Dynamic Chiropractic – October 21, 2012, Vol. 30, Issue 22

dynamicchiropractic.com >> Diagnosis & Diagnostic Equip

Thoughts on Technique and Diagnosis

By Marc Heller, DC

What does the word technique mean to a chiropractor? First and foremost, it refers to the methods they use to adjust the spine. But technique goes far beyond that. What words do we use for our diagnosis? We are constrained by the ICD system, which oversimplifies diagnosis.

Are we really treating a lumbar strain, or a lumbar dysfunction, or a lumbar degenerative disease? I think that shortchanges what we do. We know most imaging does not correlate well with pain patterns.

I like to add a brief discussion to my initial chart note. What are the fixable biomechanical problems that I suspect are contributing to the pain? Yes, they will include the joint dysfunctions; yes, they will include motor control patterns, muscular atrophy and poor firing patterns; and yes, they will include soft-tissue issues, whether we call them trigger points, fascial restrictions or fascial densifications. How does this whole pattern add up; how does it contribute to and/or create the pain with which the patient presents?

Mastering the Basics

Do you use one main technique? Do you integrate multiple methods? Do you primarily adjust the spine, or are you interested in integrating nutrition, soft tissue, exercise, and/or other modalities? Some well-known techniques are focused on a protocol for adjusting the spine in a step-by-step manner. Activator technique comes to mind for me here. Others are more like a whole set of methods, with a lot of variation, such as applied kinesiology.

The first step in learning any skill is to master the basics. Learning how to palpate for tissue texture changes and joint restrictions fits that category. Learning to perform and assess basic functional or orthopedic tests also fits. Anyone who has been in practice for a while can attest to how these skills are honed with endless repetition. Assessing via leg checks, muscle testing or any other tools has the same kind of learning curve.

Once you are comfortable with the basics, the tools become so much more. The musician who knows their keyboard can improvise. The chiropractor who has truly mastered assessment can begin to go beyond the basics. It is useful to study systems of treatment and techniques. But don't believe the guru when they say something will fix 100 percent of the problems. The guru has to believe their own jargon in order to be singleminded enough to develop the technique. But when you are stuck in your treatment room with a difficult patient who is not getting better, you need to let go of your own belief systems.

Beyond the Basics: Using Reality Checks to Fine-Tune Treatment

I believe we can get in trouble when we believe too much of our own jargon. I think one of the ways we can fool ourselves is to just use the internal checks of any system. Your leg length has evened, so you must be better. The muscle tests strong, so we fixed the problem. Your side plank has longer endurance and better form, so why do you still hurt? Any time your testing protocol is completely internal, you are inherently shortsighted.

Is there another way? I believe so. Use your internal checks; they are useful. Get good at whatever systems you choose to use. Yes, you have to have the basics down; but then step outside your own system and use some kind of reality checks. One of the wonderful things about what we do is how fast it can work. A good indicator of a profound effect from a treatment is an immediate change. Useful changes include an immediate decrease in perceived pain, improvements in range of motion or other functional tests, and/or a decrease in tenderness over a previous hot spot. (I like to mark the spot with ink to be sure I am not fooling myself.)

A within-office-visit positive change is a strong indicator of a good prognosis. I'll say it a different way: You need to pay attention to the response of the patient, the one on the table, the only one you are treating right now. You need to pay attention to both their objective changes and their subjective experience. This is really important. You can improve your results by re-evaluating during or after the treatment. This increases the patient's confidence, enhancing self-healing mechanisms.

The tools of reassessment can improve your clinical skills; your intuition, if you will. If you are just doing the same thing over and over, you do not change. If your failures lead you to trying something different, you will learn when to use what.

This relates to the expanded view of diagnosis that I outlined in the first paragraph. Which of the biomechanical problems that the patient has are really contributing to their ongoing pain? On some level, this is a fool's quest. It probably is a combination of factors. On another level, I can often know what is most significant, especially when my first few treatments have failed or not given the patient relief. Using a post-testing protocol, both you and the patient often can know what made the change.

What to Do When the Usual Technique Isn't Working

What does one do when the technique, the adjustment, the soft-tissue treatment, the exercise that works for most everyone, does not work? Try something else. Step outside of your comfort zone. This is real challenge in becoming extraordinary. It could be a different adjustment. It could be a different style of soft-tissue treatment. It could be remembering that pain is a liar, so you may need to search above and below the pain.

Here is a fun example: A patient presented with three years of severe lower back pain. His father, a good spine surgeon, said to him; "I am not going to operate on you; your MRI does not look bad enough." After trying several physical therapists, various injections, and meds, he finally ended up in my office.

When I assessed his lower back, I couldn't find much, but still adjusted his low back and showed him some basic exercises. By the third visit, it was clear that the usual approach was not working. I assessed his whole spine and found a significant restriction of the atlas, C1. I did my usual low-force adjustment of that segment. He got off the table, moved around, and tried to find his pain. It was gone and has remained gone. Not the usual patient, not the usual response, but you have to be willing to think outside the box to correct difficult and chronic problems.

That's a dramatic example, but it's rare. Most of the time with chronic pain, you are slogging through multiple dysfunctions, some local to the pain area, some distant; some that stay corrected and some that need more soft-tissue work and/or more exercise to stay corrected. You have to be both patient and impatient. Be patient; know that the person may not get well instantly. Be impatient; know when to switch gears and try something different.

I say two things to the patient: One, if you are not somewhat better within 3-6 visits, I am not going to keep treating you. Two, you need to know that this is a cooperative effort, that we are both part of this process. You, the patient, need to do the work. Exercise instruction is not just to improve biomechanics. It is also very useful in engaging the patient in their own healing process; in helping enhance the very real placebo effect.

I don't know what to do on everyone; I don't know what is going to work before I try it. I am continually surprised. Diagnosis and prognosis are imperfect arts. If I am a good doctor, I am good because I pay attention to what is working in the moment. If I am a good doctor, I am good because I know that doing the same thing over and over and expecting a different result is insanity.

We all have different personalities that we bring to the table. Some of us like a more definitive, clear-cut approach. Others are more comfortable living in the mystery. You have to know yourself. Not every doctor is interested in this kind of approach. You have to train yourself to think on your feet. You have to be willing to switch gears; to admit you are wrong. It doesn't quite work as a "first do this, then do that" technique protocol.

Technique is useful; you do have to master the basics first and then expand. But to go beyond technique involves constant study, both in and out of the office. It requires curiosity. What this approach will do is to keep you engaged. I have been a chiropractor for 32 years; I am never bored. I still love the day-to-day challenges my patients bring me. I hope that you are learning, that you are constantly challenging yourself, and that you are becoming a better doctor every day.

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