I have recently established good relationships with two massage therapists in my area. They both have established clientele and good reputations in the communities in which they practice, treating some very challenging and difficult cases. They have both worked with numerous chiropractors, but were less than satisfied with these relationships because the chiropractors had this "love of the bone."
My practice has changed drastically since I started using active release techniques, as it did years ago when I learned friction massage from Warren Hammer. Personally, I tend to agree with the therapists. Why is it most chiropractors address myopathology verbally, which in my experience is the most damning component of the subluxation complex, yet fail to address it in their treatment plans with anything other than heat or some type of physiotherapeutic modality?
Last week I heard Dr. Nikitow talk about CBP and a years worth of chiropractic (three times a week) to correct the subluxation complex and change the mechanics of the spine. It is only $5,000 for an entire family to join the club and the kiddies get checked for free. Although he was undoubtedly well read and could quote the literature, like some quote the bible, regarding the scientific validation of what we do, he said nothing of correction of muscular lesions. The literature is quite clear on the effect of spinal lesions (subluxation) on autonomic nervous system function, yet many of the well learned in our profession now acknowledge there is more to nerve dysfunction than just pinched nerves. Some doctors like Nikitow say there are two types of chiropractors: those who treat subluxations, and those like myself who diagnose and work toward a specific health goal with the patient. While this may open a philosophical can of worms, I believe Dr. Nikitow is right to a point. I believe there are two types of chiropractors: those who do therapeutic muscular work on their patients; those who ignore myopathology altogether, depending on constant joint manipulation with or without physical therapy.
To the best of my knowledge, the literature says nothing about treatment of three times per week for a year as being efficacious or cost-effective. Although I may be considered close-minded by some, I believe that this much manipulation may be harmful, especially because people can become habituated. I believe I and many others in our beloved profession have become habituated to being adjusted. I also believe from experience that therapeutic soft tissue therapy can reduce or possibly eliminate the effect of habituation. Incidentally, there are some in our profession that recommend weekly maintenance adjustments, using the literature or contorting it to prove their point. I believe we should make our patients less dependent on being adjusted weekly to feel relatively good.
In 1990, the Annals of Rheumatic Diseases published the study, "Effect of Habitual Knuckle Cracking on Hand Function." Two groups, knuckle crackers and non-knuckle crackers were evaluated. Although neither group had an increased incidence of arthritis, habitual knuckle crackers had hand swelling and lower grip strength. Their conclusion was habitual knuckle cracking results in functional hand impairment without arthritis. Personally, I believe that this can happen to any joint that is over manipulated. My neck is a perfectly good example. How many of you remember what happened to your necks while in chiropractic college?
Since using Dr. Leahy's active release on patients and having it done at his seminars on myself, I believe there is a way to reverse this process. You simply must address the lesions that exist in the patients' soft tissues (muscle, ligaments and nerve root and muscular adhesions). Dr. Warren Hammer is one of the biggest proponents of soft tissue therapy and acknowledges its importance in chiropractic practice. I spoke with him recently at an active release technique seminar and he stated that even though the methods are time consuming and require much effort on behalf of the doctor, the results on people were worth it. Managed care obviously doesn't reimburse us enough for the extended amount of time necessary in most cases, but we are here for the patients, not for ourselves. After all, no patients, no us. Isn't this a patient driven profession?
I get adjusted by my colleagues and within days my neck is in pain or stiff again, in need of an adjustment. The best results I ever had were when deep active release work was applied to my neck muscles prior to adjustment. It was the longest I held an adjustment in years. I realized my neck needs more of this type of work. After that experience, I knew I was helping my patients by putting great emphasis on soft tissue treatment techniques. It is not uncommon for me to get a patient who failed with another chiropractor and succeeded in my office because of my emphasis of soft tissue methods. Often maintenance patients return to our office either monthly, bi-monthly or quarterly, and after active release is done to their necks and backs, they are consistently looser, more pain free, and most of their adjustments hold.
Am I better than everyone else? No, but I know I am doing all that it takes to get the job done on my patients. Cash patients find much greater value with someone who is willing to give them their money's worth and really try to work out the problem versus a one to three minute adjustment. I now firmly believe that to truly eradicate most extremity and spinal subluxations that are chronic, deep soft tissue techniques are mandatory for getting superior, consistent results. The major drawback is that performing them properly is time consuming and uncomfortable for most patients.
In my experience, most patients will undergo the discomfort to get good results if your explain to them what they should expect. They also adjust better when you do not have to fight through poorly functioning soft tissues to adjust their spine. Michael Schneider, DC, recently wrote an article regarding patients who were on maintenance care and questioned the validity (see "Another Look at Preventive Maintenance," April 10, "DC"). I believe, from my own experience that maintenance is necessary and I believe appropriate soft tissue techniques make maintenance adjustments not only much more effective, but free up the joints so they are truly mobile. Isn't an immobile joint the same type of joint that degenerates over time? The adjustments are also much more comfortable for the patient and they are much less likely going to feel stiff following their adjustment.
Before, I mentioned the two massage therapists. I now get regular referrals from them, many of whom are very challenging cases: MS, Dupuytren's contracture, cases that failed with chiropractic previously. They like my approach and the results build confidence in our capabilities. They are introducing many patients to chiropractic who have never been before, or who may never have returned. Why is it that we preach subluxation, its five components, and don't practice what we preach? In my opinion, you can't have proper joint function, which leads to proper nerve function, which leads to improved joint proprioception, without proper muscle function. My experience dictates it is impossible no matter how many times you manipulate the patient. The entire profession would get superior results if they were willing to embrace the concepts of Hammer, Leahy, Cyriax and others who emphasized the importance of rectifying the soft tissue lesions.
Would manipulation under anesthesia be necessary if deep soft tissue work could loosen the multifidi to such an extent that they allow for a relatively pain free, thorough adjustment? Couldn't a doctor deliver a more effective adjustment without having to fight all of the patients muscle guarding. Patients who receive myofascial therapy do better as a whole. I'll bet my reputation on it, and I expect that future studies will prove I am correct. Perhaps my colleagues might be inspired to take one of the many courses now available on the various methods or the MPI course with Warren Hammer. Our profession will get better results, be more cost effective with better long-term outcomes and our patients satisfaction will increase.
I have used various methods and have found that active release gives me the most consistent results and outcomes in my office are more consistent than they ever were. Active release explains many problems patients have that seem to defy explanation and it all makes sense, not only to the doctor but to the patient as well. Sure, new methods creates change and havoc, but with managed care, what is one more change. After all, as a profession we should be used to change by now. It takes commitment to learn techniques like these and guts to implement them. Are you up for the challenge?
William D. Charschan, DC, CCSP
North Brunswick, New Jersey
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