When the Adjustment is not Enough

The Abridged Rant

Summary

• Chiropractic is physical medicine aimed at restoring both limited and painful movement patterns
• Positional faults are responsible for both limited and painful movement patterns
• Positional faults are caused by one of the three things:

1. Tissue Extensibility Dysfunction (trigger points, tight muscles and fascia, ect)
2. Joint Mobility Dysfunction (problems occuring at or within the joint capsule)
3. Somatic or Motor Control Dysfunction (signals going to and from the brain)

• Typical healthcare practitioners only focus on local sites of pain and miss the source
• GCMC screens movement patterns globally, allowing us to find the source of the pain
• GCMC uses:

1. Graston Technique for Tissue Extensibility Dysfunction
2. Mulligan Mobilization for Joint Mobility Dysfunction
3. Reactive Neuromuscular Training for Somatic or Motor Control Dysfunction

The Full Story

Chiropractic and Faulty Movement

Most would agree that chiropractic in its most simple of forms is centered on the detection and correction of faulty movement. The chiropractic adjustment or manipulation is the profession's most common and most accepted treatment intervention, designed to correct faulty movement occurring at any joint surface in the spine or in the extremities. But why do some chiropractors utilize more than just the manipulation? We at GCMC have a wonderfully simple reason based on very complicated science as to why we have multiple tools in our toolbox and why we feel that sometimes the chiropractic adjustment is just not enough.

The Definition of Faulty Movement

Let us first start with our concept of manual medicine and what we mean by faulty movement. Movement occurs at a joint. We have different types of joints that provide for different types of movement that allow us to move freely through our world and perform all of our activities of daily living. But sometimes movements become painful and can become limited. When this happens, manual medicine steps in to help break the cycle of pain and restore proper range of movement to allow you to continue to enjoy the activities you were temporarily prevented from enjoying.

The Three Components of Movement

Movement at a joint requires for three components to be functioning properly: joint mobility dysfunction, tissue extensibility dysfunction and somatic or motor control dysfunction. Failure of any one of these three components will lead to decreased and possibly painful movement. Traditional chiropractic would refer to the decreased and painful movement as the subluxation. At GCMC we use the term positional fault to describe the improper and painful movement occurring at one or many joints in the body. Arguably we are saying the same thing but we feel that the term subluxation has been misused and abused by so many uneducated people inside and outside of the chiropractic profession that we would like to make a point of limiting the number of ways you can interpret our intentions.

Why the Chiropractic Adjustment Works

So if there are three components, why do so many chiropractors use the manipulation as their first choice? Whether by intention or luck, there are three good reasons why manipulation is an effective treatment for positional faults: pain relief from endorphin release, increased blood flow outside of and nutrients within the joint, and neuromuscular retraining for improved range of motion. These three benefits were all explored in the article titled the Neurophysiological Effects of Spinal Manipulation. In the most recent edition of the Journal of Manipulative and Physiological Therapeutics, Taylor and Murphy's award winning paper showed how spinal manipulation alone could improve motor function in humans. But sometimes the adjustment is just not enough. Sometimes it only temporarily corrects the faulty movement and sometimes it simply just does not help.

Why the Adjustment is Not Enough: a Story of Symptom vs Cause

The most obvious answer we have as to why the manipulation is not enough is that sometimes the patient's chief complaint, the most obviously limited and painful movement, is nothing but a secondary symptom. Much like a headache caused by tension from the stresses of your occupation, aches and pains can be the result of repetitive stresses and strains put on your body from the demands of your daily life. And unless the injury was caused by blunt trauma from an object impacting your body, many times your aches and pains began as small compensations starting at one part of your body that eventually injured an entirely different area of your body. For example, maybe your first problem was limited mobility at your right hip. Eventually your lumbar spine adapted to the limited rotational ability of your hip and as a result became hypermobile. The hypermobility of your lumbar spine led to poor spinal stabilization at your core, robbing you of the ability to effectively use your upper extremities to perform push and pull movements. Your poor core stability eventually leads to you straining your supraspinatus muscle and results painful and limited arm movements, difficulty sleeping throughout the night and many painful trigger points along the muscles surrounding your shoulder. So you go to a chiropractor and complain of pain in your right shoulder with lifting and pushing, as well as difficulty sleeping at night. If all your chiropractor does is spinal adjustments, he or she will adjust your thoracic spine to help the dynamic of shoulder movements occurring between the glenohumeral joint and the thoracic spine. Even if your chiropractor addresses the other joints of the shoulder girdle or even the strain in your supraspinatus muscle, this is nothing more than taking Advil to temporarily cure your tension headache that occurs every Monday as you try to catch up on all the work that accumulated during the weekend. You must address the hip mobility issue and you must address the poor core stability if you are ever going to truly stop the shoulder pain from reoccurring.

GCMC's Global Take on Health

Poor movement screening techniques is one reason why we at GCMC feel that the chiropractic manipulation is sometimes not enough. No matter how good you are at fixing something you must first know what to fix. Many healthcare practitioners are stuck thinking locally while GCMC takes a more global look at your body. This is why GCMC uses an innovative evidence-based screening technique to identify not just the pain but the true cause of the pain. Once we have identified your painful and limited movement patterns we use three specific treatment techniques as well as many other more common treatment tools to correct the three main causes of painful and limited movement: to joint mobility dysfunction we use Mulligan Mobilization Techniques; for tissue extensibility dysfunction we use Graston Technique; and finally, to correct somatic or motor control dysfunction we use Reactive Neuromuscular Training.

Day 1: Pillars for Preggos an Addendum to What You Should Expect While Expecting

Approximately one year ago my father and I attended the 2009 functional training symposium for the NSCA. What followed was nothing short of inspiration for the work done at GCMC. It is no secret that the tide of health care is shifting towards prevention. Gone are the days of sick care, the kind of circular passive care that keeps on going, and going, and going, until your benefits are exhausted for the calendar year. GCMC is about supporting active lifestyles. It's the kind of health care facility that wont tell you to stop living. Juan Carols Santana, the representative for the NSCA at the symposium, provided us all with the vernacular to translate our heavy medical jargon into real words and concepts that everyone could understand. Thus was the birth of "pillar training" at GCMC and specialty classes like Pillars for Preggos.

It is all well and good that we should know proper lifting techniques; however, recent studies indicate that teaching proper lifting techniques does not simply translate into a world free of back pain. While the study did not answer why teaching proper lifting techniques did not prevent low back pain I have a theory of why and how that answer can lead to a better method of preventing low back pain in pregnant women and women with small children.

The answer is one of efficacy versus effectiveness. What I mean is that in theory and in ideal conditions, proper lifting techniques should help to prevent low back pain. However, we live in a less than ideal world and in less than ideal conditions. So while there may be some efficacy in lifting techniques, the advice has little to no effectiveness in the real world. And this is not a new concept; athletes do not train solely in ideal conditions. The distance runner does not adhere to only short sprints, on sunny days, with zero humidity, at zero elevation, and then go run a full marathon in Denver, Colorado in November.

This principle means a few things to the expecting mother. You can expect changes in the core musculature supporting your low back. Patterns of weak and tight muscles that will predispose you to certain aches and pains. You can also expect balance changes to come as your pregnancy progresses. Core strengthening exercises like the pelvic tilt, dead-bug, quadraped, and plank can help to recondition your core, while balance training can help prevent falls. However, you can also expect that your baby, once delivered, will put you in all kinds of precarious lifting situations, ones that making proper lifting techniques impossible.

As Juan Carlos Santana said at the Functional Training Symposium, "try to explain to a mother how to use proper squatting and reaching techniques while bending over across the back seat of a car to place a small child into a car seat or to take one out of it." It just is not possible. This is why Pillars for Preggos has the potential to be a success and help many new mothers. Life is movement, and bodies that move well, live well. It is important that you train for life. Being a mother is a full time job, 25 years later my own mother reminds me of this fact every day. So why not train your core in the positions it will be exposed to? We are all athletes of sorts. Some by vocation, some by recreation and some of us are industrial athletes. Consider yourself a domestic athlete, possibly one with the most physical demands.

Pillar Training for Preggos will be held every Saturday at 1:00pm. We had our first class today and it was a success. The group was small but there was a lot of learning and training, even for me. Of all the things I had accounted for, after all the training in classes and on my own, the one thing I did not anticipate was nausea. Needless to say we now have that under control. Today, some expecting mothers took their first steps to putting their pregnancy on a strong foundation and GCMC took their first steps towards fine tuning their first specialty group program. For more information about pillar training click here and to schedule online for the next Pillars for Preggos class click here.

I Think I can! I Think I can! Mind over low back pain.

Acute low back pain (LBP) is an interesting animal. Affecting 80% of the population and much more popular among the younger crowd, LBP is generally overwhelmingly harmless and in most cases resolves naturally within a couple of weeks. But sometimes this seemingly benign condition takes a turn for the worse. Two weeks turns into two months, two months turns into two years and now your harmless LBP has turned into a disability. LBP is the leading cause of work absenteeism in America for ages 19-45 and the second most common reason for seeing your primary care doctor. Are you curious as to why this happens? What if I told you its all in you mind?

One article in The New England Journal of Medicine compared medication, bed rest, mobilization exercises and simple reassurance and encouragement to continue normal activities in the treatment of LBP and found that simply advising people that it is safe to continue living life normally was more effective than the other options. In fact it has been shown that providing self-care advice and reassuring the patient that there is no need for fear or anxiety provided an nine-fold decrease in risk of LBP becoming chronic.

A fancy term used to describe this phenomenon is fear-avoidance beliefs (FAB). FAB turn acute pain into chronic by mentally disabling you. Vlaeyen stated that a misconception of pain being a threat can cause an individual to completely avoid physical activity and become deconditioned based on fear and anxiety. Deconditioning coupled with a feeling of hopelessness delays the recovery process.

The Agency for Health Care Policy and Research has properly stated that "the main goal for treatment of back pain has shifted from treatment of pain to treatment of activity intolerances related to pain." This means that your health care provider's job is to not simply treat your pain, but to strengthen your ability to live your life normally as quickly as you will let him or her. There is no problem with laying on a table while your health care provider attempts to decrease the pain for you, at least not initially. The problem arises when there is not a speedy transition from passive treatment to active treatment (ie full range of motion exercises).

No, chronic LBP is not purely mental. You can not just think happy thoughts and make it disappear. However, you can control how quickly you will recover. Happy thoughts can help get you pain free again. So be optimistic, the sky is not falling. Live your life, only bed rest could
truly hurt you.

Fear-Avoidance Beliefs Questionnaire

Arthritis Foundation's 2009 Women's Health Summit

I wanted to take a moment write about a first time experience I had on multiple levels. My father, Matt and myself were recently asked to give a presentation on the importance of exercise with arthritis for the Arthritis Foundation's 2009 Women's Health Summit. There were multiple speakers in different rooms with various background ranging from the Chief of Geriatrics at a nationally ranked hospital to the nutritional advice presented by an RD.

As I mentioned, this was my first of many: this was my first public presentation for GCMC, this was my first time speaking in front of an elderly population, this was my first time working with the Arthritis foundation, this was my first time presenting along side MD's and DO's, and this was my first time bring our message of "Life is Movement" to a larger, non-athletic audience. And for all of those reasons I was slightly nervous. We have conveyed our ideas to many types of athletes with great reception; however, I have never tried to communicate our message to those indifferent to exercise.

I thought that my biggest problem would be my message being lost in translation to an indifferent crowd, but the real challenge wound up being much more primitive. When given the choice of which presentation to attend, the vast majority was more interested in attending a lecture on which medication they could use to manage the pain then to listen to about how maintaining a quality of life is two-sided contract. As health professionals at a movement center, our end of the contract is to get them moving again and their end is to actually take responsibility for their health and not to accept a defeatist mentality. What I found was that people are much more inclined to wave the white flag then to fight for their quality of life.

It is sort of ironic in a way, I did include in my presentation how nearly a third of those with arthritis live completely sedentary lives. I knew that the problem was a misconception that movement was the problem and that exercise would only hurt them, when in fact even Harvard has recently published that one to two hours of moderate exercise can prevent pain from osteoarthritis all together.

So I guess that my point is we have more of an up hill battle than I expected. The good news is that those that chose to listen to our presentation were very receptive to our concepts. They very much understood what I said and felt that we understood their battles. Now what is left is for us to really push the concept of exercising to reduce or eliminate pain. We have lived in a sick care nation for a very long time. We have conditioned the aging population to accept defeat: loss of hearing, loss of memory, loss of vision, loss of balance, loss of strength, loss of driving, ect. It is time to take the focus away from pain and towards performance.

At GCMC we acknowledge that everyone has a goal and desired level of performance. That can mean you want to run an ultra-marathon or that could mean you want to walk pain-free around the mall. The point is we are all training for something and that, at the very least, we are training for life.

The Exercise Experience in Adults with Arthritis

This October 3rd I will be representing GCMC, along with my father and Matt, at the Women's Health Summit for the Arthritis Foundation. The topic we will be presenting is the importance of exercise with Arthritis. It almost would seem counter-intuitive that someone with a degenerative or inflamed joint should be moving that joint freely, but it is in fact true. And not just true, but imperative. The subject touched me and I feel it is important to help shed light on the facts.

Studies have shown that despite the importance of exercise, 31% of those with arthritis live completely sedentary lives. Those that were athletic before the arthritis tend to remain active after the diagnoses. They seem to have better handle on how to exercise and how to modify an exercise due to pain. However, those that were not athletic to begin with tend to be fearful of exercise, especially if they attempt exercise and experience an copeless amount of pain.

There are over 100 types of arthritis, the most common being osteoarthritis followed by rheumatoid arthritis. Osteoarthritis (OA)is the leading cause of disability, affecting more than 22 million adults in the United States. There is no cure; however, there is a lot you can do to slow down the progression and manage the pain. I have a busy class and work schedule, so in the interest of time I will list the evidence supporting exercise and provide a link to the Arthritis Foundation for further information on how to be healthy with arthritis. Besides, the journals could not be any more to the point.

Harvard's Women's Health Watch stated that regular exercise strengthens muscles and improves flexibility and balance. It not only eases pain and stiffness but improves overall health. New research suggests that older women may be able to prevent OA pain by getting as little as one to two hours of moderately intense exercise per week.

The American Journal of Health and Behavior stated that, "regular exercise by people with arthritis delays disability; improves physical function; improves quality of life, mental health, aerobic capacity and muscle strength; promotes functional independence; and reduces pain." (Am J Health Behav. 2006;30(6):731-744)


The Journal of Rheumatology printed, "it is now established that well-designed physical exercise programs promote prolonged improvements without inducing harmful effects on disease activity and joint damage” Rheumatoid arthritis, cardiovascular disease and physical exercise: a systematic review." (Rheumatology 2008;47:239-248)

Archives of Internal Medicine stated that, “Aerobic and resistance exercise may reduce the incidence of ADL disability in older persons with knee OA. Our study suggests that a physical exercise program may be an effective strategy for increasing the active life expectancy of older adults.”(Arch Intern Med. 2001 (161). 2309-2316)

Link for Arthritis Foundation

Primary Care: The Bastard Child of the Health Care Industry

With the economy in a recession and health care as the main topic of conversation, one thing is for certain: you can believe in change, even if it won’t be a change you believe in. There are a variety of ideas on how to improve the cost of health care and while I admittedly have not ready all of them, I will make the assumption that none involve pay increases for doctors.

Recently released in the Modern Physician’s 16^th annual Physician Compensation Survey was that more than half of the specialties that were tracked had compensation increases less than the rate of inflation . Primary care doctors were at the very bottom of that list, which should come as no surprise. It’s no wonder that the AAMC is forecasting a shortage of 124,000 physicians by 2025. How does this affect a universal health care plan, you might ask? Well when you decrease the number of physicians but increase the number of patients you find yourself in a predicament much like Massachusetts in 2006. 26 percent of residents had difficulty finding care and 35 percent of doctors stopped accepting new patients.

The Annals of Family Medicine reported that nearly one half of a primary care physician’s is spent on activities outside the examination room, predominately focused on follow-up and documentation of care for patients not physically present. Health Affairs that doctor interactions with insurers costs $23.2 billion to $31 billion a year. That is an average of $68,274 per physician per year for interactions with insurance companies.

Who is going to fill the void in primary care? It seems that either we would need 124,000 Mother Teresa's or that we would need the health care industry to brush up on it’s parental skills and coddle the primary care field. I personally do not know the answer on how to cure America’s health care woes, but it does not take a genius to see the problem. We have a rising cost for health care, a growing number of uninsured Americans, an increase in reimbursement below that of the rate of inflation and a shortage of graduating doctors willing to gamble their +$300,000 school debt on an under-appreciated and under-valued specialty. Just a fun closing fact, the top seven CEO’s for health care insurance policies earned a total of $14.2 million in 2008-2009. One source reported that over the past five years, health care insurance companies have posted 1000 percent increases in profits. Not to point fingers or anything but that increased health care money has to be going somewhere and it's certainly not going to the primary care doctor's pocket.

The Problem with Pain

What is your pain from zero to ten, ten being the worst pain you have ever felt? Does that look like anything you have come across before at a doctor’s office? If you have a child you may have come across the faces pain scale. A common variation found in many pediatric clinics. There is a long list of pain scale variations, each with their own set of advantages and disadvantages. The major problem across the board is that you can not collect true objective data in a subjective manner.

“Pain is an unpleasant feeling that is conveyed to the brain by sensory neurons. The discomfort signals actual or potential injury to the body. However, pain is more than a sensation, or the physical awareness of pain; it also includes perception, the subjective interpretation of the discomfort. Perception gives information on the pain's location, intensity, and something about its nature. The various conscious and unconscious responses to both sensation and perception, including the emotional response, add further definition to the overall concept of pain.”(Online Medical Dictionary)

Philosophy has dealt with the problem with pain as far back as Plato’s The Republic, written in 380 BC. Plato speaks of reality through his theory of forms. In his famous allegory of the cave, Plato speaks of reality being like shadows on a wall. We do not ever see the truth, just the shadows that we use to make inferences of reality. Rene Descartes (1596-1650) proclaimed “Cognito ergo sum” or “I think therefore I am.” He explains how perception must be part sensory and part cognitive. This is, for example, how one can observe a candle melt into liquid wax yet still know that the solid candle and the melted wax are one in the same. In fact, the oldest quantitative law in psychology is the Weber-Fechner law, a law concerned with the relationship between the intensity of physical stimuli and their perceptual effects. Ernst Weber found a logarithmic relationship between stimulus and perception.

What all of this means is that on a pain scale, my severed arm might feel like your stubbed toe. But with a stubbed toe and a pain rating of ten, I have learned something valuable about you and your road to recovery: you have a very low pain threshold and it’s going to be a long road. And that is in fact the value of the pain scale. Its benefit and its downfall walk hand in hand. You can not accurately describe pain with severity alone but you can use the data for other purposes. Maybe you will be less aggressive; maybe you will start with a more passive approach, either way you can avoid scaring off a patient and formulate the best way to approach his or her treatment.

And what if I walk into your office years after my severed arm and I circle a ten again for my pain? You better give me some immediate medical attention because something is seriously wrong. Unlike the other guy, when I cry wolf granny has been eaten and I am about to be dessert. However, if I walk in with a stubbed toe and a pain level of two you can more than likely be as aggressive as you would like for a quick recovery.

Pain scale ratings are important and very necessary. Use them as a basis for treatment approach and use them as a way to monitor progress. If you would like something more reliable, use more complex pain scales such as the McGill Pain Questionnaire which uses twenty subclasses of words that break down into four major groups to describe the sensory qualities of pain, the affects of pain, the overall experience of pain and some miscellaneous characteristics of pain. No matter which pain scale you use and how you use it just remember this: perception is reality and perceiving is believing.