WELLNESS CLINICS - YOUR PRACTICE PARTNER Issue 1: January 20, 2020 chiroeco.com - Chiropractic Economics
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YOUR PRACTICE PARTNER
Issue 1: January 20, 2020 chiroeco.com
WELLNESS
CLINICS
Moving Chiropractic into 2020
CBD for New DME Point-Counterpoint:
Inflammation Rules on Pediatric
and Anxiety Horizon Chiropractic
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V O L U M E 6 6 , I S S U E 1 • J A N U A R Y 2 0 , 2 0 2 0 • TA B L E O F C O N T E N T S
FEATUREDCONTENT
18 Positioning chiropractic for 52 Case study: Modern chiropractic,
wellness in 2020 laser therapy helps powerlifter to record year
The industry needs to shore itself up on Formerly-debilitated patient returns to competition at age 71
several fronts to enter the mainstream BY JEROME RERUCHA, DC, BS, CSCS, CHPS
BY TIMOTHY J. BURKHART, DC, BCIM, AND
RYAN M. BURKHART, BS, DC
70 Book reviews, latest releases
8 books by chiropractors, for chiropractors
40 How CBD supports health during pain, BY CHIROPRACTIC ECONOMICS STAFF
inflammation, anxiety and more
An endocannabinoid deficiency can result
in a host of patient afflictions 76 Buyers Guide: Supplies
BY CHRIS D. MELETIS, ND
PROFESSIONALDEVELOPMENT
ST U D E N T D C
64 Mentoring benefits the mentor and mentee 72 Point-Counterpoint: Pediatric Chiropractic
From CAs to office staff to fellow DCs, mentoring and finding
a mentor has wide-ranging benefits to the profession
BY GARY BORING, DC, BCOA, LCP (HON.), FICA
PERFECTPRACTICE
C L I N I C A L CO N C E R N S P R AC T I C E C E N T R A L
28 Lower extremities and 46 How to avoid burnout
Follow these tips to extend your career
whole-body wellness and retire on your own terms
Even a neck or upper-back issue can start at the feet BY JAMES R. FEDICH, DC
BY KEVIN WONG, DC
F I N A N C I A L A DV I C E
34 Chiropractors beware 58 2020 Medicare DME changes
Employment laws that formerly exempted
small offices are changing and chiropractic
BY KEITH GUTSTEIN AND KAITLIN SILLETTI New competitive regional DME provider bidding on
patient care is coming — how to minimize the impact
BY CHIROPRACTIC ECONOMICS STAFF
“DCs are uniquely positioned to
help address the growing opioid
crisis, skyrocketing health care
costs, generally poor allopathic BACKLOG EVERYISSUE
management of musculoskeletal 14 H ealth News, New 8 Letter from the Editor
Technology, Awards
injuries, and chronic pain.” & Practice Advice
10 ChiroEco.com Resources
— Jason Garrett, DC, managing vice
74 Product Showcase
14 Don’t-Miss Events
76 Buyers Guide
president of Airrosti 15 By The Numbers:
Wellness 84 Datebook
15 Staff Product Pick 86 Marketplace
15 Profitable Practice 88 Ad Index
PHOTO CREDITS: ALL IMAGES ARE FROM ADOBESTOCK.COM UNLESS OTHERWISE NOTED.
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6 CHIROPRACTIC ECONOMICS • JANUARY 20, 2020 CHIROECO.COM
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LETTER FROM THE EDITOR
NEW POLL SHOWS THE “...AMONG GENERAL AND FAMILY PRACTICE PHYSICIANS,
LANDSCAPE HAS CHANGED?
THE MOST COMMONLY-RECOMMENDED WAS CHIROPRACTIC
We are in the midst of an inte- OR OSTEOPATHIC MANIPULATION...”
grated medicine revolution where
MD slander and attacks on chiro- reason: doctors were prescribing — and the industry was supplying
practic, for the most part, are being — stronger pills.”
cast aside in the best interests of Also introduced last year was The Chiropractic Medicare Coverage
patients. We’re increasingly seeing Modernization Act of 2019, which could align Medicare’s coverage of
MDs, DCs, PTs, etc., working side by chiropractic services with other federal health care providers.
side in facilities that have broken
LET ME KNOW WHAT’S down the walls of health care. New poll shows changing attitudes
ON YOUR MIND: But perhaps the best news for integrated medicine and chiro-
EDITORIAL@CHIROECO.COM MD attack dogs still remain practic emerged last month when a study published in the Journal
The AMA for years waged a coordi- of Alternative and Complementary Medicine revealed that U.S.
nated campaign to destroy chiropractic, “a plan of containment physicians were recommending CHAs (complementary health
and elimination by the American Medical Association” that approaches) to their patients at a significantly-increased rate.
became embedded in its MD membership.¹ The 2012 Physician Induction Interview of the National
This coordinated effort and mis-education is largely aging Ambulatory Medical Care Survey was used to assess whether
out of the profession, but is unfortunately continued today U.S. physicians recommend CHAs to their patients, and showed
by a handful of MDs through coordinated websites such that among general and family practice physicians, the top most-
as ScienceBasedMedicine.org and PainScience.com. In a commonly-recommended CHA was chiropractic or osteopathic
review of the book The Medical War Against Chiropractors, manipulation (54%). “These findings may enable consumers,
ScienceBasedMedicine.org itself admitted, “The AMA did some physicians, and medical schools to better understand potential
very regrettable things. They used inappropriate language, differences in use of CHAs with patients,” the authors write. And
referring to chiropractors as rabid dogs. They attacked surely the numbers have advanced additionally over the last eight
chiropractors as killers without any supporting evidence. Their years since the survey.
intent was to destroy chiropractic. They tried to conceal what These findings may also indicate that a new generation of
they were doing. Their biggest mistake was to prohibit MDs from doctors, like their patients, are ready and willing to embrace an
associating with chiropractors … The AMA distributed ‘Quack integrated care and wellness approach that is patient-centered.
Packs’ and 10,000 copies of an anti-chiropractic book…”² We’re 33 years removed from United States District Judge Susan
The remaining modern attacks by these websites end up in Getzendanner ruling that the AMA and its codefendants were guilty
publications such as Forbes, the Washington Post and Wired, of violating the Sherman Antitrust Act and that in the ruling “the
and on television on CNN and Dr. Oz. The industry’s Foundation AMA decided to contain and eliminate chiropractic as a profession”
for Chiropractic Progress (F4CP) responded to all these outlets’ and “to destroy a competitor.”
attacks in 2019, refuting false claims with facts. As all health care entities in 2020 deal with a difficult, ever-
changing landscape, statistics show we’re moving on from turf
The good news … and more good news battles to find ideal multidisciplinary solutions for patient care.
In 2019 we saw the U.S. government recommend opioid patients
referred to DCs for pain management, and a crackdown on To your practice’s success,
opioid manufacturers who recruited and encouraged some MDs
to up their prescriptions to further hook consumers.
As Fortune reported last year, “In 2012, as the death toll from
the nation’s opioid crisis mounted, drug companies shipped out Richard Vach
enough of the powerful and addictive painkillers for every man, EDITOR-IN-CHIEF
woman and child in the U.S. to have nearly a 20-day supply. The References available at chiroeco.com.
EDITOR-IN-CHIEF DIRECTOR OF SALES Creighton Blanchard
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SOCIALMARKETING FACEBOOKQUESTION
Be known as a one-stop shop 17,014 followers
for whole-body wellness What services do you offer patients besides adjustments?
What are your most popular of these services?
Many people think of chiropractors as spine specialists only — so if you are expanding your practice
with other therapies, use social media marketing to position yourself not only as a spine doctor, but
also as a practitioner of a whole-body wellness approach.
Consider all the services your practice currently offers besides adjustments. This may include
nutrition counseling, weight loss, massage therapy, assisted stretching, chronic pain interventions,
headache help, muscle and joint injury or disorder treatments, laser therapy, TENS therapy or
custom orthotics, just to name a few. You probably also carry a range of dietary supplements and
other retail products.
Instead of cramming all your products and services into one ad, consider creating specific
marketing materials for each service you offer, then promote them individually using your social media
networks. Patients may be coming to your practice for an adjustment and a massage, for example, but
may not know you can provide them with help losing weight or managing headache pain.
Use your Twitter, Facebook, Instagram and other social channels for promoting your ancillary
services, via photos and video clips with appropriate hashtags. Any one of your services could bring
in a new patient who can then find out all that your practice has to offer. Each month we’ll ask a new question on our Facebook page.
For more information on social media marketing, visit the Business Tips section of ChiroEco.com.
Join the conversation at facebook.com/ChiroEcoMag
TWITTER DISCUSSION MISSED THE LAST ISSUE?
What is the best way to educate potential 2020 BUYERS GUIDE
patients on the value of chiropractic care? The best in chiropractic
products, services and
Use the hashtag #CE65 companies serving the
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Tag #ChiroEcoMag for your chance to be featured
palmercollege
Are chiropractors real doctors? It’s a question our profession is
asked often so we want to be a part of the solution in educating
the public. The answer is “Yes!”
chiroecomag
Life isn’t perfect, but after an adjustment it definitely feels a little closer!
dc.macphee
Chiropractic isn’t just for your spine! We treat chirowell250
extremities as well. Adjusting the ankle can Make your appointment with us today. Your health is our letschalkaboutchiropractic
help restore mobility and reduce pain. TOP priority! Get adjusted and then TACO ‘BOUT it with someone!
meridian_chiropractic_mn
Bookmark this shoulder stretch for later!
chamberlainchiro drhansen_rhinochiropractic
I don’t know about who your chiropractor is but I sure know that Chiropractic adjustments help to drbraglia
the doctors at our office are totally awesome! relieve stress in several ways. When things change inside you, things change around you too.
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BACK CATCHING UP ON THE LATEST NEWS, TRENDS AND
INNOVATIONS FROM THE CHIROPRACTIC COMMUNITY
“ONE KEY TO [PATIENT] LIFESTYLE CHIROPR AC TIC N E WS
CHANGES IS EDUCATION. IT IS OUR
RESPONSIBILITY TO INTERPRET New UnitedHealthcare benefit for low-back pain
CURRENT HEALTH INFORMATION, reduces invasive procedures, addresses opioid epidemic
EVALUATE THAT INFORMATION AND
PROVIDE OUR PATIENTS THE HIGHEST On Oct. 29, UnitedHealthcare announced a
QUALITY CARE…NO MATTER WHAT new benefit for people with acute low-back
THE LEVEL OF AN INDIVIDUAL’S pain that makes it more affordable to access
HEALTH, WE CAN IMPROVE UPON IT.” physical therapy and chiropractic care,
helping to improve health outcomes, reduce
— SHANE SILVER, DC,
ON CHIROPRACTIC AND WELLNESS costs and avoid often unnecessary invasive
treatments and opioid prescriptions.
DON’T MISS
CONFE RE NCES With this new benefit design, plan
Parker Seminars Las Vegas participants enrolled in certain employer-
February 6-8 • Las Vegas, NV sponsored health plans can pay $0 out-
The Expo Hall at Parker Seminars in of-pocket (waived deductible or copay) if
Las Vegas will showcase more than they select physical therapy or chiropractic
200 industry-leading companies care for the treatment of low-back pain, noninvasive treatments such as physical
displaying the latest advancements and helping encourage people to choose these therapy and chiropractic care. For example,
technology that will allow chiropractors noninvasive options.* people with a co-pay of more than $30 were
to stay ahead of the competition. Based on a UnitedHealthcare analysis, by 29% less likely to see a physical therapist
This year the theme is Mastery, so 2021 this benefit design has the potential to than patients whose co-pay was $0. There
join industry movers and shakers for reduce the number of spinal imaging tests was a similar correlation between deductible
a weekend of education, networking, by 22%, spinal surgeries by 21%, opioid use and choice of physical therapy as the care
entertainment and much more. by 19%, and lower the total cost of care for option for low-back pain, according to a
eligible plan participants and employers.1 recent study published in The American
Activator Methods International: “This new benefit design may help Journal of Managed Care.
Hawaii Seminar encourage people with low-back pain [to] get Nearly 70% of people experience low-
February 22-23 • Honolulu, HI the right care at the right time and in the right back pain at least once in their lifetime, and
The Hyatt Regency Waikiki Beach setting, helping expand access to evidence- about one-quarter of adults in the United
Resort & Spa hosts the seminar, based and more affordable treatments,” said States report experiencing the condition in
featuring clinical topics such as Internal Anne Docimo, MD, UnitedHealthcare chief the past three months.2, 3 Despite clinical
& External Rotation of the Proximal medical officer. “With millions of Americans recommendations against it, opioids are
Tibia, Anterior, and Posterior Proximal experiencing low-back pain currently or prescribed for nearly 9% of new back-
Tibia; Inferior, Lateral & Medial Patella; at some point during their lifetimes, we pain cases, with this condition ranking as
Inferior First Metatarsal and Inferior believe this benefit design will help make a the most common reason for an opioid
Medial First Cuneiform, Inferior meaningful difference by improving health prescription.4
Metatarsal Heads; About the Shoulder, outcomes while reducing costs.” To treat low-back pain, the American
Frozen Shoulder Syndrome, Rotator Cuff The benefit covers, at no additional out- College of Physicians (ACP) recommends
Involvement; and more. of-pocket cost, three physical therapy or exercise and the use of non-pharmacologic
chiropractic visits, along with additional and non-surgical approaches including
WEBINAR visits normally covered under the plan, to physical therapy, chiropractic care,
CBD to Support Pain and a qualified care provider. This design helps acupuncture and nonsteroidal anti-
Inflammation, Adrenal make it more affordable for people with inflammatory drugs.5
Fatigue, and Anxiety low-back pain to obtain treatment from * Eligible plan participants must have
On Demand chiropractors and physical therapists in remaining physical therapy or chiropractic
Dr. Chris Meletis helps separate the UnitedHealthcare’s network. visits under their plan; the new benefit design
hype from the science, helping DCs The benefit design was informed by does not increase the maximum number of
thrive with insights into how the a recent analysis by OptumLabs and the covered physical therapy or chiropractic visits
endocannabinoid system functions. Boston University School of Public Health per year.
Watch now at ChiroEco.com/cbdpain. that showed higher out-of-pocket costs
made it less likely for patients with low-back Read more: ChiroEco.com/new-uhc-benefit
Learn more at ChiroEco.com/events. pain to choose clinically-recommended References can be found online at chiroeco.com
14 CHIROPRACTIC ECONOMICS • JANUARY 20, 2020 CHIROECO.COMINDUSTRY NEWS BY THE NUMBERS:
Manual therapy providers
attend spine conference
WELLNESS
“For the last three years, life expectancy in the United States, the richest
nation on Earth, has declined. This decline in life expectancy is being
driven by rising death rates in young and middle-aged Americans.”
57%
— The Washington Post
More than 160 members of the chiropractic,
physical therapy and osteopathic professions
forged a new spirit of cooperation and Americans who see sleep as a
understanding during the Interprofessional “luxury” and not a necessity
Collaborative Spine Conference (ICSC), which Source: National Sleep Foundation
678,000
took place Nov. 8-9 in Pittsburgh, Pa.
Organizers of this event hope to enhance
patient outcomes as well as increase People who die each year due to an unhealthy diet
integration of manual therapies for back pain Source: The Center for Science in the Public Interest
$15,000
in the wake of the ongoing opioid crisis.
ICSC was organized and hosted by the
American Chiropractic Association, with
the support of the American Academy of
Orthopaedic Manual Physical Therapists and
the Academy of Orthopaedic Physical Therapy,
which represent three of the major provider
groups of non-drug manual therapies for pain.
Manual therapies such as spinal Approximate health care costs per U.S. employee annually
Source: National Business Group on Health
3outof4
manipulation, physical therapy modalities,
massage and acupuncture have received
increased attention and support in recent
years from the Centers for Disease Control
and Prevention and the American College
of Family Physicians for their ability to
effectively manage many cases of back pain
and in some cases reduce or alleviate the
need for prescription opioids. Employers who say health care apps have
“The chiropractic profession was honored increased their employee participation
367%
Source: National Business Group on Health
to take part in the Interprofessional
Collaborative Spine Conference,” said Michele
Maiers, DC, MPH, PhD, vice president of the
ACA. “We are committed to working together
with our colleagues in physical therapy and
osteopathy to raise awareness and promote
integration of non-drug manual approaches.”
Read more: ChiroEco.com/icsc
Increase in internet searches for CBD information in 2019
Source: Gear Hungry
CHIROECO.COM JANUARY 20, 2020 • CHIROPRACTIC ECONOMICS 15BACKLOG
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Palmer College of Chiropractic opens new student clinic
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FEATURESTORY POSITIONING CHIROPRACTIC FOR WELLNESS IN 2020 The industry needs to shore itself up on several fronts to enter the mainstream B Y T I M O T H Y J . B U R K H A R T, D C , B C I M , A N D R YA N M . B U R K H A R T, B S , D C TIME TO READ: 10-12 MIN. T H E TA K E A W AY DCs adopting new technologies and techniques to expand practices into wellness can further propel chiropractic into the mainstream. Every DC should be open to utilizing advanced therapies as well as educating patients and the public as to the benefits of regular chiropractic treatment. AS AN ALTERNATIVE TO TRADITIONAL MEDICINE, AN INCREASING NUMBER OF PEOPLE ARE SEEKING CHIROPRACTIC CARE CENTERED AROUND WELLNESS AS WELL AS SPINAL-RELATED COMPLAINTS. Chiropractic wellness care can foster lasting value through improved bodily function, a welcome change from drugs, surgery, basic biometric screening and late intervention offered by allopathic counterparts. Standard medical recommendations for back pain, such as bed rest and medication, have been shown to be ineffective. Incorporating chiropractic care and other conservative options allows for improved outcomes that last.1 Growing public awareness and compelling research are creating multiple opportunities in the health care marketplace for doctors of chiropractic. CHIROECO.COM JANUARY 20, 2020 • CHIROPRACTIC ECONOMICS 19
FEATURESTORY
Most individuals seeking chiropractic care will require
management rather than a singular intervention. Working
together with you, patients who are informed, committed to
their care plan, and want to avoid the dangers of drugs and
surgery are those chiropractic care serves best.
A bigger pond to fish in Becoming the leading force
Governing agencies and insurance companies are helping to From a wellness standpoint, the understated power of the body
create a larger marketplace for chiropractors in the field of pain to heal itself and the lack of long-term outcomes noted with
management. Data collected by large health systems across allopathic interventions is the strength of chiropractic.5 A greater
the United States confirm the benefits of a natural approach role of non-invasive care for chiropractors will allow for patients
compared to drugs and surgery. Research presented by the to avoid devastating outcomes associated with medicine and
American Academy of Pain Medicine suggests that chiroprac- spinal surgery.
tors can play an important role combating the opioid epidemic Chiropractic should be a leading force for non-surgical and
in America, and one recent study found a 50% reduction in drug-free approaches. The profession is poised to fill this niche
filled opioid prescriptions for patients who utilized chiropractic through both traditional manual treatment and utilizing state-
services for pain management.2 This echoes many previous of-the-art equipment. Optimizing each individual practice for
studies, which show how utilizing chiropractors as primary care excellence might mean updating equipment, adding a new
providers reduces the likelihood of undergoing spinal surgery technique, or utilizing advanced therapies. Reading trade
and incurring additional health care costs.3-4 magazines or attending conventions can assist doctors in
determining which protocol or device could be the best fit for
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The validity and value of treatment is not determined by the
patient, insurance company or even Medicare policy. Value
and the care plan are determined by the clinician.
his or her practice. Every doctor of chiropractic should be open Barriers to advancement
to adopting new technologies and techniques to provide better Despite the advancement seen in the chiropractic profession,
measurable outcomes and proven results. Providing a better there are still barriers that limit practice to the fullest. The most
way for our communities begins with excellent care through common barrier is misconceptions. Often due to a lack of educa-
great results and building relationships. tion, many patients perceive chiropractors as the doctor who
“cracks bones back into place.”
Technology will lead the way Furthermore, we are sometimes labeled as quasi-scientific,
Great strides are already being made in chiropractic to provide unessential, expensive or outright scammers despite little basis
the best outcomes with repeatable treatment protocols. Many for these accusations. As a profession, doctors of chiropractic
clinics are now adopting and utilizing app-based software or should avoid making concessions in patient education that
smart devices. support these views or devalue our services. It is our job as
This disruptive technology, applied with adjusting or providers to tell both existing and new patients the benefits of
traditional manual care, allows for treatment to become more treatment.
potent and efficient.6 Enhanced technology also shapes our Whether improved bodily function, reduction in frequency
knowledge and understanding of the conditions commonly and severity of a symptom, or better health, there should be an
treated in practice. Advanced imaging provides clarity for soft aim or goal to care. These objectives should be reviewed every
tissue evaluation; detecting spondylolysis before displacement, few visits. This may be accomplished with outcome assessments.
improved understanding of tendinopathy and arthropathy, Regular re-evaluations will create an opportunity to reiterate the
and visualization of disc bulging or herniation. Neurological progression of care. The outcome of care should be focused on
evaluation is also boosted through ever-advancing imaging the measurable rather than the nebulous results. This creates a
techniques and evaluation. As health care technology continues purpose behind care, and effort should be made in separating
to advance, chiropractors should also be adapting clinical visits with purpose from a redundant appointment without a
practice to keep pace. clear intention. Doctors and patients both benefit from this
consistency in communication and goal-setting.
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Chiropractic organizations work against
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“Home exercise with advice or training is recom- doctors over-exaggerate the extent of an
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Instead of relying on the same few [chiropractic] analogies,
challenge patients to reassess their views on health care.
Many patients are misinformed.
patient can misinterpret this to mean a visit to the chiropractor is Follow-up management will build better long-term
only necessary one or two times per year to optimize their health. relationships between the patient and the provider for a lasting
A common correlation that should change surrounds the outcome that will foster further referrals and improved practice
intervertebral disc. Is the disc really like a jelly donut? That image. This will serve the profession well for 2020 and in the
equivalence sounds silly. If it really is like a donut, why can’t we future.
get a new donut full of jelly just like at the donut shop? Disc
physiology, as well as pathology, is far more complex. RYAN M. BURKHART, BS, DC, is committed to delivering innovative
Comparisons to everyday life are useful to explain ideas health care solutions to maximizing patient quality of life through
such as misalignment, spinal maintenance and other complex chiropractic care. He is accomplishing this mission through the
disorders of human physiology. Instead of relying on the same integration of the latest technologies and rehabilitation protocols into
few analogies, challenge patients to reassess their views on his family practice, Burkhart & Chapp Chiropractic PLC. He graduated
health care. Many patients are misinformed. After all, a majority Summa Cum Laude from Sherman College of Chiropractic and is
of people accept the concept that putting an addictive chemical a member of the Michigan Association of Chiropractors. He can be
in their body to relieve pain, for example, is a good idea. contacted through burkhartchappchiropractic.com.
Follow-up management and wellness TIMOTHY J. BURKHART, DC, BCIM, has successfully treated thousands
Advancements in technology and practice, with improved clinical of patients with acute to chronic neck and back pain since 1984. He
research, allow for care to be cutting-edge. Symptoms are often is an authority on the integration of NSSD into clinical practice. He
not homogenous in etiology, and patients are more than a label is a member of the ACA and MAC, and serves on the Davenport
or diagnosis. University Health Professionals Advisory Board. He also developed the
Most individuals seeking chiropractic care will require Hill DT Solutions certification program. He can be contacted through
management rather than a singular intervention. Working hilldtsolutions.com.
together with you, patients who are informed, committed to
their care plan, and want to avoid the dangers of drugs and Weigh in with your opinion at editorial@chiroeco.com.
surgery are those chiropractic care serves best. References can be found online at chiroeco.com
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26 CHIROPRACTIC ECONOMICS • JANUARY 20, 2020 CHIROECO.COMCLINICAL
CONCERNS
LOWER EXTREMITIES AND
WHOLE-BODY WELLNESS
Even a neck or upper-back issue can start at the feet
BY K E V I N WO N G , D C
TIME TO READ: 9-10 MIN.
T H E TA K E A W AY
Foot issues impact the entire axial kinematic chain, creating muscle issues and general biomechanical instability and stress.
The feet, ankles, knees, hips and lower back are the first things to check and are intimately related to the upper body parts.
THE ROOTS OF THE CHIROPRACTIC PROFESSION COME FROM listening to them. However, let’s not chase the pain at the
AND FOCUS ON THE SPINE. It is something we learn very early expense of finding and fixing the actual cause.
on in our training and we carry this proudly into practice.
The power the spine has in helping or hindering the nerve Whole-body wellness
impulses coming from our spinal cord to innervate every Let’s take an average patient who presents to our clinic with
part of the body is significant. We have all had the chance lower-back pain. It is the most common reason a patient seeks
in practice to see how effective adjusting the spine is on chiropractic care. In fact, we are pigeonholed and stereotyped
biomechanical and symptomatic relief. In practice, we often as “back doctors.” That means we are known for treating
find our patients presenting to us with specific pain. Of course mostly that area, but that does not mean we treat “only”
we want to address this pain and show the patient we are that. Lower-back pain can be caused by or have a significant
28 CHIROPRACTIC ECONOMICS • JANUARY 20, 2020 CHIROECO.COMCLINICALCONCERNS contributing factor from multiple areas of the lower extremity. Let’s take a look and break this down so it makes more sense. Visualize a patient standing with their back toward you, barefoot and in anatomical position (Fig. 1). Figure 1 You are an artist and the human body is your canvas. A patient can present with pain in the lower back, pelvis, hips, knees, ankles, feet — we never know how they will present. Will it be one area? Will it be all of them? It doesn’t matter how many parts are painful. It matters that you understand why they are all painful. Because we tend to learn about the body in pieces as we go through school, we tend to treat the body in pieces in practice. But I want you to think of the body parts as they all relate to each other. That’s the key to whole-body wellness. Start with the foundation The feet are the foundation of our whole body. You know there is not just one arch under each foot, as the general population CHIROECO.COM JANUARY 20, 2020 • CHIROPRACTIC ECONOMICS 29
CLINICALCONCERNS
Once you know how the lower extremity body parts are
intimately related to the upper body parts, you see the
patterns of subluxation and misalignment that emerge.
believes. There are three functional foot arches (medial longi- Over-pronation of the foot
tudinal, lateral longitudinal, and transverse) and their main The three functional arches collapse and cause the foot to
jobs are to maintain balance and proper weight-bearing prop- over-pronate. This process happens slowly and silently most
erties of the feet. In up to 87% of the population, the three of the time. Yes, we do get cases of plantar fasciitis, meta-
arches are falling, collapsing or over-pronating. This results in tarsalgia, neuromas and heel pain, but many of our patients
their feet flattening. never have any pain in their feet. They have no idea this foot
Now think about this: Approximately nine out of 10 people in flattening is occurring. If they feel no pain, they pay it no mind.
the world have feet that are flat to some degree. The pronation Once the feet flatten out enough, the force of the pronation
ranges from mild to severe and usually involves both feet, with begins to internally rotate the tibia bone.
one being worse than the other. Flat feet have consequences The knee cap now feels an inward pull, so it starts to
biomechanically on the rest of the body. It’s impossible for track medially within the patello-femoral groove. The inward
them not to. rotation of the tibia continues to get stronger and stresses the
Look at the picture (Fig. 2) and notice this individual who has femur bone right along with it. As the femur bone experiences
a left foot that is pronating worse than the right. Follow the medial rotational stress, the medial knee is now compromised.
pathway from the over-pronating left foot as it moves up the ACL, MCL, patello-femoral tracking, meniscus and arthritis
axial kinematic chain. Let me explain further. conditions are often seen here.
The fun doesn’t stop there, folks! As the feet get flatter and
worsen with time, the medial rotational force on the femur
worsens. We now observe stress at the hip, sacroiliac joint
and pelvis. Go back up and reference the picture I showed
you earlier. Notice that the hips tilt inferior on the side of the
flatter foot. You can even feel and observe slight to moderate
lateral lumbar spine curvature that will be worse according to
how over-pronated the foot is. We began at the bottom of the
feet and we have traveled up to the lumbar spine, following the
wave of negative effects the excessively-pronated foot inflicts
upon the body.
The axial kinematic chain
When you see this picture, realize that to some degree this
represents 80-90% of the patients who walk through your clinic
door. You can see the pattern of what the feet do to the rest
of the body. You and your patients are living proof of this. You
are likely an over-pronator yourself and are no different than
your patients. If you take 10 chiropractors, 8-9 of us will be
over-pronating.
To finish referencing the overall picture, note what is
happening above the lumbar area. There is rotational stress
on the spine (which happens to cause the misalignments and
subluxations you keep finding). The shoulders become unlevel,
then round forward, and the neck translates forward. Shoulder
pain, neck pain and headaches are just a few of the symptoms
we hear patients complain of.
Don’t forget that while this process of excessive foot
pronation is happening and we see the effects on the entire
axial kinematic chain, muscles throughout the body are
reacting as well. Patients love telling us about tight muscles,
Figure 2 muscle spasms and pulled muscles. You and I both know
30 CHIROPRACTIC ECONOMICS • JANUARY 20, 2020 CHIROECO.COMCLINICALCONCERNS
Once the feet flatten out enough, the force of the
pronation begins to internally rotate the tibia bone.
tight muscles are indicators of bones that are out of place. addressed, they have a positive effect on the thoracic and
Biomechanical instability and stress will create muscle cervical spine and shoulders.
problems as well. I know checking the feet and lower extremity is not the
most obvious thing to do — especially if someone is presenting
with only neck pain, headaches or shoulder pain. But take one
PERCENTAGE OF last look at the picture of the pronating person and now see
how much sense it makes. You really don’t have to memorize
THE POPULATION anything because you understand it.
Once you know how the lower extremity body parts are
AFFLICTED BY intimately related to the upper body parts, you see the
patterns of subluxation and misalignment that emerge. Once
ARCH ISSUES you know the patterns it’s harder to miss the big picture of
what is actually the cause of patients’ pain when they come
RESULTING IN in to you for care. Please remember: The lower extremities
have a profound effect on the entire spine and on whole-
FEET FLATTENING body wellness.
Start low KEVIN WONG, DC, is an expert on foot analysis, walking and standing
When you have a patient who has pain in different parts postures, and orthotics. He discusses spinal and extremity adjusting
of the body, you should always check the lower extremi- at speaking engagements and writes for Foot Levelers. He can be
ties. Once the feet, ankles, knees, hips and lower back are contacted through orindachiropractic.com.
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