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CLEAR Scoliosis: Case Study
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Written by Dennis Woggon, DC, B.Sc.   
Thursday, 23 September 2010 14:15

CLEAR Scoliosis: Case Study

by Dennis Woggon, DC, B.Sc.

 

THE PATIENT PRESENTED in 2008 with a 48 degree right thoracic Cobb angle. It was initially diagnosed in 2005 at 25 degrees. The patient had a history of birth trauma. The scoliosis previously was treated with traditional Chiropractic Care. The standard CLEAR Scoliosis examination was performed. Her X-rays revealed a loss of the cervical lordosis and forward head posture (FHP) with left alar ligament damage. There was a primary right thoracic Cobb angle of 48 degrees, with compensatory left cervical dorsal Cobb angle of 35 degrees and a left lumbodorsal Cobb angle of 24 degrees. When the addition of the “compensatory” Cobb angles is larger than the primary Cobb angle (35 + 24 = 59), the scoliosis will advance. Treatment consisted of CLEAR protocols with 11 visits. The Mix, Fix, Set procedures consisted of warm-ups, adjustments and rehabilitation. The Mix phase consisted of cervical traction to improve the cervical lordosis and decrease forward head posture and vibrating traction (VT) to improve the cervical and lumbar lordosis. This mechanical traction (VT) allowed relaxationof soft tissue, specifically ligaments and discs to allow for separation between joint surfaces. Cervical drop traction was used to reduce the forward head posture and increase normal lordosis. The Spinalator allowed mechanical traction to decrease the degree of tension in the soft tissues and also allowed for more separation between joint surfaces. The Eckard Table created mechanical traction with mirror image positioning of the patient's X-ray configuration. The Eckard Table provided motion as well as traction for therapeutic exercises and decreased disc wedging.  The Fix or adjusting phase consisted of specific spinal adjustments based on 8 precision X-rays and the supine neurological leg check. They included anterior thoracic adjustments, lumbodorsal pelvic side posture and drop adjustments, cervical dorsal adjustments using the Arthrostim, long axis traction adjustments, as well as extremity adjustments to the shoulders, 1st ribs and TMJ. To correct the scoliosis, the upper and lower cervical angles must be corrected and the legs must be balanced. The Set phase teaches the spine to stay in position. This included the: LD ball exercise, ball twist exercise, standing strap stretch exercise and vibration therapy and rotatory twist exercise. These exercises are therapeutic and assist in developing strength, endurance, range of motion and flexibilit. Pneumex gait training with spinal weighting is a style of walking including rhythm and speed. The patient also used the Scoliosis Traction Chair (STC), which is a combination of traction and whole body vibration (WBV), with a mirror image placement of the patient and tension straps utilized to pull rather than push the spine towards normal alignment. Tightrope exercises were utilized for gait training with spinal weighting. Next, The VibeTM was used with head, shoulder and hip weighting. This is a vibrating platform for proprioceptive neuromuscular re-education with cervical traction. Spinal weighting with WBV causes the spine to “react” to the unbalanced forces returning the spine to a normal position. The patient’s re-evaluation revealed an improvement of the scoliosis. The right thoracic Cobb angle of 48 degrees decreased to 34 degrees, the left cervical dorsal Cobb angle of 35 degrees decreased to 18 degrees and the left lumbo-dorsal Cobb angle of 24 degrees decreased to 11 degrees. More importantly, the forward head posture (FHP) returned to normal. The patient showed significant improvements in the cervical and lumbar lordosis, correction of the upper and lower angles as well as other spinal units, stabilization of the alar ligament, and a balanced neurological leg check. Lastly, the patient was instructed to continue with home protocols including head weights with limited vision glasses (to improve the cervical and lumbar lordosis, decrease forward head posture, and improve neuromuscular re-education for movement, balance, coordination, kinesthetic sense, posture and proprioception), specific spinal isometric exercises and scoliosis stretching exercises (to develop strength, endurance, range of motion and flexibility), cervical traction, and the Scoliosis Traction Chair (STC), as well as continued chiropractic care and a follow up evaluation every three months. Discussion: The scoliotic spine does not follow what we would consider normal spinal biomechanics. Therefore, normal chiropractic procedures may not be effective in some cases. This patient did benefit from previous chiropractic care symptomatically, but not structurally. The CLEAR hypothesis is that Adolescent Idiopathic Scoliosis (AIS) is caused by a combination of neurological (subluxation) and biomechanical deficits, FHP and a loss of normal spinal lever arms. Additional follow up and research is necessary to improve upon the chiropractic profession’s understanding of the scoliotic spine.

 
Stroke… A Different Perspective
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Written by John L. Stump D.C., Ph.D., Ed.D.   
Thursday, 23 September 2010 14:09

Stroke…  A Different Perspective

by John L. Stump D.C., Ph.D., Ed.D.

 

In May 1999, upon returning Sunday evening from one of his many trips, John Stump and his wife went out for dinner. Arriving home they decided to begin packing for the upcoming lecture he was scheduled to do in New Zealand. He glanced at the clock; it was five minutes before midnight when a strange feeling went to his right arm and a few seconds later his right leg went weak. He fell over on the bed; he tried to call for his wife but nothing would come out of his mouth but gibberish.

By the time they got him to the hospital, he was unconscious. They rushed him into the ER. "When I saw the doctor’s face, it didn’t look good. In the waiting room, he looked at me and said he would do all that he could, "but your husband has had a massive stroke and is hemorrhaging in the brain. We’re trying to get the blood pressure under control. I’ll get back to you when I can," Diane Stump recalls.

"They confirmed my worst suspicion; he had suffered a stroke. But why? He’s not a smoker, or over weight, and has been an avid athlete all of his life…. What would cause this sudden brain attack? It was not until later that I realized the doctor on duty was trying to tell me there was not much hope. The ER physician told me he had called the neurosurgeon and the cardiologist but not to expect anyone very quickly. It was midnight Sunday."

 

What Every Doctor of Chiropractic Needs to Know

What you have just read was an account pulled from the book A Stroke of Midnight. Alternative Concepts publishing, 2007. This book strives to enlighten not only chiropractors but also the general public about the epidemic of stroke in America.

Stroke is now the number two-killer in the west, behind heart disease, and replaces cancer. Every 43 seconds someone suffers a stroke. One out of three of those people is lucky and has only mild symptoms from the episode; yet a second dies and the third suffers permanent physical disability. Stroke is the number one cause of physical disability, at a cost of 6 billion dollars each year to the taxpayer. Disability accumulates year-after-year due to this ever-increasing condition. It is estimated by the World Health Organization that stroke will become our number one cause of death in the modernized world by 2020. The worst thing about these awful statistics is 80 percent of these strokes are preventable!

Today we find ourselves defending the profession and our procedures regarding stroke and stroke information. Let us turn the tables and issue statements from the profession supporting Stroke Awareness. We should not have to continually take a defensive posture about our position. Let us begin to show we are interested in the total health and wellness of each of our patients.

 

About Stroke

During a stroke, a blood vessel carrying oxygen and nutrients to the brain either burst or is blocked by a clot. This prevents brain cells from getting the blood (and oxygen) they need, and can result in a possible death. A stroke usually doesn’t just happen; it comes on gradually over a period of years. Signs and symptoms are seen well in advance of the incident, if you know what to look for.

This is why blood pressure should be checked at the time of an examination. If there is an increase in BP over a period of months or years, another risk factor should be noted. The main problem is the fact that, by the time the stroke signs and symptoms appear and present themselves, it is almost too late. Not too late to save the person’s life, but too late to use preventive health care methods like diet, exercise and lifestyle changes.

Our practice is very different from a medical practice. We are seeing patients more often and usually on a wellness basis first and an acute basis second. In as much, we keep better records of weight, cholesterol, blood pressure, neurological signs, arm numbness, tingling and differences in speech and articulation.

We are not asking the DC to become anything but a little more observant, especially with the over 40 patient. A few years ago it was felt that only the 60-year-old was at risk for a stroke; now the 40-year-olds have begun to suffer heart attacks and strokes. The American Heart Association (AHA) has recently issued advisories for all doctors to begin screening twenty-year-olds. (AHA, 2009)

 

Types of Strokes

Ischemic Stroke: This type accounts for about 83 percent of all cases. They occur as a result of an obstruction within a blood vessel supplying blood to the brain. The underlying condition for this type of obstruction is the development of fatty deposits lining the vessel walls.

Hemorrhagic Stroke: This type accounts for about 17 percent of stroke cases. It results from a weakened vessel that ruptures and bleeds into the tissue of the brain. The blood accumulates and compresses the surrounding brain tissue.

Transient Ischemic Attacks: (TIA’s) are minor or pre-strokes. In a TIA, conditions indicative of an ischemic stroke are present, and the typical stroke warning signs develop. However, the obstruction (blood clot) occurs for a short time and tends to resolve itself through normal mechanisms. Even though the symptoms disappear after a short time, TIA’s are strong indicators of a possible major stroke, and preventive steps should be taken immediately. (American Stroke Association. (www.strokeassociation.org)

 

Teach a Preventive Lifestyle

Diet: Chiropractors know diet is probably the most important of all the lifestyle modifications patients have to make. Growing up in the South as we did, nearly everything was deep fried all the way to the tomatoes! Patients must avoid and limit fried foods that contribute to clogged vessels. Red meat is another red flag food, as well as sugar and junk food. We ask all of our patients to limit their consumption of processed foods from a can, bottle or box, due to the excessive amount of additives like sugar, salt and other chemicals. We are not asking you to change your practice; just be a little more aggressive in your advice on diet, exercise and lifestyle.

Physical Activity: We know not everyone can spend as much time in the gym as we would like, but daily physical activity is a must for overall good health. Make simple choices for more activity, take the stairs, park a little further away and walk an extra block or two, stop using remotes and begin being more physical. Everybody needs 30-45 minutes of daily physical activity—walking, bicycling, swimming, volleyball or golf—to keep the body, mind and spirit functioning properly.

Sleep and Rest: Just as they need physical activity, they also need rest and relaxation. Sleep depravation has become a big health issue within the last three decades. Sleep medications are a top pharmaceutical draw. A few years ago, it was a miniscule seller for the pharmaceutical industry. Tension, stress and fatigue are all by-products of lack of enough sleep. Today, sleep, rest and relaxation are being robbed by society’s demands. We recommend more activities like Tai Chi, Yoga, Qigong and Meditation each day, something that will both relax and refresh the mind and body. These can be done in a class or on an individual basis, depending on the patient. That’s why these ancient exercise and meditation systems are very old and still popular. Plus, they require no equipment and they can be done at anytime with no expense.

 

Let us point out one thing further. In February 2007, at an International Stroke Conference held in New Orleans, it was learned that the rate of strokes among middle-aged women has tripled in the last six years. Nearly 2 percent of women ages 35-54 reported a stroke in the most recent federal survey, from 1999 to 2005, while only 0.63 percent did in the previous survey, from 1988 to 1994.

Health officials think that women may be less attentive when it comes to acknowledging their own signs and symptoms. Women tend to ignore signs and symptoms in themselves, because they don’t want to upset their ability to take care of their family.

While statistics show women and men suffer strokes at about the same rate and time during their lives, this latest study gives us reason to believe the statistics are about to change toward the female suffering strokes at a younger age and at a faster rate.

 

Summary

We want to emphasize, chiropractors are in the prime position to recognize, teach and follow up with patients about the devastating effects of stroke. This was the primary reason why the book A Stroke of Midnight was written. Once John knew he was going to live and could write again, he decided everyone should be more aware of stroke and its consequences. It seems everyone knows about heart attacks but few know stroke is now the number two killer and will soon become number one. People must wake up and begin to change their habits and lifestyles. Chiropractors are "Wellness Oriented" and in prime position to help curb this tragic epidemic.

This is where the DC can project an entire new image of the profession as being on the cutting edge of the American "Stroke Awareness" movement.

 
Review of the Literature: Non - Operative Scoliosis Treatment
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Written by Marc J. Lamantia, D.C., and Gary A. Deutchman, D.C.   
Thursday, 23 September 2010 14:04

Review of the Literature: Non - Operative Scoliosis Treatment

by Marc J. Lamantia, D.C., and Gary A. Deutchman, D.C.

 

Without intervention, Adolescent Idiopathic Scoliosis (AIS) is a condition which is likely to progress between the time of detection and the time of skeletal maturity.1 This makes early detection, with the intent of early intervention of paramount importance to the success of a non-surgical treatment regiment.2 Unfortunately, the current medical standards recommend observation until a curvature has shown progression of five degrees or more, and the measurement exceeds thirty degrees. This leaves a very small window where brace treatment is suggested and, more importantly, lessens the patients’ chances of successful non-surgical treatment. Studies confirm, as the curvature increases, the likelihood of further progression increases as well.3 Therefore, the current standards are not congruent with the scientific observations reported in these studies. Early intervention should be coupled with early detection.

 

Progression and Protocols:

Nachemson, et al., 4 reported both girls and boys between the ages of ten and twelve, who had at least a thirty degree curvature at the time of detection, have the highest risk of progression before skeletal maturity, approaching 100%. If this is, in fact, accurate, recommendations of early screening and early intervention until the patient reaches skeletal maturity make the most sense. Unfortunately, the pediatric orthopedic community continues to recommend watchful waiting, often waiting until surgery is the only option.

It is my belief, from a clinical standpoint, following a comprehensive evaluation of vestibular function, movement analysis, gait evaluation and the like, patients can be trained to optimize postural muscle synergies through repetitive movement therapy and vestibular rehabilitation.

Although the highest risk of progression is clearly between the time of detection and skeletal maturity, a second significant progression has been reported to occur between skeletal maturity and a thirty year follow-up.5 In a longitudinal study, Weinstein, et al., (1981) followed one hundred and twenty patients over forty years. The authors reported a high likelihood of adult progression in those patients with thirty degree lumbar and thoracolumbar curvatures at the time of skeletal maturity. Thoracic curvatures of fifty degrees or more were also reported to have a high likelihood of progression during this same time frame. This is an important study because it highlights the necessity to treat lumbar curvatures which are thirty degrees or more, even when progression is not suspected. Although bracing alone has been the only accepted medical standard since 1951, as of 1984, there had not been any prospective or randomized clinically controlled studies to demonstrate its efficacy. In 1984, Miller, et al., demonstrated insignificant cant differences between bracing and observation in regards to the natural progression of AIS.6 Researchers such as Focalize, et al., (1991) and Goldberg, et al., (1993) corroborated these findings, and went as far as to recommend discontinuance of screening programs and challenged the usefulness of bracing at all.7,8 In a 1997 article printed in the Journal of Bone and Joint Surgery, a meta-analysis was performed to evaluate the efficacy of Non-Operative treatment of AIS. Nineteen studies were included in the analysis, with over 1900 participants. Although the findings clearly showed full time bracing (23 hours per day) did, in fact, significantly alter the natural progression of the disease, current trends continue towards reduced bracing hours and, in some cases, no recommendation of bracing at all.9 Furthermore, the type of brace being prescribed was also a signify cant variable. The Charleston brace was significantly less successful than the Milwaukee brace (64%), however the authors admit difficulties in comparing the cases due to reporting parameter and classifications amongst patient groups. In general, rigid bracing uses three point pressure systems to reduce the lateral deviation of the spine. More recently, the Spine or Brace has been gaining popularity among non-surgical providers (we have been providing Spine or in our offices for the past five years). Invented in 1992, the brace consists of a fabric bolero designed to help control rib cage positioning, four fabric elastic band and a pelvic belt. The brace is fitted to induce a corrective posture as first described by Dr. Christine Collaird. Depending upon curvature location, the brace is fitted accordingly. Spine or is the first dynamic elastic tension brace designed to provide neuromuscular rehabilitation through derotation of the rib cage in relation to the shoulder and Pelvic. belt. The brace is fitted to induce a corrective posture as first described by Dr. Christine Collaird.16 Depending upon curvature location, the brace is fitted accordingly. Spinecor is the first dynamic elastic tension brace designed to provide neuromuscular rehabilitation through de-rotation of the rib cage in relation to the shoulder and pelvic girdle. In a study published in the Journal of Pediatric Orthopedics, patients fitted with the Spinecor brace were monitored continuously for two years beyond the weaning period. Of the 172 participants with a definitive outcome, thirty-nine required surgery prior to skeletal maturity and twelve dropped out; fourteen patients were weaned out due to positive outcomes and stability prior to skeletal maturity. So the remaining one hundred and one patients observed had a 59.4% success rate, with an additional 10.6% who had progression of more than 6 degrees but did not require surgery. Of the 59.4% who achieved curvature reduction or stabilization, 95.7% maintained the corrections achieved two years prior. Five of the patients continued to improve despite being out of brace for two years. Interestingly, the authors report lumbar curvatures to respond most favorably (83.3%), then thoracolumbar curvatures (69.4%), thoracic (56.8%) and double curvatures of equal magnitudes being least favorable (42.8%). Furthermore, when initial curvatures measured between 25 and 29 degrees, the rate of success was 70.1% as compared to 50.2% success when the curvatures measured from 30-40 degrees. These findings are consistent with findings of others who report early detection and intervention as necessary for the most successful outcomes and are suggestive that Spinecor is more successful than any other brace when the patient begins treatment with curvatures measuring between 25 and 29 degrees.

In May 2007, Dr. Gary Deutchman and I presented the first study on the use of Spinecor in adults entitled, A retrospective study of twenty-three adults treated for scoliosis using the Spinecor Orthosis.10 Although adult treatment has been relegated to pain relief, it was our belief that neuromuscular rehabilitation would be a successful approach to reducing spinal deformities in adults as well as children. The patients were separated into three groups based on curvature location. The patients in the "thoracic" group (n = 20) had a mean average change of -5.27 degrees. This is considered by the Scoliosis Research Society to be a borderline significant reduction. The "thoracolumbar" group (n = 3) had a mean average change of -6.0 degrees, and the lumbar group (n = 15) had a mean average change of -4.40 degrees. A questionnaire survey revealed the adult group to be “extremely satisfied” and would recommend Spinecor to other adults. I should also add, due to the comorbid nature of scoliosis, chronic pain and degenerative joint disease, alterations were made to the brace configurations on a case by case basis. Many of the adults treated were fitted in an extension-type set-up (often used to treat kyphosis), irrespective of curvature location. After the patients were tolerant of brace wearing, we then switched many to a more conventional “Spinecor” set-up as described by Collaird. Although pain reduction was the most significant finding, this study highlighted the possibility of adult curvatures responding to non-surgical management. In my experience, adults with scoliosis are unaware that anything can be done to help them in regard to curvature or pain reduction. Of course, cosmesis is another consideration; improving posture and outward appearance is oftentimes the motivating factor for adults who seek treatment. Studies performed by Griffet, et al., indicated gibbosity reduction as a significant outcome of treatment with the Spinecor brace.11

Neuromuscular Influences in Idiopathic Cases:

Neuromuscular rehabilitation of the posture in both adults and children should include a thorough neurological evaluation of the vestibular system. Studies confirm the presence of vestibular disturbances in scoliosis patients12 which may not resolve without specific rehabilitation techniques. In an article published in the Scoliosis Journal 2007, I reported on my findings of vestibular dysfunction in a population of scoliosis patients.13 Vestibular dysfunction left untreated influences postural tone, in particular extensor musculature activity during dynamic balance. This includes ambulation as well as specific balancing tasks. Studies confirm abnormal activation of extensor musculature during walking in scoliosis patients.14 The authors of this particular study were concerned with post operative changes, but failed to explore possible non-surgical approaches to influencing muscle recruitment patterns. It is my belief, from a clinical standpoint, following a comprehensive evaluation of vestibular function, movement analysis, gait evaluation and the like, patients can be trained to optimize postural muscle synergies through repetitive movement therapy and vestibular rehabilitation. Although vestibular rehabilitation is well accepted, scoliosis care providers rarely offer evaluations and treatment along these lines. Interestingly, the adolescent population with vestibular pathology are often without symptoms, much in the same way they are typically without pain. On the other hand, the adult population often suffers from dizziness, imbalance, anxiety and vestibular headaches as a direct result of their vestibular disorder, and experience chronic pain syndromes as well. For those who embark on a course of postural rehabilitation for patients, whether it be working on sagital curve restoration or otherwise, its efficacy will be lessened in the presence of abnormal vestibulospinal function. Treatment of any movement disorder is most effective when vestibular function is robust, as would be the case in any population, adult or adolescent. To date, vestibular rehabilitation and, really, any rehabilitation of movement remains controversial in the United States.

1. Rowe D., Bernstein S., Riddick M., et al. A meta-Analysis of the Efficacy of Non-Operative Treatments for Idiopathic Scoliosis. J Bone Joint Surg 1997: 79-A; 664-74

2. Focarile, F.;Bonaldi, A.; Giarolo, M.;Ferrari, U.; Zilioli,E.; and Ottaviani, C.: Effectiveness of nonsurgical treatment for Idiopathic Scoliosis. Overview of Available Evidence. Spine 1991; 15:395-401

3. Weinstein, S., Zavala, D., Ponseti, I.; Idiopathic Scoliosis. Long-term follow up and prognosis in untreated patients. J. Bone and Joint Surg. June 1981: 63-A:702-712

4. Nachemson, A.,: Lonstein, J. E.; and Weinstein, S. L: Prevalence and Natural History Committee report. Rea dat the Annual Meeting of the Scoliosis Research Society, Denver Colorado, Sept 25, 1982

5. Weinstein, S., Zavala, D., Ponseti, I.; Idiopathic Scoliosis. Long-term follow up and prognosis in untreated patients. J. Bone and Joint Surg. June 1981: 63-A:702-712

6. Miller, J.; Nachemson, A.; Schultz A.: Effectiveness of braces in mild idiopathic scoliosis. Spine 1984; 9:632-635.

7. Focarile, F.;Bonaldi, A.; Giarolo, M.;Ferrari, U.; Zilioli,E.; and Ottaviani, C.: Effectiveness of nonsurgical treatment for Idiopathic Scoliosis. Overview of Available Evidence. Spine 1991; 15:395-401

8. Goldberg, C.;Dowling, F.; Fogarty, E.; and Moore, D.: School Scoliosis screening and the U.S. Preventive Services Task Force. An examination of Long-term results. Orthop. Trans. 1995-1996; 19:590-591

9. Rowe D., Bernstein S., Riddick M., A meta-Analysis of the Efficacy of Non-Operative Treatments for Idiopathic Scoliosis. et al. J Bone Joint Surg 1997: 79-A; 664-74

10. Deutchman, G.; Lamantia M.,; Indelacato J.; Raykhman M.: A Retrospective Study of twenty three adults treated for scoliosis using the Spinecor Orthosis. From 4th International Conference on Conservative Management of Spinal Deformities Boston, MA, USA. 13–16 May 2007.  Scoliosis 2007, 2(Suppl 1):S23doi:10.1186/1748-7161-2-S1-S23

11. Griffet et al. Relationship between gibbosity and cobb angle during treatment of idiopathic scoliosis with the spinecor brace. Eur Spine J (2000) 9:516-522

12. Manzoni D, Miele F.Dipartimento di Fisiologia e Biochimica.  Vestibular mechanisms involved in idiopathic scoliosis (Arch Ital Biol 2002 Jan;140(1):67-80 Universita di Pisa, Via S. Zeno 31, I-56127 Pisa, Italy)

13. Lamantia et al. A retrospective study of thirty six cases of vestibular hypofunction in adolescents with idiopathic scoliosis. Scoliosis Oct 2007. 2(suppl 1):s37.

14. Hopf C, Scheidecker M, Steffan K, Bodem F, Eysel P. Orthopaedic Department, Lubinus Klinik Kiel, Germany Gait analysis in idiopathic scoliosis before and after surgery: a comparison of the pre- and postoperative muscle activation pattern. Eur Spine J. 1998;7(1):6-11

15. SPINECOR: a new therapeutic approach for idiopathic scoliosis. Coillard C, Leroux MA, Badeaux J, Rivard CH. Research Center, Sainte Justine Hospital, 3175 Côte Ste Catherine, Montreal, Canada.       Stud Health Technol Inform. 2002;88:215-7

 
Crash Course on Personal Injury Practice Success
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Written by TAC Staff   
Wednesday, 22 September 2010 15:51

Crash Course on Personal Injury Practice Success

Interview with Personal Injury Practitioner Dr. Tom Arnold

 

 

Dr. Tom Arnold is a december 1989 graduate of Texas Chiropractic College and moved to Albuquerque, New Mexico, and began practicing in early 1990.

In an interview with The American Chiropractor (TAC), Dr. Arnold explains what it is like to be a doctor with approximately 95 percent of his patients being
Personal Injury.

TAC: What inspired you to become a chiropractor? Do you have a specific story?

Arnold: Frankly, as a kid I started giving myself adjustments. It started with popping my knuckles, then my knees and then neck and back. I was always athletic and it helped me get through my sports, so I had a firsthand experience of the benefit it provided even though it was not administered by a chiropractor. As an adult, I started going to a chiropractor just to stay tuned up for sports and it made an enormous difference. After several years in the financial world as a stockbroker, I was burned out. And I quit. During the next year, I discovered a special God given gift in my hands and, with the encouragement of friends and family, I pursued that gift through chiropractic.

 

TAC: What type of patients do you generally treat or attract?

Arnold: Approximately 95 percent of my practice is Personal Injury. I concentrate on automobile collision injury cases and I enjoy caring for the injured. It offers me a challenge to use more of my clinical skills in ways that aren’t necessary when treating chronic pain patients. I can empathize with auto collision victims.

 

TAC: What was it about Personal Injury that led you to develop a clinic almost exclusively treating that condition?

Arnold: My interest in automobile injury cases developed in my last year of chiropractic school. During that time I married a young lady who had been injured in an automobile collision three years before we met. She was hit from behind and continued to deal with severe headaches, neck and upper back pain. She is a registered nurse and, at the time of the accident, she didn’t know anything about chiropractic and therefore pursued the medical model of treatment which was prescription medications and physical therapy. As she said, "It really didn’t help." When we met, she was living on handfuls of ibuprofen just to get through the week. As I cared for her, her condition greatly improved. The sad news is that her problems never completely resolved and developed into a long-term chronic condition. I can say without reservation that her situation and experience deeply influenced me. I have made a life-long commitment to develop my clinical skills through post-doctoral training as much as I can to provide my patients a recovery experience intended to prevent or at least improve the chances that they will not suffer like my family has. I say "family" because, when one person suffers, it affects the whole family.

 

TAC: What did you do specifically that changed your practice in building a PI patient base?

Arnold: I started looking at the legal community in a completely different manner than I used to. I used to think of them as a "necessary evil" of the Personal Injury world and they looked at me as a "necessary evil" when they represented my patients, because my documentation was horrible. I have since come to realize that, in order to help my personal injury patients as much as I can, I must think outside of the box of just treating their injuries. I had to learn to objectively and effectively communicate my patient’s situation to his or her attorney. This now gives the attorney an articulate explanation to allow the truth to be the deciding factor in a trial or settlement. Since then, my relationships have flourished as I am now looked upon as an expert by the medical-legal community.

 

TAC: Are you required to testify, or do depositions frequently?

Arnold: Yes, I am asked to testify several times per year.

 

TAC: How important is your clinical knowledge when doing Personal Injury cases?

Arnold: This is the most important question you can ask. Your clinical knowledge is the most important component and that has little to do with your knowledge of adjusting the spine. If it wasn’t for my post-doctor training in spinal related subjects like disc pathology, neuropathology and crash dynamics, I wouldn’t be able to articulate or testify about my patients’ injuries from a factual base. That is especially true when being cross examined in a trial or deposition, because lawyers will come at you and the only way for the truth of case to prevail is to be clinically excellent.

 

TAC: What type of knowledge base and CE Courses do you feel are necessary to succeed in a PI Practice?

Arnold: Prior to my commitment to personal injury, I only took continuing education courses to keep current with my adjusting skills. Since making the decision to be the best of the best in the Personal Injury arena, I have taken courses in advanced imaging, neuro-diagnostics, crash dynamics and documentation, to be able to apply a broader understanding of the legal challenges that face the plaintiff attorneys who represent my patients. Clearly, establishing high-quality working relationships with the plaintiff attorney community is vital. To do so, I have to demonstrate that I speak their language by providing them a quality product in the form of reports and documentation on their clients’ conditions, especially if there are residual disabilities.

 

TAC: How is what you do now, after having practiced this way for a while, differ from when you started?

Arnold: Back then, I didn’t know that I didn’t know. But now I’m committed to keep growing in my knowledge to expand my practice. I realize it is a life-long journey.

 

TAC: Have your credentials affected your ability to work with the legal community and, if so, how?

Arnold: I have to admit that, for a long time, I was clueless about the importance of credentials. There’s no way to calculate what that has cost me in lost opportunities. Now that I have "seen the light," so to speak, my curriculum vitae reflects the efforts that I have made over the years to elevate my standing in the Personal Injury arena, through my credentials vs. through rhetoric. As a result, I’m working with attorneys who otherwise would not have given me the time of day.

 

TAC: What kind of notes system do you use, and is there a reason?

Arnold: My daily patient progress notes are taken in a standard S.O.A.P. format. This format covers the requirements for proper documentation. The last thing I or any other doctor needs is an insurance audit that reveals substandard and inadequate documentation that leads to a demand for a refund to the insurance company. I can live without that nightmare.

 

TAC: What were the biggest mistakes you made that affected your PI practice?

Arnold: I don’t know that this was a mistake…more like a blessing in disguise; but, a few years ago, I was one of the early adopters in the field of nonsurgical spinal decompression. For over a year, I stopped taking PI cases and concentrated just on decompression. I began to miss the automobile injury cases and finally returned to my roots. In retrospect, it was good for me to get away from Personal Injury cases for awhile, because now I believe I have renewed energy and empathy for this unique segment of the patient market.

 

TAC: What type(s) of diagnostic testing procedures do you use and why?

Arnold: For functional diagnostic testing like computerized ranges of motion and computerized muscle strength tests, I am equipped to do them in my office. However, when the patient needs electro-diagnostic procedures like an Electromyography/Nerve Conduction Velocity study (EMG/NCV), Somatosensory Evoked Potential test (SSEP), brainstem auditory evoked response (BAER), Video Electronystagmography test (VENG) or visual evoked potential (VEP), I refer them to the appropriate specialist and treat in a team environment.

For structural diagnostic procedures, I have plain film X-ray in my office and refer out for magnetic resonance imaging (MRI), computed axial tomography (CT) scans and bone scans.

The short answer to why is simply to arrive at the most accurate diagnosis possible.

 

TAC: What has really impacted your growth as a chiropractor and that of your practice?

Arnold: I would have to give a well deserved round of applause to Dr. Mark Studin for sharing with me his vast wealth of knowledge and experience in dealing with the legal community and for encouraging me to strive to be, as he says, "the best of the best." One of the not so obvious secrets I picked up from him was the importance of developing a strong "infrastructure" composed of the curriculum vitae, effective narrative report format, and medical-legal educational and communication system.

 

TAC: With your practice being Personal Injury, can you give our readers your advice about setting up and maintaining such a practice in today’s healthcare system?

Arnold: If you don’t have a strong empathy for the automobile collision victim, then don’t bother. I like this niche and I’m sure it is much different than a family practice. I like the specialization and the unique challenges of providing admissible documentary evidence and testimony to the legal community. Keeping up with the medical literature is a bit of a challenge because there is a constant flow of new research that validates these injuries and supports what we do to treat automobile injury patients.

 

TAC: What general advice would you give an established chiropractor whose PI practice might be struggling?

Arnold: It’s probably struggling because he or she has not established a solid infra-structure of credentials, narrative reports, and medical-legal educational and communication systems that lets the legal community know that he or she is the real deal. Like I did, there are programs in the chiropractic community that can guide you through the process so you do not have to "re-invent the wheel" and which will shorten the learning curve.

One thing I learned, simply advertising or marketing will not get you the Personal Injury practice you want; that will only be achieved by becoming the best at what you do through your knowledge and a solid infrastructure.

 

TAC: Any final words for our readers?

Arnold: Through this whole process of working effectively in the Personal Injury world, the biggest winners are more than just my patients. The legal community in my area now has a "new-found respect" for chiropractic because they realize that chiropractors have the same knowledge base as their medical counterparts. The end result is that chiropractic wins and that makes me proud!

 

You may contact Dr. Arnold at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

 

Editor’s Note: Do you know an Amazing Chiropractor that you’d like TAC to highlight in our The Amazing Chiropractor series? Contact TAC’s editor Jaclyn Busch Touzard, by phone/fax at 1-305-716-9212 or email This e-mail address is being protected from spambots. You need JavaScript enabled to view it . We want your inspiring story! Contact us today!

 
Evidence Based Wellness Care
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Written by Dr. James L. Chestnut , D.C., F.I.C.C., F.A.C.C.   
Wednesday, 22 September 2010 14:47

Dr. James L. Chestnut has been studying human wellness for over 25 years. He has a Bachelor of Physical Education degree, a Master of Science degree in exercise physiology with a specialization in neurological adaptation, is a Doctor of Chiropractic from the Canadian Memorial Chiropractic College in Toronto, Canada, and holds a post-graduate Certification in Wellness.

 
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