Integrated  Chiropractic Technique <ul><li>What is it? </li></ul><ul><ul><li>A diversified, meaning  eclectic  approach </...
Analytic cornerstones <ul><li>postural evaluation </li></ul><ul><li>global range of motion </li></ul><ul><li>pain and tend...
Adjustive cornerstones <ul><li>manipulation / adjustment as appropriate </li></ul><ul><li>leverage </li></ul><ul><li>patie...
ACC Paradigm:  Subluxation <ul><li>Chiropractic is Concerned with the preservation and restoration of health, and focuses ...
Where is “the” subluxation? <ul><li>Listings: </li></ul><ul><li>ASEX (AS-lat) </li></ul><ul><li>PIIN (PI-med) </li></ul><u...
Chiropractic Listings <ul><li>“ Sticky joints” and “crooked bones”  (Stonebrink) </li></ul><ul><li>Segmental and regional ...
Which lumbar motion unit is primarily affected? <ul><li>Resisted adjustment </li></ul><ul><ul><li>Above contacted bone </l...
Dueling paradigms: Segmentalism vs. regionalism Motion segment Skull – spine postural configurations From Harrison CBP Tech
Analytic cornerstones:  Segmentalism <ul><li>Misalignment </li></ul><ul><ul><li>The original chiropractic precept </li></u...
Analytic cornerstones:  Structuralism <ul><ul><li>Postural substrate primary </li></ul></ul><ul><ul><li>Adjusting “as if”:...
Segmentalism/structuralism, Alignment/movement Segmentalist Structural  approach approach Alignment L3-4    lumbar problem...
Dueling paradigms: Restriction vs. misalignment <ul><li>Where is the chiropractic Rosetta stone? </li></ul>Detail of hiero...
The question of specificity <ul><li>Adjustive: where is the segmental contact, what moves? </li></ul><ul><li>Diagnostic: w...
Postural chiropractic <ul><ul><li>Examine related areas </li></ul></ul><ul><ul><li>Identify primary and secondary problems...
Postural chiropractic and specificity <ul><li>Mortimer Levine hated being accused of practicing “general adjusting,” as di...
Listing systems <ul><li>Gonstead </li></ul><ul><li>Upper cervical </li></ul><ul><li>Logan technique </li></ul><ul><li>Dive...
Analytic cornerstones
The MAN algorithm: Subluxation components Motion Alignment Neurological Thermograpy Leg checks Soft-tissue palpation refle...
Analytic cornerstones: PARTS acronym <ul><li>P ain </li></ul><ul><li>A symmetry </li></ul><ul><li>R ange of motion </li></...
Kuchera on somatic predictors of chronic low back pain <ul><li>TART: an acronym standing for </li></ul><ul><ul><li>T issue...
Analytic cornerstones: Examination procedures <ul><li>Static and motion palpation </li></ul><ul><li>Global range of motion...
Analytic cornerstones:   Segmental range of motion <ul><li>Motion palpating for excursion, or quantity of movement </li></...
Quantity vs.quality of movment: Excursion and endfeel Right side initially more mobile, but locks abruptly with harder end...
Analytic cornerstones:  Global range of motion <ul><ul><li>Underlying  assumption : asymmetry is pathological </li></ul></...
Analytic cornerstones:  Pain and tenderness <ul><li>&quot;He who treats the site of pain is lost.“ (Liebenson, citing Lewi...
But the location and degree of pain: <ul><li>Does identify tissue damage </li></ul><ul><li>Is a patient-relevant finding <...
Interpreting pain  on joint challenging <ul><li>Restrictions of joint motion may occur  at any point  within the joint's R...
Analytic cornerstones:  Ortho-neuro findings <ul><ul><li>Identify location and means of likely intervention </li></ul></ul...
Specific diagnostic procedures <ul><li>Leg checking </li></ul><ul><li>Palpation </li></ul><ul><li>Manual muscle testing </...
Adjustive cornerstones:
How much force to cavitate? When the majority of total force is applied  directly to the lumber spine , as opposed to more...
Adjustive cornerstones: Adjustive procedures <ul><li>Choice of methods: </li></ul><ul><ul><li>Blocking, drop-table, side-p...
Adjustive cornerstones:  Technique selection <ul><li>Patient characteristics </li></ul><ul><ul><li>Age </li></ul></ul><ul>...
Adjustive cornerstones:  Adjustment biomechanics <ul><li>Assisted and resisted adjustments </li></ul><ul><ul><li>not yet f...
Which lumbar motion unit is primarily affected? <ul><li>Resisted adjustment </li></ul><ul><ul><li>Above contacted bone </l...
Is the thrust in the same direction or opposite  pre-adjustive tension? <ul><li>Resisted adjustment:  opposite </li></ul><...
Assisted-Resisted paradigm:  Not completed!   A, R  ? A, A  ASSISTED Level below contact primarily affected = A R, R RES...
Assisted/resisted example Resisted: contact on sacral base gaps L5-S1, segment superior to contact hand Assisted: contact ...
Adjustive cornerstones:  Segmental approach <ul><li>Segmental problems often acute </li></ul><ul><ul><li>Torticollis </li>...
Adustive cornerstones: Postural (structural) approach <ul><li>Regional problems often chronic </li></ul><ul><li>Multisegme...
Postural chiropractic <ul><ul><li>Examine related areas </li></ul></ul><ul><ul><li>Identify primary and secondary problems...
Adjustive cornerstones:  Case management <ul><li>Kinetic chains </li></ul><ul><ul><li>Optimizing interventions </li></ul><...
Counterproductive for chiropractic?
‘ Twas always thus . . .
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Part I: ICT

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Part I: ICT

  1. 1. Integrated Chiropractic Technique <ul><li>What is it? </li></ul><ul><ul><li>A diversified, meaning eclectic approach </li></ul></ul><ul><ul><li>Synthesizes technique procedures from many technique systems </li></ul></ul><ul><ul><li>Integrates technique procedures and world views </li></ul></ul><ul><ul><li>Analytic and adjustive cornerstones </li></ul></ul>
  2. 2. Analytic cornerstones <ul><li>postural evaluation </li></ul><ul><li>global range of motion </li></ul><ul><li>pain and tenderness </li></ul><ul><li>segmental findings </li></ul><ul><li>segmental palpatory findings (misalignment and fixation) </li></ul><ul><li>ortho-neurological findings </li></ul><ul><li>interpretation of pain-provocation patterns </li></ul><ul><li>radiographic findings </li></ul><ul><li>reflex findings </li></ul><ul><li>identification of kinetic chains </li></ul>
  3. 3. Adjustive cornerstones <ul><li>manipulation / adjustment as appropriate </li></ul><ul><li>leverage </li></ul><ul><li>patient selection </li></ul><ul><li>doctor selection </li></ul><ul><li>assisted and resisted adjustments </li></ul><ul><li>joint kinematics (synkinetic adjusting) </li></ul><ul><li>structural findings </li></ul><ul><li>segmental intervention </li></ul><ul><li>regional intervention </li></ul><ul><li>rehabilitative procedures </li></ul><ul><li>case management </li></ul><ul><li>addressing kinetic chains </li></ul>
  4. 4. ACC Paradigm: Subluxation <ul><li>Chiropractic is Concerned with the preservation and restoration of health, and focuses particular attention on the subluxation . </li></ul><ul><li>A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health. </li></ul><ul><li>A subluxation is evaluated, diagnosed, and managed through the use of chiropractic procedures based on the best available rational and empirical evidence. </li></ul>
  5. 5. Where is “the” subluxation? <ul><li>Listings: </li></ul><ul><li>ASEX (AS-lat) </li></ul><ul><li>PIIN (PI-med) </li></ul><ul><li>SAL </li></ul><ul><li>AI sacrum, R </li></ul><ul><li>Post ischium, L </li></ul><ul><li>PLI-m, lumbars </li></ul><ul><li>Helical dist., L </li></ul>
  6. 6. Chiropractic Listings <ul><li>“ Sticky joints” and “crooked bones” (Stonebrink) </li></ul><ul><li>Segmental and regional listings </li></ul><ul><li>Dynamic and static listings </li></ul><ul><li>Nomenclatural rules do not equal joint kinematics </li></ul><ul><ul><li>Assisted/resisted paradigm </li></ul></ul><ul><li>System techniques and jargon </li></ul><ul><li>Examples: </li></ul><ul><ul><li>orthogonal, Houston codes, MPI, Gonstead, Palmer, CBP, SOT, upper cervical, Thompson-PST </li></ul></ul>
  7. 7. Which lumbar motion unit is primarily affected? <ul><li>Resisted adjustment </li></ul><ul><ul><li>Above contacted bone </li></ul></ul><ul><ul><li>eg, using P-A thrust on crossed elbows or shoulder </li></ul></ul><ul><li>Assisted adjustment </li></ul><ul><ul><li>Below contact hand </li></ul></ul><ul><ul><li>eg, using significant body drop and lateral-medial LOD </li></ul></ul>
  8. 8. Dueling paradigms: Segmentalism vs. regionalism Motion segment Skull – spine postural configurations From Harrison CBP Tech
  9. 9. Analytic cornerstones: Segmentalism <ul><li>Misalignment </li></ul><ul><ul><li>The original chiropractic precept </li></ul></ul><ul><li>Fixation </li></ul><ul><ul><li>Vertebra immobilized in position it would normally occupy during physiological movement (including an aligned) (Sandoz) </li></ul></ul><ul><li>Restriction </li></ul><ul><ul><li>Named by degree of freedom that is limited </li></ul></ul><ul><li>“ Incoherent” postures often segmentally explained </li></ul><ul><ul><li>Trauma increases likelihood </li></ul></ul><ul><ul><li>Aging decreases relevance </li></ul></ul>
  10. 10. Analytic cornerstones: Structuralism <ul><ul><li>Postural substrate primary </li></ul></ul><ul><ul><li>Adjusting “as if”: </li></ul></ul><ul><ul><ul><li>Increased chance of good outcome even w/o postural change </li></ul></ul></ul><ul><ul><ul><li>Partial, occasional improvement may occur </li></ul></ul></ul><ul><ul><li>Stretches contractures </li></ul></ul><ul><ul><li>Tips of segmental iceberg may change day-to-day </li></ul></ul>
  11. 11. Segmentalism/structuralism, Alignment/movement Segmentalist Structural approach approach Alignment L3-4 lumbar problem misalignment curvature Movement L3-4 fixation reduced lumbar problem lateral flexion
  12. 12. Dueling paradigms: Restriction vs. misalignment <ul><li>Where is the chiropractic Rosetta stone? </li></ul>Detail of hieroglyphic and demotic script on the Rosetta Stone The Rosetta Stone
  13. 13. The question of specificity <ul><li>Adjustive: where is the segmental contact, what moves? </li></ul><ul><li>Diagnostic: what level or region is implicated by an exam procedure? </li></ul><ul><li>A matter of consistency between test and adjustive procedure </li></ul>
  14. 14. Postural chiropractic <ul><ul><li>Examine related areas </li></ul></ul><ul><ul><li>Identify primary and secondary problems if possible , often chicken-egg situation </li></ul></ul><ul><ul><li>Multiple pathways to clinical success exist </li></ul></ul>Why will treating this man’s neck not help with his chronic headache?
  15. 15. Postural chiropractic and specificity <ul><li>Mortimer Levine hated being accused of practicing “general adjusting,” as distinguished from the vaunted “specific adjusting.” He said: </li></ul>“ As long as an adjusting [sic] is applied according to a corrective hypothesis after analysis of the patient's distortion, that adjusting is specific” Levine M. The Structural Approach to Chiropractic. New York, NY: The Comet Press, Inc.; 1964.
  16. 16. Listing systems <ul><li>Gonstead </li></ul><ul><li>Upper cervical </li></ul><ul><li>Logan technique </li></ul><ul><li>Diversified </li></ul><ul><li>Thompson/PST </li></ul><ul><li>Motion palpation </li></ul><ul><li>Houston codes </li></ul><ul><li>SOT </li></ul><ul><li>CBP </li></ul>
  17. 17. Analytic cornerstones
  18. 18. The MAN algorithm: Subluxation components Motion Alignment Neurological Thermograpy Leg checks Soft-tissue palpation reflexes Motion palpation Stress x-rays Orthopedics Gait ROM Static palpation Plain x-ray Manual muscle testing Reflexes Postural analysis Palmer West Subluxation
  19. 19. Analytic cornerstones: PARTS acronym <ul><li>P ain </li></ul><ul><li>A symmetry </li></ul><ul><li>R ange of motion </li></ul><ul><li>T one, T exture, T emperature change </li></ul><ul><li>S pecial tests </li></ul>Bergmann T. P.A.R.T.S. joint assessment procedure. Chiropractic Technique 1993;5(3):135-136.
  20. 20. Kuchera on somatic predictors of chronic low back pain <ul><li>TART: an acronym standing for </li></ul><ul><ul><li>T issue texture changes </li></ul></ul><ul><ul><li>A symmetry </li></ul></ul><ul><ul><li>R estriction of Motion </li></ul></ul><ul><ul><li>T enderness </li></ul></ul><ul><li>Good interexaminer reliability </li></ul>Degenhardt BF, Snider KT, Johnson J, Snider E. Retention of interexaminer reliability in palpatory evaluation of the lumbar spine. Journal of the American Osteopathic Association 2002;102(8):439.
  21. 21. Analytic cornerstones: Examination procedures <ul><li>Static and motion palpation </li></ul><ul><li>Global range of motion </li></ul><ul><li>Postural evaluation </li></ul><ul><li>Pain/tenderness provocation </li></ul><ul><li>Orthopedic testing </li></ul><ul><li>Neurological testing </li></ul><ul><li>Imaging </li></ul><ul><li>Muscle testing, manual </li></ul><ul><li>Thermography </li></ul><ul><li>Leg checking </li></ul>
  22. 22. Analytic cornerstones: Segmental range of motion <ul><li>Motion palpating for excursion, or quantity of movement </li></ul><ul><ul><li>mm or degrees </li></ul></ul><ul><li>Motion palpating for end-feel, or quality of movement </li></ul><ul><li>Difficult to derive static listings from motion findings </li></ul>
  23. 23. Quantity vs.quality of movment: Excursion and endfeel Right side initially more mobile, but locks abruptly with harder endfeel. Left side more mobile throughout range.
  24. 24. Analytic cornerstones: Global range of motion <ul><ul><li>Underlying assumption : asymmetry is pathological </li></ul></ul><ul><ul><li>Defines reasonable adjustive vectors </li></ul></ul><ul><ul><li>Identifying pathological side: </li></ul></ul><ul><ul><ul><li>Hypo vs. hypermobility </li></ul></ul></ul><ul><ul><li>Allows appropriate choice of adjustive method according to ROM limitation </li></ul></ul>
  25. 25. Analytic cornerstones: Pain and tenderness <ul><li>&quot;He who treats the site of pain is lost.“ (Liebenson, citing Lewit) </li></ul><ul><li>Identifying the pain generator is necessary but not sufficient to determine what tissue is treated </li></ul><ul><ul><li>Kinetic chains </li></ul></ul><ul><ul><li>Primary and secondary problems </li></ul></ul><ul><ul><li>Referred pain </li></ul></ul><ul><ul><li>Trigger points </li></ul></ul>
  26. 26. But the location and degree of pain: <ul><li>Does identify tissue damage </li></ul><ul><li>Is a patient-relevant finding </li></ul><ul><li>Can be reliably identified </li></ul><ul><li>Is an important outcome measure </li></ul>
  27. 27. Interpreting pain on joint challenging <ul><li>Restrictions of joint motion may occur at any point within the joint's ROM. They may be minor or major in nature and encountered within the joint's active or passive range. </li></ul><ul><li>In the spine, the counteropposing pressures are commonly applied against the spinous processes . Pain during movement is theorized to result from increased tension on injured or inflamed articular tissue. </li></ul><ul><li>The assumption is that pain is increased when subluxated vertebrae are pushed in directions that increase the misalignment (into lesion) and that pain is decreased in the direction that reduces the misalignment (out of lesion). </li></ul><ul><li>But if manual therapy is directed to stretch the shortened and contracted tissue, the adjustment should be made in the direction of encountered joint restrictions, even if it is associated with some tenderness. </li></ul><ul><li>Based on Peterson and Bergmann, Chiropractic Technique 2 nd ed. </li></ul>
  28. 28. Analytic cornerstones: Ortho-neuro findings <ul><ul><li>Identify location and means of likely intervention </li></ul></ul><ul><ul><li>Pain-provocation patterns noted on orthopedic testing guide choice of adjustive setups, minimizing patient resistance </li></ul></ul><ul><ul><li>Exception : stretching shortened tissues may provoke pain, but is indicated </li></ul></ul><ul><ul><li>May necessitate referral and/or concurrent care </li></ul></ul>
  29. 29. Specific diagnostic procedures <ul><li>Leg checking </li></ul><ul><li>Palpation </li></ul><ul><li>Manual muscle testing </li></ul><ul><li>X-ray line marking </li></ul><ul><li>Thermography </li></ul><ul><li>Instrumentation </li></ul>
  30. 30. Adjustive cornerstones:
  31. 31. How much force to cavitate? When the majority of total force is applied directly to the lumber spine , as opposed to more peripheral sites, the probability of not achieving cavitation is greatly increased.
  32. 32. Adjustive cornerstones: Adjustive procedures <ul><li>Choice of methods: </li></ul><ul><ul><li>Blocking, drop-table, side-posture, instrument, distraction? </li></ul></ul><ul><ul><li>Prone, supine, sitting, standing? </li></ul></ul><ul><li>Evidence base very limited for particular adjustive methods. </li></ul><ul><li>Construct-validity (does this make sense?) varies, but in many cases is all we have, for or against a procedure. </li></ul>
  33. 33. Adjustive cornerstones: Technique selection <ul><li>Patient characteristics </li></ul><ul><ul><li>Age </li></ul></ul><ul><ul><li>Sex </li></ul></ul><ul><ul><li>Psyche </li></ul></ul><ul><ul><li>Condition </li></ul></ul><ul><ul><li>History </li></ul></ul><ul><li>Doctor selection </li></ul><ul><ul><li>Athleticism </li></ul></ul><ul><ul><li>Body condition </li></ul></ul><ul><ul><li>Tastes and belief structures </li></ul></ul>
  34. 34. Adjustive cornerstones: Adjustment biomechanics <ul><li>Assisted and resisted adjustments </li></ul><ul><ul><li>not yet fully characterized </li></ul></ul><ul><li>Joint kinematics </li></ul><ul><ul><li>synkinesis to minimize joint trauma </li></ul></ul><ul><ul><li>asynkinesis to increase specificity </li></ul></ul>
  35. 35. Which lumbar motion unit is primarily affected? <ul><li>Resisted adjustment </li></ul><ul><ul><li>Above contacted bone </li></ul></ul><ul><ul><li>eg, using P-A thrust on crossed elbows or shoulder </li></ul></ul><ul><li>Assisted adjustment </li></ul><ul><ul><li>Below contact hand </li></ul></ul><ul><ul><li>eg, using significant body drop and lateral-medial LOD </li></ul></ul>
  36. 36. Is the thrust in the same direction or opposite pre-adjustive tension? <ul><li>Resisted adjustment: opposite </li></ul><ul><ul><li>eg, PI ilium push move </li></ul></ul><ul><li>Assisted adjustment: same </li></ul><ul><ul><li>eg, modified rotary break (MRB) </li></ul></ul>
  37. 37. Assisted-Resisted paradigm: Not completed!   A, R ? A, A ASSISTED Level below contact primarily affected = A R, R RESISTED A, R ? Level above contact primarily affected = R Pre-stress opposite thrust = R Pre-stress same as thrust = A
  38. 38. Assisted/resisted example Resisted: contact on sacral base gaps L5-S1, segment superior to contact hand Assisted: contact on L5 introduces motion to L5-S1, below contact hand
  39. 39. Adjustive cornerstones: Segmental approach <ul><li>Segmental problems often acute </li></ul><ul><ul><li>Torticollis </li></ul></ul><ul><ul><li>Tortithoracis </li></ul></ul><ul><ul><li>posterior sacrum </li></ul></ul><ul><ul><li>Herniated disk </li></ul></ul><ul><li>May result in regional disturbances </li></ul><ul><li>May be acquired (trauma) or congenital (eg, hemivertebra) </li></ul>
  40. 40. Adustive cornerstones: Postural (structural) approach <ul><li>Regional problems often chronic </li></ul><ul><li>Multisegmental (regional) intervention often indicated </li></ul><ul><li>Vectored multisegmental intervention is specific </li></ul><ul><li>Making the “punishment fit the crime” </li></ul><ul><li>Identifying the “global iceberg” </li></ul><ul><li>“ As-if” adjusting: adjust as if to correct the posture, even where it can’t be corrected </li></ul>
  41. 41. Postural chiropractic <ul><ul><li>Examine related areas </li></ul></ul><ul><ul><li>Identify primary and secondary problems if possible , often chicken-egg situation </li></ul></ul><ul><ul><li>Multiple pathways to clinical success exist </li></ul></ul>Why will treating this man’s neck not help with his chronic headache?
  42. 42. Adjustive cornerstones: Case management <ul><li>Kinetic chains </li></ul><ul><ul><li>Optimizing interventions </li></ul></ul><ul><ul><li>Addressing individual components </li></ul></ul><ul><li>Rehabilitative procedures </li></ul><ul><li>Referral and co-management </li></ul>
  43. 43. Counterproductive for chiropractic?
  44. 44. ‘ Twas always thus . . .

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