A bigger toolbox: Adjunctive therapies expand the chiropractic repertoire
Take a look in many chiropractic offices these days, and you’ll spot some equipment that you probably wouldn’t have found there a few years ago. Exercise balls and tubes? Weight machines and free weights? Balance mechanisms? Trampolines? At least some of these tools turn up in more and more practices, alongside more traditional adjunctive therapeutic equipment. Although spinal manipulation remains the centerpiece of chiropractic care, the use of adjunctive therapeutic modalities – basically, anything other than chiropractic adjustment – has become an increasingly important part of chiropractic practice.
Doctors of chiropractic have always been attuned to the use of adjunctive therapies. “As professionals, doctors of chiropractic have utilized adjunctive physiologic therapeutic procedures for decades,” says Glenn D. Manceaux, PT, DC, a member of the ACA’s Council on Chiropractic Physiological Therapeutics and Rehabilitation who practices in Houma, Louisiana. “Obviously, as a non-drug, non-surgical healing art, we searched for and often developed those procedures and techniques that allowed us to address frequently encountered conditions such as pain, muscle spasm, edema, muscle and ligament tightness, and muscle weakness and atrophy.”
The orientation toward adjunctive therapies has only expanded in recent years. Although many of the most common, and still most reliable, adjunctive therapies are passive – done to the patient, rather than with the patient’s participation – an evolving understanding of the importance of strength training and neuromuscular re-education has led many doctors of chiropractic to increasingly emphasize active therapies as part of a patient’s recovery and rehabilitation.
“Personally, I think active approaches are by far the best because they allow the patient to have some control over the pain or dysfunction, which in itself has psychological benefits that enhance what you’re trying to do – return them to normal function,” says David Juehring, DC, DACRB, CSCS, director of the Rehabilitation and Sports Injury Department at Palmer College of Chiropractic. “If you try to ‘chase the pain’ with passive approaches alone, you’re not likely to make any headway on it.”
Timing It Right
Understanding the healing phases of a patient’s condition – from the acute phase to the repair phase to the remodeling phase – is critical to selecting the right adjunctive therapies, says Donald Fedoryk, DC, DACRB, CSCS, also a member of the Council on Chiropractic Physiological Therapeutics and Rehabilitation, who practices in Hillsborough, New Jersey. “The DC needs to know the patient’s current phase of healing and pick the appropriate adjunctive therapies to help the patient progress from passive to active care. If passive therapies are used for too long without progressing to more active therapies, the patient will not achieve the fullest recovery.”
The continuum of adjunctive therapy starts as soon as a patient enters the chiropractic office, perhaps with a recent traumatic injury or the sudden flare-up of a chronic or undiagnosed degenerative condition. The acute inflammatory phase lasts from 48 to 72 hours. In this phase, passive types of adjunctive therapy are most appropriate. They reduce the inflammation, swelling, and pain. That’s the main focus of treatment during this phase since the patient isn’t ready yet to participate in active rehabilitation.
“At this phase, one of the simplest and most commonly used treatments would be applications of cold,” says Dr. Manceaux. “Doctors of chiropractic understand the physiology of inflammation and also recognize that injured skeletal muscle and synovial, diarthrodial joints respond better to cold (ice) therapy during the initial, acute phases of recovery.”
Cold packs or ice – which can be used almost interchangeably to treat inflammations of most injuries a doctor of chiropractic sees, from an acute knee sprain to an acute lumbar strain – help to control symptoms and reduce the inflammatory response with their anti-spasmodic, analgesic, and vasoconstrictive effects. More care must be taken with heat therapy – although it also relieves muscle spasms and pain, its vasodilatory effect can promote swelling and further inflame tissue, so it’s better used during the repair or remodeling phases to relieve sore muscles that are not acutely injured or to stretch tight muscles prior to manipulation.
A number of forms of electrical therapy are also available during the acute injury phase to help bring swelling down and relieve initial inflammation. Among them are microcurrent, interferential therapy, and interferential and high-volt galvanism. “There are multiple forms of electrical therapies that can be used during this phase, forms that differ in their types of current and how they’re applied to the body,” says Dr. Fedoryk. “I think the choice between different electrical therapies is largely a matter of personal preference, based on what doctors may have read in the literature or been exposed to while in chiropractic school. I understand that microcurrent has become more popular lately, but all of the therapies are very effective.”
Many DCs are switching to medium-frequency currents in their electro-therapy, says Dr. Manceaux, because of their versatility. “Having used electro-therapy modalities for over 25 years, I believe medium-frequency currents are universally superior because of safety, depth of penetration, analgesic effects, and the ability to help re-educate and rehabilitate injured, weak muscles,” he says. “Because medium-frequency currents flow transcutaneously through the superficial tissues with less resistance, muscles and nerves can be more easily stimulated with greater patient comfort. Having this modality in the clinical armory can assist greatly with the management of muscle spasm, pain, joint swelling, and muscle rehabilitation.” Less than $2,000 can put a good-quality medium-frequency electro-therapy machine in the DC’s office, he adds.
As the repair phase begins, Dr. Fedoryk explains, the DC should complement spinal adjustment with adjunctive therapies that promote the deposition and formation of collagen and the repair of tissues. Here’s where hot packs and other heat therapies come in, as well as other types of therapy that increase vasodilation and circulation to facilitate new tissue formation and damaged tissue removal. “Ultrasound uses high-frequency sound waves that can penetrate one to four inches, causing vasodilation, increased circulation, and increased heat, while promoting collagen synthesis and deposition to form new tissue,” Dr. Fedoryk says. “It also has a secondary effect of diminishing pain as a result of the vasodilation.”
“Now that ultrasound generators offer dual frequencies of 1 MHz and 3 MHz, the 3-MHz frequency allows better and more focused distribution of ultrasound applications to superficial areas such as tennis elbow, wrist tendinitis, and shoulder bursitis,” adds Dr. Manceaux.
Also effective in promoting heat in the tissues is microwave or short-wave diathermy, although ultrasound has replaced diathermy in most chiropractic practices.
Another type of adjunctive therapy that can be initiated in the subacute phase is traction, which “most mimics the clinical results sought by the chiropractic adjustment,” says Dr. Fedoryk. Traction stretches the spinal muscles and ligaments, decompresses compromised or irritated spinal nerve roots, and increases the biomechanical function of degenerative spinal and discopathic conditions. “The most popular forms of chiropractic-applied traction are cervical intermittent and lumbar flexion-distraction techniques,” says Dr. Manceaux. “Both of these offer an added dimension and can enhance the chiropractic adjustment.”
Indeed, Dr. Fedoryk says, when he asks chiropractic equipment companies where they get most of their business, they tell him that cervical/lumbar traction tables account for as much as 50 percent of their sales these days. “It’s really starting to take off; the 3-D ActiveTrack type of table, in particular, is very popular,” he says. “It works on cervical and lumbar distraction and positioning to decompress the disks.”
With many adjunctive therapies used during the acute and repair phase, says Dr. Fedoryk, more is not always better. “The mistake a large number of DCs make is that they use many of these therapies for too long over the course of treatment, when they should be switching to other therapies that are more appropriate for the specific phase of healing that the injury has reached,” he says. “In other cases, they use therapies that duplicate the physiological response of the therapy just used during the treatment session. You don’t need to do multiple different therapies that all accomplish the same thing.” And fancy bells and whistles on the latest adjunctive therapy machine don’t necessarily mean a better tool. “There will always be equipment and technique peddlers claiming superior clinical efficacy,” notes Dr. Manceaux. “Doctors of chiropractic should use large trade shows as opportunities to see new equipment, and most companies do allow 30-day trials, which should be adequate for evaluation in the clinic. If a procedure relies on sound principles of treatment physiology, it should be safe and rational to use. More complex equipment does not necessarily provide any significantly enhanced clinical results, and that’s the bottom line.”
One particular caveat in the use of any kind of adjunctive therapy is that the practitioner should pay careful attention while taking the patient’s history to determine if there are any contraindications for its use. For example, is there inflammation, infection, cancer, or a pacemaker present in the treatment area? Does the patient have any metallic implants such as pins or screws? Using ultrasound or electrical therapies may be contraindicated in these situations, depending on the application site. “Therapeutic devices can potentially do more harm than good,” says Dr. Fedoryk. “If there’s an infection, heat may facilitate its spread. With patients who have pacemakers, no electrical therapies should be used in the vicinity of the heart. There are lots of factors that doctors need to be aware of in deciding what adjunctive therapies to use with particular patients. Taking a thorough history during the initial visit is one of the most important steps to ensure that the patient receives proper care.
Although all those interviewed tor this article recommend ultrasound, traction, hot and cold therapy, and other modalities as important components of the DCs repertoire, the adjunctive therapies that really excite them are the active modalities. “The most important therapeutic procedure that a doctor of chiropractic can implement into practice is an active therapeutic plan,” says Terry Shaw, DC, DACRB, president of the American Chiropractic Rehabilitation Board and past president of the ACAs Board of Chiropractic Specialties. Dr. Shaw practices in Ouincy, Illinois.
“That’s what we’re looking for in rehabilitation: an active approach to helping the patient get better,” Dr. Fedoryk agrees. “It complements the chiropractic adjustment, which restores joint function, but if you don’t strengthen the surrounding musculature, it will end up becoming subluxated again.”
Indeed, virtually all guidelines on the subject – those from AHCPR, the Quebec Task Force, the Mercy Guidelines, and others – stress the need for an active approach involving neuromuscular re-education, rehabilitation, and exercise. “The functional and psychological benefits are all well documented,” suys Dr. Juehring. “From a guidelines perspective, it’s out there, but from the practitioners perspective, it can be challenging to implement a rehabilitation program. There’s a wide variation in education and knowledge and background, and a lot of people aren’t well-versed in it, nor do they have a comfort level because they just haven’t used it that much.”
The point of all active patient rehabilitation is not only to bring the patient back to full function – or as close as physically possible – after an injury or degenerative condition, but also to prevent the same problem from recurring. “What caused the disk to herniate or the elbow to develop tendonitis? If you don’t correct the patient’s spinal alignment, improve muscular strength, and educate the patient to bend, lift, and do other physical activities properly, he or she will not improve. Combining chiropractic adjustment and other adjunctive therapies with neuromuscular re-education and rehabilitation achieves optimum healing,” says Dr. Fedoryk.
There are a couple of general categories of active adjunctive therapies recognized by CPT coding, including “neuromuscular re-education” and “therapeutic exercise.” What’s the difference, exactly? “Neuromuscular re-education encompasses those procedures where the clinician is attempting to enhance a patients movement, balance, coordination, kinesthetic sense, and/or propnoception for sitting and standing activities,” explains Dr. Manceaux. “For example, if a patient is receiving instruction and active involvement in muscle stretching and slrengthening exercise, it would be more appropriate to bill for therapeutic exercise. If, on the other hand, a patient is rehabbing an ankle sprain and using a ‘wobble board’ or other balance equipment and proprioceptive activities, then neuromuscular re-education is the code to use.”
“Neuromuscular re-education uses a combination of exercises and postural activities to correct muscular imbalances that have resulted due to specific injury or over time because of muscular deconditioning – such as inactivity, sedentary lifestyle, or a repetitive activity,” explains Dr. Fedoryk. “Specific muscles eventually become overactive and hypertonic, while the antagonistic muscle or muscles become weakened and mechanically and neurologically inhibited. This is often referred to as Sherrington s Law of Reciprocal Inhibition.” It’s like putting two people of greatly different weights on a seesaw; the small person on one side can’t do anything. As a result, the body adapts to the new stresses placed on the musculoskeletal system. “This is referred to as the ‘SAID Principle’: Specific Adaptations to Imposed Demands. The specific adaptations, in many instances, develop into altered movement patterns involving the neck, shoulder, back, and hip. These altered movement patterns/muscular imbalances result in musculoskeletal dysfunctions and pain,” he explains.
With neuromuscular re-education, the doctor of chiropractic works to correct these muscular imbalances by relaxing the hypertonic muscle and strengthening the weakened antagonist muscle that has become inhibited over time because the other muscle doesn’t give it a chance to work. “You’re trying to restore the original, correct muscular sequence of coordination balance or muscular contraction when the person moves an arm, walks, or gets up from a chair,” Dr. Fedoryk says. “PNF, or proprioceptive neuromuscular facilitation, involves techniques to improve muscle and joint function. The treatment is geared toward treating the whole body.”
“There are volumes of documentation on the success of rehabilitation programs in minimizing injury and maximizing health,” says Dr. Juehring. “Hence, you see a lot of programs in businesses that are designed to drive premiums down for individuals and companies while you’re increasing a healthy lifestyle. But we still spend more time bringing people back to where they-were, as opposed to preventing the problem from occurring again-or in the first place.”
How can the DC who hasn’t incorporated active patient rehabilitation into his practice get started? One option is to pursue certification courses and, ultimately, diplomate status through the American Chiropractic Rehabilitation Board. “They have various levels of certification, and they’re very contemporary in the literature that’s taught and the current protocols for rehabilitation,” says Dr. Juehring. “I’d really recommend that if you want to integrate rehabilitation into your clinical practice. It’s a tremendous asset to our profession that could be utilized more.”
If the DC doesn’t have the time to devote to further certification, another possibility might be adding a staff member who has a background in rehabilitation. “For example, the DC could hire a recent graduate from a school that teaches rehabilitation or has it integrated into its facility, as Palmer does,” says Dr. Juehring. “Athletic trainers and kinesiologists are also very talented and have a lot of skills to offer in the clinical setting. Or, depending on the size of your facility and your belief system, you could consider adding a physical therapist.”
Adapting the chiropractic practice for on-site rehabilitation programs is not expensive, says Dr. Juehring. “You can start with simple exercise tear-off sheets; there are a lot of companies that will let you prepare customized exercises that you want the patient to perform. At the most basic level, all you need is a room with a mat and clear exercise instructions. The next level could involve therabands and Swiss ball activities, which are very effective in rehabilitation, along with other low-tech, inexpensive equipment like trampolines, balance boards, and BOSU balls.”
Low-tech is just as effective as high-tech in this case, Dr. Shaw agrees, and much less costly. “You’ll probably spend less outfitting your practice for active rehabilitation than you would on an interferential unit,” he says. “If you invest in one or two big gym balls and a couple of small gym balls, some resistance tubes and bands, a flat bench, a stationary bike, and Foot Levelers or Synergy wall tubing systems and any tabletop or stand-alone upper-body ergometer, you could probably put all of that together for under $1,500.”
This doesn’t mean you can just put patients in an equipment room with a list of exercises to perform. “You have to monitor patients and work directly with them,” says Dr. Shaw. He is quick to caution that for any patient, a cardiac risk assessment is an absolute must before the doctor of chiropractic initiates an active rehabilitation program. Blood pressure, medications, and past heart history should be checked. If the patient is over 50, review the treatment plan with his or her family physician. “If there are any red flags, then you need to get a medical clearance before moving into active care,” he notes.
“After that’s done, you can start out by assessing cardiovascular efficiency on a three-minute step test, and then check flexibility with exercises like toe touches and sitand-reach, strength with back arches and abdominal crunches, and so on,” Dr. Shaw says. You can assess balance by having a patient stand on one leg first with eyes open, then closed.” You can usually expect the average patient 50 and under to balance 30 seconds with eyes open and about 15 seconds with eyes closed; for older patients, an adequate response is about half that time.
“What you’re doing with these exercises is assessing proprioception, cardiovascular strength, endurance, and flexibility,” Dr. Shaw says. “Those are the things you want to improve on by putting patients on an active program.”
Once the doctor of chiropractic has established the patient’s baseline levels at the beginning of rehabilitation, a series of exercises can be taught and used both in the clinic and at home to improve all those categories of musculoskeletal function. “You want to incorporate exercises for the lower back and core stabilization to get the abdomen and back strong,” says Dr. Shaw, suggesting seated crunches, side crunches for the transverse abdominals, arch-ups, and the “dead bug” (an extension of the pelvic tilt in which the patient extends alternating arms over the head while, at the same time, lifting the legs alternately to about six inches) as potential core exercises. Working with an exercise ball, he notes, is also an excellent way to improve core stability while improving balance.
Some forms of rehabilitation can be initiated even in the acute or subacute phases, using what’s known as “passive and passive-assist exercises,” Dr. Shaw says. “Say a person has a bad shoulder and can’t lift the arm very far. After the patient lifts it as far as possible pain-free, the therapist can help him lift the arm through an entire range of motion, and then the patient can try to lower it by himself. If it hurts too much, the practitioner helps the patient,” he explains. “Or we can do proprioceptive neuromuscular facilitation-gentle movement patterns that can be used with patients who have acute or chronic conditions or stubborn pain. Having patients repeatedly contract and relax against resistance in a pain-free range will improve the patient’s range of motion and strength.”
With each targeted area and for each exercise, patients should gradually increase their abilities, doing multiple sets with more repetitions as time goes on. “Keep track of their improvement-perhaps the first week they can do one set of 10 crunches. In week two, they may improve to doing three sets of 10. Maybe by week four or five, they’ll be able to do three sets of 20,” Dr. Shaw says. The DC can also document the patient’s progress from simple exercises to more complicated ones, and observe how the blood pressure improves after the three-minute step test.
“During the first week of rehabilitation, the blood pressure may go from a resting rate of 120/80 to 165/90 after the step test and take three minutes to normalize. If after a few weeks of rehabilitation, the patient’s blood pressure after the step test is only 150/85 and returns to normal in two minutes, that’s measurable improvement.”
Here lies the challenge with the simple, low-tech approaches to rehabilitation. They’re effective – but they’re more demanding to document. “These methods do very well when it comes to outcomes and functionality, but the challenge is that it’s harder to document what’s being done,” says Dr. Juehring. “It has a certain subjectivity to it, but there are a lot of data documenting the clinical efficacy of these low-tech rehabilitative methods. The doctor really has to document everything: times, number of repetitions, increased weight, increased endurance time or balance time, and so on.5
Despite strong evidence tor its effectiveness, however, active rehabilitation as an adjunctive therapy still hasn’t been adopted by the majority of DCs. “I think a lot of doctors of chiropractic still don’t utilize stretching and strengthening exercises in their practices to transition the patient from passive care to active care,” says Dr. Fedoryk. “If they improve muscle strength, the spine will function better after the adjustment.”
“Most clinicians tend not to move toward areas that aren’t their primary treatment modality and that they’re not as comfortable with. We’re very similar to a lot of other professions in that way,” agrees Dr. Juehring. “But the evidence is out there: Active approaches with patients are very effective both at returning them to pre-injury status and preventing further injury. The challenge is implementing these principles into practice with the economic realities that we have.”
The Compensation Question
Speaking of those economic realities, when it comes to adjunctive therapies, documentation and proper coding for third-party compensation becomes all the more important since these modalities are not the primary mode of chiropractic care. “You can do all the modalities you want, but in order to get reimbursed, you need to document what you’re doing and how effective it is,” says Dr. Shaw.
For each adjunctive therapy, then, the doctor must tie the therapy in to the symptom or the diagnosis, and document that connection in the patient’s record. “If, for example, someone comes in and he’s been lifting and he has an acute disk in his lower back, document the use of low-setting, low-pulse ultrasound designed to relieve pain without increasing vasculanty and bleeding into the tissue,” Dr. Shaw says. “Document the setting you use, and how long it’s used, in the treatment plan. Use the same approach with all of the modalities, as well as active therapeutic procedures: Record m detail the time, the amount, and the setting.”
One excellent way to establish a record of the improvements in functionality achieved through an active rehabilitation program is through the use of outcomes tools like the Oswestry Index. “Medicare and increasing numbers of insurance companies don’t really care about pain too much-what they want treatment for is the loss of function,” says Dr. Shaw. “The Oswestry and other outcome assessment instruments can be used to document that and the subsequent improvements that go hand in hand with your rehabilitation program.” Dr. Juehring and other experts agree that outcomes assessment tools are one of the best ways to document the effectiveness of a rehab program.
Once the doctor of chiropractic has established a patient’s disability indices using a tool like the Oswestry, he or she can set short-term goals for recovery and restoration of functionality that should be achieved through active rehabilitation. “Perhaps after two weeks, you want to reduce the patient’s lower-back pain by 20 percent, improve range of motion by 15 percent, increase the time during which he can walk or drive a car without pain by 15 minutes, and allow him to return to light duty at work,” says Dr. Shaw. “Then, you establish long-term, four-week goals that should build on those.”
Of course, predicting how much improvement a particular patient is going to achieve through an active rehabilitation program is a “best guess” estimate, “Let’s say in two weeks, the patient has only had 15 percent pain relief and only 5 percent improvement in daily living activities,” Dr. Shaw suggests. “Then, the DC reassesses the patient. Is he progressing? Yes. But is he progressing as well as you wanted? No. So you have to ask why not and document the answers in the treatment plan. Did the patient perhaps exacerbate the injury? Does he have a chronic disease that might not be responding as well as predicted because of its chromcity? The treatment plan requires a rationale to continue with care.”
If the patient is no longer improving, it’s time to move into maintenance or supportive care. But if the DC can demonstrate continued improvement, active rehabilitation can continue-as far as Medicare and the insurance companies that follow its “gold standard” are concerned. “As long as you’re improving both function and pain, and the patient still has some loss of function, some pain or disability, you can continue with treatment,” Dr. Shaw says.
Combining cardiovascular conditioning, strength, flexibility, balance, and nutritional support with adjustments, according to Dr. Shaw, is “the complete plan for any chiropractic patient. There isn’t any adjunctive therapeutic procedure as good as active rehabilitative exercise programs that goes as naturally hand in hand with chiropractic,” he says.
Do Try This at Home
With guidance from a doctor of chiropractic, patients can invest in a few simple adjunctive therapeutic tools to use at home to build strength, improve function, and remain pain-free. Some possible choices include:
The Wrist Wand(R): Many DCs and their patients swear by this simple $15 stretching device, which when used on a regular basis helps to prevent repetitive stress injuries. It can be ordered online at www.wristwand.com.
Stability balls: After learning to use them in the DC’s office or with a sports trainer, patients can use these popular fitness balls to practice a host of core strength, flexibility, and stability exercises. They’re available at almost any athletic store and from many online sources. Make sure your patient has the right size ball for his or her height and weight.
Exercise tubing: Resistive-motion exercise using simple exercise tubes is also available at almost any athletic store. Exercise tubing has been shown to offer pain relief and improve strength and conditioning for patients recovering from many joint injuries. With a couple of sessions’ instruction in the chiropractic office, the patient can be taught to use exercise tubing for almost any upper – and lower – body strengthening exercise. They’re portable, simple to use, and don’t take up nearly as much space as free weights.
Copyright American Chiropractic Association Jul 2003
Provided by ProQuest Information and Learning Company. All rights Reserved