Certainty, Outcomes and Excellence
By David Fletcher DC FRCCSS(C)
By David Fletcher DC FRCCSS(C)
“You can afford to wait without hesitation when you are certain of the outcome.”
“You can afford to wait without hesitation when you are certain of the outcome.”
Many times in my presentations and lectures, I draw comparisons between orthodontic care and chiropractic care. You might think that this has to do with the clinical work of straightening and changing structure. Actually, I use this association to acknowledge the profession of orthodontics’ incredible sense of certainty when offering a care plan.
Without hesitating, an orthodontist can recommend many months of care, all at a pre-determined fee. The patient rarely knows how many visits they are going to have scheduled, but what they are assured of, from the very beginning, is that change will happen under the guidance of a highly skilled professional and that this change will be amazing.
Chiropractic adjustments are transformative. Our highly skilled approach to isolate and alter spinal dysfunction is a starting point for many patients. But, is that the goal for both the doctor and the patient? What would differentiate this chiropractic approach from another therapist’s methodology? The answer lies in the perceived outcome by both the patient and the doctor.
Chiropractic’s uniqueness stems from its approach of looking at the whole person while relating to the immediacy of a patient’s needs. By developing a care model with measurable outcomes that focus on the advancement and reorganization of the patient’s spinal-neural-dural core, the healing and wellness of a patient can be addressed simultaneously. It would seem logical, therefore, to ask the following questions when building a doctor-patient
- “What would this care plan look like?”
- “What evidence-based measurements could be used to track a patient’s progress?
- “What outcomes are measurable and attainable beyond spinal function?
Let’s look at how to zero in on these concepts when building care plans for your patients.
THE TRADITIONAL CONTINUUM OF CARE
A traditional therapeutic model of care usually progresses through three successive levels. These can be named, in succession: relief, correction and maintenance.
The initial goal in this form of care is symptomatic improvement and it is regionally focused. As relief is attained, the patient is instructed on how to avert another episode and so corrective strategies are employed. Because of the mechanical nature of the discussions, the goals of outcome and perhaps the approach to care, the discussion typically follows an exercise and avoidance theme. Finally, when the area of chief complaint and the severity of the episode have stabilized, a form of checkup and maintenance can be recommended. As you can see, this model aims towards a ceiling of improvement relying upon the patient to seek out his or her own health and wellness strategies.
Maintenance care, by its name, can hardly be referred to as a true wellness model. At best, it can be viewed as a standard for spinal stability and spinal well-being.
Imagine, then, if we were to view spinal correction and relief as only one part of the whole process. If the overall goal of care was shifted to the advancement of the person’s state of health and adaptability, what role could a chiropractor logically play in that lofty outcome? Could there be a connection between the spine and reorganizational healing?
A Bigger Picture
The answer is, of course, yes. This is why chiropractic exists: to release unhealthy and damaging tension from the spinal-neural-dural core; enter into a rebuilding alliance with the patient that focuses on new and more powerful strategies; and finally revitalize the adaptive process with ongoing, effective chiropractic approaches. Replacing the therapeutic model with an advanced, chiropractic continuum of release, rebuild and revitalize would shift the intent of care, and the certainty of the outcome, from being “spine-centric” towards wellness. The parameters of measurement would have to be adapted or enhanced but the role of the chiropractor would be unshackled in both the patient’s and the doctor’s perspective.
A Continuum of Accountability
Whichever care plan model is adopted, there must be accountability embedded at all stages. Minimally, care should be recommended on an exam-to-exam basis. If we expand our parameters in the early stages of care from relief to release outcomes, we can realign the goals towards a more potent wellness outcome. This is where it gets exciting as we expand the perspective of the adjustment to incorporate core neurology.
What is a Release Outcome?
Release implies liberation from tension. Musculoskeletal tension and neural tension can be benchmarked as a care plan begins. Sensors can be used to detect variations in the tension within the different aspects of the spinal core. For example, gravitational forces cause the muscle systems along the spine to work. If chronic stress or overwork has altered the symmetry and amplitude of the firing along the motor pathways, then fatigue and the loss of normal tension can be identified using safe and reliable surface EMG. This evidence-based approach gives the clinician a validated benchmark to which other exams can be compared as the continuum of care progresses. Instead of trying to use the data from this test to locate hypertonic muscle groups, the interpretation can be focused on a more global perspective. The overall expenditure of neuromuscular energy can exhaust the individual. Dysponesis is a term that can be applied to EMG interpretation as it describes the “reversible physiopathologic state consisting of errors in energy expenditure, which are capable of producing functional disorders. Dysponesis consists mainly of covert errors in action potential output from the motor and premotor areas of the cortex and the consequences of that output.”1
This allows the clinician to correlate the existence of overworked core muscle function with an overall loss of energy and generalized fatigue in the patient. Instead of being limited to an outcome of back or neck relief, the patient and the doctor can focus on the restoration of the patient’s vitality while monitoring spinal balance and tension.
Thinking outside of the spine
The jewel of the chiropractic story, to which evidence is adding increasing weight, is the adjustment’s potential to impact non-spinal health issues. Patients need to be made aware of the powerful effects that adjustments can have beyond the musculoskeletal system. Altering the pressure or tension within a spinal nerve creates a cascading effect that engages the sensory, motor and autonomic nervous systems.2 The ability to regulate blood vessels, organs and glands falls under the responsibility of the autonomic portion of the nervous system.
Another sensor that looks through the window of the paraspinal sympathetic motor system is thermography. Vasoconstriction is associated with maladapted tension in this division of the spinal-neural array. Using calibrated thermal sensors, a fast, reliable and reproducible test gives the clinician a snapshot of which spinal regions are out of sympathetic balance. The consequence of unmanaged autonomic imbalance is widely connected to end-organ malfunction and can be viewed as a precursor of chronic disease states.3,4 Chiropractic has always been linked to the improvement of patients’ organic health and now there is a validated procedure that allows the practitioner to observe the release of this noxious tension.
An exciting advancement in instrument-based examination in the chiropractic field is Heart Rate Variability (HRV).5,6,7 This non-spinal test is viewed as a marker of a patient’s overall adaptability. This is a procedure that is widely used in other disciplines – it is relied upon in cardiology, exercise physiology and psychology to observe reactive states in a person’s overall autonomic function. A clinically valid test can be performed in a quiet, unattended setting in less than six minutes. The detailed calculations inherent in the testing can determine whether a patient is locked into a sympathetic or parasympathetic state while assessing how much “reserve” the patient has in his or her stress management system. As spinal-neural tension is released through adjustments, and new strategies are rebuilt, HRV can help track autonomic activity and balance; both are indicators of performance and overall well-being.
Because HRV looks at the cumulative effects of stress over time, successive HRV tests can indicate the path of recovery within the patient. The results seen with this testing in a chiropractic research setting confirm the power of an adjustive care plan.8,9 Studies published on HRV indicate that chiropractic care, alone, is a powerful modulator of HRV results. This becomes an invaluable procedure when the parameters of care are extended from the relief of spinal dysfunction towards the expression of wellness.
Armed with the new care plan paradigm and an array of technologies that are relevant for the chiropractic setting, chiropractors can now begin to do as orthodontists do, that is, develop and propose a care plan with certainty. Recommended outcomes are aligned with the measurable release of spinal-neural tension. As the spine is improving, so is the capacity of the central nervous system to become more adaptable. Together, these improvements relate to increased performance, a heightened sense of body awareness, comfort and, of course, a re-energized state of coherence. Furthermore, the goal of the care plan can now exceed the limits of spinal well-being. It can now be crafted to improve the patient’s overall state of wellness.
The goal of wellness-based care is incredibly appealing to patients who have struggled with declining spinal function and an overall increase in an array of stress-related symptoms. Handling a patient’s immediate spinal needs can be an incredible starting point to discuss the damaging effects of stress, subluxations and the power of the adjustment. However, today’s chiropractors can be armed with the finest training and knowledge in managing beyond the limits of the spine. Using technologies that pinpoint areas of change, while continuously re-examining the patient along their path to wellness, confirms the value of progressive care planning.
The concept of using an adjustment to revitalize a patient can be so much more appealing than striving to reach the imposed ceiling of maintenance care.
- Whatmore GB, Kohi DR: Dysponesis: a neurophysiologic factor in functional disorders. Behav Sci 1968;13(2):102.
- Budgell B, & Polus B (2006, October). The effects of thoracic manipulation on heart rate variability: A controlled crossover trial. Journal of Manipulative and Physiological Therapeutics, 29(8), 603-610.
- Uematsu S, Edwin DH, Jankel ER, et al.: Quantification of thermal asymmetry. J Neurosurg 1988;69:552.
- Goldstein DS, Holmes C, Cannon III RO, et al.: Sympathetic cardioneuropathy in dysautonomias. New Engl J Med 1997;336(10):696.
- Dixon EM, Kamath MV, McCartney N, Fallen EL: “Neural regulation of heart rate variability in endurance athletes and sedentary controls.” Cardiovasc Res 1992;26(7):713.
- Kautzner J, Camm AJ: “Clinical relevance of heart rate variability.” Clin Cardiol 1997;20(2):162.
- O’Brien IA, O’Hare P, Corrall RJ: “Heart rate variability in healthy subjects: effect of age and the derivation of normal ranges for tests of autonomic function.” Br Heart J 1986;55(4):348.
- Zhang J, Dean D, Nosco D, Strathopulos D, and Floros M. “Effect of Chiropractic Care on Heart Rate Variability and Pain in a Multisite Clinical Study.” Journal of Manipulative and Physiological Therapeutics 29(4) (2006): 267-74. Print.
- Zhang J, Dean D: “Effect of shortterm chiropractic care on pain and heart rate variability in a multisite clinical Study.” International Research and Philosophy Symposium: Abstracts. Sherman College of Straight Chiropractic. Spartanburg, SC. October 9,10, 2004.
Chairman and chief clinical officer, CLA / CWA, Dr. Fletcher has been sharing the message of neurologically based chiropractic for over 30 years. He is a Fellow of the Royal College of Chiropractic Sports Sciences and lectures throughout the global chiropractic community on the devastating effects of spinal nerve tension. Dr. Fletcher is the developer of the COREscore, a simplified patient reporting tool based on the INSIGHT scanning technology, and CLARITY, a web-based cloud platform that provides training, marketing and patient communication materials. For more information, contact Dr. Fletcher at email@example.com or visit CLA at www.Subluxation.com , or www.claCLARITY.com/introducing .