The Art of Diagnosis

 

Full confession, I really do not like the word diagnosis. It is a little too limited, definitive, and stodgy for my tastes. I believe that we would be better served just identifying dysfunctional body parts than knowing fancy words that typically just describe symptoms. That saying, understanding symptoms and how they relate to dysfunctional body parts is extremely beneficial when coming up with treatment options. Understanding anatomy, biomechanics,  and physiology can make diagnosing musculo-skeletal injuries so easy it is a wonder why most doctors get it wrong most of the time.

It is important to understand location and type of symptoms to make a proper diagnosis. Location of symptoms does not necessarily indicate location of dysfunction. Many dysfunctional body parts refer symptoms to other parts of the body. Luckily, there are patterns which come is handy for those clever enough to recognize those patterns. The type of symptoms tell a good doctor what kind of structure is dysfunctional.

Embryologically speaking, there are three types of structures: bone, consisting of bones, joints, ligaments, discs, and cartilage; muscle, consisting of muscles, tendons, and organs; and nerve, which encompasses tissues of the brain, spinal cord, cranial nerves, autonomic nerves, nerve roots, and peripheral nerves. Bone symptoms are typically described as a deep dull ache and can refer to other bone-like structures. Muscle is also an ache but feels more like fatigue and soreness. Muscle is more superficial and usually stays within the same structure. Nerve symptoms are more electrical in nature; numbness and tingling, just numbness, burning, shooting, etc. Nerves stay in the network of nerves. Knowing this will get you pretty far.

Consultation is the first step. I ask for location and have the patient describe the symptoms. I also look for the mechanism of injury knowing that some structures are more likely to fail, depending on the stress placed on them, than others. With a good consultation, I have a fairly solid idea of what the problem is.

The second step is to do an exam. Bone structures cannot move themselves. For these tests, I do the movement on the patient checking for instability, pain, and altered movement. When I isolate joint movements, I can narrow down the location of dysfunction. Instability tests will suggest ligament issues (assuming we are not dumb enough to do a stability test on a complete fracture). X-ray is helpful to see fractures and degenerative changes. MRI is helpful to see disc bulges, ligament tears, and pathology. Repetitive movement works great for determining how to reform a bulged disc.

Muscles and tendons move bones. To test a muscle or tendon, resisting the muscle’s movement is an easy way to determine which muscle is injured. Why most doctors do not do this is baffling. Pain with resistance at the end of the muscle is usually tendon related and anywhere else is usually the muscle itself. If the type of pain is described as muscular but cannot be recreated with resisted movement, it could be an organ referring pain. Here again, repetitively resisting movement can really help determine how to help treat the injured structure.

Nerve symptoms require some specialized tests in the form of reflexes and sensation testing. True neurological injuries are very difficult to diagnose and to treat. In addition, any of the above can cause secondary and tertiary issues in other parts of the body, like muscles spasms or nerve pain due to encroachment with a disc herniation, for example.

Finally, one of the best ways to diagnose an issue is to treat the issue and see if it helps. Obviously you cannot do this with everything, but as a chiropractor, I can do this for most injuries. Even a surgeon will tell you that nothing is definitive until they open you up and see it in real life. The point being do not get too caught up with figuring out what something is before trying to treat it. Ruling out conditions is still valuable.

There you have it. Instead of plugging symptoms into WebMD to discover that you have a rare, incurable, terminal illness, just step back and look at the anatomy, physiology, and biomechanics of the body and go from there. Or, see your local chiropractor and let them help you through your issues or point you in the right direction. We spend a tremendous amount of time learning about all aspects of the human body.

 

Tennis Elbow? I Do Not Even Play Tennis!

tennis-elbow-pictureIn a world where we have so much access to information, I find that when it comes to diagnoses, there are some overly-simplified patterns. If there is pain in the foot, it is plantar fascitis, pain down the leg is labeled sciatica, and elbow pain is tennis elbow. Not that these conditions are not common; just not that common. Tennis elbow is particularly over-diagnosed. Pain in the elbow is common. Tennis elbow, however, is specifically pain resulting from injury to the extensor tendons which insert at the lateral epicondyle causing inflammation and dysfunction. Simply put, to be tennis elbow, the pain must be right around the little knob on the outside of the elbow and get worse when trying to extend the wrist with resistance. It is called tennis elbow presumably because repetitive backhand swings in tennis will cause such a condition. Incidentally, pain on the inner knob is known as golfers elbow.

I have found that neither tennis elbow or golfers elbow are more common than just a regular subluxated elbow. As a hinge that rotates and pivots and is made up of three bones and two joints, dysfunction is easy to come by. Often, the radial head will get stuck farther back than it should be. This will cause a strain on the muscles that insert in that area and mimic or create tennis elbow. The good news is that with an adjustment or a few, the condition typically responds quickly. If it is, indeed, tennis elbow, the best thing to do is to make sure the elbow is adjusted and functioning properly, then focus on the tendons with ice, stretching, and myofascial massage or active release. So, the next time somebody complains of tennis elbow, tell them to see their local friendly chiropractor.

 

The Cost of Waiting

Abraham Lincoln once said, “You cannot escape the responsibility of tomorrow by evading it today.” The same is true for addressing your health concerns. Several times each day I have patients come in who tell me they have been hurting for days, weeks, months, or even years. The story is usually that they just thought it would get better on its own but it never did. Inevitably, they express their remorse at waiting to come in.

The truth is that with any injury, the body starts the healing process immediately. The concern is whether you will heal correctly. The body will compensate in whichever way it can to stabilize. If muscles are tight or ligaments are overstretched, it will alter the proper movement of joints. Such improper movement causes the nervous system to become confused and ultimately desensitized. Consequently, the body will lay down scar tissue that will promote the new and improper movement patterns which leaves the body susceptible to reinjury or to injury of surrounding tissue.

As a chiropractor, if I can help move the joints in a proper manner before inflammation and scar tissue sets in, then the healing process is a much easier ordeal. If you wait until scar tissue repair has set in when you come in to see me, the first step will be for me to tear down most of that process so the healing can start over. As with remodeling kitchens, the demolition can be ugly. The old adage of getting worse before it gets better is often in play and can lead to a few days of discomfort.

Another caveat to waiting is establishing movement patterns that can be difficult to retrain. Old habits are harder to change than simply making new ones in a fresh environment. Chronic conditions can take years to correct for this very reason. Muscles and joints have memory locked in to the nervous system. In my experience, it typically takes around three months of consistent treatment to change that memory.

Finally, with altered movement, the the body will degenerate quicker. At a joint level that means that tissues will dry up and bone spurs will form. Once a bone spur has formed, everything changes. No amount of adjusting, taking supplements, acupuncture, or whatever is going to remove that. Tissues can be rehydrated but they are never as good as they used to be. This is mortality. However, we can help slow down the degenerative process. At the end of the day, if we just improve the function it is worth it.

All conditions will change over time. The body will strive to compensate but that compensation can lead to issues down the road. If you have an injury or if dysfunction has been brewing for too long, get in! Better yet, come consistently and do your best to maintain good health and function.

 

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How Do I Know If My Chiropractic Treatments Are Helping?

adjustlumbarK

One of the most fulfilling yet difficult aspects of my career is helping people navigate their journey to better health. Healing is a process that can take a lot of time. We tend to think of that process as a straight road from disease or injury to health but that is the exception rather than the rule. Often, things feel worse before they feel better and there are always plateaus and valleys. Helping patients to have faith in the process and continue care inspite of bumps in the road is a worthy challenge.

Everyone comes into the office with disfunction. Not all disfunction is symptomatic but it all has potential to become so. Sometimes people come in with symptoms that are just starting to show but during further examination, I discover that those symptoms are just the tip of a very large disfunctional iceberg. I know that when I start chipping away at the disfuntion below the surface it is going to make those symtoms much more obvious. This can be very alarming. In addition, symptoms can change or move locations. People who are more prone to worry, often need a lot of reassurance to stay the course. There are several signs and symptoms that may cause concern but are actually indicative of progress. Most of these happen in early stages of care.

Pain will often increase with increased movement. Adjustments are designed to move joints that have been stuck or moving improperly for some time. Getting them to move again can cause pain. It is not always pleasant but it is a necessary step. As a rule, the pain should be more of an ache or soreness. Furthermore, pain can centralize and therefore increase in intensity. Centralized pain, or pain that is focalizing on the disfunctional joint, is usually more painful than a broad spread out pain. In this phenomenon, the pain is going back to where it belongs which is a very positive step. The closer your symptoms are to the structure that is actually causing the symptoms, the better the body will be at promoting healing in that area.

Symptoms often change especially when nerves are involved. If a nerve is significantly injured, the worst thing is complete numbness with zero sensation. There is actually no pain. When we lessen the irritation, the sensation is one of pins and needles and achiness. This can be followed by soreness. These symptoms will wax and wane for some time before a complete recovery.

Another change that can happen that will cause a patient mental anguish is when a symptom switches sides. We often see this is disc related injuries. This is not necessarily a bad thing either. It tells me that the disc is not completely stuck in one bulging position and can change or, even better, that it has not degenerated to the point of no return. The ability to change means it can heal.

I find it much better to not focus on symptoms but to look at movement patterns, muscle tone, and inflammation. If range of motion is improving and muscles are calming down, then progress is being made, and it is only a matter of consistency and time before symptoms start to go away for long stretches of time. When people ask if they are getting better, or complain that they are not any better, when I know they are, I usually ask them how they feel after an adjustment. More often than not, they feel significantly better but it just does not last as long as they think it should. As we get better, we also tend to forget how bad the pain was. The contrast of any pain when you have experienced little to no pain promotes the idea that one is not improving. Perspective is the key.

If you feel like chiropractic is not helping you, please take a step back and consider the big picture before you cut your care short, thus nullifying all of the hard work you and your doctor have done to help you become functional again.

 

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Even If I Want to, I Cannot Help Everyone. Neither Can Chiropractic.

The great Aristotle once wrote that “The more you know, the more you know you do not know.” For me, the more experience I gain, the more I realize my limitations. People who know me well, know that I do not lack confidence. I try not to be arrogant but I do my best to assure myself that I can be a force for good in this world. That saying, I must confess that no matter how much I may want to make everyone better, there are just some people that I cannot help.

Recently, I had a patient come in that I hadn’t seen in a couple of years. She did not come in for an adjustment. She came in to explain why I couldn’t help her. You see, back then I gave her several adjustments which provided little to no relief and then she started heading south so she discontinued care. As a doctor, that is the most helpless feeling. It is made significantly worse when there is no explanation why. In her case, she was born with a birth defect called a Chiari Malformation where the lower part of the brain drops below the skull. This can lead to a syringomelia, a pocket of fluid in the spinal cord which can be very painful and dangerous. Anyway, this was never mentioned in her MRI report from years earlier. The neuro/spine specialist that she saw some time after seeing me saw it on the MRI. This little bit of information explained everything. I am grateful she came in and shared that with me.

There will always be conditions that are too far advanced for me to help. I don’t like it, but that is the way it is. We do not always know when a condition is beyond help until after we have tried. I have had many patients with serious back pain come in and ask if I can help. As a chiropractor, I know I can adjust them. In most cases, this will help in the healing process. At the very least, it is a conservative start. Most patients get better and we can manage. Others do not. I have recommended MRI’s and surgery when it is beyond my help. For the most part, those patients have seen good results and have come back to me for care after their surgeries.

Finally, there are people who either do not really want to be helped or have unrealistic expectations of how long and what it will take to heal. Healing takes time and effort. One adjustment can make a big difference in how a patient feels but it does not mean that their injury has healed. Consistent care is tentamount to healing properly. Likewise, just because there is still pain, it does not mean that injury is not healing. Pain can be tricky and is not a very good indicator of the level of damage.

In short, I sleep at night knowing that I do my best to help others live healthier lives. There are always challenges and there will be people that despite my knowledge, skills, and determination, I cannot help. For those people, I am sorry. I feel bad for you and hope there is some one out there with the answers and approach to help you in your journey.

Momentum of Healing

It is always interesting when a new patient who has never seen a chiropractor before,  and knows very little about it, asks what it will take to get better. When I explain that we are going to start off adjusting them three times a week, their eyes usually get very big and the eventual question is, “Why so often?” My answer is always the same, because you need consistency and momentum to heal.

Healing can be like climbing up a sand hill. When you first start out, the sand is the thickest and you are very prone to getting stuck or sliding back down. Likewise, if you are not concentrating on healing correctly, you can start going sideways and waste a lot of energy but not get anywhere. Heading in the right direction with enough momentum to gain traction is the only way.

Getting adjusted three times a week in the beginning of care provides the momentum necessary to progress up the sandy hill of healing. A little higher up on that hill it does not take as much energy so twice a week is sufficient to keep healing. However, stopping or slowing too much can make it difficult to get started again and complete the healing process.

Preventative Health Care?

For you football fans out there, you will get this analogy. Your team is up by 2 with just over a minute remaining in the game. Your offense has done just enough to be up but your defense has played lights out. Now they start playing “prevent defense” and everyone drops back. What are the odds the other team drives down the field and kicks a field goal despite your screaming at them through the television to keep playing aggressively? Prevent defense stinks!

Likewise, preventative health care in most forms either does not work or does not exist, no matter how popular the term is. What exactly are you trying to prevent anyway? In chiropractic we mostly treat injuries either from a one time big traumatic event or cumulative trauma. How does one prevent that? In medicine they talk about preventing disease. Besides the fact that most of their tools are designed to fight existing disease, the premise is wrong. What is disease other than the body not functioning the way it is supposed to? Shouldn’t we then focus on health rather than disease? If we focus on health, then what we are really saying is that we want to maintain good health. In my opinion, “maintenance health care” is a far superior term.

When we maintain good health we focus on the positive. Instead of trying to create scenarios where the possibility of injury or becoming sick is prevented, shouldn’t we put our energies into helping our bodies work the best they can? In this way, when pathogens or traumas come around, our bodies will be better equipped to either fight or heal in an efficient manner. We cannot live in a protective bubble!

Let us focus on attaining and maintaining proper health. If we improve function and keep making the healthy choices that helped us achieve better health, we will avoid all of the issues that so called preventative health care seeks to treat. Let’s make maintenance care our priority and get rid of the term prevention care.

Strengtheining the Core Through Coordination

When we talk about “the core” of the body, we are typically referencing the musculature around the abdomen and low back. These muscles consist of the abdominal muscles (rectus abdomini,  internal obliques, external obliques, and transversi) and the muscles of the back (lattisimus dorsi, serratus posterior inferior muscles, erector spinae, multifidi, interspinalis muscles, lateral intertransversi muscles, quadratus lumborum, and to some degree the iliopsoas).

Strengthening the core has become a fairly popular mantra these days. Many of us are walking around with poor posture and a fair amount of dysfunction as a result of poor core stability. A weak core leaves one susceptible to a host of joint and disc injuries as well as overly tight butt and leg and muscles. In contrast, a strong core can prevent a host of back injuries.

The word strength, however, needs some clarification in the context of strengthening the core. When most people think of strengthening muscles, they picture muscles moving against  significant resistance like lifting weights or power movement against gravity or some other force. These type of exercises can actually be detrimental to the core muscle and increase the risk of injury to the spine. Coordinating the movement of all of these muscle is what is most beneficial.

I mentioned in my last article that postural muscles are slow twitch, white fiber muscles designed for endurance. They need to be strong enough to hold you up all day. Strength in this case does not come from bigger muscle fibers but from having all of the muscle firing in a controlled and proper order. For example, if you lift a box, ideally your abdominal muscle and your spinal muscle would contract at the same time to stabilize the body so the shoulder and arms and hips and leg muscles can utilize their power to lift it. What often happens is that core muscle lay dormant until a significant strain forces is to respond. So, when you lift a box, you first engage your back muscles until you are upright then, if you go past vertical, the abdominal muscles will engage. Then, they will fire back and forth while they try to find a semblance of stability.

I bring this all to your attention to encourage you to strengthen your core appropriately. Exercises that promote coordinated movement like yoga, pilates, and modified exercises from yoga can make a huge difference. It can take time to build coordination  and it takes a consistent effort. In the following videos I demonstrate four very useful exercises for coordinating core muscles and therefore, strengthening it.

Cat/Cow

Bird Dog

A Safe Crunch

Side Bridge

ObamaCare and Chiropractic

How does ObamaCare affect chiropractic care in my office? That is a great question! I will tell you honestly, it doesn’t, at least not on my part. Say what you want about the Affordable Care Act, I do not need the Federal Government or anyone else to tell me that people are struggling with paying for healthcare insurance let alone healthcare.

However, for me the crisis in America is less about affordability and more about health. Don’t get me wrong, I know how expensive health insurance premiums, deductible, co-pays, and non-covered services can be. When all is said and done this year, between surgery on my knee, my son’s broken arm, my wife’s pregnancy and my daughter’s eye surgery, I am going to be out a large chunk of money before the insurance company that I faithfully pay $600 a month to contributes a dime.

Setting aside the debate about how insurance should be regulated, the truth is that Americans are among some of the least healthy people in the world. Contrarily, we spend more than every other country on health care. Timeout while I clarify something. We are not really talking about healthcare. Healthcare is cheap! No, we are talking about sick care. That is where the money is. Compare the cost of a healthy person over a lifetime with one who is in and out of doctors’ offices and hospitals and there is no comparison. OK, now that that is out of the way, my question is how can a highly developed country who spends a ridiculous amount of money on doctors, hospitals, medications, and technology, have a higher infant mortality rate than… anyone? The answer is simple. Money doesn’t make you healthy; doing things to improve or maintain your health does!

At the end of the day, the healthier you are, the less you will have to spend on medical bills. In theory, if everyone made a concerted effort to be healthy, insurance premiums would drop as they would not have to shell out so much for expensive procedures and tests. This is where chiropractic comes in. If you believe as I believe (and I am assuming that as my patient you agree with me on some level), then chiropractic is a powerful health promoting tool.

Because I know and you know that chiropractic is effective at helping improve and maintain your health, it makes sense that getting regular adjustments helps to reduce your overall healthcare costs. Furthermore, I am committed to making sure that everyone who walks in my office can afford the care they need. This is why ObamaCare will not change anything here. If you are desirous to continually work on your health and I am here to help with your chiropractic needs, you have the start of a pretty good team to not only reduce your healthcare expenses but, more importantly, keep you healthy.

Why Do Babies and Kids Need Chiropractic Adjustments?

This is one of the most frequently asked questions in my office, especially when patients see me adjusting a new-born or small child. The truth is that there are many reasons why babies and kids need adjusting. The sweeping reason is because, like adults, they experience trauma that causes their joints to work improperly. The difference is that children adapt much better and do not degenerate. However, like a sapling that is not staked to grow straight into a healthy tree, the consequences can set a child up for problems in adulthood.

The most common reason I adjust infants is due to digestive issues. The term “colicky” comes from the same root as colon. Infants cry and scream for long and unbearable periods of time because of gas or some other digestive issue. If you have had a child with colic, you know how miserable it can be for everyone involved. My second child was colicky and I still haven’t recovered 10 years later from sleepless nights of attempting to console him in vain. For this very reason, however, I learned to adjust infants. I was in chiropractic school at the time and was at my wits ends. I met a pediatric chiropractor and took my son to her. She was generous enough to teach me. It made all the difference in the world!

With colicky infants, adjusting the pelvis and low back calms down the sympathetic nervous system which stimulates the parasympathetic. The parasympathetic nervous system controls digestion and works opposite the sympathetic nervous system. When this happens, babies are typically constipated and gassy. I warn parents that after the first adjustment or two, they should plan for a “blow out.” If you are a new parent and your child has always been a little constipated, a “blow out” is where the diaper cannot contain the mess.

Another common reason I adjust babies is because they are having a difficult time nursing. Usually, they are uncomfortable feeding on one breast or the other due to a restriction in the neck. Nursing mothers will tell you that there is not much that is more uncomfortable than a full breast and a hungry baby that refuses to nurse from it. Such a scenario can also cause mastitis also known as a breast infection. A gentle neck adjustment will help the baby move her neck freely and comfortably nurse.

As for kids, if they are like mine, they can do some wild things that cause trauma to the spine. For example, my two year old loves to jump off the back of the couch. About every third time she misses the pillows she positioned to break her fall and comes crying for help. I check her regularly to make sure everything is adjusted properly. I adjust my 12 year old when his asthma flares up due to allergies. This helps to drain the sinuses but also frees the ribs allowing him to breath better. Adjustments also help to regulate the immune system.

I have adjusted kids for too many reasons to name all of them. Here are some reasons I can think of: Sensory issues (a common Autism Spectrum disorder), bed wetting, reflux, constipation, to help start walking, scoliosis, sports injuries, general trauma, headaches, and more.

The follow up question, in case you are wondering the same, is how I know when babies need to be adjusted. This is simple but has been known to alarm a few mothers. This only works with infants. I take the infant by the ankles and hold them upside down in front of me. If they hang with a nice arch, they are just fine. It they twist or bend or look from side to side, that is an indication that they need an adjustment.