PostureRay®: Building your practice through objective data!

Many times when either answering emails through our website or when at seminars, doctors question us on how we have used technology to aid in building and sustaining a thriving practice. For chiropractors who understand the need for x-rays and especially CBP® Doctors; x-rays do the talking when it comes to patient care, education and retention.

In the early years of CBP®, we were taught to give patients a “New Patient Report Package” which is like what many of you do every day.

The difference is that instead of simply using “tear off sheets” which though helpful – are generic, especially that you have to hand write on them which is unfortunately less professional, custom or specific to the patient. With x-rays, it was always challenging to make something patients would understand, and also objective and comprehensive enough that if they were shown to another doctor would be objective, concise, and in lay terms.

Before PostureRay®, we had a word document template and then would take digital pictures of the x-rays, insert them manually (of course painstakingly resizing, cropping and editing each image prior to importing into the word file), then edit the text for the patient as well as their pertinent subluxation findings and deviations from normal (i.e. Percentage the patient was from our normal model).

A new patient report handout is nothing new; Dr. Don Harrison trained us all to give this to all new patients. The difference now is to incorporate patient’s x-rays and have the reports that are very professional. The old manual way, each report would take at least half an hour to make, not to mention that we actually had to measure the subluxations by hand and calculate deviation percentages ourselves!

On follow up reports, we had to do the same thing, showing the patient’s pre and post x-rays, without the capacity to actually compare digitized numbers – again having to calculate everything and measure everything by hand.

The manual way works very well until an office gets busy, and you soon realize you have to dedicate a CA to make all new patient packets, taking them away from actually aiding in more critical office and patient procedures.

Now fast forward to today. Using the PostureRay® system, all x-rays are easily digitized, and the time to perform this task is mere minutes! Once digitized, any variety of reports can be generated, not to mention those comparison reports that took so much time at the resolution of a program of care.

Educating the patient at the time of the patient’s report of findings is necessary and should be common as nearly every chiropractor does this to some magnitude in his/her office.

Here are three tips for better exposure of your office using PostureRay®.

1. Place clinical x-ray reports in the x-ray jackets every time a patient checks his/her x-rays out of the office to go to a general practitioner, physiatrist, or surgeon. This should be done every time! Soon, the local doctors in your area begin to understand why you are on top of patient care due to the detailed nature of Posture Ray’s Impression reports, not to mention when comparison reports are placed in the jackets. Doing just this task has increased medical referrals back to our offices, and opened lines of communication with many top doctors in our local areas.
2. Another tip is to always find out the patient’s primary doctor and send him/her your initial reports with, of course, the PostureRay® Impression reports — regardless if the doctor ‘actually’ referred him/her to your office or not. You would be surprised on how many primary doctors begin referring patients, when they along with their staff realize that chiropractors such as yourself actually perform quality patient care and documentation.
3. For those doctors who care for patients involved in motor vehicle crashes or work-related injuries, here is a very easy tip: Find attorneys in your area and demonstrate how subtle ligamentous injuries such as instability can clearly and objectively be documented using the technology of PostureRay®. If attorneys know that your notes are bullet proof, and you have x-ray images that clearly demonstrate injuries, they will be more likely to refer to your practice.

It is common that many PostureRay® equipped offices report that attorneys actually ask to have the marked images exported by their office for them to use in the mediations as well as at trial. Of course, once the x-rays are digitized, generating reports, comparative reports (pre-post care or following injuries, Figure 1 & Figure 2), exporting marked x-ray images with normal spinal models superimposed is a snap to perform!

So if you are ready to take the next step in letting your x-rays market your practice, consider becoming more objective in your x-ray documentation on every case regardless if they are personal injury, cash, or Medicare, because not only does using PostureRay® save you precious time, it also makes your practice that much more marketable and bullet proof.

For more information on PostureRay®, please email sales@postureco.com or go to their website at www.postureco.com.

PostureRay®, Case Series, and Case Studies

In February, CBP® Researchers traveled to Huntsville Alabama to digitize more than 150 x-rays. Dr. Deed Harrison, Dr. Joe Ferrantelli, and Dr. Don Meyer met with Tad Janik, PhD, MSE to measure the reliability and concurrent validity of the PostureRay® system compared to CBP’s validated x-ray digitizer. At the same time, they digitized a Case Series of Dr. Meyer.

In the near future, several Case Studies are planned for x-ray information from the digitizer and PostureRay® system. The PostureRay® systems utilize code from the CBP® x-ray digitizer within a report of finding setting.

Why My Patients and Practice and the ICA Guidelines?

What I Didn’t Know

Some time ago, I received my annual statement from an insurance company telling me I was over-treating my patients. When I went through the numbers, they said for the people in that particular plan I had treated the average patient nine times over the past year. Thinking there must have been some mistake, I called the insurance company to ask about the nine visits being marked as over-treatment to help them correct their error. I knew based on my chiropractic education as well as research I had read personally, this must have been a mistake. When the representative from the insurance company came on the phone, they explained to me in their plan (which I was in the network for) they flagged any practitioner averaging over seven visits as likely over-treating / over-utilizing and implied abusing patient care. Luckily this insurance plan worked with a third party company responsible for approving clinical chiropractic treatment and really never approved many visits for their patients.

Needless to say, I sent a letter to leave the network quickly. Once authorization for care was not granted, I explained to any patients in need of additional chiropractic care, they should go to an out of network practitioner who did not need special permission from their insurance company to treat them appropriately.

I thought about this block to helping people. I thought, maybe the policy is there to save insurance companies money? Could the policy be there to protect the general public from overzealous chiropractors? I wondered if the consumer who purchased the insurance policy in the first place had been completely informed of how the policy they were purchasing for themselves or their employees actually behaved when put to use.

I called the insurance company back. When I spoke to my representative again, they asked me if I would consider not leaving their network if they made their pre-authorization paperwork more clear or if they approved a higher rate of payment for the treatment codes I billed. I let her know I was not interested in any of those things. I let her know I simply wanted to know what they were basing their seven visit treatment number on. She let me know they had research saying this was all the chiropractic care anyone needed to get better. When I asked what research she was speaking about she did not know. She only knew that in their company their training said this was the case.

I have the unusual honor of holding the role of vice-chair for the ICA Best Practices & Practice Guidelines, which is currently under review at the National Guideline clearinghouse where we are confident it will be installed as a major chiropractic professional guideline very soon.

While performing my tasks as vice-chair for the project over the past several years, it became clear to me that across approximately 1,400 published pieces of original clinical science utilizing chiropractic treatment including spinal manipulation and spinal adjustments; the numbers speak for themselves. The average number of treatments shown in the research was 24. Actually this number is misleading, because in the vast majority of cases only one health challenge was being addressed and co-morbid factors complicating healing and necessitating further treatment were not considered. In those cases more complex than one health challenge with co-morbid complications, the number of treatments needed for clinical success may go up depending on the case. Understand the low number of treatments in the research was merely one and the high number was nearly 300. It would seem research commonly uses one treatment as a means to control measurement of results.

In papers where specific clinical cases were discussed, treatments were commonly higher than the 24 number to achieve a comprehensive positive result. I didn’t bother telling this to the insurance representative on the phone as I am confident she was not familiar with all the clinical research that has been performed.

Protecting Patients

It is my perception the governing boards of chiropractic in each state and every country that has one have been charged with the responsibility of protecting the public from professional practices which may prove detrimental to that population of people. Insurance company politics and policy aside, is chiropractic clinically and cost effective? The overwhelming evidence says the answer is YES! Our ICA Best Practices & Practice Guidelines has three purposes:

“1. Locate, summarize, categorize, evaluate, and rate the evidence for Chiropractic Care of a variety of health conditions.

2. Assist the practicing Chiropractor in making sound, fundamental, clinical decisions when providing Chiropractic Care in clinical practice.

3. Provide Chiropractic colleges and educational institutions with a document to help assist future chiropractic practitioners in the criterion standard of care.” (Text in this article in quotations was cited directly from the ICA Best Practices & Practice Guidelines available at www.ICABestPractices.org.)

Let’s discuss clinical (Risk/Benefit ratio) and cost effectiveness of chiropractic care. Chiropractors are unique in that they are largely taught to treat subluxation rather than a medical clinical diagnosis. “According to a 2003 survey by Ohio Northern University, almost 90 percent of practicing Chiropractors adhere to the tenet that spinal subluxation creates interferences with normal nerve function.11” In treating subluxation versus a named symptomatic medical diagnosis, the chiropractor has the potential to affect holistically entire body health and not merely relief of a specific symptom. Contrary to popular belief, the scientific demonstration of subluxation has been well documented (see www.Chiropractic.org, www.IcaBestPractices.org, and www.PCCRP.org)

“It has been estimated that approximately 7-10% of the USA population seeks chiropractic care,7 this document is for practicing chiropractors and their millions of patients. It has been suggested that the majority of chiropractic patients seek chiropractic services for spinal (axial) pain syndromes. However, without considering patients with axial pain, patients who have been medical failures with a variety of diseases and structural abnormalities have sought chiropractic care in the past and continue to do so. In fact, our evidence appears to demonstrate that the majority of chiropractic patients prior to the introduction of anti-biotics sought care for a variety of non-pain syndromes, diseases and disorders.” In the vast majority of these cases, the patient’s health improved without detriment.

“Chiropractic care has a very low risk benefit ratio and very low costs compared to standard medical care… evidence in Chapter IV indicates that more utilization of chiropractic services would result in more saving in reduced utilization of medical services… From the British Medical Journal’s website (BMJ),75 one can determine that of about 2500 [medical] treatments supported by good evidence, only 15% of treatments were rated as beneficial, 22% as likely to be beneficial, seven% part beneficial and part harmful, five% unlikely to be beneficial, four% likely to be ineffective or harmful, and in the remaining 47% the effect of the treatment was, ‘unknown’.”

Wait a minute; did they actually conclude the result of chiropractic care is likely health cost savings? Yep. It looks that way. What about herniated discs? Can chiropractors cause them? Treat them? “It is very likely that reports of disc herniations caused by manipulation are in fact pre-existing conditions… In the Mercy Center Guidelines, it is stated that manipulation is only contraindicated in the case of, “extensive disc prolapse [herniation] with evidence of severe nerve damage”.100… Critical to the discussion of pre-existing disc herniations is the fact that chiropractic manipulation is actually the standard of care for patients who have cervical disc herniations.84, 91, 97-99…

In a prospective study of 27 individuals with MRI confirmed cervical disc herniations, BenEliyahu91 demonstrated statistically significant improvements in visual analog scales, pain intensity, return to work, and a reduced size of the disc herniation following chiropractic care… He states, “Chiropractic management of disc herniation, including spinal manipulation, may be a safe and helpful modality for the treatment of cervical and lumbar disc herniation”.91 Not only does spinal manipulation not cause disc herniations, there is strong evidence that it is of benefit to these cases.””

Ok, we now know chiropractic care should be healthy for helping those with disc herniations. What about the risk factors of spinal manipulation? “In 2007, Thiel et al11 studied treatment outcomes obtained from 19,722 patients…Data were obtained from 28,807 treatment consultations and 50,276 cervical spine [neck] manipulations. There were no reports of serious adverse events.”

Educating

As a chiropractor, I believe a large part of my job is to help educate patients and the general public about their health and the role chiropractic can play. For those too scared or skeptical to go to a chiropractor, the information here should be helpful. If they remain scared or skeptical, they will miss out on a safe, powerfully effective and natural means to address their overall health. The honor in playing a role in the ICA Best Practices & Practice Guidelines is I get to see first hand what the research actually says about the benefits of chiropractic care and collaborate with patients in my office on a safe and cost effective way to address their health needs. For many, not using chiropractic care results in unnecessary furthering of health problems they may not have even known about without a chiropractic evaluation. As for insurance policy and politics, I am still not sure which research they are using to get their data for granting permission for chiropractors to help people.

Practice Success In a Recession

In tough economic times it becomes increasingly more important to put your attention and energy into strategies which are proven to work. There is less room for error and there can be a fine margin between success and failure. So, what has proven to work in times like these?

The most important thing for you to possess is knowledge. Not random knowledge but the specific knowledge required to succeed in practice.

In my experience, a successful practice in today’s environment requires knowledge in at least these key areas…

1. Service Delivery

2. Communication

3. Marketing

4. Management of Staff

5. Organization

6. Handling of Finances

Most doctors are competent with the service that they deliver. This is not to say that this area shouldn’t be improved, but for the purpose of this article, I shall move on to #2.

Every aspect of what you do in practice can be viewed as a communication. Whether you look at treatment, marketing, a Report of Findings, or billing an insurance company, it is all communication.

The Prescott Group has worked with thousands of doctors and staff over the years and discovered that most people are deficient in the basics of communication. A lack of these basics can result in the rote use of scripts in situations where they don’t really apply—or to some degree of failed communication.

If this occurs in marketing, it means less new patients; in the ROF, it means less patient compliance; in patient education it means less understanding; in billing, a lack of communication basics means less pay for your services.

To handle this problem, we train each of our clients on the basics of communication. With these basics understood and applied, every aspect of practice is easier.

Without marketing to create a consistent flow of new patients into the office, it is impossible to operate a viable business, and it is unlikely that you will achieve your purpose—to any great degree.

There are two aspects to the Marketing Training that we teach our clients. One aspect is training on all the successful actions of chiropractic marketing—some of which you’re familiar, and some which will be new to you. In either case you’ll be trained and drilled in proper procedures to maximize efficiency.

The second aspect that we teach is the key to marketing success—and is generally not known by most chiropractors. We teach all of our clients the fundamentals behind what makes any marketing activity succeed. It is the underlying basics of how your message is formulated, delivered, and then received by another person. Without this understanding a doctor is left doing the motions of marketing without an ability to control the outcome because he is doing something he does not understand.

With mastery of both aspects of the Marketing Training, our clients have plenty of new patients in need of chiropractic care.

The proper management of staff is the foundation for sustained growth and efficiency. Although every area of my practice has been improved over the years, the successful management of staff has been the breakthrough that has allowed me to achieve long term success in a stress free practice.

Having staff that are trained to competence and can produce at a very high level is the foundation on which to build a stable practice that thrives in any economy. At The Prescott Group, we assist our doctors by not only teaching them how to hire and train competent staff, but we also actually help train the staff, as well!

If you have to run around your practice and do almost everything to make sure it is done right or you have the revolving door syndrome of staff replacement, our training will help you handle these problems.

A system of standard organization is the hallmark of a well run efficient practice. It is also what gives a practice the ability to

survive in the long term. This is important for the long term survival of chiropractic, as well as provides you with a stable economic future.

We train our clients on the basic fundamentals of organization and help them to implement standard systems. That is why our clients can achieve long term success, take vacations, phase out of any aspect of practice they prefer not to do day to day, sell their practice for a significant price, or run multiple clinics.

In today’s economy the proper handling of finances is essential. We train our clients on proper strategies for creating a reserve fund, paying down debt, and expanding income. We teach our doctors to plan their income in advance rather than wait until the end of the month to see what is left over after practice expenses.

Maybe the best aspect of our training aside from the fact that it works, is that we guarantee your skills for life by allowing you to return at any time to retrain on your courses—at no additional cost. Every month we have former clients return to retrain on their courses and sharpen their skills.

The first step for you to learn more about what The Prescott Group can do for you is to call our office and schedule a free practice analysis. I look forward to working with you!

Be Proactive & Consistent on Informed Consent

Effective risk management requires every chiropractic practitioner’s daily attention. Consistent attention to detail and regular examination and re-evaluation of the risk-management basics are essential to your practice’s protection and your peace of mind. It is vital, however, that on key risk management issues and procedures, you never let your guard down and do not let staff members drop the ball or cut corners on record keeping, confidentiality issues, and, on the doctor’s “MUST DO” list, make sure that informed consent documents and procedures are always in place and consistently applied.

Informed consent has emerged as a cornerstone of risk management procedures because the lack of it in malpractice cases has become a common and effective claim. Clever and aggressive lawyers have hit upon the informed consent issue as a means to strengthen otherwise weak claims of clinical misjudgment or injury, based on a number of landmark court decisions and trends in other professions. In a landmark 2005 Wisconsin case, the state court found:

“Chiropractors, like medical doctors, are health care professionals involved in the application of procedures and treatments to the human body. We see no reason why the scope of an individual's right to be informed of the risk inherent in bodily intrusions via chiropractic treatment and procedures should be any different from his right to be informed of the risk inherent in bodily intrusions in medical treatment and procedures.”

Thus, the fact that chiropractic is non-invasive provides no additional margin on demands for informed consent according to the Wisconsin court, a position reaffirmed by an often cited 1999 New Jersey Supreme Court decision, which similarly held that: “…informed consent applies to both invasive and noninvasive procedures,” holding that physicians must inform patients of the possible risks and benefits of all “medically reasonable” treatment options—including those he or she does not recommend. If that is not complicated enough, courts are regularly finding that patients must be updated throughout their course of care in terms of relative risks and alternate care choices, and that not telling a patient about other care pathways and their risks becomes an issue in itself.

In fact, actions based solely or largely on the lack of formal and written informed consent have emerged as a malpractice growth industry, even though such charges may have nothing to do with whether a chiropractor has actually committed an act or acts of malpractice as it has historically been understood.

The message here is clear: Be consistent and proactive in obtaining both written and verbal informed consent from every patient, in advance of both examination and the active delivery of care. Yes, get informed consent prior to care to cover your examination procedures, as well as in advance of delivering chiropractic adjustive care.

Informed consent starts with a standardized form. Your malpractice carrier is always a good place to obtain a model form, followed by your state or provincial association, with, as is almost always the case, close attention paid to any direction available from your state or provincial regulatory board. On this form, the key information needed will always include the patient’s name, address and of extreme importance, the date.

The exact nature of the form’s contents should reflect the requirements in your jurisdiction. This is why a visit to the regulatory board’s website or information from your local association is so vital. Different jurisdictions have different specifics on informed consent. You will need to comply with state and provincial directions as to the degree of specificity regarding risks inherent in the procedures you are about to apply.

In recent months, as more and more technology and especially mechanical devices are incorporated into chiropractic practice (from mechanical adjusting devices to spinal decompression units) it is becoming important to obtain separate informed consent forms for each new level of intervention applied by your clinic. A form for the adjustment, a form for traction, a form for mechanical spinal decompression, and a form for any procedure that can be argued to be separate and different, and not arguably covered by a general form, will serve you well. Remember also that the absence of such forms becomes a problem in and of itself.

In addition to the form itself, most legal advisors will encourage that a note be added to the patient’s file stating that the form was signed and that a verbal exchange took place, with you as the provider (not a member of the staff) highlighting the contents of the form. Indeed, some malpractice experts argue that the verbal exchange is the essence of informed consent, where the patient has the opportunity to question the doctor’s choice of procedures, and that without the verbal component, the written form loses much of its meaning.

Rather than look at the required informed consent exercise as a burden, practitioners should look at the interaction with the patient on relative risk and informed consent as an opportunity to orient them to what they can expect from the adjustment process, especially if they are first-time patients. While most patients feel an immediate sense of relief from the adjustment, a frank discussion on possible temporary or short-term discomfort from a first adjustment, possible stiffness, etc., helps patients keep things in a much better and more realistic perspective, and puts you in a position of both greater credibility with the patient, as well as defensibility should any unforeseen issue arise. Such frank and open dialogue can only strengthen the doctor-patient relationship and enhance the positive nature of their chiropractic experience.

In today's litigation-happy (or many might argue litigation-crazy) society, even the best, most conscientious and responsible doctors of chiropractic, applying the highest standards and most established procedures and protocols, can still be named in a malpractice claim. When it comes to informed consent, a whole new dimension of malpractice reasoning comes into play, where patients and their attorneys regularly argue that if a patient was fully informed of all risks and possible negative outcomes, then they may have decided not to receive the care and would not, as a result, been injured. The proactive doctor of chiropractic will respond accordingly, with sound and well-researched forms and procedures, all consistently applied and included in the patient’s file. It pays to do the work and, consequently, minimize the risk.

And, as every doctor of chiropractic should know by now, a reliable malpractice insurance carrier is your best partner in protecting your practice and yourself from malpractice claims. In that process, ChiroSecure stands ready to serve and assist in making sure that you have the coverage you need, and in implementing risk management procedures that will provide the best possible firewall to jeopardy.

Shop around, compare and see what you find. Then, call ChiroSecure today and find out how you can have the best protection on the market, multiple policy options at highly competitive rates. The result will be both excellent coverage and peace of mind. You deserve both.

Call ChiroSecure toll-free today at
1-866-80-CHIRO or 1-866-802-4476, or visit ChiroSecure on the web at http://www.chirosecure.com.

Hanumans v. Boyson, No. 2003AP1527, 2005 WL 1522624 (Wis. June 29, 2005).

Matthies v. Mastromonaco, 160 N.J. 26, 37, 733 A.2d 456, 462 (1999).

Schreiber v. Physicians Insurance Company of Wisconsin, 223 Wis.2d 417, 588 N.W.2d 26 (1999).

I Can't Cure Patients

As a young chiropractic student, I once heard a famous D.C. state, “I can’t cure patients anymore than I can cure a ham.” The statement struck me funny in the late seventies. It took many years to not only agree with him, but to understand his flamboyant statement.

The biggest problem with young and old chiropractors alike is not believing and seeing the fact that they do not cure people. The greatest chiropractors and philosophers in this profession have reiterated this in many different forms. “Take no credit, accept no blame.” “The body heals itself.” “Innate knows better than you.” The real problem is for you to get this understanding and to see and believe it. The more the science of chiropractic grows, the more it demonstrates that you are in charge of finding and correcting interference to the expression of nerve impulses from brain cell to body cell and from body to brain cell and not the treatment of diseases.

Your life and practice would be so much more successful and fulfilling if you were to only be responsible for correcting nerve energy and not cure back pain, neck pain, asthma and allergies or any other diseases that some of our peers believe that we do.

The most miserable chiropractors in the world are those who think it’s his or her job to make people feel better or have less pains and aches. These poor chiropractors spend minute to minute in their practices feeling ultra successful or feeling that they are the worst doctor in the world. All of this pain is based on their belief that they are responsible for the patients’ health, well being and level of pain. Quit this today, do the research, read the books and know that you are not responsible for your patient’s state of health or lack thereof.

You are only responsible for finding and correcting the interference to the expression of nerve energy in the body, NOT CURING THEM! See yourself in your mind’s eye correcting subluxations, allowing free flow of the nerve energy. This is what you do, what you are. Anything else you do in your practice takes away from the essential truth of what chiropractic is, and that takes energy, time and focus away from you serving more people. Yes, people need advice on exercising, diet, mental attitude and more, give it to them. But always remember the only true job you have and are qualified to do is to reverse nerve interference.

Til next time…

Setting the Standard

I recently read a statement by a chiropractor which stated “Neither the government nor my chiropractic associations nor my local colleagues set my standards. I do!” While I might agree in principle with this guy, the reality is that the legal standard of care is established by the government (state boards) whether we like it or not. The choice we have is what role we as individuals can do to help determine what those standards are.

Over the years, there have been many attempts to establish guidelines and standards which have done more to limit chiropractic care than to encourage. Many of the documents boasted of an unbiased review of the literature when, in fact, the review consisted of a very narrow selection of “research” which promoted the often used bogus line of “6-8 visits” or “80 percent self resolve in 6-8 weeks.”

The ICA has worked hard over the last four years researching this issue and has developed the most comprehensive ‘Best Practices Guidelines’ in the history of the profession. When combined with the ICA’s x-ray guides, PCCRP, the chiropractor of today is equipped with the tools he/she needs to provide the care his/her patient’s need. These guides are not intended to be a cookbook for care, but rather a comprehensive tool to enable the chiropractor to provide better care for the patient. And after all, isn’t that what it’s all about.

When I was first elected ICA President, my primary goal was to re-establish ICA’s role as an international association defending your right to practice. The completion of these guides I count as my proudest moment as President. It was accomplished through the unselfish and sacrificial work of a few dedicated chiropractors under the leadership of Don Harrison. This team did more than just write letters, or complain. They did something. They took time out of their schedules, and money out of their pockets and did a greater service for this profession than many of us will ever realize. They have a standard of devotion to this profession that we all should be proud of and be willing to copy.

If this small group of dedicated individuals can accomplish so much for our profession, imagine what an entire association of likeminded chiropractors could do. This group has indeed set a standard, a standard of commitment to chiropractic. How about you? Are you willing to commit to THIS standard? If so, support the association that is actively defending our profession. Join the ICA today so that we can continue to set the standard for the future, go to www.chiropractic.org .

Cyber Update: Follow CBP on Facebook and Twitter

With more than 175 million subscribers worldwide, Facebook is a social networking site that aids people in communicating more efficiently. We believe that Facebook offers an exciting way for CBP® Seminars and the chiropractic community to interact and thus have created the official Chiropractic Biophysics Facebook page. If you are on Facebook, please stop by, join, and stay in touch with all of us here at CBP®!

If you are a little more tech savvy, and like to have up to the minute updates on what we at CBP® are doing, you can also follow us on Twitter. Twitter is another style of social networking service which has been termed “micro-blogging” and is a hybrid between text messaging and instant messaging, but with the reach of large communities of people who choose to “follow you” on Twitter.

If you are on Twitter, you can follow us as “CBPseminars.”

Stay in touch and see you online!

J Chiropractic Medicine becomes PubMed

From the JCM website, PubMed, the prestigious search engine of the National Library of Medicine, has now included the Journal of Chiropractic Medicine (JCM). JCM, first published in 2002, is a peer-reviewed journal devoted to providing practical and applicable information for the practicing doctor of chiropractic.

JCM offers a wide range of topics including: sports chiropractic, care of children, chiropractic technique, nutrition, rehabilitation, care of aged patients, public health issues, diagnostic imaging, somatovisceral effects, and many other topics that may be included within the scope of chiropractic care. “We are thrilled that the JCM is now indexed in PubMed,” said Dr. Winterstein, President of the National University of Health Sciences, which publishes the journal. “Indexing in PubMed will allow greater access to this important research so that doctors of chiropractic and other healthcare providers may use this knowledge to provide best possible care for their patients.”

JVSR Publishes Important ICA Research

On February 14, the Journal of Vertebral Subluxation Research (JVSR) published the second ICA research on frequency and duration of treatment for pain.The paper is entitled “Program of Care Derived from Pain Data Reported in RCTS on Low Back Pain” and was authored by Maltby JK, Harrison DD, Harrison DE, Betz JW, Ferrantelli JR, and Clum G. The previous paper concerned the neck, upper back pain and headaches, while the present paper analizes low back pain.

These papers taken together refute Managed Care Organizations claims that low back pain should resolve in 6-12 visits. From 65 RCTs on low back pain and SMT/mobilization, an average visit number of eight was determined, with only 43 percent reduction of pain achieved. Extrapolating this data provides over 20 visits needed to resolve pain. However, as doctors we are required to document and manage such cases for exacerbations. Thus, if we add some visits for examinations and post-evaluations with some four weeks of supportive care, one attains nearly 30 visits.

DCs can now question Managed Care Organizations on their fabricated claims of 6-12 visits. These two systematic reviews of the literature determined the true data and results, i.e. patients with pain are less than 50 percent improved with SMT in 6-12 visits.

CBP Technique Re-Aligns with Omni Tables

Beginning in the summer of 2008, Chiropractic BioPhysics® (CBP®) Technique has re-kindled a relationship with Omni Manufacturing & Design to meet the Drop Table equipment needs of CBP® Chiropractors. I personally re-established this relationship with Omni due to the concerns from CBP® Chiropractors that they were not having their adjusting table needs met at CBP® Technique seminars and in the profession on the whole. Omni is one of the largest Chiropractic Drop Table suppliers in the profession and more specifically, Omni drop tables are specifically designed to meet the needs and demands of Chiropractors utilizing CBP® Technique mirror image® adjusting procedures.

Of importance, Omni Manufacturing & Design has several distributors where drop table supply needs can be met including: 1) Omni Manufacturing & Design headquarters www.omnitables.com, 2) Access Equipment Corp. (www.chirocity.com), and 3) www.chirotables.com. No matter which one of these table distributors you choose, you’ll receive a quality drop table capable of performing hundreds of unique CBP® mirror image postural adjustments for abnormal spine/posture rotational and translational subluxations.

I’m excited about this ‘new’ relationship. Look for Omni drop tables to be featured at all CBP® Seminars in 2009; see the CBP® Seminar schedule on the back page of this issue.

HERE’S WHY YOUR RETENTION SUCKS!

It’s not that your retention sucks. I would never judge your stats. I only attempt to help you with systems so most all of your patients achieve full spinal correction INCLUDING maintenance care.

Because you are a corrective care doctor potentially using CBP®, when your retention, PVA (office visits per week/new patients per week) prevents a number of your patients to completely follow through with their corrective care recommendations including maintenance care, you are left FEELING frustrated, like your systems for retention SUCK! If you are a principled, corrective care doctor, this can be very upsetting. I know in my years of practice as a corrective care doctor, I was left feeling VERY FRUSTRATED when some of my patients quit their care prematurely before achieving full spinal correction. What’s worse, there were no management systems technique specific enough to help me fix my problem. I had to create CBP® corrective care systems for high retention myself.

If you have a 0 – 25 PVA, your Day #1 and #2 are weak. Your problem is in the first week, most commonly Day #1. They didn’t buy you as their doctor on Day #1, and you may feel as though you are selling your care at the ROF on Day #2.

If you have a 30 – 50 PVA, you need a better re-exam and need to have the patient set better long term health goals and the doctor setting 30 day goals to each re-exam. With this PVA, they are completing the first phase of Corrective Care. If they are not completely corrected, they are probably not following through with the second 36 visits or continuing with maintenance.

I know what you are thinking. You are thinking, “I have patients completing care.” We are talking about the average patient, NOT all your patients. This may be a hard stat to confront, but stats don’t lie. In the last year of evaluating MANY, probably over 100 CBP® practice stats, frequently I see practices with PVA’s of 30 – 40, I often see the PVA stat in the 20’s and a handful at most, in the 50’s.

CBP® research states the average patient will achieve 50 percent structural correction in the first 36 visits. This means if you are making 36-visit initial recommendations, the average patient must commit to an additional 36 visits PLUS maintenance to achieve full correction. Isn’t that our responsibility? That is about a 90-visit recommendation by the time they are corrected with two (2), 36-visit recommendations and some maintenance visits for stabilization of their correction. In truth, a CBP® practice should have a 60 – 90 PVA. There are several reasons why most CBP® practices don’t have this level of retention. Briefly, here are a few of those reasons.

You are waiting to recommend the second 36 visits at the re-x-ray. This may be a practice with a 30-40 visit PVA. The challenge is the patient agreed to your initial recommendation, but perceived 36 visits to be an end point, regardless of what you communicated in the beginning of care and their initial intentions. If you wait until the END of their first block of 36 visits to convince them to commit to another block of 36 visits, you have a much higher probability of failing.

The re-exam and re-x-ray at the end of the initial 36 visits should be communicated as a check point, NOT an end point. From the BEGINNING of the first 36 visit block, the patient should be trained that you will be checking their progress and they should expect the next set of recommendations. In fact, two weeks before the re-x-ray, they should be quizzed on the next set of recommendations if they do not achieve full correction and how they will financially invest in the next phase of care. When their recommendations are handled in this manner, you will not see patients drop out of care prematurely. They know in advance and have already committed to their next set of 36 visit recommendations and their financial investment is already planned. This is a system of communication and management that is rock solid.

You are ONLY focusing on fixing the spine.

Our job is NOT to fix their spine. Our job is to teach them the philosophy and lifestyle of Optimal Spine = Optimal Health for LIFE! When new patients come in on Day #1, their spine is subluxated, their health is compromised and we teach them why and how to achieve a life of optimal health through spinal correction. Our first job is to fix their spine to get their body in a healthy state of homeostasis. Our ultimate job is to teach them how to keep an optimally functioning spine, posture and health for the rest of their lives. We teach and sell LIFESTYLE! If you teach and sell correction, they quit when they are close to corrected, at the end of 36 visits. The problem is they never set a goal for life long health.

This is why we have systems to set 30 year health goals in the beginning of care. We focus on the lifestyle AND, most importantly, their individual emotional reason to desire to live their optimal life, NOT just to fix their spine. Set their goals for LIFESTYLE, NOT just correction, have a system to support it and your PVA will increase dramatically.

You may be coaching with a system that is not technique specific.

Many coaching systems boast a 40-40-40 model. That’s 40 new patients per month, 40 PVA and $40.00 per visit. These management groups may recommend CBP®, yet they are not technique specific to handle the unique challenges of a CBP® practice. They do create successful practices and they are good consulting systems, yet you may find some of the demands of a CBP® practice are not being specifically addressed.

A 40 PVA system is low for CBP® technique and $40.00 per visit (total collections per month/patient visits per month) is low for a rehab based technique with higher overhead and time demands for the doctor and staff. Some groups will outwardly state this is their model. Some may not outwardly make this statement, but their model supports this PVA and visit reimbursement. Again, they may be a great group, just not CBP® specific with systems that support a 60 – 90 visit PVA.

I am committed to helping CBP® practices become the most successful practices in the profession. If you are experiencing any of these challenges, please call me for questions, advice or a practice evaluation to help you accelerate through these challenges in 2009. My number is 253-851-8353. We also give seminars and boot camps on how to attain a 60 – 90 visit PVA. Please visit our website at elitecoachingllc.com. Thank you.

“Can The Economy Recover?”

This has been one of the most common questions over the past several months. Indeed, it is the million dollar question. Concerned about the outlook for our country, one of my clients sent me the following insightful quote from Dr. Adrian Rogers, (1931 – 2005):

“What one person receives without working for, another person must work for without receiving. The government cannot give to anybody anything that the government does not first take from somebody else. When half of the people get the idea that they do not have to work because the other half is going to take care of them, and when the other half gets the idea that it does no good to work because somebody else is going to get what they work for, that my dear friend, is about the end of any nation. You cannot multiply wealth by dividing it.”

Many hard working chiropractors are likely asking: Where should I invest when the economy is in a freefall and the outlook is so bleak?

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 — FEAR. Fear is 2.4 times more powerful of an emotion than greed (F=2.4G). Fear dictates decisions for many investors.

I have often asked retired investors what their most vivid memory of investing was. Many of them have said, “I missed an opportunity that was right in front of me.”

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. This is a time to capitalize on sectors of the economy that are well poised for a rebound.

Whose face is on the $100 dollar bill? Hint: he was the revered sage who said, “An investment in knowledge pays the best dividend”.

Benjamin Franklin wrote a book in 1758 called, “The Way To Wealth”. It is just as relevant in 2009.

What is “The Way To Wealth”? Besides being a fantastic book that I have purchased thousands of copies of, it is a philosophy for obtaining and protecting wealth in your life.

For instance, if a doctor is going to make meaningful progress with a scoliosis patient, the doctor is going to need to see a clear picture of what he or she is working with. Without that X-ray, and perhaps future X-rays, the patient can’t receive significantly measurable corrective care.

The questions below this article all ultimately have a bearing on wealth. Yet, most investors never ask or address these critical questions. However, it is only when the answers to these questions are discovered that weaknesses in a wealth plan can be pinpointed and meaningful progress can be made. Put your family first by taking ten minutes today to email, a CPA, trusted attorney, or this author and discover which questions below are the important ones to you.

Chiropractic BioPhysics® (CBP®) College Course Updates

We are excited to let the reader ship of the American Journal of Clinical Chiropractic know that Chiropractic BioPhysics (CBP®) Technique is now offered at several Chiropractic Colleges including a new course that began in January of 2009 at the University of Quebec at Three-Rivers. CBP® Technique has seven elective courses at various Chiropractic Colleges and one core curricula course offered at Life Chiropractic College West. See Table. Below you will find a brief overview of the CBP® course acceptance by the students and general feel offered by several of the instructors.

Dr. Abe Cardwell

Instructor Life Chiropractic College

We had 37 young doctors in the elective this quarter (Jan 09). We are the second largest elective on campus; our size is only restricted by the fact that the Clinic has not yet authorized use of Chiropractic BioPhysics (CBP®) technique. However, good headway is being made. Students are currently allowed to have initial and follow-up radiographs taken by following the appropriate technique/treatment guidelines set forth at the clinic. Response to the CBP® class is very enthusiastic, with near unanimous acceptance by the students of the material presented. Class reviews filled out by the students rank the class #1 in satisfaction, and encourage the administration to include CBP® in core curriculum. Becoming core-curriculum is my ultimate goal, but I understand that this is a slow process with many logistics that need considering. I am proud to be part of opening young doctors’ minds to the science of spinal correction and improved health through CBP® Technique.

Dr. Louise Marcotte

Instructor University of Quebec at Three-Rivers

I had 30 students in my class this time that were 4th and 5th year students. Although 24 hours was very little time for even an overview of CBP®, the course went very well. The comments I got in general was that the students appreciated the very well documented and scientific, as well as concrete and hands on aspects of CBP®. Whether they choose to practice with this technique or not in the future, I am confident that they now understand better the importance of posture for their patients and themselves, and how detrimental spinal subluxation is to their nervous system and therefore general health. I certainly hope that I was able to inspire some of them to take the road less travelled for the good of Human Health and Chiropractic.

Dr. Karri Cardinal-Barr

Instructor Life Chiropractic College West

CBP® became part of the core-curriculum at Life West approximately one year ago. Since then, roughly 30 students per quarter learn the science, philosophy, and art of CBP® I in a core curricula course. Students learn posture analysis, x-ray analysis, basic coupling pattern theory, and mirror image® drop table/instrument adjusting (pelvis to feet, thorax to pelvis, and head to thorax). Those who wish to further their knowledge of CBP® can also take the CBP® II Advanced course as an elective, where they will learn advanced coupling pattern theory, Nasium theory and analysis, short leg theory and analysis, x-ray projection theory, cervical rehabilitation, thoraco-lumbar rehabilitation, Posture Print application, pediatric adjusting, practice skills and case management. The students at LCCW express a deep desire to learn and CBP® challenges their intellect and fulfills an important part of their education.

Dr. Mike Landry

Instructor RMIT, Melbourne, Australia

In Sept 2008 I ran a one hour course on CBP®. It was a brief PowerPoint showing postural patterns and set ups. I discussed the need for traction and how a one size fits all approach does not work. I believe it was well received. Because of a new appointment at RMIT, a Thompson technique was given preference. Approx 40 students out of the 5th year were in attendance. RMIT only has one intake per year of new students with average class size of over 50. The previous year (2007) I also had a practical portion. The challenge was the tables were basic (Gonstead benches) and I had no assistance. I did bring in blocks, adjusting instrument and other postural remodeling equipment for the students to use. I'll be in contact with the school to set up times for later this year. I believe that more of the basic CBP® courses need to be offered to give students and practitioners a start in CBP® and to gain a greater foothold here in Australia.

Lastly, it would be great if CBP® Non-Profit, Inc. could assist us in getting CBP® Technique adjusting equipment to the school this year.

The Ultimate Combination: Power Plate® & CBP®

While researching ways to improve the outcome of mirror image® exercises and spinal remodeling techniques, I discovered a technology called Acceleration Training™ from Power Plate®. Professional sports teams, astronauts and the U.S. Olympic team were currently using the technology. The outcome I was so desperately looking to improve was my own.

Case History:

I have a grade 2 spondy, severely degenerated L5-S1 disc, radicular left leg pain, and a lot of instability in the lumbar spine. To add insult to injury; add a left structural short leg length inequality of 15mm to the equation.

About four to six times per year, I would have a flare up that would incapacitate me. I was doing everything — mirror-image® adjustments, pelvic traction, and postural exercises. Every time I got going on core stabilization exercises, I would have a set back. How ironic, taking care of patients and I could not take care of myself. I felt as if I kept going backwards. My activity level was fairly low, and doing basic chores was a Herculean task.

This pain and frustration prompted me to start researching new technologies that could not only help me personally, but that could assist me with my practice as well. After thoroughly investigating many options, I came across the current research for a new technology called Power Plate®. I realized this was everything I was looking for; it was the miracle I was praying for!

February 2007 was when I got my first Power Plate®. The learning curve was steep. Included in the package were basic exercises, but none for a disc and a spondy.

Now what??

I had to find a way to make the Power Plate® work for me. Daily, I would experiment with different positions, and gradually I was doing more and more on the plate, in pain free movements. It has now been two years since I started using the Power Plate®. I feel stronger now than when I was 25, but more critically, I have not had a low back episode since being on the Power Plate®.

Benefits of Acceleration Training™ from Power Plate®

Power Plate® creates 25-50 vibrations per second, forcing the body’s kinetic chain to respond each and every time, requiring stabilization, coordination, strength and power. The vibrations enhance motor unit recruitment and synchronization, resulting in an increased force production and efficiency of movement. Individuals can produce up to 95 percent of their voluntary force potential while performing safe and possibly pain free movements.

Other Benefits:

• Multi-Planar Movements (X, Y And Z Planes)

• Decreased Pain

• Improved Stability And Mobility

• Improved Balance And Coordination

• Improved Recovery And Regeneration Of Damaged Tissue

• Increased Flexibility

• Improved Blood Circulation

In September of 2008, I presented case studies at the CBP® Annual Seminar using CBP® protocol and incorporating Acceleration Training™ for the functional component.

In Office Exercises:

Raising the Bar!

By assessing the posture and x-rays using Posture Print® and Posture Ray®, we have provided the patient the most detailed and comprehensive analysis of their spine and posture available to date.

Expecting your patient to do 100-150 reps of mirror image® exercises correctly in the office was a very challenging task. It was not just the number of reps; it was also the time factor.

Today, when patients come to the office, they perform their mirror image® exercises using one of six Power Plates®, and the number of repetitions performed for each exercise is in the thousands. Remember, 25-50 contractions per second, so in 30 seconds they have done over a 1000 reps.

Spinal stability exercises are added to the mirror image exercises in order for the spine to have greater stability. These exercises address three key muscles: 1) Transverse Abdominis; 2) Multifidus; and 3) Quadratus Lumborum (medial fibers).

Combining the Mirror image and spine stabilizing exercises using Acceleration Training™ from Power Plate® offers the patient the most advanced technology to rebuild their spine to a stronger, healthier, more stable position.

Power Plate® has revolutionized my life and changed my practice forever!!

Chiropractic Medicine, the Spine Specialist and Subluxation-Based Chiropractic—Our Way or the Highway!

While observing the politics of chiropractic as a current board member of both my state association and the International Chiropractors Association, several things become glaringly apparent. The old “mixer” versus “straight” infighting has evolved over the years. There are now really three different elements to our profession: 1) The Chiropractic Medicine (CM) group, 2) the chiropractor as “Spine Specialist” (SS) group, and 3) the Subluxation-Based (SB) Chiropractic Care group.

While the CM and SB groups desire a full access to patients with various conditions, the SS group desires to limit chiropractic to Spinal Manipul-ative Therapy (SMT) for low back pain (now even the “chronic” variety), neck pain and if we are lucky, a couple other pain conditions (see the CCGPP guidelines). The SS group outlined their aspirations a few years ago.1 This fringe SS group, composed of academicians, researchers and individuals involved with the insurance industry, stated, “Three specific characteristics of the profession are identified as impediments to the creation of a credible definition of chiropractic: Departures from accepted standards of professional ethics; reliance upon obsolete principles of chiropractic philosophy; and the promotion of chiropractors as primary care providers.”1 They blame the subluxation-based (SB) chiropractors and the “primary care provider” chiropractors (CM group) for all that is wrong with the profession and believe that if chiropractic is limited to musculoskeletal care only (with “proven” treatments) that we will assimilate into mainstream medicine. Only then would we become both viable as a profession and credible to their medical peers. This fringe group cannot be dealt with due to their complete intolerance with 90 percent of the profession and their desire for limited scope of practice.

The CM group and the SB group, while completely different in diagnostic and treatment scope of practice, desire to care for most sick and ill patients. Neither wants to be limited to musculoskeletal care only. Neither group is enamored with the resultant brain child of the SS group, the CCGPP guidelines. Both the ACA and the ICA have expressed their disappointment in that product. However, for some reason, the ACA still seems to provide shelter for this SS group under their umbrella.

The CM and SB groups are far from mutual agreement on just about any other topic. They really are the old “mixers” vs. “straights.” However, if there was mutual respect, then both groups could co-exist due to their desire for a common, broad patient base. As long as one group doesn’t try to impose its will on the other, forcing them to practice “our way or the highway,” this should be possible. This is demonstrated by the success of states with only one association.

However, as history demonstrates, this is easier said than done on the national level. In a recent article in the “Dynamic Chiropractic” discussing these three groups within our profession,2 Dr. James Winterstein, president of National University of Health Sciences, stated, “I see those who believe no one but the chiropractor can truly know how to ‘correct subluxation,’ so there is nothing to worry about as long as we can convince people to sign up for lifelong ‘chiropractic corrective adjustments.’ These people believe correcting the subluxation improves vitality and promotes ‘wellness’.” He continues that the SB chiropractors “depend on convincing a lot of people to buy into their version of ‘wellness.’ This is successful in many instances, but is unsupported by any legitimate evidence grounded in science.” I assume it’s “our way or the highway” with Dr. Winterstein.

Ironically, in the same issue of the Dynamic Chiropractic, Dr. Christopher Kent lays out both the scientific evidence for SB care and the general acceptance of the subluxation as a concept by the vast majority of the profession.3

The fact is that evidence exists for SB care while not discrediting the methods of the CM group and evidence exists for the methods of the CM group while not discrediting the SB group. One is not mutually exclusive to the other. Obviously, most chiropractors practice somewhere in the middle. Neither side is going away anytime soon, nor must they. However, “market share” drives selfish agendas.

And this is precisely the problem with the profession and why it always sounds like “our way or the highway” to the DC in the middle. In the meantime, less than 20 percent of practicing DC’s belong to the ACA and ICA combined and we may get run over by national healthcare as a result. However, in my opinion, we don’t need one unified national association. Yeah, I said it. No unity! We just need higher membership in both associations. One side is not going to ever trust the other to be fair, nor should they when there is such a lack of mutual respect.

The truth is that we have a unique check and balances system in our profession when it comes to our identity. Frankly, I am glad. If something detrimental to either the practice of the SB or CM groups is proposed (perhaps by a college president), instead of one side losing by one vote in committee, the group can petition legislators to end it. You can never trust someone who lacks mutual respect. However, we clearly need to overcome our differences in national legislative issues and work cooperatively, as so many states do. There is plenty of common ground upon which we stand.

Legislation can be crafted to be beneficial for Chiropractic, not only for Chiropractic Medicine or only for Subluxation-Based Chiropractic. This is demonstrated by the Chiropractic Summit meeting over the past couple years. Now we need to stop stabbing each other in the back and promoting our “our way or the highway”.

References:

1. Nelson CF, Lawrence DJ, Triano JJ, Bronfort G, Perle SM, Metz RD, Hegetschweiler K, LaBrot T. Chiropractic as spine care: a model for the profession. Chiropr Osteopat. 2005 Jul 6;13:9.

2. James Winterstein, DC . Our Shrinking Chiropractic Practice Box. Why it’s happening and what we can do about it. Dynamic Chiropractic. March 26, 2009, Vol. 27, Issue 07.

3. Christopher Kent, DC, Esq. Subluxation, Science and the Flat Earth Society. Dynamic Chiropractic. March 26, 2009, Vol. 27, Issue 07.

Structural Rehabilitation of the Thoracic Kyphosis: Part I: Average and Ideal Alignment Values and Models

The thoracic spine might be one of the most overlooked regions of human spine in health care practices. In my experience, there is a general lack of appreciation of both the need for radiographic views of the thoracic spine and the influence of the thoracic spine on whole body alignment and health potential. It is for these reasons that I offer this series of articles detailing the thoracic kyphosis to readership of the American Journal of Clinical Chiropractic. Also, this series of articles are pre-cursors to chapters in the new CBP® Structural Rehabilitation of the Thoracic Spine & Case Management textbook due out later this year.

Average Thoracic Kyphosis Angles

Prior to presenting normative alignment for the thoracic kyphosis, measurement methods must be developed and tested for reliability. Fortunately, for thoracic kyphosis, several groups including CBP® researchers have presented measurement methods and found these to have small standard errors of measurement and good to excellent intra- and inter-examiner reliability.1 Figure 1 shows the Harrison posterior tangent method for measurement of the thoracic kyphosis.

Several studies have reported “normal” values of thoracic kyphosis for people in a wide range of age groups.2-23 The density of the upper ribcage in the coronal plane in many people, causes an inability to accurately identify and measure the vertebral segments T1-T4. Thus, in the literature, various authors report different vertebral levels of kyphosis measurement. Table 1 provides an overview of different kyphosis measurement levels with their respective mean values from the literature. Taking two standard deviations from the reported mean values in Table 1 as a proposed type of statistical normal, a large range of values for thoracic kyphosis from 20° to 50° might be considered within normal limits.2-23

Problematically, some of this normal subject data is contaminated with subjects that should not be considered healthy. For example, Fon et al22 presented thoracic kyphosis measurement in 316 “normal subjects” aged 2-77 yrs. Their22 definition of normal was: “while the general status of some of these patients was not optimal, it was assumed that the patients were sufficiently fit to be ambulatory…” and if they could raise their arms above their shoulder!

In the past 6-7 years, CBP® researchers have proposed a more narrow distribution of thoracic kyphosis values as normal.2,17

For example, in Table 1, the reported values for Cobb T1-T12 and ratios of values from Cobb angles of T3-T11, T4-T11, T2-T12, T3-T12, T4-T12, and T5-T12, the mean thoracic kyphotic value would be between 40° and 50° for a Cobb angle from the superior endplate of T1 relative to the inferior endplate of T12.

Furthermore, Harrison et al24 identified that translated postures of the ribcage relative to the pelvis in the sagittal plane can have a strong influence on thoracic kyphosis. Specifically, a total change of 26° in thoracic kyphosis was found for maximum posterior translation to maximum anterior translation in normal subjects. See Figure 2. Regarding sagittal ribcage plane translation postures, biomechanical models have predicted large increases in extensor muscle loads and consequent increased compression and shear loads on the thoraco- lumbar spine discs.25,26 These high compressive and shear loads may produce pain and initiate or contribute to a degenerative remodeling response in the disc.

The issues associated with sagittal plane ribcage translation prompted Harrison et al17 to present thoracic kyphosis data from a group of 50 normal subjects whose sagittal translation was within one (1) standard deviation of the mean. This data is presented in Table 2.

Average and Ideal Thoracic Kyphosis Models

Looking at the data provided in Table 1 and more specifically two studies on thoracic kyphosis with large population groups, it is apparent that a near normal (bell shaped) distribution for thoracic kyphosis has been found.11,23 Statistically speaking then, there would be an average subject based ideal model for thoracic kyphosis at the top of the bell shaped curve (mean value).

Investigations have presented several types of thoracic kyphosis models in the literature.2,17,18-21,23 For example Harrison and colleagues2 presented average geometric models of the thoracic kyphosis (T1-T12, T2-T11, and T3-T10 segments were modelled) as a segment of an ellipse using pooled data from 80 normal subjects’ lateral thoracic radiographs. Figure 3 shows the average elliptical model of the segments T1-T12.

Harrison et al17 followed this paper with an optimized elliptical model of thoracic kyphosis based in part on data from 50 optimized normal subjects (sagittal translations within one (1) standard deviation from the mean). Since, the thoracic vertebral bodies increase in size considerably from T1 to T12, a uniformly increasing model was derived of disc and vertebral body sizes were derived from the anatomical literature. They found that the major axis of the ellipse (long axis of an oval) is parallel to the posterior body margin of T12, whereas the minor axis of the ellipse (short axis of the oval) passed through the superior endplate of T12. The minor axis to major axis ratio was computed to be 0.69.17 Figure 4 shows this optimized elliptical model in a template form that can be used for any height of a patient. Their17 modeling results were compared to mean values of 678 normal subjects and the data were found to compare closely with their proposed optimized elliptical model.

In the more recent literature, investigators have begun to develop individual subject optimized geometric sagittal plane curve models for thoracic kyphosis.18-21 There are certain anatomic variables that have been shown to have a striking influence on sagittal plane curvature. When these anatomic variables are outside of normal tolerances, a change in sagittal curvature can result. This information will be detailed in Part 2 of this series.

Summary

Using different types of kyphosis models as a normative starting positions of thoracic kyphosis, it becomes possible to characterize both normal thoracic kyphosis alignment and abnormal alignment. Chiropractic has a long history of identifying and trying to restore normal alignment to the spine; where abnormal alignment is specifically referred to as the mechanical component of vertebral subluxation. The key is to fully understand when the modelling and alignment data presented herein is useful in differentiating a subluxated thoracic spine from a normal spine and how to modify the data in specific patient situations.

Till next time.

References

1. 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.

2. 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.

3. Itoi E. Roentgenographic analysis of posture in spinal osteoporotics. Spine 1991;16(7):750-6.

4. Propst-Proctor SL, Bleck EE. Radiographic determination of lordosis and kyphosis in normal and scoliotic children. J Pediatr Orthop 1983;3:344---46.

5. Rajnics P, Pomero V, Templier A, Lavaste F, Illes T. Computer-assisted assessment of spinal sagittal plane radiographs. J Spinal Disord 2001; 14: 135-142.

6. Korovessis PG, Stamatakis MV, Baikousis AG. Segmental roentgenographic analysis of vertebral inclination on sagittal plane in asymptomatic versus chronic low back pain patients. J of Spinal Disorders 1999;12(2): 131-137.

7. Korovessis PG, Stamatakis MV, Baikousis AG. Reciprocal angulation of vertebral bodies in the sagittal plane in an asymptomatic Greek population. Spine 1998; 23: 700-705

8. Stagnara P, De Mauroy JC, Dran G, Fonon GP, Costanzo G, Dimnet J, Pasquet A. Reciprocal angulation of vertebral bodies in a sagittal plane: Approach to references for the evaluation of kyphosis and lordosis. Spine 7:335-342, 1982.

9. Bernhardt M, Bridwell, KH. Segmental analysis of the sagittal plane alignment of the normal thoracic and lumbar spines and thoracolumbar junction. Spine 1989; 14: 717-721.

10. Vedantam R, Lenke LG, Keeney JA, Bridwell KH. Comparison of standing sagittal spinal alignment in asymptomatic adolescents and adults. Spine 1998; 23(2):211-215.

11. Boseker EH, Moe JH, Winter RB, Koop SE. Determination of “normal” thoracic kyphosis: A Roentgenographic study of 121 “normal” children. J Pediat Orthop 2000; 20: 795---98.

12. Voutsinas SA, MacEwen GD. Sagittal profiles of the spine. Clin Orthop 1986; 210:235-42.

13. Jackson RP, McManus AC. Radiographic analysis of sagittal plane alignment and balance in standing volunteers and patients with low back pain matched for age, sex, and size. Spine 1994; 19: 1611-1618.

14. Jackson RP, Kanemura T, Kawakami N, Hales C. Lumbopelvic lordosis and pelvic balance on repeated standing lateral radiographs of adult volunteers and untreated patients with constant low back pain. Spine 2000; 25(5): 575-86.

15. Gelb DE, Lenke LG, Bridwell KH, Blanke K, McEnery KW. An analysis of sagittal spinal alignment in 100 asymptomatic middle and older age volunteers. Spine 1995; 20(12): 1351-8.

16. Kolessar DJ, Stollsteimer GT, Betz RR. The value of the measurement from T5to T12 as a screening tool in detecting abnormal kyphosis. J Spinal Disord 1996; 9(3):220-223.

17. 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;463-469.

18. Berthonnaud E, et al. Analysis of the sagittal balance of the spine and pelvis using shape and orientation parameters. J Spinal Disorders & Techniques 2005; 18(1):40-47.

19. Vaz G, Roussouly P, Berthonnaud E, Dimnet J. Sagittal morphology and equilibrium of pelvis and spine. Eur Spine J 2002; 11(1):80-87.

20. Vialle R, Levassor N, Rillardon L, Templier A, Skalli W, Guigui P. Radiographic analysis of the sagittal alignment and balance of the spine in asymptomatic subjects. J Bone Joint Surgery 2005;87Am:260-267.

21. Legaye J, Duval-Beaupere G, Hecquet J, et al. Pelvic incidence: a fundamental pelvic parameter for three-dimensional regulation of spinal sagittal curves. Eur Spine J 1998;7:99-103.

22. Fon GT, Pitt MJ, Thies AC Jr. Thoracic kyphosis: range in normal subjects. AJR 1980;134(5):979---83.

23. Beck A, Killus J. Normal posture of spine determined by mathematical and statistical methods. Aerospace Med 1973; 44(11):1277-81.

24. Harrison DE, et al. How Do Anterior/Posterior Translations of the Thoracic Cage Affect the Sagittal Lumbar Spine, Pelvic Tilt, and Thoracic Kyphosis? Eur Spine J 2002;11:287-293.

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Our Schools, Autism, and Vitamin D

On Sunday, July 13, 2008, the San Francisco Chronicle published an article titled:

State’s Schools Lack Cohesive Plan For Autism:Autism a “Public Health Crisis”

Using the Autism Society of America, the Autism Clinic of the University of California, San Francisco, and the California Department of Education as sources, this article shows disturbing statistical trends concerning autism, mental retardation, speech and language disability, and learning disabilities in the state of California. Specifically, between 2000 and 2007 autism incidences increased 229%, mental retardation increased 6%, and speech and language disability increased 7%. In 2007, the number of children with autism was officially recorded as 46,196; the number of children with mental retardation was 43,113; the number with speech and language disability was 176,265; and the number with learning disabilities was 297,933.

A major concern is not only the sheer number of cases and their statistical escalation, but also their public cost. As an example, the article notes that the average annual cost per pupil with autism is $36,000 per year. The cost for autism alone (in California) is about $1.7 billion in 2007. With the realization that cases of speech and language disabilities and learning disabilities dwarf the number of autism cases, the costs are staggering.

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In November 2008, researchers from Cornell University, Indiana University, Purdue University, and from the Children’s Hospital of Philadelphia, published a study in the journal Archives of Pediatric and Adolescent Medicine titled:

Autism Prevalence and Precipitation Rates in California, Oregon, and Washington Counties

The objective of their study was to investigate the possibility of an environmental trigger for autism. They note that 30 years ago, one (1) in 2500 children had autism; today the number is one (1) in 150 children. They found that “autism prevalence rates and counts among school-aged children were positively associated with a county’s mean annual precipitation.” In other words, bad weather is associated with increased autism rates.

The authors offer three possible explanations for their findings:

1) When the weather is bad, children stay indoors and watch more television and video. They state “television and video viewing by very young children has previously been associated with psychopathological characteristics in the pediatric literature, including problems concerning language development, cognitive development, and the development of later behaviors consistent with attention-deficit hyperactivity disorder.”

2) When children stay indoors, they have greater exposure to household chemical cleaners, or other types of chemical pollutants or pesticides.

3) When children stay indoors, there is a vitamin D deficiency. They state: