Chiropractic to Make a Splash at the 2009 APHA Annual Meeting

Claire Johnson, DC, MSEd

Communications Chair, Chiropractic Health Care section - APHA

cjohnson@nuhs.edu

The annual meeting of the American Public Health Association (APHA) will take place November 8 to 11, 2009 in Philadelphia, Pennsylvania. This is the largest gathering of public health professionals in the world with attendees numbering over 12,000. The Chiropractic Health Care (CHC) section is one of 25 major sections in APHA. Once again the section will present five strong scientific sessions along with two business meetings and a joint social with the Public Health Education and Health Promotion (PHEHP) section and the School Health Education and Services (SHES) section. We will have a notable presence on the convention floor with our Megabooth in conjunction with Vision Care, Oral Care and Podiatry.

The CHC section will hold its annual business meetings on November 8 and 9 and the scientific sessions will be held on Monday November 9. Presenters representing many of the major chiropractic colleges and research departments will be presenting their research at the following sessions:

1. Chiropractic Education and Public Health: This session will look at a number of topics related to chiropractic education, including surveys of student attitudes, creation of a new program in a prominent medical college, and needs assessment for chiropractic at the state level.

2. Current Research in Chiropractic: This session will look at the attitudes chiropractic students have toward the use and teaching of physical therapy, at how different strategies can be used for testing, and how baseline levels of pain and other outcome measures can predict final self-reported pain.

3. Developing Integrative Approaches to Patient Care: This session provides papers looking at the use of chiropractic in military settings, both in terms of integration and of the characteristics of those already in the system. In addition, utilization issues are described for referral patterns between MDs and CAM practitioners, as well integration patterns at a chiropractic college teaching clinic setting.

4. Models of Wellness Care in Practice: The primary topic discussed in this session is health promotion, and this is looked at in different settings. In addition, health diets are described as they were developed and implemented in a community-based chiropractic college teaching clinic. Information is given on influenza biology, in recognition of the global H1N1 flu crisis, and chiropractic attitudes toward immunization are described and reviewed on way to a new proposal for same.

5. Adverse Event Reporting and UPIRTSO: The primary purpose for this session is to examine adverse event reporting within chiropractic research settings. In addition, this session will look at how fractures have been reported in the chiropractic literature, and it will provide information relating to a public health website for use by chiropractors.

Chief among the goals for the coming year is to expand awareness of musculoskeletal issues as a major public health concern. The time has come for the CHC take a leadership role in the Association. Musculoskeletal disease is a significant public health problem that is contributing to the rising costs of healthcare. The CHC through joint efforts with the US Bone and Joint Decade (USBJD) will work to elevate awareness of this issue and be an integral part of working toward efforts to improve prevention and work toward more cost effective care. The goal of the incoming chair is to see the CHC submit a resolution to have the Governing council endorse the tenets of the USBJD and also to see the APHA have a dedicated session to addressing public health issues associated with musculoskeletal disease. For more information about attending the APHA annual meeting, please visit the website http://apha.confex.com/apha/137am/webprogram/CHC.html.

The Chiropractic Health Care Section of the APHA (APHA-CHC), founded in 1995, has maintained a critical role in public health issues such as wellness, health promotion and disease prevention in the context of chiropractic policies and practices. For more information about the CHC, please visithttp://www.apha.org/membergroups/sections/aphasections/chc/

Open Adjusting

Dwight DeGeorge, D.C., MS

Practice Coach & Mentor

CBP Instructor

The initial reaction of visiting doctors at my office is one of interest and apprehension. The first obstacle visiting doctors have is the open adjusting and therapy rooms. The therapy performed at my office involves corrective traction and some ice for acute patients. A very common question asked by visiting DC’s is, “Don’t patients have a problem with being adjusted out in the open like that?” My response is always, “No, not at all. But sometimes our visiting doctors do!” Everyone thinks the “open” adjusting concept is a new and progressive one. Yet, hanging on the wall behind the adjusting tables is a picture of B.J.’s clinic in Davenport, Iowa. The picture shows an auditorium-like room with at least twenty doctors on a staging platform. The doctors are side-by-side adjusting as a line of patients are entering and exiting the stage. People are packed into the auditorium waiting for their turn to be adjusted. This picture was taken in the 1940’s. It seems patients have never really had a problem with open adjusting and those doctors who have been able to overcome their fears of the open adjusting concept report that they could not imagine working any other way now.

Let’s discuss some possible aspects of open adjusting. Our office does not reflect, in any way, a sterile type of medical establishment. It is bright, open and lively; even noisy at times. There is a definite air of energy and enthusiasm apparent to both patients and visitor alike. I have observed chiropractors, in my time, who wear surgical scrubs and spend most of their time evaluating, diagnosing and writing reports who may be appalled at this office concept. I believe our office is a nice mixture of old time DE philosophy and present day science of spinal correction. The main benefit of open adjusting is better patient education. The average patient has little understanding about health, or more so, chiropractic. With open adjusting and therapy patients can listen to other patient’s problems, some they are experiencing, while some a family or friend are experiencing. They hear the same messages over and over, and for many patients this repetition leads to their education. Dr. Jim Zigafoose tells a story about a female patient who had to have the same report of findings explained to her about “ten” times before she either claimed to understand it or was ready to accept it!

The open adjusting concept naturally lends itself to many educational benefits and often can be a determining factor of whether a patient will follow through with their care plan. For example, a patient recently started care with you and is apprehensive about chiropractic and still very symptomatic after several visits. Before you can adjust him, the patient complains about his continuing symptoms and is questioning whether he should continue with chiropractic care. A patient on the next table overhears and begins to interject with his positive experience and encourages him to stay with care. In some instances, this encouragement can be more effective than when it comes from the doctor.

Open adjusting makes it very easy to stimulate referrals. A patient who sees you for low back pain, often only understands that chiropractors can help low back pain. However, the patient next to him is telling you how much better his asthma (headaches, blood pressure, hip pain, etc…) is since he has started under your care. Often, the doctor will find his patients sharing “war” stories, ask each other questions, and encourage each other. Friends and family members who are with your patient during a visit are experiencing these exchanges as well. The doctor will observe a lot of chiropractic education occurring among patients while they are working with another.

The patient who fears being adjusted will often relax while watching other patients receive an adjustment. How nervous can a person be about being adjusted when he just watched the five year old next to him receive an adjustment and enjoy it? Patients observe newborns receive their first adjustment and listen as a mom brings in her family for adjustments because the flu has hit the schools. All these scenarios lend to an educational benefit to others in the room.

The open adjusting concept is also attractive to busy clientele. Patients do not like to wait or feel that they are waiting longer than they should for their time to see a doctor. Open adjusting lends to less waiting, and patients appreciate the respect given to their time. There is very little, if any, wait time in our office. Patients are treated and educated within a short time and the quality of their care is never compromised. Dialogue with patients requiring privacy is easily dealt with by stepping into an exam or consult room to discuss any issues.

In my experience, the overwhelming majority of patients who have treated in my office have been extremely pleased and comfortable with the open adjusting concept.

I could not imagine practicing any other way than using an open adjusting concept for treating patients. Many doctors who have come to use the open concept in their offices regret not converting to the idea earlier in their practice. If you want to bring some life and energy into your practice, this might be an important step for you to take. As Dr. Guy Riekman has said many times, “You need to be able to step outside the nine dots if you want to break out of your self-imposed cages.”

Chiropractic BioPhysics

A New Cervical Lordotic Home Traction Device: The Denneroll—An Initial Case Series

Deed E. Harrison, DC

President CBP Seminars, Inc.

Vice President CBP Non-Profit, Inc.

ICA Nevada State Assembly Rep

Chair PCCRP Guidelines

Editor—AJCC

In a previous issue of the AJCC (2008), I presented the evidence for in office CBP^® Technique structural rehabilitative procedures. According to the CBP publications, mirror image^® exercises and traction procedures should be performed in-office at least 3-4 times per week for 9-12 weeks in order to obtain significant improvement in abnormal alignment of the spine and improvements in a patient’s chronic disorder(s).^1-5

However, the evidence based practice guideline/protocol of care for CBP technique, recommends home exercise and home traction for patients as a supplementary procedure to the in-office intervention program.^4,5Also, home traction and exercise may be the only viable means of rehabilitation for patient’s whom live many miles away from a given practice or for schedules that are simply not conducive to regular care.

Problematically, to my knowledge, there exist no formal publications documenting the potential benefit/effect of different types of home traction procedures aimed at rehabilitation of the sagittal plane curvatures of the spine. Thus, the purpose of the present article is to present preliminary information on the immediate effect of one traction session using a new cervical orthotic device termed the Denneroll.

Materials and Methods

The Denneroll (Designed by Adrian Dennewald, D. C. of Australia) is a new cervical sagittal plane orthotic device designed to passively stretch the cervical lordosis into a more lordotic position. See Figure 1. Its unique design allows it to support the upper thoracic

curvature while simultaneously create a 3-point bending extension load on the cervical spine.

Most commonly, the Denneroll has 3 primary positions that are used for aiding in the rehabilitation of the cervical lordosis:

1) The apex of the Denneroll orthotic is placed in the upper cervical region (C2-C4) region. This position allows extension bending of the upper cervical segments while causing slight anterior head translation. An upper neck setup and example x-ray subluxation is shown in Figure 1. The red line represents the ideal curvature after Harrison et al.⁶ while the black line shows the patient’s subluxated alignment.

2) The apex of the Denneroll orthotic is placed in the mid-cervical region (C4-C6) region. This position allows extension bending of the mid-upper cervical segments while creating a slight posterior head translation. SeeFigure 1.

3) The apex of the Denneroll orthotic is placed in the upper thoracic or lower-cervical region (C6-T1) region. This position allows extension bending of the majority of cervical segments while creating a significant posterior head translation. See Figure 1.

Figure 1. On the top row from left to right, 3 uniquely different subluxated lateral cervical curvatures are shown; the red line represents the ideal curvature of the neck after Harrison et al.¹ On the bottom row, three primary placements of the Denneroll cervical orthotic are shown. The Denneroll placement should match both the shape of the cervical curve and the amount of sagittal head translation correction that is desired.

For a preliminary investigation, 11 Chiropractors volunteered for an initial neutral lateral cervical radiograph and completed a neck disability index. One out of the 11 lateral cervical came out with digital artifacts that could not be corrected and was discarded; while another had a normal cervical lordosis on the initial lateral x-ray. This left 9 subjects.

The 9 subjects were asked to lie supine on the floor over the Denneroll orthotic device for 10-13 minutes. Only 1 traction-session was used. The Denneroll location was selected by a trained practitioner.

Following the 10-13 minute traction session, the subjects were asked to relax comfortably for 3-5 minutes without stretching or bending the neck. Once the 3-5 minute interval elapsed, a second neutral lateral cervical radiograph was obtained.

Results

The initial and follow-up lateral cervical radiographs were analyzed with the PostureRay x-ray digitization system. Only 2 of the many reported variables are shown in Table 1. The cervical lordosis using the posterior body margins of C2-C7 and the sagittal plane translation of C2-C7 were recorded. From Table 1 it can be seen that a significant improvement in the cervical lordosis (9.8°) and reduction in sagittal plane head translation (7.4mm) were obtained.

Figure 2 shows subject #9’s initial and after lateral cervical alignment. Here the green semi-circular line represents the ideal cervical lordosis after Harrison et al.⁶; while the red line represents his lateral cervical alignment.

Figure 2. Before and After Denneroll x-rays. With the subject supine, the Denneroll was placed in the lower neck as in Figure 1 for 11 minutes. The following up x-ray was taken after 5 minutes of recovery (no Denneroll). Good improvement in cervical lordosis was found after 1 session indicating likely benefit.

Discussion

It is significant that following only one 10-13 minute session on the Denneroll orthotic device, a significant improvement in both the cervical lordosis and anterior head translation. Obviously the results presented herein are preliminary and follow-up should be and will be performed on this device.

From Table 1, the astute reader will see that a couple of the subjects showed remarkable change in lordosis while a couple of subjects showed little only slight change. This type of situation is typical of any/all treatment devices and is due to many variables:

· The elasticity of the individual subject’s tissues,

· The age of the subject,

· The state of degenerative joint disease-stiffness of the tissues,

· The shape of the thoracic curvature,

· Improper application during traction,

· Perhaps the device just won’t work for some individuals, etc.

Most of the above variables can be overcome with continued effort on the patient’s and the doctor’s part. However, as with all interventions, there is no such thing as a one size fits all.

To me, the information presented herein, is preliminary data indicating the Denneroll orthotic may be a viable home traction device to supplement a CBP Chiropractors in office rehabilitative treatments. When the shape of the cervical curve indicates, the Denneroll could be used on off days from office treatments; and in difficult cases, it could be used daily once tolerance is developed.

Hopefully, the information presented will stimulate further research into the effects of home traction units. After all the majority of us (including me) recommend home products to our patients and believe in their effects; but wouldn’t it be nice to know?

Note: If you would like more information on the Denneroll Cervical Orthotic device contact:drdeed@idealspine.com or see www.idealspine.biz.

References

1. Harrison DD, et al. J Manipulative Physiol Ther 1994;17(7):454-464.

2. Harrison DE, et al. Arch Phys Med Rehab 2002; 83(4): 447-453.

3. Harrison DE, et al. J Manipulative Physiol Ther 2003; 26(3): 139-151.

4. Oakley PA, et al. J Canadian Chiro Assoc 2005; 49(4):270-296.

5. Harrison DE, Harrison DD, Haas JW. CBP® Structural Rehabilitation of the Cervical Spine. CBP Seminars, 2002; pgs:147-151. ISBN 0-9721314-0-X.

6. Harrison DD, et al. Spine 2004; 29:2485-2492.

cervical lordosis, Chiropractic BioPhysics, Denneroll Orthotic, subluxation, traction

What Is Chiropractic BioPhysics® (CBP®) Technique?

Donald D. Harrison, PhD, DC, MSE Deed E. Harrison, DC

INTRODUCTION

In December 1980, Chiropractic BioPhysics^® or CBP^® Technique, was originally named by Drs. Donald Harrison, Deanne Harrison, and Daniel Murphy for “physics applied to biology in chiropractic”. Since that time, Drs. Donald and Deed Harrison, (along with a number of other contributors) have authored Seven CBP Texts Books and published more than 130 scientific studies investigating different aspects of CBP.^1-7 Thus, today, CBP Technique is one of the foremost investigated techniques in Chiropractic and both Dr. Don and Dr. Deed are among the leaders in the profession’s researchers.

Table 1.

CBP Technique Scientific Publications. These publications detail different aspects of the technique procedures, protocols, and outcomes.

CBP Goals of Care

CBP Technique emphasizes optimal posture and spinal alignment as the primary goals of chiropractic care while simultaneously documenting improvements in pain and functional based outcomes (See Figure 1). The uniqueness of CBP treatment is in structural rehabilitation of the spine and posture. In general the goals of CBP Care are:

1. Normal Front & Side View Posture
   1. Center of mass of head, rib cage & pelvis vertically aligned in Front and Side views.
2. Normal Spinal Alignment
   1. Front view: vertical alignment
   2. Side View: Harrison Ideal or Average Spinal Model
3. Normal function

a. Improved Range of Motion and quality of movement,

b. Improved muscle strength,

1. Improved Health & Symptom Improvements
   1. Neck disability index,
   2. Oswestry low back index,
   3. SF 36 or Health Status Questionaire

Ideal Postural Alignment

Figure 1. Ideal postural alignment is depicted in both the frontal and side views. In each view, the center of mass of the skull, thorax, and pelvis are in a vertical line with respect to gravity. In the frontal view, the spinal column is vertically aligned-a straight column- with respect to gravity. In the side view, the spine has three primary curvatures which will be described below:

1. Neck Curve---Cervical Lordosis,
2. Ribcage Curve---Thoracic Kyphosis,
3. Low back Curve---Lumbar Lordosis

©CBP Seminars & Deed E. Harrison, LLC.

Ideal Spinal Alignment: Harrison Full Spine Model

As in all fields of study dealing with the human body, i.e. physiology, hematology, anatomy, etc., there exist normal values for alignment of the spine. The Harrison Spinal Model is an evidenced based model for side view spinal alignment. It is the geometric path of the posterior longitudinal ligament or the backs of the vertebra from the 1^st neck vertebra to the bottom of the lower back or top of the sacrum. See Figures 2-6 below detailing the Harrison Spinal Model

CBP researchers have extensively published ideal and average models for the human spinal curvatures as viewed from the side. This research has lead to the finding of the ‘Harrison Spinal Model’. This model details both Ideal and Average geometric shapes for the curves of the spine from the side. Additionally, ideal and average ranges for the spinal segmental angles for each of the spinal regions have been identified. The neck or cervical spine should have a geometric shape that approximates a ‘piece of a circle’. The ribcage or thoracic spine should have a geometric shape that approximates an oval-elliptical shape. And the low back or lumbar spine should have a geometric shape that approximates an oval-elliptical shape.^26-31

These are “evidence based” models. In fact, the CBP neck-cervical circular model²⁷ and the low back- lumbar elliptical model²⁹ have both been found to have discriminative validity between pain and non pain subjects. In other words, the Harrison Spinal Model has been found to be able identify pain subjects versus non-pain subjects by what their spinal x-ray shapes are.

Figure 3. The three figures above demonstrate the concept that each spinal region has a normal ‘geometry’ or shape of the spinal curves. On the readers left is the Neck or Cervical spine-Here the shape in the neck curve should approximate a piece of a circle. In the Center is the Ribcage or Thoracic spine—Here the shape in the ribcage should approximate a piece of an oval or ellipse. On the Right is the Low back or Lumbar spine—Here the shape in the low back should approximate a piece of an oval or ellipse. ©CBP Seminars & Deed E. Harrison, LLC.

Figure 4. The Harrison Full Spine Model. On the readers left is the exact geometric model of the side view of the spinal curves as identified by Harrison and colleagues. This model can be used to determine what is wrong-abnormal with a given patient’s side view of the spine. For example, a full spine x-ray on the right is shown. The red-curved line represents the Harrison spinal model and this shows where the patient’s spinal vertebra should be lined up. It is apparent that this patient has altered spinal alignment as they do not fit even close to the Harrison Idealized Spinal Model.

©CBP Seminars & Deed E. Harrison, LLC.

Figure 5. The Harrison Spinal Model in the Neck-Cervical region. The Harrison spinal model is depicted as theGREEN curved line in this figure. On the Right is a normal curved patient x-ray. On the Left is an abnormal curved patient x-ray; where the patient’s abnormal shape is shown by the Red dashed line. The Harrison Spinal Model in the neck has been shown to reasonably predict which person will have neck pain compared to normal subjects. ©CBP Seminars & Deed E. Harrison, LLC.

Figure 6. The Harrison Spinal Model in the Low back or Lumbar region. The Harrison spinal model is depicted as the RED curved line in this figure. On the Right is a normal curved patient x-ray. On the Left is an abnormal curved patient x-ray; where the patient’s abnormal shape is shown by the faint dashed line. The Harrison Spinal Model in the low back has been shown to reasonably predict which person will have low back pain compared to normal subjects. ©CBP Seminars & Deed E. Harrison, LLC. ©CBP Seminars & Deed E. Harrison, LLC.

X-Ray Analysis and Utilization

To establish optimal and average sagittal models, x-ray analysis and line drawing procedures are utilized. CBP protocols require that the doctor must measure the displacements on spinal radiographs (segmental Subluxation). Both lateral-side view and anterior to posterior (AP) or frontal view CBP x-ray line drawing procedures have been studied and found to be reliable.^32-36 Furthermore, CBP utilizes standardized x-ray positioning procedures that have been studied and found to be reliable.³⁶

As with measures of pain intensity, range of motion, and quality of life, periodic assessment of spinal structural alignment is important to evaluate progress and determine when maximum patient improvement has been reached. In CBP Technique, the use of initial and follow-up spinal x-rays or radiographs is deemed necessary; however, some in chiropractic have condemned the use of follow-radiographs to collect alignment data.^37-39Importantly, there is data to show that the use of medical/chiropractic x-rays constitutes a very minor health risk and in fact has been shown to be of benefit (decreased sickness and cancer mortality rates) in some studies.^40-42

In reality, the only way to see what an individual patient’s spine alignment looks likes, is to obtain spinal imaging such as Radiography or X-ray. No-one would not take their car to the mechanic and say: “Something’s wrong with my engine but don’t look under the hood”--Would you? Then why would anyone want a Chiropractor to adjust-treat their spine without having an x-ray to see what the person’s spine looked like?—Would You?

CBP Postural Analysis

Previously, engineering concepts were used to describe all spinal-vertebral segmental movements as rotations and translations in 3-dimensions.¹⁰ However, Dr. Don Harrison was the first to describe abnormal postures of the head, rib cage, and pelvis in this manner.^1-3,9 Figures 7 and 8 depict the twelve simple motions in six-degrees of freedom as rotations and translations of the human head, ribcage, and pelvis:

· Rotation is a turning, twisting, or tilting movement and is an ‘angular’ movement,

· Translation is a straight line movement (up, down, left, right, forward, backward)/

Figure 7. The possible translation postures (Tx, Ty, Tz) of the head, rib cage, and pelvis are depicted in 3-dimensions. In 1980, Dr. Don Harrison termed these pairs on any one axis as Mirror Images®. Whichever Abnormal postures were found to exist in the patient, these postures would be placed into their Mirror Image® before a force was applied with an adjusting instrument, drop table, exercise and/or traction. ©CBP Seminars & Deed E. Harrison, LLC

Figure 8. The possible postural rotations (Rx, Ry, Rz) of the head rib cage and pelvis are depicted in 3-dimenesions. In 1980, Dr. Don Harrison termed these pairs on any one axis as Mirror Images®. Whichever postures were found to exist in the patient, these postures would be placed into their Mirror Image® before a force was applied with an adjusting instrument, drop table, exercise and/or traction. ©CBP Seminars & Deed Harrison, LLC.

The postural and spinal displacements are the determining factors for deriving a patient’s individualized program of care. Prior to performing CBP Mirror Image® postural set-ups, the patient’s initial presenting abnormal posture(s) must be exactly determined. Ideal posture can be precisely described as vertical alignment of the centers of mass of the head, ribcage, and pelvis with respect to gravity (Figure 1 above). In other words, none of the rotations and translations in Figures 7 and 8 can be present. Using this definition, abnormal postural rotations and translations can be determined.

Mirror Image^® Postural Adjustments

In March 1980, Dr. Don Harrison originated postural Chiropractic adjusting procedures that he coined “Mirror Image^®”. Clinically, these adjusting set-ups were found to result in postural and spinal alignment improvements verified with follow up x-ray; this impression would be subjected to studies later as shown in Table 1 above.

For each of these postures illustrated in Figures 7 and 8, Dr. Don Harrison and his brother Glenn Harrison originated drop table adjustments, instrument adjustments (both table and hand-held). For these new Mirror Image® patient positions, Dr. Don Harrison placed the patient in their opposite posture. These Harrison Mirror Image® positions can be described as “reflecting” the patient’s head, rib cage, and/or pelvis across the median-sagittal plane in the AP view, and positioning the head, rib cage, and/or pelvis across the mid-frontal plane in the lateral view.⁹ Figures 9 and 10 demonstrate two examples (there are literally thousands more as there can be many postural combinations of each region) of Mirror Image® Adjustments utilized in CBP Technique.

Mirror Image Adjustments, assists the Chiropractor in the rehabilitation of the patient’s posture. In theory, these adjustments ‘re-balance’ the bodies sense of proper balance or alignment by way of triggering improved muscle and nerve reflexes. Thus, postural adjustments as performed with drop table, hand-held instrument, or evenmirror imageÒ manipulation procedures, are performed for resetting the nervous system regulation of postural muscle balance.⁵¹

Figure 9. Mirror Image adjustment example for the head posture. The patient has forward head posture (translation) and the skeletal animation shows what happens to the spine with this posture. On the right is the CBP Mirror Image adjustment. The posture is placed in its opposite position and then a Chiropractic adjustment is performed. ©CBP Seminars & Deed E. Harrison, LLC.

Figure 10. Mirror Image adjustment example for the ribcage posture. The patient has right lateral ribcage posture (translation) and the skeletal animation shows what happens to the spine with this posture. On the right is the CBP Mirror Image adjustment. The posture is placed in its opposite position and then a Chiropractic adjustment is performed. ©CBP Seminars & Deed E. Harrison, LLC.

Mirror Image^® Postural Exercises

Further, in 1980-1986, Dr. Don and Dr. Glenn Harrison began developing and testing Mirror Image® posture exercises.^1-3 Mirror imageÒ exercises are performed to stretch shortened muscles and to strengthen those muscles that have weakened in areas where postural muscles have adapted to asymmetric abnormal postures. Although strength and conditioning exercise has not proven to correct posture,⁴⁶ postural exercises performed in the mirror imageÒ have shown initial promise in the reduction of posture and spinal displacements.^47-50Figures 11 and 12 demonstrate Corrective Mirror Image exercises for the same postures as in Figures 10-11.

Figure 11. Mirror Image exercise example for the abnormal forward head posture. The patient has an abnormal forward head (translation) posture and the skeletal animation shows what happens to the spine with this posture. On the right is two different CBP Mirror Image exercises—one with just the patient’s muscles and body as resistance and the other with an elastic band for increased contraction effort. The patient actively maneuvers their posture into the opposite or Mirror Image position. ©CBP Seminars & Deed E. Harrison, LLC.

Figure 12. Mirror Image exercise example for an abnormal lateral shifted (translated) ribcage posture. The patient has right lateral ribcage posture (translation) and the skeletal animation shows what happens to the spine with this posture. On the right is two different CBP Mirror Image exercises—one with just the patient’s muscles and body as resistance and the other with an elastic band for increased contraction effort. The patient actively maneuvers their posture into the opposite or Mirror Image position. ©CBP Seminars & Deed E. Harrison, LLC.

Mirror Image^® Postural and Spinal Traction

Additionally from 1980-1986, for use in difficult cases, Dr. Don Harrison and Dr. Glenn Harrison originated several Mirror Image® postural traction (rotations and translations of the head, rib cage, and pelvis) and cervical extension (backwards bending) traction methods to restore the sagittal cervical curve. These CBP Technique cervical extension traction methods were improved upon over the years by several other CBP practitioners.

From 1996-2000, several postural and spinal traction methods to restore thoracic and lumbar sagittal curvatures were developed by Dr. Deed Harrison; Dr. Don Harrison’s son.^11-13 Dr. Deed began to further refine the CBP Technique cervical traction methods with an analysis of head posture, curve configuration, thoracic curvature, gender, and body size.⁴ From 1992-2004, six non-randomized clinical control trials,^13-18 one randomized clinical control trial,¹⁹ and five case studies^20-24 have been performed on these CBP Technique Mirror Image®procedures.

Postural mirror imageÒ and extension traction for the side view spinal curves provides sustained loading periods of 10-20 minutes and is necessary to cause visco-elastic deformation to the resting length of the spinal ligaments, muscles, and discs.⁵² In clinical controlled trials, extension traction, as done in CBP Technique, is the only proven method (without surgery) shown to consistently correct abnormal spinal curvatures back towards their normal alignment.

There are MANY types of spinal extension traction methods used in CBP Technique; some are more aggressive and technical than others. Whereas some forms of spinal extension traction are available for patients to use at home; the examples shown in Figures 13-14 are in office types only. Note: Each patient’s spine is unique and thus, a variety of traction devices are used depending upon the exact condition of the patient.

Figure 13. Three different subluxations (abnormal alignment) of the cervical curve and their respective Mirror ImageÒ traction methods. In A, hypolordosis with mild anterior head translation requires compression extension traction in B. In C, slight kyphosis with posterior head translation requires 2-way non-compression traction in D. In E, reversal of the upper cervical curve with mild anterior head translation requires compression extension 2-way traction in F.^4,14-16 ©CBP Seminars & Deed E. Harrison, LLC.

Figure 14. Two different subluxations of the lumbar curve and one of the thoracic curve and their respectiveMirror ImageÒ traction methods. In A, lumbar kyphosis with anterior thoracic translation requires 3-point bending extension traction in B (shown standing). In C, slight lumbar kyphosis with posterior thoracic translation requires 3-point bending in D (shown supine). In E, hyper-kyphosis of the thoracic curve requires 3-point bending thoracic traction in F (shown standing). ©CBP Seminars & Deed E. Harrison, LLC.

CBP Protocol of Patient Care

Treatment Interventions

The CBP protocol of care recommends that relief care (traditional chiropractic management) be separated from structural rehabilitation of the spine and posture. In this regard, the typical patient would receive an initial 3 weeks of care (4 times per week or 12 visits) aimed at improving segmental and overall spinal range of motion (RoM) and pain intensity/frequency. Treatment interventions/methods would consist of any number of segmental adjusting techniques the chiropractor prefers to utilize (Diversified, Gonstead, Activator, etc…).

After, the initial relief care examination (average 12 visits), CBP structural rehabilitation procedures would begin and include Mirror Image® exercises, adjustments, and traction (referred to as the E.A.T protocol). The mirror image® posture positions are the rotation and translation pairs in or about each coordinate axis (Figures 3 and 4 above). Thus, CBP care is multi-modal and is consistent with Bolton’s ideas of clinical applications in evidence based practice.⁴⁵ Table 2 outlines treatment interventions recommended by CBP for each of relief and structural rehabilitative care.

The reason for postural mirror imageÒ exercises, adjustments, and traction procedures is to address all the tissues involved in spine and posture alignment.

Unlike the relief care phase (approximately 12 visits), which includes segmental adjusting procedures from other named techniques, the E.A.T corrective care protocol is unique to CBP. In combination, these “E.A.T.” methods are unique to CBP Technique.

Table 2.

CBP recommended treatment methods for each phase of care, relief and structural rehabilitation of the spine and posture.

Frequency & Duration of CBP Technique Care

Previously it was stated that a typical patient is started with relief care at a frequency of 4 times per week for 3 weeks or 12 visits. After this 12 visit relief care regiment, a patient is re-evaluated to document improvements in initial (visit 1) positive exam findings, pain scales, disability indices, health status, and range of motion. Following this re-evaluation, the patient is transitioned into CBP structural rehabilitative E.A.T. procedures.⁴

To determine if the CBP E.A.T protocol of corrective care for each individual (based on his/her posture and spinal displacements) is achieving the desired normalization of posture and spinal alignment, re-examinations are suggested at 36 visit intervals. In other words after 24 visits of CBP E.A.T interventions added to the initial 12 visits of relief care. This 36 visit number is not based on personal opinion, but rather is an average duration from our six CBP clinical control trials.^13-18 In order to arrive at this 36 visit time period, one could use a frequency of 4 visits per week for 9 weeks or 3 visits per week for 12 weeks.

In six clinical control trials detailing the outcomes of chronic pain patients with CBP Treatment interventions, the average chronic pain patient achieved a 75-80% improvement in their chronic pain and a 50% correction of their initial subluxated (abnormal spine alignment) position towards ideal and average spine alignment.^13-18 This data indicates that, on average, a typical chronic pain patient may need 2 blocks of 36 visits of intensive structural rehabilitative care (defined as 3 or 4 visits per week) to achieve as near normal spinal alignment as possible.

Table 3.

CBP Protocol and Phases of Care showing the timing of different Treatment methods.

The frequency and duration of further care recommended to the patient at the 36 visit re-evaluation depends on their improvement in both structural and functional based outcomes. For example, if a patient achieves near-normal posture and spinal alignment at the 36 visit re-evaluation, then a reduced frequency of treatment is recommended for stabilization care (1-4 times per month depending upon the case). However, if at the first corrective care re-evaluation, less than average improvement is attained on comparative radiographs and postural examination (PosturePrint™), then this is indication that another block of 36 visits may be necessary for continued spinal correction. With CBP’s six completed clinical control trials, our methods have moved from the clinical opinion arena to having foundation in the category of “evidence based” care.

Conclusion

In our present era, ‘evidence-based’ medicine was coined as a means to improve patient outcomes and quality of care. CBP Technique uses postural and radiographic analysis procedures that have been shown to be reliable and valid. Significantly, CBP Technique has multiple types of peer-reviewed publications in scientific journals as evidence for its’ patient treatment methods. What remains for CBP technique is further refinement of technique protocols and evaluating the effects of subluxation reduction using the E.A.T. procedures in more advanced study designs. CBP is a technique practiced by a large number of practitioners, is a leader in the chiropractic technique and biomechanics research arena, and has shown good potential to improve chronic pain conditions in several patient populations and selected case studies.

References

1. Harrison DD. CBP^â Technique: The Physics of Spinal Correction. National Library of Medicine #WE 725 4318C, 1982-97. Harrison DD. CBP Technique: The Physiscs of Spinal Correction.

2. Harrison DD. Spinal Biomechanics: A Chiropractic Perspective. National Library of Medicine #WE 725 4318C, 1982-97. Harrison DD. CBP Technique: The Physiscs of Spinal Correction.

3. Harrison DD. CBP X-ray Work Book. National Library of Medicine #WE 725 4318C, 1982-97. Harrison DD. CBP Technique: The Physiscs of Spinal Correction.

4. Harrison DE, Harrison, DD, Haas JW. CBP® Structural Rehabilitation of the Cervical Spine. Evanston, WY: Harrison CBP Seminars, 2002.

5. Harrison DE, Harrison, DD, Haas JW, Oakley PA. Spinal Biomechanics for Clinicians, Volume I. Evanston, WY: Harrison CBP Seminars, 2003.

6. Harrison DE, Harrison, DD, Haas JW, Oakley PA. CBP® Structural Rehabilitation of the Lumbar Spine. Evanston, WY: Harrison CBP Seminars, 2005.

7. Harrison DE, Betz J, Harrison, DD. CBP® Structural Rehabilitation of the Thoracic Spine. Evanston, WY: Harrison CBP Seminars, 2005.

8. Chiropractic Biophysics Online. www.idealspine.com. Services/research papers. Accessed 12-15-04.

9. 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.

10. Panjabi MM, White AA, Brand RA. A Note on Defining Body Parts Configurations. J Biomech 1974; 7:385.

11. Harrison DE, Harrson DD. The Lumbar Spine: Rehabilitation with the CBP^â method. National Library of Medicine #WE 725 4318C, 1997.

12. Harrison DE, et al. Changes in sagittal lumbar configuration with a new method of extension traction. Presented at the 27^th annual meeting of the International Society for the Study of the Lumbar spine. Adelaide, Australia April 9-13, 2000;151.

13. Harrison DE, Harrison DD, Cailliet R, Janik TJ, Holland B. Changes in Sagittal Lumbar Configuration with a New Method of Extension Traction: Non-randomized Clinical Control Trial. Arch Phys Med Rehab 2002;83(11):1585-1591.

14. Harrison DD, Jackson BL, Troyanovich SJ, Robertson GA, DeGeorge D, Barker WF. The Efficacy of Cervical Extension-Compression Traction Combined with Diversified Manipulation and Drop Table Adjustments in the Rehabilitation of Cervical Lordosis. J Manipulative Physiol Ther 1994;17(7):454-464.

15. Harrison DE, Harrison DD, Betz J, Colloca CJ, Janik TJ, Holland B. Increasing the Cervical Lordosis with Seated Combined Extension-Compression and Transverse Load Cervical Traction with Cervical Manipulation: Non-randomized Clinical Control Trial. J Manipulative Physiol Ther 2003; 26(3): 139-151.

1. Harrison DE, Cailliet R, Harrison DD, Janik TJ, Holland B. New 3-Point Bending Traction Method of Restoring Cervical Lordosis Combined with Cervical Manipulation: Non-randomized Clinical Control Trial. Arch Phys Med Rehab 2002; 83(4): 447-453.

2. Harrison DE, Cailliet R, Betz JW, Harrison DD, Haas JW, Janik TJ, Holland B. Harrison Mirror Image Methods for Correcting Trunk List: A Non-randomized Clinical Control Trial. Eur Spine J 2004; In Press.

3. Harrison DE, Harrison DD, Haas JW, Betz JW, Janik TJ, Holland B. Conservative Methods to Correct Lateral Translations of the Head: A Non-randomized Clinical Control Trial. J Rehab Res Devel 2004;41(4):631-640.

1. Zaleski BW, Wood J. A comparison of Palmer package and Chiropractic Biophysics for the treatment of pain. Proceedings of the International Conference on Spinal Manipulation 1992; Chicago, IL., May 15-17.

2. Paulk GP, Bennett DL, Harrison DE. Management of a chronic lumbar disk herniation with CBP methods following failed chiropractic manipulative intervention. J Manipulative Physiol Ther 2005;in press.

3. Ferrantelli JR, Harrison DE, Harrison DD, Steward D. Conservative management of previously unresponsive whiplash associated disorders with CBP methods: a case report. J Manipulative Physiol Ther 2005;in press.

4. Haas JW, Harrison DE, Harrison DD, Bymers B. Reduction of symptoms in a patient with syringomyelia, cluster headaches, and cervical kyphosis. J Manipulative Physiol Ther 2005;in press.

5. Harrison DE, Bula J. Non-operative correction of the flexible flat back using lumbar extension traction: A case study of three. J Chiropractic Education 2002;16(1).

6. Bastecki A, Harrison DE, Haas JW. ADHD: A CBP case study. J Manipulative Physiol Ther 2004; 27(8):e14.

1. Harrison DE, Harrison DD. Chiropractic Biophysics Technique. Part I: The Scientific Basis. Eur Chiropractic J 2005;

2. Harrison DD, Janik TJ, Troyanovich SJ, Holland B. Comparisons of Lordotic Cervical Spine Curvatures to a Theoretical Ideal Model of the Static Sagittal Cervical Spine. Spine 1996;21(6):667-675.

3. 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.

4. Janik TJ, Harrison DD, Cailliet R, Troyanovich SJ, Harrison DE. Can the Sagittal Lumbar Curvature be Closely Approximated by an Ellipse? J Orthop Res 1998; 16(6):766-70.

5. Harrison DD, Cailliet R, Janik TJ, Troyanovich SJ, Harrison DE, Holland B. Elliptical Modeling of the Sagittal Lumbar Lordosis and Segmental Rotation Angles as a Method to Discriminate Between Normal and Low Back Pain Subjects. J Spinal Disord 1998; 11(5): 430-439.

6. Harrison DE, Janik TJ, Harrison DD, Cailliet R, Harmon S. Can the Thoracic Kyphosis be Modeled with a Simple Geometric Shape? The Results of Circular and Elliptical Modeling in 80 Asymptomatic Subjects. J Spinal Disord Tech 2002; 15(3): 213-220.

7. Harrison DD, Harrison DE, Janik TJ, Cailliet R, Haas JW. Do Alterations in Vertebral and Disc Dimensions Affect an Elliptical Model of the Thoracic Kyphosis? Spine 2003; 28(5):463-469.

8. Harrison DE, Harrison DD, Cailliet R, Troyanovich SJ, Janik TJ. Cobb Method or Harrison Posterior Tangent Method: Which is Better for Lateral Cervical Analysis? Spine 2000; 25: 2072-78.

9. Harrison DE, Cailliet R, Harrison DD, Janik TJ, Holland B. Centroid, Cobb or Harrison Posterior Tangents: Which to Choose for Analysis of Thoracic Kyphosis? Spine 2001; 26(11): E227-E234.

10. Harrison DE, Harrison DD, Janik TJ, Harrison SO, Holland B. Determination of Lumbar Lordosis: Cobb Method, Centroidal Method, TRALL or Harrison Posterior Tangents? Spine 2001; 26(11): E236-E242.

11. Harrison DE, Holland B, Harrison DD, Janik TJ. Further Reliability Analysis of the Harrison Radiographic Line Drawing Methods: Crossed ICCs for Lateral Posterior Tangents and AP Modified Risser-Ferguson. J Manipulative Physiol Ther 2002; 25: 93-98.

12. Harrison DE, Harrison DD, Colloca CJ, Betz J, Janik TJ, Holland B. Repeatability of Posture Overtime, X-ray Positioning, and X-ray Line Drawing: An Analysis of Six Control Groups. J Manipulative Physiol Ther 2003; 26(2): 87-98.

13. Haas M, Taylor JAM, Gillette RG. The routine use of radiographic spinal displacement analysis: a dissent. J Manipulative Physiol Ther 1999;22:254-259.

14. Phillips RB. Plain film radiography in chiropractic. J Manipulative Physiol Ther 1992;15:47-50.

15. Taylor JAM. Full-spine radiography: a review. J Manipulative Physiol Ther 1993;16:460-474.

16. Kauffman JM. Diagnostic radiation: are the risks exaggerated? J Amer Phys Surg 2003;8(2):54-55.

17. Cohen BL, Lee IS. A catalog of risks. Health Physics 1979;36:707-722.

18. International Atomic Energy Agency. Facts about low-level radiation. American Nuclear Society, 1982.

19. Janik TJ, Harrison DE, Cailliet R, Harrison DD, Normand MC, Black P. Validity of an algorithm to estimate 3-D rotations and translations of the head in upright posture from three 2-D digital images. 2005; In Review.

20. Harrison DE, Janik TJ, Cailliet R, Harrison DD, Normand MC, Black P, Perron DL. Validation of an algorithm to estimate 3-D rotations and translations of the thorax and pelvis in upright posture from three 2-D digital images. 2005 In Review.

21. Bolton JE. The evidence in evidence-based practice: what counts and what doesn't count? J Manipulative Physiol Ther 2001;24:362-366.

22. Hrysomallis C, Goodman C. A review of resistance exercise and posture realignment. J Strength Cond Res 2001;15:385-390

23. Den Boer WA, Anderson PG, Limbek JV, Kooijman MAP. Treatment of idiopathic scoliosis with side shift therapy: An initial comparison with a brace treatment historical cohort. European Spine J 1999;8:406-410.

24. Weiss HR. Influence of an in-patient exercise program on scoliotic curve. Ital J Orthop Traumatol 1992; 18:395-406.

25. Weiss HR, Lohschmidt K, el-Obeidi N, Verres C. Preliminary results and worst-case analysis of in patient scoliosis rehabilitation. Pediatr Rehabil 1997;1:35-40.

26. Pearson ND, Walmsley RP. Trial into the effects of repeated neck retractions in normal subjects. Spine 1995; 20(11): 1245-51.).

27. DeVocht JW, Pickar JG, Wilder DG. EMG activity levels of paraspinal muscles during spinal manipulation. Proceedings from the 29^th annual meeting of ISSLS 2002; Vancouver, Canada.

28. Oliver MJ, Twomey LT. Extension creep in the lumbar spine. Clin Biomech 1995;10:363-368.

    29. Harrison DE, Harrison DD, Troyanovich SJ. Three-Dimensional Spinal Coupling Mechanics. Part II: Implications for Chiropractic Theories and Practice. J Manipulative Physiol Ther 1998; 21(3): 177-86.

    30. Harrison DE, Cailliet R, Harrison DD, Troyanovich SJ, Janik TJ. Cervical Coupling on AP Radiographs During Lateral Translations of the Head Creates an S-Configuration. Clin Biomech 2000; 15(6): 436-440.

    31. Harrison DE, Cailliet R, Harrison DD, Janik TJ, Troyanovich SJ, Coleman RR. Lumbar Coupling During Lateral Translations of the Thoracic Cage Relative to a Fixed Pelvis. Clin Biomech 1999: 14(10):704-709.

Chiropractic BioPhysics

Education Requirements for a Doctor of Chiropractic (D.C.) Degree

There is great confusion on the part of the public and prospective patients regarding the education of a Doctor of Chiropractic (D.C.). Several years of pre-requisite undergraduate courses are required prior to the application process of the potential student pursuing a Doctorate in Chiropractic. Most students entering Chiropractic College have already earned their bachelors degree. For their profession education, D.C.’s undergo similar hours in their educational requirements when compared with their Medical Doctor (M.D.) counterparts.¹ (See Table 1.)

Table 1.

A comparison of typical curriculum content and hours from accredited four-year programs in chiropractic and medicine.^2,3

Doctors of Chiropractic generally choose their future clinical focus while in school by taking numerous courses in a variety of Chiropractic Techniques. Most D.C.’s choose to focus their time mastering one “Technique” instead of being a “jack-of-all-trades”. Chiropractic BioPhysics^® (CBP^®) is one of these Techniques many D.C.’s choose to master. Doctors of Chiropractic who choose to earn their certification from CBP Seminars take coursework above and beyond the 4800 hours required for graduating a Chiropractic College.

Certification Training in Chiropractic BioPhysics^® Technique

The Techniques of Chiropractic BioPhysics have been proven in practice for nearly 30 years. And, for the past 15 years they’ve been subjected to several clinical trials, case studies, and the scrutiny of other types of peer-reviewed research publications. There are two levels of Certification Training offered by Chiropractic BioPhysics Seminars for D.C.’s wishing to master this technique. All of the CBP Training courses are approved for Continuing Education Credits by Chiropractic licensing boards in the majority of each of the 50 states; D.C.’s need Continuing Education to maintain an active license in their respective states each year.

Primary CBP Certification involves a D.C. attending 6 seminars to learn the fundamentals of CBP and successfully passing a test to demonstrate mastery of the technique methods. These 6 primary Certification courses total a minimum of 76 hours of training.

Advanced Certification is achieved through additional training in 6 more specialized seminars. Testing for Advanced Certification includes presenting a patient case study using CBP procedures to peers at a CBP conference (or in written form) and verifying the use of CBP-related spinal rehabilitative equipment in the doctor’s practice. These 6 Advanced Certification courses and the case study total a minimum of 88 hours of training. Thus, the D.C. whom achieves Advanced Certification training in CBP Technique has committed a minimum of 164 additional hours of Continuing Education Training!

So it’s safe to say that CBP practitioners know their stuff. And CBP certification shows they know it well.

References:

1. Chiropractic in the United States: Training, Practice, and Research. Agency for Health Care Policy and Research (AHCPR). Publication No. 98-N002. December 1997. Chapter III. Chiropractic Training.

2. Center for Studies in Health Policy, Inc, Washington, DC. And

3. Unpublished data from Meredith Gonyea, PhD.

chiropractic BioPhysics, chiropractic education

“Market Recover: Have I Missed the Boat?”

Vince Covino

Wealth Management Advisor

Vince@Covinors.com

Vince Covino is a Wealth Management Advisor specializing in wealth protection and accumulation for chiropractors. He currently works with over 200 doctors in 37 states.

Are you participating in, or even outperforming the markets in this steep financial recovery? The primary reasons that the average investor underperforms the market are:   a. Lack of a clearly defined strategy, b. having an undisciplined approach to investing, c. allowing emotions to drive decisions, and d. being overconfident and having unrealistic expectations for performance.

In my April article, “Can The Economy Recover”, I wrote, “While it certainly sounds counter intuitive, I believe many millionaires will be made out of this recession. It will likely be those who are paying close attention to the unprecedented opportunities this emotionally based market anomaly has created.   Unfortunately, most investors will continue to make critical investment decisions with their gut feeling…When you look back in five or ten years, are you going to say this is one opportunity that didn’t get away from you? This is a time to recognize that great value comes in time of great uncertainty.”

If you didn’t have a large portion of your portfolio in the financial markets over the last five months, you are probably feeling like you “missed the boat”. The reality is that the stock and bond markets have historically gone up more often than they have gone down.

Many doctors fled to safe or guaranteed products at the worst time possible, and will likely continue to miss the boat.   With government deficits and spending at record levels, now maybe the time to hedge against inflation risk. If you still have several years before you retire, you should consider the risk of not investing in assets with growth potential to protect your purchasing power. For instance, if you want to pay for your children’s college education, are you aware that from 1984-2008 the cost of college tuition and fees are up 459%? (1) Is your portfolio poised to keep pace with these inflationary pressures over the long term? If you want a great lesson on inflation, ask your parents what they paid for their first home, then ask them what they paid for their most recent car purchase. You will likely you’re their recent car purchase was more than their first home!

From 1989-2008, the average equity investor averaged a dismal 1.8% return while the market averaged 8.4% in the same period (2). Why the depressing disparity? Certainly making emotional decisions and not paying close attention to your financial roadmap to success is the culprit in most cases.

Talk to your financial advisor today to make sure you are strategically positioned for an economic recovery.

Note: The strategies discussed involve risk, including the potential for principal loss. This should not be considered individual investment advice; you should consider your investment objectives and risk tolerances before making any financial decisions.

(1) Source: U.S. Department of Labor Bureau of Labor Statistics

(2) Source: DALBAR, Inc. Quantitative Analysis of Investor Behavior, 2008

The S&P 500 Index is an unmanaged group of stocks and considered to be representative of the U.S. stock market in general. An investment cannot be made directly in an index. Past performance is no guarantee of future results.

Securities & Advisory Services Offered through VSR Financial Services, Inc. A Registered Investment Adviser and Member FINRA/ SIPC Financial Alliance for Chiropractors is independent of VSR

New Patient Marketing 101- The Chiropractic Business Academy

Eric Huntington, DC

Co-Owner Developer of the Chiropractic Business Academy

No matter the location or size of your clinic, or the relative success you’ve experienced to this point in your career, you probably have at least some attention on the number of new patients in your practice. Here are some things you should know about attracting new patients into your office.

1. There is an exact technology on how to attract new patients into a chiropractic office. You just need to learn it and apply it.
2. The better that you and your staff are trained on new patient marketing, the more control you will have over the number of new patients your practice gets.
3. Every factor limiting the number of new patients you currently get is an internal factor—meaning it’s not because of the economy, or your town, or anything else outside of your practice. This is good because it means you have control.
4. The Chiropractic Business Academy can teach any chiropractor how to get high numbers of new patients on a consistent basis.
5. If you feel your service is valuable, you should share it with more people!

Some doctors are surprised to learn that there are exact formulas and strategies that will literally guarantee you see more new patients. I teach these exact strategies to my clients through the Chiropractic Business Academy Marketing Courses, through the Academy Workshops and One on One Consulting. Although the exact marketing strategies are reserved for our clients, I can share with you some basics.

Your marketing success starts with your viewpoint on marketing. To find out what your viewpoint on marketing is at this moment, try this simple exercise.

Write down in single words or short phrases how you feel about marketing your practice. Successful marketing is going to require application. So, you can start now by doing this exercise. Please take a minute and write down your feelings about marketing, before reading on.

Take a look at what you wrote. Do your responses indicate that you are excited about introducing chiropractic to new people? Can you see evidence in your responses of back-off to creating a strong marketing effort? If so, you’d really benefit from handling those points.

One of the most effective ways to change your viewpoint is to acquire correct data in that area. The more you know about chiropractic marketing for instance, the more logical your conclusions will be when making marketing decisions. And let’s face it, if you know how to be successful at something, don’t you feel better about it?

Our Marketing Course covers over 40 ways to market a practice. Knowing and understanding ALL of these techniques makes it easy to attract 80-100 new patients per month, or more.

A strong marketing program has multiple sources of new patients. Here are some examples of the kinds of programs our clients use.

1. A program to acquire as many names and phone numbers of local people as possible. To do this we teach our Public Gift Certificate program. This gives our clients endless leads to contact for introductory services.
2. Multiple strong Business to Business programs. This is an alliance with a local business which allows you to farm leads from their clientele or employees. We teach numerous ways to do this including Corporate Massage programs, Lectures and other introductory programs. The key is to offer a truly valuable intro service- businesses will literally invite you in!
3. An Internal Referral Program. This should be an active, strategic (and fun) activity. In communicating with each patient you must direct their attention in a very precise manner—for instance, using symptoms, conditions or circumstances. Your goal is to get a name AND contact information—so you can invite the referral into your practice.

No matter the target audience or the strategy used, there are some key factors on which to build a consistent marketing effort.

1. Structure each marketing activity so that it can be done by a non-doctor. This will allow you to pass the activity to another staff member.
2. The more you market, the more new patients you will have. There is a direct relationship between the number of hours allocated to marketing and the number of new patients a practice sees.

*For an exact breakdown of how to calculate how much marketing you need to do to get a certain number of new patients starting care, visit my website and click “Free Stuff” www.chirobizacademy.com

1. Whatever marketing you do must communicate a concept which the consumer will understand and be interested in. This is one of the most important but least understood aspects of chiropractic marketing.

To learn more about how to market concepts that will create interest in your audience join me on my next teleconference. I will cover this topic in detail and will give you examples of how to do this effectively! See ad!

To continue this discussion on new patient marketing visit my website www.chirobizacademy.com

Chiropractic Business Academy

CCGPP: Deceit and Consensus Opinion-When Will it End?

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

ICA Board Member,

Idaho Chiropractic Association

CBP Fellow & Instructor

In their initial attempt to review the scientific literature and formulate an evidence synthesis, the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) asserted that visit frequency and duration parameters would not be developed in their work product. They made great effort to avoid the phrase “guideline” opting for “Best Practices” instead and avoiding developing parameters associated with typical guideline recommendations. This was their position until they decided to develop frequency and duration recommendations in California on the topic of chiropractic management of low back pain.

In California, the CCGPP didn’t rely upon the vast amount of high quality research published on the topic of low back pain. Instead, they formed a Delphi panel of chiropractors who arrived at a consensus for particular “seed statements” that were derived from a separate committee (non-democratically elected, of course).

The parameters they adopted stress the importance of incorporation of “active” treatments, frowning upon “passive” treatments, including the chiropractic adjustment, beyond 12 visits. Additionally, the patient is given 6 visits to show “satisfactory [emphasis mine] clinical gains utilizing commonly accepted outcomes assessment methods.” It is important to note that these parameters were based upon EXPERT OPINION only.

These types of “Consensus” projects are very common; but more and more are being frowned upon. According to a report by Culleton in 2009, “Traditionally, clinical practice guidelines were consensus-based statements, often riddled with expert opinion. It is now recognized that clinical practice guidelines should be developed according to a transparent process involving principles of bias minimization and systematic evidence retrieval and review, with a focus on patient-relevant outcomes.”¹

Despite the CCGPP’s assertion that consensus opinion is warranted, nothing could be further from the truth. There is a plethora of reports on the topic of Chiropractic management of Low Back disorders and on chronic pain of spinal origin. As you can imagine, consensus opinion has the ability to become a very biased tool when used in inappropriate situations.

Problematically, the CCGPP is recruiting the usual suspects for a similar adventure for an opinion consensus document on care for chronic pain conditions. Again, there is more than enough evidence upon which to base recommendations for chronic pain conditions. So, why is the CCGPP seeking opinions of researchers and clinicians? Expert and consensus opinion is for situations where there is no evidence.

It is my opinion that the CCGPP clearly has set an agenda. It is an organization that was out of control years ago. For example, the ICA critique of the Low Back document argued ad nauseum that the CCGPP was not representative of the profession at-large. ICA noted the ties of the Team lead with insurance companies and guideline distribution companies. ICA remarked that when finished, this document would become a tool used as a club to beat down Chiropractors that practiced outside of CCGPP frequency and duration parameters (which ICA also predicted would develop somehow).

In defense, the CCGPP maintained that they would fight the unfair interpretation of their document. Now that their money has dried up, I wonder who will be left to “defend” the CCGPP when this invariably happens.

I recently became aware of a lecture that was given by the CCGPP to the Federation of Chiropractic Licensing Boards (FCLB) in 2006. ² Within this lecture there is a section titled “Best Practices & Regulation: How does the Best Practices affect our Boards? How may the BP be applied by the Boards?”

The slides describe how the CCGPP documents can be used by the State Licensing Boards to define intent to commit fraud through over-utilization and breaching what the CCGPP would define as “appropriate care”. It has been my suspicion that the purpose of the CCGPP process has always been to contain and eliminate those Chiropractors that practice outside of what the CCGPP and related organizations that support the CCGPP, consider as “appropriate” treatment.

Unfortunately, based on the above document, I believe that the CCGPP will encourage the licensing boards to consider the following circumstances as fraudulent:

1) Care is beyond a defined frequency/duration;

2) Care for most everything beyond pain conditions (this includes methods used by mixers and straights);

3) Whether you take X-rays for detection of subluxation; and

4) The type of Technique you choose to practice.

This is purely speculative, but many of the ICA, the professions, and my predictions regarding the CCGPP have come to fruition thus far. I believe it only a matter of time until CCGPP tries to push these issues more and more as they initiated in their 2006 lecture to the Federation of Chiropractic Licensing Boards.²

The CCGPP process needs to be controlled by the organization that created it; the Congress of Chiropractic State Associations (COCSA). COCSA is the accountable organization. The members of the COCSA organizations are comprised of the state associations. Basically COCSA is a national association representing state associations. The majority of state associations have rightly opposed the work products of the CCGPP when they were reviewed, particularly the first version of the Low Back Disorder chapter. We understand the CCGPP has lost much of their financial support. Yet, they still exist and continue to produce these “consensus” projects.

If CCGPP was “commissioned” at the behest of COCSA, then that same organization should be able to “decommission” them as well. I urge all of you to do 3 things:

1. Contact your state association (join if you have not yet done so) and urge them to “decommission” the CCGPP at the next COCSA convention in November; 2009.

2. Join the ICA as a member and support the continued efforts through appropriate guideline development.

3. Support other research endeavors that advance the science of subluxation correction by joining CBP^® Non-Profit.

References

1. Culleton B. Development and limitations of clinical practice guidelines. Methods Mol Biol. 2009;473:251-61.

2. Best Practices Documents and Licensing Boards - A Quick Update. By Dr. David Taylor.http://www.fclb.org/Meetings/MeetingsHome/2006PortlandOregon/tabid/473/Default.aspx

CCGPP Council on Chiropractic Guidelines and Practice Parameters

Chiropractic Utilization

Len Siskin, D.C.

Promote Chiropractic

Co-Chair ICA Best Practices

How many of us would have become chiropractors if we knew how much scrutiny and justification would be required to simply try our best through our training to help our patients? In this world right now, where are students of chiropractic and chiropractic doctors? What does the research say and what do we know? My experience is many of us forget the power we have in helping people. Fear is a great way to stifle learning. It is the opinion of this author that knowledge can bring the confidence needed to allay these fears which result in neglect of both doctors of chiropractic and their patients.

I recently visited a chiropractic college and spoke with a group of middle and senior students about subluxation and chiropractic. Our discussion leaned in the direction of understanding why research is important and how to gage what research is worth taking seriously. I thought this was important because when discussing research I kept hearing students use the phrase, “The research says…” When asked, “What research? What were the outcomes of that research? How were variables measured? Were the conclusions of the researchers reasonable?” I received blank stares back from the group. For fun I asked how many of the students knew what a nasium view x-ray was. A few had an idea. When asked how many of them had experienced upper cervical evaluation x-rays for subluxation not a hand was raised. I went on to explain to the students I thought that was funny because when I was in school having upper cervical x-rays taken of myself was an academic requirement. They were shocked.

I had lunch with a younger colleague after visiting the chiropractic college. They expressed their frustration that they just felt they were not getting their patients better. They explained after about 2 weeks of care if the patient’s symptoms were not resolved they simply gave up. The same chiropractor was looking for ways to supplement their income because they were not making money as a chiropractor and the frustration was wearing on them.

In my own practice when patients ask, “Doc, when will I be fixed?” I generally respond by saying, “Well, I’m going to try to apply principles of physics and engineering to your spine under the silly notion that you might heal from your problem if we take the barriers to healing away. If we go a period of time and I have no evidence you are improving I am obligated to kick you out or send you to another professional. I hope your body does not put either one of us in that position.”

Why is it that I respond so differently than the friend I had lunch with when interacting with patients? We have the same basic education.

421 chiropractic treatment visits¹

Apparently in 1930 this many visits were not considered overutilization. To the best of my ability to tell, this BJ Palmer case study represents the largest amount of chiropractic treatment documented on a single patient. In this particular case, the patient was not suffering from generalized non-complex low back pain. She was suffering from bronchial asthma, headaches, and nervousness with failed past medical history. Using HIO upper cervical technique caring for a C2 PR listing the patient was adjusted daily for 9 months, and then 5 times per week for 7 months. This all happened before the treating doctor recommended she go onto a schedule of maintenance chiropractic checks and treatments which she was encouraged to do as part of her lifestyle for the rest of her life as a proactive health maneuver.

I challenge anyone reading this to submit a treatment plan to your local insurance company looking like the one above. If you want to spend some time in jail relaxing this might do the trick. In 1930 it didn’t matter because in many places you would go to jail just because you were a chiropractor. At the time of publication of the case study the treating doctor noted that all the patient’s symptoms had, “Cleared up”. Her weight was normalizing and her attitude in general had become enthused and encouraged toward normalcy.

One chiropractic treatment visit

Out of approximately 1400 original human subjects based chiropractic research papers documented in the ICA Best Practices and Best Practice Guidelines², 174 papers base their research findings on only one treatment visit. Why? When performing research it is important to have controls so you are more likely to measure the actual effect of the intervention performed in the research observing the patient quickly after only one treatment has been performed. Many studies choose to evaluate based on a single treatment. If you take into consideration the BJ Palmer paper and all the papers where they only treated one time you start getting a feel for how the average number of visits used to treat patients in chiropractic research ends up at about 23 visits.

Looking deeper, from 1909 to 1960 the average number of treatments showed as 27. From 1961-1980 the average number of chiropractic treatments shown was 47. From 1981-1990 the average number of chiropractic treatments shown was 22. From 1991-2000 the average number of chiropractic treatments shown was 25. From 2001-2007 the average number of chiropractic treatments shown was 24. Nobody knows why these numbers vary but the inclusion of chiropractic into insurance reimbursement might have something to do with the shift in treatment reported dropping after 1980. It makes me wonder whether the more recent numbers represent patient progress as much as they do the policies and laws governing chiropractic practice in the past three decades. Remember, this is not a report of what chiropractors did. It is a report of what chiropractic research reported in several arbitrarily selected ranges of time in published research.

According to officials at the ICA, they are currently receiving daily calls from chiropractors and the representatives of chiropractor’s worldwide making inquiry about the ICA Best Practices and Best Practice Guidelines² document. These inquiries are being made for purposes of understanding what care plans are reasonable, how to protect against scrutiny from insurance and state board inquiries, and what is expected of chiropractors in today’s technological and documentation intense environment.

The ICA guidelines are available at www.ICABestPractices.org. These guidelines are extremely straight forward and simple to digest. They review and report on all original chiropractic research from 1909 to present. Recommendations in the guidelines are largely made based on research numbers and not from personal opinion (consensus of experts). Authors of the guidelines are professional chiropractic experts who are not on the payroll of any insurance company. They have been largely created by practicing chiropractors who are also ICA members. They were created in an effort to see if the evidence can support and defend the way a practicing chiropractor would practice in a real, clinical setting.

1. Palmer, Bj DC, PHC. Book: The Hour Has Arrived. 1930; Pages 53-71.

2. www.ICABestpractices.org / www.Chiropractic.org

Chiropractic BioPhysics, ICA Best Practices Chiropractic Guidelines

That Pretzel Thing

R.J. Hammett, DC

I was taught years ago, give people what “they” want and you can have anything you want. But, you must give the people what they want first! Practicing CBP for as many years as I have, I have come to realize that not everyone wants what’s good for them. In fact, some want nothing to do with what will help them live longer, pain free functioning lives. Caring and compassion are the cornerstones of being a Chiropractor, waiting for Innate to do her thing while you’re doing yours can be exhausting, tedious and downright frustrating. But wait, think about the patient who doesn’t understand that Innate heals and corrects in her own time, not the doctors or even the patients. People want what they want, if it will not harm them, and improves their quality of life… Why not? Give them what they want.

So goes the “pretzel thing!” I don’t perform a lot of side posture moves on the lower lumbar spine. First it’s hard on the patient and it’s hard on me. So when I do adjust side posture, it’s for a very good reason, usually the patient’s spine needs it. Recently, I had a patient ask me for that “pretzel thing” adjustment, you know, she said, “I lie on my side and you ‘pop’ my back, that feels great.” Initially I thought no, that’s not going to correct her spinal Subluxation and is really a waste of time when it comes to doing the work I think needs to be done.

In the same second, I thought, what will it hurt? It mobilizes the spine, loosens up adhesions and helps the patient feel better. Notice, I said feels better. No, it doesn’t correct anything, but it does improve the patient’s sense of well being, improves her range of motion, and reduces her pain. Basically, it gives her what she came for.

So, here’s the question for your practice. Are you giving people what they want, or are you selling them what you want? Yes, you’re the doctor, yes, right! The patient is always the doctor, and the patient is always right, even when he/she are wrong.

Serving a sick and confused humanity is a tough job, as I’m sure you are aware of, serving your patients, and community for what “they” want can sometimes be impossible. But, remember the higher purpose, the big idea which is to remove nerve interference, to improve the life flow from brain cells to tissue sells. It’s not a sell-out to give patients what they want. So, yes, sometimes the pretzel adjustment is just what the patient ordered. Give it to them because this is why you exist… to serve.

Till next time…

Chiropractic BioPhysics