Denneroll Combined with Pope 2-Way Aids Patient Suffering from Chronic Whiplash Associated Disorders & Advanced S.A.D.D.

Joseph Ferrantelli, DC

Private Practice New Port Richey, FL

CTO CBP^® Seminars

CEO PostureCo.

Deed E. Harrison, DC   

President CBP Seminars, Inc.

Vice President CBP Non-Profit, Inc.

Chair PCCRP Guidelines

Editor—AJCC

INTRODUCTION

In this case report we present CBP Technique management of a patient with chronic whiplash associated disorders (WAD) and associated cervical spine kyphosis, flattening of the upper thoracic kyphosis, and moderate-severe spinal arthritis and disc disease (S.A.D.D.). The patient recently had over 50 visits with another chiropractor in the state of Florida which failed to improve his condition.

Case Report

In addition to the recent 50-plus Chiropractic treatments, the patient has had ‘regular’ chiropractic care for 10 years prior to his previous doctor. Furthermore, he was suggested surgery 10 years prior due to severe disc herniations, stenosis and instability of the cervical spine.

The patient’s most recent chiropractor recommended the use of an un-named at “home wedge” type of fulcrum-traction in the cervical spine for approximately 6 months; it is unknown how often and for how long the patient performed this or if it was indicated for the type of curvature and condition. Regardless, the patient still being symptomatic, found his way to the office of one of the current authors (Dr. Joe) where new cervical spine x-rays were obtained.

• Patient Complaints
• • Patient reported that his average pain per day was an 8/10 on a numerical rating scale.
  • Patient reported a limitation to his activities of daily living on a Neck Disability Index.

• Radiographic Findings

In the initial x-ray (Figure 1A), the patient has severe degenerative changes, along with significant instability upon flexion and extension radiographs. Additionally, the patient x-ray shows:

• A reversed cervical curve measuring +8.4° from C2-C7 posterior body lines,
• A straightening of the C7 posterior body line relative to vertical; indicating flattening of the upper thoracic kyphosis. See Figure 2.

Given the patient had such advanced S.A.D.D., and having no problem with treating in the office, he elected for an intensive 36 visit plan over the course of 9 weeks (35 total rehab sessions were performed).

Figure 2. C7-Body Tangent to Vertical. A line is drawn along the posterior body margin of the C7 vertebra (black line) and measured in flexion or extension relative to a vertical line originating either at the posterior inferior body of C7 or T1 (shown in Red from T1). In the Harrison Ideal Model, the ideal value of this angle = 21.5° of flexion relative to vertical.

If the value is ≤ 21.5° it indicates potential hypo-thoracic kyphosis of the upper thoracic region, T1-T4. If the value is ≥ ≤ 21.5°, then there is a potential hyper-thoracic kyphosis from T1-T4. A patient can’t have a normal cervical lordosis without a normal upper thoracic kyphosis!

• CBP Treatment Approach

In office treatment consisted of mirror image® adjusting setups to increase the upper thoracic flexion angle and increase the cervical lordosis(Figure 3). Given the mild retrolisthesis in the lower cervical spine and the flattening of the upper thoracic spine, no cervical extension exercises were given in this case as the treating clinician anticipated that this would flatten the upper thoracic kyphosis (T1-T4) even further. Additionally, Pope 2-way in office traction was performed with a lower neck front pull and an elevated back pull of approximately 45-60° above horizontal.

At home he used the Denneroll orthotic in the lower cervical-upper thoracic region (Figure 4), working up to 2 sessions per day of 20 minutes on his ‘off days’ from Dr. Joe’s clinic, and 20 minutes in the morning on the days he treated at night in the office. A total of 40 Denneroll home sessions were performed along with 35 in office CBP procedures.

Figure 3. Mirror image adjustments were given in extension and NO posterior head translation to improve the lordosis. Also, a wedge shaped block is placed in the mid-thoracic spine in order to round-increase the mid-and upper thoracic kyphosis. The thrust is given P to A in the lower cervical spine. This corrective adjustment aims to improve the cervical lordosis while simultaneously increasing the upper thoracic kyphosis.

Case Outcome

Subjectively, the patient while not totally asymptomatic, had his average pain reduced to a 2-3/10 from 8-9/10 and he was able to return to more vigorous activities of daily living with less intense painful episodes.

The follow-up lateral cervical radiographic exam found:

• That the disc spaces at C5-C7 appear to be improved in height and alignment following treatment regimen;
• The cervical kyphosis is now a cervical lordosis measuring -12.5° of extension from C2-C7 (a 21° correction);
• The C7 posterior body angle relative to vertical is moving into a more normal flexion alignment.

SUMMARY

The patient obtained quite a dramatic correction in cervical lordosis (21°) considering the extent of S.A.D.D. and the short amount of treatment duration. We believe the successful results are attributable to the addition of the Denneroll orthotic use at home in combination with the in office Pope 2-way traction and proper mirror image adjusting setups. Further, this case suggests that good patient compliance can be readily achieved with CBP protocols provided in the clinic and at home.

cervical lordosis, Chiropractic BioPhysics, disc degeneration, kyphosis, PostureCo, PostureRay, PostureRay, subluxation, whiplash, x-ray digitization software, x-ray digitization software, x-ray digitization software

Foot Posture – Rockers, Pivots and Vaults

Stuart Currie DC,

Director of Research, Sole Supports.

www.solesupports.com

INTRODUCTION

The foot is the primary interface with the ground allowing smooth locomotion through space: a simple enough concept perhaps, but how is forward movement really accomplished? Through a complex system of pivots, vaults, and rockers, the foot absorbs force and enables movement – a truly brilliant design. One question that is often asked is does the foot push, pull, or act as a spring?

DISCUSSION

The following is a presentation of what we know about how downward directed forces are converted into sagittal plane forward momentum. Dananberg stated that the amount of sagittal plane motion of the foot required during gait is 500% that of the frontal and transverse planes the significance of which cannot be minimized¹. Dananberg’s article is considered a critical treatise on sagittal plane biomechanics as it applies to the foot. A summary of points made in the article is as follows:

• Working models of “muscle-less” walking machines have been constructed, tested and proven accurate.
• Bipedal gait is based inherently on the integration of gravity and momentum.
• The power for walking is predominantly by the swing leg, pulling the body over the standing limb.
• The stance limb is passive.
• Restrictions in this system (through a loss of range of motion) cause compensations.
• The magnitude of forces involved is sufficient to create deformity.
• Pathologic ligamentous laxity or neurologic absence of the muscle guarding response can contribute to an accommodation in which the body forms its own rocker deformity of the foot.
• Failure of one joint to move properly alters the motion of the entire structure.
• The power to propel the body forward is extrinsic to the foot.

From Kapandji, IA, The Physiology of the Joints, Vol.II, p.199

It becomes evident when evaluating these concepts, that the foot can function as a relatively passive rocker in the transmission of movement and that this rocker is affected directly by its posture. The three key contact points at the base of this vaulted posture are the first metatarsal head, the fifth metatarsal head, and the heel. It is this posture that defines the stabilized position of the foot that is so important in maintaining supination against body weight.

In her chapter on basic functions, Jacqueline Perry describes three rockers of the foot: the heel rocker, the ankle rocker and the forefoot rocker.² The heel rocker preserves forward momentum of the body as weight drops onto the leg by rolling forward. The ankle rocker is a fulcrum for continued propulsion as the tibia continues to advance and is dependent on the soleus muscle to allow forward progression of the tibia. As the heel rises and the center of pressure advances past the metatarsals, the forefoot rocker allows continued unimpeded forward progress as the phalanges extend on the metatarsal heads. During the stance phase, while the foot is on the ground there is also a pivot shift as weight transfers from the lateral aspect of the foot to the medial side just before toe-off. The overall function of the rocker system is to convert the momentum of the moving body at heel strike into an efficient forward roll.

Sagittal restrictions cause blockages in forward motion. These restrictions can include ankle and meta-tarso-phalangeal joint limitations, both of which can be addressed with manual therapy techniques and manipulation.

The various arches of the foot, medial longitudinal, lateral and transverse provide selective planar stability to the foot. As a whole, they can be considered a plantar vault. Any one of these arches is only a 2D slice of the 3D architecture of the foot. The stability of the vault and rockers is related to the degree of re-supination the foot can achieve. The rockers of the foot can be made or broken by foot posture – i.e. a well formed plantar vault. If a proper plantar vault is not present in a pathologic foot it is benefitted by an orthosis that is casted in a corrected position providing a spring mechanism for gait that the foot did not have otherwise. A study investigating the effects of an orthotic designed to support the plantar vault in a specific corrected position has shown that these foot orthoses can increase the economy of gait.³

For the clinician it is important to realize that in order to see sagittal plane compensations properly, you must evaluate your patients from the side during walking. Restrictions in flexion and extension at the knee, hip and foot can only be visualized from the side. This is important because Dananberg also showed these blockages in hip extension and toe dorsi-flexion (hallux limitus) are also causative factors in chronic low back pain.⁴

It is generally accepted in the realm of orthopedics that joint loads are affected by posture, position and motion. It is therefore logical to assume these concepts are at work in the foot, and the morphology that is observed can have a profound effect on the transmission of forces through the body during gait.

Reference List

1. Dananberg HJ. J Am Podiatr Med Assoc 2000 January;90(1):47-50.
2. Perry J. Gait Analysis: Normal and Pathologic Function. Thorofare: SLACK Inc.; 1992.
3. Trotter LC, Pierrynowski MR. J Am Podiatr Med Assoc 2008 November;98(6):429-35.
4. Dananberg HJ. J Am Podiatr Med Assoc 1993 August;83(8):433-41.

SoleSupports

Chronic Upper Thoracic Hyper-Flexion and Headaches

Don Meyer, DC

Private Practice Huntington Beach, CA

President Circular Traction Supply

CBP Instructor

INTRODUCTION

It is sometimes difficult to differentiate between a simple forward head posture problem and an upper thoracic hyper-flexion subluxation problem. Their symptoms and appearance can be very similar, but their corrective treatment is quite different. In this article, I will present a case study that illustrates the differences between these two conditions.

Case Study

A 23 year old male presents with chronic severe headaches that he has suffered with (2-3 times per week) for the last 2-3 years. He rates the headaches as a 7-10 level on a 0-10 numeric pain scale. He also denotes having occasional left upper thoracic/neck pain that he rates as a 4-7 level.

The patient’s initial cervical ROM exam demonstrates a restriction of flexion, rotation and lateral flexion (3% whole person impairment). His postural exam shows a general forward head carriage on lateral inspection. His AP head/thoracic posture is relatively normal. His initial lateral cervical x-ray analyses was preformed with the Posture Ray™ digitizing program and denoted 28.3 mm C2-C7 anterior translation and a 33.1% loss of normal lordosis (see x-ray #1). He has a positive foraminal compression test bilaterally in the upper cervical region indicating a chronic upper cervical facet joint inflammation.

The patient was started on a rehabilitative treatment program to strengthen the deep anterior neck flexors and reduce the Forward Head Posture (FHP). This consisted of posture corrective head weighting and ambulatory use of the Cervical Remodeling Collar™ (10-15 minutes each). Diversified spinal manipulation was also preformed. After 14 treatments the patient was re-evaluated.

The patient’s pain levels and frequency had now decreased. His new cervical ROM exam reveals grossly improved rotation and flexion, but only a mild improvement of lateral flexion. His new lateral x-ray showed only a mild improvement of the FHP to 27.4 mm and a moderate improvement of the lower cervical lordosis.

Because of the persistent FHP, the patient’s lateral cervico-thoracic posture was re-evaluated with the patient and on the new lateral x-ray. On closer inspection, it was determined that this patient’s upper thoracic spine was fixated in a state of hyper-flexion. To confirm this on the radiograph, lines are drawn on the back of the body of C7 and vertically up from the posterior inferior body corner of C7. The angle these two lines create should be approximately 22-24° in the normal upper thoracic spine. A much larger angle is indicative of an upper thoracic hyperkyphosis and a much lower angle indicates a straightened upper thoracic spine. This patient’s C7 to vertical angle was increased to 37°, confirming the upper thoracic hyperkyphosis.

The CRCollar™ and head weighting was discontinued and the patient was started on motorized axial extension traction as shown in

Figure 1. This traction targets the lower cervical/upper thoracic spinal regions and provides passive intermittent extension traction at a rate of 13 times per minute

.

The patient performed 10 more treatments of this new traction (10-12 minutes) and continued manual manipulation of the thoracic and cervical regions. The patient’s symptoms continued to decrease in frequency and severity throughout this last phase of his treatment. On his final re-evaluation not only did this patient’s lateral flexion ROM notably improved, but his FHP was reduced to only 11.6 mm and his cervical lordosis was completely restored (see x-ray #2).

CONCLUSION

The typical patient with moderate FHP will usually have an extension fixation of the upper cervical spine (restricted flexion). Performing posterior head translation traction (CRCollar™) will induce flexion into the upper cervical spine and along with muscle rebalancing (head weighting) will nicely correct this aberrant condition. But as this case demonstrates, it is possible that the FHP can be secondary to an upper thoracic flexion fixation which usually shows itself as restricted cervical lateral flexion. Upper thoracic extension traction must be performed to correct the FHP in these patients.

Chiropractic BioPhysics

Prescription Drug Spending in USA Double

• “Over the last 10 years, the percentage of Americans who took at least one prescription drug in the past month increased from 44% to 48%. The use of two or more drugs increased from 25% to 31%. The use of five or more drugs increased from 6% to 11%.
• In 2007–2008, 1 out of every 5 children and 9 out of 10 older Americans reported using at least one prescription drug in the past month.
• The most commonly used types of drugs included: asthma medicines for children, central nervous system stimulants for adolescents, antidepressants for middle-aged adults, and cholesterol lowering drugs for older Americans.”¹

Furthermore, spending on prescription drugs in the U.S. totaled more than $234.1 billion in 2008 and this figure is more than double the amount spent in 1999.¹

Key Take Home Points

Research demonstrates that conservative chiropractic interventions may help offset one of the primary cost drivers in the current healthcare system: drugs. For example, a 2004 study by Sarnat and Winterstein⁴ conducted on nearly 22,000 patients over a four year period, demonstrated the following cost reduction when care was directed by a doctor of chiropractic:

1. 1. 51.8% reduction in pharmaceutical costs!
2. Assuming a simple extrapolation, a 51.8% reduction in prescription drug expenditure would have saved the US Health Care system over $121 BILLION in the last decade had Chiropractors directed patient care or at least were a major part of it.
3. Instead of 1/5 children being on prescription drugs in the US, perhaps parents should consider Chiropractic care as the first line of care. See Dr. Len Siskin’s article in this issue.
4. Perhaps the increase in prescription drug use in the USA is one of the driving forces behind the CCE’s recent attempt to change the course of the Chiropractic profession towards the use of drugs (see Dr. Joe Betz’ article in this issue). Chiropractors—THE PROFESSION—need to promptly steer CCE back to our roots and livelihood and away from the use of drugs and surgery as the first line of defense of Chiropractic patient care.

References

1. Gu Q, Dillon CF, Burt VL. Prescription Drug Use Continues to Increase: U.S. Prescription Drug Data for 2007–2008 NCHS Data Brief, No. 42, September 2010 US.
2. http://www.usatoday.com/yourlife/health/healthcare/2010-09-04-prescription-drugs_N.htm
3. http://www.cdc.gov/nchs/data/databriefs/db42.htm
4. Sarnat R, Winterstein J. Clinical and Cost Outcomes Of An Integrative Medicine IPA. Journal of Manipulative and Physiological Therapeutics 2004; 27: 336-347.

Untitled

Life Chiropractic College West (LCCW) Highest in Alumni Satisfaction

“Life Chiropractic College West alumni continue for the third year in a row to honor their alma mater in an independent survey administered and tabulated annually by New York Chiropractic College (NYCC).”

Analysis of the survey data demonstrated that LCCW ranked #1. Respondents were chiropractors who graduated three, five, and seven years ago. A questionnaire was administered to each Alumni covering 17 different issues regarding the quality of Chiropractic education and satisfaction with the profession. LCCW alumni ranked highest of all the participating colleges in the key areas of "satisfaction being a chiropractor" and with the "overall value of your education."

Additionally, LCCW alumni ranked among the highest levels of "feelings of success," of being "prepared to effectively use techniques and treatments," and of being "prepared to manage patient care."

Need more reasons to attend Life Chiropractic College West? Call 800-788-4476 and ask for the Admissions office.

AJCC Editors Note: My wife and I are both graduates of LCCW and valued our education and time there. Furthermore, LCCW is the only Chiropractic College to offer CBP Technique as a core curricula course that each student sits in their first year; additionally, it is the only Chiropractic College to permit CBP Technique protocols and procedures to be practiced in the last year of out-patient clinic.

Second Class Doctor

R.J. Hammett, DC

Do you have this syndrome? Do you consider yourself a second class doctor as compared to a medical physician, a dentist, or a podiatrist? Do you feel less when a patient talks about their medical care? If you have even a slight disregard of chiropractic, you have a second class doctor mental state… Don’t!

While it is true that medical life saving care is wonderful, it is not a Health profession. It is a profession based upon many scientific inaccuracies, many money oriented individuals, and power hungry ego’s whose last thought is health of the patients. Recently, I had the opportunity to first hand witness several consultations with a stroke patient. I witnessed a Neurologist, Speech Pathologist, General Practioner, Physical Therapist, an O.T. and a parade of other consultants with this stroke patient. They not knowing who I was (only a chiropractor) went on with their normal business of patient care. Curiously, they all started and ended the same. Mr. Patient, you have had a slight stroke we don’t know why, we are going to do more test, prescribe some medications and then we’ll see what happens. All of these professionals had almost the same “pat” statements, approaches and answers. Watching the patient in total bewilderment was heart breaking for me. Nowhere was an action plan, a solid course of care explanation or recommendation to this patient.

What needed to be done? Just we’ll see. For those of you secretly aspiring to gain the respect as a medical physician has or mimic them by wearing scrubs to your clinic while walking around with a stethoscope around their neck. Wake up!! Chiropractic is so much more then this side show of health care called medicine. You want to ape the M.D. and P.T.? Why?

Medical care cannot hold a candles flame to the power of a correctly preformed spinal adjustment, that’s right an adjustment, not a manipulation. If you think I’m ranting and raving, go spend some serious time with these “real” doctors, really learn what it is really all about. To end this, I say “quit trying” to be an accepted member of the medical community, this is not chiropractic, be different, show the world that your spinal adjustment is more powerful than any drug, or any surgery, and quit being afraid.

Insufficient Evidence for Pediatric Chiropractic!

Len Siskin, DC

Promote Chiropractic,

Co-Chair ICA Best Practices

INTRODUCTION

Communication and honest reporting of scientific observations are the goal of healthcare research. In a recent overview of systematic reviews of randomized clinical control trials (RCT) using complimentary and alternative medicine (CAM) treatments, Katherine Hunt and Edzard Ernst of Peninsula Medical School in the UK point out that chiropractors, among other CAM professionals, have nearly failed to show RCT’s supporting claims of helping children¹. I would like to thank Dr. Matthew McCoy for bringing this to paper to our attention². The authors reinforce that they were simply using literature searches to overview existing reviews and did not actually read the original research papers themselves. They noted the failure of CAM professions, including chiropractic to produce adequate numbers of these types of reviews which are common in mainstream medicine. Be careful.

I am a practicing chiropractor and at first I became defensive when reading this paper. I was prepared to discuss the limitations of RCT’s in guiding clinical practice and the masses of research omitted by these authors. When I thought for a moment I realized the world of evidence based medicine values these types of evaluations so much they might not be so interested to know the volumes of research that exist. They are looking for a certain type of research performed by each healthcare profession and in the absence of reviews on chiropractic RCT’s they conclude that chiropractic care is ineffective for things chiropractors claim they can help in the pediatric population.

When looking at the numbers, 99 articles were located covering reviews of RCT’s spanning CAM professions of acupuncture/acupressure, Alexander technique, Aromatherapy, Bach Flower remedies, chiropractic, craniosacral therapy, herbal medicine, homeopathy, hypnotherapy/hypnosis, massage, naturopathy, osteopathy, spiritual healing, Tai chi, traditional Chinese medicine, and yoga. Twenty of these articles were included in this overview of which 4 appear to be chiropractic.

In their critical review aimed at assessing the effectiveness and safety of CAM for infants, children, and adolescents, the authors looked only at reviews of RCT’s to maximize reliability and validity of the review. Admittedly this excludes all other forms of evidence which is a problem when RCT’s are not available. The authors observe only one of three total RCT’s for colic using chiropractic was performed reasonably and showed no significant improvement with chiropractic treatment. This does not take into account the information in the ICA’s Best practices database which shows only 2 (not 3 because the third RCT reviewed has not yet been incorporated to the database) RCT’s and than 20 additional papers on colic and chiropractic where all papers showed improvement with chiropractic care and no adverse effects were noted.

It should be mentioned that because 19 of the 20 additional studies were case reports here a system of rating traits of the case report mathematically shows the data equivalent to .6 RCT value per paper on average and the total quality score is equivalent to about 12 RCT’s. Unfortunately for both our profession and for the understanding society has about chiropractic, the tendency in healthcare science is to ignore the lower profile and often more clinically representative research but in CAM professions, there has notoriously been little no funding with little emphasis for higher quality research so the lower quality research represents the vast majority of what exists for us to communicate the benefits of what we do to the scientific world.

The authors suggest claims about chiropractic helping otitis media are baseless as they were unable to find any reviews on this topic of RCT’s. Fifteen level III and IV studies were found in the ICA Best practices research database equivalent in point scores to nearly 10 RCT studies. Fourteen of the 15 papers showed positive treatment outcomes and one paper was inconclusive. No adverse effects were noted in any paper.

As for nocturnal enuresis, the authors found insufficient RCT reviews to suggest chiropractic can help. The ICA Best practices database shows 9 papers published on chiropractic helping this condition equivalent to 6 RCT’s in quality points where all papers showed positive outcomes and no adverse effects.

The truth of the matter is the Best Practices Database of the ICA shows about 290 papers on chiropractic treatment in children where all but 2 show positive outcomes and none show adverse effects. Many dozens of named medical conditions were shown to improve in these papers because of chiropractic care. The authors of the overview paper discussed here make the statement, “Our analyses do not reveal consistent evidence to suggest that CAM is effective for pediatric conditions.”

When I want to eat Chinese food in New York City I would not go to Little Italy even though it is across the street from Chinatown. If I want Chinese food I should cross the street to Chinatown! If I were looking for Chinese restaurants in Little Italy I might conclude that New York City is void of Chinese restaurants. Dr. McCoy recently urged chiropractors to subscribe to peer reviewed chiropractic journals to show that chiropractors are conscientious about the research in our profession and to prove to the world we care. Furthermore, he urged chiropractors and chiropractic organizations to publish more research. The discussed overview of reviews of CAM RCT’s written by professionals in mainstream medicine sadly conclude what this author found to be negative about the entire CAM industry. Without good quality chiropractic research and a vehicle to communicate and publicize that research our profession will continue to be represented in this negative light.

Problematically, insurance companies, guideline developers, and ‘other reviewers’ are likely to use papers like the Hunt and Ernst¹ one which misrepresent our existing research and to some extent vilify CAM to deny payment for care. Consumers will be left with the personal financial responsibility without the real information behind what we do. If you are reading this and want to defend what you do a good step would be to go online to www.chiropractic.org and purchase a copy of the very readable ICA Best Practices Guidelines and also a copy of the ICA’s Practicing Chiropractors Committee on Radiology Protocols (PCCRP) Guidelines if you take chiropractic x-rays. The monies spent to purchase these materials go to educating accrediting bodies, law firms, state boards, malpractice insurance companies, etc.

These two ICA based Chiropractic practice guidelines also help defend chiropractors in lawsuits. The information in these resources will prove vital to any chiropractor writing a report to a patient, other professional or third party payer. Support our great profession and protect your practice by purchasing these materials and subscribe to a scientific journal! Join organizations within our profession who support your philosophy of chiropractic and be very careful when discounting what role research will play in your future ability to help the people who honor you with their trust and health status.

References

1. Hunt, Katherine; Ernst, Edzard. The evidence base for complimentary medicine in children: a critical overview of systematic reviews; ADC Online July 6, 2010; 10.1136/adc.2009.179036 BMJ Publishing Group
2. McCoy, Matthew Ernst Slams Chiropractic for Children; http://researchupdate.mccoypress.net/2010/07/29/dont-just-sit-there.aspx

Chiropractic BioPhysics, ICA Best Practices Chiropractic Guidelines

From Success to Significance: A Vision for a Significant Chiropractic Career

Yurij Chewpa, DC

Practice Coach & Mentor

Co-Founder Warrior Coaching

Co-founder Chiropractors with Compassion

www.warriorcoaching.org

www.chiropractorswithcompassion.org

INTRODUCTION

If you took the time to hang out at most chiropractic seminars and conferences, and listened to the conversations in the hallways and restaurants of the hotel for long enough, you would come away with one common, two-part definition of success in practice: patient volume and practice income. Inherently, there is nothing wrong with volume and income as long as they are a byproduct of devoted service, or an indicator for the level of service the doctor is bringing to the community. However, most often the volume and income are the end point. They are not merely the indicator, they are the goal. There is likely a lot of cover up about the actual intent of the practice. There will be a nice mission statement on the wall stating that the mission is to save lives and change the world. Everybody on the staff is scripted to say the right things.

Unfortunately, you cannot fool the patients for long. They will quickly see through the charade. It doesn't take long to figure out that it's all about the Doctor and not about them. They will stop referring and they will stop coming in for care. This, of course, will sabotage the volume and income goals of the practice. This is the first failed practice scenario: missed goals, and chronically low volume and collections, will lead to mounting financial pressure and the doctor's dissatisfaction with practice.

But let's say that the doctor practices in a larger urban center, he has a good marketing program in place and he can continue to find enough new patients who don't yet know his true motives. He can continue to build his volume and income by attracting more new patients. This is where the second problem scenario kicks in. If it's just about the volume and income, the practice quickly becomes too difficult and too much work to maintain. Both scenarios, not enough volume and too little income, and too much volume and lots of income, both done for the wrong reason and with the wrong motive, lead to the same problem: a tired, frustrated and burned out doctor that is looking for an exit strategy. Whether driving the same old Pinto from college or a new Mercedes with DC plates, he just wants out.

DISCUSSION

How can you avoid this trap? In my 25 years of practice, and 10 years of coaching experience, I have come to the conclusion that there is only one solution, and that is to change the doctor's vision. To achieve significance, the doctor's vision needs to change from volume and income (leading to early retirement and an unfulfilled life) to one of service to the sick and lost in the community.

Doctor, it cannot be about making as much as you can in as short a time as possible so you can eventually stop practice and go do what you really love to do. If you really love something else, then go do that now, and you will be successful at it. Otherwise, decide that you are going to serve the people as a chiropractor for as long as you can remember their names and have the strength to accurately move the bone. If you make this decision, you will have more love, joy and peace in your life than you could ever imagine.

Changing Your Vision

Here are some of the benefits that you will experience if you change your vision for your chiropractic career to that of service to others over the long run:

• You will lessen the short-term pressure on your life. This will allow you to keep your priorities straight, which is putting family before practice and God before family.
• Patients will recognize that you are there to serve them. If you make them your number one priority they will thank you by following through on your recommendations.
• Your patients will stay long enough to get the results that they came for. This will exponentially raise the level of their experience in your practice and will increase your personal satisfaction in practice.
• Your patients will refer their family members. You will be able to serve families in a lifetime wellness model.
• Your patients will refer their friends. You will finally have that referral practice of which you always dreamed.
• Your patients will pay you a fair fee for your adjustments. You will be able to eliminate the insurance companies before they eliminate you, and have a cash practice.
• You will attract a great team, because people want to work for an organization that has a purpose beyond the bottom line. They, too, want to make a difference in people's lives.
• You will have much less stress, because a referral practice is much less stressful then a marketing practice.
• You will remain significant and become more and more valuable as you get older because of your experience and expertise.
• You will achieve much higher service goals, because we always underestimate how much we can get done in the long term and overestimate how much we can do in the short term.
• You don't have to worry about financing your retirement, because when your friends are retiring and dying you will be entering into the most productive and profitable years of your career.

SUMMARY

As you progress in your career during the decades ahead, you will be able to attract, train and mentor young doctors to work alongside you. This will allow you to focus on the things in practice that you really love to do and delegate everything else.

1. When you go to sleep at night, you will have peace.
2. You will have the resources, both human and monetary, to take time away from the practice to renew and rejuvenate your life.
3. Your practice will carry on after you are gone, and your life will leave a legacy of service for future generations to model.

The above are just a few of the benefits of changing your vision. I could keep going but I think you get the point. Only you can decide which way you want to go. A shift in vision sounds simple but it will not be easy. It will require a willingness to change as well as stepping into fear, but in my opinion it's the most important thing that you could do. The stakes are high - your life depends on it!

warrior coaching

50-100 Patient Visit Increase in 30-90 Days

Eric Huntington, DC

Co-Owner Developer of the Chiropractic Business Academy

The Challenge

A friend challenged me to write a one page blueprint article on increasing your patient visits by 50 to 100 visits in 30 -90 days. Since this sort of increase is typical of new CBA clients, I figured I’d give you my viewpoint on the topic.

Step One – Capacity

Decide what increase in patient visits you want and then add that to your current volume. Look this new number and figure out if your current facility can handle it. Who is holding what posts? How close to maxed out are the staff now and what would it be like at the new volume?

For prediction, you can use this simple tool. It shows the number of staff, weekly volume and minimum monthly collections

1 DC + 0 Staff = 50 pv/wk = $10K Month 1 DC + 1 Staff = 100pv/wk = $20K Month 1 DC + 2 Staff = 150pv/wk = $30K Month 1 DC + 3 Staff = 200pv/wk = $40K Month

These numbers tend to hold fairly true throughout the spectrum of various styles of chiropractic, however once a practice goes over 200 pvs, and depending on what post the owner doctor chooses to hold, the staff complement will vary.

This is only a tool. If you’d like help evaluating your practice against this guideline, call CBA and one of our consultants will go through it with you.

Hiring

If you determine you need to hire, start now. Chiropractors often fail to predict the amount of time it takes and the number of people you’ll interview/hire before you find one person to hire. Want to know how CBA clients hire? Read my article “How to Hire Staff” at: chirobizacademy.com/wordpress/

Assess the Capacity of your Space

Look at the space in your office compared to the volume you want. Do you have the necessary space and equipment for the increase? If so, great—if not, decide to either adjust your space/ equipment or settle for a smaller increase that will fit the office.

Step 2 –Current Procedures

First we will take up what you are already doing. This is a first line of action that can increase many clinics by 50 visits, alone.

How Well Are You Keeping Them? Look at your new patient procedures. Do you have an effective initial office visit and report of findings that is resulting in 90% or more of referral patients and 75% or more of all patients accepting your recommendations?

Are your recommendations exactly what you believe the patient should receive? Or are you basing it on something else such as insurance coverage or what you think they will accept or can afford?

Look at the rate of fall off in your clinic. This can often be hidden in a disorganized office. However, most doctors know roughly how often this is occurring. Most patients should be finishing your recommended plan.

Now take a look at the percentage of patients that resign onto maintenance care. CBA strategies often result in a resign rate for our clients that ranges from 70%-90%. CBA also teaches a procedure that will encourage every patient to return to your office for a checkup within a few months even if they don’t elect routine maintenance.

Do whatever it takes to address deficiencies in these areas, quickly.

Step 3 - Marketing

New patients into a practice is the gas pedal of the clinic. What will it take to hit your targets? Determine how many additional patients starting on care you’ll need to increase by the desired 50-100 visits. One way is to divide the increase you want by 3. This is assuming new patients start care at 3x/wk.

The other factor is how many weeks at 3x/wk. Let’s assume it’s 8 weeks. You then have 8 weeks to pump up the volume before patients who started in week one begin to decrease frequency. Take your desired visit increase (ie 50) and divide by 3. This is how many additional starts you need. Take that number and divide by how many weeks you want to put between you and your goal. To get a 50 visit increase in 8 wks you need 2.1 additional starts/wk.

Determine your New Patient to Patient start ratio over that same time period. For example, if you’ve averaged 3 starts per week off of 4 new patients, then you see how many more new patients you need in order to hit the starts target.

In our example above, if you determine you need 2.1 additional starts per week for 60 days to hit your target, then you would need 3 additional new patients per week. However, if you are mainly a referral practice, and you decide to start external marketing, it is important to realize that starting non referral patients onto care is more difficult, so you may want to build in a cushion, so let say you’ll need 4-5 additional new patients.

How To Get More New Ones!

Internal marketing is a great place to start. However, depending on your target, this may not be enough. CBA teaches many very effective internal and external strategies.

When it comes to external marketing, CBA clients have found it most efficient to train non doctors to this. However, unless a doctor is trained on how to manage this activity effectively, it can be a total flop. So, for many of our new CBA clients, we will teach them the most efficient external marketing they can do, without staff. This includes lectures, corporate massage events, and internet marketing.

For example, one massage or lecture event per week can generate an additional 5-10 new patients per week. So, for the doctor who knows how to do this, it can be an efficient way to spend a couple of hours.

So figure out your plan today and target out for a 50-100 visit increase in the next 30-90 days! CBA would be happy to help you plan out your expansion (in a free consultation), or just provide you with more info on our program. It’s up to you!

October through December is the best time to start working with CBA. This is because we can teach you our Incredible Holiday Promotion which has proven to increase practices by 50-100 visits per week in the months of January and February!

Learn more about the CBA program or our holiday marketing program. CALL 888-989-0855

Chiropractic Business Academy

Cervical Spine Kyphosis: Disc Degeneration and Spinal Cord Ischemia

Dan Murphy, DC—

Private Practice of Chiropractic;

Diplomate American Board of Chiropractic Orthopedist;

Faculty Life Chiropractic College West;

Vice President ICA 2003-2009;

ICA Chiropractor of the Year 2009

INTRODUCTION

Since at least the 1970s, chiropractors have been taught that cervical spine kyphotic angulation is associated with a number of adverse effects, including:

• Chronic muscular contraction stress as a consequence of mechanically shifting the center of mass of the head forward, requiring muscle contraction as an effective counter balance. This is well described in the writings of rehabilitation specialists Rene Cailliet, MD.¹
• The acceleration of degenerative disc disease. This is well described in the writings of radiologist Lee Hadley, MD,² and orthopedic surgeon Ruth Jackson, MD.³
• Spinal cord tethering, ischemia and dysfunction, and possibly demyelinating disease. This is well described in the writings of neurosurgeon Alf Breig, MD.⁴

In this current article, I will review two recent studies that supports these teachings:

Kyphosis One Level Above the Cervical Disc Disease: Is the Kyphosis Cause or Effect?⁵

Key points from Ozer et al 2007⁵ include:

1. Reversal of the cervical lordotic curve into a cervical kyphosis “can be due to degenerative, inflammatory, traumatic or neoplastic conditions of the cervical spine.”
2. Cervical spine kyphosis may be a factor in the development of cervical disc herniation and spondylosis.
3. “With a loss of the normal sagittal alignment in kyphosis, the weight-bearing axis shifts anteriorly, and constant muscular contraction is required to maintain upright head posture. Eventually fatigue and pain occur, and the kyphosis progresses. The anterior shift of weight onto the vertebral bodies and degenerated discs results in a vicious cycle of disc degeneration and the formation of vertebral osteophytes. Thus, kyphotic sagittal alignment may provoke further degeneration at the adjacent segment. The increase in weight born by discs at lower level(s) may also cause the nucleus pulposus to herniate or degenerate. In the case of cervical disc disease associated with kyphosis at one level above, instability and kyphosis may perhaps be the initiating event, which later may act as a factor in the development of disc herniation and degeneration one level below.” These concepts of muscular contraction and developmental discogenic degeneration are consistent with the writings of Cailliet, Jackson, and Hadley.
4. Uncorrected cervical spine kyphosis, especially if greater than 11°, can be associated with the following:

1. Cervical disc disease.
2. Progression of the kyphotic angulation.
3. The spinal cord becomes draped and flattened over the posterior aspect of the vertebral bodies, diminishing the microvascular supply to the spinal cord.
4. Adverse stretching or tethering of dentate ligaments and cervical roots.
5. “Direct neuronal injury and myelopathy with progressive deformity may result from both spinal ischemia and increased spinal cord tension.” These concepts are consistent with the writings of Breig.

1. Even mild cervical kyphosis may put the spinal cord at risk for histopathologic and vascular changes. “Maintaining normal cervical anatomy with its lordosis in this region of prominent movement may optimize the cord function.”
2. In kyphosis, “radicular symptoms and findings may develop secondary to foraminal narrowing from uncovertebral and/or facet joint hypertrophy.”
3. Kyphotic angulation one level above the level of cervical disc disease “may be a factor in the development of cervical disc herniation and spondylosis, rather than its result.”

Figure 1. Measurements of cervical spine segmental instability on the lateral cervical x-ray.

Cervical Spondylotic Myelopathy Associated with Kyphosis or Sagittal Sigmoid Alignment⁶

Key points from Uchida et al 2009⁶ include:

1. “The kyphotic deformity associated with cervical spondylosis is the result of progressive subluxation of the apophyseal joints due to degenerative changes in the facet joints and discs.”
2. “In patients with kyphotic deformities, the spinal cord shifts to the anterior portion of the spinal canal and abuts the posterior aspect of the vertebral bodies at the apex of the deformity.”
3. “Dynamic forces caused by segmental instability, which is often seen at the level of kyphosis particularly in cervical flexion movement, contribute to compromised cord function.”
4. These factors are indicative of segmental instability, as determined by evaluation of the flexion lateral cervical radiograph:

1. Segmental anterior vertebral translation ≥ 3 mm in the sagittal plane.
2. Segmental anterior rotation ≥ 10° in the sagittal plane; this angle is constructed by the intersection of the lines drawn on the inferior and superior aspect of adjacent vertebral bodies.
3. Reversed dynamic spinal canal stenosis of ≤ 12 mm on the flexion film; this is measured as the distance between the posterior superior edge of the vertebral body and the anterior edge of the lamina from the segment above, in the flexion position.

1. “Loss of lordosis or kyphotic alignment of the cervical spine and spinal cord may contribute to the development of myelopathy, and in patients with cervical kyphotic deformity, the spinal cord could be compressed by tethering over the apical vertebra or intervertebral disc or by ossification of the posterior longitudinal ligament.”
2. Longitudinal spinal cord distraction is a possible factor in progressive spinal cord dysfunction, and this issue is “often discussed clinically in the pathophysiology of tethered spinal cord syndrome.”

1. Cervical flexion produces flattening of the small feeding vessels to the spinal cord. “If the kyphotic deformity continues, there may be progression of myelomalacia and spinal cord atrophy. Patients with long-standing kyphotic deformities are at risk for progression of myelopathy with resultant permanent damage to the spinal cord.”
2. “We conclude that the sagittal kyphotic deformity related to flexion mechanical stress may be a significant factor in the development of cervical spondylotic myelopathy.”

SUMMARY

These articles emphasize the adverseness of cervical spine kyphosis: accelerated spondylosis, spinal cord tethering and myelopathy. In addition, kyphosis often has concomitant cervical spinal instability as contributing to the myelopathy, and we should check for spinal instability in all patients with cervical kyphosis of greater than 10°. The information presented herein, indicates that cervical spine kyphosis is often a serious clinical finding, especially if greater than 10° of angulation.

REFERENCES

1. Cailliet R. Soft Tissue Pain and Disability, Davis, 1996.
2. Hadley LA, Anatomico-Roentgenographic Studies of the Spine, fourth printing, Charles Thomas, 1979.
3. Jackson R, The Cervical Syndrome, Thomas, 1978.
4. Breig A, Adverse Mechanical Tension in the Central Nervous System: An Analysis of Cause and Effect. 1978. Almqvuist & Wiksell International, Stockholm, Sweden.
5. Özer, Ercan MD; Yücesoy, Kemal MD; Yurtsever, Cem MD; Seçil, Mustafa MD; Kyphosis One Level Above the Cervical Disc Disease: Is the Kyphosis Cause or Effect? Journal of Spinal Disorders & Techniques 2007, Vol. 20, Issue 1, pp 14-19.
6. Uchida K, Nakajima H, Sato R, Yayama T, Mwaka ES, Kobayashi K, Baba H. Cervical Spondylotic Myelopathy Associated with Kyphosis or Sagittal Sigmoid Alignment: Outcome after Anterior or Posterior Decompression; Journal of Neurosurgery: Spine 2009; Vol. 11, pp. 521-528.

Chiropractic BioPhysics, Dan Murphy, DC, Instability Ligament Laxity