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. It is 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 acuity are needed for the diagnostic palpation of motion segments, craniosacral 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.
One caution when trying to model a particular technique expert or “guru” is a mismatch between their capabilities and your own. There are many master practitioners who develop their own style and methods of adjusting empirically, and these can be idiosyncratic to them. They may not harmonize with your particular characteristics, or be readily transferable to a broader audience. The best techniques to learn are systematized to an extent that they can be effectively learned by the general student and professional community.
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; 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 8 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 objectives.
Further, you may decide to use a branded technique in your practice for business and marketing purposes. This can serve as your flagship approach or an ancillary offering. It is advisable to make sure any clinical procedures you adopt are not incongruous to your primary methods, or your practice’s philosophy and modus operandi.
Research Findings. There are few studies on the effectiveness of specific manipulative and adjustive approaches in patient care. Most use the term “spinal manipulation” without identifying the particular technique utilized. Some that do include:
The “The boot camp program for lumbar spinal stenosis” by Carlo Ammendolia, DC, Phd has shown evidence of effectiveness. A combination of HVLA manipulation, soft tissue, and neural mobilization, lumbar flexion-distraction, and manual muscle stretching is used in this program.
The NUCCA technique of Atlas adjusting whcih has been found to reduce blood pressure in patients with hypertension.
HVLA diversified side posture spinal manipulation, flexion-distraction manipulation 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 neurological findings.
Side posture HVLA manipulation involving rotation is effective for patients with lumbar disc herniation.
Ross has shown that segmental specificity is not as critical in the delivery of a thoracic manipulation as was previously assumed.
Embracing The Art of Practice: 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. Over time you will go through phases of learning, doing, modifying, innovating, forgetting, and relearning. Dr. Frank Langiolotti , one of my technique instructors at NYCC, would frequently say, “That’s why they call it practice, because you never get it right!”
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,” Chiropractic & Manual Therapies, vol. 24, no. 1, p. 25, 2016.
Bakris G, Dickholtz M Sr, Meyer PM, Kravitz G, Avery E, Miller M, Brown J, Woodfield 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-distraction 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 Success. Back Bay Books; 2011.
Hondras MA, Long CR, Cao Y, Rowell RM, Meeker WC. A randomized controlled trial comparing 2 types of spinal manipulation 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.
Ross JK1, Bereznick DE, McGill SM. (2004). Determining cavitation location during lumbar and thoracic spinal manipulation: is spinal manipulation accurate and specific? Spine (Phila Pa 1976). 2004 Jul 1;29(13):1452-7.
Sikorski DM, KizhakkeVeettil A, Tobias S (2016) The influence of curricular and extracurricular learning activities on students’ 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
Triano J, Budgell B, Bagnulo A, Roffey B, Bergmann T, Cooperstein R, Gleberezon B, Good C, Perron J, Tepe R: Review of methods used by chiropractors to determine the site for applying manipulation. Chiropr Man Ther. 2013, 21 (1): 36-10.1186/2045-709X-21-36.
About The Author
Dr. David Graber is in private practice in Parsippany, NJ. He teaches seminars on spinal and extremity adjusting, and is the chairperson of the ANJC Council on Technique and Clinical Excellence. His blog is ChiroExcellence and can be found at: drgraber.wordpress.com. He can be reached at: DrDavidGraber@gmail.com
(This is a revised article originally published in The New Jersey Chiropractor, Vol. 14, No.1,Winter 2018)
ChiroExcellence 