Schedules of care for children, by Dr. Ogi Ressel

Monday, April 6th 2009

Warm hellos to all;

This week's THOT is a little different - it is on an issue which is the topic
of considerable controversy and is rarely discussed.
It will also be the topic of my Kids First column in the WCA Journal in June:
Schedules of Care for Children

I just returned from lecturing in San Francisco and many doctors in the
audience were very concerned about schedules of care for children in
light of the Masters Circle class action lawsuit.

So...Let's see if we can shed some light on the issue of corrective & Wellness
care for kids: First of all, I'd like to be emphatic and state that children do
need Chiropractic care - it is not a luxury.
It is a necessity.

Let's look at this from a clinical perspective:
In the child, neuromuscular and functional adaptive reflex development
represents a critical period of time when the young developing nervous
system assimilates, differentiates, and adapts to external and internal stimuli.
By means of these processes, the nervous system learns proprioceptive
patterns and acquires future neural habits and reactions by responding
to repetitive stimuli.

However, such a developing nervous system is not always able to
distinguish between proper and improper stimuli; therefore it responds
to both. This is the conundrum - the response is neither "good" nor "bad",
but rather adaptive to the presented stimulus. These adaptive responses
are remembered, patterned, habits are formed, and the young nervous
system is conditioned for future response - this is the key!

This process of neurological "learning" or "programming" of the central
nervous system with respect to locomotion, posture, proprioception,
function, and body kinetics begins within a few short months after birth.

You are wondering what this means....
Health issues such as Scoliosis, Colitis, Colic, "Growing Pains", bowel
and bladder problems, Asthma, Infertility, etc., just to name a few, are
clear examples of such faulty neural programming in children. Many, if
not most, of the problems seen in children, are the result of an adaptive
neurologic response to some sort of a stimulus.

For example, Scoliosis is often the result of an error in pelvic function.
Infertility caused by decreased peristalsis of the Fallopian tubes, is another, etc.

Let's look at this more closely for a moment: If you consider the pelvis for
example, you'll see that the main function of the pelvic musculature it seems,
is not to generate motion but rather to stabilize the pelvic mechanism for
effective load transduction - the process of transfer of both elastic and
gravitational forces between pelvic components in kinetic motion. Thus,
sacroiliac articulations can be assumed to be large mechanoreceptors located
in the centre of considerable force streams being transferred by the pelvis
from the upper body to the lower limbs. Further, these articulations are
essentially ground into shape according to impulsive loading and learned
kinetics and their ligamentous apparatus shows adaptations to strong
long-time stresses.
Looking at this learning process from an adaptive perspective, it is not
difficult to understand why a child would develop Scoliosis, or "Growing Pains",
or Colitis, or....

As chiropractors, our main course should be concerned with chronic "low-grade"
efferents from the autonomic nervous system that result from and thereby
not only disturb normal neurological "learning" but also initiate "learned"
and adaptive reflex kinesiopathophysiology. It is then of paramount importance
to eliminate any faulty programming as soon as possible.

Your mission - the reason you became a chiropractor - is to initiate specific
corrective procedures designed to correct vertebral subluxations, alter and
change errors in learned and adaptive kinesiopathophysiological patterns,
restore normal articular function, reduce disc stress, and optimize neurologic integrity.
Have I missed anything?

In light of the above, do you think it is reasonable to expect that the above
can be accomplished in just a short few office visits?

The Masters Circle lawsuit, it seems, was borne out of thinking that there is
no need for corrective and wellness care for children - that it is a misnomer
designed specifically for the sole purpose of extracting money from unsuspecting
parents. That such care, if rendered, would represent "unnecessary Chiropractic
treatment" - whatever that means. Nothing could be further from the truth.

And here lies the crux of the matter: Medicine looks at what we do as some
sort of a "treatment" or "therapy"- physicians are unable to understand the
reality of a Wellness approach. ...And from their perspective, their thinking
makes perfect sense - why would you continue to see a therapist for life?
The basic tenet of therapy, after all, is that it has a beginning and an
end - so does medical care. It has a start and at some point in time, it's over.
Not so with Chiropractic. There is no "end" - a difficult concept for the medheads to grasp.

Let's examine the concepts which Medicine uses as a political sword in order
to attempt to invalidate Chiropractic in the public eye. I would also like to
add that these same concepts are often used by regulatory boards, and
chiropractors who are thus singled out, are often faced with the gargantuan
task of explaining their rationale for care - with little research to reinforce
their reason - until now:
A. Unnecessary care and Over-Treatment:

The doctrine that patients can be "over-treated", and its subsequent implications,
has been a political sword for many regulatory groups and associations
within and outside the profession.

I feel that there is no such commodity as "over-treatment" and here are my
reasons for departure from this commonly held view:

1.The words "unnecessary" and "over-treatment" have been borrowed from
   Medicineand other allied health careprofessionswhose paradigm is the
   treatment ofvariedconditions and diseases ofthe human body. Because
   the basic tenet underlying this concept is vastlydifferent from chiropractic,
   I feel it should have no place in chiropractic lexicon. Inother words,one
   cannot compare and scrutinize Chiropractic care with a medical microscope.

2. "Over-treatment" implies that chiropractic is based on "treating" some
    condition. This is totally incongruent with chiropractic philosophy of
    subluxation correction.

3. Chiropractic care is not predicated on a framework of allopathic thought - 
   ergo, concepts and ideology which are upheld by other health care delivery
   professions should not necessarily apply and dilute the Chiropractic Principle.

4. There is no rational manner with which one could to impose the concept
   that a patient has been "over-treated." To assign a numerical figure would
   be blindly self-limiting. If normal and accepted care of a certain patient
   necessitates, for example, 50 adjustments, and the patient receives 51,
   that would constitute "over-treatment" by definition. If, however, a patient
   receives 49, that would necessarily mean that she/he was not cared for
   adequately by that same definition. Absurd.

5. The other discrepancy is that within the profession, different groups, 
   associations, etc., have varied definitions of what they consider "over-treatment"
   to be. I contend that if there is such an entity as "over-treatment," then that
   definition should be uniform throughout the profession. That regulatory bodies
   of Georgia, Nevada, Ontario, Florida, Alberta, and such, should have the same
   understanding. That is not the case.  This reality can lead to dangerous
   conclusions. A doctor could be accused of "over-treatment" in Florida, but be
   found to be practicing within accepted standards in Texas, or Nevada, or Ohio.
   This inconsistency of philosophy and understanding can be devastating, as
   it is never set down in written word in any Professional Standard. Most often 
   it is only a "perceived" or "reasonable" standard that doctors are asked to
   abide by - whatever that means.

6. The other aspect of this quandary I take issue with is its very reality - members
   of our profession taking care of their own families. Many chiropractors check
   and adjust their children and families 1-2 times per week - you probably
   do as well. That in itself translates into 52-104 adjustments in the course
   of a given year for each family member. Many would consider that figure and
   frequency as "excessive" if it applied to an actual paying patient. "Unnecessary"
   comes to mind. Yet when it applies to a family member, it seems to be totally
   permissible, reasonable, and utterly accepted. We seem to have two sets of
   values within the profession when it comes to the issue of "over-treatment" -
   one which is real, and one which is politically convenient. This is a contradiction
   according to Dr. Patrick Gentempo.

 B. Frequency of Care:
    The second "doctrine" which has hampered care of patients and patient recovery
    has been the issue of "frequency of care." It is nowhere written, yet every
    chiropractor seems to be familiar with the recipe of seeing a patient on a schedule
    of care, which would initially start with a frequency of 3x per week.
    This would be eventually reduced to 2/week, once/week, etc....And at some
    point patients are placed on Wellness care.I would not be out of line when stating
    that the majority of chiropractors approach patient care in a somewhat similar
    manner. To venture outside this accepted formula is to leave oneself open for
    possible repercussions from insurance and governing organizations.

 I contend that the above view may be considerably limiting and even
detrimental to the health of the public. 

I would like to point out that when I was in practice, many children patients  
of our Center were often placed on long-term care schedules whose primar
y goal was to alter and cause a change in existing neural programming,
physiology, and pattern habituation. Many were seen on daily visits initially,
in order to cause a change in their learned kinesiopathophysiology and break
their subluxation patterning.

I feel that patient care should be dictated by patient needs and not be limited 
 by some unquestioned yet ambiguous standard. I believe that whatever needs
to be done to help a patient regain their health, should be done. Sometimes
 that necessitates very frequent patient contact; sometimes not. The decision
should rest entirely on the attending practitioner. At the same time, such a
chiropractor should not feel pressured into providing sub-standard patient care.

I have seen, as you have also, that many times patients are simply not seen
frequently enough to enact a change in the pattern of their subluxation. This
can have serious consequences. It may not enable the chiropractor to correct
the problem the patient has consulted him with.

This in itself can have devastating implications not only for the patient, but
also for the doctor and the reputation of the profession. In the most serious
circumstances, it can be perceived as providing care which can be seen as
fraudulent - it is provided under false pretenses.

I also feel that doctors often do not see the results they should, as they do
not see a patient on a schedule of care that is conducive to actual correction
of a subluxation. To correct a subluxation habit, one that has become deeply l
earned, often an aggressive approach seems to work best - even in babies and infants.

Long-term schedules of corrective care, with very frequent initial contact - often
daily, seem to yield amazing results. Such an approach tends to change neural
programming and learned patterning much faster and more completely than
any other approach. This strategy provides excellent results, is cost effective
for the patient in the long-term, and provides the doctor with a base-line
approach that is built on certainty and data rather than dogma and rote.

The regimen of care should not be rushed, and patient care should not be
based on symptomatology - recovery should be measured by objective
findings - it is essential that regular progress examinations be done to
measure patient progress.

I hope that the above has given you some food for thought, and some research
rationale for the care of children who cross our thresholds.

For those who would like to read more, please check out my paper
"Vertebral Subluxation Correlated with Somatic, Visceral, and Immune Complaints:
An Analysis of 650 Children Under Chiropractic Care" at www.jvsr.com <http://www.jvsr.com>

Warmest wishes,
Dr. Ogi Ressel