16 I Winter 2018 www.anjc.info www.njchiropractors.com I 17 TECHNIQUE Council The heart of Chiropractic care is the adjustment. It’s the intervention that defines our uniqueness in the healthcare market, and the basis for much of what we do. The technique a doctor chooses to use day-in and day-out in practice is one of the most important clinical decisions they can make. Matching the right technique or techniques to one’s philosophy, body type, clinical goal, prac- tice style, and physical capabilities can make the difference between a fulfilling or frustrating career in chiropractic. In 30 years of teaching and speaking with thousands of doctors, I’ve come across several factors in determining a “best fit” technique for an individual doctor. Here are some for you to consider: Chiropractic School Training. The college you graduated from trained you in a philosophy, theory, approach, and methodology to practicing chiropractic. The degree to which you accepted or rejected what was taught affects how you practice. The college’s chiropractic technique curriculum and your expe- rience with chiropractic practitioners have been found to have the greatest influence on your choice of chiropractic technique for future practice. Extracurric- ular activities, including technique clubs and seminars, also figure in your practice technique preferences. The quality of the training you received also affects whether you utilize the tech- niques after graduation. I have observed numerous doctors gravitate away from practicing adjusting techniques and into alternative procedures like rehabilitation, soft-tissue therapies, nutrition, and more esoteric approaches primarily because they never developed the skills needed to deliver an effective adjustment. Research by Triano has shown it takes one to five years of continuous practice to develop proficiency in an adjusting technique. Much of the skill development in practicing chiropractic, or any healing art, comes as on-the-job training and continuing education. I’ve come across many doctors who continue to do only what they were taught in chiropractic school, even decades after graduation. Our college’s responsibility is to train us as students to be good beginners and to be safe for public consumption. They give us a basic skill set to grow and expand on as we practice our profession. Healing Philosophy. The key distinction in healing philosophy is whether you view your role as a facilitator or inter- ventionist. If you approach your care as a facilitator, you will utilize techniques that work the patient’s innate healing ability and attempt to facilitate it. This includes many light-force and so called non- force techniques, as well as educational methods. If you approach your care as an interventionist, you will utilize techniques that demand a response from the body that it can’t achieve on its own. This includes most of the thrust and non- thrust techniques we employ. Clinical Goal. In chiropractic, there are several outcomes that doctors strive to achieve: Pain reduction, vertebral subluxation correction, improved segmental mobility, locomotor or neurological functional improvement, and changes in global spinal alignment. Techniques appropriate for one goal will be less effective for another. Knowing the clinical results you’re aiming for in advance is essential for choosing the best way to get there. Body Type and Physical Capacities. A doctor’s height, weight, limb length, muscular development, gender, and physical health are considerations in try- ing to make a fit between the technique and their body. A side posture adjustment is performed differently for a long legged Chiropractor who is 6’2” than one who is 5’3”. Likewise, a female doctor needs tends to have less upper body strength and needs to use her hips and legs to generate adjusting forces more than her male counterpart. Aging and injuries also play a role. Older practitioners, like older athletes, need to be more attentive to their body mechan- ics and physical conditioning. Utilizing adjustment aids such as drop pieces, tables that have breakaway, moveable sections, and/or traction ability, and the use of adjusting instruments can help make up for these concerns. Psychomotor Aptitude. Doctors vary in the amount of natural coordination and ability to perform certain techniques. While some have an instinctive affinity, others may have to work consistently and patiently at developing the skills that high velocity, low amplitude adjusting (HVLA) and other techniques require. This is especially true of end range techniques. Good technical skills are not a gift conferred by nature’s lottery on a few chosen individuals. They are obtained and maintained by consistent intentional practice. Malcolm Gladwell simplified and popularized the work of Anders Ericsson when he wrote about the “10,000 hour rule.” Namely, it takes an average of 10,000 hours of “deliberate practice,” which involves constantly pushing oneself beyond one’s comfort zone, to become world class in any field. Adjusting skills are no different. Similarly, there is a range in the amount of tactile sensitivity doctors possess to develop advanced palpation literacy. High levels of specific types of kinesthetic Choosing Your Chiropractic Adjusting Technique At All Stages Of Practice By Dr. David Graber Council on Technique and Clinical Excellence Chairman acuity are needed for the diagnostic palpation of motion segments, cranio- sacral motion, muscle tone and tension, skin texture and tone, etc. I use the guiding adage, “If you can’t feel it, you can’t heal it.” Some doctors exhibit such exceptional acuteness in their palpation skills it can seem they are almost psychic. Often more intuitive than conscious, this is a form of tacit knowledge - the kind of knowledge that is difficult to transfer to another person by means of writing it down or verbalizing it. Personal Experience. You are more likely to adopt that technique as your own if a certain technique has helped you; a charismatic teacher or exemplar of a particular method has impressed you; or early in your career you have had success with it. Direct personal experience is a strong influencer and often is relied upon more than any other factor. Practice Style. An often overlooked aspect in selecting your technique is your business model and practice style. If you have a goal to see 50 patient visits in an eight-hour day, using a technique that requires 15-20 minutes of direct patient contact time will create a conflict. If you have small adjusting rooms, it’s difficult to get the additional knee-chest and pelvic bench tables in them to practice Gonstead. If you want to see pediatric patients, you need techniques different from adults. The same is true treating a patient population of athletes, pregnant women, geriatrics, or chronic systemic disorders. Start with the end in mind and choose a technique that aligns with your global practice. Research Findings. There are few studies on the effectiveness of specific manipu- lative and adjusting approaches in patient care. Most use the term “spinal manipu- lation” without identifying the particular technique utilized. Some that do include: “The Boot Camp Program for Lumbar Spinal Stenosis” by Carlo Ammendolia, DC, Phd has shown evidence of effec- tiveness. At the last ANJC Summit he demonstrated the techniques used in the program. The NUCCA technique of Atlas adjusting which has been found to reduce blood pressure in patients with hypertension. HVLA diversified side posture spinal manipulation, flexion-distraction manip- ulation and lumbar mobilization that all demonstrate positive effects on patients with chronic low back pain. HVLA cervical manipulation with rotation to the opposite side and lateral flexion to the same side of the affected arm is effective for patients with cervical disc herniation with upper extremity neuro- logical findings. Side posture HVLA manipulation involv- ing rotation is effective for patients with lumbar disc herniation. Ultimately, it is you the practitioner who chooses and develops your own style and techniques. These adapt and develop with your ongoing learning and experiences of practicing the art of the chiropractic adjustment, and changes in your physical condition and practice goals. Like all arts, it is both a means to an end (in this case healthier patients) and an expression of you the artist. Choose well and you will practice with passion and excellence! References: Ammendolia C, Cote P, Rampersaud R, et al., “The boot camp program for lumbar spinal stenosis: a protocol for a randomized controlled trial,” Chiro- practic & Manual Therapies, vol. 24, no. 1, p. 25, 2016. Bakris G, Dickholtz M Sr, Meyer PM, Krav- itz G, Avery E, Miller M, Brown J, Wood- field C, Bell B. Atlas vertebra realignment and achievement of arterial pressure goal in hypertensive patients: a pilot study.J Hum Hypertens. 2007 May;21(5):347-52. Epub 2007 Mar 2. Cassidy JD, Thiel HW, Kirkaldy-Willis KW (1993) Side Posture Manipulation for Lumbar Intervertebral Disk Herniation, J Manipulative Physiol Ther 16(2):96-103. Choi, J., Hwangbo, G., Park, J., & Lee, S. (2014). The Effects of Manual Therapy Using Joint Mobilization and Flexion-dis- traction Techniques on Chronic Low Back Pain and Disc Heights. Journal of Physical Therapy Science, 26(8), 1259–1262. http://doi.org/10.1589/jpts.26.1259 Ericsson, KA, Krampe, RT, & Tesch-Römer C. (1993). The role of deliberate practice in the acquisition of expert performance. Psychological Review, 100(3), 363-406. Gladwell M. Outliers: The Story of Suc- cess. Back Bay Books; 2011. Hondras MA, Long CR, Cao Y, Rowell RM, Meeker WC. A randomized controlled trial comparing 2 types of spinal manipu- lation and minimal conservative medical care for adults 55 years and older with subacute or chronic low back pain. J Manipulative and Physiol Ther; 32:330-43 Peterson CK, Schmid C, Leemann S et al. Outcomes from Magnetic Resonance Imaging-confirmed symptomatic cervical disk herniation patients treated with high-velocity, low-amplitude spinal manipulative therapy: a prospective cohort study with 3-month follow-up. J Manipulative Physiol Ther 2013; 36: 461-467. Sikorski DM, KizhakkeVeettil A, Tobias S (2016) The influence of curricular and extracurricular learning activities on stu- dents’ choice of chiropractic technique. Journal of Chiropractic Education: March 2016, Vol. 30, No. 1, pp. 30-36. Triano, J. Does Treatment Force Matter? A Look at Manipulation Skill in Patient Contexts. Webinar. Aug 18, 2011 David Graber, DC, CCSP, DACBSP is the chairman of the ANJC Council on Technique and Clinical Excellence. He maintains a private practice in Parsippany, NJ. He can be reached at: GraberDC@aol.com. Dr. David Graber adjusting a patient