As long as chiropractic is a separate and distinct discipline of healing, vertebral subluxation will be the cornerstone of its focus. However, it should not be the exclusive focus of our study and attention as chiropractic physicians.
If we are to live up to our potential as holistic physicians and healers, we must expand our focus and look beyond the spine to include whole-body functional alignment and balance. It will require an expansion of thinking and terminology that will encounter resistance from some members of our profession but will be warmly embraced by others.
Joint complex dysfunction is a more inclusive term to describe the misalignments and imbalances that can occur throughout the neuromusculoskeletal system.
Joint complex dysfunction and the resulting neuropathophysiological effects are eloquently described in The Journal of Manipulative Physiology and Therapy published in May 1998. It provides the description and explanation of what should become the comprehensive objective of chiropractic care.
In this well-researched and documented paper, you will find chapter and verse describing dysafferentation, a term that is more appropriate and technically correct than “nerve pressure or interference,” which is commonly used by chiropractors.
Dysafferentation includes the effects of the subluxation and those involving the entire musculoskeletal system, especially those of the associated joint complex dysfunction commonly seen in the extremities. Dysafferentation is the deviation from normal afferentation of peripheral structures to the central nervous system via the spinal tracts into the cerebellum and sensory cortex and, ultimately, the motor cortex.
It begins with the suppression of normal mechanoreceptors’ output and the commensurate activation of nociceptive output due to tissue stress or injury as triggered by the stimulus specific to the individual types of mechanoreceptors and nociceptors.
The body’s response to dysafferentation is pain and the compensatory protective actions we see as antalgic postures, muscle splinting spasms, and guarding. When pain and distress reach a certain threshold, there is a point at which the sympathetic portion of the autonomic nervous system will be engaged with the associated fight-or-flight stress reaction, depending on the individual’s personal pain tolerance level.
The Koch Functional Whole-Body Chiropractic Protocols share the goal of the restoration of spinal alignment with traditional chiropractic techniques. The difference lies in the added focus on the importance of the extremities and their role in synchronous whole-body movement and balance necessary for walking and all physical activities people must engage in, as well as those they enjoy and want to be able to continue to do.
The main distinguishing difference between the Koch methodology and most others is that it is less of a direct bone-and-joint moving approach than other traditional chiropractic techniques. Rather, it is based on our ability to reset and activate the suppressed joint and muscle mechanoreceptors and interrupt the overly active nociceptors by applying specialized techniques using handheld electronic adjusting instruments.
The resetting of mechanoreceptors and interruption of nociceptors is received in the cerebellum, sensory cortex, and ultimately, the motor cortex, employing the unique function of brain neuroplasticity to remap the brain image of the injured area to reflect its improved ability to move and function without the need for the protection of muscle splinting, guarding, and antalgic postural accommodation.
That is important because, with the obvious exception of acute injuries and the time necessary for them to heal, most conditions that chiropractors treat are chronic and exist long past the time when those protective mechanisms are necessary. When normal afferentation movement and function are not restored after an injury is healed, altered function and motion and body imbalance persist, causing body balance and synchronous movement to be chronically and even permanently altered.
Chiropractic corrections accomplished via the Koch methodology occur more quickly, effectively, and comfortably because they access the neural control centers rather than working on the nervous system’s peripheral reaction to stress and injury. ment in chiropractic technology. If widely adopted, it has the potential to improve public perception and the trajectory of the profession.
A Functional, Whole-Body Approach to Chiropractic
My approach to chiropractic is not only spinal, but it also involves whole-body function and balance. To achieve that balance, we must address issues in the upper and lower extremities. The upper extremities include the TMJ, shoulder, elbow, wrist, and hand. The lower extremities include the hip joint, knee, ankle, and foot.
To maintain long-term spinal alignment and balance of the pelvis and lumbosacral and cervical gimbals, we must achieve and maintain a steady and balanced stance. Whole-body balance depends on how we “plant” ourselves, so stability and proper functioning of the lower extremities are essential.
This represents a true twenty-first-century developThe foot, ankle, and knee directly affect the hips and, therefore, the entire pelvis. Think about the kinetic chain of lateral joints (see my article in the Dec 2018 issue of The American Chiropractor). When any of these joints become dysfunctional, they cause pain, torsion, and pressure on the connective tissues. When we torsion the fascia, it can potentially affect the entire body. The importance of this cannot be overstated because fascia is connective tissue and functions as a semiconductor extension of the nervous system.
When we have pain and dysfunction in an extremity that limits freedom of motion, it causes compensatory antalgic gaits, postures, and dysafferentation.
Therefore, dysfunction and pain in the extremities could create such imbalances in the body, no matter how well subluxations are corrected. They will continue to resubluxate, causing confusion and frustration for both the doctor and patient. In these cases, correction of extremity issues can be the ultimate solution to stabilizing and maintaining spinal alignment.
Correction of issues in the lower extremities is also important in preventing injury due to falls. The importance of extremity correction is punctuated by a research study conducted at the New Zealand College of Chiropractic under the direction of Dr. Heidi Haavik.
This study clearly demonstrates that the dysafferentation resulting from foot/ankle joint complex dysfunction adversely affects lower extremity proprioception, specifically step compensation.
Step compensation is a reflex-like response that allows the individual to instantly react to uneven surfaces and the little slips and trips we all experience. Loss of this function is a primary cause of falls among the elderly. Falls are a leading cause of injury and hospitalization in that population, with one-third of them experiencing falls each year.
The multisensory processing provided by normal afferentation from the foot/ ankle complex allows the brain to build an accurate picture of the internal and external environment. Multisensory integration of auditory and visual information with tactile sensation in the foot and ankle enables us to respond quickly and appropriately to prevent falls.
The Koch method is a functional whole-body approach to chiropractic. Even asymptomatic dysfunction in the extremities can affect the rest of the body’s balance, alignment, and function. Therefore, I always assess and evaluate the extremities, whether or not they are symptomatic, and correct any issues I find.
Like the three regions of the spine and the seven joints of the pelvis, the multiple joints of the upper and lower extremities each require a specific approach to evaluation and correction. Any part of the kinetic chain may affect any or even all the others, so all joints of the extremities should be assessed and corrected to achieve optimal results for our patients.
Evaluation of the Lower Extremities Aligning the Kinetic Chain of the Lower Extremities
The objective of all chiropractic correction is the reestablishment of the alignment of the six spinal motor units and restoration of full freedom of motion. That is unlikely to happen without correction of any faults in the alignment and motion of the kinetic chain of the lower extremity.
The kinetic chain of the lower extremity consists of the feet, ankles, knees, hips, sacroiliacs, 5L-S1 facets, and the symphysis pubis. Any alteration in alignment or motion will necessitate compensatory changes in alignment and motion of the joints above that point. Since I have already detailed the examination and correction of the pelvis, I will now proceed to the feet, ankles, and knees.
If we do not address faults of the foot, ankle, and knee, our correction is likely to be incomplete and compromised. The foot and ankle form an amazing complex — a Rubik’s Cube-like arrangement of 26 bones and 31 joints that must fit properly together to function and move well. The foot has three arches — lateral, medial, and transverse — that are critical to the flexibility and shock absorption of the feet.
The four bones that make up the knee are key components of the same kinetic chain. The extreme leverage exerted by the long bones of the leg, femur, tibia, and fibula apply tremendous force to the hip, knee, and ankle joints and can magnify the effects of even small misalignments in any of the involved joints.
The kinetic chain of the lower extremities is first evaluated generally and then in detail. First, observe the lateral relationship of the joints of the hip, knee, and ankle, which should be aligned vertically. Next, observe the A-P alignment of the upper leg to the pelvis and the upper leg to the lower leg. Is the patient bow-legged or knock-kneed? Do the feet flare out or in? Do the feet pronate or supinate?
Like the alignment of the spine, the alignment of the bones and joints of the lower extremities are of utmost importance to the overall structural correction. Because of the length of the upper and lower leg bones, even slight deviations of the proximal or distal ends are magnified at the opposite end. This causes excess friction, heat, and inflammation. The piezoelectric and pyroelectric charges generated cause a separation of electrical charges at the surface of the joints, ultimately causing the deposition of calcium and destruction of the articular cartilage. This is the leading cause of osteoarthritis cases that we see in our offices.
On A-P pelvic views, if there is DJD of the hip joint, it is almost always on the anatomically or chronically functional long-leg side. That is because the hip joint on the long-leg side experiences more pressure and wear and tear with each step than the short leg.
To correct foot, ankle, and knee misalignment, I use both manual and instrument techniques, which I will demonstrate in class and in future videos.
When the foot is properly mobilized and the subtalar joint adjusted, we often correct old, unresolved misalignments caused by ankle sprain.
Next, the knees must be addressed. Knee misalignments are corrected by adjusting posterior translations of the tibia and fibula. Rotations of the tibia are corrected when the anterior tubercle of the tibia is positioned directly below the center of the patella.
Once the foot, knee, and ankle are properly adjusted, we have successfully realigned the kinetic chain of the lower extremities.
With the body, as with any other structure, a strong, stable, and balanced base is essential. Every sound structure must be well grounded.
Because of this, it is incumbent upon us to include assessment and correction of weaknesses in the foot, ankle, and knee if we are to be successful in attaining our goal of whole-body balance.
Evaluation and Correction of the Foot and Ankle
Whenever possible, I like to provide my readers with practical technique instructions that they can immediately use to help their patients.
So, let’s begin with the feet. The foot is one of the most mechanically and neurologically dynamic parts of the body. To fulfill its role, it must be adequately mobile and flexible enough to adapt to the many variable contours and consistencies of the surfaces on which we walk. The feet have 26 bones and 31 joints to allow them to adjust to the various surfaces found in the natural world, like sand, mud, grass, and rocky terrain. Problems for the feet arise when we put them in shoes that restrict their natural dynamic movement. Many shoes act like a cast, putting unhealthy pressures on the bones and joints and forcing the foot into unnatural positions.
Reduced mobility of the joints of the foot coupled with an imbalanced stance alters the mechanics of the entire lower extremity and ultimately the entire body. It is difficult to separate the function of the foot from that of the ankle since they are so interactive and interdependent.
Evaluation
Observation and evaluation of the foot are done first with the patient standing, walking, and then supine.
• When the patient walks, do they strike heel or toe first?
• When walking, do the feet slap the ground, or do they walk quietly?
• When walking or lying supine, do the feet flare out or toe in?
• When lying supine, do the feet roll out or supinate? (Rolling out is often associated with a sprained ankle.)
• Do the feet roll in or pronate?
• Are the feet flat, or do they have a visible medial arch?
• Are the arches of each foot equal in height?
• Are there bunions or callouses (indicating excessive pressure)?
Major evaluation and the corrective procedure will be done with the patient lying supine and feet and ankles hanging slightly off the end of the table.
Note inward or outward foot flare. In most cases, you will find one or both feet flared outward. In many cases, the foot also rolls inward, which is often associated with a sprained ankle that can be new or decades old.
The foot/ankle complex dysfunction will persist indefinitely unless corrected. It is easily diagnosed by palpating the lateral talocalcaneal and extensor retinaculum ligaments. If a sprain exists, these ligaments will be surprisingly painful to moderate palpation pressure.
Correction Procedure
The purpose of this corrective procedure is to remove excessive foot flare (either internal or external), normalize pronation or supination, reset the subtalar joint, and generally mobilize the foot.
The patient is supine with the foot and ankle off the table.
• Use the VibraCussor Instrument with either the rounded half sphere, or, if the patient’s feet are very tender, the flat, soft padded head. Percuss the entire plantar surface while flexing, extending, and circumducting the foot and ankle for about 20 to 30 seconds.
• Switch to the ArthroStim instrument fitted with the narrow bifurcated padded sleeve. With one hand, normalize the foot position and apply slight traction. With the ArthroStim instrument in the other hand, percuss the median surface of the calcaneus for 20 to 30 seconds using a comfortable amount of pressure.
• Switch to the single-ball sleeve and percuss the medial arch, paying special attention to the navicular bone. Next, percuss the lateral and transverse arches. Then percuss the cuboid bones anterior to the calcaneus and the cuneiform bones posterior to the heads of the metatarsals while flexing and extending the foot. Next, percuss the individual metatarsal heads while flexing and extending the toes.
• Remove the ball sleeve and use the bare tip of the ArthroStim to gently percuss the interphalangeal joints. There can be some exquisitely tender spots in this area, so warn the patient that there could be a “hot spot” between one or two of these joints and proceed carefully.
• Follow the instrument work with some gentle manipulation of the toes. I call this TLP or “this little piggy”
• Last, reset the subtalar joint by grasping the calcaneus in one hand and the dorsum of the foot at the ankle joint with the other hand, normalizing the foot position to the leg. Traction the joint and caution the patient that there will be a strong sudden pull. First test with a light to moderate pull to be sure that it is well tolerated. If this is not painful, follow through with one or two strong pulls in a straight footward direction. Sometimes there will be an audible release as the subtalar joint resets, especially if the ankle joint had a previously uncorrected sprain.
This entire procedure should take only one to three minutes per foot. The benefit can be enormous because it not only mobilizes the foot and ankle complex, but also allows the patient to place the foot more evenly on the ground.
Dr. William H. Koch is a 1967 Cum Laude graduate of Palmer College of Chiropractic in Davenport, Iowa. He practiced in the Hamptons of Eastern Long Island, New York for 30 years and in the Bahamas for 15 years aboard his motor yacht, The Coastal Chiropractor. He is licensed to practice in New York, Florida and The Bahamas and currently splits his time between Abaco in The Bahamas and his newest practice in Mount Dora, Florida.
Now, wanting to give back to the profession he loves, he offers courses on "The Koch Protocols for Integrated, Advanced, Chiropractic Techniques." Simple, Effective, No Nonsense and Hands On. He may be reached on DrWilliamHKoch.com or by email [email protected].
