As my plane touched down at Chicago’s O’Hare Airport in April, 1999, I felt a sense of excitement. I was scheduled to spend the next three days in the Chicago Bulls’ locker room with Coach Al Vermeil, the head strength and conditioning coach for the Bulls. Coach Vermeil had helped take the Bulls to six World Championships, and I was about to hand him a young athlete who was to get a personalized conditioning program from him during our three-day visit.
The first thing Coach Vermeil did was spend two hours structurally evaluating this young athlete. “You can’t miss a link in the athlete’s Kinetic Chain,” he said. “You never know where the underlying weakness, imbalance, or distortion will originate from.”
dHe checked the arches of the feet, leg lengths, muscle balances, muscle strengths, muscle flexibility, joint range of motion, posture, spinal curves, and much more. He did it with a precise detail, similar to what I’d picture a Russian coach in the 1950s doing. He did it with a precise detail that I didn’t do my exams with. He did more looking for structural defects than I’ve ever done on a patient.
This visit to Chicago became more of a retreat for me, a self-reflection as to what I was and wasn’t doing with my patients. By the time I left three days later, the Structural Fingerprint Concept was born.
The Crisis Graph
The New England Journal of Medicine featured an article in February, 2001 on “Low Back Pain.” The author stated that in 85% of low back pain cases, an exact patho-anatomical diagnosis could not be made. He went on to say that instead of doing an exhaustive exam, examiners should ask themselves three questions:
- Is the pain due to a systemic disorder?
- Is the pain due to a social or psychological disorder?
- Is the pain due to the compromise of a nerve, necessitating surgery?
Nowhere in this article were biomechanics or structural defects mentioned. The content of the article supported The Crisis Graph (Fig. 1). Millions, if not billions, of dollars are spent each year in the “sphere of stress”—that cycle patients live in (doing just enough to get out of pain, treating only the symptoms, and being vulnerable to go right back into pain). With this neglectful approach, dysfunction (degenerative changes, fixations, disc herniations, muscle and ligament weakness, etc.) becomes the ultimate result for most patients. Costs and disabilities continue to soar.
In every aspect of life, whether it be sports, industry, or everyday living, repetitive motion and stresses are common. Structural injuries are going to happen. However, the approach we’ve taken to date is to deal with the external. In industry, we change the position of the monitor, we put the phone in a more ergonomically centered position, we lower the keyboard, we split the keyboard, we sit in an orthopedically designed seat, and we wear wrist supports so our carpal tunnel syndrome doesn’t get worse.
In sports, athletes are encouraged to stretch more, use lotions that remove pain, and wear joint braces and muscle wraps. In everyday life, the average person is sent from doctor to doctor, getting MRIs to rule out herniated discs, blood tests for arthritic changes, and physical therapy or Chiropractic care for 12 visits for the relief of symptoms. All testing is done to determine what pathology is causing the problem and the treatment provided is for the relief of symptoms only. Pathology is not the cause of musculo-skeletal disorders in most cases.
This palliative approach has begun to redefine Chiropractic. Many Chiropractors are now functioning under the guidelines of managed care, where there is a limited number of visits per year they are able to see a patient before the patient has to pay out of pocket. This leads to a less involved relationship, one that focuses more on the pain rather than the cause of pain.
Many Chiropractors have sold their X-ray machines and now enter patient relationships with less structural knowledge, an incomplete diagnosis, and less ability to ultimately help the patient. This is an erosion to the foundation that all Chiropractors have worked so hard to build. Our profession is in a position to become the experts of structure, a specialty desperately needed by all people, and we can’t let this golden opportunity pass us by.
The Structural Fingerprint™ Exam
There are many factors that influence a person’s structural fingerprint. Factors such as heredity, prior injuries, weight, height, conditioning or lack of, job, footwear, mattress quality, car seat quality and angle, diet, habits, common sense, hobbies, etc. will dictate the present status of this patient’s structure. Just like our fingerprint, our structures are also totally unique.
It’s virtually impossible to say with certainty why a person has the structural distortions they have, but what can be done with certainty is to identify the distortions that do exist, and create a plan to begin correcting them.
The patient must be looked at as an architectural structure. No profession currently measures the entire structure of a patient on a dynamic or functional level. Orthodontists look at the alignment and positioning of kid’s teeth, but who’s looking at structure? People spend $3,000–$5,000 and commit to three years of care to straighten their teeth. The human structure should command more importance and consideration. Chiropractors need to claim responsibility as structural experts in the industrial, athletic, and mass markets. We need to raise the importance level of the human architecture. This task should never be left to others, such as strength coaches. We are the experts and we need to aggressively educate our communities of our role and the importance of architectural evaluations.
The detection of imbalances, fixations, degenerative changes, and distortions must occur in either the presence or absence of symptoms. The cost of musculo-skeletal injuries has exploded today and it’s clear why. We’ve become a nation of pathological testing and symptomatic treatment. We need to embrace the importance for biomechanical evaluations leading to rehabilitative corrective measures for everyone.
This exam incorporates all of the tests necessary to collect a set of reference points, a blueprint of sorts, giving us a snapshot of the patient. These normal and abnormal findings now become the starting point when setting up a treatment and exercise program for the patient.
The tests begin with a visual exam (Fig. 2) from all sides. Any obvious imbalances are noted. This is followed by an examination of the arches of the feet (Fig. 3). Any deviations from normal, imbalances between the two feet or stresses felt by the patient in the feet requires the fitting for Foot Levelers custom orthotics. The feet are the foundation of the entire structure, and must never be overlooked when correcting a patient’s structural defects.
Range of motion of all joints, muscle size, compliance, integrity and flexibility are also critical findings. Leg lengths, measured from the greater trochanter to the lateral malleolus (Fig. 4) must be done to determine whether an anatomical or functional leg length difference exists. The Q Angle (Fig. 5) will highlight the architecture of the knee joint and uncover valuable information when ultimately determining a corrective plan for the patient. Neurological testing, such as deep tendon reflexes, muscle strengths and sensory testing should also be done.
Standing X-rays should be taken on every patient. If the patient has recently had X-rays in the supine or prone position, new X-rays must be taken. Limiting the series to A-P (Fig. 6) and Lateral L-S (Fig. 7) and A-P Open Mouth (Fig. 8) and Lateral Cervical (Fig. 9) X-rays reduces the chance for over-exposure. These four views give a comprehensive structural impression of most patients. Obviously, if other views are needed, they should be considered. But, it’s important to minimize initial exposure as re-X-rays are important at a later date.
X-ray findings should include the positioning of the atlanto-axial segments (odontoid process and SP of C2 should line up), joint space balance (atlanto-odontoid space as well as atlanto-axial space), disc spaces should be full and even, curvatures (normal, hypo, hyper or reversed), gravity lines (center of skull straight down, should go through all cervical vertebrae and in the low back, from the center of L3 straight down and should bisect the anterior 1/3 of the sacral base), the sacral base angle (normal 36°-42°), pelvic heights, pelvic rotations, congenital anomalies, vertebral rotations and vertebral unleveling.
Any abnormals should be noted and considered when designing a corrective program. The first consideration should be the relief of symptoms, if that’s what’s brought the patient into your office. Treatment can consist of Chiropractic care, habit modifications, physical therapy, nutritional supplements, home recommendations, Foot Levelers orthotics, or any other specifics a doctor feels will help the patient get relief quicker. Once the pain and symptoms are under control, this is where the program truly begins. Specific Chiropractic treatment, proper orthotics and footwear, a graduating exercise program, and an education of what habits are good and which are bad is the beginning of the process. The next critical factor is time and frequency. Most Chiropractors under-treat patients. Consider how long it takes to get someone in shape to run a five mile race who has never run before.
Now, how about if they’re hurt to begin with? That adds to the total time. Well, that’s how you have to look at a patient’s condition. There is a re-education process of all of the muscles and joints, as well as habit modifications the patient needs to establish. Secondly, the degree of distortions found on the initial exam will either add or subtract time to get the patient to MMI. Any time frame less than 5-6 months of active care is too little. In some cases, the time needed can exceed a year.
Rick L. came into my office with low back pain, neck pain and headaches. He had been suffering with these symptoms for several years. He was a utility worker with a power company, and enjoyed running as a hobby. He was now limited in his ability to run and was worried about his future. As a 50 year old, he was concerned he’d have to give up running and live with the pain. The suggestion by his family doctor to take anti-inflammatories as a course of action was thoroughly inadequate for Rick.
Looking at Rick’s Kinetic Chain began with the arches of his feet in the standing position. In his particular case, he suffered with bilateral pronation. We then checked his Q Angles, which were normal. Upon active range of motion, Rick had pain and restriction in all directions of the low back and neck. Standing X-rays of the neck showed a loss of normal lordosis with degenerative changes in the C5/C6 disc space (Fig. 10). Standing X-rays of the low back (Fig. 11) showed a severely anterior gravity line with a 53° sacral base angle. There was also an advanced degeneration of the L5 disc space.
Rick was put under a comprehensive treatment program. He was restricted from running for about two weeks. Foot Levelers custom orthotics were fit for Rick immediately, and he was instructed to wear them at all times. His active treatment lasted eight months, and ultrasound therapy was originally done over the L5 disc space on each visit. Approximately two months into treatment, the discomfort in the low back was gone, and ultrasound was then placed over the cervical spine on each visit. He was given home recommendations, and an exercise program was given to him one month into treatment. Our objective was to increase the range of motion without pain. After four months, we re-X-rayed Rick’s low back and the lateral L-S showed a 47° Sacral Base Angle, a substantial improvement over his original findings (Fig. 12).
It’s been almost one year now, and Rick continues to be active and pain free. With the degenerative changes, he will always have some residual discomfort. He continues to run with no pain and continues managing his structure at home while receiving treatments in my office once every four weeks.
Someday, all kids will have complete structural exams on a yearly basis. So many structural changes occur in a 12-month period, and this information is critical in providing kids with beneficial recommendations. A school physical will mean much more than checking only for hernias and blood pressure.
I can see industry performing the Structural Fingerprint Exam on all incoming employees before any job is offered to them. Maybe they won’t be able to not hire based on findings, but they can certainly employ some corrective care and treatment prior to subjecting this employee to a strenuous job. Chiropractors will be hired by companies large and small to continually evaluate and treat as needed.
And I can see all athletes at all levels getting this exam prior to every off-season, so that a specific conditioning program can be set and before every pre-season so that proper treatment can be provided during the season. Strength coaches and Chiropractors will intimately work hand in hand.
I’ve now hired a strength and conditioning coach in my office to work with each patient on a six month graduating exercise program. The exercises are designed for the specific structural needs of the patient and compliment the treatments I provide. The results continue to be overwhelming.