Evidence Based Chiropractic from a Modern Practical Practice Perspective

Len Siskin, DC

Promote Chiropractic,

Co-Chair ICA Best Practices

A friend emailed me an article recently where I learned that one in four Britain chiropractors are currently under investigation for allegedly making misleading claims about being able to help a list of named medical conditions in their advertisements. (http://www.guardian.co.uk/science/2010/mar/01/simon-singh-libel-case-chiropractors) Another friend sent an email with an article written by chiropractors, paid for by the UK General Chiropractic Council (GCC) and published in, “Chiropractic and Osteopathy” which reviews chiropractic research.²⁷

Problematically, the Bronfort et al²⁷ paper leans heavily on Level I Randomized Clinical Control Studies (RCT’s) particularly from the past 5 years. After having read the article, I have to commend the authors for the scope of dimension they looked at which includes the use of a research grading system, and consideration of various clinical guidelines as well as 46 RCT’s considering twenty six named medical conditions which chiropractors historically claim to have helped in clinical practice. The authors mention that RCT’s are the highest quality of clinical research, and respected critics of the RCT acknowledge that with the level of controls used to measure the effectiveness of a procedure, they may not commonly represent typical clinical scenarios in an everyday chiropractic or healthcare practice.

If a person were to research data-searching-algorithms for modern computers, it would be foolish to look at the information published 30 or 50 years ago when computers either didn’t exist or took entire buildings to do what most mobile phones can do now in a fraction of a second. In contrast we still use laws of physics established hundreds and sometimes thousands of years ago as these are established universal laws. In the case of human physiology and the benefits and effectiveness of the chiropractic adjustment, it seems that neither has really changed much since the inception of our great profession. See the contemporary best Practices Document of the International Chiropractors Association (http://www.icabestpractices.org/) which can be found in the National Guideline Clearinghouse (http://ngc.gov/).

The best practices database shows greater than 80% of chiropractic research consists of Level IV studies, which are mostly case studies or case series without controls. Looking primarily at RCT’s and reviews of the literature as well as a list of professional guidelines may not represent what the research actually has to show. How does this influence the findings published in the Chiropractic and Osteopathy²⁷ article mentioned above? How would policymakers view chiropractic any differently given more detail on this information? The authors should be applauded for discussing the importance of several clinically relevant factors. These include:

1. Doctor experience and the importance of understanding factors such as the high safety value in chiropractic risk assessment

2. The cost effectiveness of chiropractic treatment as compared to other available modalities to help the named conditions

3. The importance of patient education and the patient’s right to choose the type of care which may be best for them, when properly informed about the potential risks, benefits, and known research outcomes related to their individual clinical picture.

So many research efforts in healthcare have focused on co-morbid factors in healing and treatment, it would have been nice to have seen a discussion on some of these co-morbid factors here, and how the existing research might incorporate an awareness of such clinical complexities which prolong the healing process, complicate the healing of patients, and influence the crafting of a care plan under a given treatment modality. Simply typing, “co-morbid influences on healing”, into Google yields 63,100 hits which are predominantly reflective of clinical research on topics relevant to crafting treatment guidelines. These considerations are accounted for in the ICA Best Practices document which takes all chiropractic treatment research into consideration without exclusion so long as the research was original clinical research and not research reviews or meta-analysis.

Furthermore, the ICA Best Practices document utilizes a research grading system extremely similar to that used in the Chiropractic and Osteopathy paper discussed here. Common factors on the note of co-morbidity would be things like obesity, smoking or a history of smoking, history of multiple physical traumas, life stressors like divorce, debt, family health issues, etc. It is unfortunate the chiropractic profession does not have the money or funding of the pharmaceutical industry where entire multinational corporations are dedicated solely to performing randomized clinical control trials for the pharmaceutical products. What the chiropractic profession has the most of is simply Level IV evidence.

The ICA Best Practices Guidelines draws information from approximately 1500 research papers showing positive benefit from chiropractic care on over 330 named medical conditions. In their paper, Bronfort et. al. came up with 26 named medical conditions which have been reported to receive help from chiropractic intervention. When crafting the ICA Best Practices Guidelines, all original research papers since the beginning of chiropractic time were summarized and questions were answered about findings by unpaid practicing chiropractor volunteers. Only after the data was entered was a search done to learn what conditions received help from chiropractic according to the existing research. That search yielded a list of over 330 healthcare conditions shown to receive help from chiropractic intervention.

As a comparison below I have made a table of conditions listed By Bronfort et. al. and a comparison table for similar conditions listed in the ICA Best practices Guidelines document. The only condition not listed by the Best practices Document was, ‘Myofascial Pain Syndrome’, which was analyzed specially for this paper as indicated below for comparison and evaluation purposes. Also included in the table is a ranking of where each condition listed by Bronfort et. al. falls in terms of research power in the ICA Best practices list of conditions helped by chiropractic. This reflects a progression from high to lower quality evidence shown by already existing research. I included headache in the list but think it is important to note names of conditions as reported by research have changed over the years. For example, 8 of 670 pubmed.gov hits for, ‘cervicogenic headache’, were before 1961. Thirty Four of 140 papers summarized by ICA BPG were prior to 1961 on this topic. The research indicates headaches and even cervicogenic headache have existed and been researched well before the past 5 years no less the past 5 decades.

In Evidence based healthcare, research is used to indicate the truth about making the best possible clinical decision and in providing the best truth in informing patients of their treatment options. When the research is under-represented or misrepresented it is a detriment to the consumer of healthcare. It is important to understand which treatment modalities have existed for many years (like spinal manipulation) and which are more recent (like cold laser or disc decompression traction). Spinal manipulation simply has not changed much at all over many years time. Most chiropractic techniques used today are the same or extremely similar to what was used nearly a century ago. The difference is in the way we understand what chiropractic does to help consumers heal, advancements in information insuring consumer safety, and in the depth of insight to the dangers of not instituting chiropractic treatment for those who could benefit from it.

In the below table, rank refers to the point score as dictated by the rating generated by the best practices database and where each condition falls in the pool of available research performed in chiropractic since the beginning of time through approximately the middle of 2008. Approximately 338 conditions were identified as having research done on chiropractic treatment where there was a benefit shown. For more details or to check numbered references, please go to www.ICA Bestpractices.org. Level’s I-IV represent types of research performed where Level I is an RCT and Level IV is an observational study like a case study. ‘R^*’, indicates the grading system used in the ICA Best Practices Guidelines which is similar to that used by Bronfort et al.²⁷ as discussed above.

**Myofascial Pain Syndrome (inclusive)-- Medline search indicates this terminology is modern and historically this vague description has also been referred to as Fibrositis or muscular rheumatism; Fibropathic Syndromes… Data searches intermingle this condition with fibromyalgia as well. The numbers here reflect a search of the ICA Best practices Database for all these conditions except for fibromyalgia. Myofascial Pain Syndrome was not included in the list of over 330 conditions shown to receive help under chiropractic care by published clinical chiropractic research. It was investigated solely for demonstration in this paper.

***Myofascial Pain Syndrome (Strict) refers to a search of the exact phrase, “Myofascial Pain Syndrome” in the ICA Best Practices Database and the found results. Note, on the grading scale, omitting the scope of the research changes the grade of evidence found from an, ‘A’, to a, ‘C’.

**** These references are specific to this paper and do not correlate with ICA Best practices Guidelines References. No rank was assigned as this was not included in the ICA best practices Guidelines symptom list.

Chiropractic BioPhysics, ICA Best Practices Chiropractic Guidelines

Newly Published Guidelines to Save Chiropractic in Europe?

Dr. Joe Betz, B.S., D.C

ICA Board Member,

Idaho Chiropractic Association

CBP Fellow & Instructor

Here we go again! Findings from an “extensive” review of the “literature”¹ conclude that spinal manipulation is only effective for the following conditions:

· low back pain;

· migraine and cervicogenic headache;

· cervicogenic dizziness;

· several extremity joint conditions;

· neck pain (only using thoracic manipulation)

Cervical manipulation alone for neck pain of any duration, manipulation for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, and over 300 other health conditions was either found to be not effective, or was ignored in the review.

This group, which I assume is presenting themselves as “coming to the rescue” of the Chiropractors in Europe, also supports the findings of the equally maligned (and, in my opinion, poorly performed and biased) “Red Flag Only” X-ray Guidelines put out by Bussieres et al.¹ This guideline intended to limit the use of X-ray in Chiropractic practice. However, it is flawed due to the fact that it is based upon the findings of the medical profession on their utilization of X-ray for musculoskeletal conditions. Frontline management by MD’s for low back pain, for example, is the utilization of medication. Of course X-rays are not warranted in this type of management. However the Chiropractic “Red Flag Only” guidelines by Bussieres et al.¹ attempt to loosely apply these MD protocols to the practice of Chiropractic. Obviously, the practice of Chiropractic with mechanical force application to the spine as the primary treatment intervention, should be quite different in its radiography utilization needs, applications, outcomes, indications and contra-indications, etc.

Now back to the main issue at hand in this editorial. With regard to the scope of conditions effectively managed by the application of spinal manipulation, findings of “saviors” of Chiropractic in Europe do not surprise me to any extent. This is what they perpetuated in their CCGPP Guidelines.

However, it is the implications of this particular publication that is most disturbing. Some of you who pay attention to the events unfolding on one side of the world that invariably affect the profession on the other, are well aware of the ongoing situation in the United Kingdom between the British Chiropractic Association and the popular press, in particular a journalist named Simon Singh. Singh is being sued by the British Chiropractic Association for libel for an article he wrote critical of the chiropractic profession.

Singh has since teamed with a medical researcher and author known for being extremely critical of Chiropractic in recent years, and has blasted back at the profession resulting in a significant backlash. What has come into question is the scope of conditions for which Chiropractors should be allowed to claim success within their advertising and marketing materials. Specifically, advertising claims made by Chiropractors asserting benefits of Chiropractic care for non-musculoskeletal conditions have come under aggressive attack. This well-orchestrated effort has resulted in an onslaught of 600 board complaints against Chiropractors filed with the General Chiropractic Council (GCC), Europe’s centralized regulatory agency. This aggressive barrage of complaints equals a complaint against one out of four licensed Chiropractors in Europe. Obviously, these complaints were not filed against the Doctors of Chiropractic by their patients, but rather by disgruntled readers and supporters of Singh, most of whom one would assume had never been to a Chiropractor.

These publicly dramatized activities in Britain have moved the General Chiropractic Council (GCC), the UK-wide statutory body with regulatory powers, to commission a group of researchers to evaluate the evidence of manipulative and manual therapies for conditions. Unfortunately, many of the same researchers that did the horrid CCGPP documents, performed this review. Without much surprise, these individuals ONLY REVIEWED Randomized Clinical Trials (RCT’s) and systematic reviews of RCT’s. So again, as they did with the flawed CCGPP Low Back Pain document, they ignored 90% of the literature on the topic.² The GCC argues that only RCTs are appropriate to consider when determining what can be advertised by Chiropractors.

In my opinion, their findings, published in the journal Chiropractic and Osteopathy,³ work to shift the position of the BCA from defending Chiropractic as a healing profession that has 115 years of experience and published studies helping people with over 300 various conditions, to a glorified musculoskeletal therapist (of only selective regions of course). It is important to know that not all European associations have accepted these findings in Europe. Some groups maintain their position supporting Chiropractic and are adamantly opposed to the direction that these GCC commissioned researchers are driving the profession in Europe.

The International Chiropractors Association developed a COMPLETE Guideline that reviewed ALL levels of evidence, not the RCT exclusively. This guideline has been accepted for inclusion at the National Guideline Clearinghouse (NGC) a project by the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. The findings of this clinical practice guideline showed benefits of Chiropractic care for over 300 different health conditions using many different techniques. Chiropractic organizations in Europe who do not want Chiropractors to be reduced to a limited musculoskeletal pain therapists, should consult these documents. Many national and state associations from around the world have officially adopted these guidelines to support their position that Chiropractic is a health care profession, not a limited therapeutic musculoskeletal modality.

Whether you practice Chiropractic in Anytown, USA or some remote corner of Scotland, the ICA Guidelines are continuously being updated for the benefit of you and your patients. You can support this process by joining the ICA and purchasing a copy of the ICA Best Practices and PCCRP X-ray Guidelines. All proceeds go to future revision of the document. Call the ICA today 800-423-4690. While you sit on the sidelines, others are working to strip the purpose of Chiropractic out of the profession.

References

1. Bussieres AE, Taylor JA, Peterson C: Diagnostic imaging practice guidelines for musculoskeletal complaints in adults-an evidence-based approach-part 3: spinal disorders. J Manipulative Physiol Ther 2008, 31: 33-88.
2. ICA Committee’s Critique of CCGPP’s Best Practices: Chiropractic Management of Low Back Pain and Low Back Pain Related Leg Complaints. June 2006.
3. Bronfort G, Haas M, Evans R, Leiniger, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiro Osteopath 2010; 18(3): 1-113.

Chiropractic BioPhysics, Chiropractic Guidelines

New RCT Finds Vitamin D Prevents Influenza & Asthma Attacks in Children

Monday morning March 22, 2010, the American Journal of Clinical Nutrition published a multicenter, randomized, double-blind, placebo controlled trial of school children showing vitamin D3 prevents influenza. A secondary finding was that asthmatic children on placebo had six times more asthma attacks than did children on vitamin D3.

Over the course of 4 months, Urashima et al¹ compared the rate of incidence of influenza A diagnosis in 167 children using a nasopharyngeal swab. The children were randomized into 1 of 2 groups: Group 1 received 1200 IU/d of vitamin D(3) while Group 2 received a placebo. Only 10.8% of children receiving the Vitamin D(3) were found to have acquired Influenza A, whereas 18.6% of children in the placebo group acquired Influenza A; results were statistically significant. Also of importance, only 2 of the children with a diagnosis of asthma reported an attack whereas 12 children in the placebo group reported an asthmatic episode.

Key Take Home Points for Chiropractors and Their Patients

1. Vitamin D3 is a vital nutrient for immune system function, cardio-vascular function, and brain development and activity.^2,3

2. Vitamin D3 is produced naturally in humans by direct exposure of the skin to sunlight. In Winter and even other seasons, we do not expose our skin to adequate time periods of Sun light. ^2,3

3. It takes approximately 20 minutes per day of full body exposure (that means in the NUDE) to direct sunlight in order for your body to produce adequate levels of natural Vitamin D3. ^2,3

4. Thus, most Adults and Children need to supplement daily with Vitamin D3, especially in the winter months.

5. According to the results of Urashima et al.¹ vitamin D3 supplementation in school children may decrease the incidence of children developing signs and symptoms of the flu and may also decrease the rate of asthma attacks in asthmatic children.

References

1. Urashima M, Segawa T, Okazaki M, Kurihara M, Wada Y, Ida H. Randomized trial of vitamin D supplementation to prevent seasonal influenza A in schoolchildren. Am J Clin Nutr.2010 Mar 10.

2. Toohey L. Vitamin D: The versatile nutrient. American Journal Clinical Chiropractic 2010; 20(1):4 and 21.

3. Murphy DJ. Our schools, Autism, and Vitamin D. American Journal Clinical Chiropractic 2009; 19(2).

Chiropractic BioPhysics, Nutriwest

ICAC Guidelines for Whiplash Disorders Accepted at National Guidelines Clearinghouse

Charles G. Davis, DC, FICA, FICAC(H)

Ever get deposed and try to explain why the natural course of a whiplash injury may not be 6 weeks? The necessity and appropriateness of the treatment rendered? The medical reasonableness of the modalities utilized? The medical reasonability of the duration of treatment rendered?

The management guidelines for Whiplash Associated Disorders by the International Chiropractors Association of California has met the stringent criteria of the Federal Agency for Healthcare Research & Quality (AHRQ), and has been accepted for inclusion in the National Guidelines Clearinghouse (NGC), located at www.guidelines.gov. The NGC is a comprehensive database of evidence-based clinical practice guidelines and related documents produced by the Agency for Healthcare Research and Quality (AHRQ), in partnership with the American Medical Association and the American Association of Health Plans. The purpose of the NGC database is to provide health care professionals and providers access to objective, detailed information on clinical practice guidelines and to further the dissemination, implementation and use of those guidelines.

This guideline of Management of Whiplash Associated Disorders by the International Chiropractors Association of California provides integrated treatment guidelines for Whiplash Associated Disorders (WAD). These management guidelines for Whiplash Associated Disorders are evidence-based suggestions for appropriate care of patients seeking care. Recommendations are made for assessment along with time parameters, treatments, frequency & duration of treatment, staging and grades of injury, prognosis, criteria for discharge, and a variety of implementation tools, including a Pain Disability Questionnaire (PDQ), a Core Whiplash Outcome Measure, and an Impact of Event Scale.

While no guideline can replace the clinical decisions made by a practitioner in the course of caring for an individual patient’s health problem, the suggestions contain herein, are based on the best available published evidence. Any approach, by a practitioner, that is different from this ICAC-Management of Whiplash Disorders Guideline, does not necessarily mean that the approach in question was below the standard of care. However, any practitioner, who adopts a course of action different from this ICAC-Management of Whiplash Disorders Guideline, is advised to keep sufficient patient records to explain why such an action was undertaken.

Adherence to these ICAC-Management of Whiplash Disorders Guideline will assist the practitioner by allowing him/her to practice based on the most current scientific data available. Following the ICAC-Management of Whiplash Disorders Guideline, it is expected that the chiropractic practitioner will follow a reasonable course of action based on the best available knowledge. It is expected that with the assistance of the ICAC-Management of Whiplash Disorders Guideline, the practitioner will use the assessment and care suggested herein to deliver safe and effective care.

Main Participants in the guideline development included: Charles G. Davis, DC – Editor, Art Croft, DC, MS, MPH, FACO and Dan Murphy, DC, DABCO. However many other authors contributed to information, draft suggestions, critical reviews, and the final version of the document.

The nature of a science is that it is constantly evolving. Due to the variety, complexity, severity, and intricacy of human health conditions it is impossible to always determine the appropriate examination, appropriate diagnostic analyses, and to predict with absolute certainty the patient’s response to care. The ICAC-Management of Whiplash Disorders Guideline advances previous research and guidelines on this issue.

Copies are available from the ICA of California, 9700 Business Park Drive #305, Sacramento, CA 95827. 800-275-3515

Chiropractic BioPhysics, ICA Best Practices Chiropractic Guidelines, whiplash

CBP® NonProfit Research Update

CBP Research Presented at ACC-RAC 17

The research of CBP NonProfit, Inc. was represented at the seventeenth annual Association of Chiropractic Colleges Educational Conference-Research Agenda Conference held in Las Vegas, NV March 18-20. Dr. Paul Oakley represented himself and Dr. Deed Harrison’s case report featuring an MRI-documented complete resolution of an L4-5 disc herniation/sequestration after only 6-weeks of lumbar extension traction. The abstract is published in a special issue of The Journal of Chiropractic Education (Oakley P, Harrison DE. Lumbar extension traction and disc herniation/sequestration: A CBP case report. J Chiropr Educ: Spr 2010 (24:1): 136).

Berry Translation Traction to be Investigated by Dominican College, New York

In February of 2010, Dr. Bob Berry and Dr. Deed Harrison were contacted by the Department of Physical Therapy at Dominican College, New York. Two graduate students in the Doctorate of Physical Therapy program were inquiring as to the likelihood of acquiring a Berry Translation Traction Table and whether Dr. Berry and Dr. Harrison would be willing to assist in a research project. This research project is a requisite to be submitted-completed for partial fulfillment of the requirements for the Doctorate in Physical Therapy Degree at Dominican College.

The title of the project is: “Lateral Translational Traction to the Cervical Spine and its Reflection on Center of Gravity”; the main authors are Daniel Y. Lerner, SPT, Ailene M. Matusevich, SPT, and Project Advisors are: Michael Gallucci, EdD, Andrew McDonough, EdD, Deed Harrison, DC, Robert Berry, DC.

Drs. Berry and Harrison are excited about this project as it should further the understanding of translation traction intervention in chronic neck pain subjects. It is hoped that this project will aid in the determination of the effect of translation traction as a stand-alone intervention for correction of postural deformities in neck pain populations.

Chiropractic BioPhysics, Research

HOW TO FIND GREAT STAFF

Eric Huntington, DC

Co-Owner Developer of the Chiropractic Business Academy

While there are many aspects to a successful practice, one key element is hiring the right staff. At the Chiropractic Business Academy we provide chiropractors with the skills and procedure necessary to not only find quality staff, but to also train those staff to become super effective team members. In fact, one of the reasons that we are so popular with our clients is because WE TRAIN THEIR STAFF!

It all Starts with Finding the Right Person to Hire

You have to confront the fact that a great majority of the people who will come to your office to interview are not employable. From my experience of owning a large staff run office for ten years and the hundreds of chiropractors we consult every week, I estimate that on average, one in thirty people that you interview are employable—and about one in one hundred are that super star that will help bring your practice to the next level. You may get lucky and find a great person in the first five or ten, but realize that you were fortunate, and don’t stress if you really have to search for your next one.

So, this means that you have to set up your hiring strategy so that it can manage large numbers of people without disrupting the rest of your practice. Here is one way to do that.

Interview every week, even if you don’t necessarily need to hire someone right now. You always want to be on the lookout for that one in one hundred. If you find that super star, you can always find a place for them which will grow your practice. I recommend to my clients that a marketer, if well trained and productive, will always make you more money than they cost you. So marketing is one place you can put an “extra” person.

When we are fully staffed, we only use free advertising mediums on the internet or flyers on cork boards around town. When we really need new staff, we pay for newspaper ads, etc. Always keep a file of decent prospects if you can’t hire them right away.

Hold a group interview at the same day and time each week. Have a dedicated phone number that goes to a voicemail which nobody picks up (you can use a cell phone for this as well). On the recording, leave the day and time of the interview—so if it’s always the same, you never have to change it. On the message be sure to leave all necessary data--address, directions, etc. Remind them not to leave a message.

Train your receptionist to have employment applications on clipboards with pens ready on the day of your interview-- as people often come early. You do the first part of the interview in a group. Tell the whole group your name and that you will be meeting with them briefly. Starting with the first person who is done with their application (or the first person who walked in, if you don’t care whether or not they finish the application) peel them off from the group, somewhere that is semi-private.

If your office space allows, don’t take them into a room, as you’ll find yourself getting trapped and wasting time. In my office, we can have them walk out of the reception seating area and meet the interviewer next to the front desk-- They are literally standing for this part of the interview.

Three things that I look for in this short interview are,

1. Do they communicate well: Can you understand what they are saying—volume, accent, properly structured sentences, etc? When they answer questions, are their answers truly answers to your questions, or is it sort of off the topic? When they originate something, is it appropriate to the setting and is it consistent with the conversation?
2. Do they present well: Did they dress appropriately? Are they well groomed—as opposed to dirty or messy? Did you feel comfortable with them near you and would you feel comfortable that they could help you handle something really important to you?
3. Are they positive: Are they cheerful, excited about life and an opportunity to work?

There are other very important things to look for which take more extensive training to learn. These things are covered in our client workshops and courses.

For those people that you do not wish to have back for a second interview, tell them that you are reviewing applications and will only be contacting those that seem to be a good fit for the position, and have them back for a second interview—tell the person that you’ll make those phone calls within a few days. Thank them for coming to the office, shake their hand and end it quickly—but very politely. A key to getting yourself to do this weekly is not wasting time.

For those that you think might be a good candidate, have a short test on hand which you can have them do right in the office-- on that first interview.

If you’d like the test I use, you can call into The Chiropractic Business Academy and ask for Brian. He can give you the test I use.

Call 888-989-0855

The Next Step is a Working Interview for Your Best Candidates! To learn how to conduct this interview visit our website and read the rest of this article. www.ChirobizAcademy.com

Chiropractic BioPhysics

Audits, Accounting and Problems

R.J. Hammett, DC

Chances are that at some time in your practice life, you’re going to be hassled. An insurance company won’t like you, a fellow chiropractor will turn you into the board, you’ll do or say something stupid. Whatever the case, some “authority” will come knocking at your door. Trust me, it is not a good experience. So what do you do? Well, prevent defense is the best game plan. It won’t solve all your problems or totally protect you, but it may give you a fighting chance. By the way, if you’re doing something illegal or unethical, nothing will save, so quit now and stand up right.

Here is a check list of things you should look over:

1. Are you HIPPA compliant?

2. Do you use informed consent on all patients?

3. Do you “really” listen to your patients and write down what is said and done?

4. Do you re-x-ray or re-exam every patient every 15^th-30^th visit or so?

5. Do you re-examine those who just ‘drop in’ for a quick adjustment?

6. Do you review your outgoing billing at least twice a year? Do your codes match your documentation?

7. Are you keeping up on continuing education courses?

8. Do you know when to refer a non-responding patient?

9. Are you answering patients concerns?

10. Are your staff members working with you or against you?

11. Do you examine/x-ray the parts you adjust or treat?

12. Do you watch your promotions i.e : “Guarantee a cure” practicing outside your licence law?

13. Are you using outregous techinques or other on the edge stuff in your clinic?

14. Are you keeping up with changes in the laws of your state?

Ok, you have done everything right but someone wants a piece of you? What do you do?

1. Never, ever talk to any investigator from the board or person without the presense of an attorney. Ignore the inclination to cooperate fully until you have legal representation.

2. Do not grant an entry. Do not turn over patient records or other office material, send them to your attorney to send to any requesting authority.

3. Do not allow your staff to be interviewed.

4. Do not allow any authoriziation into your office without an attorney present.

5. Be respectful and polite, and tell the investigator that you will cooperate through your attorney.

6. The investigator is NOT your friend.

7. If you receive a subpoena, verify it with your attorney first.

8. Talk to a lawyer that is specialized in your type of case; NOT a general practice attorney.

I hope this helps, in fact, I hope you never need this information. But remember, bureaucracies are not your friend, nor will they ever be. Their job is to police, let them do their jobs, you do yours.

Til next time. RJH

Chiropractic BioPhysics

Restoration of an Abnormal Cervical Lordosis Using the DENNEROLL: A CBP® Case Report

Brian Paris, BS, DC	Deed E. Harrison, DC
Advanced CBP Fellow Private Practice Rockville, MD	President CBP Seminars, Inc. Vice President CBP Non-Profit, Inc. Chair PCCRP Guidelines Editor—AJCC

Introduction

In surgical^1,2 and non-surgical literature^3-5, it has been found that patients with less cervical lordosis have statistically significant increases in neck, upper thoracic, and shoulder pain and likely overall poorer health outcomes. The following case report suggests that the loss of cervical lordosis, forward head carriage, spinal arthritis and disc disease (S.A.D.D.), with concomitant sympomatology is consistent with current literature relating to cervical lordosis and pain.^1-5

Case History Key Features

A 59 year old female present to the practice of one of the authors (BP) seeking help for recurrent and chronic dizziness, neck and shoulder pain and stiffness, left arm tingling, sleep deprivation, and generalized fatigue. Her initial visit was on 10-7-2009 and she indicated that the current episode of her ailments had been present for at least the previous 2 months.

Cervical radiographs consisting of a neutral lateral and anterior-posterior were obtained. The lateral cervical radiograph revealed signs of spinal arthritis and disc disease (S.A.D.D) increasing in severity at the C5-C7 levels with possible rheumatoid changes in the upper cervical region. The patient had a large forward head carriage (58 mm from C2-C7) and a 70% reduction of the normal cervical lordosis. Radiographic analytical measurements and comparison to normal values were performed with the PostureRay^® computerized software system from PostureCo. See Figure 1.

Figure 1. Patient Pre-Lateral Cervical Radiograph and segmental alignments relative to ideal values. The green semi-circular curvature is the ideal curvature proposed by Harrison et al and the dashed red line represents the path of the patient’s posterior vertebral bodies and visually depicts the amount of displacement. The initial cervical lordosis demonstrated a 70% reduction, 12.6° from C2-C7 using the Harrison Posterior Tangent method.^6,7 The initial forward translation was 58 mm; using posterior superior body corner of C2 relative to a vertical line originating at the posterior inferior body corner of C7.

CBP Mirror Image^® Interventions

The patient was recommended and agreed to a treatment plan of spinal correction using CBP Technique mirror image adjustment, exercise, and traction methods. The treatment frequency was 3 times per week for 40 visits over approximately 13 weeks. The Patient presented to and actively participated at all appointments. Each visit consisted of mirror image adjusting, mirror image exercises and the Denneroll cervical orthotic to improve the cervical lordosis and reduce abnormal posture displacements.

• Mirror Image Adjustments

Beginning on 10-9-09, the patient was administered mirror image adjustments to correct Right Head Translation and Anterior Head Translated postures. See Figures 2 and 3.

• Mirror Image Exercises

Active rehabilitative care was administered to the patient beginning on 10-9-09. Since the patient’s abnormal posture was found to be Right Head Translation (-TxH) and Anterior Head translation (+TzH), the patient began mirror image exercises in left head translation to correct right head translation and posterior head translation without extension due to dizziness. See Figures 2 and 3.

Figure 2. The patient presented with the abnormal posture of Right Head Translation (-TxH). Mirror image adjustments were given in Left Head Translation. Mirror image exercises in Left Head Translation were given to the patient as part of CBP Active Rehabilitative care.

Figure 3. The patient presented with the abnormal posture of Anterior Head Translation (+TzH). Mirror image adjustments were given in Posterior Head Translation with extension to improve the lordosis and reduce forward head translation. Mirror image exercises in Posterior Head Translation (extension exercises caused increased dizziness) were given to the patient as part of CBP Active Rehabilitative care.

• The Denneroll Cervical Orthotic Intervention

The patient experienced considerable difficulty in performing passive and active cervical extension. Accordingly, the more advanced types of CBP in office traction methods could not be performed by the patient.¹ Thus, the Denneroll cervical orthotic device (Figure 4) was provided to the patient as the sole method of in office cervical corrective traction-stretching. Denneroll (adult small size) corrective stretching began on 10/19/2009 and continued for a total of 34 treatment sessions. Patient time started at 3 minutes per session and then increased up to 10 minutes per Denneroll session each visit in the office.

For the current patient, the Denneroll was placed in the upper thoracic/lower cervical region (Figure 4). This placement of the Denneroll will cause significant posterior head translation, will increase the upper thoracic curve if the large device is used (this is why the small device was used herein), and will increase the overall cervical lordosis.

Figure 4. Denneroll corrective orthotic application in the lower cervical region. This lower neck placement is for abnormal cervical curvatures having:

· Normal or a mild loss of the upper thoracic kyphosis;

· Loss of the mid-lower cervical curve;

Anterior head translation of approximately ≤ 40mm

Figure 5. Patient Post-Lateral Cervical Radiograph and segmental alignments relative to ideal values. The green semi-circular curvature is the ideal curvature proposed by Harrison et al and the dashed red line represents the path of the patient’s posterior vertebral bodies and visually depicts the amount of displacement. The Follow-up cervical lordosis demonstrated a 56% reduction, 18° from C2-C7 using the Harrison Posterior Tangent method.^6,7 The initial forward translation was 19 mm; using posterior superior body corner of C2 relative to a vertical line originating at the posterior inferior body corner of C7.

Re-Examinations:

In addition to the initial examination, 2 follow-up evaluations were performed over the course of the 40 sessions. At each examination, structural and functional responses to care were evaluated and patient symptoms were recorded and monitored using the Neck Disability Index and the Rand 36- Health Status Questionnaire. See Table 1. The brief examination findings are summarized here:

• 11/12/2009: Decreased dizziness; thinking more clearly; energy level (fatigue) same; left arm tingling improvingànow only intermittent;
• 12/14/2009: Infrequent bouts of dizziness, only occasional tingling in left arm;
• 1/13/2010: No reports of dizziness, occasional tingling in left arm.
• Overall Improvements: Significant health improvements were noted by patient since beginning treatment: “No dizziness”; “more clear-headed”. At most recent follow-up, dizziness had not returned. Only occasional tingling in left hand was reported and the patient has elected to continue with a 2^nd phase of CBP Corrective Care.

Table 1. Initial and Follow-up Neck Disability and Rand-36 Questionnaire results.

Questionnaire	Initial Exam 11-12-2009	Re-Exam 1-13-2010
Neck Disability	22% Pain interference with ADL’s	12% Pain interference with ADL’s
Rand-36-Health Status Questionnaire 12-14-09 1-13-10
Physical Function	60	75
Social Function	62.5	75
Role Physical	100	100
Role Emotional	0	100
Mental Health	64	72
Energy-Fatigue	45	55
Pain	45	67.5
Health Perception	77	52

Discussion

The Denneroll orthotic applies a passive 3-point bending force to the cervical spine that is generally well tolerated and is most consistent with the Pope-2-way type of in office corrective traction force.⁶The Denneroll is available in 2 adult sizes (adult large and adult small) and the adult small device was used for the present patient. The Denneroll size and placement of the device must be consistent with both the shape of the cervical curve and the amount/type of sagittal head translation correction that is desired for the given patient.

In the current case report, the combination of CBP mirror image methods resulted in improvement of cervical spine vertebral subluxation towards normal alignment. The Denneroll Orthotic for cervical lordosis corrective traction-stretching was the only type of CBP Traction utilized herein. Thus, it appears that the Denneroll Orthotic device assisted in cervical spine correction and improvement in chronic patient symptoms, disability, and altered health when applied in combination with mirror image adjustments and active mirror image exercises.

We will continue to test the Denneroll device in appropriate patient cases and provide the results in future articles.

References

1. Lowery G. Three-dimensional screw divergence and sagittal balance: a personal philosophy relative to cervical biomechanics. Spine: State of the Art Reviews 1996;10:343-356.
2. Kawakami M, Tamaki T, Yoshida M, Hayashi N, Ando M, Yamada H. Axial symptoms and cervical alignments after cervical anterior spinal fusion for patients with cervical myelopathy. J Spinal Disorders 1999;12:50-56.
3. Kai Y, Oyama M, Kurose S, et al. Traumatic thoracic outlet syndrome. Orthop Traumatol 1998;47:1169-1171.
4. Harrison DD, Harrison DE, Janik TJ, Cailliet R, Haas JW, Ferrantelli J, Holland B. Modeling of the Sagittal Cervical Spine as a Method to Discriminate Hypo-Lordosis: Results of Elliptical and Circular Modeling in 72 Asymptomatic Subjects, 52 Acute Neck Pain Subjects, and 70 Chronic Neck Pain Subjects. Spine 2004; 29:2485-2492.
5. McAviney J, Schulz D, Richard Bock R, Harrison DE, Holland B. Determining a clinical normal value for cervical lordosis. J Manipulative Physiol Ther 2005;28:187-193.
6. Harrison DE, Harrison DD, Haas JW. CBP Structural Rehabilitation of the Cervical Spine. Chapters 2 & 6. CBP Seminars, 2002; pgs:147-151. ISBN 0-9721314-0-X.
7. Harrison DD, et al. Spine 2004; 29:2485-2492.

cervical lordosis, Chiropractic BioPhysics, Denneroll Orthotic, Posture, rehabilitation, Research, subluxation, traction

PostureRay: Mirror Image® Traction Links Here We Come!

Joseph Ferrantelli, DC

Private Practice New Port Richey, FL

CTO, CBP^® Seminars

CEO, PostureCo

Many Chiropractors have successfully begun using PostureRay®in their practices and have provided us feedback on how it has aided in growing the practice by reducing the time for objective and reliable x-ray analysis, as well as generating patient friendly Report of Findings marketing materials, not to mention the multifunctional digital view box.

Well now we have some more exciting news! We have just begun the process of programming the most requested of additional modules, that being, linking a patient’s x-ray findings with mirror image^® traction protocols and set up procedures. This module will be aimed at reducing mistakes in traction selection when considering the all pertinent x-ray biomechanical findings. For example, occasionally we receive calls from Chiropractors to our CBP hotline where they have pursued traction treatment for a patient with a cervical kyphosis, adjusted them, and exercised them, all with only minimal improvement in their post x-ray findings. Now to a less experienced structural based doctor, one might jump to the conclusion that CBP methods have failed. However, more often than not, it was merely an incorrect mirror image traction setup for the patient, or worse yet, the wrong traction method may have been administered.

Consider the sagittal cervical spine as an example where many patient cases have altered thoracic alignment coupled with the abnormal cervical lordosis. Mechanically, the subluxated thoracic kyphosis would change the choice and set up for the patient’s cervical spine traction. Unfortunately, many chiropractors do not routinely obtain lateral thoracic x-rays which would limit the chances for the patient’s success. There are at least 16 categories of abnormal cervical curvatures encompassing the type upper thoracic kyphosis and the type of sagittal plane head posture. In relationship to these categories there are 4 -primary types of in office CBP Traction equipment with each having several types of possible setups specific to the curve and posture. Furthermore there are now 3 types of viable home traction units. Thus, choosing the appropriate mirror image traction application type and setup for a specific lateral cervical subluxation is not a 'simple task'.

Consider the case in Figure 1 (lateral cervical) and Figure 2 (lateral thoracic). Looking at the cervical curvature we can identify:

· A straightened lower cervical lordosis with a ‘flattened’ or near vertical C7-T1 posterior vertebral body alignment,

· A cervical kyphosis from C2-C5 segments—mid cervical kyphosis if you will,

· A numerical value of C2-C7 anterior translation is found and seen, however, this is not true head translation. The reason C2 is anterior to C7 is due to the cervical kyphosis from C2-C5,

· There is a mild flexion of the skull on the atlas.

Now, looking at the thoracic curvature we can identify:

· Anterior translation of T3 relative to T10,

· A nearly straight thoracic kyphosis showing an 83.8% reduction in curvature.

Clinical Questions Concerning This Case:

1. What is the appropriate type of cervical curve traction to be used in the office?

2. What would the exact setup look like for this type of in office traction?

3. What is the appropriate type of home orthotic traction to be administered in this case?

4. What would the exact setup look like for this type of home orthotic?

Solutions

In the near future, PostureRay will be able to guide you to the likely most appropriate traction types and setups. In cases like these, the treating Chiropractor can become frustrated, especially in higher volume settings, and worse yet - the patient may remain subluxated due to ineffective interventions. The result may be that the patient and doctor are left believing chiropractic may not be able to ‘correct’ their condition and that only symptomatic care is appropriate.

With this new module under development, under direction of Dr. Deed Harrison, we aim to remove as much guess work as possible, suggesting better set up protocols with both angles of pull, patient positioning, and of course, choice of appropriate traction methods based on patient specific x-ray analysis, conditions and symptomatic ailments.

Look for this additional module to become available towards the end of this year!

If you have questions about how PostureRay can help your practice, feel free to visit our website atwww.postureco.com or email us at sales@postureco.com or direct questions to myself atdrjoe@idealspine.com. Always remember, a digital x-ray machine is NOT required to utilize PostureRay^®.

Chiropractic BioPhysics, PostureRay, PostureRay, subluxation, x-ray digitization software, x-ray digitization software, x-ray digitization software

Leg Length Inequality: Recent Studies & A New Full Length Shoe Lift Orthotic

Deed E. Harrison, DC

President CBP Seminars, Inc.

Vice President CBP Non-Profit, Inc.

Chair PCCRP Guidelines

Editor—AJCC

Introduction

The assessment of the patient with observed postural distortion and spine disorders would seem incomplete without the analysis of a weight bearing radiographic view of the pelvis and lumbar spine, including the femur heads. One of the more common structural findings in patients with lumbar spine disorders is the presence of an anatomical leg length inequality (ALLI). See Figure 1 for Postural Consequences of the ALLI. Although there is a significant body of literature discussing the epidemiology of ALLI, considerable controversy still exists over ALLI’s significance in patient populations with spinal disorders.^1,2

In the CBP Lumbar Rehabilitation Textbook (2007),³ we presented a contemporary and complete review of the literature pertaining to ALLI and its biomechanical consequences, appropriate analysis, and interventions. In this current report, I would like to present a few recent investigations delineating some important findings regarding ALLI and its conservative treatment with lift intervention.

Figure 1. Typical Abnormal Posture Caused by a Left Anatomical Short Leg. In A (left photo), for a left ALLI, the thoracic cage will translate to the left side and laterally flex to the right. Often, the pelvis will translate slightly towards the side of ALLI (left in this case). In B (right photo), the pelvis will rotate anterior on the short leg side. If the shoulders and feet are aligned parallel, this means that the thorax has rotated posterior in the exact degrees that the pelvis rotated anterior. In other words, the thorax typically rotates posterior on the short leg side.

Recent Study #1⁴

In a 2010 prospective study of 3026 patients 50-79 yrs of age, Harvey et al.⁴ sought to determine the correlation of ALLI to prevalent, incident and progression of knee osteo-arthritis (OA). They⁴ measured ALLI using full leg x-rays. Their findings are striking:

• ALLI ≥ 1 cm was associated with prevalent and symptomatic OA of knee. OR = 1.9

• The shorter leg had increased incident symptomatic and progressive OA of the Knee. OR = 1.5 & 1.3.

Conclusion: “Radiographic LLI was associated with prevalent, incident symptomatic, and progressive Knee OA. LLI is a potentially modifiable risk for Knee OA.”⁴

Recent Study #2⁵

In a 2009 cohort study of 3012 people, Golightly and colleagues⁵ examined the relationship between chronic Knee and/or hip symptoms to ALLI. In 2006 of the subjects, there was an ALLI of ≥ 2 cm. Subjects in their sample with ALLI were statistically more likely to have knee symptoms (p<0.001). After adjusting for several confounding variables, knee symptoms were statistically associated with the presence of an ALLI (OR= 1.41 p< 0.001).

They⁵ stated, “LLI was moderately associated with chronic knee symptoms and less strongly associated with hip symptoms. LLI may be a new modifiable risk factor for therapy of people with knee or hip symptoms” .⁵

Orthotic Correction of ALLI Improves Chronic Pain

In a 2005 randomized trial, Defrin et al⁶ found statistically significant improvements in chronic low back pain in patients receiving shoe lifts compared to no treatment in the control subjects. In both the control and lift treatment groups, the measured LLI was between 5-10mm as measured via pelvic radiographs. This important study provides evidence that patients with chronic low back pain with concomitant ALLI between 5-10 mm may benefit from orthotic intervention aimed at leveling the sacral base and femur head heights. They stated,

“Shoe inserts appear to reduce CLBP and functional disability in patients with LLDs of 10mm or less”.

In 2007, Golightly et al⁷ reported on improvements in twelve (6 males and 6 females) consecutive chronic low back pain patients between the ages of 19-62 years of age with radiographic ALLI between 6.4-22.2 mm. Subjects were treated with orthotic intervention determined by the height that best relieved patient symptoms. Using the visual analog scale and disability questionnaires, statistically significant reductions in chronic pain intensity and disability scores were found.

Figure 2. Sole Supports full‐foot lifts are made of an easily cleanable, non‐compressible vinyl. If you are a Sole Supports certified provider, you receive a discounted rate for the full foot lift in combination with a Custom Orthotic order. However for non-Sole Supports certified providers, CBP Seminars has arranged to be a distributor for these innovative, contemporary, and biomechanically sound full-foot lifts. See www.idealspine.biz for details and ordering information.

New Full Length Shoe Lift for ALLI Correction From Sole Supports

An exciting product has just been launched on the market by Sole Supports as a new option for treatment of anatomical leg length inequality (ALLI). See Figure 2. This product is a full‐foot lift, made of non‐compressible vinyl and is available in 1mm peel able increments. Each lift consists of six, one‐millimeter layers of vinyl that allow you to adjust the height of the lift to suit your patient’s needs. See Figure 3.

Figure 3. Sole Supports Full Foot Lift. Each lift consists of six, one‐millimeter layers of vinyl that allow you to adjust the height of the lift to suit your patient’s individual needs. They are available in a range of both men’s and women’s sizes. The 6 mm size was chosen as a limit of what will generally fit in the average shoe.

Biomechanical Benefits of Full-Length Foot Lift

Problematically, the standard heel lift has a gradual taper being larger at the heel and smaller towards made foot. Though these tapered heal lifts have been found to be effective at relieving patients chronic pain syndromes, biomechanically there can be consequences to the functionality of the foot-ankle complex over long-term use.

Figure 4. Different types of shoe lifts available. Note that all of these lifts have a strong increased heel height and taper towards the mid-foot. Theoretically this taper may alter forefoot forces and heel-achilles tendon tightness due to ankle plantar flexion.

In contrast, use of the new full foot lift allows for correction of ALLI without changing ankle angulation or increasing plantar flexion of the foot; thus not compromising proper foot biomechanics. In theory, with a full‐foot lift, the foot will remain level (not considering the slope of the shoe itself) and the leg is lifted as a platform. The full foot lift would also limit changes in forefoot pressure and heel-achilles tendon tightness that can result because of ankle plantar flexion due to a tapered lift. These Sole Support full‐foot lifts should be used to address both acquired or functional leg length discrepancies, as well as anatomical discrepancies.

Editor’s Note: Sole Supports has graciously licensed CBP Seminars to distribute their innovative, contemporary, and biomechanically sound full-foot lifts. See www.idealspine.biz for details and ordering information.

References

1. Knutson GA. Chiropractic & Osteopathy 2005;13(11):1-10.
2. Brady RJ, Dean JB, Skinner MT, Gross MT. JOSPT 2003; 33:221-234.
3. Harrison DE, Harrson DD, Haas JW, Oakley PA. Chapter 4. CBP Structural Rehabilitation of the Lumbar Spine. Evanston, WY: Harrison CBP Seminars, Inc., 2007.
4. Harvey et al. Assoc of leg-length inequality with knee osteoarthritis. An Intern Med 2010; 152:287-95

5. Golightly et al. Symptoms of knee and hip in individuals with and without LLI. Osteoarthritis Cartilage 2009; 17: 596-600.

1. Defrin R, et al. APMR 2005;86:2075-2080
2. Golightly YM, Tate JJ, Burns CB, Gross MT. J Orthop Sports Phys Ther. 2007; 37(7):380-388.

anatomical short leg, Chiropractic BioPhysics, Heel lift, Shoe Lift, SoleSupports