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Billing One-on-One, Direct Patient Contact
This is often misunderstood and leads to trepidation when documenting and subsequently billing timed services.
A Different Way of Looking at It
The way you and your chiropractic colleagues access information has changed over the past decade. According to a recent survey conducted by Dynamic Chiropractic, almost half (48 percent) of DCs read online articles on their personal computer or laptop daily.
Living Well: Lessons From Our Oldest Old
Aging is a significant public health problem, important to chiropractors in practice and important to DCs who teach students training to become chiropractors.
Holistic Skin Care and Modern Technology
Anti-aging is a concept that we hear in reference to skin rejuvenation and growing older on a daily basis. Aging begins as soon as we are born; therefore "pro-aging" is embracing all stages of life gracefully, with vitality, wisdom, joy, and gratitude as the goal.
Constructing Our Reality, Part 2
My last article discussed perception and its relationship to the primary channels. Before we get to the channels most commonly used to treat sensory disturbances, the small intestine and triple heater, we should first talk about the bladder channel.
With Low-Back Pain, Sometimes Little Things Matter
Typical treatments for low back pain involve large muscles like the quadratus lumborum, iliopsoas, and piriformis. However, there are situations when a very small muscle, the multifidus, can play a significant role in the diagnosis and treatment of low back muscular or spinal injury.
Transforming Las Vegas
On a warm spring day in Las Vegas, Sonia Kim, clinic front desk staff, is busy preparing for a full day of intern shifts at Wongu Health Center. She greets patients, makes sure documents are properly signed, and lets the interns know that their patients have arrived.
Sleepless nights, anxiety, mood swings, euphoric energy bursts, obsessive thinking, and a strange feeling in his chest. That is what Matt was experiencing when he first entered my practice. Rather than being concerned, he was loving every minute of it.
Billing Timed Services
Q: I do not always use physical medicine services but in my state I do have a scope of practice that allows me to provide many of these services. I am trying to understand what "direct one-on-one patient contact" means in relation to physical medicine services.
Distal Style Treatment of Neurogenic Pain
Treat locally or distally? This question has frequented my thoughts for the treatment of pain throughout my acupuncture career. Each style has strengths and weaknesses, thus the versatile practitioner would do well to forgo dogmatic adherence to any one style in deference to the needs of the individual patient.
Understanding Levels of Evidence
The concept of levels of evidence is a cornerstone of research literacy and a great starting point for understanding basic principles of how research works.
Building Bridges with Discipline
As practitioners of traditional Chinese herbal medicine, our role is to educate patients and medical practitioners about the various safety aspects of our medicine. Medical doctors that embrace Chinese medicine want to collaborate and include Chinese herbal medicine in more aspects of clinical care to support their patients.
Keeping Malpractice Allegations at Bay
It has been suggested that in the litigious environment in which we live, the practice of chiropractic should be defensive and practitioners should constantly be watching their backs. An element of defensive practice is a good idea.
One of the most common trends to see in clinical medical practice and public health is the cycles of health "buzzwords." These come and go depending upon the current cultural zeitgeist. One year, "parasites" are causing all the issues, and the next year it's "candida."
Finger (Pad) Pointing: Repetitive-Use Injury Waiting to Happen
"My wrist and hand hurt. I spend all day working on computers and then I come home and spend more time on a computer, usually playing video games."
A Whole-Body Approach to Chronic Tension Headaches
Nearly every day in our practices, we see patients with chronic headaches that have not responded to traditional treatment. They present in our offices with a feeble hope that "maybe" a chiropractor can help.
The Need for Standards
ISO-TC-249: You may look at these letters and numbers and wonder what they are and what they might mean. They turn into: International Standards Organization- Technical Committee – 249. There is a global organization called The International Organization for Standardization.
Discovery: Finding Insights and Each Other in Different Disciplines
Recently I've been thinking about all sorts of things which are hidden from our daily direct experience. That general category is what links nearly everything that catches my attention and then demands some kind of investigation.
How to Reach Your World With the Chiropractic Message
My latest effort to share chiropractic occurred in mid-May while I was sitting at an introductory parent information night for high schoolers. The IT instructor informed us that each student would be receiving a computer for all their studies.
Prostate Cancer Risk
A large study published in January 2016 in the American Journal of Clinical Nutrition showed that men who are vegans had a 35% lower risk of developing prostate cancer compared to non-vegan men. The study followed more than 26,346 men who are part of the Adventists Health Study-2.
Parker University Embraces New Era
Change is in the air at Parker University, which recently announced the selection of both a new president and a new consultant for its seminar program.
In This Current Age of Anxiety
Anxiety, also referred to angst or hysteria, goes by many names. One, popularized by the sagacious Zhang Zhong Jing, who many practitioners of Chinese Medicine may be familiar with, is known as Restless Zang/Fu disorder.
Hip Flexor Contractures & LBP in Above-the-Knee Amputations
Patients with above-the-knee amputations (AK or AKA) are particularly prone to developing hip flexor contractures. Not to be confused with muscle tightness, contractures are a permanent shortening of tissues which cause deformity or distortion.
Streamline Your Front Desk
Your front office can be your greatest source of efficiency or it can be a constant bottleneck. Increasing the productivity of this area, while not sacrificing the quality of patient interaction, can be a little tricky. However, with some focused effort and intention, your front desk can keep your practice running smoothly.
News in Brief
NYCC Aggregates Degree Programs in New School; Palmer Chancellor Receives Education Award From ICA; Oklahaven Announces "Have a Heart" Winners.
December, 2006, Vol. 06, Issue 12
The Pelvic Floor Paradox
By Leon Chaitow, ND, DO
When I started writing this periodic column, I mentioned that every now and then, a "wow-factor" enters my life; synchronistic events and pieces of information coincide to illuminate what was previously foggy.As the fog lifts, simultaneous thoughts often occur. The first thought is, "It's obvious why I didn't see it before" coupled with "Is there evidence to support this?" As I hope you will agree at the end of this short article, "it" is obvious, and there is abundant evidence. So what is "it" and what is "the problem?"
Let's start with a clinical fact I have been aware of, but have been unable to explain. In recent years, more and more of my younger female patients have reported symptoms ranging from variable to acute pelvic pain to stress incontinence, interstitial (i.e., nonbacterial) cystitis, vestibulitis and painful intercourse (dyspareunia). Many of these patients had seen appropriate experts in genitourinary medicine and/or physical medicine, and most had been prescribed what can best be described as "toning" (Kegel-type) exercises for presumed laxity in their pelvic floor muscles, along with various forms of medication.
Now, clearly, the patients I was seeing were the ones in whom such treatment had failed. However, because the practitioners prescribing these methods continued to do so, I must assume they worked for many. But they had not worked for those distressed (mainly) young ladies consulting me, whose lives were in turmoil because of considerable and sometimes constant pain in a very intimate part of their anatomy. All too often, these women were socially incapacitated due to their incontinence; with many unable to have normal relationships. And most of these women were no older than their early 20s.
Structural evaluation often revealed very well-toned musculature. Many had a history involving athletics, gymnastics or dance, and it also was common to have a report of emphasis on Pilates toning exercises with insufficient emphasis on flexibility. Frequently, there was extreme shortness of some of the muscles attaching to the pelvis, particularly the adductors, hip flexors and the ("core stability") abdominals.
In the United Kingdom, my license as a doctor of osteopathy allows me to conduct internal examination and treatment with informed consent, but this was not part of my usual assessment protocol - until recently, that is.
Nowadays, with a clinical chaperone or member of the patient's family present, such examinations are always suggested (and sometimes declined) in such cases.
What changed my approach? Evidence that the problems in most of these unfortunate patients was not reduced tone, but increased and excessive tone, together with the wonderful work of (mainly U.S.-based) medical and manual therapy practitioners who rediscovered something demonstrated many years ago1 - that trigger points can cause all of these symptoms, and that the trigger points and the symptoms frequently can be removed manually.
Diversion to Australia
Before going more deeply into the high-tone/trigger-point connection, I want to take you to Melbourne, Australia, where a part of the complex picture began to fall into place.
The 5th World Congress on Low Back and Pelvic Pain (November 2004) was held in beautiful (magnificent might be a better word) Melbourne, where I was presenting a paper on the influence of breathing pattern disorders and motor control associated with back pain. On the same panel was the wonderful Diane Lee, PT, from Vancouver, B.C. In front of some 2,000 delegates, she was discussing and showing video clips of paradoxical behaviour of the pelvic floor in women with stress incontinence.2 Ultrasound images of the pelvic floor and bladder were shown in which, when asked to "retract" or "draw the pelvic floor upward," quite the opposite happened and the pelvic floor, along with the bladder, dropped toward the floor with the incontinence consequences.
In real life, such women would try to prevent from wetting themselves by the natural response of tightening and drawing up and in, but what if the muscles trying to tighten and draw up already were as tight as they could possibly be? Perhaps the better response would have been to learn to relax these clenched muscles (or to have them manually relaxed), and to be able to influence the pelvic floor via a relearned awareness of muscle control?
This was Diane's objective. To me, the "wow factor" was the recognition that these women were almost certainly also going to demonstrate paradoxical diaphragm behaviour and unbalanced breathing (and most do), which is one of my main areas of interest.3 It would be fair to say that, after that presentation, my area of interest moved south to incorporate that other diaphragm, the pelvic floor. My belief is that if normal diaphragm (breathing) function can be restored and the pelvic floor muscles relaxed, re-education can take place efficiently and relatively easily. A part of that process requires that active trigger points - in the lower abdomen, inner thigh and sometimes internally - be deactivated as the muscles are restored to their normal length and tone. Is there evidence for any of this?
Sometime before World War II, a physician named Thiele developed a technique in which coccygeal prostate problems were treated by means of massage of specific muscles, mainly levator ani.4 This approach (see description in the third bulleted item below) currently is used in major centers in the U.S. to treat prostate pain and the sort of pelvic floor problems discussed above.5 Examples include:
So, this story is not just about pelvic pain and incontinence, but possible irritable bowel disease and, in some instances, sacroiliac dysfunction. Is this not a remarkable conjunction of influences, often linked to hypertonicity and dysfunctional patterns such as breathing?
The Tennis Ball Trick
For many practitioners, the Thiele form of massage may be in contravention of their license. In such cases, a referral to an appropriately licensed and trained practitioner is one option. Even where this is seen to be a good clinical choice, focus on normalizing the associated pelvic muscles and breathing function offers a positive option.
Another option was offered to me by a therapist (ex-dancer) at a recent workshop. She reported she had suffered many of the symptoms outlined above, and had been instructed in Kegel exercises for her incontinence. She noted that these exercises had aggravated rather than helped her. A yoga therapist had then advised her to purchase a tennis ball and sit on it with the ball (placed on a firm surface such as a carpeted floor) strategically placed under the perineum, between anus and the vagina; and to allow the pressure onto the ball to deeply relax the pelvic floor muscles for five to 10 minutes daily. She reported that this procedure was somewhat uncomfortable at first, but that the effects were dramatic in terms of her symptoms. I have since recommended this to several patients for home use and all have reported benefit.
Don't Forget the Psychological Aspect
This is a complex story, and I don't want to leave you with the impression it can all be solved by a tennis ball, although this might offer symptomatic relief for many. It's essential to note that in many such cases of clenched pelvic floor muscles, there is a background of assault or abuse (although a great many seem to be caused by nothing more than mechanically-produced, excessive tone with a background of dance, athletics and bad Pilates). Where there is a psychosocial or psychosexual element to the condition, appropriate professional support usually is needed along with bodywork.
The information offered above should at least provide a sense of what might be happening in some patient's bodies. Those trained in neuromuscular therapy know that aspects of this work usually are a part of that training. Information on the inter-rectal NMT approach is provided in Clinical Applications of Neuromuscular Techniques, Volume 2 (pp. 384-387)11 for information only, unless the methods are within your scope of practice.
Working on relaxation of the region (adductors, etc., as a first focus!), possibly deactivating trigger points if they are readily accessible, along with breathing rehabilitation, offer practical ways forward. And the tennis ball trick might just be an answer for some.
Click here for more information about Leon Chaitow, ND, DO.
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