In chiropractic circles, we often talk about trauma, toxins and stress as the core underlying substrates of the subluxation. While we recognise that these three things can be physical, chemical, emotional or mental, it isn’t often we stop to think about another factor: the trauma that arises from adverse events in childhood – collectively called “ACEs”. So, let’s take a pause to talk about a new paper calling for awareness and action around ACEs and trauma-informed chiropractic care.
When we are talking about adverse events in childhood, we are usually talking about things like abuse, neglect or assault – we are referring to things that challenge a child’s sense of safety and elicit a significant psychological response and occur before the age of eighteen. Increasingly, research is pointing to these events having a significant impact across the lifespan. As chiropractors who may find these nervous systems literally in our hands, understanding what to look for and how to respond is vital.
A new paper published in the Journal of Chiropractic and Manual Therapies has run this issue up the flagpole in a call for chiropractors to understand and enact trauma-informed care for their practice members. In the paper, authors Baca and Salsbury point out that people with three or more ACEs in childhood are significantly more at risk of “poor mental health outcomes, and may be more likely to engage in high-risk behaviours, predisposing them to long-term health impacts, such as metabolic diseases, anxiety, depression, substance use, and chronic pain [1].”
These effects are true across the lifespan, and not just at the time at which they occurred. So what do chiropractors do, given 64% of American adults self-report exposure to one ACE, and 15% report exposure to four or more. [2, 3]
While there are several conceptual frameworks proposed for trauma-informed care, but the authors recommend what is arguably the simplest of those outlined in the original paper. Simply put, the model is the 4 R’s: Realize, Recognize, Respond and Resist-Traumatisation. So let’s break it down
Realize
In this part of the model, Baca and Salsbury recommend that chiropractors inform themselves of the widespread effects and impacts of trauma. Likewise, an understanding of the potential paths for recovery is vital. While we know many of the impacts are physiological, being able to pass on good referral information as part of supportive care may make a big difference.
Realizing the impact and reach of ACEs includes knowing the chronic stress impacts, the brain effects during key developmental milestone, and the hormonal impacts that may also ensue. (A good place to start is the article cited below, which outlines five key milestones – the Adverse event, Compromised Allostasis, Physiologic Changes, Disease and Disability, and then potentially premature death).
Recognize
Though none of the four items in the model are more important than another, the ability to recognize signs of trauma and triggers in the person under care. Research indicates that ACE exposure “is linked to neural sensitization (chronic pain), depression, anxiety, metabolic illness, autoimmune disease and high-risk behaviour. [1]” As for the premature death piece, this really stems from risk-taking behaviours or chronic pain and illness conditions. As to triggers, chiropractors may notice a person under care reacting to stimuli in a different way, and this may indicate a trauma-reaction to a sensory link to the traumatic event.
The paper recommends chiropractors seek to identify potentially triggering situations and prevent them from occurring. This can create a safe space in which a person can engage with care. While chiropractors inherently understand the fight, flight, freeze and fawn responses bedded down into the sympathetic nervous system, a patient experiencing a trigger is the most acute version of this situation – and it can be happening in real-time in your office. Thus, avoiding triggers, practising creating a safe space, and being trauma-informed is paramount. So watch out for changes in muscle tension, such as involuntary recoil or shock.
Respond
Part of the response recommended by Baca and Salsbury, is more training. Knowledge is power in this scenario. Creating safe spaces and avoiding triggers is vital, but so too is building ACEs into your intake screening. Responding adequately may involve external referrals to trauma-specific care, so awareness of these services in your area is also important.
Finally, Resist-Retraumatising
By informing yourself, finding out early if this may be an issue for your patient, and by creating safe spaces without potential triggers, you are avoiding the retraumatisation of the patient. But other things can gently reinforce the safe space too. Things like informed consent, letting people know if close physical contact is about to occur, and responding appropriately if they show signs of shock or distress. All this is geared at providing better care and reducing patient fear – both of which are vital in caring for the nervous system and the whole person.
The full paper is available below and is absolutely worth a read as chiropractors continue to provide exemplary care. Make sure you give it a read.
References:
- Baca, K.J., Salsbury, S.A. Adverse childhood experiences and trauma informed care for chiropractors: a call to awareness and action. Chiropr Man Therap31, 30 (2023). https://doi.org/10.1186/s12998-023-00503-2
- Preventing adverse childhood experiences: data to action (PACE:D2A) |Violence prevention|Injury center|CDC. 2022. https://www.cdc.gov/violenceprevention/aces/preventingace-datatoaction.html. Accessed 18 Jul 2022.
- Adverse Childhood Experiences (ACEs). 2022. https://www.cdc.gov/violenceprevention/aces/index.html. Accessed 10 Aug 2022.
