There is no doubt that chiropractic spinal care is a necessary part of the healing world. There is a movement within chiropractic to establish us as the "back doctors," so the general public will have a unified concept as to what we are about. From a public-relations standpoint, this idea has merit; but from a therapeutic standpoint, it may limit us.
Our education must emphasize the connective-tissue relationships going on in our bodies. Back and extremity problems cannot be solved solely by the "adjustment," as is taught in many of our colleges. No doubt a percentage of spinal problems have an articular causation, but our profession will never survive in the long term if we stress a singular causation for what are mostly multifactorial etiologies. Without an understanding of functional evaluation of the musculo skeletal system and soft-tissue methods of healing, our approach to the spine and extremities is limited.
There are several excellent rehabilitation courses being taught, but our schools must be the prime originators of evaluation and treatment of soft tissue. There still are colleges teaching the concept of evaluating the spine based on static spinal segmental position or unproven instrumentation detection. What function of the spine are they evaluating? Based on the static "out of place" concept, every scoliosis patient should be writhing in pain. In most of these colleges, the teaching of soft-tissue relationships to the spine is minimal, at best. Even the colleges that proclaim they teach soft tissue are severely lacking in their education of the DC.
There are numerous examples of the effect of soft tissue on spinal function. For example, the sacrotuberous ligament, if restricted by shortened hamstrings and gluteus maximus muscles, will significantly diminish ventral rotation of the sacrum. Restriction of sacral movement by attached muscles influences sacroiliac function by way of the kinetic chain.1
I usually point to the levator scapulae muscle as an example of the effect of soft-tissue impairment in relation to the spine. This muscle arises from the dorsal tubercles of the transverse processes of the first to fourth cervical vertebrae. It is associated with the fascia that surrounds it, attaching to the occiput and down to the thoracolumbar fascia. Mere adjusting cannot reduce cervical pain if there are fibrotic nodules often associated with this muscle/fascia, especially at the superior angle of the scapula where it inserts. This applies to every muscle and fascial attachment that directly inserts into spine, along with the extra spinal muscles and fascia involved with the kinetic chains of our body.
Does it not make sense to evaluate this area for chronic shortening in a patient with cervical pain or in a patient who is not responding to cervical adjustments? It is so obvious to include the connections to the spine with our adjustive approach that I am embarrassed having to mention it. Unfortunately, a great percentage of doctors in the field remain hampered by some sort of spinal "philosophy" that stifles advancement. It is difficult to blame practitioners who are saddled with a "just adjust" philosophy, since they have to make a living; but I do blame them if they do not examine the literature and continue their education. I blame most of all the schools that educated them. We need some kind of Flexner report, like medicine went through in 1910, revealing that medical schools were not uniform and keeping up to date.2
The approach to extremity problems often is based solely on a manipulative approach. Yes, this approach is necessary, but the kinetic chain must be emphasized, and again, the attachments must be evaluated and treated. An elbow problem can be related to a lack of shoulder internal rotation. A tennis elbow mostly involves treatment of the extensor carpi radialis brevis and extensor digitorum, along with rehabilitation. Are these muscles being evaluated properly and treated by soft-tissue methods?
My problem with chiropractors being known as "back doctors" is that we are leaving out a huge market of musculoskeletal problems we should be expert in treating. As a result, we often hear patients state, "I didn't know chiropractors treat elbows or shoulders." Shoulder problems are probably the second most common complaint reported in chiropractic offices, after problems with the spine. Chiropractors have resorted to becoming "sports injury" doctors in order to become recognized as experts in extremity problems. Yes, treating sports injuries requires additional education, but our colleges should be training us so we all are sports injury doctors.
The literature is filled with information relating treatment of the spine and extremities to the various connections. Treating the whole musculoskeletal system creates a successful department store with added services compared to the one-item "crack the back" store. Our future depends on chiropractors becoming the prime experts in the evaluation and treatment of the whole musculoskeletal system. The general public and the insurance companies, among others, have been educated to consider us as "back crackers" and our profession has suffered.
References
- Vleeming A, Wingerden JP Van, Snijders CJ, Stoeckart R, Stijnen T. Load application to the sacrotuberous ligament; influences on sacroiliac joint mechanics. Clinical Biomechanics 1989;4(4):204-209.
- Flexner A. Medical Education in the United States and Canada. New York, NY: Carnegie Foundation for the Advancement of Teaching; 1910.
