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Decompression: Myth, Magic, or Miracle
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Written by Eric Kaplan, DC, F.I.A.M.A   
Wednesday, 25 September 2013 22:11
O
nce again, our profession is at odds with itself over something whose benefits it should be welcoming with open arms – “spinal decompression”.One of my early mentors told me, “Chiropractors circle the wagons and then shoot at each other.” Today it seems that everyone is an expert on either traction or decompression (the latter wasn’t even taught when 98% of us were in school). Moreover, if you don’t hold an opinion in favor of one or the other, you know nothing. Doctors are well known for naming techniques after themselves, yet decompression, as you will learn, was neither pioneered nor developed by chiropractors. I will receive a lot of heat for this article, but, after 34 years in the profession, I can take it. “You gotta face the music if you wanna lead the band.”
 
spine5In school, I was taught that chiropractic was a philosophy, an art, and a science. That paradigm bothered me for 35 years, so I decided to create my own; a new paradigm for the 21st century, and one that remains at the center of all my teaching: “Chiropractic is a science that has an art and embraces a philosophy.”
 
Before I continue, I’d like to make it clear that I make no claims to being the ultimate authority on either decompression or chiropractic. I am a student of both, and shall be for the rest of my life. There is, however, one thing that I am the world’s greatest expert on, and that is me. I believe with every cell in my body that decompression is working wonders for our profession. It has done for chiropractic what cosmetic dentistry did for dentistry. Never before in our history would patients from all over the country — regardless of their insurance coverage — pay cash for a service. “But,” I hear you ask, “isn’t it controversial?” I don’t think so; but there will always be naysayers ready to create controversy, even if it hurts our profession.
 
The Facts
The amount of money spent on the treatment of low back pain is staggering. Back pain is a billion dollar industry. In 2005, according to Karen Springer in her Newsweek article “The Price of Pain", Americans spent $85.9 billion looking for relief from back and neck pain through surgery, visits to the doctor, X-rays, MRI scans and medication; that’s up from the 1997 figure of $52.1 billion, as recorded in the Feb 13 1997 issue of the Journal of the American Medical Association (JAMA).
 
Ms. Springer went on to report, “Not only are more people seeking treatment for back pain, but the price of treatment per person is also up. In the JAMA study, researchers at the University of Washington and Oregon Health & Science University compared national data from 3,179 adult patients who reported spine problems in 1997 to 3,187 who reported them in 2005 — and found that inflation-adjusted annual medical costs increased from $4,695 per person to $6,096. Spinal patient costs were also significantly higher than for nonspinal patients. ‘People with back problems cost 76 percent more on average, than people without back problems each year,’ says study co-author Brook Martin, a research scientist at the University of Washington. “

A research study by Binod Prasad Shaw, MD of Albert Einstein Medical College and Michele K. Shaufele, MD of Emory University states: “In recognition of the extreme burden and impact that musculoskeletal disorders have on society, the United Nations and the World Health Organization (WHO) have designated 2000-2010 as the bone and joint decade.” The study goes on to report that 10 million Americans are currently disabled due to back pain. 
 
So, we know the sums of money involved are staggering but where do we go from here? It would be folly to let the medical world take over decompression while we fight amongst ourselves. Who better to treat disc injuries than today’s chiropractor? In a nation where back pain has reached epidemic proportions, is there a better way, a cheaper way? In her Newsweek article, Ms. Springer states, “Educating doctors about alternative treatments — even when a patient may be clamoring for high-tech intervention —may be another key to reducing costs and relieving pain. ‘They [patients] can't order drugs and tests for themselves. Somebody has to be offering them,’ says Dr. Michael Haak, a spine specialist and orthopedic surgeon at Northwestern University's Feinberg School of Medicine. ‘You need to encourage [doctors and patients] to be aware of all the alternatives.’"
 
The time for decompression is now. Now is the time to take what we deserve. Yet, we are a profession governed by two associations: the ICA and the ACA. Anyone who knows me knows that I have tried not to be a democrat or a republican. How many other professions have two ruling bodies? It’s time for both associations to recognize that “working as one” would be in the best interests of chiropractors and patients. Our associations should be outraged that physical therapists are paid more for therapy than our doctors.
 
How do we become experts on anything? We read, we research, we challenge, we acknowledge. To learn, we must be open-minded; those who claim to be “the one and only” are simply attempting to “educate” through insecurity and intimidation.
 
So where did all this begin? In order to find out, we must go back to the beginning in order to allow you, the educated reader, to draw your own conclusions. 
 
It all began in Ontario in 1987 with Canada’s former minister of health Dr. Allan Dyer. Already recognized as a pioneer in the development of the external cardiac defibrillator, Dr. Dyer designed and developed this new technology to be distinctly different from conventional traction tables. Although traction has been around for centuries, research into its effectiveness remains inconclusive. Dr. Dyer took the concept of traction and made critical engineering improvements to yield a treatment of unprecedented efficacy. 
 
He called his invention Vax-D, (Vertebral Axial Decompression). While Vax-D did manage to overcome many of the limitations imposed by conventional traction, it still had a number of drawbacks. The rigid horizontal table made it difficult for some patients to use, and it was not designed to provide decompression for the neck.
 

He called his invention Vax-D (Vertebral Axial Decompression).

Although Vax-D could treat the lumbar spine, patients were only able to lie on the table in the prone position. Today Vax-D technology has been reengineered to put the patient in the supine position. The people who attack Vax-D would doubtless have attacked Henry Ford when he altered the Model T. Technology has advanced at a rapid pace, from our computers to our televisions. Old-schoolers never want to change; they fail to see that change is the only constant thing in life.
 
Numerous studies have been carried out on spinal decompression. To me, a decompression table is only as good as its research results. When teaching decompression, I urge my students to read, understand and embrace the research. One of the first and largest available studies on the efficacy of non-surgical disc decompression was the data compiled by Gose, Naguszewski and Naguszewski and published in Volume 20 of the journal Neurological Research. The data presented the outcomes of 778 patients from 22 medical centers. These patients had had pain for an average of 40 months. Thirty-one of them had previously undergone low back surgery. The treatment consisted of 10 to 20 treatment sessions. Six patients were excluded from the study because they improved before 10 treatments.
  • 34 patients had extruded discs.
  • 195 had multiple disc herniations.
  • 382 had single disc herniations.
  • 147 had degenerative discs without herniations.
  • 19 had facet (joint) pain.
  • 31 of these 778 patients had previous low back surgery.
The Results Were Extraordinary
  • 1% reported increased pain.
  • 7% reported no change.
  • 92% reported improvement. Of these, 5% improved by 25-50%; 17% improved by 50-75%; 70% improved by 75-100%.
  • Before treatment, on a pain scale of 0–5, the average pain for all subjects was 4.1. After treatment it was 1.2—a difference of 71%.
  • 71% reported that their pain reduced to 0–1 on the 0–5 pain scale. 
  1. Extruded disc patients reported an average 56% reduction in pain and 53% reported that pain reduced to 0–.
  2. Multiple herniated disc patients reported a 71% reduction in pain and 72% reported that pain reduced to 0–1.
  3. Single herniated disc patients reported a 71% reduction in pain and 73% reported that pain reduced to 0–1.
  4. Degenerative disc disease patients reported a 70% reduction in pain and 72% reported that pain reduced to 0–1.
  5. Facet syndrome patients reported a 72% reduction in pain and 68% reported that pain reduced to 0–1.
  6. Of patients who had reported decreased spinal mobility before treatment, 77% reported improved spinal mobility.
  7. Of patients who had reported limited activities before treatment, 78% reported improved activities.
On a scale of 0–3, the average level of satisfaction with treatment was 2.4, in other words, “very satisfied” to “completely satisfied” with their treatment.
 
This prestigious study paved the way for the use of spinal decompression.
 
Although research was and has been positive, many insurance companies  concluded that these statistics were misleading and inconclusive. Study after study showed the efficacy of spinal decompression but whenever these positive studies appeared, there was always a naysayer on hand to find fault. 
 
Clinical Research
The numerous studies that have been conducted on decompression therapy have consistently upheld its efficacy.
 
1. Sherry E, Kitchener P, and Smart R, “A prospective randomized controlled study of VAX-D and TENS for the treatment of chronic low back pain.” Journal of Neurological Research, Vol. 23, October 2001. A randomized study which compared VAX-D to transcutaneous electrical nerve stimulation (TENS) in the treatment of patients with chronic (> 3 months in duration) low back pain. Successful outcome was defined as a 50 % decrease in pain using the Visual Analog Pain Scale and an improvement in the level of functioning as measured by patient-nominated disability ratings. The TENS-treated group (n = 21) reported a success rate of 0%, while the group treated with VAX-D (n = 19) showed a success rate of 68.4 %. In spite of this positive finding, Blue Cross reported, “While a 68% success rate was associated with VAX-D compared to a 0% success rate associated with TENS therapy, without a true placebo control, the results are difficult to interpret scientifically.”
 
Let’s face it; insurance companies have no desire to pay anything to anyone. I can accept the fact that they don’t consider spinal decompression therapy to be reimbursable but, as professionals, we do not need the approval of the insurance companies; the important thing is to continue with  the research.
 
The medical community has provided countless studies that have showed the efficacy of spinal decompression, and while our profession openly and subjectively debates it, modern medical journals have documented its success. I have the opportunity to work with developers, inventors, and engineers while studying the materials and protocols of Dr. Norman Shealy  in detail.  Norman Shealy  in detail.   Dr.Shealy, MD, PhD, a former Harvard Professor who has more published articles than any other doctor in our nation On Spinal Decompression, published a review of over 50 traction device studies which led to his identification of mechanisms of action improvements. His observations resulted in the development of the first targeted angle approach by implementing the fixed tower, which, in my opinion, is germane for an accurate angle of pull. Researchers and engineers have confirmed this. His use of the fixed tower in the original DRS system boosted outcomes significantly above the 68% success rate of Vax-D. The DRS patented by Shealy-Becerra, et al. demonstrated an 82-86% success rate. In 2001 the Spina/Accu-Spina IDD Therapy systems further advanced multiple patented technologies which contributed to those device studies, and raised the bar yet again. In the McClure study, carried out by neurosurgeon Dr. Dennis McClure, over 500 patients cleared for spinal surgery were instead given spinal decompression utilizing IDD Therapy. This resulted in 92% of participating patients being able to avoid surgery, and to report continued relief even after the one year follow up period. Medical research has determined the efficacy of spinal decompression. We as chiropractors need to embrace this research and I challenge each and every chiropractic school to begin doing so today. 
 
Additional reading and areas for further research:
Eyerman E, “MRI Evidence of Mechanical Reduction and Repair of the Torn Annulus Disc.” International Society of Neuroradiologists, October 1998; Orlando.
 
Shealy, C Norman and Borgmeyer V, “Decompression, Reduction and Stabilization of the Lumbar Spine: A Cost-Effective Treatment for Lumbosacral Pain.” AJPM, 1997.
 
Dr. C. Norman Shealy, MD, PhD, and Vera Borgmeyer, RN, MA, iconic figures in the field of decompression, reported the following:
 
SUMMARY —American Journal of Pain Management Vol. 7. No. 2 April 1997 Emerging Technologies: Preliminary Findings
 
“We have compared the pain-relieving results of traditional mechanical traction (14 patients) with a more sophisticated device which decompresses the lumbar spine, unloading of the facets (25 patients). The decompression system gave ‘good’ to ‘excellent’ relief in 86% of patients with RID and 75 % of those with facet arthroses. The traction yielded no ‘excellent’ results in RID and only 50% ‘good’ to ‘excellent’ results in those with facet arthroses. These results are preliminary in nature. The procedures described have not been subjected to the scrutiny of review nor scientific controls. These patients will be followed for the next six months, at which time outcome-based data can be reported. These preliminary findings are both enlightening and provocative. The DRS system is now being evaluated as a primary intervention early in the onset of low back pain especially in workers' compensation injuries.”
 
Tilaro F, “An Overview of Vertebral Axial Decompression.”
 
Naguszewski W, Naguszewski R and Gose E, “Dermatomal Somatosensory Evoked Potential Demonstration of Nerve Root Decompression after VAX-D Therapy.” Journal of Neurological Research, Vol. 23, October 2001.
 
Ramos G and Martin W, “Effects of Vertebral Axial Decompression on Intradiscal Pressure.” Journal of Neurosurgery,1994.
 
Shealy C Norman and Leroy P, “New Concepts in Back Pain Management: Decompression, Reduction, and Stabilization.”

Pain Management: A Practical Guide for Clinicians, Vol. 1, 1998.
 
Tilaro F and Miskovich D, “The Effects of Vertebral Axial Decompression on Sensory Nerve Dysfunction.” Canadian Journal of Clinical Medicine, January 1999.
 
In his article on the subject of traction versus decompression, Dr. Alan Presswood states the following: “Traction is designed to try to take pressure off the nerves, period. Spinal decompression is designed to relieve pressure and heal the disc so the patient can perform normal movement in the area once again without fear of the problem returning.” The Shealy, Borgmeyer, study confirms this difference based on quantifiable results. 
 
So what do you do? Where do you go from here? Don’t just put a table into your office to make more money; focus on results, embrace the research. When looking to get into the decompression business, do your homework and make an educated decision.
 
Dr. Eric S. Kaplan, a former President COO of  a NASAQ traded public company, which included Nutrisystem, Currently he is CEO of Concierge Coaches, Inc., www.conciergecoaches.com,  a comprehensive coaching firm with a successful, documented history of assisting doctors create profitable practices nationwide, providing over 30 New Patient marketing Programs. Dr. Kaplan is a member of the adjunct faculty at Parker. Parker University now offers a National Certification course on spinal decompression. For more information on coaching or spinal decompression, call 1-561-626-3004.
 
Diabetes…a Gut Feeling
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Written by Mark R. Payne, DC   
Wednesday, 25 September 2013 04:39
H
ere’s a study from Spain published in February 2013 that should be of interest to a great many chiropractors. Although nutrition certainly isn’t my forte, occasionally an article comes along that I simply can’t ignore. Since a very large percentage of the profession engages in some level of nutritional advice/treatment, I hope this will be of value.
 
digestivesystemFollowing recent publication of a rat study that indicated differences in gut microbial concentrations at the time of type 1 diabetes onset, the authors designed a small human study to test their hypothesis that type 1 diabetes in humans could also be linked to specific microbes in the human gut.
 
This was a case-control study that compared 16 healthy children to 16 with type 1 diabetes.
 
Fecal bacteria composition was analyzed on all children.
 
When compared to healthy children, the diabetic subjects  showed significantly decreased quantity of Actinobacteria and Firmicutes strains. Additionally the quantity of Bacteroidetes organisms was significantly increased, thereby further altering the ratio between strains. 
 
At the genus level, Clostridium, Bacteroides, and Veillonella were all increased, while Lactobacillus, Bifidobacterium, Blautia coccoides/Eubacterium rectale and Prevotella were all decreased.
 
The number of Bifidobacterium and Lactobacillus correlated negatively with blood glucose levels (i.e., when bacterial levels were low, plasma glucose tended to be high).
 
The authors claim this is the first study to show “compositional changes in gut microbiota” associated with diabetes. 
 
A previous study by Giongo et al. observed that the Firmicutes to Bacteroidetes ratio was already changing during the first six months after birth before the development of type 1 diabetes. This previous study showed “successive decline in Firmicutes and an increase in Bacteroidetes number in the gut microbiome over time until the children became diabetic.”
 
Take Home: 
Type 1 diabetes appears to be associated with changes in the populations of gut microbes. The authors conclude: “The quantity of bacteria essential to maintain gut integrity was significantly lower in the children with diabetes than the healthy children. These findings could be useful for developing strategies to control the development of type 1 diabetes by modifying the gut microbiota.” 
 
Reviewer’s Comments:
On the downside, it’s a relatively small study and certainly doesn’t firmly establish causality in and of itself. On the upside, a causal relationship looks more likely when considering the previous study by Giongo et al. In practical terms, probiotic supplements generally are pretty safe. I probably ought to point out that I’m not in the business of selling probiotics, but it seems to me that a good probiotic with the appropriate microbes might provide a bit of insurance, especially for at risk babies. That’s my gut feeling, at least. 
 
Reviewer: 
Mark R. Payne, DC
 
Reference:
Gut microbiota in children with type 1 diabetes differs from that in healthy children: a case-control study Murri M, Leiva I, Gomez-Zumaquero JM, Tinahones FJ, Cardona F, Soriguer F, Queipo-Ortuño M. BMC Med 2013 Feb 21;11:46
 
Link to Full Text:
 
Dr. Mark R Payne, Phenix City, AL is Editor of ScienceInBrief.com, a scientific literature review for busy chiropractors. He is also President of Matlin Mfg Inc. a manufacturer of postural rehabilitation products since 1988. Subscription to ScienceInBrief.com is FREE to doctors of chiropractic and chiropractic students. Reviews of relevant scientific articles are emailed weekly to subscribers.
 
Posture and Pain in Children
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Written by Mark R. Payne, DC   
Sunday, 25 August 2013 20:39
I
t’s probably fair to say that most chiropractors treat children in their practices to one degree or another. A 2012 survey of European chiropractors reported that children under age 18 comprised slightly over 8% of the patient mix among more than 900 practices surveyed.1  That’s a significant number of kids and I suspect the numbers aren’t much different here in the US. But that’s not really the study I wanted to discuss this month. I mentioned that paper so I could tell you about another paper that I personally think is important.
 
childslouchingThis paper, a 2012 study from Spine, examined the relationship between posture and spinal pain in young people. The authors looked at 1,196 Flemish adolescents. The average age of the 639 male participants was 12.6 years; it was 10.6 years for the 557 females. The authors acknowledge that data relating posture to pain, particularly in young people, are “sparse.” As a profession, chiropractors historically have placed a great deal of emphasis on the relationship between spinal structure and spinal pain, although that emphasis has waned in recent decades. In spite of our profession’s history, a number of previous studies, several of which looked at the status of the spinal curves, have failed to show any clear correlation between posture and spinal pain. Other studies that focused more on regional or segmental misalignment have also failed to show a correlation between spinal structure and pain.  
 
This study was done a bit differently. The authors assessed the habitual standing posture of the children using digital “head to toe” photographs. The photos were then measured to assess the global alignment of the large body segments (head, trunk, and pelvis) relative to a vertical gravity line extending upward from the lateral malleolus. What they found should be of interest to our profession. It appears, at least in the study, that posture does indeed matter.

How we hold our bodies is intimately related to how our bodies move and function.

 
Global misalignment of the large body segments appeared to be associated with spinal pain. The authors suggest that “orientation of various body segments with respect to the gravity plumb line (i.e., anteroposterior translations of the head, trunk, and pelvis) may be paramount compared with the local spinopelvic characteristics with respect to the development of symptomatic IASP [idiopathic adolescent spinal pain].” There were some observed differences between sexes (results appear to be more applicable for boys than girls) and final conclusions are probably further down the road. As always, more research is needed.
 
However, this approach of looking at global postural alignment may have exciting possibilities for the chiropractic profession. Although early chiropractors embraced an admittedly flawed model (single segmental misalignment) to explain how and why our adjusting methods seemed to work, chiropractic in recent decades has poured much effort into embracing a more dynamic/functional approach to manipulative therapies. In doing so, we may have inadvertently developed a case of professional tunnel vision and failed to note the obvious—how we hold our bodies is intimately related to how our bodies move and function. 
 
Take Home:
Young people make up a significant percentage of patients treated by chiropractors and idiopathic adolescent spinal pain is a significant problem. Poor postural alignment of the large body segments, an easily observable phenomenon, appears to be associated with spinal pain in adolescents. The authors point out that by age 18 the prevalence of back pain in adolescents is approaching that of the general population. The authors also point out that spinal pain during adolescence may represent a risk factor for spinal pain/problems in adulthood as well. This article provides a useful reference for those practitioners already interested in a structural/postural approach to chiropractic care and perhaps food for thought for the rest of us.
 
Special thanks to Chiropractic Sciences Contributor Roger Coleman, DC of Othello, Washington for his recent review at ScienceInBrief.com.
 
Reference
  1. .Marchand AM. Chiropractic care of children from birth to adolescence and classification of reported conditions: an internet cross-sectional survey of 956 European chiropractors. J Manipulative Physiol Ther. 2012 Jun;35(5):372-80.
  2. Dolphens M, Cagnie B, Coorevits P, Vanderstraeten G, Cardon G, D’hooge R, Daneels L. Sagittal standing posture and its association with spinal pain: a school-based epidemiological study of 1196 Flemish adolescents before age at peak height velocity. Spine. 2012;37:1657-66.
Link to Abstract:
 
Dr. Mark R Payne, Phenix City, AL is Editor of ScienceInBrief.com, a scientific literature review for busy chiropractors. He is also President of Matlin Mfg Inc. a manufacturer of postural rehabilitation products since 1988. Subscription to ScienceInBrief.com is FREE to doctors of chiropractic and chiropractic students. Reviews of relevant scientific articles are emailed weekly to subscribers.


 
IME and Peer Review Tactics to Reach a Desired Conclusion
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Written by Mark Studin, D.C., F.A.S.B.E.(C), D.A.A.P.M., D.A.A.P.L.M.   
Sunday, 25 August 2013 19:30
A
42-year-old male presented to the doctor’s office six weeks ago with severe low back pain radiating into his left leg after a motor vehicle accident in which his stopped car was rear-ended by a truck traveling at a high speed. He was antalgic to the left and positive for compressive syndromes via orthopedic and neurological testing. He was immediately referred out for an MRI that revealed an extruded disc with mass effect on the thecal sac central and to the left at L4/5. The patient was referred out to a neurosurgeon who confirmed conservative chiropractic care was indicated for a period of eight weeks and then a follow-up evaluation should ensue with a neurosurgeon to determine if surgery might provide a solution.
 
chessboard2At the six-week interval, the patient received a letter from AllFarm Insurance Company stating that an IME has been ordered to determine the necessity of care. The patient showed up at the appointed time for the examination with a friend who joined him during the examination and handed the IME doctor a copy of the MRI on a disc and submitted for examination. The IME doctor spent a total of four or five minutes with the patient, which included the time he spent obtaining the history and doing a physical exam. He released the patient from the examination by walking out in front of the patient and never seeing him ambulate. Two weeks later, the patient and treating doctor received letters from the carrier stating that all future benefits were denied and three out of the six previous weeks’ benefits were denied as well. Upon request of the IME doctor’s report, the treating doctor and patient found the IME doctor stated the diagnosis as lumbar spine strain/sprain resolved.
 
This above scenario is a typical result that virtually every doctor has seen in his or her office multiple times over the course of our careers. 
 
As I have stated previously and continue to firmly believe, the IME and peer review systems are an integral part of the reimbursement system. These two components help create a check and balance to prevent overutilization and only allow necessary care to be rendered to those in need based upon the contractual obligation of the third-party payer. However, as I have also contended in the past, this system has been perverted for far too long by carriers, IME companies, and IME doctors who all too often ignore the facts of the case to reach a desired conclusion. In the “real world,” most treating doctors and trial lawyers have recently reported that that it has been “almost a decade” since they have seen what would be considered a fair defense examination. Personally, this past week, I reviewed a case where, for the first time in years, I had no argument with the defense examination, even though the IME doctor disagreed with me, because he did a thorough job.
 
IME and peer review doctors are entitled to their opinions and I have no issue with their opinions whether I agree or not, provided all the results are being ethically considered. That is the crux of the matter and the biggest issue facing the injured and treating doctors across the nation, and has been endemic for years where the third-party evaluator does not consider all test results in either his or her conclusion or the entire report in its totality. Part of the problem is that the carrier and third-party intermediary companies (IME companies) in possession of records do not forward those records to the IME or peer review doctors, and/or the third-party doctors themselves ignore the results in front of them.

Knowing the laws and regulations of your state gives you the leverage to level the playing field should you have the evidence that the third-party doctor, the IME company, or the carrier was in possession of all of the information and the IME doctor then chose to either not report it or consider it in the report.

 
Historically, in this process, doctors and patients have been both victims and willing accomplices by allowing these practices to go unchecked. Most, if not all, doctors do not realize the leverage the system offers us to level the playing field against improper or fraudulent IMEs. That leverage is found in the laws and regulations that guide and govern professional practices in every state and territory in the United States. There are laws that protect the insurance carriers from doctors who steal based upon deceit, fraud, and other illegal activities as defined by law, and the IME and peer review doctors, the IME companies, and insurance carriers have a similar set of rules and regulations to protect the insured and those delivering the care from the same.

The following are examples of three states, with the understanding that all 50 states have laws to protect the insured and providers against these egregious activities:

Based upon Georgia law governing chiropractic practice 43-9-12 (2): “Knowingly making misleading, deceptive, untrue or fraudulent representations in the practice of chiropractic or on any document connected therewith; or practiced fraud or deceit or intentionally made any false statement in obtaining a license to practice the licensed business or profession; or made a false statement or deceptive registration. The provisions of these rules applicable to a particular profession may define additional acts or omissions as unprofessional conduct and may establish exceptions to these general prohibitions ‘Willfully making or filing a false report.’”

New Jersey has a similar set of regulations and according to New Jersey regulation 13:44E-2.6 (b): “A non-attending chiropractor who performs a patient record review, which evaluates prior chiropractic care or the need for continuing care or the necessity for diagnostic testing, shall make a reasonable effort to obtain all records of the attending chiropractor relevant to the chiropractic care or condition before rendering an opinion…(h)…Violations of any of the provisions set forth in this section shall constitute professional misconduct.”

Michigan takes it a step further by making “willful improper” a felony. Michigan Penal Code 750.942a states: “A health care provider or other person, knowing that the information is misleading or inaccurate, shall not intentionally, willfully, or recklessly place or direct another to place in a patient’s medical record or chart misleading or inaccurate information regarding the diagnosis, treatment, or cause of a patient’s condition.” The law continues to state, “A health care provider who intentionally or willfully violates this subsection is guilty of a felony.”

Knowing the laws and regulations of your state gives you the leverage to level the playing field

Knowing the laws and regulations of your state gives you the leverage to level the playing field should you have the evidence that the third-party doctor, the IME company, or the carrier was in possession of all of the information and the IME doctor then chose to either not report it or consider it in the report. In all cases where there are improper reports based upon the facts you possess, it is incumbent upon you and your patients to report these doctors and companies to the authorities for infracting regulations or laws. Many things happen when you do not reply or respond to an improper report. Your patient is denied necessary care, you are denied fair reimbursement, and, equally important, your reputation is compromised as a doctor, and if it is a personal injury or worker’s compensation case, it is done so via public record.

When rebutting these reports should they not be overturned, you should put the carrier on notice that these apparent infractions will be reported to your state attorney general’s office and regardless of the disposition of this claim, you and your patient will file a complaint against the IME or peer review doctor’s license. The time has long passed where “please and thank you” rule the day. There are too many IME and peer review doctors literally making more than a million dollars because of their tactics to reach desired conclusions because they know it will lead to significantly more business for them. This is big business and because of our “historical non-willingness” to rebut these at the proper level, big business just keeps getting bigger at the expense of our patients and our practices.

 
The Importance of Bone Health, Structure and Function
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Written by Scott Heun, DC, CCSP   
Sunday, 25 August 2013 01:04
I
n 2000, an estimated 9 million new osteoporotic fractures occurred. Of these fractures, 1.4 million were vertebral and 1.6 million involved the hip. At least one in three women and one in five men over the age of 50 will suffer a hip fracture caused by weakened bone. At least one in five will die within the year following a hip fracture. By 2020 in the United States, it is estimated that more than 61 million women and men age 50 and older are affected by either osteoporosis or low bone mass.1 
 
tscorechartIncreased thoracic kyphosis is associated with osteoporosis and results in a reduced quality of life (QOL). It is also associated with alteration of postural balance, resulting in increased risk of falling. Falls in the geriatric population are associated with increased incidence of fracture.2  Among older adults (those 65 or older), falls are one of the leading causes of injury and death. They are also the most common cause of nonfatal injuries and hospital admissions for trauma. In 2010, 2.3 million nonfatal fall injuries among older adults were treated in emergency departments and more than 662,000 of these patients were hospitalized.3 
 
The trend in industrialized nations is toward a sedentary lifestyle as the workforce moves toward a service model and away from more physically demanding occupations. This recognized trend has been deemed a contributing factor in obesity, and is also related to reduced participation in weight-bearing activities. There is little doubt that these factors are an additional complication for the ageing population, and contribute to the micro- and macrostructural breakdown of a large number of people in society.
 
Determining the status of each patient’s postural mechanics is essential to understanding macrostructure. Inter- and intra-examiner reliability of visual postural assessment is good4,  however the addition of standing, weight-bearing radiographs represent an indispensible tool for this purpose. Additionally, there are a number of good digital posture assessment tools available that provide a solid external analysis of posture, biomechanics, structural integrity, and balance.
 
Further testing is strongly advised for patients who have significant postural distortions and/or exhibit signs of bone loss in plain radiographs, as well as patients that are at risk for osteoporosis based upon family history, age group, or metabolic or systemic challenges. The “gold standard” test for bone density is dual energy x-ray absorptiometry (DEXA). DEXA is a relatively low exposure of radiation and is commonly administered by a trained technician through referral. The unit produces two x-ray beams, each with different intensity levels.

The penetration level of each beam is read and recorded, and based on the difference between the two scores, the density of the bone tissue assessed is determined. 
 
DEXA scanning focuses on two areas: the hip and spine. Although osteoporosis is systemic, and variations of density exist from individual to individual, measurements of BMD at one site can be extrapolated to prognosticate for fracture risk at other common sites in the body.
 
The results of a DEXA scan are provided as a “T-score” and a “Z-Score”. T-score is a comparison/contrast of a patient’s bone density to that of a healthy, young adult person. A T-score of -2.5 or lower is defined clinically as osteoporosis. The lower the T-score, the greater the risk of fracture. A Z-score is the same reading as compared to a group adjusted for age, sex, race, height, and weight.
 
According to the World Health Organization, osteoporosis is defined based on the following bone density levels:
  • A T-score within 1 standard deviation (SD) (+1 or -1) of the young adult mean indicates normal bone density.
  • A T-score of 1 to 2.5 SD below the young adult mean (-1 to -2.5 SD) indicates low bone mass.
  • A T-score of 2.5 SD or more below the young adult mean (more than -2.5 SD) indicates the presence of osteoporosis.
  • In general, the risk for bone fracture doubles with every SD below normal. Thus, a person with a BMD of 1 SD below normal (T-score of -1) has twice the risk for bone fracture as a person with a normal BMD. A person with a T-score of -2 has four times the risk for bone fracture as a person with a normal BMD. When this information is known, people with a high risk for bone fracture can be treated with the goal of preventing future fractures. 
  • Severe osteoporosis is defined as having a bone density that is more than 2.5 SD below the young adult mean with one or more past fractures due to osteoporosis.
  • The Z-score is your BMD as compared to an age-matched norm. Z-scores are calculated in the same way, but the comparisons are made to someone of the same age, sex, race, height, and weight.5
In weighting the value of the T-score and Z-score, the T-score is most important. The fact is that the aging population has an ever-greater incidence of osteopenia and osteoporosis, and an ever-growing incidence of falls and the complications associated with these conditions. Therefore, in this author’s opinion, the control group used to derive the Z-score presents a less valuable measure of macro- and microstructural health.

According to the National Osteoporosis Foundation, women who are taking an osteoporosis medication should have a DEXA scan every two years.6 There is not, however, a firm consensus on this point, as in extreme cases, or very high-risk cases, more frequent testing is advised. Many insurance companies and HMOs resist testing patients until age 65. In light of the serious impact of this disease on patients, and the trend toward a more sedentary lifestyle in industrialized nations, testing should be done much earlier. A proactive approach could represent actual preventative healthcare. Furthermore, the initial radiographic screening done by most chiropractors is an important early detection tool to assess bone health and structural integrity.

Due to many factors in the healthcare marketplace of 2013, chiropractors are often the de facto family physician for many individuals, and represent a direct portal of entry into the healthcare system. Chiropractors should be ever mindful of the nature of each patient’s macro- and microstructure in order to deliver safe, superior care and management of each patient’s musculoskeletal system. In addition, chiropractors should fully evaluate the variety of clinical approaches to treating osteopenia, osteoporosis, and abnormal posture in order to insure the delivery of the highest standard of patient care.

There is broad consensus in the literature that weight-bearing activities produce healthier bone. The fact is that bone remodels to stress imposed (Wolf’s law). The interrelationship of these two natural processes has a profound impact upon the human frame. Gravity can be friend or foe, depending upon the loading of the skeleton. Gross alignment or malalignment of the skull, thorax, and pelvis have a profound impact upon the vertebral motor units, long bones, and the bones of the ankle and foot. Attention to postural alignment and, therefore, structural loading of the spine and articulated skeleton is essential to thorough patient care.

Sustained abnormal posture produces microstructural changes to the vertebrae, and eventually, alterations in the architecture of the spine. For example, the end stage of forward head posture and concomitant hyperkyphosis is an ever-worsening breakdown of the thoracic spine, often resulting in extreme distortion of the torso and a perpetual progression of forward head and torso weight bearing. Absent a walker, patients are unable to maintain upright posture. Further deterioration often leads to a fall, and the resulting grave consequences as described earlier, or life confined to a wheel chair. Enlisting gravitational force as a “friend” instead involves specific structured exercise, ergonomic considerations, and in instances of restricted spinal mobility, manipulative procedures to improve mobility and improve the overall weight-bearing posture.

The decision to address microstructural challenges as well as gross postural distortions or macrostructural dysfunction is one each practicing clinician must address.

The safest and most effective form of spinal postural loading for purposes of improving bone density consistent with normal spinal structure is that undertaken with an “extension bias.” 7 Extension exercises are far superior to: A) flexion exercise. B) combined flexion and extension exercise, and C) no exercise at all.8 Isometric muscle contraction performed in the end range of skeletal extension, such as in pressing or pulling motions against an immovable structure while incorporating a concomitant firing of the spinal extensors in an optimized global spinal posture,9 creates skeletal loading of the long bones by direct force production and, therefore, stimulation of bone growth. It also induces vertical vertebral loading via spinal extensor muscle contraction and reciprocal recruitment of all, secondary, and tertiary muscles active in stabilizing the spine and torso stimulated by the effort.

Exercise that is either of low intensity or does not involve skeletal loading, primarily or secondarily as described earlier, is largely ineffective in countering bone loss or improving bone density in postmenopausal individuals.10 In this author’s opinion, based upon experience, low-intensity muscular loading is also ineffective in altering global postural weight bearing and in improving core strength. In order to improve posture and optimize sagittal balance, optimized maximal loading of the motor units and related musculotendinous tissues must be consistently employed.

Eccentric exercise has many benefits over either concentric or isometric exercise. The primary benefit is the fact that the metabolic demand of eccentric exercise is less than other forms of training. Also, in light of the fact that muscles are from 1 to 1.5 times stronger in eccentric contraction than concentric contraction, the potential for safe maximum loading in the performance of eccentric loading is tremendous.

In approaching the patient with abnormal posture and, therefore, altered weight bearing, further complicated by muscular deconditioning, the physician must design long bone and skeletal stimulation loading sufficient to induce desired bone density increases, while safely loading the musculoskeletal system to minimize negative consequences.

One of the most advanced methods for safely loading the musculoskeletal system involves whole body vibration (WBV). There are a number of vendors that supply these products, PowerPlate® and WAVE® Exercise are two I am familiar with that provide a wealth of information on their websites about WBV training.

In some instances, highly supervised weight training using conventional equipment can be employed. However, the risk is high for injury and the learning curve for performing most exercises or maneuvers is demanding. Static/isometric loading in optimized biomechanical positions and incorporating coaching to insure maximum possible recruitment is advisable. Specific equipment to achieve desirable loading with a less demanding learning curve and reduced risk of injury is available from Performance Health Systems, Inc., which produces a commercial product known as bioDensity®.

The decision to address microstructural challenges as well as gross postural distortions or macrostructural dysfunction is one each practicing clinician must address. This author has witnessed the tremendous benefits of integrating this comprehensive approach in clinical practice and what it means to patient’s lives.

References:

1. International Osteoporosis Foundation 2011
2. Influence of Sagittal Balance and Physical Ability Associated with Exercise On Quality of Life in Middle Aged and Elderly People Arch Osteoporos, 2011 vol. 6 (1-2) pp 13-20
3. Hornbrook MC, Stevens VJ, Wingfield DJ, Hollis JF, Greenlick MR, Ory MG. Preventing falls among community–dwelling older persons: results from a randomized trial. The Gerontologist 1994:34(1):16–23.
4. “Inter-examinar Reliabilty of the Right-Handed Cartesian Orthogonal Coordinate System for Use of Listing Postural Distortions” Bradbury and McVeigh Logan College of Chiropractic- Senior Research 1999-Dec-10
5. World Health Organization 2012
6. National Osteoporosis Foundation 2012
7. BStrong4Life® Protocol 2009-2013 Scott J. Heun, DC, CCSP, Perry Cammisa, DC
8. Archives of Physical Medicine and Rehabilitation. 1984 Oct; 65(10):593-6.
9. J Manipulative Physiol Ther. 1996 Jul-Aug;19(6):398-405. A normal sagittal spinal configuration: a desirable clinical outcome. Harrison DD, Troyanovich SJ, Harrison DE, Janik TJ, Murphy DJ.

Eur Spine J. 2002 Jun;11(3):287-93. Epub 2001 Nov 1. How do anterior/posterior translations of the thoracic cage affect the sagittal lumbar spine, pelvic tilt, and thoracic kyphosis? Harrison DE, Cailliet R, Harrison DD, Janik TJ.

Eur Spine J. 2011 September; 20(Suppl 5): 699–703. Published online 2011 August 3. doi: 10.1007/s00586-011-1938-8 PMCID: PMC3175932

Sagittal imbalance cascade for simple degenerative spine and consequences: algorithm of decision for appropriate treatment J. C. Le Huec,corresponding author1 S. Charosky,2,4 C. Barrey,3 J. Rigal,1 and S. Aunoble1

10. Mayo Clin Proc. 1989 Jul; 64(7): 762-9.Efficacy of non-loading exercises in prevention of vertebral bone loss in postmenopausal women: a controlled trial. Sinaki M, Wahner HW, Offord KP, Hodgson SF.

Dr. Scott Heun is a practicing chiropractor in Napa, CA with over 30 years of clinical experience. He is also the co-founder of B•Strong4Life® www.bstrong4life.com a revolutionary company dedicated to improving core strength, balance and bone health using a proprietary system of analysis, training and patient management. In addition, he is also a sought after chiropractic advisor and mentor, specializing in patient-centered practice and doctor patient communication www.chiropracticementoring.com

Dr. Heun can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it
 
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