President's Article

The New Year has begun, we are in the middle of winter (although not too bad for Minnesota), and there is a lot of activity at the Minnesota Chiropractic Association.

With the 2021 legislative session underway, be ready for updates and action alerts sent out by our legislative committee. You should have also received an email asking to become, or recruit a colleague to become, a Key Doctor in your legislative district. This will be very important during this legislative session as there are likely no in person events at the capital and grassroots efforts will be key.

Changes in insurance billing and documentation are inevitable with every new year. There are several changes with Medicare including elimination of E/M codes 99201 and 99211, and changes in documentation related to level of E/M code you use related to time or medical decision making. Check the MCA website for Medicare and other insurance updates.

The new Member Forum is up and running (replacing the email-based listserv). Members can access the forum through their profile on the MCA website, and have the ability to select the level of participation and frequency of notifications that come to their email. All conversations are archived so members can go back and find information that they may have missed or need access to in a current situation.

Our new Communities of Practice will be launching soon. These communities are built for like-minded doctors of chiropractic to discuss, share, and learn about a particular topic or area of practice. The first four communities will be in nutrition, neurology, animal chiropractic and Next Gen (doctors under 5 years of practice). For more information, visit the MCA website and select Communities of Practice under the resources tab.

As you can see, the resounding theme is to check the MCA website. We strive to make the website the source of all the information you need regarding the association and important practice and business information. Updates are constantly being made and we are currently working on making the navigation easier than ever. New features coming to the website include an FAQ page and listing of sponsors and associated business members partnering with the MCA to offer their services and discounts.

In order to continue improving our membership benefits and increasing our service to the profession, it is vital that we grow our membership. For those of you who are already members, we are grateful! We ask that you share your MCA experiences with your colleagues and ask that they consider joining the association. Our voice is loudest when working together!

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Heat Therapeutics in Clinical Application

As more patients seek out alternative modes of care, in part, due to changes in recommendations put forth by the American College of physicians, treatment modalities including Chiropractic, Acupuncture, and massage are gaining prominence. Over 30 billion dollars each year go to these doctors and practitioners. As this number increases year over year, common therapeutics used in these interactions are getting more attention.

The number one reason patients see chiropractors and physical therapists is pain, both acute and chronic. A study from 2014 published in the Journal of Chiropractic Manual Therapy reports that 360 surveyed physical medicine therapists, primarily chiropractors and physical therapists by correspondence, showed use of thermal therapies 73% and acupuncture 43% of the time as the most commonly used adjunct therapies in the therapeutic interaction.[1] This paper seeks to look at each of the most popular types of dry and moist heat interventions found in chiropractic offices including, dry saunas, far-infrared (FIR) lamps, ultrasound, moist heat hydroculator packs, and fire cupping.

Heat therapies have been used for thousands of years from soaking in hydrothermal baths in Greece, Eastern Europe, and Asia, moxibustion (burning of mugwart) and fire cupping in China, to more recent inventions of electric heating blankets, infrared heating lamps, and dry saunas. All of these modalities introduce thermotherapeutic interventions aimed at keeping tissue muscle tissue pliable, perfuse with blood, and speeding recovery from DOMS (delayed onset muscle soreness). The following therapies are explained in order of heat penetration depth.

Dry heat is used to calm muscle soreness, improve blood flow in local tissue, and relieves chronic joint discomfort. Dry heat is typically delivered in three main forms in a chiropractic office including table warmers, therapeutic ultrasound, and far-infared (FIR) heat lamps and dry sauna. Dry heat, as opposed to moist heat, takes much longer to penetrate deeper into the tissue.

Table warmers and heating pads are the safest version of the dry heat and are used for extended periods of time making them a favorite for self and home care. Table warmers and heating pads are the least penetrative therapy. Risk of adverse events is low using warming pads/blankets, though used for prolonged periods of time on high settings increases risk of heat stroke. Traditionally, where table warmers are used on massage tables, smaller heating pads are placed over specific problem regions.

Dry saunas or sauna bathing has been around for thousands of years. It has gained in popularity over the last 100 years in this country being found typically in rehabilitation and sports training facilities. Dry sauna therapy has been associated with the treatment of cardiovascular, respiratory, inflammatory disorders, and sports related injuries. In fact, the installation of private saunas and public sauna facilities are on the rise. Physiological effects of sauna bathing include increased core body temperature and autonomic activation of the hypothalamus-pituitary-adrenal complex which causes sweating, thermoregulation, and homeostasis [4]. A systemic review of sauna bathing/dry sauna found systemic improvements with repeated sauna usage.[4] Care should be taken during therapy to monitor hydration and risk of heat stroke.

Infrared heat, delivered by a lamp with an infrared bulb, is commonly found in offices that perform acupuncture and other modalities that require patients to remain in place for longer than 10 minutes. Heat lamps utilize a similar technology to dry saunas with a more focal area of treatment versus full body therapy. A randomized control study from 2006 found that IFR lamp therapy showed twice the improvement in intractable low back pain over a placebo light source [5].

Therapeutic ultrasound is produced by a pizeoceramic crystal located at the head of a wand where unfocused beams of ultrasonic energy are sent into tissue. The heat is produced due to absorption of ultrasonic energy. Common uses of ultrasound in chiropractic offices often include tendonitis and bursitis. The handheld wand emits a frequency of 1-3MHz either in continuous or repeated bursts with its main function of deeply warming tissue. Typically, conduction jelly is used on the skin to facilitate transmission of the unfocused beam. Research shows moderate therapeutic results and the overall risk is low. [3]

Moist heat is ubiquitous to chiropractic, acupuncture, and massage offices. Moist heat is typically delivered by the application of clay filled hydroculator packs kept in hot water to particular area of the body. The benefits of moist heat including treating muscle pain, improving poor local circulation, and deep tissue relaxation. Moist heat has been shown to penetrate deeper into muscle tissue than dry heat. One study showed two hours of moist heat is near equivalent to eight hours of dry heat in tissue response and heat penetration [2]. To control heat penetration, multiple layers of towels or covers are placed between the moist heat pack and the skin.

Fire cupping typically uses glass cups, 91% alcohol, and an open flame. The use of warming gels on the treatment area is common produce a surface to glide the cups over the skin. The act of heating the cup delivers thermotherapy to the superficial tissue while the suction induced by the cups introduces heat to deeper tissue. The technique can be used as static cupping where the cups are placed over particular regions and kept in place for 5-15 minutes, or moving cupping where cups are moved over the skin like a massage. How long you keep the flame in the cup will determine the amount of suction. It is common for the cups to leave circular bruises typically thought to be released toxins from the superficial layer of tissues. Caution must be taken during treatment to protect the skin and superficial tissue. Prolonged retention of cups can cause blistering and pain.

Because many chiropractors in Minnesota are certified in acupuncture, the use of traditional Chinese moxibustion is applicable as a final heat source to discuss. Moxibustion, the burning of female mugwart, either compressed into a long stick above the skin or “rice” moxibustion directly on the skin over an anti-burn salve, is an adjunct traditional therapy ubiquitous to acupuncture treatments. Though the smell of the burning herb and smoke are prohibitive to many offices, research shows that moxibustion may have clinical application for osteoarthritis [7], pregnancy pain [8], and low back pain [9].

In conclusion, heat therapies are an excellent adjunct that can help hold your treatments longer, empower patients with home care, and provide deep relaxation to tense muscles and joints.

References:

1. Carlesso, L. C., Macdermid, J. C., Gross, A. R., Walton, D. M., & Santaguida, P. L. (2014). Treatment preferences amongst physical therapists and chiropractors for the management of neck pain: results of an international survey. Chiropractic & manual therapies, 22(1), 11. https://doi.org/10.1186/2045-709X-22-11
2. Petrofsky J, Berk L, Bains G, et al. Moist heat or dry heat for delayed onset muscle soreness. J Clin Med Res. 2013;5(6):416-425. doi:10.4021/jocmr1521w
3. Miller DL, Smith NB, Bailey MR, et al. Overview of therapeutic ultrasound applications and safety considerations. J Ultrasound Med. 2012;31(4):623-634. doi:10.7863/jum.2012.31.4.623
4. Hussain J, Cohen M. Clinical Effects of Regular Dry Sauna Bathing: A Systematic Review. Evid Based Complement Alternat Med. 2018;2018:1857413. Published 2018 Apr 24. doi:10.1155/2018/1857413
5. Gale GD, Rothbart PJ, Li Y. Infrared therapy for chronic low back pain: a randomized, controlled trial. Pain Res Manag. 2006;11(3):193-196. doi:10.1155/2006/876920
6. Al-Bedah AMN, Elsubai IS, Qureshi NA, et al. The medical perspective of cupping therapy: Effects and mechanisms of action. J Tradit Complement Med. 2018;9(2):90-97. Published 2018 Apr 30. doi:10.1016/j.jtcme.2018.03.003
7. Song GM, Tian X, Jin YH, Deng YH, Zhang H, Pang XL, Zhou JG. Moxibustion is an Alternative in Treating Knee Osteoarthritis: The Evidence From Systematic Review and Meta-Analysis. Medicine (Baltimore). 2016 Feb;95(6):e2790. doi: 10.1097/MD.0000000000002790. PMID: 26871839; PMCID: PMC4753935.
8. Miranda-Garcia M, Domingo Gómez C, Molinet-Coll C, et al. Effectiveness and Safety of Acupuncture and Moxibustion in Pregnant Women with Noncephalic Presentation: An Overview of Systematic Reviews. Evid Based Complement Alternat Med. 2019;2019:7036914. Published 2019 Dec 3. doi:10.1155/2019/7036914
9. Leem J, Lee S, Park Y, et al. Effectiveness and safety of moxibustion treatment for non-specific lower back pain: protocol for a systematic review. BMJ Open. 2017;7(6):e014936. Published 2017 Jun 23. doi:10.1136/bmjopen-2016-014936

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RICE: Slowing the Healing Process

Melissa E. MacDonald DC ICIS CCSP® NREMT ART® FAKTR

Research is always changing, and our understanding is growing each day. Research has caused changes to “proven trusted” methods of care. When patients come in and ask which should they use ice and rest or movement or heat? What to tell them? Is pain type considered? Acute? Chronic? Area of the body? What is the correct answer?

History of Our Attempt to Heal the Musculoskeletal System

In 1978 Dr. Gabe Mirkin coined the acronym RICE for the treatment of musculoskeletal injuries. The biggest concerns that were being managed were symptoms – pain and swelling. Understanding how we heal came later and caused changes, but when it initially came out, the question of whether it made the healing time shorter was never asked (1).

• R – Rest
• I – Ice
• C – Compress
• E – Elevate

Rest was utilized to offload the injured joint and theoretically prevent further injury. If a patient has a broken or shattered leg, it is important not to walk and further displace the fracture. If it is a sprained joint, is the same true? Ice was used for pain management and inflammation control. This all sounds good, but what is inflammation? Our bodies are brilliant and will try to do the best thing for themselves. Inflammation is our body's response to an injury or an illness. Signs of inflammation are redness, swelling, pain, stiffness, and loss of function in the joint. Inflammation is caused by chemicals in our white blood cells, B and T type lymphocytes. The substances are released to increase blood flow and create pain as a protective measure to prevent movement. Two types of inflammation are essential to understand – acute and chronic. Acute inflammation occurs within minutes and is generally short-lived. Chronic inflammation is a long-standing disease process that is typically associated with an issue with the immune system. These two types of inflammation are essential to consider when deciding on care. Another way to manage inflammation is compression. An ace wrap can be used to provide gentle compression to prevent too much swelling. However, be careful; too much compression can cut off blood supply, accidentally creating a tourniquet. The last step is to elevate, which is to use gravity to help with the swelling. Furthermore, there is no research supporting this makes in a difference in recovery (2).

Now, things have started to change, initially with the addition of “P,” resulting in the acronym PRICE. The “P” stood for protection. Protection, such as bracing, was utilized to prevent further injury and potentially allow for returning to activity before complete healing. This can be important if there is a need to return to work.

The next change was in 2010 when the “R” was dropped for “OL,” making the mnemonic POLICE. The shift from “rest” to “optimal loading” came with the understanding that our body heals better with controlled stress. With too long of a rest period, there is a loss of range of motion and function; also, fear-avoidance to activity can set in.

The most recent change is the largest and was developed based on the need to load the tissue to heal. The new mnemonic is PEACE & LOVE.

• P – Protect

Used for 1 to 3 days to minimize bleeding, prevent further tearing of the injured tissue, and reduce the risk of more significant injury.

• E – Elevate

Utilizes natural gravity to help reduce swelling of the tissue. Must be above the heart.

• A – Avoid anti-inflammatory modalities

The research has determined that their use can have a long-term effect on tissue healing. Each part of the inflammatory process is essential, and ice and over the counter medication impede different steps and increase healing time. Ice has no evidence of benefit other than reported pain relief while numb.

• C – Compress

Use of taping and bandages to help limit inter-joint swelling and tissue bleeding.

• E – Educate

Teaching individuals that the best way to heal is to move. Research has shown some passive care options such as muscle stim, massage, or manual therapy can be counterproductive long term when not combined with rehabilitative exercise.

• L – Load

Research has shown that movement and exercise is the best way to recover from an injury. Loading the injury to pain tolerance instead of only loading while remaining pain-free has led to quicker recovery times.

• O – Optimism

With all injuries, there is a psychological factor in how we see the damage. Catastrophisation, depression, and fear can create barriers to recovery. Pessimistic thoughts can create suboptimal outcomes and a worse prognosis. Meaning keeping a positive outlook will create a more optimal recovery.

• V – Vascularization

Pain-free cardio training is a cornerstone of recovery. The exact dosage has not been researched, but early mobilization increases blood flow and improves motivation. Determining the dose will be patient-specific and injury-specific, so in-office instruction and tracking will be necessary.

• E – Exercise

The final step, if it is not clear yet, is to get back to movement. Improving mobility, strength, and proprioception (awareness in space) creates the best environment for recovery.

We have now covered the history of how we have changed our treatment recommendations. Now let us talk about when to use ice and heat.

When should ICE, HEAT be used

Ice has been moved to the emergency medicine realm of pain management and extreme acute care. It is truly one of the best pain managers. Using ice days after an injury is not a great option unless used to reduce pain to do rehab exercises. Quite a few musculoskeletal conditions can be caused by the spasming of the muscles. Adding ice may make them feel better for a short period, but it will further tighten the muscles. Heat can be a better option for managing pain because it will help to loosen the tight muscles. (3)

This is a shift in care, but using the best evidence for care is how injury and disability times are shortened, and the patient can get back to their best life.

References:

1. Mirkin, G., MD. (2015, September 16). Why Ice Delays Recovery [Web log post]. Retrieved December 24, 2020, from https://www.drmirkin.com/fitness/why-ice-delays-recovery.html
2. Bekerom, M. P., Struijs, P. A., Blankevoort, L., Welling, L., Dijk, C. N., & Kerkhoffs, G. M. (2012). What Is the Evidence for Rest, Ice, Compression, and Elevation Therapy in the Treatment of Ankle Sprains in Adults? Journal of Athletic Training, 47(4), 435-443. doi:10.4085/1062-6050-47.4.14
3. Yerht, P., Stensrud, T., Wienkers, B., & Durall, C. (2015). The Efficacy of Cryotherapy for Improving Functional Outcomes Following Lateral Ankle Sprains. Annals of Sport Medicine and Research, 2(2).

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Investing in Your Practice’s Most Important Asset

Dr. Ray Foxworth, ChiroHealthUSA

I came across an article that I wrote several years ago when one of my employees shared a Facebook post. She said, "I am praying to find a good job, a place where I can be happy and have a long career." This year, she will be celebrating nine years with us. She was our 4th full-time employee and over the years, we have undergone so many changes within the company. The one thing that has remained the same was the decision to invest in my team through internal and external training. We have annual team training but, depending on their positions in the company and their interests, we have sought out individualized training. That same employee just became a Certified Professional Biller. Another is a Certified Professional Coder. And, we have a Certified Professional Compliance Officer. We also have employees getting certified in software and marketing training through Salesforce.

Training is becoming a forgotten priority in the business world. We live in a world where we are so busy being busy that we throw new employees, and even our existing ones, into the eye of the storm with little to no instruction on how to do their jobs, much less how to do them well. In today's complex and compliant healthcare environment, we must take the time to cultivate and develop talent in our offices. Training is not an expense but an investment in our business. To quote my friend Dr. Nathan Unruh, “training isn’t something you did, it’s something you do.” With each new training course and certification that my team completes, we see improvements in productivity, customer service, and company morale.

Start by picking an area for improvement at each team meeting. Discuss billing, coding, your financial policy, and patient communication. Explore out-of-office training on leadership and communication. Take your team to conventions and seminars once we can attend in person. Before the pandemic, I found myself not looking forward to attending my annual convention for the mandatory CE needed each year. Now, I long to see old friends, meet new ones, and truthfully, attending in-person rejuvenates my spirit and love for this amazing profession. Encouraging your team to experience these events with you is a great way to ignite their passion for chiropractic, too.

Employees want to do their jobs well. A lack of training in your practice can create unhappiness and lack of motivation and ultimately leads to higher turnover. Employees want to know what is expected of them and would welcome the tools to perform well. Investing in your team builds a more compliant, efficient, and profitable practice. When employees are happy to be in the office, they spread that happiness to your patients. I’ve told almost everyone I’ve ever hired, that MY job is to make their job the best one they have ever had. When I focus on this one thing, I am rewarded with hard-working, dedicated, and loyal employees like you wouldn’t believe. It almost eliminates turn-over and creates stability in any organization.

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Dr. Ray Foxworth is a certified Medical Compliance Spe¬cialist and President of ChiroHealthUSA. A practicing Chiropractor, he remains “in the trenches” facing challenges with billing, coding, documentation and compliance. He has served as president of the Mis¬sissippi Chiropractic Association, former Staff Chiro¬practor at the G.V. Sonny Montgomery VA Medical Center and is a Fellow of the International College of Chiropractic. You can contact Dr. Foxworth at 1-888-719-9990, info@chirohealthusa.com or visit the ChiroHealthUSA website at www.chirohealthusa.com. Join us for a free webinar that will give you all the details about how a DMPO can help you practice with more peace of mind. Go to www.chirohealthusa.com to register today.

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2020 President Award Winners

• Dr. Carrie Getzmier
• Dr. Lyle Coleman
• Dr. Sara Cuperus
• Kevin Goodno
• Dr. Rick Hueffmeier
• Katie Wallstein

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The 3-Minute Functional Exam

This practical and entertaining class will cover a 3-minute functional evaluation for identifying seven commonly overlooked problems that delay recovery. In one way or another, these seven “functional” diagnoses contribute to many, if not all, of the “structural” diagnoses that chiropractors treat.

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1.0 Regular Credits - Approved

Speaker: Tim Bertelsman, DC, CCSP, DACO