560- Exploring the Overlooked Connection Between Airway Health and Posture in Chiropractic Practice

Welcome to The Evidence-Based Chiropractor, where each week we deliver the latest chiropractic research and marketing strategies, all in the time it takes to get to your office. Now here's your host, Dr. Jeff Langmaid.

Hey everybody, I am excited to be sitting here with Dr.

Cameron Smith. We recently connected and we talked all about really the intersection of what happens between the airway and posture, a massively missed opportunity for, I'm going to say, 99% of chiropractors out there. And we're going to evaluate what this means, how it impacts your practice, what Cameron has seen in his practice, as well as some clinical pearls that you can take away and utilize starting today. So Cameron, great to connect with you.

Yeah, it's great to be here and great to talk with you and kind of educate your listeners about this topic.

Well, it, it is my pleasure. You got my attention because this is something I, and I told you on the phone when we first chatted, I said, man, I don't know anything about this. And this is an area of, of, I'm going to say expertise that you've built throughout your career, just really evaluating, learning. Let's pick it up right at the beginning. How'd you get involved in this?

Yeah, so it kind of all started, honestly, I was doing DOT physicals. I don't know if you've ever done any of those, but When you're evaluating those people for their physicals, you find that a lot of 'em meet the criteria. The, the DOT has set guidelines that we look at for what meets the need for a sleep study. And so started noticing like, wow, there is a lot of people that probably have this that don't realize they do. And I looked in the research and certainly, yeah, it's a very underdiagnosed condition. And so when I'd be evaluating these people, I would get their complaints, things like that. And I was starting to realize like I kind of fit the build of some of these, you know, the fatigue, waking up with a light headache, restless sleep, all these, these types of things. I go, well, maybe I have this. So I went out, got sleep study, found out I do. I have mild sleep apnea. Got a CPAP machine, started feeling immensely better with some of those. But I started realizing with those same drivers, they were always the ones that were like, oh, you're a chiropractor. My neck's killing me all the time and my low back's hurting. And you can chalk that up to what they do for a living, of course, just their normal posture. But I also thought, well, why is it that the ones that have sleep apnea seem to have a higher rate of these complaints, or at least they're telling me about it compared to the ones that don't meet the criteria for sleep apnea? So that kind of got me thinking about it a little bit and then my own diagnosis and then it really funneled into my daughter. So this was the basically the turning point for me is my daughter was starting to mouth breathe at night. So we'd notice that and we're like, that's kind of weird. And then she'd start snoring a little bit, tossing and turning, wasn't getting restful sleep. And then we noticed she would like roll her head around and she started complaining about her neck and started getting forward head posture. So I'm like, I'm a chiropractor, that's my, that's my realm here. And we'd work with her and it would just keep happening. And so eventually she started getting this It was like an end-phase expiratory wheeze, if that makes sense. So I'm thinking, better get her into the doctor, see if she has asthma. That, that runs in the family. Maybe she's dealing with that. Took her in, the doctor's evaluated, said, nope, lungs sound good. I don't think we should be worried about that. I think it's a tic. That's what they said. And she's just doing it. It's a tic. She's gonna grow out of it. Well, I kind of thought maybe she's not growing out of this problem. Maybe she's growing into a bigger problem with her musculoskeletal system and that this isn't gonna go away. So we fast forward a year of that and just back and forth, took her into an airway-based dentist. And what they did was they did this thing, it's called a CBCT scan. So basically they look at her airway through this and they told me, hey, guess what? She has a very narrow palate, narrow maxilla. She has dental crowding, all things that I could see, but I'm not a dentist, right? So they ended up, they're doing a palate expander and she got that a few weeks ago. And so we're seeing a little bit of difference already, but we're hopeful that that's going to better her life in an immense way. And it's something that as a chiropractor I was missing. So I don't, I don't, I don't want anybody else to miss this as a parent for the, for their kids and then a chiropractor for their patients. So yeah, that's kind of what got me thinking about this and deciding I wanted to educate people about it.

So I think, I, I think of sleep apnea, CPAPs as older people that might have a few extra pounds on them. Did you think about that the same way? What have you learned that maybe opened your eyes? Is that mostly the case and sometimes not, sometimes the case and mostly not? How have you seen that play out?

Yeah, so sleep, sleep apnea is a huge issue and there's lots of different reasons for it. But like you said, yeah, clinically, typically I would always think overweight male over 50, high blood pressure, thick neck, you know, those are the kind of the, the typical things you're gonna see with, with those types of presentations. But it's just sleep apnea, it's just disordered breathing in general, right? So when you're looking at the adult population, that may be predominantly what you're gonna refer out is people for sleep studies or, or to talk to their primary and, and talk with 'em about those things. But for kids, you're gonna notice a totally different subset of symptoms that, that you're gonna notice with that. Not typically Sleep apnea, although they could have that, but you're going to notice different symptoms for kids than you are for adults. So yeah, it's a broad range.

And is this something that I'm imagining the answer is no, because you're, you know, yourself and your family has been under chiropractic care, but I'll ask the question and then you can elaborate on it, which is, is this something where you can adjust them? They, they, they get better. It's not that you need to worry about it. Is this something that needs to be referred out for every time? How does the process work, and how do you use this process and this knowledge now in your practice with your existing patients or new patients?

That's great question. So I think it's not instant referral unless there's enough red flags. You know, we're gonna obviously evaluate. I'm gonna use children as the example because they're gonna be the ones that probably don't know how to explain all their symptoms. So you look at them, and if they have enough of these presentations, whether it's You know, I mean, forward head posture, that could be explained by a lot of different things, but you might see that you're seeing a mouth breathe. You're— they look tired. Their parents are complaining about their sleep, and you just, you know, say, open your mouth, say ah, and you see this giant tongue, maybe some scalloping, things like that. Well, that's probably gonna be an instant referral, or enlarged tonsils. So that's kind of like the start of the cascade is they have a basically an airway challenge. And so if you see enough of those, yeah, I would definitely send them to an ENT. That'd be my first referral. As far as can we treat them? Well, we can treat anybody, right? We can get them adjusted. We can get benefits in just their, their thoracic mobility, obviously just for breathing. There's, there's some several studies, one back in 2023 recently, about how that does actually benefit patients with that. But ultimately, you want to make sure you're referring them to somebody else to get a second pair of eyes on it and make sure that it's not enlarged tonsil or something that another provider needs to treat on top of what you're doing. So yeah. That's a good question.

And then what, what is, what is the typical treatment? You mentioned with your daughter, I saw you mention it, but a palate expander, you, what, how does this typically play out? Or is that still, we're learning as things unfold?

Yeah, I think it's a growing space in all professions, right? And, and definitely sleep medicine's evolving all the time. Airway dentistry is evolving all the time. I mean, chiropractic just hasn't really been a thought about that, but I think We got to look at it as the the signs and the symptoms that are showing up, and what we can do at each stage so that maybe potentially it doesn't turn into the the following consequence. Using my daughter's palate expander, you know, if we'd have got if we'd have addressed the nasal the poor nasal breathing and the open mouth breathing and some of her sleep issues and maybe dental issues sooner, maybe it wouldn't evolved into this. And then that's kind of that kind of leads me to the whole airway cascade. aspect of all this. So I can kind of tell you about that if you'd like.

Yeah, please go for it.

Yeah, so let's say we got a kid that comes in and we notice that they, or their parents tell us that they're mouth breathing. Usually that's gonna start with an airway challenge. Like I said, enlarged tonsils, enlarged adenoids, maybe chronic congestion. I imagine if you've ever had a cold or something and your nose is all plugged up, what do you do? You breathe outta your mouth, right? We have to get We have to get air in. And so our body's gonna prioritize breathing over posture, right? So you're gonna start noticing that they're gonna open their mouth to breathe and eventually long-term that could turn into habitual mouth breathing. Okay? So that's, that's a problem. It, one reason it's a problem is cuz their tongue posture's gonna change. So this is kind of important because you're typically, your tongue is supposed to rest at the top of your palate when you breathe. And you imagine if you're mouth breathing, you can't breathe while your tongue is up in the outta your mouth, right? So long-term you're gonna adapt and start continuously breathing through your mouth and then you're gonna adapt your posture. Likely it's gonna be forward head posture and cervical extension, right? So to get more air in, you're gonna lean forward, tilt your head back to make that easier. So that's kind of the cascade that leads people to seek chiropractors, right? We're treating people more predominantly for those types of issues. But while that's happening, if they don't have proper tongue posture, they can have craniofacial development issues. And so that's what my daughter had. So that's kind of that step, right? We're there, we're dealing with that. That's where we're referring to an airway dentist to help address those issues. 'Cause the palate eventually it fuses, right? And it's gonna be much harder to address that with an adult as it is a kid. So we wanna get to these problems before that. And then like I said, then it turns into chronic postural compensations and that's what we're treating. So we can treat that, All day, every day. But if we never address the root cause of the problem, likely these, these adaptations are going to keep coming back because the body prioritizes survival over posture every day of the week. So that's, that's kind of the cascade of how these things happen.

And let me ask a follow-up to that. When you think about how a chiropractor could approach this in their practice, I'll throw out a variety of things. Is this something where chiropractors have an opportunity to attract new patients by getting information out in their community? Is this something that maybe they are just looking at with their existing patients to potentially take care of or refer? What are the dynamics of this and what do you see as the opportunities within those dynamics?

Well, I think opportunity would be just talking to patients about this issue and letting them know there is things we can do with the breathing mechanics as well as cervical stabilization. Some of these things that we do help these issues to some degree, but The biggest one would probably be getting your name out there with the other professionals, right? If you're speaking the language of an ENT, of an airway-focused dentist, or a sleep medicine doctor, and they know that you understand how this works, well, when they have a patient that maybe is complaining about their neck hurting or something like that, they're more likely to say, you should go to Dr. Cameron, you know, or you should go this place because they know you actually know that condition. And so I think that's probably the biggest. way to build your practice with it is not marketing that you're an airway chiropractor, because, you know, there's scope of practice things with that too. But just knowing that you understand this, this connection, and a lot of these other professions somewhat do, but they're not adjusting patients. So I think that's probably the best way to build your practice within this mindset.

And you mentioned a few different types of doctors there. I'd love to drill down into some of those. So, and I'll use a correlative example. This is This is my personal opinion, my personal opinion only.

Yeah.

Uh, I, you know, I am probably less likely to refer to a pain management doctor. Why? Because I view that most of them, most of the time, are immediately going to go to injections, which for most cases, most of the time, are completely counterintuitive to what's going on. So I might rather refer an orthopedic case if it's beyond, you know, what I feel comfortable with, or the patient's not progressing, or there's a red flag. I might go to an orthopedic doctor rather than a pain management doctor. You mentioned a few different types of docs there—a dentist that might have airway expertise, a sleep doctor, etc. I know it's not apples to apples because there are some differences just inherently in how those doctors—you know—who they take care of and how they approach care. But if you had to rank for docs listening and saying, "I get it. I see what Dr. Cameron is talking about." I think I got a few patients right now that. might be good, uh, to have a second set of eyes on. Are there any of those professions where you would, so to speak, rank them higher than others in terms of whether it be being complementary to what we do, uh, aligned with how we might approach care, or maybe some that you have found are maybe just inherently by their training a little more aggressive than we would like? Or is it totally doctor-dependent?

I think it's dependent on where you catch the airway progression at, right? So I think first and foremost, ENTs, whether they agree with chiropractic or not, um, if you have an airway obstruction from enlarged tonsils, adenoids, things like that, well, they're going to be the people that can address those issues. So that's— and since that's the first kind of step in the cascade, that would probably be, um, one of the first people that I would refer to. Probably the best aligning with this, I think, I guess in my opinion it'd be either a myofunctional therapist actually, or airway dentist because they kind of understand the changes that are happening within the airway through, through their dental work. But they also realize, and when they're looking at these films, they even talk about the cervical spine with those. And a lot of the studies that have, I guess, proven this, this theory are done by airway dentists. And so I think that'd probably be, The most likely to actually send referrals back. And then sleep medicine, you know, they're probably likely gonna go with CPAP machines and, and, or whatever type of treatment they do, Inspires and other sleep apnea treatment. So I imagine that'd be secondarily referring to a chiropractor because of their musculoskeletal complaints, maybe not necessarily working with you.

Yeah.

Was there any others? Yeah, I think those are the main ones that I would think. So I couldn't really rank them in order of which one works best. It's more about what's going on with the patient at that time.

Yep, yep, yep. And if we pull it back to the beginning, for the docs that are tracking, they're seeing what you're talking about, they're understanding it, and they're just looking for that first few implementation steps. You mentioned a few things, analyzing, or at least visualizing, I should say, the airway, et cetera. Maybe I'll ask you, what are a few either specific questions and/or specific visual assessments, evaluations, examinations that you would recommend for somebody that's just saying, hey, I'm going to start taking a look at this. Where do I start?

Yeah. So once again, kind of goes down to either adults or kids with these issues. If you're noticing an adult, I would say a STOP-BANG questionnaire is like the gold standard for, okay, you meet enough of these criteria. As well as the same guidelines that the DOT has, you know, the neck circumference, those types of things. Now for kids, it's going to be— you're going to— I mean, when a patient walks into our office, we look at them, right? That's like the first part of the exam is just seeing what's going on. So I think if you're going to implement this tomorrow, it's just look at them, but look at them through a different lens. Like, could this be an airway case? Because if you're just looking at their posture, that doesn't tell the whole story if you have an airway mindset. So looking at Airway screening type of mindset in that, in the sense of, okay, I'm gonna look in their mouth. Like I said, look in their mouth, look at how they're breathing. Are they, are they chest breathing? Are they doing some of these tells? And then questioning them with the parents if, if their kids are with them, like, how'd you sleep? How do you sleep? Do you notice they mouth breathe? Are they snoring? Have you witnessed an apnea? You know, so these types of questioning would be kind of the second part of that. And then just talking with them about what you think may be going on and having that conversation of here's some avenues that you maybe wanna look into, whether it be, you know, any of the providers we talked about or with chiropractic, like here's what we may be able to help with, with some of these issues that I'm seeing versus what I think another professional may be more appropriate to deal with.

Yep. No, that makes sense. I'll ask 2 pretty basic questions, but just so I make sure I get my terms correct, is technically apnea the stopping of breathing and is there like over a certain amount of time. And then I'll ask you, follow up immediately on that, which is snoring. Is this one of the primary, secondary, or tertiary airway issues, reasons for snoring? I've never really thought about that.

Yeah. Yeah. So apnea is anything over 10 seconds. So, like, if you're on a CPAP machine, it's gonna measure that every single night. They call it the AHI. So anytime you are not breathing or don't have enough breathing during that 10-second timeframe, it's gonna mark it as a, as an apneic event. There's hypoxias too, where, you know, obviously the, The oxygen saturation drops. There's, there's several other things they look at and that's more, like I said, the sleep medicine realm. But yes, and then snoring would be basically the, the body's way of opening that airway back up, right? The tongue starts vibrating cuz you're not getting air in or you're not able to cuz it fell back. So it's going to, you know, make that noise as it's, as it's forcefully trying to get the air back in there. So they're very correlated, probably honestly, probably one of the number one things you're gonna notice with somebody that may have sleep apnea, but you could snore without it too.

So yeah, got it, got it. Um, so I'm going to recommend every doc, uh, listening or watching, uh, visit airwaybridge.com. We'll be sure to drop that in the show notes and down below as well. That's an easy way to connect with you, airwaybridge.com, and we'll drop that down below.

Uh, before we wrap up, what haven't I asked that you think is important for docs to know about? Yeah, so I think that would be one thing that I would bring up is figure out a way that you want to speak to these professionals and speak in their language. So study it a little bit, like what do airway dentists do? What are they evaluating? And how can I present that I have a patient with these issues, or even make a template of, you know, whether it's sending out a report to them. Here's what I'm seeing. I wanted you to check them over. That just kind of builds that rapport with them. So that's, that's something that I would add. The other thing is we didn't really ask too much about like actually a protocol you would do in your office with somebody that has some of these issues. So for me, I think you have to start with the initial problem, which is breathing. So you want to, I guess I could give you kind of my protocol. So if somebody comes in, I'll call phase 1, the first week we're just gonna work on breathing. So we're gonna work on diaphragmatic breathing and nasal breathing. We're gonna wanna make sure that they're doing them properly. So we're gonna have them doing, you know, 5 to 10 sets a day of a various, whether it's 90-90 breathing or Kraken cat-al breathing. We're gonna have them work on that for that first week without any sort of other therapies involved, as well as the adjustment, hopefully. Then that, that second visit they come in, we're gonna see if they're still doing it correctly, 'cause we wanna retrain their brain to do it properly. So the next step I would say would be we do those, those breathing techniques, those breathing mechanics coupled with a stabilization exercise. So like a, a chin hold for example, right? We wanna disengage the SCMs, the scalenes while they work their deep neck flexors or try to make them so they're not hypertonic. But we wanna be able to have them do that while breathing correctly because if they're breathing improperly while doing those, they're reinforcing that poor pattern, I guess if that, if that makes sense. And then the next step would be when the next time they come in, I would have them doing something functional while nasal breathing, while diaphragmatic breathing to make sure that once again, it's all about that neuromuscular connection. we're breathing properly, we're moving properly, and we're doing it all together. Otherwise they're probably just gonna fall back to that same pattern. So that's something I think a chiropractor could actually implement in their offices to actually help these patients, whether with, when it's not just adjusting them, if that makes sense. So that's, that's something I wanted to touch on too.

Yeah, I think that's really important. There are, I mean, all of us look at posture. I think very few of us look at airway. And as you've elaborated today, There's just such a connection between the two. So I'd make a strong case for any doc that is interested in in looking at posture, whether through static assessment, whether through dynamic assessments. Visit again. Go over to airwaybridge.com. Connect with Dr. Cameron. I know you're available and you're happy to answer questions. You additionally have some resources that you're building over there. So I'm going to encourage every doc if you are working with which you are posture in your practice. It's a really good idea to keep exactly as you said, a mindset towards airway as well, because it may be an item that is underserved for that patient, and it may be something that's actually blocking you getting the best results possible until you're able to address that, which then dives into reviews, referrals, and practice building, because patients are happy because you're giving them everything that they need. Cameron, any words that you want to close with on today's episode?

No, you did great there. That's exactly what I'm hoping for here. And I just appreciate the time from you and hopefully from your listeners to kind of reassess the lens that they're looking through their practice and think about other ways that we can help patients rather than just looking at posture and just looking at what's happening downstream. Let's look about what's happening that started all of this. So no, I, I'm appreciative. Thank you very much.

And a big shout out to our partners and sponsors, including Leander Tables. We're gonna hook you up with a big discount on a Series 950 for being a listener, as well as Shockwave Centers of America, discount and a free cart for being a listener. Rehab Fix, Grant can hook you up with programs to build a hybrid practice, extend beyond your 4 walls, make more money, and help more people, as well as Care Plan Pro. Our new software that really helps you sell more care plans, memberships, and concierge. Without having to feel like a salesperson, but we make it really, really easy. Thank you so much for tuning in. Thank you for being a chiropractor. Have a fantastic week in practice, and I will talk to you soon.

Thank you for joining us on this episode of The Evidence-Based Chiropractor. If you want to grow your practice, come back for next week's episode. If you want to grow faster, visit theevidencebasedchiropractor.com. And join our MD Marketing membership today.