Patient Management

Report
Patient Management
And Patient Education
1
How Dr. Wm. G. Blair Practiced


Chiropractors should Locate, Analyze
and Correct Vertebral Subluxation
To Detect Subluxation…
- NeuroCalograph… 2-3 graphs.
- Need pattern on sequential visits
- Need 1-2 primary Breaks for
pattern.
- Used a prone leg check (only)
2
How Dr. Wm. G. Blair Practiced



List misalignments on x-ray to
categorize them. (1o, 2o, 3o)
1o would be the segment putting the
most distortion on the cord, found off
the APOM through neural canal
measurement.
Only one segment was adjusted at a
time.
3
How Dr. Wm. G. Blair Practiced



“Whatever you are going to do,
Pattern it”, Dr. Blair on Chiropractic
techniques.
Once the first adjustment is given
you lose the information for that
specific subluxation.
You can not rely on symptoms.
4
How Dr. Wm. G. Blair Practiced
Pattern established with 3 graphs taken on
at least 2 separate days no more than 7
days apart.
 Coined the Tern “Slippage”.
- 1 of 2 things will happen
1- Your body will regain control
2- You will subluxate
If Dr. Adjusts while patient is in slippage
they can cause a bigger problem than the
original Subluxation.

5
How Dr. Wm. G. Blair Practiced
What happened when he didn’t adjust?
2 concerns:
1. Your Health
2. My reputation
6
How Dr. Wm. G. Blair Practiced
Patient Management:
 Patient checked 2 times per week until
they held their adjustment for 6 weeks.
 Then 1/wk until they held their
adjustment for 6 weeks.
 Then 1x/2wks. Until they held their
adjustment for 8 weeks.
 If they didn’t comply, they weren’t allowed
to be seen. (checked 90 patients per day)
7
How Dr. Wm. G. Blair Practiced

1.
2.
3.
If patients missed an appointment:
They were called to reschedule
They were called to reschedule
They were written a letter and released
from care.
“Never let it be economical to miss an appointment”
He had sick people to take care of and didn’t
have time to mess around. Remember,
he was living on borrowed time.
8
How Dr. Wm. G. Blair Practiced


If you keep seeing pattern, you are
missing something.
If legs are short but there is no
pattern, the patient is not checkable.
9
Upper Cervical Protocol
Blair Technique
in the Palmer Clinics
In your Clinic
10
Patient Management





1st Visit
Consultation, Exam and X-ray
2nd Visit
(Finish X-Ray if needed) ROF and 1st
adjustment Schedule of Care for visits
3rd-11th visits
Visit 12
Documents
11
1st visit

1.
2.
3.
4.
5.
6.
7.
Consultation
Ask name
Acknowledge referral
Introduction to chiropractic care
8 parameters
Listen to what they say then ask direct
questions
Look at (touch) symptom area
Patient “Yes – Yes” agreement
12
Communicating with a Patient




Speak in language they can understand.
Most every word you use, they should
already know. If they have to think about
the meaning of words, they wont hear the
meaning of what you are saying.
NEVER lie to or mislead your patients.
Never try to scare them into care.
Be honest about what you do, what you
can do to help and what your limitations
are.
13
Explanation of Chiropractic

Chiropractic is a conservative form of
health care. We do not prescribe
drugs or perform surgeries. If we
feel that is necessary for you, we will
refer you to those who specialize in
those areas.
14
Explanation of Chiropractic

Everything that happens in the body starts
with the brain. The brain uses the brain
stem, spinal cord and peripheral nerves to
link every tissue, organ and cell to the
brain. We call this system the nervous
system. It is very important to the body.
So much so that the body as built a skull
to protect the brain, and 24 bones in the
spine, plus the tail bone, to surround and
protect the spinal cord.
15
Explanation of Chiropractic

The problem with this is that every
now and then these bones of the
spine will become stuck, locked, or
just not move as freely as they were
designed. When this happens, the
communication along the nerves in
that area become irritated causing a
“short circuit” or “static on the lines”.
The communication from the brain to
the body becomes compromised.
16
Explanation of Chiropractic

In chiropractic we call this “bone out
of place and irritation to the nervous
system” a Vertebral Subluxation
Complex or a “Subluxation”.
17
Explanation of Chiropractic

A subluxation may have symptoms
around that joint such as pain,
muscle spasms and/or swelling.
However, you may not have
symptoms at all. For example, if the
nerves to the heart are
compromised, you may not notice
the symptoms until you are
experiencing high blood pressure.1
18
1. Bakras
Explanation of Chiropractic


The goal of chiropractic is to take the
irritation off these nerves by finding
and correcting the bone(s) that are
causing the problem. To allow your
spine to function the way it is
supposed to so your body can
function the way it is supposed to.
Now, that being said, how can I help
you?
19
History




The patient explains his/her problem.
Doctor gets out of your chair and
looks at the area of complaint (if
applicable).
8 parameters
Explain to the patient what will
happen for the rest of the visit
(exam and possible x-rays)
20
1st visit Exam
Patient Agreement
“You need to have a condition we treat.
Chiropractors treat subluxation. Which is a
misalignment of a spinal bone that causes
nerve pressure. Wherever that nerve goes
you may have problems with that area.”
“We need to find the cause of your
symptoms and any secondary problems (what
condition you’ve gotten yourself into)”
C. “Once we find out what is going on I will be
able to tell you if and how I can help”
Exam:
a. Orthopedic
b. Neurologic
c. Chiropractic
21
1st Visit
5.
Exam (Give pt a brief explanation of what you are looking for)
a. Orthopedic
b. Neurologic
Do as much as you can while the patient is in one position
c. Chiropractic
- Thermography
– Leg Checks
- Palpation
d. Organic vs. Non-organic
6.
Explanation
22
NECK BOURNEMOUTH QUESTIONNAIRE
Patient Name ________________________________________________
Date ___________________________
Instructions: The following scales have been designed to find out about your neck pain and how it is affecting you. Please answer ALL the
scales, and mark the ONE number on EACH scale that best describes how you feel.
1. Over the past week, on average, how would you rate your neck pain?
No pain
Worst pain possible
__________________________________________________________________________________
0
1
2
3
4
5
6
7
8
9
10
2.Over the past week, how much has your neck pain interfered with your daily activities (housework, washing, dressing, lifting,
reading, driving)?
No interference
Unable to carry out activity
___________________________________________________________________________________
0
1
2
3
4
5
6
7
8
9
10
Over the past week, how much has your neck pain interfered with your ability to take part in recreational, social, and family
activities?
3.
No interference
Unable to carry out activity
___________________________________________________________________________________
0
1
2
3
4
5
6
7
8
9
10
4. Over the past week, how anxious (tense, uptight, irritable, difficulty in concentrating/relaxing)
Not at all anxious
Extremely anxious
___________________________________________________________________________________
0
1
2
3
4
5
6
7
8
9
10
5. Over the past week, how depressed (down-in-the-dumps, sad, in low spirits, pessimistic,
Not at all depressed
Extremely depressed
___________________________________________________________________________________
0
1
2
3
4
5
6
7
8
9
10
unhappy) have you been feeling?
6. Over the past week, how have you felt your work (both inside and outside the home) has
Have made it no worse
Have made it much worse
___________________________________________________________________________________
0
1
2
3
4
5
6
7
8
9
10
7. Over the past week, how much have you been able to control (reduce/help) your neck
Completely control it
No control whatsoever
___________________________________________________________________________________
0
1
2
3
4
5
6
7
8
9
10
have you been feeling?
affected (or would affect) your neck pain?
pain on your own?
________________________________
_________________________________
Patient Signature
Examiner
OTHER COMMENTS: _________________________________________________________________________________________________________
With Permission from: Bolton JE, Humphreys BK: The Bournemouth Questionnaire: A Short-form Comprehensive Outcome Measure. II. Psychometric
23
Properties in Neck Pain Patients. JMPT 2002; 25 (3): 141-148.
http://64.233.167.104/search?q=cache:AAv7g1HZdb4J:www.outcomesassessment.org/Bournemouth%2520Neck.pdf+Bournemouth+
Questionnaire&hl=en&gl=us&ct=clnk&cd=1 (Accessed 9-25-2006)
Exam
Points of Interest for
Evidence Base Practice
(It is not recommended that you
perform all of these tests on
every patient. All exams should
be modified to the individual
patient)





Posture
3 minute step test
One leg balance test
Hamstring length
Thomas test
• Psoas
• ITB
• Quads
24
Organic vs. Non-organic


1.
2.
3.
4.
5.
Organic signs (ortho-neuro-chiros)
Non-Organic Signs (Waddell signs)
Superficial or nonanatomic tenderness —widespread
sensitivity to light touch, and pain referred to other areas.
Simulation—axial loading (light pressure to the skull should not
significantly increase low back pain. Passive rotation of the
shoulders and pelvis together in a standing patient should not
reproduce low back pain.
Distractions—difference of 40 to 45 degrees between the supine
and seated straight leg raising tests.
Regional disturbances —sensory or motor disturbance ("giving
way") that is not neurologically correlated.
Overreaction—inappropriate overreaction such as guarding,
limping, rubbing the affected area, bracing oneself, grimacing, or
sighing are all signs of illness behavior.
25
Evaluation of muscular imbalance


Posture – Important for a starting point
for spinal stability
3 minute step test – Pre and Post HR
• Avg. Men bpm = 101-115, Avg. Women bpm = 112-120




One leg balance test – 30 seconds
Hamstring length Grip Strength – 47-49K g
Thomas test • Psoas
• ITB
• Quads
Yeomans S. Yeomans Way to physical fitness with permission
of the YMCA of the USA, 101 N. Wacker Dr., Chicago, IL 60606
26
Physical Performance Ability
Mobility Tests
 Ankle dorsiflexion mobility/gastrocnemius and
soleus length
 Knee flexion mobility/quadriceps length (Nachlas
test)
 Hip flexion mobility/hamstring length (Straight
leg raise test)
 Hip extension mobility (modified Thomas test/
psoas-rectus femoris length)
 Hip rotation mobility (internal and external)
 Lumbar spine mobility
 Cervical spine mobility
27
Liebenson C. Rehabilitation of the spine, a practitioner’s manual second
Edition. Lippincott Williams & Wilkins, Philadelphia, Pennsylvania. 2007
Strength/Endurance
1.
Squat Endurance Test
a. Repetitive
b. Static
2.
Trunk Flexor Endurance Test
a. Repetitive Sit-up endurance test
b. Static quarter sit-up test
c. Isometric sit-up test
28
Liebenson C. Rehabilitation of the spine, a practitioner’s manual
Second Edition. Lippincott Williams & Wilkins, Philadelphia,
Pennsylvania. 2007
Balance/Motor Control

One Leg Standing
• Eyes Open (30 sec.)
• Eyes Closed (21-28
sec.)
• Tested with each leg
Document your Findings
29
1st Visit
Thermography,
“Here we have 2 infrared
cameras mounted on a
wheel. I am going to bring
this up the back of your
neck. John Hopkins
University tells us that the
heat coming out of each side of your spine
should be off by no more than .3o C. If it is
more than .3o C, there is something going on
we need to take a closer look at.”

30
Thermography


We then look at the differential temperature and
the absolute temperature of the right and left
sides.
Each visit we will take the temperature of your
spine. Eventually we will want to see the lines
becoming straight. However, it is not uncommon
for the scan to have some major deflection due
to the change in blood flow after the first few
corrections. If an area hasn’t been getting the
blood supply it needs, the increase in blood flow
after the adjustment will cause us to see a large
swing on the graph.
31

Leg Checks, 1st
explain posture and
the short leg (Clark
Poster). Have the
patient prone and do
all leg checks
Prone Leg Checks: “I’m going to be looking at your feet to see
what’s happening with your spine. When you are standing we notice
the high hip and shoulder. When you are lying down, we notice a
short leg; due to the contracted muscles of the pelvis and spine being o
of balance. I am going to isolate and stress these muscles along your
spine, what we call para-spinal muscles. These tests will help me
locate the muscles and nerves involved with your condition so we
can find the cause of your problem.”
32
Palpation:
 palpate the spine.
 Make sure patient knows when you have
found what’s wrong.
 palpate the chief complaint.
 Follow the Protocols of Palmer and record
your findings. Document your findings.
 When you locate t&t fibers don’t be afraid
to ask your patient about them. This will
confirm that you have found something.
33
st
1
visit
Explanation:
“What we have found is you do have a spinal
subluxation in your neck that is causing a reflex in your
spine and pulling it out of balance. When we isolate
these nerves & muscles, your spine and legs are
unbalanced. When I take these nerves & muscles out
of the equation, your spine balances and your legs
become level.”
“So now we know where the problem is. What we need
to know is how to fix it. That’s what the x-rays are
for.”
“We take the most diagnostic set of x-rays,
Chiropractically or Medically, for an articular
misalignment of the spine. When we are finished we
will know exactly what’s going on with every one of the
17 joints in your neck”.

34
1st visit

X-rays
Base Posterior First
APOM, AP and Lateral
Stereo Laterals
Protractos
35
1st Visit


Dismiss for 1st day
Tell them what to expect for the
second day.
“It will take me approximately 1 hour
to go over with you everything we
have found today and give you your
adjustment.”
-Give icing instructions if needed
36
Blair Upper Cervical
Spinographic Analysis Sheet
37
2nd Visit

1.
2.
3.
4.
ROF –High points of ROF
Welcome Back
What is a Subluxation (KISS)
What we found (Good & Bad)
How we are going to help (stages of care
and frequency)
5.
6.
7.
Program of care
Patient’s Responsibility
Informed Consent
(Follow instructions)
38
Explanation of X-Rays
Explain the x-rays by starting with the APOM and Lateral in the view box.
Explain the findings of the x-rays in plain terms the patient can understand.
39
Explanation of X-Rays
If you want to show them
your protracto views, bring
them out, explain that
“these are the pictures we
take to give us the exact
position of the first neck bone”. You can show them the Atlas and Condyles
But do not go further. They will be confused and loose focus. I them I
“used to explain more but found patients just got a headache, however, if
40
they want” me to explain more I will.
2nd Visit




Adjustment – explain what will
happen and show the drop headpiece
Rest – Take them back and have
them rest (Dr. should do this the first
time)
Re-check after first adjustment
Have patient schedule for 1st stage of
their care
41
Explaining the Adjustment


You are going to lie on your side with your
head resting on this headpiece.
I am going the lift up on the headpiece
(cock the headpiece), tap on your neck
like this (with your finger, tap on the
patients arm mimicking the adjustment)
and the table will drop (push down on the
headpiece, it will make a noise when it
drops). You will hear that noise, and it will
be load because your ear is right there.
42
Explaining the adjustment


Most people don’t feel much during the
adjustment. You may not feel much more
than the headpiece drop. What we want is
the type of physics that by being light and
quick with the adjustment, it would be like
pulling a cloth out from under a vase of
flowers. We can get the bone to move
without having you feel much of the
correction at all.
After the adjustment I would like you to
hold still for a few moments. I will tell you
how to get up off the table when it is
time.
43
Program of Care

Initial Frequency:
3 times per week for 2 weeks, followed by
2 times per week for 4 weeks, followed by
1 time per week for 6 weeks.
 Re-Exam in 6 weeks
includes a Neutral Lateral Spinograph
Goals: Should include Functional ADL

1st 2 weeks is pain relief, next 10-20 are corrective
and strengthening care, further care is typically
supportive… however, every case is an individual
and a longer corrective and strengthening phase
may be necessary.
44
Care Management:
Daily Check List
Daily Office Visit
 Graph
 Prone Leg checks
 Document
 Review Symptoms
 Review Pt. Mgmt.
Protocols
 Course for care
 Teach time
 Adjust
6 Points
 Pt tells what’s wrong
 Dr. Show what’s wrong
 Fix what’s wrong
 Pt acknowledges fix
 Make smile (One liner)
 Give hope (but don’t
lie)
45
Patient Management Protocol:
 Reduce Subluxation
(Adjust when indicated)
 Allow Healing to Take Place
(Lesions heal, scar tissue to
form) Stop Inflammation
(Cont. Adjusting, Ice,
Biofreeze)
 Passive ROM Stretching
(Dr. Motions Joints)
 Restore Posture
 Active ROM
Stretching/Exercises
(Chin Glide, ROM stretching)
 Restore Strength in
Muscles/Ligaments
 Restore Balance and Coordination
 Restore Aerobic Conditioning
 Restoration of Spinal
Biomechanics
(Re x-ray – C-spine, Flex/Ext)
 Active Daily Living Rehabilitation
(For Pt. Specifically) Start Back
into Sport/Job/ADL
 Return to Normal Function
(Objective testing to indicate end
of repair treatment)
Exercises Given:
(Both Patient and File need a copy)
46
Care Management:
CHIROPRACTIC EDUCATION






Subluxation
Tytron Thermographic
scan
Leg Checks
Safety Pin Cycle
Educate Patient of Injury
(ROF, Class, Video, Brochure)
Stop Patient From
Hurting Themselves
PRACTICE MANAGEMENT
 Thank Referral
 Share the Secret
 Dz of the week
 Get excited about pt
results
 Red Cross Certified Back
Care Instructor
(Instructions for Lifting, ext.)

Educate Patient on How
to limit Regression
(Follow up Health Care Instructions)
47
Care Management:
Upper Cervical Care in the 21 Century
What is it about?
1. Detecting and Correcting
Subluxations
2. Focus on Keeping the Spinal
Correction as long as possible
3. Evidenced Based Practice/Care
48
Detecting and Correcting
Subluxations




Tytron Thermographic Pattern
Analysis (Subluxation Present)
Specific Blair Spinographic
Radiographs (Misalignment)
Leg length Indicators (Segment
involved)
Monitor the Patient’s progression
through the cycles of healing
49
Evidenced Based Practice/Care


Use Questionnaires (Oswestry,
Bournemouth) to follow progression
of patient.
Perform examinations that can
actually help you with the evaluation
of the chiropractic patient.
• Steve Yeoman’s Text “The Clinical
Applications of Outcomes Assessment
(www.yeomansdc.com)
50
Using Functional Performance
Tests





Safety – Protecting patients from injury
Reliability – Test scores are dependable
across the evaluation
Responsiveness – Tests should uncover
meaningful deficits in patient’s condition
Validity – Test scores can predict the
response to care by the patient
Practicality – Tests are easy to administer
and exercises are easily preformed.
51
Focus on Keeping the Spinal
Correction as long as possible





Teach patient proper posture
Teach patient how to lift, sit, work…
Use exercises that are focused on
improving patient’s functional deficits
Exercise (just do something)
Bracing, Taping
52
Teach patient proper posture
53
Teach patient proper posture
Have patient do the cat and camel exercise
54
Bracing, Taping
55
If you are to Adjust to the Lower Spine
(The Blair technique does not recommend adjusting the lower spine. However, each DC
must make the decision of how they will practice chiropractic with their patients. This is
my recommendation if you feel you must adjust the lower spine.





Give it at least 2 weeks before you do anything (longer if the
patient lets you) allow for the body to correct itself.
Monitor the spine to confirm a consistent and persistent problem.
Indicators must show up for more than 2 visits in a row.
Use the Tytron C3000, Dual Probe or stress/pressure checks to
confirm neurologic interference.
I have found that I have lost control of my patient care more often
when I have adjusted the lower spine before the body was ready
to correct it. I tried to give the patient a little pain relief and end
up causing a bigger problem.
Once you have given the lower spinal adjustment, monitor the
patient closely to control the reaction to the new adjustment. Do
not get in the habit of multiple manipulations up and down the
spine on every visit.
56
Putting it all together: Visits 3-12
Biggest complaint from doctors who
turn a full spine or mixing
practice into an upper cervical
practice is that they do not see
their patient’s enough or see
enough patients to make it
work.
Here is a simple example of how it
works:
A complete history and Initial
Examination
1.
Adjust the patient when needed
and leave them alone when
needed
2.
Help the patient help
themselves by leading them
through the development of a
healthier lifestyle.
a. Functional improving
exercises
b. Referrals when needed
c. Re-evaluate your patient on
a timely basis and MANAGE
their care.
Something to think about:
CPT Code:
98940
98941
RVU:
.69
.96
97110
97530
.74
.77
57
Converting Blair Listings to Palmer
Listings:
C1:
ASR
ASL
PIR
PIL
=
=
=
=
ASR
ASL
AIR
AIL
Lower
PRI =
PLI =
ARS =
ALS =
Cervicals:
PR
PL
Sp-R, ESR
Sp-L, ESL
To be used if you are being observed by a doctor not comfortable with
The Blair technique or if it is a medicare patient where a staff doctor has
To adjust the patient.
58
59

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