“As much as we talk about diversity, we fail to embrace it in clinical practice,” says Dr Michael Hall. “We give the same questionnaires to the male and female. It’s got to change. We need to revamp the examination.”
In part one of Spinal Research’s recent interview with Dr Hall, we discussed the sexual dimorphism of the human brain and how this impacts physiology, symptomology, and fundamental needs. (Read that interview here before getting into this one.)
While it is certainly helpful to be across this subject, as it affects every patient that walks through our doors, Hall is keen to address a need that hasn’t yet been acknowledged in practice: its time our patient assessments reflect our diversity. If they don’t, there are things we can neglect, and ways in which our take-home advice can miss the mark.
“Here is the thing that I’m hoping the Foundation will get behind – we need to revamp the examination,” he said following his interview on the sexual dimorphism of the human brain. “We need an examination for the female and we need an examination for a male. There needs to be different history questions for the female and the male, because they are not the same. Healthcare needs to embrace the differences…. What will work treatment wise for you [a female writer] will not be the same treatment plan that works for your husband.”
It’s a reality that is reflected in brain imaging, too. “When you look at things imaging wise, you could ask the same question of a male, and get a completely different brain-based response to what you would get from a female.”
While the same brain components exist in both sexes, there are marked differences. The female brain has fewer neurons but more connections across the corpus callosum, which allows for more inter-hemispheric brain activity. The male brain has more neurons, but fewer connections between the hemispheres. This has significant impacts for the genders (see more detail here), as do the key hormones that drive them. For men, testosterone is a significant hormone creating a key requirement for physical activity. For women, progesterone is a key hormone and there’s a different corresponding core need – that of connectedness.
Here’s where things urgently need to change.
“Right now we are having regulatory bodies make decisions about the chiropractic treatment of a number. Not you. Not me. Just a number. It has to change. You [referring to a female Spinal Research Writer] having back pain could be due to a completely different onset and etiology than for a male and be given the same course of treatment.
I can’t just adjust you just so you can go back and sit in a cubicle by yourself for the next several hours. As a female, there is a stronger need or sense for social engagement, a sense of family. The female requires it. Males, not so much. That doesn’t mean we don’t need family. It just means we can go hunt and fish and be by ourselves and we are fine. We require physicality. If you take a male who is testosterone-driven and sit him behind a computer all day, how much physicality does he exhibit? Is he more or less likely to suffer from low testosterone? These days, you can’t open a sports magazine without reading something about low testosterone.”
The testosterone issue is one that many health practitioners will have noted. It has specific impacts on men, their drive, concentration, physicality and generally wellbeing. So too is the way in which sympathetic dominance or chronic stress will impact a woman, and her physiology and wellbeing. But as of yet, our assessments haven’t reflected the dimorphism of the sexes, and our recommendations haven’t tuned in to their core needs. Dr Hall explains:
“Here’s the thing? How many pills do I give you to make you get out of that chair? How many adjustments do I give you before I change your mortgage payment? See if I don’t identify the stress and the causation, and chiropractic has always prided itself on dealing with causation, then we need to identify this elephant in the room. Men need to be physical. Otherwise we decline in health and you can watch it right in front of your eyes. Men who once had pecs and a chest, now have…well you know what I’m talking about. Men who should have tree trunk legs now can’t walk up a flight of stairs without becoming breathless. Men are now being treated for cardiopulmonary disease so they can sit at their computers for longer periods of time.
We have to realise – the Foundation, and practitioners like me – we have to take ownership and create a strategy that is successful for our patients. Technology is not going to go away. We can harness it but the chiropractor has to develop a strategy and say, “You know what? I have to help my patients know what to do.” In years gone by, we could say, “You need to go outside and play more.” Today’s millennial doesn’t know what that looks like. They’d go outside and say ‘what do you do outside?’
Their environment is more virtual. So we as the chiropractors need to create office environments of what they could be doing at home to reinforce the basic human functions that maintain our brain health so we can become creative and innovative again.”
He’s talking about a need for more specificity in our recommendations. “If we are going to address that chiropractic is about the health and wellness of the nervous system, then its time for us to do something about it.” We know that Alzheimer’s research (a condition more prevalent in women) is showing a need for good diet, exercise and social engagement, based on the way the brain is functioning and what it requires. But it something we haven’t known how to apply in practice.
“How many chiropractors prescribe social engagement but tell their patients what that looks like?” he says of the need to empower our patients through more specificity when it comes to their core needs. “I can’t just say, ‘go exercise.’ I need to tell you how. People walk into a gym, get on a treadmill and watch TV. But we need to do two or three interval activities throughout our day and not just first thing in the morning or last thing at night. We need to create a strategy that is successful for our patients.”
We also need to measure it. There are things we already measure in practice. But there are also things unique to each sex that are currently (largely) being missed. “Men need to be pushed for strength. But how many male patients have had their wall sit timed or been asked how many push ups they can do? Its all well and good to say we need to breathe, but we need to measure it [the upper thoracic chest excursion].”
He cites other things we are likely missing as well. “It matters, what is going on in the body,” he says before explaining that when the brain is affected, we can often see light sensitivity, but few of us assess it. It is something that is more likely to affect females under stress. So too is the sense of smell, often the second thing to be affected in chronic stress. “Picky eaters usually can’t smell. One of the first things lost in neurodegenerative conditions is the sense of smell. Yet most chiropractors do not know how to adequately assess it.” He goes on to talk in more detail about taste, heart and lung conditions and gut conditions like IBS.
It’s a fair challenge – to better understand exactly how the sexes differ, and how brain structure and hormonal realities change our physiology and core needs. These are topics he delves further into in his education program Brain DC, and the details are far too plentiful to condense into a few blog posts.
Thank you to Dr Hall for raising this important challenge, and for putting the hard yards in on a challenging and detailed topic.
References:
[1] Joel D, Berman Z, Tavor I, Wexler N, Gaber O, Stein Y, Shefi N, Pool J, Urchs S, Margulies D, Liem F, Hanggi J, Jancke L and Assaf Y (2015), “Sex beyond the genitalia: the human brain mosaic,” Proceedings of the National Academy of Sciences of the United States of America, http://www.pnas.org/content/112/50/15468 retrieved 29 March 2017
[2] Hall M, McIvor C (2017), “Interview with the Australian Spinal Research Foundation,” Personal correspondence. Video available by request to members only.
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