part i: ict

Integrated Chiropractic Technique

• What is it?– A diversified, meaning eclectic

approach– Synthesizes technique procedures

from many technique systems– Integrates technique procedures

and world views– Analytic and adjustive

cornerstones

Analytic cornerstones

• postural evaluation• global range of motion• pain and tenderness• segmental findings• segmental palpatory findings

(misalignment and fixation)• ortho-neurological findings• interpretation of pain-provocation

patterns• radiographic findings• reflex findings• identification of kinetic chains

Adjustive cornerstones

• manipulation / adjustment as appropriate• leverage• patient selection • doctor selection• assisted and resisted adjustments• joint kinematics (synkinetic adjusting)• structural findings• segmental intervention• regional intervention• rehabilitative procedures• case management• addressing kinetic chains

ACC Paradigm: Subluxation

• Chiropractic is Concerned with the preservation and restoration of health, and focuses particular attention on the subluxation.

• A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.

• A subluxation is evaluated, diagnosed, and managed through the use of chiropractic procedures based on the best available rational and empirical evidence.

Where is “the” subluxation?

Listings:

- ASEX (AS-lat)

- PIIN (PI-med)

- SAL

- AI sacrum, R

-Post ischium, L

-PLI-m, lumbars

- Helical dist., L

Chiropractic Listings

• “Sticky joints” and “crooked bones” (Stonebrink)

• Segmental and regional listings• Dynamic and static listings• Nomenclatural rules do not equal

joint kinematics– Assisted/resisted paradigm

• System techniques and jargon• Examples:

– orthogonal, Houston codes, MPI, Gonstead, Palmer, CBP, SOT, upper cervical, Thompson-PST

Which lumbar motion unit is primarily affected?

• Resisted adjustment– Above contacted bone– eg, using P-A thrust on crossed

elbows or shoulder

• Assisted adjustment– Below contact hand– eg, using significant body drop

and lateral-medial LOD

Dueling paradigms: Segmentalism vs. regionalism

Motion segment

Skull – spine postural configurations

From Harrison CBP Tech

Analytic cornerstones: Segmentalism

• Misalignment– The original chiropractic precept

• Fixation– Vertebra immobilized in position it

would normally occupy during physiological movement (including an aligned) (Sandoz)

• Restriction– Named by degree of freedom that is

limited• “Incoherent” postures often

segmentally explained– Trauma increases likelihood– Aging decreases relevance

Analytic cornerstones: Structuralism

– Postural substrate primary– Adjusting “as if”:

• Increased chance of good outcome even w/o postural change

• Partial, occasional improvement may occur

– Stretches contractures– Tips of segmental iceberg may

change day-to-day

Segmentalism/structuralism,Alignment/movement

Segmentalist Structural approach approach

Alignment L3-4 lumbar problem misalignment curvature

Movement L3-4 fixation reduced lumbar problem lateral flexion

Dueling paradigms: Restriction vs. misalignment

• Where is the chiropractic Rosetta stone?

Detail of hieroglyphic and demotic script on the Rosetta Stone

The Rosetta Stone

The question of specificity

• Adjustive: where is the segmental contact, what moves?

• Diagnostic: what level or region is implicated by an exam procedure?

• A matter of consistency between test and adjustive procedure

Postural chiropractic

– Examine related areas

– Identify primary and secondary problems if possible, often chicken-egg situation

– Multiple pathways to clinical success exist

Why will treating this man’s neck not help with his chronic headache?

Postural chiropracticand specificity

• Mortimer Levine hated being accused of practicing “general adjusting,” as distinguished from the vaunted “specific adjusting.” He said:

“As long as an adjusting [sic] is applied according to a corrective hypothesis after analysis of the patient's distortion, that adjusting is specific”

Levine M. The Structural Approach to Chiropractic. New York, NY: The Comet Press, Inc.; 1964.

Listing systems

• Gonstead

• Upper cervical

• Logan technique

• Diversified

• Thompson/PST

• Motion palpation

• Houston codes

• SOT

• CBP

Analytic cornerstones

The MAN algorithm: Subluxation components

Motion Alignment

NeurologicalThermograpy

Leg checks

Soft-tissue palpation

reflexes

Motion palpation

Stress x-rays

Orthopedics

Gait

ROM

Static palpation

Plain x-ray

Manual muscle testing

Reflexes

Postural analysis

Palmer West

Subluxation

Analytic cornerstones:PARTS acronym

• Pain

• Asymmetry

• Range of motion

• Tone, Texture, Temperature change

• Special tests

Bergmann T. P.A.R.T.S. joint assessment procedure. Chiropractic Technique 1993;5(3):135-136.

Kuchera on somatic predictors of chronic low

back pain

• TART: an acronym standing for– Tissue texture changes

– Asymmetry

– Restriction of Motion

– Tenderness

• Good interexaminer reliability

Degenhardt BF, Snider KT, Johnson J, Snider E. Retention of interexaminer reliability in palpatory evaluation of the lumbar spine. Journal of the American Osteopathic Association 2002;102(8):439.

Analytic cornerstones: Examination procedures

• Static and motion palpation• Global range of motion• Postural evaluation• Pain/tenderness provocation• Orthopedic testing• Neurological testing• Imaging• Muscle testing, manual• Thermography• Leg checking

Analytic cornerstones: Segmental range of motion

• Motion palpating for excursion, or quantity of movement– mm or degrees

• Motion palpating for end-feel, or quality of movement

• Difficult to derive static listings from motion findings

Quantity vs.quality of movment: Excursion and endfeel

Palpatory force

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join

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ion

exc left exc right

Hard end-feel

Palpatory force

Bo

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or

join

t ex

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exc left exc right

Right side initially more mobile, but locks abruptly with harder endfeel.

Left side more mobile throughout range.

Analytic cornerstones: Global range of motion

– Underlying assumption: asymmetry is pathological

– Defines reasonable adjustive vectors

– Identifying pathological side:• Hypo vs. hypermobility

– Allows appropriate choice of adjustive method according to ROM limitation

Analytic cornerstones: Pain and tenderness

• "He who treats the site of pain is lost.“ (Liebenson, citing Lewit)

• Identifying the pain generator is necessary but not sufficient to determine what tissue is treated– Kinetic chains– Primary and secondary problems– Referred pain– Trigger points

But the location and degree of pain:

• Does identify tissue damage

• Is a patient-relevant finding

• Can be reliably identified

• Is an important outcome measure

Interpreting pain on joint challenging

• Restrictions of joint motion may occur at any point within the joint's ROM. They may be minor or major in nature and encountered within the joint's active or passive range.

• In the spine, the counteropposing pressures are commonly applied against the spinous processes . Pain during movement is theorized to result from increased tension on injured or inflamed articular tissue.

• The assumption is that pain is increased when subluxated vertebrae are pushed in directions that increase the misalignment (into lesion) and that pain is decreased in the direction that reduces the misalignment (out of lesion).

• But if manual therapy is directed to stretch the shortened and contracted tissue, the adjustment should be made in the direction of encountered joint restrictions, even if it is associated with some tenderness.

Based on Peterson and Bergmann, Chiropractic Technique 2nd ed.

Analytic cornerstones: Ortho-neuro findings

– Identify location and means of likely intervention

– Pain-provocation patterns noted on orthopedic testing guide choice of adjustive setups, minimizing patient resistance

– Exception: stretching shortened tissues may provoke pain, but is indicated

– May necessitate referral and/or concurrent care

Specific diagnostic procedures

• Leg checking

• Palpation

• Manual muscle testing

• X-ray line marking

• Thermography

• Instrumentation

Adjustive cornerstones:

How much force to cavitate?

Cavitation No Cavitation pMean Spine Force (SD) 38.0 (42.4) 94.31 (117.2) 0.13Mean Pelvis Force (SD) 459.8 (217.7) 284.9 (180.2) 0.02Mean Thigh Force (SD) 356.1 (198.2) 134.3 (106.2) 0.0002Mean Total Force (SD) 853.9 (187.3) 517.8 (201.2) 5.39 E-05

Mean Spine/Total Force (SD) .048 (.0554) .176 (.184) 0.03

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

0 1 2Cavitation No Cavitation

Spine/TotalForce

When the majority of total force is applied directly to the lumber spine, as opposed to more peripheral sites, the probability of not achieving cavitation is greatly increased.

Adjustive cornerstones: Adjustive procedures

• Choice of methods:– Blocking, drop-table, side-

posture, instrument, distraction?– Prone, supine, sitting, standing?

• Evidence base very limited for particular adjustive methods.

• Construct-validity (does this make sense?) varies, but in many cases is all we have, for or against a procedure.

Adjustive cornerstones: Technique selection

• Patient characteristics– Age– Sex– Psyche– Condition– History

• Doctor selection– Athleticism– Body condition– Tastes and belief structures

Adjustive cornerstones: Adjustment biomechanics

• Assisted and resisted adjustments– not yet fully characterized

• Joint kinematics– synkinesis to minimize joint

trauma– asynkinesis to increase specificity

Which lumbar motion unit is primarily affected?

• Resisted adjustment– Above contacted bone– eg, using P-A thrust on crossed

elbows or shoulder

• Assisted adjustment– Below contact hand– eg, using significant body drop

and lateral-medial LOD

Is the thrust in the same direction or opposite pre-adjustive tension?

• Resisted adjustment: opposite– eg, PI ilium push

move

• Assisted adjustment: same– eg, modified

rotary break (MRB)

Assisted-Resisted paradigm: Not completed!

Pre-stress same as thrust = A

Pre-stress opposite thrust = R

Level above contact primarily affected = R

A, R ? R, R

RESISTED

Level below contact primarily affected = A

A, A

ASSISTED

A, R ?

Assisted/resisted example

Resisted: contact on sacral base gaps L5-S1, segment superior to contact hand

Assisted: contact on L5 introduces motion to L5-S1, below contact hand

Adjustive cornerstones: Segmental approach

• Segmental problems often acute– Torticollis– Tortithoracis– posterior sacrum– Herniated disk

• May result in regional disturbances

• May be acquired (trauma) or congenital (eg, hemivertebra)

Adustive cornerstones: Postural (structural) approach

• Regional problems often chronic• Multisegmental (regional)

intervention often indicated• Vectored multisegmental

intervention is specific• Making the “punishment fit the

crime”• Identifying the “global iceberg”• “As-if” adjusting: adjust as if to

correct the posture, even where it can’t be corrected

Postural chiropractic

– Examine related areas

– Identify primary and secondary problems if possible, often chicken-egg situation

– Multiple pathways to clinical success exist

Why will treating this man’s neck not help with his chronic headache?

Adjustive cornerstones: Case management

• Kinetic chains– Optimizing interventions– Addressing individual

components

• Rehabilitative procedures

• Referral and co-management

Counterproductive for chiropractic?

‘Twas always thus . . .