The Underhydration Problem: There is an underlying hidden phenomenon commonly occurring in most of our patients. Identification and modification of underhydration can improve your patient outcomes.
Understanding Scar Tissue: A review of scar tissue physiology will prepare the doctor to revisit and improve how to support injury healing in their patients.
Clinical Applications of Cartilage Physiology: A review of cartilage tissue physiology will prepare the doctor to revisit and improve how to support acute conditions are well as prevention and maintenance of your patients’ joint health.
Solving for Posture: You will review in depth negative effects of chronic postural distortions and learn simple interventions to incorporate into your practice to compliment your chiropractic adjustments.
Osteoporosis: We are going to discuss osteoporosis risk factors, imaging modalities, especially as it relates to vertebral compression fracture, and prevention. Then bring it all together to give the doctor better management options for your patients with low bone density.
The Effects of the Vertebral Subluxation Complex: After this in depth look at the neurophysiology of abnormal movement the chiropractor will appreciate the amazing effects the restoration of movement by chiropractic adjustment has on their patients’ health.
Perspectives on Peripheral Neuropathy: After taking this course the chiropractor will have an understanding of current theories behind peripheral neuropathy and additional options for management of this condition for their patients.
What Did You Do Scenarios: These short clinical case studies give the chiropractor a chance to use their knowledge in decision making in a variety of circumstances.
Thoracic Outlet Syndrome: The chiropractor will review relevant anatomy and come away with a simple and effective method of evaluation for thoracic outlet syndrome, as well as a framework for clinical management.
Case History: The Chainsaw Artist: The chiropractor will discover co-management strategies and review lumbar spine surgery statistical insights and factors slowing recovery.
Case History: A Dad Through the Decades: This course covers treating a patient with multiple medical conditions and how they influence overall care.
Case History: An Unlucky Bus Driver: The chiropractor has many considerations for a patient’s general health and these factors inform not only our clinical decisions, but also our treatment approaches. This course is a great overview of several conditions we see often in practice and reminds us of these important decisions.
Mystery Patient #33: Improve your differential diagnosis skills with this difficult patient’s case.
Ehler-Danlos and Marfan’s Syndrome: We don’t see them often, but when we do we need to know the ramifications of their existence. Brush up on why we need to know about them.
Rib Cartilage Injury: Learn identification and treatment strategies for these common injuries.
A Complex Wrist Injury: Anatomy, imaging, and case histories combine to give an in depth review of how to manage wrist injuries in your practice
Goal: To have the chiropractor be confident when selecting advanced imaging procedures in daily clinical practice.
Objectives:
1) For the chiropractor to learn the most common causes, locations, and hallmark x-ray findings of compression fractures and spondylolysis.
2) For the chiropractor to know the benefits of X-ray, MRI, CT, and Ultrasound so they can properly select the most appropriate imaging modality in different scenarios in daily practice.
The chiropractor will revisit ethical considerations in daily practice and explore strategies both in the office and online that will assist them in maintaining a professional boundary with their patients.
Thoracic Outlet Syndrome
I. Thoracic outlet anatomy:
II. 3 types of TOS
III. Examination for TOS
IV. Patient Case History
A. Presentation
B. Exam
C. Radiographic findings
D. Treatment Description
1. Adjustments and therapies manual, lighter on the neck. 80% response, but…
2. She returns: About 4 mo later
3. The arm fatigue was present and her worst complaint was the click in her neck.
4. My impression was that she had been better off than she really was.
a) Patient’s pulses were normal, but ULTT was positive for numbness and pain in the left arm (symptomatic side), also spasm and ROM in neck were much better. But her affect was much declined.
b) Surgical referral
1) Surgeon ordered an ultrasound of the upper extremities= normal
2) Surgeon said I cannot help you.
c) I sent her for ortho evaluation of facet joints
1) She happened to see a retiring surgeon
2) additional testing
E. Surgery performed
F. Follow up
Case History: The Chainsaw Artist
I. Initial Presentation with right mid thoracic pain
II. MVA: Rearended.
A. driver, seat belted
B. Treated for a 4-5 months
III. I see him again intermittently, 1x/year or two for several years
IV. WC Injury due to lifting heavy
A. Symptoms
B. Xrays
C. Treatment
V. Slip and fall on the ice
A. LBP w/right leg pain and right knee pain
B. I see him a handful of times and then he disappears. New job, divorce, remarry, etc.
VI. Next time I see him a couple years later: 9 mo post lumbar fusion.
A. He has been in excruciating pain since the surgery
B. CT scan shows
C. Surgery required to correct…No surgery until fusion is complete!
E. Treatment considerations
F. He improves and disappears
VII. Surgery finally able to happen
VIII. SI Joint pain comes back again
IX. Additional surgery
X. 20% of lumbar spine surgery patients have a repeat surgery in 10 years.
A. Risk factors:
B. Huge increase (doubled) in lumbar fusion surgeries early 1990’s compared to late 1990’s
Case History: A Dad Through the Decades
I. Vietnam: Freiberg’s infarction left foot
II. Severe Lumbar spine stenosis w/radiculitis
A. Conservative care for 10 years Chiro, Acu, PT, Injections, Vicodin
B. Lumbar Spine Decompression Surgery
C. Maintenance
III. Knee replacement on the right
IV. Biceps tendon tear
V. Fell off of bike and broken hand and dislocated fingers
VI. Psoriasis
VII. High Cholesterol
VIII. Statin drug reaction and resolution
IX. Kidney stones
A. episodes
B. treatment
A Case History: An Unlucky Bus Driver
I. Initial Presentation with right mid thoracic pain
II. Repetitive Strain injury with school bus driving
A. the following Spring = similar pain, but much worse (now burning), and affecting a broader area.
B. Same modalities. Some help. Treated for about one week.
III. Rearended by a co-worker @ 40mph
A. Headache, Dizziness, Neck, MBP, LBP, right radicular leg pain, wrists, right foot and ankle
B. X-rays right away:
C. T/spine MRI: 4 herniations and a bulge, also DJD/DDD at essentially every spinal level.
D. Referral to get her some relief
F. Difficult to function: sit up straight, wear bra, drive, laundry, get dressed, all significant; waxed and waned.
G. Referral to neurologist for headaches and dizziness: Warren Hammer wrote a Case Study about the suboccipitals and compression of the vertebral artery= dizziness
H. Dizziness slowly relapsed after a few months: she fell down a flight of 12 or 13 stairs= broken fibula.
I. All issues flared back up: HA, neck, back, etc.
J. Slow progress
IV. 9 mo after MVC…slipped on ice coming off of her school bus
V. Breast cancer
A. Support structure in the meantime
B. Be mindful of the past and upcoming procedures
Mystery Patient #33
I. History: 38 yo female whom I have seen for 9-10 years.
A. Vitals
B. She has a history of
II. Mystery condition: #33 presents on a Monday morning with LBP so severe she is in tears, 10/10 pain.
A. In the year before this she has begun to use a portable electric wheel chair at work.
B. Exam
C. Treatment= She gets zero relief, which is rare for her.
D. Day 4 = no improvement. She can’t work, can barely sleep. She now cannot heel walk. There is right foot drop. I refer for same day MRI as this has progressed.
E. Lumbar MRI=
F. Differential Diagnoses
G. Additional MRI options
H. MD says to go to ER.
I. She spends 10 hrs in the ER. They refused… lumbar puncture.
III. What mistake did I and her MD make?
IV. What would you do next?
A. Refer to whom?
B. Any ideas on what is going on? I didn’t yet.
V. Two weeks later…Neurologist does…
A. NCV/EMG=normal
B. lab results
C. Mystery condition identified
D. Primary symptoms
E. Secondary symptoms
F. Etiology
G. Treatment
Ehlers Danlos and Marfan’s Syndromes
I. Ehlers-Danlos Syndrome (EDS): Case History
II. Presentation of Maria
III. Rare connective tissue disorder: skin fragility and hyperelasticity, articular hypermobility, and vascular fragility (1 per 5000 births).
A. 13 subtypes (I-X). Typed with genetic testing.
B. A variety of complications arise
C. Radiological Findings to note
IV. She has chronic pain
V. I treat her a dozen times. She gets some short term relief, for which she is grateful, but ultimately she has so much pain that she decides to move onto other options.
VI. Surgical consultation
VII. Surgery performed
VIII. Ongoing poor quality of life
Marfan’s Syndrome
I. 4-6 per 100k births: Connective tissue disorder causing abnormal collagen production.
II. 3 systems affected: skeletal, ocular, cardiovascular
III. Radiographically:
IV. Case Histories
A. Scuba class
B. Tall middle age man
C. Teenage basketball player
Rib Cartilage Injury
I. Patient with 3 year history of severe rib pain after injury
II. Rib cage Anatomy review
III. Responded well to chiro adjustments and therapies
IV. Poor diet, lots of alcohol intake = pro-inflammatory
V. He could not do much for a while due to pain
VI. He goes back to school and has another injury
VII. He is able to be about 80-90% functional with treatment 1x/mo.
VIII. Interesting recommendation along the way @ VA
IX. Examples of other patients
X. Adjusting strategies
A. costosternal
B. costovertebral
XI. Exercises
A. Pec major, and minor
B. Mid/Low trap
C. foam roller for increasing extension of thoracic spine
A Complex Wrist Injury
I. FOOSH injury can lead to a variety of problems
A. scaphoid fracture
B. subluxation
C. S-L ligament tear-
D. Additionally
II. Patients
A. 40 yo female gets into head on crash @ 55 mph
B. Exam
C. Imaging
D. Referral
E. Injuries in a standard pattern we expect from this, but the main pain is her left wrist.
III. 52 yo female teacher fell playing soccer, FOOSH but thumb first
initial pain in 1st MCP joint
A. better with adjustment, then pain moves to mid wrist
B. x-ray =
IV. 60 yo RN falls at work after catching her foot on broken cabinet door
neck and back pain, with right wrist pain.
A. Fell again 2 wks later= R>>, but also L wrist pain
B. x-rays =
V. 35 yo female real estate industry lifts water bottle onto cooler
no images, but suspect she had partial tearing.
A. tape, ice, neutral position
VI. These can occur other ways too
A. push open heavy door
B. push-ups
C. essentially impact in wrist extension
VII. Treatment suggestions
A. Exercises
B. Adjustment considerations
C. Surgical considerations
VIII. I think we can support these injuries conservatively
The Underhydration Problem
I .’Under-Hydration’ defined
II. How this shows up in everyday practice
A. Muscle spasm
B. Constipation
C. Plantar Fasciitis
III. Reasons
A. low water intake
B. Processed foods
C. mineral deficiency
D. caffiene
E. Alcohol
F. Blood sugar imbalance
G. Adrenal fatigue
IV. Solutions
Clinical Applications of Cartilage Physiology
I. 3 types of Cartilage
A. hyalin
B. elastic
C. fibrocartilage
II. Cartilage is hydrophilic: Structure
A. Chondrocytes in an extracellular matrix.
B. Chondrocytes synthesize collagen and proteoglycans.
C. Chondrocytes dependent on long range diffusion of nutrients via synovial fluid.
D. avascular, alymphatic, aneural
III. Joint Anatomy
A.Histologically the three joints in the body are fibrous, cartilaginous, and synovial.
B. Functionally the three types of joints are synarthrosis (immovable), amphiarthrosis (slightly moveable), and diarthrosis (freely moveable).
C. The two classification schemes correlate: synarthroses are fibrous, amphiarthroses are cartilaginous, and diarthroses are synovial.
D. Synovial joints are often further classified by the type of movements they permit, which we will not cover here
1. Synovial joints
a) Joint capsule is a fibrous connective tissue that is attached to each participating bone just beyond its articulating surface.
b) Synovium/Synovial membrane
1) Synovium produces synovial fluid Inner layer has villi like small intestine
2) Joints contain relatively little synovial fluid.
IV. Degradation
A. Trauma
1. Acute
2. Repetitive strain
3. Effects
a) Damage= release of cytokines = inflammation
b) Avascular, aneural, alymphatic
c) Osteoarthritis affects whole joint, but primarily hyaline cartilage.
d) Study: hardening of bone leads to degradation of cartilage = viscious cycle.
V. Osteoarthritis
A. Age related vs Secondary to trauma
1. 20 yo vs 80 yo
2. what is the definition of ‘trauma’
3. Chiropractic vs medical view
VI. Role of Chiropractic in maintaining synovial joint health
A. adjustments = better balanced movement
1. intersegmental
2. global movements
3. ROM both local and regional
B. Other factors
C. Nutrition
1. anti-inflammatory diet
2. nutritional supplementation
3. How to navigate all the options
4. Hydration
VII. Clinical Uses
A. Joints
1. Facet Joints
2. SI joints
3. Knees
4. Shoulders
B. Joint inflammation is a different type of pain and often harder to resolve than muscle ache
Understanding Scar Tissue
I. Causes of Damage
II. Physiology of scar tissue formation
A. Non-dividing cells
B. Role of Collagen
III. Stages of Wound/Injury Healing
A. Inflammatory
B. Proliferative/Regenerative
C. ReModulation/Maturation/Remodeling
IV. Nutritional Supplements to consider:
V. Implications
A. Consider the tissues injured: muscle, ligament, tendon, disc (or all of them)
B. Complex structures= uneven, incomplete tearing (microscopic)
C. Have realistic timeframes for healing
D. Educate: prepare for worst, hope for the best
E. Application:
F. Patient examples:
Solving for Posture
I. We use a tremendous amount of energy fighting the effects of gravity.
II. Posture has a long list of negative affects on our health
III. Tech neck is even worse than what we have seen traditionally
IV. Weight of the head= 10 lbs per inch
V. Effects:
VI. Muscle
A.Upper Cross Syndrome
1. Description
2. Intervention
B. Lower Cross Syndrome
1. Description
2. Intervention
VII. Fascia
A. Connective tissue envelope
B. The fascia’s function
VIII. Good News
A. most people have
B. you can still address this issue effectively with a fairly easy home rehab program
C. Do not have to spend a lot of time on this.
D. Simple, but works really well.
Osteoporosis
I. Definition
A. The big picture first
1. Bone fractures, particularly in the spine or hip, are the most serious complications of osteoporosis.
2. Hip fractures often are caused by a fall and can result in disability and even an increased risk of death within the first year after the injury.
3. Vertebral body fractures
II. Physiology Review
A. Bone is a combination of protein (mainly collagen) and minerals
B. Your bones are in a constant state of renewal
C. How likely you are to develop osteoporosis depends partly on how much bone mass you attained in your youth.
III. Risks
A. A number of factors can increase the likelihood that you’ll develop osteoporosis — including your age, race, lifestyle choices, and medical conditions and treatments.
B. Unchangeable: Some risk factors for osteoporosis are out of your control, including:
1. Your sex. Women are much more likely to develop osteoporosis than are men.
2. Age.
3. Race.
4. Family history.
5. Body frame size.
6. Hormone levels
C. Dietary factors
1. Low calcium intake.
2. Eating disorders
3. Gastrointestinal surgery.
D. Steroids and other medications
E. Osteoporosis has also been associated with medications used to combat or prevent:
1.Seizures
2. Gastric reflux
3. Cancer
F. Medical conditions: The risk of osteoporosis is higher in people who have certain medical problems
G. Lifestyle choices
IV. Based on all of the above it can inform your imaging considerations
A. acute pain may be fracture
B. refer for evaluation of Bone Mineral Density (BMD)
C. adjusting technique of choice
D. diet, exercise, supplementation
V. Diagnosis of OP:
A. Plain film radiography (X-ray)
B. CT Scan
C. DEXA scan: Dual x-ray absorptiometry
VI. Imaging Overview for OP concerns: Vertebral Compression Fracture and Hip fracture
A. Plain Film Radiography (x-ray):
1. pros:
2. cons:
3. Considerations for VCF
4. Hallmark Xray findings of VCF:
5. VCF also needs to be differentiated from other possibilities
6. Hip fracture
a) Types of Hip Fracture
b) Femoral neck (approx 50%)
c) Intertrochanteric (approx 45%)
d) Subtrochanteric (approx 5%)
e) X-ray findings
B. CT scan
1. Spine: detects vacuum sign better than x-ray
2. spine and hip both
C. MRI
1. Spine
2. Hip
D. Bone scan (scintigraphy w/ Technitium99)
E. Chiropractic considerations for OP:
VII. Prevention
The Effects of Vertebral Subluxations: a neurologic perspective
I. Philosophy
The 33 Principles of Chiropractic are chiropractic’s core foundational philosophical tenants
This may not sound very ‘Science-y’ to many modern day scientists, researchers, and physicians, however:
II. Science: Neurology Basics
A. Types of mechanoreceptors (I-IV)
B. Mechanoreceptor stimulation (movement of joints) brain affects
C. These extensive connections means movement positively affects
1. movement, muscle tone, posture, balance, positively affect emotions, coordinates visceral functions, improves immunity, learning, supports endocrine balance, coordinating/organizing thought
D. Afferent input is a basic nutrient that the brain needs for proper function and regulation of the human experience
E. Mechanoreceptor stimulation reduces nociception
F. It is well known and understood, not just in chiropractic…
1. Abnormal joint position and abnormal joint movement causes:
III. Also known: Mechanoreceptors are very dense in suboccipitals muscles, intersegmental spinal muscles, TMJ, and atlanto-occipital joint.
IV. The nervous system has a plasticity to it.
A. Plasticity has been defined
B. PNS sensitization occurs from mechanoreception/nociception imbalance
C. C fibers proliferate
V. These are all well-known hard neurologic, anatomic, physiologic facts
A. Therefore Subluxations are
1. chronic stressor that stimulate many brain areas
2. Deep dive on the Cerebellum
3. Pain is not reliable indicator of need for care (we known this)
B. Regardless of technique DC adjustments work
1. effects
2. reasons
C. If DC adjustments are so beneficial than why are they so hard for many of our patients to hold?
Perspectives on Peripheral Neuropathy
I. Background
II. Need for intervention b/c chronic condition
A. Not well addressed by available traditional methods
B. Prevalance
III. New Perspectives
A. PN= caused by ischemia
1. lack of dilation of arterioles= lack of oxygen and healing/everyday nutrients and removal of normal waste products.
2. Reasons
a) Nitric oxide cycle interruption
1) Diabetes, chemo, toxins
IV. Where do we as DC’s fit in?
V. Case Examples:
A. Chemo
B. B12 def neuropathy post gastric bypass
C. IBS = nutrient deficiency
D. Vegetarian
E. statin drugs, or even high doses of red yeast rice.
VI. Observations
VII. General Considerations
VIII. Neuropathy specific nutritional supplements
“What Would You Do’? Patient Scenarios
I. Roofing Contractor Supervisor: Slipped on ice in someone’s backyard, hit head. Unconscious for 4 hours
II. Guy shows up with a right elbow the size of an orange. It is dripping yellow.
III. You see a large bump on the back of your patient’s neck. It is yellow and oozing. He is diabetic.
IV. Pt shows up with a cast/boot and crutches
V. Patient comes in intoxicated and wants to wrestle…
VI. 19 yo male. Wrestling with friend. Pushed into a cement wall. He has Klienfelter’s.
VII. 75 yo male walks into your office reporting right arm and hand mm spasms and lack of control. BP: 88/66, P: 65; slower communication
VIII. Painless limp in a 5 yo boy
IX. 18 mo old boy won’t bear weight on leg
X. 18 mo old girl has pain and won’t lift arm after fall off of bed
XI. 14 yo female soccer player with heel pain
XII. Teenage swimmer shows up with px in upper traps and numb hands
XIII. 15 yo male hockey player with local LBP
XIV. When you suspect labrum tear
XV. Pregnant patient presents with severe pubic bone pain post MVA:
XVI. Elderly patient falls: need to consider…
Radiology Practice Essentials Outline (click to open PDF)
Chiropractic Boundaries In the Office and Online
I. DC-patient relationship
A. depends on confidence and trust
B. crossing boundaries has many consequences
II. Types of crossings
III. Consequences
IV. Reasons
V. Understanding/Acknowledging Differences
A.Patients have different ideas and expectations about appropriateness
1. Cultural, religion, ethnicity, medical history, assault, abuse, personality
B. Behavior grey area/Warning Signs
VI. DC if you develop feelings for a patient
A. find alternative care for the patient (refer)
B. ensure a proper transfer of care occurs
C. transfer care in a way that the patient does not feel that they have done anything wrong.
VII. Two year minimum in MN between discharge from your care and beginning a personal relationship.
VIII. Things to consider
A. How long was the professional relationship, was there a significant imbalance of power,
was the patient vulnerable (and to what degree) during the professional relationship, would you (DC) be exploiting any imbalance, knowledge, or influence obtained professionally to develop or further the relationship
B. Responsibility
C. If a complaint is ever made the burden is on the DC to show that they acted professionally and appropriately in any situation.
D. No matter who or how the relationship is initiated.
IX. Reporting
A. If you are aware of a colleague having an inappropriate relationship you have an ethical, in some cases legal, and professional duty to report the situation to the Chiropractic Board.
X. Prevention
XI. Communication
XII. Documentation
Ethics
I. Ethical Considerations
A. AMA Journal of Ethics article
1. Example of a doctor that helped a long-time patient get a job.
2. Some doc’s are very strict and would not intervene at all
3. HIPPA to consider
4. Consider other ramifications
II. Guidelines for Social Media Use
A. Social Media= what, when, and where
1) Marketing, Education, Trust
2) Need to be prepared for…
a) Request for your help, opinion
b) Urgent/Emergent situation
c) HIPPA
B. posts can be copied, reshared
1) context may be lost
2) fleeting action, with many permanent possible meanings.
C. Framework
1) start with your usual professional conduct
2) consider confidentiality, privacy, and respecting personal space
3) this goes both ways
D. Consider separate profiles
1) personal, but plan for friend/connection requests from pts
2) professional
a) staff monitor?
b) still need HIPPA and consider the ramifications of staff posts/communications
3) either way, pause before you post
4) consider it the same as a public speaking engagement
5) when posting professionally assume your patients/prospective pts are recipients
E. periodically review socials, website, 3rd party rating sites
1) is the info accurate?
2) how does it portray you?
III. Social Media is everywhere and anytime, both private and public. It is here presently, is a mark of the past, and will continue into the future. Consider how you interact with it.
I. Underhydration
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2. Liska D, Mah E, Brisbois T, Barrios PL, Baker LB, Spriet LL. Narrative Review of Hydration and Selected Health Outcomes in the General Population. Nutrients. 2019 Jan 1;11(1):70. doi: 10.3390/nu11010070. PMID: 30609670; PMCID: PMC6356561.
3. Institute of Medicine (US) Committee on Military Nutrition Research. Caffeine for the Sustainment of Mental Task Performance: Formulations for Military Operations. Washington (DC): National Academies Press (US); 2001. 2, Pharmacology of Caffeine.
4. Azzouz LL, Sharma S. Physiology, Large Intestine. [Updated 2022 Aug 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507857/
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II. Case History: A Dad through the Decades
1. Yochum, T., Rowe, L., Essentials of Skeletal Radiology, Vol.1, pg.895-904, Williams & Wilkins, 1996.
2. Kelempisioti, A. Et al. (2011). Genetic susceptibility of intervertebral disc degeneration among young Finnish adults. BMC Medical Genetics. 2011, 12:153.
3. Yang, X. Eet al. (2019). CHRNA5/CHRNA3 gene cluster is a risk factor for lumbar disc heriantion: a case-control study. Journal of Orthopedic Surgery and Research. 2019 14:243.
4. Ji, D. Et al. (2019). Correlation fo EYS polymorphisms with lumbar disc herniation risk among Han Chinese population. Molecular Genetics & Genomic Medicine. September 2-19., V7, Issue 9 e890.
5. Grotle, M. Et al. (2019). Lumbar spine surgery across 15 years: trends, complications and reoperations in a longitudinal observational study from Norway. BMJ Open 2019;9:e028743.
6. Jung, J. Et al. (September 2020). The long-term reoperation rate following surgery for lumbar stenosis. Spine: Sept 15, 2020; v45:i18:p1277.
7. R.K. FUCHS, S.J. WARDEN, C.H. TURNER, 2 – Bone anatomy, physiology and adaptation to mechanical loading, Editor(s): Josep A. Planell, Serena M. Best, Damien Lacroix, Antonio Merolli, In Woodhead Publishing Series in Biomaterials, Bone Repair Biomaterials, Woodhead Publishing,2009, Pages 25-68.
8. Chan, D. Et all. (2006 Aug). Genetics of disc degeneration. Eur Spine Journal. 15(Suppl 3);317-325.
III. Case History: Chainsaw Artist
1. Teichtahl, A.J., Wluka, A.E., Wijethilake, P. et al. Wolff’s law in action: a mechanism for early knee osteoarthritis. Arthritis Res Ther 17, 207 (2015). https://doi.org/ 10.1186/s13075-015-0738-7
2. Kelempisioti, A. Et al. (2011). Genetic susceptibility of intervertebral disc degeneration among young Finnish adults. BMC Medical Genetics. 2011, 12:153.
3. Yang, X. Eet al. (2019). CHRNA5/CHRNA3 gene cluster is a risk factor for lumbar disc heriantion: a case-control study. Journal of Orthopedic Surgery and Research. 2019 14:243.
4. Ji, D. Et al. (2019). Correlation fo EYS polymorphisms with lumbar disc herniation risk among Han Chinese population. Molecular Genetics & Genomic Medicine. September 2-19., V7, Issue 9 e890.
5. Grotle, M. Et al. (2019). Lumbar spine surgery across 15 years: trends, complications and reoperations in a longitudinal observational study from Norway. BMJ Open 2019;9:e028743.
6. Jung, J. Et al. (September 2020). The long-term reoperation rate following surgery for lumbar stenosis. Spine: Sept 15, 2020; v45:i18:p1277.
7. Chan, D. Et all. (2006 Aug). Genetics of disc degeneration. Eur Spine Journal. 15(Suppl 3);317-325.
8. Khurana VG. Adverse impact of smoking on the spine and spinal surgery. Surg Neurol Int. 2021 Mar 24;12:118. doi: 10.25259/SNI_6_2021. PMID: 33880223; PMCID: PMC8053459.
IV. Case History: An Unlucky Bus Driver
1. Salter, R., Textbook of Disorders and Injuries of the Musculoskeletal System, 3rd ed., Williams &Wilkins, 1999.
2. Xin J, Wang Y, Zheng Z, Wang S, Na S, Zhang S. Treatment of Intervertebral Disc Degeneration. Orthop Surg. 2022 Jul;14(7):1271-1280. doi: 10.1111/os.13254. Epub 2022 Apr 29. PMID: 35486489; PMCID: PMC9251272.
3. Burton, Kim., Adams, Michael A.., Dolan, Patricia., Bogduk, Nikolai. The Biomechanics of Back Pain. United Kingdom: Elsevier Health Sciences, 2012.
4. Chan, D. Et all. (2006 Aug). Genetics of disc degeneration. Eur Spine Journal. 15(Suppl 3);317-325.
5. Hammer, W., Functional Soft Tissue Examination and Treatment By Manual Methods : The Extremities, Aspen Pub., Rockville, MD, 1991.
6. Dock, Daniel, “Whiplash Trauma”. Duluth, MN: Self Published, 1995.
V. Case History: Ehlers-Danlos and Marfan’s patients
1. Dean, J. (2007). Marfan syndrome: clinical diagnosis and management. European Journal of Human Genetics. 2007, 15, 724-733.
2. Gilliam, E. Et al. (January 2020). Urogenital and pelvic complications in the Ehlers- Danlos syndromes and associated. Hyper mobility spectrum disorders: A scoping review. Clin Genet. 2020 January; 97(1): 168-178:10.1111.
3. Fikree, A. Et al. (2017). Gastrointestinal involvement in the ehlers-danlos syndromes. Am J Med Genet Part C Semin Med Genet 175C:181-187.
4. Yochum, T., Rowe, L., Essentials of Skeletal Radiology, Vol.1, pgs. 607-608, 611-613, Williams & Wilkins, 1996.
VI. Case History: Thoracic Outlet Syndrome
1. Sanders, R. (2007). Diagnosis of thoracic outlet syndrome. The Society for Vascular Surgery. Doi:10,1016
2. Qaja, E. Et al. Arterial thoracic outlet syndrome secondary to hypertrophy of the anterior scalene muslce. Journal of Surgical Case Reports.2017;8, 1-4.
3. Sanders, R. Et al. (2017). Pectoralis minor syndrome: Subclavical brachial plexus compression. Diagnostics 2017, 7,46.
4. Connolly, M. (2021). Anatomy and embryology of the thoracic outlet. Thoracic Surg Clin 2021 February;31(1):1-10.
5. Yochum, T., Rowe, L., Essentials of Skeletal Radiology, Vol.1, pg.239, Williams & Wilkins, 1996.
VII.Case History: Rib Cartilage Issues
1. Lou-Ren, C, et al. (21 Oct 2021). Anatomy, Cartilage. NCBI Bookshelf. 2021.
2. Grubbs, H. Et al. (21 May, 2022). Wound Physiology. NCBI Bookshelf. 2022.
3. Kollar, T. (17 March, 2020). Mechanosensitive aspects of cell biology in manual scar therapy for deep dermal defects. International Journal of Molecular Sciences. 2020, 21, 2055; dos:10.339/ijms21062055
4. Salter, R., Textbook of Disorders and Injuries of the Musculoskeletal System, 3rd ed., Williams &Wilkins, 1999.
5. Everts P, Onishi K, Jayaram P, Lana JF, Mautner K. Platelet-Rich Plasma: New Performance Understandings and Therapeutic Considerations in 2020. Int J Mol Sci. 2020 Oct 21;21(20):7794. doi: 10.3390/ijms21207794. PMID: 33096812; PMCID: PMC7589810.
6. Bradley S. Polkinghorn, Christopher J. Colloca, Chiropractic management of chronic chest pain using mechanical force, manually assisted short-lever adjusting procedures, Journal of Manipulative and Physiological Therapeutics, Volume 26, Issue 2, 2003, Pages 108-115.
7. Wang HJ, Zakhari S, Jung MK. Alcohol, inflammation, and gut-liver-brain interactions in tissue damage and disease development. World J Gastroenterol. 2010 Mar 21;16(11):1304-13. doi: 10.3748/wjg.v16.i11.1304. PMID: 20238396; PMCID: PMC2842521.
VIII. Case History: Wrist Injury
1. Murphy, B. Et al. (2020). The epidemiology of scapholunate advanced collapse. American Association for Hand Surgery. 2020, Vol 15(1) 23-26.
2. Stabler, A. Et al. (1990 Nov). Carpal instability and secondary degenerative changes in lesions of the radio-carpal ligaments with various etiology. Handchir Mikrochir Plast Chir. 1990 nov;22(6):289-95.
3. Lane, R. Et al. (27 June, 2022). Scapholunate Advanced Collapse. NCBI Bookshelf. 2022.
4. Terzis, A. Et al. (28 May, 2021). Inter-rater reliability of magnetic resonance imaging in comparison to computed tomography and wrist arthroscopy in SLAC and SNAC wrist. Journal of Clinical Medicine. 2021, 10, 3592.
5. Yochum, T., Rowe, L., Essentials of Skeletal Radiology, Vol.1, pg.755-765, Williams & Wilkins, 1996.
IX. Clinical Applications of Cartilage Physiology
1. Lou-Ren, C, et al. (21 Oct 2022). Anatomy, Cartilage. NCBI Bookshelf. 2021.
2. Yochum, T., Rowe, L., Essentials of Skeletal Radiology, Vol.1, pg.803, Williams & Wilkins, 1996.
3. Salter, R., Textbook of Disorders and Injuries of the Musculoskeletal System, 3rd ed., Williams &Wilkins, 1999.
4. Salter, R., Textbook of Disorders and Injuries of the Musculoskeletal System, 3rd ed., pg 20-22, Williams &Wilkins, 1999.
X. Understanding Scar Tissue 1. Grubbs, H. Et al. (21 May, 2022). Wound Physiology. NCBI Bookshelf. 2022.
2. Kollar, T. (17 March, 2020). Mechanosensitive aspects of cell biology in manual scar therapy for deep dermal defects. International Journal of Molecular Sciences. 2020, 21, 2055; dos:10.339/ijms21062055
3. Salter, R., Textbook of Disorders and Injuries of the Musculoskeletal System, 3rd ed., Williams &Wilkins, 1999.
XI. Patient Mystery #33
1. Tsokos, G., Systemic Lupus Erythematosus: Basic, Applied and Clinical Aspects, 2nd Ed., April 2021, Academic Press.
XII. Neuropathy Perspectives
1. West, B. (2011). The implications of statin induced peripheral neuropathy. Journal of Foot and Ankle Research. April 2011.
2. Stuhlinger, M, et al. (November 2001). Homocysteine impairs the nitric oxide synthase pathway. American Heart Association Vol 104, Issue
3. Burke TJ. Infrared Photo Energy May Reduce Neuropathic Pain. Practical Pain Management. 2007;7(6):57-63.
4. Prendergast JJ, Miranda G, Sanchez M. Improvement of Sensory Impairment in Patients with Peripheral Neuropathy. Endocrine Practice. 2004;10:24-30.
5. Delellis S, Carnegie DE, Burke TJ. Improved Sensitivity in Patients with Peripheral Neuropathy: Effects of Monochromatic Infrared Photo Energy. Journal of the American Podiatric Medical Association. 2005; 95(2):143-147.
6. Harkless L, Delellis S, Burke TJ. Improved Foot Sensitivity and Pain Reduction in Patients with Peripheral Neuropathy after Treatment with Monochromatic Infrared Photo Energy-MIRE™. Journal of Diabetes and Its Complications. 2006;20(2):81-87. 28.
7. Mohan IK, Cas UN. Effects of L-arginine-nitric oxide system on chemical induced diabetes mellitus. Free Radic Biol Med. 1998 Nov 1; 25(7):757-65.
8. Zeiher, A.M., Schachinger, V., and Minners, J. Long-Term Cigarette Smoking Impairs Endothelium-Dependent Coronary Arterial Vasodilator Function. Circula-tion. 1995; 92:1094-1100. 9. Fried R, Merrell WC. The Arginine Solution. New York, New York. Warner Books, 1999.
XIII.What Do You Do Scenarios
1. Radswiki T, Knipe H, Tan W, et al. Spondylolysis. Reference article, Radiopaedia.org (Accessed on 26 Feb 2023) https://doi.org/10.53347/rID-12262
2. Yochum, T., Rowe, L., Essentials of Skeletal Radiology, Vol.1, pg.327-372, Williams & Wilkins, 1996.
3. Ferlin, A. Et al. (March 27, 2010). Osteoporosis in Klinefelter’s syndrome. Mol Hum Reprod. 2010 Jun;16(6):402-10.
4. Chan, D. Et all. (2006 Aug). Genetics of disc degeneration. Eur Spine Journal. 15(Suppl 3);317-325.
5. Burton, Kim., Adams, Michael A.., Dolan, Patricia., Bogduk, Nikolai. The Biomechanics of Back Pain. United Kingdom: Elsevier Health Sciences, 2012.
6. Salter, R., Textbook of Disorders and Injuries of the Musculoskeletal System, 3rd ed., Williams &Wilkins, 1999.
XIV.The Effects of Subluxation
1. Chesnut, J., Fourteen foundational premises for the scientific and philosophical validation of the chiropractic wellness paradigm. Victoria Press, 2003.
2. Seaman, D., Winterstein, J., Dysafferentation: A Novel Term to Describe the Neuropathophysiological Effects of Joint Complex DysfunctionJ Manipulative Physiol Ther 1998 (May); 21 (4): 267-280. 3. Gebhart GF. Scientific Issues of Pain and Distress. In: National Research Council (US) Committee on Regulatory Issues in Animal Care and Use. Definition of Pain and Distress and Reporting Requirements for Laboratory Animals: Proceedings of the Workshop Held June 22, 2000. Washington (DC): National Academies Press (US); 2000.
XV.Solving for Posture
1. Dalton, E.,Concepts and Corrections For Head, Neck and Back Pain, Myoskeletal “techniques” for Upper Crossed Syndrome, Freedom From Pain Institute, Oklahoma City, OK, 2005.
2. Chaitow, L., Walker DeLany J., Clinical Application of Neuromuscular Techniques : Practical Case Study Exercises, New York : Elsevier Churchill Livingstone, 2005.
3. Seidi F, Bayattork M, Minoonejad H, Andersen LL, Page P. Comprehensive corrective exercise program improves alignment, muscle activation and movement pattern of men with upper crossed syndrome: randomized controlled trial. Sci Rep. 2020 Nov 26;10(1):20688.
4. Richardson, Jull, Hodges, Hides, “Therapeutic Exercise For Spinal Segmental Stabilization In Low Back Pain”. London, UK: Churchhill Livingstone, 1999. 5. Bordoni B, Mahabadi N, Varacallo M. Anatomy, Fascia. [Updated 2022 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.
XVI.Osteoporosis
1. Morri, M, et al. (2019). One-year mortality after hip fracture surgery and prognostic factors: a prospective cohort study. Scientific Reports.
2. Dimet-Wiley, A, et al. (Jan-Mar 2022). One-Year oostfracture morality rate in older adult with hip fractures relative to other lower extremity fractures. JMIT Aging 2022;5(1):e32683
3. Basaraba, S. (March 17, 2022). Hip fracture dangers and mortality rates. www.verywellhealth.com
4. Pizzorno, L. (August, 2015). Nothing boring about Boron. Integrative Medicine.
5. Panda, et al. (May-June, 2014). Imaging of vertebral fractures. Indian Journal of Endocrinology and Metabolism.
6. Chiodini, I. (June, 2008). Role of cortisol hyper secretion in the pathogenesis of osteoporosis. www.pubmed.com
7. Guzon-Illescas, O., Fernandez, E., et al. (2019). Mortality after osteoporotic hip fracture: incidence, trends, and associated factors. Journal of Orthopedic Surgery and Research.
8. Konig, D. (December 4, 2017). Specific collagen peptides improve bone mineral density and bone markers in postmenopausal women- a randomized controlled study. www.mdpi.com
9. Schnell, S. Et al. (2010). The 1-year mortality of patients treated in a hip fracture program for elders. Geriatric Orthopaedic Surgery and Rehabilitation I(I)6-14.
XVII. Chiropractic Ethics and Professional Boundaries
1. Mazzullo, J. (May 2015). Does helping a patient find a job violate professional boundaries? May 2015.
2. Kind, T. (May 2015). Professional Guidelines for Social Media Use: A Starting Point. May 2015.
3. Goodyear-Smith F, Buetow S. Power issues in the doctor-patient relationship. Health Care Anal. 2001;9(4):449-62.
4. College of Chiropractors of British Columbia, Clear Sexual Boundaries Between Chiropractors and Patients: Responsibilities of Chiropractors, January 2016, available at www.chirobc.com/wp-content/uploads/2014/12/Sexual-boundariesfinal.pdf
XVIII. Imaging of Compression Fractures
1. Panda, et al. (May-June, 2014). Imaging of vertebral fractures. Indian Journal of Endocrinology and Metabolism.
2. Choi, W., et al. (2012). Usefulness of SPAIR image, fracture line and the adjacent discs change on magnetic resonance image in the actor osteoporotic compression fracture. The Korean Spinal Neurological Society.
3. Kim, C. et al. (2009). Enhancing box sign: Enhancement pattern of actor osteoporotic compression fracture. The Korean Neurosurgical Society Hanrahan, C, Shah, L. (December, 2011). MRI of spinal bone marrow: part 2, t1- weighted imaging-based differential diagnosis. Integrative Imaging.
4. Hatgis, J, et al. (August 27, 2018). Radiologic evaluation of chronic vertebral compression fractures and role of vertebral augmentation. Cureus 10(8).
5. Mauch, JT, et al. (September, 2018). Review of the Imaging Features of Benign Osteoporotic and Malignant Vertebral Compression Fractures. www.ajnr.org
6. Sarli, M. (February 25, 2005). The vacuum cleft sign: an uncommon radiological sign. Epub.
XIX. Spondylolysis
1. Radswiki T, Knipe H, Tan W, et al. Spondylolysis. Reference article, Radiopaedia.org (Accessed on 26 Feb 2023) https://doi.org/10.53347/rID-12262
2. Yochum, T., Rowe, L., Essentials of Skeletal Radiology, Vol.1, pg.327-372, Williams & Wilkins, 1996.
XX.Imaging Modalities in Daily Practice
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2. Panda, et al. (May-June, 2014). Imaging of vertebral fractures. Indian Journal of Endocrinology and Metabolism.
3. Choi, W., et al. (2012). Usefulness of SPAIR image, fracture line and the adjacent discs change on magnetic resonance image in the actor osteoporotic compression fracture. The Korean Spinal Neurological Society.
4. Yochum, T., Rowe, L., Essentials of Skeletal Radiology, Vol.1, pg.1-138, Williams & Wilkins, 1996.
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10. Snyder E, Kashyap S, Lopez PP. Hepatobiliary Iminodiacetic Acid Scan. [Updated 2022 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan.
Kyle Hagel, DC
Dr. Hagel has over 20 years of practice experience with a diverse practice background that includes Evaluation and Management of Auto Injuries, Functional Muscle Evaluation, Sports Medicine, Postural Reeducation, Structural Correction, Disc Injury Management, Spine and Extremity Bracing, Neuropathy Pain Management, Weight Loss, Functional Medicine, and Acupuncture. He also has benefitted greatly from working cooperatively with Physicians, Physician Assistants, and Nurse Practitioners in an integrated clinic for the last 14 years and continues to do so.
Educating patients has always been very important to Dr. Hagel in his practice. Patients that understand their condition make better decisions about their care. He is excited to now be involved in chiropractic continuing education and helping other doctors to do the same for their patients.