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Perspective
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Perspective
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Written by Jay Kennedy, D.C.
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Saturday, 28 January 2012 05:51 |
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W hat is the minimal time per session for successful traction/decompression? Do we need to deliver 15-plus minutes of mechanical traction to have a clinically important outcome…could we instead use just 1-3 minutes and have a similar clinical result?
 Over the last sixty years the application of traction (to create decompression) has been perceived as a time-dependant therapy, i.e. the minimal effective dose tends to be seen as durational, or time-dependant. Like manipulation, massage and other passive interventions, several sessions (of whatever duration used) are probably necessary to be most effective and most studies suggest from 3-12 sessions. However, how long those sessions need to be is perhaps open to debate and this article is simply a discussion of that possibility. Few if any research studies have undertaken a minimum-dose control.
Interestingly, the CPT have never imposed a time frame to traction application. 97012, unlike every other modality traction, has no minimal time. If it lasts twelve hours or twelve seconds it’s the same price. And the reimbursement hovers around $12-16.00 nationally, substantial for two minutes, paltry at thirty.
When we examine the research of traction comparisons of session-duration, we find it has never been undertaken with any sense of precision or focus. With the myriad of disagreements it appears that everyone tends to be in agreement that traction must be done over a relatively extended time frame, at least 20 minutes (often up to 45 minutes). Initially “hospital traction” was done for days or weeks at a time; however, that was the era of seven days of post partum bed rest as well. In a 1996 study by Shealy et al., albeit biased on the nascent DRS system (which eventually spawned the infamous DRX9000), they conclude: “sessions less than 45 minutes tended to give inconsistent results.” Having treated hundreds of patients on a DRS I found that suggestion dubious. Quite the contrary, as patients approached 45-minute sessions (typically at 50% bodyweight plus 10-20 pounds) iatrogenic pain and dysfunction followed almost linearly. Often, sessions would need to be skipped due to an increase of pain.
It is no coincidence that the more expensive the decompression system the longer the manufacturer suggested the sessions last. Leasing a $50,000-125,000.00 system required a defined patient management solution: high patient cost and elongated sessions.
Recently published trials tend to follow a “new” standard approach of approximately 10-15 minutes (the observation that 45 minutes was a necessity was not compelling to those actually using the units). An ongoing University of Colorado study involving 140 patients is also following these shorter parameters. This in my estimation is a good thing; as the old saying goes: “Tradition is what you rely on when time, money and new ideas are unavailable.” Anyone having suffered through a HNP or similar disc-related pain can attest that the traction cure can sometimes be worse than the disease. Many times when trying to arise after having been treated for 30 minutes on either our VAX-D or DRS I questioned the wisdom of lying for that long. I ignored the suggestion in those early years from many patients that less would be preferred (I refused to lose faith in the non-clinicians who sold me the magic machine and admonished me to stick with the program).
 When we examine the how and why of axial traction we are faced with several ineffable physiological and anatomical considerations. Why can’t the disc react to unloading in just 1-3 minutes with a substantive, clinically relevant benefit? Since we have no definitive answers we’re left with speculation (and future research), but clinical experience can give us some insight. Presently clinicians practicing the Kennedy Technique have been observing patient responses to very short duration sessions and the preliminary results are not disappointing (unless you really love keeping patients on your table).
What can’t be ignored is the fact that many traction studies often show little real benefit anyway, and often show more negative reactions than other modalities. Clearly too much force and too much time could be the culprits. As to the pain-gate relief achieved with any joint ‘motion’ therapy the durational component may not be ultimately important.
Anatomically, decompression is osmosis, i.e. fluid moving from high pressure to low pressure through a semi-permeable membrane. Changes in gravitational stress alter fluid inflow, assuming the proteoglycans matrix of the nucleus is intact (not degenerative). Any recumbent posture begins the process (both hyper-extension and flexion decompress the disc and restore height).
The process is potentially expedited dramatically with the addition of (dis)traction. Flexion tends to raise intradiscal pressure, linear distraction reduces it. Less forced flexion and more distraction leads to the most mechanically feasible means of rapid reduction of IDP. However, a decreased IDP then leads to an increased osmosis and fluid in-flow pressure, especially after arising.
This begs the question: Where does the fluid diffused via osmosis go once it has entered the nucleus? Doesn’t it then in fact act as an annular-distender, pressurizing the damage zone and increasing pain when upright? It would seem the negative IDP of the initial few traction pulls would achieve this effect, with further pulls possibly being superfluous.
This is the confusion of traction. Wouldn’t it be more reasonable to distract the spine once or twice (for 45-60 seconds) and release, then arise? We speculate that collagenazation and movement of nutrients occurs during decompression (and this is likely true). What actually happens internal in the disc is only speculative. Bogduk has maintained that any elongation is lost within 20 minutes after arising and thus the effect from traction must be a “phasic phenomena”, i.e. momentary and not from any resultant effect post (though the tissues and the CNS may continue to react over time, enhancing the initial benefit as well).
The relevant clinical question is whether these effects occur immediately and need not require redundant application over 10-20 minutes. I’ll keep you posted as to any new findings, but as for now we suggest (like the SAID principal): Use the lowest time/force necessary to achieve an effect (“first do no harm”), further imposition of time and force may be unnecessary or possibly, in some cases, detrimental.
References
- Adams, M., Bogduk, N., Burton, K., & Dolan, P. (2006). The Biomechanics of Back Pain. 2nd ed. Edinburgh: Churchill Livingstone. p. 177-194.
- Fritz, J.M., Thackeray, A., Childs, J.D., Brennan, J.P. (2010). A randomized clinical trial of the effectiveness of mechanical traction for sub-groups of patients with low back pain: study methods and rationale. BMC Musculoskeletal Disorders, 11, p. 81.
- Shealy, C.N., & Leroy, P.L. (1998). New concepts in back pain management: Decompression, reduction and stabilization. Pain Management A Practical Guide for Clinicians, Vol. 1, Fifth Edition. St. Lucie Press: Boca Raton, FL.
Kennedy is a 1987 graduate of Palmer Chiropractic College and maintains a full time practice in western Pennsylvaina. He is the principal developer of the Kennedy Decompression Technique. Dr. Kennedy teaches his non-machine specific technique to practitioners who want to learn clinical expertise required to apply this increasingly mainstream therapy.
Kennedy Decompression Technique Seminars are approved for CE through various Chiropractic Colleges. The author can be contacted @
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Perspective
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Written by Kirk Lee, DC
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Saturday, 28 January 2012 04:30 |
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W hen you developed your yearly marketing program, you probably thought about how to attract more children or geriatric patients to your office. Have you ever considered trying to attract more athletes, especially runners? There is a large, growing population of runners that could use your expertise and care. According to Running USA’s “State of the Sport” report, from 2008 to 2009 the running population increased 18 percent to more than an estimated 35 million people. There was also a 15 percent increase in trail runners (almost 5 million people). While the overall sports industry’s growth declined or remained flat in 2009, retail sales dollars of the running/jogging category of footwear were up 5 percent (to $2.3 billion). (1)
 We are great at spreading the word about chiropractic: about how healthy eating habits, regular exercise and chiropractic adjustments will help you live a healthy lifestyle. We are great at educating our patients about how subluxation complexes can lead to degeneration, restricted ranges of motion and pain, just to name a few. It is second nature to educate the patient that neurologically it is “above, down and inside out,” and biomechanically it is from the ground up. That is simple anatomy, physiology and biomechanics. But what if a runner asks you how asymmetrical biomechanics of her gait cycle can cause symptoms of low back pain, mid back pain, neck pain, plantar fascitis, chondromalasia, iliotibial band syndrome, tibial stress syndrome or greater trochanteric bursitis? Or better yet, if she has no signs or symptoms, could you tell her why she needs chiropractic care?
Let’s consider developing a wellness-based practice and the time it takes to educate a patient on the importance of wellness. Who do you think is easier to educate and take hold of the principle: the couch potato, whose life revolves around going to work, eating and watching television, or the runner who eats healthy and exercises regularly? I think the answer is quite clear – THE RUNNER. Want to attract excellent wellness patients? Attract those runners!
Case Study
Mary Jane is a 38-year-old female who has changed from what she calls the “boring runs on pavement” to the unlevel, changing of surface thrill of the trails. She previously notes a history of mild tibial stress syndromes, but changing of shoes and more stretching has helped. Since switching to trail running, she has noticed an increase in her tibial stress syndrome. She again has tried several types of shoes, more stretching, and self medications with the thought process that it will go away. In addition, she gives mention to several falls from tripping over tree roots, but nothing that caused her to discontinue her running.
Or better yet, if she has no signs or symptoms, could you tell her why she needs chiropractic care?
Orthopaedic and neurological exams showed no significant findings. Functional examination did note decreased strength of the abductor muscles on the left. Gait appeared normal with symmetrical heel-to-toe transition. Radiographs demonstrated mild lumbar degenerative changes with mild axial rotation in the lumbars. A-P pelvic view shows a left leg insufficiency of 12mm at the iliac crest and 15mm at the femoral heads. Foot scan shows asymmetry or an imbalance of the three arches. Her Pronation/Stability Index™ number is 110, indicating moderate pronation. Body assessment screen indicates Mary Jane’s left foot as 57 percent, while her right foot indicates 43 percent. These findings are also supported by the left leg insufficiency noted on the A-P pelvic film, indicating more weight bearing on the left leg.
Since Mary Jane is a runner, we performed a video gait analysis that included walking and running. Findings from the gait analysis showed a decreased stride on the left leg compared to the right. The video analysis also pointed out excessive pronation on midstance of the gait cycle, which was more pronounced on the left. All findings are consistent with previous ones noted.
Comparing all our clinical findings, the recommendations for Mary Jane included:
- Stabilizing orthotics to create symmetry and balance of the foot and the rest of the kinetic chain.
- Rehabilitation exercises to strengthen her core with special focus on the weak abductors.
- Soft tissue techniques to help reduce pain in the anterior and posterior compartments’ musculature (tibial stress syndrome).
- Chiropractic manipulative therapy to reduce subluxation complexes and restore joint integrity.
Runners are a growing section of the population that could benefit from your care. They can turn to you for treatment when they are injured, or they could just be looking for help to stay healthy and fit. How do you find more runners? Contact your local running clubs and do a lecture on proper gait biomechanics. Explain how asymmetry of the normal movement patterns of the gait cycle lead to overuse injuries, resulting in subluxation complexes and the other common injuries that are experienced by runners. Reaching out to your community to help runners is one more way that you can help serve others with chiropractic.
Reference:
- Running USA: “State Of The Sport 2009.” Published: Jul 15, 2009. www.running.competitor.com/2009/07/news/running-usas-state-of-the-sport-2009_3711.
A 1980 graduate of Palmer College of Chiropractic, Dr. Kirk Lee is a member of the Palmer College of Chiropractic Post Graduate Faculty and Parker College of Chiropractic Post Graduate Faculty. He has lectured nationwide on sports injuries and the adolescent athlete, and currently practices in Albion, Michigan.
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Perspective
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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.
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Wednesday, 26 October 2011 22:14 |
F oreman and Stahl wrote in Chiropractic and Osteopathy in 2010 that, due to a myriad of reasons, the 10 year attrition rate of chiropractic in California rose from 10% for graduates licensed in 1970 to 20-25% for those licensed between 1992 and 1998. In New York, the number of new chiropractic license applications are down approximately 20% over the last 5 years compared to a similar, prior time frame, according to the former Legal Counsel to the New York State Higher Education Committee to the New York State Senate.
 These statistics mean there are less chiropractors practicing in both of these states, and as a result the Cleveland Chiropractic College has closed its California division. The question that remains is how do we reverse this trend? Recently, in a conversation with a chiropractic college administrator, I heard that if the leadership in our profession was more pro-active and we had read the signs 20 years ago, chiropractic would be in a better place. I agree.
I am one of those leaders who, 20 years ago, splintered the profession in New York by helping create a new (second) organization in the state. The end result was abject failure in every legislative initiative that both organizations attempted to pass. For a period of time, there were three organizations in New York and we all failed legislatively. Over the years, we thought the enemies were part of the medical society, businessmen's associations and unions. The truth was we were the true enemies. We were all fighting so hard for our piece of the "turf" that we neutralized each other and got nothing done, but spent a lot of hard-earned money and supported a lot of legislative campaigns; in retrospect a failed strategy.
The legislators, lobbyists and administrators of both organizations laughed all the way to the bank because one thing we were good at was creating two and three jobs to accomplish one task which was paid for by our hard-earned dues in difficult economic times. Today, those two organizations, the New York State Chiropractic Association and the New York Chiropractic Council, have promised their members that there will be a dissolution of the two organizations with one unified organization in their place, similar to the successful Michigan merger. Unfortunately, it is now almost 4 years later and for reasons that do not matter there are still two viable active organizations and that is unacceptable and shortsighted, a perfect example of the poor leadership cited by the chiropractic school administrator previously mentioned.
Being just one doctor in a large state gives me but one voice and with that voice I am putting these organizations on notice. If by January 1, 2012 they haven't created one organization, I will send e-mails and letters to every doctor in the State of New York urging them to quit both organizations. Why not? Without a unified profession in New York, doctors of chiropractic will simply be getting more of the same, NOTHING. Perhaps this is because of personal agendas of those that provide the leadership. Conversely, should the leaders put their personal agendas aside, I will vigorously work on getting every doctor of chiropractic to join the one state organization because that is the solution in New York, which is also is a microcosm of the national picture.
A group of "well meaning" but misguided doctors in Wisconsin is currently considering the creation of a new, second organization because of leadership issues in the current organization. These doctors need to realize that Wisconsin needs clearer leadership that will meet the needs of all DCs in Wisconsin and not create division. Look at both the successful Michigan model and the current failure model of New York for the end result of multiple organizations and learn from others’ mistakes. The best plan of action is to infiltrate the current organization and fix whatever needs to be fixed, as the end result is to protect the DCs and afford every citizen in Wisconsin the right to see a chiropractor.
The formula is simple and I have said it before. We need one organization in our nation with 50 chapters and if you don't like the direction of that one administration, fix it from the inside. Years ago, many republicans did not like President Carter. Did they start a new republic? No. They worked hard and got him voted out of office. More recently, the democrats did not like the direction that President Bush took the country in. Did they start a new government? No. They worked hard and got President Obama elected. The message is simple; it is called balance of power and requires very smart people working within the system to fix the issues. REFERENCE:
- Foreman, S. M., & Stahl, M. J. (2010). The attrition rate of licensed chiropractors in California: An exploratory ecological investigation of time-trend data. Chiropractic & Osteopathy, 18(24), Retrieved from http://chiromt.com/content/pdf/1746-1340-18-24.pdf
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Perspective
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Written by Dr. Ray Foxworth
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Tuesday, 23 August 2011 20:04 |
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A simple true or false would be nice. Unfortunately, it depends on who you ask, what state you are in, if the patient is federally insured, AND their particular circumstances. So much for straight answers to a simple question!
When consultants do answer questions about discounting , it is usually followed by “consult with your health care attorney before offering any type of discounts”. This would be great advice , except most of us do not have a health care attorney. Others will tell you discounting is perfectly legal, as long as it is done consistently and in accordance with your written compliance program. More great advice, but the reality is many of us still haven't put a full compliance plan in place.
So who cares if the answer is True or False?
What’s all the fuss about discounting anyway? Can’t you charge what you want to whomever you want? Can’t you just down code your adjustments, exams or X-rays to save a patient some money? What’s the big deal in charging more for PI, Workers Comp and insurance patients than you do for cash? All you are doing is trying to help a patient right? It’s no big deal…right?
WRONG!
 In the days before insurance, third party reimbursement, state and federal payers, things were simpler. When someone else is paying part or all of the costs for health care, especially the government, rules change and regulations apply. This is when discounting the wrong way can cost you. It’s called doing the right thing the wrong way.
You may be trying to help an uninsured or underinsured patient by offering discounts, but many doctors end up putting themselves at risk in the process.
Dual fees schedules, (charging more to insurance companies than you do to your cash patients), improper time of service discounts, (reductions that are really MORE than a reasonable bookkeeping reduction), are illegal in most states . Offering discounts that do not fall into one of Medicare’s safe harbors can cause an inducement and is absolutely a violation of federal regulations in EVERY state, subject to a $10,000 fine PER OCCURRENCE!
Violation of state and federal regulations against inducements or triggering anti-kickback statutes can lead to serious fines and career ending penalties as well.
So what is the right answer to the True or False question?
Discounting your fees CAN be illegal, if you do it the wrong way! Keep reading and find out how to offer discounts the RIGHT way, in every state and for any patient group.
Follow the rules.
1. Document correctly. The rules in this area are quite clear and there are many resources and guidelines to follow.
2. Code correctly. Again, follow the rules. Do not up code for more reimbursement when insurance is available and do not down code to reflect lower charges as a means to offer discounts. It is just as improper and illegal as up coding.
3. Discount correctly. That is a new one for most doctors.
Here is how you offer discounts the RIGHT way. Hire a health care attorney if you’d like, put your compliance plan in place…AND, if you don’t do anything else, consider joining, and encourage your patients to join a Discount Medical Plan Organization (DMPO). DMPO’s are regulated by the Department of Insurance in most states and have been around for years.
Why a DMPO? Simple. These plans use the contract model similar to what you use now, which allow you to contract with multiple insurance companies for different rates on the same codes without it being a “dual fee schedule”. Using a DMPO, you can still bill your UCR fees and have the protection of a “contract” that allows you to offer network-based discounts to your cash and underinsured patients. Most all patients are familiar with “buying clubs” such as Sam’s Club and they are familiar with networks. Experience shows they do not hesitate to join these network plans to save money!
Using a DMPO really is one of the most logical, legal, and ethical ways to allow you to accept a lower fee than your normal UCR clinic fees. It helps you help your patient, and it does not put you at risk! A good cash discount plan solves so many of the potential problems for you and really helps the patient…the RIGHT way!
Article submitted by ChiroHealthUSA.
Dr. Ray Foxworth is a certified Medical Compliance Specialist and is President of ChiroHealthUSA.
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Perspective
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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.
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Tuesday, 19 July 2011 20:22 |
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Where is the research to explain subluxation?
Where is the research to explain chiropractic? and...
scoliosis?
pediatric care?
asthma?
colic?
infertility?
otitis media?
etc....
 The answer...IT DOESN'T EXIST! There is supportive research about chiropractic and musculoskeletal conditions and that is a very, very, very GOOD START!
When you do not have the supporting research, you leave yourself and the entire chiropractic profession exposed to negative legal sequella. The following (which was obtained from http://vertebralsubluxation. mccoypress.net) happened to the RMIT Chiropractic Paediatric Clinic in Australia in 2010, with the bulk of the information used against them coming directly from their Web site.
"A 'Request to shut down RMIT Chiropractic Paediatric Clinic for teaching disproven treatments that target pregnant women, babies, infants and children' has been filed with the Australian Minister for Health and Aging. Ms. Loretta Marron, the author of this report, claims that the RMIT Chiropractic Paediatric clinic is 'teaching inappropriate, potentially dangerous, techniques that target pregnant women, babies, infants and children...[who] are particularly vulnerable groups, easily exploited by chiropractors.'”
Citing a lack of appropriate evidence for chiropractic treatment of these population groups, she requests that the RMIT clinic be shut down until further evidence can be produced. Ms. Marron continues on with a request that other institutions, such as Murdoch and Macquarie, also be investigated for similar actions.
The author also suggests that a 're-education campaign be urgently initiated to provide information to both consumers and chiropractors as to what they can or cannot claim, based on the balance of evidence-based medicine.' The basis of her claims refer to expert testimony such as that of Dr. Simon Singh and several medical doctors, and the United Kingdom General Chiropractic Council's May 2010 Guidance on the Vertebral Subluxation Complex. Ms. Marron also cites claims on chiropractic practitioner websites and calls on the Council on Chiropractic Education Australia (CCEA) to reassess competency standards for chiropractors...".
While the article goes on to explain how unjust the claim and suit is, the fact is that there is a law suit against not just an individual or individual practice, but against an entire profession. This suit will be able to create precedent utilizing the courts to further define the scope of chiropractic within the reach of the courts and will be just the beginning.
It doesn't matter if you believe in adjusting, manipulation, subluxation care, structural care or adjunctive therapy. All of the above is chiropractic. You don't have to believe me; read the scope of practice for chiropractic in the entire 50 states of our country and you will find provisions for treating patients within those scopes that account for everything in the beginning of this paragraph.
The nonsense of abandoning the language of adjusting in order to give away what makes chiropractic unique is so self-serving. No one cares whether we "adjust" or "manipulate" them other than ourselves. It is inbreeding at its worst. On the other hand, if you do not teach and practice the correction of nerve interference using the adjustment/manipulation, you are creating a more sophisticated class of physical therapists or physician assistants, if you believe adding prescriptive rights is the solution in the absence of correcting the nerve interference at the spinal level.
Whether you are on the far left or far right of chiropractic, please stop shooting the rest of us in the feet. The public, the referral sources and the legislators really don't care what we call what we do; they only want the proof that what we do works. We have given them the rhetoric for 116 years with a smattering of scientific evidence to back it up. In Australia, for the issue to go away, all it would take is a peer reviewed scientific piece of literature to be put on the front cover of every newspaper with a headline that reads, "Chiropractic Works for Children." Quite a change of perspective and that slight change is the difference between being "king of the hill" and not having a hill.
Stop being defensive and fighting for what your individual dogmatic beliefs are and fight for chiropractic and all chiropractors because, no matter your beliefs, we are all chiropractors whether on the left, center or the middle. Support the only avenue to bringing all of chiropractic to where everyone wants it, via research. That is the only way chiropractic will survive. Today they are looking to take pediatric care away; next week, it could be scoliosis care and on and on until we have nothing left, but to be glorified physical therapists or extinct as a profession. The choice is yours.
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