Updated: Aug 2
By: Stephen Knoyer
I am going to start this series by stating I have opinions and you're probably not going to like them. The honest answer is you shouldn’t. Providers (chiropractors, physical therapists, osteopaths, medical doctors, athletic trainers, personal trainers and anyone else I forgot to mention) should educate patients with the necessary exercises, ergonomic changes or whatever is needed to resolve the pain/condition. Best practice is to begin with passive modalities (heat, ice, stim, ultrasound...etc) and move into active therapies (exercise, ergonomic changes, injury prevention education, etc.) as soon as the patient can tolerate it.
One example would be teaching a patient how to resolve tension headaches and back pain from working in front of a computer for 8 hours. Soft tissue manipulation, dry needling and spinal manipulation are all great therapies, in the beginning, to reduce pain, increase recovery and improve function. Adding exercises like wall angels, band pull aparts, chin retractions, triplanar psoas activation and bird dogs will help resolve the issue. Simply manipulating the cervical spine will not resolve the pain. It will help, and possibly resolve the pain temporarily, but most likely end up being the scenario of a patient needing to return for constant treatment. There should be more to the patient's treatment plan other than manipulation.
Now for the immediate “what-if” arguments. What about patients with migraines, spinal fusions, occipital neuralgia, occupational strains, or manual labor aches? I had one patient who had neck, shoulder, and finger pain because his job in a lab involved measuring chemicals with a pipet. No amount of therapy could change the requirements for his job, but I was able to keep him from severe flare-ups, managing the patient twice a year. A second example is migraines. There is evidence that manual therapies are great for reducing the intensity of pain and the frequency, and some migraines resolve completely. (I suffer from migraines and know what works for me to control them, but sometimes I do need medication.)
Now, my favorite, the one that will agitate many providers. Providers that practice a “PI mill” or conveyor belt approach are often the most frequent offenders. They offer packages, often incentivized with a discount or tout that a certain piece of equipment shows results with a minimum amount of treatments. X-rays are required and compared with an illustration showing the stages of degeneration. I was briefly at a practice that used this system and believed you must hurt the patient during the exam. They told the patients they should not have pain then reveal the x-ray “findings.”
This combination of pain during the exam and comparing x-rays yields a high conversion rate with patients signing up for multiple appointments. Package everything together and tell the patient “it’s a good thing you came in when you did, look how bad your spine is. I can help you but you have to come in 3 times a week for 12 weeks.” Many patients would schedule on the spot. After 4 weeks there was never any change to the curve in the spine or improvements on imaging. Here’s one of my personal favorites: a provider once switched the x-rays to show improvement in order to keep the patient coming back. The sad part is I had another colleague tell me the individual he worked for did the same thing.
Now for the outlier arguments. What about the patients with “X” disease?! Yes, if you add a perfectly constructed context to any argument it can be won. Understand you are talking about a fraction of the population. What about severe muscle spasms? If you treat them, the curve will return, I have seen it! Take a deep breath and refer to the title. This can be true but not every patient with neck pain is this example. Car accidents often cause a reduction in the curve from the guarding which is severe muscle spasms. When the spasms resolve the curve will improve but severe accidents leave permanent changes. Again this is a perfect argument and I am not referring to this scenario. I am referring to the practices that treat every single neck pain and headache patient with the same diagnosis and management.
A popular scare tactic is holding a weighted ball. The patient will be seated and asked to hold the weight at eye level with a bent elbow and the wrist must be straight. Then ask the patient to bend the wrist with the palm facing up, similar to pushing weight over your head. They will ask which one felt easier knowing the bent wrist position was easier. The wrist bent is representing the curve in the neck and the straight wrist is the neck without the curve. If you have poor posture and less than the average curve in your neck it will. It will be used to reinforce how much you need treatment in order to restore the curve in the neck. Again, poor posture does play a role because it migrate stress into tissues of the body causing overloading and injury, HOWEVER, this is a ridiculous idea because adjustments with traction will not restore the curve. They spend the next 23.5 hours out of the office and another 8 hours or longer in front of the computer. Ergonomic assessment/correction and a DNS 3 month position with breathing/bracing is a better management.
What was the point of all of this? If you come across a provider that offers a similar type of format to treatment you should leave. Don’t schedule and reach out to the Forward Thinking Chiropractic Alliance to find a better provider. If you are not improving and your current provider keeps using the same exercises and treatments you need to leave. A good provider will offer a treatment plan with an option for improvement, and a second option if no improvement is seen.
I hope you enjoyed this entry and learned something new.