Review the latest news:
Top undiagnosed causes of hip pain
High false positive carpal tunnel rate for NCV’s
Therapeutic tape for tennis elbow and shoulder dysfunction
Low vitamin D may contribute to scoliosis
Surprise: ultrasound works for ______ but not _______
Head & Spine
1. A small study of 31 patients with forward head posture found “The combination of upper cervical and upper thoracic spine mobilization indicated better overall short-term outcomes in craniovertebral angle, numeric pain rating scale, and respiratory function, compared with deep cervical flexion exercises.” Cho J et al. Upper cervical and upper thoracic spine mobilization versus deep cervical flexors exercise in individuals with forward head posture: A randomized clinical trial investigating their effectiveness. J Back Musculoskelet Rehabil. 2018 Dec 10. doi
2. Manual Therapy Wins Again!
A new JAMA randomized clinical trial of 259 lumbar spine stenosis (LSS) patients compared the effectiveness of three non-surgical options and concluded ”Manual therapy/individualized exercise had a greater proportion of responders in symptoms and physical function (20%) and walking capacity (65.3%) at 2 months compared with medical care (7.6% and 48.7%, respectively) or group exercise (3.0% and 46.2%, respectively). Although LSS is a chronic degenerative condition, patients with LSS can show improvement in walking capacity with nonsurgical approaches.”Schneider MJ, Ammendolia C, Murphy DR, et al. Comparative Clinical Effectiveness of Nonsurgical Treatment Methods in Patients With Lumbar Spinal Stenosis: A Randomized Clinical Trial. JAMA Netw Open.2019;2(1):e186828. doi:10.1001/jamanetworkopen.2018.6828
3. Short-term rigid and Kinesio taping may help improve scapular dyskinesis and pectoralis minor length in overhead athletes.” Ozer, S. T., Karabay, D., & Yesilyaprak, S. S. (2018). Taping to Improve Scapular Dyskinesis, Scapular Upward Rotation, and Pectoralis Minor Length in Overhead Athletes. Journal of Athletic Training (Allen Press), 53(11), 1063–1070.
4. Another study of 30 overhead athletes confirmed positive effects of therapeutic taping on scapular joint position sense and movement control. Shih, Y.-F., Lee, Y.-F., & Chen, W.-Y. (2018). Effects of Kinesiology Taping on Scapular Reposition Accuracy, Kinematics, and Muscle Activity in Athletes With Shoulder Impingement Syndrome: A Randomized Controlled Study. Journal of Sport Rehabilitation, 27(6), 560–569.
5. A study of 23 minor league baseball players found: “Stretching the contralateral SI joint improved Glenohumeral Rotation Deficits (GIRD) more than the sleeper’s stretch.”
Left SI stretch for Right-sided GIRD – While lying supine, grab your left knee with your right hand and forcefully pull your knee toward your right shoulder while fully abducting your left arm and shoulder in the opposite direction. Hold this position for 30 seconds and repeat three times. Romano V, Romano J, Gilbert GE. Sacroiliac Stretching Improves Glenohumeral Internal Rotation Deficit of the Opposite Shoulder in Baseball Players in a Randomized Control Trial. J Am Acad Orthop Surg Glob Res Rev. 2018;2(10):e060. Published 2018 Oct 8. do
6. A study of 46 participants with shoulder impingement concluded: “The effect of high-intensity laser therapy plus exercise is not higher than exercise alone to reduce pain and improve functionality in patients with subacromial syndrome.” Aceituno-Gómez J, Avendaño-Coy J, Gómez-Soriano J, García-Madero VM, Ávila-Martín G, Serrano-Muñoz D, González-González J, Criado-Álvarez JJ. Efficacy of high-intensity laser therapy in subacromial impingement syndrome: a three-month follow-up controlled clinical trial. Clin Rehabil. 2019 Jan 23.
7. A study of 30 lateral epicondylopathy patients found: “Therapeutic taping in addition to exercises is more effective than sham taping and exercises only in improving pain in daily activities and arm disability.” Giray E, Bingul DK, Akyuz G. The effectiveness of kinesiotaping, sham taping or exercises only in treatment of lateral epicondylitis: A randomized controlled study. PM R. 2019 Jan 4.
8. In patients with acute tennis elbow symptoms: “A counterforce brace provides significant reduction in the frequency and severity of pain in the short term as well as overall elbow function.” Kroslak M, Pirapakaran K, Murrell Gac. Counterforce Bracing Of Lateral Epicondylitis: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Clinical Trial. J Shoulder Elbow Surg. 2019 Feb;28(2):288-295. Doi: 10.1016/J.Jse.2018.10.002.
Did you know that radial tunnel syndrome mimics lateral epicondylopathy?
While a counterforce brace may help LE, it will likely aggravate RTS. Take our 7-question quiz to test your ability to differentiate.
9. A study of 50 patients found that “extracorporeal shock wave therapy (ESWT) and therapeutic ultrasound are equally effective in the treatment of lateral epicondylosis.” Yalvaç B, Mesci N, Geler Külcü D, Volkan Yurdakul O. Comparison of ultrasound and extracorporeal shock wave therapy in lateral epicondylosis. Acta Orthop Traumatol Turc. 2018;52(5):357-362.
10. A study of 40 asymptomatic hands found that nerve conduction studies had a high false positive rate (43%) for carpal tunnel syndrome; while the false positive rate for diagnostic ultrasound was lower (23%).
Fowler JR et al. False-Positive Rates for Nerve Conduction Studies and Ultrasound in Patients Without Clinical Signs and Symptoms of Carpal Tunnel Syndrome. J Hand Surg Am. 2019 Jan 8. pii: S0363-5023(18)30599-9. doi: 10.1016/j.jhsa.2018.11.010. [Epub ahe
11. In patients with mild carpal tunnel syndrome, use of a splint is an appropriate and sufficient treatment.
Hesami O, Haghighatzadeh M, Lima BS, Emadi N, Salehi S. The effectiveness of gabapentin and exercises in the treatment of carpal tunnel syndrome: a randomized clinical trial. J Exerc Rehabil. 2018;14(6):1067-1073. Published 2018 Dec 27. doi:10.12965/jer.1
SI & Hip
12. In patients younger than 50, greater than 85% of hip pain that is undiagnosed or misdiagnosed by primary physicians falls into one of the four following diagnoses:
13. The A study of 36 patients with patellofemoral pain found “altered gluteus medius, vastus medialis oblique (VMO), and vastus lateralis (VL) muscle activity during single leg stance and single leg squat compared to healthy subjects.”
Mirzaie GH et al. Electromyographic activity of the hip and knee muscles during functional tasks in males with and without patellofemoral pain. J Bodyw Mov Ther. 2019 Jan;23(1):54-58. doi: 10.1016/j.jbmt.2018.11.001. Epub 2018 Nov 9.
Hip Abductor Weakness & Knee PainTo learn more about hip abductor weakness and knee pain, check out this ChiroUp 15 minutes to excellence webinar.
14. “The addition of therapeutic ultrasound did not improve the efficacy of conservative treatment for plantar fasciitis. Therefore, the authors recommend excluding therapeutic ultrasound from the treatment of plantar fasciitis and agree with results of previous studies that stretching may be an effective treatment for healing plantar fasciitis.”
Wagner, Eric R.; Solberg, Muriel J.; Higgins, Laurence D. The Utilization Of Formal Physical Therapy After Shoulder Arthroplasty. Journal Of Orthopaedic & Sports Physical Therapy Nov2018, Vol. 48 Issue 11, P856
15. A systematic review found that “low-level laser therapy (LLLT) in patients with plantar fasciitis significantly relieves the heel pain and the excellent efficacy lasts for 3 months after treatment.”
Wang W et al. Clinical efficacy of low-level laser therapy in plantar fasciitis: A systematic review and meta-analysis. Medicine (Baltimore). 2019 Jan;98(3):e14088. doi: 10.1097/MD.0000000000014088.
16. Consider testing scoliosis patients for vitamin D deficiency: “We postulate that vitamin D deficiency and/or insufficiency (negatively) affects Adolescent Idiopathic Scoliosis development by its effect on the regulation of fibrosis, postural control, and bone mineral density.”
Ng SY, Bettany-Saltikov J, Cheung IYK, Chan KKY. The Role of Vitamin D in the Pathogenesis of Adolescent Idiopathic Scoliosis. Asian Spine J. 2018;12(6):1127-1145.
17. A systematic review of 22 studies found: “strength training is beneficial and can be used to treat fibromyalgia. The main results included reduction in pain, fatigue, number of tender points, depression, and anxiety, with increased functional capacity and quality of life.”
Andrade A et al. A systematic review of the effects of strength training in patients with fibromyalgia: clinical outcomes and design considerations. Adv Rheumatol. 2018 Oct 22;58(1):36. doi: 10.1186/s42358-018-0033-9.
18. “A single session of chiropractic manipulative therapy was shown to have an immediate effect of reducing the time required for asymptomatic special operations forces personnel to complete a complex whole-body motor response task.”
DeVocht JW et al. Effect of chiropractic manipulative therapy on reaction time in special operations forces military personnel: a randomized controlled trial. Trials. 2019 Jan 3;20(1):5. doi: 10.1186/s13063-018-3133-2.
Your office may be the place where good ideas come to fruition and productivity soars, but it can also be a place that triggers back pain, neck strain, and carpal tunnel. Imagine the amount of strain that is placed on your body while simultaneously sitting in a chair, hunching over a keyboard, and balancing a phone between your shoulder and ear. And full-time workers do that for over 2,000 hours each year! Consider these tips to help pain-proof your office or workstation.
1. Choose the right chair – Finding the right chair is as important as finding a good quality mattress. Remember – 2,000 hours a year… that’s a lot of sitting. Make sure you’re comfortable. You don’t want anything that lacks support for your lower back and make sure you can adjust the seat height. Your feet should always rest flat on the floor so your knees are level with your hips.
You could always skip the quest to find the perfect chair and opt for a standing desk instead; which has been shown to combat many of the scary consequences associated with prolonged sitting.
2. Think ergonomically when setting up your workstation – Computer monitors should be visible without having to lean in or strain. The top line of type should be at or 15 degrees below eye level. This helps you maintain proper posture and prevent neck strain from looking down. Also, use audio equipment that keeps you from bending your neck (i.e., Bluetooth, speakerphones, headsets).
Keep carpal tunnel symptoms at bay by making sure your wrists are not forced to bend to use the keyboard. Your forearms and wrists should not be leaning on a hard edge.
3. Take breaks – Taking a 10-second break every 20 minutes will be very beneficial. Standing, walking, or moving your head in a “plus sign” fashion are a few ideas. And don’t be afraid to stretch. One exercise we often recommend is called the “Bruegger Relief Stretch”. Click here to learn how it’s done.
Preventative care is the best solution for workstation injuries. Small adjustments to your workstation and posture will make a noticeable difference in how your body feels at the end of a long workweek.
Download this helpful infographic to learn more about proper workstation set-up.
With cortisol igniting our response, our muscles get tense and ready to fight. Prolonged stress will cause prolonged muscle contractions that cause tension headaches, migraines, joint pains, back spasms, eyestrain and a bunch of other muscle joint conditions.
If you're lifting weights and lots of them, cortisol may be literally eating away at your muscle building potential. Recent research has shown that high cortisol levels also increased protein breakdown by 5% to 20%-27%. An excess of cortisol can lead to a progressive loss of protein, muscle mass weakness and shrinking. Also the loss of bone mass through increased calcium excretion and less calcium absorption. With the amount of stress that athletes' place on their bodies, they generate high levels of free radicals as well as cortisol. Excess cortisol can also adversely affect tendon health, and causes a redistribution of body fat to occur. Basically, the extremities lose fat and muscle while the trunk and face become fatter.
One of the signs of over-training is higher cortisol levels, which may cause depression-type effects. Cortisol excess can also lead to hypertension because it causes sodium retention, which makes you appear bloated. It also causes excess potassium excretion. A major undesirable effect of elevated cortisol is, it causes insulin resistance by decreasing the rate at which insulin activates the glucose absorption. This is the next step towards Diabetes.28
Stress to the body can include trauma, anxiety, infections, surgery, and even resistance training and aerobics. Recent research has shown that high cortisol levels also increased protein breakdown by 5% to 20%.29 A mild increase in cortisol can increase glucose concentration and protein destruction within a few hours in healthy individuals.30 Cortisol increases with increasing time of intense exercise. In over-trained individuals, cortisol levels increase while testosterone levels decrease. A great way to measure the possible damage of over-training is a low or decrease in the testosterone to cortisol ratio.
Over-training is defined as an increase in training volume and/or intensity of exercise leading to a decrease in performance. Excess cortisol can increase body fat levels especially when it's increased dramatically in the body. Increased cortisol levels lower testosterone levels. One of the primary negative effects of testosterone and other steroids is the direct adverse effect on muscle cortisol metabolism.31
Elevated cortisol can inhibit growth hormone levels – the direct impact is that you age faster! Cortisol has other harmful effects on several hormones. Cortisol can directly slow sex and thyroid hormones. 32 When it does this the sex organs and growth hormones become resistant to the thing that they need the most. It may also suppress an
enzyme that creates the active thyroid hormone. This can decrease metabolic rate and make it harder to lose body fat.
During a specific stage of sleep, cortisol levels are elevated because protein is being re-cycled. This is one reason that iStressedOut™ should be taken before bedtime to help minimize excess cortisol production during sleep.
Prolonged high levels of cortisol can throw the immune system into chaos and increase body fat. When athletes get high levels of stress they can get a runny nose, a little cough and feel like they are getting a cold or the flu.
Cortisol reduction/suppression may be an essential part in the recovery process for athletes involved in rigorous training programs. A major and destructive sign of over training is elevated cortisol levels. Moderating but not completely diminishing cortisol levels is an essential factor in allowing weight training athletes to completely recover from their exercise session and maximize results.
Calls have come from the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA) and the Institute of Medicine (IOM) for a shift away from opioid use toward non-pharmacologic approaches to address chronic pain.
Overdose deaths involving prescription opioids have quadrupled since 1999, as have sales of these prescription drugs. From 1999 to 2014, more than 165,000 people --- three times the U.S. military deaths during the twenty years of the
Vietnam War -- have died in the U.S. from overdoses related to prescription opioids. Today, at least half of all U.S. opioid overdose deaths involve a prescribed opioid. In 2014, more than 14,000 people died from overdoses involving these drugs with the most commonly overdosed opioids -- Methadone, Oxycodone (such as OxyContin®), and Hydrocodone (such as Vicodin®) -- resulting in death. Regrettably, overdose deaths resulting from opioid abuse have risen sharply in every county of every state across the country, reaching a new peak in 2014: 28,647 people, or 78 people per day – more than three people per hour. The newest estimates on the cost of opioid abuse to U.S. employers is estimated at $18 billion in sick days, lost productivity and medical expenses. An important non-pharmacologic approach in helping to solve this crisis is chiropractic care. This discussion offers greater understanding of the scope of the opioid situation the elements that have contributed to it and an approach that emphasizes non-pharmacologic care. Collectively, we must begin to extricate ourselves from our current ineffective, dangerous and often fatal reality.
AMERICANS WANT AND DESERVE CHIROPRACTIC CARE
For the overwhelming number of people who suffer with chronic pain, chiropractic care offers a drug-free, non-invasive and cost-effective alternative to opioid drugs. Chiropractic is the largest, most regulated and best recognized of the complementary and alternative care professions. In fact, patient surveys reported in the Annals of Internal Medicine show that chiropractors are used more than any other alternative provider group and patient satisfaction with chiropractic care is very high. Patient use of chiropractic in the United States has tripled in the past two decades. The importance of chiropractic care is further amplified since many individuals are prescribed opioids for back, low back and neck pain, headaches, neuro-musculoskeletal conditions and other related conditions. An estimated 126.6 million Americans (one in two adults) are affected by a musculoskeletal condition.
Low back pain (LBP) accounts for over 3 million emergency department visits per year in the United States alone. Worldwide, LBP affects approximately 84% of the general population, so eventually almost EVERYONE will have lower back pain that requires treatment! There is evidence dating back to the early Roman and Greek eras that indicates back pain was also very prevalent, and that really hasn’t changed. Some feel it’s because we are bipedal (walk on two legs) rather than quadrupedal (walk on four limbs). When comparing the two, degenerative disk disease and spinal osteoarthritis are postponed in the four-legged species by approximately two (equivalent) decades. But regardless of the reason, back pain is “the rule,” NOT the exception when it comes to patient visits to chiropractors and medical doctors. Previously, we looked at the surgical rate of low back pain by comparing patients who initially went to spinal surgeons vs. to chiropractors, and we were amazed! Remember? Approximately 43% of workers who first saw a surgeon had surgery compared to ONLY 1.5% of those who first saw a chiropractor! So, the questions this month are: How successful IS spinal surgery? What about all those patients who have had surgery but still have problems – can chiropractic still help them?
A review of the literature published in the Journal of the American Academy of Orthopaedic Surgeons showed that in most cases of degenerative disk disease (DDD), non-surgical approaches (like chiropractic care) are the most effective treatment choice. They report the success rate of spinal fusions for DDD is only 50-60%. The advent of artificial disks, which originally proposed to be a “cure” for symptomatic disk disease, has fared no better with possible worse long-term problems that are not yet fully understood. The authors of the review wrote, “Surgery should be the last option, but too often patients think of surgery as a cure-all and are eager to embark on it… Also, surgeons should pay close attention to the list of contraindications, and recommend surgery only for those patients who are truly likely to benefit from it.” Another study reported that, when followed for ten years following artificial disk surgery, a similar 40% of the patients treated failed and had a second surgery within three years! Similar findings are reported for post-surgical spinal stenosis as well as other spinal conditions.
So what about the success rate of chiropractic management for patients who have had low back surgery? In a 2012 article, three patients who had prior lumbar spinal fusions at least two years previous were treated with spinal manipulation (three treatments over three consecutive days) followed by rehabilitation for eight weeks. At the completion of care, all three (100%) had clinical improvement that were still maintained a year later. Another study reported 32 cases of post-surgical low back pain patients undergoing chiropractic care resulted in an average drop in pain from 6.4/10 to 2.3/10 (that means pain was reduced by 4.1 points out of 10 or 64%). An even larger drop was reported when dividing up those who had a combination of spinal surgeries (diskectomy, fusion, and/or laminectomy) with a pain drop of 5.7 out of 10 points!
Typically, spinal surgery SHOULD be the last resort, but we now know that is not always practiced. IF a patient has had more than one surgery and still has pain, the term “failed back syndrome” is applied and carries many symptoms and disability. Again, to NOT utilize chiropractic post-surgically seems almost as foolish as not utilizing it pre-surgically!
When I recommend phosphatidylserine (PS) to patients I emphatically recommend iStressedOut™, a convenient, chewable and great tasting tablet available in the office. We need to start someplace and the easiest way is to simply chew 1 tablet 3 times a day for 30 days. During this time you will begin to experience some changes and see how the PS can help you. Some people will feel dramatic changes and relief from stress, others will have more subtle gradual changes.
Phosphatidylserine Will Help With Specific Conditions
There are specific times when I recommend that patients take iStressedOut™ in a specific way.
Sleep – if you are having trouble falling asleep then chew 1 tablet of iStressedOut™ 30 minutes before bedtime; 1 tablet 90 minutes before bedtime; and 1 tablet 2.5 hours before bedtime. If your bedtime is 10:30pm then you take your iStressedOut™ in the following timing:
Chew 1 tab at 7pm Chew 1 tab at 9pm Chew 1 tab at 10pm
After Exercise – If you are working out at least 3 times a week for a minimum 60 minutes then make sure that one of the times you take iStressedOut™ is immediately after working out. Chew 1 to 2 tabs after workouts. Initially start by chewing just 1 tablet after workouts for about 2 weeks and see how you do. If you continue to feel residual muscle soreness after workouts or there is some improvement, then increase your iStressedOut™ to 2 tabs after workouts.
Under Stress – if you know ahead of time that you are heading into a stressful situations like giving a presentation, going for your job review or interview, or going to your in-laws – then you can pre-load with iStressedOut™, a pre-emptive strike if you will, to ward off the increase in cortisol levels before they get out of control. Chew 2 iStressedOut™ about 30 minutes before your anticipated stressful situation.
Before Exams – Do you get nervous before and during exams? Do you under perform during exams and finals inspite of doing well for the entire semester leading up to finals? For these students I recommend chewing 1 iStressedOut™ 1 hour before the exam and a 2nd tablet 30 minutes before the exam begins. The ideal situation would be consistently taking iStressedOut™ 1 tab 3 times a day for the weeks and month before exams even begin.
Anxiety – if you have a history of anxiety and panic attacks there will be a transition period where your cortisol levels will gradually decrease. We want to try and prevent the anxiety and panic attacks from even getting started by initially taking iStressedOut™ 1 tab 3 times a day. If and when you find yourself slipping into an anxiety attack you can chew 1 iStressedOut™ tablet every hour until you calm down.
Statistics suggest that low back pain (LBP) will plague most of us at some point in our lives, if it hasn’t already. Most healthcare professions that manage patients with low back pain focus on pain management. In fact, studies have reported that 67% of patient satisfaction is driven by pain elimination. One of the most common strategies for reducing pain is managing inflammation. The “easiest” way to do this (according to the many TV commercials and magazine advertisements) is to take one of the many non-steroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen (Advil, Nuprin), Piroxicam Flurbiprofen, and Indomethacin. Let’s take a closer look to see if this is a good or bad idea!
In a recent March 2015 article, researchers investigated the use of NSAIDs between 1993 and 2012 in patients who had fractures that failed to heal, technically called “non-union fractures.” They found that non-union fractures increased during years when NSAID use was increasingly recommended for patients with fractures and dropped in years when NSAID use declined. This isn’t the first study to report poor fracture healing results from NSAIDs when they’re used as the primary form of pain relief and in fact, studies on this subject date back to the early 1990s. So how does this equate to LBP? Most directly, fractures are one of the many causes of LBP, so for that population, the answer is clear. However, LBP is much more commonly caused by sprains (ligament injuries) and strains (muscle/tendon injuries), as well as cartilage injury. Here too, studies show that the healing rate of sprains, strains, and cartilage is also delayed when NSAIDs are used as the primary pain relief approach. This healing delay is reportedly due to NSAIDs’ inhibition of “proteoglycan synthesis,” a component of ligament and cartilage tissue regeneration and repair. NSAIDs also inhibit release of prostaglandins (especially prostaglandin E2), which is needed for tissue repair. These effects are ESPECIALLY observed with long-term use, but recent studies show injured athletes are best off NOT taking NSAIDs AT ALL as these drugs delay the healing process and thus the athlete’s ability to return to their sport.
In a January 2015 study, researchers criticized the common use of NSAIDs in elderly patients for the treatment of non-cancerous pain. They found 75% of the elderly population studied was prescribed NSAIDs which, in retrospect, the researchers determined to be inappropriate! Because NSAIDs interfere with healing, the net effect is an ACCELERATION of osteoarthritis and joint deterioration! In 1995, a North Carolina School of Medicine study compared four groups of patients with soft tissue injuries (tendon strains): Group 1 received NO treatment (control group); Group 2 received exercise only; Group 3 received exercise AND Indomethacin; and Group 4 received Indomethacin only. At 72 hours post-injury, ONLY the exercise group had an INCREASE in prostaglandins (E2 particularly – necessary for healing). This effect was even more profound at 108 hours after injury. The research team also found DNA synthesis in the fibroblasts (an important part of the repair mechanism) was greatest in the exercise group and was completely lacking in the NSAID-only group.
We realize you have a choice in whom you consider for your health care provision and we sincerely appreciate your trust in choosing our service for those needs. If you, a friend, or family member requires care for back pain, we would be honored to render our services.
Phosphatidyl Serine(PS) supplementation has shown to be beneficial for children with attention-deficit hyperactivity disorder.109,110 Phosphatidyl serine is described as a super prescription for ADHD because it helps brain cells function properly. PS may stabilize the function of brain cells by normalizing brain-lipid content. Remarkably, one study found that almost 90 percent of subjects administered 200 to 300 mg of phosphatidyl serine daily experienced improvement in ADHD symptoms. ( 2 tabs of iStressedOut™ per day)
A fantastic ground breaking study examined 36 children, aged 4-14 years, with no history of any previous drug treatment related to ADHD, received 200 mg day of PS for 2 months. The results showed that PS supplementation produced significant improvements in ADHD symptoms’ short-term auditory memory and working memory; mental performance to visual stimulation as well as inattention and impulsivity. PS was well-tolerated and showed no side effects. 111
We Offer Affordable, Short Term Care For Your Relief Of Most Stress Related Health Issues. Phosphatidyl Serine is now in stock at our Stuart office!
Cliff Atwell, B.S., D.C.