Having a sport and rehab facility demands great expertise and close attention to detail in treatment protocols.  In such settings, doctors often rely on objective findings of manual testing.  Nonetheless, given the explosive level of technology available today, it is ludicrous for any doctor to rely strictly on “manual findings.”  One of the greatest sources of objective findings available, to date, to all doctors but especially in rehab and sport facility settings is the use of diagnostic radiology.  Indeed, the information that can be gathered using diagnostic radiology is very impressive. 

What is the benefit of diagnostic radiology?
After a thorough physical examination has been done and the need for the X-rays has been established, X-rays are sent to a specialized company which uses highly technical equipment and techniques to produce computerized enhancement of the radiographic plain films.  One of the enhancements is called digital radiographic mensuration.  The X-rays are scanned, and multiple landmarks are selected and stored in a location separate from the image.  The numbered data, “landmarks,” are later used to reconstruct a variety of biomechanical relationships and measurements that are useful to the doctor and the patient.  The diagnostic analyses, as well as biomechanical data, are extracted from these plain film radiographs and are then displayed on high-resolution monitors using comparative standards and technical procedures.  These visuals of radiographic imaging are used objectively to analyze the biomechanical properties of the spine.  At least fifty-nine biomechanical analyses for diagnostic purposes can be performed on such instruments.  (See Table 1 to for a list of a few examples)
Using highly technical equipment and techniques produces computerized enhancement of the radiographic plain films, that can then be used to perform at least fifty-nine biomechanical analyses for diagnostic purposes. Here are some Examples:

• Atlas Skull Line
• Stress Line 
• Skull Line Baselines 
• Thoracic Apex                          
• Baseline Atlas                         
• Stenosis
• Spinal Length 
• Occiput Angle  
• Ferguson’s Angle 
• Sacrum Angle
• Penning’s Range of Motion 
• Thoracic Kyphosis  
• Jackson’s Angle 
• Lumbar Instability  
• Motion Segment Integrity 
• Vertebral Offset 
• George’s Line 
• Atlas/Axis Angle  
• Lumbar Gravity Line 
• Vertebral Body Rotation 
• Pelvic Rotation 
• Lumbar Lordosis  
• Cobb’s Angle 
• Spondylolisthesis

It becomes medically necessary for a sports and rehab facility to fully assess the degree of injury and its effect on the patient’s health and future well-being.  Reports obtained from digital analysis include impairment ratings, per the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment. 

Defining “disability”
American Medical Association Guides evaluate Medical Disability as well as Permanent Impairment.  The term disability has historically referred to a broad category of individuals with diverse limitations and the ability to meet social or occupational demands.  However, it is more accurate to refer to the specific activity or role the “disabled” individual is unable to perform.  Several organizations are moving away from the term disability and, instead, are referring to specific activity limitations to encourage an emphasis on the specific activities the individual can perform and to identify how the environment can be altered to enable the individual to perform the activities associated with various social or occupational roles.  Nonetheless, Guides to the Evaluation of Permanent Impairment defines disability as “an alteration of an individual’s capacity to meet personal, social, or occupational demands or statutory or regulatory requirements because of an impairment”.  (American Medical Association. Guides to the Evaluation of Permanent Impairment. 5th  ed. Chicago, Ill: American Medical Association; 1993)

What are the benefits to the patients?
We live in an age when patients are particular about their health care needs and are demanding that their doctors under- u u stand not only the need for specific treatment, but also the findings of the objective testing.
Using diagnostic radiology will bring the following benefits to the patient:

• Films read by a board certified radiologist 
• Photographic reproduction of the patient’s film images, printed with complete measurements and displayed next to comparatively normal images, should be shown to the patient to explain the findings and insure patient retention.  If the healthcare practitioner has expertise and is well acquainted with the individual’s activities and needs, then he or she must express an opinion about the presence or absence of the specific disability and how this will impact the patient’s daily activities.

Benefits to a Rehab Center
Rehab centers are often made up of exercise physiologists, body trainers, physical therapists (Pt’s), Pt aids, Pt assistants, chiropractic practitioners and others.  These sports and rehabilitation oriented practitioners, although very knowledgeable in assessing a patient’s diagnosis, can greatly benefit by the highly technical, yet diversified, information which is gathered from diagnostic radiology.
Because every patient’s injury or disease is different and every patient responds differently to treatment, the information obtained from the digital analysis of radiographic images can prove or disprove the necessity for further treatment.  This information is then used to customize the most effective treatment protocol for the patient’s injury and/or disease and may cut down on or eliminate unnecessary treatment.
Biomechanical measurements are vital and are critical to the appropriate diagnosis analysis, treatment, and prognosis of the sports injury patient in a clinical environment.  With accurate measurements, a fundamental base line can be determined and can further be explored for an accurate and reliable assessment of the patient’s condition and outcome potential. 
There is also a financial benefit, since the referring doctor gets reimbursed u  u for the professional confirmatory component above and beyond the X-ray coding.

Below are a few samples of indications for diagnostic radiology.

• Sprains/ Strains
• Trauma
• Motor vehicular accidents
• Sports induced injuries
• Work related injuries

On a side note, and as a fundamental basis, DC’s often deal with the dynamics of the musculoskeletal system, whether or not the clinical neurological components exist. 
Simply stated, the science of chiropractic is founded on the premise that adequate nerve supply is of prime importance in regulating body function.  Hence, radiographic measurements obtained from diagnostic radiology and utilized in a rehab facility can:

• Increase Personal Injury referral
• Enhance reputation
• Increase patient compliance
• Support insurance claims with scientific medical proof
• Provide attorneys with professional documentation
• Increase collections 

How to implement diagnostic radiology

1. Determine need for X-rays.
2. Take flexion/extension study of cervical or lumbar area (or both, if needed).
3. Referring doctor reads films and gives brief impression to patient.
4. Films are sent for digitization and for impression by Board Certified Radiologist (licensed in the state where patient is being treated).
5. Analysis is done and returned to referring doctor.
6. Treatment protocol is established and information is given over to patient.
7. Service is billed for consultation to proper carrier.

In conclusion, other procedures (i.e., NCV, SSEP, MRI, US, Electromyography, etc.) should always be correlated to clinical history, physical examination and radiographic findings for a more comprehensive and complete picture of the patient’s status.  Digitized radiology has shown reliability, accuracy and benefit paralleled to this time in history with respect to spinal radiographic analysis.  In determining need for treatment, type of treatment to be administered, and/or monitoring of changes of treatment resulting from re-injury, for prognosis, digitized analysis for radiology is an effective outcome assessment device and methodology for chiropractic services in a rehab facility.

Aadam Quraishi, MD, was a clinical instructor at New York University Medical Center.  He is board certified in radi-ology and has additional fellowship trained qualifications.  He has seventeen years of medical practice experience.
Dr. Quraishi specializes in Vascular and Interventional Radiology MRI (Neuro and Musculosketal), MRA Mammography, Breast Localization, Nuclear Medicine CT and Ultrasound.  Dr. Quraishi has board certification in Diagnostic Radiology, and can be contacted at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .  For more information and/or sample reports, go to www.aboutpdi.com.

About 83 million people in the U.S. (42% of the adult population) used at least one alternative therapy in 1997.  Usage among those 35-40-years-old is even higher, at 50%.

The estimated number of visits in 1997 to providers of “unconventional therapy”  (629 million) was greater than the number of visits to all primary care medical doctors nationwide (386 million).
Americans spent $21 billion out-of-pocket on visits to alternative practitioners in 1997 (an increase of 45% over 1990’s total).  This does not include money spent on retail products, such as herbal products ($5.1 billion), books, classes and equipment ($4.7 billion).  By comparison, out-of-pocket expenditures for physician visits were $29.3 billion and for hospitalizations were $9.1 billion.

We have to ask why 42.1 percent of U.S. citizens surveyed used at least one of sixteen alternative medicine practitioners, increasing from 427 million in 1990 to 629 million in 1997, exceeding the total visits to primary care physicians.  What is of greater interest is that these statistics have continued to increase—by 3.6% between the years of 2001 and 2002. 

None of these statistics, however, come close to the billions Americans spend on exercise and fitness.  Over 50% of the American population is overweight and the number is growing.  What does this all mean for the primary healthcare provider such as a DC?  The DC, basically, has to be prepared to diversify his/her services and, most of all, create a center where exercise and rehabilitative therapy are key components.
DC’s have always looked for ways to increase their income, often by learning new techniques or buying some expensive piece of diagnostic equipment.  While these can be valuable investments, they are not as effective as knowing how to establish, manage and/or promote a rehab center.

Following are the basic protocols, which have to be put into place to establish a rehab center. (See Table 1).

Table 1. basic protocols to establish a rehab center
1. Necessary Education:  Proficiency in sports medicine.
2. Professional Staff:  Exercise physiologist, physical therapist, physical therapist aide, and/or assistant, fitness trainer, massage therapist.
3. Equipment: Minimum equipment necessary is a full body station, treadmill, enlarged physical therapy table, various weights, stationary bike, exercise mats.  Miscellaneous:  towels, theraband, cold packs, etc.
Approximate initial cost of total equipment, between $10,000 to $15,000
Certification is a must for all professionals
Ideal size room, 800 sq. ft.

Table 2. Most Common Scenario Used in Rehab Facility
1. Doctor initial exam
2. X-Ray/ancillary services
3. Treatment protocol established and started
4. Diagnostic testing
5. Rehab with PT (4 weeks)
6. Re-exam to update or change diagnosis
7. Rehab with PT (4-8 weeks)
8. Discharge

Table 3. 10 Steps to Opening Date
1. Plan out (draw out) rehab room space
2. Interview and hire professional staff
3. Design marketing plan (newspaper ads, coupons, flyers, etc.) and allocate marketing budget ($3,000 to $5,000)
4. Purchase equipment (ask accountant if leasing is better option)
5. Understand billing codes and implement rehab form (See Table 4)
6. Create appointment script for front desk
7. Train office staff
8. Send letter to all local businesses
9. Send announcement letter to all active patients
10.Have grand opening day (balloons, prizes, music…)

Expected Reimbursement in Rehab Exercise Facility
The above scenario is by far the most practical flow that will allow the highest reimbursement.  It is important to take into consideration that insurance companies do not approve “medical maintenance care”.  Insurance companies will pay for treatment, but not for exercise physiology and/or rehabilitative medicine when used to enhance a patient’s stamina or endurance.  Insurance companies are interested in treating patients and rehabilitating them, given serious practice medical diagnosis.

Table 4. reimbursements for rehab patients
Total reimbursements for rehab patients vary between $4,500 to $6,500. CPT codes most often used are as follows:
97535   Activities of Daily Living
97112   Neuromuscular Re-education of movement, balance, coordination, kinesthetic sense, Posture, and/or proprioception for sitting and/or standing activities
97110   Therapeutic procedure, each  15 min., therapeutic exercise to develop strength and endurance, range of motion and flexibility.
97530   Therapeutic activities, direct patient contact by the provider, each 15 min.
97799   Unlisted Physical Medicine/Rehab service or procedure
97139   Unlisted Therapeutic Procedure (specify)
97150   Therapeutic procedure(s), group (2 or more individuals)
97750   Physical Performance Test or Measurement w/report
97504   Orthotic(s) fitting and training, upper and lower extremities, each 15 min.
97520   Prosthetic Training, each 15 min.
97140   Manual Therapy techniques (Manual Traction), each 15 min.
97124   Massage Therapy, including effleurage, petrissage, and/or tapotement
97113   Aquatic Therapy with therapeutic exercises
97537   Community/Work Reintegration Training, direct contact, each 15 min.
97542   Wheelchair Management/Propulsion Training, each 15 min.
97703   Checkout for orthotic/prosthetic use established patient, each 15 min.
97545   Work Hardening/Conditioning (initial 2 hrs.)
97546   Each additional hour (list separately in addition to code for primary procedure).  (Use 97546 in conjunction with code 97545)
97116   Gait Training
95833   Total Evaluation of Body w/o Hands
95834   Total Evaluation of body w/ Hands
95851   ROM Measure w/Report, each extremity
95852   Hand w/ or w/o Comparison to Normal Side

Objective Testing That Can Be Used to Support Medical Necessity and Enhance Medical Records
1. X-Rays
2. Digitized Radiographic Mensurations
3. MRI
4. Neurological Diagnostic Testing

General Discussion
Overall, a rehabilitation center is a great addition for any practitioner.  Using diversified healthcare, the doctor has the ability to promote the best treatment protocol available.  The core problem in healthcare today lies in the fact that there are currently not significant entities that can provide quality care at sufficiently low prices on a large enough scale to service the overwhelming needs of the population.
By creating a rehab sport center, a clinic will provide a viable solution to the healthcare crisis, by integrating the skills of the chiropractor and various other healthcare practitioners, such as exercise physiologist, physical therapist, etc., leading to the development of a profitable venture.  This, by all means, is the wave of the future.

Dr. Daniel H. Dahan owned and operated one of the most successful clinics in Southern California.  As previous chairman of the West Coast Medical Advisory Board and writer/editor for the Sun’s Weekly Health Column, Dr. Dahan, the President of Practice Perfect, developed a successful management and consulting health care system for doctors throughout the United States.  His seminars are rated among the best and most proliferate lectures in the country.  Dr. Dahan has taught over 4700 doctors and integrated 800+ offices in 45 states.  He can be contacted at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .  For more information, go to www.dahan.com.