Treating The Whole Person

Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it. ~Plato

Physical motion is a fundamental aspect of human existence. The question of why we are here may perplex humankind forever. However, from a musculoskeletal standpoint it is much more apparent: we are here to move. Proper movement must occur at all levels - from the ability to walk and run, right down to the correct interplay between each vertebral articulation.

Identifying and treating vertebral abnormalities (the incorrect interplay or mobility between adjacent vertebrae) will help to improve a patient's health in a variety of ways. The direct effects include improving organ function, reducing pain and facilitating the body's self-regulating mechanisms. Indirectly, proper vertebral function can help to improve a patient's mood, posture and their ability to engage in regular physical activity. As a result of these far-reaching effects, identifying vertebral dysfunction and restoring proper mobility is an essential part of the naturopathic assessment and treatment program.

The concept of self-regulation

The healing power of nature (Vis medicatrix naturae) and treating the whole person are two closely related naturopathic principles. The healing power of nature is based on the concept that both the body and nature are capable of self-regulation, and if given the right opportunity, are capable of healing themselves. Treating the whole person is closely connected to this concept - when devising an effective and comprehensive treatment plan, obstacles to cure must first be identified and removed in order to support this self-regulating process.

Chiropractic medicine and osteopathy also share the belief that to function properly, the body must be structurally sound in order for the natural recuperative powers to restore health. Andrew Taylor Still (1828-1917) was the father of osteopathic medicine and he referred to this power as the life force. He concentrated his therapy on the manipulation of osteopathic (spinal) lesions, and believed that treating structural and mechanical spinal derangements could relieve mechanical pressure on blood vessels and nerves. This abnormal pressure produced ischemia and eventual necrosis, which in turn obstructed the life force traveling along the nerves.1

This life force is referred to in many different ways by naturopathic modalities as well. In Traditional Chinese medicine it is called the Qi, Homeopathic medicine refers to it as the vital force, and in Chiropractic medicine it is called the body's innate intelligence. Regardless of what the term is referred to, many practices are based on the fact that the body has an innate ability to heal itself and to self-regulate. If this is disrupted somehow, then many health problems may follow.

Structural abnormalities that can interfere with the body's ability to heal include changes in the patient's vertebral alignment.2 The skeletal system responds to this change in a direct fashion by stimulating osteoblastic and osteoclastic activity, causing bone remodelling to occur. This change is reflected by Wolff's Law which states that stresses applied to a bone stimulate re-modeling of the bony architecture for optimal withstanding of the forces being applied. Rapid disuse osteopenia results when normal forces are withdrawn from a healthy bone.3

The viscera are another part of the body affected by dysfunction within the vertebral column. This is partly a result of the neuro-anatomical changes occurring at the level of the spinal cord, as well as the additional pressure placed on the organs themselves. These organs end up becoming compressed due to the lack of support by weak muscles.4

To fully understand how proper vertebral function relates to visceral disorders, one needs to become reacquainted with the neuroanatomy and neurophysiology of the particular disease.2 For each disorder there may be a variety of spinal levels that are negatively affecting this outflow. Gonstead's empirical work with many patients during his 55 yrs in practice provides a large source of information regarding the association between visceral and vertebral dysfunction2. He hypothesized that many chronic multi-factorial diseases (e.g. cancer, OP, migraine h/a's etc) were related to imbalances of biochemistry from long-term glandular or organ dysfunction (e.g. thyroid, adrenal, ovary, liver, kidney etc). Resolution of these conditions usually did not respond until the organ or glandular function had been restored. He found that local spinal improvement often occurred before visceral changes in long-standing conditions.2

An anatomical basis for this neuro-visceral connection was demonstrated in experiments performed by Sato and others.5 They found a crossover effect of the 2 systems and referred to it as somatoautonomic or somatovisceral relexes.6 These reflexes show that stimuli on skin and muscle have a direct impact on organ function. One of the ways this crossover effect is made possible is by the mixed composition of the spinal nerve which includes somatic efferent, somatic afferent, sympathetic postganglionic, and ANS afferent fibers5. These reflexes provide an anatomical basis for the therapeutic effects of acupuncture, spinal manipulation and other reflex techniques.5

Nervous system dysfunction caused by vertebral fixations will not only affect organ function directly - it may also interfere with the brain's regulation of various physiological processes.7 It is known that sympathetic outflow occurs between T1 and L3 whereas the parasympathetic division is found in the cervical and sacroiliac regions.8 Impaired outflow within these segments due to vertebral dysfunction can negatively impact the function of the related organ or gland.

Take for example, the adrenal glands - Gonstead found that dysfunction in the upper cervical region (C0-C5) was associated with a heightened state of adrenal cortical activity.9 Cervical misalignment can cause a decrease in parasympathetic activity resulting in a relative sympathetic overdrive in the thoracic and lumbar regions. Also, it has been shown that lesions of the upper cervical region can create dysfunction (e.g. edema) of the pituitary gland in lab animals.10 This dysfunction can lead to an increased pituitary secretion of ACTH resulting in a hyper-stimulation of the adrenal cortex.5

The CV system is another area affected by this neuro-anatomical connection.2 In a blinded, randomized investigation of somatic dysfunction in patients with a myocardial infarction (MI), qualitative palpatory findings (increased firmness, warmth, ropiness, edema and heavy musculature) were significantly associated with the upper thoracic segments T1-T4.11 It was concluded that these findings were not only useful in identifying an MI but also as a predictive tool of those cases which may develop into one.

The mind-body connection to structural dysfunction: The patient's structural health is not only determined by neurophysiological process' occurring throughout their body - it is also shares a close relationship with the patients state of mental-emotional well-being. This is due to the cycle of events that can stem from vertebral dysfunction. In addition to altered organ function, pain can also result from vertebral fixations or subluxations. Following this, an individual's ability to engage in regular activity is often reduced - and this alone can lead to feelings of depression. An interesting study that examined the role of exercise and endorphins in depression compared the beta-endorphin levels and depression profiles of 10 joggers with those of 10 sedentary men of the same age. The 10 sedentary men tested were more depressed, perceived greater stress in their lives, and had a higher level of cortisol and lower levels of beta-endorphins.12 As the researchers stated, this "reaffirms that depression is very sensitive to exercise and helps firm up a biochemical link between physical activity and depression".13

TCompleting the cycle, decreased activity can have a negative impact on vertebral alignment. The development of muscular imbalances and areas of weakness in the core muscles often result from inactivity. These weak and unbalanced muscles are unable to hold the vertebrae and pelvis in their proper position. Postural changes follow, which put additional stressors on the vertebral bodies, thus impacting proper alignment.

Assessment

In order to effectively treat a patient with these types of dysregulations, a thorough assessment needs to take place in order to come up with an accurate diagnosis. This assessment needs to occur on all levels, including both the case history as well as the physical assessment - the hands off approach is not sufficient. Most practitioners have heard patients state that the previous doctor "never even touched me". The better statement would be, "doctor, how did you know that area was painful?" An experienced doctor should be able to literally "feel' the patient's pain. The inflamed warm tissue and the nodular, lumpy, leathery, doughy, springy, taut sensations are all reflective of the soft tissue or bony lesion.14 Every practitioner does their assessment differently, however when examining the patient's structure, it is essential to know the history. This will provide clues as to the chronicity of the complaint(s). The assessment should also include visual assessment of the patient's stance, their gait as well as motion palpation of their vertebral bodies.

Observation of their static posture should reveal; straight shoulders that are inline with the horizontal pelvic line, even and symmetrical musculature, head placement squarely on top of the shoulders and proper maintenance of the arch of the feet.

Observation of their static posture often reveals a common postural stance that is characterized by a head forward position (forward placement of their head in relation to their shoulders), and drooped shoulders that are anteriorly and medially rotated. Increased time at the computer and muscular imbalances between the anterior and posterior muscles are often to blame. Structural consequences that can result from this stance include increased strain on the posterior cervical, rhomboid and trapezius muscles as they attempt to maintain proper posture. Also commonly found are shortened, hypertonic pectoral muscles. Conditions such as thoracic outlet syndrome (TOS) often follow. TOS in this case may be characterized by pain, motor loss or changes in temperature of the upper extremities due to compression of a portion of the brachial plexus and the subclavian vein as they exit through the costoclavicular or subpectoralis minor space.15 These changes in posture commonly also lead to stress and potential fixations in the cervical and thoracic regions.

A proper gait is the basis for motion and requires many factors to be in place. The hips, core muscles and gluteal muscles all need to work together to properly balance the body. Abnormalities with vertebral alignment are often revealed upon observation of the patient's gait. Small adaptations to the site of fixations are often made - for example, the patient may not swing both legs or arms equally, their heads might be carried forward or to the side or they may land differently on each foot.16

Normally, the weight transfer moves from the heel over the arch of the foot, which should ideally roll into slight pronation. There are 2 main arches of the foot (tarsal and plantar). These arches support the entire weight of the body and simultaneously allow it to stay upright as it moves across varied terrain, balancing the load as it shifts.17

A fallen arch is a commonly seen condition of the foot called pes planus, otherwise known as flatfoot. It is estimated that up to 23% of the public may have this condition. It can be caused by a ligamentous laxity in the longitudinal ligament, or an abnormality in alignment between the tarsal bones. Flatfoot is less common in societies where shoes are not worn during infancy and childhood. Flexible flatfeet persisting into adolescence and adulthood are usually associated with familial ligamentous laxity and can be identified in other family members.18 This structural or functional instability often leads to eversion of the foot and an altered heel-toe gait pattern. This is accompanied by changes in muscular function higher up as the body attempts to compensate for the foot's inability to maintain proper balance and foot mechanics.17 In clinical practice, a commonly observed structural compensation that results from pes planus is dysfunction in the contralateral SI joint - this is caused by increased forces being transmitted upwards from the lost arch.

Motion-Palpation of the spinal column will reveal valuable pieces of information such as the exact level of vertebral or sacroiliac dysfunction (upper or lower). Each vertebra should move in the correct direction when moving the patient through the 4 ranges of motion; these include flexion, extension, lateral flexion and rotation. Special note should be made by the doctor to the patient's vertebral segments that are associated with the pathology or concern discussed in their case taking process.

Full physical examination including all of the body's systems and laboratory tests are also indicated for structural concerns. An example of a time additional lab work would be helpful to have is if tissue changes or vertebral fixations were found at T1-T4 in a patient over the age of 40 who has a family history of cardiovascular disease. In this case it may be helpful to run a variety of tests including a lipid panel along with a homocysteine count.

Treatment Guidelines:

Treatment of the whole person involves restoring the body's ability to adapt and self-regulate. Considerations include: removing vertebral or other joint fixations through naturopathic manipulation, correcting the posture, restoring proper biomechanics of the foot by referring the patient for orthotics if indicated, and also the implementing a reasonable exercise plan if one is not already being followed. Even if the only tolerable activities are treading water or walking for short distances, it is essential for some form of movement to occur. Assisting the patient with self-esteem issues if they are present, and using naturopathic therapies to relieve symptoms of depression or anxiety are two other important areas to focus on. This will help to increase your patient's motivation and compliance levels.

In conclusion, when treating the whole person one cannot focus solely on just one set of symptoms, one causative factor, one mechanism of action, or on one part of the body.4 To treat the whole person is to see the patient beyond the disease, and to address all of these aspects in an attempt to find the root cause. Each person is an individual in a unique environment with a unique set of personal circumstances. A major reason why Naturopaths have the potential to be so effective in their treatments is because they do not treat disease, they treat people. They do this by taking into account all of the different aspects of a patient's health and then facilitating the self-healing process through therapeutic intervention. A patientÕs own metaphor for healing can be a powerful stimulus if recognized and put to good use.

About the Author

Susan Slipacoff, ND received a BA in Kinesiology at the University of Western Ontario in 2001 and her ND from the Canadian College of Naturopathic Medicine in 2005. Since this time she has received additional training in injection therapy through the Naturopathic Academy of Therapeutic Injection, and Medical Acupuncture through McMaster's Contemporary Medical Acupuncture Program.

Susan maintains 3 naturopathic practices in Bolton, Hamilton and in Mississauga where she maintains a strong pain management and physical medicine focus. She is also a part-time clinical supervisor at the Robert Schad Naturopathic Clinic and an Acupuncture TA for the first and second year CCNM programs.

References

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  16. Townsend Jr CM, Beauchamp RD, Evers BM, Mattox KL. 2007. Townsend: Sabiston Textbook of Surgery, 18th ed. Saunders Elsevier, Philapdelphia, PA.
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  18. Egoscue P, Gittines R. 1998. Pain free: A revolutionary method for stopping chronic pain. Bantam Books, Broadway, New York.
  19. Hosalkar HS, Spiegel DA, Davidson RS. 2007. Kliegman: Nelson Textbook of pediatrics, 18th ed. Saunders, Philadelphia, PA.

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