Category: Rehabilitation

Depression Era Marketing for Today

by Mark R. Payne D.C.

O   kay…so, I said it. The dreaded “D” word. The pundits may debate whether our economy is in recession or a true depression but, if you’re out there trying to survive this economic mess, I suspect that technical distinctions don’t matter much. Fact: If chiropractors can’t figure out a way to serve their patients and survive this financial downturn, a whole bunch of us won’t be here a year from now. That sounds like a depression to me.

I talk to lots of doctors and things are tough all over. But don’t lose sight of the fact that times are tough on your patients right now, too. The fact that they are losing their jobs doesn’t change one thing about whether or not they need your care. Regardless of their economic circumstances, people still need your help. They’re still in pain, still sick, and still depending on you.

With that in mind, I want to relate something from my first quarter in chiropractic college—something that stuck with me and is just as relevant now as ever. Fall of 1976, the college was all abuzz about a famous doctor from Wisconsin who was visiting the campus. As a dumb freshman, the name didn’t mean anything to me, but everyone else seemed impressed, so I went to listen. For about an hour, the older gentleman shared his insight on treating patients and how he managed to grow a thriving practice during the throes of the great depression. The doctor was Clarence Gonstead.

It was 1929, and a terrible flu epidemic was in full swing. In some towns, as much as thirty percent of the population was sick at any given time. More than 50,000 people died in the winter of 1928-29 from flu and related pneumonia…more deaths than in the entire Vietnam War. Dr. Gonstead worked his Mt. Horeb clinic six and a half days a week from early morning until late evening. Very sick patients were often seen multiple times daily. Mrs. Gonstead would often bring lunch so he could treat patients straight through the day. On Fridays and Saturdays, he would close the office, go home for a quick supper and be back to open the doors at 10:00 PM for folks who were exiting the “picture show” and wanted to stop by for an adjustment while they were in town.

There was no such thing as health insurance and no one but the patients to pick up the bill. But, still, they came. Unemployment was approaching twenty percent, but patients still referred their friends and relatives. In a rapidly deflating economy, dollars were in very short supply and, yet, they still valued the service enough to part with much needed cash.

And Dr. Gonstead wasn’t the only chiropractor to survive and flourish during the depression. There were nearly eighty chiropractic colleges operating by 1930 and many doctors did quite well, considering the bleak economy. But, of course, success was measured by a different set of standards then. There were no such things as a BMW or Lexus, no dreams of a new mansion in a gated community, no expectations of working three days a week and retiring at fifty. Doctors were quite happy with a dependable Ford, a modest home in a decent part of town, and enough money at the end of a long week to support their families. Hard work was the order of the day and Dr. Gonstead was as good an example as this profession ever had.

Were there other factors responsible for pushing the Gonstead clinic and chiropractic to uncommon success during tough times? Perhaps. For one thing, professional fees had to be affordable for the patients. For another, chiropractic promoted a simple, understandable model of health care…a simple bone out of place pinching a nerve. True, that old single bone model of subluxation is now outdated, but the old acronym of K.I.S.S. (Keep It Simple, Stupid) is just as relevant as ever. That’s one of the things I love most about practicing around a “posture paradigm.” It allows me to communicate with patients in factual, yet very simplistic, language. Patients can see and understand postural imbalance when they view it in a mirror or on an X-ray.

Chiropractic was founded around the “unique selling proposition” (little bit of marketing lingo there) of the relationship between spinal structure and bodily function. That simple, understandable concept played a central role in the rapid growth of the profession. Things are quite different now. Most chiropractors can’t explain succinctly what they do; the doctor-patient relationship has been complicated by third party pay plans, and most new doctors can’t imagine working twelve hour days, or making a house call for a sick child. They work nine to five, take a three hour lunch, and keep their home phone numbers unlisted.

Are you struggling to survive in today’s economy? I would submit that, in some respects, building your practice today isn’t really all that different than in the Great Depression. It still makes sense to communicate with patients in simple terms they can understand. Hard work and frugality are still at the heart of success. Finally, making your services affordable and becoming an example of service-based leadership within your community will do more to build your reputation than any marketing gimmick or management seminar. As it turns out, even in the midst of a depression, patients can still spot a doctor who really has their best interests at heart.

Science, Posture and Personal Injury

by Dr. Mark R. Payne D.C.

Personal injury patients inevitably present with a unique set of challenges. From a clinical standpoint they are often in more acute, severe pain. Pre existing conditions are extremely commonm and need to be taken into account. Finally, there will almost always be real and legitimate concerns related to any number of “third” parties involved in the chiropractic-legal process. Obviously, the patients have needs and priorities related to their physical health and well being, but building the successful PI practice is often dependent upon the doctor’s ability to fairly meet the legitimate concerns of all parties involved.

I wanted to take this opportunity to discuss some of the scientific literature relevant to postural rehabilitation of the personal injury case. If you intend to step into the chiro-legal arena, it’s vital that you understand what the scientific literature does and doesn’t support. Proper documentation of your rationale for treatment is always of primary concern. In personal injury cases, it is doubly important. Here’s a brief overview of some of the literature available to back you up, should you decide to include postural rehab as a part of your treatment program.

First, the good news:

• There are now several studies indicating that significant disruption of the normal spinal curves is associated with spinal pain and/or headache of cervical origin (Spine ’94, JSD ’98, JMPT ’92, HA ’93).

• Loss of the cervical lordosis has been shown to be a common result of cervical trauma (Spine ’97, SAMJ ’78, JBJS ’63).

• It’s possible to objectively analyze the patient’s postural status using simple, geometric radiographic analysis (See Figs. 1 & 2). These methods have shown a very high degree of both inter and intra examiner reliability in several studies (JMPT ’93, ’92,’95,’98,’03).

• There is also good evidence in the literature to support the need for healthy spinal curves to prevent future onset of problems (JBS ’74, JMPT ’02).

• Finally, we now have proven effective methods of restoring both the cervical and lumbar lordosis. Including postural exercise and traction procedures puts you on firm ground should someone question your methods (APM/R ’04,’02). My point is that radiographic analysis of the patient’s posture is simple, straightforward, and reliable. Such analysis of spinal imbalance is well documented and easily understood by patients and attorneys alike. Simple biomechanical analysis should be a basic part of your work up on every PI patient.

Now for the bad news:

• Many doctors in the field continue using poorly documented methods of X-ray analysis, IF they even bother to measure the X-rays at all. The profession has become so oriented toward “functional” based care that many doctors give little more than passing notice to postural imbalance and fail to document what is often strong prima facie evidence of injury.

• Many doctors continue to use advanced spinal degeneration as justification for questionably long periods of “corrective” care programs often consisting of little more than adjustments or passive therapy. With the exception of one small study which suggests considerable improvement with Activator^® Methods (JMPT ’03), there is little evidence that spinal adjustments do very much to improve spinal structure. At this point, postural exercise and traction procedures appear to be the most effective tools for improving patient posture.

• Many doctors are using effective traction and exercise methods to address postural imbalance but making excessive recommendations for care based on erroneous advice from their practice managers or technique gurus. I want to be very clear about my position on this. Just because some particular method appears effective over a given trial period, there is no indication that further treatment will continue to produce improvement at the same rate. In fact, almost any treatment program will reach a point of diminishing return. One popular seminar continues to teach that, if twelve weeks of care is good, then thirty-six weeks must be three times as good. There’s certainly no evidence to support such long programs of care, most of which conveniently include an expensive series of adjustments of little or no proven value.

Such long programs of care are naïve at best and grossly irresponsible at worst. I mention it here because many well meaning doctors are hanging their reputations on such questionable logic. Prolonging care for PI patients beyond that necessary to return them to their pre injury status is not only unfair to third party payors, it’s actually counterproductive in the long run to building a successful PI practice. Building your reputation in the PI arena revolves largely around three basic things: using solid, well documented methods of analysis and treatment, returning the patient to pre injury status as quickly as possible, and keeping professional fees to a level every one involved can live with. Attention to those simple details will likely improve your standing in the community as an ethical doctor who deals fairly with all parties involved.

Are Knee Injuries Really Knee Injuries?

by Dr. Kirk A. Lee, D.C., C.C.S.P.

We see patients in our offices daily with arthritic knees—sometimes bilateral, other times affecting only one leg. Some patients can point to an old football injury or car accident as the probable cause. But, frequently, they cannot tell us why their knee hurts, only that they have a new friend called “Arthur” that causes their knee to swell and hurt.

Each day we are faced with patients whose musculoskeletal complaints may not appear spinal related. Many times no mechanism of injury is retained from our consultation or examination. Orthopedic tests are quite often absent of a positive finding other than maybe a little discomfort. So what is the cause? It is easy to figure out from a diagnostic view of the patient who sustained a direct injury to the knee from a fall, or car accident, or of the athlete who received a traumatic blow to the knee.

In runners, the chief complaint is commonly lower leg pain. This could be determined as tibial stress syndrome (shin splints), or perhaps strains of the soleus and gastrocnemius muscles. The second most common complaint is of the knee—generalized soreness anywhere around the knee to advancing conditions like chondromalacia. The foot is third, with conditions like plantar fascia, bunions, blisters, ankle sprains and strains. Fourth is the hip, followed by the upper leg and, finally, low back conditions. As we look at this list of most common areas of chief complaint, do you feel the order is correct?

When we analyze the gait cycle, we have a good understanding from previous articles and our own general knowledge that the foot is made up of three arches (medial, anterior and lateral) and three distinct segments (rearfoot, midfoot, forefoot). Together, when patients ambulate, they transition from some form of heel strike through midstance followed by toe-off. We know all three arches work together for structural support of the foot. If one arch is affected by misalignment, plastic deformation or wrong or ill-fitting shoes, it will affect the normal movement pattern of the foot. We know that, when the foot goes into its pronation pattern (foot rolling inward), the tibia medially rotates (turns in). This medial rotation can be excessive as in hyper-pronation or restricted as in hyper-supination, or it can be an abnormal movement pattern through the foot, as in a patient who just picks the foot up and sets it down and does not have heel-toe transition. The stresses placed at the knee are excessive.

We also know that subluxation complexes of the spine and pelvis will affect posture and alignment (which in turn affects Q angles), while anteriority and posteriority of the hips affect the anglulation of the femur. When we think about the knee joint, itself, it is a hinge joint. It primarily functions in flexion and extension. It has the simplest joint movement and one of the less stressful joint movement patterns.

When you think about a door hinge and how many times it swings back and forth, what usually causes a door hinge to start to fail? It’s not that it wears out. It’s usually because the door, itself, starts to misalign or the house shifts and the door no longer closes properly, causing angulated stresses on the door hinges. This is no different than what our bodies do. There is no doubt that, “neurologically it is from above-down-inside-out” but, “biomechanically, it is from below-up.” Or to put it another way, “When the foot hits the ground, everything changes.” These phrases just point out that, in our treatment of patients’ knee conditions, we must always look to what the real cause of the knee condition is and not just look at the knee itself for the treatment of the condition. We must evaluate abnormal patterns in gait and posture, and we must help our patients with treatment plans that can include rehabilitation, specific chiropractic adjustments (CMT), or supportive measures like custom-made Spinal Pelvic Stabilizers. Our patients can be assured they are getting the best we have to offer as doctors of chiropractic.

Healthy Doctors: Practicing and Preaching

by Dr. Mark R. Payne D.C.

Can you imagine an overweight doctor counseling patients on nutrition? How about a physician who smokes urging patients to quit? Or a well-intentioned couch potato handing out exercise advice? We’ve all encountered doctors who dispense advice freely but rarely seem to follow it themselves. The inevitable result, of course, is that no one ever takes such advice, or the doctors who dole it out, very seriously.

I know plenty of doctors who recommend extensive programs of corrective care to their patients, but are totally unwilling to put in the effort or discipline needed to really correct their own spinal problems. But there’s a flip side to this coin as well. Over the last few years, I’ve encountered a number of doctors who recommend different standard of care for their patients than for themselves. Here’s an example. A middle aged chiropractor came to our clinic to determine the cause of his chronic neck pain and headaches. The loss of cervical lordosis and associated spinal degeneration was readily apparent. The doctor, a proponent of lengthy programs of adjustment only care, had been adjusted weekly for decades. He was quite aware of the advancing degeneration and lack of correction in his own neck, yet had never altered his own treatment program. Instead, he just continued to drop by a colleague’s office for a quick adjustment whenever his symptoms worsened.

I developed a simple self care program for the doctor consisting of Compression Counterstressing traction and basic posture exercises. I explained that the advanced disc degeneration would make full correction difficult at this point, but that continued traction and exercise should improve the posture, slow further degeneration, and keep symptoms at bay. In just a few weeks, his symptoms were dramatically improved. I spoke with my colleague occasionally and everything seemed fine—at least for a while.

Six months later, he returned to the office. The headaches and neck pain had returned—slowly at first, but gradually increasing until now they were just as bad as ever. You guessed it. Almost as soon as the symptoms disappeared, our friend discontinued traction and exercise and was back into his old routine of getting adjusted whenever symptoms occurred. I have to confess that I was pretty flustered. We were making great progress and, yet, he had lapsed right back into the same old routine. Biting my tongue, I reinforced the importance of dealing with the postural aspects of the problem and politely pointed out that, if thirty years of adjustments hadn’t fixed it yet, it was unlikely more of the same would do much good.

The good doctor is once again feeling better and is working harder at his home rehab program. That would conclude our story except for one little sticking point. Absolutely nothing has changed about the way our friend approaches the treatment of his own patients! Here’s a doctor who has seen first hand that adjustments simply won’t correct some problems. He understands how contracted soft tissues perpetuate postural subluxation and the importance of rehab. He knows all this but hasn’t changed anything in his office.

Instead, it’s just business as usual. Just like always, patients get an exam, a report of findings focused on segmental dysfunction/misalignment, and a fairly lengthy program of “adjustments only” care to correct their problems. There’s no objective analysis. No way, other than symptomatic improvement, to measure progress and certainly no effort to actually rehabilitate and strengthen the spine. Whenever I call his hand, he always says he’s going to implement posture based rehab into his clinic “pretty soon.” It would seem that old habits really do die hard.

In the end, much of what we do comes down to little more than habit and routine. Whether we are talking about our own health, how we treat patients or manage our practices, much is done simply out of habit. We do what we do, because it’s what we’ve always done. There’s a certain amount of intellectual inertia which tends to keep us all immobile. We fail to do the things we know are important for our own health. We don’t look objectively at our own treatment outcomes. We postpone learning new skills because we are comfortable in our old rut. We hope the practice will grow and prosper but we never change a thing.

The specific challenges are different for each of us, but the underlying theme here is constant. If you want better results, you’ve got to rise out of the rut. Lip service doesn’t cut it. Only actions count. Some of us need to get off the couch and head to the gym, if we expect our patients to exercise. Maybe we could drop a few pounds if we want to change the way our patients eat. That’s practicing what we preach. But, as we learn and grow, it’s also vital that we share the benefits of our new discoveries with our patients as well. That’s preaching what you practice.

Is It Osteoarthritis?

by Kirk Lee, D.C.

“Abnormal movement patterns

and too much early resistance

will aggravate the joints”

How often do you hear from a patient, “I would exercise, but it hurts!”? Let’s look at a case study which will be very familiar to you.  Mrs. Bones is a 56-year-old female who has a history of on-and-off left hip pain and bilateral knee pain, with her right knee pain being worse. She grades the hip pain as a 4 out of 10, the left knee a 5 out of 10 and the right knee a 6 out of 10 on a visual analog scale. She denies any history of trauma to the spine or knees. Mrs. Bones also gives reference to recent weight gain of 15 pounds over the last year. She feels her weight gain and sedentary office job has contributed to her condition.

Continue reading “Is It Osteoarthritis?”

Seems like today everything is described by initials–in part due to email and texting shortcuts–including how children with special needs can be labeled, ADD (Attention Deficit Disorder), and DD (Developmental Delay) to just name a few. Even many anatomy parts or common chiropractic phrases are better known for their initial description than listing the whole word, such as ACL for anterior cruciate ligament or CMT for chiropractic manipulative therapy. A commonly used term in our history taking of a patient involves their “activities of daily living” or better known as “ADL’s.”

It is important that we ask our patients about their ADL’s for two important reasons. First, to have a better understanding of what their personal lifestyle involves. Second, it helps in our assessment to identify possible biomechanical stresses that are caused from the biomechanics they use or do not use when performing their job, hobbies, etc.

Often new patients will present to our office with no idea of why they hurt. They have no history of an accident, fall or trauma. In this scenario, we have to rule out other contributing factors like diet, possible pathology, socioeconomic factors as well as alterations in normal movement patterns or biomechanics. These are all factors that can occur over time and result in causing vertebral subluxation complexes. We consider these types of injury mechanism as repetitive stress syndromes or microtraumas. Let’s look at a case study where multiple ADL’s contribute to the neuro-musculoskeletal problems of a 25-year-old secretary, who is a mother of two young children and is training for her first half marathon.

Continue reading “Are We Checking for ADL’s?”

I recently got some great questions from a doctor in south Florida who frequently encounters aging patients with large forward head translations, yet have pronounced, sometimes even hyperlordotic, cervical curves. We’ve all observed this posture, common among elderly patients, but many doctors aren’t aware it needs to be managed differently than the typical case of FHP associated with cervical hypolordosis.

Typically, we find cervical HYPOlordosis and FHP occurring together. Normally, forward head translation occurs as the cervical lordosis is lost. Such cases typically present with disc degeneration beginning in middle age and progressing rapidly throughout the years. Advanced disc disease is quite common by age sixty in most such cases.

But, the cases I want to focus on today are actually quite different. These are individuals, typically older, in which the head appears to have translated forward without any accompanying loss of the cervical lordosis. In many of these cases, you will actually observe a HYPERlordotic cervical spine! This preservation of the lordosis seems to provide a great deal of protection from cervical disc degeneration even when degeneration is rampant throughout the rest of the spine. So what happens to make the progression so dramatically different? And what can we learn in order to better manage these unique postures?

Continue reading “Managing FHP in the Elderly”

Last month I discussed why there’s no adjusting technique which is demonstrably better in terms of spinal correction. Obviously, there may be a host of situations when one technique is indicated (or contraindicated). That’s just common sense. But, in terms of actually effecting real structural change to the spinal curves, it just doesn’t matter much how or which technique system you use. Why? Because adjustments, regardless of technique, just aren’t very effective at correcting postural imbalance. Bummer.

So, if our adjustments aren’t really cutting it, then what should we be doing to correct spines? (Drum roll please.) And the short answer is extension traction. Yes, I know extension traction only addresses one aspect of spinal structure…the sagittal spinal curves. But loss of the normal spinal curves is a big time problem for almost all of your adult patients. It also happens to be the one area where almost every chiropractor experiences consistent difficulty in producing corrections. It’s true that there are other methods for addressing the sagittal curves, but none with a comparable track record. Extension traction is, hands down, the most effective and well documented method of postural correction available. And, with that authoritative sounding pronouncement by yours truly, you are no doubt ready to begin immediately equipping your office with the latest and greatest in extension traction modalities. Before you do though, you’ll want to know which of the many available methods is most effective. (You do want to know about the “World’s Best Traction” method don’t you?)

Well of course you do! (Which is convenient, since I’m already two full paragraphs into this article.) So let’s take a quick look at three tried and true methods of applying extension traction forces and highlight the pros and cons of each.

Compression Traction Methods

Compression Traction earned its nickname by virtue of the fact that the equipment used is designed to bend the head backward and inferiorly. (Hence the term “compression”.) In Fig. One, the patient is placed on a popular compression traction device…the Dakota Traction. Force (in the direction of the yellow arrow) is applied to the forehead with an elastic band, bending the head backward and downward into full extension. The purpose is to stretch anterior ligament and musculature to allow for a more complete return of the neck to its normal lordosis. Compression traction was first studied in 1994 and found to produce nearly three times the correction of adjustments alone.¹

Pros? Affordable, simple to use, works well on all neck configurations (military, S-shaped, etc.). Cons? Best suited for home use. Some patients may find compression traction uncomfortable. If this happens, you will need an alternate method (see Fig. 2).

Compression CounterStressing Traction Methods

It didn’t take long before chiropractors began to experiment with variations on simple compression traction. One such variation was first contributed by Dr. Joe Stynchula (Harrisburg, PA). Dr. Joe combined the seated use of a weighted head harness with a “counter stressing” strap to pull anterior into the lordosis. A couple of variations on the method have popped up over the years, but the basic concept remains the same. The head weight pulls the head backward and inferior, while the counterstressing strap functions as an adjustable fulcrum to introduce a buckling force into the mid neck.

Stynchula’s method (AKA “Compression-CounterStressing” Traction) has also been studied and found to be essentially equal to compression traction in terms of restoring the cervical lordosis.² Advantages include patient comfort, space efficiency, and ease of use. Fig. 2 shows the method in use. Compression-CounterStressing Traction is ideal for use in the professional office and also serves well as a backup method for home use, if patients can’t handle the Dakota Traction (See Fig. 1)

Lumbar Extension Traction

Extension traction can also be effective at restoring the lumbar lordosis.³ Fig. 3 shows a simple method of passive lumbar extension traction for home use. The patient is shown tightening the unit to apply force into the lumbar lordosis (see yellow arrow.) The patient then relaxes for the duration of the treatment. The device can also be used seated for use in the office. Advantages of the method are its affordability, effectiveness, and ease of use.

So what’s the “World’s Best Traction“? Well, while I would love to pitch my own products, the truth is that almost any form of extension traction is likely to be effective, regardless of the manufacturer. The laws of physics apparently don’t extend any special consideration to my company’s products. If a product extends the spine effectively, and holds it in the desired position for the requisite amount of time, there will almost certainly be some correction. Certainly, quality, value, and customer service will always dictate who you should do business with and I’ll be just bold enough here to say that we work very hard at those things. But that’s where it ends. Be wary of manufacturers making claims of therapeutic superiority. In the same way that there’s no “best” adjusting technique there’s, likewise, no “best” traction method. I’ve shown you three basic ways of applying corrective forces which have been proven to work well. Just be sure any equipment you buy works in the general manner described here and I think you’ll be pleased. In our next article, maybe we can talk about some other methods available to corrective care practitioners.

Dr. Mark Payne is the president of Matlin Mfg., a manufacturer and distributor of postural rehab products since 1988. A FREE SUBSCRIPTION to Postural Rehab…electronic newsletter on corrective chiropractic methods is available upon request. CALL 1-334-448-1210 or email [email protected].

References

1. Harrison DD; Jackson BL; Troyanovich S; Robertson GA; DeGeorge D; Barker WF. The efficacy of cervical extension-compression traction combined with diversified manipulation and drop table adjustments in the rehabilitation of cervical lordosis: A pilot study. J Manipulative Physiol Ther 1994; 17:454-464.

2. Harrison DE; Harrison DD; Betz JJ; Janik TJ; Holland B; Colloca CJ; Haas JW. Increasing the cervical lordosis with chiropractic biophysics seated combined extension-compression and transverse load cervical traction with cervical manipulation: nonrandomized clinical control trial. J Manipulative Physiol Ther. 2003 Mar-Apr;26(3):139-51.

3. Harrison DE; Cailliet R; Harrison DD; Janik TJ; Holland B. Changes in sagittal lumbar configuration with a new method of extension traction: nonrandomized clinical controlled trial. Arch Phys Med Rehabil. 2002 Nov; 83(11):1585-91.