Logic, Chiropractic and Medicine

"Logic, Chiropractic, and then Medicine." I am repeating something told to me one day many years ago and I have never forgotten the importance of this statement. I have used this principal to govern my actions in day-to-day practice. This principal, along with a focus on being the best I can be as a CBP practitioner has never failed me. For me, CBP emanates what Chiropractic is; in it's purist form.

When it came to building a practice I instinctively applied the same principle! I applied logic to what I heard and put it in context. This meant removing the grandstanding and the self promoting infomercials and really listening and thinking through everything that was presented as solutions. Building a practice requires that we stretch our thought process/comfort zone on several levels. Each of us may have different issues to tackle; but applying logic when stretching our thought process /comfort zone can never be overlooked.

There are three general principles one needs to follow when building or maintaining any level of a practice. First is the benefit of effective systems, procedures and order within your practice. This principle is almost universal in design regardless of where you practice. The second principal is regional; factors one needs to consider in building or maintaining a practice. The requirement for effective development of a practice within the heart of New York City is dramatically different than those in the heartland of upstate New York. Lastly, the third principle is doctor individuality. As doctors of Chiropractic we have many belief systems in common. The flip side to this is we are all very different. It is important for each doctor to enhance the positive side of their individuality.

When considering a practice management person or group, here is some of the questions I would ask and then apply my own logic to their responses:
- How may years have you been in active practice as the primary adjusting doctor?
- Did you start up your practice or did you buy an existing practice?
- Where was your practice located?
- How many practices did you have? past and present?
- This might sound funny but make the connection of years in practice to their family dynamic; are they single or married, is their wife a chiropractor, are there children? What was the timeline in relation to their practice? In other words, were they starting a practice with other responsibilities requiring their time and attention or did other responsibilities come later, after the practice was established?
- How may years have you been in practice management?
- Names and location of the top ten practices that they consult/ manage? Are these doctors still in practice?

Management has its place but it can't replace logic and some of the non-physical laws that govern our existence, such as compassion, empathy, etc… Management, at times, oversteps its boundaries. If there is one inherent fault with management, it is that they try to hang onto a client longer than they should. A good teacher (coach) knows what they can teach. At a certain point, a good teacher knows when to stop teaching. At this point, the teacher needs to let that student go, either to succeed or fail on their own, and in this process, learn even more than he could if he stayed on as a student. During this time a student will learn what he knows and what he doesn't. This is how one gets to the next level, and maybe, moves to the next teacher.

Chiropractic is governed by innate. I innately treat others, as I would want to be treated! I try to never be judgmental or sanctimonious in regards to any patient's decision to choose a medical route to care. After all, whose health is it anyway?

By the way, Don Harrison told this principal to me during a very stressful time in my early years of practice. By using this principal, it kept me focused and I was able to help my wife make some very good health care decisions at a very critical time in her life.

On Remaining Chiropractors…

“If you’ve got a job, keep it.” This is what the manager of my local convenience store said to me when I went in for a cup of coffee this morning. Bob mentioned to me last week his father had been a shoemaker in the town next to my clinic for 50 years and was about to retire when he passed away suddenly a few years ago. Bob related to me the reportedly minor health issue his dad went to the hospital with and that they gave him the wrong med and before his family could blink his dad was in a coma and they had to ultimately, “Decide to pull the plug”.

I don’t know about you but stories like this make me grateful to be a chiropractor and keep me motivated to push every day to educate my patients about their body and the difference between sick care and wellness care and the importance of addressing the subluxation as part of this scientific and vital process. Still, every day I wonder if I will be able to keep my job. Here in the US there is an environment of fear about the economy and world resources. When I speak with people these days this is what they are talking about. Many people have stopped doing anything they perceive to be non-essential in their lives. This makes me wonder how essential they perceive their chiropractic care to be and how they are being educated about chiropractic.

I am not a lawyer but it is my perception the governing board’s who issue licensure to chiropractors, at least in the US, are responsible to ultimately protect the general public against chiropractors. These boards have been charged with the responsibility of deciding what laws to advocate for chiropractic in their state to best accomplish this goal. When reviewing individual chiropractors they make judgment based on the most prevalent available information based on what the profession advocates, what the research shows and what is considered standard of practice. When so many chiropractors practice so differently from each other and have potentially different clinical goals for their patients this task easily becomes confusing. To further confuse the matter, groups and individuals within the chiropractic profession often misrepresent what information actually exists. Many push for a pain management, symptom based model for chiropractors to follow and many push for a purely vitalistic approach. Many claim there is no science to support subluxation treatment and in my experience, even most chiropractors I meet are unclear about what our own research says and its’ implications. It is no wonder the research is so easily misrepresented.

I want to help give lawmakers tools to make laws to support chiropractic. I want the lawmakers and policymakers to understand there is strong science in support of treating subluxation. More so than even wanting lawmakers to understand this I would like chiropractors to understand it. At a party several weeks ago I met a chiropractor from another state. I told him he should go online to www.IcaBestpractices.Org and take the online survey there. I explained to him I feel we are fighting an environment of fear and apathy within our own profession and that if action is not taken to critique and provide constructive and honest feedback on this current draft of these ICA Best Practices and Practice Guidelines, laws might be made in far greater favor of a pain management model of solely spinal manipulation treatment. This chiropractor had just finished speaking with me about how important addressing subluxation is to him in his practice. He had just finished explaining he thought the policies of third party payers in his state and even the state board in his state had policies on how he should practice which are far too limiting for him to help his patients to the extent that in his experience and in his training they need and desire. When I told him this Best Practices document is the strongest current piece of advocacy for chiropractors to use existing research and the implications of chiropractic research to support subluxation based treatment and that if the profession stands behind it then chiropractors will have even more power to help their patients, he had one simple comment for me. “I have a cash practice so I don’t care about any of that stuff.” I asked him what he would do if the state he practices in limits him by law based on other organizations recommendations for chiropractic treatment parameters. To this he said, “I’ve been in practice for years. They’ll never do that.” I don’t know about you; I for one am not getting rich being a chiropractor. My patients pay my very reasonable fee and because they hire me to help them, I strive to understand their goals and give them options in the extent of care we can offer them. I shutter to think one day the law might limit me to offering merely pain relief care. I am also not a gambler. I don’t have the nerve to sit back and believe laws will not be made to restrict my ability to help my patients. In my opinion it is my duty as a chiropractor to protect my patients against the creation of healthcare policies which will restrict my ability to use the knowledge I have about the body and about chiropractic to help them to the greatest extent of my ability.

There is a trend in the mainstream medicine toward, “Evidence based medicine”. This is a problem for chiropractors when few people in our profession can agree on what the evidence actually says or which evidence to look at when making these considerations. Also as a result of this are the erroneous claims on what research actually exists. Just not too long ago a major insurance company sent me an email announcing they could not support chiropractic care for children or headache sufferers. My recollection was the reason for making this policy was a lack of supporting research.

When looking at the published indexed peer reviewed literature it turns out there is plenty of supporting research on chiropractic and pediatrics and also on headaches. The ICA commissioned myself, and a host of other chiropractors, most of whom run successful practices, to read, summarize and computer-catalog every piece of existing chiropractic research published since the beginning of time. In doing this our group has created a searchable database to end the confusion about what research chiropractors actually have to support what we do. This database represents real chiropractic data. It was created because of the ICA but in fact the research statistics within it are generic to chiropractic research as the research represents all chiropractic groups. We used original research only. There is no discrimination based on who published that research. It is this research which is the backbone of treatment and duration recommendations made by the ICA in chapter 11 of the document. Though the document is a strong advocate of the importance of the individual doctor’s experience and the individual patient’s desire for help as well as the doctor’s commitment to treating subluxation, the document is written with the world of Evidence Based medicine in mind. This is the current language of lawmakers, policymakers and third party payers.

Why? As it turns out the research shows it takes about 25 visits of chiropractic care to achieve significant improvement for a symptom. What the research does not show is how complex the scenario gets when treating subluxation. It also does not show how much more care should be considered necessary when more than one problem exists. If co-morbid factors are present such as measurable subluxation, diabetes, obesity, sleep deprivation, stress at home or in the workplace, history of trauma or multiple occurrences of a chronic problem; based on the published research it would seem 25 visits should begin to look simply like a start. For those of you with cash practices who are aggravated by this conversation, what evidence and what support will you provide lawmakers in your area to allow you to continue practicing the way you want to without restricting you to minimal symptom relief treatment or basing procedures like radiographs on red-flag only parameters?

Chiropractic needs you to look through the ICA Best Practices Guidelines Draft document and take the online survey. We don’t need a small panel of people deciding what we should do in the absence of, “determinate answers (eg., hard data or well established theory)”¹. In reality both hard data and well established theory do exist in chiropractic. Let’s speak out in defense of our patients and not ignore this fact.

1. http://www.fernuni-hagen.de/ZIFF/v2-ch45a.htm: The Delphi Methodology by Norman C. Dalkey, co-creator of the Delphi Methodology.

In Office or At Home CBP® Exercise & Traction Procedures: Evidence vs. Opinions

Introduction
In the January 2005 issue of the American Journal of Clinical Chiropractic Dr. Scott Heun authored an article entitled ‘Do You Practice CBP® or CBP® In Name Only”? In this article Dr. Heun discussed the inherent inconsistency with recommending a CBP® spinal correction (structural rehabilitation) program of care to a patient and providing only the postural adjustments in office while referring the patient to home exercises and home corrective traction as the sole means of spinal rehabilitation. In the current article, I would like to discuss the evidence for at home spinal rehabilitation vs. in office spinal rehabilitation providing my views as a CBP® clinician, researcher, and educator.
At Home Exercises and Corrective Traction: The Advocates
Arguably, many practicing Chiropractors treating a patient for more than 12 visits (sometimes 6 visits) have experienced an ‘independent medical evaluator’ (IME) review of said patient’s treatment records. Often, these IME’s or the managed care organization (MCO) claim that the patient should be sent home with spinal exercises or CBP® corrective traction instead of becoming ‘dependent’ on the Chiropractor’s services. In my opinion, this ‘at home only’ IME and MCO mindset is based on a cost-savings model and not based on legitimate scientific evidence.
Similar to this ‘at home only’ mindset but for different reasons, there are certain Chiropractic Coaching groups that recommend their clients (the Chiropractors) exclusively send patients home with exercise and CBP® corrective traction programs. Of interest, these Coaching groups follow the same cost savings model. For example, most coaching groups will tell you, the Chiropractor, to provide exercises and corrective traction at home for the following reasons:

• You need more square footage to have in office spinal exercise and traction equipment; • You need more staff to support the in office management of patient’s on this equipment; • You can’t see as many patients per hour doing in office spinal rehabilitation because it slows you down,

In my opinion, both the IME/MCO and Chiropractic coaching paradigms are based on opinions that are financially motivated and not in the best interest of the patient nor supported by the current available evidence and are thus, not ‘evidence based practices’.
Furthermore, the Chiropractic coaching mindset is really an internal perception problem that can be easily overcome if the Chiropractic coach and Chiropractic clinician recognized the value of the in office services being provided. In other words, providing in office exercise and corrective traction services allows proper billing for these procedures and enables the cash Chiropractor to charge more for his/her services due to a higher quality service model!

In Office Exercise Intervention Programs: The Evidence
Currently there is moderate to strong evidence to support in-office supervised exercise programs compared to outpatient (at home) or no care programs; though home exercise is generally recommended during off days from the in office regimen. This evidence comes from randomized trials comparing in office to at home exercises with several studies reporting long-term follow-up of the data.1-9
Not only are strength and flexibility improved in supervised programs, in-office rehabilitation programs have increased rates of patient compliance and greater improvements in patient pain and disability levels compared to non-supervised programs. Also communication of goals, expectations of rehabilitation, and lessening anxiety levels are enhanced in the in-office setting.6-9

CBP® Peer Reviewed In Office Exercise Evidence
Now specific to CBP® mirror image® exercise interventions, 2 non-randomized clinical control trials have been performed investigating the effect of in-office mirror image® exercise, adjustments, and postural traction for reductions in lateral head and thoracic translations in chronic pain subjects.10,11 Figures 1 and 2 depict the in-office mirror image® methods used.





For example, in 2004, we investigated fifty-one patients, with chronic neck pain and lateral head translation posture (side shift), receiving inpatient (in-office) rehabilitation including mirror image® postural exercises and postural traction in the Berry translation table.10 The treatment subjects were compared to a control group of twenty-six subjects with lateral head translation posture and chronic neck pain. The in-office treatment group attained statistically significant improvements in both pain intensity and postural alignment of the cervical spine compared to no improvements in the control group.10

In Office Corrective Traction Intervention Programs: The Evidence
Cervical Spine
CBP® technique researchers have performed 3 separate non-randomized clinical control trials investigating the effects of in-office cervical extension traction procedures and 1 trial on in-office lateral head traction for improvements in abnormal alignment of the cervical spine and improvements in chronic pain intensity.10,12-14 In all 3 of these clinical trials, the treatment group received in-office cervical extension traction using either the compression extension chair by Dr. DeGeorge,12 the Pope 2-way traction frame by Dr. Pope,13 or the 2-way compression extension traction method as modified by Dr. Harrison.14 Figure 3 depicts the in-office mirror image® methods used in the 3 trials.
In addition to the 3 clinical trials on the cervical spine, CBP® researchers and clinicians have reported the outcomes in several case studies where CBP® mirror image® in-office exercise and traction methods were utilized.15-19 In all of these case reports improvements in spine and postural alignment were achieved as well as improvements in pain and disability levels in a variety of chronic conditions.15-19
Lumbar Spine
CBP® technique researchers have performed 1 non-randomized clinical control trials investigating the effects of in-office lumbar extension traction procedures20 and 1 trial on in-office lateral thoracic traction11 for improvements in abnormal alignment of the lumbar spine and improvements in chronic pain intensity.11,20 Figures 2 and 4 depict the in-office mirror image® methods used in these 2 trials.
In addition to the 2 clinical trials, CBP® researchers and clinicians have presented several case studies where in-office 3-point-bending lumbar traction and/or Berry lateral translation were utilized.20-24 These studies found the CBP® in-office procedures improved both the alignment of the lumbar spine and posture as well as improved the patient’s chronic pain, disability, and health disorder.20-24






Summary
The evidence from the peer-reviewed literature indicates that in-office spinal rehabilitation exercise programs are superior in all aspects (except for cost) of patient outcomes. The evidence specific to CBP® mirror image® exercise interventions only supports the use of in office spinal rehabilitation as not a single study to date has looked at home exercise as the intervention. The evidence specific to CBP® mirror image® spine/posture traction methods only supports the use of in-office intervention programs as not a single study to date has looked at home traction as the exclusive intervention. In fact, the evidence based practice guideline/protocol of care for CBP® technique recently published in the JCCA only recommends home exercise and home traction for patients as a supplementary procedure to the in-office intervention program.25
If a given Chiropractor is not doing in-office mirror image® exercise and in-office mirror image® traction, then that doctor is not legitimately applying CBP® Technique protocols. If an MCO or Practice coach recommends ‘at-home-care only’ for CBP® Technique, the Chiropractor should challenge their motives and challenge them with the evidence presented above.
Lastly, the Chiropractor may not be aware of the issues presented herein and thus, I encourage those interested in learning and applying CBP® Technique protocols and procedures to attend our certification seminar series. At these seminars the Chiropractor will learn the details of CBP® Technique in-office patient management from day 1 through maximum spinal correction to supportive care and maintenance. Also, at these seminars, the Chiropractor will learn of Practice Coaching systems that support CBP® in-office protocols and learn to achieve improved financial levels based a higher quality service model of Chiropractic care.

References

1. Hayden JA, van Tulder MW, Tomlinson G. Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Ann Intern Med 2005; 142:776-785.
2. Jordon A, Ostergaard K. Rehabilitation of neck/shoulder patients in primary health care clinics. J Manipulative Physiol Ther 1996; 19(1): 32-35.
3. Torstensen TA, Ljunggren AE, Meen HD, et al. Efficiency and costs of medical exercise therapy, conventional physiotherapy, and self-exercise in patients with chronic low back pain: A pragmatic, randomized, single-blinded, controlled trial with 1-year follow-up. Spine 1998; 23:2615-24.
4. Jordon A, Ostergaard K. Implementation of neck/shoulder rehabilitation in primary health care clinics. J Manipulative Physiol Ther 1996; 19(1):36-40.
5. Reilly K, Lovejoy B, Williams R, Roth H. Differences between a supervised and independent strength and conditioning program with chronic low back syndromes. J Occ Med 1989; 31:547-50.
6. Harkapaa K, Jarvikoski A, Mellin G, Hurri H. A controlled study on the outcome of inpatient and outpatient treatment of low back pain. Part I. Pain, disability, compliance, and reported treatment benefits three months after treatment. Scand J Rehabil Med 1989; 21: 81-89.
7. Mellin G, Hurri H, Harkapaa K, Jarvikoski A. A controlled study on the outcome of inpatient and outpatient treatment of low back pain. Part II. Effects on physical measurements three months after treatment. Scand J Rehabil Med 1989; 21:91-95.
8. Harkapaa K, Mellin G, Jarvikoski A, Hurri H. A controlled study on the outcome of inpatient and outpatient treatment of low back pain. Part III. Long-term follow-up of pain, disability, and compliance.
9. Mellin G, Harkapaa K, Hurri H, Jarvikoski A. A controlled study on the outcome of inpatient and outpatient treatment of low back pain. Part IV. Long-term effects on physical measurements. Scand J Rehabil Med 1990; 22:189-194.
10. 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.
11. 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 2005; 14:155-162.
12. 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.
13. 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.
14. 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.
15. 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; 28:205e1-205e8.
16. Haas JW, Harrison DE, Harrison DD, Bymers B. Reduction of symptoms in a patient with syringomyelia, cluster headaches, and cervical kyphosis: A CBP case report. J Manipulative Physiol Ther 2005; 28(6):452.
17. Bastecki A, Harrison DE, Haas JW. ADHD: A CBP case study. J Manipulative Physiol Ther 2004; 27(8):e14.
18. Oakley PA, Harrison DE. Use of Clinical Biomechanics of Posture (CBP) protocol in a postsurgical C4-C7 total fusion patient. A case study. J Chiropractic Education 2005;19(1):66.
19. Harrison DE, Fisk J, Harrison DD. Structural rehabilitation of anterior head translation in a patient suffering post-surgical cervical pain and impairment. A Chiropractic Biophysics case report. 8th Biennial Congress of the World Federation of Chiropractic, International Conference on Chiropractic Research, Sydney, Australia, June 16-18, 2005:285-6.
20. Harrison DE, Cailliet R, Harrison DD, Janik TJ, Holland B. Changes in Sagittal Lumbar Configuration with a New Method of Extension Traction: Non-randomized Clinical Control Trial. Archives Phys Med Rehabil 2002; 83(11): 1585-1591.
21. 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 2004;27:e15.
22. Harrison DE, Bula JB, Harrison DD. Non-operative correction of the flexible flat back using lumbar extension traction: A case study of three with follow-up. J Chiropractic Education 2003;17(1):13-14.
23. Harrison DE, Oakley PA, Harrison DD. Reduction of deformity after chiropractic biophysics mirror image care incorporating the non-commutative property of finite rotation angles in five patients with thoracolumbar scoliosis. J Chiropractic Education 2006;20(1):19-20.
24. Oakley PA, Berry RH, Harrison DE. A structural approach to post-surgical laminectomy: A case study. J Vertebral Subluxation Res 2007; March 9th:1-7.
25. Oakley PA, Harrison DD, Harrison DE, Haas, JW. Evidence-Based Protocol for Structural Rehabilitation of the Spine and Posture: Review of Clinical Biomechanics of Posture (CBP®) Publications. J Canadian Chiro Assoc 2005; 49(4):270-296.

Headaches

By Daniel J. Murphy, DC, DABCO

My favorite article addressing the relationship between the cervical spine and headaches was written by Australian physician, anatomist and researcher Nikolai Bogduk in 1995. Important aspects from this article are reviewed below:

N Bogdu. Anatomy and Physiology of Headache. Biomedicine and Pharmacotherapy
1995, Vol. 49, No. 10, 435-445


FROM ABSTRACT:

All headaches have a common anatomy and physiology.

All headaches are mediated by the trigeminocervical nucleus, and are initiated by noxious stimulation of the endings of the nerves that synapse on this nucleus, by irritation of the nerves themselves, or by disinhibition of the nucleus.

DR. BOGDUK ALSO NOTES:

The brainstem contains a region of grey matter called the trigeminocervical nucleus. This nucleus is causally continuous with the grey matter of the dorsal horn of the spinal cord. The trigeminocervical nucleus is “defined by its afferent fibers.” [Key Point]

The trigeminocervical nucleus receives afferents from the following sources:
1) Trigeminal Nerve (Cranial Nerve V)
2) Upper three cervical nerves
3) Cranial Nerve VII (Facial Nerve)
4) Cranial Nerve IX (Glossopharyngeal Nerve)
5) Cranial Nerve X (Vagus Nerve)
All of these sources of afferents terminate on common second-order neurons in the trigeminocervical nucleus.

Trigeminal Nerve afferents will descend to the level of C3 and perhaps as low as C4. The trigeminocervical nucleus is the sole nociceptive nucleus of the head, throat and upper neck. “All nociceptive afferents from the trigeminal, facial, glossopharyngeal and vagus nerves and C1-C3 spinal nerves ramify in this single column of grey matter.”

Because the ophthalmic branch of the trigeminal nerve extends the farthest into the trigeminocervical nucleus, cervical afferent stimulation is most likely to refer pain to the frontal-orbital region of the head.

The stimulation of any neurons that activate the trigeminocervical nucleus can cause headache, which includes cranial nerves V, VII, IX, X, and C1-C3. “Any structure innervated by these nerves is capable of causing headache.”

“The C1 and C2 spinal nerves are distinctive in that they do not emerge through intervertebral foramina.”

The C1 spinal nerve passes across the posterior arch of the atlas behind its superior articular process, descending in front of the C1 transverse process to descend as a part of the cervical plexus.

C1 spinal nerve does not supply the skin, but does supply sensory innervation to the suboccipital muscles. The sensory root of C1 can be found with the motor roots of the spinal accessory (cranial nerve XI) nerve.

The C2 spinal nerve crosses the posterior aspect of the C1-C2 facet joint; its dorsal root ganglion is opposite the midpoint of the C1-C2 facet joint.

The anterior primary rami of C1-C2-C3-C4 join and form the cervical plexus to innervate the prevertebral muscles: longus capitis, longus cervicis, rectus capitis anterior, rectus capitis lateralis, sternocleidomastoid and trapezius.

The anterior primary rami of C1-C2-C3 form the recurrent meningeal branches of the sinuvertebral nerves. These nerves innervate the anterior surface of the upper cervical dura mater, and then pass through the foramen magnum to innervate the dura mater between the pituitary gland to the anterior occiput (the clivus). They also innervate the medial portion of the C1-C2 joint capsule, the transverse and alar ligaments.

In the posterior cranial fossa, C1-C3 sinuvertebral nerves add components to cranial nerve X (vagus) and XII (hypoglossal). [Important]

The anterior primary rami from C1-C3 join the vertebral nerve, the plexus of nerves that travels with the vertebral artery, and supplies sensory branches to the fourth part of the vertebral artery.

The posterior primary rami of C1 innervate the 4 suboccipital muscles: inferior oblique, superior oblique, rectus capitis posterior major, rectus capitis posterior minor.

The motor component of the C2 posterior primary rami innervates the longissimus capitis and splenius.

The sensory component of the C2 posterior primary rami becomes the greater occipital nerve. It winds under the inferior oblique muscle, ascends and pierces the shared aponeurosis of the trapezius and sternocleidomastoid muscle to supply the posterior scalp.

The motor components of the C3 posterior primary rami also innervate the longissimus capitis and splenius muscles as well as the C2-C3 multifidus muscle.

The sensory component of the C3 posterior primary rami runs across the posterior aspect of the C2-C3 facet joint (which it innervates) and ascends as the third occipital nerve to supply the suboccipital region.

Stretch on the dura mater can initiate mechanical pain. [Important]

The posterior cranial fossa and its contents are innervated by cervical nerves.

“Vertebral artery disease, such as an aneurysm becomes an important differential diagnosis of what otherwise might seem to be neck pain with referred pain to the head.”

Arthritis of the upper cervical synovial joints (including C2-C3) can cause neck pain and headache.

Injury and damage to the alar ligaments can cause upper cervical pain and headache. The diagnosis is made with upper cervical rotational CT scanning, showing significant greater unilateral rotation.

Posterior cervical muscle tears are not a cause of chronic headache.

C2 neuralgia is a neurogenic headache that can be caused by “scar tissue following trauma to the lateral atlanto-axial joint.” [Important]
[Fibrosis of the C1-C2 facet joint affecting the adjacent C2 root]

KEY POINTS FROM DAN MURPHY

1) All headaches have a common anatomy and physiology.

2) All headaches are mediated by the trigeminocervical nucleus, and are initiated by noxious stimulation of the endings of the nerves that synapse on this nucleus, by irritation of the nerves themselves, or by disinhibition of the nucleus.

3) The brainstem and upper cervical spinal cord contains a region of grey matter called the trigeminocervical nucleus.

4) The trigeminocervical nucleus is “defined by its afferent fibers.” [Key]

5) The trigeminocervical nucleus receives afferents from the following sources:
A)) Trigeminal Nerve (Cranial Nerve V)
B)) Upper three cervical nerves
C)) Cranial Nerve VII (Facial Nerve)
D)) Cranial Nerve IX (Glossopharyngeal Nerve)
E)) Cranial Nerve X (Vagus Nerve)
All of these sources of afferents terminate on common second-order neurons in the trigeminocervical nucleus.

6) Trigeminal nerve afferents will descend to the level of C3 and perhaps as low as C4.

7) The trigeminocervical nucleus is the sole nociceptive nucleus of the head, throat and upper neck. “All nociceptive afferents from the trigeminal, facial, glossopharyngeal and vagus nerves and C1-C3 spinal nerves ramify in this single column of grey matter.”

8) Pain in the forehead can arise as a result of stimulation by cervical afferents of second-order neurons in the trigeminocervical nucleus that happen also to receive forehead afferents.

9) Pain in the occiput (primarily innervated by C2) may arise from trigeminal nerve stimulation.

10) Because the ophthalmic branch of the trigeminal nerve extends the farthest into the trigeminocervical nucleus, cervical afferent stimulation is most likely to refer pain to the frontal-orbital region of the head.

11) The stimulation of any neurons that activate the trigeminocervical nucleus can cause headache, which included cranial nerves V, VII, IX, X, and C1-C3. “Any structure innervated by these nerves is capable of causing headache.” [Key Point]

12) Structures innervated by C1-C3:
Dura mater of the posterior cranial fossa
Inferior surface of the tentorium cerebelli
Anterior and posterior upper cervical and cervical-occiput muscles
OCCIPUT-C1, C1-C2, and C2-C3 joints
C2-C3 intervertebral disc
Skin of the occiput
Vertebral arteries
Carotid arteries
Alar ligaments
Transverse ligaments
Trapezius muscle
Sternocleidomastoid muscle

13) “The C1 and C2 spinal nerves are distinctive in that they do not emerge through intervertebral foramina.”

14) C1 spinal nerve does not supply the skin, but does supply sensory innervation to the suboccipital muscles.

15) The C2 spinal nerve crosses the posterior aspect of the C1-C2 facet joint and innervates it.

16) The anterior primary rami of C1-C2-C3-C4 join and form the cervical plexus to innervate the prevertebral muscles: longus capitis, longus cervicis, rectus capitis anterior, rectus capitis lateralis, sternocleidomastoid and trapezius.

17) The anterior primary rami of C1-C2-C3 form the recurrent meningeal branches of the sinuvertebral nerves. These nerves innervate the anterior surface of the upper cervical dura mater, and then pass through the foramen magnum to innervate the dura matter between the pituitary gland to the anterior occiput (the clivus). They also innervate the medial portion of the C1-C2 joint capsule, the transverse and alar ligaments.

18) In the posterior cranial fossa, C1-C3 sinuvertebral nerves add components to cranial nerve X (vagus) and XII (hypoglossal). [WOW!]

19) The anterior primary rami from C1-C3 join the vertebral nerve, the plexus of nerves that travels with the vertebral artery, and supplies sensory branches to the fourth part of the vertebral artery.

20) The posterior primary rami of C1 innervate the 4 suboccipital muscles: inferior oblique, superior oblique, rectus capitis posterior major, rectus capitis posterior minor.

21) The motor component of the C2 posterior primary rami innervates the longissimus capitis and splenius.

22) The sensory component of the C2 posterior primary rami becomes the greater occipital nerve. It winds under the inferior oblique muscle, ascends and pierces the shared aponeurosis of the trapezius and sternocleidomastoid muscle to supply the posterior scalp.

23) The motor components of the C3 posterior primary rami also innervate the longissimus capitis and splenius muscles as well as the C2-C3 multifidus muscle.

24) The sensory component of the C3 posterior primary rami runs across the posterior aspect of the C2-C3 facet joint (which it innervates) and ascends as the third occipital nerve to supply the suboccipital region.

25) Nociception pain can be initiated by the accumulation of inflammatory chemicals.

26) Nociception pain can be caused by mechanical stimulation following a “distortion of a network of collagen” such as ligament or dura mater. [Important: this supports the mechanics of the subluxation]

27) Central pain involves no tissue damage but results from dysfunction of the descending pain inhibitory pathways. [Important: the journal Pain in November 1996 suggests that spinal adjusting relieves pain because it activates the descending pain inhibitory system.]

28) Stretch on the dura mater can initiate mechanical pain. [Important: there exists a connective tissue bridge between C1-C2 that attaches to the inferior oblique muscle and attaches to the dura mater. Biomechanical problems in this region can stretch the dura mater, initiating mechanical pain.]

29) The posterior cranial fossa and its contents are innervated by cervical nerves.

30) “Vertebral artery disease, such as an aneurysm becomes an important differential diagnosis of what otherwise might seem to be neck pain with referred pain to the head.”

31) Arthritis of the upper cervical synovial joints (including C2-C3) can cause neck pain and headache.

32) Injury and damage to the alar ligaments can cause upper cervical pain and headache.

33) Posterior cervical muscle tears are not a cause of chronic headache.

34) C2 neuralgia is a neurogenic headache that can be caused by “scar tissue following trauma to the lateral atlanto-axial joint.” [Important]
[Fibrosis of the C1-C2 facet joint affecting the adjacent C2 root]

Build Relationships That Inspire Patients Through Corrective Care - Guest Column

Inspiring patients to commit and complete a corrective care program is one of the unique challenges of choosing a practice using spinal corrective techniques. In my opinion, it is the best choice. Chiropractic philosophy was founded on the principle that we are here to correct subluxations, spinal curves, posture and inspire people to choose to live a life of better health with an optimally functioning spine and nervous system. We can also give our patients an opportunity and way of thinking that can affect generations to come.

The reality is “if we are going to fix them, you have to keep them first.” We must have a patient visit average of 60-90 visits consistently. If your practice does not have this level of retention, you may not be fixing as many patients as you would like to believe regardless of your intention. With corrective care practices, great intention/desire is not enough. You must have great systems of communication.

In order to have great retention, you must have systems to create great relationships with your patients that are far above them thinking you are just a nice person and a good doctor. You must have a trusting, inspirational relationship where they will follow your leadership through the most uncomfortable of conditions. Those conditions are;

1. Repetitive and frequent appointments for months.

2. Exercises which may be very uncomfortable, if not painful.

3. Home care exercises they must perform regularly for extended periods of time.

4. Extended office visit times.

5. Financial investment for spinal correction far more costly than just back pain.

6. You can predictably overcome their time and money objections.

Traditional communication systems taught by most management groups today teach telling a patient the answers to the 3 major questions. This communication system is not as effective in a spinal rehabilitative model.

1. What is their problem,

2. How much time?

3. What is the cost?

Telling a patient what to do is consulting. Have you ever noticed some people don’t listen? If you want to be more effective with your results with patients, you will have to do coaching.

Coaching is helping a person find their own answers within themselves. When you coach a patient, you build a trusting, inspirational relationship where you guide them to find their own emotional, inspirational reason to commit to a corrective program. When it becomes their idea because of their own emotional and individual reason, they will commit to ANY treatment recommendation and pay you the true value for your corrective, rehabilitative care.

How does this system of communication and patient flow work? I will give you a brief glimpse of 5 of a 10 step system for guaranteed success.

1. 4 Step Consultation on Day #1 — Most patients have health concerns that are far more emotionally important than their back pain. This 4 step consultation will help you find each patient’s emotional hook. For example, a 42 year old male comes to you with back pain. In this consultation, he tells you 3 males in his family have died of heart attacks before the age of 50 and he currently has high blood pressure just like these 3 men. He’s afraid he is going to DIE and leave his family. If you can correct his spine and help his heart become healthy, he will commit to your recommendations for whatever it takes and pay you whatever you want for him to be healthy. The reality is you can save his life. Why would you talk to him about his back pain? It becomes irrelevant at this point because he is not even concerned with it anymore. He will now send you patients with heart problems.

2. New Patient Exam — Relate his posture to organ problems. When you find forward head translation and a high shoulder in his posture, talk about the effect those postural distortions are having on his heart. He will commit to postural correction and send you new patients with forward head translations and high shoulders.

3. Day #2 ROF — Show the patient their x-rays and ask them questions to ensure they understand their condition, it is progressive and it is URGENT! When THEY SAY IT, they will commit. If YOU SAY IT, they may not commit. They have to tell you these answers and emphasize urgency. If you are doing all the talking at your ROF, this is where you may be beginning to lose more long term retention. You can order our “2 Secrets to Double Your Practice at Your ROF” CD for more training on this.

4. Teach a New Patient Workshop — Patients will commit when they accept responsibility. Your new patient workshop should be taught in a way where patients and guests admit to themselves they are subluxated, their health is not where it could be, their health will get worse if they don’t become proactive in a postural corrective program and they are ready to change their life RIGHT NOW! An effective workshop is not about just great information. It is about creating responsibility to admit the patient has a problem and they want to change their life RIGHT NOW! This too, is a system.

5. Getting an Emotional Commitment to Their Long Term Health Goals – Each patient should write their health goals that are set at least 20 years from now. Most doctors attempt to get a commitment to recommendations. When you get their emotional commitment to their health goals THEY wrote and signed, you will have a much higher compliance. Why? Because it was their idea. They are committing to their own goals that originated from their own emotional inspiration. This is the most powerful tool you can use. This is great coaching.

These are 5 of 10 Tips that will guarantee your success building inspirational relationships that will flourish your corrective care practice. If you would like to see the more practice tips to build lifelong relationships with your patients, go to www.elitecoachingllc.com and order “10 Practice Tips that will Build Lifetime Relationships with Patients.” Thank you for assisting in flourishing spinal correction in chiropractic.

October AJCC 2008 Full Print Version (PDF)

Download the actual full color print for the AJCC 2008 issue. The document is in a pdf format so you will need to use Adobe reader.

Download the AJCC October 2008 Issue.

CBP® NP Had 4 Papers Published in Fiscal Year 2008

Even though my husband, Don, had a near fatal illness in March 2008, CBP® Nonprofit had four papers published from September 2007 to September 2008. A lot of research time was spent finalizing the ICA Best Practices/Guidelines. These Guidelines can be viewed and reviewed at the ICA Website www.chiropractic.org. These 4 CBP® publications were:

1. Normand MC, Descarreaux M, Harrison DD, Harrison DE, Perron DL, Ferrantelli JR, Janik TJ. Three Dimensional Evaluation of Standing Posture as Rotations and Translations: Inter-examiner and Intraexaminer Reliability of the PosturePrint®. Chiro & Osteopathy 2007; 15:15 (24 September 2007)
2. Harrison DE, Janik TJ, Cailliet R, Harrison DD, Normand MC, Perron DL, Oakley PA. Pelvic Posture as Rotations and Translations in 3-D from Three 2-D Digital Images: Validation of a Computerized Analysis. J Manipulative Physiol Ther 2008;31(2):137-
3. Harrison DD, Harrison DE, Betz JW, Ferrantelli JR, Maltby J, Clum G. Frequency and duration for care of Headaches, Neck pain, and Upper Back Pain with SMT. J Vertebral Subluxation Res 2008; Aug 21:1-12.
4. Colloca CJ, Keller TS, Moore RJ, Gunzburg R, Harrison DE. Intervertebral disc degeneration reduces vertebral motion responses. Spine. 2007 Sep 1;32(19):E544-50.

However, we have one more manuscript in review which is extremely important for practicing DCs and has to do with the ICA Guidelines. It has to do with frequency and duration of care by DCs. It shows that RCTs do not support claims by IMEs that low back pain should resolve in 6-12 visits. I provided the table once again; if you want references, go to www.idealspine.com.
The CBP® Research team is working on the last Australian sheep study and is performing a systematic review on xray reliability studies.

DC’s Fight Back to Protect Chiropractic in Brazil

From WFC

PT Certificate Course in Chiropractic Stopped by Authorities

On June 26, the Federal Police in Brazil, acting on a complaint from physiotherapy leaders, detained visiting doctors of chiropractic and students from Palmer College’s Clinics Abroad program on the grounds that they were practicing physiotharapy without a license.
This was part of the PT profession’s aggressive campaign to have chiropractic declared a specialty of physiotherapy by law in Brazil. this campaign is a response to draft chiropractic legislation promoted by the Brazilian Chiropractors’ Association (ABQ), representing Brazil’s duly qualified 360 DCs. They are challenged by Brazil’s 95,000 PTs. Currently there is no law regulating or recognizing the practice of chiropractic.
To support their position, some PT leaders and entrepreneurs have established short technique courses of up to 300 hours in chiropractic for PTs, graduating these PTs with a certificate in chiropractic. One such sourse is being given by the organization Physion, in partnership with the University of Ribeirao Preto.
The ABQ, acting through lawyers, government authorities and legal processes in the capital Brazilia, has now been successful in getting an injunction against Physion and its ‘chiropractic’ teachers, on grounds of lack of qualifications and public safety. On July 18, process servers armed with this injunctiion halted a Physion weekend course getting underway at the Novo Hamburgo Business Hotel in Rio Grande do Sul in the south of Brazil.
“It was Friday afternoon when the officials arrived with the injunction,” says Dr. Juliana Piva of Rio de Janeiro, ABQ President, “and the Physion lecturers resisted at first.” However on learning that there was a $10,000 fine for each teacher daily, and $5,000 fine for each student daily, the course was quickly abandoned.
Physion and CREFITO, a regional representative of the COFFITO, the national authority for PTs in Brazil, have challenged the injunction, but the judge denied this challenge on July 27. An appeal has been filed.
“This battle for an independent chiropractic profession in Brazil is far from over,” explains Dr. Stathis Papadopoulos of Cyprus, President, World Federation of Chiropractic (WFC). “It would be a disaster not only in Brazil but internationally if chiropractic was ever recognized as a specialty of physiotherapy — and the WFC continues to appeal to its members and all others for funding support for the legal and campaign costs being incurred by the ABQ.”

Insurance Audits Hit Unprepared Providers The Hardest

As living proof that nothing is certain in health care, all providers are facing a wave of audits by third-party payers, both public like Medicare and Medicaid, and private insurers, seeking to find some basis, however flimsy, to seek repayment for services you have provided. After you have delivered care to a patient, often after having the services “pre-approved” or “qualified,” and after having received payment for what you felt was a closed file, you get a letter stating that an “audit” was conducted for the case in question, and more and more often for a group of cases, and that based on that audit, a refund is being demanded because the care was determined to be not “medically necessary” or in excess of the usual and customary frequency or duration for the condition in question.
This is a rapidly increasing trend in all forms of insurance, both public and private, and is being extended not just to providers but to beneficiaries to determine eligibility for benefits from the consumer end. As well, hundreds of private audit contracting firms aggressively push themselves on insurance companies, offering great recovery and even prosecution results. And, there appear to be big payoffs for the insurance industry so it is a reality that is clearly here to stay.
Like most realities, you have only one choice and that is to understand the audit process and calibrate your clinic procedures and especially your record keeping, to put yourself and your practice on the firmest possible defensible ground. Be prepared to deal with audit requests with sound, accurate and clinically compelling patient records as a matter of routine. Don’t wait to be hit with an audit request and then rush to bring your files up to a defensible state, because you can never play catch-up fast enough or good enough to adequately defend yourself.
Where does the authority to retrospectively review claims come from, even after payment is made? In private insurance, it is almost always expressly stipulated in the provider contract, which you signed. In some states, the insurance laws have been written to provide that, even though you never saw, read or signed a contract with a private insurance company, the act of endorsing their payment check is held to be the equivalent of agreeing to their contract terms. With Medicare and Medicaid, it is part of those programs’ formal rules. Thus, you do not have much choice but to comply with such audit requests and the successful practice should have procedures in place to log in all such requests and a policy of prompt provision of the materials requested.
What triggers an audit can vary from a complaint by a patient to your individual utilization pattern. With computers, even the largest third-party payment agency has the wherewithal to monitor claims patterns and flag a provider that, for example, submits the exact same clinical narrative of findings and the exact same care plan for 50 or 100 consecutive patients. Other frequently reported audit triggers are complaints from employees, competing professionals, advertising copy and/or claims, and the submission of claims for clinic employees or family members. Some carriers also conduct random audits of small samples of claims on a routine basis, and here, your selection for such an audit is simply a matter of your name being drawn from the provider pool.
Some audit methodologies get into what are called extrapolation formulas, where a carrier examines a sample of claims, identifies a percentage of error, and then seeks to project that error rate over all the claims you submitted over a specific period and demands that level or refund for all of those claims. Thus, if they identify a 30 percent error rate, they want 30 percent of all they paid you over the past period of months, or years. Medicare is famous for this, though in recent months it appears the various regional carriers have stepped back from this very unpopular behavior.
This methodology has also attracted the attention of some state insurance regulatory bodies, sensitive to the potential for abuse it represents. Where a pattern of demonstrated abuse, fraud or false statements is demonstrated, most states allow for some latitude by the insurance industry in making refund requests based on an extrapolation formula. Where the issue is disputed clinical necessity, which as has already been noted is subject to widely differing opinions, the State of New York, for example, has ruled that: the use of extrapolations by an insurer where there is a dispute as to medical necessity under New York Insurance Law Article 49 and New York Public Health Law Article 49 is not allowed.1 In any instance where the extrapolation approach is applied to your practice, consult your statute and insurance regulations and do not hesitate to invoke any protections those official rules offer you.
The consequences of the audit process have also evolved from a mild dispute over payment and a possible request for a partial or even full refund, to formal charges of “over utilization,” unprofessional conduct or other accusations that insurance carriers are bringing to state boards in the form of complaints, or outright fraud. This dramatic and ugly sea change has taken place in part because third-party agencies have learned that the threat of such charges, even if there is no substance behind them, drives providers into quick settlements and refunds. It is a shameful and offensive tactic, but one proven to be successful.
The audit process can be as simple as a written request for copies of one or more patient files. No provider should be intimidated by such a request and you should be prepared to swiftly respond with complete records at the appropriate professional standard. The good faith third-party payment agency has a right and an obligation to be certain that payments are for legitimate claims on behalf of qualified beneficiaries. However, the more aggressive the audit investigation becomes, the more the provider must be on careful watch, since the motives of such processes are to find a reason, any reason, to deny payment or justify a call for a refund. Money, not quality or necessity of care is the motive.
There appear to be few limits to which insurance companies will go in the audit process, including meetings with patients about your care, about which you are not informed, interviews with employees and sending sham patients to your practice, trained in methods to trip you up in some way. When such aggressive means are applied, it is clear that the carrier is looking for more than a dispute over clinical necessity, which is subject to very wide and divergent opinions. The ultimate disaster for the practitioner is a charge of outright fraud.
Any provider engaged in outright fraud deserves to go to jail. The chiropractic profession must have a policy of zero tolerance for such behavior. What constitutes health insurance fraud is clearly codified in every state’s civil code. You should obtain a copy of that statute in your state, read it and become familiar with every detail. A brief review of any health insurance fraud statute reveals an immediate list of things that you should never do:
• Never bill for any service not provided.
• Never falsify a patient record, for any reason.
• Never bill for a service that was provided by a non-professional staff member, as if provided by the doctor.
• Be absolutely accurate with the insurance codes you use, and never “upcode” any service for any reason.
• Never waive a co-payment or deductible that you are obligated to collect under contract or regulation.
• Never promise a cure or specific result.
Calculated fraud is an offense for which there can be no excuse. There are, however, gray areas where an oversight, a delay in doing the record keeping paper work, illegible case notes, notes recorded by someone else than the attending doctor, or a situation where a patient is billed, within the rules for a missed appointment is interpreted for a bill for services not delivered, can trip up even the most well-intentioned provider. It is here, where an insurance company is seeking to stretch an oversight into a fraud charge, that every practitioner should stand and fight. It is also here where a malpractice carrier should provide coverage and support, and where your professional organization should be mobilized to assist in your defense.
In every instance, regardless of the auditing agency, your best defense is a documentation and records keeping system that accurately, thoroughly documents all phases of evaluation and care, and does so on a timely basis for every patient. Good records are your best defense in all contested arenas, from claims processing to, heaven forbid, malpractice claims. On the other side of the equation, inadequate records are the major reason doctors have claims rejected or disputed, regardless of the necessity for the care given, the validity of the procedures applied or the wishes and needs of the patient.
You cannot avoid the audit process, but you can commit to doing the work and conducting your practice in a responsible, defensible manner, as every doctor of chiropractic should. Know the laws and rules and make sure you have every possible defensive asset in place, before trouble hits.
Here is where ChiroSecure can help like no other professional liability carrier in chiropractic. We offer the profession’s most comprehensive legal and audit expense coverage: including up to $50,000 defense and audit expense coverage for:
• Board investigation and hearings
• HIPAA
• Insurance Audits
• Billing errors and omissions
ChiroSecure can be a sound, reliable partner in what is proving to be one of the most unnerving and time consuming dimensions to contemporary chiropractic practice. We are ready to help.

1. “Audit of Health Insurance Claims,” Opinion of September 5, 2005, Office of General Counsel, New York State Insurance Department, Howard Mills, Superintendent, Albany, NY.

What is the one thing?

According to the renowned Nielson organization, as of June 2008 in the US, 72% of the population is using the Internet. In his excellent book, Micro Trends, Mark Penn states that the fastest growing trend in health care is “DIYD” (Do it yourself doctors). The last time you needed information, how did you search for it? I contend that patients have well formed opinions about chiropractic care. Their opinions may not be accurate, or necessarily represent the truth, however, they do in fact have them, whether they voice them initially or not. Face it, patients Google. They text, and collaborate. Facebook, MySpace, LinkedIn allow for the concept of six degrees of separation to take on a whole new level and pace of connection. News travels fast.
Two of the essential components of connecting with patients on day one, are; establishing what their expectation truly is, and what they actually know about what you do. Obtaining this information is essential to set the stage for communication going forward. Failure to ascertain expectation and the level and source of their understanding of chiropractic care will impede your ability to connect positively with them and endanger the development of your doctor-patient relationship. Without a solid doctor-patient relationship, you will have poor patient retention, and all the wonderful chiropractic science we can now bring to bear to help our fellow man is effectively, useless.
What is… the one thing?
You must first know the source of the new person who may choose to become your patient. Were they referred? Did they read about you on your website? Perhaps they read an ad, brochure, newsletter or flier? Did they learn about you from a less than direct source, perhaps from multiple acquaintances? Whatever the source of this new person, you must determine the one thing that motivated them to call and schedule. You must focus your inquiry, specifically.
For example your questions could be posed, “What was the one thing your husband said that convinced you to call and schedule to see me?” or “What was the one thing you saw on my website that motivated you to call and schedule?” “What was the one thing you heard that led you to contact me regarding your problem?”
The decision to phone and schedule is an emotional decision in every case. You must determine what motivated the patient to choose to call. The answer may be as simple as, “I found you in my insurance book.” Or “My friend told me you were the best doctor she had ever met, and if anyone could help me you could.” Another example might be “When I saw your photo and read about you on your website, you sounded like someone who really cares about her patients.”
Regardless the response, the information obtained is essential to understanding the psyche and motivation of your patient. You simply must know what the patient feels. You must know the emotion that spurred the patient’s decision to choose you for care. This approach will allow you to frame your communication with each new person in a concise way; directed toward what is important to them. This protocol is consistent with essentially all the research on patient satisfaction. In other words, this practice is what patients expect from a thorough and understanding doctor.
Once you have fully fleshed out the answer to the “…what was the one thing?” question, it is time for a follow up question. “What made you choose chiropractic care to try to relieve your [state specific pain or complaint here] pain?” Or a variation, “What do you anticipate chiropractic care can do for you?” Still another, “What do you know about what chiropractic care might do for your problem?”
The person may respond, “You are my last resort!” or “I saw a chiropractor in 1978, and he popped my back for me, and it has been great ever since!” Still another example, “I have a back problem, and you are a back doctor, so I came here.”
If the answers to your follow up questions have a technical slant, it probably means the patient has been researching chiropractic on the Internet. But which sites? What is the source and extent of their knowledge? You must explore a line of questioning to determine what they are feeling and thinking about this decision to see you for chiropractic care. (As a side note, I suggest you google; chiropractic, subluxation, chiropractic biophysics etc. and read the top 5 links of each search…the others are far less important. You should read and understand the marketplace and what patients are exposed to regarding our profession.)
If the potential patient has had chiropractic care in the past, you must fully understand all aspects of their chiropractic experience before moving forward. They have a fully formed expectation, and you must know the full extent of their opinion to manage them effectively.
Regardless the answers to your questions the information obtained, invaluable. You must ascertain what the patient thinks about their problem, and how chiropractic intervention may be able to help them before progressing with your clinical examinations.
When you have fully explored these two questions, you have a reasonable grasp of the expectation and understanding of your new patient. It is a starting point you can build upon. You can begin to re-define or enhance their level of expectation and understanding as you progress with your history review, examination, radiographs and of course their presentation of findings. When you know the mind and emotions of each new person, you have the ability to connect with them in a sincere and meaningful way. You may be able to address any misinformation they have found as a “DIYD” on the Internet, and thereby provide them with the care they want initially, and as you build trust and earn their respect, the care they need in the future. As chiropractors, we do the best for our patients when the doctor-patient relationship provides care throughout the patient’s life. To do so, we must first take simple, common sense steps. Define what patients feel, and whenever possible, ascertain the facts they used to substantiate their decision to seek your care. Respond accordingly, it is one critical step to establishing a life-long patient-doctor relationship and helping humanity with chiropractic care using the powerful science at our disposal to the fullest extent possible.

I Think You Forgot!

I was recently reviewing a deposition on a “Chiropractor” accused of causing a stroke while “manipulating” a patient’s cervical spine. They asked this doctor what a subluxation was. I read and reread his reply in amazement. This doctor was a graduate of one of the oldest Chiropractic Colleges in the world and he could not put together a coherent sentence as to what his profession professed to do, or what a subluxation was! Not only was this disappointing and embarrassing to the doctor, more importantly, to the profession. It is a warning.
Our profession is the portal of entry for millions of people looking for answers to health outside of mainstream medicine. It is our duty and moral obligation to educate the public what chiropractic does and does not do for them. D.D. Palmer and his son, B.J. founded and developed chiropractic. It is their definition that is and must be the standard. It is not the definition of any so called “Health-Sciences” Colleges. The definition of chiropractic must be answered and agreed upon by all who practice.
“The practice of Chiropractic focuses on the relationship between structure (primarily the spine) and function (as coordinated by the nervous system) and how that relationship affects the preservation and restoration of health.”
There it is; simple, truthful, exact and understandable. Structure equals function! Can and do you explain this to your patients, your staff, and the public? Or do you get tongue tied and confused? Memorize this very simple fact. We chiropractors work with structure that affects function of health. That is it. Notice, nowhere does the definition mention or imply “Pain.” The purpose of chiropractic is to optimize health, it is not a pain relieving tool, it is not an adjunct therapy to medical care, or any other care. Be it physical therapy, vitamins and nutritional therapy, laser therapy or anything else! What you do is to affect structure which affects function, which affects health. Anymore than this is not chiropractic. Yes, it’s great that we educate on diet, exercise, stress and more, but these are the adjuncts.
Maybe this is the problem with our newly graduating chiropractors. The definition is too simple for them. They need a “complex” “multi-focused” “multi-therapy” definition of chiropractic to make themselves feel important, because nothing with this simple of a definition could be worth this much.
Listen to me young Jedi’s of chiropractic. Long before you and I were born, our forefathers of chiropractic saved millions from untold suffering and dis-ease. Long before you were a twinkle in your parent’s eyes, chiropractors practiced a simple skill and philosophy that, believe it or not, still works today without third party coverage or quadruple double blind research studies.
The principle is simple: Structure equals function. Correct the structure, affect the function. Do it correctly and you will witness miracle after miracle in your office. Do it sloppy, without correct “subluxation” case management and your patients will think you are a massage therapist!
So, here it is:
1. Get knowledge of the subluxation and its components.
2. Take a course of action to correct the subluxations you have found.
3. Monitor your subluxation correction results.
4. Report to the patient what is being done to improve their function (health).
5. Repeat 1 through 4.
6. Have fun in the knowledge that chiropractic is well and in good hands, yours!

Till next time…

Don's Opinion: Chiropractic Research is Being Controlled by a Small Minority

It has become painfully apparent in the past five years that Chiropractic Research is being controlled by a small minority of academics, who comprise about one percent of the profession. This actually started a long time ago, but recent actions by JMPT and Chiropractic and Osteopathy make it more blatant. As far as CBP® Research has gone, we were lucky enough to have projects that were good enough science to get into medical journals when rejected by JMPT in the 1990’s.

However, when one has a topic that is important to the Chiropractic profession and not medicine, one has only two other alternatives: 1) try to get into the Journal of the Canadian Chiropractic Association, which is indexed in Pub Med, or 2) send to the Journal of Vertebral Subluxation Research, which is ICL (Index of Chiropractic Literature). My last few papers have gone into JCCA or JVSR when rejected at JMPT.

In the past history of chiropractic, research was done on a shoestring by field doctors and taught to attendees in seminars. This was how knowledge was created and passed on. If the field doctor had enough funds to donate to a college, then the knowledge was passed on in the curriculum to students.

Now a small minority of academics want to change this. They want all research done at the colleges by faculty and they control the journals in the Index Medicus for Chiropractic. They reject most all papers coming from field doctors. This control comes in the form of personal opinion reviews of manuscripts by a chosen set of manuscript reviewers and editors who will not over-ride unfair reviews.

The only alternative is have good enough science for a medical journal, get into JCCA, or send to JVSR in order to get one’s message in print.

Congratulations, Dr. Don!

(Left) Dr. John
Maltby,International Chiropractors Association President, presented Don Harrison
with the Dr. Herbert Ross Reaver Award in recognition of a lifetime of service, sacrifice and historic achievement on behalf of the ICA and the Chiropractic Profession.

Drs. Dwight DeGeorge and John Baird Receive Honors

At the 30th CBP® Annual Convention in Las Vegas, Nevada, Dr. Dwight DeGeorge of Saugus, MA received the 2008 CBP® Chiropractor of the Year for the work on CBP® projects and ICA Best Practices Committee. The 2008 CBP® Researcher of the Year award was given to Dr. John Baird (not pictured) of Markham, Ontario, Canada who had read the most research articles for the ICA Best Practice Guidelines.

JVSR Publishes ICA Research

At the end of August, the Journal of Vertebral Subluxation Research (JVSR) published an ICA Paper on Frequency and Duration of care for head aches, neck pain, and upper back pain. This important paper was entitled “Frequency and Duration of care for headaches, neck pain, and upper back pain” and was authored by Maltby JK, Harrison DD, Harrison DE, Betz JW, Ferrantelli JR, and Clum GW. This paper reported the truth on needed visits for these conditions. It has been reported by IMEs and academics that only 6-12 visits are necessary to resolve these conditions, while in fact a detailed analysis of randomized clinical trials (RCTs) on these conditions indicate that the patients are less than 50 percent improved with 6-12 visits. Compiling results for over 50 RCTs indicated that on average 24 visits are needed to resolve, stabilize, and document care by DCs for these conditions.

PostureRay® Update Dr. Don Harrison’s Software Legacy — Chiropractors Thank You!

Software developed by technology companies such as PostureCo™ and BioTonix™ have been powered by the inspiration and knowledge of Dr. Don Harrison and his team. His contribution has allowed us to bring you the best in leading edge, scientifically based tools for clinical practice. The first product to emerge under his guidance was the PosturePrint® system. Today almost four years later, the PosturePrint® system continues to stand alone unparalleled in the world of postural assessment for the clinical setting. Dr. Don along with his colleagues, especially Tad Janik, PhD, went on to publish PosturePrint® related research in JMPT, European Spine Journal, and Chiropractic & Osteopathy proving not only its validity, but also its reliability and repeatability, making it the “Gold-Standard” for anyone serious about analyzing and correcting posture.
Following development of PosturePrint®, Dr. Don had several requests from chiropractors in the field for a simple and quick tool for posture assessment to be used outside the office for health talks, health fairs, and other typical spinal screening venues. This led Dr. Don to deliver the “screening” tool which finally became PostureCo’s first product known as PostureScreen®. Although not a scientific clinical tool such as PosturePrint®, it fits well in the suite of products to support doctors in educating the public on posture and its adverse effects on health when spinal screening time is a precious commodity. Again, Dr. Don was at the helm of making this product become a reality.
Next, Dr. Harrison’s real dream finally came to fruition late last year — an advanced, yet simple to use x-ray digitization program known as PostureRay®. This software takes all the CBP® line drawing and analysis (as well as other chiropractic technique and orthopaedic specific analysis) into a digitizing tool that can generate not only patient-centered presentation of findings, but also impression reports (doctor-centered reports) for objective documentation aiding in justification of patient care. Not only is this tool essential for your patient’s understanding of their spinal subluxation, but it proves to be an essential marketing tool for potential patients, attorneys and medical doctors.
This digitizing program allows the doctors to quickly analyze films quantitatively and have all the data in a report form, for patients, insurance companies and for referral/marketing purposes. It is Dr. Don’s vision that all chiropractors will want to treat patients with the best care possible and these tools make the delivery of the care seamless and a painless addition to any chiropractic practice. By using these tools, the doctor can focus once again on the patient’s need and the adjustments, saving the doctor substantial time on painstaking biomechanical subluxation analysis.
At this year’s CBP® annual seminar, it is a historical moment for us all – Dr. Don is officially retiring from CBP® seminars, and passing the torch to his son Dr. Deed Harrison. While Dr. Don will no longer be at most CBP® seminars, he has vowed to keep his advisory role in the development, testing, and related research of PostureCo™ products. This will allow, the doctor, to continue benefiting from time-saving, scientifically-scrutinized software.
Dr. Don, we — along with chiropractors across the world — thank you! May your next years of retirement bring you the relaxation you very much deserve.
For more information or examples of the PostureRay® reports, please email PostureCo at sales@postureco.com.

Joseph R. Ferrantelli, D.C. graduated with honors from Florida State University in 1995 with a B.S. in Biological Sciences and earned his Doctor of Chiropractic (D.C.) degree from Life University School of Chiropractic, graduating Magna Cum Laude in March 1999. Dr. Ferrantelli is a distinguished Fellow of Clinical Biomechanics of Posture and a Certified Instructor for CBP® Seminars. Dr. Ferrantelli was named the “CBP® Chiropractor of the Year” by CBP®Seminars in 2002. Additionally, he has co-authored manuscripts published in top journals such as Spine, European Spine Journal, and JMPT. Dr. Ferrantelli is the webmaster for CBP® OnLine, www.idealspine. com and currently is in private practice in New Port Richey, FL.

Dr. Denise Perron has a Bachelors Degree in Biology and received her DC degree from Palmer Chiropractic College in the middle 1980s. She ran a high volume practice in Montreal, Quebec, Canada from 1986 to 2001. Her interest is in posture digitizers, and she has been working in that field since 2001. She is currently a consultant for business organizations and Chiropractors in Canada, USA, and Japan.

Getting your Priorities Right

By John Maltby, DC
President ICA

Someone asked me recently how I found the time to be President of the ICA, maintain a busy solo practice, travel over 40,000 air miles last year and still have a great relationship with my wife of over 32 years and my kids and grandkids (new one in January). I guess it all comes down to getting your priorities right. BJ said “Get the big idea and all else follows.” I think this applies to more than just chiropractic, this applies to life itself.
You might or might not be surprised to learn that the ICA and chiropractic are not the first things on my list. First is my personal relationship with my Savior, then my wife, children and grandchildren, then my patients and practice, then the ICA. This is my list, not yours, though I would highly recommend it. There are a zillion authors and self help gurus out there telling you that the most important person for you to take care of is yourself. I think I would rather listen to the guy who said “The greatest in the kingdom is the servant of all.” Perhaps that is the perspective we need to have when we start to evaluate what our real priorities are in life.
I might ask at this point, are you measuring your success based on the number of patients you see a week, or the amount of money you collect? If that is the case, you are not service oriented. Your focus is on getting, not giving.
How important is it that we get our priorities right? Perhaps CS Lewis, the English author of the Chronicles of Narnia, said it best in his book God in the Dock, “Put first things first and we get second things…You can’t get second things by putting them first; you can get second things only by putting first things first.”
I have said many times that the ICA is not here to build your practice. It is here to protect and defend your right to practice, not so you can make more money and drive a nicer car, but so you can give the gift of chiropractic, unhindered, to as many people as possible.
The last time I wrote, I spoke of mathematical probability of chance. If you didn’t get a chance to read it, basically, the probability of DNA happening by chance is impossible, or as the mathematicians would say, absurd. I believe we have been placed in this profession for a purpose.
What is first on your list of priorities and why is it there? If it is not based on your need and desire to serve, then I fear you will never have the time, energy or desire to fulfill what should be the ultimate chiropractic goal, to serve humanity with love and compassion, keeping them from the adverse effects of drugs and surgery, as much as it is within our power to do.
ICA’s commitment to you is to help us all to fulfill that purpose. In order to be successful, we need to help each other by supporting the association that understands the importance of getting priorities right.

140 Attend CBP®’s 30th Annual Convention in Sept. to Celebrate Dr. Don Harrison’s Retirement

In Las Vegas, at the Tuscany Hotel & Casino, on Sept. 26-28, over 140 attendees came to honor Dr. Don Harrison at the CBP® Annual Convention. After a long illness in the winter and spring of 2008, Dr. Don Harrison announced his retirement at 62 years of age. This event was the 30th year of Dr. Harrison doing Annual seminars. The program and camaraderie were excellent.

CBP Seminars Under New Management Starting 2009!

It is with great sadness and excitement in my heart that I inform the readership of the American Journal of Clinical Chiropractic (AJCC) and the CBP® community of the changing of the guard at CBP® Seminars, Inc. As many of you may be aware, my parents (Drs. Donald and Sang Harrison) have decided to retire and step down from running CBP® Seminars, Inc. and pass the baton to my wife, Dr. Shirlene, and I. Obviously this is not a simple undertaking, and we have rather large shoes to fill. However, I’m confident that we can rise to the occasion merging past and present CBP® Seminars/Technique concepts, values, and traditions with future ones. The transition will take place between December 08 and January 09 with several key changes occurring:
1. CBP® Seminars headquarters will be moved to Spring Creek, NV.
2. A new CBP® business receptionist and customer service representative will answer the phones. The familiar voice of knowledge, Dr. Sang Harrison, will no longer be present when calling CBP® Seminars. As such, the calling Chiropractor will have to excuse the fact that the new business receptionist is not a doctor and can’t answer patient management questions involving CBP® Technique.
3. The 1-800 Toll-Free CBP® seminar phone number: 1-800-346-5146 will remain the same but the other numbers will be changed from Wyoming to Nevada in December of 2008. These new business numbers aren’t available yet.
4. Any doctor with detailed questions will be directed to my email: drdeed@idealspine.com where I will respond promptly to your queries with either answers, or I will direct you to the appropriate resource.
5. A CBP® customer service representative will be present at each seminar to handle seminar registration, license renewal, and all other business.
6. In addition to the main technique core material, new seminar course content (scoliosis seminar, thoracic seminar, and more), new CBP® products (DVD’s, texts, training materials, on-line courses, and more), and affiliate equipment supply companies will be offered.
7. There will be new locations where CBP® Certification Seminars will be held.
8. We will be incorporating new CBP® business strategies at seminars to assist the attendee in implementing key concepts into actual practice building systems.
The above are but a few of the items that will be implemented in 2009. As in the past, the core group of CBP® instructors who have supported my parents will still be in attendance with CBP® in the future; though there will be a couple of new faces. Also, rest assured that my parents, Drs. Don and Sang will still be assisting in CBP® Technique, CBP® Non-Profit® and editing this journal but not in the daily business role as they need free time to experience and live some of their retirement dreams!
I can only hope that Chiropractors will continue to support CBP® Technique and Seminars under my guidance as they have under my parents’ leadership for the last 25-30 years.
For the fall 2008 and 2009 winter and spring CBP® Seminar schedule, please turn to page 13 of this issue. If you would like to offer your comments on this transition, I’d be happy to receive your emails, so please feel free to contact me at my personal email: drdeed@idealspine.com.

Deed E. Harrison, D.C., completed his undergraduate pre-chiropractic courses at the University of Utah and graduated from Life-West Chiropractic College in 1996. He has authored more than 80 peer reviewed manuscripts in a wide variety of index medicus journals and has co-authored three CBP® Text Books. He is a peer reviewer for several scientific journals including: Spine, Clinical Biomechanics, European Spine J, Clinical Anatomy, and the Archives of Physical Medicine and Rehabilitation. He is a member of the orthopedic society: The International Society for the Study of the Lumbar Spine (ISSLS). Dr. Harrison is the lead instructor for CBP® Seminars, and is Vice-President of CBP® Nonprofit, Inc. He maintains a clinical practice in Elko, NV.