double vision it should be an alarm to all of us. Now again, we're not talking about a little bit of blurriness in the vision after getting an adjustment. For me personally, if I lay face down on an activator table or a high low table for a couple minutes, when I get up I have trouble focusing my vision. Even if you never touch me, I have a little bit of a problem focusing my vision for a few minutes afterwards. I put my glasses on, 4 or 5 minutes later I'm fine. That's not what I'm talking about. I'm talking about frank double vision. When that presents on the front end or it presents subsequent to an adjustment, we need to be very attentive to that. The fourth consideration, the fourth D from Allan is Dysarthria. Excuse me, no pun intended. If the patient has an inability to speak or is speaking in an abnormal pattern, speaking with an abnormal cadence, their speech has been altered from what you know to be the norm as a result of something before they presented for care or aftercare, is something you should be concerned about. Then the fifth D, dysphagia. If the individual has difficulty swallowing, indicating a potential cranial nerve involvement, something of that nature, then obviously you want to be responsive to that. The A that Allan made reference to is ataxia. You want to watch the gait of that patient. Is their gait normal? Are they needing the wall? How are they moving about in the office after their care? Do you see anything unusual about it? Then we move on to the 3 N's. The 3 N's are nausea, nystagmus, and numbness. If the patient experiences nausea after an adjustment, it should be something that concerns all of us. If the patient experiences numbness, particularly facial numbness after an adjustment, it should be something that concerns the practitioner. Then if the patient develops a nystagmus type response after an adjustment, again, it should be something that concerns the practitioner. Now the issue isn't one of these symptoms, but more the development of a constellation of symptoms. Now having said that let me go back to drop attacks for example. If we're talking about drop attacks we don't need many other symptoms to decide that we might want to get this patient out for referral, but if we're talking about dizziness, if we're talking about a little bit of blurred vision, if we're talking about a little bit of a change in the gait, maybe we're not talking about anything other than positional changes and given 15, 20 seconds, a minute or 2, everything's normal. When we're talking about persistency and we're talking about the development of a constellation of symptoms, everyone's red flags ought to go up geometrically at that point. It's the development of a pattern, it's the development of a cluster of symptoms that all have neurologic origins, that all have cranial nerve relationships that begin to cause us to be concerned. "This is before an adjustment or after an adjustment?" The concern should be there. I said before that up to 50% of patients with VAD present with a primary complaint of neck pain and headache. It's important when patients present with, out of the blue, neck pain and headache. They weren't playing sports over the weekend, they
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