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Lumbar Spine Trauma

Compression fractures are the most common fractures of the lumbar spine.  They result from combined flexion and axial compression.1,2  The most common segmental levels to develop compression fractures are T12-L1.3  The extent of the vertebral compression and degree of comminution are dependent upon the severity of the force applied and the relative strength of the vertebra.4  In children, they are torus-type fractures.  In the elderly, osteoporosis can precipitate spontaneous compression fractures during everyday activities, which technically render them classifiable as insufficiency fractures (“grandma fractures”).  Up to 35% of compression fractures in female patients over the age of forty-five years may be due to early menopause and 30% to secondary osteopenia, most often from corticosteroids (15%), hyperthyroidism (8%), and malignancy (less than 2%).5  The disruption of the cortical vertebral endplate causes acute symptoms of only ten-to-fourteen days, duration, as long as no dislocations accompany the fracture.6

Below are X-rays of different patients who have sustained traumma to the lumbar spine.  The two most common fractures in the lumbar spine are demonstrated in the figures below.  Can you identify them?

Figure 1

Figure 2

Figure 1. Compression Fracture of the L1 Vertebral Body.  Observe the linear white band of condensation (zone of impaction) seen throughout the mid vertebral body.  This is a positive radiographic sign for vertebral compression fracture, along with the wedge-shaped vertebral body.

Figure 2. Transverse Process fractures of L1, L2 and L3.  Note the transverse process fractures on the left side of the L1, L2 and L3.

 Post-fracture stability is determined based on the classification by Denis.7  Three columns are recognized:  anterior column (from the anterior longitudinal ligament to the midvertebral body), middle column (from the midvertebral body to the posterior longitudinal ligament), and the posterior column (from the posterior longitudinal ligament to the supraspinous ligament).  If two or more compartments are disrupted, the fracture complex is unstable.  The likelihood of neurologic injury is high and interventional surgery is likely to be necessary.

 
Radiographic Signs of
Vertebral Compression Fracture

Radiographs of optimum quality are necessary in order to adequately demonstrate these fractures.  Lateral radiographs best demonstrate fracture features.  Radiographic signs of vertebral compression fracture include a step defect, wedge deformity, linear zone of condensation, and displaced endplate.

The Step Defect

Since the anterior aspect of the vertebral body is under the greatest stress, the first bony injury to occur is a buckling of the anterior cortex, usually near the superior vertebral endplate.  This sign is best seen on the lateral view as a sharp step-off of the anterosuperior vertebral margin along the smooth concave edge of the vertebral body.  In subtle compression fractures, the “step” defect may be the only radiographic sign of fracture.  Anatomically, the actual step-off deformity represents the anteriorly displaced corner of the superior vertebral cortex.  As the superior endplate is compressed in flexion, a sliding forward of the vertebral endplate occurs, creating the roentgen sign.

Wedge Deformity

In most compression fractures, an anterior depression of the vertebral body occurs, creating a triangular wedge shape.  The posterior vertebral height remains uncompromised, differentiating a traumatic fracture from a pathologic fracture.  This wedging may create angular kyphosis in the adjacent area.  The superior endplate is far more often involved than the inferior endplate.  Up to 30% or greater loss in anterior height may be required before the deformity is readily apparent on conventional lateral radiographs of the spine.8  Normal variant anterior wedging of 10-to-15%, or 1-3 mm, is common throughout the thoracic spine most marked at T11-L2.9,10
In all compression fractures, there should be clear differentiation from an underlying pathology that has produced the fracture. Key features of pathologic fractures may be identified by loss of the posterior body height, pedicle, and other sites of destruction. A paraspinal mass on MR imaging with abnormal marrow can be demonstrated.11

Linear White Band of Condensation
(Zone of Impaction)

Occasionally, a band of radiopacity may be seen just below the vertebral endplate that has been fractured.  The radiopaque band represents the early site of bone impaction following a forceful flexion injury where the bones are driven together.  Callus formation adds to the density of the radiopaque band later, in the healing stage of the fracture injury.  This radiographic sign is striking when present; however, it is an unreliable sign, since it is not present as often as might be expected.  Its presence, however, denotes a fracture of recent origin (less than two months’ duration).  It is nicely demonstrated in Figure 1.

Disruption in the Vertebral Endplate

A sharp disruption in the fractured vertebral endplate may be seen with spinal compression fracture.  This may be difficult to perceive on plain films and tomography; CT (computed tomography) provides the definitive means to identification.  The edges of the disruption are often jagged and irregular.  The superior endplate is more commonly fractured than the inferior endplate.

Transverse Process Fractures

Transverse process fractures are the second most common fractures of the lumbar spine, with compression fracture being the most common.  They occur, usually, secondary to a severe hyperextension and lateral flexion blow to the lumbar spine from avulsion of the paraspinal muscles.  The most common segments to suffer transverse process fractures are L2 and L3.
Radiographically, the fracture line appears as a jagged radiolucent separation, usually occurring close to its point of origin from the vertebra.  Frequently, the separated fragment is displaced inferiorly.  If the fracture line is horizontal, close inspection for a transverse or Chance fracture should be performed.  Fractures often occur at multiple levels.  Fractures of the fifth lumbar transverse process are frequently found in association with pelvic fractures, particularly fractures of the sacral ala, or disruption of the sacroiliac joint.  Occasionally, loss of the psoas shadow may occur secondary to hemorrhage.  Ossification within the hemorrhage (myositis ossificans) can result in bony bridging between transverse processes (lumbar ossified bridging syndrome, LOBS).12   Renal damage may occur which may be associated with hematuria.
A pseudofracture of the transverse process can be simulated by developmental nonunion, especially at L1, the psoas margin where it crosses the tip of the transverse process and overlying fat lines, or intestinal gas.  Oblique or tilt views may be necessary to rule out fracture.13 TAC

Dr. Terry R. Yochum is a second-generation chiropractor and a cum laude graduate of National College of Chiropractic, where he subsequently completed his radiology specialty.  He is currently Director of the Rocky Mountain Chiropractor Center, in Denver, CO, and Adjunct Professor of Radiology at the Los Angeles College of Chiropractic, as well as an instructor of Skeletal Radiology at the University of Colorado School of Medicine, Denver, CO. Dr Yochum is, also a consultant to Health Care Manufacturing Company that offers a Stored Energy system. For more information, Dr. Yocum can be reached at: (303) 940-9400 or by e-mail at [email protected].

Dr. Chad Maola is a 1999 Magna Cum Laude Graduate from National College of Chiropractic.

TAC’s MISSION:

We are dedicated to the continuing education & advancement of the chiropractic professional – YOU!

Chiropractic News Around the World

The Passing of a Revolutionary Diet Doctor
NEW YORK:  On Tuesday, April 8, Dr. Robert C. Atkins slipped on an icy sidewalk outside his Manhattan office and suffered a head injury.  After undergoing emergency brain surgery at Cornell University Medical Center in New York City, he remained in a coma until his death on April 17.  At age 72, Dr. Atkins still worked full time, attending to patients and overseeing the Atkins Center for Complementary Medicine.
Jenny Thompson, a spokesperson for Health Sciences Institute, commented following the death, saying, “HSI has worked closely with Dr. Atkins in the past, and so his death was both a great personal and professional loss.  Most of the news stories I read described him as a diet “guru,” and, in the sense that he was an influential, groundbreaking leader in the field of complementary medicine, he was indeed something of a guru—a trusted counselor who helped millions of people regain their physical health with his unconventional ideas about nutrition.”
After many years of abuse by mainstream nutritionists, there was a sea change for Dr. Atkins and the Atkins diet last summer, illustrated by a cover story in the Sunday New York Times Magazine, which showed how a steadily growing minority of establishment researchers were beginning to take seriously the low-carbohydrate diet made famous by the author of Dr. Atkins’ Diet Revolution.
Over the course of 30 years, Dr. Atkins never wavered from his controversial dietary ideas.  In a nutshell, the Atkins plan advises us to eat as much meat and other high protein and high fat foods as we care to, while avoiding starches and refined carbohydrates such as breads, pasta, rice, and sugars.  This plan has won many millions of readers worldwide, but has drawn numerous, often passionate attacks from the nutrition and diet establishment.
The American Heart Association has long condemned the Atkins diet as an unhealthy regimen for the cardiovascular system.  So it must have been thoroughly galling to many in the AHA “low-fat” camp when the results of a Duke University study were announced last November, as part of the 75th annual AHA meeting.  In all of the heart health categories in that trial, the Atkins diet scored equal or higher marks than the AHA’s “Step 1” low-fat diet.
This was a major victory for Dr. Atkins—to be vindicated with prestigious research, and to have it announced in the camp of his most vocal detracters.
Health Sciences Institute www.hsbaltimore.com

Traveling Chiropractor Accused of Practicing without License
FLORIDA:  A doctor and his wife who travelled the country performing what investigators said was an unusual form of therapy were arrested last month, accused of practicing without a license in Florida.
The Brevard County Sheriff’s Office charged Dr. Dean Howell and his wife, Trisha Howell, of Tonasket, WA, with practicing naturopathy, massage therapy and chiropractic medicine without a license after arresting them at an acupuncturist’s office in Cocoa, FL.
According to Howell’s Web site, the procedure, known as neurocranial restructuring, or NCR, involves a combination of deep muscle massage and the brief insertion of inflatable balloons into a patient’s nose and throat to return the body to its natural shape.  The site says the procedure can help ailments ranging from Alzheimer’s disease to wrinkles within four days.
Howell was licensed in the state of Washington, though that license was suspended in 1989 for five years, said Karen Newell, an investigative technician with the Sheriff’s Office.
Newell said an insurance company tipped the Orlando Health Department that Howell was not licensed in Florida.  A schedule on Howell’s Web site indicated that he would be in Cocoa Beach between May 8-11.
The Howells have been released on bonds and are scheduled to appear in court in early June.

State Licensing Boards Can’t Get Quorums to Work
GEORGIA:  Several state licensing boards were forced to call off their May meetings because they couldn’t get enough people to make a quorum.
The Georgia Board of Chiropractic Examiners only had one member on its six-person board.  The meeting was canceled for lack of a quorum.
Three other state professional licensing boards—for dispensing opticians, for licensed dietitians and for private detectives and security agencies—called off their meetings for the same reason, reported The Atlanta Journal-Constitution..
Five other boards were also left without quorums after the state Senate refused, on the last day of the legislative session, to confirm members that then-Gov. Roy Barnes had appointed since the previous General Assembly.
The situation has thrown professionals all over the state into turmoil as they wait to receive licenses or have their licenses renewed, the Atlanta newspaper reported.  Consumers who have filed complaints also have to wait, because such disciplinary actions as a fine or expulsion cannot be taken without a vote by the licensing board.
The Senate confirmed only forty of the 210 appointments Barnes made to boards, commissions and authorities.
Associated Press

Clermont Physician Cleared of Malpractice
FLORIDA:  A six-member jury last month dismissed claims that Clermont chiropractor Kenneth Felt acted irresponsibly in caring for an elderly patient who broke her right hip.
Marguerite Leggett, 74, filed a civil complaint against Felt and Clermont Chiropractic in October 2001 claiming Felt should have prevented her from falling onto the floor during an examination.
Felt had asked Leggett, during a Sept. 23, 1999, examination to turn onto her back during a spinal manipulation treatment.  Leggett, who was lying on her stomach, reportedly put her right leg on the floor in attempting to stand to shift her position when her leg gave way and she fell to the floor.
Continues u
The fall broke her hip.  She has had to have three hip surgeries since the fall, her attorney Linda Schwichtenberg of Orlando said.
A half dozen experts testified during the three-day civil trial trying to determine the exact cause and time of the hip fracture and whether Felt acted properly during the examination.
Pembroke chiropractor Donald Woeltjen, who testified for Felt, said examiners do not normally help patients shift their position in order to avoid hurting them.
He also said getting off a 22-inch exam table is not a difficult task requiring additional assistance.
“Getting off that table is not different than getting out of bed,” he said.
Felt’s attorney, Kurt Spengler of Orlando, argued that Felt followed standard procedures during the examination.
Daily Commercial

Damaging Report, Highlights Chiropractic Costs
CALIFORNIA:  Chiropractic costs and frequency of services have increased noticeably in California, which spells bad news for the industry.
A report released by the California Workers’ Compensation Institute (CCWI) shows a 153-percent increase in chiropractic costs from 1996 to 2001 and an increase from 59 to 120 in the average number of chiropractic procedures per claim.  The study shows that though the percentage of claims involving chiropractic treatment dropped from 1993 to 2000, the amount paid for chiropractic care increased.
The report states that chiropractors are now the leading medical providers in California’s worker compensation system, news that only fuels the fire for insurers and employers pushing state lawmakers to control medical costs.  Legislation already introduced in the state senate would limit chiropractic visits to fifteen per year.
Chiro Wire

Nationally Syndicated Comic Strip Highlights Chiropractic
The widely read “Broom Hilda” comic strip featured an amusing and very positive depiction of the role chiropractors play in caring for the daily health needs of people. The March 23rd edition of the comic strip showed a chiropractor’s office filled with people injured doing their spring gardening.  While comic, the intention of the creator, Russell Myers, served as a reminder to millions of readers that doctors of chiropractic are there when you need them, whatever the season.  To view this great positive message, visit the Broom Hilda website at http://www.comicspage.com/broomhilda/ and go to the March 23rd archive.

Court Approves $470 Million Dollar Settlement in Aetna Case
NEW YORK:  On May 29, U.S. District Court Judge Federico Moreno of the Southern District of Florida preliminarily approved a settlement agreement announced earlier between Aetna and the plaintiffs representing over 700,000 physicians, state and other medical societies.
The ruling conditionally certifies a class for settlement of physicians who provided services to Aetna or any of the other defendants, allows notice to be sent out to class members informing them of the agreement and schedules a fairness hearing for October 13, 2003, whereby the judge will consider whether to finally approve the settlement presented by the plaintiffs and Aetna.
In reaction to the decision by Judge Moreno, Tim Norbeck, Executive Director of the Connecticut State Medical Society commented today: “This country’s patients and physicians alike should hail Judge Federico Moreno for his approval of the Aetna settlement with 700,000 medical doctors on terms that will favor their patients’ actual medical care over the intrusive technicalities and oppressive minutiae that have long plagued managed care systems.
“We recognize Judge Moreno for his pioneering the way by which health insurers and medical societies can come together in the interest of their common constituency—the patients that insurers and physicians alike are pledged to serve.  This historic settlement gives everyone reason for optimism and it is Judge Moreno’s wisdom that has made possible the better healthcare system that will result for all.”
PR Newswire

Judge Dismisses Chiropractors’ Case Against Trigon
VIRGINIA:  In what defense lawyers are calling a significant victory for the managed-care industry, a federal court in Virginia has granted a health insurer summary judgment in a lawsuit alleging antitrust conspiracy.
The U.S. District Court for the Western District of Virginia granted summary judgment to Trigon Healthcare Inc.—which merged with Anthem Inc. (NYSE:ATH) in July 2002—in a lawsuit brought by the American Chiropractic Association, the Virginia Chiropractic Association and individual chiropractors.
Plaintiffs had said the case was the most significant legal action ever taken by the chiropractic profession against the insurance industry and called it a test of future action, according to a statement from Trigon’s attorneys at McGuireWoods law firm. The court also said Trigon wasn’t liable for attempted monopolization because it didn’t compete in the market for treatment of neuromusculoskeletal disorders, the attorneys said.
The ACA, VCA and ICA called the opinion from U.S. District Judge James P. Jones “legally and factually wrong” and “full of holes.”  They will “vigorously appeal” the unfavorable ruling.
Chiro Wire TAC

Healthy Sleep for Rehab Patients

Patients receiving rehab care for various chronic or acute neck problems often come across advertisements promoting special “neck support” pillows.  Cervical support pillows are recommended by many chiropractors, physiotherapists, and even surgeons.  In a 1998 comparison study of three types of bed pillows, the authors write, “From a patient’s perspective, neck support is an important part of a comprehensive physiotherapy program.”1  Most bedding stores and sleep shops have at least one special pillow (and often there are several) for people with neck pain. 
While many doctors of chiropractic have recommended cervical support pillows for years, the scientific evidence for benefit has been skimpy, at best.1-5  Empirical and anecdotal reports from patients who report “improved sleep” and “decreased pain” have often been all that is available.

Scientific Studies

Let’s review three scientific studies2-4 which have attempted to address some of the questions regarding cervical pillows.  Although each of these three took different investigative approaches and evaluated different pillows—which means that the findings are not directly comparable, and no definitive conclusions can be made—the results are still worth consideration, since they give us some guidance in selecting a support pillow for our patients.
Two-pillow comparison study.  In a study2 performed at the Johns Hopkins University School of Medicine, Drs. Lavin, Pappagallo, and Kuhlemeier recruited forty-six subjects with chronic neck pain and cervicogenic headaches.  The investigation compared the subjects’ daily pain levels, sleep quality, and medication consumption during one week on their own pillows, followed by two weeks each on two special neck support pillows.  One of the pillows was a “cervical roll” style and the other was a “water-based cervical pillow.”  A statistically significant improvement in all scores was recorded when using the water pillow.  Most subjects preferred the water pillow to their own pillow, and many had a very difficult time sleeping on the roll pillow.  In fact, the researchers reported that some of the patients had to discontinue the two-week trial of the roll pillow due to significant discomfort. 
The investigators felt that the higher satisfaction ratings of the water pillow were due to its ability to conform better to the position and shape of the subjects’ head and neck during various sleep positions.  They believed that the roll pillow was not well tolerated due to its tendency to exaggerate the extension of the neck when supine (since there was no support underneath the head).
Single-style study.  A small feasibility study3 at Canadian Memorial Chiropractic College seemed to find very different results.  After recording two weeks of baseline pain ratings in thirty subjects with chronic neck pain, the researchers supplied a roll-type cervical pillow (a soft cylinder shape).  Of those who persevered in using the pillow for four weeks (many subjects found the pillow to be very uncomfortable initially), most reported decreases in neck pain.  However, three subjects described increased neck pain during use of the pillow, and two women dropped out of the trial, saying they were unable to tolerate the discomfort they experienced while using the cylindrical pillow.  Since the data collected do not reflect these “pillow failures,” and since there was no placebo or comparison with other pillows, this study’s conclusions should be considered overly optimistic.  This demonstrates the difficulty in designing a scientifically valid and practically useful scientific investigation.
Six-pillow comparison study.  At Lund University Hospital in Sweden, researchers4 studied the responses of fifty-five subjects to three nights on each of six different pillows.  However, none of the six pillows included their own pillows, and none was the same as the two types studied in the previous experiments.  Since no “roll-type” pillows were included, we are left without a practical comparison to the other studies. 
The subjects in this experiment rated the six pillows for comfort, but were also asked about pain reduction and sleep improvement.  The six pillows varied in their designs, materials, and construction. 
One pillow stood out from the rest as the most comfortable, and also the most likely to decrease chronic pain.  Rated the “best” by both men and women, this pillow was made of soft polyurethane with two firm supports along the edges—one side high and the other side lower.  This pillow supplied an easily tolerated support for the neck, while the two different sides provided a choice of heights.  The pillow that rated the lowest was the one which most closely resembled a roll pillow.
The investigators concluded that the optimal neck pillow to reduce neck pain and improve night rest was a soft, not-too-high pillow with support for the cervical lordosis from a choice of firmer cores.  Since the participants used each pillow for only three nights, and only comfort ratings were evaluated, no conclusions can be drawn from this study regarding the long-term effect of these pillows on pain or sleep patterns.

The Search for Healthy Sleep.

When patients report chronic neck pain, cervicobrachialgia, and/or cervico-genic headaches, or when a patient has been instructed to perform rehabilitative cervical exercises, a cervical support pillow should be considered.  This is especially true when the pain is described as being worse in the morning and improving during the day.  If sleep disturbances are part of the history, or accompanied by a history of injury to the neck, a comfortable, yet supportive pillow should be a part of the chiropractic treatment recommendations. 
The right pillow will vary depending on the size of the person and on the amount of neck support that can be tolerated.  Roll-type cervical pillows are initially uncomfortable, and may worsen some patients.  A pillow which supplies a choice of sides is more likely to be helpful to a broader range of patients.  It is also important to re-evaluate your patients’ pillows, to ensure that proper cervical support continues over time.
Recommending the use of a good cervical support pillow (and supplying one that has a good track record) can be one of the most useful adjunctive procedures to rehabilitative treatment of neck pain.  Patients appreciate the doctor who goes beyond the office setting to give advice regarding supportive home activities, and even specific sleep  recommendations. TAC

Kim D. Christensen, DC, CCSP, CSCS, DACRB, founded the SportsMedicine & Rehab Clinics of Washington.  He is a popular speaker, and participates as a team physician and consultant to high school and university athletic programs.  Dr. Christensen is currently a postgraduate faculty member of numerous chiropractic colleges and is the president of the American Chiropractic Association (ACA) Rehab Council.  He is a “Certified Strength and Conditioning Specialist,” certified by the National Strength and Conditioning Association.  Dr. Christensen is the author of numerous publications and texts on musculoskeletal rehabilitation and nutrition.  He can be reached at Chiropractic Rehabilitation Assoc., 18604 NW 64th Avenue, Ridgefield, WA 98642 or by email at [email protected].

Million Dollar Chiropractor Interview with Dr. Deane Mink

 

Dr. Deane Mink’s M$C Profile

PERSONAL
Married to wife, Sue, for 15 years; 7 children:  Mark, 43; Debbie, 41; Mike, 39; Matt, 36; Mitch, 29; Cheri, 32; and Christie, 25; 10 grandchildren.
Recreation and Leisure:  Fishing and/or netting shrimp almost every week; boating; weekends at Florida waterfront properties; season ticket holder for Univ. of Florida football team. “GO GATORS!”
Professional Affiliations: Georgia Chiropractic Assn., Florida Chiropractic Assn., International Chiropractic Assn., Palmer College Alumni Assn., Valdosta Chamber of Commerce, Better Business Bureau.
Seminar Attendance:  Georgia Chiropractic Assn. license renewal seminars; various other technique and nutritional seminars.
Vacations:  Many extended weekends, mostly to Gulf Coast and Atlantic Coast of Florida; weeklong family vacation the week of July 4th (25+ folks).

PRACTICE PARTICULARS
Clinic:  9000 sq. ft., freestanding building, includes 13 treatment Rooms, 2 massage Rooms, Rehab Room and Vitamin Shop.
Office Hours:   7 A.M. to 6 P.M., Monday through Friday; Saturday, 8 A.M. to noon.
Techniques:  Palmer, Full Spine, Diversified, Activator, Flexion Distraction.
Staff:  Dr. Mink’s office employs 2 DC’s, 1 Rehab Director, 6 Licensed Massage Therapists, 2 receptionists, 4 chiropractic assistants, an office manager (wife, Sue Mink), and 4 staff in business office.

M$C:   Dr. Mink, what influenced you to become a chiropractor?
Mink:  I was a minor league baseball player, from 1952-1958, with the Dodger organization.  My first chiropractic experience was for treatment of an injured shoulder that threatened my baseball career.  As a result of that experience, I made the decision, with the encouragement of my chiropractor, to pursue chiropractic.

M$C:   What type of practice  do you have?
Mink:  Mink Chiropractic Center is a subluxation-based practice.  We currently have over 4300 active patient records.  The breakdown is as follows:  54% health insurance, 25% cash, 12% Medicare, 8% personal injury, 1% workers comp.  We have all our new patients attend a health care class offered each Tuesday night, and have them bring their immediate family members to get the whole family educated about a drug-free lifestyle.  We treat patients for pain management, but strive to build a wellness-oriented practice.

M$C:  How many hours a week do you work?
Mink:  Our office is open from 7 A.M. to 6 P.M., Monday through Friday, and on Saturday, 8 A.M. to noon.  I presently treat patients on a three-day work week (Monday, Wednesday, Friday), working about thirty-two hours per week doing patient treatments and the related patient paperwork and records.  My associate, Dr. Ken Register, works about thirty-eight hours per week, Tuesday through Saturday.

M$C:  What’s the income service level that you provide annually?
Mink:  I treat an average of 230 patients per week and my associate, Dr. Ken Register, treats an average of 280 patients per week.  The practice averages one hundred new patients per month.  In 2002, the gross collections for the clinic were 1.6 million.

M$C: Is there someone in particular to whom you attribute your success?  Any mentors, perhaps? 
Mink:  In the early 1960’s, I approached Dr. William Harris for guidance in growing my practice.  Dr. Harris is a retired Georgia chiropractor that still contributes his time and his wealth to the advancement of chiropractic on a state and national level. 
My patients are responsible for my success, as I am now treating the 3rd, 4th  and even 5th generations.  My success is due not only to my own efforts but, also, to the hard working and dedicated staff in our clinic that believes in what we do and in the health of our community.

M$C:   What marketing strategies do you use to attract new patients and to keep current patients?  
Mink:  I have mailed an in-house newsletter quarterly consistently for over forty years.  My patient mail list is updated and maintained in my office.  This listing is of great value.  Patients may drop out of care, but they will come back; and not only the patient that previously received care, but the family, friends and acquaintances of that patient. 
I am, also, involved in the community and contribute to the success of our community.  The local Chamber of Commerce named our office the “Small Business of the Year” for 1999.  The local paper sponsors the “Best of South Georgia”, where the readers’ vote on various categories.  Our office has won the “Best Chiropractor in South Georgia” for the three years since this feature began.  Being a very active positive aspect of our community draws patients to our office. 
Dr. Register has a booth at many of our community shows and health fairs and offers in-business lectures and training. 
We offer lots of TLC to our patients.  We have a state-of-the-art new office, and equipment that projects to the patients that we are here to serve their health care needs for now and the future.  We encourage a family-type everybody-needs-adjustments attitude.

M$C:  Do you enjoy your work?  How do you feel about going to work in the morning?
Mink:  I LOVE IT.  I am committed to the healing power of chiropractic, and serving my patients is so much a part of my life that I cannot imagine full retirement.  I work because I love it.  We have such a wonderful fully equipped, well-maintained, and professionally staffed office that going to work everyday is like going to Disney World.  My wife and I work together, and when we work—we work hard.  But when we’re off –we play hard.   This makes life well balanced and very satisfying and rewarding.

M$C:  Having such a successful practice which has served the same community for your long professional career, what is your advice about setting up and maintaining such a practice in today’s healthcare system? 
Mink:  Determine your demographics and make a plan that works in your area.  Start and maintain a mailing list of your patients.  Newsletters are a wonderful way to communicate to large numbers of previous and potential patients and to keep your services in their minds on a regular basis.  Potential patients must feel confident and comfortable with your office, and your staff, as well as yourself.  Your office must be patient friendly. 
Be sure everything you do is ultra ethical—your reputation and your future depend on it.  You must genuinely care about chiropractic and the lifestyle it offers; and you must care about your patients and their families’ health.

M$C:   Other than traditional chiropractic care, do you include any other type of services or products in your clinic which further help your patients, as well as bring in additional revenue to your practice?
Mink:   We have a nutritional shop in our office with everything that works; and we keep it well stocked.  We have a free nutritional class each month for our patients, staff and any family members or guests they wish to bring.  We have all necessary support belts, collars, traction devices and pillows.  We offer custom fitted orthotics.  Our facility has a completely equipped rehab room and we do computerized range of motion and muscle testing. 
We also have two massage rooms available each day for full body massage therapy.  Every day we have licensed massage therapists as part of our staff to do eight minutes of specific trigger point therapy as part of the patient’s chiropractic visit.

M$C:  Any final words for our readers?
Mink:  Chiropractic practices are the reflections of the concept the chiropractor has about his profession.  There are lots of one-man-show type practices around.  This is the concept of the chiropractor and, is perfectly all right.  I know many of these chiropractors, and they are happy in what they do.
My concept has always been “bigger can be better” and we’ve “biggie sized” chiropractic in South Georgia by building the new building and offering so many health related services and products.  We keep it simple for our patients.  Almost 100% of our patients—whether active or occasional—have a good taste in their mouths about chiropractic and are happy to send their family and friends to us.
After forty-two years in my profession, all this sounds like so much hard work for me; but I’ll be the first to admit that having a wife “who runs the whole place,” a young associate who is a wellness disciple and very dedicated, and lots of great employees (total of eighteen) makes my job much easier.
You may contact Dr. Deane Mink by telephone at 229-242-3042, or by e-mail at [email protected].  Visit his web site at www.minkchiro.com.

Our sincere thanks to Dr. Mink and his Staff at Mink Chiropractic Center, LLC, of Valdosta, Georgia. TAC

10 More Great Techniques Part III

Here is what you can find in this article: 

  • Previous Techniques Featured
  • Introduction by Donald Epstein, D.C.
  • 10 More Great Techniques:
     
    1) Advanced Muscle Palpaption
    2) Blair Cervical Technique
    3) Directional Non-Force Technique
    4) The Graston Technique
    5) Logan Basic Methods
    6) Matrix Repatterning
    7) Dr. Mally’s Extremity Adjusting Technique
    8) McTimoney Technique
    9) Neuro Emotional Technique
    10) The Toftness System of Chiropractic

    “10 More Great Techniques” is the third in an annual series of technique features presented by The American Chiropractor.  For your reference, below are alphabetized lists of techniques highlighted in previous years.  Still no info on your favorite technique or one your curious about?  Let us know what we’re missing!

2001
Advanced Biostructural Correction—Jesse Jutkowitz
Atlas Orthogonal Technique—Roy. W. Sweat
Bio-Geometric Integration—Sue Brown
Chiropractic Biophysics—Donald D. Harrison
Dynamic Spinal Analysis—Jerry Hochman
Network Spinal Analysis—Donald M. Epstein
Ortho-Spinology—Kirk Eriksen
Pettibon-Spinal Biomechanics—Burl R. Pettibon
Sacro-Occipital Technique—Marty Rosen and Major B. DeJarnette
Torque Release Technique—Jay M. Holder

2002
Access Technique—Dr. Robert Wiegand
Activator Technique—Dr. Arlan Fuhr
Applied Kinesiology—Dr. George Goodheart
Bio Energetic Synchronization Technique—Dr. M.T. Morter
Charrette Protocols—Dr. Mark Charrette
Diversified Technique—Dr. Tom Bergmann
Gonstead Technique—Dr- Clarence Gonstead
Thompson Technique—Dr. Wayne Zemelka
Toggle Recoil Technique—Dr. Steve Hoffman
Total Body Modification—Dr. Victor Frank.
10 More Great Techniques
The following article is the result of a cooperative effort among The American Chiropractor, Dr. Donald Epstein, and leading authorities on the techniques featured.

Chiropractic Technique:  Finding the Right Fit
 by Donald Epstein, D.C.
Dr. Donald Epstein is the developer of the Network Spinal Analysis technique and a very active seminar speaker and technique instructor.

Chiropractors generally take their technique(s) personally.  A technique is a strategy to achieve specific objectives for the patient or practice member.  In choosing your techniques, it is wise to first investigate your true objective in caring for those you serve.  Finding the right technique fit is not so much about the technique, itself, as much as it is about knowing yourself, your values, beliefs, chiropractic culture and where you feel your future is pulling you.

In my opinion, we all get to the point where our future self requires more of us presently, and this is reflected in our personal and professional lives.  At this point, we may experience frustration and may question our selves and our treasured techniques.  When this happens we are ready for change—sometimes radical change—and it seems that we can’t wait one moment longer. 

At that point, a practitioner may ask, “What do I like, or what do I enjoy?”   Self-assessing from this perspective will often lead you to more frustration.  Instead, I suggest asking, “Which technique supports who I am becoming and how I can step up my commitment to humanity and to my profession?” Often, from this perspective, the direction in which you need to move will become more evident.

A segment of the profession plays technique roulette, rolling from one technique to another like the ball over the numbers on a roulette wheel, hoping for the magical win.  On the other hand, some merge their personal and professional identities with their technique.  Their commitment to their technique can resemble a religious fervor.  The former individuals may switch from a segmental high force approach to a low force approach, or from a palpation-based model to an X-ray based technique, or switch between anatomical regions.  Still others may choose a new method by finding something that is 180 degrees different from what they were doing to see how this impacts their patients or practice. 

Many practitioners choose their technique based upon their personal experience as a patient or based upon the health or wellness success achieved in care by a family member, friend or former patient.  Some choose their method based upon compatibility with their cultural, academic, or philosophic chiropractic models.

 A trend has occurred during the past two decades.  Diversified and regional spinal manipulation classes have replaced chiropractic systems or packages.  There has been a political movement in chiropractic to discredit “named” techniques or to relegate technique developers to a term such as entrepreneurs.  Unfortunately for the profession and for the schools, new thought, new approaches and new techniques have not, as a general rule, come from the schools.  These so-called technique “entrepreneurs” are the individuals keeping the profession and the vision of chiropractic alive.  They should be applauded for their efforts and contributions.  Those chiropractors who serve our profession by sharing their unique clinical wisdom at technique seminars deserve to be honored and financially rewarded for their help of humanity.  Similarly, those who have dedicated their lives to bringing forward and evolving these methods in our changing world should be rewarded and acknowledge by the profession.  Developing a technique, systematizing your concepts for reproducibility and conducting clinical trials or research, all without the support of the existing academic structures, is not an easy path to take.  However, this is the way it currently is in the profession.  Hopefully, in the future, the chiropractic colleges will nurture emerging models and encourage means of assessing effectiveness for stated objectives and strategies.  With greater diversity, we will all be enriched, and so will those we serve.

When I was first introduced to “diversified” technique at Columbia Institute of Chiropractic, almost thirty years ago, I was taught it as adjunctive force applications to be utilized after chiropractic spinal analysis was performed.  If the practitioner had already determined the primary or secondary subluxations through his or her chiropractic analysis, and the suggested force application did not appear sufficient, diversified offered alternative effective means of applying the forces.

Chiropractic technique includes an assessment strategy and a force application toward a specific goal or objective.  Before choosing a technique, the practitioner would do well to ask what his or her highest objective is for those coming to him for chiropractic care.  What is the chiropractor attempting to achieve?  Correction of subluxation, fixation, somatic anchors to emotional experiences, enhanced range of motion, change in spinal curves, etc., are part of the picture, but are strategic goals, not objectives.  The question, again, to be asked is, “Why am I practicing as a chiropractor?  What would I like to see happen for my patient in her spine and in her life, health and wellness?”

Once the practitioner has decided his short- and long-term objectives for correcting a subluxation, spinal distortion, nerve pressure or tension, etc, how does the practitioner really know if the technique chosen is the appropriate one to accomplish those objectives?  A closer look at technique may be of help.  In my opinion, the following elements compose a chiropractic technique:

A philosophy of health and or wellness and its relationship to structure, function, energy and elements of spinal and neural integrity.

A system of categorizing distortions or deviations from optimal structural, energetic, neurological states, and a priority system as to appropriateness of clinical focus.

A system of force application consistent with the above.

A systems of outcomes assessment to changes in the above, and the movement of the patient toward greater health, wellness, structural and energetic adaptability, function, wholeness, or integrity.

Some techniques seek to influence factors which promote, perpetuate, or initiate the causative pathophysiology, or subluxation.  Others may include exercises, lifestyle intervention, emotional or psychological or nutritional intervention, or physical applications to minimize the spinal/neural stress or structural or energetic distortion.

There are approaches, such as the one I developed, which predispose subluxations and mechanical spinal tension, leading to self correction of the same.  Some methods may include wellness or structural education programs, as well.  I see chiropractic techniques as falling into the two following categories:

Structural Causation:
The subluxation or spinal distortion is seen as the cause of the individual’s loss of health or a significant impediment to healing and recovery.

I classify the subluxation into two categories, into which most methods fit.

The Class A, or Structural subluxation, is associated with segmental distortion and IVF nerve pressure.  It is most commonly addressed with a high velocity adjustment or force to restore the segmental distortion/fixation/misalignment.  This is usually addressed to correct the posterior distortion, or rotation of the segment.

The  Class B, or Facilitated subluxation, is associated with stretching of the spinal cord and nerves due to lack of recovery from emotional or chemical stressors.  It is associated with tension within the vertebral-meningeal-postural relationships.  This is a central nervous system process with adaptive structural changes.  The forces applied to correct this are usually low force or a rapid oscillatory impulse, and are most commonly associated with the segmental levels of vertebral dural attachments

Structural Adaptation:
The spinal distortion is an adaptation to a culmination of stressors which have exceeded the structural, energetic, emotional integrity of the system.

Techniques of this nature intervene to minimize the ongoing adaptive stress response from past traumas, or develop more efficient adaptive strategies.  The subluxation is seen as a sign of an adaptive challenge, rather than the cause of this.

Beyond this simplification of techniques are the models in which they are practiced.  This gets back to the idea of WHY the practitioner is utilizing the technique.  A practitioner whose objective is to reduce or eliminate back pain may switch between various chiropractic techniques, yet still be frustrated that the technique of the moment is not always effective.  Perhaps, in this case, the objective of the chosen technique was not to remove pain but, instead, to enhance spinal function and structure.  Our assessment of success is dependent upon the objective.

In conclusion, I suggest that the inquiring practitioner first assess the “Why’s” of patient care before choosing a new technique to replace an existing one.  All techniques are applied within a particular culture and have specific outcomes.  Here are some questions for your personal consideration:

What is the highest good I wish to bring to my patients?

What style and culture, as a practitioner, will stretch me to be a more effective healer, healing facilitator, chiropractor and human being?

Which techniques allows me room to grow at least slightly beyond my current models and sensory motor and communication skills, so that the approach will not be too restrictive to my growth?

What type of force applications would I want to receive, and also deliver, with the least fear of harm, and to the widest range of the population?  Or, which force application matches the culture I wish to best serve?

What type of assessments for causation, for intervention, and for improvement will allow me to feel most professionally fulfilled, consistent with the chiropractic/health/wellness culture with which I wish to be identified?

Do I see myself as a technician, healer, healing facilitator, or a wellness educator or coach, and does this technique fit into my evolving self-image?

Do I enjoy being with others that practice this method?  In general, how would I personally assess the healing, growth, vitality, personalities, compassion, success and humanity of those doing this work?  Do those practicing and attracted to this method reflect the type of healer, chiropractor, professional I wish to be?

Can practicing this technique and living the subculture within the profession which it represents, assist me to reach a level of clinical and professional excellence, serving my practice members with greater loving service, compassion, humility, confidence, precision, artistry, reproducibility, and mastery?

The techniques described in this issue are diverse and involve therapeutic and non-therapeutic models.  They include the structural causation and structural adaptation models, as well as structural and facilitated subluxation approaches.

Don’t short change yourself.  Please sample many chiropractic models, applications, and cultures until you find the perfect fit. Perhaps it may be a bit stiff at first, but in time you will grow into the healing facilitator, chiropractor, or wellness educator that you always wanted to be.

For more information about Dr. Donald Epstein, Network Spinal Analisis 

The Following are alphabetized descriptions of several chiropractic techniques with brief discussions of their evolution, theories and applications.

 

 

 

 Advanced Muscle Palpation (AMP)
Nick Spano, DC, teaches AMP at various seminars nationwide.
Advanced Muscle Palpation is a method of analyzing the spine for vertebral subluxations.  AMP began as a logical outworking of chiropractic’s recognition that the body strives toward homeostasis and must, therefore, be capable of responding to the subluxation.  It is apparent that an inherent attempt by the body to correct the subluxation would be based on the system’s advanced knowledge of its own biomechanical needs. 

AMP recognizes that the body uses precise physiologic mechanisms to monitor and maintain proper joint position.  Uniquely invested with numerous muscle spindles, the intersegmental muscles are thought to be responsive to facet joint positioning.  The muscles of the spine are, consequently, highly sensitive to any difference between the intended and actual movement of the vertebrae because of these mechanoreceptors.  This results in activity within the transversospinal and suboccipital muscle groups when there is a slight mismatch between the spinal segments.  Thus, as a method of analysis, AMP relies on the body’s own homeostatic mechanisms to determine a specific level of subluxation and direction of force application for the adjustment. 

Chiropractors and chiropractic students are instructed in finding vertebral subluxations using static palpation of these deep stabilizing muscles.  AMP seminars are filled with hours of hands-on application demonstrating this guarding-muscle activity to analyze subluxations from Atlas to the Sacrum.

If your state organization or student club would like to sponsor an AMP seminar in your area., contact Nick Spano, DC, at [email protected], http://home.flash.net/~unsublx8/ (note the missing “u” in unsublx8) or call (570) 265-2225.

 

 

 

Blair Cervical Technique
William G. Blair, DC, PhC, FICA, was the developer of the Blair Cervical Technique.

William G. Blair, DC, PhC., FICA, graduated from Palmer School of Chiropractic and established his practice in Lubbock, Texas, in 1949.  Practicing the classical Upper Cervical Specific (HIO) method, Dr. Blair soon noticed that osseous asymmetry seriously affected the accuracy of traditional spinographic X-ray analysis in many patients.  His clinical research led him to develop totally new concepts of the misalignment pathways of the cervical vertebrae, a radically different X-ray analysis to image cervical misalignments directly at the articulation, and a full-torque adjustive thrust (the Blair Toggle-Torque) which duplicated, finally, the adjustment given by Dr. B. J. Palmer.  Despite the proliferation of orthogonally-based upper cervical techniques, Blair Cervical Technique remains the only non-orthogonal precision spinographic and adjustive technique for the cervical spine in the chiropractic profession.

Blair Technique considers subluxations of Cl through C4, though many contemporary practitioners extend the analysis throughout the cervical spine.  Subluxated segments are analyzed as they displace the neural rings, thereby occluding the neural canal and compromising cord space.  The clinical objective of the technique is to restore maximum patency of the neural canal in the cervical region.

Cervical nerve interference is detected by the presence of both a persistent differential paraspinal thermographic pattern and a functional leg length deficiency (usually assessed prone).  The Blair Cervical Spinographic Series, comprised of Base Posterior, A-P Open Mouth, and Scout Lateral Cervical views, a Blair Oblique view of each atlanto-occipital articulation, and a Blair Lateral Cervical Stereoscopio view, allow assessment of vertebral misalignment at the articular margins, as the articulations are formed in each individual patient, eliminating asymmetry as a source of error in the analysis.  The Blair Protractoclamp, a patented positioning device, is used to take cervical radiographs at specific degrees of patient rotation.

The Blair Toggle-Torque adjustment is a distinctive toggle mechanism without recoil by the adjuster and incorporating a 180-degree torque (for most listings) with a “pisiform lead”.  One unique feature of Blair Technique is that the clinician has a choice of ipsilateral or contralateral segmental contacts for any adjustment.

See the Blair Society website at www.blairchiropracticsoc.org for more information.

 

 

 

Directional Non-Force Technique (DNFT)
Christopher John, DC, currently teaches DNFT, a technique originally developed by Dr. Richard VanRumpt.
Directional Non-Force Technique is a low force method of chiropractic originally developed by the late Dr. Richard VanRumpt (1904-1987), and presently being taught by Dr. Christopher John of Beverly Hills, CA.  Known familiarly by its acronym, DNFT is unique in conception and has been the fountainhead for many other low force techniques in use today.

DNFT is a patient oriented technique, capable of resolving the most difficult of chiropractic problems in a swift manner and with long lasting results.  Philosophically, it is in line with the roots of traditional chiropractic:  analyze and correct subluxations wherever they occur, and allow the body to heal.

The diagnostic system for subluxation analysis consists of a gentle challenge and a unique leg check.  This testing allows the body, itself, to indicate the directions of misalignment of structures that are producing nerve interference.  A directionally specific thumb impulse provides a long lasting correction to bony and soft tissue structures.  DNFT is able to achieve structural corrections without torqueing, strong thrusts, and associated articular sounds that are most often associated with traditional chiropractic.

DNFT adjustments include: spine, pelvis, cranials, shoulder, upper and lower extremities, TMJ, and organ reflexes.  There are very few contraindications for Directional Non-Force Technique chiropractic, and it may be safely applied to babies, geriatrics, post surgical patients, and those who have disc herniations and osteoporosis.

Christopher John, DC, maintains a website containing extensive information at: www.nonforce.com.  Phone (310) 657-2338; Fax: 310-657-2279; e-mail: [email protected].

 

 

 

The Graston Technique
Technique owner Michael Arnolt proudly displays the tools used by the chiropractor to reduce manual stress and “catch” on fibrotic tissue for performing the Graston Technique.

The Graston Technique is an innovative technique for treating soft tissue injuries.  It gives clinicians and patients something they want and need—relief.  This patented and researched technique is an advanced form of instrument-assisted soft tissue mobilization that incorporates the use of six stainless-steel instruments to identify, evaluate, diagnose and treat soft tissue injuries.  Use of the Graston Technique instruments reduces manual stress to the clinician’s hands and joints and allows the clinician to effectively comb over and “catch” on fibrotic tissue, immediately identifying the areas of restriction.  Once the damaged/affected tissue has been identified, the instruments are used to break up the fibrotic tissue so it can be absorbed by the body.  The result is better outcomes and greater patient satisfaction.

The Graston Technique is performed by skillfully trained and certified chiropractors, as well as other qualified clinicians, such as athletic trainers, occupational therapists and physical therapists.  It is effective for acute and chronic soft tissue injuries, including cervical and lumbar sprains/strains, rotator cuff tendonitis, carpal tunnel syndrome, patellofemoral disorders, plantar fasciitis, Achilles tendinitis, lateral epicondylitis, medial epicondylitis, fibromyalgia, scar tissue, shin splints and trigger points. 

Other benefits of the Technique include faster rehabilitation and recovery, a reduction in the need for anti-inflammatory medication and a decrease in the overall treatment time for patients.  The number of treatments to attain maximum resolution generally ranges from six-to-ten, with most patients attaining a noticeably favorable response within the first three visits, and treatment time is thirty-to-sixty seconds per area treated.  The Technique—used in outpatient clinics, industry and athletics since 1994—has been added to the core curriculum at National University of Health Sciences and Northwestern Health Sciences University.

For more information on the Graston Technique, visit www.grastontechnique.com or call toll-free 1-866-926-2828.

 

 

 

Logan Basic Methods
Brian J. Snyder, DC, helps keep Hugh B. Logan’s work on the Logan Basic Methods alive through his work at Logan College of Chiropractic. (Dr. Logan’s photo to the right)

Basic Technique is a chiropractic adjustment protocol that was developed by Dr. Hugh B. Logan in the mid 1920’s and continued throughout the early 1930’s, which led to the establishment of Logan College of Chiropractic in 1935.  Dr. Logan, a pioneer doctor of chiropractic, developed this specialized method of adjusting after extensive research and investigation of the body’s framework.  This low force adjusting procedure also became known as Logan Basic Methods that has become the title of the textbooks used in the teaching of this technique.

The use of low force techniques is not unusual in the chiropractic profession, however Dr. Logan’s approach to the human framework sets this procedure apart from the rest.  The examination of the patient includes a weight bearing postural analysis and full spine A-P and Lateral X-ray.  The adjustment utilizes a light pressure contact held in the lower sacral region in an effort to balance the sacrum and pelvis, which acts as the foundation of the spine.  This can be equated to any building or structure that relies on a strong foundation to achieve balance and integrity.  One of Dr. Logan’s premises about the spine states, “…as the sacrum goes, so goes the spine.”  Logan Basic Methods recognizes this unbalancing of the sacrum and pelvis to be a major cause of spinal distortion, which may lead to spinal curvatures.

This unique concept continues to be taught at Logan College of Chiropractic in St. Louis, Mo, and is an integral part of the present day chiropractic student’s education.

For more information contact Brian J. Snyder, DC, by calling 636-227-2100, ext 250.

 

 

 

Matrix Repatterning
George Roth, DC, developed the Matrix Repatterning technique based on the research of Ingber, Levin, & Wang and the structure of organic tissue referred to as “the matrix”.

Matrix Repatterning was developed by Dr. George Roth as the result of his pursuit of a consistent and congruent system to assess and treat structural dysfunction at its most profound level.  It is a revolutionary, easily learned method to accurately locate primary restrictions anywhere in the body and release them gently and permanently.  Dr. Roth has been teaching this program since 1993 and it is currently co-sponsored by Logan College of Chiropractic.   

The matrix refers to the now well-established structure of organic tissue, based on the research of Ingber, Levin, Wang, etc.  This structure is composed of a lattice of protein filaments, held together in a continuous, prestressed framework defined by the term tensegrity (a combined word coined by Buckminster Fuller meaning tensional-integrity).  It has been shown that this structure exists at every level, right down to the cytoplasm and the DNA.

The tensegrity matrix explains the effects of injury not only on muscles, ligaments and joints, but also on bone, itself, and the deeper layers of fascia surrounding the internal organs.  Matrix Repatterning practitioners have found that these aspects of the injury complex, often ignored by most practitioners, are the keys to successful resolution of many painful and debilitating conditions.

Matrix Repatterning is now being used by practitioners on six continents and has been successful in treating a wide range of conditions previously thought beyond the reach of conventional therapy.  It is currently in use in the treatment of professional and Olympic athletes as well as in veterinary practice (see “If the Shoe Fits?” in the January 2003 issue of The International Thoroughbred Digest).

For more information on Matrix Repatterning please contact Wellness Systems, Inc., Toll Free: 1-877-905-7684; e-mail: [email protected]; Web Site: www.matrixrepatterning.com.

 

 

 

Dr. Mally’s Extremity Adjusting Techniques
Mitch Mally, DC, bases his extremity adjusting techniques on the link between spinal/vertebral subluxations and extremity subluxations.

In 1978, as a pre-med student turned chiropractic student, Dr. Mitch Mally found the early offerings of his chiropractic education to include many loopholes and cause for skepticism.  In particular, scholastically, Dr. Mally was being taught that the spine is the cause for most extremity problems and, by correcting the vertebral subluxation, this would resolve the extremity conditions.  While this may be somewhat true, Dr. Mally’s scientific mind questioned and has since proven, that based on the mathematics formula, if A=B then B=A, in fact, the spinal/vertebral subluxation may be the result of extremity subluxations.  Thus, began a diligent effort and since proven triumphant quest to learn peripheral joint biomechanics. 

The result was an exclusive discovery of Dr. Mally’s Extremity Adjusting Techniques for Sports and Occupational Injuries.  Years of research, trial and not much room for error, these techniques gained widespread acclaim by virtue of specificity, vectors, lines of application, forces and Dr. Mally’s remarkable speed with amazing accuracy.

Today, with nearly twenty-three years of clinical experience, Dr. Mally has been recognized as an icon in the field of treating Sports and Occupational Injuries.  Presently conducting seminars at the State Association and Convention levels, also a frequent speaker for Parker Seminars and numerous chiropractic colleges, Dr. Mally’s 5 Star Seminar Series includes:

  • Upper Extremities
  • Lower Extremities
  • TMJ
  • Cervical Spine
  • Low Back
  • Leg Length Seminar, and
  • The International Conference on Carpal Tunnel Syndrome and Cumulative Trauma Disorders.
  • All seminars are license renewal, however the ultimate decision is predicated on State approval.

For inquiries, or to schedule, sponsor, or host Dr. Mally for your State Association, convention, chiropractic college, or independent group, contact Jules with Mally enterprises at (800) 779-HAND (4263).

 

 

 

The McTimoney Method
John McTimoney’s technique, the McTimoney Method, is used by one-quarter of all chiropractors in the United Kingdom.

The McTimoney Method is used by about one-quarter of all chiropractors in the United Kingdom.  It is based on a whole-body assessment of the individual, concentrating not only on the structure of the body, but also on their general well being and quality of life.  The aim is to stimulate the body’s own self-healing mechanism and facilitate a return to optimum health.  

John McTimoney (1914-1980) was trained in the UK in the early 1950’s and, once in practice, he soon started to develop the techniques he had learned using his engineering background.  He started formally teaching his method in 1972, and the college he founded has become the McTimoney College of Chiropractic today.

The method is characterized by an assessment of the whole body, including posture, followed by light force adjustment of the full spine and sacrum.  This is achieved largely through a series of fast, toggle-recoil adjustments, but with added torque for greater speed, leading to a very light touch.  The pelvis can also be corrected with a variety of techniques, and the cranium is adjusted using fast directional thrusts and light-to-firm pressure as required.  Extremities are routinely addressed at every treatment.  A wide range of adjustments can be selected and used as necessary, with over fifty-five different individual adjustive techniques available to the chiropractor to correct the structure of the body and restore function.

For more information contact The McTimoney College of Chiropractic, Abingdon, England +44-1235- 523336 or email [email protected] or visit the following websites: College, www.mctimoney-college.ac.uk; Association, www.mctimoney-chiropractic.org. 

 

 

 

 Neuro Emotional Technique (NET)
Scott Walker, DC, developed NET based on 7 scientifically validated foundations. He and his wife, Deborah Walker, DC, have taught NET to over 4000 practitioners.

Aside from the specific (and often remote-from-the-problem) vertebral adjustment correction, NET is based on seven scientifically validated foundations:

1.  Muscle Testing (MT).  More specifically semantic muscle testing.  Recently (1999) scientifically validated. 
2. The concept that emotions are physiologically based.  DC’s know first hand about this in effectively dealing with PMS for example.
3. Pavlovian Responses.  Humans, too, are conditioned—sometimes by one event (this is termed a one time trial). 
4. Emotions/meridian system correlations.  A 1,500-to-4,000-year old principle.  Example: “Anger” correlative—Liver meridian.
5.  Repetition Compulsion (RC).  A Freudian term.  Essentially, what has tramatized you earlier in your life will come back to do it again in like circumstances—if unresolved.  (See the works of Bessel A. van der Kolk, MD)
6.  The role of memory and physiology.  When we remember a traumatic event, the body tends to replicate the physiology which occurred at the time of the event. 
7.  Semantic Responses (and Stimulus Generalization).  The physiology of the body may not only be reactive to the sight of a spider, but also the word “spider”

NET was developed by Scott Walker, DC (Palmer Chiropractic College, 1965).  He and his wife, Deborah Walker, DC (Los Angeles Chiropractic College, 1978) have taught over 4000 practitioners worldwide how to eliminate the emotional component of the causes of the recurrent subluxation.  NET research projects are ongoing at Macquarie University in Sydney, Australia, and Thomas Jefferson Medical School in Philadelphia.

For more information about NET, call (800) 888-4638, or visit www.netmindbody.com.

 

 

 

The Toftness System of Chiropractic
After the technique developer Dr. I.N. Toftness’s death in 1990 , Dr. David Toftness became the president of the Foundation for the Advancement of Chiropractic Research that is the research arm of the Toftness System

With post-graduate training on-going from offices in Wisconsin, Missouri and, now, Japan, the Toftness Chiropractic technique celebrates its 50th anniversary with hundreds of practitioners across the country and around the world.  Practitioners, and students, in Europe, Central America, Australia, Japan and the U.S. are attracted to the technique because of its low-force, high precision, extensive documentation of benefits, and ongoing research into its efficacy.

The Toftness technique features the application of low-force pressure with high precision.  Practitioners first use noninvasive instrumentation to detect stress in the spine.  They then apply low measured force– 4-6 ounces – to specific locations along the spine or other off-spine areas.  The pressure is applied for  set lengths of time until the doctor has achieved his/her goal: removing the nerve interference and, thereby, restoring a healthy energy flow.

The gentleness of the technique makes it suitable for the youngest of infants as well as for adults coping with the pain of injury or illness.  Practitioners also report that the low force technique is less taxing on their own bodies and allows them to remain active practitioners longer.

Toftness practitioners from around the globe continue to contribute to one of the largest libraries of documentation in the field.  The collection currently comprises thousands of before and after X-rays and slides of skin pathologies which dramatically illustrate the benefits of the technique to patients of all ages and conditions.

For more information, contact Toftness Foundation for the Advancement of Chiropractic Research, (715) 268-7500 or by e-mail at [email protected].  www.toftness.org.

 

AXIAL DECOMPRESSION THERAPY A New Perspective

Mechanical traction has been judged as a reasonable and logical treatment method for spinal pain for centuries.  Since compressed discs are often a source of chronic back and leg pain, stretching the spine is an intuitive remedy.1,2  However, it has never gained widespread popularity in the chiropractic profession, nor have its results been consistent in clinical trials.3  Cumbersome equipment, time consuming and uncomfortable procedures and its historical connection to physical therapy have kept it out-of-favor with perhaps the one profession best suited to its unique capabilities.

Within the last decade, however, traction has been making a reemergence in our profession.  It has taken on a new name and a new efficient profile.  It is now called decompression.4

Decompression or decompressive traction refers to a decrease in intradiscal pressure (and the resultant circulatory improvement and phasic healing concomitant with it).5  Specific protocols and systematic procedures reduce misapplication and the haphazard nature of previous methods.  In effect, decompression is best thought of as a hybrid traction method.

Several decompression units have entered the chiropractic market in the last ten years, most with a plethora of bells and whistles and extremely high price tags.  In the era of managed health care, lower equipment costs and lower overhead are the key to profitability, yet many DC’s have opted to purchase these units on the promise of dramatic outcomes and huge reimbursements.
Excellent results and patient satisfaction have always been the fuel that has powered the successful practice.  The promise of extraordinary results and reimbursements of $150 per treatment can be very persuasive in our competitive marketplace. 

Many chiropractors looking for a niche have discovered that, very often, patients unresponsive to manipulation or flexion do respond to the proper application of axial decompressive traction (that these units work is not really at issue).  They have discovered, additionally, that offering “…non-surgical decompression for disc problems” is an excellent means to attract new patients.6  This is due to its safety and comfort vs. traditional methods, not to mention the reduced strain on the busy doctor’s body!

However, the extremely high costs have often created undo financial stress on many practices.  The per-treatment reimbursement must be very high to validate the cost of equipment that leases for $1500+ a month for sixty months, or a charge of $50 each time you turn it on!

Many insurance companies are now enacting post-payment audits of DC’s billing decompression.  Any billing code other than traction (97012) can result in repayment, fines and penalties.  There is actually no decompression code, and rarely is an insurance company willing to pay $150 per treatment simply because the doctor paid  $50-125,000 for the equipment.7  I’ve owned several of these expensive decompression units over the last eight years and have been subjected to two audits u u resulting in six-figure reimbursements.  Of course, having the ability to up-sell a cash patient (or doing several additional modalities to generate $150 per session) begs the question, why not simply utilize an equally effective device costing one-tenth the price and watch your profits rise exponentially?

Recently, such equipment has become available.  One system which I particularly favor includes not only the unit, but also supportive diagnostic, and low-tech therapeutic devices.  Moving from passive to active procedures is a vital step in outcome-based care.  The included low-tech rehab device allows monitored exercise in the vital segmental stabilizers (the so-called local muscle system).8  Additionally, there are two methods of cervical traction and carpal distraction quickly and efficiently accommodated, all at a price around $10,000.  It becomes apparent to the experienced user that it’s the necessary utilitarian features, not the price, that allows for effective treatment.

An honest and objective analysis of the phenomenon of decompression brings us to the realization that it is an outcome that can be consistently produced by the adherence to several utilitarian characteristics and protocols.  It is probably not an overstatement to say, they are absolutely necessary for the most consistent, effective therapy. We contrast decompressive traction (i.e., decompression) from traditional mobilization traction methods by these characteristics.9   See Table 1.
These characteristics work in synergy to enhance the efficacy of Y-axis traction.  The synergistic effect of these characteristics is patient comfort and relaxation.  They reduce conscious and sub-conscious anticipatory guarding.  It has been suggested that muscle guarding reduces the ability of traction to distract the vertebrae sufficiently to decrease the internal pressure of the disk for a pre-determined time so healing can occur.  Thus, a slow, graduated application of tension and exact, reproducible forces make up a substantial aspect of decompression.12  It should be obvious that roller type tables and automated axial elongation on a flexion table have no ability to deliver real decompression.  Continued use of a traction code for that type of treatment can also lead to post-payment insurance troubles.

I can tell you from personal experience, it is unnecessary to spend extraordinary amounts of money in order to offer this beneficial therapy in your clinic.  Decompression therapy is now available for the cost of a quality adjusting table.  Look around!

 

Dr. Jay Kennedy has been practicing Chiropractic Biophysics (CBP) in Western Pennsylvania since graduating Palmer College in 1987.  In the last eight years, he has owned and operated several decompression systems treating over 2000 patients on them in his multi-disciplinary clinics.  He lectures extensively and has authored various articles on axial decompression.

Homeopathic Miasms: Breakthroughs in the Cure of Desease

Dr. Samuel Hahnemann, the Father of Homeopathy, used the term “miasm” to describe the transgenerational causes to disease.  The word miasm means an obstacle  to cure, and Hahnemann asserted that unless this “obstacle to cure” is dealt with, the cure of disease will always be incomplete.  In modern terminology, miasm means diathesis or constitutional susceptibility or predisposition to a particular disease.  The deeper roots to disease can be traced back generationally to five primary diseases Hahnemann referred to as miasms.  The good news is that these predispositions to disease can all be corrected and cleared using homeopathy.
The five miasms are cancer, gonorrhea (sycotic), syphilis, tubercular (TB), and psora.  Miasms alter the ideal genetic blueprint for our health and can affect our entire being, physically, mentally, and emotionally.
Miasms can be either acquired or inherited.  One can acquire a miasm, for example, by contracting gonorrhea, say, at age eighteen.  When treated with antibiotics, this form of suppressive therapy can cause gonorrhea to go dormant and become active or show up later in life in the form of allergies, sinus, herpes, virginities, warts, tumors, suspiciousness, jealousy, selfishness or uncontrolled sexual desires.  Hence, acquired miasms are attained during our lifetime.
The far majority of miasms, however, are inherited.  The chance of inheriting miasms from thousands of years deep into our family tree is much greater than what we might acquire in our own lifetime.  Inherited miasms can be active or dormant.  A miasm that is active actually causes a present symptomatic picture or expression.  And, the best time to consider using a miasm formula is when the symptoms are present.  A dormant miasm is one hidden deep within the body, not expressing any of its possible symptoms.  It is recommended not to attempt treating dormant miasms unless other testing procedures, such as electro-diagnostic or reflex response tests, indicate the need for a specific miasm formula.
Homeopaths have experienced how miasms exist in various layers within the body, and understand that, as we work at correcting disease and building health, it is like pealing away the layers of an onion.  Regular homeopathic formulas work to strengthen and restore health to the body according to the symptomatic expressions the body is communicating.  When these conditions have a tendency to recur or be non-responsive, a deeper acting remedy, like a miasm, may be needed to more completely correct the condition.  As we continue to peal away the disease layers impairing our normal healthy expressions, we frequently discover various miasms along the way.
Miasm correction is essential to both the restoration of our health and the eradication of disease from our planet.  I have now used homeopathy long enough to see genetic disease patterns in people corrected and observe the liberation of those diseases later on in their own offspring conceived after miasm correction.  I have seen this remarkable healing phenomenon in cases such as childhood obesity, allergies, breathing disorders, skin disorders, and certain behavioral disorders, phobias and in anxiety-or nervous-prone people.  What a wonderful reward, not only to see both children and adults healed of devastating genetic or life-long health problems, but also to see their children born and grow up free of those inherited health problems and weaknesses in their families!

How do you treat miasms?

Miasms are matrixed—or integrated—into our inner most being from thousands of years deep into our family tree.  Although they are not difficult to correct with homeopathy, they are not always wiped out in a single blow.
Homeopaths have shown how disease patterns are trapped in and throughout the layers of our lives.  These layers are like clear overlays, as seen in global maps demonstrating how global shifts and changes in boundaries of countries have taken place over time and warfare.
Treating miasms can cause extreme changes in one’s health.  Commonly these changes can cause a wonderful enlightening euphoric experience, as well as times when a more intense cleansing crisis may occur, creating a temporary discomfort from the eliminative process.  Some of the commonly experienced cleansing symptoms may include emotional releases, skin breakouts, itching, fever, fatigue, bowel movement changes, breathing changes, and various forms of pain.  These symptoms, although temporary and non-damaging to the body, can be severe at times.  Remember, the body is orchestrating the healing crisis and will not harm or cause any permanent damage to it, even though it may feel like it at times.  Although the healing crisis is not always comfortable or convenient, it is essential to our optimal healing and restoration!
It is best to monitor patients closely when using the miasm formulas.  It is helpful to explain that there is a 60% chance of experiencing some form of cleansing response when taking a miasm formula.  This way, when they do experience these symptoms, they will understand the good purposes of eradicating the miasms.  Eradicating miasms not only helps us to better correct our present disease(s); it can also help prevent diseases in the future, both in our future offspring and ourselves.  Explaining ahead of time makes a big difference in the attitude of your patients when they go through a cleansing crisis.  When your patients are going through these uncomfortable times, it is much better to be praised for your wisdom than to be cussed in distrust.
Starting out a new patient who has not had experience with natural healing or detoxification with miasm treatment is not recommended.  They may not be strong enough to handle the elimination of the miasms in the most graceful of ways, especially if the patient is in a weakened state of health.  I recommend addressing the primary symptoms with symptom specific formulas first, along with detox and drainage formulas.  These products will help strengthen and restore the natural healing and eliminative functions, so that they can better deal with the deeper issues of the miasms later.

Miasms are great to use when patients:

  • Don’t respond to homeopathic treatment;
  • Don’t respond to other natural treatment;
  • Reach plateaus where they seem to level off in their health enhancement;
  • Continue to have reoccurrences with the same problem.

Miasms have a tendency to show up periodically throughout the healing processes over years.  Even miasms that didn’t show up previously in testing may show up later on in the treatment program, as more of the layers of disease have been pealed away.  Either the same miasm treatment or different miasm treatments will commonly be needed periodically over our lives.  It’s likely that almost everyone has at least one miasm; many people have more than one; and basket cases can have many miasms. TAC

 

Frank J. King Jr., N.D., D.C., is a nationally recognized researcher, author and lecturer on homeopathy.  In addition, Dr. King is the founder and director of King Bio Pharmaceuticals, a registered homeopathic manufacturing company dedicated to completing chiropractic destiny with the marriage of homeopathy.  Dr. King offers, complimentary to all Doctors of Chiropractic, his turnkey procedural system for the high volume practice called, The Chiropractic Enhancer systemÔ (CES).  It is so easy to use that you can successfully apply homeopathy in your practice using any company’s products in one day. Call King Bio Pharma-ceuticals, Asheville, N.C. 1-800-543-3245 or e-mail: [email protected].

The New Patient Phenomenon

Scheduling the New Patient
When scheduling a new patient, it is very important that you are conscientious to do the following three things in order to insure the new patient will not have to wait and that their first visit will be a successful one.
1. Select an appropriate time, allowing the doctor enough time to consult with, examine and X-ray the new patient.
2. Make sure the appointment time you communicate to the new patient is fifteen minutes earlier than the time actually scheduled in your appointment book.
3. Make sure you have properly recorded the new patient appointment in the book.

Allow Enough Time for the Doctor
Iorder to provide the doctor with adequate time to see a new patient, typically you will need to block out forty-five minutes to an hour.  However, this may vary depending on the individual doctor and whether or not your clinic has an examination doctor or a certified X-ray technician on staff.
The best way to insure that you have forty-five minutes to one-hour blocks of time available to see potential new patients is to “cluster book.”  The cluster booking technique is briefly described below for the purpose of understanding how to schedule a new patient.

Cluster Booking
Cluster booking is the primary method of patient control and provides increased efficiency in time management. It allows the doctor to keep his mind in a treatment, examination, or paperwork mode for a segment of time. It is extremely exhausting, both mentally and physically, for the doctor to do paperwork, treat a patient, examine a patient, sit down, treat a patient, etc. 
The cluster booking technique involves establishing four treatment modes, or clusters, per day in which you schedule patients for adjustments and therapy.  Each treatment mode has a start time, from which you begin scheduling patients continuously towards the next cluster,  lunch or closing time.  There are two morning clusters and two afternoon clusters.
By scheduling treatment in clusters, there will naturally be holes or blocks of time between the treatment modes.  These holes are used to schedule new patients and other special services, such as re-exams, report of findings, etc.  This way the doctor is able to devote the necessary time to the new patient, without making other patients wait.
Note:  If the patient is acute and needs emergency relief, work them into your schedule, even if you do not have enough time available for a new patient.  You can do a brief examination and give the patient relief care, scheduling the complete chiropractic, orthopedic, and neurological exam for the following day.  Remember, new patients are the lifeblood of your practice; you must be available when they need you.

The Appointment Time Communicated to the Patient Should Be 15 Minutes Earlier than the Actual Appointment Time
By having the patient come fifteen minutes early, you allow time for them to fill out the necessary paperwork, without throwing the doctor off schedule.  If the new patient arrives at the actual scheduled time, the doctor has to wait while the patient fills out the necessary forms and, consequently, is fifteen minutes behind schedule when other patients begin to arrive.

Make Sure You Properly Record Appointment in the Book
When scheduling a new patient appointment in your book, make sure you write NP in the services column to the left of their name.  (Personally, I like to color code my appointment book).  You must also be conscientious to write their phone number under their name so that you can call to remind them of their appointment, or call them to reschedule if they miss the appointment
Be sure to block out the necessary time below their name, so someone else cannot be scheduled in that time and cut the new patient appointment time in half.
Finally, make sure that you highlight the new patient appointment in yellow, so that it stands out in your appointment book.  This will help you to remember to do the necessary preparation prior to the new patient appointment.

New Patient Flow
Now that the patient has scheduled his first appointment, proper procedures must be followed.  There are three important procedures that must be performed in order to deliver the best quality care to each patient.  These procedures are comprised of three steps.

  1. Consultation and preliminary examination;
  2. Orthopedic, neurological, chiropractic and physical examinations, and X-rays, if indicated;
  3. Report-of-Findings and treatment.

The consultation and preliminary examination are used to determine if a new patient is a chiropractic candidate.  The complete orthopedic, neurological, chiropractic and physical examinations are administered to provide the doctor with the necessary findings for diagnosis, prognosis and a recommended plan of treatment.  X-rays usually play an important role in the diagnosis of spinal problems, and are generally necessary to rule out conditions that would require the patient to be referred to another specialist.  However, some new patients may be transferring care from another physician who might be able to provide you with recent X-rays.  Finally, the Report-of-Findings allows the doctor to explain the documented findings and treatment plan to the new patient.
Once again, these procedures can be performed over one or two visits, depending upon individual circumstances; however, all three steps must be covered thoroughly.  It is also to be noted, a patient may require emergency (relief) care on the first visit.  In the new world of compliance, we must document what we do.  It begins with the first visit of any new patient. TAC

Dr. Eric Kaplan is the CEO of MBA, Inc., one of the nation’s largest multi-specialty consulting companies.  Dr. Kaplan ran and operated five  of his own clinics, seeing over 1000 patient visits per week.  He is the best-selling author of Dr. Kaplan’s Lifestyles of the Fit and Famous, endorsed by Donald Trump, Norman Vincent Peale and Mark Victor Hansen.  He was a recent commencement speaker at New York Chiropractic College and regularly speaks throughout the country.  For more information about Dr. Kaplan or MBA, call 561-626-3004.

CHIROPRACTIC ON THE STATE LEVEL Featuring the Florida Chiropractic Association

Background

The Florida Chiropractic Association (FCA) began in 1931, and was established by Florida’s chiropractic pioneers, who attained state licensure for the profession.

As Florida’s largest professional chiropractic association, representing over 4,000 active members, the FCA enjoys the support of 80% of the practicing Florida-resident DC’s and several hundred out-of-state doctors who either hold Florida licenses or attend FCA conventions for license renewal in their home states.

Volunteer leaders in the profession representing all of the geographic areas of Florida are responsible for the mission, policy and direction of the organization, while a dedicated full-time staff headquartered in Orlando carries out the day-to-day operations. They, in turn, are aided by a variety of consultants who offer their specialized talents in areas ranging from government relations to association marketing. Together, they work to help educate, inform and assist FCA members in delivering only the highest quality of care to the citizens of Florida.

The primary function of the Florida Chiropractic Association is the protection and welfare of its individual members, regardless of philosophy, as well as education of the public concerning the chiropractic profession.

“The FCA wants nothing less than total parity—even the lead role—for chiropractic within the health care community, and complete and easy access to chiropractic for Floridians,” says Debra Brown, CEO. “As the FCA has grown in strength and effectiveness, so chiropractic has been elevated in the state of Florida.”

What this translates to is the achievement of many historic firsts in chiropractic, through FCA legislative victories in areas such as Medicaid funding for chiropractic, chiropractic insurance equality and the granting of $750,000 in state dollars to establish a Research Center in Chiropractic and Biomechanics at Florida State University, to name a few.

What’s New?

And, recently, in some late-breaking news, it looks like they’ve done it again! According to a FLASH report prepared by Paul Lambert, FCA General Counsel, and Jack Hebert, FCA Director of Government Relations, “The FCA and its coalition friends were victorious in completely reversing [some of] the onerous provisions that the insurance industry had placed on [Florida Personal Injury Protection (PIP) legislation]. Although the bill is not perfect, it represents a compromise greatly in our favor as providers.

“The Florida Senate gave its preliminary approval to SB 1202, a series of new proposals targeting fraud in PIP automobile insurance. Originally this bill was a hated ‘wish list’ of denying and delaying tactics desired by the insurance industry, disguised as anti-fraud measures. Now, a series of amendments have significantly changed the character of the originally hated bill. The amendments, supported by a coalition including the FCA, the Academy of Florida Trial Lawyers, the Florida Medical Association and other provider groups, dramatically changed the character of the legislation.”

The report went on to say that only the day prior, the Florida House of Representatives passed an amended version of their PIP anti-fraud legislation. And that the House version is substantially different than the Senate version, in that it is far less broad in scope and is limited primarily to anti-fraud provisions. That bill was to have been before the House the following day for final passage, after which it could have moved to the Senate for its consideration. At that time, though, it was uncertain whether the Senate would consider the House proposal.

Anyway, you get the idea…. Those Florida folks really know how to coordinate their efforts on behalf of chiropractic! Congratulations, and keep up the good work!

For more information on current developments in this latest coup by the FCA, or on related activities, be sure to check out

www.FCAChiro.org. TAC

Tarsal Tunnel Syndrome & Orthotic Support

Tarsal tunnel syndrome (TTS), while not common in the general population, is occasionally seen among athletes.  In addition, many TTS symptoms can be confused with conditions commonly treated in the chiropractic office.1  Because its etiology is often related to hyperpronation and, therefore, spinal complaints, TTS patients may be concentrated in the chiropractic office.  When a patient complains of burning pain or numbness of the foot or ankle, keep TTS on your list of differential diagnoses, including plantar fascitis, Achilles tendinitis, and lumbar radiculopathy.

Similar in function to the carpal tunnel, the tarsal tunnel is formed by the following borders:  medial calcaneus, medial malleolus, posterior talus, and flexor retinaculum.  Structures passing through these confines include tendons, blood vessels, and the posterior tibial nerve, including its branches, the medial calcaneal, medial plantar, and lateral plantar nerves.

These sensitive structures are susceptible to any direct trauma or lesion that decreases the available space.  The athlete runner with a recent history of increased activity is particularly vulnerable, but also consider any auto accident victims who have jammed their lower extremities.  The energy at impact, sent through the pedals or floorboard and into the feet and ankles, supplies the force necessary for traumatic TTS.  On the other hand, consider the simple act of walking on an excessively pronated foot, which is far more common among patients. 

The review of eighty-seven TTS cases revealed that biomechanical deformities, including tarsal jamming and hyperpronation, were to blame and could be documented radiographically.2  Furthermore, it has been proposed that even minimal trauma during weightbearing activities in persons with pes planus is the most likely mechanism for TTS.  This same study postulates that when pes planus is functional and associated with malposition of the tarsals, the posterior tibial nerve is stretched with each step taken.3  Tarsal malposition is evident with toe out greater than fifteen degrees and with excessive bowing of the Achilles tendon, when viewed from behind.

The symptoms of TTS can be easily confused with plantar fascitis and, in extreme cases, with lumbar radiculopathy.  In the case of biomechanical overuse, the patient will report poorly localized numbness and tingling of the medial ankle and on the plantar surface, which may extend into the lateral two toes (the lateral plantar nerve being more commonly involved). 

Unlike plantar fascitis, which is generally worse in the morning, TTS is worse at night after activity and may include pain radiating up the medial calf.  The physical exam may reveal loss of two-point discrimination and muscle strength in the distribution of the lateral plantar branch and a positive Tinel’s sign, found when tapping directly over the site of the tarsal tunnel.  A normal Achilles reflex should help rule out lumbosacral radiculopathy.

Initial treatment of TTS includes inflammation reduction of the involved tissues.  This means no weightbearing without the foot and ankle taped or without orthotics in place.  Next, adjustments should be used to restore normal biomechanics throughout the entire kinetic chain (foot, ankle, knee, hip, and spine).  Special attention must be given to the valgus misalignments of the talus and calcaneus.  Additionally, deep friction massage over the flexor retinaculum may release adhesions responsible for compression symptoms.
Most importantly, correct the underlying foot dysfunction (hyperpronation or otherwise).  Pes planus causes tightening of the flexor retinaculum, which can then compress structures within the tunnel.  Although the inflammation may go away, the nature of ligament stretch means that any plastic deformation is permanent (barring surgical intervention).  Therefore, effective and lasting treatment necessitates the use of custom-made, flexible orthotics, which have been demonstrated to control the degree of pronation, as well as the percent of time spent in pronation.

Although relatively uncommon, tarsal tunnel syndrome can present a diagnostic and treatment challenge.  Understanding the etiology of this entrapment syndrome is important for providers concerned with the treatment of athletes and auto-accident victims.  Also, because TTS is often associated with hyperpronation, patients will likely experience other conditions also associated with a faulty foundation, including knee, hip, and low back pain.  Many of these patients will seek care from chiropractors, where treatment consisting of adjustment, soft-tissue technique, and the use of flexible orthotics can offer excellent symptom relief.

Dr. John J. Danchik is the seventh inductee to the American Chiropractic Association Sports Hall of Fame.  He is the current chairperson of the United States Olympic Committee’s Chiropractic Selection Program.  He lectures extensively in the United States and abroad on current trends in sports chiropractic and rehabilitation.  Dr. Danchik is an associate editor to the Journal of the Neuromusculoskeletal System and the Journal of Chiropractic Sports Injuries and Rehabilitation.  He has been in private practice in Massachusetts for twenty-six years.