Dynamic Chiropractic has a website which gives you the opportunity to follow up any articles with pertinent questions. Some of these questions have brought out very important points which I think clarify some of the chief topics I regularly discuss in my columns. A few of the more valuable dialogues are reproduced here from the website. I hope that all of you will continue to ask me any questions which arise.
Stabilization Training
Question: Since I am going to the sports diplomate program at Northwestern and would eventually like to take the rehab diplomate from LACC, I am always looking for new low-tech ways to help out patients. The one thing that has been emphasized considerably to our patients has been the ability to sustain the neutral spine. I wonder if, when using the words "abdominal hollowing," it would make doctors unfamiliar with this technique teach the patient to suck in and "hollow" their abs instead of bracing and keeping their neutral spine?
Answer: Hollowing is a good term, and I am in favor of it. The key is to draw the navel in when performing abdominal exercises, but not to suck it in by raising the ribs. This would interfere with normal respiration and is a key to training.
Question: I have been trying to find an article on coactivation exercises. Could you steer me in the right direction?
Answer: There are several good sources available for information on coactivation exercises. Key articles and books include:
Question: You often quote the natural history of LBP. An FCER tape quotes a study by Van Koff that seems to indicate that the majority of acute cases will be recurrent within the next 12 months. This conflicts with the theory that the minority of cases will wind up chronic. Is there supportive literature in favor of one or the other?
Answer: You raise an interesting point. The literature is quite clear about natural history. The vast majority of acute episodes are not activity limiting or disabling within six weeks.1-3 However, the vast majority tend to have recurrences one year later.1,2 These recurrences are usually similar to the first event in that they also tend to resolve within six weeks.3 It is still the case that most of the costs are due to the minority of acute cases which do not resolve in six weeks but become chronic (not recurrent) pain problems.3,4 These chronic activity limiting or disabling problems represent the minority of cases (<15%) but represent the majority of the costs (>85%).3,4
The key is to realize that we have acute, acute recurrent and chronic patients. The most important issue is to view the subacute phase as the critical one in which we need to draw a line in the sand and prevent the onset of chronic pain behaviors (physical and psychological deconditioning) before they emerge.3-5
Answer: That's quite a loaded question! The epidemiological data shows that most low back pain episodes resolve within six or seven weeks, but that they also recur within about a year. These recurrences also resolve within six or seven weeks. The truly chronic group is much smaller - less than 15%. Most of the costs of LBP arise from the chronic group, not the acute recurrence group. In fact, about 85% of the costs arise from the smaller group. There is also evidence that some common acute management is iatrogenic (i.e., bed rest) or unnecessary (i.e., imaging in those without red flags).
Does this data support longer term care? Certainly not, until it can be shown that such care reduces either the recurrence rates one year later or the percentage of cases which become chronic. Research should look at this question. In particular, evidence is accumulating which shows that many acute patients do quite well with simple advice (reassurance that recovery is likely; that there is no serious disease process involved; and that resuming near normal activity is safe and actually therapeutic even if it hurts somewhat).1-3 So the evidence is starting to show in many cases that less of a physical medicine type of care, not more, is better.
Finally, when is more aggressive conservative care justifiable? I think it is justifiable in those patients who can be identified early on to be at increased risk of chronicity. Research has shown that these individuals can be identified before they are chronic in about 85% of cases.4-6 It is defensible to offer more aggressive care for these patients so long as it is evidence-based: for instance, manipulation and active care coupled with appropriate biopsychosocial advice.
When sports chiropractors first appeared at the Olympic Games in the 1980s, it was alongside individual athletes who had experienced the benefits of chiropractic care in their training and recovery processes at home. Fast forward to Paris 2024, where chiropractic care was available in the polyclinic for all athletes, and the attitude has now evolved to recognize that “every athlete deserves access to sports chiropractic."
It is estimated that 61% of patients with CTS avoid taking surgical options due to postoperative complications and costly surgical procedures. Chiropractic care offers a comprehensive and effective treatment for carpal tunnel syndrome, addressing the condition from multiple angles. Recent studies also have unveiled a game-changing adjunct to chiropractic treatments for CTS: nerve flossing.
Some doctors thrive in a personality-based clinic and have a loyal following no matter what services or equipment they offer, but for most chiropractic offices who are trying to grow and expand, new equipment purchases help us stay relevant and continue to service our client base in the best, most up-to-date manner possible. So, regarding equipment purchasing: should you lease, get a bank loan, or pay cash?
