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.

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

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.

The Chiropractic School Self-Esteem Issue

Coming from a family of 7 chiropractors has allowed me to see some of the amazing benefits of the profession. Growing up in a large chiropractic family went so far as to provide me the delusion that chiropractic was as main stream as any other health profession. I was rarely sick, I was surround by successful doctors and all I encountered were amazing testimonials to the credit of chiropractic care. Attending chiropractic school has given me a much different perspective.

I was a rather distinguished undergraduate student. I graduated with a gpa north of 3.8 and dual degrees in Biochemistry and Chemical Biotechnology. I won many awards and made many friends. My original thought was to pursue medical school and specialize as a non-surgical sports physician. I had the ability and honestly figured, "why not?" To make a long story short, just before I officially signed off on my acceptance to medical school and began that journey I decided that, if I was going to be non-surgical then why not just be a chiropractic sports physician like my father. He does very well and I could finish with a lot less debt and in less time. When I told my parents I had changed my mind and would be attending chiropractic school instead they all but disowned me. You would think I told them I was quitting school all together and telling them I would just live off of them at home for the rest of my life.

The reaction confused me as I'm sure it confuses you. Why would a successful chiropractor coming from a family of chiropractors be upset that his first born was following his foot steps? The answer was quite simple, he warned me that I had only been exposed to one side of the profession. He warned me that I would not be challenged and that I was throwing away everything I ever did in undgrad. He told me anyone with a pulse can go to chiropractic school and that that was one of the professions largest problems. I did what any other good child would do, I ignored him.

Going into my third year of chiropractic school, I have seen where my father was right and where he was wrong. I am very much proud of my decision and of chiropractic. I was fortunate to go to a good school with some amazing professors. In a profession that is a relative underdog in main stream health care I can say I have been given the best advantage at UBCC. I have been given a much larger diagnostic ability than I ever imagined and arguably more than I ever cared to know. This truly is pleasing because my father has always said, "the manipulation does not make the chiropractor a doctor: anybody can master that skill. What makes us doctors is our ability to diagnose. That is what differentiates us from the person that cracks their friends back", and I feel whole-heartily that he was right. Nothing aggravates me more than when someone references a student that has recently failed out of chiropractic school and they say "its a shame, he was such a great adjuster." The adjustment is a tool and a skill that anyone with a good book and a daring friend can master with enough time.

My father was wrong about the level of education I could attain from chiropractic school. It is something he gladly admits defeat in. If anything, I have made him a believer again in the longevity of the profession. Where he was undoubtedly right though was in the acceptance issue of chiropractic schools.

Our best doctors in chiropractic dominate over the medical general practitioner when it comes to soft tissue dysfunction. However, our worst chiropractor doctors make the worst medical practitioner look like a Nobel laureate. It is a conflict that must be reconciled for us to achieve true positive recognition from our medical peers. Dissenters do not look for the best chiropractor to make an example out of, they look for the worst and we give the worst to them.

Chiropractic suffers from a self-esteem issue. It believes it isn't good enough to attract the eights, nines and tens out there so it settles for the threes and fours, discarding of any self-worth or value. It is insulting to someone that truly wants to be a chiropractor to sit next to the students that simply do it because they know they can get in and that if they can pass the classes they can make a good living. The schools are not doing the profession or the student any favor when they blatantly ignore the fact that a particular student should not represent the profession and probably will not succeed either as a student or as a business person. It would seem unethical to allow someone to go into great debt knowing that they will undoubtedly fail, harm every other chiropractor, or even worse harm a patient. A pulse is simply just not good enough to be the test for admission. We desperately need to raise our standards. Life as a chiropractor does not have to be an uphill battle. I am tired of defending our profession due to the below average students we falsely label doctors. Chiropractic schools, I say to you, have some self-worth and stop proselytizing yourselves to the low caliber applicants. Is it really that simple? Probably not. This may mean the closure of the privately owned schools and growth of the chiropractic colleges that exist with the university setting. Perhaps this will be my next blog. Thank you for reading.

Share Openly and Share Freely,

John Giacalone Jr

Type and Number of Schools	% with Bachelor's Degree	Avg. Minimum GPA Required	Avg. GPA of Enrollees
Medical (17)	99.35%	3.16	3.56
Optometry (16)	76.88%	2.55	3.30
Osteopathic (16)	97.00%	2.68	3.26
Dental (15)	66.87%	2.79	3.13
Podiatry (7)	89.40%	2.76	3.06
Chiropractic (16)	42.25%	2.38	2.90

Reference

1. Doxey TT, Phillips RB. Comparison of entrance requirements for health care professions. Journal of Manipulative and Physiological Therapeutics 20:86-91, 1997.

Chiropractic, a Profession or a Service?

This being my first blog, I wanted to touch on a subject that I felt strongly about. Something that struck enough of a dissonant chord with me, that I could effectively convey some semblance of feeling to you, the reader. After all, I'd hate for my first blog to be your last blog due to boredom.

One problem I have had with the the public and my future profession is the usage of the term chiropractic. I cringe when I read a journal article that differentiates treatment modalities and they mention heat, ice, physical therapy and chiropractic. Or when a news article or even worse, another chiropractor, speaks of how chiropractic care works and then fades into a cervical manipulation. Now my years are few and my experience is limited to the 7 chiropractors in my family and the conversations we have all had over the years; however, i always thought that chiropractic is profession and not a treatment. Manipulation is not what makes us special, it is our understanding of functional pathologies and how to treat them quickly and effectively.

I could probably look past this nuance if it weren't for the fact that, if a study is looking at the effectiveness of chiropractic care and it is limiting chiropractic care to just the manipulation, it seems to me you are not really looking at the effectiveness of chiropractic. Rather, you are looking at the effectiveness of one aspect of chiropractic in relation to other treatment options.

Do chiropractors not use heat? Do they not utilize the same manual therapy techniques that fall under the title of physical therapy or rehabilitation? The answer is yes. Words matter and for that reason they should be used carefully. It should be taught that even if the manipulation has less effectiveness in relation to low back exercises for a particular case (purely being hypothetical right now), the chiropractic profession utilizes both tools in their toolbox. Therefore, when the public has to choose which health care professional to pursue for a given complaint, they should know that chiropractic is not a place to get your back "cracked."

Chiropractic is physical medicine. My reality is that life is movement and that bodies that move well, live well. Our job is to use the best evidence provided and our clinical judgment to restore movement and improve a quality of life. Whether this means manipulation, physical therapy, manual therapy techniques or any of the other treatment options, the point is chiropractic the profession provides all of these services.

Thank you for reading my first blog. I hope that you follow me from time to time. I promise to share openly and freely.

- John Giacalone Jr