Peeing in the Wind

As a parent, I appreciate this phrase – in a way that only a father of two young boys could. We’ve all stopped on the highway to rush little Johnny out of the car, run to the side of the road, and brace ourselves for the impending mayhem. You see, three-year old’s that “need to pee” can hit a target from ten feet away. But if you don't give them a goal… lookout. And heaven forbid if the wind is blowing in the opposite direction! Simply telling little Johnny to let it rip can yield damp consequences reaching from the tire of your car to your shoes, and sometimes even the family dog. However, if you tell Johnny to hit the nearest pine tree, he will spell his name on the trunk.

Herein lies the difference between a chiropractor and an evidence-informed chiropractor. Providing the same unfocused treatment to every patient, for every condition isn't acceptable. Research-driven diagnosis and treatment strategies allow evidence-based chiropractors to become the most clinically competent musculoskeletal providers. Today's blog will explain how accurately identifying the source of tissue dysfunction will focus your management and prevent undesirable outcomes.

Watch Dr. Steele explain how to achieve better clinical results and increase patient satisfaction with this two-step process.

"The man who grasps principles can successfully select his own methods. The man who tries methods, ignoring principles, is sure to have trouble." 

-Ralph Waldo Emerson

In chiropractic practice, action without a clear plan results in wasted time and disappointed patients. As evidence-based physicians, we must understand the principles behind what we do in order to avoid wasting our patient’s time and money. Our education, bolstered by continuing research, should guide which treatments are selected for each presentation. Today's blog will highlight the importance of understanding the current principles of musculoskeletal (MSK) care and differentiate this from the traditional model of chiropractic education that was focused on the methods behind the care.

A clear understanding of how a tissue was injured and why symptoms are present.

Treatment techniques to alleviate symptoms or heal tissue associated with a specific diagnosis.

MSK Diagnoses are based upon the use of clinical prediction rules to confirm a tissue source of pain. If orthopedic testing reproduces the patient's chief complaint, then, and only then, are treatment techniques selected — choose treatments based upon an understanding of the principal dysfunction. One example of a primary dysfunction is nerve irritation or compression at the IVF. Using the model of cervical radiculopathy, I will explain why having a clear idea of the principal dysfunction is necessary before prescribing treatment, ADL modifications, and home rehabilitation exercises.

Dx. Cervical Radiculopathy

1. How do you know?

Clinical Symptoms: Neck and upper extremity pain in a dermatomal pattern with potential sensory, reflex, and motor deficits in the affected nerve root distribution. 

Clinical Signs: Based upon symptoms and patient history, select tests and movements that decrease the size of the IVF.

• Spurling test

• Distraction test

• Upper-Limb Tension Test 1

• Ipsilateral cervical rotation <60 degrees. (1)

Do these tests reproduce the patient's chief complaint? If yes, this indicates that compression of the IVF reproduces the patient's complaint. If no, keep looking for areas of compression/irritation of the nerve root, possibly in the wrist, elbow, or shoulder.

2. What are you going to do about it?

Use best-practice management skills to determine the best treatment methods for the principal dysfunction. The research suggests that no single treatment is effective in reducing cervical radicular problems. (2) Rather, cervical radiculopathy responds most favorably to a multimodal treatment approach that includes a combination of techniques including manipulation, mobilization, and traction - all designed to restore motion and open the IVF.

While manipulation is safe, appropriate, and useful for the management of most radiculopathies, also consider non-thrust techniques for those cases that may not respond well to HVLA:

• A recent paper by Azful (2019) found that a Manual Intervertebral Foramen Opening Method, as described by Mulligan, is useful in the treatment of cervical radiculopathy. (1)

• Cervical traction is useful for both discogenic and degenerative causes of IVF encroachment. Cervical traction provided relief in 81% of patients with symptoms from mild to moderate cervical spondylosis. (3)

3. What can the patient do about it?

Carefully assessing the patient's habits, hobbies, and daily activities will often highlight fundamental postural faults that perpetuate tissue dysfunction. Identification and correction of these faults is crucial for timely healing and prevention of future reoccurrence.

Be the solution and not the problem

The more we understand the principles behind the patient's disability, the better we will be at applying the best-practice methods to solve the problem. And the reasoning described above is not unique to neck pain:

• Rotator Cuff Tendinopathy- Do we suppress the inflammation of tendonitis or generate a controlled inflammatory reaction for chronic tendinopathy?

• Low Back Pain- Do we prescribe knee to chest exercises for the flexion-biased patient, or recommend sphynx movements for the extension-biased patient?

• Lateral Elbow Pain- Do we use a compression band for tendinopathy, or avoid compression for radial tunnel syndrome?

In each of these cases, identifying your target of tissue dysfunction is crucial. The correct assessment leads to success while employing a shotgun approach and guessing wrong leads to “pissed off” patients.

What’s in your clinical toolbox?

ChiroUp’s online platform contains best practice protocols for 96 conditions plus patient education reports to pair. Step up your clinical game & let ChiroUp be your online toolbox. It’s time for you to join our community of evidence-based providers who are committed to delivering the best possible treatment to every patient, every time.

• References

  1. Afzal R, Ghous M, Rehman SS, Masood T. Comparison between Manual Traction, Manual Opening technique, and Combination in Patients with cervical radiculopathy: Randomized Control Trial. J Pak Med Assoc. 2019 Sep;69(09). Link

  2. Waldrop MA. Diagnosis and treatment of cervical radiculopathy using a clinical prediction rule and a multimodal intervention approach: a case series J Orthop Sports Phys Ther 2006; 36: 152-9. Link

  3. Swezey RL, Swezey AM, Warner K. Efficacy of home cervical traction therapy1. American journal of physical medicine & rehabilitation. 1999 Jan 1;78(1):30-2. Link