CBP NonProfit Research Update- CBP Research Team Member Passes from ALS

Dr. Burt Holland, Ph.D (1946-2010)

Burt Holland, a professor at Temple University, died of ALS (Lou Gehrig's disease) at home Monday evening, June 21st. He was 64. He is survived by his wife Margaret, his children Andrew, Ben, Irene, son-in law Jeremy, his sister Joan, his brother David, and 4 cats. Burt most likely inherited this disease from his grandmother, who died after the same progression of symptoms as his. He courageously fought the disease for nearly 3 years.

After receiving a Ph.D. in Statistics from N.C. State in 1969 at age 23, he served as a professor in the Department of Statistics in the Fox School of Business and Management for the next 39 years. He was department chairman during 1991-1996 and was an elected Fellow of the American Statistical Association. He taught a variety of graduate and undergraduate courses, and supervised doctoral dissertations, often helping his doctoral candidates secure employment upon graduation.

In 2006 Professor Holland created a new and innovative course entitled “Statistics in the News” for Temple University’s Quantitative Literacy Program. This course has become very popular, with at least 120
students registered each semester. Burt Holland's graduate textbook Statistical Analysis and Data Display, coauthored with Richard M. Heiberger, is a contemporary presentation of statistical methods that features extensive use of graphical displays for exploring data and for displaying the analysis.

Professor Holland's research covered several topics, particularly multiple comparison procedures, an area to which he made significant contributions. This research continued until a week before his death.

Burt's interests included both domestic (he took pride in having set foot in all 50 states and visiting a plethora of baseball parks) and international travel. He was also an avid tennis player and Philadelphia sports fan, and had a keen interest in classical music.

A memorial service will take place at the Diamond Club of Temple University. Please email bellapeggy@gmail.com for the date and time. The Holland family would appreciate donations to the ALS Association, 321 Norristown Rd, Ambler, PA 19002.

chiropractic BioPhysics, Research

Active Cervical/Thoracic Exercise Rehabilitation with Pro-Lordotic Traction

Don Meyer, DC

Private Practice Huntington Beach, CA

President Circular Traction Supply

CBP Instructor

INTRODUCTION

It is usually more difficult to re-establish a lordosis in patients that present with a kyphotic cervical curvature and advanced degenerative joint disease (DJD). These patients usually complain of chronic cervical pain, muscle rigidity and restricted motion. Long term relief for these patients is generally not possible without some form of effective structural and soft tissue rehabilitation.

In this article I would like to present a case study of this type of difficult patient and an inventive solution I have found to help facilitate structural correction and soft tissue rehabilitation of these cases.

CASE STUDY

A 53 year old woman came to my office for evaluation and treatment of constant slight neck and upper back pain. On a 0-10 numeric pain scale, she rated her average pain as a two and her worst pain as a four. She also had constant tightness of her upper thoracic region. Her Neck Pain and Disability Index (Vernon-Mior) questionnaire revealed an eight percent restriction of her activities of daily living (ADL). The pain interfered with her reading and caused a mild disturbance of her sleep (1-2 hours sleepless). The use of a heating pad and 25 years of previous Chiropractic care provided her with only temporary relief.

On examination, her range of cervical motion demonstrated an eight percent impairment of normal motion, primarily restricting her lateral flexion and rotation. Her postural evaluation revealed a mild flattening of her upper thoracic kyphosis, mild forward head posture and a right lateral translation of her head on thorax with an associated left high shoulder. The AP and lateral radiographs were analyzed with Posture Ray™ digitalization and denoted a 20.2 mm anterior head translation with a 15 degree mid to lower cervical kyphosis (See Figure 1). The AP view showed 18 mm of right head translation.

Figure 1. Patient initial lateral Cervical X-Ray #1 (analyzed by the PostureRay® system).

A treatment program of progressive resistance (head halter and tubing) neck ROM exercises with mirror-image left head translations, mirror-image diversified spinal manipulation, standing left head/neck translation traction and seated and supine cervical 2-way axial extension (Pope) traction was initiated.

After one month of treatment (16 visits), and again after two months of treatment (16 more visits) the patient was re-evaluated. The patient stated that she was now pain free with no restrictions of her ADL, but her ranges of motion and post lateral and AP cervical x-rays were basically un-changed. Due to the lack of objective change, the seated and supine 2- way axial extension traction was stopped and supine, motorized 2-way compression extension traction was added to her treatment program for 12 additional visits. Even though this is not the ideal traction for her lateral neck/upper thoracic structure/ posture, I was desperate to get some objective change for this patient.

Re-evaluation again demonstrated no objective improvement, so the patient was released to monthly maintenance care. Some return of subjective pain was observed once the frequency of treatment was reduced. After five months of maintenance care, the patient also started getting symptoms of radicular left hand paraesthia with increased physical stress.

For the past two years I have been working on developing an inexpensive, motion-based home 2-way cervical traction device. At this point in time, I had been testing a new device design on myself. I was experiencing daily upper cervical pain and headaches after having whiplashed my neck while side-posture adjusting a very large patient. Spinal adjustments and various forms of physical therapy only provided temporary symptomatic relief. I developed eight different active exercises that I could perform with the device. After daily 5-10 minute application of these exercises for two weeks, not only had all my chronic neck and head pain subsided, but my lateral cervical curvature was also improved. So I asked my patient if she would like to try the device herself. She was instructed to stop use of the device if her pain or radicular left hand symptoms increased.

I termed the new lordotic exercise device: “the Pro-Lordoic Neck Exerciser™ (Figure 2)”. This device was modified after the CBP posterior neck traction strap exercise taught by Dr. Deed Harrison in CBP Cervical Rehab Seminars for the past several years (Dr. Deed taught this exercise to increase the upper thoracic kyphosis and load the lower cervical spine forward in Type 2-3 neck curves in the Cervical Rehab Text Chapter 6).¹ I modified this, CBP neck traction strap by adding resistance tubing and padded grip handles on each side. The patient used the device, which for one month and returned for another re-evaluation. The patient’s first comment to me was “I don’t really care if my neck curve is getting any better or not. I feel and can move my head and neck so much better since starting to use this device that I do not want to stop.”

Figure 2. Pro-Lordoic Neck Exerciser™. This device was modified after the cervical neck strap used and taught for this exercise by Dr. Deed Harrison in the CBP Cervical Rehab Seminars for the past several years. Resistance straps and padded handles were added to the posterior traction neck strap.

The patient’s range of motion impairment had decreased from eight to five percent, her persistent 15 degree kyphosis had reduced to 10 degrees and her forward head posture of 20.2 mm was now 17.3 mm. (See Figure 3).

Figure 3. Patient initial lateral Cervical X-Ray #2 (analyzed by the PostureRay® system).

CONCLUSION

This case is a good example of why it is so important to achieve objective functional and structural improvement with your patient care if you expect the patient to receive any long-term benefit from your treatments. Even after 46 in-office exercise sessions (with head halter and tubing resistance), this patient shown only mild functional improvement, no structural improvement and no lasting relief from her chronic condition. It was only through the application of daily home Pro-Lordotic™ traction exercises that a positive outcome was achieved. I have since seen this occur in numerous other cases.

References

1. Harrison DE, Harrson DD, Haas JW. CBP Structural Rehabilitation of the Cervical Spine. Evanston, WY: Harrison CBP Seminars, Inc., 2002, ISBN 0-9721314-0-X. Chapter 6.

Chiropractic BioPhysics, traction

Maximizing And Protecting Your Income: A Winning Combination

Tom Necela, DC, CPC, CPMA

Founder of The Strategic Chiropractor

Dr. Necela teaches chiropractors better billing, coding, documentation, collections and business strategies to improve their practice and work smarter, not harder. He can be contacted at www.StrategicDC.com.

Editor’s Note: Dr. Necela is one of the featured speakers at the upcoming 32^nd CBP Annual Conference on Sept 24-26^th, Scottsdale, AZ. See center page of this issue and www.idealspine.com for details.

INTRODUCTION

Most chiropractors would love to get paid better for what they do. If they are honest, most would also admit that they don’t necessarily want to work harder to increase that income! Similarly, few chiropractors intentionally engage in risky or questionable activities that put their assets at risk, regardless of the size of the potential gain.

If you can identify with these three statements, there is a winning combination available to you. In fact, it’s right under your nose! This combination will allow you to increase reimbursements without increasing your patient volume or working harder AND it will allow you to reduce your exposure to risks that could potentially rob you of your livelihood. It is an improvement which you can utilize every day of your career and an investment that can pay off for years to come, multiple times over.

In a recent article, health care consultant Keith Borglum plainly states one way doctors can do this: "The most cost-effective improvement is usually in improving your coding." Here's his reasoning why:

"An extraordinary number of physicians fail to stay current in their knowledge of coding, resulting in reduced reimbursement or delayed and denied claims. Many physicians purposefully under-code out of fear of penalties for up-coding or unbundling. Others leave their coding to support staff - an inappropriate approach virtually guaranteed to result in errors."

In my experience, his comments are right on the money. In chiropractic school, we were taught examination procedures so that we could accurately assess the patient's condition and create an appropriate plan of care. In many respects, our exams were also about protecting ourselves from malpractice resulting from potential hazards that could go undiagnosed.

But I have yet to meet a chiropractic graduate from any school who was taught how to properly document an exam for purposes of correct coding and billing. Unfortunately, the requirements are not necessarily the same. Upon learning what they are required to document to appropriately bill a certain level exam code, most DC’s are stunned because they are either way off the mark or they are performing many unnecessary tests that gain them nothing extra in the way of income or billable services.

As a result, most chiropractors fall into one of the two camps mentioned above. Conservative chiropractors tend to under-code or under-bill, thus denying themselves reimbursement for procedures they actually performed. More aggressive chiropractors tend to over-bill or up-code in ways that may not necessarily match up with coding or documentation requirements.

The worst news is that these same trends do not only apply to exam coding, but to all billable services we perform in our office. In this respect, most chiropractors can reliably improve income by making sure they are being paid for what they are already doing. Because most chiropractors lack proper training in this department, they are literally robbing themselves of potential income because they don’t know what they don’t know!

By learning proper billing, coding or documentation strategies, you have a fantastic return on your investment that allows you to both increase income AND save money. Here’s why:

The cost of attending a seminar such as the upcoming CBP Annual (hint, hint!) could easily uncover at least one item that you could help you improve your billable services. Even if that one item resulted in a $25 increase for a service or procedure you performed just a few times a week, it could add up to a $5,000 increase over the course of a year – better than a 12:1 ROI! Previous seminar attendees have confessed to me that one coding strategy I gave them would equal a $25,000 increase for their practice that year – how’s that for a ROI?!

In the wake of insurance audits, denials and payment delays, utilizing proper billing, coding and documentation can save you money and help protect your biggest asset – your practice! By helping you avoid post-payment demands, fines, legal costs to defend yourself, trouble with your state board and by helping you save the time it takes to jump through all the hoops to get yourself paid, doing things right the first time goes a long way towards keeping you out of trouble and protecting your money.

CONCLUSION

Regardless of what technique you use, what school you went to, and how big or small your practice, the reality is the same: looking outside your practice to increase your income potential makes little sense when you are already leaving plenty of income on the table through poor billing, coding or documentation procedures.

Sure, you can work harder and try to make up for it in volume by seeing more patients. But why not work smarter and make sure that you are getting maximum reimbursements from the patients you already have? In the process, you can slow down a little and make sure you are doing everything correctly so that you also protect your income from exposure to audits, delays and denials.

Finally, if you’re ambitious and willing to learn new strategies, you can do all of the above simultaneously and improve your practice exponentially!

Chiropractic BioPhysics

Chiropractic BioPhysics® College Course Updates

Cindy Boyd, DC Life Chiropractic College West

CBP^® at Life Chiropractic College West (LCCW) is in full swing! Currently CBP is taught in two parts. CBP Technique I is core curriculum with an average of 30 students per quarter and Advanced CBP II is an elective with 10 students on average. I am finishing up my first year of teaching both classes and am starting to get a grasp on all of the changes that have occurred over the last year, including the responsibility of running a busy CBP practice in Alameda, CA while implementing new and exciting things related to my classes at LCCW.

As a graduate of LCCW and a previous CBP club president, it brings me great joy to witness the evolution of the technique in the Chiropractic College setting. Many of us worked tirelessly for many years to make this all possible. Not only is CBP core at this point, but it is readily accepted by the students and clinic staff. Students have the ability to practice CBP with ease in the clinic setting due to fabulous clinic directors, and the new traction and adjusting equipment that has been donated over the past year. Since the 2009 CBP Annual in Scottsdale Arizona, the school has received many generous donations including: All new CBP teaching materials for the classroom, new CBP posters for the clinic, Denneroll™ home traction devices, PostureRay®, 4 Impulse^® Instruments, IMPAC^® brand adjusting tools, and a new Pope traction unit. Dr. Deed has donated the Denneroll home traction device to EVERY student in my class, and I have been able to give students class notes on CD’s similar to the CBP seminar notes. Class lectures are taught with new and improved Power Point presentations which are closely aligned with CBP seminar standards.

Over the next year, I will continue to improve the class and work with Dr. Kerri Duggins to improve the systems in the school clinic for CBP Technique applications. I hope you all will continue to support CBP Non-profit and donate to Life Chiropractic College West in the name of CBP.

Don Meyer, DC Cleveland Los Angeles

My first class has only five students this semester (May 2010); but the students have great enthusiasm for Chiropractic BioPhysics (CBP) technique. The students have been learning about the Harrison Spinal Model, how to read and list posture, and marking/measuring x-rays. They have also been improving each other’s abnormal posture with Mirror Image® Drop Table Adjusting in the Lab portion. I have been told that the students are enjoying the opportunity to learn CBP.

Jean-Guy Daigneault, DC UQTR

This past March I received a phone call from Dr. Deed Harrison to see if I would be interested in teaching a basic CBP course at the University of Trois-Riviere in Quebec , Canada. Without hesitation, my answer was yes. I thought it would be a privilege to help further advance the basic knowledge of Chiropractic BioPhysics in the French speaking province of Quebec. The course was given thru the Chiropractic technique department. There were 20 students that registered for the class and it was very well received. The class was a seven credit hour basic introductory course. I covered postural analysis, mirror image adjusting as well as mirror image exercises. We also covered the Harrison spinal model and an introduction to cervical traction. Now, I’m very excited to announce that the college would like me to return for another semester CBP Technique course! This time around we are expecting greater interest with approximately fifty students to register.

Abe Cardwell, DC Life Chiropractic College Marrietta, GA

Here at Life in GA, we are offering the Introduction to CBP class as an elective for upper class students, 10th quarter and above. The class is continuously filled to capacity; around 50 students each quarter. I am considering adding another lab section in order to open the class up to greater numbers. My hopeful objective is to have an Intro to CBP added into the core curriculum, much earlier in the curriculum, with an advanced class added as an elective; similar to how Life West CBP courses are offered.

If CBP can be added to the core curriculum, the technique will be included in the clinical experience, as well. At present, the young student docs cannot practice CBP in the clinic. They are somewhat frustrated in this regard, as you can imagine. There is a curriculum review taking place this year, and I am hopeful we will be added to core curriculum as part of this process. The students and many faculty are very supportive of the new data, and very grateful for the good work CBP has done to help us be better Chiropractors. I feel it is just a matter of time, patience, good communication, and open mindedness. All in all, things are going very well here.

Chiropractic BioPhysics

Postural Alignment & Health Disorders: A Scientific Connection?

Deed E. Harrison, DC

President CBP Seminars, Inc.

Vice President CBP Non-Profit, Inc.

Chair PCCRP Guidelines

Editor—AJCC

Editor’s Note: Dr. Deed will be presenting a comprehensive, contemporary review of this topic at the upcoming 32^nd CBP Annual Conference on Sept 24-26^th, Scottsdale, AZ. See center page and www.idealspine.com for details.

INTRODUCTION
Posture has probably been one of the longest studied aspects of Humans. The correlation of posture and health has driven us to study our posture since at least the time of Hippocrates.1 Since Hippocrates’ time, many have attempted to categorize man into constitutional posture types.1-3

Even in present times, the criteria for normal and abnormal posture continue to be ill defined without clearly defined and agreed upon categories and measures. Before any possible consequences of abnormal posture can be addressed, normal posture must be defined and precise measurement methods developed.

DISCUSSION

• Ideal Upright Postural Alignment:

Herein, we use the definition of ‘Ideal Posture Alignment’. Ideal Posture is really a matter of simple engineering. The human body is designed such that the centers of mass of the head, ribcage, and pelvis should be perfectly centered and balanced on each other. From the front, the spine is perfectly aligned with gravity. But the spine, when viewed from the side, contains three curves to properly balance the weight of the body and allow free movement. Figure 1 depicts the proposed Ideal Posture Alignment. Note that we will ignore the ideal spinal curvatures that give rise to optimal postural alignment for the purposes of this short presentation.

• Abnormal Postures as Rotations and Translations:

Now that we have an Idealized Posture Alignment as an origin, we can now look at categories of abnormal postural displacements. In 1974, Panjabi, White, and Brand4 presented a right-handed central orthogonal (Cartesian) coordinate system where local systems (i.e. body joints or segments) may be used to define human body joint and segment static positions or relative motions from the central system. My father (Dr. Donald Harrison) originally (in 1982) implemented this system to define human body posture as rotations and translations of the head, thoracic cage, and pelvis as 12 simple movements in 6 degrees of freedom.5-7

A center of origin to describe the global orientation of the major body masses was defined as right-handed Cartesian coordinate systems describing the origin of the head movements from T2, the thoracic cage from S2, and the pelvis from the mid-talus centered between the feet and in some movements from the femur heads. The single posture component rotations and translations of the head, thorax, and pelvis are shown in Figures 2 and 3.

While there are only 36 possible single movements of the head, thorax, and pelvis shown in Figures 2 and 3, complexity of this system of description is inherent. There can be singles, doubles, triples, quadruples, quintuples, and sextuples of rotations and translations for the head, thoracic cage, or pelvis.
Using just the head, there are 6 degrees of freedom (Rx, Ry, Rz, Tx, Ty, Tz) and three possible choices for direction ( -, 0, +) for a total number of permutations of 36 = 729. In other words, there are 729 unique postural displacement combinations for the head relative to the ribcage; 728 of these would be abnormal postural displacements and 1 would be the ideal alignment position shown in Figure 1.

• Measurement of Ideal and Abnormal Posture Alignment:

Previous investigations into postural analysis systems have suffered from an incomplete analysis, including use of only one examiner, small sample sizes, and measurement of only one region of the body, or a limited number of degrees of freedom of postural displacements.
Recently, CBP researchers developed a new computerized system (PosturePrint®), to measure head, rib cage, and pelvic postures as rotations and translations in three-dimensions (3-D) in upright stance. In three separate validity studies,8-10 the PosturePrint system was found to be sufficiently accurate in measuring head, thoracic cage, and pelvic postures in five degrees of freedom (vertical translations were not assessed) on inanimate subjects: errors ≤ 3mm and 3°. Further, intra and inter-examiner reliability of the process required for the PosturePrint computer systems’ analysis of upright human posture was evaluated; the PosturePrint measurements were found to have good to excellent examiner reliability.11
The use of the PosturePrint system allows detailed postural measurements to be used clinically to gauge an individual’s response to intervention and/or for research purposes assessing correlations between postural alignment and health disorders. Figure 4 depicts the AP Postural Alignment using the PosturePrint system and the consequent displacements measured: Left pelvic translation, Left thoracic translation, Left thoracic bending, and Right Head translation are the significant findings.

• Postural Deformity, Pain, Disability & Health:

The cause-effect relationship between postural deformity-abnormality and health disorders has been the subject of numerous investigations and review articles and it has advocates on both sides of the debate. A comprehensive review of this information is behind the scope of the current short presentation. However, recent high quality case control investigations have found interesting and significant differences between condition groups vs. control groups and significant correlations between abnormal posture alignment and a number of health disorders including:

• Abnormal thoraco-lumbar alignment and back and neck pain in children and adolescents;12,13
• Hyper-kyphosis-round back and health perceptions and function in adolescents;14,15
• Hyper-kyphosis and rigid anterior head translation and functional impairments in seniors;16
• Hyper-kyphosis and early mortality in seniors;17
• Abnormal cervical spine postures in women with chronic pelvic pain;18
• Abnormal forward head posture and neck pain, headaches, disability, range of motion, respiratory muscle function, and carpal tunnel syndrome.19-23

At the upcoming 32nd CBP Annual conference in Sept, I will be presenting a comprehensive and contemporary review of this type of information from the scientific literature. However, scientific studies aside, ask yourself or others this question: Which one of the four persons in Figure 4 visually appears to be in good health and which one of the four persons would you say has poor health?
Your eyes (and mind), may in fact be pointing you to answer for the questions regarding the scientific connection between good posture and good health and poor posture and poor health. In the end, how do you wish to age with respect to gravity may be the only question that need be answered.

SUMMARY
This short paper has presented a fundamental yet rigorous model of ideal posture and consequent abnormal posture alignments as components of rotations and translations after Dr. Don Harrison. The use of this posture model has many advantages over previously ill-defined postural ideologies. It is simple to implement into the clinical or research settings and easy to record and communicate between professionals.

References
See AJCC Online at www.idealspine.com for the detailed list of references accompanying this article.

• Goff CW. J Bone Jt Surg Am 1952;34:115.
• Beck A, Killus J. Aerospace Medicine 1973;44:1277-1281.
• During J, et al. Toward standards for posture. Spine 1985;10:83-87.
• Panjabi MM, White III AA, Brand RA. A note on defining body parts configurations. Journal of Biomechanics 1974;7:385-387.
• Harrison DD. CBPâ Technique: The Physics of Spinal Correction. National Library of Medicine #WE 725 4318C, 1982-97.
• Harrison DD. Spinal Biomechanics: A Chiropractic Perspective. National Library of Medicine #WE 725 4318C, 1982-97.
• Harrison DD, Janik TJ, Harrison GR, Troyanovich SJ, Harrison DE, Harrison SO. Chiropractic Biophysics Technique: A Linear Algebra Approach to Posture in Chiropractic. J Manipulative Physiol Ther 1996;19(8):525-535.

1. Harrison DE, Janik TJ, Cailliet R, Harrison DD, Normand MC, Perron DL, Ferrantelli JR. Validation of an algorithm to estimate 3-D rotations and translations of the rib cage in upright posture from three 2-D digital images. Eur Spine J 2007; 16(2):213-218.
2. Janik TJ, Harrison DE, Cailliet R, Harrison DD, Normand MC, Perron DL. Validation of an algorithm to estimate 3-D rotations and translations of the head in upright posture from three 2-D images. J Manipulative Physiol Ther 2007;30(2):124-129.
3. Harrison DE, Janik TJ, Cailliet R, Harrison DD, Normand MC, Perron DL, Oakley PA. Upright static pelvic posture as rotations and translations in 3-dimensional from three 2-dimensional digital images: validation of a computerized analysis. J Manipulative Physiol Ther 2008 Feb;31(2):137-45.
4. Normand MC, Descarreaux M, Harrison DD, Harrison DE, Perron DL, Ferrantelli JR, Janik TJ. Three dimensional evaluation of posture in standing with the PosturePrint: an intra- and inter-examiner reliability study. Chiropractic & Osteopathy 2007; Sept. 24th 15:15.
5. Murphy S, et al. Classroom posture and self-reported back and neck pain in schoolchildren. Appl Ergon 2004;35(2):113-120.
6. Smith A, et al. Classification of sagittal thoraco-lumbar pelvic alignment of the adolescent spine in standing and its relationship to low back pain. Spine 2008;33:2101-2107.
7. Korovessis P, et al. Comparative multifactorial analysis of the effects of idiopathic adolescent scoliosis and Scheuermann kyphosis on the self-perceived health status of adolescents treated with brace. Eur Spine J 2007;16:537-546.
8. Petcharaporn M, et al. The relationship between thoracic hyperkyphosis and the scoliosis research society outcomes instrument. Spine 2007;32:2226-2231.
9. Kado DM. Narrative Review: Hyperkyphosis in older persons. Ann of Intern Med 2007;147:330-338.
10. Kado DM, et al. Hyperkyphosis predicts mortality independent of vertebral osteoporosis in older women. Ann Intern Med 2009; 150:681-687.
11. Mary LLS MontenegroPostural changes in women with chronic pelvic pain: a case control Study. BMC Musculoskeletal Disorders 2009, 10:82.
12. Fernández C, et al. Forward head posture and neck mobility in chronic tension-type headache: a blinded, controlled study Cephalalgia 2006;26(3):314
13. Yip CH. The relationship between head posture and severity and disability of patients with neck pain. Man Ther 2008;13:148-154.
14. Kapreli E, et al. Respiratory dysfunction in chronic neck pain patients. Cephalgia 2009;29:701–710.
15. De-la-Llave-Rincón A, et al. Increased Forward Head Posture and Restricted Cervical Range of Motion in Patients With Carpal Tunnel Syndrome.J Orthop Sports Phys Ther 2009;39(9):658-664.Lau KT, et al. Relationships between sagittal postures of thoracic and cervical spine, presence of neck pain, neck pain severity and disability. Man Ther 2010; April 28 (E-pub ahead of print).
16. Lau KT, et al. Relationships between sagittal postures of thoracic and cervical spine, presence of neck pain, neck pain severity and disability. Man Ther 2010; April 28 (E-pub ahead of print).

Chiropractic BioPhysics, chiropractic research, subluxation, Posture

Update on Spinal-Visceral Relationships: The Nucleus Intermedius

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

The intermedius nucleus of the medulla: A potential site for the integration of cervical information and the generation of autonomic responses.

Edwards IJ, et al. Journal of Chemical Neuroanatomy November 2009, 38, pp. 166–175.

KEY POINTS FROM DAN MURPHY

1) The intermedius nucleus of the medulla (InM) [nucleus intermedius] receives afferent information from:

a) The neck musculature

b) The vestibular nuclei

2) The nucleus intermedius sends monosynaptic projections to the nucleus of the solitary tract (NTS)

3) The nucleus intermedius integrates information from the head and neck and relays this information on to the nucleus of the solitary tract where suitable autonomic responses are generated.

4) The nucleus intermedius also communicates with the hypoglossal nucleus to influence movements of the tongue and upper airways.

5) Outputs from the nucleus intermedius to the nucleus tractus solitarius and hypoglossal nucleus suggest a role in the co-ordination of tongue movements and autonomic responses to changes in posture. [Very Important: the nucleus intermedius co-ordinates autonomic responses to postural changes]

6) The nucleus intermedius has a spinal cord component called the “central cervical nucleus” or the “medullary portion of the central cervical nucleus” or the “intercalated nucleus” or the “nucleus intercalatus of Staderini.”

7) The spinal cord component of the nucleus intermedius (central cervical nucleus) is “located lateral to the central canal at the border of the dorsal and ventral horns.”

8) Sensory fibers from the upper cervical dorsal root ganglion (DRG) directly enter the nucleus intermedius. [Very Important]

9) Sensory nerves from the suboccipital muscles, the sternocleidomastoid muscle and the longus capitis muscle project to the nucleus intermedius via the upper cervical spine dorsal root ganglion. [Very Important: the sensory projections from these muscles are mechanoreceptors and proprioceptors; alterations of mechanical afferent input from these muscles alters the input to the nucleus intermedius, then to the nucleus tractus solitatius and to subsequent autonomic responses]

10) “These projections from the cervical DRG to the nucleus intermedius have been proposed to be proprioceptive, which suggests that activity within the nucleus intermedius is heavily influenced by the position of the head relative to the trunk.” [Very Important]

11) “Chemical or electrical stimulation of the nucleus intermedius causes monosynaptic excitatory and inhibitory postsynaptic potentials in the nucleus of the solitary tract (NTS).”

12) The authors suggest that the greatest influence of the nucleus intermedius is to the “autonomic circuits relating to the cardiovascular system.”

13) Nucleus intermedius neurones are “under the influence of information arising from the neck region, in particular the dorsal neck muscles.”

14) One of the functions of the nucleus intermedius is to elicit autonomic responses to movements of the head to complement those triggered by the vestibular system.

15) The vestibular system regulates cardiovascular autonomic (sympathetic) responses to head movements.

16) Innocuous mechanical stimulation of the neck of humans that does not activate the vestibular system evokes changes in heart rate and blood pressure, perhaps through the nucleus intermedius. [This is like saying that altered mechanical afferent input from the neck {innocuous mechanical stimulation} subsequent to the chiropractic subluxation alters the neurological influence to the nucleus intermedius, in turn influencing the autonomic control of heart rate and blood pressure. Recall that the study in the Journal of Human Hypertension, March 2007, showed that specific upper cervical chiropractic adjustments (NUCCA) significantly reduced blood pressure, and the outcomes remained stable during an 8 week follow-up period]

17) Low threshold stimulation of the nerves entering the C1 and C2 DRG can elicits changes in the activity of both sympathetic and respiratory nerves. [Very Important: supports chiropractic adjustments influencing sympathetic neurology]

18) Proprioceptive information can play a role in modulating the autonomic nervous system. [Very Important: this is a central theme to chiropractic clinical approaches to many non-musculoskeletal syndromes]

19) “Neurones in the nucleus intermedius are under the influence of sensory afferent information arising from the neck region.” [Very Important]

20) The nucleus intermedius receives afferent input from the vestibular nuclei. [Important because the vestibular nucleus also receives monosynaptic inputs from upper cervical spine afferents]

21) Upper cervical DRG afferent fibers project to the nucleus intermedius, and these fibers are “proprio- and mechano-ceptive afferents” and not nociceptors. [This is very important because it implies that non-painful aberrant mechanical afferent input from the upper cervical spine can alter autonomic function. In the study from the Journal of Human Hypertension, March 2007, which showed a significant reduction of blood pressure with specific upper cervical chiropractic adjustments, the authors noted that none of the patients were suffering from neck or back pain]

22) The authors suggest the primary afferents influencing the nucleus intermedius are from the upper cervical muscles “adding weight to the theory that the nucleus intermedius is under the influence of cervical muscles.”

23) “Changes in the positioning of the head relative to the trunk, or sensory information arising from the neck musculature, have been clinically implicated in the control of heart rate and blood pressure.” [Very Important: the upper cervical chiropractic subluxation is a change in the “positioning of the head relative to the trunk, or sensory information arising from the neck musculature”]

24) “The nucleus intermedius acts to integrate information from both the neck musculature and the vestibular system before relaying this information on to the nucleus tractus solitarius.”

25) This pathway from the neck musculature to the nucleus tractus solitarius might be behind the “changes in heart rate and blood pressure observed following upper cervical chiropractic manipulations and autonomic disturbances observed in whiplash patients.” [Very Important: these authors acknowledge the ability of upper cervical chiropractic adjustments to influence heart rate and blood pressure, both autonomic functions]

26) “The nucleus intermedius neurones are strongly targeted by afferent fibres projecting via the upper cervical DRG,” and this “information can manifest as changes in autonomic variables.”

27) The nucleus intermedius “plays a role in the generation of autonomic responses to movements of the head,” especially as it is monosynaptically connected with the nucleus tractus solitarius.

COMMENTS FROM DAN MURPHY

This is a very important article for chiropractors. It explains the neuroanatomical relationship between upper cervical spine subluxation (a mechanical problem) and visceral autonomic neurology. The authors use chiropractic adjustments of the upper cervical spine influencing cardiac function as support for their neuroanatomical findings. This study supports the 115 years of clinical observations of chiropractors. It shows the “biological plausibility” of the influence of chiropractic adjustments on non-musculoskeletal syndromes.

Chiropractic BioPhysics, Dan Murphy, DC, Neurology

Custom Foot Orthotics: Are they really Custom?

Stuart Currie DC,

Director of Research, Sole Supports.

www.solesupports.com

When is a custom foot orthotic not a custom foot orthotic? Practitioners prescribing these devices need to know. The word “custom” is often used in the foot orthotic industry and critical thought as to its meaning is warranted for the astute practitioner. We are bombarded in both the public and professional domains with advertisements and claims for the “Custom Foot Orthotic”. As the American physicist and Nobel Prize winner Richard Feynman once said, “For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.”

There are two main considerations when determining the level of custom that an orthotic provides: (1) How it is casted, and (2) how that cast is manufactured. What will become clear very quickly is that the notion of “custom” is not entirely black or white, but a scale ranging from completely prefabricated devices, to “best fit” devices pulled from a library of molds or feet, to truly custom devices based on a model of the foot in a corrected position.

To start, let us review a description of the casting process for a custom-made orthotic:“The cast is taken in a position that minimizes mechanical anomalies by either improving foot alignment or accommodating foot alignment when necessary. A three dimensional mold of the foot is necessary in order to fabricate a truly custom-made orthotic”.¹Any provider dispensing a custom foot orthotic, therefore, must know how they intend to influence the foot’s alignment (or posture). The biomechanical goals and how they can be achieved through a cast of the foot are crucial to a custom prescription and have been outlined in a previous AJCC article.² In order to attain a corrected position with an orthotic device it must be achieved in the cast and then communicated to the lab. A cast that is taken in full weight-bearing therefore, would have to be altered by the lab in some way to achieve correction of any mechanical abnormalities. Because this is performed using assumptions, this type of alteration lessens the custom properties of the doctor’s prescription.

Any discussion of casting as it relates to a custom orthotic needs to address the issue of digital casting and manufacturing methods. There exists significant confusion as to the efficacy of the digital methods used today. A digital impression of the foot may have utility in conjunction with a proper physical assessment in at- risk populations such as diabetics and those diagnosed with rheumatoid arthritis.³ However, two dimensional data alone cannot provide exact information for the third dimension in order to manufacture a custom-made foot orthotic. So while there is no inherent flaw in the digital technology itself, it is incapable of providing the data needed for a custom-made orthotic. From the Pedorthic Association of Canada on casting technique: “Casting does not include taking an imprint on an ink pad or forceplate”¹.

Accurate vertical dimensions of a foot cannot be predicted from footprints or measurements of the plantar surface area. In one study only 27% of the vertical arch height could be estimated by plantar surface data⁴, so using this data alone would negate roughly three-quarters of the clinical picture. This is not a confidence level most would be comfortable with for the manufacture of a custom device. I have heard the analogy worded this way: Estimating arch height from plantar pressure data is akin to trying to draw the skyline of a city using only the weights of the buildings.

FIGURE 1. True custom-made foot orthotics are fabricated from a 3D volumetric model of the patient’s foot that duplicates its unique plantar anatomy in a corrected position, to which raw materials are molded to create the orthotic.

The Prescription Foot Orthotic Laboratory Association (PFOLA) differentiates between two types of orthotic manufacture. Those that use anatomical models and those which use extrapolated models. This second type of model is a digital model that “approximates” a person’s anatomy using mathematical models to extrapolate pressure, temperature or light data.⁵ A third type of manufacturing with an even less custom process uses a library of pre-made orthotic shells choosing a “best fit” approach to the cast in question; sometimes the criteria can be as vague as foot length or size.

The above information helps us draw a distinction between “customized” and “custom-made”. A customized orthotic uses an extrapolated model or a library of shells in the manufacturing process, while a custom-made orthotic uses anatomical three-dimensional data from the patient’s foot.

When trying to determine if your orthotic company makes custom-made or customized orthotics, ask yourself this question: How does the lab determine the three dimensional height of the corrected arch? If you are not providing it in your cast then there must be a lab extrapolation. Other variables that increase the custom properties of an orthotic include the patient’s weight, the patient’s foot flexibility, and the patient’s activity levels.

There is no secret to the process of manufacturing a truly custom-made device. Your lab should be forthcoming with any and all information concerning the manufacture of the devices you prescribe. As a doctor it is your responsibility to provide the most custom orthotic to your patients, after all, the diagnosis and treatment of patients is a custom business.

Reference List

(1) Pedorthic Assoc. of Canada. www.pedorthics.ca. Internet Comm.

(2) Currie S.J. AJCC 2009;19(4):4,26.

(3) Randolph AL, Arch Phys Med Rehabil 2000 May;81(5):573-8.

(4) McPoil T. J Am Podiatr Med Assoc 2006;96(6):489-94.

(5) PFOLA. www.pfola.org. Internet Comm.

Chiropractic BioPhysics, Shoe Lift, SoleSupports

Tocotrienols – The Sleeper Nutrients

Dr. Lynn Toohey, Ph.D, Nutrition

Colorado State University in Ft. Collins, CO

Research Consultant NutriWest

The word “tocotrienols” doesn’t exactly roll off the tongue. This 5 syllable word describes the lesser known players of the vitamin E molecule. Many people think that alpha tocopherol is vitamin E, but that is incorrect. Alpha tocopherol is just the portion of vitamin E that has been used in most of the clinical trials existing in the research.

The synthetic variety, DL alpha tocopherol, was used in these studies, instead of the natural form, D alpha tocopherol. When you couple this with the fact that alpha tocopherol was not given with the other synergistic members of the molecule in these studies, it is no wonder that “bad press” occasionally comes out about “vitamin E”, even though vitamin E was not studied. Using alpha tocopherol alone may actually interfere with the action of the other parts of the molecule.

There are many who believe that studies done with just the alpha tocopherol portion of the vitamin E would have been much more efficacious if the studies had taken advantage of the properties, both synergistic and stand-alone characteristics, that the tocotrienols possess.

“Disappointments with outcomes-based clinical studies testing the efficacy of alpha tocopherol need to be handled with caution and prudence recognizing the untapped opportunities offered by the other forms of natural vitamin E”¹

While alpha tocopherol has cornered much of the press in recent years, the alpha, beta, gamma and delta tocotrienols are very important parts of the vitamin E molecule. As we have seen, it has been suggested that the vitamin E research done only with the alpha tocopherol portion of vitamin E (and the synthetic DL variety at that) does not do justice to the properties of the vitamin.

Besides the fact that the tocotrienols balance the alpha tocopherol portion of the vitamin E molecule and work in synergy with it, tocotrienol research demonstrates that the tocotrienols have many health benefits over and above that of alpha tocopherol alone. The tocotrienols have emerged as vitamin E moieties with functions in health and disease that are clearly distinct from that of alpha tocopherol, and properties that are synergistic with alpha tocopherol. There are many instances where the tocotrienols surpass the tocopherols in potency and performance; neuroprotection is one of those areas.

Tocotrienols and Neuroprotection:

Tocotrienols have been called a “potent neuroprotective form of natural vitamin E”² , and have been named “potent neuroprotective agents against stroke”³ Another study confirms the neuroprotective qualities of the tocotrienols, and reports that “tocotrienol protects against stroke-associated brain damage”, and that “taken orally, tocotrienols are bioavailable to all vital organs” (Sen CK, et al. 2007)

Significant protection from mercury-induced neuronal cell death has been observed with both tocopherols and tocotrienols. Even though tocopherols were effective, researchers observed that tocotrienols are multi-fold more potent than tocopherols in protecting brain neuronal cells against mercury neurotoxicity, and that it only took a micro-molar concentration of tocotrienols (but not tocopherols) to show complete protection by an antioxidant mechanism. “These results suggested that oxidative events may contribute to methyl mercury (MeHg) toxicity in isolated cerebellar granule neurons, and that tocotrienols are potent supplements for pharmacological protection of the developing brain exposed to MeHg”⁴

Tocotrienols and the Heart:

Several studies suggest that the tocotrienols are very cardioprotective. One study even rated the tocotrienols as to their cardioprotective power, and found that, “The gamma-isoform of tocotrienol was the most cardioprotective of all the isomers followed by the alpha- and delta-isoforms” (Das S, et al. 2008.)

“Tocotrienols attenuate myocardial ischemia-reperfusion injury, atherosclerosis, and reduced ventricular arrythmias”, in addition to the fact that “tocotrienol-mediated cardioprotection is also achieved through the preconditioning-like effect, the best yet devised method of cardioprotection”⁵

Additionally, while it is known that high dose (1200 IUs or more) of alpha tocopherol may have adverse effects on blood pressure because it lowers the levels of synergistic components like tocotrienols, the tocotrienols appear to have a favorable effect on blood pressure.⁶

Tocotrienols and Cholesterol:

Another area in which the tocotrienols seem to outperform the tocopherols is that of cholesterol. Natural methods of tackling cholesterol are constantly being sought, and the tocotrienols are making headlines in this arena too. Additionally, the tocotrienols provide antioxidant protection of the cholesterol that many believe to be more important than lowering the quantity of cholesterol. The tocotrienols have been shown to reduce Total cholesterol; reduce LDL (the bad) cholesterol (over 40% in some studies; 90% in cell studies!); reduce triglycerides; reduce Apo B; improve the HDL profile; and increase coenzyme Q 10 levels (up to 300% in vitro!)^7,8

Another study reported that tocotrienols “possess potent antioxidant, anticancer, and cholesterol lowering activities”, and they additionally reported that they possess potent anti-inflammatory activity, probably by inhibiting substances like cox 2 and NF-kappaB expression.⁹

Summary

The tocotrienols are powerful substances, and they work together synergistically to accomplish all the benefits described in the literature. It is clear that the more they are researched (and the more that people learn how to pronounce the tricky name), the more we will learn about the sleeper nutrients called tocotrienols.

References

1. Sen CK, et al. Tocotrienols in health and disease: the other half of the natural vitamin E family. Mol Aspects Med. 2007 Oct-Dec;28(5-6):692-728.

2. Sen CK, Khanna S, Roy S. Tocotrienol: the natural vitamin E to defend the nervous system? Ann N Y Acad Sci. 2004 Dec;1031:127-42.

3. Das S, et al. Cardioprotection with palm oil tocotrienols: comparision of different isomers. Am J Physiol Heart Circ Physiol. 2008 Feb;294(2):H970-8.

4. Shichiri M, et al. Protection of cerebellar granule cells by tocopherols and tocotrienols against methylmercury toxicity. Brain Res. 2007 Nov 28;1182:106-15.

5. Das S, et al. Tocotrienols in cardioprotection. Vitam Horm. 2007;76:419-33.

6. Rasool AHet al. Arterial compliance and vitamin E blood levels with a self emulsifying preparation of tocotrienol rich vitamin E. Arch Pharm Res. 2008 Sep;31(9):1212-7.

7. Qureshi, AA. et al. Dose-dependent suppression of serum cholesterol by tocotrienol-rich fraction (TRF25) of rice bran in hypercholesterolemic humans. Atherosclerosis. 2002 Mar;161(1):199-207;

8. Bentinger M, et al. Polyisoprenoid epoxides stimulate the biosynthesis of coenzyme Q and inhibit cholesterol synthesis. J Biol Chem. 2008 May 23;283(21):14645-53.

9. Wu SJ, et al. Tocotrienol-rich fraction of palm oil exhibits anti-inflammatory property by suppressing the expression of inflammatory mediators in human monocytic cells. Mol Nutr Food Res. 2008 52(8):921-9.

Chiropractic BioPhysics, Nutriwest

Advertising and Patience Make Patients

Lisa Holmes, MBA, MHA

Lisa Holmes is president of Holmes & Co., a health-care-specialty marketing communications firm.

We live in an “I want it now” culture. Patience may still be a virtue, but it’s an increasingly uncommon one. Look at correspondence: letters gave way to faxes, which were pushed aside by e-mails, which lost ground to instant messaging. Now “tweets” seem to be the order of the day. We send someone a question or request, then teeter on the edge of a panic attack if the response is not immediate.

Like it or not, this “want it now” attitude affects all of us to some degree. And it bleeds into every area of our lives, including business.

And advertising.

Many people in business, unfamiliar with advertising and its ways, expect to place an ad and instantly be overwhelmed with customers. Unfortunately, it doesn’t work like that. At least not often.

That said, advertising does work. It remains an important tool in building a business. But it takes purpose. Planning. Proficiency. Persistence. And patience.

Look at it from the consumer’s perspective (which is essential anytime you’re talking about advertising). Every one of us (we’re all consumers) is exposed to thousands—literally—of commercial messages of one kind or another every day. Online, on signs and billboards, on television and radio, in newspapers and magazines—in short, on almost any surface our eyes encounter.

Add to all this clutter the fact that we’re busy. We’ve got more important things on our mind than paying attention to everyone who’s trying to sell us something. So, the chance of any single advertising message being noticed—let alone paid attention to and remembered—are infinitesimal.

Overcoming those barriers is possible. Let’s start with the basics. In preparing advertising strategies for our clients (all of whom are in health care, by the way), we start with three basic questions: Who are we talking to? What do we want them to believe? Why should they believe us?

Simple questions, but the answers aren’t always simple or easily arrived at. Often, we rely on market research, but not always. Critical thinking and simple logic can work, too.

Knowing “who” you’re talking to is crucial, not only in devising your appeal, but also in developing you voice and selecting the advertising media that will carry your message. And “who” may not be who you think. For instance, we know that when it comes to health-care decisions, women either make or are the primary influence in those decisions some 80% of the time.

“What” you want prospects to believe simplifies and clarifies your sales message. For example, the new advertising campaign for whiplash treatment available to all CBP-trained chiropractors seeks to persuade people that CBP techniques can provide relief from whiplash pain even when other treatments fail.

But consumers are skeptical. They know you’re trying to sell them something, and they won’t believe what you say just because you say so. So, you have to support your sales message with convincing proof—facts, figures, endorsements, and the like.

Now that you’ve answered all the questions and used the answers to create effective advertisements (which often requires professional help), patience comes into play. Repeated exposure is necessary. Years ago—long before the clutter we face today—research found a prospect must be exposed to a message seven times before being noticed. More often to make an impression. Still more often to be remembered.

But, like chiropractic, advertising works. And the better the advertising, the better it works. Ad campaigns create awareness of you and your practice, which is the first step in attracting new patients. After all, they can’t come to you if they don’t know about you.

Put advertising to work for your practice. The CBP whiplash campaign might be a good place to start. Start now.

And be patient. The patients will come.

Chiropractic BioPhysics

#1 Biggest Mistake in Patient Management: “MAKING STATEMENTS AND NOT ASKING QUESTIONS.”

Fred DiDomenico, DC

Practice Coach and Mentor

Drfred1@msn.com

Almost ALL new patients come into our clinics with a pain relief intention and perspective. As corrective care chiropractors, our core value in practice is to influence their thinking and inspire them to desire life changing spinal corrective programs so they may live up to their full potential in life without the progressive, degenerative health conditions resulting from a subluxated posture. Our challenge is we figuratively and literally have 5 minutes on Day #1 to make a powerful impression that can shift their perspective and captivate their attention so we can inspire their INTENTION. In order to fulfill this purpose we MUST create a shift in our communication from making statements to asking questions so the patient does not reabsorb themselves back into their fast paced, subluxated life after leaving our office. This is a great responsibility, not to be taken lightly, and is a much greater responsibility than the average doctor treating for pain relief. In fact, it is our calling.

In order to create accelerated influence, we must change from teaching information on subluxation, to asking questions guiding the patient through their own thought process, revealing their emotional impression while increasing their understanding of the effect a subluxated posture is having on the most important aspect of their lives. Questions create influence because they bring a person through their own thought process that helps them derive their own conclusions. When they answer, “yes,” to a question that brings them into agreement with the truths and principles of a subluxated posture and the effects it is having on their body, you have just accelerated their learning rate, created more impression which has allowed them to make your care THEIR IDEA. “When They say it, they believe it.”

When you make statements, they feel they MUST conform to your idea, which they may not agree with. As you all may have experienced, they don’t always agree with you and/or your ideas. When they don’t agree you will hear, “I want to get another opinion,” “I don’t have time,” “I can’t afford it right now,” etc.

Their answers to your carefully and intentionally directed questions confirm in their mind they are speaking truth. When your question directly applies to their individual emotional condition weakening their life and emotional priorities, they will take action NOW, almost the moment they answer your question because it is THEIR DECISION.

Your job is to recognize their objection, handle it directly with a question that brings them closer to the thought process you are attempting to teach and inspire. You can create a question that shifts their thoughts and brings new understanding in one sentence from you, and a one word answer by them. Your ability to influence their decisions and behavior now instills self empowerment. This is coaching. Elite Coaching is a “coaching” system and is HIGLY EFFECTIVE for spinal rehab practices.

Our responsibility is to empower patients to take responsibility for their lives and their condition. When they derive conclusions regarding their life and health from the energy of empowerment, they are inspired to go above and beyond their normal efforts to become or do something that may be atypical of previous behavior with any other doctor or chiropractor. Empowering patients to complete a spinal rehabilitative program will require energy and effort that many have not exhibited in their past. To reap the benefits of a healthy lifestyle through spinal correction, they must dig deep inside themselves with unbridled inspiration. All of us have that inspiration innately inside us. Many have not taken the opportunities in life to unleash their deepest passions. We have that responsibility to help each person find that which may have remained dormant and bring out their divine inspiration to reach and be their best. As corrective care chiropractors, we can help them achieve this level of inspiration. In fact, it is our responsibility, purpose and mission.

Inspire EVERY patient to be their best. Help them find their own individual emotional commitment for a healthy life through spinal correction by asking them specific questions taking them through the thought process and accelerate their understanding and inspiration to be their best.

“I had a new patient come to me from another chiropractor around the corner who recommended a program for 70 visits for $1700.00 for corrective care. He left his office rejecting his care. After taking him through the Elite Coaching communication systems and learning how to ask the right questions, he payed me $5000.00 for 41 visits. The patient told me he trusted me more as he wrote the check. Most importantly, I know we will correct his spine.”

Dr. A. G., Miami FL.

Chiropractic BioPhysics, Elite Coaching