Special Feature

Personal Injury Collections by State: 2011 vs. 2013
Special Feature
Written by Mark Studin, D.C., F.A.S.B.E.(C), D.A.A.P.M., D.A.A.P.L.M.   
Thursday, 25 July 2013 18:09
Comparison of Collections vs. Cost of Living Analysis

n February of 2011, I wrote in The American Chiropractor magazine, “Why is a life in Tennessee, South Dakota, and Texas worth more than a life in Hawaii and New York?” There is really no reason other than insurance companies and state politicians allow it to be. We are a country of laws and regulations, and these laws dictate the marketplace and reimbursements for doctors’ services. In most states, it is based upon the usual and customary fees of the doctors and the carriers paying a percentage of those fees. However, in states like New York, the state sets the doctor’s fees and they are driven by politics at their ugliest.
usamapThe collections listed in the following table depict what fees chiropractors collected as of May 2013 on a per-visit basis for a typical treatment versus fees collected in February 2011. They are rated against the cost of living for each state in comparison to other states. The dollar amounts exclude examinations, x-rays, supports, and any other ancillary services or testing.  
These numbers of reporting doctors do not reflect a large enough sample size to reflect the average. However, the numbers do reflect accurate amounts that can be collected. I choose to publish the highest amount reported by doctors per state. If a carrier will pay a doctor for one visit using the parameters above, then that is the potential for collections in that state. In some states, the highest number was not available, so the amount cannot be lower than reported.
As I established in my article in 2011, cost of living is not an indicator for reimbursement in personal injury as one would logically conclude. In a reasonable system, the more it costs to rent an office and run a business, the more doctors should be entitled to charge and collect. Unfortunately, politics determine your fees on a state-by-state basis and the stronger the insurance lobby, the lower the reimbursable fees. 
As it was reported in 2011, and as it is still consistent today, two of the most expensive states to live in are New York and Hawaii, yet they have the lowest levels of reimbursement nationally. New York, which in spite of its ranking as 47th for cost of living, undoubtedly a result of its vast rural areas, pushes it out of the highest ranking. However, a 500-square-foot office in downtown New York City can cost $7,000 per month to rent, yet the maximum reimbursement a chiropractor can receive is $43 per visit, no matter what services the doctor provides. In addition, if the carrier sends for an IME after a few visits in order to limit the amount of care, a further reduction in the doctor’s ability to receive fair and equitable reimbursement may occur. 
The reimbursement comparison between 2011 and 2013 revealed a potential 9% increase in collections for a personal injury visit on average when you combine all of the states. This statistic revealed a trend in the chiropractic profession that the personal injury population of patients is a financially stable sect within the industry. (Please note that this author is not suggesting that a doctor maximize his or her charges inappropriately and that only clinically indicated services should be performed based upon clinical necessity.)

The solutions are a strong political lobby with a unified chiropractic voice both nationally and statewide.

Many doctors who read this report will feel that they must increase those portions of their practices with personal injury patients. From a reimbursement perspective and business plan, that would appear to make sense. However, is that doctor qualified? Treating trauma cases requires a very specific skill set and training no different than any specialist in any health care field. You wouldn’t want a psychiatrist performing open-heart surgery without the requisite training. At the very least, a doctor of chiropractic should have basic training in MRI interpretation and triaging the injured. Understanding the difference between a herniated, bulged, extruded, or migrating disk is critical in creating an accurate diagnosis, prognosis, and treatment plan in triaging and guiding the patient through care. Although the delivery of chiropractic may not change, when you can and cannot treat your patient might change because collaborative care with a medical specialist and or surgeon might be indicated. The etiology of pain in the trauma case is often dramatically different from in a chronic pain geriatric or pediatric patient.
The only way to spiral upward in success is through clinical excellence and the acquisition of knowledge and skill sets. Based upon past and currently published research, chiropractic outcomes have outpaced most other forms of treatment for conditions within our scope to treat. As a profession, the most direct avenue for these published studies to help increase utilization is for each doctor to be expert and credentialed in the area of desired practice. Treating personal injury patients is included in this formula.
In personal injury or any financial category, fair and equitable reimbursements will determine if a doctor can afford to live in any community nationally, and wise legislators will take into account the reimbursement statistics so as not to be “penny wise and dollar foolish,” unlike those elected officials in New York and to a lesser extent in Hawaii. The solutions are a strong political lobby with a unified chiropractic voice both nationally and statewide. 

  1. Studin, M. (2011, February) Personal Injury Collections by State: 2010 Comparison of Collections vs Cost of Living Analysis, The American Chiropractor, 33(2) 52-53
  2. CNBC (n.d.). Top States 2012: Overall Ranking, Americas Top States For Business 2012, Retrieved from: http://www.cnbc.com/id/100016697
Megatrends in Chiropractic: Circa 2013 Your Success Depends Upon It
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Special Feature
Written by Mark Studin, D.C., F.A.S.B.E.(C), D.A.A.P.M., D.A.A.P.L.M.   
Tuesday, 25 June 2013 20:10
rending: this word is what should be the guiding force behind the future of every practice and business worldwide. Why is it that some offices seem to thrive in any economy, yet others are always struggling to pay the rent, the staff, the bills and often oneself? How many weeks a year do you NOT take a paycheck? In 1982, John Naisbitt wrote the New York Times bestseller Megatrends, which accurately prognosticated shifts in the world economy and changed the relationship of people to economics. The principles of success in foretelling the future that held true in 1982 still hold true today. If you know where to look and how to interpret the economic or practice indicators, you will ensure your success for years to come IF you are willing to adapt based on the trends and indicators and IF you are willing to take the action steps required.
markettrendThese changes have nothing to do with how you practice. You can be a "far-right conservatist" practicing in a pure "Tic" environment or a "far-left liberal" using every modality, treating extremities, using nutrition and every other avenue your scope allows, or somewhere in the middle like the majority of us. The rules are the same for all. Trends dictate how we triage, document, bill and collect our fees, not how we deliver chiropractic care to our patients.
When looking for trends in a professional setting, we must examine what the carriers, chiropractic boards, courts and legislators are dictating through rulings and legislation. First, we cannot be Pollyannaish and think that the carriers are outside influencing any of the above entities, as their profit base is purely derived from rules, regulations and laws. When looking at trends, we look for bellwethers nationally, and currently there are 2 states that are leading the pack, New York and, to a greater degree, New Jersey. 
The First Trend Is Evidence-Based:
In December, 2010 New York revamped its workers’ compensation guidelines, mandating evidence in the form of peer-reviewed literature to expand the amount of reimbursable care. New York also forbade treating workers’ compensation patients in a fee-for-service scenario outside of the workers’ compensation system. This changed the historical usual and customary amount of care based upon a doctor’s findings to that centered on the literature. Although this was limited to workers’ compensation, it laid the foundation for future legislation.
On January 4, 2013 New Jersey enacted regulation that says:
N.J.S.A. 39:6A-4a provides that the Commissioner, in consultation with the Commissioner of the Department of Health and Human Services and the applicable licensing boards, may reject the use of protocols, standards and practices or lists of diagnostic tests set by any organization deemed not to have standing or general recognition by the provider community or applicable licensing boards. Although the Department is not adding to the list of rejected protocols, the Department is proposing to add a definition of standard professional treatment protocols to guide the acceptable evidence of standing or general recognition for a specific medical procedure or test. These are defined as evidence-based, clinical guidelines published in peer-reviewed journals. The Department has become aware that the medical necessity of a procedure or test is being supported by articles, books and practice or treatment guidelines that are published by the proponents of the treatment or test in journals that are not peer-reviewed and where the evidence supporting the treatment or test is anecdotal. These types of treatment protocols and guidelines cannot be used as evidence that a treatment or test is medically necessary.
Evidence-based practice is NOT the trend. A perversion of what evidence-based practice was intended to be has become the trend and is here for the foreseeable future. In order to understand the trend, we must understand evidenced-based practice as it was intended. "The most common definition of evidence-based practice (EBP) is taken from Dr. David Sackett, a pioneer in evidence-based practice. EBP is 'the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research'"

(Schardt & Mayer, 2010, http://www.hsl.unc.edu/services/tutorials/ebm/whatis.htm).
EBP is the integration of:
  1. Clinical expertise: The clinician's cumulated experience, education and clinical skills.
  2. Patient values: The patient's own personal and unique concerns, expectations, and value.
  3. The best research evidence into the decision making process for patient care: The best evidence is usually found in clinically-relevant research that has been conducted using sound methodology (Schardt & Mayer, 2010, http://www.hsl.unc.edu/services/tutorials/ebm/whatis.htm).
"The evidence, by itself, does not make a decision for you, but it can help support the patient care process. The full integration of these three components into clinical decisions enhances the opportunity for optimal clinical outcomes and quality of life. The practice of EBP is usually triggered by patient encounters which generate questions about the effects of therapy, the utility of diagnostic tests, the prognosis of diseases, or the etiology of disorders. Evidence-based practice requires new skills of the clinician, including efficient literature searching, and the application of formal rules of evidence in evaluating the clinical literature"

(Schardt & Mayer, 2010, http://www.hsl.unc.edu/services/tutorials/ebm/whatis.htm).
There are a myriad of articles published on the cons related to a purely evidence-based "published only" approach and its potential to be used to deny care. In a recent article by Carr (2008), published in the Journal of Regional Anesthesia and Pain Medicine, he writes, “Yet even as I was preparing that talk, the climate of pain medicine was changing. It was already clear that powerful stakeholders in the healthcare enterprise were looking to evidence-based medicine (EBM) for answers about effectiveness, cost effectiveness, appropriateness, and even efficacy beyond what EBM could reasonably provide. Since then, over- and mis-application of EBM to support health policies such as 'pay for performance' and to restrict payment has created a crisis. This ongoing crisis threatens the survival of important forms of pain therapy, restricting health care offered..." (Carr, 2008, p. 229). The biggest concern in his article and among healthcare providers is clarified when he states, “…I realized that the practice of EBM dates to antiquity, but what is new today is that EBM is being used as a rationale to restrict physician payment and/or autonomy" (Carr, 2008, p. 229).
Proponents of evidence-based, clinical guidelines published in peer-reviewed journals argue that it would eliminate waste and reduce costs while providing patients with the most up-to-date care available. That is a dangerous partial truth. Those currently practicing don't argue, but understand, through daily patient care, that this is too limiting and would eliminate many procedures that fall under this narrow definition and remove clinical decision making and professional experience from the equation. What would be left is denial of valid and often critical therapies with the concurrent stifling of innovation, since the process of establishing a research study, following its participants and publishing those findings can take many years. This delay could eventually cost lives and/or severely diminish the quality of life for those who could have been helped during the research and publication processes.
With the understanding of EBP, the legislation in New Jersey has set forth a path that ONLY therapies and diagnostic testing that have been published are reimbursable with far-reaching effects. The trial lawyers’ concerns are that non-published tests or treatments will be barred as evidence in the courts with further implications not yet illuminated, as future court rulings will further define this regulation.
Although managed care companies and workers’ compensation carriers are not regulated, within weeks of the regulation becoming effective, denials were being rendered quoting these standards. The carriers took it to the next step and cited "standard of care" as a result. These same types of denials are being reported in multiple other states because the carriers realize that the rationale has been clearly defined and, in the end, many courts will uphold their reasoning, again citing "standard of care". Therefore, the first significant megatrend in chiropractic is to utilize peer-reviewed evidence.
The second trend is credentials and certifications:
In the Fall of 2012, a trial court in New Jersey ruled that the chiropractor for the plaintiff was not allowed to testify on MRIs for his patient because of his insufficient certification (and credentials) in the "eyes of the court" on MRI interpretation. During direct and cross-examination, the specifics of this doctor's MRI education were clearly detailed and the judge went further and ruled that ALL chiropractors in New Jersey couldn't testify on MRIs based upon this one doctor's account of his training.

Therefore, the second significant megatrend in chiropractic is to be prepared with the appropriate credentials and certifications. MRI spine interpretation is only one example.

This ruling, which is being challenged in the appellate division and has amicus briefs by both the Association of New Jersey Chiropractors and the New Jersey Association for Justice (Trial Lawyers Association in New Jersey), has far-reaching negative implications for our profession, both locally and nationally, should it be both upheld and followed blindly by other judges. This judge cited how this one doctor's MRI course was structured and monitored along with the content and institutions accrediting the certification in his ruling. Understanding the needs of the courts and the power of credentials, 3 different doctors during the week of February 17, 2013 testified in 3 different courts, and in each instance the same qualifying questions were asked as in the case where the one doctor was ruled against. In all 3 recent cases, the DCs were qualified as experts and allowed to testify on MRI. These 3 doctors understood that it is no longer "business as usual" and although their treatment protocols haven't changed, they have chosen to ensure that they are qualified as expert. These doctors were certified by the Federation of Chiropractic Licensing Boards, the University of Bridgeport College for Chiropractic and the State University of New York at Buffalo School of Medicine and Biomedical Sciences for CE and AMA Category 1 PRA credits in MRI spine interpretation. These credentials were ruled by the courts as acceptable for DCs to be expert in interpreting MRI.  These credentials, unlike those obtained by the other doctor, have met not only New Jersey court standards, but those of every other state where they have been challenged in court.
This, too, has far-reaching implications for the chiropractic profession. The limited reach is being able to treat personal injury patients, with both lawyers and patients not fearing the loss of cases as a result of involvement by a chiropractor because the doctor of chiropractic will not be able to represent them in court. The long-term implication is the courts will now view chiropractors as well-credentialed experts on par with all other specialists, and when future utilization issues are considered, we will not be considered subservient. Therefore, the second significant megatrend in chiropractic is to be prepared with the appropriate credentials and certifications. MRI spine interpretation is only one example.
In order to meet the trends for today and the future, we all must meet the "highest standard" in the nation regardless of our individual state's requirements. Do the New York or New Jersey laws affect you in your state? Maybe or maybe not, but, given time, some form of these standards WILL affect you and your practice, whether it be today, tomorrow, next week, next month or next year. These are the indicators of today and demonstrate that you must be prepared.

To accomplish this, your choices are either to go to Google Scholar, Pubmed or Ovid and hunt for each citation or use a service that provides you with those citations.

When documenting care in your records, you should strongly consider adding peer-reviewed evidence in your reports to support your recommendations. To automate the process, your EMR (electronic medical records) program should have macros to add those citations. To accomplish this, your choices are either to go to Google Scholar, Pubmed or Ovid and hunt for each citation or use a service that provides you with those citations (Historically, the latter has not been an expensive option.). Either way, this is a trend that cannot be overlooked and gives you a much deeper appreciation for the research community and what it provides to the chiropractic profession. 
Credentials are important, but the right credentials are critical, and whether you get cross-credentialed with another profession or a diplomate within chiropractic shouldn't matter. The only criteria should be learning the material and having credentials that are legally defensible.  Learning how to perform an EMG, interpret an MRI or rehabilitate the paraspinal musculature, although integral to the practice of chiropractic, is not knowledge exclusive to chiropractic. However, the credentials and subsequent certifications are crucial for the DC to be able to function in today's economy and the trends of the courts that we currently see in most states dictate that a continuing education course lasting a few hours, given by your state organization in a hotel, is often nothing but a great start.
New Jersey is a prime example and, thankfully, those 3 doctors (with many more to come) who were in court last week chose to go beyond the few hours in a hotel room and instead got certified.  Over time, more and more New Jersey (and other states') courts will recognize that chiropractors are qualified to render expert opinion on MRI and overcome the negative opinion of this one judge, protecting chiropractic and your right to represent your patients and your profession. As a result of this case being an Allstate case, it is one that is significant, as this is one of the wealthiest carriers in the world, literally, who has the ability to leverage this lower court ruling nationally. Having DCs in other courts in New Jersey recognized as experts after the fact of this ruling minimizes the impact of this one judge's ruling and essentially limits the negative influence of that case only to its specific facts and circumstances, and not to the entire profession as viewed by that one New Jersey court.
With these 3 doctors, was it necessary to get credentialed through a chiropractic university and earn category 1 AMA PRA credits through a medical school in addition to the chiropractic state board for the doctor's chiropractic license? No. However, the judge saw these credentials and the work that was required for the certification as meeting much more stringent standards and qualified the doctor of chiropractic as expert. That is meeting the standard at the highest level and winning as a profession through clinical excellence.
No matter your philosophy, politics or manner of practice, this is where the profession is trending today and the near future. You need to meet the highest standard in the nation and let everyone else wonder why you are always doing well while THEY continue to struggle. 
  1. New Jersey Department of Banking and Insurance, Retrieved from: http://www.state.nj.us/dobi/proposed/prn11_163.pdf
  2. Schardt , C., & Mayer, J. (2010, July). What is evidence-based practice (EBP)?  Retrieved from http://www.hsl.unc.edu/services/tutorials/ebm/whatis.htm
  3. Carr. D. B. (2008). When bad evidence happens to good treatments. Regional Anesthesia and Pain Medicine, 33(3), 229-240.
  4. Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: What it is and what it isn't. British Medical Journal, 312(7023), 71-72.
  5. Lamb v Allstate Ins. Co., Docket No: ESX-L-5830-09, Sup. Ct NJ, Essex Cty (2012).
WBV, EBP, and Y-O-U: How to Implement Whole-Body Vibration Therapy in Your Office Responsibly
Special Feature
Written by Joshua Woggon, DC   
Tuesday, 25 June 2013 19:50
he concept of evidence-based practice (EBP) is a recent innovation in health care that strives to combine the best available scientific evidence with the doctor’s clinical expertise, in line with the preferences of the patient, to improve treatment outcomes.1 Those who find EBP unpalatable are often the victims of its improper application by third-party payers or other independent auditors of clinical care, who may find it convenient to rely too heavily upon the research leg as they neglect the clinical expertise of the doctor or, worse, the preferences of the patient. As an example, if a patient is against surgical intervention and in favor of pursuing a chiropractic approach to resolving a condition, all of the research in the world in favor of surgery is irrelevant, and only the chiropractic data need be considered. If no such data exists, EBP standards then suggest the doctor’s clinical expertise is sufficient to justify the chosen approach. Since nearly half of all medical procedures currently in use appear to lack sufficient evidence to justify their use,2 quite often the clinical expertise of the doctor is the primary deciding factor in the judicious application of care. When used properly, EBP “facilitates the process of practitioners finding solutions to their patients’ individual clinical problems.”3 For those who may have been unjustly injured by an improper application of EBP, I offer one ironic statistic in hopes of alleviating the bitterness. According to a study published by Straus et al. in the Canadian Medical Association Journal in 2000,4 the process of evidence-based practice itself has not been evaluated according to its own standards. So, although suggestive evidence exists in favor of this,5 we cannot claim with certainty that following these standards truly results in improved patient outcomes. Regardless of this fact, understanding the principles of EBP is fast becoming a necessity in the 21st century healthcare arena. Considering that most chiropractors do not possess an understanding of basic research principles,6 this should be a matter of serious concern for our profession. In this article, I aim to educate the clinical chiropractor about some of the basics of research methods and the proper application of EBP as it pertains to whole-body vibration (WBV) therapy, and to aid them in making the correct statements regarding the safety and effectiveness of this increasingly popular therapy.

First, it is important to understand that research terminology is often confusing in its exactitude

First, it is important to understand that research terminology is often confusing in its exactitude. The apparently contradictory nature of this statement can be resolved by considering two studies. The first is by Clinton Rubin,7 lead researcher whose department received funding from NASA to study the potential of WBV therapy to prevent bone and muscle loss in astronauts. This study showed that WBV therapy successfully prevented bone loss in postmenopausal women. Compare this to a randomized trial, which found no effect of WBV therapy in postmenopausal women.8 These two studies say the exact same thing — essentially, there was no change in bone mineral density (BMD) after WBV treatment — but one frames it as a success and the other as a failure. One key point to remember when evaluating research articles is this: No evidence of effect is not the same as evidence of no effect.9 To misquote F. Scott Fitzgerald, "The test of a first-rate intelligence is the ability to hold two opposed ideas in the mind at the same time, and still retain the ability to function."
So, while we must recognize that the appropriate standards for the use of WBV therapy as a potential treatment for any condition have not yet been established or verified for any segment of the population,10 we should also realize that EBP is in favor of efforts to advance our understanding of WBV therapy and continues to justify its use under carefully controlled circumstances. However, this confusion is often exploited by marketers, so the responsible researcher is right to encourage caution and a “buyer beware” type mentality. Claims made by advertisers must be evaluated with great care, as the evidence is contradictory, even in the area where the greatest research on WBV therapy has been performed, namely osteoporosis. In regards to WBV therapy and osteoporosis, the honest man will tell you that some studies show good results, while others report no results, and hopefully opine that further research is needed to understand this apparent contradiction (in research circles, the technical term for this is “job security”). One of the reasons for the conflicting research has to do with the high number of variables involved with WBV therapy. Totosy de Zepetnek et al. quoted five factors that influence the response of the human skeletal system to WBV therapy (vibration direction, frequency, magnitude, duration, and body position),11 but this still leaves out the variables that occur within the population being studied. Prescription drug use,12 nutritional and hormonal status,8 gender, and age13 are just a few of these variables that could influence the results, and provide false information to the busy clinician who is ultimately seeking specific benefits for specific patients in the office. If all of the various types of WBV are placed together into one category without understanding how the involved variables can alter the critical effects experienced by the patient, this will confound the data and render it invalid. 
The Bone and Joint Decade calculated that the financial burden borne by our society as a consequence of falls and fractures was $24.2 billion in 2004.14 This is not an insignificant finding, and, considering the recent concerns that the drugs being prescribed to mothers and grandmothers to promote their bone health may actually be causing bone death,15 non-drug efforts to reduce the societal cost of fractures are worth the effort of further research. As we endeavor to do so, however, we must always place the safety of our patients above all other concerns. As quoted by Wysocki et al. in a comparative effectiveness review by the Agency for Healthcare Research and Quality, questions such as the optimal population that could benefit from WBV therapy and the ideal treatment protocol for osteoporosis remain unanswered; as I stated earlier, EBP favors research into fields where it is needed. However, in their research, Wysocki et al. noted that “safety concerns emerged . . . including unknown long-term harms from the use of whole-body vibration therapy, and the potential inability of consumers to clearly distinguish low-intensity platforms intended for osteoporosis therapy from platforms intended for high intensity exercise.”16 
A greater sustained research effort has been made about the potential negative effects of WBV therapy than has been done concerning its potential benefits. Because of the detailed research conducted by the International Standards Organization, OSHA, and others, we can state with confidence that the safety of WBV therapy has been validated, but only for specific frequencies, amplitudes, and durations, and under specific conditions.17 Exceeding these established safe levels is dangerous, just as exercising too much can be harmful to your health. For instance, there is no published research showing any negative effect to exposure to vibration at 30 Hz and 0.3 g, and the established guidelines for the safety of WBV exposure indicate that four hours of exposure to vibration at this level would be required to exceed safe levels. 

Some chiropractors may be using WBV products in their offices which have the potential to harm their patients’ skeletal systems

When it comes to the safety of WBV, amplitude (measured in acceleration) is the most important factor in this regard. The human body is designed to operate in a 1.0 g environment, and we can safely withstand forces at this level or below it for long periods. We can also tolerate short exposures to g-forces in excess of this amount (when we jump and land, for instance, that’s a short-term exposure to increased g’s). It is important to recognize, then, that according to Clinton Rubin, “g-forces that greatly exceed 1.0 are the very basis of devices referred to as PowerPlate, Galileo, SoloFlex, Galaxy, Nemes, and others, and should be approached with extreme caution. Conditioned athletes, should they knowingly understand these dangers and still wish to put their body at risk is one thing, but to use interventions on the elderly, osteoporotic, or functionally impaired individuals is dubious, at best.”18 When Rubin’s statement is combined with the statement made by Wysocki et al. regarding “the potential inability of consumers to clearly distinguish low-intensity platforms intended for osteoporosis therapy from platforms intended for high intensity exercise,” it should be readily apparent that some chiropractors may be using WBV products in their offices which have the potential to harm the skeletal systems of their patients. What, then, is the difference between the chiropractor claiming to help elderly patients with osteoporosis by exposing them to dangerous levels of vibration, and the medical doctor who treats osteoporosis by prescribing drugs that may cause bone death? 
A constant amplitude will change with increasing load; someone weighing 80 lbs is going to experience greater g-forces than someone weighing 180 lbs because increased weight will dampen the vibration. Amplitude can also vary depending upon foot placement, especially with oscillating platforms; the farther away your feet are from the axis of rotation, the greater the forces inputted into the body. While amplitude is the primary variable of interest, frequency also factors into the safety equation as well; for example, it’s easy to move your hand up and down three inches twice in one second. However, try moving your hand up and down three inches eighteen times in one second; this requires a great deal more exertion of force and the result is a higher amount of kinetic energy. So, in reviewing the literature, in order to have a safe product, you should ensure that the maximum amplitude never exceeds 1.0 g, and preferably remains closer to 0.2 or 0.3 g. This is an especially important concern with children, as their lighter weights will result in increased amplitude, and exposure to excessive vibratory forces could potentially affect the growth plates in a negative manner. If using an oscillating device, correct foot placement must be determined with care. In one report, a healthy athlete experienced hematuria (blood in the urine) after using an oscillating platform; the researchers suggested that something as simple as foot placement may have been at fault for the traumatic forces.19

I hope this article will serve as a warning to the chiropractic clinician who has purchased an unsafe vibration therapy product, and as an admonition to the manufacturers who are profiting without considering the true impact of their products upon those who use them. As the public becomes educated regarding the harmful effects of the misuse of WBV therapy, these individuals and organizations will increasingly render themselves vulnerable to the legal consequences of their decisions in the same manner that searching on the web for bisphosphonates and osteonecrosis brings up numerous articles written by attorneys. 
  1. Sackett DL et al. Evidence-based medicine: What it is and what it isn’t. BMJ. 1996. 312(7023):71-2.
  2. Lewith G (cited by Cope J): Healthwriter. April 2007, p 2. Data retrieved from http://clinicalevidence.com/ceweb/about/knowledge/jsp visited 06-05- 07
  3. Haneline MT: Evidence-based Chiropractic Practice, Jones and Bartlett Publishers 2007, p. 7.
  4. Straus SE and McAlister FA: Evidence-based medicine: a commentary on common criticisms. CMAJ. 2000. 163(7):837-41.
  5. McGuirk B et al.: Safety, efficiency, and cost-effectiveness of evidence-based guidelines for the management of acute low back pain in primary care. Spine. 2001. 26(23):2615-22.
  6. Feise R: The evidence-based approach. J Amer Chiropr Assoc. 2002. 39(8):30-3.
  7. Rubin C, Recker R, Cullen D, Ryaby J, McCabe J, McLeod K: Prevention of postmenopausal bone loss by a low-magnitude, high-frequency mechanical stimuli: a clinical trial assessing compliance, efficacy, and safety. J. Bone Miner. Res. 19 (3) (2004), pp. 343–351.
  8. Slatkovska L, Alibhai SM, Beyene J, Hu H, Demaras A, Cheung AM: Effect of 12 months of whole-body vibration therapy on bone density and structure in postmenopausal women: a randomized trial. Ann Intern Med. 2011. Nov 15;155(10):668-79, W205.
  9. Tarnow-Mordi WO, Healy MJR: Distinguishing between “no evidence of effect” and “evidence of no effect” in randomized controlled trials and other comparisons. Arch Dis Child, 1999. 80(3):210-11.
  10. Prisby et al.: Effects of whole-body vibration on the skeleton and other organ systems in man and animal models: what we know and what we need to know. Ageing Research Reviews. 7, 2008, 319-329.
  11. Totosy de Zepetnek et al.: Whole-body vibration and the skeletal system. JRRD. 2009;46(4):529-542.
  12. Iwamoto et al: Effect of whole-body vibration exercise on lumbar bone mineral density, bone turnover, and chronic back pain in post-menopausal osteoporotic women treated with alendronate, Aging Clin. Exp. Res. 17 (2) (2005), pp. 157–163.
  13. Merriman et al: Systematically controlling for the influence of age, sex, hertz, and time post-whole-body-vibration exposure on four measures of physical performance in community- dwelling older adults: a randomized cross-over study. Curr Geront Geriat Res. 2011.
  14. The Burden of Musculoskeletal Diseases in the United States: Prevalence, Societal, and Economic Cost. United States Bone and Joint Decade. Chapter 5; p. 107.
  15. Sedghizadeh PP et al.: Oral bisphosphonate use and the prevalence of osteonecrosis of the jaw: an institutional inquiry. JADA. 2009 Jan;140(1):61-66.
  16. Wysocki et al.: Whole-body vibration therapy for osteoporosis [Internet]. AHRQ Comparative Effectiveness Reviews. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011 Nov. Report No.: 11(12);EUC083-EF.
  17. ISO Guidelines Section 2631-1: Mechanical vibration and shock – Evaluation of human exposure to whole-body vibration.
  18. Rubin C: Contraindications and potential dangers of the use of vibration as a treatment for osteoporosis and other musculoskeletal diseases. April 2007.
  19. Franchignoni F et al.: Hematuria in a runner after treatment with whole body vibration: a case report. Scand J Med Sci Sports. 2012 May 17 [Epub ahead of print].
Dr. A. Joshua Woggon, a 2010 Graduate of Parker College, serves as a consultant for Vibe For Health (www.vibeforhealth.com), a company that supplies vibration therapy equipment to chiropractors specializing in structural corrective care. He is also the Director of Research for the CLEAR Scoliosis Institute, a non-profit organization dedicated to advancing chiropractic scoliosis correction (www.clear-institute.org). He can be contacted at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .
Extremity Adjusting: A Vital Part of Chiropractic
Special Feature
Written by Kevin M.Wong, DC   
Saturday, 25 May 2013 11:23
here is no question that the root of chiropractic lies in the use of the hands on the axial spine and pelvis. It has been something originally developed by D.D. Palmer and passed down the ages from our forefathers to us. It is important to remember the roots of our profession as placing the hands on the spine releases innate power so the body can heal itself. Traditional chiropractic has helped us all form a strong foundation for the knowledge we use in daily practice. In school, we start with the basic understanding of anatomy and working with patients helps reinforce the key relationships between the bones, joints and muscles. In just about every patient, we observe the biomechanics of not only the spine, but of the extraspinal areas as well. 
clavicleThe concept of extremity adjusting has been growing in momentum, especially in the last 10 years. In the past some have been lukewarm at the idea of truly adjusting anything but the spine. They felt extremity adjusting was not part of chiropractic. If we adjust the spine, it should be able to heal the body, right? In many cases, this is quite true. In many cases, however, this is not.
There are instances when the extremities themselves are the standalone causes of pain and without treating them, we are not addressing the true nature or source of the problem. Just as we ask patients to be open minded when getting their spine adjusted for the first time, so must we be when considering the extremities.

Chiropractic Is Not Just For The Spine!
One of the main reasons why some of us do not gravitate towards adjusting extremities is because of the perception we are saddled with by the general public. Chiropractors are stereotypically pigeonholed as "back and neck doctors.” Patients do not realize that we can also treat the extremities. In fact, many of your patients right now have no idea you have the ability to do this; unless you tell them and show them!
Getting exposed to extremity anatomy and adjusting in chiropractic school was one thing. Really using the information and developing your skills in this area is another. Whether you are seasoned at working with extremities or a novice, practice, practice, practice helps bring confidence and great results.
It is amazing to assess someone's foot, ankle, hip, hand, wrist, shoulder or TMJ when they are in pain. The power and effect of our hands to realign those bones is marvelous. Seeing the improved motion, muscle relaxation and pain reduction is just as amazing in an extremity as it is in the spine.
Extremity Care Contributes to Whole Body Care:
Often there are examples of spinal pain caused by an extremity. The most common example of this in my practice is lower back pain that is actually coming from the collapse or over pronation of the three arches of the feet. Once the foot arches drop downwards and the feet fall to the floor, there is an inward rotation of the tibia and femur bones that put lateral pressure on the hips. The resulting tipping of the pelvis stresses the lumbosacral region creating muscle hypertonicity, altered biomechanics and pain. This example is so common in my office that if I missed checking the feet, I would never be able to stabilize the lower back.
Another example is upper/mid back, neck pain and headaches that are caused by shoulder girdle misalignments. When the glenohumeral, the acromioclavicular and the sternoclavicular joints are subluxated, the humeral head tends to move anteriorly. The resultant stress on the clavicle, ribs and scapula eventually create hypertonicity in the surrounding muscles. Of these, trapezius muscle hypertonicity (due to its’ origins on the mid/upper back, neck and occiput) especially creates a lot of pain and reduced shoulder biomechanics. Very often, shoulder misalignments will present as spinal pain. If we miss the shoulder joints, it will hard to completely stabilize the region.
Almost anywhere there is a joint in the body, chiropractic can help!

Chiropractors are stereotypically pigeonholed as "back and neck doctors.”

Just about every joint in the body has the potential to subluxate or misalign. How many times have you found someone’s jaw to be out of alignment? How about when ribs go out of place? The extremity joints are prime examples of these. All of them can exhibit the same kind of pain, local muscle hypertonicity and swelling that we see in the spine. 
Often, these smaller joints are located in areas of the body that are very critical to everyday activities. Try going about your daily routine when your wrist is hurting or you can’t put weight on your foot/ankle because these areas are out of alignment. What is important here is for you to think of the big picture. Although we should always address the pain, try not to chase it! The body likes to fool us sometimes.
Add an element to your skill set that will help you treat more patients.
The more proficiency you have with analyzing and adjusting the extremities, the more patients you will help. It is rare to find any patient who does not have some kind of ache and pain in an extraspinal body part. The more people you treat, the more extremity issues you will find. It’s a bit tricky at first, but you will get the feel for working with them. 
The nice thing about adjusting extremities is that there does not tend to be as much soft tissue to have to work through or push through to get right on the bones of the joint. Palpation is a bit easier as a result. This allows you to really feel when the bones are misaligned, especially comparing bilaterally. This ease of palpation allows you to assess range of motion, swelling, tenderness and general anatomy of the area without too much difficulty.
Go the Extra Mile for Your Patients!
The body ends up being a sum of its parts. Your knowledge of the spine can only be strengthened by your extremity work. You start to put together patterns that the body exhibits when the extremities are out of sorts. It helps you become a better practitioner and it opens a whole new source of patients you can help. 
Extremities have always been so fascinating to me but getting really proficient with them is a skill I keep developing every day. I hope that wherever you are in your career, you see extremity adjusting as an important component to your practice. I hope working on these areas enhances your practice as much as it has mine. 

Dr. Kevin M. Wong is an expert on foot analysis, walking and standing postures and orthotics. Teaching patients and chiropractors is a passion for him, and he travels the country speaking about spinal and extremity adjusting. Dr. Wong practices full-time in Orinda, California. Contact Dr. Wong at 925-254-4040 or This e-mail address is being protected from spambots. You need JavaScript enabled to view it .
The 5 Things Every Recent Graduate Should Know or Do Before Opening or Joining a Practice
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Special Feature
Written by Ray Foxworth, D.C, FICC, MCS-P   
Monday, 25 March 2013 20:41
 can honestly say, after 27 years in practice, there has never been a better time to start a career in Chiropractic. Even with national healthcare reform moving forward, you can build a practice of your dreams by following some simple rules and taking time to look before you leap.
1. “Trust But Verify” 
confuseddoctorIt was President Ronald Regan who said, “Trust, but verify,” and it is still good advice today. You have so many things to consider in opening or joining a practice. Do not let the excitement of getting into practice lead you into making decisions that you may later regret. Take time to complete a careful review of associate agreements, building and equipment leases and provider agreements. Before you sign anything or join an existing practice, use your head and seek wise counsel from trusted colleagues and/or legal counsel. Never just take someone’s word for what you should and should not do, can and cannot do when it comes to running your practice or what is acceptable in operating a practice. This is not meant to be harsh toward those with good intentions who are offering advice to help you succeed, but it is meant to encourage you to protect your license to practice. As a medical compliance specialist, I  have seen far too many cases where a doctor is facing fines and penalties and their only defense is, “Well, my buddy said it was okay and he does it all the time,” or “I heard my board of examiners said it was okay.” Verify what you hear about your state’s rules and regulations with your board of examiners, your state association, a trusted consultant, or established colleague with an impeccable reputation. When possible get verification in writing. This is most important when it comes to billing, coding, documentation and financial policy. Why? Because signing a bad lease can surely cost you money and aggravation. But improper billing, coding, documentation or faulty financial policies that lead to dual fee schedules or inducement violations can cause you serious financial harm, or worse, can cause you to lose your license. Game over. 
2. Never forget, your license is a privilege to practice… not a right.
Despite the years and thousands of hours devoted to completing chiropractic college and for some, hundreds of thousands of dollars spent, never forget, your license to practice is not a right but a privilege. And like any privilege, it can be taken away. Your license is extremely valuable and should be treated as such. Do not jeopardize your license by engaging in or participating in poor business practices or joining a practice that can clearly put you at risk. Violating rules and regulations from your Board of Examiners is bad enough, but the risks do not stop there. Make sure that your new practice, or the practice you join, is in compliance at all levels, from your State Board of Chiropractic Examiners or other licensing boards to the Department of Insurance for your state. Also, consider the rules and regulations from your Provider Agreements, State and Federal Anti-kickback Statutes, the Centers for Medicare and Medicaid (CMS/Medicare) and the Office of Inspector General (OIG). While this may seem overwhelming, it really is not that hard to accomplish with the proper guidance. If and when you find there are rules that conflict, and they do at times, take the safest and most conservative approach in determining your policy and document in your compliance manual what your decision was based on. Again, protect your license. It is, in essence, your passport for life to prosperity, so guard it carefully.

3. Remember, times are never good or bad, they are just different.
You may have heard of the Mercedes ‘80s, a time when you could put anything on an insurance claim form, send it in, and a check appeared. Or perhaps you have heard the horror stories of managed care where only two visits were permitted by an insurance carrier. Having practiced through these times, as you might imagine, the truth lies somewhere in between. Never was it that easy in the 1980s, and if you documented properly to support medical necessity, rarely would you be limited to two visits. What is clear and beyond debate now is that you are entering practice at a time where all professions, including chiropractic, are under more scrutiny than ever before. There are more fraud and abuse investigations now than at any other time in history. Billions of dollars are being recouped by the federal government and insurance companies for fraudulent claims. It has been reported that the Office of Inspector General stated that for every dollar spent in healthcare fraud and abuse investigations, they recoup $17.00. So, do not look for audits to decrease; they are making money. Unfortunately, some of the scrutiny in chiropractic is warranted, and it will continue. My intent is not to instill fear, but to empower you with facts so you can minimize the risks of audits, fines and penalties and practice with some peace of mind.

Here is the UPSIDE!

Again, protect your license. It is, in essence, your passport for life to prosperity, so guard it carefully.

More doctors are taking a look at their billing, coding and documentation and are taking steps to be more compliant with all the layers of regulations. Make sure you start off the right way by knowing and following the rules. If you are joining an existing practice, make sure you know they are aware of the rules and regulations and are proactive in making sure they are running their practice in a compliant fashion. I can tell you, far too many docs like me who have been practicing for many years ignore the fact that the rules have changed, and we must change. If you run into a great opportunity to join a practice, but the doc’s head is in the sand, use the opportunity to help them bring needed change to their practices if they are open to it. If they are not, then it is simply not in your best interest to join that practice.

4. Know how joining an existing practice can put you at risk.
When you treat a patient, whether in your own practice or not, you have an NPI number that is recorded on the claim form. The NPI identifies you as the treating/ordering doctor. Even if someone else owns the clinic, your NPI is on the claim form and you are responsible and accountable for what is on the claim form. Box 31 of the CMS 1500 form is an attestation that the information is accurate, and you agree to the statements on the reverse side of the form, including:

I certify that the services shown on this form were medically indicated and necessary for the health of the patient and were personally furnished by me or were furnished incident to my professional service by my employee under my immediate personal supervision, except as otherwise expressly permitted by Medicare or CHAMPUS regulations.

So whether you are personally responsible for sending out the claims or not, you are held responsible because you have allowed them to use your NPI number as the treating/ordering doctor, and you are at risk if the practice is not operating in a compliant fashion.

5. Look and ask before you leap.
If you have decided to join an existing practice, even the family practice, there are things to consider and respectfully ask about before signing on. Yes, it is okay to ask questions of mom and dad or other family members. As a second generation chiropractor who did, I can tell you it may not be easy, but you have a right and an obligation to know some key things about the practice. Here is a short list:
  • Do you have sound financial and billing policies in writing? Ask for a copy and review them.
  • Is there more than one fee schedule? If so, why? And is it legal? In some states, charging more to insurance patients than you do for cash patients is considered a “dual fee schedule” and could be illegal. Ideally, there should be one fee schedule. One of the safest policies is to only offer discounts when they are part of a written financial policy, which could include contractual or network discounts, mandated fees like those established by Medicare, or when there is a documented financial hardship. Other legal discounts could include a defensible time of service or prompt payment discount, if and only if permitted in your state. If you would like a copy of a simple, one page financial policy that is rock solid, send an email to This e-mail address is being protected from spambots. You need JavaScript enabled to view it and put FORM in the subject line.
  • Does the clinic up code, or down code based on the type of insurance coverage? Meaning, do they bill a higher level of Evaluation & Management code for PI or Worker’s Compensation cases and a low-level code just because they are cash patients?
  • Do you waive deductibles or co-payments? This is clearly a violation of rules and regulations and most provider agreements unless a true financial hardship is established by the clinic.
  • Do you have a written financial policy that is covered with patients? Many complaints to Boards of Examiners seem to be triggered by a poor financial policy, which is easily eliminated by written policy.
  • Does the clinic have a compliance plan in place to minimize the potential for fraud and abuse and to ensure compliance with all layers of regulations? There are many steps that can be taken today to minimize the potential for audits and mitigate potential fines and penalties.
  • Has the practice ever been audited? If so, what was the outcome? Today, it is not a matter of if you will be audited, but when. And, keep in mind, just because there has been an audit does not mean someone did something wrong. It could just be their number came up.
For further advice on developing office financial policies, request a copy of our “7- Steps to a Sound Financial Policy,” recently published in The American Chiropractor. If you are a recent graduate or will be soon, start learning about compliance now. It is never too soon and never too late. I often say, compliance is not an event, it is a process, and it should be ongoing. Start learning more about billing, coding, and documentation and what a sound financial policy should contain. If you or the practice you are considering joining offers discounts to your patients, learn about the role of Discount Medical Plans and how they can help you help your patients by offering legal network-based discounts without putting yourself at risk. 

Finally, despite what seems like a list of overwhelming decisions and concerns, you are embarking on a career as a doctor of chiropractic at a time that has opportunities like we have never seen before. Expect the best, give your best to the profession and your patients, and you will not be disappointed.

Dr. Foxworth is a certified Medical Compliance Specialist and President of ChiroHealthUSA. A practicing Chiropractor, he remains “in the trenches” facing challenges with billing, coding, documentation and compliance. He has served as  president of the Mississippi Chiropractic Association, former Staff Chiropractor at the G.V. Sonny Montgomery VA Medical Center and is a  Fellow of the International College of Chiropractic. He founded ConservaCareCorp, the first chiropractic network selected by the State of Mississippi to serve over 195K covered lives in the State Health Plan. You can contact Dr. Foxworth at 1-888-719-9990, This e-mail address is being protected from spambots. You need JavaScript enabled to view it or visit the ChiroHealthUSA website at www.chirohealthusa.com

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