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Orthotics
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Orthotics
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Written by Dr. Mark Studin DC, FASBE, DAAPM, DAAMLP
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Wednesday, 22 September 2010 13:56 |
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President Obama, the Insurance Industry & Chiropractic
by Dr. Mark Studin DC, FASBE, DAAPM, DAAMLP
On May 11, 2009, in New York Newsday, The Associated Press reported a coalition between insurance companies, drug makers, hospitals and doctors to contain and control health care costs to lower the premiums, so that the 50 million Americans who are currently uninsured can get insurance. This is reported to be as a result of President Obama’s health care reform push.
Health care industry leaders have pledged a two trillion dollar voluntary reduction in spending over the next ten years in order to pay for the program and will report to the government in concert with President Obama’s health care reform plan. Although this doesn’t resolve the health care problem, it gives enough room to insure many of those uninsured, and will allow those special interest groups to maintain their influence over Congress in writing the legislative bill.
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Orthotics
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Written by TAC Staff
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Wednesday, 22 September 2010 13:53 |
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Dear Sirs,
 I read with interest the two letters that appeared in your May 2009 issue regarding Personal Injury. Dr. Anonymous raised a few issues but he painted with a very broad brush. More interesting was Dr. Studin’s reply. I quite enjoyed Dr. Studin’s thoughtful, articulate and imaginative article in response to the anonymous and clearly disgruntled DC regarding the PI issue.
As a long term PI practitioner here in Boston, I have quite a few thoughts and opinions on the matter myself. My office, Boston Spine Clinics, Inc. was, once upon a time, the biggest office system in the Northeast with our six clinics, 11 doctors and support staff. We did mostly PI…..
As for the suggestion that chiropractic be legislated out of the PI arena, I must disagree. Patients do get injured in ballistic impaction accident and no amount of complaining will ever change that. These patients need care and who better to deliver the most efficacious care than chiropractors? The truth is, there has been fraud and abuse in the PI arena sadly propagated by a small group of DCs. I’ve seen it here in MA. Most of the offenders have been caught and licenses have been pulled. But it is a small group that behaved that way and the entire profession should not be smeared by these few….
… So no, don’t deny patients an opportunity to see a chiropractor for whatever reason. Better to have strict but fair Boards and stiff punishment for all abusive doctors on either side of the PI issue.
Sincerely,
John Haberstroh, DC, DABCN, DACAN, FACFE
Boston Spine Clinics
(This is a shortened version of the letter received by The American Chiropractor. To read the full body of the text, and read other letters received by TAC, go to www.amchiropractor.com/forum )
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Orthotics
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Wednesday, 04 August 2010 00:00 |
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History and Presenting Symptoms
The patient is a 32 year-old female who has been building up a running program for weight loss and wellness. She reports a recent onset of pain around her right ankle and heel, which is becoming worse as she gradually increases the length of her longest runs. She plans to participate in a 10-mile run in two months, but is concerned that her heel pain is worsening. She has been taking over-the-counter anti-inflammatory drugs after each run, but has persisting pain that she rates around 4.0 on a 10cm. VAS scale.
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Orthotics
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Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.
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Friday, 25 June 2010 00:00 |
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History and Presenting Symptoms
A 66 year-old female presents with aching lower back pain and numbness extending into both feet. She reports having had occasional lower back pain for many years, but has only noticed the foot numbness in the past six months. This is getting more constant, which concerns her. She recalls no specific back or foot injuries. On a 100mm Visual Analog Scale, she rates her low back pain as usually 20-30mm. Both feet are equally numb, with no noticeable pattern or causative activity.
Exam Findings
Vitals. This 5’4’’ aging female weighs 168 lbs, which results in a BMI of 29. She is aware that she is bordering on obesity and has been unsuccessfully trying to lose weight. She hasn’t been able to exercise recently because of her back pain and numb feet. Her blood pressure is  elevated at 144/96 mmHg and her pulse rate is 84 bpm.
Posture and gait. Standing postural evaluation finds evidence of abdominal obesity, with a loss of the lumbar curve, and an accentuated thoracic kyphosis. There is no significant lateral listing of her pelvis or spine. She demonstrates bilateral calcaneal eversion, with no evidence of medial arches bilaterally. During gait, both feet pronate substantially and flare outwards (toe-out).
Chiropractic evaluation. Motion palpation identifies numerous limitations in intersegmental spinal motion: the left SI joint, the lumbosacral junction on the left, L3/L4 on the right, T11/12 generally and at the cervicothoracic junction. Palpation finds generalized paraspinal muscle tenderness, but no specific muscle spasm in these regions. All active thoracolumbar spinal ranges of motion are limited slightly by aching pain and stiffness. Provocative orthopedic and neurological tests for nerve root impingement and/or radiculopathy are negative.
Lower extremities. Both feet are generally insensitive to both pinprick and dull pressure evaluation. No specific dermatomal or peripheral nerve pattern is identified. Manual testing finds no significant muscle weakness in the fibular (peroneal) or anterior tibial muscles on either side. The feet and ankles are moderately edematous and the skin is somewhat blotchy.
Imaging and Lab
A weightbearing lumbopelvic X-ray series finds generalized loss of lumbar disc heights, most obvious at the lumbosacral joint and L3/L4. The L3 vertebral body is translated forward approximately 5 mm. The sacral base angle and lumbar lordosis are both decreased, consistent with her postural analysis. Fasting glucose level is found to be 134 mg/dL.
Clinical Impression
"Diabesity" (central obesity and type 2 diabetes) with early peripheral neuropathy. This is accompanied by degenerative lumbar spondylolisthesis. She also provides evidence of poor support from the lower extremities, with hyperpronation and substantial calcaneal eversion bilaterally.
Treatment Plan
Adjustments. Specific, corrective adjustments for the SI joints and the lumbar and cervicothoracic regions were provided as needed, with good response. Manipulation of the feet and knees was also performed.
Support. Custom-made, flexible orthotics were provided, made of comfortable and supple viscoelastic materials. She was given instructions in proper shoe selection, including the importance of correct sizing. It turned out that her shoes were too small and she purchased better-fitting shoes (one full size larger), which then accommodated the inserts without difficulty.
Rehabilitation. She received instruction in a comprehensive spinal stabilization exercise program using elastic resistance tubing. She was shown how to incorporate an exercise log with her food diary, which she brought to each visit so her continued adherence to diet and exercise recommendations could be encouraged.
Response to Care
The adjustments were well-tolerated, and orthotics made a noticeable improvement in her postural alignment at the feet and the lumbopelvic region. Her low back symptoms resolved and her foot numbness decreased significantly. At eight weeks of 12 adjustments and daily home exercises, including wearing her orthotics, she was released to a self-directed maintenance program. She was encouraged to continue her diet and exercise program.
Discussion
The combination of obesity and type 2 diabetes (insulin insensitivity) is a growing problem. Once referred to as "adult onset," this type of diabetes is now seen in adolescents. One result of altered glucose levels is peripheral neuropathy, which can present as bilateral "glove and/or stocking" paresthesiae. If numb feet are repeatedly traumatized, they develop sores and infections, with a real risk of amputation. Proper shoe fit and frequent foot self-examination are necessary in order to prevent further deterioration of foot health.
Dr. John J. Danchik, the seventh inductee to the ACA Sports Hall of Fame, is a clinical professor at Tufts University Medical School and formerly chaired the U.S. Olympic Committee’s Chiropractic Selection Program. Dr. Danchik lectures on current trends in sports chiropractic and rehabilitation.
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Orthotics
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Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.
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Sunday, 25 April 2010 00:00 |
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History and Presenting Symptoms
A 56 year-old female describes a history of numerous episodes of lower back pain and disability. She reports that she has previously had physical therapy and chiropractic care, and has been evaluated by an orthopedic surgeon. None of the prior treatments has provided any long-term relief, since her low back pain returns, in spite of treatments and exercises. She says that she has evidence of spinal degeneration on her X-rays, but an MRI ordered by the orthopedic surgeon found no disc herniation or spinal stenosis. On a 100mm Visual Analog Scale, she rates her low back pain at about 45mm, with an occasional 80mm.
 Exam Findings
Vitals. The patient is a petite woman, who stands just over 5’ and weighs 122 lbs, resulting in a BMI of 23–she is not overweight. She has never smoked, and her blood pressure is 116/78 mmHg with a pulse rate of 68 bpm. She drinks wine and beer occasionally, and exercises regularly by walking briskly each morning with a neighborhood friend.
Posture and gait. Standing postural evaluation finds a lower iliac crest on the left, and a low left greater trochanter. The right shoulder is somewhat lower than the left, with no history of fracture or surgery. Her knees are well-aligned and there is no significant calcaneal eversion, foot flare, or low medial arch. Inspection of her shoes finds some scuffing and wearing at the lateral aspect of both heels.
Chiropractic evaluation. Motion palpation identifies several limitations in spinal motion at the right SI joint, the lumbosacral junction, L2/3, and at the cervicothoracic junction. Except for the right SI joint and the right piriformis and gluteus medius muscles, palpation elicits no significant tenderness, and all active spinal ranges of motion are full and pain-free. Her hip ranges of motion are also full and pain-free bilaterally.
Imaging
AP and lateral lumbopelvic X-rays in the upright, standing position are taken with the patient weight-bearing, heels aligned directly under the femur heads, and both knees extended. A substantial discrepancy in femur head heights is noted, with a measured difference of 8mm (left low femur head). A moderate left convex lumbar curvature (9°) is noted, and both the sacral base and the iliac crest are lower on the left side. There is noticeable loss of the L5/S1and L4/5 discs, with moderate osteophyte formation involving both motion segments. The sacral base angle and measured lumbar lordosis are within normal limits.
Clinical Impression
Multiple chronic lumbopelvic fixations, with an apparent anatomical leg length discrepancy (left short leg) and associated pelvic tilt and lumbar curvature. Evidence of chronic biomechanical stress is seen in the degenerative changes of the lowest spinal motion segments.
Treatment Plan
Adjustments. Specific chiropractic adjustments for the lumbosacral and sacroiliac joints were provided. Side-posture techniques were well tolerated in the lumbopelvic region, and resulted in very good articular releases.
Support. She was fitted with shock-absorbing, flexible custom-made orthotics based on imaging the foot in mid-stance (weightbearing). On a trial basis, she was temporarily fitted with a 4mm heel lift. A 6mm heel lift was permanently built onto the left orthotic. The stabilizing supports were introduced immediately, following the first week of regular adjustments. She had no difficulty in adapting to the heel lift or the orthotics.
Rehabilitation. She was instructed in a daily, at-home core strengthening program using elastic exercise tubing. The focus was on activation of her transverse abdominis and quadratus lumborum muscles, for improved spinal-pelvic stability.
Response to Care
This patient responded well to her spinal adjustments, and adapted well to her custom-made orthotics with the heel lift. After six weeks of adjustments (eight visits) and daily home exercises, she was released to a self-directed maintenance program.
Discussion
This patient had chronic lumbopelvic fixations, caused by her anatomical discrepancy in leg length, that had not been previously identified. In addition to spinal adjustments, her treatment included correction of her left short leg using a heel lift.
Dr. John J. Danchik, the seventh inductee to the ACA Sports Hall of Fame, is a clinical professor at Tufts University Medical School and formerly chaired the U.S. Olympic Committee’s Chiropractic Selection Program. Dr. Danchik lectures on current trends in sports chiropractic and rehabilitation.
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