Sacrooccipital Technique
Thompson Technique
First of all, do no harm.
Hippocrates
Although chiropractic patients of all ages require careful examination and diagnosis before applying adjustive procedures, chiropractors working with older patients must give special consideration to age-related changes of the spine and other structures of the musculoskeletal system. Through the years, chiropractors have developed a broad range of manual techniques to accommodate the needs and preferences of their patients.12345 and 6 In deciding which technique to use for a particular patient, the doctor of chiropractic should bear in mind that in health care, many questions have more than one correct answer.
This chapter explores chiropractic techniques and their application in the care of older patients, briefly describing the core procedures for each adjustive method along with its potential advantages and limitations. Based on a review of the technique literature, clinical experience, and observation, the authors present a range of options.
Though chiropractic procedures entail less risk to patients than more invasive medical procedures, caution is always appropriate. Thoroughly assessing the overall health status of the older patient, considering issues that affect safety in chiropractic adjusting, and then selecting a course of care appropriately matched to the patient’s clinical picture is important.67 and 8 Also important is for the technique choices to take into consideration the patient’s stage of degeneration as described in the Kirkaldy-Willis (K-W) model discussed in Chapter 16. 8 Good rules of thumb to avoid patient injury or discomfort include the following:
• Performing a thorough assessment of patient’s health status
• Using the least amount of thrust necessary
• Always maintaining cognizance of patient tolerance
• Monitoring patient progress
• If positive outcomes are achieved, continuing with this adjusting strategy
• Continuing to monitor patient progress, noting any negative outcomes
• Adjusting patient care plan to meet patient’s needs as health status changes
AVOIDING ADVERSE OUTCOMES
Although injury resulting from spinal adjustive procedures is uncommon, minimizing potential adverse outcomes of the geriatric chiropractic adjustment is important. The following are possible adverse outcomes related to chiropractic care of older patients. All results, except transient muscle soreness, are very rare occurrences.
• Muscle soreness or discomfort around adjustment site
• Hip fracture, injury, or dislocation of hip prosthesis
• Injury to shoulder and rotator cuff injury
• Falls from chiropractic table
• Burns from hot packs or ice
Stroke is exceedingly rare. See Chapter 26 for detailed discussion.
The best risk management tool you have in chiropractic practice is good communication with the patient.
Director of Claims, National Chiropractic Mutual Insurance Company
As with all patient interactions, when caring for an older patient, the chiropractor must take sufficient time to explain procedures and give a reasonable description of the expected (and perhaps unexpected) outcomes of care. Good communication with patients, young and old, is the best way to avoid a negative doctor-patient experience in practice.
Although few absolute contraindications to chiropractic care exist, some clinical scenarios require careful consideration of the technique choices and specific maneuvers used. 11normal age-related changes may indicate the need for careful selection and administration of chiropractic adjustments (Table 17-1).
| Changes in the Aging Body | Impact on Chiropractic Practice and Decision-Making | Proposed Solutions |
|---|---|---|
| Decreased bone density | Increased risk of fracture | Low-force techniques, broader contact points, pediatric adjusting protocols |
| Decreased muscle mass | Decreased resistance to adjustive force | Lighter palpation, lighter adjusting, exercise to increase muscle mass and strength, soft tissue techniques to decrease hypersensitivity |
| Decreased ligament and tendon elasticity | Increased risk of sprain or strain after adjustment, decreased range of motion | Techniques that do not take joints past physiologic range of motion, prone adjusting techniques |
| Increased capillary and skin fragility | Increased risk of abrasion and bruising from adjusting | Lighter tissue pull; care should be taken not to slide contact along skin |
| Increased atherosclerosis | Increased risk of clotting, stroke, and blood vessel tears | Extension, rotation, double thrusting, and high amplitude adjusting near vessels with plaque should be avoided |
REGIONAL ADJUSTING CONSIDERATIONS
Cervical Spine
Excessive rotation and extension of patient’s cervical spine must be avoided, particularly in patients who have a history of stroke, show signs and symptoms of stroke, or are at high risk for stroke. 11
Practitioners using higher amplitude adjustments should consider altering their technique to limit rotational and extension vectors as part of the adjustive process, or else they should shift to the application of lower force procedures. The needs of patients, including geriatric patients, vary widely, and all chiropractors must evaluate each patient individually, adapting their technique appropriately. For the patient in the stabilization phase of the K-W model8 (see Chapter 16), additional strategies should be employed to maintain range of motion and enhance intrinsic muscle strength in the cervical spine. 7,8
Thoracic Spine
The posterior-to-anterior (P-A) force of a chiropractic adjustment is unlikely to cause damage to the bodies of the thoracic vertebrae in an osteoporotic patient. Thoracic spine fractures generally result from compressive axial forces applied to the body of the vertebra, not a force vector used in specific chiropractic adjusting of the thoracic spine. Rib fractures, however, are a greater concern. Avoiding the typical expiration thrust may be advisable (e.g., thrusting when patients’ ribs are at their most flexed or “bent” position). The chiropractor should adjust using lower force techniques in the thoracic spine of osteoporotic patients, or use manual but light thrusts with broader contact on inspiration, or both. Allowing the chiropractor’s hands to contact the ribs should be avoided by keeping the adjusting hand or hands close to the spine. Although some chiropractic technique instructors recommend using spinous contacts to avoid a potential fracture of the transverse process, the spinous contact may be quite tender and uncomfortable in older patients who have decreased muscle mass and epidermal thinning. “Anterior” thoracic adjusting, wherein the adjustive forces are translated through the sternum and ribs, is not recommended by the authors in patients with osteoporosis or advanced osteoarthritis.
Lumbopelvic Region
In frail patients, those with a history of hip injury, surgery, or instability, or those with neurologic symptoms in lower extremities, the best course is not to use the femoral neck area as a fulcrum in the adjustive procedure. In addition, for patients who have had a hip replacement, the ipsilateral knee should never be forced to cross the patient’s midline, because of the risk that prosthesis dislocation or injury to the hip joint may occur. Avoiding lumbosacral side posture adjustive maneuvers altogether may be prudent in such patients. Although caution should be exercised when using lumbosacral side posture maneuvers in elderly patients, many skilled chiropractors have carefully and safely used such techniques for decades. Prone adjustments of patient’s lumbar, sacroiliac, and pelvic regions may offer appropriate and effective alternate adjusting strategies and have the additional advantage of easier placement of the patient on the adjusting table.
Suggested adjusting strategies include methods such as Thompson, Logan, sacrooccipital technique (SOT), activator, or the alternate prone maneuvers taught in several manual high-velocity, low-amplitude (HVLA) techniques such as Gonstead, diversified, or segmental meric recoil procedures.
Extremities*
*For a discussion of rib fractures, see the Thoracic Spine section.
As with the technique considerations addressed earlier, wide variation may be found in the chiropractic profession regarding manual approaches to rib and extremity problems. Because adjustments to ribs may be simply and safely achieved with instrument adjusting, practitioners may wish to explore instrument-assisted methods, at the very least for use in cases in which more forceful methods may be contraindicated. Practitioners choosing to use more classical, or cavitating, adjustive methods need to be especially cognizant of the decreased bone density and ligament elasticity, as well as the increased pain sensitivity, of older patients. 11
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