Static Surface EMG: The Blood Pressure Cuff for Chiropractic Care

:dropcap_open:B:dropcap_close:lood pressure measurement has become well-accepted as a means of screening for cardiovascular health and tracking effectiveness of treatment. But the American Heart Association states clearly that test-retest reliability is poor, with variables including proper training, positioning of the patient, and selection of even cuff size impacting reproducibility.(1) Even with its questionable test-retest reliability, blood pressure measurement is considered a “gold standard” and a  required element of even the most basic physical exam.  How then is it so well accepted? Viewed in context over a long period of time, a clear pattern emerges which provides the doctor and patient with valuable clinical data in evaluating cardiovascular health and long-term treatment. 
 
bloodpressureStatic sEMG shares similar concerns with regards to reproducibility. Patient position, user training and proper test technique are as important with Static sEMG as with BP.  And clinical value parallels BP measures in the world of spinal health. When viewed in context over a period of time, patterns of muscular compensation clearly emerge providing valuable clinically meaningful, spinal-specific data to aid the Chiropractor and patient in determining need for care and tracking of progress. It is however crucial that one utilize proper equipment, test protocol and consider individual patient variables (e.g. height, medication, exercise) when interpreting results.  At minimum, think of Static sEMG as an electronic form of palpation.  It augments palpation by providing purely objective data which unlike palpation is quantifiable.  
 
Much of the criticism regarding reproducibility of Static sEMG stems from poorly designed equipment, outdated equipment, poorly maintained equipment and errors caused by improper test technique.
 
Clinical value has been established in several major studies. Both the Veteran’s Administration and the University of Michigan’s Spine Program have published analyses on the validity of Static sEMG, with a new paradigm regarding Static sEMG emerging.(2, 3)  Specifically, a new statistical analysis of the Static sEMG data has proven that Static sEMG can definitively track patient progress by accurately identifying patients who respond to care, and those who do not with clear statistical significance.(3) 
 
Interestingly, an overwhelming majority of studies finding clinical value in Static sEMG performed the test in the standing posture.  Not only is the Standing sEMG match more closely the fundamental principles of “loading” established as important by Chiropractic X-Ray, but by requiring that the patient maintain their own posture, the test becomes a biomechanical “stress test”.  The result is a magnification of compensatory muscular patterns which expose underlying spinal issues.  By sitting, the biomechanical stability provided by the chair masks these compensatory muscle patterns.
 
That being said, there is a trade-off between clinical relevance and reproducibility which comes with this “stress test” when standing.  Seated, the body is stabilized by the chair, providing sEMG data which is more stable and reproducible, but clinically less relevant. Essentially, if you want to see the body’s response to pain or subluxation, perform the test standing.  Lower reproducibility is inherent in stress testing, but data obtained is almost always clinically more meaningful.
 
One study pointed to the reality that the quality of sEMG equipment, (like all equipment) varies greatly with the resultant effect on the clinical value.  Researchers concluded that the use of more advanced sEMG equipment contributed to the statistical significance found. Prior to this study, it had always been assumed that all sEMG equipment was equally as accurate.(4)
  
There are a few quick and simple practical tests which can evaluate quality of any Static sEMG prior to use in the clinical setting. In addition, these tests can help determine the need for maintenance or calibration as even high quality equipment requires upkeep. 
 
Two Step Procedure for Evaluating Static sEMG Instrument
 
1.  Utilizing clean, new electrodes, and following the skin preparation procedure recommended by the manufacturer (utilize electrode prep gel/liquid if required), enter the data capture screen of your program.
 
Making certain to place electrodes directly on skin in an area with no hair, see if the readings drop rapidly.  Upon skin contact, readings should drop within 1-2 seconds.  If readings do not drop quickly, this gives you an indication that the device may have difficulty with electrical interference and may provide questionable data.
 
2.   Next, following the same process, touch the probes to the skin on the forearm flexors.  While holding the device on the forearm flexors, alternatively make a fist, hold it, and relax.  The readings on the screen should go up and down correlating with the contraction required to make a fist.  If readings do not correlate with this action, there may be an issue with the instrument.
 
:dropcap_open:Gathering good data can only lead to better patient care and the resultant practice growth.:quoteleft_close:
If you do not get good results with the above tests, perform the same tests a different physical location (like the home) with the computer running on battery power (if a laptop).  This can help determine if there are electrical interference issues at your office. 
 
Now that you have ensured that your Static sEMG equipment is working properly, apply these simple procedures below to maximize reproducibility. 

1. Always test with the shoes off. Shoe height varies (greatly in some cases) and this variable will make the readings meaningless if not taken into account.  This of course cannot be done at a screening.  
 
If asked about test validity at a screening, explain the limitations at a screening, and offer a free exam in your office for a more clinically valid exam. 
 
2. Make certain to follow proper skin preparation for each test.  Don’t expect to get the same results twice if you clean the skin with alcohol the first test, and don’t on the second.  Make sure to use manufacturer recommended conductive gel/liquid at every measurement point.  
 
3. Stand the patient so you can see the screen, but they cannot. Even a peripheral view of the screen will lead them to turn their head, thus throwing off the readings. 
 
4. For measurements done on individuals who exercise daily, or have a job involving heavy manual labor, it is important to look at the pattern of activity, and less at the amplitude of readings. In general, testing after heavy exercise is less accurate.
 
5. If there is any build-up of conductive gel or liquid on the device, electrodes or mounting posts, readings will be consistently high or unpredictable.  Use Isopropyl Alcohol on a paper towel to clean the device and electrode posts, making certain there is no residue left anywhere near the electrodes or electrode posts. Make sure the posts are dry prior to remounting electrodes.
 
6. Replace electrodes per manufacturer requirements or if you start noticing erratic readings. When doing so, make certain to clean their mounting posts as well (see #5).
 
7. Be aware that when testing patients who are very tall, that variability in the results will be greater due to the simple biomechanics of height.  
 
8. If getting consistently high readings, eliminate sources of electrical interference by unplugging all devices in the room used for testing (unplug monitors, TV’s etc.).  Ungrounded TV’s with bad power supplies cause abnormally high readings.  If using a laptop, unplug the power supply from the wall and the laptop, and test with battery power.  If still seeing high readings, test at your home, or another location altogether.  There is the possibility that your office has a bad or missing ground connection. If readings are fine at home, but high at your office, contact the management to have the wiring evaluated. Improper grounding not only causes inaccurate readings, but can affect other office equipment as well.
 
9. If using a TV/LCD without a grounded power plug (three prong power plug), move the patient as far away from it as practical.  Electrical interference is generated by ungrounded equipment, but moving the patient even a few feet from the screen can prevent this interference from contaminating the signal.  
 
A rationalization I’ve heard for using faulty equipment and/or poor test protocol is that the tool is purely to convince patients to seek care.  You are a Doctor and a professional.  As we would find it completely unacceptable for an MD to provide false blood test results to get us on medication, it is actually inappropriate to present data you know as questionable as a means of inducing patients into care.  As Chiropractors we need to have higher standards especially if we are to garner the respect of a tech savvy population growing ever more discerning.  Gathering good data can only lead to better patient care and the resultant practice growth.
 
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. Follow some simple guidelines, and you will enjoy all the advantages of technology without the stress. 

Dr. Nancy Miggins has over 25 year’s clinical experience as a chiropractor. She excelled in the areas of procedures, ethical business practices and management. After spearheading the development of a integrative health and fitness center, she spent 6 years as director of this clinic. Although her main focus was in family practice, she also has aided Olympic Athletes and professional cyclists with optimizing sports performance through chiropractic. She is currently the Director of Clinical Applications & Product Development for Precision Biometrics, Inc. Contact at : [email protected] or visit www.myovision.com or call 800-969-6961

David Marcarian, MA, founder of Precision Biometrics, and inventor of the revolutionary MyoVision 3G Wirefree PhysioMonitoring™ System. A former NASA researcher, Marcarian was awarded a $450,000.00 NIH grant to develop the MyoVision.  As an expert witness, Marcarian was credited one of the largest PI awards in US history, and established the validity of sEMG in a major State Superior Court Decision. Recently the AMA selected his 3G Wirefree System as the “tool of choice” as presented in the medical text  “The Practical Guide to Range of Motion Assessment”. Contact at : [email protected] or visit www.myovision.com or call 800-969-6961

Range of Motion Testing: What DC’s Need to Know

:dropcap_open:R:dropcap_close:ange of motion and muscle testing are critical to developing treatment plans, and insurance reimbursement depends on providing accurate reports that demonstrate need for care and document improvement objectively; however, this necessity is time-consuming to perform if done manually.
 
rangeofmotiontestingBut today you no longer have to go the manual route, with relatively inexpensive automated systems where the entire process can be reduced – both testing AND reporting – to an average of mere minutes.
 
Range of Motion and Muscle Testing – coupled with a suite of easy-to-use, integrated software modules – can be used for accurate measurement and serve as instant documentation. Oftentimes, the devices and their associated modules can be purchased separately or as a package.
 
A computerized testing system not only creates instant reports to submit for insurance reimbursement, it also creates reports needed to get the patient approved for more visits if necessary, with clear documentation that is easy to understand and implement. 
 
The reports can compare the patient’s range of motion with the published AMA guidelines, clearly itemizing improvement and limitation on any test date during the treatment period. For documenting muscle weakness, for instance, the reports can compare the patient’s left and right sides for each muscle (asymmetric muscle strength, if applicable). A system may print out the patient’s limitation at any time during the treatment period, thus clearly being able to document limitation or impairment and demonstrate improvement over time.
 
Defining “Medical Necessity”
 
According to healthinsurance.com, medical necessity is defined as follows: 
 
“Health insurance companies provide coverage only for health-related services that they define or determine to be medically necessary.”
 
Medicare, for example, defines medically necessary as: “Services or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice.” 

Medical necessity refers to a decision by your health plan that your treatment, test, or procedure is necessary for your health or to treat a diagnosed medical problem. Chiropractors must now provide proof of medical necessity or risk not only declined reimbursement, but also risk having an insurance company seek to be paid back claims they have already paid to the doctor. It is not uncommon for insurance companies to request to be paid back $50,000 or $100,000. For most chiropractors, having to pay back thousands of dollars of their hard-earned money would not result in a good day. With a computerized testing and documentation system, a doctor can virtually eliminate this concern and sleep better at night. 
 
Single vs. double inclinometers:  What’s the difference?
 :dropcap_open:Chiropractors must now provide proof of medical necessity or risk not only declined reimbursement, but also risk having an insurance company seek to be paid back claims they have already paid to the doctor.:quoteleft_close:
The basic idea of inclinometry is to measure the difference between two angles or the difference between a neutral position for a specific range of motion and an ending position.
 
A single inclinometer is a “singular” measuring device. It reads one angle measurement or the difference between two positions of the inclinometer, the neutral or starting position and the ending position. The chiropractor would then subtract the second measurement from the first to obtain the range of motion. For digital single inclinometers that are part of a testing and documentation system the work of documenting and calculating angles and measurements is automatically taken care of.
 
“Dual” inclinometers are two devices that can read two angles at the same time.  When taking a spinal range of motion reading, the primary inclinometer is centered in the starting position, and the secondary in the ending position. As the patient is going through the range of motion, the doctor would lock in the starting position and, after movement, the ending position of the range of motion. For lumbar flexion, for example, the chiropractor will place one of the inclinometers on T12 and the other inclinometer on S1. Then the sacral measurement is subtracted from the T12 measurement to obtain true lumbar flexion. If the dual inclinometers are communicating with software, the program would typically automate the calculation of the angle, calculate improvement between visits and quantify any limitations in accordance with published guidelines.The software is capable of creating instant documentation for insurance, patient, and doctor.
 
Digital dual inclinometers can also function as a single inclinometer (just disconnect the secondary from the primary).   For diagnosing and assessing back problems, spinal range of motion measurements are simpler and more accurately taken with dual inclinometers. To ensure that the patient is giving maximum effort the reproducibility criteria is followed. Having dual inclinometers and a software system takes out the headache of repeatability, calculating validity manually, and just the pure frustration that comes with keeping track of all the numbers consistently. The doctor could take two single inclinometer readings and then subtract one from the other manually, but one may consider that method inefficient and prone to error. However, dual inclinometers do cost a little more; it is up to the doctor to assess if it is worth the extra cost. “But, as they say, time is money.”

Daniela Birkelbach is the founder and owner of Kennebec, Inc., makers of the Proof Preferred system. You can reach her at 412 278-2040 or email any questions to [email protected] or visit www.proofpreferred.com

On-Site Electrodiagnostic Testing: What to Consider

:dropcap_open:T:dropcap_close:here has been a dramatic rise in marketing from on-site electrodiagnostic testing companies and there are several things you must consider when deciding whether or not to offer these services. Most companies tout large incomes for your office; however, they don’t warn you of the many pitfalls. Here are some considerations:

If you order a Nerve Conduction Study (NCS) and a company sends a technician to perform the test and you bill for the technical component, it is assumed that you have performed a proper neurological evaluation to determine medical necessity, as the electrodiagnostic examination is an extension of the physical/neurological exam. It is also assumed that you have the appropriate training in performing and interpretation of the results. 

electrodiagnostictestingNCS without EMG’s are considered experimental by most insurance companies, which is why you have seen a recent trend in companies now offering NCS and needle EMG; however, many are hiring and training physicians (including chiropractors) who take a weekend training course. Again, this raises questions as to the understanding and expertise of the person performing the test, and unless a competent exam is being performed you may again be exposing yourself to liability. In addition, many states require the use of the 6th Ed. of the AMA Guides to Impairment of Permanent Injury and this text clearly explains that in order to impair and rate a radiculopathy you must have “needle” EMG evidence (pgs. 579-580). Please do not get drawn in by the allure of Somato Sensory Evoked Potentials (SSEPs) or Dermatome Evoked Potentials (DEPs) as they are not medically necessary in the vast majority of cases. 

Also of concern are the contractual arrangements made between the testing company and your office. Be aware that many of these contracts do not protect you from anti-kickback statutes. 

Solution: Refer to a specialist in your own profession (should your state scope have such provisions). A Diplomate in Chiropractic Neurology who is specially trained in electrodiagnostics is your best bet. They are not only qualified to perform the tests, they may be able to assist you in developing a treatment plan. 

If your state does not provide for chiropractic neurologists, then refer to a qualified medical provider. Here are some things to consider:
  1. You may consider referring to a neurologist. Be aware that not all neurologists are trained in electrodiagnostic medicine. In fact, according to the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) less than 10% of medical neurologists have had any training in electrodiagnostic medicine. You might consider being a little delicate when asking about their training. Also be aware that the medical community offers their physicians a certification program that entails only one weekend of training,
  2. If you prefer, refer the case to the physiatrist as most all physiatrists are trained in electrodiagnostic medicine.
If you have any questions or need some assistance, please feel free to email us at [email protected]
 
Dr. Petryk is a Graduate of Life University and a Diplomate of the American Chiropractic Neurology Board. In addition to his DACNB, he earned his Fellowships in both Functional Neurology and Electrodiagnostic Specialties.

Dr. Petryk is founder of NeuroDx Associates, LLC which provides physicians on site electrodiagnsotic testing.

Can You Explain Delayed Onset of Muscle Soreness?

:dropcap_open:T:dropcap_close:he most common complaint of beginning any exercise program is the soreness or general stiffness the next day that may last one or several days. It may leave and then return when you feel that you have done very little to stress your muscles. This sign or symptom is commonly called Delayed Onset Muscle Soreness (DOMS). It should be anticipated that your patients will develop some degree of soreness when we introduce an exercise or rehabilitation program. The question is, when this happens and the patient looks to you for an answer as to why, can you answer the question? This can be especially difficult when the patient is an athlete that has been exercising for some time. Many patients may become frustrated as to why they are experiencing DOMS when they feel they are in good shape from a cardiovascular and flexibility standpoint.

This phenomena has been studied by many researchers since working out has become a popular thing to do. DOMS can affect anyone, from the elite athlete to the patient who is beginning a simple, supervised-rehabilitation program. It is easy to predict it in someone beginning a workout program or the patient that is coming off a layoff (whether it’s due to an injury or just simply taking some time off).

soremusclesThe primary cause is from overstressing a particular muscle group or joint. Your muscles and joints become accustomed to the repetitive movement patterns in which you place your neuro-musculoskeletal system. Does the term “muscle memory” ring a bell? When you do a new workout or activity that causes those muscles and joints to be used in a different pattern of movement, your muscle tissue must respond. We all have heard of the physical stress theory or the theory of adaptation and Wolf’s law. It is easy for our patients to understand why they have the soreness after bending over and picking up sticks from their yard after a wind storm if they normally do very little bending as part of their activities of daily living. Or if the patient typically has a sedimentary lifestyle and begins an exercise program, there is usually no questioning why he or she is sore. Keep in mind when you recommend an exercise program to patients that they may be hesitant on beginning it if they have experienced delayed onset muscles soreness before and remember it to be a painful experience.

The more difficult explanation comes when talking with the patient who exercises often and feels physically in good shape. Let’s use a runner for an example. Runners are creatures of habit; they generally run the same mileage and follow the same course. Many fall into this “location trap” because it is the only place where they can run without having to dodge cars and encounter unfriendly dogs. When we think about the biomechanics of running and walking, it is an A-P, P-A movement pattern. If they are running roads, the rule is to run facing oncoming traffic. This means that they will always run on a sloped plane, with the left being the low side, creating angulated stresses or repetitive stress through each and every step. Generally runners take 70-90 strides per minute. Each time the foot makes contact with the ground, we absorb anywhere from 4- 10 percent of our body weight through the kinetic chain affecting the neuro-musculoskeletal system. I love using the term when lecturing or explaining this principle that neurologically it is “from above down inside out”, but biomechanically it is “from the ground up.” It can best be described by the saying, “When the foot hits the ground, everything changes.”

Should we be concerned about delayed onset muscle soreness or DOMS? Look at it as an early warning signal. From a patient educational view, we ask patients questions geared toward identifying changes in their activities of daily living as the underlying cause. Typical questions include:

  • Did you change something in your workout?
  • Did you change the mileage you run, the surface you run on?
  • Have you added plyometric routines?

If the patient can tell us “yes” to the question, “Did you change something in your workout?”, then you can consider DOMS as a form of cross training, where the runner stressed the muscles or joints and the tissue responded like any normal healthy tissue would. 

If the runner answers “no”, then a more thorough consultation may be needed to help identify underlying causes. Other questions that you can ask include the following:

  • How old are your running shoes, and how many miles do you have on them?
  • Have your sleeping and dietary habits changed in the last 90 days?
  • Are you staying hydrated properly?
  • Does your gait pattern feel different?
  • When was the last time you changed your training program?

In addition to a good consultation, a new evaluation maybe in order to help identify postural changes and muscle imbalances. Focus on the hip extensor, adductor and rotator mechanisms. Another option is to perform a new digital foot scan to look for asymmetry between the arches of the foot. You could do a new gait analysis looking for asymmetry in a patient’s stride.

If your patient continues to develop episodes of delayed onset of muscle soreness, use this as a good precursor to re-evaluating your patient.

 

A 1980 graduate of Palmer College of Chiropractic, Dr. Kirk Lee is a member of the Palmer College of Chiropractic Post Graduate Faculty and Parker College of Chiropractic Post Graduate Faculty. He has lectured nationwide on sports injuries and the adolescent athlete, and currently practices in Albion, Michigan.

Computerized Diagnostic Technology

Computerized Diagnostic Technology

by Aaron Ford, D.C.


Radiographic distortion has been a cause of disagreement together with the compounding inaccuracy of manual line drawing. Not mentioned, however, is the fact that computer technology has become available that is capable of recalculating the configuration of the spine, thereby correcting vertebral anatomy to its proper size and scale, as well as marking precise lines and providing exact measurements.

A simple analogy is to explain that the newly manufactured automobiles have engineered crumple zones designed into the belly-pan that supports the body of the car. If this car were to be in a front or rear-end collision, the vehicle would be sent to a body shop. Depending upon the manufacturers, there are pre-engineered salient points that are marked on the belly-pan for the purpose of measurement. Laser beams are set between these points and measurements are taken. If these measurements exceed specific tolerances, then this vehicle is removed from the nation’s highways.

X-ray digitization software analyzes and measures the salient points on the human body’s framework, the spine. If the tolerances are exceeded, according to the AMA Guidelines to the Evaluation of Permanent Impairment, the patient is offered a 25 percent whole person impairment. This is where we can document a permanency of the injury that requires ongoing chiropractic care.

 

 

 

Dr. Chung Ha Suh, chairman of the department of mechanical engineering at the University of Colorado (Boulder), developed the first software during the 1970’s and, by 1984, presided over the 15th annual Biomechanics Conference, held in his homeland of Korea, devoted to computer graphics.

Dr. Suh originated the algorithms necessary to correct for 99 percent of the distortion on plain film X-rays. Moreover, the software programs incorporate most commonly used line drawings, so that these are also reproducible with a precision and exactness impossible to achieve manually, especially in the hectic surroundings of a working clinic.

Computerized Spinographic analysis is used by chiropractors to objectively analyze the biomechanical improprieties of the spine. (Rome) It is medically necessary to assess the degree to which an injury has affected the patient’s health and future well being; i.e., an impairment rating.

Imaging methods shall be utilized for obtaining information concerning the vertebral subluxation and other malpositioned articulating structures and ligamentous instability (sub-failure) during motion. Chiropractic concerns are primarily the spinal misalignment component, although advanced imaging can also provide valuable information regarding foraminal alteration, nerve impingement, and aberrant motion.

Spinal X-rays are deemed appropriate when the patient’s history and subjective complaints indicate a probable musculoskeletal involvement. Computerized Spinographic analysis is clearly called for in order to undertake biomechanical analyses involving small units of measurement (millimeters and degrees), in order to arrive at a differential diagnosis, or to determine treatment protocols, besides providing a definitive baseline for follow-up radiological examinations.

The insurance industry requires three things:

1. Was the patient injured on a more probable or not basis?

2. Is there objective evidence to validate the injury?

3. Can an objective based treatment plan be designed in an attempt to return the patient to pre-injury status?

These are logical and legitimate questions that a third-party payer requires. If the doctor can accomplish these three steps, they will be less likely to have the treatment prematurely terminated.

Dynamic Motion X-ray and digitizing provides the chiropractor with the best possible information on the biomechanical status of a patient’s spine. The informed chiropractor can accurately assess the patient and, as an added, educational (and motivational) bonus, the patient can visualize his/her structural improprieties when that spine is compared to the standard spine, side-by-side. This process, additionally, empowers patients in their own treatment plans, enabling them to view the desired anatomical goal, as well as boosting motivational levels to persevere through the often-tedious rehabilitation process; especially, if a time frame is established, and each progressive stage is met from the outset.

Digitizing follow-up X-rays again utilizes scientific imaging analysis to determine treatment progress, or lack thereof, assisting the chiropractor in assessing the efficacy of the treatment protocol and associated needs (including: therapy, rehabilitation, reducing job activity). It further assists in arriving at a more accurate impairment assessment or, as a last resort, determining actual levels of permanent impairments in those patients who will not completely recover from their injuries.

While it remains true that the technological explosion in health care delivery has advanced far beyond valid clinical utility, no matter how many instruments become available, the key device in chiropractic diagnosis remains the X-ray machine. Indeed, in virtually every state, a chiropractor is specifically required by the state legislature to be responsible for the diagnosis of vertebral subluxations (or other synonyms) from X-ray analysis.

More recently (Smith versus Yohe, Supreme Court of Pennsylvania, 1963) negligence was confirmed after a failure to take X-rays.

“If a physician, as an aid to his diagnosis (i.e., his judgment) does not avail himself of the scientific means and facilities open to him for the collection of the best factual data upon which to arrive at his diagnosis, the result is not an error of judgment but negligence in failing to secure an adequate factual basis upon which to support his diagnosis or judgment.”

If we may speculate on the near future, merely taking X-rays is not going to be the end of the story. While, of course, it is implied that anyone taking an X-ray would have diagnosed the conditions due to biomechanical improprieties, remembering that negligence applies to things that were left undone, one can consider a condition requiring a precise measurement of the X-ray, such as Alteration of Motion Segment Integrity. If utilization of computer digitization to analyze and measure spinal subluxation becomes an established clinical procedure, then it will become the gold standard for such measurements.

One might conclude, then, that: computerized digitization of plain film X-rays is not just a matter of clinical efficacy but a clinical necessity. (Cockburn)

Bould’s study found the human eye calibration of a digital caliper to be accurate to 0.26 mm and reproducible to +/-0.1mm. The resolution of the caliper is given as 0.01 mm and it is certified for 0.02+/- mm.

Bould, also, succinctly points out that accuracy requires the elimination of errors. If we are confronted by a known error, as with radiographic distortion, it must be corrected in order to achieve accuracy of the measurement.

The Dynamic X-ray Analyzer (DXAnalyzer©) software model has the ability to perform statistical evaluations of inter- and intra-examiner reliability studies and has been tested and found to be accurate to 0.0023mm, which assures that injured patients receive the best digital spinal analysis available. This system is designed to digitize any known format of X-ray image and correct for the 30 percent error in X-ray image distortion for Focal Film Distance and Object Film Distance to less than 1 percent error, simultaneously, from any known image source. The DX Analyzer has an interactive database to include: patient’s age, height, weight, gender, and genetic heritage. Chiropractic can now be made bullet proof when qualifying and quantifying spinal injuries and subluxations.

The term “qualifying” refers to the ability of the computer to identify the true landmarks, ignoring any subjective misperceptions, and erroneous markings. (Bellamy)

The term “quantifying,” of course, refers to the property of things that can be measured. Included measurements are:

Motion segment integrity—angular

Motion segment integrity—translation

The Guideline Protocol for Radiographic Digitization was established for undertaking radiographic digitization:

1. When examination findings are equivocal and radiographs have been taken, in the presence of apparent normal radiographic findings.

2. When a patient’s symptoms do not agree with examination findings and X-rays are deemed necessary and may rule out or detect factual presence of a biomechanical instability.

3. When a patient is not responding favorably to care and a degenerative or insidious process is suspected.

4. When biomechanical information is deemed helpful in the direction of the treatment plan.

5. When assistance may be necessary in assessing activities of daily living, temporary or permanent disability or in apportionment issues.

6. In determining progress or lack of it in a condition, this has required post-radiographic examination of the patient.

This digital analysis of a specific X-ray produces an outcome assessment process which helps establish the following:

1. A diagnosis for the correction of specific motion segments and functional units.

2. A scale to assess the patient’s current condition, compare serial studies and determine maximum clinical improvement.

3. A specific treatment plan, with the clinical goal of restoration of the patient’s functional biomechanics.

4. Unique graphical information of the patient’s biomechanical findings for at-a-glance reference in establishing the treatment plan.

5. A reference norm.

6. A line drawing or graphical measurement (depending upon the analysis selected).

7. A bar graph (depending upon the analysis selected).

A practice that utilizes computer-aided X-ray digitization analysis might lead to an increase in the number of patients with positive X-ray findings, as well as positive diagnoses. Indeed, as the experience with the protocol increases, one might conjecture that patients will begin to utilize the chiropractic profession more readily, based upon its ability to provide more accurate objective diagnoses.

It is imperative that today’s practicing chiropractor keep abreast of the advancement in imaging technology and measurement analysis. During the 1980’s, we were obligated to identify the patient’s name and policy number and summarily submit a bill. Today, the call is for fraud investigation based on inadequate documentation and the use of “special investigative units,” of which the number has tripled, to perform post-payment reviews. Utilizing evidence-based, objective documentation will demonstrate a responsible position of the attending chiropractor to establish what is reasonable and necessary for his/her care.

 

Aaron Ford, D.C., is a 1998 graduate of Parker College of Chiropractic. He is the Managing Director of Digital Spinal Diagnostics, the only digitizing service company to utilize the DXAnalyzer© X-ray digitizing software, which is compliant with the AMA Guidelines to the Evaluation of Permanent Impairment, 4th, 5th, and 6th Editions. To request more information on diagnostic computer-aided X-ray digitization services, call 1-866-608-4373 or link to www.digitalspinaldiagnostics.com.

The Lateral Films–Objective and Reliable Evidence

The Lateral Films–Objective and Reliable Evidence

by Dr. Mark R. Payne D.C.

 

For years, we’ve been bombarded about the need for objective evidence to support our care programs. Third party payors and peer review types are the first to nail doctors who fail to document clinical findings with hard, objective evidence. In a time when our very right to take X-rays is under assault, many doctors aren’t aware of how much scientific documentation is available to support the validity of certain X-ray measuring techniques. This is particularly true if a biomechanical analysis of the lateral radiographs is included as part of the workup. Since this issue’s focus is on X-ray and other diagnostics, let’s talk about the reliability of the information we get from the lateral films.

Many chiropractors will perform a radiographic exam on a typical new patient. Once the decision to X-ray has been made, two perpendicular views (Ex. A-P and lateral) are generally considered the accepted minimum. For the purposes of our discussion here, let’s assume that you have elected to get A-P and lateral films on your patient. What kind of information can we get from a simple lateral film and how reliable is that information?



As it turns out, we can learn a lot from the lateral films. In addition to the diagnostic value of the films, the amount of biomechanical information we gain is significant. I would make the case that no other films offer the chiropractor as much relevant information as the lateral spinal views. By taking just a few moments to make some simple measurements, we can actually get a great deal of reliable, objective information about our patient.

Jackson’s Angle: First popularized in the late fifties by Ruth Jackson, MD, in her landmark book, The Cervical Syndrome, this simple measurement gives us a wealth of useful information about the patient’s biomechanical status. Measurement of Jackson’s angle generally requires the construction of only two simple lines and a measurement of the resultant angle of intersection between the two. Fig. 1 shows how lines are constructed along the posterior body of C2 and C7 and drawn down and upward respectively until they intersect. Once this is done, it is a simple matter to use a protractor to accurately measure the acute side of the angle. The method can be used equally well in the thoracics and lumbars as well.


 

Jackson’s Angle tells us exactly how much lordosis is present in our patient. While there is some disagreement in the scientific literature as to how much lordosis is needed for long term spinal health, there is basically no disagreement at all regarding the validity and reliability of measuring the angle on the films. A number of studies have looked at this measurement and determined that the angle can be reliably measured with a very small margin of error.

Occasionally, the lines from C2 and C7 won’t intersect in the neck. This typically happens when the patient’s sagittal posture has assumed some sort of “S-shaped” configuration. If that happens, it becomes a simple matter of just drawing a third line off one of the middle vertebrae so as to best represent the middle of the “S.” (See Red line in Fig. 2) Now, instead of two lines intersecting to form a single angle, we have three lines intersecting to form two angles. In this case, we drew the additional line off C4.


 

By convention, degrees of lordosis are recorded in negative numbers and degrees of kyphosis are recorded in positive numbers. With this in mind, values for the lordotic neck in Fig. 1 would be recorded as -31 degrees. The kyphotic upper portion of the neck in Fig. 2 would be recorded as +10 degrees OVER the -16 degrees of the lordotic lower spine (or +10/-16). Pretty easy, eh?

Anterior Head Carriage: Finally, we can easily get one more important piece of information…an accurate analysis of the weight bearing status of the spine. We do this by simply extending a line straight upward from the posterior-superior corner of T1. That line should intersect the C1 vertebrae at the junction of the posterior arch and the lateral mass. If the head is held forward of the line, a common finding, we would record it in millimeters as a positive number. If the head is carried posterior of the reference line from T1, we would record the position as a negative number. Fig. 3 shows a patient with pronounced forward head carriage.

With one simple film and a couple of quick measurements, we now have an accurate picture of the patient’s overall spinal status and an objective benchmark against which we can gauge the efficacy of any treatment efforts directed at restoring normal posture. Best of all, this method of measurement is well established in the scientific literature and should stand up very well, if you are ever questioned about your findings.

Dr. Mark Payne is the president of Matlin Mfg., a manufacturer and distributor of postural rehab products since 1988. To learn more about implementing postural rehab into your practice, call 1-334-448-1210 or link to www.MatlinMfg.com to request our FREE REPORT, “The Best Corrections of Your Career.”

The Real Necessity for Diagnostics and Imaging

The Real Necessity for Diagnostics and Imaging

by Dr. Mark Studin DC, FASBE, DAAPM, DAAMLP

 

You get a letter from the insurance company stating that your utilization of MRI’s is not within their acceptable standards and they give you a warning that you will be excluded from their panel if your referral pattern continues. At first, you are angry, then confused and, finally, you call every friend you have in chiropractic to solicit their opinion. The consensus is that you will now treat the patient for as long as possible, until all else fails, and then consider ordering the MRI, so as to meet the standards of the insurance company. As a result, you have also influenced everyone within your sphere of influence to behave in the same manner.

My personal journey was similar to many of yours; approximately fifteen years ago, I was denied the ability to refer MRI’s to the imaging center, as they were told by the insurance companies that the scans would be denied. The parameters set forth in arbitration, the lowest level of Court in New York State, ruled that an MRI is compensable only if it is deemed an emergency and then must be performed in an emergency room in a hospital, if done prior to six weeks of conservative care.

Armed with this information, I placed two calls: one to the New York State Department of Education, Secretary to the Board of Chiropractic, and the other to the New York State Department of Education, Secretary to the Board of Medicine, as those were the two highest ranking officials in the State of New York that govern over both chiropractic and medical doctors’ licenses. I wanted to get both opinions to make sure the “world was not flat” all of a sudden.

The answers given to me by both were the same: If you suspect that your patient has spinal cord or root pathology, you treat without a conclusive diagnosis and they get hurt, or proper care is delayed, be prepared to lose your license, no matter what the insurance company says. They do not govern the standard of your care. The New York State Department of Education does. Armed with that knowledge, I found an imaging center to work with who would take MRI’s of my patients as long as my documentation was thorough. We prevailed in overturning that ridiculous ruling within a very short amount of time as a result of the documentation and reasonable minds in the courts.

Your standard of care is the same as mine and every other chiropractor’s in the nation. We are governed by our state board’s standard, not the insurance industry and, after a careful review of numerous states, it has been determined that most states have similar standards. The goal of your state board is not to help your practice or to protect you, the chiropractor. The goal is to protect the people of your great state and that is a covenant taken very seriously by all state boards.

The next question is, “What are your standards of utilization of advanced imaging of the spine, specifically, MRI?”

During your clinical evaluation, you would be on very safe ground to order an MRI if there are documented findings of myelopathic and/or radiculopathic findings. The opposition would argue that you should treat the patient conservatively for approximately six weeks to see if those symptoms resolve. That is a very dangerous gamble on your part. What if there is a space occupying lesion and your well intentioned adjustments create further damage? What if there is a tumor and your six weeks’ delay contributed to the metastasis of that tumor? What if, what if…?

Doctors…DO NOT TOUCH YOUR PATIENTS IF YOU DO NOT HAVE A CONCLUSIVE DIAGNOSIS. This is a non-negotiable issue.

Here is the language you use with your patient:

“Mrs. Jones, your evaluation revealed some neurological involvement that I believe a series of adjustments will help. I will give it five to six weeks to respond and, if it doesn’t, I will then consider an MRI to see what’s preventing you from getting well as quickly as I think you should.”

Quite eloquent…. However, here is what you are really saying: “Mrs. Jones, I have examined you and have taken X-rays and can’t determine what is wrong with you. I am going to commence with a series of high velocity thrusts into your spine and hope that I have guessed correctly and you do not have a space occupying lesion in your spinal cord or spinal nerve roots. If you do, and I have guessed wrong, you could end up needing surgery that could have been avoided and, in the worst case scenario, you could end up a paraplegic or be diagnosed with cancer that has spread unnecessarily. Let’s get started.”

What’s the difference between the first and second explanation? The answer is simple. The second explanation is the truth and the first is eloquent nonsense.

Would a neurologist, neurosurgeon, orthopedic surgeon or oncologist treat their patients without a conclusive diagnosis? The answer is a resounding, “No.” We are no different. Simply because the chiropractor does not perform surgery, that does not mean we are exonerated from practicing within the standards of our license. I challenge every chiropractor in the United States to ask their Chiropractic Board if it is acceptable to render care without a conclusive diagnosis.

Do not practice to the standards of the insurance company. Your covenant is between you and your patient.

 

Dr. Mark Studin is the President of CMCS Management which offers the Lawyers Marketing Program, Family/MD Marketing Program and Compliance Auditing services and can be contacted at www.TeachChiros.com.

Heart Rate Variability; Insight into the Nervous System

The heart, the brain, and the autonomic nervous system.

Heart rate variability (HRV) is an exciting technology for evaluating autonomic nervous system balance and activity.  HRV enables doctors of chiropractic to objectively evaluate how effectively the nervous system is regulating the activity of a vital organ.

There is a two way communication system between the brain and the heart. Analysis of the beat to beat patterns of the heart may be used to evaluate balance between the sympathetic and parasympathetic divisions of the autonomic nervous system. When the two branches of the autonomic system are working together at maximum efficiency, you feel “in sync.” This is because the sympathetic and parasympathetic divisions are not fighting one another. This state of being is called “entrainment.”1

Variability in heart rate reflects the vagal and sympathetic function of the autonomic nervous system, and has been used as a monitoring tool in clinical conditions, characterized by altered autonomic nervous system function.2 Spectral analysis of beat to beat variability is a simple, non invasive technique to evaluate autonomic dysfunction.3

Wellness 

Normative data on heart rate variability have been collected.4,5,6 This technology appears to hold promise for assessing overall fitness. Gallagher et al.7 compared age matched groups with different lifestyles. These were smokers, sedentary persons, and aerobically fit individuals. They found that smoking and a sedentary lifestyle reduces vagal tone, whereas enhanced fitness increases vagal tone. Dixon et al.8 reported that endurance training modifies heart rate control through neurocardiac mechanisms. In occupational health, the effects of various stresses of the work environment of heart patients and asymptomatic workers may be evaluated using heart rate variability analysis.9  Low heart rate variability is predictive of mortality from all causes.10

Chiropractic care

Zhang et al. reported the results of an exciting study involving 520 subjects in a single visit group, and 111 subjects in a four week group. The purpose of the study was to investigate the effect of chiropractic care in a multi-clinic setting on the balance of the sympathetic and parasympathetic nervous system using HRV (heart rate variability) analysis. The study demonstrated consistent changes in HRV. The authors reported, “The decreased heart rate and increased total power from the HRV analysis indicated a healthy autonomic nervous system balance after correction of vertebral subluxation.”11,12

Autonomic dystonia, or acquired dysautonomia, is one of the three elements in the three dimensional model of vertebral subluxation.12 Skin temperature changes, reflecting alterations in vasomotor tone, are used clinically to assess autonomic changes associated with vertebral subluxations, as well as nutritional, exercise, and lifestyle interventions.  

Heart rate variability represents an exciting, non-invasive technology to assess subluxation related autonomic function.  HRV technology will empower the practicing chiropractor to assess and communicate the far reaching impact of subluxation correction and a healthy lifestyle.


Christopher Kent, D.C.

Christopher Kent is co-founder of the Chiropractic Leadership Alliance.  Dr. Kent is a chiropractor and an attorney.  He was honored as Chiropractor of the Year by the International Chiropractors Association, and received Life University’s first Lifetime Achievement Award.  He may be contacted at
 cbke[email protected].


 

References
1.  Childre D: “One Minute Stress Management.” Planetary Publishers. Boulder Creek, CA. 1998.
2.  DeDenedittis G, Cigada M, Bianchi A, et al: “Autonomic changes during hypnosis: a heart rate variability power spectrum analysis as a marker of sympatho vagal balance.” Int J Clin Exp Hypn 1994;42(2):140.
3.  Kautzner J, Camm AJ: “Clinical relevance of heart rate variability.” Clin Cardiol 1997;20(2):162.
4.  O’Brien IA, O’Hare P, Corrall RJ: “Heart rate variability in healthy subjects: effect of age and the derivation of normal ranges for tests of autonomic function.” Br Heart J 1986; 55(4):348.
5.  Toyry J, Mantysaari M, Hartikainen J, Lansimies E: “Day to day variability of cardiac autonomic regulation parameters in normal subjects.” Clin Physiol 1995; 15(1):39.
6.  Sato N, Miyake S, Akatsu J, Kumashiro M: “Power spectral analysis of heart rate variability in healthy young women during the normal menstrual cycle.” Psychosom Med 1995; 57(4):331.
7.  Gallagher D, Terenzi T, de Meersman R: “Heart rate variability in smokers, sedentary, and aerobically fit individuals.” Clin Auton Res 1992; 2(6):383.
8.  Dixon EM, Kamath MV, McCartney N, Fallen EL: “Neural regulation of heart rate variability in endurance athletes and sedentary controls.” Cardiovasc Res 1992; 26(7):713.
9.  Kristal Boneh E, Raifel M, Froom P, Ribak J: “Heart rate variability in health and disease.” Scand J Work Environ Health 1995; 21(2):85.
10. Dekker JM, Schouten EG, Klootwijk P, et al: Heart rate variability from short electrocardiographic recordings predicts mortality from all causes in middle-aged and elderly men.  American Journal of Epidemiology 1997; 145(10):899.
11. Zhang J, Dean D: “Effect of short term chiropractic care on pain and heart rate variability in a multisite clinical Study.” International Research and Philosophy Symposium: Abstracts. Sherman College of Straight Chiropractic, Spartanburg, SC. October 9 10, 2004.
12. Zhang J, Dean D, Nosco D, et al: Effect of chiropractic care on heart rate variability and pain in a multisite clinical study.  J Manipulative Physiol Ther 2006; 29(4):267.
13. Redwood D, Cleveland III CS: Fundamentals of Chiropractic.  Mosby.  St. Louis.  2003.  ISBN 0-323-01812-2.

Diagnostics as a Part of an Evidence Based Chiropractic Practice

Chiropractors attend four-year college programs that teach the art, science and philosophy of chiropractic—or do they? Currently, chiropractic colleges do a great deal to teach and to prepare chiropractors in the art, philosophy and delivery of the clinical science of chiropractic, but the colleges are not doing enough to train chiropractors in the science of case management.  If the clinical chiropractor can create a more evidence-based practice approach utilizing diagnostic tests, the chiropractic profession would be able to gain the respect and acceptance of legislators that control healthcare dollars.  Our national organizations could make a much stronger argument for the effectiveness of chiropractic care versus the next alternative, if the chiropractic profession would utilize diagnostic tests to provide the needed clinical evidence.

Chiropractors learn a great deal of philosophy and history in school that transforms them into very passionate and dedicated practitioners.  I know this, because people I talk to about chiropractic in social settings outside of the office often state that they “believe in chiropractic,” as if chiropractic were a religion or faith that requires a higher than average conviction in order for them to accept what chiropractic does.  In school, the chiropractor also learns a great deal on the art of chiropractic in the form of compulsory adjusting classes as well as other optional techniques offered during weekend seminars. The chiropractic profession is well equipped with a plethora of techniques to choose from, each with its own philosophy of the how and why of the adjustment.

The art and philosophy portion of chiropractic training does not need to be improved; it is the science portion of the training that needs modification, specifically the case management in clinical science.  Doctors of chiropractic are very poor case managers.  A majority of chiropractors recommend treatment plans that are baseless.  This is a very serious weakness.  Chiropractors wonder why insurance companies deem care to be “NOT MEDICALLY NECESSARY” when they have treated a patient over a 40-50 visit treatment schedule with no evidence from re-examinations and/or diagnostic tests that supports that level of care. A weakness of chiropractic case management lies in the fact that those chiropractors that actually do perform re-exams are performing exams that are useless.  They are useless in that the initial examination and re-examinations performed contain orthopedic tests that are only positive 1 percent of the time and range of motion examinations are visualized or, at best, utilize testing equipment and procedures with very low levels of reproducibility.  The same type of situation is evident for muscle testing and neurological testing on re-examinations.  The majority of the evidence that chiropractors are gathering to determine the validity and effectiveness of their care is subjective, not objective.

The medical profession utilizes diagnostics tests for 90 percent of the care given to their patients.  Actual treatment from the medical doctor makes up 10 percent of the care given to the patient.  In chiropractic, just the opposite is true, ten percent of the care given the patient is diagnostic and the treatment portion makes up 90 percent of the care.  A majority of chiropractors use X-rays as their only source of objective evidence to justify a patient’s care for 40-50 visits.  That is not good enough.  The insurance companies know that it is not good enough, and that is why they continue to deny care for chiropractic patients.  Documenting a patient’s condition with objective evidence is the only way to prove that the care you provide in your office is medically necessary.

When a patient comes into the office with subjective complaints, a chiropractor must document those subjective signs and symptoms in the notes and then determine the exact nature of those complaints with objective evidence.  As a chiropractor, you treat spinal conditions.  The spine is comprised of three distinct tissues that need evaluation: 1) the bones, 2) the nerves, and 3) the muscles/ligaments/discs.  In chiropractic college, chiropractors learn about myopathology, neuropathophysiology, and kinesiopathology.  Chiropractors also learn to evaluate these entities with a number of orthopedic exams, range of motion evaluations, neurological exams, as well as palpation and percussion.  This exam process is fine.  The problem with this type of examination process, though, is that it stops there.  The only evidence gathered from an examination process of this type, which is in chiropractic colleges across the country, is subjective in nature. The information that needs to be gathered on each of the tissue pathologies above needs to be objective in nature.  The chiropractic physician needs to take the subjective signs and symptoms and put them in an objective form so they can easily be retested to determine that the treatment strategy chosen has worked.  Gathering objective evidence and comparing that objective evidence throughout the treatment allows the profession to go from an “I believe that chiropractic works” profession to an “I know that chiropractic works” profession.  Patients know they are getting better in an evidence-based practice, rather than relying on faith that the doctor can sense, in some mysterious fashion, that they are doing better and the treatment is working.

The diagnostic tests that should be performed on a regular basis in a chiropractic office or referred to a diagnostic testing center should include the following: computerized range of motion, computerized muscle testing, MRI, CT, X-ray, and NCV (Nerve Conduction Velocity).  Other objective evidence needs to be gathered in the form of outcome assessment forms such as the Visual Analogue Scale, Rand-36 Item Survey, Low Back Pain Questionnaire, Neck Pain Disability Questionnaire, and the Roland Morris.  If the patient has a decreased range of motion (ROM), then the doctor ought to evaluate the kinesiopathology of the patient utilizing computerized inclinometry (cROM) tests to document the exact loss of ROM.  This initial ROM exam will be the standard to which future ROM examinations will be measured.  Any future ROM examination should show an increase, if the treatment was effective.  If the cROM tests do not show an increase, then treatment must change in a manner consistent with the evidence gathered.  A decrease in muscle strength needs to be evaluated utilizing computerized muscle testing (cMT).  The numbness, tingling, radiculopathy, hand pain, and arm pain need to be evaluated with electrodiagnostics and computerized muscle testing. Suspected disc problems should be viewed with MRI, disc degeneration with an X-ray, and osteoporosis should be evaluated with a dexa scan.  These tests should be redone on a regular basis, for example, every 12 visits for cROM and cMT, or every three months for a dexo scan, so that the doctor can determine the treatment effectiveness. 

The chiropractic profession is in a period of change, and we have to embrace that change.  Whether it was for good or bad, the chiropractic profession joined the insurance industry; but the Mercedes 80’s are over.  Doctors of all disciplines are being held more accountable for the level of care they are providing.  The chiropractic profession must learn the rules of the insurance industry so they can receive a fair reimbursement for all services provided in the office.  One of the bigger rules is documenting the level of care recommended; and the only way to objectively provide evidence is through the use of diagnostic tests.

Dr. Dwight C. Whynot is a 1999 graduate of Logan College of Chiropractic.  He can be reached by email at [email protected].

Blood Chemistry Analysis as a Nutritional Diagnostic Tool

bloodtestvialsIf you are like many other doctors or students interested in nutrition, you must be able to determine when you should adjust physically or when a chemical adjustment is needed to keep that physical adjustment in place.  Whether it is from

• a high sugar diet causing midthoracic pain,
• a thyroid imbalance causing neck pain,
• a pituitary condition causing headaches,
• or  a patient’s being just plain overweight from the wrong diet, which is resulting in low back pain,

how you distinguish what to do is what makes you an expert.

Using a saw (physical adjustment) when a hammer (nutritional protocol) is the tool of choice will not benefit you or your patient. So how do you determine the cause, be it physical or biochemical? More importantly, once you determine that this is a nutritional problem rather than a physical problem, how do you now determine if your patient has a problem with diet, or with an organ or glandular malfunction.

For example, if a patient has a high cholesterol, how do you distinguish if it is a dietary problem or an endocrine imbalance with the liver, adrenals, gonads, thyroid, or from a mid thoracic (T4-T9), or a vagus or phrenic nerve irritation? Or, if a patient comes in complaining of fatigue, is it because of a much-needed upper cervical adjustment, or is the patient suffering from a liver, pancreatic, adrenal, or immune system weakness?

The only method that I know of to determine the difference is a blood test. A blood test is:

1. a sound practice procedure to diagnose chemical imbalances in the body,
2. embraced by other professions,
3. considered rational with scientific data to back up the findings,
4. objective rather then subjective,
5. and it can be duplicated and is reproducible!

I have been utilizing biochemical blood chemistry evaluations for over 25 years and have written a 600-page book on the subject. I’ve also developed a software program that saves time and helps pinpoint any chemical imbalances in the body along with a recommended diet and nutritional program.

So, if you are looking for a great nutritional diagnostic tool and want to be an expert in nutrition instead of dabbling in it, then I suggest that you learn more about blood chemistry analysis and nutritional protocol.

For more information on Dr. Cima and the many books he has written, you may visit his web site at www.cimasystem.com.  For software information, visit http://www.famtech.com/CBA/web/splash.htm.