The Chiropractic Pendulum

The chiropractic profession is seeing a unique and rapidly growing shift, or it seems so from the inside looking out.  We, as DC’s, have more access than ever to quality research, best care practices, and high- quality, ethical practice growing resources.  We have quality resources in the areas of patient customer relation management (CRM's), research reviews, social media, case management and presentation, video instruction, ethical modern chiropractic marketing, practice scaling and management.  However, it seems we still insist on fighting amongst ourselves about the things mentioned above. We have seen an explosion of social media, digital and online resources that help guide new and old DC’s alike.  We have quality resources from the likes of ChiroUp, the Modern Chiropractic Marketing group, the Chiropractic Success Academy, World Spine Care, MPI, and many others. We are seeing a surge of high quality research and evidence based practices throughout the landscape of chiropractic. Yet, in typical chiropractic fashion, we can’t seem to get out of our own way.

Evidence-based practice (EBP), is the modern chiropractic term for those DC’s who use research and best practices to help guide them in clinical decision making and communication with patients and other healthcare providers alike. MPI has always embraced and chased the research. Originally, I feel we did it to create waves and change the paradigm. For example, Dr. Len Faye was one of the first to espouse the idea that manipulation does not move bones or change vertebral positions.  This was found to be true and it cannot be denied now in the research that we DO NOT move bones.  Dr. David Seaman and others added to this by explaining dysafferentation.  We know manipulation has various and powerful AFFERENT neurophysiological effects and not efferent “nerve-freeing” affects. Following this movement was a period (Dr. Winchester and I’s first 5-8 years teaching) that we used it as validation and a teaching tool. Now, we look at the research in awe. I know I look at the neurophysiologic and biochemical research in amazement.  There are things happening in the neuro and biochemical realms that are being studied that we haven’t even thought of and we’re just scratching the surface. One thing is certain, the combination of manipulation, soft tissue techniques, active care/functional rehabilitation (and nutrition…even though the research doesn’t add in the other components in research often) rule the day when it comes to musculoskeletal dysfunction and performance enhancement.

Knowing all this still doesn’t seem to stop the in-fighting and arguing amongst ourselves. Yes, we still have very end-spectrum, bone-out-of-place, subluxation-based DC’s and they can be very dogmatic, loud and confrontational.  Personally, this group really doesn’t bother me.   WHAT?!? Here’s why.  The principles they support are mostly wellness based and that is fine.  They can NOT support their stance anymore because the research and the truth has passed them by.  Regardless of their unfounded and unsupported beliefs, most still are exceptionally good with their hands and I can respect that.  This isn’t about them.  This is about the other end of the spectrum. 

The pendulum has swung away from the subluxation-based group for all the right reasons.  It has swung to the EBP side for the sake of progress and advancement.  We know more and have more at our disposal clinically than we ever have.  The pendulum has swung away from the structural, dogmatic and philosophical side for all the right reasons.  Yet, a pendulum is meant to move and not stay at the extremes of the arc. Now, it seems our desire to distance ourselves from the subluxation-based side was so great that we are stuck on the other side. We are in an interesting phase in that if it’s not smothered in research, we don’t do it. We have used the EBP side to avoid giving credence to the importance of the SKILL and ART and what we are known and sought by from patients.  Palpation and adjusting are skills. These particular manual skills that are difficult to measure in research settings.  The inter and intra-rated reliability of motion palpation in isolation, which all gold standard research is done, is poor.  There are a few good studies that give it some validity, but in general most research doesn’t support it. Staunch research and EB practitioners would even say it so unsupported that it’s thrown out as a diagnostic tool and liken joint palpation to dog whistles.  This is like saying reading braille is myth or that you can’t tell the difference between the bed post and the bed in the dark. Joint palpation is more complicated than that of course, but you get the point. 

There are 3 main reasons palpation gets crushed on message boards, social media sites, and the narrow space at the far arc of the pendulum.

• It takes time and long hours of practice to get good at it. The mastery of palpation takes all of those 10,000 hours Malcom Gladwell speaks of, and then some. The nuances of palpation across varying patients, stiffness coefficients, and MSK dysfunctions is great. It is a life-long learning curve that opens itself to many layers the more you do it.   It’s a SKILL and probably the most difficult skill in chiropractic.  It’s most likely the reason we gravitate towards easy protocols, algorithms, and pain chasing. 
• It is difficult to study in research settings. Once you touch a patient or study participant things change. It is difficult to control variables.  Think of what it’s like to be palpated by a first-time student and Mark King, DC (president of MPI and full-time practitioner of 30+ years). There are differences in pressure, end-range control, and body and hand control and positioning (skill).  This makes it difficult to control in a research setting.
• There is no universal, systematic approach to palpation. Consistency and reproducibility lead to reliability and palpation doesn’t seem to have that yet. Functional Movement Screens (FMS) is a great example of building in consistency, reproducibility, and redundancy. Having a systematic approach to palpation that builds in these 3 components would go a long way to clearing up the reliability in-fighting arguments. MPI promotes a systematic approach to palpating patients that utilizes at least 2, sometimes 3 different palpation approaches to the junctional areas of the spine and extremities. Please see https://www.youtube.com/watch?v=5BR0tprUz-0 for video demonstration of this system. Having a system that is reproducible and redundant will help you become a more skilled and competent palpation assessor of the joint system and it will hold you accountable to checking key links in the musculoskeletal system that you may skip otherwise.

Be clear, MPI promotes the evidence-based movement…it always has.  Yet there is a skill to what we do.  That skill is what people come to see us for in most cases. If you want buy-in from your patient of all the other techniques and concepts we can utilize (DNS, MDT, SFMA, etc.) then deliver with your hands.  Throwing joint palpation out because the research does not support it is like throwing out the proverbial baby with the bath water. Palpation is diagnostic and therapeutic, and it is a SKILL.  Possibly the greatest manual skill we have.  It is not easy and it may never be mastered, but without it we are simply guessing at what we are adjusting. Easy never made great. Our patients come to us with a certain level of expectations, we should have higher expectations of ourselves.  Don’t hide behind the research or use it as an excuse to avoid putting in the work. Chasing excellence and reveling in the grind of the hard task of being a great joint palpator should be your focus…not running from the challenging.  Roll up your sleeves and get to work, your patients will appreciate it, and the profession will be better because of your efforts.

Corey Campbell, DC