Stabilize Your Practice With Structural Supports

When Marianne came in as a new patient with back pain I examined and adjusted her. She immediately felt better and I gave her instructions to get another couple of adjustments in the next few days to get her out of the acute stage. She didn't return. When my CA called her a week later Marianne reported that her low back hurt again by the time she had gotten home, and so decided that she needed an MD instead of a chiropractor!

What a way to lose a patient. I knew her adjustment had been highly effective; she left the office functioning and feeling better. So what happened? She must have done something to mess her body up herself sometime between getting adjusted and getting home. The fact is that I had given the right treatment that got the patient better. Then, she did something to make her body worse and I got the blame for it because "the adjustment didn't work."

How many patients have you lost simply because the patient didn't see the value of chiropractic care after one or two adjustments, as happened with Marianne? Unfortunately, all patients aren't created equal; "good patients" become good patients over time. Our first emphasis then should be on giving them what they want… pain relief, so that you have the extra time you need to make them into good patients. Along with your adjustment there are a few aids you can use to support your adjustment and assist with pain relief.

What Can Cause Problems After An Adjustment?

There aren't that many things patients can do to mess up their body so quickly. It's your job to understand what they are, then prevent them from happening. The problem is that it doesn't seem like these patients did anything wrong by simply driving home. But they did. They actually did two things that nearly everyone does which makes their body worse; they 'walked' out of the office, and then they 'sat' in their car.

Similar scenarios played out many times over the next several years of my practice. Trying to fix the damage after the fact seemed to me pretty much like treating the symptom but not the cause. Obviously this isn't the only reason patients drop out of care. It is however, one that happens all too often, costing us patients so unnecessarily when we could easily prevent it by paying attention to the cause.

I am going to urge you to spend a little time initially with your patients to explain a few simple things that will help them support their adjustment. If they don't do these things then there is a good possibility that they will feel worse than they otherwise could. You may not get a second chance with them.

Shoeless

I never made the connection that this was what was happening with my patients until one day, when a painful knee (that was putting a damper on my vacation) got me going to a chiropractor in Los Angeles. He worked me all up and down and when he was done I felt great. I was standing straight, I could breathe easier, and my knee pain was gone. I started to put on my sandals to leave when he stopped me. He took the sandals and threw them in the trash. These were $200 Italian sandals and he got my attention.

I pulled my sandals out of the trash. He showed me how much worse my body became – immediately – when I put them on. I took them back off and threw them in the trash myself! Making my way back to my hotel in the midday heat of August, as I was hopping around, dodging melted gum on Los Angeles sidewalks, I had plenty of opportunity to reflect on my newly acquired knowledge on how shoes might mess up the body and make a person feel worse. (This chiropractor I visited in Los Angeles was Jesse Jutkowitz, D.C.)

Simple Tests

Unfortunately, we were not taught all that we need to know in school to do the best job we can on this. The big idea here is for patients to be supported into a more upright position. This is consistent with being more upright after their adjustment.

Get an image in your mind of someone who is leaning forward, their breathing is shallow, and their face shows pain. If you have your patients who are in pain simply breathe in and out and let their body slump, this is what you will see if they have a structural problem.

Now get an image of someone who is upright, their breathing is easy and full, and their face is relaxed. This is how your patients look when you have improved their structure.

This simple test above and its resulting indicators of posture, breathing and pain, may be used to gauge the effectiveness of support aids and any other structural modifications you may make. You'll quickly see if they are helping improve your patients' bodies– or making them even worse. The two activities – sitting and walking – when done incorrectly, have a dramatic and immediate effect on how patients feel after their first adjustment. Their first visit therefore is the critical time to check them both, and if need be, correct them.

[pb]Generally, if you analyze and correct your patients' shoes, and then take the time to make sure that they are sitting properly in their car and in their home and work places, you are well on your way to making them into a good patient. Remember, at this point in their care, your goal with supports and modifications is simply to support them enough so they won't get worse and blame it on you. You can always go into more detail later with other aspects of these as needed.

Test Which Supports Your Patients Need

I like to have the patient notice things for themselves. If I do it for them then they really don't get it. I start with their shoes. After their adjustment I simply have them stand there while barefoot or in socks. I have them take in a deep breath and slump, and then observe if their breathing is easier or fuller than before the adjustment. I then have them notice if they are more upright, straighter, taller, stronger, and more stable (not swaying). They can feel this or even see it in a mirror. Essentially, we're checking the indicators described above. Once they see how the adjustment made them better than before, I have them put their shoes on. I don't bother having them fasten the shoes because they may have to take them on and off a few times. Once their shoes are on I have them take stock of the same indicators as before while helping them to observe any changes. If I see a difference but they don't yet, we repeat the process until they can tell. The next step is to fix their shoes as best I can with heel lifts, insoles, or whatever they need so that their indicators will be better while they are wearing them.

There are many things that could be wrong with shoes. Some you can change and some you can't. This will be a trial and error process as you gain experience, but there are a few guidelines for immediate success. With nearly every patient at this point, the changes made to their shoes will need to be done bilaterally. You can see this for yourself by testing the indicators such as breathing and slumping when you make changes to just one shoe or both.

Some things to consider and possibly change with shoes: reducing arch support height, adjusting heel height, and removing or replacing the insoles. Some shoes fix easily with only one change, while others may require more than one change; some shoes, no matter what you do to them, will just never work (like my cherished Italian sandals). Now it's time to take a look at sitting. In order to sit and not cause undue stress to the body, a person's hips must be higher than their knees.

I have personally looked at over 1000 car seats and never found one that puts bodies in the correct sitting posture with good indicators. Regardless all the possible position adjustments and fancy designs they may have, they are still basically shaped like bucket seats with the back part lower than the front, putting the hips lower than the knees.

The way to deal with this is to sit on a wedge-shaped seat cushion. This raises the hips up a bit while balancing and strengthening the upper body.

I don't ask others to take my word about the body mechanics involved or the supports needed to help. In fact it was Dr. Jutkowitz who figured these things out, not me. I encourage you to test these ideas for yourself. Once you see the changes you can make with patients simply by fixing what their shoes and seats are doing to the rest of their body, you will have more control of their care. You will also gain their respect and gratitude as you empower them to accept some responsibility for their own improvement.

As you gain experience doing this with your patients you will gain appreciation for just how important supports are in keeping patients aligned in the first place, and then in helping to maintain their correction in ongoing care. The additional benefit is that needing new supports from time to time will ensure that your patients stay in touch with you.

You will also be able to determine if your patients are in pain due to an injury (new or old), or if they are just continuing to mess themselves up with poor shoes and seats. This will provide ample opportunities to discuss their use of support products, and any need for temporarily increasing the frequency of their care.

I believe you will be thrilled with the enhanced results for your patients, and find deep satisfaction in improving your skills, which will make you better known in your community and field.

Patients are still going to drop out of care at times but, you can minimize this by "plugging the holes in the bucket". How patients feel in the beginning of care is important enough to them that they use it as their own indicator as to whether to stay with you or not. Realize that patients often get worse from what they do and it isn't necessarily a problem with your adjustment "not holding". Understanding and using these concepts will give you the confidence and tools to build a stronger practice.