Learn How to Keep Your Practice From Hurting You (Part 2)

Editor's Note: This is the second in a series of articles based on the new technique book, A Guide to Alternative Chiropractic Technique: How to Keep Your Healing Practice From Hurting You. Part 1 appeared in the September 2014 issue.

Before I enrolled in chiropractic school, I wondered if I was physically capable of being effective at manually adjusting patients in a diversified practice. I was hesitant to enter into a profession that might inevitably cause me injury or render me disabled from the trade I had worked so hard toward, especially considering the cost of a chiropractic school education that would mean six figures of student-loan debt to pay off.

Being only 5 feet, 3 inches tall and weighing only 115 pounds, I worried that I wasn't going to be strong enough, tall enough or forceful enough in my adjusting technique to deliver effective treatments to patients - especially when a large, muscular and/or overweight male walked into my office seeking chiropractic treatment for lower back pain.

What's more, the number of graduates from chiropractic programs who are not in practice 10 years after graduating is quite high compared to other professions.^1-3 This was another reason why I wanted to be sure my physical ability to perform my job duties would not contribute to making me one of those statistics.

Size Considerations

In order to accommodate a practitioner's petite frame and/or to avoid injury, modifications to commonly used techniques have to be made, particularly when encountering heavy and/or muscular patients. General considerations for the overweight population are that their bodies will take up more space; and when lying prone, they are closer to the ceiling, while when on their side, they are higher on the table. Trying to reach around their bodies for anterior thoracic or lumbar side-posture adjustments becomes more challenging for a petite practitioner with a smaller arm span.

Don't be afraid to get your body into the most advantageous position for you to make the adjustment happen, even if that means kneeling on the table beside your patient during prone thoracic adjustments, or hiking your leg up to be parallel with the ground for side-posture adjustments.

The "Fire Hydrant" Adjustment Technique

Working with the larger patient body type, often you will encounter decreased flexibility and increased tissue turgor. These factors can work to your advantage if you pay attention. Lumbar side posture is often challenging in this subset of patient body types, but it doesn't have to be. Patient positioning is critical to making your body's biomechanics work for you. Again, in many cases there will be decreased flexibility in general, which equates to decreased lumbar rotation and the patient's limited ability to flex their hip with the knee bent in side posture.

This adjustment is also useful in the patient presenting with acute lower back pain with significantly decreased range of motion due to pain. Allowing the patient to remain as comfortable as possible by eliminating too much pre-stress tension aids in their ability to relax enough to allow for a smooth and easy adjustment. As an extra clinical pearl, I always adjust the more painful side first in these cases, so the patient doesn't tense up in apprehension for what they know is coming next.

Place the patient in side posture with the arm that is down on the table drawn toward you so the patient is lying on their scapula, rather than their humerus. Because the patient's body will take up more space due to its larger size, their bent knee will also be higher off the ground than is typical. To combat this, press down on the patient's bent knee to bring it closer toward the floor and hike up your leg to meet theirs, positioning your inferior patellar pole inside the crease of the patient's bent knee.

Contact the lamina of the desired segment with the distal pad of the middle finger, keeping your elbow in close to your body to limit the chance of shoulder strain. Then guide the patient's body through lumbar flexion as you move your knee with theirs to find the point of greatest intersegmental restriction.

Rotating as much as necessary to achieve end feel by applying increasing pressure with your contact knee and simultaneously pulling on the lamina of the desired segment toward you, which usually doesn't require much rotation in this population. Then employ the kick-start adjustment, kicking your contact knee down toward the ground. The thrust is quick and forceful, but typically doesn't have to be deep due to the patient's limited flexibility.

With proper positioning and pre-stress tension applied, the additional lumbar rotation achieved through the thrust does not have to be extremely dynamic. It is also helpful for the practitioner to tighten their abdominal muscles during the thrust for further concentrated force, and to avoid the chance of self-inflicted lower back stress.

Technique Execution

• Doctor position: Standing with your cephalad leg against the table for stability, your caudad leg becomes your contact knee by placing your tibial tuberosity in the crease of the patient's bent top leg.
• Patient position: Side-lying with top leg bent and foot hooked behind the opposite knee.
• Contact hand: Digit contact on the lamina of the affected segment.
• Non-contact hand: Firmly applying counter-pressure on the patient's crossed forearms.
• Line of drive: P to A with rotation toward the doctor.
• Thrust: Swift, hard kick down with a firm digit pull deep through the patient's torso.

Women are an ever-growing population force in the chiropractic profession, with almost a quarter of the currently licensed practitioners across the United States now female. Nearly half of new enrollees in chiropractic school programs are also women.^4-5 Unfortunately, all of the technique books guiding future female chiropractors are written by males, and most of the methods instructors are male as well. Our profession needs to address this issue to ensure a bright future not only for up-and-coming female chiropractors, but also for anyone interested in a long, fulfilling career in a physically laborious profession. Doing so will help lower the statistic of self-inflicted injury while performing on-the-job manual adjustment techniques.

References

1. Foreman SM, Stahl MJ. The attrition rate of licensed chiropractors in California: an exploratory ecological investigation of time-trend data. Chiropr Osteopat, 2010 Aug 12;18:24.
2. Ross MK, Turner S, Ibbetson RJ. The impact of General Dental Council registration and continuing professional development on UK dental care professionals: (2) dental technicians. Br Dent J, 2012 Oct;213(8):E13.
3. DeMarais DR. Dental student attrition. J Am Dent Assoc, 1977 May;94(5):817-20.
4. Johnson CD, Green BN. Diversity in the chiropractic profession: preparing for 2050. J Chiropr Educ, 2012 Spring;26(1): 1-13.
5. Kargus A. "Women Leaping to the Forefront: As Their Numbers and Opportunities Increase, Female DCs Search for Ways to Balance Family, Practice and More Participation in Chiropractic Leadership." American Chiropractic Association.

Danielle Trego Finden, DC, has been in private practice for six years developing and implementing the techniques described in her new book, A Guide to Alternative Chiropractic Technique: How to Keep Your Healing Practice from Hurting You. Supporting videos with narration of each technique can be accessed through a subscription to the website www.HowToAdjust.com with a seminar schedule for hands-on instruction as well. She serves as adjunct faculty at Northwestern Health Sciences University both as a classroom instructor and as a community based internship supervisor. Contact her at .