Grading the effectiveness of a chiropractic adjustment; 'Click, Clack, or Clunk'

 I have been practicing chiropractic for about 20 years now and have been exposed to, and taught a number of techniques to help realign and stabilize joints in the body.

One thing I have noticed is that none of the techniques* I have learned or studied have a grading system for the adjustments.  Mostly it tends to be a functional matter; pain decreases, mobility increases, etc.  But each adjustment can be so different and get the exact same results.  Likewise, the same adjustment, even on the same person, can get different results each time.  I generally use what is called a "diversified" technique, which really is not a technique at all, but a collection of procedures to move a vertebrae or other joint where you think and feel it should go.  Most of the time, we get a 'pop', but not always.

When doing such adjustments (especially the spine) I am always looking for how well it worked.  I have my own grading system... the "click, clack, clunk" range.  When you perform a simple P-A adjustment (pushing on the back when the patient is face down) you typically get a sound as the joint 'cavitates' (More on that later).  This results in  a click if it is a surface joint, like the facets, a 'clack' if it is a deeper joint like the rib head or neck, and a distinct 'Clunk' with the deeper part, that being the disc.

Now, I have absolutely no research on this, and there are no studies that I know of that have researched if this is at all true.  But, empirically, IN MY experience I see this as true.   I figure I have done well over 75,000 adjustments in my career and that is what I base my info here on.  I have also found that when we get the 'Clunk' the patient almost always has a great release of tension and takes a much needed and happy sigh.

Having said all that, the Click, Clack, or Clunk are really just sounds.  I prefer to get the right sound at the right time for the right reason.  This is all about personal preference of the patient, their goal for treatment and my sense of the issue at hand.  Sometimes a 'clunk' would be a bad idea for someone that has never felt a real adjustment before, or for someone that has lots of pain.  Again, I use common sense, compassion and experience...

The 'feel' of the adjustment.  With practice, palpation skills become very refined.  With chiropractic care, the patient too becomes more refined in knowing how a joint segment feels before, during and after a manipulation or adjustment.  In the case of the doctor; I am feeling for misalignment as well as muscle tone around that segment as well as the slight motion of the segment areas as I move the patient's neck, torso or lumbar area with some  simple passive range of motion testing.  With that we can both feel the restriction, the tightness, the resistence etc.  Once the adjustment is delivered it may not even give any audible clue like the 'click, clack, clunk', but be an improvement in both subjective and objective findings like feel, tenderness, alignment, range of motion and segmental motion.  

We must also understand though, an 'audible' or pop, click, clack, or clunk is NOT at all necessary to have a good result.  In fact, many techniques offer no such sound but have all the benefit of the later. Since anyone can push or hug someone and get a pop, that is not really doing an adjustment.  An adjustment is a very specific intentional movement of a joint just past it's fixation point to bring about more normal physiology in the area (as well as cut the pain spasm cycle).  Sometimes now called a 'High Velocity, Low Amplitude' (HVLA) manipulation, or in the physical therapy sense, a grade 5 manipulation or mobilization.  To perform these types of treatments takes great skill and practice as well as a keen sense of anatomy of the area and possible pathological issues that may make the adjustment/treatment contraindicated...  Most are pretty obvious and do not need to be reviewed.

Although there is no necessity of an audible click, clunk or clack as I described, there is a change in the physiology of that sesgment, the bones do move, the ligaments are challenged, the tendons and muscles stretched and the area soothed.  It is a good way to explain to patients the value of a timely adjustment as well as the stiffness that they reported as being verifiable in my evaluation.  Something like 'yes, I can tell how tight it is, it only clicked, when we get a deeper adjustment it is more often a clunk'.  This of course is not limited to just the lumbar area, but can be seen in all areas of the spine, ribs and appendicular skeleton. 

Feel free to contact me at 720-325-9886 or send me an email with any questions or comments.  Thanks!

Techniques that are used by chiropractors vary as wide as personalities it seems.  You can find a list anywhere.  Here are some that I use; Diversified, Gonstead, Full Spine Specific, Meric, Thompson, Cox Flexion Distraction, SOT, Activator, Motion Palpation, English Bone Setting, Tui Na, Mobilization, among others...

Of the techniques I use these are the ones that usually have no audible sound; SOT, Activator, and English Bone Setting.

Five stress elimination tricks in meditation

When did Mother Nature become an enemy?

 You may be old enough to remember the Margarine commercials 'Don't fool with Mother Nature' campaign.  It was followed by the 'I can't believe it's not butter' one we mostly know. 

I was taught that the natural processes of the body need to be respected, well learned and worked WITH instead of against.  That is the basic definition of wholistic in health care.  Not 'allopathic' which is what modern Western medical doctors practice.  Instead of working with the body, we try and overcome its natural processes, force action, speed time, hold back death.  An allopath basically gives cold for heat, heat for cold etc.  He or she does the opposite of what the body is doing to control it to an imaginary or often arbitrary 'normal'...  

Imaginary, arbitrary?  Really?  When studying the body and the way it works (physiology) we find a range not a set point.  Everyone knows someone that runs a little cool or a little warmer than the set point temperature of 98.6 degrees Fahrenheit.   Some people have a resting blood pressure well above or below that 120/80 mmHg we all are taught.  In fact, temperature, pulse rate, blood pressure, weight, hydration, pulse oximetry values are no more than a snap shot of the constant flux of levels our bodies go through. 

I have had a few patients that had very stressful events occur and began to feel 'not well'.  My advice was always natural treatments, relaxation, good food, water, chiropractic and acupuncture... Well, that is what I do.  They would go to their medical doctors on my advise to 'get checked and make sure it is not something else'.  They would come back with diuretics or other pills to help with blood pressure.  This is good! I would tell them, they needed something to show them they needed to take better care of themselves and this might be just the thing.  If I could convince them to get rest, change their diet (even just a LITTLE) they would see the benefit in no time.  Without fail this happens, they change just a few small things, get their stress under control (or like all things it changed).  and then all the sudden start feeling 'not well' again. Over the years I have had the luck to learn to look back to the start of things.  I would take blood pressure, find it was far too low.   That meant the pills WORK!  That is excellent.  

We don't take a pain killer when there is no pain unless...

I would suggest to these patients to talk to their prescribing doctors and lower or eliminate the medication as the problem has passed.  Not ONE has ever done that.  I have had the doctors tell the patient all sorts of things to keep them under care.  One fellow, had his blood pressure under too good control, it was so low he was getting dizzy and feeling tired.  His doctor told him he HAD to remain on the medication for life.  Now he simply needed a pacemaker implanted to up his heart rate to a more normal level.  I cannot tell someone to stop a prescription and I don't ever.  I would rather work WITH the medical doctor and find some answer.  The patient stopped the medications on his own. 'Against Medical Advice' or with a disclaimer AMA, and sent on his way.  Quickly his heart rate and pressure was as normal as could be expected for his age.

When we take any pill for too long it causes more trouble and may be a sign of addiction.  This of course needs care.  Care that medicine usually does not have time to do.  Instead fear and hopelessness are instilled in small conniving ways that gaslight a patient into thinking they are more ill than they are.  Basically a 'Munchausen'  situation.  

The distrust of the natural ability to heal. 

When I got to Colorado from the Los Angeles area of California I was appalled at the number of patients that were having or had some orthopedic surgery.  Granted, Colorado is a very active state, people are out and about a lot.  My office demographic was just not that group like they were in California.  In my California office I had many more active patients, sports, firefighters, police, construction workers and lots of other manual labor people.  Almost none would even consider a surgical repair.  Of course the socioeconomic differences and cultural differences (in California I had many Hispanic and Asian patients, in Colorado it was very few in comparison).  

So many people were almost excited to get a surgery for what I often considered a mild to moderate issue that would very likely respond well to very conservative care and a more 'natural' approach.   Second surgeries are also a thing, the explanation was often that the surgery was indeed successful, but the degeneration had progressed and needed to be repaired.  

This all denied and dismissed the natural ability of the body to heal, repair and rebuild all on its own if given the right 'ingredients'.  I have had many patients tell me their doctors would suggest a very strong steroid and if that did not work, a surgical procedure to repair a problem with the large or small intestine.  Not once did I see a patient that told me of the dietary changes that needed to take place to help the gut heal.  In fact I used to teach mindfulness and meditation techniques to a group of 'ostomy' patients.  These people had either a colostomy, ileostomy or urostomy.  I would sit through a class and listen to their stories.  Interestingly very very few spoke about the diet changes they made.  Some actually were there to find ways to eat what they did before and not have to bear with the consequences.  It was surprising. 

People have no trust of nature.  They would so much rather just take a pill or cut out the offending organ.  It is certainly easier in the short run.   Later there is scar tissue, other side effects etc. 

That brings us to the current healthcare crisis in the world.  People are terrified because of the news, social media and pharmaceutical companies reports and recommendations.  Always skewing the story to highlight the benefits of medicine rather than ever promoting self care, home care, nutrition, supplements, rest, relaxation techniques, exercise, or herbs.  Well the obvious reason is there is a lot more money to be made with a patented pill than telling someone to eat more apples... 

People post how happy they are that they are getting the latest injection.  That THEY were in the first group to get a booster, are taking the latest 'FDA' approved medicine.  While those that are doing self care are afraid to tell anyone in fear they will be labeled a loony or 'Antivaxer' or in the worst case, not let into some event or have their children be at risk for a visit from the social worker.  It is amazing that natural health is so underground. 

Bumps and grooves in the brain

The brain is called the cerebrum, it is about 3.3 pounds in weight and 75% of the weight is water. the mass of the brain tissue consists of about 50% fat.  This 

The brain is covered in a wrapping of grey matter called the cerebral cortex.  Grey matter is the nerve cells that do not have an insulation on them called myelin.   The myelin insulation helps the nerve information travel more directly, the grey matter or unmyelinated neurons can send, connect and hold information.  White matter covered nerves can send impulses at 150 meters per second, while grey matter cells tend to send information at about 5-10 meters per second. 

This grey matter covering, if flattened out is about 2.5 mm thick and about Or about 1935 square centimeters that  is around 300- square inches, so think of a square 17" by 17"...  That, according to my findings is about the size of an average adult male, of course that is totally different for children and people that are either smaller or larter.   The brain though sits in the skull, technically called the cranium.  The cerebrum (brain) sits in a bath of fluid inside that case, but it is not 17 inches square.  The cerebrum has all sorts of folds and bumps and grooves.  The bumps and grooves on the surface of the brain were once thought to be pretty similar with everyone.  That is, most people seemed to have the same gyri (those are the bumps) and sulci (the grooves).  However, since we have been studying much more about the brain and the similarities and differences among people we have found a few new things.   These convolutions (as they are also called) are more pronounced and the sulci are deeper and the gyri are bigger or closer together depending on how much activity occurs in that part of the brain.  For example, when Albert Einstein died many scientists were interested in his brain.  Figuring they could find out which parts of the brain he used to be so smart they dissected it after he died (of course).  Curiously, they did indeed find an area of his brain that was more 'wrinkly' than other parts or other brains from similar aged men.  That area was on the right side about where the corresponding nerves that control the hand are located.  This was confusing at first, but when they finally realized that Mr. Einstein would practice the violin in order to relax and think about the problems, it all seemed to make sense.  They never did find an area in his brain that seemed to correspond with 'physics' or math, but with more advances in functional MRIs and the like we are getting closer.  Currently, brain scans have been done on criminals and those that are diagnosed as psychopathic.  These scans do show differences than the average brains in the prefrontal cortex.  It has long been assumed that there would be structural changes in the brains of those that have aggressive tendencies.  If you remember the film Young Frankenstein, the brain that Igor brought back was from 'Abby Normal' which turned out to actually be 'Abnormal'.  Which although was a gag for the film, was rather true to what we find in science today.  

Gyri can be wide or narrow, they can be rounded or flattened.  Now rounded or flattened have not been studied and we cannot at this time know what that means, nor do we know if them being wider has any difference in thinking, abilities or other factors related to personality traits.  

In general we have an ok idea of what areas of the brain do what, but there is still much to learn.  The general idea is that the front areas (called the prefrontal cortex) is responsible for planning and 'higher thinking' this is where it is also thought that personality lies.  Other basic areas are the top sides of the brain (called the parietal cortex) is where we sense pain, touch and temperature.  The back of the brain, called the occipital cortex is where vision is perceived, and the sides (temporal cortex) is where hearing and language is produced.   That is the most general aspect of the brain topography (surface).  Other functions are in smaller areas and since there are two halves of the brain there are more subtle actions on either side. Right now we will just concentrate on the basics of the four lobes; frontal, parietal, temporal and occipital.  There are also other parts of the brain we can touch on later, the cerebellum, midbrain, diencephalon, corpus callosum and the insula.  

When you fold and scrunch up that 300 square inch cortex it can be folded into the small space that is our cranium.  Turns out though that some people can have over 400 square inches and it can be over 3 mm thick!  That is a lot of brain tissue to stuff into that small brain case (the cranium)!  

MEDITATION: So what does this have to do with meditation?  Well, we find that those that meditate can have a great variation in not only the topography of the brain but also the size of areas inside the brain as well.  We now know that places in the brain like the amygdala, which is linked with fear and aggression do decrease in size as we practice more meditation and that in people that are aggressive, like the psychopaths I mentioned, have larger amygdalas.  

Meditation has shown to increase the thickness of the cortex especially in the prefrontal cortex. but how?  When you use more neurons and use them more frequently those established connections become stronger and take up more cell space.  That would account for the thickness.  As more and more of the brain tissue is used it begins to grow, and since it cannot grow to the sides it has to fold over, bigger gyri and sucli result.  One common idea is that 'neurons that fire together wire together' a phrase coined by Psychologist Donald O. Hebb, now it is called 'Hebbs Law'.  Although more current research does better explain the physiology and neuronal growth, pairing down and reconnections made as we age, learn and grow, it is still considered a useful 'law' of psychological brain theory. 

We do know these areas which I will cover in more detail later. 

Left Precentral Gyrus:  Called by some the Motor Strip or the primary motor cortex. On the lateral surface of each frontal lobe, anterior to the central sulcus and runs parallel to the central sulcus.  This is part of the body-motor or somatomotor cortex. It controls voluntary movements of the opposite side of the body, generally the face and head.   If damaged it can cause paralysis of the part of the body it serves.  If we do body scans it can get more action and therefore it stands to reason that it would become thicker. 

Right Fusiform Gyrus, on the inferior (bottom side) of the temporal and occipital lobes.  This is basically just deep to your ear and a little behind it..  It helps us recognize faces and has a special area, the 'Fusiform Face Area' that helps us recognize facial expressions.  This area is also implicated in 'Autism Spectrum Disorders' as if there may be damage to those neurons.  Oxytocin, a neurotransmitter called also the 'love hormone' is at work here as with an abundance of it we recognize faces easily, and with a depletion of the neurotransmitter we find faces to be unfamiliar and this could be a link for anxiety, fear, paranoia as well as the ASD patients. 

Right Anterior Dorsal Insula, (gets more defined with more years of meditation).  Remember when we were discussing the four lobes of the brain?  The frontal, temporal, parietal and occipital?  Well there is one more. It is the insula.  (that means basically it is insulated or covered on the outer layers by the frontal, parietal and temporal lobes.  It has to do with the sense of interoception, that is the homeostatic emotions of thirst, pain, fatigue.  Subjective perceived dyspnea (shortness or difficulty of breath as in a panic attack seems to be registered here).  This part, being on the right, dorsal (towards the top or back of the head, and anterior (towards the front) is very close to the amygdala and is a very emotionally related part of the brain.  fear, disgust, anxiety and happiness are related to the activity of this area.   Oddly if this area is damaged loss of libido, a sense of apathy and the inability to tell fresh from rotten food occurs.  This seems to be where the mind and body are integrated... This is the seat of empathy. 

Left Anterior Dorsal Insula-See above, although, this area is associated with affective-perceptual and cognitive-evaluative forms of empathy.  Cognitive perception is the ability to infer another's thoughts or beliefs.  Affective perceptual basically means emotions, amd being able to make inferences about others emotions and feelings.  THis is the basis of empathy. 

Another very interesting area of the brain, well, a few areas of the brain that do work together is the Default Mode Network.  This is the day dreamer part of the brain, active when we are not thinking about something directly.  These areas of the brain are also thought to be the 'center of the self'.  Our memories and emotional descriptions of ourselves, it seems to not be very analytical, but is reactionary.  It is like the brain that keeps track of the brain.  Now very linked to things like depression, anxiety and reactionary issues. 

A lot of this is in the realm of cognitive science and psychology, but now the science of meditation is showing it has a stake at the table too.  Now that we are getting an idea of the functions of the different parts of the brain as well as the combination of those functions and the emotional association areas we can start to ask; 

"So how do we enhance or work with that within the meditative arena of techniques? " 

Well, that is my question indeed . 

White matter changes: https://www.healio.com/news/psychiatry/20120620/mindfulness-meditation-associated-with-changes-in-brain-white-matter?utm_source=TrendMD&utm_medium=cpc&utm_campaign=Healio__TrendMD_1

CNS and ANS changes: https://www.pnas.org/content/pnas/106/22/8865.full.pdf?__cf_chl_jschl_tk__=pmd_DzINzwJG1bVAkltNU8aWhvHM5psU2JU96t56d8r4oO8-1631679209-0-gqNtZGzNAfujcnBszQd9

Neural oscillations related to meditation: https://www.frontiersin.org/articles/10.3389/fnins.2018.00178/full

Posterior Cingulate Cortex and meditation: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.737.2700&rep=rep1&type=pdf

Anxiety and mindfulness: https://pubmed.ncbi.nlm.nih.gov/20350028/

Default mode increase: https://www.sciencedirect.com/science/article/abs/pii/S0304394010014096

Right Fusiform Gyrus, ASD?  https://www.sciencedirect.com/topics/neuroscience/fusiform-gyrus

The RIght Ant Dorsal Insula and empathy.  https://www.sciencedaily.com/releases/2012/10/121024175240.htm

Perspective taking and empathy.  https://www.frontiersin.org/articles/10.3389/fneur.2018.00491/full

Mammal empathy; https://www.semanticscholar.org/paper/Mammalian-empathy%3A-behavioural-manifestations-and-Waal-Preston/246eafeed9825257764d4c37cbad21558227afca/figure/4

https://www.med.wisc.edu/news-and-events/2011/november/psychopaths-brains-differences-structure-function/

https://www.historyofinformation.com/detail.php?id=3902

https://www.gatewaypsychiatric.com/default-mode-network-and-depression/

STRESS (Fight, flight, flee, faint) It is all in the spine.

 The sympathetic chain of the nervous system is part of what we call the autonomic system.  Think of it as an 'automatic' preset of how you relate to the world and your thoughts.   The sympathetic chain as it is called is a set of nerves all connected together on the sides of the front of the spinal column from the base of the neck (at the first thoracic segment) down to about the first of the lumbar segments (L1).  To find that area on yourself, put your hand behind your back and have your pinky finger touch where your belt would sit then spread out your hand.  Where your thumb comes to rest is about L1...  

In chiropractic and osteopathy it is common to do mobilizations of that entire area which can stimulate the sympathetics to act a little more normally.  When they are over toned or too tense they do not work as they should.  More about that later. 

The sympathetic system has a couple different connections that use acetylcholine to send information.  Acetylcholine is a neurotransmitter released by nerve endings to either glands or ganglions (ganglions are collection of nerve cell bodies which attach to other nerves.).  Generally the release of acetylcholine at the connections to the ganglions will stimulate the release of norepinephrine (another neurotransmitter that can also act as a hormone).  This will cause constriction of blood vessels, glands to secrete, and the heart muscle to increase force and speed of beats.  

The sympathetic system, when active and effective is essential for survival. When we find ourselves in a life threatening scenario we release norepinephrine and epinephrine and go into stress mode.  This helps us to be ready to run from danger (flee), act for our protection (fight), be still to not be noticed (freeze) or go limp (faint).  Each has a place of use in different situations.  For example, in the Boston Marathon bombing of 2013, you can see the different reactions of the victims.  It was an event that was highly filmed and many cameras were facing the explosion and aftermath.  If you watch the video there are some that momentarily freeze, some faint (even those not struck by debris) some run away (flee) and some run towards the incident (fight)... These people had a huge diversity of training and mindsets at the time of the bombing but they reacted based on their nervous systems' settings.  Now, some initially froze then ran away or towards etc, that is also a part of this system.  No one of the presets is the only reaction you may have.  One can bounce through all of them in a matter of minutes and if hard set in the system will lead to post trauma stress.  (PTSD).   That is for a later discussion where we will discuss ways to reset and rehabilitate the system to a more normal range.  

Generally it has been understood that the sympathetic system is short lived.  It will be active during and for a short time after an incident that causes the stress.  We all understand that this is too simplistic.  Stress of an event may be short lived, but the body and nervous system is in a hightened state of awareness for a long time after the problem has passed.  If it lasts more than a couple weeks it is PTSD and other such neurological maladies. 

Time to ask questions. If you have the disease that shall not be named.

 We (chiropractors and other natural health providers) have had a hand in the health of people in many ways throughout our histories. Sometimes we are berated (at least for a while) until we are found to be correct... (a whole history lesson is in there)...

What do you do in the current events? How will you find us in history? I watched this video: https://youtu.be/QAHi3lX3oGM He outlines some things that SHOULD have been done, how medicine and politics and social media fail so many people. In there is a little gem that you as a natural health care provider PROBABLY told people to do. Look it up.

https://aapsonline.org/covidpatientguide/

That is the guide, look at the nutritional info... something many, if not all natural health providers have told many throughout the years of flu season and the like now the big 'disease that cannot be named online'... I posted a few posts on blogs, Facebook and YouTube that were deleted or erased for simple things like drink more water, do breathing exercises and other totally unharmful practices... This outlines how we can help people ask the right questions, get the right information and not be afraid, because fear will fuel every disease (dis-ease)... Keep treating, fear and stress are deadly and your work helps (or should help people) dispel fear, improve relaxation and calm thinking...

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When and how to take a break from practice when it is going stagnant.

 They say "the difference between a rut and a grave is the depth".... Finding yourself frustrated or saddened with your current practice, some (as in the Zen tradition) would tell you, if you are frustrated with zazen, then sit in zazen. There is certainly something to that. Often you are at the precipice of some real insight or breakthrough when you notice you 'are not getting it' or are frustrated or what ever. However sometimes it is good to stop and do things differently . (It is also said, "The definition of insanity is continuing to do the same thing over and over and expect a different result." ) in Buddhism and the Buddha's teachings in general were good for all but some were not 'one size fits all' especially if you read into his direct teachings. He continually changed the guise of his lessons depending on the ability of the learner, using examples, direct lessons, simile, metaphor and the like. This is an important concept to adopt, maybe sitting (this or that way) is not for you? How have you changed your practice that helped you out? Have you found yourself against a wall? What did you do that worked? What didn't work?