AXIAL DECOMPRESSION THERAPY A New Perspective

Mechanical traction has been judged as a reasonable and logical treatment method for spinal pain for centuries.  Since compressed discs are often a source of chronic back and leg pain, stretching the spine is an intuitive remedy.1,2  However, it has never gained widespread popularity in the chiropractic profession, nor have its results been consistent in clinical trials.3  Cumbersome equipment, time consuming and uncomfortable procedures and its historical connection to physical therapy have kept it out-of-favor with perhaps the one profession best suited to its unique capabilities.

Within the last decade, however, traction has been making a reemergence in our profession.  It has taken on a new name and a new efficient profile.  It is now called decompression.4

Decompression or decompressive traction refers to a decrease in intradiscal pressure (and the resultant circulatory improvement and phasic healing concomitant with it).5  Specific protocols and systematic procedures reduce misapplication and the haphazard nature of previous methods.  In effect, decompression is best thought of as a hybrid traction method.

Several decompression units have entered the chiropractic market in the last ten years, most with a plethora of bells and whistles and extremely high price tags.  In the era of managed health care, lower equipment costs and lower overhead are the key to profitability, yet many DC’s have opted to purchase these units on the promise of dramatic outcomes and huge reimbursements.
Excellent results and patient satisfaction have always been the fuel that has powered the successful practice.  The promise of extraordinary results and reimbursements of $150 per treatment can be very persuasive in our competitive marketplace. 

Many chiropractors looking for a niche have discovered that, very often, patients unresponsive to manipulation or flexion do respond to the proper application of axial decompressive traction (that these units work is not really at issue).  They have discovered, additionally, that offering “…non-surgical decompression for disc problems” is an excellent means to attract new patients.6  This is due to its safety and comfort vs. traditional methods, not to mention the reduced strain on the busy doctor’s body!

However, the extremely high costs have often created undo financial stress on many practices.  The per-treatment reimbursement must be very high to validate the cost of equipment that leases for $1500+ a month for sixty months, or a charge of $50 each time you turn it on!

Many insurance companies are now enacting post-payment audits of DC’s billing decompression.  Any billing code other than traction (97012) can result in repayment, fines and penalties.  There is actually no decompression code, and rarely is an insurance company willing to pay $150 per treatment simply because the doctor paid  $50-125,000 for the equipment.7  I’ve owned several of these expensive decompression units over the last eight years and have been subjected to two audits u u resulting in six-figure reimbursements.  Of course, having the ability to up-sell a cash patient (or doing several additional modalities to generate $150 per session) begs the question, why not simply utilize an equally effective device costing one-tenth the price and watch your profits rise exponentially?

Recently, such equipment has become available.  One system which I particularly favor includes not only the unit, but also supportive diagnostic, and low-tech therapeutic devices.  Moving from passive to active procedures is a vital step in outcome-based care.  The included low-tech rehab device allows monitored exercise in the vital segmental stabilizers (the so-called local muscle system).8  Additionally, there are two methods of cervical traction and carpal distraction quickly and efficiently accommodated, all at a price around $10,000.  It becomes apparent to the experienced user that it’s the necessary utilitarian features, not the price, that allows for effective treatment.

An honest and objective analysis of the phenomenon of decompression brings us to the realization that it is an outcome that can be consistently produced by the adherence to several utilitarian characteristics and protocols.  It is probably not an overstatement to say, they are absolutely necessary for the most consistent, effective therapy. We contrast decompressive traction (i.e., decompression) from traditional mobilization traction methods by these characteristics.9   See Table 1.
These characteristics work in synergy to enhance the efficacy of Y-axis traction.  The synergistic effect of these characteristics is patient comfort and relaxation.  They reduce conscious and sub-conscious anticipatory guarding.  It has been suggested that muscle guarding reduces the ability of traction to distract the vertebrae sufficiently to decrease the internal pressure of the disk for a pre-determined time so healing can occur.  Thus, a slow, graduated application of tension and exact, reproducible forces make up a substantial aspect of decompression.12  It should be obvious that roller type tables and automated axial elongation on a flexion table have no ability to deliver real decompression.  Continued use of a traction code for that type of treatment can also lead to post-payment insurance troubles.

I can tell you from personal experience, it is unnecessary to spend extraordinary amounts of money in order to offer this beneficial therapy in your clinic.  Decompression therapy is now available for the cost of a quality adjusting table.  Look around!

 

Dr. Jay Kennedy has been practicing Chiropractic Biophysics (CBP) in Western Pennsylvania since graduating Palmer College in 1987.  In the last eight years, he has owned and operated several decompression systems treating over 2000 patients on them in his multi-disciplinary clinics.  He lectures extensively and has authored various articles on axial decompression.

Homeopathic Miasms: Breakthroughs in the Cure of Desease

Dr. Samuel Hahnemann, the Father of Homeopathy, used the term “miasm” to describe the transgenerational causes to disease.  The word miasm means an obstacle  to cure, and Hahnemann asserted that unless this “obstacle to cure” is dealt with, the cure of disease will always be incomplete.  In modern terminology, miasm means diathesis or constitutional susceptibility or predisposition to a particular disease.  The deeper roots to disease can be traced back generationally to five primary diseases Hahnemann referred to as miasms.  The good news is that these predispositions to disease can all be corrected and cleared using homeopathy.
The five miasms are cancer, gonorrhea (sycotic), syphilis, tubercular (TB), and psora.  Miasms alter the ideal genetic blueprint for our health and can affect our entire being, physically, mentally, and emotionally.
Miasms can be either acquired or inherited.  One can acquire a miasm, for example, by contracting gonorrhea, say, at age eighteen.  When treated with antibiotics, this form of suppressive therapy can cause gonorrhea to go dormant and become active or show up later in life in the form of allergies, sinus, herpes, virginities, warts, tumors, suspiciousness, jealousy, selfishness or uncontrolled sexual desires.  Hence, acquired miasms are attained during our lifetime.
The far majority of miasms, however, are inherited.  The chance of inheriting miasms from thousands of years deep into our family tree is much greater than what we might acquire in our own lifetime.  Inherited miasms can be active or dormant.  A miasm that is active actually causes a present symptomatic picture or expression.  And, the best time to consider using a miasm formula is when the symptoms are present.  A dormant miasm is one hidden deep within the body, not expressing any of its possible symptoms.  It is recommended not to attempt treating dormant miasms unless other testing procedures, such as electro-diagnostic or reflex response tests, indicate the need for a specific miasm formula.
Homeopaths have experienced how miasms exist in various layers within the body, and understand that, as we work at correcting disease and building health, it is like pealing away the layers of an onion.  Regular homeopathic formulas work to strengthen and restore health to the body according to the symptomatic expressions the body is communicating.  When these conditions have a tendency to recur or be non-responsive, a deeper acting remedy, like a miasm, may be needed to more completely correct the condition.  As we continue to peal away the disease layers impairing our normal healthy expressions, we frequently discover various miasms along the way.
Miasm correction is essential to both the restoration of our health and the eradication of disease from our planet.  I have now used homeopathy long enough to see genetic disease patterns in people corrected and observe the liberation of those diseases later on in their own offspring conceived after miasm correction.  I have seen this remarkable healing phenomenon in cases such as childhood obesity, allergies, breathing disorders, skin disorders, and certain behavioral disorders, phobias and in anxiety-or nervous-prone people.  What a wonderful reward, not only to see both children and adults healed of devastating genetic or life-long health problems, but also to see their children born and grow up free of those inherited health problems and weaknesses in their families!

How do you treat miasms?

Miasms are matrixed—or integrated—into our inner most being from thousands of years deep into our family tree.  Although they are not difficult to correct with homeopathy, they are not always wiped out in a single blow.
Homeopaths have shown how disease patterns are trapped in and throughout the layers of our lives.  These layers are like clear overlays, as seen in global maps demonstrating how global shifts and changes in boundaries of countries have taken place over time and warfare.
Treating miasms can cause extreme changes in one’s health.  Commonly these changes can cause a wonderful enlightening euphoric experience, as well as times when a more intense cleansing crisis may occur, creating a temporary discomfort from the eliminative process.  Some of the commonly experienced cleansing symptoms may include emotional releases, skin breakouts, itching, fever, fatigue, bowel movement changes, breathing changes, and various forms of pain.  These symptoms, although temporary and non-damaging to the body, can be severe at times.  Remember, the body is orchestrating the healing crisis and will not harm or cause any permanent damage to it, even though it may feel like it at times.  Although the healing crisis is not always comfortable or convenient, it is essential to our optimal healing and restoration!
It is best to monitor patients closely when using the miasm formulas.  It is helpful to explain that there is a 60% chance of experiencing some form of cleansing response when taking a miasm formula.  This way, when they do experience these symptoms, they will understand the good purposes of eradicating the miasms.  Eradicating miasms not only helps us to better correct our present disease(s); it can also help prevent diseases in the future, both in our future offspring and ourselves.  Explaining ahead of time makes a big difference in the attitude of your patients when they go through a cleansing crisis.  When your patients are going through these uncomfortable times, it is much better to be praised for your wisdom than to be cussed in distrust.
Starting out a new patient who has not had experience with natural healing or detoxification with miasm treatment is not recommended.  They may not be strong enough to handle the elimination of the miasms in the most graceful of ways, especially if the patient is in a weakened state of health.  I recommend addressing the primary symptoms with symptom specific formulas first, along with detox and drainage formulas.  These products will help strengthen and restore the natural healing and eliminative functions, so that they can better deal with the deeper issues of the miasms later.

Miasms are great to use when patients:

  • Don’t respond to homeopathic treatment;
  • Don’t respond to other natural treatment;
  • Reach plateaus where they seem to level off in their health enhancement;
  • Continue to have reoccurrences with the same problem.

Miasms have a tendency to show up periodically throughout the healing processes over years.  Even miasms that didn’t show up previously in testing may show up later on in the treatment program, as more of the layers of disease have been pealed away.  Either the same miasm treatment or different miasm treatments will commonly be needed periodically over our lives.  It’s likely that almost everyone has at least one miasm; many people have more than one; and basket cases can have many miasms. TAC

 

Frank J. King Jr., N.D., D.C., is a nationally recognized researcher, author and lecturer on homeopathy.  In addition, Dr. King is the founder and director of King Bio Pharmaceuticals, a registered homeopathic manufacturing company dedicated to completing chiropractic destiny with the marriage of homeopathy.  Dr. King offers, complimentary to all Doctors of Chiropractic, his turnkey procedural system for the high volume practice called, The Chiropractic Enhancer systemÔ (CES).  It is so easy to use that you can successfully apply homeopathy in your practice using any company’s products in one day. Call King Bio Pharma-ceuticals, Asheville, N.C. 1-800-543-3245 or e-mail: [email protected].

The New Patient Phenomenon

Scheduling the New Patient
When scheduling a new patient, it is very important that you are conscientious to do the following three things in order to insure the new patient will not have to wait and that their first visit will be a successful one.
1. Select an appropriate time, allowing the doctor enough time to consult with, examine and X-ray the new patient.
2. Make sure the appointment time you communicate to the new patient is fifteen minutes earlier than the time actually scheduled in your appointment book.
3. Make sure you have properly recorded the new patient appointment in the book.

Allow Enough Time for the Doctor
Iorder to provide the doctor with adequate time to see a new patient, typically you will need to block out forty-five minutes to an hour.  However, this may vary depending on the individual doctor and whether or not your clinic has an examination doctor or a certified X-ray technician on staff.
The best way to insure that you have forty-five minutes to one-hour blocks of time available to see potential new patients is to “cluster book.”  The cluster booking technique is briefly described below for the purpose of understanding how to schedule a new patient.

Cluster Booking
Cluster booking is the primary method of patient control and provides increased efficiency in time management. It allows the doctor to keep his mind in a treatment, examination, or paperwork mode for a segment of time. It is extremely exhausting, both mentally and physically, for the doctor to do paperwork, treat a patient, examine a patient, sit down, treat a patient, etc. 
The cluster booking technique involves establishing four treatment modes, or clusters, per day in which you schedule patients for adjustments and therapy.  Each treatment mode has a start time, from which you begin scheduling patients continuously towards the next cluster,  lunch or closing time.  There are two morning clusters and two afternoon clusters.
By scheduling treatment in clusters, there will naturally be holes or blocks of time between the treatment modes.  These holes are used to schedule new patients and other special services, such as re-exams, report of findings, etc.  This way the doctor is able to devote the necessary time to the new patient, without making other patients wait.
Note:  If the patient is acute and needs emergency relief, work them into your schedule, even if you do not have enough time available for a new patient.  You can do a brief examination and give the patient relief care, scheduling the complete chiropractic, orthopedic, and neurological exam for the following day.  Remember, new patients are the lifeblood of your practice; you must be available when they need you.

The Appointment Time Communicated to the Patient Should Be 15 Minutes Earlier than the Actual Appointment Time
By having the patient come fifteen minutes early, you allow time for them to fill out the necessary paperwork, without throwing the doctor off schedule.  If the new patient arrives at the actual scheduled time, the doctor has to wait while the patient fills out the necessary forms and, consequently, is fifteen minutes behind schedule when other patients begin to arrive.

Make Sure You Properly Record Appointment in the Book
When scheduling a new patient appointment in your book, make sure you write NP in the services column to the left of their name.  (Personally, I like to color code my appointment book).  You must also be conscientious to write their phone number under their name so that you can call to remind them of their appointment, or call them to reschedule if they miss the appointment
Be sure to block out the necessary time below their name, so someone else cannot be scheduled in that time and cut the new patient appointment time in half.
Finally, make sure that you highlight the new patient appointment in yellow, so that it stands out in your appointment book.  This will help you to remember to do the necessary preparation prior to the new patient appointment.

New Patient Flow
Now that the patient has scheduled his first appointment, proper procedures must be followed.  There are three important procedures that must be performed in order to deliver the best quality care to each patient.  These procedures are comprised of three steps.

  1. Consultation and preliminary examination;
  2. Orthopedic, neurological, chiropractic and physical examinations, and X-rays, if indicated;
  3. Report-of-Findings and treatment.

The consultation and preliminary examination are used to determine if a new patient is a chiropractic candidate.  The complete orthopedic, neurological, chiropractic and physical examinations are administered to provide the doctor with the necessary findings for diagnosis, prognosis and a recommended plan of treatment.  X-rays usually play an important role in the diagnosis of spinal problems, and are generally necessary to rule out conditions that would require the patient to be referred to another specialist.  However, some new patients may be transferring care from another physician who might be able to provide you with recent X-rays.  Finally, the Report-of-Findings allows the doctor to explain the documented findings and treatment plan to the new patient.
Once again, these procedures can be performed over one or two visits, depending upon individual circumstances; however, all three steps must be covered thoroughly.  It is also to be noted, a patient may require emergency (relief) care on the first visit.  In the new world of compliance, we must document what we do.  It begins with the first visit of any new patient. TAC

Dr. Eric Kaplan is the CEO of MBA, Inc., one of the nation’s largest multi-specialty consulting companies.  Dr. Kaplan ran and operated five  of his own clinics, seeing over 1000 patient visits per week.  He is the best-selling author of Dr. Kaplan’s Lifestyles of the Fit and Famous, endorsed by Donald Trump, Norman Vincent Peale and Mark Victor Hansen.  He was a recent commencement speaker at New York Chiropractic College and regularly speaks throughout the country.  For more information about Dr. Kaplan or MBA, call 561-626-3004.

CHIROPRACTIC ON THE STATE LEVEL Featuring the Florida Chiropractic Association

Background

The Florida Chiropractic Association (FCA) began in 1931, and was established by Florida’s chiropractic pioneers, who attained state licensure for the profession.

As Florida’s largest professional chiropractic association, representing over 4,000 active members, the FCA enjoys the support of 80% of the practicing Florida-resident DC’s and several hundred out-of-state doctors who either hold Florida licenses or attend FCA conventions for license renewal in their home states.

Volunteer leaders in the profession representing all of the geographic areas of Florida are responsible for the mission, policy and direction of the organization, while a dedicated full-time staff headquartered in Orlando carries out the day-to-day operations. They, in turn, are aided by a variety of consultants who offer their specialized talents in areas ranging from government relations to association marketing. Together, they work to help educate, inform and assist FCA members in delivering only the highest quality of care to the citizens of Florida.

The primary function of the Florida Chiropractic Association is the protection and welfare of its individual members, regardless of philosophy, as well as education of the public concerning the chiropractic profession.

“The FCA wants nothing less than total parity—even the lead role—for chiropractic within the health care community, and complete and easy access to chiropractic for Floridians,” says Debra Brown, CEO. “As the FCA has grown in strength and effectiveness, so chiropractic has been elevated in the state of Florida.”

What this translates to is the achievement of many historic firsts in chiropractic, through FCA legislative victories in areas such as Medicaid funding for chiropractic, chiropractic insurance equality and the granting of $750,000 in state dollars to establish a Research Center in Chiropractic and Biomechanics at Florida State University, to name a few.

What’s New?

And, recently, in some late-breaking news, it looks like they’ve done it again! According to a FLASH report prepared by Paul Lambert, FCA General Counsel, and Jack Hebert, FCA Director of Government Relations, “The FCA and its coalition friends were victorious in completely reversing [some of] the onerous provisions that the insurance industry had placed on [Florida Personal Injury Protection (PIP) legislation]. Although the bill is not perfect, it represents a compromise greatly in our favor as providers.

“The Florida Senate gave its preliminary approval to SB 1202, a series of new proposals targeting fraud in PIP automobile insurance. Originally this bill was a hated ‘wish list’ of denying and delaying tactics desired by the insurance industry, disguised as anti-fraud measures. Now, a series of amendments have significantly changed the character of the originally hated bill. The amendments, supported by a coalition including the FCA, the Academy of Florida Trial Lawyers, the Florida Medical Association and other provider groups, dramatically changed the character of the legislation.”

The report went on to say that only the day prior, the Florida House of Representatives passed an amended version of their PIP anti-fraud legislation. And that the House version is substantially different than the Senate version, in that it is far less broad in scope and is limited primarily to anti-fraud provisions. That bill was to have been before the House the following day for final passage, after which it could have moved to the Senate for its consideration. At that time, though, it was uncertain whether the Senate would consider the House proposal.

Anyway, you get the idea…. Those Florida folks really know how to coordinate their efforts on behalf of chiropractic! Congratulations, and keep up the good work!

For more information on current developments in this latest coup by the FCA, or on related activities, be sure to check out

www.FCAChiro.org. TAC

Tarsal Tunnel Syndrome & Orthotic Support

Tarsal tunnel syndrome (TTS), while not common in the general population, is occasionally seen among athletes.  In addition, many TTS symptoms can be confused with conditions commonly treated in the chiropractic office.1  Because its etiology is often related to hyperpronation and, therefore, spinal complaints, TTS patients may be concentrated in the chiropractic office.  When a patient complains of burning pain or numbness of the foot or ankle, keep TTS on your list of differential diagnoses, including plantar fascitis, Achilles tendinitis, and lumbar radiculopathy.

Similar in function to the carpal tunnel, the tarsal tunnel is formed by the following borders:  medial calcaneus, medial malleolus, posterior talus, and flexor retinaculum.  Structures passing through these confines include tendons, blood vessels, and the posterior tibial nerve, including its branches, the medial calcaneal, medial plantar, and lateral plantar nerves.

These sensitive structures are susceptible to any direct trauma or lesion that decreases the available space.  The athlete runner with a recent history of increased activity is particularly vulnerable, but also consider any auto accident victims who have jammed their lower extremities.  The energy at impact, sent through the pedals or floorboard and into the feet and ankles, supplies the force necessary for traumatic TTS.  On the other hand, consider the simple act of walking on an excessively pronated foot, which is far more common among patients. 

The review of eighty-seven TTS cases revealed that biomechanical deformities, including tarsal jamming and hyperpronation, were to blame and could be documented radiographically. Furthermore, it has been proposed that even minimal trauma during weightbearing activities in persons with pes planus is the most likely mechanism for TTS.  This same study postulates that when pes planus is functional and associated with malposition of the tarsals, the posterior tibial nerve is stretched with each step taken.3  Tarsal malposition is evident with toe out greater than fifteen degrees and with excessive bowing of the Achilles tendon, when viewed from behind.

The symptoms of TTS can be easily confused with plantar fascitis and, in extreme cases, with lumbar radiculopathy.  In the case of biomechanical overuse, the patient will report poorly localized numbness and tingling of the medial ankle and on the plantar surface, which may extend into the lateral two toes (the lateral plantar nerve being more commonly involved). 

Unlike plantar fascitis, which is generally worse in the morning, TTS is worse at night after activity and may include pain radiating up the medial calf.  The physical exam may reveal loss of two-point discrimination and muscle strength in the distribution of the lateral plantar branch and a positive Tinel’s sign, found when tapping directly over the site of the tarsal tunnel.  A normal Achilles reflex should help rule out lumbosacral radiculopathy.

Initial treatment of TTS includes inflammation reduction of the involved tissues.  This means no weightbearing without the foot and ankle taped or without orthotics in place.  Next, adjustments should be used to restore normal biomechanics throughout the entire kinetic chain (foot, ankle, knee, hip, and spine).  Special attention must be given to the valgus misalignments of the talus and calcaneus.  Additionally, deep friction massage over the flexor retinaculum may release adhesions responsible for compression symptoms.
Most importantly, correct the underlying foot dysfunction (hyperpronation or otherwise).  Pes planus causes tightening of the flexor retinaculum, which can then compress structures within the tunnel.  Although the inflammation may go away, the nature of ligament stretch means that any plastic deformation is permanent (barring surgical intervention).  Therefore, effective and lasting treatment necessitates the use of custom-made, flexible orthotics, which have been demonstrated to control the degree of pronation, as well as the percent of time spent in pronation.

Although relatively uncommon, tarsal tunnel syndrome can present a diagnostic and treatment challenge.  Understanding the etiology of this entrapment syndrome is important for providers concerned with the treatment of athletes and auto-accident victims.  Also, because TTS is often associated with hyperpronation, patients will likely experience other conditions also associated with a faulty foundation, including knee, hip, and low back pain.  Many of these patients will seek care from chiropractors, where treatment consisting of adjustment, soft-tissue technique, and the use of flexible orthotics can offer excellent symptom relief.

Dr. John J. Danchik is the seventh inductee to the American Chiropractic Association Sports Hall of Fame.  He is the current chairperson of the United States Olympic Committee’s Chiropractic Selection Program.  He lectures extensively in the United States and abroad on current trends in sports chiropractic and rehabilitation.  Dr. Danchik is an associate editor to the Journal of the Neuromusculoskeletal System and the Journal of Chiropractic Sports Injuries and Rehabilitation.  He has been in private practice in Massachusetts for twenty-six years.

Understanding is key to Retention

Patient Retention in a chiropractic practice is defined as the number of times a patient visits your office for chiropractic care.  In order to increase your Patient Retention, you need to increase your patient’s level of understanding.  Patients will follow your recommendations for care if they have a high level of understanding about how your care is helping them.  Retention is equal to understanding.

The entire chiropractic profession needs to work together to improve our patients’ levels of understanding of chiropractic.  The best place to begin this educational process is with a new patient.  When a new patient walks into your office, their level of understanding, on a scale of zero to ten, is at zero.  As a chiropractor, it is your job to change their “Medical Model of Thinking,” and move them up the “Chiropractic Ladder of Understanding.”  As you increase your new patient level of understanding, you will also increase your patient retention level.

Patient understanding is built through patient management.  The ideal time to conduct patient management is during the patient consultation.  Some very critical decisions are made during this interaction between the doctor and the patient.  The manner in which you ask the consultation questions, how the patient answers, and the correct way you respond to their answers, builds the foundation for advancing their level of understanding.  It is important to take advantage of every opportunity to educate and teach your patient about the benefits of chiropractic care.

You continue your patient management during the “Report of Findings.”  You and your staff must remain consistent and precise with all communication during the first several patient visits.  This increases the patient’s level of comfort and confidence in your care.  This is the time that you must “reset the decision criteria.”  When you reset the decision criteria, you move your patient up a level of consciousness, so they are more willing to continue with chiropractic care.

When a person fully understands how they are benefiting from and what the advantages are to chiropractic care, they have reached the “ten” on the understanding ladder and you have increased your retention percentage.  You no longer need to sell the concept on a visit-by-visit basis.  Instead, your efforts must focus on routing the patient through their treatment plan with continued emphasis on their understanding.
Taking each patient through the following process will increase your retention rate and help move your patients from their first visit to participating in a treatment plan.

First Visit
– Patient knows they have a problem
– Patient knows there is a solution to their problem
– Patient knows and is committed to returning to your practice for a Report of Findings

Second Visit
– Patient agrees to chiropractic treatment
– Patient agrees to attend your in-office workshop
– Patient commits to returning for “treatment plan review” visit

Third Visit
– Patient knows the solution is “Corrective Care” over “Relief Care”
– Patient commits to treatment plan
– Patient has taken financial responsibility

A practice’s percentage of retention is equal to the number of patients on a care plan out of the total number of new patients seen during the same timeframe. You hold the key to unlocking the mystery of Patient Retention. Educate on the benefits of chiropractic care, educate on the specific condition and educate on the success of your treatment.  Education equals understanding.  Understanding equals retention. TAC

Dr. Maurice A. Pisciottano, CEO and founder of Pro-Solutions for Chiropractic, is a practicing chiropractor, noted lecturer, author, producer and research and development technologist.  He is well known for his practice management expertise, as well as new patient development programs.  He has devoted the past twelve years to the development of the instrumentation and the computerization of chiropractic treatment and documentation.  Dr. Pisciottano regularly lectures at Palmer College of Chiropractic in Davenport, IA, and at Logan College of Chiropractic in St. Louis, MO.  He can be reached at Pro-Solutions for Chiropractic in Pittsburgh, PA, at 1-877-942-4284.

Low Back Pain Needs a Nutritional Adjustment

No matter what chiropractic college you went to, your main approach to patient care is likely to be the chiropractic adjustment.  This statement is not surprising to most, and it gives a clue as to how we think as chiropractors.  We, basically, utilize a mechanical or biomechanical approach to care for our patients.  Whether you believe the adjustment is replacing misaligned bones or restoring motion to previously hypomobile joints, your treatment approach involves mechanically thrusting into spinal tissues, i.e., a mechanical approach to patient care.  Although we DC’s think and treat our patients structurally, we must realize that it is the chemical mediators of inflammation that activate nociceptors, resulting in pain, which drives patients to our offices.
Low back pain needs a nutritional adjustment

For many years, it has been known that an acidic pH works synergistically with the chemical mediators of inflammation to activate and sensitize tissue nociceptors.1  Evidence existed regarding low back pain and pH at least as early as the 1960’s.  At the time of surgery, Nachemson discovered that the pH of lumbar discs ranged from 5.7-7.5.  The lower the pH, the greater the pain, disc degeneration, and fibrous tissue deposition.2  Hambly and Mooney state that it has been noted that “sick” discs, as reflected by pain on discography, have consistently demonstrated an acidic pH.3  In more recent years, researchers have demonstrated that the intervertebral disc can release potent inflammatory mediators, which naturally leads MD’s to medicate injured low backs.  We DC’s should, of course, continue to adjust the spine, and also consider addressing the inflammation with a nutritional adjustment.

 

Discs, Back Pain and Chemical Mediators

Recent research demonstrated that intervertebral discs which cause low back pain and sciatica secrete high levels of pro-inflammatory mediators.4  At the time of surgery, disc specimens were collected from sixty-three patients undergoing primary discectomy for sciatica, and from twenty patients undergoing interbody fusion for discogenic low back pain.  The average age of these patients was forty-one, so they were all young individuals who, theoretically, should be healthy and functional.
A biochemical analysis of the disc specimens revealed that discs from the sciatica and low back pain groups produced significant quantities of interleukin-6 (IL-6), interleukin-8 (IL-8), and prostaglandin E2 (PGE2).4  None of the specimens produced interleukin-1 (IL-1) or tumor necrosis factor (TNF).  Additionally, not all discs produced IL-6, IL-8 or PGE2, which suggests that either other inflammatory mediators were responsible for the pain generation, or that altered chemistry was not responsible for the nociception and pain in these subjects.

 

A Simple Nutritional Method to Reduce Cytokines and PGE2

A recent review article by Simopoulos explains that the omega-3 fatty acids in fish oil supplements can reduce the synthesis of IL-6, PGE2, and many other inflammatory mediators, such as IL-1, TNF, thromboxane A2 (TXA2), leukotriene B4 (LTB4), fibrinogen and platelet-derived growth factor.5  For many years now, it has been known that fish oil has a dramatic anti-inflammatory effect that can help prevent heart disease, cancer, migraine headaches, psoriasis, ulcerative colitis, rheumatoid arthritis, and many other conditions.5  Sierkerka was the first DC to publish an article that urged DC’s to use omega-3 fatty acids to accelerate the disc’s healing process.6  About 1-2 grams of EPA/DHA is a common recommendation to improve omega-3 fatty acid status.
Magnesium deficiency is also known to increase the release of IL-6 and PGE2, as well as IL-1, TNF, TXA2 and LTB4.7  Animal studies suggest that substance P release from nociceptors may be responsible for stimulating such mediators to be released by local immune and tissue cells.8  About 400-1000 mg of supplemental magnesium is the typical recommendation.
Botanicals such as ginger and turmeric are known to inhibit the production of PGE2 and LTB4.9  These substances can be viewed as natural COX2 inhibitors, and have been used for thousands of years in India to reduced pain and inflammation.  Ginger is the best buy for patients.  About 2 grams per day is the typical recommendation for powdered ginger, and about 500-1000 mg, if a standardized extract is used.
In addition to the above, consider using a multiple vitamin/mineral to insure that your patients are getting all the micronutrients necessary to drive the multitude of cell reactions required for tissue health.
From a dietary perspective, make sure your patients eat lots of fruits and vegetables, and drink lots of water, perhaps one-half gallon per day.  Avoiding seeds, grains and flour products is also a must, as these foods contain inflammatory omega-6 fatty acids, which is heightened by the addition of omega-6 oils, including corn, sunflower, and safflower oils. TAC

 

 

Dr. Seaman is the Clinical Chiropractic Consultant for Anabolic Laboratories, one of the first supplement manufacturers to service the chiropractic profession. He is on the postgraduate faculty of several chiropractic colleges, providing nutrition seminars that focus on the needs of the chiropractic patient. Dr. Seaman can be reached by e-mail at [email protected].

“Technologize” Your Screenings for 10 Times More New Patients

Visiting the Seattle Boat Show recently, I was amazed to find a perfectly located and great looking booth, with energetic DC’s chomping at the bit to sign up new patients.  They were literally following people as they walked by, but everyone kept on walking.  I said to the doctor in charge, “Why would you spend all this money on this show, and not be using a Static SEMG?”  Although he had never used one, he had no trouble listing a million reasons why it was a waste of time.  I suggested we try it for an hour just for grins.  He begrudgingly agreed. 
Needless to say, with the SEMG setup, potential new patients were literally lining up to be tested.  One screener said, “Wow!  I can’t believe they are actually coming to us.”  After an hour, I was getting bored, so I packed it up when he wasn’t looking and left.  I did not even make it to my car before my cell phone started ringing.  It was the doctor, of course.
“Where did you go?” he said. 
“You told me it was a waste of time to use an SEMG, so I left,” I responded.
“No, No, No….  Please, bring it back!” he said.    
What made the huge difference?  Technology.  Our society eats, breathes, and believes in technology.  We don’t trust it unless it has been “blessed” by a computer of some sort.  Add to this the fact that 80% of us are visual learners, and it is obvious. 
Doctors report a five- to ten-fold increase in number of new patients when using instrumentation in comparison to traditional screenings, and agree that the machines are paid for in their first couple of screenings
1. Instrumentation:  Static Surface EMG (approximately $5000):  Why?  SEMG’s can be used in all environments, regardless of temperature (unlike thermography), and people naturally understand muscle tension, making it simple to explain.  Since they can feel it, you establish credibility with them very quickly.  What characteristics make an SEMG optimal for screenings?
a. The lighter the weight, the better.  Every piece of equipment, including the SEMG, should be as light as possible.  A solid, easy-to-use transport case is a nice option, but is not totally necessary. 
b. Standing Neutral SEMG tests are optimal for screenings.
i. Load bearing, “chiropractically” sound standing tests bring out more abnormalities, and you don’t have to lug a couple of chairs with you.
ii. You are more visible than when doing seated tests, as you are at or above eye level when testing.
iii.Psychologically, people associate the seated position with making a commitment, as with purchasing a car.  People are much more likely to allow you to test them standing, as they feel less threatened. 
c. Software should be simple to use, fast and should not require that you enter patient names (both for speed and HIPAA).  Systems that use Function keys instead of the mouse allow you to test in sunlight where the screen is less visible.  This is particularly important in spring and summer screenings, which are often outdoors.
d. Graphics should be clean, simple and are much more powerful if presenting a sample “ideal” test alongside the results, for comparison purposes.
e. Voice prompts and/or sound is very important, as the more senses appealed to, the more people you will attract.
2. MONITOR:  Price:  $180 to $3000.  Best value:  19” Color Monitor.  Most “Punch”:  Data Projector or Plasma Screen.
a. Considering that 19” monitors are under $180, it makes more sense to use a monitor than a TV.  If you can afford an LCD, purchase at least a 17” screen.  42” Plasma screens are great, but cost upwards of $3000.
b. If you can afford a data projector, they are very powerful when used indoors.  (Must be at least 1000 lumens, and 800 x 600 resolution).  The best projector screen is the Dalite Instatheater 60” (around $350).  The screen rolls itself into a solid carry case, and looks like an expensive big screen TV when setup.  
3. SPEAKERS:  $20 to $40.  Labtec “Spin” series computer speakers are inexpensive, small and work well. 
4. MONITOR RISER: Fellowes Premium Monitor Riser (model 91717, approx. $22) allows you to place the monitor on top of the SEMG, not only making the monitor more visible, but saving space.
5. POWER:  AC when available (call ahead to secure it).  The next best thing is a deep cycle marine battery (120 amp hours) with a 400-watt power inverter (available from West Marine, or auto parts stores).  You will also need a part from Radio Shack which provides a cigarette lighter adapter wired to red and black alligator clips (to connect to the battery).  Plug the inverter into the cigarette lighter adapter, and you have power!  Don’t forget, you need a charger for this.  Honda 1000 watt generators are also good, but ONLY if you can place them far enough from your screening to avoid the obvious noise problems.   
6. PRINTER:  I am very impressed with the new HP 450ci printer ($299).  It is fast, rugged, and small.  Set it to draft mode for the greatest speed.

Instrumentation makes screenings not only more efficient and effective but, also, more fun.  Don’t forget to have a positive attitude, and remind each potential patient that results are not as accurate as they would be in the clinic.  This not only is the truth but, also, provides motivation for them to visit your office for a complete exam.
Technology can be your best friend or worst enemy.  By finding the best product and support for your needs, you will have a great partner in building your practice. TAC

The author, David Marcarian, MA, is founder and president of Precision Biometrics, supplier of the MyoVision SEMG and Thermoglide systems.  He has worked for NASA, and was awarded a $450,000 grant from the NIH for developing the MyoVision.  He lectures for Palmer College of Chiropractic, and his course is endorsed by all U.S. chiropractic associations that mandate SEMG training.  He has personally instructed more than 6,000 chiropractors on proper SEMG use.  Mr. Marcarian can be reached at 800-969-6961, by email at [email protected], or visit his company’s Web site at www.myovision.com.

The Positive fat-pad sign: what is it?

A useful sign of an intraarticular fracture of the elbow is the clear depiction of displaced humeral capsular fat-pads.1  In the normal elbow, a layer of fat (“fat-pad”) lies between the synovial and fibrous layers of both the anterior and posterior joint capsules.  In the lateral projection of the normal elbow, the anterior fat-pad is seen as an obliquely oriented radiolucency.  When acute intracapsular swelling is present from any origin (hemorrhagic, inflammatory, or traumatic), the anterior fat-pad is elevated to be oriented horizontally, while the posterior fat-pad, when visible, is the most reliable sign of intraarticular effusion.  In children and adolescents, 90% of posterior fat-pad signs will have an associated fracture.1  In adults the sign is less frequently seen, and its absence does not exclude the presence of a fracture.2, 3 

 

 

 

 

Figure 1. Observe the displacement of the posterior fat-pad from the olecranon fossa (arrow). This usually indicates a hidden fracture Figure 1
Figure 2 Figure 3

 

Figure 2 and Figure 3. There is an impaction fracture of the radius (arrow). This patient fell on outsreched hand, locked her elbow and had a positive fat-pad sign.

 

References

  1. Norell G:  Roentgenologic visualization of the extracapsular fat.  Its importance in the diagnosis of traumatic injuries to the elbow.   Acta Radiol 42:205, 1954.
  2. Hunter RD:  Swollen elbow following trauma.  JAMA 230:1573, 1974.
  3. Yochum TR, Rowe LJ:  Essentials of Skeletal Radiology, 2nd ed., Williams & Wilkins, Baltimore, Maryland, 1996.

Dr. Terry R. Yochum is a second-generation chiropractor and a cum laude graduate of the National College of Chiropractic, where he subsequently completed his radiology specialty.  He is currently Director of the Rocky Mountain Chiropractic Radiological Center, in Denver, CO, an Adjunct Professor of Radiology at the Los Angeles College of Chiropractic, as well as an instructor of Skeletal Radiology at the University of Colorado School of Medicine, Denver, CO.  Dr. Yochum is, also, a consultant to Health Care Manufacturing Company that offers a Stored Energy system.  For more information, Dr. Yochum can be reached  at: (303) 940-9400 or by e-mail at [email protected].

Dr. Chad Maola is a 1999 Magna Cum Laude Graduate from National College of Chiropractic.

Chiropractic News Around the World

 

 

Arkansas Chiropractic Board Fines PT

 

ARKANSAS:  Until recently, Arkansas had never had a case in which a physical therapist appeared before the state chiropractic board in a disciplinary hearing.
But last month Michael Teston, a physical therapist who allegedly performed “spinal manipulation” on a patient and a private investigator, incurred $10,000 in fines ordered by the Arkansas State Board of Chiropractic Examiners, the Arkansas Democrat-Gazette reports.  One of Teston’s patients claims Teston “popped” her back, and that sound usually indicates spinal manipulation, the board executive director explained.  Under state law, physical therapists can only manipulate joints and not the spine, so they can perform “spinal mobilization” but not “spinal manipulation.”
The state Board of Physical Therapy, however, backs Teston.  The PT board’s chairman states that Teston’s case will have “some huge ramifications,” such as pressuring therapists to treat patients more conservatively, the Democrat-Gazette reports.
Teston plans to appeal the chiropractic board’s order in circuit court.
Chiro Wire

Watch your timing!

NEW JERSEY:  A New Jersey man practicing chiropractic without a license was sentenced to probation and a hefty fine under the Civil Insurance Fraud Prevention Act in early January.  Thomas S. Boselli was sentenced to two years probation, and also was ordered to pay a $100,000 fine.
Boselli had had chiropractic training, but he wasn’t properly licensed at the time he submitted claims for services to several insurance companies.  He pleaded guilty on Oct. 28, 2002, to a criminal accusation filed by the Division of Criminal Justice-Office of Insurance Fraud Prosecutor, which charged one count of falsifying records.
The accusation alleged that on Jan. 24, 2001, Boselli sent a claim form to Horizon Blue Cross/Blue Shield as if he held a valid chiropractic license, when he didn’t have one.
PressofAtlanticCity.com

The Latest on LIFE

GEORGIA:  Remember back in December of 2000 when four professors at Life University filed a discrimination lawsuit against the school, saying they were humiliated when Sid kept referring to them as “New York Jews”?  Well, in mid-December 2002, a federal judge ruled that a jury can consider the claims of the former faculty members who contend they were subjected to a hostile work environment and fired based on their Jewish faith.
6 of 11 complaints made in that lawsuit are being allowed to go to trial.  Other complaints made by two of the professors, including slander and disability-related discrimination, were dismissed.  The former employees are seeking damages including back pay.
That’s another kick in the teeth for Life; and Life is mad as heck, and not going to take it anymore!  Finally fighting back, Life filed a lawsuit in early January, asking that a federal judge immediately reinstate its chiropractic accreditation, and seeking damages from the Council on Chiropractic Education for stripping them of their good standing.
In its decision last June to revoke the accreditation, the CCE cited management and academic deficiencies, including insufficient supervision of students in Life’s public chiropractic clinics.  Life lost its appeal of the decision last October.
Life’s lawsuit contends the CCE has become dominated by proponents of a philosophy of chiropractic that advocates a closer relationship with the medical field, whereas Life was founded to promote an approach that maintains a division in treatment and diagnosis between chiropractors and physicians.
The lawsuit says CCE violated its own policies by sending representatives of competing chiropractic schools to review Life’s accreditation.  Review team members from schools in Texas, California and Missouri “aggressively solicited” transfer students from Life, the lawsuit states.  A representative of Logan College of Chiropractic near St. Louis was on an appeal panel that revoked Life’s accreditation. Within days, the chairman of Logan’s board of trustees made an offer to purchase Life, the lawsuit states.
And Life goes on…
The Atlanta Journal-Constitution TAC