Many doctors of chiropractic know firsthand that using their own bodies to help relieve patient pain can backfire. Kerwin Winkler, DC, is philosophical about it. "Ergonomically, pain goes with the territory. Sore necks are common to electricians. After all, they're always looking up -- and we're always adjusting."

Many DCs develop ligament strains, vertebral disc conditions, tendinitis, and muscle strains -- in addition to problems that arise from degeneration.  Wrists, thumbs, shoulders, and lower backs are among the most typical pain-producing sites, according to Ronald L. Rupert, MS, DC, director of research at Parker College Research Institute.  

Warren Hammer, DC, singles out the carpal metacarpal (CMC) thumb joint as "probably the most injured area"* because it was never designed to do what doctors of chiropractic require of it.  "This joint, which is also a common location for osteoarthritis, is not a weight-bearing joint.  Direct vertical pressure cannot be tolerated, nor can hyperextension, over time."  Dr. Hammer explains that because the CMC is a saddle joint, "due to an incongruous surface, there is increased contact stress where only small areas of the joint surfaces articulate.  This trapeziometacarpal joint is built for mobility and relies heavily on ligamentous and muscular restraints to control joint stability. Increased pressure on this joint over time results in hypermobility and eventual degeneration." P. Thomas Davis, MUP, DC, retired associate professor with Northwestern Health Sciences University, says he used to his "steel thumbs" for years on patients -- when he wasn't demonstrating technique with them for students. "Now," he says, "my thumbs are permanently damaged from overuse and arthritis."

When their preferred treatment "modality" breaks down, many doctors of chiropractic make a switch.  Dr. Davis says that DCs with sore thumbs may choose to use their elbows to work on patients' soft-tissue problems, which shifts the stress over to the shoulder joints. These joints were never designed to handle the amount and frequency of exertion a full-time doctor of chiropractic can put on them in the course of a day, and while the thumbs do get a break, it's at the shoulders' expense.

Dr. Hammer says that most of the pain suffered by field practitioners arises not from adjustment-related traumatic injuries, but from aggravating pre-existing injuries.  Dr. Davis admits that he came into chiropractic with an old sports injury that affected his lower back and caused him to modify what he did for patients.  But degeneration, he says, was also an issue.  "I was 39 when I started chiropractic school as a second career.  My body was no longer as resilient as it was in my 20s. I find that many chiropractic students today are older, too -- or they come to the profession with physical disabilities.  They need to stay aware of what’s going on with their bodies—and they must be careful."

Practice Forever?

Even younger DCs should be thinking about the toll that time and chiropractic will take if they habitually mistreat their bodies. A doctor of chiropractic who is hoping for a decades-long career needs to weigh many factors, including techniques, equipment, posture, and types of practices.

- Techniques -
Dr. Davis points out that Arlan Fuhr, DC, the originator of the Activator technique, developed his own technique out of necessity.  Dr. Fuhr would go home and have to soak his elbows and hands in ice water for half an hour every day after work.  "A lot of DCs do that," says Dr. Davis.  "When I lived in Alaska, I recall that at the end of my day, I'd fall asleep on my roller table after getting rolled for an hour to ease the pain.  My wife would call, wondering when I was coming home.  We DCs use different methods to help keep us functioning."

Some DC pain, he says, comes from performing certain kinds of manual therapy techniques. "I was a Gonstead practitioner," says Dr. Davis. "Physically, that's a very demanding technique.  It may not be politically correct to say it, but aches and pains made me modify my approach."

In time, Dr. Davis switched over to flexion/distraction, finding that it allowed him to continue to help patients, but was not as hard on his body.  "When I used flexion/distraction with a manual table, however, I developed medial epicondylitis in both elbows, so I had to stop."  He then bought a distraction table, which "tended to make my job easier."

- Posture -
Dr. Rupert says that doctors of chiropractic must be aware of their posture at all times while working with patients.  Many DC injuries, he says, happen when the practitioner is bending or twisting to perform an adjustment.  Dr. Davis recommends that DCs experiment with the bent-kneed "fencer's stance."  "It's easier to hold," says Dr. Davis, "and it's much easier on the back."

- Equipment -
Another concern is table height.  "I'm tall, so my tables have always been tall," says Dr. Davis.  He believes, however, that any doctor of chiropractic should have a height-adjustable table to benefit not only the DC, but also shorter patients or patients who are older or who have difficulty climbing.  (He says the Americans with Disabilities Act may make it possible to get a tax break on such a table, and he recommends discussing this with a knowledgeable tax person.)  Another point to consider is the need to have equipment that can be used by DCs of differing heights. "If you have a two-DC practice and one is tall while the other is short, you'll need an adjustable table, anyway."

Dr. Davis says that if you're using a manual table and it hurts, a motorized table may be a worthwhile investment. A motorized table can also make it easier for the DC to use certain techniques. "If you're doing distraction on a manual table," says Dr. Davis, "it takes two hands and arms almost fully extended while you press down on the patient toward the table.  Since you're providing all the power, there is a potential for low-back problems.  With a motorized table, you can put one hand on the patient, inferior to superior on the back -- while holding the patient posterior to anterior with the other hand.  You have much better function, and it's easier on the DC's elbows -- and the rest of the body." 

Dr. Davis favors highly motorized tables.  "I used a powered table like a Leander to do the flexion, which helped tremendously. Cox tables are more expensive, so for budgetary reasons, I recommend my students look into a Leander when they start practicing.  It will save wear and tear on their bodies."

Dr. Davis believes the best table never made it to the market.  It was a highly engineered table designed by Tom Hill, DC, who developed a motor and camming system that was very smooth and that did linear distraction in the long, or Y, axis.  "The previous ones just went up and down and caused the lower section of the body to flex and even extend."  Dr. Davis says that Dr. James Cox later developed his own table to do linear distraction in the long axis because he wanted to be able to stretch people before flexing them.

- Practices -
Another issue to be considered is the type of practice the doctor of chiropractic chooses. Years ago, Dr. Davis's patients were mostly laborers.  Because they consistently overworked their bodies, Dr. Davis employed some strenuous physical responses to help them -- and his body paid the price. 

Many graduates of chiropractic colleges come to the profession by way of a powerful interest in sports.  While a sports practice can be lively and interesting, Dr. Davis says it's physically harder than practices with older or less-active populations.  If a DC's body is feeling the effects of overwork and the practice is physically demanding because of the predominant type of patient, a practice with a mix of patients or one whose patients are mostly older may be preferable.  But, as Dr. Davis says, "older people have problems that younger ones generally do not—and that should be taken into consideration as well."

- Individual Issues -
There is another consideration—the uniqueness of the individuals physical reaction to stressors.  "The important thing to remember," says Dr. Davis, "is that if it hurts, you need to modify what you are doing."  In other words, "no pain, no gain" does not apply to the work of the doctor of chiropractic.

Prevention and Wellness for DCs

In addition to standard regular exercise, good nutrition, proper chiropractic care as needed, and other healthy habits, doctors of chiropractic may want to look into something more specific to a DC's needs.

Ethan Feldman, DC, developed an abiding interest in teaching injury prevention to doctors of chiropractic by accident -- quite literally.  "It didn’t seem like such a big deal at the time," he says, "but I was adjusting a patient on a busy Friday afternoon.  I had invited a DC in to observe -- he was interested in becoming an associate."

It was a bad combination.  As Dr. Feldman says, Fridays tend to be busy, and while he was paying attention to the young DC, he momentarily lost focus on his body and the patient. "I pulled a patient by the hips to reposition him on the table and felt a little "give" in my back that never quite went away.  About 3 months later, it actually paralyzed some inner-thigh muscles -- in other words, something -- a psoas spasm, perhaps -- had entrapped the femoral nerve. It took quite a while to rehab from that. Coming from a dancing and fencing background, I thought I already knew how I was supposed to do it -- but I still injured myself by losing my awareness."

Dr. Feldman experimented in several directions, including the Alexander technique.  He finally relieved his pain with Tai Chi-based movements.  "Tai Chi breaks down the art of pushing and pulling -- in the forms of punches and kicks -- but the movements are so slow that you know immediately if you aren't centered because you lose your balance.  Being physically centered is crucial to the prevention of injury for a doctor of chiropractic." Dr. Feldman says chiropractic adjusting is mainly a matter of pushing, while bending over patients is a form of pulling.  He reminds doctors that for every action, there is an equal and opposite reaction, so preparation and centering are crucial if DCs are going to avoid repetitive-strain injuries.  "I translated the pushing movements of Tai Chi into those we use in chiropractic.  Once I had mastered the forms I needed, the back problems disappeared—and my adjusting skills improved, as well."

Dr. Feldman has developed a number of exercises that are helpful to the field practitioner.  "I use the principles of proper biomechanics included in Tai Chi -- or in any sport or movement form.  They all use the same rules; I just happen to teach what applies to chiropractic.  The position of a basketball player preparing for a free throw is exactly the same as the one a DC should use during a leg check. It provides a doctor with back protection."

- Adaptability Important -
"A doctor of chiropractic who uses one contact point for adjustment is like a ballerina who always dances en pointe.  The big toe is not meant to take that much weight all the time—any more than the thumb, the wrist, or the index fingers are," says Dr. Feldman.  DCs who alternate among various parts of the body, using the elbow or the sides of the hand, will get a lot more longevity out of their hands. "When I adjust a lower cervical, I no longer use my index finger because it causes ulnar deviation, which compresses the triangular fibrocartilage at the wrist.  Instead, I use the knife-edge contact of my 5^th metacarpal.  It makes a huge difference." Dr. Feldman says he figured this method out when he sprained his wrist and had to come up with a way to continue adjusting patients.  "Necessity," he says, "is definitely the mother of invention."

- Spinal Positioning -
One thing doctors of chiropractic should keep in mind, says Dr. Feldman, is the position of their spines. "DCs are really at an advantage because they know what a good lumbar curve looks like.  What they don't know," he says, "is that the curve needs to maintain its lordosis while they bend over their patients."

Dr. Feldman says that most of the injuries suffered by doctors of chiropractic are to the lower back.  He suggests they not only keep their knees bent, but also maintain that lumbar curve exactly as it is when they are standing erect.  "That will give them the proper strength to support their weight plus the patient's weight while they are in a leaning-forward or a pulling position."

- Lifting and Bending -
"When I ask a doctor to show me how he bends over his patients, he usually twists because he is standing at the side of the table," says Dr. Feldman.  "He reaches with his arms, slumps the shoulders, and bends from the waist, losing his lumbar curve."  He says DCs are always telling patients not to bend over and twist, but they do it themselves all the time.  Bending and twisting taxes muscles, ligaments, and discs. It's vital to keep the back long, the lumbar lordosis intact, and to bend at the knees and the hip sockets, rather than at the waist.  "Lordosis is only lost," he says, "during the pushing, or thrusting, phase, which is momentary."

- Proper Thrust -
In the thrust, for most moves, the DC needs to tuck the pelvis. "When the pelvis is tucked and the lumbar lordosis becomes straight or kyphotic, that's good. It allows the abdominals, pectorals, psoas, and any other necessary flexor or stabilizing muscle groups to engage.  The lumbar spine is an arch that can bend both ways.  Think about a stringed bow.  If you were to try to straighten it, the string would give you resistance.  The 'string' is your abdominals and other flexor muscles.  Similarly, when you are pulling, lifting, or bending, the string is the multifidii and erector spinae muscle groups. Trying to push when you are in lordosis or pull when you are in kyphosis is like bending the bow from the side opposite the string—there is no strength.  The majority of the time that we bend over patients, however, our lumbar spine needs to stay lordotic."

- Whole-body Adjusting -
Dr. Feldman says that chiropractic schools are good at teaching students how to "set up on a vertebra the right way" and that they sometimes teach how to thrust through the fixation.  "But," he says, "there is never any attempt to try to teach how the whole body of the doctor of chiropractic is involved in the adjustment."  If you don't learn that part of it, he says, it's no better than teaching a judo throw -- without including the "throw" part.

The doctor of chiropractic, like the martial artist, must come from his or her center, which is usually the center of gravity, he advises.  In men, this is the area around the lower abdomen.  In women, it's a bit lower into the pelvis.  "No matter what segment you are thrusting into," he says, "the doctor must have a convergence of vectors coming from the shoulders, sternum, and pelvic or abdominal center, with the feet either dropping away (as in an upper- or middle-posterior thoracic move) or pushing in an opposing vector to the thrust (as in a cervical adjustment)." Dr. Feldman says that doctors who practice healthy body awareness can, in time, come to know when their bodies are properly aligned and ready to adjust.

- Soft-tissue Treatment -
Dr. Hammer believes that practice-induced and practice-aggravated injuries to the DC's hands, wrists, and other areas would respond well to the use of Graston instruments.  He says the instruments have a number of advantages -- including the detection of areas of restrictions.  "Instead of repetitive flexion and extension of the wrist or exerting pressure with the fingers, these instruments can be utilized without repetitive carpal or phalangeal motion," he says. "It's a matter of just lightly holding the instruments and freeing soft-tissue restrictions."

Physician, Heal Thyself

Dr. Tom Hyde adds, "Doctors of chiropractic are always concerned with treatment that will make others feel better, but DCs should heed their own advice and take care of their bodies—so they can care for their patients longer."

 

Reference
*Snodgrass SJ. Thumb pain in physiotherapists: potential risk factors and proposed prevention strategies. J of Manual & Manipulative Therapy. 2002 10(4): 206-217.