Like many chiropractors, you may be looking for ways to better serve your patients.
If so, it makes sense to explore alternative treatment modalities, ranging from traditional types of physical therapy, to wrapping, to the latest equipment involving percussion, light, and lasers.
All of these require an investment on your part—starting with the time and money to get the appropriate training—but all of them can pay off with successful health outcomes for your patients. This, of course, helps with both patient retention and patient recruitment.
Dana Mackison, DC, director of education at Performance Health, says that adjunct treatments are important in supporting chiropractic. Look at the evidence of how the modality you’re interested in works, he says. “We’ve moved beyond just adjusting the spine. Don’t say, ‘That’s not chiropractic,’ say ‘If I do this, I’ll get a better outcome.’”
Regardless of the specific modality selected, practitioners who take this approach start with what the patient needs. Ask the patient, “What outcome do you want to accomplish?” Mackison continues:
“For an older patient, it might be to be able to pick up their grandkid. A 25-year-old might want to complete a marathon, but be having problems with their knee; another patient might want to take yoga, but be experiencing back issues. So always start by asking the patient what they want to achieve.”
This question makes the patient an active participant in his or her care: “You’re basically saying, ‘Let’s work together to get a good outcome,’” Mackison says. “This approach—which is now being taught in chiropractic training—leads to better results overall.” Those improved results can be achieved through a variety of approaches.
Let’s get physical
Mackison’s primary focus is on traditional physical therapy and rehabilitation tools such as bands and balls. Over the last 20 or 30 years, Mackison says, chiropractors have changed the way they look at rehab. “There was a stigma against it,” he says, but “Today we have come to call it active care. Craig Liebenson, who’s the guru of rehab in our profession, was the one who really started emphasizing it, encouraging people to implement the tactics of PT [physical therapy] and physical medicine.”
Practitioners who operate under this philosophy make functional movement—looking at the whole person’s patterns of movement—the starting point for analysis and diagnosis. They also “make the patient an active participant in their treatment—there has to be an engagement,” Mackison says.
“You have to think about the fact that in-office care also has to be directed to at-home care.” Toward that end, many active-care- oriented practitioners offer in-home equipment for purchase.
“Most of these items aren’t reimbursed by insurance, so I emphasize the 3 Cs,” he says. The first C is for convenience: the patient can buy the equipment right after learning how to use it. The second C is for confidence in the quality of the equipment. “They could go to the dollar store and buy a similar ball, but that ball could break and injure them.” The third C is for compliance: the patient is more likely to follow through at home. This can affect insurance reimbursement, which is often based on full compliance with the treatment plan, including any in-home component.
“There are billing codes for doing rehab in the office, if that rehab is well documented,” Mackison says. That documentation includes the patient doing certain exercises at home, and a code for checking the results of that in the office.
“You’re just leaving money on the table if you’re not doing this right,” he says.
Let’s go to the kinesiology tape
Many chiropractors tape patients to provide stability and support to joints and muscles, and to relieve pain. Kinesiology tape is a particular kind of adhesive tape that, according to manufacturers, facilitates lymphatic drainage by microscopically lifting the skin, which forms convolutions in the skin, thus increasing interstitial space and allowing for a decrease in inflammation of the affected areas.
That’s why Michael Pridham, DC-APC, NRCME, CKTI, says he uses kinesiology tape with 50 to 75 percent of his patients for issues including pain management, wellness, and sports injuries. “It’s not invasive,” he says, “and people are not nervous about it.”
Richard S. Cheung, DC, ATC, treats athletes and weekend warriors for shoulder and knee sprains, strains, and pains. “After I do tissue work,” he says, “I apply appropriate taping, which seems to make the benefits last longer.” He tapes about 25 to 35 percent of his patients, and sees benefits in both the quality and quantity of patients’ range of motion, especially in the shoulder.
And while Christina M. Lujan, DC, AT, CKTI, works primarily with pediatric patients, she also likes the gentler approach afforded by kinesiology tape, which she uses with about 90 percent of her patients. “I don’t necessarily go to chiropractic right away; I prefer to start with the gentlest techniques,” she says. “I use taping to gain the patient’s trust, which is key.” Over time, as her patients’ trust increases, she can ease them into chiropractic care.
Lujan has patients with musculoskeletal issues, such as scoliosis; taping, she says, helps a child to align naturally. She also treats patients with neurological issues, such as cerebral palsy: “You can calm down the nervous system” with taping, she says. She’s also had success treating colicky babies with tape. She emphasizes that it’s crucial that you know the population. “Pediatric patients are completely different—it’s all developmental,” she says.
All three of these practitioners emphasize the importance of the training they received (and now provide for others) through the continuing education programs in kinesiology taping. Look online for seminars and workshops, as well as self-paced study. “You have to know what you’re doing,”
Cheung says. “As an expert, though, patients refer their friends and relatives to me. I have better patient retention and more referrals because of my success with taping.”
A bang-up job
A number of companies have developed percussive instruments that operate at high frequency to achieve therapeutic results. “Devices that oscillate at 100 to 200 times per second elicit the tonic vibration reflex, or TVR,” says Jeff Maier, an expert who works in this area. “The vibrations target scar tissue with resonance. Like an opera singer can shatter a wineglass, the scar tissue being targeted sympathetically resonates, and when it vibrates, it breaks up and disappears.”
These devices can be used to treat athletes for muscle spasms and cramps, or after injuries. The Olympic ski and snowboard teams used them to treat injuries in 2014, Maier says, and they will be used by several teams in Rio this summer—he expects to see great results. It can also be used for smaller- scale conditions such as TMJ, edema, and headaches. The therapy is both easier on the patient (it doesn’t hurt) and easier on the practitioner, who doesn’t experience as much stress on the hands.
Because this modality is so safe and effective, an assistant can be trained to use it, freeing up the doctor’s time. “We provide training videos on our website, most of them looking at specific issues, and provide webinars for training as well,” Maier says, “Basically it’s common sense, so laypersons can use it effectively. But in the hands of an expert, results go off the charts.”
The therapy offers several advantages, Maier says. “It’s unique in that it offers instant and lasting results. With lasers, the patient doesn’t feel anything right away, maybe not for a few days, so they might not tie the results to the therapy.” With percussive therapy, the patient knows what generated the results and then is more willing to return, and to refer others. “It thus creates three conditions for growing your business: it brings in more patients, increases visit frequency, and yields more value per visit,” he says.
TENS (Transcutaneous Electrical Nerve Stimulation) devices are used mostly for acute and chronic nerve- related pain. They act on the body by blocking out pain signals before they can get to the brain, says Stephen Johnson, an expert in this field.
Using the device doesn’t help with the underlying issue causing pain, it just relieves the sensation of it. They are particularly useful for sports injuries and conditions like back pain, but will not benefit someone suffering from a herniated disk.
All of the different kinds of TENS devices (which include some new portable units) are considered durable medical equipment (DME), and many manufacturers provide practitioner information and training about the specifications and uses of the different types. In addition to practitioner training, patient training is required for those using a device at home, Johnson says. That training should include basic safety information (e.g., don’t use a TENS device near the carotid artery, which could cut off blood flow) as well as contraindications (e.g., a device shouldn’t be used if the patient has had a knee replacement, because of the metal used).
You’ll need a DME license to prescribe these machines for in-home use—and to be able to bill major medical for that. The requirements for a DME license vary from state to state, so you’ll have to decide for yourself if the amount of time and effort needed to obtain one will pay off. That will depend, in part, on the nature of your practice.
“In order to prescribe [a TENS unit], you have to document the medical necessity,” Johnson explains, “as well as all the coding and billing paperwork. You’ll have to weigh the resulting impact on staff and collections needs against what you’re doing now.
“The bottom line is your patient profile,” he says. “If you work with a lot of people with sports injuries, it may make sense to explore this. Wellness doctors and coaches will probably not see enough patients [who would benefit] to warrant a unit.”
Shine a light
Lasers—specifically, therapeutic class 4 lasers, the beams of which have output powers of more than 500 milliwatts (mW)—can also be used to treat pain. They operate at a light wavelength that is therapeutic, not surgical, explains Perry Nickelston, DC, NKT, SFMA, of StopChasingPain.com.
“Any time you have injuries, you have chemical damage to cells—that damage is why you perceive pain,” he says. “Every cell has perceptors, or chromophores, that absorb the light, which accelerates healing in the mitochondria. Because laser stimulates the healing part of the cell, it regenerates, which it wants to do anyway,” he says.
Lasers can be used for a wide array of acute and chronic conditions. “Put in the name of any musculoskeletal condition, you can use it for that,” Nickelston says. “You can also use it in conjunction with other therapies—it’s not all or nothing.” The advantages of laser treatment, he says, are that it’s noninvasive, safe, fast-acting, and it doesn’t hurt.
These sophisticated devices require training to be used properly. “The tech- nique changes depending on the exact brand of laser you have,” Nickelston says, “so you must do due diligence [in choosing a vendor]. Make sure the vendor will send someone to your office to train you and your staff on site.”
The vendor should offer other resources as well: user and safety manuals, instructional videos, and the ability to consult with a doctor or clinician as needed. “And they should offer continuing education seminars on treatments,” Nickelston says, “since there are always new developments and research, updates in techniques and applications.”
Nickelston credits the use of lasers with growing his practice. “I was able to treat conditions that are hard to treat—I was the last-shot guy,” he says. “Because of that, I helped a lot of people who’d lost hope—I could help those who hadn’t been helped before with traditional therapies. If you get the right laser, and use it right, it works.”
In choosing any modality to add to your practice, you have to consider a number of factors: What is your primary patient population, and would they benefit if you used this modality? What investment, in training time and equipment costs, would be involved in getting started? What investment, in staffing and documentation, would be involved in making it a regular part of your practice?
Only you can answer those questions, but, as Mackison says, “The days of the patient just lying down so you can adjust the spine are gone.” Today’s patients are looking to become more actively involved in their healthcare.
Judy Weightman is a writer and editor based in Philadelphia. In addition to health, she writes on higher education, gardening, and sustainability for both print and the web. She can be contacted at firstname.lastname@example.org or followed on Twitter at @JudyWeightman.