Does Chiropractic Care Work?

Intro:

Welcome to Dr. Ruscio Radio, providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics, as well as all of our prior episodes, make sure to subscribe in your podcast player. For weekly updates, visit DrRuscio.com. That’s D R R U S C I O dot com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor. Now let’s head to the show.

DrMichaelRuscio:

Hey everyone. Today I speak with Dr. Devin Waterman about chiropractic and musculoskeletal care. He is the doctor that I see for aches and pains and little things that pop up here and there, and I’ve always appreciated his approach. I’ve referred to him a number of people who have all been elated with the care that he has delivered. So I wanted to discuss more about the field of chiropractic. What are things to look for, what are things to avoid, and to try to discuss the field broadly, which seems to mirror functional medicine in that there is a lot of good and a fair amount of bad. I guess it just seems to be a human constant that the more I look into any field, there’s this dichotomy where some people make you want to pound your head against a wall and then others seem to be really doing a great job. Maybe it’s just me having too critical of a way of analyzing these things.

DrMR:

But in any case, we had a very constructive discussion about the field, including what works, what doesn’t work, what to look for, what to avoid, how it’s helped me, how it’s helped some others. We do a brief review of what some of the literature has found along with some of my musings on politics and medicine and healthcare, if you will. So I think this will be a really enjoyable discussion. This was the portable podcast setup, so you’ll probably get some background notes from the coffee shop. Oh, and I should mention that this music that you hear playing in the background right now is actually Dr. Devin Waterman, who is quite the talented musician. On the back side of the podcast, the outro will be one of his songs. He’s a dedicated clinician, but his pet hobby is music, and I think it’s a nice song so I wanted to share that with you guys at the end of the podcast. Okay, so that’s it. We’ll go to the show now and the interview with Dr. Waterman. And remember if you’re enjoying the show, please leave us a review on iTunes.

DrMR:

Hey everyone. Welcome back to Dr. Ruscio Radio. This is Dr. Ruscio here with my good friend and colleague Dr. Devin Waterman. We are on the mobile podcast setup at Sideboard in Lafayette, California. I apologize that the background noise is a touch high. The only seat with an outlet, which I need for the power obviously, is right under the speaker. So I’m hoping it’s not going to be too loud, but today I wanted to have on the guy that I see for my musculoskeletal chiropractic needs. Devin is someone who’s helped straighten me out, almost literally. When the office was in California, we were essentially neighbors in the sense that you are in San Ramon and I was in Walnut Creek. I would refer people to you and everyone raved about you.

A Background in Chiropractic Care

DrMR:

So not only have you helped me, but the feedback was great from other people that I’ve sent over to you. And by the way, for our audience, some of these people are not health enthusiasts. They were a little bit uncomfortable going to see someone outside of “the box,” so to speak, and even they were like, “Wow, this guy really knows his stuff. He helped me immensely.” And so what I wanted to do today was talk about chiropractic care, sports chiropractic, musculoskeletal care, what you see, maybe give people some tips and tricks for how to find a good doctor, and things to be on the lookout for regarding functional medicine. Just try to give people that broad overview. So maybe we should start with you, a little bit about you, your practice, and what you do.

DrDevinWaterman:

Absolutely. I’ve been in practice for a little bit over 10 years. In fact, growing up, my father was a chiropractor. So I’ve always been in the field; I grew up with it. It was just my natural way of looking at health through the holistic standpoint. I remember my dad was all about eating clean and he’d be feeding me supplements. I didn’t know that this wasn’t normal. My dad was always the sports doc. So in high school, anytime there was an injury, my dad would be the one running on the field. I played high-level soccer, and he’d get all these athletes fixed up and ready for the next game or in the middle of the game for after halftime, they’d be back out on the field. That was just a cool perk of having a chiropractor as a dad.

DrDW:

When I was a junior, I ended up tearing my ACL and had to have a surgical repair. I went and saw an orthopedist who basically fixed my knee up with surgery. That was my first big surgery, and after that I was like, “Great. I want to be an orthopedist. I think this is what I want to do.” My dad was like, “Perfect,” just super supportive of me. So after high school, I went to UC Davis, studied pre-med, and was just gung-ho on going to med school. I was also an intern with the athletic trainers, so I was the one out on the field then taking care of these injured athletes and helping to rehab them. And the funny thing is that my dad would come up to visit to see what we were doing. He would take care of these athletes and he would just blow when I was doing out of the water. What he was doing just looked like magic. These athletes would always ask, “When’s your dad coming back? When’s Dr. Waterman coming back? Which was cool.

DrDW:

But then I shadowed some orthopedist because I figured this is what I want to do, I might as well go shadow someone out in the field. That’s when it really hit me that, oh my gosh, I grew up holistically. Everyone that came in either had a surgical option or injection. At that point it was a lot of opioids, a lot of them. And after that, I remember calling my dad and saying, “Look, I don’t think I want to become an orthopedist anymore. So then I started talking to him about chiropractic and he was like, “Let’s do it.” In fact, I remember him saying, “You’ve made the right choices, the best decision and best lifestyle ever.”

DrDW:

Then I went to chiropractic college and my whole goal was still more of like rehab or a sports practitioner. So when I wanted to practice, that’s who I saw, all post-injury high-level athletes. Then what happened was my clientele started getting a little bit older, and then they started having families and kids. And all of a sudden, now I’m seeing spouses and their kids, and then my practice totally just morphed. So I’m incredibly good at doing musculoskeletal, taking care of all that, but now a lot of my practice is just lifestyle-based. I’ve noticed that chiropractic is one of the best biohacks that I’ve found. Whether someone’s on a solid nutrition plan and trying to take care of that, if their body is balanced systemically, they’re able to better absorb their nutrition and they get better results. So my patients really like to use me as a biohack for their body, so that way they can heal in the other realms.

DrMR:

Nice. Well, we have a similar starting point as I wanted to go into orthopedic medicine also. It is interesting how there’s this veil about conventional medicine. When you get a chance to look behind the veil, I guess it depends on your proclivities and interests, but for me and I think for you also, it wasn’t quite as great as it looked from the outside. I think there’s a lot of stereotyping around Grey’s Anatomy and these TV shows that glorify it. This is not a knock; I’m just stating my personal preference. I think if you’re a surgeon or you’re working in the ER or the hospital, that’s amazing work that people need to do. I can say for me, that would have sucked the soul out of me. I can work really hard, but I think that sort of environment would have just crushed me eventually. So I think we ended up in the right place.

Sample Size and Discounting Chiropractic

DrMR:

So I spent a little bit of time just poking around on PubMed to look at what the evidence base is regarding chiropractic. We really try to use the scientific database to inform decision making. It’s interesting when you start searching around, and this is something I want to share with the audience to try to arm them with a better ability to cut through bias on the other side of the equation. You’ll see some of these self-proclaimed science-based — I think the actual website is something along the lines of science-based medicine, and they wrote a really snarky review.

DrMR:

One of the things I think we all need to be cognizant of is that there’s a difference between there being a minimal amount of evidence or small trials. Like with probiotics, as an example, there’s good data, but they’re not thousand some odd patient trials. They’re normally 30 patients or 70 patients, smaller sample sizes. So a “science-based,” in this case, I would say heretic could try to tear down probiotics by saying that there’s low-quality evidence. That’s not really accurate, but the valence is correct in terms of if we’re comparing it to trials for something like the drug Rifaximin for SIBO that has thousands and thousands of patients in a given trial and a really large sample size. Not as good as that.

DrMR:

So how that maps on to this conversation is you’ll see that in some of these “science-based” reviews that are pretending to be objective and on the side of science, they’ll write these really snarky review papers that there’s no evidence or there’s really poor evidence. There’s a difference between saying that there’s some limitations in smaller sample size trials. Clearly from my quick review, there is a trend showing that those smaller sample size trials have demonstrated benefit with chiropractic care, whether it be for back pain, neck pain, there was also a systematic view with meta-analysis on migraine. And while not every study seemed to show a positive finding, there were clinical trials showing positive findings and there seems to be a trend in that direction, which I would expect. There are always going to be variations in study findings, but we’re looking for what the trend shows.

DrMR:

So the point I’m trying to make here, maybe in a circuitous fashion, is I think our audience should be mindful not to be thrown off of alternative therapies when people who are seemingly in positions of power are trying to say that this is quackery or that people in alternative medicine are trying to hoodwink you. What I think is the optimum balance is that we want to be looking for all the therapeutics that can help people. This is what I’ve described in Healthy Gut, Healthy You. We want to be evidence-based but not evidence-limited. Meaning we don’t want, “Well, unless there’s a clinical trial of 2,000 subjects, then we’re never going to use this.” Because if that doesn’t exist, but the therapy can help people, we don’t want to withhold that because now we’re withholding things from our clinical model that only have a certain level of funding. And so if you’re framing things that way, it’s not about what the best therapy is, it’s about what therapy has the most money behind it because they can produce these large trials.

DrMR:

So for the facet of our audience that’s leaning more in the evidence-based direction, I just offer that as something to prevent you from falling into what I really find distasteful in some realms of medicine and healthcare, which is hiding behind these kinds of laurels and credentials and scoffing at alternative therapies as if they’re complete quackery. There is quackery, and I am calling out quackery all the time on the podcast, but there are also therapeutics that have less evidence behind them that show promise, and that we should be open-minded to if our primary objective as clinicians is helping people and not just shouting all over therapies that may be different than what we think or what we philosophically gravitate towards.

The Chiropractic Art

DrDW:

It’s interesting because with my clientele, a lot of the people that come in have already seen everyone else. They’ve been through all the trials, they’ve been to the best doctors, and then they come to me saying, “Hey, you’re my last hope. I was told I need to come see you. What can you actually do for me?” It’s interesting that in chiropractic, it’s so much about a few things. One is being good at diagnosing what’s in front of you, trying to figure out where this patient has been in their past, why they have this injury or whatever their ailment is and why it’s not actually healing. The body should be able to heal from whatever happens to it, in some degree. So it’s getting the correct diagnosis, but the biggest issue that I see in chiropractic is the art. You can have the same patient in front of multiple, different doctors, and they all have their own art of how they adjust and take care of their patients.

DrDW:

It’s like in baseball, you see there are people that don’t make it out of high school baseball, and then you have people that go all the way through the professionals. They’re still throwing a baseball. So you just really have to find a practitioner that you trust, that connects with you, that has your best interest in mind, who is basically like a high-level athlete of their profession. I try and teach that too. I teach a lot of students about the art of chiropractic, how to make the correct adjustments, when not to adjust, when to adjust, when to do the correct thing so the patients can heal. A lot of it just comes with practice over time. That’s why they call it practice.

DrDW:

So now when patients come in to see me, it typically isn’t the first time I’ve seen that issue before, I’ve just seen it in another body. So as soon as I put my hands on them, I can already tell them how long it’s going to take to heal and how well they’ll do. So that’s the issue with these clinical trials. It’s like, who’s the doctor who’s adjusting? Are they great adjusters? Are they using the instrument? Are they students?

DrMR:

I think you’re pointing to one of the things that is a challenge for the field, which is that it’s harder to standardize the care. Let’s say I’m trying to set up a trial. I can give anyone a probiotic. If you’re a new provider or if you’re someone who’s been in practice for 20 years, I can say, “Here’s the study design. Follow this process. Give this treatment. Follow up with this interval. Use this subjective follow-up questionnaire.” With some of the musculoskeletal disciplines like bodywork, there seems to be this degree of tactile sensation. How does the tissue feel if you’ve been to a good massage therapist? They literally are assessing you with their hands. That can be objectively documented and described, but I think there’s a challenge with decompressing what you have into your mind, articulating that to someone else, and then they have to try through words to understand what you’re feeling.

DrMR:

This seems like a challenge for the field that whoever can do a better job of solving this will really allow the field to expand and do a better job. And there might be some limitations there that are just difficult to get around, but what are your thoughts regarding how the field could try to put a better scientific foot forward? I think this is an opportunity for the field to do more and to do better. One of the reasons why I think this is valuable is regarding your other point about students. If we can give students even better training and get a little bit more standardization, it won’t be so hit or miss. And I do feel like with musculoskeletal therapists and doctors, it’s more of a hit or miss.

DrDW:

Yeah, it’s absolutely hit or miss. That’s a great question because for me, I’m busy. I don’t think I have time to start a clinical trial, and that’s not my specialty. I think the colleges need to get more involved with putting out better research, and then also when they’re doing the research, not having the students do it, but having doctors do it.

DrMR:

Is that something that happens? Are some of the studies being done with the student intern population partially vectoring the care?

DrDW:

I just know when we were in school and they were putting studies through, a lot of the better interns would do it, but they’re still interns. It’s interesting because it’s such an art, especially with what I do in my practice. I may have a patient who’s already seen six other chiropractors and they need some other modalities or some other additional support so that way their adjustments can heal. So that’s where you need to build your own personal network of people to refer to. Like I’ll refer people to you. I do that quite often.

DrMR:

You have. You’ve referred a lot of people over. Thank you for that.

DrDW:

Why are they not healing? That’s always my biggest question. Why are you not healing? It could be a chemical issue that their body’s just so inflamed that their SI joint is not a priority right now. So go get something else healed, come back, and we’ll definitely be able to clear it up, or we do it simultaneously with another practitioner. But chiropractors like to just hold everyone in. They don’t like to refer out. I think we need to really start teaming up with other professions. That’s a great way to not only build your practice, but to become more legitimate.

Alternative vs. Conventional Therapies

DrMR:

There’s an interesting concept here that you’re touching on. I’m learning this recently as we’re doing a lot of work behind the scenes to try to pioneer new research agendas, and we’re hitting some resistance in certain areas. Without going into a lot of detail, there’s this partial resistance from political realms in medicine and healthcare that seem to be attempting, whether it’s directly or indirectly, to stifle alternative therapies. It’s interesting that as we’re trying to do more with the research in the clinic, there are progressively larger roadblocks that are being thrown at us. We’re trying to step up the science of natural medicine and there are roadblocks. It’s like, “What the F?” Here are people who are trying to do the right thing, to do larger trials as one example, or to treat diseases. We’re having to really wiggle more difficultly to get these institutional review board approvals. My understanding is in it’s nascence, but it’s harder to get approval to treat a disease like IBS with a natural therapy.

DrMR:

What’s challenging about that is now you’re railroading your competition out of business. If we’re telling people that science is important to vet therapies, but we’re making it really hard for other therapies to do the science, then where does that lead us? That leads us to a monopolistic model of healthcare, and I think part of what you see in the chiropractic profession is a derivative of the stifling of the field. There is less money going into the field, less interest, less money, and it makes it harder for providers to survive. And therefore there’s more of, as you said a second ago, holding things in.

DrMR:

I pose this thought so our entire audience can be aware of this. I’m becoming progressively more convinced that it’s really important for people to support alternative therapies, because if we don’t, they will wither on the vine and die. We want to be careful to call out quackery. I think we are trying to do a great job of that, but at the same time, I think it’s important to support alternative therapies because if we don’t, then all you’re going to have is the super in the box perspective. And I always think of the 60 Minutes probiotic exposé with Patricia Hibberd, Professor of Medicine at some medical school, and she point blank said there’s no evidence for probiotics and IBS, which is ridiculous. But if things keep drifting in that direction, that’s what you’re going to get. “Well, only medicines have the level of trial that are needed,” ignoring the myriad of smaller clinical trials showing that probiotics are helpful for IBS.

DrMR:

It’s scary to think about that 20 years down the line, if there’s not a counter force, then the only information people could get is, “You have IBS? Here are the two approved drugs. Everything else is quackery. End of story.” I’m not a conspiracy theorist type guy, but when you see some of these things, whether it’s intentional or indirect, as one colleague who we’re speaking with who will remain nameless but is a faculty at a Tier 1 medical school said, and I love the way he termed it, “There is a degree of credential bigotry that still exists.” So whether it’s this bigotry of different credentials, or if it’s this behind the scenes Illuminati-like trying to stifle other therapies, I’m not sure, but the end result is still the same in that there is a subtle undercurrent of trying to stifle some of these therapies. In any case, that’s why I think it’s important to support alternative therapeutics.

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Selecting a Chiropractor

DrMR:

In any case, that’s why I think it’s important to support alternative therapeutics. To that end point, what are some things that you think people should be on the lookout for? I’ve heard a lot of things when you’re trying to find a functional medicine provider. Red flag, red flag, red flag. Are there things that you would suggest when someone’s shopping around for a chiropractor or someone else who does musculoskeletal work? What are some key indicators that either are someone you want to work with or you may want to run out of their office as fast as you can?

DrDW:

I mean, I’m just like purely results focused in my practice. So my big thing is having a good referral source, speaking to someone else who has gone to that practitioner, and seeing what it really looks like, because people can fake reviews online. And there are so many different techniques, so you need to figure out what it is that you like. There’s a lot of different techniques in chiropractics, so you need to figure out is it something where you want like an instrument style adjusting, or do you want someone who’s really hands-on that gets into soft tissue, or more neurological based.

DrDW:

But really when you’re looking for a good practitioner, it’s all about having a good referral. So hopefully you have a network of doctors that have a great chiropractor that they refer to. And if not, if you go in and see a chiropractor and you feel confident with them, you really mesh with them and you like their diagnosis, you like where they’re taking you with your health, give them a therapeutic trial in the office and see if it works. That’s why in my practice we have re-exams set up to make sure that our patients are healing at the speed that we expect. And if not, then we change what we’re doing or I’ll find them someone who’s better for them.

DrMR:

And how long does it take to get in to see you? I’m asking this question with the secondary question of should you be looking for someone who has some degree of a wait, some degree of when you can’t get in to see them tomorrow? Does that not tend to matter in your experience?

DrDW:

I don’t know if that matters. For me, it’s typically like a two week type of a deal to get in. Sometimes if you’re in really acute pain I’ll stay after and try to figure out a time to get you in for that. But I don’t think the waiting list practice necessarily means that the care’s going to be that great.

DrMR:

Good marketers can get there too.

DrDW:

Yeah, exactly. So I don’t know. I’d really just try and ask your friends and see who they like and who they don’t like. Oftentimes, your friends have seen multiple practitioners and then they’re like, “Oh wow. I love this one doc. You should see them and go from there.” It’s like a wild, wild west out there.

DrMR:

I know. So this is the downside of freedom. I think one of the pluses about conventional medicine is there’s a fairly well-established standard of care and you’re going to get something similar across multiple different providers. The con of that is it partially stifles creativity. Now on the other side of the coin, in the alternative camp, you’re not going to have a standard of care. So that allows more creativity, problem solving, and unique therapeutic combinations and algorithms to come out, but it also cuts both ways because then you can just have the person who’s totally off their rocker nuts, fully ensconced and confirmation biased. So there’s definitely a pro/con there. I think your comment about finding someone who a friend has worked with is smart.

Types of Chiropractic Specialties

DrMR:

Zooming out for a second, are there a few different buckets of care we can break down for people? I mean, there’s upper cervical, there’s this active release technique, ART, that are really soft tissue. There’s neurological, there’s sports. I mean, are there a few buckets that you can paint for people so that a different audience member may say, “Okay, I fit into this bucket and I’m going to try to see this type of provider?”

DrDW:

There are a lot of different techniques out there. In our profession, with my technique they’d call me a mixer. Meaning I’ll do chiropractic and then I’ll add in some nutrition or cold laser, I’d look at the whole body approach. It’s hard, and I can’t really pick a specific bucket for you, but typically people gravitate towards what they like. So you’ll go on the practitioner’s website and be like, “No, I don’t like this.” Or you’ll see something that really sparks your interest and you’ll get very excited.

DrDW:

I don’t really know exactly to answer your question. There’s no gold standard website that’s like, “These are the great doctors and these are the ones that you shouldn’t see.” Some of the busiest practices have the best marketing teams, and they’re not really getting the greatest results, but they see a lot of people.

DrMR:

This is sadly true. Maybe we can draw a partition between neurological, because there’s chiropractic neurology and we’ve had Titus Chiu on the podcast twice. There’s a certain patient sub-type here, which would be traumatic brain injury, car accidents, concussions. That’s pretty straightforward. That would be a chiropractic neurologist, and I think they do pretty excellent work. So that’s one.

DrMR:

And then there’s when you have more of a musculoskeletal issue that’s not so much directly neurological. Are you seeing something like Active Release Technique as an important facet to incorporate? I’m asking this question because what I’ve learned as part of my personal experience is this active release technique or discipline can be quite helpful, but I noticed for me it was really viscerally compelling, meaning she got in there and stripped this. But outside of that, I found it was a little bit of a miss where I think it was treating the end result of a dysfunction that was occurring upstream and the upstream wasn’t always impacted. That’s where I’ve really gravitated toward your care, because it seemed like it was less, “Well, this muscle is tight, so let’s strip the muscle.” So how would you comment on the interplay there?

DrDW:

I’ll do Active Release style work on my patients when they need it and when their body says it’s ready for it. If you see a practitioner and that’s all they do, and they pinhole you into their specific technique, you just don’t have many options for your health. If all they do is strip out muscles, well then that’s what you’re going to get when you go there, versus someone who has multiple things that they can guide your health towards to heal. I may not start doing muscle work on my patients until a few weeks in, because their body’s just not ready for it.

DrDW:

I know I’m not really answering your question, but yeah, that’s something I think our profession needs to work towards, making it so patients can get guided towards the clinician that will get them the best results. That’s why I say to ask your friends. That’s the biggest thing, or other clinicians who they’re referred to, clinicians who you love and trust, and go from there.

DrMR:

I mean, it certainly maps onto one of the things I harp on, which is looking at outcome and not getting so wrapped up in mechanism, theory, and speculation. Clinical trials are one way of measuring outcome, but in this case, you’d be at these “N of one” clinical trials, so to speak, and what does your friend have to say? Obvious caveat here, factor in the believability of your friends, because we have some friends who with everything they do say, “Oh my God, that was great!” Then they try something else and say, “That was great!” Then they try something else. I mean, nothing ever doesn’t work phenomenally well. So with those people, I take they’re recommendation with a grain of salt.

DrDW:

I think the biggest thing is that chiropractic works, so don’t be afraid to go see a practitioner. All doctors get great results, some just get better than others. We see that general chiropractic takes care of 80% of the issues. So if you have something that you feel is not that big of a deal, go see a doc and you’ll get better. If you have something that’s a little bit more intense or something that you’ve had for a long time and you need someone who’s more of a specialist, look towards that.

DrMR:

Yeah, I think that’s a great point. We don’t have to go to someone who’s uber-talented if you have more of a basic problem. I think that has a carry over to functional medicine also.

Dr. Ruscio’s Chiropractic Case

DrMR:

So one of the things that I’d like to get your take on, using me as an example, is what are common imbalances that you see? I’ve been complaining of this slight feeling of hip instability. Sometimes my left leg and gait feels just a touch unstable. It’s almost imperceptible, but it’s almost like there’s a bolt that’s one screw loosened. There’s that little bit of how this could be optimized a bit. I’ve been back in California seeing you for two weeks, and I have to admit, I do feel like it’s gotten better. It’s a little early to say because I try to look for a longer-term skew because I think after a time if there is a placebo effect that will wear off and you’ll have the more substantial therapeutic results either there or not there. So it’s a touch early for me to report, but so far I’m feeling pretty good. And so what did you find on me? I think there may have been a sacroiliac joint issue or just general weakness as I’m pretty much just weak from head to toe.

DrDW:

Even though you have big muscles, they really just don’t do anything.

DrMR:

I’m just a show pony?

DrDW:

I mean, if it’s okay for me talking about our visits. You’re not my typical patient. So when you come in, you’re overall healthy. You don’t have these huge imbalances that we need to work through first. So for you, it was pretty easy. It was just changing biomechanics of your pelvis and then integrating the muscles around that neurologically through the adjustment just to get them turned back on. So now as you walk out of my office and you live everyday life, everything just connects. Your brain knows exactly where you are in space. So as you hit the gym or sit and do podcasts, your body can heal. I know you had a little bit of a ligament injury, but a lot of the patients that come in to see me have these huge fixations. A lot of scar tissue, a lot of old damage, you didn’t really have that. So you’d be a quick healer.

DrMR:

A pretty simple case.

DrDW:

Yeah. That’s why we also integrated some cold laser with you. It was more like some soft tissue damage.

DrMR:

I’m blanking on the name, but I remember him really opening my eyes to this feed forward mechanism that adjusting helps to potentiate. Let me frame this first. According to my understanding, it’s been a few years since I’ve looked into this, but I’m assuming this physiology hasn’t changed, before a prime mover muscle engages, the smaller stabilizer muscles are supposed to turn on 30 milliseconds before or something like that. So what adjustments can do mechanistically is help correct aberrances where perhaps the small stabilizer muscles aren’t turning on just before the prime movers. And so I’m wondering with me, it feels like that could be exactly what’s going on in the hip/pelvis where the reason why my left leg feels a touch unstable is some of the hip, pelvic, and even knee stabilizers aren’t turning on that 30 milliseconds before. With the adjustment, you helped correct that aberrance, and now those little muscles are firing every step that I take with the right timing.

Helpful Diagnoses

DrDW:

Yeah. And it’s not why your left leg feels a little bit unstable, it’s why it did. That’s in the past; it’s better now. It’s very interesting actually that I bring that up. A lot of this comes from the brain. I see with a lot of my patients that they’ve seen so many practitioners and they’re literally just blocking their body’s own ability to heal.

DrMR:

Same observation, by the way.

DrDW:

I mean, I want to term it as from their other doctors, I feel like it’s black magic. So they’ll go in and see their medical doctor who will diagnosis them with this condition based off of a lab test or something that’s not very accurate. They just make a statement that pigeonholes them into a certain diagnosis, and then they literally grab onto that and they won’t let go. And it could be complete misdiagnosis, like when you go into Google and you type in your symptom and you can have anything.

DrDW:

So I had patients coming into me and they swear they have this condition. They don’t have it at all. And then really a lot of it is with my adjustments, it’s neurologically basically like reprogramming their brain to realize that they don’t have that at all. Because if you keep thinking you’re going to have it, you literally will manifest it. That could be considered placebo or not, but that’s real.

DrMR:

Certainly I’ve observed the same thing. We’ve discussed that on the podcast quite a bit in terms of fixing on to a lab finding and really entrenching themselves connected to SIBO or whatever it may be. And especially with radiograph findings, according to my understanding, there’s not a great correlation between what you see in terms of the tissue structure and the function. One family member comes to mind. Obviously a family member so I love him to death, but he has a story of, “Oh, my L5-S1 is not…” and this is why he has chronic low back pain and hip pain, not the fact that he doesn’t exercise, has a terrible diet, probably has sleep apnea. That’s almost for certain something that would not be an issue if you address those other items. But he just latches on to that one finding from seven years ago.

DrDW:

You are so right on that. I have patients that come in and they bring their X-rays in from other doctors and they’re like, “I have degenerative disc disease of my L5.” I look at their X-ray and I’m like, “Oh, well you do, but it’s like 10%.” It literally is like nothing. I’m like, “This is just normal.” My last patient that came in, he literally is bone on bone, doesn’t realize he’s bone on bone, and has zero issues there.

DrMR:

Are you saying that testing isn’t supremely helpful and tells you everything you need to know? What?

DrDW:

Right, yeah. One of the worst things that you could do as a practitioner is just like take an X-ray of someone, and then let’s say they come in, they don’t have any low back issues, but you had to take an X-ray of their hip, and their L5 gets in there. You see their L5 is like bone on bone; it’s nasty looking. The worst thing you want to do is point that out to the patient and be like, “Oh my gosh, look at your low back. It’s terrible.” And then all of a sudden, guess what they start having? Terrible low back pain and all the symptoms that go along with it. Early on, I wanted to just explain to the patient everything that we see on those X-rays. I don’t like doing that anymore.

DrMR:

Some of the things that I think the field needs to remedy is overuse of X-ray and then this point by point analysis of the X-rays. The same thing is mirrored in functional medicine with doing all these labs and then, “Let’s spend 45 minutes in a console going over all the labs. The ALT isn’t high, but it’s high normal. And your eosinophils, they’re not high, but they’re high normal. And your ratio of this and that is a little bit…” I really think this needs to stop. So it’s a very important point. I’m so glad that you raised it.

DrMR:

Let’s talk about X-rays specifically, because I think X-rays are overused in the field. I’m assuming that there are some people who are pushing back on this. What’s the state of the field as it pertains to X-rays?

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The Use of X-rays and MRIs

DrMR:

What’s the state of the field as pertains to X-rays? I mean, that’s a big, multifaceted, pretentious question, but as best you can to answer it.

DrDW:

Well that’s kind of a thing I didn’t even realize, but I know in Canada, they’re trying to pull X-ray rights from chiropractors, which I think is crazy. I mean, we take X-rays in my office, and I can’t even tell you how useful that is when you need to take them. So I don’t take them on everybody, and then when I do take X-rays, I’ve found that just taking a static film of someone isn’t very useful. So we do motion study X-rays. We take pictures of our patients in flexion, extension, and lateral flexion so we can see exactly how everything’s moving. So that shows us the biomechanics, and that lets me know where there’s been trauma, where there’s ligament laxity, where to adjust, where not to adjust. That’s very important. So I think if your doctor’s not taking X-rays or doesn’t recommend X-rays, I think it’s a very important part of your care, but also I don’t think that’s right for everyone.

DrMR:

So what percentage of patients do you think need to obtain an X-ray?

DrDW:

It’s condition specific? If it’s a very fresh injury, I don’t necessarily think that you need an x-ray, unless there’s some ligament instability that you want to rule out, or obviously if you think there’s a fracture. I really find X-rays most useful with chronic conditions where the body has a physiological change to an old injury or it’s adapted and you actually need to see that with your own eyes. As much as you feel like your hands can tell you everything that’s going on, oftentimes you need to really get a good look through the X-ray.

DrDW:

If you go and get an X-ray in a hospital, oftentimes you’re non-weightbearing. So you may be on your back versus in my office where we do them weightbearing, which I think clinically gives us a lot of information of what’s going on. It’s kind of like if you get an MRI and you’re non-weightbearing in the tube, they’re like, “Oh, you have a five millimeter disc bulge,” but then when you’re weightbearing, it’s an eight millimeter disc bulge. That’s a huge difference.

DrMR:

Are there any changes in how MRIs are being done? Is there such a thing as one that is weightbearing?

DrDW:

Yeah, definitely. There’s weightbearing, and we’ll re refer our patients to those.

DrMR:

Is it just seated though?

DrDW:

Yeah, it’s seated, which is great for a low back disc, because that’s where you end up putting the most compression on that disc anyways, but those are typically open MRIs. The patients that we refer to those typically have some psychological issues. They don’t want to be in confined spaces, or we want to see weightbearing what their disc looks like. But those also don’t have the same quality of images like a standard tube MRI.

Concussions

DrMR:

What are some of the most common imbalances that you see? I know it’s a broad brush question, but as a couple of examples or fodder for this question, we’ll see people who are maybe doing a paleo-like diet, and they’re just sensitive to FODMAPs. Helping point that out is going to help a decent facet of people. And with probiotics, they’ve kind of hopped from one product to the other. We get them on probiotic Triple Therapy and they see big results. So there’s a few kind of commonalities that seem to be helpful for a fair number of people. I’m assuming there are things like sitting too much, but what are some things that you’d want people to be aware of if you had a moment to give them some advice?

DrDW:

Honestly, the biggest thing is a neurological disconnect that patients don’t understand. Typically, I see this from an undiagnosed concussion. It could be from when you were in fourth grade. You were playing a sport, you got a minor concussion, and it was never actually addressed. You’ve spent your whole life thinking that what you’re feeling in your body is normal, and it actually isn’t. As soon as you get the neurologicals in the upper cervical region released and give your brain the proper feedback, I’ve literally had patients…

DrDW:

I have this one patient, it was pretty wild in fact. We went to high school together, and I remember he had some insane concussions playing football. Now this is like 20-something years later. I was taking care of his whole family. They’re like, “You have to see our dad,” because I was taking care of his kids. So he comes in, we do an assessment and full workup. I remember the first adjustment was adjusting his occiput. That’s right where the base of your skull attaches onto your neck. He opens his eyes after the adjustment and he looks up at the lights, and he’s like, “Oh my gosh, the lights are white!” And his wife is like, “What do you mean? The lights are white.” He’s like, “They were yellow before.”

DrDW:

So he was living his entire life with even the colors that he was seeing being completely off. And those were from concussions that supposedly had healed, but they were altering his sense of self. So for me, one of my biggest passions is I’ve had some pretty serious concussions. If it wasn’t for chiropractic care, I don’t even know where I’d be right now. But if you’ve had a concussion and you haven’t been adjusted, you need to go right away,

DrMR:

Said simply if it can be, there’s this compensatory holding pattern that you’ll see in the upper regions of the spine?

DrDW:

Yeah, upper regions of the spine. Oftentimes limited range of motion is something that you’ll feel, but really what it does is it locks your body into what’s basically a sympathetic stress state. So you’re not as well adapted to dealing with stress. You don’t sleep well. Typically you have gut issues. The Vagal nerve starts getting impaired with that, so headaches are common from there, but a lot of people don’t have that except for the bad concussions. We see visual disturbances and jaw issues, all stemming from these old injuries. And when you get that released, it is literally like you’ve seen God, like patients are crying on the table. They just feel like themselves again. It’s amazing. It’s one of my favorite things to take care of in the office.

DrMR:

This is corroborating what Titus Chiu has discussed. It seems like he’s going more squarely after post-concussion syndrome cohorts, but interesting that you guys have this overlapping observation. And I’m assuming that he’s doing some adjusting, but also some neurological exercises. Let’s maybe put on the table that there’s a few different ways that we can come at rehabbing the brain. Maybe you agree or disagree, but you could maybe make the argument that with certain range of motion and eye exercises and things like this, you can rehab the brain.

DrMR:

Taking from my time studying with the late Dr. John Donofrio, the extremities and then the upper cervical spine is a really rich method of proprioceptive input, which can really help to give that neurological feedback to help correct some of these things. So how do you parse the neurological level and then the structural level? I mean, they’re kind of intertwined because when you make an adjustment to the cervical spine, you’re going to be potentially freeing up some of these locked patterns, so to speak, but you’re also getting an immense amount of neurological or proprioceptive input. So how do you look at unraveling this knot? I know it’s complicated, I’m asking you lots of complicated questions here.

DrDW:

These are great questions. I’m actually enjoying this. This is a good topic of conversation. The biggest thing for me too is that if you’ve had post-concussion syndrome and you come in, sometimes the best thing for you isn’t an upper cervical adjustment right away. It’s knowing when your body can handle that. So if you already have neurological issues, sometimes it’s better to strengthen parts of the brain. And that’s when you want to do different eye exercises and different motion exercises. In fact, that’s when I refer out to a chiropractic neurologist. I’m not super passionate about doing the brain rehab side of things, so I’ll refer them out for that, and then when their brain’s stable, that’s when we’ll really open up their biomechanics to start feeding their brain. The last thing you want to do is take an unstable brain and then give that brain all this sensory input from the upper cervical when it hasn’t been adapting to that for 40 years.

DrMR:

I just want to quickly corroborate that. One of the things that I do in the clinic is refer people who I suspect have post-concussion syndrome to Titus Chiu’s book, BrainSAVE! because it has a self-help protocol. And for me, this can be an easy and inexpensive starting point. You don’t have to go to a doctor’s office, just go through the book protocol and read it. There are some personalizations, go through them. And what I’ve seen with some individuals is they go too gung-ho into the protocol and they get flared, which is a good thing because it tells us that we’re on the right therapeutic track, but we’re just going too aggressive. So I just want to corroborate that I’ve seen that same thing with a handful of cases.

DrDW:

Yeah, that’s exactly it. Really, as a clinician, it’s being a great observer. So if I start to do a little bit of work through the upper cervicals and I see the patient isn’t responding well, that’s when I know they’re not stable enough for this, so we have to refer out. But we know we’re on the right track because it’s creating a little bit of a flare-up. Sometimes flare-ups are the best thing for the doctor because then they really can understand what’s going on with you.

Proper Treatment of Patients

DrMR:

Yeah, and I just want to echo that. I oftentimes tell people in the clinic that if you have a flare that’s indirectly diagnostic. We may have that battle, but it’s valuable data in winning the war or advancing us to our goal. And I just want to echo that again a third time, because I think when patients are flaring, myself included, you kind of hit this despair. And I think just having knowledge that these things can be constructive really helps prevent you from going on to Google, looking up your symptoms, and just getting the worst case scenario, WebMD, cancer, or other serious disease, where you oftentimes end up.

DrDW:

Sure. Yeah, it’s the wild west out there. But as a clinician and as a patient, most of the people listening to this podcast are highly educated. If you’re noticing a flare, that’s a good thing. It lets you know you’re onto something and you’re actually making changes. So pay attention to that. And then also whatever practitioners you’re working with, make sure you’re having an open conversation with them about what’s going on.

DrMR:

Yes. Bring that data back to your doctor. Don’t just not follow up. Given that you have confidence in your doctor, that’s the main caveat to this statement, but given that you have confidence in them, one of the worst things you can do is have a flare and then go see someone else, because that’s just part of the data needed to feed into the equation to solve.

DrDW:

It is so wild. Sometimes I’ll be doing a re-exam with a patient and then they’ll bring something up to me that would’ve been so useful. Whether it’s that they had some insane result, like a patient who had constant diarrhea for 22 years or something like that, and then after their fifth adjustment, all of a sudden they had normal digestion ever since then. And she didn’t tell me, but during the re-exam on our sheets we asked if there are any other things that you’ve noticed since getting adjusted she put that down. I was like, “Well, tell me more about that.” I had no idea. Or if they’re getting a specific flare up, we need to know that right away so that way we can alter our care and make changes for our patient.

DrMR:

This is one of the reasons why I I’m drifting more and more in the direction of giving people forms where they can just give you a high-level synopsis of how they’re feeling. I think certain personality types get so wrapped up in the narrative of how they’re feeling that you’re awash in context. What the provider really needs to know is your top symptoms, are they the same, better, or worse? It can be hard if someone is talking with you because there’s so much narrative that they drift away in the story. But if they have to write it down or type it in they’re more like, “Diarrhea is gone. Bloating is better. And oh, by the way, this chronic low-level urinary incontinence I didn’t even mention has also gotten better.” So for patients, in case you ever feel a bit irritated and rightfully so, since I don’t think anyone likes filling out forms, I’m becoming progressively convinced that this is a good thing for providers to be asking patients to fill out.

DrDW:

Yeah, I agree. The other side of that is the last thing I want to do is talk to the patient about their terrible bowels during every visit. Also from a concept thing, as a practitioner I don’t want to keep telling them that they have terrible bowels and talk about it every time. One of the things that I teach patients is to disassociate from the symptoms that they’re feeling. If they come in and they’re like, “My headaches, my headaches, my headaches…” or “My migraines…” the first thing I say is, “They’re not your migraines.” Let’s let that go. The migraines, you can give those to someone else. You can do that with any issue that you have. You just don’t want to own it. You want to give those to someone else, maybe someone who you don’t like.

DrMR:

Well, I mean, these are the words of an experienced clinician and one of the reasons why, like we’ve discussed on the podcast before, we want to be careful with the language that we use. Even in the clinic, we’re changing a lot of the syndrome names. With mast cell activation syndrome, we now just say histamine intolerance, because mast cell activation syndrome sounds too pathological. And so yes, fully agreed that these things carry weight. For all the providers out there, I think it’s better to use the field terminology in your chart notes, at conferences, and with other doctors, but don’t use all these syndrome names that sound scary for patients because it’s even more stuff you can SIBO them with.

DrDW:

That’s exactly it. And the last thing you want to do is scare your patient into care.

DrMR:

Which happens. This is something that I think needs to be reformed in both functional medicine and in chiropractic, very much so.

DrDW:

Maybe in the old days that was good, but now there’s so much information on the internet and so much on YouTube that patients just start typing it in and then they become the experts on the syndrome that you gave them. You don’t want that.

DrMR:

And that they may not even have. This syndrome may only be relevant for three months. Irritable bowel syndrome will oftentimes go away, but people will look up that it’s a chronic, relapsing, remitting condition. This is true in a sense, but if you do the right stuff, then you’ll probably never have those issues again.

DrDW:

I don’t know why this just popped into my head, but I’ve had patients where their whole life has revolved around their specific condition. Everything they do, and they’re not even working because of their issue. I’ve had it where they come in, they go through an eval, we work on them and then all of a sudden it’s gone, and they’re mad. Because what else are they going to do? Their whole life has been driven towards healing this specific thing. They’ve done everything under the sun, and then all of a sudden you’ve taken their condition away from them. And then they get upset. I don’t know if you see that in your clinic.

DrMR:

Yes, we’ve talked about this on the podcast. We oftentimes will use something known as limbic retraining, which is kind of this mindfulness meditation that gets them out of that sick type of thinking. But to your point also, sometimes people come in and it’s really strange to see when I map out how simple it can be, they almost get offended. They want it to be harder and take longer than it has to. There’s kind of like that identity shift of, “What do you mean? We need to be reviewing my labs for an hour and a half. This has got to be really intense and it’s got to be even more strict advice than I’m currently on, and even more supplements.”

DrDW:

And it has to be even more expensive.

DrMR:

Right. Those are some of the most challenging cases to work with because if you’re trying to help them, but they want to make it harder than it has to be, what do you do as a clinician? Do you humor that? I mean, that’s an ethical compromise. So yeah, it can be challenging.

DrDW:

We have to sit down and have a heart to heart and we’re very goal-oriented in my office. So if you’re coming in with a shoulder issue or a low back issue or whatever it is, our biggest question is if this is gone, what is it that you want to do? What do you want to achieve? Because fixing a low back, great. It’s not that exciting to me. What’s exciting for me is getting you back to running your marathons or living your life. That’s the big goal.

Focusing on Life Goals

DrMR:

You see a lot of this in people’s presentation and in their paperwork. This is why we’ll sometimes just really address the limbic retraining as one of the first things. If it seems that people have nothing else in their life that they’re talking about, then to your point, where do they go once the symptoms are gone? There’s nothing else for them to go to. Just a reminder for people even if you’re not feeling well, that’s why it’s so important to maintain a social life. I’ve actually been thinking about this recently because like anyone else I grapple with different things, and I’ve found that there are times I don’t want to go to the gym, I force myself to, and I’m almost always happy I did. And I’m trying to catch myself in the same, “Well, so-and-so wants to grab a glass of wine, but I’m kind of in wind down mode and I don’t know if I want to go out.” I’m trying to catch myself there and push myself to do those things.

DrMR:

I mean, there are limitations. If someone sends you a text at 11 o’clock at night and you’re about to go to bed, maybe you don’t want to partake. But the point I’m trying to drive at is sometimes it’s helpful to push yourself. And I think with socialization and expanding some of those non-health related fronts, like hobbies and socialization, that can be really helpful to prevent you from falling into that reclusion. I’m always at home, I’m always thinking about food quality, I’m always monitoring my supplements and journaling about my symptoms. There needs to be a counterbalancing of that.

DrDW:

Sure. I mean, we’re looking at, like you’re saying, balance in life and it’s really living your life through your biggest values. So I think sitting down and trying to figure out what your three biggest values are in your life. For me, it’s family, healthcare, being a chiropractor, learning about health, and then music. So those are the three big things I spend all my time on. If I’m being forced to do something that’s not in my value system, that’s not going to make me happy. That’s not going to breathe life into me. It’s not going to make me healthy. So if you have values that you’re not touching on a daily basis, you have to reevaluate your life or delegate. So if you have a certain value or something that you need done and you’re always doing it and it’s not highest on your priority list, well, hire someone to do it.

Musical Inspiration

DrMR:

I completely agree that’s an important exercise to go through to make sure that you’re not drifting and you’re not maybe just doing stuff that’s totally antithetical with what you want. And I’m glad you said something about music, because I think we’re going to try to get one of your songs and put it somewhere in the podcast. Maybe intro, maybe outro, because you’ve been putting in some commendable hours, and I have to say some of your latest tracks are pretty awesome.

DrDW:

Thank you. It’s just been a hobby of mine for a long time. With coronavirus, obviously everything shut down, so I had to figure out something to do at home. I’ve always played music, but I’ve never actually written songs, and I decided to learn how to produce, record, and make some tracks. So yeah, I have some tracks out on Spotify.

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DrMR:

What’s the one? There was one in particular that we were going to use. Do you want to tell people about that song? I think what we’ll do is we’ll probably just put it as the outro. What was the song and what was the inspiration behind the song?

DrDW:

This song is called Silver Linings, and I think it will hit a lot of people, especially this past year. It hits you pretty hard. Even with all the trouble that’s going on, there’s always a light at the end of the tunnel, and this song speaks about that, but then also I wrote it so it puts you into a state of sadness and then euphoria, and then you feel like you’re breaking out of the tunnel at the end, and it’s joy. So it’s been a fun song to work on.

DrMR:

And with this song, you did the guitar, the background guitar, the guitar solos, all the vocals, and then you had a drummer and a bassist?

DrDW:

Yeah, so I don’t play drums or bass, and I don’t pretend to play those. Those are very difficult instruments. I hired some session musicians to come in and play on the track, and it was awesome. From there, once I got everything done, then I sent it out to someone who specializes in mixing and mastering and then makes it radio ready, ready for our ears.

Episode Wrap-Up

DrMR:

Well, we’ll put that as the outro music here momentarily, but before we wrap up, anything that you want to leave people with? And will you tell them about your website and where else they can find you online?

DrDW:

Sure. So I’m in Northern California at San Ramon, California. It’s like 40 minutes from San Francisco. And watermanchiro.com is where you can find me. If you want to reach out, call my office. They’ll get you in touch and we can set up a time to go over what’s ailing you. That’s about it.

DrMR:

Awesome, brother. Well, thank you for taking the time, my friend. This was a fun coffee talk and I’m glad we had a chance to expand a bit on chiropractic because in recent reflections it’s something that I have been using. It’s been helping me. And I know there can be a little bit of controversy, like almost anything. You ask different people with different interests and they may have a contentious view on conventional medicine, on alternative medicine, on diet. So I wanted to unpack some of that for people so that they have a little bit of a better understanding, and if they wanted to utilize a chiropractic professional, they’d be able to hear the good work that you’re doing and get your thoughts on how to navigate the system, so to speak. So thank you for taking the time.

DrDW:

Like I said before, chiropractors aren’t going to hurt you. Our profession is filled with doctors who all they do is care too much about their patients. So if anything, you’re not going to get great results, but you’re still going to get results. So don’t be afraid to reach out for practitioners. And if you want, you can call my office and if you want me to refer you to a doctor around you, I can definitely do that.

DrMR:

Sweet, well thank you, sir.

DrDW:

Awesome. Pleasure.

Outro:

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