Don’t Be That Doctor

This article will wind up the third (and final) year of my column here with American Chiropractor. I’ve used a lot of ink in the past thirty five issues dealing with various aspects of postural rehabilitation, so I’d like to take this opportunity to tie up just a few loose ends relevant to this month’s emphasis on diagnostics.

A Failure to Diagnose

We all worry about missing hidden pathologies…the camouflaged cancer, the sinister subtlety. But in fact, many of us fail to accurately diagnose and treat, the very condition which should be most obvious to every chiropractor on the planet…vertebral subluxation. The original chiropractic hypothesis of subluxation described a single vertebra out of place pinching on a soft nerve. That was over a hundred years ago and although most every doctor certainly knows subluxation to be a much more complicated phenomenon, our approach to spinal analysis and diagnosis has actually changed very little. We are still for the most part, a profession that only looks for mechanical lesions of the spine on a segmental level. And the failed logic of this outdated  approach is staggering.

Most of our chiropractic training in technique continues to concentrate on  mechanical lesions involving only a single joint. Yet when you look at Fig. 1, it’s easy to see the entire neck is held in a kyphotic position. There’s no single segment we can objectively identify as the cause of the straight neck-head forward posture. Worse yet, we now have multiple studies showing that traditional adjusting, regardless of technique, does very little to correct the overall structure of the spine.  Not to be deterred, most chiropractors will still try to correct spinal configurations like this one using single segment adjusting. Don’t be that doctor.

Missing large scale postural imbalances while you search for subtle, single level, subluxations is like not seeing the forest for the trees! Because we are trained to think of subluxation as a single level problem, we fail to recognize the much more obvious problem of entire groups of vertebrae no longer held in their normal posture. In fact, these multi segment, large scale, spinal misalignments produce all of the very same effects we attribute to our more familiar conceptualization of the vertebral subluxation complex: kinesiopathology, myopathology, histopathology, neuropathophysiology etc. So, in simple terms, if it walks like a duck, and talks like a duck, it’s probably a duck! Postural imbalance IS subluxation. It simply exists across a number of vertebral levels as opposed to a single segment.

Science Ain’t Everything
(But It Isn’t Nothing Either!)

We’ve talked a lot about science over the past three years. Many in our profession believe we absolutely must have scientific proof for every single thing we do in our offices. In a perfect world that would be nice, but unfortunately there will always be gaps  between what we have empirically experienced to be true and those things which the scientific literature can objectively verify. That said, it’s one thing to employ reasonable procedures in your office for which little or no evidence exists. It’s quite another thing to continue using methods when there is strong evidence to the contrary. Adjusting away on your patients forever in the vain hope that the spine will just magically return to its normal posture is a good example. Please don’t be that doctor either.

It’s not “All or None”

We now know that postural misalignment must be addressed differently, but that certainly doesn’t mean you need to replace your current adjusting technique. Incorporating postural rehab into your treatment plan simply allows for the reasonable possibility of an additional outcome over and above what we might expect with adjusting alone. Consider the concepts I’ve covered like items on a buffet line. Take what you like and just leave the rest. You don’t need to practice like I do in order to get great corrective care results.  And if you do happen to see a tool or method which appeals to you, then by all means give it a try. You’ll learn by doing. Too many doctors are reluctant to try anything new until they have time to take a seminar or “get certified.”  Don’t be that doctor! Postural rehab methods are too simple and too easily mastered to allow yourself to be unnecessarily inhibited.

Rehab Isn’t For Everyone

Every patient doesn’t need postural rehab. Some patients with spinal dysfunction will present without postural imbalances sufficient to warrant intervention. Others are poor candidates because of contraindications or problems so severe as to make a successful outcome unlikely.  Still others may actually need corrective care badly, but simply aren’t interested in putting in the work and persistence required to make long term  spinal change. And you know what??? It’s okay! Traditional chiropractic adjusting has been doing a great job of helping patients feel better for over a hundred years now. Sure you can probably twist their arm and get them to agree to a treatment plan not in keeping with their real desires, but I hope you won’t be that doctor. Instead I hope you’ll allow your patients the autonomy to determine what is appropriate in terms of their own health care goals.  After all, they’re the ones who hired you! There will be plenty of other folks willing and able to spend the time, effort, and yes…money, to get the full benefit of real structural correction.

No Home Runs in Chiropractic

Finally, three decades after hearing this little truism in chiropractic college, I’m absolutely certain of its validity. No single technique works every time.  No guru has all the answers. It’s as true for the methods I recommend and use as for whatever you do in your office. I certainly don’t correct every spine that walks in my door and neither does anyone else. The trick in practice is to learn as we go and hopefully improve our “batting average” along the way. Hopefully,  I’ve been able to stimulate your thoughts about new ways of looking at the spine. Maybe you’ll find some of the methods I’ve discussed to be useful as you work toward improving your corrective care outcomes. The surest route to mediocrity I can imagine is to resist all change, never daring to embrace newer, more effective methods.

Thanks to all of you who have contributed great questions and input over the past three years. The honest exchange of ideas is what makes all of us better in the long run. And while I know that many of you won’t stay in touch once my column is concluded,  I genuinely hope you won’t be that doctor.

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