Robert D. Borman
Michelle came to our office last year after she was diagnosed with multiple sclerosis. She had been having so much difficulty with her balance and ability to walk that she was in danger of becoming an invalid while only in her thirties. Our chiropractic adjustments were unable to cure her MS, of course, but we were able to level the pelvis and improve cervical function. In a short week Michelle was walking faster and more steadily, and was able to participate more fully in life.
Unfortunately, Michelle then had to return to her home in Maryland. You see, the most interesting part of this chiropractic success story is that she felt she had to fly almost 2,000 miles to Colorado to be adjusted in a way that did not scare her. Michelle had been to chiropractors previously. Now her MS made her feel much more fragile and vulnerable than she had before. The prospect of her local chiropractor "kick-starting her like a Harley-Davidson motorcycle" or "making her see stars" was more than she could bear.
Fear of chiropractors is easy for the public to buy into. The American Medical Association has certainly delighted in fostering this negative view of our profession, but popular culture has also played a powerful role. Thrusting manipulation seems to be the focus of this fear. Do you remember the only movie to come out of Hollywood with a chiropractor as a hero? It was called "Jacob's Ladder," and featured Danny Aiello performing rotary cervical adjustments with loud audible releases in stereo. Everyone in the theater gasped and shrank back from the screen at the spectacle. "Oh, my God!" exclaimed the lady next to me, as if someone had just been brutally knifed.
Another example: Our local paper, the Boulder Daily Camera, carries a comic panel called "Close to Home." Recently, one featured a chiropractor atop a stepladder. Looking for all the world like an Acapulco cliff diver, perched above his prone patient, he says, "I need you to just relax and trust me on this, Mrs. Hostrander."
Trust, or the lack of it, is a major issue when people make health care decisions. The American public currently refers to us as "back-crackers" or "bone-poppers." Their faces get that wide-eyed look that poor Mrs. Hostrander must have as she awaits the impending impact. People distrust chiropractors primarily because they fear thrusting manipulation. The thrust is chiropractic's signature in the public imagination, and the technique is not selling well. What we chiropractors call, very clinically, high-velocity low-amplitude technique (HVLA) is in fact a marketing nightmare. Elimination of HVLA from chiropractic would remove the major obstacle that keeps potential patients out of our offices. Wholesale adoption of non-thrusting techniques would lead to an ever-increasing utilization of chiropractic services and a proportional growth in our influence.
Many will object that eliminating HVLA techniques from chiropractic to increase public acceptance would cut out the very heart of our profession. The Association of Chiropractic Colleges apparently disagrees. Recently, the presidents of each and every chiropractic school stated unanimously that chiropractic is about the relationship of the spine and the nervous system as it affects the health of the body. They neglected to even mention HVLA techniques as being rock-bottom important anywhere in their historic document. Others will argue that it is the HVLA techniques which ensure our uniqueness and effectiveness. Yet it is no secret that physical therapists are now using "Grade 5" manipulation in a vain attempt to reproduce the success of chiropractic in clinical trials. Ultimately the PTs will fail, because our secret is not the thrust, but rather the paradigms we apply as we analyze and treat people.
To objectively consider eliminating HVLA, we must first understand both why it sometimes works so well, and why it sometimes does not work. Because HVLA is a tool for eliminating subluxation, it is appropriate to begin with the possible nature of that lesion, or rather more correctly, lesions, as there are both acute and chronic forms. The acute subluxation is relatively rarely seen by chiropractors; it is essentially a "tic" in the neurologic reflexes that alters local muscular activity on a short-term basis. Chronic subluxations are far more commonly seen in our offices and represent dysfunctional patterns that are "learned" by the body over time.
Chronic subluxation is a highly complex, positive-feedback system. Muscular and neurologic elements combine to create a circular self-perpetuating pathophysiology. In its simplest form, there are four steps to this vicious cycle. Muscular hypertonicity and its concomitant, impaired eccentric motion, create a dyskinesia of the vertebral motor unit. The dyskinesia irritates and inflames the disk and/or facet joints, which then engulf the adnexal intervertebral foramina (IVF) and its contents. Inflammation, within the semi-confined space of the IVF, alters the resting membrane potential of the dorsal root ganglia toward threshold, resulting in facilitation of sensory input. Exaggerated sensory data from the muscle spindles reflexively perpetuates the muscular hypertonicity and impaired eccentric motion, thus completing the circle.
Manual manipulation often seeks to influence the neurologic system by interacting with the musculoskeletal system. High-velocity technique uses a bony lever arm to rapidly stretch the muscles opposing the imparted motion. This rapid stretching is sensed by the golgi tendon organs (GTOs) which then act to override the normal muscle-spindle-based reflexes. Rather than contract against this rapid movement, the stretched muscle is directed to shut down to protect itself. HVLA techniques, therefore, use a "circuit breaker" effect to temporarily override the abnormal neurologic reflexes creating the subluxation. This is analogous to the process we use when we "power down" and then "re-boot" a misbehaving computer. Such re-booting works in a computer only if the underlying circuits are intact. Correspondingly, HVLA is most successful, often spectacularly so, when a subluxation is relatively short-term so that the underlying reflex circuits are still capable of functioning properly.
On the downside, HVLA allows for movement of the joint into the "paraphysiologic space." During this temporary shutdown of protective neurologic reflexes and muscular action, the patient is quite vulnerable. Here we see the importance of the "low amplitude" part of HVLA. The amplitude of any high-velocity maneuver must be very narrowly controlled. Too little amplitude and the GTOs will not be simulated to override the muscle spindles. Too much amplitude and the passive structures of the area (ligaments, capsule, vascular, etc.) can be traumatized in their unprotected state. To further complicate the issue of amplitude, the requisite depth of thrust can vary widely with each patient throughout the day and, from time to time, for the same patient. This high-wire balancing act of deciding how much amplitude to deliver, combined with the public exposure to Steven Segal movies wherein he is killing people with a simple snap of the neck, lends credence to the AMA and its malicious lies about our field as we struggle for market share and power.
In chronic subluxation the underlying patterns which we are trying to "re-boot" are themselves dysfunctional, hence the adjustments frequently do not "hold." Chronic problems require multiple HVLA interventions as the neurologic system relearns normal function. Each thrust carries its risk of iatrogenic injury. A vicious cycle can ensue following any perceived trauma. Even one painful manipulation will create fear and guarding behavior. Pain creates fear; fear creates guarding; guarding creates a need for higher forces; and higher forces create more opportunity for trauma.
Chronic subluxation is but one situation where HVLA techniques can exhibit a dangerously low therapeutic index. Other patients not well suited to HVLA techniques include the fragile, like Michelle with her MS. The elderly, with osteoporosis, arthritis and vascular disease, would also benefit from a more gentle technique. Likewise, extremely acute patients often do not tolerate HVLA manipulation well. Postsurgical patients certainly deserve special treatment. But by far the largest category of people that are failed by HVLA techniques are those potential patients who need chiropractic help, yet resist out of fear.
Chiropractic needs a method to normalize the neurologic reflexes and muscular contractions perpetuating subluxation that is not dependent upon the tainted thrust of HVLA. By working through the muscle spindles, we could correct problems more gently than is possible with the HVLA/GTO mechanism. Techniques which use the muscle spindle system abound. Yoga has used slow, specific stretching techniques successfully for millennia. Modern athletes don't stretch ballistically but, rather, use sustained stretching to reduce injury. Within chiropractic, for decades we have used blocking procedures to slowly move the sacroiliac joints out of subluxation. Such slow changing of the pelvis is often a necessity because the size and strength of the local muscles precludes easy GTO override. My suggestion is that we apply similar techniques throughout the spine using the same osseous contacts and lines of force we presently use, but slowing the process down. Low-velocity specific-stretch (LVSS) techniques do not override the muscle spindles with GTO input. During LVSS, the joint does not move into the paraphysiologic space; hence there is a greatly decreased chance of damaging the vulnerable passive structures. With LVSS there is no "popping," no "crunching," and no fear.
Think of the meaning of that: no fear associated with chiropractic. Would more new people come into our offices if fear were not an issue? Would our established patients follow through with recommended care better if they weren't afraid? You bet they would. Adoption of LVSS technique could precipitate a revolution in chiropractic utilization similar to what recently happened with dentists. My best friend, Dr. Dan, is a dentist who is dangerously demented while climbing or kayaking, but still does a booming business in his office. Why? Because today, everybody has a dentist, and most have good insurance coverage for their dental care.
Not long ago, people went to the dentist only in a dire emergency. The pliers and the painful removal of an abscessed, throbbing tooth were how people thought of the dentist. And indeed, the pliers were often the only available remedy by the time the average person overcame fear and sought help. Then, dentists altered their practice in a way which reduced pain and fear. First, they introduced anesthetics and continually refined their use. Today, patients don't even see, much less feel, a needle. Only after careful numbing with anesthetic swabs is the work area injected. If that is not good enough, they will give you nitrous oxide. Drills changed from large, grotesque, band-driven torture devices to small and proficient air-driven wonders. These improved tools and techniques have reduced the fear factor so well that now everyone goes to the dentist. Don't you?
Wouldn't you like everyone to go to a chiropractor just like everyone now goes to the dentist? Wouldn't you like people to take a daily walk and apply ice for their chiropractor just like they now brush and floss for their dentist? Wouldn't you like everyone to bring their children to the chiropractor just like they now take their toddler to the dentist? Wouldn't you like everyone to come for a checkup every six months whether they had symptoms or not, just like they do with the dentist? Wouldn't you like everyone to understand that spinal care should be oriented around long-term solutions? Today's dental consumer simply won't allow that tooth to be pulled. They opt instead for root canal therapy and demand that their insurance help. Wouldn't you like everyone to demand that normal motion be restored to their spine, not just that the pain be reduced? Wouldn't you like them to demand that their insurance help them towards this goal?
"Demand" is the key word. Today the health care field is being rewritten by the health care consumer. As more people began seeing their dentist for more comprehensive and continuing care, the demand for dental coverage grew exponentially. Demand for health care and insurance coverage is driven by the economic vote of consumerism. At present, only 10-20% of the U.S. population sees a chiropractor. Such low utilization translates into precious little power when chiropractors try to reform health care or insurance coverage. In a sense, HVLA and the fear it creates are acting like a subluxation by interfering with the natural growth of our profession. If we could remove that interference, there would be an explosion of new patients coming into our offices.
The one thing that most chiropractors lack is a strong flow of new patients. The masses who could benefit from our care remain only potential patients. Afraid to see for themselves, they remain subject to wild AMA inventions of paraplegia, stroke and outright quackery. Our patients are immune to such silliness because they have been inoculated by direct experience of how chiropractic helped them. Our patients know that chiropractors have a great and important concept: the health of the spine, nervous system and body as a whole, are interrelated. Our patients know that chiropractors have an excellent education. Our patients know that chiropractors are great people who care about their patients as people, not diseases. Our patients even know that chiropractors are the unacknowledged leaders of the health care revolution going on in America today. But we need many more chiropractic patients before we reach "critical mass" and move into our rightful spot in the nation's health care debate.
I see a day when 90% of the population sees a chiropractor on a regular basis. I see a day when ordinary people will understand that the spine and nervous system run the body just like they now understand that bacteria cause cavities. I see a day when people will know their chiropractor by name, exercise daily for their chiropractor, have regular checkups and bring the kids in for their adjustments. I see a day when informed patients will demand an end to the secondary status which currently plagues chiropractors and chiropractic patients. Before this can happen, chiropractors need to take a decisive step into the future. HVLA manipulation is a relic of our first century that is impeding the natural growth of chiropractic. Just like the pliers that the dentists used to be associated with, HVLA can get the job done and it can stop the pain, but it scares the hell out of people. Let's stop scaring people.
Back in Maryland, Michelle has returned to her old dysfunctional pattern and continues to go downhill. Afraid to seek local chiropractic help, she's seeing an acupuncturist, but to no avail. This article was prompted by a call from her husband who was desperately seeking an East Coast chiropractor to continue her care. We have also received calls from our patients' friends and families from around the country who want the name of a local chiropractor using this gentle and effective method. LVSS technique is now in its infancy. Even the name is only a suggestion. We believe that there are other chiropractors out there already using similar methods, but there is no list of these doctors' names.
I ask those of you reading this paper and nodding your heads in agreement to contact me at the address listed at the end of this article. By generating a network of like-minded docs we hope to increase chiropractic utilization by tapping into that vast potential market of people who need chiropractic, but are afraid of thrusting techniques. Such a network could also act as a clearing house, focused upon the refinement and application of LVSS techniques. We hope this brief paper will provoke healthy discussion in the chiropractic community and, perhaps, provide an alternative to doctors dissatisfied with the limitations of current practice.
Franklin Delanor Roosevelt once said, "We have nothing to fear but fear itself" when the future of America was uncertain. Although he did not have chiropractors in mind, it nevertheless applies to our present situation in two ways. The future of chiropractic is now uncertain, caught between managed care and physical therapist turf-poachers. Only fear (our fear) limits tomorrow's techniques and our professional growth. Only fear (the American public's fear) limits our new patient flow and the growth of our profession. Let's make the correct adjustment by removing the subluxation of HVLA technique. Let's let the power flow. The third millennium and a rosy, prosperous future await us.
Robert D. Borman, DC
1720 South Bellaire, Suite 1200
Denver, CO 80222
