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.

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The post Case Study: Post-Concussion Headache, Neck Pain And Dizziness – Chiropractor In Holland 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.

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

Case Study

Patient: 27 year-old male

Chief complaint: Left knee pain and swelling started 6 years ago

Back story: The patient was an avid road biker, but over time it had resulted in left knee swelling after rides and a constant ache above the knee cap. He eventually quit biking completely. When he visited our office, he was still experiencing the constant knee pain that was worse when going up stairs. On top of that, a couple times a week, he would get a severe sharp knee pain on the left without any warning, and his knee would give out.

Before visiting our office, he was instructed by his medical doctor to perform some quad exercises with minimal relief.

Results

After the first treatment, he was pain-free for 2 whole days. After 3 treatments, he no longer had the constant ache. He took a trip to Disney World with his family 3 weeks after the 3^rd visit. Despite all the walking and lifting, he did not experience a single episode of knee pain.

In fact, he has had 0 episodes of severe sharp pain in his left knee since his first treatment. 2 months ago, he was able to squat 315 lbs, which was something he had not felt stable to do in a long time. It’s been 4 months since his last knee treatment, and his knee continues to feel and work great.

Why Does It Work?

1. Correctly identifying the pain source. A thorough examination can help us narrow down the list of possible pain generators. Pain can arise from many different musculoskeletal structures, including muscles, joints, ligaments, and tendons. However, in this particular case, the pattern doesn’t match any of the above mentioned pain sources. The culprit was, in fact, some irritated peripheral nerves that are often overlooked by practitioners.
2. Treat the pain first. I’m not saying to chase the symptoms, BUT activation of the pain fiber inhibits activation of proper muscle groups. Before we go into active rehabilitation, we must bring the pain level down significantly.
3. Make sure the joints are moving well. Chiropractic adjustments for the knee is also important, because if the joint is not moving properly, it can also neurologically inhibit muscles around it and lead to pain and imbalance.
4. Gait analysis and retraining the muscles. Since the pain has been there many years, it has certainly resulted in abnormal muscle recruiting patterns. A digital gait analysis can help us correctly identify the weakness and prescribe specific exercises for it.

 Only by executing all these steps correctly are we able to attain long lasting results.

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