension type, but they can also be related to peripheral nerves (occipital neuralgia), to the neck (cervicogenic headache), and to medication overuse. ⁽⁸⁾ Whether you are seeking medical treatment or conservative care, there is really not one treatment that would be effective for all post-concussive headaches. If you are not getting better with treatment, maybe, just maybe, the treatment you are receiving is not specific enough. The key to an effective treatment plan is rigorous evaluation and diagnosis ⁽⁸⁾, and taking a comprehensive approach to address all possible causes of headache ⁽⁹⁾.

In my experience, headaches related to peripheral nerve irritation resolve the fastest. Sometimes, within a few visits. Tension headache and headaches coming from the neck are also fairly simple to treat. If your headaches have migrainous features, it will take a bit longer to stabilize.

Is Your Post Concussion Dizziness Lingering As Well?

If you have a concussion and immediately experience dizziness at the time of your injury, then chances are you will have a prolonged recovery (>21 days). ⁽¹⁰⁾ And chances are strict rest is not going to fix your problem. This type of concussion requires targeted therapies. ⁽⁵⁾

Without going into too much detail, the therapies are basically designed to reintegrate three of your systems that are responsible for balance—vision, muscles, and vestibular system. Therapies typically involve a lot of eye exercises, head eye coordination exercises, visual stimulations, and balance training.

Why Aren’t The Vestibular Rehab And Vision Therapy Working?

It used to be that patients had never even heard of these therapies. Now, most of the patients who came to me had already gone through a course of vestibular and vision therapy, but the relief was limited.

These therapies are a must when rehabbing post-concussive patients, but somehow they don’t always work. After talking to my patients and having all of them show me the exercises they were given, it becomes apparent why these therapies had failed them, and we are able to make changes accordingly.

1. Neglecting the neurological hierarchy. One thing I’ve learned very quickly when I started practicing is that less is more. There is a hierarchy within the nervous system. Often, one primitive function serves as the building block of a more sophisticated function. So, when it comes to rehab, you do one thing at a time, and build from the bottom up. Personally, I do not progress my patients to a more sophisticated exercise if they fail to perform the basic exercise. Too many exercises all at once are often unnecessary and counterproductive.
2. Neglecting the fatigability of the brain. Concussive brains are fragile. They get tired faster, like a muscle that hasn’t been used in a while. If you train too hard, your brain pukes out, and you continue to train, it is like lifting over and over again with bad form that makes your trainer pull his hair out. It facilitates bad patterns=bad pathways in your brain, and, again, it is counterproductive. When my patient tells me that he/she gets super dizzy for 30 minutes after his/her previous rehab, then there is something wrong. Knowing when to stop is half the battle.
3. Neglecting the imbalance between the systems. Anyone who has seen a vestibular test report knows that there can be imbalance between the right and the left vestibular system. These imbalances often become more profound in those who had sustained a concussion. So why is it that in therapy the right and the left are almost always stimulated equally? It doesn’t make sense, and we need to be more specific instead of giving every patient generalized stimulations to both sides and all directions.

If your vestibular and visual therapies don’t seem to be working for you, don’t give up. You are on the right track. You may just need to find someone who can be more specific and fine-tune your exercises for you.

Don’t Forget About Your Neck

Concussion is an acceleration/deceleration injury, ⁽¹¹⁾ so as whiplash. Concussion doesn’t really happen unless the impact generates a minimal acceleration of 70-75g. ⁽¹¹⁾ On the other hand, it only takes as little as 4.5g to cause a whiplash. ⁽¹²⁾

In other words, the impact that causes a concussion is certainly enough to cause a whiplash. If you have a concussion, get your neck checked as well.

References:

1. DePalma RG. Combat TBI: history, epidemiology, and injury modes. In: Kobeissy FH, editor. Brain Neurotrauma: Molecular, Neurophysiological, and Rehabilitation Aspects. Boca Raton (FL):CRC Perss/Taylor & Francis;2015. Chapter2. Frontiers in Neuroengineering. [PubMed]
2. Harmon KG, Drezner JA, Gammons M, et al. American Medical Society for sports medicine position statement: concussion in sport. Br J Sports Med 2013;47:15-26. [BMJ]
3. Hadanny A, Efrati S. Treatment of persistent port-concussion syndrome due to mild traumatic brain injury: current status and future directions. Expert Rev Neurother. 2016 Jul 4:1-13. [PubMed]
4. Leddy J, Hinds A, Sirica D, Willer B. The role of controlled exercise in concussion management. PM R. 2016 Mar;8(3 Suppl):S91-S100. [PubMed] http://www.ncbi.nlm.nih.gov/pubmed/26972272
5. Broglio SP, Collins MW, Williams RM, Mucha A, Kontos AP. Current and emerging rehabilitation for concussion: a review of the evidence. Clin Sport Med. 2015 Apr;34(2):213-31. [PubMed]
6. Kjeldgaard D, Forchhammer HB, Teasdale TW, Jensen RH. Cognitive behavioral treatment for the chronic post-traumatic headache patient: a randomized controlled trial. J Headache Pain. 2014 Dec 2;15:81. [PubMed]
7. Theeler B, Lucas S, Riechers RG 2^nd, Ruff RL. Post-traumatic headaches in civilians and military personnel: a comparative, clinical review. Headache. 2013 Jun;53(6):881-900. [PubMed]
8. Pinchefsky E, Dubrovsky AS, Friedman D, Shevell M. Part 1—evaluation of pediatric post-traumatic headaches. Pediatr Neurol. 2015 Mar;52(3):263-9. [PubMed]
9. Pinchefsky E, Dubrovsky AS, Friedman D, Shevell M. Part 1—evaluation of pediatric post-traumatic headaches. Pediatr Neurol. 2015 Mar;52(3):270-80. [PubMed]
10. Lau BC, Kontos AP, Collins MW, Mucha A, Lovell MR. Which on-field signs/symptoms predict protracted recovery from sport-related concussion among high school football players? Am J Sports Med. 2011 Nov;39(11);2311-8. [PubMed]
11. Broglio SP, et al. The biomechanical properties of concussions in high school football. Med Sci Sports Exerc. 2010 Nov;42(11):2064-2071. [PubMed]
12. Panjabi MM, Nibu K, Cholewicki J. Whiplash injuries and the potential for mechanical instability. Eur Spine J. 1998;7(6):484-92. [PubMed]

About the Author

Dr. Lily Semrow is a Board Certified Chiropractic Neurologist who focuses on Neuro-Structural Correction. She has a B.S. in Nutrition and a doctorate in Chiropractic. She has a passion for serving families and helping people who could not get better through traditional and alternative means.

Want to keep up with future posts?

The post Post-Concussion Syndrome: When Symptoms Persist – Chiropractor In Holland appeared first on Holland, MI Chiropractors | Brain and Body Chiropractic.