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Neck Pain - Manipulation, Medication and More
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Written by Mark R. Payne, DC   
Tuesday, 25 June 2013 21:21
talk to a lot of chiropractors from all across the country. My business (Matlin Mfg. Inc.) brings me into contact with doctors from a very wide range of backgrounds and techniques. The number of techniques and therapeutic modalities used by chiropractors is extremely varied.  But almost without exception, the vast majority of chiropractors still center much of their treatment for spinal pain around the use of spinal manipulation. Manual manipulation of the spine is most often rendered in the form of High Velocity/Low Amplitude (HVLA) adjustments. So in spite of all the differences we might observe between chiropractors of differing backgrounds, there remains this one thing which the vast majority of us seem to have in common.
I've also noticed one more thing chiropractors tend to have in common. As a group, chiropractors tend to not be lacking at all in confidence as to the value of their adjustments. By far, most chiropractors tend to strongly 'believe" in the value of the adjustment. And most of the time, that's probably a good thing. This month's covered article supports the value of your adjustments compared to medications and home exercise. But beyond the author's published conclusions, I think you might find this paper thought provoking in terms of where the profession (and your practice) may be headed in the future.
The Facts:
  • This study examined 272 patients (ages 18-65) who suffered from neck pain for two-twelve weeks. 
  • Patients were randomly assigned into one of three treatment groups which received either spinal manipulative therapy (SMT), medication (M) or home exercise (HE) with advice.
  • The authors sought to determine the relative effectiveness of the three different types of care for both acute and subacute neck pain in both the short and long term.
  • The primary outcome measured in the study was pain.  Assessments were made at 2, 4, 8, 12, 26 and 52 weeks using a numerical scale from zero (no pain) to 10 (highest severity). 
  • Secondary outcomes measured included self reported disability, general satisfaction, use of medications, general health status as reported on a health survey. 
  • Spinal adjustments (SMT) were "diversified" type manipulation delivered over a 12 week period by experienced chiropractors. 
  • The specific spinal level to be adjusted was left to the discretion of the provider as determined by "palpation of the spine and associated musculature and the participant's response to treatment." Treatment also included advice to "stay active or modify activity" as determined by the practitioner.
  • Medical treatment (M) provided by a licensed physician included NSAIDS, narcotics, and/or muscle relaxants as determined to be necessary by the physician.
  • Home exercise with advice (HE) was provided in two separate one hour sessions in a university outpatient setting. The program included "simple self-mobilization exercise" of neck and shoulders.
Take Home
Chiropractic care (SMT) proved most effective than medication both in terms of pain and in most of the secondary outcomes.  Home exercise with advice (HE) was a very close second and actually produced "similar short- and long-term outcomes."   In fact, the HE group actually showed the most improvement in terms of spinal motion. Patients in the medication group fared the worst and a number of patients in the M group reported using higher levels of pain medication by the end of the study  
Many chiropractors utilize both manipulation and exercise. The authors make note of the limited difference in outcomes for the HE group and took pains to point out that " the potential for cost savings over both SMT and medication interventions, is noteworthy." 
Obviously it's neat to have evidence supporting the chiropractic adjustment over NSAIDS, pain meds and muscle relaxers. But readers should take note. This paper also highlights the comparable outcomes and significant cost savings of active care/home care programs. Doctors who fail to provide exercise plans for acute/subacute spinal pain may well find their care plans in the cross hairs as plan administrators look continually to cut costs.
The study also made me consider that all too often pain relief may be the only thing many third parties are paying attention to. Unfortunately, that's also the case with many chiropractors who simply adjust until patients feel better and then rinse and repeat whenever another exacerbation occurs. If all we do is relieve pain, then we can hardly blame interested third parties for seeking out the cheapest method available. I submit that if the profession hopes to survive and prosper, we are increasingly going to be challenged to show exactly how we produce improved clinical outcomes above and beyond the resolution of pain.
Special thanks to our Chiropractic Sciences Contributor Roger Coleman DC for this interesting article.

Bronfort G, Evans R, Anderson AV, Svendsen KH, Bracha Y, Grimm RH. Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial. Ann Intern Med. 2012;156(1 Pt 1):1-10.
Dr. Mark R Payne, Phenix City, AL is Editor of ScienceInBrief.com, a scientific literature review for busy chiropractors. He is also President of Matlin Mfg Inc. a manufacturer of postural rehabilitation products since 1988. Subscription to ScienceInBrief.com is FREE to doctors of chiropractic and chiropractic students. Reviews of relevant scientific articles are emailed weekly to subscribers.

Evidence-Based Chiropractic
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Written by Mark R. Payne, DC   
Tuesday, 25 June 2013 20:54
n 2011, Spine published an article that bears reading by every chiropractor. The study, entitled “The Pros and Cons of Evidence-Based Medicine” (Croft et al.), takes a look at the continuing debate within the medical profession as to the proper role of “evidence-based medicine.” The authors’ comments should be food for thought for chiropractors interested in keeping their practices on sound scientific footing. As you will see, the value of EBM is a subject that may be viewed quite differently by “researchers, clinicians, and policy makers.”
The Facts:
  • spinesEvidence-based medicine is the idea that current scientific evidence can be combined with the clinician’s expertise, as well as the patient’s preferences and expectations, to obtain the best outcomes.
  • The “evidence” usually comes in the form of original research and systematic reviews of current scientific literature on a given subject. 
  • Some argue that evidence could also mean observations and the clinical experience of the practitioner, even if there isn’t published data to back up those observations. In that case, the term “evidence-based” may more rightfully be called “experience-based” medicine.
  • Often the “evidence” eventually ends up in published clinical guidelines. The authors note that “much of the evidence in any clinical guideline is likely to come from expert opinion.”
  • Guidelines often combine expert consensus, scientific research, clinical practice, observation, and clinical judgment to produce their recommendations.
  • Unfortunately, there is a significant risk of bias among “experts” and the term “evidence-based medicine” may not be entirely appropriate.
  • The authors note that EBM can help make clinical practice more transparent, reduce random variables in treatment protocols across the professions, and even help reduce or eliminate harmful/ineffective treatment methods.
  • They also state that EBM has been accused of refusing to give credence to valid information unless it is derived from randomized controlled trials. This can be very limiting because the ability to assess treatment using the rigid structures of clinical trials can often be confounded for “practical or ethical” reasons. For this reason, many common forms of treatment currently are accepted as standard practice even though there is little or no evidence in the form of clinical trials. 
  • In reality, the daily decisions that doctors and patients must make are much more complex than the structured design of clinical trials. 
  • Furthermore, too many sources of information or too many highly detailed clinical guidelines may result in practitioners choosing to simply ignore all or part of the recommended care for a given condition.
Of particular relevance to chiropractors is this comment made by the authors: “In the field of low back pain, EBM rarely provides the basis for action in a primary care consultation.” For example, most clinical trials evaluate only a single-treatment intervention. In real life, though, chiropractors often use multiple interventions (adjustments, ice, muscle stimulation, etc.) simultaneously. The use of multiple interventions may result in improved outcomes regardless of whether or not the treatment methods have ever been studied together in concert. Limiting our treatment only to those methods that have been thoroughly researched may easily hamstring our best efforts to treat patients.
As the chiropractic profession continues to move toward evidence-based practice guidelines, it’s also good to remember the ever-present potential for bias. Research by chiropractors, for example, might tend to be biased in favor of spinal manipulation as a treatment while other studies by MDs or PTs might easily be less favorable. It’s also worth remembering that treatment guidelines are to “skew toward select areas where evidence has been gathered, and away from interventions for which research is lacking, regardless of efficacy.” In the same vein, it should also be understood that the constant demand for more evidence before particular treatment methods are allowed is likely to retard progress and stifle creativity.
Finally, clinical practice guidelines are increasingly being used as far more than recommendations for treatment. Insurers frequently cite lack of evidence as justification for denial of payment. Failure to follow published treatment guidelines may too easily become the basis for a lawsuit. It’s worth remembering that a lack of good data on a particular therapy or treatment tells us absolutely nothing as to the efficacy, or lack thereof, of the method (a fact many insurers conveniently seem to overlook). 
Take Home
Taken too far, overreliance on EBM can serve to stifle professional judgment and negate the value of hard won experience. So what to do? Should we just ignore all the “evidence” and proceed to randomly do whatever we like in our clinics? Not at all, but neither should we proceed as if we’re totally blinded by the presence (or lack) of evidence. The debate about the value of EBM will likely continue. Established standards of professionalism demand we stay current as to the best available evidence. However, being the doctor has always required practitioners to think, evaluate, and temper that knowledge with professional experience and judgment. Special thanks to our chiropractic sciences contributor Roger Coleman, DC for this thought-provoking article. 

Croft P, Malmivaara A, van Tulder M. The pros and cons of evidence-based medicine. Spine. 2011;36:1121-5.
Dr. Mark R Payne, Phenix City, AL is Editor of ScienceInBrief.com, a scientific literature review for busy chiropractors. He is also President of Matlin Mfg Inc. a manufacturer of postural rehabilitation products since 1988. Subscription to ScienceInBrief.com is FREE to doctors of chiropractic and chiropractic students. Reviews of relevant scientific articles are emailed weekly to subscribers.

Integral Applications for Exercise Therapy
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Written by Jeffrey Tucker, DC, DACRB   
Tuesday, 25 June 2013 18:55
t’s common for patients to come to our office with complaints related to ‘working out’ or ‘over-training’ and not enough rest and recovery in between workout sessions. I see clients involved with athletic pursuits like cross fit, yoga, martial arts, running 5 K’s, swimming, biking, and/or other sports. We have such extremes in the population, those who sit way too much and wind up getting dehydrated and inhibited glutes from excessive and prolonged sitting (they never get physical activity), and those who are exercise ‘junkies.’ I think it’s important as part of the patient history for doctors to question clients about there past and current exercise routines and programs. My hope is that you are able to provide knowledge and have the ability to write exercise programs for home, or at-the-gym sessions for patients in a way that allows for recovery and (high) performance.
I like using the following ‘exercise template’ when educating patients on what a long-term exercise program includes:
  1. Perform self-myofascial release using foam rolls, sticks, and “knot-outs” as the beginning of an exercise session. These are tools to break up hypertonicity and tension in muscles.
  2. Perform stretching (static and dynamic) on the overactive muscles. I teach my clients techniques using the ‘Stretch straps’, yoga straps, and bands.
  3. Perform movements or isometric exercises that re-awaken and/or strengthen the core and underactive muscles. These are usually bodyweight or thera-band exercises targeted at isolated weak stabilizers muscles.
  4. Perform whole body integrated exercises that will add lean muscle and decrease fat.
  5. Next, if the client has more time and wants to perform cardio work, this is where I place it.
After talking with patients and hearing what they do or don’t do physically, my suggestions begin first with ‘remove the negatives’. I discuss proper posture, breathing, hydration, diet, supplements, attitude, and sleep. I want to make sure patients are doing the right thing and not the wrong (negative) thing in each of these categories. In addition some patients need to “add in” cardio, strength, or flexibility training depending on there goals. The ‘fatty-bomba-lattes’ who do absolutely no physical activity need to start a walking program; the long distance runner, swimmer or cyclist might need a flexibility program; the Country Western dancer’s and the ‘dance-with-the stars’ people might need some strength training; the yoga dominant person might need some free weight training; the weight lifter might need some cardio and flexibility added on. Depending on the patient’s goals (fat loss, finish a marathon, flexibility, etc), I often find the program they designed isn’t “enough” on its own.
Physique-related goals are popular these days. Women want to lose pant sizes and men want to look good without a shirt on. No matter the goal, I still like the functional approach - start with teaching patients how to use the foam roll to inhibit overactive muscles, then teach a little stretching to those same overactive muscles, then do a little bodyweight or band exercises to the underactive muscles, then teach the “conventional” weight lifting approaches, then do some cardio. For fat loss, it isn’t really necessary for someone to have to add steady state cardio. An improved nutritional plan and consistent 20-30 minute workout with bodyweight exercises, bands, balls, free-weights or kettlebells produces incredible results.
Mobility and stability: Our typical patient who has a ‘ginger’ or ‘sensitive’ low back, usually needs some mobility and some stability work. The starting point to enhanced stability training begins with improvements in mobility. The stability work gives clients joint protection, helps get them stronger, and this reinforces the new mobility and the new mobility makes improved stabilization possible. This sort of dual reinforcement (mobility and stability training) is powerful—it can motivate people to permanently adopt a healthier workout lifestyle.

Whether your patient is into yoga, power training, competitive sports, martial arts, or other athletic pursuits, I am seeing more and more clients that seem to short change their rest and recovery. I also see clients who are repetitively lifting weights using bench press and biceps curls and this contributes to a forward head and forward shoulders posture.  At the end of the article I’ll give you an example workout of how I have made a corrective exercise/conditioning program work within one of my patient’s lifestyle who has been working heavy on the chest. This patient and I have created the long-term goals of improving posture. The routine is specifically designed with enough rest days to allow for the inclusion of other sports and activities. The program I wrote for the patient is especially upper body focused, but emphasizes the back side. Just keep in mind that if your patient’s “extracurricular activities” are particularly upper body inclusive you may wish to choose a lower body routine to work with. If they are cardio dominant, make sure they have a flexibility program.

Personally, I like shorter duration workouts aimed towards skill building, optimal movement patterns, and the control of maximum tension where needed in each rep.

An important thing to remember with both cardio and weight lifting training is that less is often more. I teach my clients to keep strict form and coordinated full body tension with each exercise—while not training to failure. In my opinion, practicing flexibility, strength training (I prefer about 6 reps and 2-3 sets), balance training, and cardio workouts can be done with high intensity and short rest periods between sets. Think of a marathon vs. a sprint—to run a marathon, the athlete will need to pace themselves. In a sprint, the athlete will basically go “all out” for a short period of time. Personally, I like shorter duration workouts aimed towards skill building, optimal movement patterns, and the control of maximum tension where needed in each rep.
I like to write exercise programs for patients that I ‘change up’ about every 6-10 weeks. It usually takes patients several weeks to adapt to this type of progressive exercise training. The weeks following the example below would have variations in the band, the ball, kettlebells and free-weights. This is a fairly typical example of my program training for a patient that needs back work to improve posture:
Monday: 5-8 minutes of foam roll, stick, or “knot out” especially to the hip flexors, lats, pecs and thoracic spine; 5 minutes of stretching to the hip flexors, lats, pecs and thoracic spine; 10-15 minutes of alternating Turkish-get-ups on the right and left side and doing 20 kettlebell swings.
Tuesday: 5-8 minutes of foam roll, stick, or “knot out”; 5 minutes of stretching; 5-10 minutes of 30 – 60 second isometric plank holds, side bridges, birddog, glute bridges; 5-10 minutes of kettlebell swings. The swing technique for this workout is 15-20 reps range followed by 20-30 seconds of rest.
Wednesday: 5-8 minutes of foam roll, stick, or “knot out”; 5 minutes of stretching; 5-10 minutes of isometric planks (prone, supine, side) and “stir the pot” position holds with forearms on the ball (ensuring scapula stability); 5-10 minutes of Y-T-W-L maneuvers. I have them finish with hands held overhead with band resistance doing squats – usually 2 sets of 8-10 reps is enough. Optional: cardio work.

Sunday: Rest/Recovery/Mobility. Be with loved ones.

Thursday: Rest/Mobility/Yoga practice. I usually suggest some resisted neck retraction work using the bands on this day.
Friday: 5-8 minutes of foam roll, stick, or “knot out”; 5 minutes of stretching; 5-10 minutes of 30 – 60 second isometric plank holds, side bridges, birddog, glute bridges; 5-10 minutes of kettlebell swings. The swing technique for this workout is 15-20 reps range followed by 20-30 seconds of rest.
Saturday: 5-8 minutes of foam roll or “knot out”; 5 minutes of stretching; 5-10 minutes of Y-T-W-L maneuvers. A 5-10 minute kettlebell challenge circuit workout or band work – usually includes 1 arm rows, 2 arm rows, supine pulls.
Sunday: Rest/Recovery/Mobility. Be with loved ones.

Dr. Jeffrey Tucker is the 2012 ACA Rehab Council Doctor of the Year. He is a certified instructor for the Functional Movement Screen (FMS) workshops, on the education committee for the Hygenic Corporation, and is a post-graduate instructor for the Diplomate program offered by the American Chiropractic Rehabilitation Board. Visit his website at www.DrJeffreyTucker.com
Does Experience Really Matter?
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Written by Mark R. Payne, DC   
Saturday, 25 May 2013 15:04
ost of us who have been in practice for a while would probably prefer to think that our accumulated experience must be of some benefit to our patients. Personally, I prefer a bit of experience in some professions... airline pilots for example (I just feel better when I see a gray haired, "Captain Sully" type in the cockpit!). But as you'll see, experience may not always be the best teacher when it comes to the practice of medicine. This month's column recaps our review of a 2011 article which sought to determine how physician experience might impact patient outcomes within a hospital setting. And while we don't have a comparable study that applies specifically to chiropractic, this study should provide food for thought, especially for those of us who have been in practice for a while. Thanks to our chiropractic sciences contributor Roger Coleman, DC (Othello, WA) for this interesting article. I hope you find it helpful.
The Study: Longer lengths of stay and higher risk of mortality among inpatients of physicians with more years in practice
The Facts:
  1. It has been reported that physicians who have more years in practice do not adhere as closely to established practice guidelines.
  2. The authors sought to determine if the number of years a physician had practiced was associated with any differences in patient outcomes.
  3. They looked at 59 physicians and 6,572 patient admissions.
  4. Physicians were divided into 4 groups.
  5. The groups were composed of physicians who had practiced 0-5, 6-10, 11-20 and over 20 years.
  6. Patients who were treated by each group of physicians tended to be rather similar.
  7. The length of hospital stay for patients was shortest for physicians with 0-5 years of practice experience at 4.77 days. The 6-10 years of practice physician group averaged 5.29 days of patient stay. Doctors with 11-20 years of practice averaged 5.42 days of patient stay while those with over 20 years of practice averaged slightly less at 5.31 days of patient stay.
  8. However, both "in hospital" mortality and the mortality within 30 days of discharge was highest among patients treated by physicians having 20+ years of practice experience.
Take Home
Years of practice time may not equate to better outcomes. Regardless of experience, everyone needs to adhere to best standards of practice.

...encouragement for providers, such as yourself, who are making the effort to stay up to date with the scientific literature.

Reviewer's Comments
I was surprised because I thought more experience would result in better outcomes. This may come as a wakeup call to keep providers on their toes and motivate them to stay up-to-date throughout their career.  This would also seem to be an encouragement for providers, such as yourself, who are making the effort to stay up-to-date with the scientific literature.
Roger Coleman, DC
Southern WN, Bellin EY, Arnsten JH. Longer lengths of stay and higher risk of mortality among inpatients of physicians with more years in practice. Am J Med. 2011 Sep;124(9):868-74.
Link to Abstract:
Dr. Mark R Payne, Phenix City, AL is Editor of ScienceInBrief.com, a scientific literature review for busy chiropractors. He is also President of Matlin Mfg Inc. a manufacturer of postural rehabilitation products since 1988. Subscription to ScienceInBrief.com is FREE to doctors of chiropractic and chiropractic students. Reviews of relevant scientific articles are emailed weekly to subscribers.
What Is Functional Medicine?
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Written by Ronald Grisanti, DC, D.A.B.C.O., D.A.C.B.N., MS   
Saturday, 25 May 2013 14:29
unctional Medicine is patient-centered medical healing at its best. Instead of looking at and treating health problems as isolated diseases, it treats individuals who may have bodily symptoms, imbalances, and dysfunctions. 
diseasesandunderlyingcausesAs the following graphic of an iceberg shows, a named disease such as diabetes, cancer, or fibromyalgia might be visible above the surface, but according to Functional Medicine, the cause lies in the altered physiology below the surface. Usually, the cause of the disease and its symptoms is an underlying dysfunction or an imbalance of bodily systems.
Named diseases are just the tip of the iceberg. Below the surface, according to Functional Medicine, are the real causes of a patient's health problems.
If health care treats just the tip of the iceberg, it rarely leads to long-term relief and vibrancy. Identifying and treating the underlying root cause or causes, as Functional Medicine does, has a much better chance to successfully resolve a patient's health challenge.
Using scientific principles, advanced diagnostic testing, and treatments other than drugs or surgery, Functional Medicine restores balance in the body's primary physiological processes. The goal is the patient's lifelong optimal health. 
How Functional Medicine Heals a Key Health Care Gap
Today's health care system is in trouble because it applies a medical management model that works well for acute health problems to chronic health problems, where it is much less successful.
If you have a heart attack, accident, or sudden lung infection such as pneumonia, you certainly want a quick-thinking doctor to use all the quick-acting resources of modern medicine, such as life-saving technology, surgery, and antibiotics. We are all grateful for such interventions.
However, jumping in with drugs, surgery, and other acute care treatments often does not succeed in helping those with chronic, debilitating ailments, such as diabetes, heart disease, or arthritis. Another approach is needed.

The Two-Pronged Healing Approach of Functional Medicine
To battle chronic health conditions, Functional Medicine uses two scientifically grounded principles:
  1. Add what's lacking in the body to nudge its physiology back to a state of optimal functioning.
  2. Remove anything that impedes the body from moving toward this optimal state of physiology.
Plainly put, your body naturally wants to be healthy. However, the body may be missing things needed to function at its best, or something might be standing in the way of its optimal functioning. Functional Medicine first identifies the factors responsible for the malfunctioning. Then it deals with those factors in a way appropriate to the patient's particular situation.
Functional Medicine practitioners often use advanced laboratory testing to identify the root cause or causes of the patient's health problem. Old-fashioned medical diagnosis helps too, in the form of listening carefully to the patient's history of symptoms and asking questions about his or her activities and lifestyle.
For treatment, Functional Medicine practitioners use a combination of natural agents (supplements, herbs, nutraceuticals, and homeopathics), nutritional and lifestyle changes, spiritual/emotional counseling, and pharmaceuticals, if necessary to prod a patient's physiology back to an optimal state. In addition, educating patients about their conditions empowers them to take charge of their own health, ultimately leading to greater success in treatment. 
Treating Symptoms Versus Treating the Person
In the dominant health care model today, medication is used to get rid of people's symptoms. If the patient stops taking the medication, symptoms generally return. 
Functional Medicine approaches health problems differently. Instead of masking the problem, it aims at restoring the body's natural functioning. Although Functional Medicine practitioners may prescribe pharmaceuticals, they use medications to gently nudge the patient's physiology in a positive direction so the patient will no longer need them.

Another important saying by Osler is: "If you listen carefully to the patient, they will tell you the diagnosis."

For example, conventional doctors would normally prescribe pharmaceuticals like Prilosec, Prevacid, or Aciphex to treat acid reflux or heartburn. When the patient stops taking such drugs, the heartburn symptoms come back. In contrast, a Functional Medicine practitioner might find that a patient's acid reflux is caused by Helicobacter pylori bacteria. Eradicating the Helicobacter pylori might very well lead to the end of heartburn symptoms, permanently.
It's also important to note that in Functional Medicine treatment for similar symptoms might vary tremendously for different patients, according to their medical histories and results of laboratory tests. Factors that can come into play in producing the same symptoms include toxic chemicals, pathogenic bacteria, parasites, chronic viral pathogens, emotional poisons like anger, greed or envy, and structural factors such as tumors or cysts. 
The Roots of Functional Medicine 
You may be surprised to learn that the concept of Functional Medicine isn't new. It actually represents a return to the roots of modern scientific medicine, captured in this statement by Sir William Osler, one of the first professors at Johns Hopkins University School of Medicine and later its Physician-in-Chief: "The good physician treats the disease; the great physician treats the patient who has the disease."
Another important saying by Osler is: "If you listen carefully to the patient, they will tell you the diagnosis." This encapsulates the importance that Functional Medicine places on taking a thorough history from the patient.
Your Experience of Functional Medicine
When you consult a Functional Medicine practitioner, the first step is always your history. Practitioners are trained on how to unravel and make sense of a complicated story. Often clues in the story lead to the identification of key imbalances.
The next set of clues comes from a comprehensive physical examination, which includes many nearly forgotten examination procedures used by famous diagnosticians (both living and long gone), such as chapman reflex points, ankle brachial reflex, and nail inspection.
The final set of clues comes from advanced laboratory testing. Innovative, cutting-edge lab tests help the practitioner look deeply into a patient's physiology to identify how it has been compromised and how physiological balance can be restored.
After diagnosis and treatment, a Functional Medicine patient can expect his or her symptoms to diminish in severity, along with a renewed sense of well-being and significant increase in health and vitality.
A Functional Medicine Sampler of Case Studies

CASE 1: Sinus Infections and Allergies

Traditional Medical Approach: 
The patient was an adult male with a chief complaint of sinus infections and allergies for a period of six years. He had previously consulted with three medical physicians. Medical testing included a CT scan of the sinuses, which was negative for any pathology. Treatment consisted of the following prescriptions: Sudafed, Claritin-D, and Allegra. Results were poor.
Functional Medical Approach: 
Based on an extensive history and review of his medical records, Dr. Grisanti ordered an Airborne Allergy test and food sensitivity test. The results revealed that the patient was highly allergic to Aspergillus fumigatus and Alternaria alternata molds. Dr. Grisanti instructed the patient in how to identify molds in his residence and at work and what steps to take to eliminate them. The patient was prescribed a natural pharmaceutical that increases his immune system's defense against molds and fungi.

After three weeks, the patient was completely free of symptoms and has remained that way for the past two years.
CASE 2: Irritable Bowel Syndrome and Fatigue
Traditional Medical Approach:
The patient was a 27-year-old female with an 11-year history of irritable bowel syndrome and fatigue. She had previously consulted with four medical physicians before scheduling an appointment with Dr. Grisanti.
Medical testing included an upper and lower GI study and colonoscopy, all of which were found to be negative for any pathologies. Treatment consisted of the prescription Hyoscyamine. Results were poor.
Functional Medical Approach:
Based on an extensive history and review of her medical records, Dr. Grisanti ordered a Digestive Stool Test and Allergy Blood Test. Two bacterial pathogens were found to be infecting her intestines: Pseudomonas aeruginosa and Citrobacter freundii. The medical literature clearly linked these two pathogens to diarrhea disease. In addition, her allergy test revealed a significant sensitivity to gluten and rice. The patient was prescribed a natural pharmaceutical that helped eradicate the two bacterial pathogens and was placed on an elimination diet addressing the rice and gluten. 
After one month, she was symptom-free.
CASE 3: Menopausal Symptoms
Traditional Medical Approach:
The patient was a 61-year-old female with menopausal symptoms, including hot flashes, decreased libido, and weight gain over a period of five years. The patient had previously consulted with one medical physician, who performed no medical testing. Treatment consisted of the prescription Estrace. 

Results were fair, but the patient was concerned about the drug's potential side effects.
Functional Medical Approach:
Based on an extensive history and review of the patient's medical records, Dr. Grisanti ordered a Women's Hormonal Panel. The results were quite revealing. Her estrogen/progesterone balance was significantly compromised, with too much estrogen and not enough progesterone. This imbalance was the main cause of the patient's roller-coaster emotional challenges.
After presenting this information to her physician, she was prescribed the proper balance of estrogen and progesterone. The patient eventually went to a compounding pharmacy and had a special formula of estrogen/progesterone made. She became symptom-free and experienced an increase in energy.
In addition, she lost 54 pounds in eight months.

Ronald Grisanti DC, D.A.B.C.O., D.A.C.B.N., MS, is medical director of Functional Medicine University. If interested in improving your diagnostic skills and increasing your community reputation and recognition, we strongly recommend subscribing to our Free Clinical Rounds Series. These challenging case studies will give you the unique opportunity to test your clinical skills and, at the same time, improve your ability to handle many of the most difficult cases. Go to the following link to get your free access: www.ClinicalRounds.com.

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