A chiropractic practices’ goal should be for patients to achieve the greatest response to care in the shortest amount of time.
“This is most readily attained by broadening your scope of practice,” says John Amaro, DC, LAc. “Although chiropractic care itself is a phenomenal healing art, it is limited in its general scope compared to those practitioners who also offer complementary alternative therapies.”
Kevin Hendry BHk, DO(c), and director of movement and manual therapy at Innovative Fitness, lives by the mantra: Better in four [sessions] or treat no more [and refer to someone else].
“If you treat a patient’s symptoms and fail to address the main cause of their dysfunction, the patient will need to keep coming back,” he says. “While this may seem like a great business model, it’s much more ethical to discharge a patient if you can’t help them after several treatments.”
Consider having different types of healthcare providers on staff or becoming skilled in multiple modalities yourself, which will give patients access to multiple therapies on-site.
“In today’s era of patient-centered care, patients are becoming more educated and savvy about treatments,” says Jay Greenstein, CEO of Sport and Spine Companies. “You’ll be able to keep more patients, rather than discharge them to another type of provider, by having a multidisciplinary practice.”
Todd Singleton, DC, consultant and owner of Singleton Systems, brings up another valid point: “Patients don’t always have a lot of time, so it’s best for them to find a doctor who can meet all of their needs at once,” he says. “That way, they don’t have to visit separate clinics for their adjustments, for nutritional counseling, and for other services. It’s always better for the patient when a doctor takes a multidisciplinary approach to care.”
Here’s a look at some modalities you may want to consider offering at your practice, if you aren’t providing them already.
A chiropractor typically focuses on the skeletal system, while a licensed massage therapist (LMT) focuses on the muscular system. Because subluxations affect not only bones but ligaments, soft tissue, and the nervous system as well, when both approaches are used in tandem, you can more comprehensively address both the muscular and skeletal systems.
Given this, David Lauterstein, co- director, The Lauterstein-Conway Massage School and Clinic, believes massage therapy is a good complement to the chiropractic adjustment. “Massage therapists are specialists in working with the soft tissue aspect of subluxation,” he says. “By relaxing the muscular and nervous systems, adjustments may be easier for the patient and result in even deeper, more long-lasting benefits.”
For some patients, muscular guarding can make the adjustment more difficult for the chiropractor to perform. “If someone gets a massage immediately before an adjustment, they are more likely to be in a relaxed state and have a more effective adjustment,” Lauterstein says. Having a massage a day or two before an adjustment may also be beneficial.
Nancy Dail, LMT, of Downeast School of Massage, has also found that patients who get a massage before an adjustment have an easier adjustment and hold it longer. “Soft tissue holds the bone in place,” she explains. “When soft tissue is constricted and isn’t malleable, it’s more difficult to give an adjustment. Massage allows the chiropractor to do his or her job better.”
Massage can help with many conditions that chiropractic treats— maladies that involve soft tissue attached to the spine, such as headaches, low- back pain, postural problems, and repetitive motion injuries.
Greenstein has found that patients oftentimes have extremely tight musculature. To ensure the patient maintains the range of motion that results from an adjustment, soft tissues need to be anatomically lengthened, or relaxed, he says. What’s more, massage increases function and helps relieve pain faster, because it releases trigger points, reduces metabolic waste products in soft tissues, and gets rid of scar tissue in the muscles and fascia.
What’s more, peer-reviewed studies have proven the effectiveness of massage in conjunction with a chiropractic adjustment. A study published in the European Journal of Physical and Rehabilitation Medicine, examining the effects of manipulation plus massage therapy versus massage therapy alone in people with tension headaches, showed that the addition of manipulation resulted in larger gains of upper cervical flexion range of motion and reduced the impact of headache.1
If patients supplement their chiropractic care with motor- control training as well as strength and conditioning, they will be able to eradicate the kind of motor-control impairments and restrictions that mimic mobility impairments.
“Active rehabilitation and basic strength and conditioning assist chiropractic care because stiffness and immobility can occur when the body lacks stability,” Hendry says. “All too often, chiropractors treat a stability impairment like a mobility issue. If a patient’s deep hip rotators are extremely tight because the joint lacks stability, an approach such as active release technique (ART) will inhibit the muscles that are helping out and compensating in order to avoid more severe problems. More importantly, the chiropractor may have failed to thoroughly assess and determine what drives the dysfunction.”
To rectify this issue, motor-control movement training and strength training come into play. Motor control is the quality of movement, while strength is the quantity of movement. Individuals use motor control to activate and coordinate their muscles and limbs to perform a motor skill. “Therefore, altering motor control will change how you move,” Hendry says.
Strength is the ability to exert force against resistance, and altering strength can translate into how much one moves. Altering techniques retrains the nervous system’s strategy rather than improving its ability to generate more force.
Generally speaking, people who are impaired in this area will have the strength to perform a given task—but they’ve learned a faulty motor pattern. The body’s smaller stabilizing muscles are reflexive and require proper motor control to function, rather than rely on strength alone.
“Therefore, to improve stability the patient must train motor control to alter non-optimal motor patterns,” Hendry says. “Once these patterns are optimized, the patient can progress to building a foundation of strength on ideal motor patterns.”
Farther down the continuum, it’s vital to improve an individual’s movement capacity. “The most common way to improve strength is through progressive overload—you load an area of the body slightly more than it’s used to, so the area can adapt to a new level of stress,” Hendry says.
Adjustments help align the spine, while rehabilitation helps hold adjustments, says Al Woodruff of Synergy Therapeutic Systems. Successful rehabilitation programs consist of a series of progressions including stretches and strengthening exercises.
Get patients on board with a rehabilitation program by explaining to them how it helps. To do this, Woodruff advises breaking down muscles into two groups: large prime moving muscles (which distance themselves from joints in order to gain the leverage to create large movements) and small intricate muscles.
The key to a successful rehabilitation program is working with the small intricate underlying muscles that bridge and insert close to a joint. Small muscles guide large ones through their movement by keeping the joint properly aligned and stabilized. When perfect posture and ideal joint alignment and articulation occur, these small muscles perform optimally.
When overstretched or tightened, a joint will not articulate properly and cause the bones to rub. When a joint becomes misaligned, small stabilizing muscles are compromised. They quickly break down and lose their ability to contract and circulate essential fluids for nourishment. This leads to sensitivity, pain, dysfunction, and atrophy.
When small muscles are disadvantaged, they become inhibited and no longer protect the joint. Then, as prime moving muscles contract, the joints they control become unstable, causing bones to rub against tendons and ligaments—often resulting in ligament and tendon tears.
This imbalance causes joint pain, which leads to more joint instability and misalignment. “The cycle needs to be broken, or it most likely will continue to worsen without intervention,” Woodruff says.
Adjustments help to properly align the joints. To hold the proper alignment and promote joint health, patients need to stretch and strengthen muscles. “Gaining an understanding of which muscles are the culprits at each joint and knowing how to isolate and wake up these weakened—and sometimes inhibited muscles—is key,” Woodruff says.
Patients with musculoskeletal pain need to learn how to contract these intricate muscles. “Some exercises are easy to do and reach the desired weakened muscles, while others are not,” Woodruff says. “The reason is substitution. When intricate muscles fail to fire, other local muscles chip in and try to mimic the movement. Choosing the correct product to help isolate the movement along with the proper movement pattern or exercise is helpful in reaching and waking up the most difficult muscles.”
By offering physical therapy modalities and corrective exercises, the practice of Jeffrey Tucker, DC, has become known as a chronic pain and wellness center. “Movement is part of each patient’s treatment plan to enhance oxygen, blood flow, and the gliding of joints and soft tissues,” Tucker says. “I provide patients with corrective exercises they can do to help them heal properly and reduce the risk of future episodes.”
He uses a host of physical therapy modalities at his practice such as acoustic shockwave, lasers, Scenar therapy (bio-energy medicine), lymphatic drainage, deep-muscle stimulation, and other soft-tissue therapies. Movement therapy also increases flexibility, strength, lung capacity, and decreases body fat while increasing lean muscle mass— slowing the effects of the aging process.
As a certified chiropractic sports physician, Greenstein has found that by clearly explaining to patients the cause of their pain and relating it to functional issues, it is easy to connect the treatment to the desired outcome.
“If someone has a muscle spasm, doing soft-tissue work and applying Kinesiology tape would be an appropriate evidence-based recommendation,” Greenstein says. “If someone lost their range of motion, spinal and extremity manipulation would be an appropriate treatment.”
Acupuncture and chiropractic care are complementary healing arts that both provide pain relief. Chemical messengers—known as endorphins and enkephalins—are released not only through the chiropractic adjustment via the piezo effect at the spine but also by the stimulation of specific points on the body known as acupuncture (or meridian) points.
“The famed acupuncture points known as huo tuo chia chi—that are a half inch from either side of the spine— correlate directly with the sympathetic ganglionic chain,” Amaro explains. “When stimulated, these points create a cascade effect of endorphins and enkephalins along with serotonin.
There are few if any procedures that can mimic the pain-relieving effects of the combination of chiropractic care and acupuncture when specifically and consciously applied.”
Amaro, who practices EuroAsian medical acupuncture, says needle stimulation is extremely superficial; needles are left in place for typically less than five minutes as opposed to 20 minutes with deep needle insertion.
“Patients are not afraid of the needle because insertion is designed to be painless,” he says. “Outstanding clinical response can often be seen in less than six visits, with 12 visits being more customary,” he says.
In addition to treating injuries, helping patients get rid of unhealthy habits and toxins is part of the healing process. Nutritional programs are designed to cleanse the body and facilitate optimal health. “To help a patient with their negative thoughts, you can offer services that relieve stress or supplements that facilitate brain-based wellness,” Singleton says.
Pain is often caused by toxicity- driven inflammation. Eating healthy foods can make a huge difference in a person’s overall health, and implementing nutritional strategies can make a similarly dramatic effect on a patient’s recovery.
If the body is inflamed because the patient is eating processed food, standard chiropractic services will be less effective. When a patient switches from a toxic diet to one that is healthy and nutrient-dense, they’ll actually improve the body’s musculoskeletal and neurological function. “Nutrition helps to balance the body’s physiology, which is why a nutritionally dense diet can make chiropractic adjustments last much longer,” Singleton says.
Offering multiple modalities of care at a chiropractic practice is a win-win for both patients and practice owners. Patients have convenient one-stop shopping and should get better faster when different therapies are indicated. And delighted patients will tell others about their successful experience.
Karen Appold, an editorial consultant in Royersford, Pennsylvania, is dedicated to regular chiropractic care. She has been the president of Write Now Services, which offers writing, editing, and proofreading since 2003. Her experience includes chiropractic marketing. She can be contacted at 610-812-3040, email@example.com, or through writenowservices.com.
1 Espi-Lopez GV, Zurriaga-Llorens R, Monzani L, Falla D. The effect of manipulation plus massage therapy versus massage therapy alone in people with tension-type headache. A randomized controlled clinical trial. Eur J Phys Rehabil Med. 2016 Mar 18. http://www.ncbi. nlm.nih.gov/pubmed/26989818.