FREE Quadrant Analysis Training 2/3 - The "Abdominal" Patient

All right, so this is part 2 of this free 3-part quadrant analysis training I put together. What I'm going to talk about today is another type of patient who tends not to respond so well to your typical treatment plan. So last time we talked about a way to find hidden pattern breaks. So this is when you have a mechanical driver somewhere else in the body that is driving their symptoms, and when you find that and you adjust an area, you treat an area that, that didn't seem to be in pain, and their pain gets better, Patients are really impressed and you feel like a little bit of a wizard. I love pattern breaks. Today we're going to talk about a very different one. This is where you have non-mechanical inputs that are driving their pain, and this is a subclassification of patient that I look back and I struggled with for years. I could never really wrap my head around it. And essentially this was the kind of patient who would come in and they often had sort of chronic stiffness, things were tight, and I go, okay, I found a few things that we've got some stuff to work on. And, you know, they'd be telling me that, well, they've had— sometimes chiropractic helps, sometimes it wouldn't, sometimes massage helped or it wouldn't. It was kind of up and down like that. And, oh, sometimes exercise is helpful, but sometimes I really flare up with it as well. They had this kind of inconsistent pattern. And, you know, I'd find some things— okay, well, look, that area that you're getting pain, it's really jammed up. Let's go ahead and treat that. And I would start treating it. Sometimes it wouldn't really get that much better, and I'd be going, like, I know this is where the pain's coming from. This is the, the pain generating structure. Why are they not getting better? Why does it keep flaring up? And I'd be asking about their lifestyle and what they're doing, and I'd be trying to get them doing more active things, and I'd be trying to change around my treatment, but they wouldn't really move. Sometimes they get better, but not that much, and they get stuck. Um, sometimes they wouldn't get that much better. On the other hand, and this is the one that really threw me, is I would start with some treatment and they'd come in at visit 2 and go, oh my God, I have never felt this good in years. I slept through the night for the first time ever. I've got no pain walking down the street. 'Oh my God, you're a miracle worker.' And I'd be going, 'Yeah, we got it. Like, we found the underlying issue.' And I go, 'Great, this person's responding really, really quick.' I'd feel really, really good. I'd do the same treatment. Visit 3, they're going, 'Yeah, I don't know, it's come back since your last treatment. It's come back. And oh, you know what, now it's not so much there, but it's swapped to the other side.' And the next visit, they're going, 'It's kind of running down into the hip a little bit.' And then a couple of sessions later, 'It's sort of radiating up my back.' It was this really inconsistent pattern that I'm going, 'Wait, I'm doing similar stuff each time.' Why are you not responding the same? Why is it all over the place? And frankly, why the hell are they not getting the response they had after the first one when I was feeling really, really good? Um, so these patients, it'd be really, really hard to get a handle on it, and I never really worked out why until I studied quadrant analysis and until I learned from Rob what's known as the abdominal subclassification. Now, the abdominal subclassification, uh, when you know how to spot these people, you will spot them regularly. And if you spot them in advance, it is way easier to manage them. If I know this person is probably be up and down, or they're going to take some time. And I let them know, I get a chance to set my own and the patient's expectations rather than getting carried away thinking, oh, they're going to be great, and then they're not. Now, the abdominal sub-classification, it's called that because you tend to find tenderness and inflammation in the abdomen. These are people where, you know, gut issues can play a role, but that's not the entire thing. Um, and what it does, the abdominal sub-classification, it, it sits on a spectrum. So at one end you have people who aren't really that inflamed at all, and this isn't really an issue for them. On the other hand, you have people with autoimmune issues, whether that is RA, whether that is, um, something more like ankylosing spondylitis. So we're better as a profession now at spotting these people. If you think they've got an inflammatory arthropathy, that would be, you know, the extreme end if they have that. But it spans this whole thing, and there's these people in the middle that often get lost, that they, they look a little bit inflamed. You might go, you know what, the spade tool, it's scoring, or like they have an inflammatory type of back pain, they're really stiff in the morning, um, they maybe had history of whether it's heel pain or peripheral joint issue. They often have pain that's moved around over time, but then you go and refer them and they get tested and they get a bunch of blood tests. There's no inflammation, there's no markers, RA negative, no LhA-B27. And yeah, the GP or the rheumatologist is like, nope, you're fine, this is just mechanical. And yet they don't seem to respond to just purely mechanical input. So these are the people that get lost, and they often have this real up and down thing. What's happening with them is that they seem to have a low level of just inflammation in the system generally and that keeps mucking up your treatment. They flare up easily, they stiffen again very easily, they don't respond the way that you think that. So the things I'm looking for in the history is if they have an up-and-down relationship with, uh, exercise. Sometimes it feels great, sometimes they really flare up and they keep getting injured even for doing the same thing. They can't work out why. Or there's somebody who has a love-hate relationship with manual therapy. Sometimes it's been great and sometimes it's really flared up, you don't know why. I'm already thinking, mm, this person sounds a little bit inflamed. During the assessment, if they seem just a bit stiff I think of them as like, it's like the body's a little bit overinflated. Everything's that bit tighter, there's more pressure. Their range of motion generally isn't that great. Their muscles feel a bit tight. They're often tender in a few different points. That's another thing. The other one that I go through with every new patient is I palpate the abdomen. I'm not looking to diagnose specific organs. I'm not doing visceral manipulation. I'm not looking for anything specific. But if their tummy is generally tender when I'm poking around there That tells me we've probably got some inflammation in the abdomen. This is somebody who isn't going to respond necessarily as quickly or as well. I've now got a heads up on that. Now, what do we do with that information? So unlike pattern breaks, where when you find a pattern break, there's a good chance as a manual practitioner, a chiropractor, you can address that yourself. Abdominal patients I very rarely try to address on my own. Now, this depends on your skill set as well. It depends on how you practice and what you like to do with patients. One of the things I love about QA is it will never tell you you must do this or you mustn't do that. Whatever your style of practice, QA will fit into that. So for me, I predominantly adjust. That's most of what I'm spending my time doing with patients. The abdominal patient may really, really benefit from some soft tissue work, and for those people, we have in-house massage therapists. I will often co-manage with the massage therapist if everything seems really tight and sore and we have some massage and that helps. Great. Sometimes they're, they're alternating between us, they're going back and forth there a little bit. If you do a lot of soft tissue and you know that you're really good at that, well then great, you could do that yourself as well. QA will help you be even better and even more targeted with that if you want to dive into the, the full content there, but you might choose to do that yourself. But I'm thinking soft tissue with these people, it often seems to help more and calm things down. The other thing I'm thinking is acupuncture. Now I do dry needling with patients. I don't do it a lot, I don't claim to be an expert at it, but I do find these patients that can be helpful. So I may start doing that in my treatment. However, if we're not getting the results I like, I often then think about managing with a traditional Chinese acupuncturist. If you know a very good traditional acupuncturist in your area, they can be really helpful for some of these patients as well. It seems to just take some of that pressure that's built up and let the whole system go, ah. And sometimes that can get them feeling way better. Sometimes that then allows you to get much better results with the treatment they need because you're not fighting against the body now. So again, whether you do needling yourself in-house or whether you, um, do you massage yourself or whether you co-manage. Those are two things that I'm often thinking of, is that yes, the adjusting can be really helpful, but I'm also thinking, do we need some soft tissue release and do we need some acupuncture to take some of that tension out of the system? That can be enough for some of these patients. Sometimes you just need a good person to co-manage with, or you just need to bring in some of these techniques a bit earlier. That will make a big difference. That's good for helping calm things down, but what do we do beyond that? The thing that's often driving this usually comes down to some combination of nutrition and stress. Some people it will be pretty much all nutrition, and that's the real thing. Some people will be pretty much all stress. Often that there's an element in between there. So I also want to be thinking with these patients, okay, looking further up the stream before the dysfunction even gets in there in the first place, what are some of the things driving that that if we can address, we can make a big difference? Now, those of you who, um, know Simon Billings and he's done the Academy of Chiropractic Nutrition, or those of you who've gone full hog and done functional medicine you'll know how to handle the dietary side of these things pretty well with patients. That doesn't mean you have to do it. I love Simon, I've done his whole course, I've learned a huge amount from him, I'm fascinated by this subject. I don't want to be looking at food plans all day, it doesn't excite me, it's not what I want to be doing with my patients, it bores me, but it's very, very useful. So if it seems like, okay, we have a chat and diet may be an issue there that could be driving some of it, and the patient's on board with it, I'll give them some simple tips, I'll give them some simple lifestyle advice, like an elimination diet to try. Maybe there's a couple supplements that we might recommend. Maybe they just need to improve their eating habits a little bit better, maybe cut down some of the junk. I can give them some signposting there. If they seem like they need more help with it, or there's a lot going on, I will co-manage with a local nutritionist who I know who is very good and knows how to handle these things. These are often patients that I end up co-managing, and it's one of the reasons why it's allowed me to build a really good rela— um, referral network in my area, because I'm often saying to these people, hey, I think you could help this patient. And over time they refer back into me, and that's great too. But More to the point, I don't want to be doing all of that myself. So with these patients, if there's a lot going on there, I might refer to them. Equally with stress, with mental or emotional issues, if they just need a bit of signposting, if they just need me to give them some advice on how to sleep better, um, download a mindfulness app, you know, make some time for themselves, go for a walk, that kind of stuff. Again, I can give them some basic advice. If they need something beyond that, I will be recommending to them it might be worth talking to a professional at some point as well. Now, in my experience, most of these people, by the time they come and see me this has been going on for a long time and they're feeling overwhelmed. And if I start saying you need to go see these 4 different people and you've got to sort your life out and sort your diet out and you've got to go see a therapist, it's too much. They're not going to do that. I will mention these things to patients at the start as options that we have. I often talk about building a team with them. That might be something that's helpful over the long term, but right now, first things first, I've just got to get them feeling a little bit better. So I'll tend to think about me plus or minus massage and acupuncture initially there. Often once they're feeling better, they're like, okay, this is better. They have some hope, but they go, yeah, it's still there. How do we stop it coming back? That's when they might be ready to start thinking a bit more upstream about looking at some nutritional input, about looking at some mental health side as well. Um, sometimes you've just got to sow seeds and it takes the patient a fair bit of time for that as well. Some people will be ready to do that right away and that's great. So I will mention it to the patients at the start, but I certainly don't push it. I'm just saying this might be something that's helpful. Have a think about it. Um, we can chat about it some more next time if you want. If you're not ready for that now, you don't think that's useful, Okay, let's focus on some other things. But the really cool thing with the abdominal patients is that since studying QA and understanding them better, I have options. These are patients that I never felt I had options for. I kept trying everything I had and throwing all my tools at them, and it just wasn't really getting anywhere. And when you have options, practice feels a lot easier. It's more effective, but it's less pressure on you as well, because, okay, I tried that thing, it didn't work, that's okay, we have some other options. So that's a kind of brief, brief overview of the abdominal sub-classification there. Like I say, when you start looking for these patients, you will spot them everywhere. They're very, very common, um, certainly more in the last, you know, the last few years than they were 10 years ago there. And if you can get ahead of it, you know that's what's coming up, you know there might be an issue there, it makes it so much easier when you can prepare that and you can prepare the patient for that as well versus having to react and go, oh man, why isn't this person getting better? So have a look at that, have a look at those pattern breaks we talked about last time. If you haven't seen that video, make sure to watch that. Um, have a think about this abdominal subclassification as well. Start doing this with your patients. It's very quick and easy to do. And it'll start giving you some pointers. What I'm going to share next is how some of this stuff can come together. I'm going to run you through a case of mine, um, that I'm seeing at the moment. Actually, it's fascinating, um, to show you how we can start addressing these in different ways, and most importantly, how QA gives us options, um, and for me makes practice a lot more fun. So I'll see you in a few days for another video then.