I learned this old phrase from one of my mentors, Dr. Harry Eidenier, Jr.: “When you hear the sound of hoofbeats, think horses, not zebras.” He was referring to the common threads we see in our patient population. The center of the bell curve contains the majority, the average, but this article is about the forgotten patients who populate the lower end.
I’m talking about what I refer to as zebra patients. They are not the common horses. They populate the bottom 5% of the bell curve.
Have you ever seen a new patient, done your workup, explained everything, provided the initial treatment, prescribed some nutritional supplements, given them home exercises or a diet change, and then never seen them again? I posit to you that you may have missed the zebra patient.
Have You Treated a Zebra Patient?
These patients, mostly female in my clinical experience, are your fragile types. I used to call them my fragile patients, but found that to be demeaning. They prefer being referred to as zebras. I know them well, because I, too, am a zebra patient.
Zebras do not tolerate the standard chiropractic approach; it is too rough for them. A zebra will leave a traditional chiropractor after their first adjustment/treatment, will feel worse for days to weeks, and will not improve once that residual post-treatment pain, headache and/or fatigue subsides.
Two reasons prompted me to write this article. First, I’ve been telling my chiropractor for years that I need to write about this topic. Second, a longtime zebra patient of mine who moved out of state came for a visit while back in town.
She complained that she had tried two chiropractors, but ended up worse off than when she started for several days and did not feel any relief once the post-treatment pain alleviated. Naturally, she would not return to them.
My father was a chiropractor, a charter diplomate in applied kinesiology, and a member of the “harder is better” philosophy of applying chiropractic treatment. I could not tolerate his adjustments, so I stuck with my husband, who was gentler with me.
He has since passed, and I am ever so grateful that my chiropractor listens to me like my husband did and alters his treatment to accommodate my zebra status.
Another important clinical gem I learned from Dr. Eidenier is, “If you listen to your patients long enough, they will tell you what is wrong with them.” Not literally, of course, but keep asking them questions and you will be able to narrow down your diagnosis and order the appropriate tests.
How Do You Know You Have One?
Listen to them and ask a lot of questions during their history. They often come in and tell me that they’ve tried other types of therapies like chiropractic, physical therapy, massage, and they all make them worse, not better.
The most often-used phrase from them is, “I don’t like all that cracking.” That is a red flag right there. Many of these patients have been referred to me specifically by other zebras because I have a reputation for gentle treatment.
Ask them how they respond to medications or if they tolerate them. Many of my zebras don’t tolerate meds well; they are the 1% who experience the side effects. Same with nutritional supplements; too much overwhelms their physiology and they have a negative reaction.
On physical exam, they might exhibit palpatory tenderness everywhere.
If the zebra returns to you, ask them how they tolerated their first treatment; were they sore, did they get a headache, or were they tired afterward? These are indications that you need to lighten up even more on your treatment.
I have heard our neurology colleagues discuss utilizing pupillary dilation and pulse rate increase as physical measures of exceeding the tolerance of the patient during treatment modalities. I don’t use these measures, but they are valid and objective ways to know when you have reached their tolerance.
How Do You Care for a Zebra Patient?
Gently. If you suspect you may have a zebra, go very easy on them and see how they do. Lighten up your manipulation by 1/10th of the usual force you apply or pull out your adjusting instrument. Avoid cavitating the joints during manipulation.
We know from our neuro colleagues that the effect of the chiropractic manipulation is from restoration of the mechanoreceptor function by inducing movement back into a joint that is not properly mobile. Induce that movement gently; use repeated, but soft thrusts.
My rule with my all patients follows hormesis – a little bit of treatment gives a little response, the right amount of treatment is the sweet spot for response, and too much treatment has diminishing returns.
For my non-zebras, I explain the rule during their adjustment – if what I am doing is painful, it is acceptable as long as the pain is 5/10 or less on the Visual Analog Scale. More than a 5/10 and they are instructed to let me know so I can lighten my force. This goes for joint manipulation, muscle work, manual acupuncture treatment, reflex therapy work, etc. For my zebra patients, their rule is 2-3/10 on the VAS.
I am grateful that I learned to listen to my own needs for my adjustments and ask for what I need from my providers. I am also grateful that my early zebra patients were patient with me as I was figuring this out. They were my biggest teachers.
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