Leading All Professions in Structural ManagementFor too long now, our profession has been thrilled to be on the short list of "acceptable"alternatives available to those seeking another option in our medically designed world.
As an alternative, we've learned to fit into the space provided for us. Although being on the short list may appear to have its advantages, until we remove ourselves as an"alternative" using medical protocols, we'll never reach our maximum potential as a profession. Chiropractic's potential will never be recognized when measured in a medical paradigm. The medical paradigm works without an accurate diagnosis 85% of the time (1) and then attempts to relieve symptoms as a primary objective. It is in this paradigm that"manipulation" is measured. Is it more effective, quicker and cheaper than medication or other methods used?
To further make my point, let's flip this whole picture around. Let's imagine the chiropractic profession designing the protocols for a "back pain" program using structural testing to determine treatment and conditioning needs of the patient. If we forced the medical provider into our paradigm, which would require the detection and correction of subluxations, the medical doctor's only option would be to recommend a medication. Obviously, medication has little benefit in the detection and correction of subluxations, and therefore, medication could never be seen as beneficial under this evaluation.
Medication could then be defined as an "alternative" in this situation, but you can only imagine what little positive results pharmaceutical companies would enjoy in journals and the public media. Yet, that's the position chiropractic has lived with as an alternative. This simple imagined exercise magnifies how ridiculous it is for either of our professions to attempt to fit into the other's framework. We have different objectives and different protocols.
Chiropractic as Structural Management SpecialistsChiropractic was built on the very concept that we address the cause of the problem, not just the symptoms. Unfortunately, we live in a society that has been programmed to address the symptoms, and the public has learned to expect that. This belief is furthered by the insurance industry guidelines that pays for these palliative treatments, as well as the massive marketing campaign by the drug and medical industries that influences all of our decisions, regardless of who you are.
The human structure provides limitless information for any examiner of the sites of increased stresses, imbalances and vulnerability to injury. In any physical structure, imbalances accelerate degeneration. Needless to say, this also applies to the human structure. It is the examiner's responsibility to find and collect this data on each patient, with or without symptoms.
Furthermore, with the epidemic-like numbers surrounding osteo-arthritis today, it seems almost felonious to not consider structural defects and imbalances when attempting to find new and better treatments. Again, the medical model of care is to wait for the pathology to develop and then provide the best symptomatic care possible. In this 21st century, we must demand better than that. "Early detection" has become the marketable phrase for cancer-detection testing. Why doesn't it exist in the neuro-musculo-skeletal world? Does the breakdown of the human structure cause less pain and suffering and cost less money than the cancers that are killing people? If "early detection" applies in the cancer, tooth, colon and breast industry, why not in the neuro-musculo-skeletal industry?
As chiropractic continues to grow and define ourselves to the public, we must be concerned with symptoms, but to make a difference in someone's life, we need to be more concerned with conditions. Despite the insurance coverage an individual has, whether it's worker's compensation, no-fault or private insurance, any structural symptoms, i.e. low back pain, neck pain, shoulder or hip pain, etc. lead to a diagnosis. We've become too concerned with the diagnosis and ignore the many other contributing factors involved in structural breakdowns. We, the chiropractic profession, need to re-write our protocols and begin to fill this massive void in our industry rather than continuing as a minor role player in the highly ineffective medical system that currently exists.
Structure vs. PathologyIn an article on Low Back Pain and Imaging published in a 2002 Annals of Internal Medicine magazine (2), the article states that less than 3% of all low back pains are due to pathology, while 97% are due to mechanical disorders. The article also states that the examiners interest should lie in determining whether the patient with low back pain falls into the pathology or mechanical disorder category. Beyond this primary concern, all considerations end. What to do with the 97% of mechanical disorders is of little value, since they've been defined as benign and self-limited. It is this 97%, however, that should make the chiropractic profession stand up and be willing to do what's necessary to de-program and re-program society. Chiropractors need to become the structural specialists who address these "benign and self-limited" conditions. It is these conditions that require individualized evaluations and treatment/conditioning programs.
Chiropractic was built on the interest and respect for the human structure. Neurological interference is a result of irritations from an imbalanced musculo-skeletal system. We have always been concerned with these imbalances and we've known they are the cause of most structural conditions. But, if this is true, why have we compromised into the concept of diagnoses? Label any pain by an ICD code, and some insurance adjustor will step up and determine some level of treatment, but show no respect or interest for the other structural imbalances that are the underlying contributing factors involved in this case.
Take for example a lumbo-sacral strain/sprain injury. (847.2) is the code used by the industry, but it fails to address many of the relevant contributing factors that are also influencing the condition. What about the feet? As the very foundation of the human structure, have they been examined and determined to provide a balanced support? Or, are they imbalanced, such as bilateral pronation, supination or different between right and left? And, how about the knees, have they been examined to determine the Q angle, which we all know has a huge impact on the wellness of the low back.
Taking this a step further, how about the patient's hereditary weaknesses? What is their job? What is their conditioning status? How about their weight and lifestyle habits? And, on and on the questions go. The truth is, there are so many contributing factors for the common backache that no diagnosis could ever do justice in letting anyone know the actual cause of the problem. Structural weaknesses cannot and should not be handled as pathologies with some pharmaceutical treatment. A structural imbalance will lead to one or more sites of symptoms, but are caused by a myriad of imbalances and contributing factors. All known factors must be addressed.
New Guidelines For Structural ConditionsThe chiropractic profession must be willing to function outside of the accepted guidelines in today's industry. All current guidelines are designed for pathologies and pharmaceutical treatments. "Alternative" treatments are measured on pathological terms, not structural terms. For example, what treatment can get rid of back pain quicker?---- physical therapy, spinal adjustments, medication, meditation or exercise?
This is a ludicrous question, as back pain is the result of so many contributing factors. We must stop playing the symptom game, and stand up and give our mission statement which tells that we want to identify the reason low back pain exists, the structural imbalances and distortions that make a person vulnerable to low back pain and provide a logical and effective program for correction, that includes spinal adjustments, custom fitted orthotics, physical therapy, exercises, lifestyle changes, weight management, etc.
The new guidelines must force us to ignore the medical model of evaluation and treatment for structurally based conditions. All medical tests are performed to look for pathology, and in the absence of pathology, the patient is referred for symptomatic physical therapy. At this point, the physical therapist may claim to then evaluate the patient, however, until structural x-rays are performed in the standing position, a "fingerprint"understanding of any patient's structure is impossible.
The medical model of treatment cannot become the standard of care either. This treatment focuses primarily on symptomatic relief, and as chiropractors, that must become only "phase 1" of our care. Rehabilitation is what has to set us apart from all others. The concern that physical therapists will compete with us if they're allowed to perform"manipulation" is a position based on fear and weakness. Manipulation, or spinal adjustments, is not who we are. Have we become so pathetic that we must fight to hang onto the 10-12% of the public we treat. Have we ever considered that the other 88-90% of the public also needs what we have, but they just don't understand why. In fact, sad to say, but many chiropractors don't even believe that. Everyone's structure will break down in life, either through imbalances and injury or degeneration. The sooner they're evaluated, the sooner they can pro-actively begin to prevent damage. If chiropractors would learn to look ahead more and unite and consolidate our message and resources, there will be more patients than any of us could ever handle. And doesn't it make sense that the fact that physical therapists want to "manipulate" will only endorse who we are and what we do?
We must become the structural diagnosticians, understanding the unique and specific imbalances and weaknesses that exist in the kinetic chain of an individual so that life enhancing corrective recommendations can be made. Physical therapists cannot examine or take x-rays, so they will never become competitive if we make the definition of chiropractic"the detection and correction of structural imbalances and distortions through a thorough structural evaluation, structural x-rays, spinal adjustments, corrective exercises and lifestyle changes".
The Structural Fingerprint® ExamThe Structural Fingerprint® Exam is a comprehensive evaluation of an individual's structure, regardless of whether they're symptomatic or not. This examination provides quantitative information that will, from an engineering perspective, inform both examiner and patient of the current status of the structure, as well as predictability of what is to come.
The exam consists of a complete evaluation of the feet (Fig. 1) in the standing position. Range of motion tests of the low back and neck are important. Tests that apply controlled stresses on joints, such as cervical compression and distraction, Patrick-Fabere and Gaenslen's are extremely informative. Measurements of leg length (Fig. 2) from the greater trochanter to the lateral malleolus, determines if there is either a functional or anatomical short leg. Palpation down the entire spine informs the examiner of any subluxations, muscle imbalances, swellings, tender areas, etc. Finally, an anterior-posterior open mouth (Fig. 3), lateral cervical (Fig. 4), anterior-posterior lumbo-sacral (Fig. 5) and lateral lumbo-sacral (Fig. 6) x-rays should be taken, always in the standing position. Critical measurements need to be considered on each film, as it becomes possible to tell where a person's been in life and where they're going by viewing these films. Compared to normals, the reference points determined on these films will now become the starting point for each patient. 75% of all structural information collected on each patient comes from the x-ray series. Keep in mind there will be times when additional initial x-rays should be taken. Re-x-rays are extremely important, so minimal views should be taken on the initial exam.
ConclusionThis examination is not only for those who hurt, but should be performed on everyone as soon as possible, with or without symptoms. All athletes should be examined before a season begins with special consideration given to their sport, position and structural weaknesses. All employees should be examined before they're hired with special consideration given to their job description and structural weaknesses. Children as young as possible (x-rays should only be considered in acute cases or after the age of 12) should be examined to learn what distortion patterns exist before injuries occur. The elderly should be examined before any more degeneration takes place. Anyone and everyone needs this examination as no profession is out there educating society to the importance of structural balance and the importance of good joint health and mobility. Most of us are looking at localized areas of symptoms and subluxations, forgetting that the entire structure plays a role. We're hoping our adjustment works quicker than the pill given next door.
Chiropractic is on the verge of greatness, we just have to have the strength to defy the short-term, ineffective protocol that the industry recommends. Long-term wellness is what everyone wants, but can't seem to find. With a unified message and protocol, chiropractic can easily provide what it takes for the masses. We would go from 10% of the population to a number larger than we could handle. Until we start to think out of the box, we'll never reach our valued position in the health care industry. Hopefully, our profession will aspire to higher goals and answer the call as needed.
1) Cherkin, Dan, Ph.D., Sherman, Karen, Ph.D., Eisenberg, David, M.D., Beyond the Backache. Newsweek December 2, 2002: p. 56
2) Jarvik, Jeffrey G., M.D., MPH, Deyo, Richard A., M.D., MPH.
Diagnostic Evaluation of Low Back Pain With Emphasis on
Imaging. Annals of Internal Medicine. October 1, 2002.