“All information, content, and material on this website is for informational purposes only and are not intended to serve as a substitute for the consultation, diagnosis, and/or medical treatment of a qualified physician or healthcare provider. As health and nutrition research continuously evolves, we do not guarantee the accuracy, completeness, or timeliness of any information presented on this website. This website pro­vides gen­eral infor­ma­tion and dis­cus­sion about chiropractic, health and related sub­jects. The words and other con­tent pro­vided herein, are not intended and should not be con­strued as med­ical advice. If the reader or any other per­son has a med­ical con­cern, he or she should con­sult with an appropriately-licensed physi­cian or other health care worker. The views expressed on this website have no rela­tion to those of any academic, hospital, practice or other insti­tu­tion with which the authors are affiliated.
INFORMATION INTENDED FOR USE BY INDUSTRY PROFESSIONALS Fetterman Events is geared toward providing information to industry professionals—NOT CONSUMERS—regarding the capabilities and ranges of chiropractic care. The information contained on this website is compiled from a variety of sources and is not considered complete. The information accessed through this website is provided “AS IS” and without any warranties, whether expressed or implied.

To the Fullest extent permitted by law, Fetterman Events DISCLAIMS ALL REPRESENTATIONS AND WARRANTIES, EXPRESSED OR IMPLIED, regarding any information or other material displayed on this website, whether authored by Fetterman Events or others; Fetterman Events disclaims any liability based on information provided in this website.”

APRIL CASES

Gender:  Female
Age of Patient:  
46

Special Considerations:   

Non-surgical treatment options for labral tear of the hip.

Answers:

Mobilize the hip joint to breakup any adhesions. Balance the femoral acetabular joint by correcting any ante version or retroversion by correcting SI and associated piriformis and gamelli contracture. This will correct ante version. Correct retroversion by correcting hyper pronation of feet.
- Jack Dolbin, DC, CSCS

Hip injuries, including labral tears are often excellent candidates for kinesio tape support and treatment.
You’ll first need to make sure the involved area to be taped is free of any gels, oils, creams or hair. Place the patient in a side posture position with the involved side up and with the hips and knees flexed. Using 2 or 4 10” strips of kinesio tape apply in an “X” or star pattern with the strips of tape intersecting over the hip joint. Use little to no stretch on the tape as it’s being applied and especially use no stretch at the ends of the tape. Avoid touching the adhesive portion of the tape. I would try just 2 strips of tape in the “X” pattern initially, then adding the 2 additional strips to form the “star” pattern if the additional support is indicated.
- Dale Morgan, DC, CCSP

My spine-only approach may have some bearing (pun intended) on the injured hip but I would refer the patient to a provider who directly treats this condition.
-John Hart, DC, MHSc

There is a lot of fascinating information out there on the pain-generating tissues in relation to the spine and the hip. For example, several doctors have proposed that pain does not always arise from the labral tear, but rather from the musculoskeletal changes created from the initial injury. In fact, a systematic review performed in 2015 found that in 2,114 asymptomatic hips, labral tear was present in 68% of these patients.

Therefore, I’d like to propose that a labral tear, or rather the symptoms arising from the labral tear, is much more manageable with conservative care. There are a few things to consider with the labral tear: can you reproduce the pain with any testing? can you pinpoint the pain-generating tissues? is the condition acute or chronic? With acute onset or acute exacerbations of the hip complaint, we may look toward nutritional support. This would include eliminating pro-inflammatory foods from the diet and utilizing supplements that will balance the inflammation (cinnamon, bromelain, CBD oils, curcumin/turmeric, etc.).

Commonly with injuries, patients will have a compensatory mechanism that will alter biomechanics, or altered biomechanics led to the injury. We would assess her sit-to-stand transition, perform a squat test, and possibly do other Janda assessments for the lumbopelvic hip complex. We would use our chiropractic therapies (passive and active) to improve any muscular imbalances and then send the patient home with a home exercise program to improve biomechanics and muscular imbalances. We would go over this entire program extensively in my Rehab seminar through Fetterman Events.
- Brandon Aucker, DC

Most of the literature states that labral tears of the hip do not tend to heal on their own and that surgical correction is usually necessary. However, there is some evidence that platelet-rich plasma, or stem cell injections may help. Further, the American Physical Therapy Association says that the following may alleviate or correct the problem:
1. Movement re-education. Your back and hip may be moving improperly, causing increased tension at the hip joint. Self-stretching techniques may be applied to the lower body to decrease tension and help restore normal motion in the back, hip, and leg. There are, however, certain hip motions to avoid following an injury to the hip labrum. Your physical therapist will carefully prescribe exercises that improve your range of motion, while protecting the area that has the labral tear;

2. Manual therapy. Your therapist may apply hands-on treatments to gently move your muscles and joints to decrease your pain and improve motion and strength. These techniques often address areas that are difficult to treat on your own.

3. Muscle strengthening. Muscular weaknesses or imbalances can be the cause or the result of hip pain. Based on your specific condition, your physical therapist will design a safe, individualized, progressive resistance program for you, likely including your core (midsection) and lower extremity. You may begin by performing strengthening exercises lying on a table, for example, lifting your leg up while lying in different positions. You then may advance to doing exercises in a standing position, for example, stepping on and off a raised platform. Your physical therapist will choose what exercises are right for you.

4. Functional training. Once your pain, strength, and motion improve, you will be able to safely transition back into more demanding activities. To minimize tension on the hip, it is important to teach your body safe, controlled movements. Based on your own unique movement assessment and goals, your physical therapist will create a series of activities to help you learn how to use and move your body correctly and safely. Your physical therapist will also discuss specific positions and activities that should be avoided or modified to protect your hip, and

5. Education. Your physical therapist will work with you to identify and change any external factors causing your pain, such as exercise selection, footwear, or the amount of exercises you complete. Your physical therapist will develop a personal exercise program to help you return to your desired activities.

Note that point #2 by the APTA is manual therapy. Their description avoids the actual terms “manipulation” or “adjusting” and they do not elaborate on how manual therapy might help and by what mechanism.

My own experience over 40 years of practicing both as a physical therapist and a chiropractor, much like the shoulder, a labral tear of the hip often “heals itself.” By that I mean that in patients who chose not to have surgery and chose either no treatment or conservative treatment (including adjustments) were bothered less and less as time went on and in some cases ceased to have symptoms completely. I would imagine that this would depend on the size and severity of the tear.

In my capacity as a physical therapist, I teach patients hip and pelvis strengthening and lengthening exercises (the goal is to improve the strength and the elasticity of the muscles controlling and influencing the hip - and elasticity is not the same as flexibility). The emphasis is on the hip extensors and abductors and no emphasis on the hip flexors and adductors as these muscles are usually strong (other than eccentric lengthening procedures of these muscles to increase their elasticity while maintaining strength). Static stretching procedures for the anterior hip flexors (iliopsoas and rectus femoris) may actually worsen the condition due to the “pull” exerted into the anterior ligaments of the hip joint that further tears the labrum.

In my capacity as a chiropractor I will examine the pelvis and back for subluxations (and this is based on subluxation as defined by Panjabi and others) and treat them in order to improve the function of the muscles that control the hip, pelvis, and back in order to maximize the internal environment to allow healing (which means reducing the stress and torque into the hip labrum). If I don’t see “appreciable” improvement withing 4 weeks, I will usually refer back to the orthopedist.
- James W. Gudgel, DC, PT, Senior Instructor, Neuromechanical Innovations

Gender:  Male
Age of Patient:  
29

Special Considerations:   

29 yom, 170 # 5' 6" (corpulent, but has been working on weight loss since beginning care in office with simple "clean" diet - no system food, and has lost 6#), initially came in for non-descript but alarming S/S for which he'd gone to the ER on 2 occasions (Lt arm numbness and facial tingling), only to be "cleared" medically on both occasions. Fearing he was dying, as he kept getting symptoms of arm tingling and facial numbness he sought care in the office and had improvement in Back Pain and BP (I put him on a careful CV routine, as his MDs could find nothing wrong and decided to put him on BP Rx as that was the only "finding" they could note at the time of his ER visits. He did improve his BP and soon weaned himself off the BP meds.) His S/S are manifold, and when his progress stalled, and then he reported bilateral symptomatology, I referred him to a neurologist, asking for an MRI of his upper T spine (as this was the region where much of his initial S/S seemed to be related to) but his major CURRENT complaint is M "pain" which he describes as "the Ms feel "EXTREMELY tired" after only minimal work. Eg, lifting a table is no problem, but when he has set the table down, the Ms in his arm/s feel like they "freeze" on him (his words). When showering, his calves get SO tired (from just standing) that they do not respond to his will, and his LEGS start to shake as "though they were exhausted." Then, after 5-6" this S/S will clear up. Obviously, this is affecting his (construction) work. He can hold a tool for a moment, but then his hand and arm are "exhausted" for several minutes afterwards. His S/S can and do "change sides" (of his body). Ortho-Neuro Clinic providers did MRI exams of his head and neck (and skipped the the requested T spine, alas) and found "nothing." At least one of his "providers" has now suggested it is "mental," which confounds the pt, as he can SEE his Ms spasm (eg on his antebrachium) at times.

Answers:

My initial impression of this case would be to rule out what I think of as a classic upper cervical chiropractic subluxation complex.  

As there is no mention of chiropractic x-rays, I would get standing cervical spine x-rays, especially the A-P open mouth and the utilize chiropractic line drawing analysis looking for any misalignments in the upper cervical spine.  I would also perform a chiropractic examination and analysis including static and motion palpation.  I would do a chiropractic prone and supine leg check.  If a short let presents itself, especially in the prone position, I would then have the patient turn their head one direction, then recheck leg length, then the opposite direction, and again recheck leg length.  Finally, I would perform a prone gluteal muscle test.  For this, I have the patient prone, bend one knee 90º, have them raise the knee then muscle test by pushing down on the patients posterior thigh while the patient resists.  Then perform the same test on the opposite glute.  If any of these test are positive,  this may be an indication of an upper cervical subluxation complex.  If so, I would then adjust the upper cervical - using the method of the doctors choice, although a forward motion prone drop toggle on palpatory findings in the upper cervical may be the preferred method.  I would then recheck any previous findings in leg length or gluteal weakness post treatment.
- Dale Morgan, DC, CCSP

I would continue to share the patient with the medical doctor. From the chiropractic standpoint, I might try different chiropractic techniques, using evidence-based assessments to monitor neurological progress (or lack thereof), particularly as it relates to autonomic function. Heart rate variability would be one such assessment. When there is a hint of progress, even though only a hint, I would tread lightly and not adjust. The other missing ingredient here may be time, for the patient to heal himself.
-John Hart, DC, MHSc

This clinically sounds like a patient that may have multiple sclerosis. Lesions would be most common in his brain and cervical cord but can occur anywhere in the spinal cord. These scan should also be done with contrast to look for active lesions.
- Alicia Yochum, RN, DC, DACBR, RMSK

This patient may be suffering the “T4 Syndrome” (aka, upper thoracic syndrome) which is described as a chronic stimulation of the sympathetic system producing symptoms such as bilateral arm tingling/numbness, tingling/numbness over the head, mental confusion, anxiety, increased blood pressure, stomach “heartburn” and indigestion, restlessness, sleeplessness, adrenal fatigue, and muscle “weakness.” Imaging of this area is usually negative.

A quick Google search revealed the following: What is T4 syndrome? T4 syndrome is a clinically rare pattern of symptoms that was originally described in 1986 textbook entries by both Maitland and McGuckin.1,2 T4 syndrome has been described as a collection of symptoms resulting from autonomic dysfunction of the upper thoracic spine.

The following article elaborates on the syndrome: Clinical Presentation, Quantitative Sensory Testing, and Therapy of 2 Patients with Fourth Thoracic Syndrome Gary A. Mellick, DOa,,Correspondence information about the author DO Gary A. MellickEmail the author DO Gary A. Mellick; Larry B. Mellick, MS, MDb

Objective
The aim of the study was to describe 2 representative cases of patients presenting to an osteopathic pain practice with signs and symptoms consistent with the fourth thoracic (T4) syndrome. In addition, this article reports the application of quantitative thermosensory testing and dynamometer strength testing to confirm associated sensory and motor strength changes. Nonmanipulative therapeutic interventions are reported for the first time.

Clinical Features
Two patients experienced paresthesias in all digits of the hands, glove-like numbness of the hands and forearm, weakness (unable to open jars), hand clumsiness, upper extremity coldness, fullness or tightness, deep aching pain, and other signs and symptoms consistent with T4 syndrome. The patients were evaluated using quantitative thermosensory testing and handgrip dynamometry before and after treatment.

Intervention and Outcome
Relief of bilateral arm pain, numbness, and paresthesias occurred after intramuscular injections of 1 to 2 mL of 0.5% bupivacaine at the fourth thoracic paraspinal level. Additional therapy for associated signs and symptoms was provided using an anticonvulsant (gabapentin).

Conclusion
The clinical presentation of the patients reported in this article provides a description and additional information regarding T4 syndrome.

The medical intervention was described above. The chiropractic intervention would include “proper” and “full” correction of the damaged mechanoreceptors of the connective tissues in the upper thoracic spine that are causing the “subluxation” that continually stimulates the sympathetic nervous system. The April issue of the American Chiropractor contains an article by Studin and Owens that describes the “subluxation” complex as proposed by Panjabi.
- James Gudgel, DC, Instructor for Neuromechanical Innovations


MARCH CASES

Gender:  Male
Age of Patient:  
40

Special Considerations:   Patient presents with severe back spasms. Upon examination the patient's primary complaint is caused by a strained QL. Electrical stimlulation and adjustments were administered to the symptomatic areas. Patient responded well to first visit, but upon subsequent visits only finds temporary relief from care (several hours).

The pain usually gets worse as the day goes on. Patient's job consists of lifting and twisting. Has difficulty getting in and out of his vehicle, and when standing from a seated position has difficulty standing up straight. Massage therapy was recommended, and while I would like to recommend rehabilitative exercises, the patient's back is too painful for the patient to maneuver at this point.

I guess I am looking for ways to treat the QL that leads to symptomatic relief and, once out of the acute phase of treatment, what can be done to rehabilitate the patient and help them gain independence from care.

Answers:

It’s called Maignes Syndrome. Usually is accompanied by a trigger point lateral to L1 which refers along the Superior Cluneal Nerve. I use Nimmo technique but in a counter strain position . Also, check the talus.
- Jack Dolbin, DC, CSCS

I would obtain standing postural x-rays of the lumbar spine and pelvis and do a complete chiropractic x-ray analysis looking for any misalignments of the lumbar spine and/or pelvis that may be an underlying contributing factor to the patients complaints. Especially in light of the patient’s job involving much lifting and twisting a rotational misalignment of the pelvis seems a potential possibility, even likely. A flexible lumbar back support may be beneficial. Gait

Personally, I would follow Gonstead of Thompson protocols for correction of any pelvic or lumbar structural issues revealed by the films. Next step I would incorporate would be to utilize Kinesio tape to support the injured / involved area which will also help support the chiropractic correction.
- Dale Morgan, DC, CCSP

What struck me in this case was that the patient responded well after the first treatment but not as well after subsequent treatments. I have occasionally noticed this in some of my patients and makes me wonder if I’m providing my intervention too often. So maybe a little more time between visits might be part of the answer here.
-John Hart, DC, MHSc

The examiner in this case concluded that the patient suffered a “strained QL” muscle and was having “severe back spasms”. Nothing was said about any specific spinal subluxations other than “adjustments were administered to the symptomatic areas.” Were the “adjustments” administered to the QL muscle (yes, a muscle can be “adjusted” and this requires understanding what an “adjustment” is and how it works), to the spine (and if so, what segments), or to both? It was also mentioned that electrical stimulation was administered. For what purpose? If the muscle is truly “strained” then why make it contract when in fact it needs rest (hence the fact that the patient “usually gets worse as the day goes on” because the QL muscle is being forced to work during the patient’s lifting and twisting activities). Or is the problem primarily a spinal “subluxation” (and “subluxation” must be defined) that is causing the QL to be inhibited (short, tight, tender, and resistance to stretch) due to damage to the mechanoreceptors in the connective tissue surrounding the “subluxated” spinal segment(s)? And finally, research says that true muscle spasm is infrequent and short-lived, and most often the muscle is in a state of inhibition (both cause the muscle to become short, tight, tender, and resistance to stretch, and an EMG is necessary to differentiate the two).

First let’s address the possibility that this was solely a muscle strain. There are many and varied suggestions and recommendations for healing of a “pulled” muscle. In the case of a mild strain (1st degree) the most common recommendations is rest and that it will heal in a few days. Rest means a cessation of activities that make the muscle have to work more than “lightly.” Moderate strains (2nd degree) may take up to four to six weeks to heal and also require rest and icing, but may require support and light massage. Severe muscle strains (3rd degree) are rare but serious and may require surgery. Complete muscle ruptures are serious, require support, longer rest, and again may require surgery. But the incidence of a complete rupture of the QL muscle is very low.

Most “authorities” say that therapeutic massage helps loosen tight muscles and increases blood flow to help heal damaged tissues and can help relieve pain and improve range of motion. I agree with this because massage is a form of “mechanical stimulation” that stimulates the mechanoreceptors (Merkel’s disks and Meissner’s corpuscles in the skin) which in turn has a “relaxing” effect on the muscles controlled by those mechanoreceptors. But there is conflicting information on stretching. The main consensus now is don’t stretch. While it may seem counterintuitive, stretching a strained muscle only makes it worse (passive stretching stimulates the mechanoreceptors in the muscle fibers known as the muscle spindle and this in turn “excites” the muscle). Light stretching can assist with a minor strain, but only if incorporated a few days after the injury occurred.

So regarding this patient, if the patient just has a QL strain, it should heal with time, rest, heat, and light massage unless it is a severe strain or rupture. An MRI or CT scan would rule this out.
As previously stated, stretching is not recommended for any muscle strain. The research now has shown that as the muscle repairs itself, measures should be taken to ensure that the muscle heals with proper “elasticity” (not the same as “flexibility”) and normal strength to lessen the chances of a future strain. This is best accomplished through “eccentric” exercises. This type of exercising re-sets the damaged muscle spindle within the strained fibers so that no part of the muscle remains in a shortened and tight position (“inhibited”).

Cuthbert, Dynamic Chiropractic, May 6, 2009, said, “The body’s reaction to injury and pain is not increased muscular tension and stiffness. Instead, muscle inhibition if often more significant.” Mills & Edwards, Journal of Neurol Sci, 1983 Jan; 58(1):73-8, said, “Pain does not cause muscles to become tonically hyperactive. And, Panjabi M., A hypothesis of chronic back pain: ligament subfailure injuries lead to muscle control dysfunction. Eur Spine J, 2005 Jul 27, said, “The ability to contract them forcefully is reduced by pain, rather than increased.” And Muscles respond to pain, inflammation, and/or injury with weakness.” Therefore based on the statements of these esteemed researchers, reducing or removing the inhibition from the muscles must be performed. That then leads to the question, “What caused the muscle to become inhibited in the first place?”



Neurology teaches us that mechanoreceptors located in the muscle (Muscle Spindles), the tendons of the muscles (Golgi Tendon Organs), and in the connective tissue (primarily ligaments) of the associated vertebral and extremity joint levels (Ruffini and Pancinian – among others) initiate and control muscle function of the associated muscles. In this case, the lumbar and sacroiliac joint mechanoreceptors control the activity of the QL muscle. Damage to these mechanoreceptors causes a “disturbance” in the neural control of muscles.



So that then leads us to define what a subluxation is: is it a bone out of place? Or is it a “functional” lesion that may or may not be associated with vertebral malposition or malalignment? Panjabi has proposed the best and most scientific explanation of a subluxation:

“Joint dysfunction with disturbed kinematics, due to loss of spatial and temporal integrity due to disruption of muscles’ received receptor signals, producing corrupted motor programs.” And, it is “the result of trauma (failure) or cumulative microtrauma that cause subfailure injury in the passive restraints including ligaments, joint capsules, and discs, resulting in damage to the mechanoreceptors within these tissues” (“A hypothesis of chronic back pain; ligament subfailure injuries lead to muscle control dysfunction,” Panjabi, European Spine Journal, 2006:15 ).

Therefore the lumbar and SI joints should be examined for subluxations that have caused mechanoreceptor damage leading to disruption of the signal to the supporting muscles with disturbed kinematics. Until the damaged mechanoreceptors (and the corrupted motor pattern) are treated the QL muscle will continue to remain inhibited (short, tight, tender, resistant to stretch, and weak). An “adjustment” is the act of putting the vertebral or extremity segment(s) into motion for the purpose of stimulating and correcting the damaged mechanoreceptors and restoring normal motor patterns. Only then will the QL “relax” and return to its correct function.



So in conclusion, the lumbar spine and SI joint should be analyzed and “adjusted” accordingly, followed by analyzing the state of the QL muscles and “adjusting” it accordingly (and how does one know that the mechanoreceptors have been stimulated sufficiently and the corrupted motor program has been corrected?). Then the patient should not be allowed to move into lumbar flexion or rotation, and perform repetitive lifting for a few days. Ancillary therapy such as massage and heat are acceptable but may not add any extra benefit.
- James W. Gudgel, DC, PT, Senior Instructor, Neuromechanical Innovations

Answers from other Chiropractors:
Examine and clear out that CERVICAL SPINE and especially OCCIPUT, ATLAS and AXIS and CLEAR IT OUT. More than likely brain stem interference interfering with recovery at the other end. D.C. from PCC 1961. Chiropractic STILL works...
- Dr. D. Hughes, Ohio

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
——————————————-
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