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MARCH CASES

Gender:   Female
Age of Patient:   
38
Special Considerations:

I have a patient who had an acoustic neuroma (vestibular schwannoma) removed from the right side of her brain approximately a year ago. She has complete hearing loss on the right side as a result of her surgery. Most of her pre- and post-op symptoms have gone away, but she still has tinnitus in her right ear. Adjustments haven't been helping with the tinnitus so I was wondering if there is anything that you can recommend (specific techniques, supplements, etc.) to help decrease the tinnitus. Thank you!

Answers:

I would strongly consider acupuncture for this patient.
- Paul Jaskoviak, BS, DC, Dipl. Med. Ac., FIMA, DCRC, DACAN, CCSP, FICC

Given the reciprocal innervation with the sphenoid, I’d try the cranial adjustment first. There is also a relationship with the eustacion tube and tinnitus, and intraoral technique I learned to open the tube may help. Warm saline gargle to follow.

As a note...very strong evidence of a relationship between cell phone use and acoustic neuroma.
- Jack Dolbin, DC, CSCS

There are no imaging recommendations for this case .
- Alicia M. Yochum RN, DC, DACBR, RMSK

My approach would be the same for this patient as for my other patients: I would check her spine for subluxation and if safe to do so, adjust as indicated per exam. Adjusting the subluxation is intended to promote self-healing in the patient. It’s not a cure-all but still an important piece of the health care “pie.” Adjusting the subluxation may or may not help the tinnitus. If my adjustments are different than yours it may be worth a try. I am not familiar with treatments for tinnitus. Consequently,for a specific treatment, I would defer to a clinician who treats tinnitus.
-John Hart, DC, MHSc

Gender:   
Age of Patient:   

Special Considerations:  PROTOCOL HANDLING A ACUTE EXACERBATION OF A CHRONIC CONDITION
 
Doctors could you give us your protocol for handling acute exacerbations of a chronic condition, for example a chronic condition that becomes aggravated above the normal degree, due to an injury or aggravation (event)? Chiropractic adjustments will return the patient back to a normal functional level, and without the CMT will get worse . I realize there will become a point when the care will become supportive and no longer active by Medicare, what criteria do you best determine when it becomes supportive care, for example what documentation do you use?. ….Especially in a Medicare setting ...….thank you

Answers:

Exacerbations are covered by Medicare until they become maintenance in nature. An acute exacerbation is very easy. The history should reflect the patient having an identifiable event that is recorded. This could be a slip, fall, twist, etc. Record the exact event, the approximate time (Afternoon, morning, and the symptoms following. Remember, you have to identifiy the PART (Pain, Assymetry, Restriction, Tone) that is appropriate. One has to be asymmetry or Restriction to be acceptable. Additionally, you have to identify exactly what was treated by segment (C2, C3, C4).
Example (Mrs jones slipped on the stairway jolting her neck. This caused pain into the neck and caused her condition to worsen since the last visit. Part exam identified C3,4,5 point tenderness and assymetry on the right) I treated C3,C4,C5 PR. She responded well to care. The treatment was effective in treating this patient. I will follow up in 2-3 days.
Brad Hayes, DC

The difference between acute and maintenance or chronic care from a Medicare standpoint is as varied as the people who will be reviewing each case. If you have 10 different people review the same case, you will probably come up with 10 different opinions about the documentation, the demonstrated need for care and or the right supporting documentation to support that care.
The bottom line is that the treating doctor is the only one who actually gets to see the patient in person and is the only one who realistically has the best chance to determine the actual need for care based on the subjective and objective findings that become available. If you fail to document these findings properly, even if the patient winds up in surgery or in the hospital for acute care management, they will not pay you for your work and your care levels can and probably will be questioned.
I follow these simple rules when dealing with Medicare.
1. Is this a new condition or have they presented with this before?
2. Is the condition the patient presents with affecting their ability to complete their normal ADL’s?
3. How is this presentation different than previous episodes or care plans for this same condition in the past?
4. What new procedures, techniques or additional treatment measures will be needed to bring this patient back to their pre-flare up condition?
5. What are my expectations for their chances for recovery and what is the new time frame associated with that modified or new care plan?
6. If the care plan does or doesn’t give us the expected outcomes, what are my plans for referrals or dismissal back to a pre-flare up status?
7 Establish a time frame for an update exam to document any need for continued care, or the opportunity to release them back to their pre-flare up condition.
8. Stick to the plan, document any variations that may occur in patient compliance, weather, scheduling, holidays or anything else that may have an effect on your expected outcomes.
9. Document the release them when the care plan is completed.

Like any note, there can and will be circumstances that will need to be added based on each unique situation, but you don’t need to spell all these items out in different categories. You can combine many of these into single sentences, that create the presentation, the need, the length and the response to care as you go along.

Just imagine an 8th grader reading your notes and make sure they can understand what you are doing, why you are doing it and how long you expect it to take and you will usually come out on the right side of any review.
Rob Jackson, DC

In response to wanting to know my protocol for handling exacerbations of chronic conditions, I assume you mean the treatment protocol and not the documentation protocol.
The treatment protocol is to ascertain from the patient what happened to cause the exacerbation, what they have done on their own to alleviate it, and who else they may have seen before coming to me. After that I do the necessary exam procedures to determine if the patient has suffered an injury that might need medical attention or x-rays. If none is indicated, I perform the Impulse Procedure Analysis (taught at the Neuromechanical Impulse Adjusting seminar) to determine the medicare required P.A.R.T. I locate the subuxation(s) and treat it/them with the Impulse iQ instrument, which is safe to use even in acute situations as there is no twisting, cracking, popping, or high forces applied to any area. The stimulation (adjustment) from the instrument “re-sets” the damaged mechanoreceptors (from the injury) which in turn corrects the corrupted motor programs and restores the muscles to their correction function of moving, protecting, and stabilizing the injured segment (Panjabi) so that it can return to pre-injury status.
Dr. J. W. Gudgel, DC, PT

My documentation of the exacerbation would be the same for a Medicare patient, eg, nature of the exacerbation, whether symptoms are constant or intermittent, etc. If I thought the patient needed other types of care, I would make the referral.
John Hart, DC,


FEBRUARY CASES

February 18, 2019

Gender:  Female
Age of Patient:  10
 
She is a 10 year old girl. Cerebral palsy. Zero cervical tone. Still cannot lift or actively turn her head and relies on being in a stroller at all times and utilizes cervical collar when upright. No capacity to stand and not ambulatory. Left hip is "out of socket" as it has never even developed and acetabulum is too shallow.

 She is non verbal and actually spent whole initial visit eyes closed and would not communicate in any manner. Lying her on her stomach really upset her. She was ok on side and back. Babinski and palmar reflexes retained, but not tonic.

 Child has had several years of PT, but was just released due to "lack of progress". Only recommendations by PT was for parents to place her on stomach and continue to straighten legs out. Other previous treatment of botox in the bottoms of feet due to the hyper flaring, now toes curl too much and she had breathing issues associated with those injections. Being released from PT with no future recommendations to help her child has the mother a bit distraught and so she ended up here based on recommendation from the special ed teacher. She will of course continue to be monitored by her medical doctor and other specialists as well.

Answers:

 Tough case. I would think some upper cervical work might be of some help. Perhaps the use of laser therapy might also help. I wouldn't give the parents too high an expectation. My heart aches for this lovely 10 year old and her parents. I also have a disabled daughter. As a parent it is devastating.
Terry Yochum, DC, DACBR

 Regarding the case of a 10 year old girl with Cerebral Palsy. The first thing that comes to mind is birth trauma to the upper cervical spine. I would try to obtain a complete history of the birth process and method, first signs and diagnosis of cerebral palsy, when treatment was first initiated and results of previous treatment.

A complete chiropractic analysis is in order including spinal x-rays, especially on the upper cervical spine. There is much positive research and anecdotal findings regarding chiropractic SMT for cerebral palsy. Much of the research and articles indicates upper cervical, especially the occipital / atlantal subluxation as being the most common finding.

Googling "chiropractic and cerebral palsy" shows a number of positive articles which can help the mother better understand our chiropractic approach.

You will definitely want to discuss and have signed "informed consent" regarding treatment of the child. No guarantee of promises of successful treatment.
Dale Morgan, DC

 There is some evidence that chiropractic care in general can be helpful for Cerebal Palsy. https://www.cerebralpalsyguidance.com/cerebral-palsy/treatment/chiropractic-care/

The evidence presented is not specific to technique, but chiropractic care in general. Generally, I would recommend following standard chiropractic guidelines. 3 visits per week for 6 visits and re-evaluate. If the patient is progressing that is great. If not, change approach to care (technique). Follow standards of reducing frequency as the child progresses.

We have a clinic in Oklahoma City called Oklahaven that has a lot of experiance in that area.
Brad Hayes, DC

 

The patient is under medical care for the cerebral palsy condition.

From the chiropractic standpoint, I would examine the patient’s spine to see if there were any chiropractic problems (e.g., chiropractic subluxation). If areas were found that needed chiropractic adjustment, then gentle spinal adjustment would be recommended for the offending segment(s).

The exam and adjustment would be modified as needed, depending on the positions the patient would be able to tolerate.
John Hart, DC


JANUARY CASES
January 21, 2019

January 7, 2019

Gender: Male Age of Patient: 65

Special Considerations: Compression fractures, T12 and L2

 Your Case or Question: 65 year old female initially consulted for back pain due to compression of T12. I use an instrument, and worked above and below, and she tolerated it well. However, upon resuming weight bearing the pain was severe. This was the first treatment. She opted not to continue care on account of this, and also had abdominal surgery shortly after. Subsequently she developed a compression of L2. She returned for chiropractic care while waiting for evaluation of the spinal surgeon. She never was "cemented" for the collapsed vertebrae. So far treatments are going well and she is gaining some function (endurance for house chores, general mobility). At this point we are wondering if spinal consultation is necessary, and if it is too late to reinforce the compressions. Also, any advice on bone strengthening will be appreciated, I heard diathermy can help circulation.

Answers:

This patient should be monitored with DEXA scans to evaluate for bone density. Being weight bearing is one of the best things for increasing bone density so helping the patient get active is best. Spinal consultation should be obtained if the patient has any progressive neurological complaints that suggest significant neurological impingement. Vertebroplasty at this point would not likely a good option because if has most likely been to long. It should be done very shortly after the fracture before significant healing has occurred.
Alicia Yochum, DC, DACBR
Terry Yochum, DC, DACBR

I would definitely consider sharing responsibility in this case with a spinal surgeon. This can be a challenging situation from a risk management perspective. Informed consent to treatment needs to be discussed and proper forms signed. There is certainly concern regarding bone density and health especially with the development of the second compression at L2.
If it hasn’t been done recently, it might be a good idea to have a complete blood workup and review of prescriptions the patient is taking to determine if there are more serious underlying factors, complications or side effects of prescriptions contributing to the condition.

As far as treatment protocol, Unless there is a contra-indication due to a skin condition, I would suggest some postural taping of the involved area using kinesio tape. 10 inches of tape applied to the paraspinal musculature bilaterally from mid thoracic to lower lumbar area. Very little stretch to the tape as it’s being applied. Be sure the skin is free from any gels, lotions or oils. A postural brace is also an option, but I would prefer using the kinesio tape as it supports the area without restricting movement and can help with lymphatic drainage and capillary circulation.
Dale Morgan, DC

Here is my reply, short and sweet:
The instrument adjusting above and below the compression is reasonable. Beyond that, I would have a medical doctor manage the compression fractures.
John Hart, DC

I would assume a dexa scan was done, it appears she is suffering from compression fractures secondary to osteoporosis. My treatment for this condition would include a low back support brace, interferential for pain management, tens unit for home use. Studies do show that bone density can be increased with weight bearing exercises if tolerated, Wolfe’s Law. I’d encourage walking each day as tolerated, 30 minutes to increase as able. Calcium 1000mg/ day, Vit. D3 5000 iu. Eliminate diuretics ie: coffee, soft drinks. Curcumin for inflammation. Limit manual therapy to soft tissue techniques ie: Nimmo to paraspinal muscles and glutes.
Jack Dolbin, DC

Gender: Male Age of Patient: 70

Special Considerations: Spinal stenosis of thoracic and lumbar spine

 Your Case or Question: I have a Medicare patient who has spinal stenosis in the thoracic and lumbar spine, I have worked with him for years he has a stimulator implanted in the lower back and into the thoracic spine. It helps some but he also has severe balance problems and still has a huge amount of pain in the thoracic and lumbar spine. He comes in weekly, I try to get him to go longer between visits but when he does his symptoms increase and he will become immobile without coming in every week to 9 days. I am a walk-in clinic and file this with Medicare but am afraid of having issues with Medicare if the visits remain too frequent. I believe this is not maintenance care, he cannot function he says without CMT, he gets injections in the low back through pain management on a regular basis.

Answers:

This type of problem is much more frequent in doctor’s offices then you might think.
The stenosis means that treating this patient is like treating a diabetic. You will never “cure’ him of this, but it needs to be managed on a regular basis to keep him as functional as possible.

He should consider spinal decompression for his lumbar spine and then realize that he is treating the patient for “chronic management” of his condition, even though he is still symptomatic and reduce his billing code to a 98940. Have the patient sign an ABN form telling him that he doesn’t expect Medicare to pay for his services and collect from the patient with cash for the reduced Medicare rate for the services he is providing.

There is no happy ending for patients with issues like this where Medicare only wants to pay for acute care and not for any type of maintenance of any long term problem like stenosis. It’s not fair, it’s just how the system works for these people.

He should get some benefit from spinal decompression that can reduce his need and frequency of care, but Medicare won’t pay for decompression either, so he will have to pay for that with cash too.

This is so great we should get Medicare for everyone as a political stunt, while actually not giving them much of any benefit at all!! :-( Sorry.
Dr. Rob Jackson
——————————
The bad news is, this is Maintenance care based on the Medicare Definition. According to Medicare, Maintenance Care is defined as: Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3A)

Unfortunately, this becomes the responsibility of the patient. If there is a true exacerbation, then it is the responsibility of Medicare. Chiropractors have been hammered over this by the OIG, and because of that the carriers. At this point, there is nothing that can be done about it. Most people would consider the care necessary, and chiropractors by there nature want to help these patients, but, based on the law, it is not covered.
Brad Hayes D.C..
Former member of the Medicare Advisory Committee for Trailblazer Health and Novitas.
——————————————-
Since the doctor mentioned that CMT provides good results, it seems to me the concern is more about whether insurance will pay - for maintenance care versus no maintenance care. I would ignore the concern about insurance and provide the patient what the doctor thinks he needs rather than what the insurance thinks he needs. This may mean that the patient will have to pay out of his own pocket. If the patient is unable to pay out of pocket, then the doctor may have to treat the patient at a reduced fee.

John Hart, DC, MHSc
——————————————-
This is in response and regarding the case in which a 70 year old male patient is suffering from spinal stenosis in the thoracic and lumbar spine. Since he has responded favorably to the doctors chiropractic treatments the challenge is to find a way to enhance the affects of the adjustments and hopefully help to increase the structural integrity and stability and perhaps increase the lasting affects of each individual adjustment.

The first thing that comes to mind would be to try taping the involved areas with kinesio tape. Applications of kinesio tape can aid in capillary circulation and lymphatic drainage. Taping can also aid proprioception and enhance the biomechanics of the involved area. Also importantly, there is almost no contra-indications to applications of kinesio tape. The tape may well help the patient’s condition, with little to no risk of complications.

I would suggest a gentle application of kinesio tape to both the thoracic and lumbar paravertebral musculature. I’ve attached a few pictures of taping methods I might suggest. There is a certain art and method to properly applying the kinesio tape. The patients skin must be clean and free of any sweat, gels, lotions or oils. Any body hair in the area to be taped must be removed. I use an inexpensive beard trimmer for this purpose. T apply - the tape backing should first be torn and and a portion peeled back. You must avoid touching the adhesive portion of the tape - hold it by the backing paper as you apply the tape. Place the uncovered portion of the tape on the target area, then peel back the tape backing as you apply the tape to the involved area. In this case, I would suggest little to no stretch to the tape as it’s being applied, with no stretch (ever) at the ends of the tape. Note that the ends of the tape should be rounded (with scissors) to prevent peeling and compromise of adhesion of the tape.

Although rare, there are certain contraindications. Open sores should be avoided. Although the tape is hypo-allergenic, some people can develop mild skin conditions, such as redness, rash or itching. In those cases, remove the tape. The KT brand of Kinesio tape (my personal favorite), has several different levels of tape available. I would suggest either the basic cotton or the Pro Synthetic tape. The tape can remain in place for several days.
Dale Morgan, DC, CCSP
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It sounds like the MC patient does well with passive therapies, but does not perform any active therapies at home to help out from the limited information supplied above. I use analogies with patients to describe how and why you should be performing this “self help” therapy at home to help them understand why they’re doing it. Self help could include anything from a daily/twice-daily exercise program to promote mobility of the joints and flexibility of the muscles. Some great exercises my patients love include cat/cow yoga pose where you’re gently flexing and extending through the spine or other gentle ROM exercises. If the patient is comfortable using mobility products like a foam roller, I think he would see some great improvement. With this, I am primarily talking about the thoracic spine as you don’t want the patient to put pressure on the spinal stimulator. This can be too aggressive for some MC patients so that’s why I focus more with exercises. The more proactive they can be with their health, the more relief they will have between visits.
Explain to the patient that the more they are proactive/active, the easier it will become to stay active. One simple thing that a toddler can see between someone that is alive vs. someone is dead is the lack of movement. We see those adults that come into retirement age very quickly. I believe a lot of this is because of adapting to a sedentary lifestyle. Promoting self sufficiency will be the best way to prevent the patient from using you as a crutch.
Brandon Aucker, DC