To help you enhance your practice and increase your bottom line, we ask practicing doctors of chiropractic, like you, for ideas and solutions that have been tested in real-world environments. In this issue, we asked: "What do you find to be the most difficult area of the spine to work on? What adjustment or treatment protocol do you use to address this area?" Based on your responses, there are some common difficulties and a variety of protocols used to combat them.
Experience is Key
For many doctors of chiropractic, experience has been the key to unearthing the right treatment for a difficult area of the spine. This experience has been acquired over the course of many decades, in some cases, and after dealing with multiple patients suffering from the same issues.
Gary Humphrey (Winter Haven, Fla.) says that "frequently, most chiropractors fail to understand the distinct disrelationship that occurs between the atlas the occipital articulations. In most cases, the subluxation complex is unilateral and I have succeeded where others have failed by addressing the segmental dysfunction that occurs a this aanatomical junction.
"The treatment applied is distinctly profound and is hihgly effective to relieve a multitude of subjective crainial symptoms, described mostly as posterior occipital headaches, intracrainial pressure, eye, ear nose and throat symptoms with head allergies, even elevated blood pressure. These conditions are quickly eliminated with specific decompression manipulation to the affected area. This is by far the most dynamic and successful spinal manipulation I have ever performed on my patients. It is an extremely effective treatment that I have been using for more than 34 years and it is not taught in any of the chiropractic colleges. A dynamic new course in chiropractic treatments may emerge here if further inquiry is sought."
Kevin Ross (Tempe, Ariz.): "I had struggled with low back disc issues on patients for 18 years of practice. I would refer any that came into my office to another chiropractor in town. About 18 months ago, I took the KST seminar and, by utilizing the ability to adjust in any position (sitting, standing, lying or in motion), as well as adjusting for disk torque (both at the spine and up to five inches out from the spine), I have retained every low back disk patient and most resolve themselves in one to five visits."
The Most Common Problem
Several responses included the same problem region of the spine: T1, T2, T3 and T4. A vareity of protocols have been tried, so if you are having issues in this area, you are not alone.
James Denito (Allen, Texas): "T1 and T2 are for me the most difficult to assess and manipulate. I have to rely on x-ray, AK and patient pain response to sometimes get the listing right. Occasionally, I'll get a good supine modified rotary break on the area, but I mainly rely on a drop piece with a pisiform contact."
Mark Lopes (Calif.): "It varies from patient to patient, but the T3-T4 area and the L1-L2 areas are often more difficult for manual adjustments. A good radiograph of the region helps to provide direction and confidence in adjustment attemtps, regardless of which manual technique you choose."
Brian Mouch (Williamsburg, Ohio): "The upper thoracics, more specifically T2 and T3 are the most difficult. I find that using a Gonstead chair move is the easiest and most effective way of moving these vertebrae. This area takes a pounding with the poor posture that we see in sedentary jobs. Few people sleep on their backs which means there is a high likelihood of having a tilt at the cervicothoracic junction. It could be worse if they sleep on their bellies, as this area controls the heart and lungs. I also use cranial work (SOT) and soft tissue orthopedics to prepare the area for the adjustment."
Robert Romano (Frederick, Md.): "Two difficult areas I have to adjust are both transition areas: C7-T3 and T10-L2. I find that maybe it's the diaphragm, but the thoracolumbar junction is difficult. I know DC's who adjust on full inhale being held in, but I adjust the TL area after full exhale, sometimes with the patient's leg flexed and passively resing flexed at the knee. Then, the cervicothoracic junction is also tough, but I tend to just do a supine and give extra force while holding the neck in flexion to open the facets."
Perry Chinn (Seattle, WV): "The most challenging area of the spine for me is the upper thoracics. My solution is typically to adjust first on the cervical chair or alternatively, to get a deeper set, I adjust prone on the hilo or knee chest table. It is very important to have your CA stabilize the patient's head with moderate downward pressure (or use the head strap on the knee chest table) as this minimizes upward or posterior movement of the head during the set, an action that greatly reduces the quality of the vertebral disc set."
David Mullin (Springfield, Mo.): "Toughest segments for me to adjust are T1, T2 and T3. I juse an anterior move and have the patient bend their knees and lift their hips until I can feel their weight on my hand and then drop."
Additional Difficulties
Other challenges presented themselves as well, such as dealing with obese patients or those with limited mobility in general.
Robert Rubino (West Haven, Conn.): "I find adjusting the cervical thoracic region on muscular or overweight patients sometimes challenging. I find the best techniques to adjust these patients are in the prone position, head rotated with neutral lateral position. From here, the practitioner can choose his or her line of drive and technique."
David Loper (Georgetown, Texas): "The thoraco-lumbar region is difficult. If you want to adjust like an anterior, you have to flex their torso very far. If you want to do side posture, you have to raise the bent/top leg very high to get it to start flexing. If you push P-A, it is a very sensative area so have them hold their breath in to make it less sensative."
Loreen Daigle (Middlebury, Conn.): Adjusting the component of the sacroiliac/pelvis is the most difficult. If the patient is immoble, blocking/passive care is good. I also use my long lever techniques with the patient supine or prone with the leg bent at the knee, or straight out distraction, or rotating the femur in the pelvis, depending on the fixation. You should remember that the SI is only part of the pelvis complex, it is common for that to be just a small part of the subluxation."
Paul Firnhaber (Lincoln, Neb.): "The upper cervical area is the most difficult for me. I generally use the Kale technique."
Attitude is Everything
Sometimes, overcoming a patients own bad habits and potentially their bad attitude is truly the most difficult "adjustment" to make.
"Daniel Wills (Ohio): "I don't wish my response to sound flippant, but I would say the most difficult area of the spine to work on is the area between C1 and the top of the head. As far as a treatment protocol, I have tried them all. It continues to amaze me that people will tell you they have no money and then tell you they smoke two to three packs of cigarettes a day.
"The way I have personally treated these people has ranged from coddling to brutal honesty. I am find that honesty is the better policy. I have lost patients because I have told them to quit smoking or whatever bad habit they had or go elsewhere. The way I see it, if they continue these destructive practices, they will not get the benefit of their care and will say that either I or chiropractic failed them. I have chosen to work with people who want to get better. All I ask is that they make the effort. If they are wiling to try, then any additional technique will be 100 times more effective. The subluxation between the ears is the hardest to treat, for me.
