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.

Primary headaches, on the other hand, are a lot more elusive. The intensity of a primary headache may not be any less than a secondary headache, but there isn’t a blood test or MRI that can confirm a primary headache.

Not all primary headaches are the same. The pain can come from nerves, joints, or muscles of the neck, scalp, TMJ, tissues that cover the brain (meninges), or arteries in the brain. Most of these pain generators promote pain through isolated or combined trigeminal (sensory system for the face and head) and cervical mechanisms.

It is essential for the practitioner to understand the nervous system, particularly the trigeminal system, and how it interacts with the structures and nerves of the neck to lead to different headache presentations.

Case Study: Headaches

Patient: 61 year-old female

Chief complaint: Debilitating headaches for 30 years

Back Story: This is a patient who experienced headaches all her life, and were significantly worsened after a car accident when she was 31. Her headaches had a helmet-liked distribution, and were relentless. In 2015, she ran out of sick days at the beginning of the year due to constant 5-7/10 headaches. She had seen many traditional chiropractors, massage therapists, physical therapists, and orthopedists throughout the years, and nothing ever helped the headaches. Even when therapies provided temporary relief, they often flared her up and she would end up with a severe headache the next day. Many of her therapists eventually gave up and told her that she must be doing something wrong in between her visits. Overall, she said her headaches had not gotten better or worse in the past 30 years. In her own words, it was a “rollercoaster”.

Results

After the second treatment, the helmet-liked distribution of her headache changed, which had never happened before.

After the third visit, she was able to control the intensity and duration of her headaches with very simple breathing technique, which had never happened before, either.

By her 14^th visit, she felt that she was 80% better. Despite the stress related to a job change, her headaches were non-existent or minimal. Even when she had occasional headaches, they were fleeting.

When I last saw her, she reported no headache at all between her visits, which at the time, was at a two-week interval.

One thing that is worth mentioning is that she experienced essentially no flare-ups with specific neuro-structural treatments. To be completely honest, she did have a 7/10 headache the day after the first treatment, because her brain could not tolerate the treatment intensity. However, once we figured that out, she had no more flare-ups with any subsequent treatments.

Take Home Message

1. We must assess the stability of a patient’s nervous system, and know how much it can handle. Sometimes, less is more. Sometimes, we only know through trial and error. However, we must do this quickly, so we can attain therapeutic effects and minimize adverse responses. In other words, my job is not just knowing what to do, but when to do what and how much.

2. Understand the neurological interactions among head and neck structures. During the intensive phase of treatments, she often came into the office with different headache presentations. It is absolutely crucial to have an in-depth understanding of our dynamic nervous system, so we know exactly what to do at each specific instant. I never quite knew what exactly our sessions were going to look like until I saw her. A cookie cutter approach is not likely to work for a case like this, because the therapies are not adapting to the ever-changing nervous system and meeting its needs to heal.

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: Headaches – Chiropractor In Holland appeared first on Holland, MI Chiropractors | Brain and Body Chiropractic.

1. Does degeneration and disc herniation automatically warrant a surgery?

The short answer is NO. Although degeneration, bone spurs and disc herniations can look alarming on x-ray and MRI, they are not always relevant to one’s pain and dysfunction. In fact, a 2015 review ⁽³⁾ says what you see on your films most likely has nothing to do with your pain. In other words, pain, along with degenerative changes, are not good enough reasons for back surgery. Read more about this topic here.

2. When to consider surgery for back and leg pain?

Although there are spinal emergencies that need immediate surgical evaluations, sciatica caused by herniated disk or spinal stenosis ALMOST NEVER requires back surgery. ⁽⁴⁾ It is known that even patients with a massive disc herniation can do very well under conservative treatment. ⁽⁵⁾

If you have leg pain without neurological symptoms, then you should be treated conservatively. ⁽⁶⁾ Having a negative straight leg raise test means surgery most likely won’t work for you. ⁽⁷⁾ If you have sciatica, you are over 40, and you have severe leg pain, surgery probably won’t work for you. ⁽⁸⁾ When your MRI only shows a little compression on the nerve, you likely will do worse after surgery. ⁽⁹⁾ Most patients with chronic low back pain will NOT benefit from surgery. ⁽¹⁰⁾

Surgery may be appropriate when you have

1. severe or worsening neurological deficits ⁽⁴⁾ OR
2. leg pain that is worse than back pain AND positive straight leg raise test AND none-responsive to conservative therapy in 4-12 weeks AND imaging correlates with the symptoms. ⁽⁴⁾

3. Does back surgery have superior results compared to conservative care?

So far, most of the studies available to answer this question are low quality studies. The consensus is that long-term results of back surgery are NOT superior to conservative treatment. ^(8,11,12) As of 2016, back surgery cannot be confidently recommended for lumbar spinal stenosis, because it doesn’t provide better outcomes, and the side effects are much higher than conservative treatment (24% vs. 0%). ⁽¹³⁾

On average, one year after having a low back discectomy for disc herniation, a quarter of the patients have another herniation at the same level that received the surgery. ⁽¹⁴⁾ 22% patients have worsening low back pain in a year, and recurrent low back pain is as high as 36% among these people. ⁽¹⁵⁾

Fusion surgery is in your favor if you have a large compression onto the space surrounding the spinal cord, specifically greater than 1/3 thecal sac compression. ⁽⁹⁾ However, 1 out 10 patients will be operated on again in a couple years, and 1 out of 5 will be operated on again in 10 years. ⁽¹⁶⁾ Basically, the studies are saying patients do pretty well after the fusion surgery…the outcomes are good…except that a good portion of them will have to come back and get the surgery again in the future. ⁽¹⁷⁾ So therefore, make sure it’s risk you are willing to take if surgery is what you opt for.

The Bottom Line

If you have back pain and you visit a surgeon, there is a good chance you will end up having back surgery, as demonstrated by a 2013 study. ⁽¹⁸⁾ (see graphic below). If you see a chiropractor first, there is a good chance you will avoid the back surgery that may not be necessary in the first place.

The bottom line is if you are experiencing back pain, find a good chiropractor who is familiar with the research, who knows what to look for, who knows how to check for the different indicators and neurological signs, and recommend care (surgical or not) based on existing evidence.

References:

1. Rajaee SS, Bae HW, Kanim LE, Delamarter RB. Spinal fusion in the United States: analysis of trends from 1998 to 2008. Spine. 2012 Jan 1;37(1):67-76. [PubMed]
2. Cowan JA Jr, Dimick JB, Wainess R, Upchurch GR Jr, Chandler WF, La Marca F. Changes in the utilization of spinal fusion in the United States. Neurosurgery. 2006 Jul;59(1):15-20. [PubMed]
3. Brinjikji W, Luetmer PH, Comstock B et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. [PubMed]
4. Atlas SJ, Deyo RA. Evaluating and managing acute low back pain in the primary care setting. J Gen Intern Med. 2001 Feb; 16(2):120-31. [PubMed]
5. Benson RT, Tavares SP, Robertson SC, Sharp R, Marshall RW. Conservatively treated massive prolapsed discs: a 7-year follow-up. Ann R Coll Surg Engl. 2010 Mar;92(2):147-153. [PubMed]
6. Atlas SJ, Nardin RA. Evaluation and treatment of low back pain: an evidence-based approach to clinical care. Muscle Nerve. 2003 Mar;27(3):265-84. [PubMed]
7. Sedighi M, Haghnegahdar A. Lumbar disk herniation surgery: outsome and predictors. Global Spine J. 2014 Dec;4(4):233-244. [PubMed]
8. Lequin MB et al. Surgery versus prolonged conservative treatment for sciatica: 5-year results of a randomized controlled trial. BMJ Open 2013;3:e002534. [BMJOpen]
9. Lurie JD et al. Magnatcie resonance imaging predictors of surgical outcome in patients with lumbar intervertebral disc herniation. Spine. 2013 Jun 15;38(14):1216-25. [PubMed]
10. Last AR, Hulbert K. Chronic low back pain: evaluation and management. Am Fam Physician. 2009 Jun 15;79(12):1067-74. [PubMed]
11. Schoenfeld AJ, Weiner BK. Treatment of lumbar disc herniation: evidence-based practice. Int J Gen Med. 2010;3:209-214. [PubMed]
12. Jacobs WCH et al. Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systemic review. Eur Spine J. 2011 Apr;20(4):513-522. [PubMed]
13. Zainea F et al. Surgical versus non-surgical treatment for lumbar spinal stenosis. Cochrane Database Syst Rev. 2016 Jan 29;1:CD010264. [PubMed]
14. Lebow RL et al. Asymptomatic same-site recurrent disc herniation after lumbar discectomy: results of a prospective longitudinal study with 2-year serial imaging. Spine. 2011 Dec 1;36(25):2147-51. [PubMed]
15. Parker SL et al. Incidence of low back pain after lumbar discectomy for herniated disc and its effect on patient-reported outcomes. Clin Ortho Relat Res. 2015 Jun;473(6):1988-99. [PubMed]
16. Kim CH et al. Reoperation rate after surgery for lumbar spinal stenosis without spondylolisthesis: a nationwide cohort study. Spine J. 2013 Oct;13(10):1230-7. [PubMed]
17. Liang L, Jiang WM, Li XF, Wang H. Effect of fusion following decompression for lumbar spinal stenosis: a meta-analysis and systematic review. Int J Clin Exp Med. 2015;8(9):14615-14624. [PubMed]
18. Keeney BJ, Fulton-Kehoe D, Turner JA, Wickizer TM, Chan KC, Franklin GM. Early predictors of lumbar spine surgery after occupational back injury: results from a prospective study of workers in Washington State. Spine. 2013 May 15;38(11):953-64. [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 3 Questions You Must Ask Before Back Surgery – Chiropractor in Holland appeared first on Holland, MI Chiropractors | Brain and Body Chiropractic.