We all want success in treating our patients. We all want to be the "Hero," and provide that special treatment to our patient which sets us apart from the other doctors in our area. That may be what drives us, but what does it take for us to be that "Special Doctor" we all strive to be?

The answer to that question is, of course, complicated; but let me talk to you about one simple thought and action that could help you tremendously in your practice. First, it is important for you to realize that you must become a "Black Belt" in any technique or treatment you use. You must go beyond the casual knowledge of the treatment philosophy and techniques used to provide the anticipated results. Having said that, this article does not provide you with the depth of knowledge that you will need to have to be proficient in this technique that I am suggesting. Be sure to seek out more information, both through the written word, and at seminars.

The thought and action step I am recommending for you to consider is using the "McKenzie Protocols" for Cervical and Lumbar spinal conditions as an adjunct treatment system to your established treatment protocols.

The challenges of treating lumbar disc syndromes are many. The lumbar disc represents the toughest challenge a clinician has in his musculoskeletal practice. As I travel the country speaking to doctors in seminars about the treatment of these syndromes with axial decompression, flexion distraction, or standard manipulation, I am constantly pulled aside by attending doctors and asked one consistent query: "What is the #1 reason why a treatment plan fails to provide the results that I desire with the disc patient? What am I missing?"

The thing I see clinicians ignore, and the thing that causes patient’s treatment plans to fail most often, is a failure by the clinician to observe the "Centralization Phenomenon" in their patient’s progress, and the lack of establishing a treatment protocol that promotes centralization. Robin McKenzie first talked of this phenomenon in the early 1980’s and suggested that, by following this principle, his success rate improved dramatically with lumbar disc patients. I have found that to be true in my office as well. McKenzie defines this phenomenon as the situation in which pain that is arising from the spine and felt laterally from the midline or distally is reduced and transferred to a more central or near midline position when certain movements are performed.¹ In summary, that means any movement that reduces the pain distally and centralizes the pain should be pursued. Today, because of the advancement of biotechnology, we can now use tools such as axial decompression to lower the intradiscal pressure of the lumbar disc and facilitate restoration of the disc; but it is still the failure to observe the centralization principle in each patient that most clinician’s ignore, or fail to follow, that causes the unsatisfactory results that their treatment protocols produce.

But there is one "Missing Link" in the centralization protocols that doctors seem to omit. They forget the second part of the centralization phenomenon, which is centralizing the pain but gaining an increase in their patient’s active range of motion. They use a protocol which helps the disc repair, such as axial decompression; but they fail to use a rehab and core stabilization program to restore core stability and maintain a lordotic curve in the lumbar spine. It is my experience in teaching and talking with doctors from all over the country that use any kind of decompression as a therapy tool, that they often get bogged down with only pain reduction and centralization of that pain. The successful doctors that pay attention to the missing link, which is centralization with a restoration of normal range of motion, are the doctors who have higher success rates. This is what active rehab in your office is all about. On the business side, these are the procedures that insurance companies are looking for you to use that will increase your ratio of successful outcomes. These are the active therapeutic activities that insurance companies are willing to pay for. For more information on billing and coding, go to www.flexionextension.com for a free 15-page report produced by billing and coding experts on the content of this article.
Look for Part II in the December issue.

I've spent a lot of time and ink over the past year, writing about the importance of, and how to rehabilitate, the normal cervical lordosis. This month, I want to spend a bit more time on the lumbar lordosis.

Recall that, in the cervical spine, the normal lordosis should be a simple arc of a circle. Unfortunately, for us, the healthy configuration of the lumbar spine is just a bit more complex. Ideally, the lumbar lordosis should be an ellipse with more curve in the lower segments than in the upper ones. ( Fig. 1. ) shows a healthy (not perfect) lumbar ellipse. I have traced George's line in yellow to help visualize the accentuated curve in the lower segments.

The procedure for measuring the amount of lordosis on the lateral lumbar radiograph is similar to the cervical spine with just a few differences. We can obtain an accurate, quantitative value for the lumbar lordosis by using Jackson's angle, just as we did for the cervical spine in an earlier article. We can construct Jackson's angle using three simple steps.

Step One: Place dots on: a) the posterior-INFERIOR and b) posterior-SUPERIOR, corners of the vertebral bodies of L-1 and L-5. (See Fig. 2.) When complete, you should have drawn a total of four dots (shown here in red) on the film. 

Step Two: Construct lines for both L-1 and L-5 by connecting the dots with a ruler. Be sure to Step Three - Using a protractor, measure Jackson's angle to determine the amount of lordosis. Simply lay the base line of your protractor along the L-5 tangent line, center the protractor at the point where the lines intersect, and measure the acute (smaller) side of the angle formed between the L-1 and L-5 tangents. See Fig. 3. to see which side of the angle to measure.  

What this tells us. So, what's normal?

As measured here, Jackson's angle gives us two very important pieces of information. First, it tells us the overall amount of lordosis which is present with a simple, accurate, and proven measurement. Second, it tells us where the apex of the lumbar lordosis is located. All of which sounds good, but we still need some kind of normal value to compare it to. After all, it does us little good to know how much lordosis is present if we don't know what constitutes normal.

The best paper I've read to date was published in 1997 by Troyanovich, et al., in the Journal of Spinal Disorders. The paper, entitled Radiographich mensurations charactersistics of the sagittal lumbar spine from a normal population with a method to synthesize prior studies of lordosis, studied 552 asymptomatic subjects, in a wide range of age groups. The results lead the authors to conclude that there seems to be "an ideal sagittal lumbar curvature that may tend to protect holders of the geometric configuration against nociceptive tendencies. In other words, patients who fall within a certain range of lordotic values are less likely to experience back pain.

Here's the short version. The normal value for Jackson's angle as measured from L-1 to L-5 is from 35 to 47 degrees of lordosis. In pain free subjects, approximately 65% of the lumbar lordosis occurs between L4/5 and L5/S1 with the remainder (35%) of the lordosis occurring above L-4. Patients with acute low back pain, tended to be HYPERlordotic while patients with chronic LBP tended to be HYPOlordotic.

Now take a moment to refer back to Fig. 3. This patient presented with a Jackson's angle of approximately 46 degrees (at the very upper range of "normal") and complaining of mild lower back pain of short duration. This patient was treated successfully with a brief round of adjustments followed by a home treatment program consisting primarily of low back stretches and abdominal strengthening exercise to help reduce the lordosis back toward the middle range of normal.  

Of course, every case isn't so clean cut. There will always be some folks who fall within the "normal" values and yet are still symptomatic. Wouldn't it be great, if everything in chiropractic was so picture perfect! Nevertheless, using simple radiographic analysis to accurately determine the postural status of your patient can be a great tool in determining how to best approach management of the case. Once you start analyzing your films in this manner, I think you will be surprised at the accuracy of Troyanovich's conclusions. If you are interested in learning more about how to accurately analyze the lateral lumbar radiograph, I have prepared a FREE REPORT entitled, Measurement of the Lateral Radiographs, which explains the process in much more detail. Interested doctors may call our office for a free copy.