In chiropractic literature, it is not rare to see a single, identical technique being called by many different names, depending upon the author and the school attended. There is a single common clinical fact that should make us more willing to precisely document the technique used. On the same vertebral segment, certain techniques will be successful in bringing relief; others will not.
In your office, for example, you treated Mr. Doe six times without great success; then on the seventh visit Mr. Doe comes back and tells you: "Doc, to be frank, I was ready to see the chiropractor down the street from you, but you did something new last time, and I've being feeling fantastic for two weeks." But your enthusiasm is dampened when he adds: "A little twinge came back, can you fix it ?"
Whatever your philosophy is, you want to help this patient. You will probably look into your notes, and find very little information on the technique used.
Why Chiropractors Do Not Accurately Record What Technique Was Used
The obvious answer is technical difficulties, which can be summarized by the multiplicity of our schools, the complexity of technique positioning, and the time factor (describing each technique takes page space). Taken all together, it becomes very cumbersome.
We have been so busy adapting to the medical format that sometimes we forget what is useful to us. Chiropractors have not yet introduced a valid, easy-to-use system to describe in just one name a specific technique which will be familiar to all of us, from California to New York, independently of our backgrounds or proprietary techniques.
Not having a standard technique description has resulted in various problems:
- We are probably the only profession to assume that a description of our procedure is useless. Every week we read surgical procedures performed on our patients, yet it has not sunk in that promoting a profession involves giving a description of what we do.
- The most pertinent example of this is the complete lack of mention of a specific technique in the thousands of reports going out every day to insurance companies, lawyers or colleagues.
- Thousands of adjusters know us through our bills, but our profession has never taught them what we really do. Yet one cannot open a chiropractic journal without reading about the necessity of educating our patients. Even better, we brag about being the best in educating our patients, while not educating the ones who pay our bills. (Editor's note: See "Draft of Procedural/Diagnostic Code Book Released" in "DC", May 20, 1996.)
Don't you think it's time to change this? There are currently other professionals trying to seize vertebral manipulation to their benefit. Should they standardize their technique description, they would certainly get recognition for it, and I can bet you they would not be as shy as we are to speak about what they do.
There is an urgent necessity to implement an intraprofessional codified nomenclature that will set the standard for any professional using vertebral manipulation. There is a marketing effort to be made at all chiropractic levels to first endorse, then back up, and finally push this idea to a point where every single chiropractic report, soap note, and travel card carries a quick and easy way for anyone to know what technique has been used. We can legitimize on paper the richness, precision, and diversity of our great chiropractic profession.
Proposal for a Codification System
Various attempts have been made to implement such a system, none to my knowledge has been successful. That is why I am writing this article. I have used this codification system with great success and put it to the test with numerous colleagues and in my own office.
Here's how it works. The name of the technique contains five variables, each describing a positioning characteristic presented in a determined sequential order, each separated by a slash mark. The sequential order is easy to understand and follows the steps needed to adjust a patient.
Technique Chart
DATE __ /__ /__
__________________
VERTEBRAL LISTING |
| Based on Transverse ___ |
| Based on Spinous ___ |
= _______ |
= _______ |
= _______ |
EXTREMITY LISTINGS |
| name: |
= _______ |
= _______ |
| Articulation in |
| Flexion ... |
| Extension ... |
| Adduction ... |
| Abduction |
| Internal rotation |
| External rotation |
| Inversion |
| Eversion |
| ........................... |
| Symbol | Listing | 1 | 2 | 3 | 4 | 5 |
1 | 2 | 3 |
PATIENT'S POSITION | DOCTOR'S POSITION | PATIENT'S CONTACT |
| Standing | Position in space | Occiput |
| Sitting | Mastoid | |
| Prone | Standing | Spinous |
| Supine | Sitting | Articular proc. |
| R side down | Straddle | Transverse |
| L side down | Rib's head | |
| Knee chest | Position/eyes | Mammillary |
| PSIS | ||
4 | Front | Sacral base |
DOCTOR'S CONTACT | Back | Sacral tail |
| Caudad | Coccyx | |
| Digit | Cephalad | Ischial |
| Thumb | TFL | |
| Pisiform | Bi Elbow | |
| Hypothenar | ||
| Thenar | 5 | |
| Forearm | VECTOR/THRUST | QUALITY |
| Chest | Direct | Toggle |
| TFL | Rotary | Activator |
| Shin | Direct-rotary | Deep |
| Lift | Shallow | |
| Drop | Pull | |
| Push | ||
Notes: ...
The table below shows how the technique is named. The doctor can either fill in each box by hand, or circle the pertaining variable.
PP | DP | PC | DC | VTQ | |
1 | 2 | 3 | 4 | 5 | |
Patient's position | Doctor's position in relation to patient's head | Patient's point of contact | Doctor's contact | Vector/ Thrust quality | |
| Standing | Standing | Side | Transverse | Digit | Rotory |
| Prone | Sitting | Back | Bitransverse | Hypothenar | Direct |
| Supine | Front | Spinous | Thumb | Rotory Direct | |
| Sitting | Articular proc. | Pisiform | Toggle | ||
| Side | Rib head | Drop | |||
| PSIS | Clockwise | ||||
| Mammillary | Counterclockwise | ||||
| Shallow | |||||
| Deep | |||||
etc. | etc. | etc. | etc. | etc. | etc. |
Using the techniques from Chiropractic Technique (by Bergmann, Peterson, Lawrence), we have the following pattern:
Sitting index pillar in the cervical area (p. 283) would be named: Sitting/standing back/pillar/index/rotarly direct.
Thumb spinous prone thoracocervical adjustment (p. 353) would be named:
Prone/standing side/spinous/thumb/direct.
As you can see, you have an instant visual picture of the technique which was used on the patient.
Try it ! You'll like it!
Take a technique that you perform every day and see how easy it is to put a descriptive name to it. The order of the technique description follows the same steps as those used to apply said technique, so you will never forget it.
1. The patient takes a given position: PP
(prone, supine, side, sitting, knee chest ...)
2. The doctor takes a given position and places his body in a position related to the his patient's head: (standing front, standing side ...) DP
3. A contact point is selected on the patient: PC (spinous, articular process, mammillary ...)
4. A contact point is selected for the doctor: DC (digit, thenar, pisiform ...)
5. The doctor chooses a vector for the thrust: VT (direct, rotatory, rotatory break ...)
Voila, you're done.
The line of drive or vector, is given by two things:
- the anatomical plane of the facet and
- what they naturally allow; the chiropractic listing itself.
There is no need to repeat the name of the technique for every visit, but there is an obvious interest in pinpointing what is routinely used on this patient.
The preceding technique codification fulfills all the following criteria:
Specificity: It describes one and only one technique.
Universality: The interpretation of the technique will be the same for doctors from LACC, Chicago, or Palmer.
Simplicity: This chart follows the classical steps we use to adjust one of our patients, so you will never forget it: 1, 2, 3, 4, 5.
Flexibility: In actual practice, each doctor uses different contacts, and modifies techniques to his liking. The technique name mirrors those changes; each doctor can create a chart with a name to circle to his liking. (If you use the big toe to apply a toggle recoil on your patient's atlas, you can use this chart to name and describe the technique.)
Feasibility: You need to be able to write the name of your technique very quickly for time-saving purposes. It takes a maximum of 15 seconds to write the average six words necessary to name one of the 400 techniques available to us. You can have a "patient technique table" with six columns on each patient travel card, and a letter associated with each technique. What would normally take three pages to describe can be summarized in your soap notes by a single letter for each technique.
I truly believe that the codification of our adjusting techniques would be one of the greatest chiropractic advancements of the past 10 years. I hope this modest article will be inspirational to colleagues who have worked through entities like the Mercy Guidelines to fine tune this system. This codification should be a great tool to create new bonds from every side of the profession and eliminate the chronic problem of low referral between chiropractors.
Etienne DuBarry, DC
2700 PGA Blvd.
Palm Beach Gardens, FL 33410
Tel: (407) 622-9197