Art of Prevention
Our mission is to decrease the prevalence of preventable injuries and athletes therein optimizing performance by decreasing the time that our athletes spend benched due to injury. We are going to distill information and practices from experts in the field of injury prevention. High level coaches and top performing athletes. We believe this information should be accessible to everyone so that we can reduce the rates of preventable injuries.
Art of Prevention
Injury Prevention Strategies for Chiropractors with Tyler Kemp DC
Ever wondered why chiropractors are in the same insurance category as carpenters and construction workers? Join us on the Art of Prevention podcast as we uncover this surprising reality with Tyler Kemp. In this eye-opening episode, Tyler dives into his extensive research and personal experiences, shedding light on the significant factors behind practitioner injuries, especially during side posture manipulations. We also explore how the reasons as to why new grads and those within 5 years of graduating are at the highest risks of injury. We also discuss how careers can often become cut short due to musculoskeletal injury; moving from practitioner to patient.
In our conversation, we dissect various chiropractic techniques such as Diversified, Gonstead, and Activator, and discuss their respective injury rates. Tyler and I emphasize the importance of technique variability and load progression, drawing parallels with athletic training to highlight how practitioners can safeguard their health while managing increasing patient volumes. Practical advice is shared on transitioning from school to real-world practice, where treating heavier and less healthy patients presents unique challenges. We stress that prioritizing practitioner safety is crucial for delivering effective patient care, akin to securing your own oxygen mask first on an airplane.
To wrap up, we delve into actionable strategies for preventing common waist-up injuries among chiropractors. We highlight the benefits of strength training, proper warm-ups, and movement variability in enhancing manipulation performance and minimizing injury risks. Tyler shares personal anecdotes and practical tips for evaluating and adapting daily practices to mitigate discomfort and accommodate physical limitations. This episode is packed with insights designed to promote resilience and well-being, ensuring healthcare practitioners can enjoy long, healthy careers while providing top-notch patient care.
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Hello everyone and welcome to another episode of the Art of Prevention podcast, and today I have, as always, another special guest and a very unique topic today, and that topic is near and dear to my heart, as well as the heart of the person that I brought on, and we're going to be talking about injuries and how to prevent injuries in healthcare practitioners that perform manipulation.
Speaker 1:So this includes a variety of healthcare practitioners from, namely, chiropractors, of which myself and the guests that I have on today are both practicing chiropractors as well as physical therapists and osteopathic physicians. My guest today is Tyler Kemp. Tyler and I go all the way back to our times in chiropractic school, and since then, tyler has gone to a couple of different locations and we're going to glean some wisdom from him in a couple of different varieties of practice style, from a bit of a sports medicine style to a couple of different styles that he'll go more into depth today. So, tyler, thank you so much for coming on. This is round two of you being on the podcast, so thank you so much for really getting psyched on this topic that I know I'm going to benefit from and a lot of our friends in the profession are going to benefit from as well.
Speaker 2:Oh, absolutely, let's nerd out man.
Speaker 1:So you've been diving into the research on this topic for the last couple of months, right, and what was the impetus for you to dive into this research?
Speaker 2:Yeah, so two parts with it. Part one is it's something we've kind of known about before. You know, we went to the same same school. We had a lot of same technique instructors, lot of the same technique instructors, and there was almost there's pretty frequently comments about you know, doing this during perform manipulation, of do it this way so you don't injure yourself or don't do this or you'll have a short career, and it was kind of just felt like okay, it's always this present thing, like this is a known entity. And then there's another part with it. First year, in practice, I went to get a disability policy just because I thought all right you know, let's work with my hands, like something crazy happens, I get hit by the trash truck.
Speaker 2:I want to, I want to be prepared and I was pretty annoyed trying to get coverage because, one, it was a lot more expensive than I thought it would be, cause, you know, I'm a healthcare professional. But second, there's different injury classifications or occupational classifications, and we one company basically told me, because of what you do, your injury risk is put in the same level as a carpenter or someone in construction, which kind of took me back and, looking at it practically, you know, an insurance company doesn't care about chiropractic or manipulation, they care about just their relative risk. So we get put in that same category. There's got to be some level of risk that's being consistently, consistently happening or consistently present. So I wanted to figure that out for myself then too, if I could do anything about it or figure out how to give myself a long and safe career.
Speaker 1:Yeah, I loved. I'm going to steal a phrase that you told me before we started recording. But people that perform you know very physical aspects of health care, so you could probably loop in like massage therapists in this as well.
Speaker 1:But people that perform spinal manipulation are the blue collar workers of health care, because we're a piecemeal profession yeah, we're moving bodies around, we're performing thrust manipulation at grade five, high velocity, low amplitude manipulation with the hopes of benefiting our patients and our clients. Tell me a little bit more, because oftentimes the emphasis is really placed more on the injury risk of who the manipulation is being performed, on which we know from a lot of the research by like JD Cassidy and individuals of that nature, that the risk is fairly low, especially if we compare that risk stratification to other healthcare interventions, I mean even like Advil and things like that a lot of things happen as a result of NSAIDs or non-steroidal anti-inflammatories, like you said, that the risk of injury is quite low in comparison.
Speaker 1:But today our emphasis is going to be the risk of injury to those performing the manipulation. What are some of the factors and variables that you found in the literature, such as the five-year risk of injury for new grads and some of the things that you've gleaned from the literature surrounding risk of injury for us that are performing manipulation?
Speaker 2:Yeah, so there's not a lot of great data on the topic. There's about four or five papers that are mainly surveys, which in itself, you know there's a lot of issues with, but there's a lot of great data on the topic. There's about four or five papers that are mainly surveys, which in itself, you know there's there's a lot of issues with, but there's a couple of broad themes. So, and we can go into this paper specifically, but the the four main things were one, five years or more of being a practitioner before manipulation has been shown to, to decrease your risk of sustaining an injury, which makes sense, cause in the first few years you're inexperienced, you don't know what you're doing, you're less likely to do something silly or stupid.
Speaker 2:Um, second, in terms of location, upper limb was pretty common. Shoulder, wrist, hand, which makes sense, we're using our hands. And then, um, the area of injury was mo, in terms of where, what, what technique. What was being performed was was side posture manipulation. So the most common way to get injured was performing a side posture manipulation, which we we talked about. We saw in school, we were talking before we had an instructor that had kind of bragged about having both shoulder surgeries done but would, would critique us on certain ways to perform like a sideeline manipulation and just seemed a little. Seemed a little odd.
Speaker 1:So this is the big thing they wanted us to do side posture manipulation, the way that they had been taught, which was potentially a mechanistic factor that contributed to their shoulder injuries that they got surgery on yeah, so I'm going to kind of do a sprint through some of the main papers.
Speaker 2:Uh, first one is howarth et al.
Speaker 2:It's an occupational survey. This is based out of Ontario, good old Canada. They had about 400 respondents, the three main regions they saw there was low back, wrist and hand and neck, and about half of all those injuries occurred performing some kind of manipulation. They also lumped in some soft tissue work and then also, you know, freak accidents getting hurt on your own time, which which happens.
Speaker 2:Um, another big one was Hansen et al in 2018, again same themes where they noticed that sideline manipulation is associated with shoulder injuries. And then the last big one was home at all. This is all the way back in 2006. Um, they had over 60% of all injuries occurred while performing treatment. Again, they noticed that the low back performing lumbosacral manipulation, generally sidelined, was associated with the highest risk of injury.
Speaker 2:And a comment they made was most of the injuries were one soft tissue in nature muscle ligament stuff like that affected the upper limb and were chronic or recurrent in nature, which that tells me that a number of practitioners get hurt and are not in a position to take a day off because, frankly, we can't work remote for what we do as a profession, like we can you know instruction for exercise, stuff like that, but in terms of hands-on skill you can't do that over distance. So like if you're nursing recurrent injury, like if you ever go to a state association event or something like that, like you talk to some older docs, like it is the walking wounded, which is not not really encouraging.
Speaker 1:We are our own worst patients, right? Yeah, I remember going to a motion palpation Institute seminar and one of the instructors was telling us about one incident where he sprained his ankle. And this is a very like functionally minded, like rehabilitation minded chiropractor. He's actually like teaches for SFMA and things like that and he just put his foot in a boot and then kept practicing for like six weeks and he's like walking around the gym in a boot and then, you know, five or six weeks later he looks down at his ankle and it's no better and he goes what the heck am I doing? You know, and he finally comes to this realization that he wasn't doing the things that he's literally telling his patients to do in order to rehabilitate their musculoskeletal injuries.
Speaker 2:Yeah, we are. We are the absolute worst One. One last thing this is getting kind of picky. There is some data on the student side, like while you're learning in school, where you're donating your body to science and uncertain if your partner is going to kill you or not, unless you went to mpi. Mpi you're in safe hands, of course, but in terms of uh prevalence, like there's one out of uh I believe palmer did it had a prevalence about like 30 percent of students sustained some kind of injury in kairos school, the people receiving manipulation.
Speaker 2:So you're, you're the patient. It was generally neck and shoulder injury, which makes sense because most people don't know what they're doing. And then, in terms of administrating spinal manipulation, you're the one performing it. Hand and wrist injury was the highest. Just that makes sense. The awkward positioning you don't know where to put your hands, stuff like that. They actually found some risk factors within that. So for who performing manipulation got hurt, what was associated with that was higher BMI and non-exercising status. So if you were you know BMI is not perfect but if you were more overweight and not an active person, you were more likely to have some kind of issue. If we want to get really picky in terms of technique Diversified and Gonstead had the highest and then, I'm sure you figured, activator had a 0% injury rate.
Speaker 1:Yeah, and that's not just us being mean. That's like data-driven. That's how you extrapolated that data. I know we're probably both homers for NPI and that's kind of like us just talking about our biases, because they teach manipulation in ways that are hopefully going to reduce the risk of injury in those performing the manipulation, which is great, but not to say that anything bad about people that perform diversified technique or Gonstead technique, and we're going to. When we talk about some of the injury prevention mechanisms or ways in which we can prevent injury, we're going to talk about technique and really variability in technique as well. So tell me more about this, this five-year phenomenon why is it the new grads that get hurt?
Speaker 2:Yeah, so the data, it just it seems like it's consistently. You just don't know what you're doing and there's a number throughout the studies. They talk about how, in some of the surveys, how it's essentially, I got hurt and I had to figure out a way not to get hurt, especially if you're not in a position to take a day off or things like that. So within five years you've kind of worked out the kinks of I'm just not going to do this ever, like I would call you right now that they um, they don't. They rarely do side posture because they have a shoulder injury. They're entirely drop piece, which, like that is their choice of technique, stuff like that. But they also had a shoulder tear and they thought I'm just I don't want to ever be. They had a different issue occurred outside of the office, but they're like I don't want to ever be in a position where I have to try to practice while doing it that way and that was their way to opt out of it.
Speaker 2:So a lot of um and some of the data. There's a lot of times where people just change their technique. They reduce office hours, they modify, like there's a variety of options for people, but that's by the five-year point. You're going to kind of make enough mistakes to figure out one way or another, which you know. I think we're pretty close to the five. I think you're past the five-year mark.
Speaker 1:I'm I'm on that borderline, so we're close I'm getting there and I've got the gray hairs to show it too, so yeah, they're starting to crop up. Oh, thank you very much. Um, and tell me about load progression, because this is something that we talk about all the time with athletes is a proper progression in load if it's a runner, proper progression in mileage if it's a weight lifter, proper progression in volume, etc. But what is it? What are your ideals or ideas behind that and thrust manipulation or spinal manipulation?
Speaker 2:yeah, so we know volume is a factor we were talking about before, just how, as students like the volume you can see is just great and we use volume like I think most offices or most chiro's. Listening this podcast may see anywhere from 10 to 20 ish 25 ish a day, depending on their setting, how they're set up. Um, this is also meant general because, like I've one of my colleagues, like practices more high volume, like 50, 60, 70 a day, like that is something how they want to do. Again, we're not commenting on the choice and the quality of patient care, but that is a big jump, especially if you're a student, like we were both. You know in clinic where you're seeing a whopping two or three patients in an hour and I felt like it was all at once.
Speaker 2:If you're performing an adjustment after an adjustment, boom, boom, boom. There's no kind of modification, recovery time. We would not feel good about a runner going from 10 miles a week to 50 miles a week, but then we feel okay with a student graduating starting in an office and they could be seeing 30, 40, 50 a day. There's just all kinds of issues with that, especially if they are not comfortable with technique or how they're going to do things, or even their treatment style. It just doesn't set them up for success and that's unfortunately. There's a lot of issues with that. But that's a huge knock on the schools. Of just like having this conversation, of like you're going to have this transition, how are you going to prepare yourself for it? Or build yourself kind of an on ramp so you get used to it. You just get thrown in the deep end, depending on where you go.
Speaker 1:I totally agree, and the people that you're performing manipulation on when you're in student clinic are, or if you're practicing while you're in school, under the guidance of a supervised, licensed practitioner clinician, of course, you're typically performing manipulation on younger, healthier individuals with a lower BMI or typically a lower body weight, and the physical demands of going out into what is the healthcare state of the United States is typically larger individuals with, you know, not the healthiest joint tissue, so they're much more stiff and the tissues themselves are not as compliant as when we are learning these techniques on other students so I mean what you learn in school does not help you accommodate the patient.
Speaker 2:That's 300, 385, like I have a few of those on my schedule like like smoker, like just there's limits to what you can do. And then it's also just, if you're going to use manipulation, can you do it safely? Cause there's no, there's no point in you treating somebody, for you to become the patient.
Speaker 1:Yeah, and I think that's going to be one of the big themes, like how do we keep from becoming the patient? Um, every single time that you get in on an airplane, there's a reason that they tell you to put your gas mask on before assisting others. Right, and that's because, like, we have to make sure that we don't convert to becoming a patient, because then we can't help anyone.
Speaker 2:Yeah, exactly.
Speaker 1:If you injure your shoulder doing a side posture manipulation, you cannot help those 10, 20, 40,. You cannot help those 10, 20, 40, 60, whatever number of patients per day. So that's the objective of the prevention side of things that we're going to talk about today. Go ahead.
Speaker 2:And weaving into the prevention. The data is pretty clear. It's all waist up injuries. There's not, you're not going to, unless they have a previous problem or a surgery, something like that. There's not.
Speaker 2:A lot of chiropractors will talk about how their knee got blown out. In practice it's always low back or upper extremity. So like if those are, if these are the consistent areas where we see the problems, our prevention should be guided towards that. So in terms of recommendations, there's not a whole lot out there. There's a few of the papers comment about doing some kind of warm-up. Like we can make fun of certain groups for being rather um ninja-esque in some of their uh techniques or warm-ups or things like that. But you respect the the intent behind it of trying to prep your body for some kind of event, no different than if you would warm up for an athletic event, like if our job is athletic. I think it behooves us to at least do some kind of prep as part of your routine or things like that. Also, bare minimum. Just you know we're healthcare providers. We personally all need to be hitting the minimal physical activity guidelines of strength training two days a week, moderate cardio of 150 minutes, like. If you're not hitting that like that alone is not helpful.
Speaker 1:That alone is not helpful. Yeah, and me personally, coming from a running background, I did not have a ton of upper extremity strength or prowess, and I became a rock climber. So then my fingers were really strong, but there aren't a ton of pushing motions, which is basically what a thrust manipulation is is a little bit of a pushing motion, so I could pull really well, but I couldn't really push all that well, and I found that my performance with manipulation actually improved once I started strength training. So it seems like strength training for the upper limbs and this upper extremity would be really good things as far as improving the capacity and resilience of our upper extremities, and then we get a nice like risk reduction as a result of that. What are some of the other things that we could toy around with? So we talked about doing a proper warmup. So you talked about kind of like landing on a Swiss ball or doing a hip hinge in order to start your day. What are some other ideas that you've got for risk reduction?
Speaker 2:Yeah, another piece is just a variety, like we've all heard, at least through different courses or people we know mutually of just you want to have multiple options to treat any one area. So, whether it be you know, take the cervical spine being able to do it seated, supine, prone like having different options for you If you're in a situation where your table or equipment can do the work for you. Can the table elevate for you? Does your table have drops, reflection, distraction? Like different options for you so that you can treat your patients well but also make sure you are taken care of in the process and you can do everything safely.
Speaker 2:So just having equipment that works for you and having multiple options for you, because you might be a, you might love doing a supine thoracic, but once in a while you're going to have that patient who this one thing is going to work well, like I have a patient right now that they are, they do really well with a seated lumbar and like I don't. I don't really do that a whole lot, but they've responded really, really well to it and that that's just the best thing for them and like being able to have those options for them. They're also like a more heavyset person and, like their other chiro, did it that way. So like, if you can, if you have multiple options and you know a patient has responded a certain way to treatment, for you being able to have that ability to do that technique or treatment, that just makes things so much easier for everybody involved.
Speaker 1:You're going to have to send me an instructional video on the seated lumbar.
Speaker 2:That's going to be wild.
Speaker 1:I agree, and that goes to like the importance of like movement, variability, which we've talked about with athletes and other populations of that sort. So, having five different ways to perform any style of manipulation or a manipulation on any joint, and you should be manipulating theoretically differently depending on the patient that's sitting in front of you. However, you also have to take into account your personal style and your personal abilities. So having a bunch of tools in your tool belt can be very effective in decreasing the joint stresses that are applied to your upper extremities, which we know are at the highest risk of injury.
Speaker 2:The best audit I've heard is Dr Ty Pence. He's out of California. He made a comment one time about you need to look from the belt up, like if you finish your day and you notice you're sore or something, you need to figure out what you did during that day and then make sure it doesn't happen the next day because we've all done it. Where we're like this feels weird or like I don't know why this is bugging me or this doesn't feel right if you did something different good or bad, or it might be. You know one specific patient like you need to figure out why it felt that way. And then is this a one-time thing or it's going to become an ongoing thing, because there's nothing worse than you have something you ignore and it's sticking around week after week and you're just for how much physical activity we do, especially depending on the volume or things like that.
Speaker 1:That can build up really, really quickly yeah, and you know personal example for myself I had a previous injury to my right wrist. So a couple of months ago actually at the start of this year I was really starting to have some recalcitrant wrist pain and I had to basically switch sides and shoot left-handed for all of my thoracic manipulations and it was a little bit wonky at first, but now that I'm basically ambidextrous with that manipulation I feel much better off than what I was previously and I actually use it as a um, like an educational piece with a lot of patients of mine, because oftentimes people will have shoulder injuries because their occupation requires them to do overhead activities, whether they're, you know, um like drywall people or painters, carpenter, yeah housekeepers as well, needing to wash windows, etc.
Speaker 1:You know they're oh, my hand hurts when I, my arm hurts when I raise it overhead. Okay, what are you doing? All day at work? I'm raising my arm overhead. Can you use your left arm? Well, I never thought about that, you know. And it's like well, can you please switch hands so that while we are rehabbing this painful side and you know, it's funny, half the time they say no, they can't switch sides. And I'm like look like this, this psychomotor skill that you're doing is like not that complex. And then I give them the example of me switching to my left hand when I do these manipulations.
Speaker 1:Yeah, that it's usually yeah, and it's usually after I adjust them and they didn't ever notice any difference, so you know yeah, crazy if you did a poor job with it, then maybe I wouldn't.
Speaker 1:I wouldn't, uh, use that example. They'd probably be like, well, you're pretty bad at this, so you know, okay. Um, so we've talked about a couple of different things so far. So the majority of injuries happen or occur in the upper limb, so all injuries, or most injuries, are from the waist up. Some of the ways in which we can reduce the risk of that injury is by incorporating variability in our manipulations throughout the day, so doing different things, so not stressing the same tissues over and over. For students, a big thing would be load management, so easing into the patient load and the patient population that we're seeing. And then some of the preventative things like strength training. For me, like the thing that reduced my risk of injury and also improved my performance, was a lot of strength training for like compression moves, so like pectoral muscles, so bench press, dumbbell, bench press, bench press with a bar, whatever shoulder flies, etc. Are there any other things that you would recommend from the strength training realm for individuals looking to reduce their risk of injury?
Speaker 2:I mean something I've played around with personally and I've known a few other chiropractors that have done this is just playing with the arm bar, where you know you're in a sidelined position, you have the kettlebell there, doing that rotation just to kind of help with some of that shoulder stability and just it feels good just to have your shoulders warmed up. Um it, it looks bad if you can't do it when you're showing it to a patient. So it's not going to hurt you as a provider to have a stronger shoulder. And again, assuming you're, you know you're using it.
Speaker 2:Well, we're both not fond of doing the uh, the good old fashioned chicken move where you have your arm in a abducted position, your elbow bent, you're kind of pressing in like that's that, that's classic. You bent, you're kind of pressing in, like that's that's classic. You know we can't use impingement but subacromial pain, like that's setting up for that. So, like we kind of were trying to touch on it earlier. But just even variability with, like how you use your contact, like, instead of the arm being out, if you can use a fleshy forearm for a lot of your contacts, bringing that in, you'll use your lap more than your shoulder, like that's a much larger muscle and you're going to generate way more power from it than anything else. Uh, with the, the strength training shoulder, anything like open chained, um, whatever you want to do just to help create more strength around it, and if you want to include that as part of your warmup, totally feel free to.
Speaker 1:Yeah, and that was something that I'd almost forgotten about that we wanted to remark on is the biomechanics of manipulation, and I know like biomechanics are, you know, neither here nor there, and you'll get a decrease in joint stresses by just incorporating variability.
Speaker 1:But let's not just throw the baby out with the bathwater and say biomechanics don't matter If you're in an adducted and internally rotated position. That is that classic orthopedic test, hawkins-kennedy, and I think that you very accurately described like we have to call it subacromial pain and not impingement, because we don't really know exactly what's getting impinged when we're talking about impingement. What's getting impinged when we're talking about impingement? But being smart with our biomechanics so that we can alter joint stressors and distribute those joint stressors appropriately is going to be beneficial, and I think that you're right on. I think for some of my tests maybe I did that internally rotating, an adducted position, and that was basically the last time that I did those maneuvers, and now I utilize more of, like, my elbow and side posture or the fleshy portion of my forearm in order to improve I I get a lot more like compressive power out of it anyways, um, so I think it's enhanced my manipulation skills, um, as opposed to hurt them.
Speaker 2:Yeah, also with variability. Like you know, what we can do can be very repetitive. So being able to do a seated cervical or a prone cervical or things like that, like just that variety is, like, really, really helpful.
Speaker 1:It adds a little bit of fun into your day too, doesn't it?
Speaker 2:It does, you got to spice it up somehow.
Speaker 1:Yeah, you somehow. Yeah, you know, today is, you know, prone cervical day it's tuesdays.
Speaker 2:Yes, it's also funny. If you've had a patient you've had for a while and just do something different, they kind of look at you.
Speaker 1:You're like I'm not a one-trick pony yeah, you gotta surprise them every now and then bring them something new. You do, you do all right. And then I think that your remark on meeting the physical activity guidelines is also really important and a neglected or overlooked topic, because we are the health care providers, right? So we don't have to follow the rules, right? We don't have to meet those activity guidelines of strength training two times a week and then doing cardiovascular exercise two to three times per week, because we're the ones that we're immune to these things.
Speaker 1:You know, what I always tell people is I never had back pain until I went to chiropractic school and a lot of times that can help us with kind of like bridging the gap between provider and patient. Like, hey, I've gone through the stuff that you're doing and hey, like I I know it sucks sometimes to go to the and hit the gym or go for a run or sit on the bike god forbid for 30 minutes and watch netflix while I get my heart rate up to over 100 beats per minute for that time. But we've got to do it. You know, we've got to lead by example and if we do that, then one we're going to reduce our risk of injury in ourselves and then we can be a better example for our patients and they're more likely to follow our advice for meeting physical activity guidelines which we know it's a very poor percentage of the population in the United States is hitting those physical activity guidelines which we know it's a very poor percentage of the population in the United States is hitting those physical activity guidelines.
Speaker 2:Yeah, it's also a bad look. Like you know, you and I both use rehab or structured exercise Like it's a bad look If you're asking the patient to do something you're not able to pull off yourself. So kind of kind of destroys compliance on that one.
Speaker 1:Yeah, which is why I work on my hip mobility and flexibility every night now, because I've had multiple patients come in and I tell them all right, you're going to do this 90, 90 shin box and hopefully you can do it better than I can, um, and ironically, a lot of times they can yeah, you got to give them the easy win at some point too, though, right yeah, you know um.
Speaker 2:One last thing. This is not related to manipulation, but this is just a uh, another choice of technique. Like I know, you work with an athletic population. I've been there as well. I'm not calling out a particular technique, but there is one technique that's very well branded and marketed three letters for an athletic population and one of the offices I was in, a number of the docs had taken courses or were certified in it. One was actually full body certified and did some of the corporate work.
Speaker 2:It was like it's a really interesting setup. But from a manual standpoint I remember looking at them in our office and they were just rubbing their hands frantically, like you could see kind of a pseudo deformity along the lower portion of their thumb and like like their thenar pad and all that. Like it. Just it looked funky and like there's a choice with it, like what you're to do, like whether you use some other modality or you choose to do any kind of soft tissue work, but just being smart about it, like it. Just it was really interesting. They were, they were left-handed and you could see a very clear dominance. It wasn't just them being left-handed, but just the choice of using that treatment of modality for every single patient for a number of years every single patient for a number of years?
Speaker 1:Yeah, that's an excellent point to bring up. Is thumb manual therapy that utilizes the thumb as the only point of contact for administering manual therapy? I think that would be an accurate way to put it right.
Speaker 2:Trigger point massage. Or I know people personally chiro school, outside of chiro school, where they've had sports injuries, soccer, gamekeeper thumbs, whatever where they have some kind of laxity or instability with their thumb. So thumb moves from a manipulation standpoint, do any kind of thumb associated like trigger point work, manual work? That is not great for them and they've had to find creative alternatives to get around it. So the other part is if you're a student listening to this, do you have any previous injuries, ongoing injuries that you're trying to manage, like start tailoring how you're going to treat to that? So then you don't get into practice and say you know, shoot, I'm pissing it off every time.
Speaker 1:Yeah, don't just bash your head into the wall. I mean, if I remember correctly, clarence Gonstead developed a lot of his techniques because he had a hand or wrist arthritis. Yeah, so we can still be very, very effective practitioners. That doesn't mean that you have to use your thumb for manual therapy, even if you look at like I'm getting really psyched on like fascial manipulation right now and their contacts are the elbow and then a reinforced index finger or you know. God forbid, you got to go learn a couple of needling techniques and use some dry needles or acupuncture needles.
Speaker 1:You know wouldn't want to mix up our techniques too much, but I mean these are all viable means by which we can have a benefit for the patient without also becoming the patient. So I think that's an excellent point. One of the other practitioners in my last office he has been doing more like a thumb emphasis manual therapy technique for many, many years and you know he'll tell you, oh yeah, my thumb is like pretty trash, you know. So we've got to be thinking about the joint stressors that we're applying on a routine basis and think what is that going to do over the next? Hopefully we enjoy our profession 20, 30 years of our careers.
Speaker 2:What's sustainable. We're both on the more evidence-informed side of the spectrum within our profession. I kind of look on the the more vitalistic crowd in our profession. I kind of respect, in a way, some of their obsession with sustainability, cause if their mindset is, you know, my manipulation is the only thing that's going to help the patient on my table and I need to be able to do that for 40 plus years. Like a lot of them are actually really really intentional with it and it kind of it kind of puts the other side of the crowd to shame of. Like you know, you're trying to be take research to it and these are the people that are actually the most interested in it because they see this as their only treatment modality. So they have to do it well, sustainable and for a long time.
Speaker 1:That's something that we can all apply is looking at the sustainability of how we're doing things day to day by incorporating things such as load management, especially in those initial five years of getting out of school. Strength training, meeting physical activity guidelines, incorporating variability. Don't just use your thumb for manual therapy. Anything else that you've got for us, tyler.
Speaker 2:That's all I got man.
Speaker 1:All right. Well, tyler, if we had to wrap up all the stuff that we talked about today I know I did like a short wrap up there what would be your ounce of prevention for practitioners that perform manipulations as part of their therapeutic intervention repertoire?
Speaker 2:Two parts stay active, make sure you are in a you keep yourself healthy, like you are in a position where you can put load and force through your body, that you're able to recover, you're doing all the right things nutrition, sleep, activity, stuff like that. And then sustainable make sure that you are able to quickly, within the first six months of being in practice, find ways and modify ways that are specific to you, not to your favorite technique, instructor or technique or whatever things that you can do safely and for a very long time, that you're going to be able to take care of yourself and not be a patient.
Speaker 1:I love it, tyler, thank you so much. I think that this podcast and, just you know, making people think about this information is going to help a lot of different providers increase longevity in their careers and if we accomplish that, then we're going to be able to help a ton of people by helping those providers. Absolutely All right. Thanks again, man. I hope that you enjoyed this episode of the Art of Prevention podcast. If you did enjoy and or benefit from some of the information in this podcast, please be sure to like, subscribe and share this podcast, or please give us a five-star review on any platform that you find podcasts. One thing to note that this podcast is for education and entertainment purposes only. No patient is formed and if you are having any difficulty, pain, discomfort, etc. With any of the movements or ideas described within this podcast, please seek the help of a qualified and board-certified medical professional, such as your medical doctor or a sports chiropractor, physical therapist, etc.