John R. Bomar, DC
As with all other health care providers, unfortunately, we only prosper financially when others are suffering. Because of this, our work demands a higher consciousness and moral standard. It calls for an ethical “high ground” upon which we stand as we approach our patients.
Sure, we have to make enough money to pay office expenses and to live, but our duty is to help patients attain maximum wellness as soon as possible – and this requires a genuine effort at full rehabilitation: the recovery of lost articular function, resulting in a balanced paraspinal and gluteal resting myotonus, with full and normal range of motion.
Palliative, temporary pain relief is not healing, nor is it full recovery of lost articular function. Many criticize our profession for overlooking soft- and connective-tissue anomalies that accompany biomechanical lesions, accepting less than full rehabilitation and requiring repeated office visits.
Of course, we have all had patients who cannot attain complete rehabilitation and must therefore have some follow-up treatment, but our goal should be to develop patient self-sufficiency. Most long-term biomechanical impairment follows significant trauma, as in motor-vehicle crash. Basic structural and postural imbalances such as ankle/foot overpronation, significant leg-length inequality, idiopathic scoliosis or scoliosis from congenital lumbosacral anomaly often requires long-term care.
I have also seen many adult patients who need continuing care related to childhood trauma, especially to the pelvis in a backward falls as this can disrupt normal plumb balance in the developing spine. There have also been cases in which there was remodeling of the sacroiliac joints due to displacement without correction.
They didn’t teach comprehensive connective and soft-tissue rehabilitation at Palmer College when I attended in the 1970s. I believe our instructors did not teach rehabilitation because they were not taught this extremely valuable adjunct spinal adjustment/manipulation. There seemed to be such an aversion to teaching anything other than hands-on adjustment that even physical therapy treatments were not allowed on our patients.
Neither were we taught simple and basic ways to quell articular inflammation, such as 20 minutes on, 20 minutes off covered, repetitive cold packs – as much as possible during the acute stage combined with supine rest. We were not taught any forms of rehab stretching to balance resting paraspinal myotonus, which we know is the basis for normal articular motion. We were not taught very real and useful tools like electrical stimulation, ultrasound, iontophoresis or therapeutic mechanical massage in the recovery process.
In my first years of practice, the majority of my patients would return time after time with the same patterns of distortion – and often at the same intensity as in their first visits. Even though patients would report good relief of their conscious pain, their recurring biomechanical lesions were very persistent.
Re-exam would reveal rotary distortion, neuro-reflex guarding myospasm, tenderness to probing palpation, hypokinetic joint play, and loss of P-A springy motion. Except in mid-thoracic hypokyphotic deformities, there was always clockwise or counterclockwise articular rotation.
After some time I came to understand that inflammation in the capsular joint structures was driving the recurring biomechanical lesions through arthrokinematic reflex “guarding” of paraspinal and pelvic myospasm. I came to believe that capsular edema was responsible for conscious pain because of the concentration of nociceptors in the wall of the capsular ligaments.
If existing long enough, the pain was also generated from chronically “sick” spastic muscles. Chronic hypertonus had produced intramuscular toxemia, adhesions, fibrosis and scarring, facilitating the pathology.
As we realize, hands-on spinal manipulation involves “disturbing the disturbance.” Patients should expect increased pain consciousness following early treatment. In our practice, we composed a letter: “After Your First Treatment,” to explain the phenomenon, along with an instruction sheet for cold pack application.
Patients who fully complied often returned with much less conscious pain, and for many the improvement was quite dramatic. If the pain did not improve with these measures, I considered this a red flag warranting further investigation. Improvement was reassurance that I was dealing primarily with biomechanical disturbance.
We began applying full-spine and gluteal vibrating massage before any manipulation; this was well-received by patients, relaxing them and relieving their anxiety. We have successfully used infrared lamp for spasm; it is relatively inexpensive and creates deep relaxation and anesthesia.
We also use sine-wave electrotherapy (ES), alone or combined with ultrasound. Ultrasound breaks up scarring and adhesions; while the muscle contracture pumps metabolic wastes out, and fresh blood and lymph fluid in. I think of it as “changing the oil” in the muscle bundles, hopefully promoting more normal resting tonus.
I have come to believe that chronic paraspinal and gluteal myospasm result in lowering the threshold of neural stimulus needed to perpetuate the spasm – thus creating a positive feedback cycle of dis-ease (see illustration).
Photobiomodulation with cold laser or an inexpensive red light therapy pad has proven very effective in reducing inflammation, conscious pain, and stimulating a healing response within tissue according to the NIH. We also have a roller traction table and shiatsu massage chair.
Axial decompression through distraction/traction has long been held to be effective in spinal care. Done very patiently and progressively, this will often produce spontaneous facet release and reduce nerve root compression. The axiom with traction is “better to stop short than go too far,” as excessive distraction force can prove harmful and painful in the early stages or prior to adjustment.
I began prescribing slow yoga-form chair stretching. I kept it simple and first had patients go through the full ranges of motion. Then I gave them specific stretching instruction, always away from the side of pain and never into the side of pain.
For a (cephalid view) clockwise sacroiliac rotary displacement (probably the most common), I demonstrated how to counterstrain the pelvis by putting the left foot up on a chair and then lunging forward. I also had patients stretch the gluteus medius on the right and the piriformis on the left in such a condition.
What I hoped to produce was a balanced resting tonus and normal articular rest, which the early osteopaths called “easy neutral.” These approaches proved so beneficial that I began to chart recurring lesions from 1-4, based on the amount of mobilization I felt and the crepitation sound during joint release. Objective recovery was then charted.
From my years in practice I can say with confidence that, in my opinion, adjustment alone cannot produce full recovery of lost function except in the very young or in very acute trauma cases – with immediate attention during the six-week period. Most of the cases we see are very long-standing, often arising symptomatically only with additional stress or strain.
Hippocrates, who you may know did articular manipulation, said that relieving symptoms while not correcting the deeper causes of a condition is bad medicine. We all know that long-term biomechanical impairment produces very advanced rates of degenerative disc and joint disease.
We also accept that these mechanical lesions, often hidden, may produce sympathetic mediated “impingements,” resulting in visceral and organic pathologies relative to vasomotor disturbance in normal blood flow.
Is it not then our duty to incorporate rehabilitation into our system of healing – for maximum effect and the long-term good of our patients; and the health of our practices?
