Clinical Chiropractic: © Copyright 1995-1998 R. C. Schafer, DC, PhD, FICC
Clinical options in the chiropractic treatment of disorders of the ears and hearing, the eyes and vision, face and mouth, nose, neck and throat, shoulder and arm, elbow and forearm, wrist and hand, thorax, heart and lungs, and abdomen. Specific chapters are also included regarding headache, endocrine imbalance, selected systemic infections, and adjustive technic.
© Copyright 1995-1998 R. C. Schafer, DC, PhD, FICC
Clinical options in the chiropractic treatment of disorders of the ears and hearing, the eyes and vision, face and mouth, nose, neck and throat, shoulder and arm, elbow and forearm, wrist and hand, thorax, heart and lungs, and abdomen. Specific chapters are also included regarding headache, endocrine imbalance, selected systemic infections, and adjustive technic.
INTRODUCTION: HOW TO USE THIS BOOK
QUICK CHAPTER INDEX
Purpose of This Manual ................
How the Chapters Are Organized ........
Diagnostic Workup ...................
Ready Reference Available .........
Eclectic Diagnostic Aids ............
Spinal Majors .......................
Adjunctive Therapy ..................
Nutritional Therapy and Counsel .....
Tissue Alkalosis ..................
Nutritional Antifactors ...........
Elective Procedures .................
Using This Desk Reference .............
The Scope of the Text ..............
Clinical Laws ......................
Basic Principles of Practice ..........
Chiropractic vs the Medical Approach.
Causes vs Precipitants ..............
Other Forms of Therapy ..............
Avoid Overutilization ...............
Practice Building ...................
The Goal is Homeostasis .............
Benefits: Clinically and Economically
Master the Art of Adjusting .........
PURPOSE OF THIS MANUAL
The objective of this manual is to provide the chiropractic clinician and advanced student a ready reference to common therapeutic protocols. This will be helpful in two situations (1) a condition infrequently treated or (2) a condition frequently treated but a particular patient fails to respond as anticipated. Obviously, there is no need to refer to any manual when the practitioner is confident that he or she can treat a particular disorder efficiently and the patient responds in a mutually satisfactory manner. Even in successful cases, however, the reader may find that future clinical planning and approaches can be enhanced by the suggestions described.
The topics of this text concern common upper body complaints. A companion book has been scheduled to follow that will concern lower body complaints.
HOW THE CHAPTERS ARE ORGANIZED
Each section in the text concerning an entering complaint is developed with a standard format: (1) name and definition of the disorder, (2) background information, (3) diagnostic workups, (4) eclectic diagnostic aids, (5) spinal majors, (6) adjunctive therapy, (7) nutritional therapy and counsel, and (8) recommended elective procedures.
The subsection titled "Background" contains a brief explanation of the most pertinent clinical concerns involved. Major signs, symptoms, and differential diagnosis tips are described. This subsection is not intended to be a discourse on the etiology, pathogenesis, or diagnosis of a particular complaint; but rather, to serve as a reminder of common concerns. It is assumed that the reader is educated in the basic and clinical sciences.
Because data on infrequently treated conditions are sometimes difficult to recall, the following two companion references are suggested: (1) Physical Diagnosis: Procedures and Methodology in Chiropractic Practice, American Chiropractic Association, 1989, 1078 pp; (2) Symptomatology and Differential Diagnosis: Conspectus of Clinical Semeiographies, American Chiropractic Association, 1986, 1116 pp.
The doctor is reminded here to conduct a thorough physical examination and consider certain standard laboratory workups according to clinical judgment. A list of common laboratory procedures used in the specific disorder is provided. From the many potential tests listed, the doctor is encouraged to select a few that will be most pertinent. This will depend on the primary and associated signs and symptoms expressed by the patient. If initial tests are not fruitful, the working diagnosis can be amended and other tests can be selected until a firm diagnosis can be made.
It is then suggested, when appropriate, that the doctor (1) motion palpate the patient's spine and relate findings with the patient's complaint; (2) confirm these findings with appropriate orthopedic and neurologic tests; (3) check pertinent tendon and superficial reflexes and grade the reaction; (4) check involved joint motion and muscle strength against resistance; (5) interpret resisted motion signs; and (6) test for autonomic imbalance if suspicions of vagotonia or sympathicotonia arise.
Ready Reference Available
One unique aspect of this manual is that each suggested procedure is referenced to one or more tables or illustrations in Chapter 16 where further information can be found. For example, Tables 16.13 and 16.16 and Figure 16.1 concern common myotome and dermatome tests, an index of clinical signs and tests, and an illustration showing location, respectively. A summary of normal reflexes is shown in Table 16.2, and the classes and grades of tendon reflexes are described in Table 16.3. Table 16.9 shows grades of muscle strength, and Table 16.6 lists data for interpreting resisted joint motion. Common tests for autonomic imbalance are listed in Table 16.7.
It should be noted that the author's suggestions, based on personal experience, sometimes differ slightly from the classic recommendations described in the tabular information of Chapter 16, which report classic data.
Eclectic Diagnostic Aids
Following the standard diagnostic procedures described above, the doctor is then encouraged to consider certain eclectic procedures that will aid in the confirmation of the diagnosis such as checking alarm points (Table 6.15), visceral Valleix areas of the feet (Fig. 16.2), and potentially contributing trigger points (tables 16.28--16.31). Eclectic procedures should be used to confirm findings of standard procedures, not be a substitute for them.
The term "spinal majors" in this manual refers to those areas of the spine likely to show signs and symptoms of IVF irritation or compression. They should be used as guidelines (Table 16.17) because of their high incidence with the syndrome described. These areas deserve priority attention during the initial stage of spinal examination to target the examination for rapid elimination or confirmation. In an acute disorder, however, they are not necessarily the site of correction. This is because they are frequently sites of compensatory segmental hypermobility resulting from one or more fixations in the kinematic chain --which may be the effect of past trauma, somatosomatic or viscerosomatic reflexes, or degenerative changes in the spine.
Alloted space in this text did not allow explanation of specific adjustive technics. For detailed descriptions, refer to (1) Motion Palpation and Chiropractic Technic, Motion Palpation Institute, 1989, 426 pp; (2) Chiropractic Management of Extraspinal Articular Disorders, American Chiropractic Association, 1990, 448 pp.
After relaxing taut tissues and adjusting the subluxated/fixated segments, it is suggested that percussion spondylotherapy be applied over specific segments (Table 16.18). The core of the author's therapy is the manual adjustment followed by spondylotherapy. It has found that stimulating the cord and IVF contents enhances local arterial circulation, improves venous and lymphatic drainage, and helps to disrupt common self-perpetuating noxious reflexes (Tables 16.19--16.20). The percussion stroke of spondylotherapy must be perpendicular to the spine to produce a deep effect. Vibrators that use horizontal oscillation produce little benefit. Guidelines for vibropercussion velocity and average duration are shown in Table 16.20. Apply special care not to overtreat, else a reverse reaction may occur.
The next subsection concerns the application of various procedures designed to restore further neurologic homeostasis and enhance healing. However, in conditions in which spinal adjustments would be contraindicated, they could be considered primary therapy. These indirect (reflex) procedures include:
1. Acupoint therapy. The location of recommended acupoints, their relation to body parts, and their classic relation to specific disorders are shown in Tables 16.21, 16.22, and 16.23, respectively. Acupoints of the hands are
shown in Figure 16.5.
The reader should not feel intimidated by the number of acupoints seen in scanning this manual. Several points are used frequently and are quickly learned. The need for some may never arise in a particular practice. Recall should be developed by use and results, not by memorization.
2. Auriculotherapy. The location of auriculopoints, their relation to body parts, and their classic relation to specific disorders are listed in Tables 16.24, 16.25, and 16.26, respectively. Illustrated diagrams for the points suggested in this manual are also given. Figure 16.3 shows a lateral view and Figure 16.4 illustrates a posterior view of the ear. The location of points should be learned from Figures 16.3 and 16.4. The smaller figures shown with the text will serve as general reminders once their locations are known.
Electrostimulation is by far the most common means of stimulating auriculopoints. Needling requires selecting the precise location. With electrostimulation, however, the same effect can be obtained by sweeping the general area of the site in a circular manner (about a 3/8-inch circle). The effectiveness of needling only surpasses electrostimulation in pure neuropathic lesions (eg, Bell's palsy, shingles, twitches and tics, etc).
3. Valleix reflex areas. Common focal sites in the feet for noxious somatosomatic and somatovisceral reflexes are described. They are shown in Figure 16.2. Tender Valleix areas often serve as both diagnostic clues and sites for reflex therapy. Their acute tenderness suggests to the author the deposition of uric crystals or other metabolic by-product leakage (eg, similar to that of gout) due to an impaired distal circulation defect (likely vasomotor). Treatment is by circular massage with the ball of the thumb with pressure applied
according to patient tolerance.
These areas of tenderness (potential sites of noxious visceral reflexes) are unusual in that they are extremely tender on deep palpation, but they produce no pain to the patient when standing or walking. This is a common sign of referred tenderness. Thus, they can be distinguished form such local lesions as plantar fascitis, neuroma, plantar wart, etc.
Valleix foot points are unilateral or bilateral depending on the organs in question; eg, bilateral for the kidneys and eyes, on the right side for the liver, on the left side for the heart and spleen. This is true even if some bilateral points may be shown only on one side in the illustrations.
Personal note: The Valleix points charted in this manual were originally mapped by William Locke, MD, of Ontario who won international recognition during the 1930s. His reputation attracted thousands of patients from Europe, the Middle East, India, and the Orient, as well as throughout North America. Locke personally taught the author's father the reflex massage and foot adjusting technique and encouraged him to become a chiropractor --which he did, graduating second in his class though he was totally blind. Within a few years after graduation, he developed the largest chiropractic practice in western New York, attracting numerous patients from as far north as Toronto and as far south as Pennsylvannia and eastern Ohio. His reputation was acklowledged by the Mayo brothers in the mid 1940s.
4. Chapman's points. Tender "neurolymphatic" points are often helpful as diagnostic clues and sites for reflex therapy. Their common locations are shown in Figure 16.6. Generally, there is an anterior point and a corresponding posterior point. The points charted in this manual were supplied to the author by an osteopath who served as a student to Chapman during the 1920s.
It is unusual to find a Chapman's anterior point tender and its corresponding paraspinal point nontender. If this occurs, suspect that the singular point of tenderness is a site of local trauma, a trigger point, or referred tenderness and not a true Chapman reflex. Location and treatment anteriorly is made by deep circular pressure with the ball of the middle finger or thumb. Posterior points are generally located just lateral to spinous processes. Steady pressure is applied against the posterior point as the anterior point is deeply massaged.
Chapman posterior points for unilateral organs are often on the contralateral side of the spine. See Figure 16.6. When Chapman, Valleix, or meridian points are bilateral, it does not matter clinically which side is treated because of the integration in the CNS. It does no harm to treat both points if both sides are tender and the patient's state can tolerate bilateral stimulation. However, unilateral treatment is usually sufficient to produce a remarkable effect.
5. Trigger point therapy. Upper body disorders often linked with specific trigger points are listed in Table 16.28. Points that can produce head, face, mouth, and neck pain are shown in Table 16.29. Points that can produce abdominal or thoracic pain are outlined in Table 16.30, and those that can cause upper-extremity pain are listed in Table 16.31. Trigger points can be reduced conservatively by deep massage, vibropercussion, ultrasound, high-volt herapy, or B-complex/procaine hydrochloride injections. Phonophoresis of the latter has not been found to be efffective by the author.
The specific site of acupoints, Valleix points, and Chapman's points may differ slightly because an individual's anatomy does not always follow textbook locations. Allow a 1-inch-diameter variance. However, there will be no doubt when a tender meridian alarm point, Valleix reflex area, or Chapman neurolymphatic point is found by deep palpation. The typical patient will respond with an "ouch" and reflexively jerk away from the palpating finger (gross nociceptive response). A response less than this suggests another cause for the tenderness. Auriculopoint sites (asymptomatic) are determined by their lowered electrical resistance. They cannot be palpated.
All acupoint pathways are bilateral except the (1) Conception Vessel (CV) meridian, which passes along the anterior midline, and the (2) Governing Vessel meridian, which courses through the posterior midline. In contrast to Valleix and Chapman points, involved acupoints (except alarm points) are rarely tender. Rather, light--moderate palpation will reveal a small but distinct concave indentation in muscle surface. As with an involved auriculopoint, this site will show decreased cutaneous electric resistance over the
depression. In acute, painful disorders, it is usually preferable to treat the contralateral side of bilateral meridians. When pain is the major complaint, treat until the patient reports a positive change in symptoms. If a positive change is not noted within a few minutes, it is a signal that the point selected is in error or that a severe lesion exists (eg, a "hot" fracture).
Avoid treating more than five body points at any one visit. Rarely should more than three points be treated at the same visit for highly debilitated patients, infants, or the very elderly. The more delicate the patient's nervous status, the less stimulation is necessary to produce a distinct reaction.
Acupoint therapy stimulates the production of potent morphine-like substances from the brain and spinal cord. Excessive stimulation may cause the patient to faint. If this should occur, the patient can be aroused by placing the patient in an antishock posture and applying firm pressure with a thumbtip at the base of the nose, just above CV-24 (located in the center of the mental labial groove).
Body acupoints can be stimulated by vibropercussion with a small applicator or by rapid probing with a small blunt-tipped instrument. However, alternating-current muscle stimulators equipped with ball-point probes or the insertion of acupuncture needles by the well trained appear to be the most effective. The latter two methods are mandatory for auriculotherapy. Low-frequency therapy unit settings are shown in Table 16.27. These setting are also applicable for electrical auriculotherapy. Acupoint therapy has a powerful effect on the autonomic nervous system. Again the caution: Do not treat more than three points on a child or a debilitated patient during one session. Except for the suppression of pain, the healing effects of acupoint therapy may not become evident until 24-hours posttherapy.
The brain is a nerve center, a computer, and a drugstore. For example, the central nervous system (CNS) can be stimulated to produce dynorphins and enkephalins that are hundreds of times more powerful than morphine as an analgesic. They also greatly enhance healing, and most forms are highly tissue specific; ie, once released, they affect certain tissues but not others --depending on what part of the brain they originate.
The reader should not be confused by the fact that many points of one system overlap with those of another inasmuch as they were mapped independently. The most common examples in this manual are that Chapman's anterior intrinsic spinal muscles point is located at the same site as meridian point KI-27 (in the depression inferolateral to the sternoclavicular joint) and that Chapman's posterior eye/ear point is located at the same site as meridian point right UB-10 (in the suboccipital depression lateral to the attachment of the trapezius). Almost all Chapman's paraspinal points are on line with the meridian path of association points (not described in this book). Students of DeJarnette will also recognize many significant sites.
Nutritional Therapy and Counsel
This subsection recommends specific supplemental processed [glandular] tissues and/or prepared nutrients. Those listed have been supported by the recommendations of three or more authorities. When appropriate, the author prefers glandular supplementation for in that manner all vitamins, minerals, enzymes, cofactors, etc needed by a particular organ are supplied those known and those unknown. Only those known to date can be synthetically reproduced. There is, however, no difference between a specific nutrient's molecules formed in the field or formed in a laboratory. The difference is found in
Text recommendations often list a large number of supplemental nutrients. However, it is not good policy to prescribe more than two or three bottles of vitamins and minerals to any one patient. A doctor's office is not the place for merchandising. When several supplements are recommended, strive to find a high quality multivitamin or multimineral preparation that will fulfill the patient's needs.
In essence, all food is a collection of chemical compounds and nutrition is necessary for life. Thus, anyone who eats is not adverse to chemotherapy. The use of naturally occurring combinations can frequently avoid the side effects seen with the use of highly potent specific compounds. In this context while offering dietary advise, it is well for the doctor to keep in mind that ginger, red wine, goldenseal, honey, horseradish, and onion contain antibiotic agents. Many foods and spices have anti-inflammatory properties. Some common
ones are barley, blackberries, blueberries, carrots, cucumber, red current, ginseng, honey, lemon, rice, and peppermint. Antiparasitic properties are found in common anise, garlic, cayenne, pumpkin seeds, rose hips, and thyme. Almond, apple, barley, rice, garlic, lemon, and sweet marjoram are antipyretics. Several herbs have antiseptic qualities such as chamomile, cinnamon, comfrey, garlic, goldenseal, sage, and thyme. All infectious states will be benefited by thymus extract, pantothenic acid, and reversing cellular alkalinity. The average kitchen contains scores of natural medicinals, and these are
suggested frequently in this manual. Do not weigh their effect lightly.
Adequate innervation and tissue pH balance are necessary for optimal homeostasis. For example, calcium will not deposit (eg, in bursitis) nor will most infections flourish except in tissues with an alkaline or neutral environment. Early signs of alkalosis include transient periods of paresthesia, irritability, cool hands, tendency toward motion sickness or nausea, and an alkaline urine. Basic in-office macroscopic-reagent urinalyses that include pH, and calcium, potassium, and sodium levels should be conducted on every entering patient and periodically with established patients as dictated by their condition. In-office microscopic analysis is also convenient.
Short-term large doses of vitamin C (ascorbic acid) are an effective method to restore tissue acidity. Cranberry juice is often recommended for this purpose, but its effect is less efficient than ascorbic acid. In such situations, the author prescribes a 250-mg tablet every 2 hours during the waking hours until the urine turns neutral or slightly acidic. Some authorities recommend a 500-mg tablet each hour. The body will expel unutilized amounts of vitamin C in the urine. Special care must be used with other acidic products (eg, aspirin, acid calcium salts) to assure against a swing to acidosis. Early warning signs of acidosis are frequent yawning, lassitude, anorexia, fatigue, loose stools, peripheral vasodilation, and acidic urine. Headaches, twitches, weakness, and hyperpnea are associated with both acidosis
The author believes that it is poor counsel to advise a patient to take supplements or follow a certain dietary regimen without alerting the patient of certain vitamin or mineral antifactors. Without this knowledge, the patient can unknowingly dilute the intended effect. If not for lack of ingestion or absorption, it is likely that frequent intake of these antifactors is the cause or at least a major contributing factor in the deficiency present. For reference, antifactors contributing to vitamin deficiency symptoms are shown
in Table 16.56 and those for mineral deficiency are listed in Table 16.58. For some reason, the effect of vitamin and mineral antifactors in nutritional deficiencies has been poorly communicated to the profession.
This final subsection concerns the application of various physiotherapy modalities that have been shown helpful for the alleviation of specific disorders. Frequently, they are not necessary. At other times the use of the term "elective procedure" may be inappropriate for they can undoubtedly be used as primary therapy if spinal adjustive therapy is contraindicated or not as effective for the immediate situation at hand.
Each modality recommended here is referenced to one or more tables in Chapter 16 that shows appropriate indications, contraindications, or application concerns. Common forms include the use of cryotherapy (Tables 16.32--16.34), moist heat (Tables 16.34--16.35), shortwave diathermy (Table 16.36), ultrasound (Table 16.37), low-frequency alternating current (Table 16.27), hydrotherapy (Tables 16.45--16.48), interferential therapy (Tables 16.39--16.41), galvanism (Table 16.42), galvanic iontophoresis (Table 16.43),
local vibration-percussion (Tables 16.19--16.20), ultraviolet radiation (Table 16.44), high-voltage therapy (Table 16.38), traction (Table 16.50), tendon friction massage of involved muscles, or heel and sole lifts (Table 16.51). Doctors desiring detailed information are referred to Applied Physiotherapy: Practical Applications Within Clinical Chiropractic, American Chiropractic Association, 1986, 428 pp. At times, braces and supports (Table 16.52), therapeutic exercise, TENS (Table 16.49), and bloodless surgery are suggested.
While heat is usually contraindicated during the 48-hour interval following musculoskeletal trauma, its benefits in increasing or decreasing abdominal and pelvic circulation cannot be denied. For example, studies have shown that superficial heat applied to the abdomen decreases liver circulation while deep heat increases circulation in the liver. See Table 1.1. Hot baths are more effective than local moist heat application in decreasing circulation in the
internal organs, while a shortwave condenser field is more effective in increasing visceral circulation than interferential current.
Table 1.1. Changes in Blood Circulation in the Liver After Physical Therapy
Modality Effect on Hepatic Circulation
Hot water bath (-) Decreased circulation 27%
Moist local heat (-) Decreased circulation 11%
Infrared radiation (0) No uniform reaction
Interferential current (+) Increased circulation 12%
Shortwave condenser field (+) Increased circulation 21.9%
USING THIS DESK REFERENCE
This manual is not to be read as a novel. It is designed to be a ready reference source when specific protocols are desired for specific disorders --as one might seek the advice of a helpful consultant. Seek only the aid you need. As a help to the reader, a quick index is included at the beginning of each chapter.
The protocols suggested are based on positive results with hundreds of patients, but they are not written in stone. They should always be questioned early by the practitioner with "Why is this point or procedure recommended here?" Knowing the why is what differentiates the methodology of the physician from that of the therapist. Actions must be justified or avoided. Questioning a procedure also allows for modification to accommodate the needs of a particular patient or pathologic state.
The Scope of the Text
Become familiar with the book's contents. Do a quick scan of the chapters and especially the contents of Chapter 16 (which contains all referenced tables and figures). With this scan you will notice that many helpful tables are available which have not been cited in the text. For example, Table 16.4 lists significant points in differentiating upper motor neuron lesions from lower motor neuron lesions. Table 16.5 relates motor function signs to the neurologic level. Grade classifications are shown for IVD lesions, sprains, and strains in Tables 16.10, 16.11, and 16.12, respectively. The observant reader will also note that there are scores of specific disorders listed that are not dealt with specifically in the text. These classic protocols, however, are there if needed for reference.
For those with a special interest in nutritional therapy, tables have been included concerning the general factors involved in nutritional deficiencies (Table 16.54), the signs of specific vitamin deficiencies (Table 16.55), and the signs of specific mineral deficiencies (Table 16.57). In addition, the features of hypervitamin toxicosis are shown in Table 16.59, known nutrient and drug interactions in Table 16.60, and disorders caused by or contributing
to nutrient deficiency in Table 16.61.
At first glance, the reader may be overwhelmed with the vast resources available. Rigid memorization is not necessary. With frequent use, the facts will be retained and reference to the tables and figures will no longer be necessary. A worthy achievement is worth the effort. A doctor's reputation is based on worthy achievements.
Although the author abhors memorization in almost any form, there is one exception in this manual where it is helpful and that is the last table of Chapter 16. It defines several selected clinical laws that are basic to any application of health care. If these unquestioned principles are deeply implanted in the doctor's mental fabric, many common errors of judgment will be avoided. This knowledge will also allow the doctor to evaluate many claims about the efficacy of a certain technic or procedure.
One example is Davis' law. This law states that if the origin and insertion of a muscle are moved farther apart for a time, the muscle becomes relaxed and hypotonic. If they are approximated, the muscle contracts, becomes hypertonic, and may become contractured. Poststroke cases overtly demonstrate this principle. This readily demonstrable law forms the basis of many techniques used in Applied Kinesiology, yet the principle can be applied in almost any form of physical therapy.
Another example in this table of basic principles is the one:two:four ratio. From above downward, a 1:2:4 relationship exists between the midlumbar spine, the sacrum, and the plantar surface of the heel. This law is commonly applied in the use of heel or sole lifts for the mechanical correction of scoliosis in a flexible spine. For example, a 1/4-inch heel lift will raise the ipsilateral sacral base 1/8 inch and the midlumbar spine 1/16 inch. This can be easily shown by before-and-after spinographs. It is the result of the biomechanical relationships among the head of the femur, the pelvis, the sacrum, and the lumbar spine. It also explains much of the results of Basic Technic and was so taught by Logan. From an opposite viewpoint, raising the midlumbar spine unilaterally 1/16 of an inch will result in shortening a patient's ipsilateral leg length 1/4 inch. Rational thought must conclude that
even extremely light palpation or manipulation of the patient's spine will alter leg length --either mechanically or by proprioceptive response. Thus, to judge the effects of a corrective spinal adjustment by functional leg length of the prone or supine patient is to enter the realm where the most gullible reside.
BASIC PRINCIPLES OF PRACTICE
Chiropractic vs the Medical Approach
The medical approach to treatment, at least in theory, requires specific identification of the precipitating factor (eg, specific viral, bacterial, fungal invasion or hormonal, chemical, or electrolytic imbalance). This is not true in chiropractic whose emphasis is on the integrity of the nervous system in maintaining homeostasis in most instances. Thus, because a structure has the same innervation despite various manifestations of dysfunction, the regimens outlined in this manual for regional disorders are often closely related. This subject will be clarified in Chapter 15.
Causes vs Precipitants
It is common in health care to refer to invading microorganisms or tissue degeneration as the cause of a particular disorder. It is assumed that the chiropractic readership of this manual will realize that this attributed cause is rather a precipitating factor that would have little influence if the resistance and adaptive integrity of the tissues involved were healthy and able to respond to extra demands by utilizing the normal recuperative reserves of the body.
Other Forms of Therapy
Use what you know is effective. If you do not know the answer to a problem, learn or refer to someone who does have the answer. As a licensed practitioner, DCs are entrusted to act in the best interests of the patient at all times.
Several reportedly excellent methods are not described in this manual. Examples are the use of Bennett's neurovascular reflex techniques, applied kinesiology, craniotherapy, and chiropractic homeopathy. The reason for this is that the author has not been trained in these approaches nor has the knowledge and experience necessary to recommend them to others. This in no way diminishes their potential effectiveness. If you have knowledge of these approaches and found them to be of benefit, you should certainly include them in your clinical armamentarium. The science and art of health care is a constantly progressive quest for improvement.
Heat is heat, and cold is cold. Stimulation is stimulation, and inhibition is inhibition. There is no clinical justification, for instance, to apply more than one form of superficial heat when superficial heat is indicated. However, there are times when both superficial and deep-heat modalities can be justified during the same treatment regimen for they have different objectives.
Most disorders present with tissues that are already overstressed. To overtreat is to do more harm than good; to add further stress on already overstressed tissues. See Table 1.2.
Table 1.2. The Stages of Healing
The inflammatory stage White blood cells dissolve extravasated blood elements
and tissue debris. Swelling and local tenderness are
The reparative stage The network of fibrin and the fibroblasts begin the re-
parative process. Local heat, redness, and diffuse
tenderness are present.
The toughening stage Fibrous deposition and chronic inflammatory reactions
occur. Palpable thickening and induration in the area
of reaction are present, with tenderness progressively
A large number of procedures are described in this manual for the conditions covered. It should not be inferred that they all should be used during any one office visit. Once the patient reports distinct relief, stop further treatment and allow the patient to rest for several minutes. When distinct relief occurs, the patient's body is telling you that a change for the better has occurred. No further external treatment is necessary or justifiable at this time for the pathologic cyclic process has been broken at this time.
In the same context, overutilization of adjustive therapy should be avoided. The pioneer chiropractic axiom of "find it, fix it, and leave it alone" is still pertinent. Nerves and other tissues suffering stress and irritation need time to heal. To manipulate further without good cause is only a hindrance to natural healing processes. In addition, to manipulate a segment that is pain-free or greatly improved and not in a state of fixation is not clinically justified, it only adds iatrogenic irritation (induced trauma) to a functional joint.
Overt signs of restored segmental function in chronic cases take time to appear. It may take months or even a few years for the involved ligamentous straps, IVDs, and articular cartilages to adapt to the remobilized state of the segment and for the vertebra(e) to appear more "realigned" on a static x-ray film, though the patient becomes symptom free within a matter of days or a few weeks. This does not imply that the patient needs frequent continuous treatment, but it does mean that the patient requires monitoring a few times a
year to assure that reconstructive mechanisms are ongoing.
Allow time for healing and intrinsic mechanisms to restabilize. Just as use of a brace or crutch will produce disuse atrophy when applied over a long period, chiropractic adjustments can become a crutch. With overadjusting, there is no need for the body to restore intrinsic alignment mechanisms. What the body does not need to do, it does not do. In like fashion, if the body does not need to supply colonic lubricants (eg, in the long-term use of laxatives), the responsible cells atrophy.
In contrast to spinal adjustments, the effects of physiotherapy are short term. The greatest benefits from modalities come when application is made at least once every 2 days to be accumulative.
Acute cases generally require three office visits the first week, two the second, one the third, and then be scheduled for a checkup in a month or two. This, of course, is determined by clinical judgment. Even the "healthy" patient should be examined every 6 months. Several subclinical musculature fixations will invariably be found, and this "preventive" therapy will have long-term multiple benefits. It is unfortunate that insurance companies have not been informed of this.
No patient should be "dismissed." Every patient should leave with a scheduled appointment for sometime in the future, with the reminder to call the office immediately if new or old symptoms arise. Healthy school children should be checked at the beginning and end of summer vacation. Contestants in contact sports require much more frequent monitoring. Seasonal allergy patients that have become asymptomatic should be checked a month before the season involved and midway within that season.
The simple appointment card serves as an implied doctor-patient contract. It shows the doctor's long-term interest in the patient and builds patient loyalty. On the other hand, a "dismissed" patient feels no responsibility of returning. The dental profession learned this method of practice building many years ago. After a doctor is in practice for 8 years or more and uses this system consistently, there is no need for "new" patients except for an occasional referral by an established patient to replace those patients that have moved far from the community or died.
The Goal is Homeostasis
It is the author's belief that the primary objective of a DC is not to straighten the patient's spine. It is to provide a correction of the cause of the patient's complaints, if possible, and to provide as much long-term benefit as possible. If "spine straightening" were the objective, every patient would be referred for a complete spinal laminectomy. A stiff "ramrod" spine is not the optimal "end-all" clinical objective, despite what concept of ideal biomechanics one has been misled to believe. Human tissue is dynamically active and constantly compensating --even osseous tissue.
Two common examples seen in practice underscore this point. The first is with a complaint of headaches where an obvious occipitoatlantal subluxation exists but only an adjustment opposite to its listing brings relief. This paradoxical situation is usually found in the upper cervical and lower lumbar areas of the spine, but it may occur anywhere in the vertebral column. It is also seen occasionally in the ankles, knees, and hips. The author has never seen it occur in the upper extremities, but it should not be ruled out as a possibility dependant on compensation to past trauma or prolonged occupational stress. This process of biologic spinal adaptation will be described further in Chapter 15.
Wolff's law states that every change in the form and function of a bone, or in its function alone, is followed by certain definite changes in its internal architecture and secondary alterations in its external conformation. If such compensation is true for bone, it is likely true for all body tissues. Thus, our second example concerns a fixated odontoid in rheumatoid arthritis. This fixation is nature's attempt to provide as much relief as possible under the circumstances. To directly disrupt this process is a disservice to the patient, to the doctor as a clinician, and even to the patient's adaptive resources --a force that we should be aiding, not working against.
Benefits: Clinically and Economically
People come to a doctor's office for one reason: hope of receiving resolution of a health problem. It does not matter to them whether the healer is a DC, DO, MD, or Christian Science practitioner if they have hope of being benefited. They have a problem and hope that the selected person can correct it. They make an appointment in faith. Thus, a doctor does not have to create faith --but he or she has to firm it and sustain it. One can sustain it short term with clever dialogue, or it can be sustained for a lifetime by getting the results mutually agreed upon --quickly.
The protocols described in this book are designed to bring rapid results and establish the doctor's reputation in the community as a "healer." The length of time necessary to make a substantial correction depends on the chronicity of the condition. Nevertheless, every patient should experience some degree of improvement during every office visit. Strive for this. Expect this. Make it the basis of your reputation. It will occur if your diagnosis and treatment plan are correct. Quick relief builds patient confidence rapidly.
The only logical basis for sustained practice development is positive results. Only by obtaining results quickly when others had failed allowed chiropractic to sustain itself through the hardships of the pioneer period. Even then, hundreds were placed in jail for practicing their art. The memory of this should not be forgotten.
If signs of improvement are not forthcoming after two or three office visits, something that should be done is not being done or something that should not be done is being done. If this is the situation, re-examine. Reevaluate. Resolve the problem or refer. Patients will respect this. The doctor will have self-respect.
It will sometimes be found that a diagnosis and treatment plan are correct but necessary patient cooperation with the advice given is not adequate. This is a no-win situation in which only referral is the answer. Practice will not be enjoyable if you spend 95% of your time worrying about 5% of your patients with which you do not have a positive relationship. Not understanding this subjects many doctors to overstress and "burnout."
As explained earlier in this chapter, the objective of treatment is to have the patient feel better, never worse, immediately after each office visit if you expect him or her to return. If a patient does not return because his expectations have not been met, (1) the attending doctor has lost the opportunity to provide long-term aid, (2) lost the opportunity of establishing that patient as a center for referrals to the practice, and (3) contributed to poor community relations and possibly set-up an adversary relationship.
Do not exceed the patient's tolerance of discomfort during therapy. And keep in mind that the expectation of pain or an unexpected stimulus greatly lowers a person's pain threshold. This can be avoided by proper conditioning.
What you are going to do
Why you are going to do it
How you are going to do it
What the patient will feel
What the long term objective of your services will be.
Invite questions. Obtain agreement. Assure that the patient understands by inviting feedback. A patient that understands will never be shockingly surprised with or angered by what you do.
Master the Art of Adjusting
It is surprising how many graduates since 1960 have not been taught how to properly "deliver" a chiropractic adjustment. They have been thoroughly taught the mechanics, but not the finesse. The latter is the "art," and it is parallel in importance to the "scientific" mechanical objective. This subject will be explained further in Chapter 15. Some readers will find it quite revealing for some disclosures may be contrary to their established beliefs.
Note: If you find that this manual serves as a helpful consultant and would be interested in the scope of this book's companion concerning lower body complaints, the proposed contents are previewed at the end of this book.