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Less Time Than Required
Q: When is it appropriate to use a modifier -52? Can I use it for a timed service when I do less than the time required by the code?
Let's Talk About Biceps Injuries at the Elbow
While most muscles cross over only one joint, the biceps crosses two joints: the elbow and the shoulder. Injuries to the lower biceps cause considerable elbow pain. Here's how to assess and treat an injury to this area conservatively.
Adventures with the Pericardium
My previous column on the San Jiao deserves equal time for SJ's loving partner, the pericardium. I nicknamed SJ the travel meridian – but pericardium can also play a crucial role in air travel.
The National Institutes of Health (NIH) lists more than 80 common autoimmune diseases including asthma, Crohn's disease, Guillain-Barré syndrome, multiple sclerosis, myasthenia gravis, psoriasis, rheumatoid arthritis, and lupus.
Don't Ignore the Lower Half of the Pelvis (Part 1)
When your patient complains of lower back or pelvic pain, but your usual treatments are not getting the job done, what do you examine and treat? You may be missing important structures in the lower half of the pelvis.
Traditional Chinese Herbal Medicine in Taiwan Hospitals
This spring, a team of Western medical doctors and TCM practitioners from Cleveland Clinic traveled to Taiwan to visit Kaiser Pharmaceutical Co. (KP), and China Medical University (CMU), Taiwan's leading integrative medicine hospital.
What are the Meridians?
The meridian and collateral system (jing luo, hereinafter referred to as "Meridians") is comprised of the main meridian channels (jing mai) and the collateral vessels (luo mai). Jing takes from meaning of the Chinese word pathway (also jing) and are the main branches of the system.
Chiropractic in the Eyes of the Public: 2nd Gallup-Palmer Poll
The second Gallup / Palmer College poll has been completed, yielding significant additional data regarding Americans' experiences with and perceptions of chiropractic care.
Are Probiotics Doing More Harm Than Good?
Considerable controversy exists concerning the efficacy of probiotic supplements. Very few human studies show any real positive impact on the microbiome or health. The "promise" of probiotics is based on the few animal studies that suggest a positive effect.
International Congress on Integrative Medicine
"Bridging Research, Clinical Care, Education and Policy" was the theme for the International Congress on Integrative Medicine and Health 2016 (ICIMH).
Lessons from Functional Neurology
Chiropractic neurology, also known as clinical neuroscience or functional neurology, is moving the chiropractic profession forward by leaps and bounds.
A Study of Relationships
Sa-Ahm's five element acupuncture method is known to be one of the most effective acupuncture techniques in Korea because it gives an instant response at the time of treatment and has a high success rate in resolving chronic problems.
Work Stress and Musculoskeletal Health: Do Your Patients Get the Connection?
Most people underestimate the impact their job has on their health, especially if that job isn't particularly physically demanding. Big mistake.
The Professional and Practice Benefits of Political Activism
Welcome to election season, a vital part of our American culture. Every two years, without fail, we are bombarded with TV, print materials and phone messages seeking our vote.
Overuse Injuries in Young Athletes (Part 1)
More than 45 million children ages 6-18 participate in some form of organized athletics, and 75 percent of American families with school-aged children have at least one child participating in organized sports.
Time to Fight for Your Medicare Right
I have heard a lot of noise and a lot of debate about what is going on with Medicare. As an ACA delegate, I often get asked: 'What is the ACA even doing?'
What's New in the NCCIH Strategic Plan
The NIH National Center for Complementary and Integrative Health (NCCIH) released its draft strategic plan 2016-2021 for public comment in early spring of 2016.
Know Your Research: Tips for Evaluating Literature Reviews
Clinical and experimental studies are not the only types of published research we might encounter as we look for evidence to inform our practices. One of the most useful types is the literature review, which summarizes a group of studies.
Code Connection: Guidelines for the Use of Modifier -52
Modifier -52 identifies that a service or procedure has been partially reduced or eliminated at the physician's discretion. This is to indicate the basic service described by the procedure code has been performed, but not all aspects of the service have been performed.
Illuminating the Hidden, Freeing the Source
Amongst the Primary Channels, from a classical point of view, the small intestine is perhaps the most important channel to understand. It is one of the least used acupuncture channels in modern acupuncture, yet it within it can be found a wealth of theories from the Ling Shu.
Analyzing Acupuncture Case Studies
Confirm the answer quickly by the elimination method. Take this case study as an example. After two treatments for back pain, a patient presents for a third session complaining of rapid breathing and wheezing that is made worse during cold weather.
MPA Media Wins More Publishing Awards
The American Society of Business Publication Editors (ASBPE) has honored Dynamic Chiropractic with a national award and two regional awards for editorial excellence, and sister publication DC Practice Insights with two regional awards for graphic design excellence.
The Importance of Dosage in Manual Therapy
Research is slowly beginning to reveal the importance of optimal dosage in manual and movement therapies and it may surprise you (as it did me) to learn that very small variations in applied load (compression, stretch, etc.) can make the difference between a positive and a negative therapeutic outcome.
Recent studies have shown that variations in the:
This list should include other variables, such as whether a particular method is used alone, or in combination with others (say, stretching as well as effleurage) – and when employed with other methods - and in what sequence. In other words - how much is too much, and how much is too little?
Evidence is also emerging that the unique characteristics of the client/patient who is receiving treatment - the gender, age, past and present medical conditions, degree of physical fitness etc - are all factors capable of modifying the responses to manual treatment. (Dennenmoser, et al, 2016)
The following examples, taken from recent research studies by hand surgeons, offers us glimpses of the emerging evidence. Wang & Guo (2012) showed that quite different effects emerge when damaged tendons are mechanically loaded, for example, involving stretching. When 4% of tendon stretch was used, there was a reduction of collagen production and tensile strength of the tendon but an increase in catabolic (break-down) of tissues, slowing healing after trauma or surgery. However, 8% of tendon stretch increased collagen production (essential in the repair process) and the tendon's tensile strength, plus differentiation into tenocytes (needed for creation of new tendon tissue), while reducing formation of adhesions and inflammation. This encouraged more rapid healing after trauma or surgery. In contrast, a 12% stretch reduced collagen production and organization, while increasing inflammation, edema and tenocyte differentiation, slowing down healing after trauma or surgery.
That's the basic science, but it leaves a major (as yet unanswered) question: How are you to know the difference between loading tendons to match the ideal (8%), while avoiding the less effective degrees of load (4%, 12%) in practice, in a clinical setting?
Other examples of the clinical challenge of achieving an ideal degree of load during treatment emerge from another basic science study by Zein-Hamoud & Standley(2015). They report that, "The key components of the response to mechanical forces are fibroblasts, which [tend to] respond to different types of strain by secreting anti-inflammatory chemicals and growth factors, thus improving wound healing and muscle repair processes." They also note that, "Heterobiaxial, but not equibiaxial, strain affects fibroblast morphology - [likely due to]- actin, which mediates strain-induced cellular Ca++ release."
In their study involving fibroblast behavior during the repair of a damaged bioengineered tendon, these innovative scientists identified that:
The question arises again: How is a practitioner/therapist to know the difference between loading soft-tissues with the beneficial degree of force, approximately 6% compared with the less helpful 3% or 12% , in order to match these findings? Clearly many therapists get this right, and my personal experience and opinion is that methods that meet tissue resistance and engage restriction barriers heterobiaxially and non-forcefully (as for example in Myofascial Release, or gentle Muscle Energy Technique application), are closer to achieving the ideal, than those that employ more aggressive forms of load.
Of course, the examples described above only highlight the treatment part of the equation. There is of course another element; the nature of who and what is being treated. Dennenmoser et al, (2016), explain the results of research involving applied mechanical friction: "Electrical impedance...can be used to determine the amount of water within human tissue and to differentiate between intracellular and extracellular water. Ultrasound elasticity imaging directly reveals the physical property of fascial tissues and makes it possible to quantify changes in tissue thickness as well as stiffness before and after [treatment]." Their results revealed that the tissue (muscle and fascia) responses will be quite different depending on numerous features that are only partially related to the way treatment is applied. "Besides the expected softening-effects on the lumbar region, both kinds of tissue, musculature and fascia, react differently depending on the sex, age, pain-history and activity-level of the person"
Dosage in manual therapy is an area that is both under-researched and "under-translated" into practice, and all manual professions need to focus on ways of teaching and training that encourage optimal delivery of therapeutic load. Additionally, attention the nature of the individual and the tissues being treated presents a further educational challenge that requires our attention.