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Balancing Spring Challenges
As the winter months come to a close and warmer spring weather appears, patients may begin to present with new challenging pattern presentations.
News in Brief
ACA Adopts New Governance Model; ACA 2017 Awards; CCA Helps Calif. DCs "Share the Love"; $1 Million to Help Advance the Profession; D'Youville Raises the Bar on Anatomy Education; ErRatum.
Women's Hormones: A Western & Eastern Perspective
Sometimes it may seem that you require a degree in medicine to understand hormones and how they function.
Creating Good Business Buzz
What do patients really think about working with you? Rarely do you hear the whole truth. Those who improve may be candid in their gratitude.
Why I Quit Doing House Calls
My father was a chiropractor who did house calls, so when I became a DC, I figured doing house calls was part of the job. My March article recalled my experience as a small boy, accompanying my dad while he went to patients' homes to treat them.
New Relationships, Old Trauma: AOM & Other Healing Strategies
Being in love is one the most beautiful and enjoyable experiences. Most of us are willing to pay almost any price to have that experience, and still often find it elusive or fleeting. Navigating the ups and downs of loving relationships are often challenging — even for the most psychologically balanced among us.
Clearing Blocks: A Way to Improve Cosmetic Acupuncture
As a Five Element acupuncturist who teaches facial acupuncture classes nationally, I was surprised to learn that one of the basic principles I was taught in school is unfamiliar to most acupuncturists.
Raditation & Your Smartphone: Is it Worth the Risk?
If radial arteries could talk (and in my experience they can to some extent), they would say, "Step away from the smartphone." At least that is the message I am receiving loud and clear as I feel the pulses of many patients.
Eczema & Acupuncture: A Sound Solution (Part 1)
Eczema affects approximately 3.5 percent of the global population and is one of the most common skin complaints seen by dermatologists.
Universal Design: Principles & Practice
In many respects, universal design serves as the core of ergonomics. It's also a good tool to use when designing a return-to-work program for injured and/or ill patients. Let's take a closer look at universal design and why it should matter to you and your patients.
Give Yourself the Digital Advantage
When you see this article in the print version of this issue and swear you read it already, don't be alarmed: you probably did. That's because by that time, the May issue will have been available online in digital format for three weeks.
A Major Role in Back Pain: The Multifidus
Back pain affects roughly 80 percent of the population at one time or another and is one of the leading causes of doctor visits.
Taking the Chiropractic Message to the Press
"There is no better place on earth to have a news event," the National Press Club boasts, and it's easy to understand why: Every year, the 108-year-old Washington, D.C.-based organization hosts countless press conferences on the hottest topics impacting America and often the world.
A Daily Strategy for Heavy-Metal Detox
In modern society, we are constantly exposed to heavy metals such as cadmium, lead and mercury. These heavy metals have no essential biochemical roles in our body, and conversely, can cause us a great deal of harm if they build up to toxic levels.
The Visual Error Scoring System: A Concussion Tool
Postural stability and oculomotor function are the most easily recognized physical indicators of neurologic motor dysfunction associated with concussions.
Is It Time to Rethink Mental Illness? (Pt. 1)
Invariably, patients will ask their chiropractor about depression or various mental illnesses. Some practitioners will reflexively offer a cervical adjustment, suggest St. John's wort or contemplate a referral to a specialist.
An Integrated Approach to Chronic Pain
Findings from a unique Medicaid pilot project in Rhode Island involving high-use Medicaid recipients from two health plans were recently presented to the state's Department of Health, demonstrating stellar outcomes with regard to medication use, ER visits, health care costs and patient satisfaction.
Is the New Medicare Reporting Exemption Right for You?
What you've heard is not a rumor – there will be exemptions for providers of Medicare patients, with no penalties assessed for offices that do not do Quality Payment Program (EHR, PQRS, MACRA and MIPS) reporting.
Bill With Confidence: Learn What to Collect
Q: I am trying to understand what I may collect from my patient when there is insurance. Do I have to accept the amount allowed by the plan or may I collect up to my billed amount? Please note, I am not a member of any insurance plan.
February, 2016, Vol. 16, Issue 02
Earning Respect Through Research
By Debbie Roberts, LMT
I was very fortunate and grateful for a recent case that earned the respect and referral of an orthopedic surgeon. This was done by doing the appropriate assessments, documentation, research and a written report.He truly was thankful for my comprehensive written report and the picture I had included, which was a faulty alignment posterior view from the book Muscles Testing and Function, Third Edition by Florence Peterson Kendall, PT and Elizabeth Kendal McCreary. This picture showed how the quadratus on the left had shortened, creating a misalignment of the pelvis and the weakness of the same hip. He told the client, "You are in good hands." In fact, that same day, he had another case in his office which had a similar history and they actually passed each other in the waiting room. He immediately picked up the phone and called my office with the referral. Needless to say, I was very excited he had enough confidence in my research and documentation to give me the referral. I am sharing this particular case with you because learning how to follow through makes a widespread impact to our industry of massage therapy. Your participation doing this sort of follow through can gain two great things: an increase to your referral base and it helps to professionally expand our place in the health care industry.
The reason this report was significant is the combined fact that this orthopedic surgeon did not believe the pain pattern matched the MRI report of a torn labrum and he didn't feel that surgery at this time was necessary. He felt there was another reason for the pain pattern she was experiencing. So he referred her to a physical therapist to try strengthening exercises which shortly ended with her having increased lumbar pain. The physical therapist concluded she was a surgical candidate and referred her to another orthopedic surgeon who concurred she needed to have immediate surgery to repair the labrum. This left her confused, what was the right approach for her? She wanted another opinion so she came to see me for an evaluation and assessment of her structure.
Always ask yourself the most important question: "why is this happening to the client." The question "why" should lead you down the path of using assessments, needing to research all the possibilities and then taking the time to write a complete, detailed report in case the client needs it to take to another health care professional.
It is very important to our industry as a whole to gain a positive reception from other health care providers. We are a critical part of a clients overall well-being and health. Just because you may not file insurance, doesn't mean you shouldn't take the time to assess and do documentation. I haven't filed an insurance claim in more than 10 years, but I still conduct my business like at any given moment this client may need records as to the type of therapy I am providing for them. What if their physical therapist wants to know? What if their chiropractor wants to know? As a massage therapist, you are a health care provider. Built into that title is the responsibility to the client just like any other provider within their care to keep notes and records. You never know the far-reaching effects one report might gain.
The following is the actual case and the report that was presented to the physician. The name is left out for privacy issues. The report was done on letterhead. Save this as a reference to use as a guide for your documentations. After the report, I will talk a little further on leg-length inequalities and hip dysplasia.
This client presented to my office with the diagnosis of a torn left labrum, left hip dysplasia, left hip pain that on occasion, radiates down the left leg. She was seen by a physical therapist that evaluated her and didn't think physical therapy would help and concluded it was a surgical issue. She has been seeing a chiropractor for more than a year that performed the Graston Technique to her left hip muscles because of a previous diagnosis of hip bursitis and combined giving her adjustments to help with her rotated sacrum.
Enclosed is a picture of the myofascial dysfunction that the client presents with. She is showing a lower limb-length inequality both on the massage table and in gravity. In a supine position on the massage table, her left leg appears to be longer by assessing both the medial malleolus and the heels. On a bilateral assessment of the ASIS's, the left was lower and more anteriorly rotated than the right side. In gravity, a lift under the right foot makes her feel more balanced. She states she has always had a funny walk and wouldn't wear a bathing suit because of the ribs sticking out further on the left side. On the table, the anterior rotation of the left ribs was quite noticeable. In a prone position, her sacrum is deeper anteriorly on the right side. Her left glut lacks the same tone as the right and there was weakness on a MM test of the left glut in a prone position. She stated that in a prone position her ASIS do not touch the table equally.
When I performed manual therapy, she had a great deal of hypertonicity in the left QL. When I relieved the tension in both the left QL and the right piriformis, the medial malleolus appeared equal on the supine retest. In gravity, she stated she felt more balanced. However, the treatment did not hold as confirmed by her chiropractor the next day. He stated she had 8mm's difference and after his treatment the difference remained at 4mm's.
According to Janet G. Travell, MD and David G. Simons, MD from Volume 2 Chapter 4, page 61, there is a need to take a standing radiograph to evaluate lower body asymmetries. Manual therapy is very successful in treating muscular asymmetries, but not if there is an underlying structural issue. If the x-ray is conclusive, the patient may benefit from having a professional orthotic made. I think the quadratus muscle is trying to help stabilize her pelvic position similar to what happens in the trendelenburg sign. We have scheduled her to have manual therapy three times this week to see if her body will hold the muscular length.
Thank you for your time and if you have any questions please do not hesitate to call me at my office 772-288-0073. Deborah A. Roberts, LMT, NASM CPT, TPI Medical Level 3
Writing the Report
Now, ask me how many times I re-wrote the report. At least five times because after reading it, I wasn't being specific or to the point enough. Make your documentation short and to the point, one page is plenty. End with a title of conclusion just in case that is all the health care provider has time to read. Be sure to read it out load to yourself like you are talking to the doctor. That helps hearing if the report is making your point clear. Now, ask me how much time I spent researching before I decided to write the report. At the least six to eight hours. Yes, I knew quadratus was involved and was hypertonic to the point that when she stood her left hip was noticeably higher and on palpation there was absolutely no doubt what my hands told me. But I needed to be clinically specific which meant re-reading from the Myofascial Pain and Dysfunction Manual the entire chapter again to see what I felt related to this case. That research then lead me back to Volume 1, Upper Half of the Body, Second Edition, starting on page 179 to discuss lower limb-length inequality (LLLI). Quoted from this chapter is how correcting LLLI is often essential for lasting inactivation of TrPs in muscles that are overloaded by the length discrepancy.
Her condition was complicated with the diagnosis of hip dysplasia. Hip dysplasia is a medical term for a hip socket that doesn't fully cover the ball portion of the femur. This allows the hip joint to become partially or completely dislocated. Most people with hips dysplasia are born with the condition. This client will present with hip pain and spasms due to the fact the muscles are trying very hard to stabilize the joint. This type of client will not benefit by passive stretching and you could add to the instability. This fact is why she was told to stop doing Yoga.
He ordered the radiography and it did, in fact, show the lower limb-length inequality. For now, his approach is to treat the LLLI with a lift, continue manual therapy and see if that will manage her hip discomfort. However, there may be a need further down the road to repair the labrum, smooth out the ball of the femur, and hollow out the socket for better articulation. The real bottom line is if they had done the labral repair only, this client could have been like many who have had surgery and the pain remained the same because the underlying structural condition wasn't addressed as well.
Every client you see that is in pain always ask the simple question, "why." It may lead you down many roads.
Click here for more information about Debbie Roberts, LMT.
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