Techniques


The Structural Management™ Program
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Techniques
Written by Tim Maggs, D.C.   
Sunday, 11 December 2005 14:50

Dr. Tim Maggs has been in practice for 27 years, and travels the country speaking on his Structural Management™ Program.  He worked 4 years with the New York Giants, writes a sports medicine column for many running/triathlete magazines around the country, and also writes for many chiropractic magazines.

In an interview with The American Chiropractor (TAC), Dr. Maggs discusses The Structural Management™ Program, a system of sports biomechanics which specializes in treating musculoskeletal/soft tissue disorders.

TAC:  Why did you develop The Structural Management™?

Maggs: In 27 years of practice, I’ve recognized the flaws and have worked toward a solution in musculoskeletal healthcare.  Currently, doctors are encouraged to get the patient out of pain, and that’s what insurance will pay for.  This is insane. My life is built around conditioning and enjoying wellness and the existing system is built around getting out of pain.  Society wants and deserves better.

TAC:  Explain your program.

Maggs: The Structural Management™ Program encourages the doctor to look at the patient biomechanically, or architecturally, not just pathologically.  Most musculoskeletal pains and degenerations are due to imbalances, fixations and distortion patterns that have been ignored over a long period.  Society is on an accelerated path of degeneration and doesn’t even know it.  Our program begins with The Structural Fingerprint™ Exam, as recommendations should be based on structural, biomechanical findings, not symptoms.  This program even encourages asymptomatic groups to learn the status of their structures, and then proactively begin to work on balancing, conditioning and preserving themselves.

TAC: What do you want to accomplish with your program?

Maggs: Industry is bleeding money due to musculoskeletal costs.  Society is needlessly degenerating at an accelerated rate, only to meet the orthopedist who will replace a joint or the rheumatologist who will prescribe a lifetime drug.  Athletes are retiring prematurely.  We can do better than that, and the key is to get the person participating in a pro-active conditioning program, including chiropractic adjustments, to get in better shape.  This reduces their risk for injury and slows down the degenerative process.  It’s a lifetime issue.

I have people fly into my office from all around the country, and I answer emails globally, from people asking for doctors who provide this work.  My goal is to develop a Network of doctors and put a structural management doctor in every community in this country.  I’ve given myself 5-10 years to do this.

TAC: Why is your program controversial?

Maggs: I’ve spoken with practice management groups who have stated they know the schools aren’t truly preparing graduates for the real world, but they can’t politically say that in public.  I’m saying it loud and clear; this is a tough time to be in practice.  The climate is difficult if, you don’t know what you’re doing; and, unless we prepare our graduates with the proper tools for success, they will not be able to help chiropractic survive as well as they should.  My program does just that.

TAC: What do you say to those who only wish to treat musculoskeletal/soft tissue problems?

Maggs: Chiropractic needs to develop a more defined role of who we are, what we do and how to accept and delineate our differences from one chiropractor to another.  When I worked with the New York Giants, as with most professional teams, there were many professionals who fought for the turf they occupied.  It is clearly my opinion that our profession is making a grave error by claiming we can be all things to all people, when no one is out there providing structural management.  There is an entire market that is wide open and would take chiropractic from seeing 6-8% of the population to seeing 80-90%, yet we want to compete with the medics.  I hope our profession can see the opportunity here.  I encourage us to specialize in musculoskeletal/soft tissue in ways no one else is even thinking of, as in The Structural Management™ Program.

TAC: How does your program work with the many different techniques in chiropractic?

Maggs: The Structural Management™ Program is a framework for doctors to manage people from the very beginning—learning what unique structural issues each patient has—to a level of improvement biomechanically.  The technique the doctor uses is personal,and he/she should be allowed to use whichever technique he or she wants.  This program provides better outcome awareness, so doctors will learn more quickly if their technique is getting the job done or not.

TAC: Are there other instruments or materials needed for use with your technique?

Maggs: The only recommendations I would make would be for all doctors to use X-ray, which is very important in our program, and also a digital scanner of the feet with the patient standing (not moving), to determine weight-bearing imbalances that are found on the exam.  We also recommend custom orthotics and The Stick® to every patient.  The Stick® is a device I endorse which increases blood flow and removes harmful toxins from muscles.

TAC: Is this technique involved in a research project?

Maggs: The wonderful thing about our program is that it is axiomatic; it doesn’t require research to prove it.  All we are saying is that balance is better than imbalance, and joint mobility is better than joint fixation.  You can’t argue those facts.  And, people love it and get better.  With that being said, our Network of doctors is collecting many case histories to validate this approach.

TAC: What do you say to doctors interested in your program?

Maggs: We are on an aggressive campaign to build our Structural Management™ Network.  Our program teaches doctors how to go into high schools, industry, professional sports teams, etc., and sell a product that is desperately needed: structural management.  My goal is to build a Network of 5,000 doctors over the next 5-10 years, using this system, giving all of us a clearer identity and a whole bunch of new patients looking for a better life.

Dr. Tim Maggs can be reached by email at This e-mail address is being protected from spambots. You need JavaScript enabled to view it or by visiting his website, www.DrTimMaggs.com.

 
Clinically Justifying MUA in the Field of Pain Management
Techniques
Written by Robert C. Gordon, D.C.   
Saturday, 26 November 2005 22:36

From a clinical standpoint, MUA has never been questioned as an alternative to correcting fixated articulation, and shortened muscles. But, as a procedure performed by the chiropractic profession, it is questioned constantly.

Manipulation Under Anesthesia or medication-assisted manipulation has long been used by the orthopedic, and osteopathic professions to correct joint fixation. Chiropractic physicians started using this technique in the late 80’s as an alternative to chronic fixation syndromes, which were allowing only minimally responsive results in the office environment. Instead of losing the patient to other more invasive types of care, those chiropractic physicians who became certified in the MUA procedure now had an alternative to offer patients.

As time has progressed, more and more of these procedures have been completed by chiropractic physicians.  In response to this increase, the chiropractic profession has taken more and more abuse from the insurance industry concerning “medical necessity”; “the experimental and investigational” nature of MUA; “the proper use of surgery centers and chiropractic”; “whether the procedure is to be done under intravenous sedation, or is done under a general anesthesia”; (here’s a good one), “that the MUA procedure has a higher morbidity rate than general surgery”; and a multitude of other excuses not to have to pay for this procedure.

In the meantime, hundreds of patients owe their lives and the return of their everyday lifestyles to MUA and the certified practitioners who diligently work to make this procedure a legitimate and credible procedure in the field of pain management.  I am the first to admit that there are doctors and facilities out there that are making that very difficult by abusing the system and charging outrageous fees for this procedure.  But far and above this abuse are the quality doctors out there who are trying to make this procedure a good procedure for properly selected patients, using established standards and protocols.

Discussion

This article is written at a time when the insurance carriers of the United States are gathering what they hope will be enough documentation to eliminate medication-assisted manipulation from the health care delivery environment.  In order to do this, they have convinced several regulatory agencies in the United States, such as the American College of Occupational and Environmental medicine (ACOEM) in California and the Dept. of Insurance and Banking in New Jersey, that MUA carries no clinical basis for the results that we are achieving everyday in this field.  Shamefully, to do that, they use misinterpreted information, antiquated documentation, and the “controlled trial” rhetoric as a smoke screen to try to prevent the actual patient outcome information that is being achieved everyday in hospitals and ambulatory surgical centers, using this technique, from being disseminated to the proper sources so that denials can be made and “justified”.  Fortunately, there is now a textbook on MUA that is progressively filtering throughout the United States that will ultimately give MUA the credibility that it has needed for many years and stop this unjust opinionated uninformed nonsense from continuing.

This paper is specifically written to give clinical credence to the MUA technique, and the concepts that we are expressing are directly from the textbook, Manipulation Under Anesthesia, Concepts In Theory and Application, Taylor and Francis, April 2005.

To make this fit into the allowable content of this article, I will relate more generally to our scientific concepts rather than delving into minute details.  I will allow the reader to, instead, refer to the textbook, for continued reference.

For decades, manipulation under anesthesia, whether completed with IV sedation, general anesthesia, or local anesthesia, has been used by physicians to move fixated articulations and stretch shortened muscles.1,2,3,4,5  It has been the therapy of choice for hundreds of orthopedic surgeons, osteopathic physicians and chiropractic physicians over the past 70 years, and it has been the therapy of choice because it works.

Dr. Rob Francis relates to the changes that occur during MUA in chapter 2, pages 13-23, in the above referenced textbook as “restoring biomechanical integrity to areas of articular dyskinesia due to pathomechanical factors, including loss of joint mobility, fibroblastic proliferative changes of the supporting soft tissue resulting in decreased or lost flexibility/viscoelasticity, and neurological and vascular changes resulting from articular dyskinesia.”6  Now, that may sound foreign to some insurance carriers, but that describes almost all of the cases of fixation syndromes that they have been paying claims for over the years for various types of practitioners, including chiropractic, osteopathy, and physical medicine.

The only difference is that we are introducing medication-assisted manipulation to the equation. The difference in what has been paid by insurance carriers in the past and what we are requesting today is a comfort level for patients with chronic pain.  As an example, when a patient goes into the emergency room for stitches, an anesthesia is used to block the painful stimulus of the needle stitching the laceration.  That is exactly what we are now incorporating into the field of manual therapy today—patient comfort. Nothing is foreign, nothing is new, nothing is experimental; the procedures that we are using are all tried and true; the anesthesia that is used has been used hundreds and thousands of times with the same or similar procedures; and the practitioners are all experienced adjustors/manipulative therapists.

Conclusion

The problem that we are facing is a fee schedule, and the type of provider that is performing the procedure.  If this were not true, then why has this not been an issue for the years this procedure has been used by other practitioners besides the chiropractic physician. CPT code 22505 is listed in the CPT codebook of reimbursable procedures as a category 1 type procedure. The procedure has had a CPT code for more than 20 years.  Why is it, then, that in the last 10 years, since the chiropractic profession started using the procedure, it is considered “experimental,” or lacking the “control randomized” studies?  Why is it that other professionals can bill for this procedure and receive immediate reimbursement, and the chiropractic physician must submit documentation after documentation to “justify” the use of the procedure?  It’s the same procedure that the other professionals are using, except we are more skilled in manual therapy than any of these other professionals.

From a clinical standpoint, MUA has never been questioned as an alternative to correcting fixated articulation, and shortened muscles.  But, as a procedure performed by the chiropractic profession, it is questioned constantly.  Why is that?! Why is it that the chiropractic profession continues diligently to research this procedure, and document the results we get, and yet nothing we do seems good enough to have the insurance companies and their regulatory agencies stop harassing us?! Do we stop providing this very beneficial procedure? Or do we continue to show these carriers and agencies that they are wrong?

Yes, this is controversial.  I expect it will continue to be controversial until insurance carriers and regulatory agencies realize that we are not going to go away. We will continue to fight for the rights of our patients to receive what has, ultimately, become one of the better forms of pain management, even if our carriers don’t want to accept what we are doing.
There are two very real reasons why I continue to believe that this procedure will ultimately win this war. First is the reaction of the doctors when they see how their patients respond to the procedure. And second is the documented astonishing results the patients achieve after suffering from pain for months and sometimes even years.  With these results constantly being achieved, I, personally, will not stop fighting until we finally make these people realize that MUA is a real, viable alternative to chronic conservative care or potential preventable surgical intervention.

References

1. Clemente CD. Gray’s Anatomy. Thirtieth American Edition. Philadelphia: Lea & Febiger, 1985.
2. Davis, DGm  Manipulation of the Lower Extremity. In Subotnick, SI (ed.) Sports Medicine of the Lower Extremity. London: Churchill-Livingstone, 1989.
3. Travell, J and Simons, D. Myofascial Pain and Dysfunction: The Trigger Point Manual. Williams and Wilkins, 1992.
4. Cox JM. Low Back Pain Mechanism, Diagnosis and Treatment. Fifth edition. Baltimore: Williams & Wilkins, 1990.
5. Steiner C, Staubs C, Ganon M, Buhlinger CD.  Piriformis syndrome: pathogenesis, diagnosis, and treatment.  J Am Osteopath Assoc 1987; 87:318-22.
6. Fuhr, A et al.  Activator Methods Chiropractic Technique.  Mosby-Year Book, Inc, 1997.

 

Dr. Gordon's Comments on MUA Under Fire

TAC: Dr. Gordon, what is your definition of Manipulation Under Anesthesia?

Gordon: Manipulation Under Anesthesia is a medication-assisted form of manipulation that provides the ability to stretch and restore muscles that have been in disuse as a result of injury and/or chronic joint dysfunction. It is an extremely valuable technique that many chiropractors are now adding to their practice as another option for helping chronic pain patients.

TAC: Is MUA a chiropractic procedure?

Gordon: Not solely. Despite the accusations of some insurance carriers, MUA is a procedure that uses the very skilled services of the chiropractic physician, but via a team approach. It takes medical clearance, an anesthesiologist, the certified attending doctor, the certified co-attending doctor, and the nursing staff to run MUA procedures successfully. 

TAC: The issue of practicing medicine without a license has now come up with regard to chiropractors performing MUA in California.  Perhaps you can shed some light on what may be going on there?

Gordon: I am not intimately involved in the situation in California, but I have addressed some issues as the executive director of the National Academy of MUA Physicians.

First and foremost, it is my understanding that you are innocent until proven guilty, in this country, under the constitution; that is, unless you are a chiropractor—in which case, you are guilty by profession and then you must prove your innocence. That is exactly how I feel about this case in California.  If, in fact, there are 4 chiropractors who have abused the insurance system by falsely filing insurance claims, then maybe they should be charged with something.  If, in fact, they have actually filed these claims, and it is proven within a reasonable certainty that these chiropractors were guilty of this fraudulent practice, then I will be the first one to condemn their actions.

The problem here is that these chiropractors have been tried in the media already, and have not been given a chance to present their side of the story.

Compounding that is the ridiculous charge that these chiropractors are practicing medicine without a license because they were performing MUA in a surgery center.  No board in the United States, that I know of, determines where manipulation by a chiropractic physician is to be performed, as long as the chiropractor has a license to practice in that state, has clinically justified the procedure which he/she is performing on the patient and has the patient’s permission to perform the procedure used on them. 

TAC: Is there anything else that the reader should want to consider before becoming involved in the MUA technique.

Gordon: Yes. This is not just an additional technique to build your practice.  If you are being taught the MUA procedure as an easy way to build your practice, then you need to consider who is teaching the course.  If you perform this procedure properly and follow the standards and protocols as outlined by the National Academy of MUA Physicians, and now the textbook that is out there, then you will not only have a tremendous procedure to add to your treatment regime but, more importantly, a great new option for your chronic pain patients.  The results that we have achieved over the past 20 years since the chiropractic physicians have been involved are nothing short of amazing and, in some cases, hard to believe.  It is because we have taken an old, widely recognized procedure that was primarily performed in the osteopathic profession for many years and brought the skills of chiropractic to the arena that this procedure has achieved the results it has.  I know this, because I have been studying and performing MUA since 1985.  I’ve seen the changes; I know it works; and I’ve been privileged to see the miraculous results I speak of.

The problem today, as I see it, revolves around some of our colleagues using this procedure to enhance their financial bases and forgetting why we are doing this procedure in the first place.  And, then, there are the insurance carriers that often view chiropractors as people that don’t belong in the operating room and don’t think that the skills we bring to this procedure should be used in such a manner as MUA.

Nonetheless, this procedure has it’s own CPT code and I have written a great many articles to support my position about the validity of that CPT code for MUA.  The bottom line is, that CPT Code for MUA of the spine (22505) has been in that codebook for over 20 years.

 

Insurance Providers Benefit by Approving MUA

Manipulation Under Anesthesia is more accepted now than at anytime in the past, but it has had a long, difficult path to reimbursement. For years, MUA was denied because it was considered new or experimental. But, in the past few years, insurance carriers have had a much tougher time with that argument because of the preponderance of case studies and documentation that underline MUA’s effectiveness. In fact, the insurance companies lose almost all arbitrations brought on the grounds of non-valid treatment. So, the new battleground for MUA practitioners concerns fees.

Insurance companies are now trying to deny MUA claims because of “exorbitant fees,” and there have been abuses. However, in order to remedy the situation, there is a new organization being formed. The International Independent MUA Physicians Association (IIMUAPA) is being formed by Dr. Robert C. Gordon, along with a group of 200 other physicians, to unite MUA doctors and establish protocols and standards, including a “reasonable and customary” fee structure everybody can live with. Thus far, response from insurance carriers and regulatory agencies has been positive.

The insurance companies argue, though, that MUA is the same as regular conservative care in an office setting and should be compensated accordingly. MUA practitioners cite the multidisciplinary environment, hospital setting, use of anesthesia, and training and certification required to perform the procedure as justification for more. And, then, there is the liability issue.

“MUA is an advanced technique and practitioners should be paid fairly for their expertise,” says Gordon. “The bottom line is, insurance carriers have been so consumed with trying to deny MUA for various reasons that they haven’t realized the benefits that MUA is bringing to their own ‘claims made’ table.”  Typical results have been a staggering 70-80% good to excellent in the top range of improvement with properly selected patients, and an additional 50-70% fair results with a majority of other patients who receive the MUA procedure.  The accepted MUA failure rate is just 5% with properly selected patients. Failures continue to range either from no improvement to no worse, or involve patients who are pain dependent and would not have recovered no matter what type of care was rendered.

“So, when I look at the benefits the insurance industry is casually pushing aside, it makes me wonder what the real agenda is for this industry in the United States,” says Gordon.

The benefits to the insurance industry of approving MUA include:

• Patients return to the work site with increased productivity.
• Patients recover from months of lifestyle changing incapacities.
• Patients are able to return to the working environment, which has a distinct impact on the economy and economic output.
• Patients stop having to use their insurance coverage for neuromusculoskeletal problems that have been resolved.
• Chronic pain patients have another alternative treatment to suggest to their insurance carrier before surgery is required.  This is vital to prevent the large volume of failed back surgeries frequently seen in the MUA arena.
• Patients respond to MUA and post care at a significantly higher rate than with other, more prolonged, conservative programs of PT, minimally invasive surgeries, injection therapy, and office-based, minimally responsive manual therapy programs with properly selected cases.

References

1- Capps, S., Texas College of Chiropractic, syllabus: Manipulation Under Anesthesia; postgraduate course of study, 1992.

2- Chrisman, OD, et al. A study of the results following rotary manipulation of the lumbar intervertebral disc syndrome. J Bone Joint Surg., 1964; 46-A:517

3- Krunhansl, BR, and Nowacek CJ, Manipulation Under Anesthesia. Modern Manual Therapy, 1988, pp. 777-786.

4- Kohlbeck, F. , Haldeman, S., technical assessment: medication assisted spinal manipualtion; Spine Journal, North American Spine Society, Vol. 2, July/ August, 2002.

5- Mensor, R., “non-operative treatment, including manipulation for lumbar intervertebral disc syndrome”, J Bone Joint Surg., Vol. 5, Oct. 1955. pp. 925-936.

6- Gordon, R; Manipulation Under Anesthesia, Concepts in Theory and Application; 2005, Chapter 2, Francis, R.; CRC Press, Taylor and Francis; Boca Raton, London, New York, Singapore. pp.13-23.

 

Dr. Robert C. Gordon is the author/editor of the textbook Manipulation Under Anesthesia, Concepts in Theory and Application, published in April 2005 by Taylor & Francis (CRC Press). He is a member of the postgraduate faculty of the National University of Health Sciences in Lombard, IL. Dr. Gordon teaches MUA throughout the United States and has recently been asked to start teaching MUA outside the United States. He was recently inducted into the Royal College of Physicians & Surgeons (US) and is the Vice Chairman of the Royal College of Chiropractic Medicine.

 
Preventing SIDS: Sudden Infant Death Syndrome
Techniques
Written by R.B. Mawhiney, DC   
Saturday, 26 November 2005 22:33

OH, NO!!! PLEASE, LORD, NO!!! She has stopped breathing! CALL 911!! HURRY!!!

This happens up to five thousand (reported) times a year in the United States.

Sudden Infant Death Syndrome has become a scourge to young and old parents, alike. I have raised three children and have suffered through many nights wondering if I should shake my child to see if it’s sleeping or if something may be wrong. All new parents have this urge and, the more they hear about all the things that may go wrong, it is no accident they become paranoid. The medical profession has, since post World War II, inundated the lay public with the statement that SIDS is idiopathic.  My fifty-one years in private practice, specializing in children with scoliosis, has proved to me that SIDS is both predictable and preventable. In addition, I have taught on the post-graduate faculties of ten chiropractic colleges and my research has shown a correlation between presently accepted obstetric procedures and the incidence of SIDS.

In the year following the recognition of the seriousness of this condition, the medical profession determined that, since all SIDS deaths occur when the baby is on its stomach, that must be the cause. The profession then determined all babies should sleep on their backs to prevent the syndrome. This, of course, caused the child to develop a flat area in the occipital region of its skull. In 2004, the medical profession determined all babies should wear helmets when sleeping, for the first year of life. This would prevent the flattening of the skull.

SIDS Background

DEFINITION: The medical profession has defined Sudden Infant Death Syndrome as the “sudden and unexplained death of an infant less than one year of age.”

The American Academy of Pediatrics states SIDS, sometimes called “crib death,” takes the life of over five thousand babies every year. There are also an unknown number of children who die with listings of “unknown” causes that may be SIDS deaths.

The American Academy of Pediatrics further states that doctors and nurses do not know what causes SIDS, but they have provided some hints for parents to follow. My question would be, “If we do not know what causes the condition, on what do we base the application of prevention?”

The following are quotes from the AAP website.

• ACADEMY STATEMENT:  “Healthy babies should sleep on their backs.”

1. My understanding, from training in pediatrics, is that babies have been put on their stomachs to keep the airway open.

2. Babies are normally put down after nursing or being bottle-fed so that, if they spit up, it may not cause them to choke.

3. Another problem in continually putting a baby on its back is that its skull is very soft and I have seen many infants with the backs of their heads flat, instead of round. A child will normally roll its head from side to side, when sleeping, which is God’s design to keep the head from becoming deformed.

• ACADEMY STATEMENTS:  “The death is sudden and unpredictable; in most cases the baby appears healthy.”  “Death comes quickly, usually during sleep time.”  “After thirty years of research, scientists still cannot find one definite cause for SIDS.”  “There is no way to predict or prevent SIDS.”

The foregoing statements have been attributed to the Academy, U. S. Public Health Service, SIDS Alliance and Association of SIDS and Infant Mortality Programs.

• MY STATEMENTS:  I will provide information to show that SIDS may well be predictable and is definitely preventable.  Unfortunately, the cause and prevention do not follow prescribed medical procedures and protocols.  They fall within the realm of musculoskeletal biomechanics and neurology. It has to do with the way the body was designed to respond to trauma and the long lasting effects trauma has on the body.

Cause and Effect

Trauma to the phrenic nerve, located in the cervical spine is the most logical cause of SIDS. The following pages will present clinical information confirming my opinion as to why any extensive pressure on the phrenic nerve would cause the condition known as SIDS. The nerve controls the function of the diaphragm, which controls our breathing. The Phrenic nerve emits from the cervical spine at the level of the third cervical vertebrae.

Any occlusion/pressure on the nerve causes a disturbance in the nerve transmission—which affects the function of the diaphragm.

Each of the spinal nerves is an extension of the brain, which controls all functions of the body. Nerve stimulation, nerve block procedures and nerve testing is a part of the medical field’s procedures. Science knows where every nerve is and what area it stimulates or innervates. So, when a nerve is cut, all function, of the part it innervates ceases.  The same holds true if nerve transmission is interfered with in any way, including pressure or damage to the sheath covering the nerve. The damage to the nerve, depending how severe, may take some external action to cause the part controlled by the nerve to be affected. The external action may be a postural attitude that triggers the response.

Obstetrics

The birth process is now and always has been a miracle of life. The work performed by midwives and obstetricians makes them unsung heroes in our daily life.

The following pages show normal births along with forceps deliveries. We realize there may be no two birth deliveries alike, but you’ll notice the normal birth has the child descending the birth canal face down. When the baby’s head appears, many times the doctor will hold the head in his/her hands and rotate the head until the body turns so the baby is face up. This is where the damage is done to the neck and the predisposition for the occurrence of SIDS takes place. Another condition that can result from the pulling and turning of the neck is “Erb’s paralysis”, which affects the brachial plexus and causes paralysis of the arm.

Birth Process (based on a typical normal birth)

When the baby is ready to be born, it moves headfirst into the birth canal. The child moves into a face down position with arms across the chest and the legs crossed and bent.

The top of the head is the first to be seen. This is called” crowning.” In a natural unassisted birth, the pushing by the mother and the uterine contractions continue to move the baby through the birth canal and the child is born face down. If the mother has a child delivered, assisted by a doctor of obstetrics, a change is usually made in the delivery of the child. As the crowning takes place the doctor takes the head of the child in his/her hands and turns the head in a one-hundred-eighty-degree turn to have the child born face up. Since the body of the baby is in the birth canal when the head is turned, there is resistance. The doctor will continue to apply pressure to the head and neck until the body rotates to a face up position. The bones in a newborn are not connected to each other, but are held in position by ligaments. The bones are soft enough that you are able to bend leg and arm bones without breaking them. This will change immediately after birth, as the bones grow from the center to the ends and begin to harden. The cervical vertebrae form a solid protection for the spinal cord, give form to the neck and allow for rotation of the head. When the doctor turns the head to force the body to rotate, the doctor is applying a great amount of pressure to the very small and delicate vertebral structures.

I have witnessed many births and have marveled that the baby was resilient enough to have its neck twisted to that extent and still live. When a child is delivered, under these obstetrical procedures, the new mother will note the baby has a tendency to turn its head more to one side than the other when lying on its back. When the baby is put on its stomach, it will almost always turn its head to the side that is most comfortable. When examining a baby, I always gently rotate its head, when it is on its back, to see which way the vertebrae are rotated when in the neutral position. When facing directly forward, the average child or adult will find it is able to turn or rotate its head more to one side than the other. This is because the individual vertebrae are subject to the vertebrae serving as their foundation. If vertebrae are rotated, that forces the vertebrae above to also rotate to some degree. This is how we bend and turn our heads. When the obstetrician turns the baby’s head, to that extent, it may cause a subluxation of the third and fourth cervical vertebrae. This subluxation will, over a period of time, possibly cause inflammatory reaction in the foramina, causing occlusion.

The chiropractic profession has grown to be the largest alternative health care profession in the world, based on the philosophy and premise that God made no mistakes in designing the body and, when there is nerve impingement, it causes dysfunction.

Points to consider

Why haven’t there been studies of the following;

a. Frequency of SIDS deaths in non-obstetrical assisted births.
b. Frequency of SIDS deaths in home deliveries.
c. Frequency of SIDS death with babies under chiropractic care.
d. Frequency of SIDS death when there is no turning of the head when a child is born face down.

Over the years I have treated hundreds of babies, but one case is indicative of the cervical problem suffered by thousands of babies. A young mother came to the office with her one-month-old baby with diagnosed infantile torticollis, or stiff neck. This child’s head was turned to the right as far as it could turn and the child could not turn its head. The mother said this had been present since birth and she had discussed the problem with the doctor who delivered the baby and the pediatrician. Both doctors had diagnosed the case but had indicated the child would grow out of the problem. When the condition did not change, she was sent to an orthopedic surgeon who confirmed the diagnosis.  He told her to put the child on its back, hold its head in her hands and rapidly turn the head from right to left fifty times. She was to do this three times a day.

The mother was so shocked by the suggestion, she immediately left the doctor’s office. She had been recommended to our office, since I had treated many of these cases. It took two weeks and four cervical adjustments to correct the problem. When the cervical ligamentous tissue and musculature are stretched to that extent during the birth process, they will not return to normal without proper treatment.

Critics of this hypothesis will say that babies’ neck vertebrae are incapable of being displaced. These critics will be medical doctors who do not receive training in musculoskeletal conditions. Chiropractic physicians have been treating cases of infantile torticollis for over one hundred years. In the early part of the last century into the 1930’s, most children were born at home with midwives or neighbors attending. SIDS became an issue after the majority of births began taking place in hospitals and standard delivery procedures were established.

The hypothesis is based on the premise that the brain, which is the first nerve center to be formed in embryo, controls the function of all systems through the nerves. The areas of concern are the cervical nerves emitting from the cervical spine.

During the obstetrical birth of a child, the trauma induced in the cervical spine sets into action a foraminal occlusion.  In a matter of time, this will affect the function of the diaphragm and result in disturbed breathing. The medical community will not accept this cause and effect, since it does not fall within the philosophy of cause and effect in the field of medicine.

There has never been a study, controlled or otherwise, to determine how many babies under chiropractic care died of SIDS. In my forty-seven years of providing care to infants, I never had a baby die of SIDS. During my years of teaching clinical sciences on the postgraduate faculty of ten colleges, I never found a SIDS death among the thousands of field doctors that I instructed.

NOTE: The previous information was taken, in part, from the book SIDS, by the author. More information, research and copies of the book may be obtained from R. B. Mawhiney, D.C., D.I.S.R.C., by mailing to 9196B SW 89th Terrace, Ocala, FL. 34481, or emailing This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

 
Piriformis Syndrome: Assessment & Correction of Affected Structures
Techniques
Written by Arlan Fuhr, DC   
Saturday, 26 November 2005 22:31

Is sciatica a frequent complaint in your practice? Did you know that the piriformis muscle, when inflamed, releases a biochemical agent that irritates the sciatic nerve? Find out how the Activator Adjusting Technique can help you bring relief to these patients.

One of the more common complaints in any chiropractic office is that of buttock and/or posterior thigh pain, generally referred to as sciatica.  Once a radicular origin has been ruled out, the diagnosis of piriformis syndrome is considered. The piriformis muscle, located deep to the gluteal group, is a major external (lateral) rotator of the thigh. Originating on the anterior aspect of the sacrum and inserting into the greater trochanter of the femur, the piriformis is also a synergist for abduction and extension of the thigh.1  Piriformis muscle contracture can present with a pain deep in the buttock of the affected side.  The muscle, especially at the musculotendinous junction near its insertion on the greater trochanter, is frequently tender to palpation.2  It is not uncommon for piriformis syndrome to present with pain and paresthesias in the buttock, hip, posterior thigh and leg to the foot. Prolonged sitting or activity aggravates piriformis syndrome.3  Due to the approximation of the sciatic nerve and the belly of the piriformis, spasm of the piriformis may occur with apparent sciatic neuralgia.4  The piriformis, when inflamed, has also been found to release a biochemical agent that irritates the sciatic nerve, possibly causing sciatic neuritis.5   Consequently, orthopedic tests like the straight leg raise test (LaSègue test) and Braggard test may be positive.  However, with piriformis syndrome affecting the sciatic nerve, the Well leg raise test and Fajerstajzn test (contralateral Braggard) will not elicit a pain response.6

With piriformis syndrome, the greater trochanter tends to be pulled posterior, designated in Activator Methods Chiropractic Technique as external hip rotation, and a toe-out foot flare is typically observable in the patient’s walking gait. The prone patient on the adjusting table may also demonstrate pronounced toe-out foot flare. When a patient suffers from symptoms resembling sciatic neuralgia, hypertonicity of the hip extensors and rotators, and point tenderness over the greater trochanter, perform stress tests and adjustments as necessary for external hip rotation. Due to the muscle’s medial attachment on the anterior surface of the sacrum, test for an AI sacrum and adjust as indicated. The piriformis muscle, itself, can be adjusted with the Activator adjusting instrument.

With the patient out of weight-bearing posture, in the prone, extended position, leg length analysis will most likely reveal a functional or an apparent short leg. AMCT protocol would begin with testing and correcting this first.  However, an actual LLI may aggravate the piriformis syndrome and should be measured and corrected, if necessary.  Once the pelvis is balanced by correcting the functional PI or AS ilium, consider testing and correcting sacral malposition, for example, shortening of the left piriformis producing a left anterior inferior sacrum.  With the Activator instrument contacting under the involved sacrotuberous ligament. The line of correction is superior, lateral and posterior.

External rotation of the hip should be considered when the patient demonstrates unilateral “toe-out” foot flare. A normal gait and resting stance will show slight toe-out flare, but it is symmetrical and balanced.  If the hip has been in external rotation for an extended time, the patient’s shoes are likely to show excessive and asymmetrical wear on the posterior and lateral aspect of the heel on the side of involvement. Test for external hip rotation and adjust by contacting the posterior aspect of the greater trochanter with the Activator adjusting instrument. The line of drive is anterior and slightly inferior.

When a patient suffers from pain in the SI joint, buttock and/or posterior thigh or sciatica, consider testing the piriformis muscle.  To stress test the piriformis, flex the involved side leg and, while stabilizing the medial distal tibia, ask the patient to externally rotate the hip against your resistance. This is the active resisted muscle test. Adjust the piriformis muscle with 3 thrusts.  First, contact ½ inch lateral to the sacral border.  The line of drive is posterior to anterior.  The second contact is ½ inch medial to the greater trochanter; and the last is on the attachment of the piriformis to the greater trochanter.  The line of drive is also posterior to anterior for each of these contacts.

After correcting the pelvic imbalance and commonly affected structures, following up with appropriate rehabilitative exercises to stabilize the pelvis and hips, postural and ergonomic corrections as well as corrective care for the rest of the patient’s spine would be vital to the reduction and prevention of symptoms.  Activator Methods Chiropractic Technique can help you to determine where, when and when not to adjust, based on its series of isolation and stress tests and leg length analysis protocol.

References

1. Clemente CD.  Gray’s Anatomy.  Thirtieth American Edition.  Philadelphia: Lea & Febiger, 1985.
2. Davis, DGm  Manipulation of the Lower Extremity. In Subotnick, SI (ed.) Sports Medicine of the Lower Extremity.  London: Churchill-Livingstone, 1989.
3. Travell, J and Simons, D.  Myofascial Pain and Dysfunction: The Trigger Point Manual.  Williams and Wilkins, 1992.
4. Cox JM. Low Back Pain Mechanism, Diagnosis and Treatment.  Fifth edition.  Baltimore: Williams & Wilkins, 1990.
5. Steiner C, Staubs C, Ganon M, Buhlinger CD.  Piriformis syndrome: pathogenesis, diagnosis, and treatment.  J Am Osteopath Assoc 1987; 87:318-22.
6. Fuhr, A et al.  Activator Methods Chiropractic Technique.  Mosby-Year Book, Inc, 1997.

Dr. Fuhr is the co-founder and president of Activator Methods International. He brings nearly 40 years of chiropractic experience and knowledge to the development of the Activator and the Activator Method. Activator Methods, Intl., is presenting the topic of rehabbing Piriformis Syndrome, along with many other common clinical conditions, during their 2005-06 seminar series.  For more information and for a seminar near you, visit www.activator.com.

 
CranioSacral Therapy Releases Hold on Subluxations
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Techniques
Written by Lisa Upledger, D.C.   
Saturday, 26 November 2005 22:28

This gentle hands-on method of working with the craniosacral system, has helped thousands of practitioners effectively remedy a wide range of medical problems associated with pain and dysfunction. You, too, can learn how to enhance the body’s natural healing process.

Like most chiropractors, I spent many years focused on the subluxation factor. Ironically, it wasn’t until I began practicing a different hands-on modality—CranioSacral Therapy—that the chronic subluxations I released through chiropractic began to resolve themselves permanently.

CranioSacral Therapy is designed to free restrictions in the craniosacral system, which is formed by the dura mater membrane, the cerebrospinal fluid within the membranes, the systems regulating fluid flow, the bones that attach to the membranes, and the joints and sutures interconnecting these bones.

Because it houses the central nervous system, it’s easy to see how the craniosacral system can affect subluxations so dramatically.  A restriction in the meninges or any dural reflections—the falx cerebri, the falx cerebelli, the tentorium cerebelli—and even contractures within the dural tube can play into a subluxation pattern.  Indeed, restrictions anywhere in the body, whether fascial, bony or muscular, can refer into the craniosacral system and affect chronic subluxation.

Consider that nerve roots are covered by dural sleeves.  A restriction in the sleeve that compresses the root and affects the nerves from the root to the vertebral muscles can cause the vertebrae to compress together or become misaligned.

Just manipulating the involved vertebrae doesn’t necessarily affect the restriction of the dural sleeve, nor any pulls from other parts of the dura mater membrane.  But, by using CranioSacral Therapy, you get to the root of the problem by directly releasing the dural restrictions that are compressing the nerves in the first place.

Consider, also, the effects of the facilitated spinal cord.  When nerve roots refer increased impulse activity into the spinal cord from their peripheral domains, they can create a facilitated condition of the related spinal cord segments.  Hyperactivity in the facilitated spinal cord segments then causes impulses to be sent out to the related dural sleeves, nerves and end organs, which then refer back into the spinal cord.

The result?  More dural tube tightening and loss of mobility, with increased nerve pressure and more dural tube sleeve contracture, resulting in continual neuronal firing.  And, because the nerves in the area go to the intervertebral muscles, the condition causes them to contract and create fixation and subluxation.

In clinical applications, CranioSacral Therapy effectively helps release dural tube restrictions to normalize the activity of the facilitated spinal cord segments.  To locate these areas of restricted mobility, the evaluator tests the mobility of the dural tube and releases restrictions as they’re found, using gentle traction techniques.

Keep in mind that, if a peripheral restriction is released but the dural tube restriction and facilitated spinal cord segments are not, the peripheral problem usually reoccurs. That’s why it’s been so helpful to me to combine CranioSacral Therapy with chiropractic, to more effectively release the hold on chronic subluxation patterns.

A 1981 graduate of Palmer College of Chiropractic, Lisa Upledger, D.C., is Vice President of Clinical Services at The Upledger Institute, Inc., in Palm Beach Gardens, Florida, where she has been a staff clinician and instructor since 1991.

Dr. Upledger will explore CranioSacral Therapy and subluxation in depth at seminars and demonstrations at the CHIROPRACTIC ’06 Symposium being held in the Republic of Panama on Feb. 12-15, 2006.  You can register at
www.chiropractic06.com.

To learn more about CranioSacral Therapy and how it enhances chiropractic, contact The Upledger Institute toll-free at 800-233-5880,
www.upledger.com, or by e-mail to This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

 
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