A “REGULAR CASE” has a relatively short history, does not have any other complicating health issues, is straightforward diagnostically, has a well-described and evidence-based path of treatment and rehabilitation with a good chance of recovery. For example, we see low back and pelvic/hip conditions, knee and shoulder conditions, mild spine-related headaches, tennis elbow, plantar fasciitis, and the like. We expect to be able to assist with most of these conditions.

We don’t have to spend too much time with our regular patients, they are usually able to easily follow instructions, and rarely miss or change appointments.

Most of our regular patients already recognize the importance of exercise and good nutrition and value returning for regularly spaced chiropractic assessment and correction of spinal dysfunction. They also expect the assessment of their exercises to ensure the prevention of future problems (often four to six times per year).

Regular Patients usually deal with setbacks in their condition immediately and are rarely put off seeking quick and effective chiropractic treatment.

They usually do what is necessary to STAY WELL.

Below is are descriptions of three examples of a COMPLEX CASE that might attend our clinic.

Case A

Mr. Smith is a 40-year-old male who was diagnosed with fibromyalgia ten years ago. He has lived with this condition and has managed it reasonably well. He has been seeing his rheumatologist, naturopath, osteopath and clinical psychologist, all of whom have made major contributions to the stability of his condition. He exercises regularly, is careful with his diet, and is aware of his work-life balance issues. Six months ago, after a gym session with his personal trainer, he developed severe pain in his lower back. He attended his osteopath who was unable to provide any relief. He visited his rheumatologist, who organised MRI scans, which were clear of anything sinister. His naturopath increased his anti-inflammatory supplements, as he was allergic to pharmaceutical non-steroidal anti-inflammatories (NSAIDs). Some four months after the onset, his pain has spread down both legs, and he is suffering headaches and dizziness. His osteopath recommended that he attend Small Street Clinic for complex case management.

Case B

Miss Jones is a 45-year-old school teacher. 2 years ago she went on a cruise. Following her return, she has experienced persistent dizziness and neck pain. She has had full brain imaging all of which has been found to be normal. She has seen an ENT, who has cleared her of anything sinister. She has been attending her physiotherapist for treatment for 6 months, with no consistent relief. Her neighbour has suggested she attend the Small Street Clinic for a complex case consultation.

Case C

Mr. White is 65 years old and has been diagnosed with Parkinson’s Disease some 6 years before attending Small Street Clinic. He is well managed by his neurologist. His medication protocol is working well, and he is living a relatively normal life. Six months ago he developed persistent right shoulder pain. He attended his chiropractor for an assessment. He was recommended to have an ultrasound examination. The results were non-conclusive, and he had a steroid injection with no relief. His chiropractor recommended that he attend the Small Street Clinic for a complex case assessment.

The chiropractors at Small Street clinic have post-graduate training in clinical neuroscience. We have seen many hundreds of cases such as the ones described above. Each case has a common theme. That is – a neuromusculoskeletal problem with an underlying complicating neurological disorder. We feel that each of these cases can respond to a graded, titrated, individualized, manual therapy approach. We do not treat the underlying neurological (or medical) condition. We always recommend that our complex patients maintain their specialist or general medical treatment.

However, we believe that the manual therapy (Dr. Noone is a registered chiropractor) approach should be modified by deep and detailed knowledge of the underlying neurological condition, and how that condition may mitigate the therapeutic benefit of manual therapy.

The cases described above are not “real world”. Many chronic pain and dysfunction patients do not comply with treatment and exercise routines. They only deal with their issues when the pain becomes overwhelming, and drop off treatment and rehabilitation programs when the pain eases. Many of these patients are dependent on medication for relief (external locus of health control) and find it hard to make personal changes in their health behaviour and everyday life (internal locus of health control).

This makes them REALLY COMPLEX.

Case D

A REALLY COMPLEX CASE ( A real case at our clinic)

Mr. Black, 50 years old has been a type 2 diabetic for 15 years. He struggles with the management of his diabetes. He exercised as a young child and teenage years but gave up when he left school. He could never see the sense in all that running around. His sweet tooth prevails, and he finds it hard to give up full strength coca-cola; he drinks at least 2 litres per day. He is significantly overweight and is suffering from chronic knee and hip pain. He is on a waiting list for a knee replacement. His GP has recommended that he work hard on reducing his weight and blood sugar levels before his operation, but he cannot. He has had chronic foot pain. He has seen a physiotherapist (twice), osteopath (once), myotherapist (three visits), and acupuncturist (once), and a podiatrist (has orthotics), and states at the initial consultation that none of them have helped, and he feels most health practitioners are useless. His podiatrist has recommended that he visit the Small Street Clinic for treatment.

There has been a mountain of research into the health behaviour of patients who develop chronic complex NMSK health issues such as chronic low back pain and other chronic pain conditions.

(Dr. Noone completed his Doctoral Thesis-PhD in this area)

see this link for information on Dr. Noone’s PhD

A patient experiencing a “complex NMSK health problem” who visits Small Street Clinic is usually (but not always) a patient who

• has a chronic condition (“chronic” means having his or her problem for a long time; often greater than a year);
• has seen many healthcare practitioners from different healthcare disciplines for this problem without success;
• has undergone many investigations (such as X-ray, CT and MRI imaging, blood tests, etc) and has not received an adequate diagnosis and
• despite repeated attempts at therapy has not had their condition or pain resolved.
• most of the chronic, complex cases we see are related to NMSK pain and dysfunction.
• typical of these cases are chronic non-specific low back pain (CNSLBP), chronic cervicogenic headaches, fibromyalgia, chronic temporomandibular disorder, chronic neck pain, chronic central or cervicogenic balance disorders.
• Many of our complex cases have primary neurological conditions (Multiple Sclerosis, Parkinson’s Disease, Strokes, Brain Injury, Neurodevelopmental conditions, Meniere’s Disease, etc) who are seeking non-pharmaceutical treatment for chronic pain or dysfunction.
• Many complex cases are pharmaceutically well managed by their medical physicians and are seeking a complementary manual therapy approach for their problem.
• You can read some recent research (an update on systematic reviews on spinal manipulation for CNSLBP) here
• You can read some recent research on manual therapy treatment for headaches here

You most likely have many questions about our approach to complex health conditions at Small Street Clinic.

You are going to read this page and may think that we are a little bit tough on you if you are suffering from a complex NMSK health condition.

Sometimes we have to take a positive “move forward” approach with our chronic, complex cases.

Especially if you don’t want to waste your valuable time and financial resources (and we don’t want you to).

Health Psychology research reveals that if we ensure good compliance (i.e you do what we instruct you to do) from you in the first month of our treatment, your chances of achieving an improvement in the types of complex cases we see are good  (not 100%- but good).

As mentioned above, complex-case patients have good and poor health behaviours. We love those patients who have good health behaviours.

We try to identify those who have poor health behaviours. Some of these health behaviours are out of their hands (due to chronic pain or disability or access to transport), some are in their hands (long history of poor exercise and poor health choices). They can be tough to help, and unfortunately, these poor health behaviours impact their recovery and the running of our clinic (regularly forget or make late changes to appointments, are late for appointments, do not follow home instructions).

Here is a list of undesirable health behaviours of our chronic cases. This does not mean our complex cases are undesirable!! Just their behaviours, which of course they can change. (Have a good look at this list. Do you have these types of behaviours? If you do, and you are not prepared to change them, we would advise you not to come to the Small Street Clinic. You will be wasting your time and financial resources, as well as our time.)

Typical health behaviours of our REALLY COMPLEX CASES

1. find it difficult to maintain good health and nutrition behaviours due to poor health beliefs ;
2. tend not to exercise regularly-if at all;
3. sometimes feel that the resolution to their problems has nothing to do with their lifestyle;
4. have poor compliance to health instructions (miss appointments, and don’t follow through on exercise prescriptions);
5. often have a history of taking medication or receiving constant therapy as the only approach to their health problems (external locus of health control);
6. present to their health practitioner in a very bad state (typically just before Christmas) and think that many months of personal neglect can be fixed by the practitioner in one visit (and get very annoyed when that does not happen);
7. shop around to many different health care practitioners, often only seeing someone once or twice and move on when a problem lasting many months does not clear up in a couple of days;
8. due to a sense of helplessness feel “let down” by the health care system, and find it difficult to motivate themselves to engage in appropriate health behaviours;
9. constantly try to GET WELL rather than STAY WELL. (once the pain has gone, they stop doing what got them better. These patients have very short memories.)

Have a good look at that list above, and have a good look at your own health behaviours. Does this describe you? If it does, I can assure you that your health care practitioner takes a deep breath whenever s/he sees you!!

REALLY COMPLEX NMSK cases often wait too long to have their problems assessed, and by the time they do attend their health practitioner, their condition has often escalated to a very bad state. They then resort to extreme measures out of desperation, reach for strong painkillers (opioids) and rush to seek out unnecessary surgery.

We do our best to identify complex and really complex cases before they come into our clinic. We ask you to complete a questionnaire outlining your problem, and then we usually send you back a detailed email outlining all of the costs and what we expect of you before you come in. We find that less than 50% of those enquiring will not make an appointment. We feel that we have helped those patients avoid wasting their time and money, and just as importantly, our time.

 

FURTHER INFORMATION ON OUR COMPLEX CASES.

 

Complex NMSK cases sometimes develop symptoms that have nothing to do with their original trauma or illness. (see below).

The treatment of complex cases often begins by attempting to highlight aspects of their health behaviour, with an aim of changing them, and that can be very difficult!

You can see why these types of cases require more care and attention!

Who suffers from complex illness conditions?

The scientific literature does provide some guidance in answering this question.

Some people with complex health problems who attend our clinic often have more central nervous system (CNS) sensitivity than others.

They may have a genetic predisposition or experienced some sort of physical or emotional trauma during very important development years when they were quite young.

These people might experience an illness or trauma or exposure to an environmental toxin and the impact on their CNS can be quite profound compared to others.

Such patients are considered to be in a state of Central Sensitization (CS)

For a more detailed discussion on CS please click here.

What kind of conditions are considered to be Complex and due to Central Sensitization?

Scientific research experts in the area of chronic complex health conditions consider the following conditions to actually be a result of Central Sensitization in the nervous system: fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, interstitial cystitis, chronic non-specific spinal pain, tension-type headache, temporomandibular syndrome amongst others.

Unresolved spinal problems such as low back pain, mid back pain, neck pain, pelvic pain can in some cases progress to chronic complex conditions.

Trauma such as whiplash or disc injuries can trigger complex spinal pain.

The reasons why some patients’ problems become complex are myriad and often unknown. Scientific research is uncovering some answers.

It appears that higher brain and nervous system functions might be impacted by disrupted spinal function.

What kind of symptoms do complex cases experience?

Complex-case patients often have many more symptoms than those they experienced at the commencement of their illness.

Long-term unresolved spinal conditions and pain can cause patients to experience dizziness, heart rate and blood pressure changes, gut and breathing issues, (all called dysautonomia) as well as “brain-fog”. Many similar symptoms are experienced by those who have had whiplash, or mild traumatic brain injuries.

People who experience unresolved balance and dental conditions can often experience similar symptom patterns.

Similarly, poor recovery from viral infections and contact with neurotoxins found in food and some medications can lead to similar central nervous system symptoms.

How do we manage complex clinical cases at Small Street Clinic?

Most of the complex cases we see are referred by other practitioners. Ultimately, we see ourselves are part of a multidisciplinary healthcare team aiming to restore health to patients who have often been suffering for quite some time.

In many cases, we are able to identify areas we can recommend to treat or rehabilitate, but we often cannot make a specific diagnosis.

This may sound strange to potential patients looking to visit our clinic.

However, we feel that being totally honest with our complex-case patients at all times is the best way for us to proceed.

We certainly don’t hold any illusions that we have all the answers to treating a complex case. We don’t think anyone should.

Successful management of complex cases often requires a contribution from many dedicated healthcare providers.

What do Small Street Chiropractors do when managing complex cases?

Firstly, we spend a lot more time on the first consultation than we do with our “regular” patients. This can be up to an hour. We really want to find out as much about you and your problem as we can. We try to identify problems in a patient’s nervous system.

We use some safe, gentle, and scientifically validated computer tests to assess your spinal postural stability and compare your results to (ooooh, I hate using this word, but it is the scientific term) “normal” patients.

We also perform some neurological tests (that we are trained and qualified to perform) to determine how well your sensory and motor systems are working.

We then devise a combination of in-office and home-based treatment and exercises to improve your spinal biomechanical and postural function.

Research has found that improving the neurological control of your postural systems can significantly improve some complex health and pain conditions.

We then re-test you on those original assessments to see if you have improved. Sounds simple, doesn’t it? We try to make it smooth and seamless for you, but we are doing a lot of work in the background.

What happens then?

After all that, we sit down and attempt to design a rehabilitation program that matches your problem.

We expect you will do these exercises daily for at least 8 weeks (we actually prefer 12 weeks, but our experience tells us that if you can make it to 8 weeks of daily rehabilitation exercises, you will do well)

It needs this period of time to maximise neuroplasticity.

After all our examination and education, we know that you will not be the complex patient who does not do the exercises.

We find those patients quite taxing!

We don’t persist with them for too long, just to let you know.

We just don’t want you to spend all your money and time with us, and then you don’t do the home exercise routine that we recommend.

So, really, we would prefer it if you don’t come along if you are not prepared to do 10 minutes of simple neuro-training exercises (all done sitting, no running or jumping up and down!) per day.

Really….don’t come.

If you are improving, do you have to come back?

Oh yes! We are not miracle workers!

We know that the first phase of our treatment will promote neuroplasticity.

Your nervous system is starting to make new, tenuous neural connections that will ultimately help you adapt and experience some resolution in your symptoms. You will be naturally nervous and anxious during this phase, as you become aware of the sensation of neuroplasticity.

However, research has shown it is only when you have done many repeated neurorehabilitation exercises that you will experience neural binding.

This is when those new connections become strong and are less likely to be easily disrupted. The older you are the longer the process of neural binding (this can take up to 2 years)

It is during the neural binding phase that most complex-case patients cease their treatment with us. This is so unfortunate, but we understand that that is the nature of the beast. We will try our hardest to convince you to keep up the program we have set for you.

But ultimately, we are only facilitators of your health, it is really in your hands.

Your natural tendency as a patient who experiences a complex health problem will be to forget about all the information we have told you and stop doing your exercises as soon as you feel a little better.

If you do that, and you cancel or don’t turn up to a scheduled appointment, we will suspend your treatment program.

We will ask you once more to commit to the home program we have devised for you.

In the first month, you will see us weekly.

During these first four weeks, we will do a little bit of special treatment in our office, assess your recovery, and alter your rehabilitation program.

This will happen weekly for 4 weeks.

This is mandatory.

If you can’t come weekly in those 4 weeks, then don’t make an appointment.

If you live interstate or more than 3 hours away from Hampton, we do Skype/Zoom assessments with you on a weekly basis.

If you are persistently failing at doing your exercises, we stop your care at the end of a month. We have most likely tried and tried to get you to do them, but you have made up all sorts of excuses to not do them.

We just don’t have the resources to deal with that type of patient, and we will sack you from the clinic, I am sorry to say.

After that first month, we will see you every 2 weeks, then once per month for a couple of months. You should be feeling significantly better, maybe not 100%, but we will go to great lengths to remind you how bad you felt when you first visited us. It is sometimes amazing to us how our complex patients quickly forget how poorly they were!! But to be honest, that type of disconnection is a persistent feature of complex cases.

Then what happens??????

Well, when we feel you are better than 70% improved, we leave the remainder of your recovery up to you. You should keep up your exercises, be careful with your exercise, nutrition, and stress (they are all big factors in complex cases).

We will have explained to you at the beginning that we rarely achieve 100% recovery, and we will remind you of this at this stage.

We won’t book you in for further treatment but will hope you will start to take responsibility for your health, and return for intermittent, regular assessments.