The ‘One Hour’ New Patient Visit
After more than 35 years in practice, I still think it’s fun, exciting, intense and often challenging to meet and engage new patients.
During the history portion we talk for however long the patient needs to talk. Sometimes it’s short; sometimes it’s quite a while. I’m looking for messages…I’m trying to gather and assess a wide range of information: current chief complaints, past and present health and physical condition, previous injuries, medical history, family precondition, mental status and toughness, athletic background, nutrition, sleep habits, etc. (Since we’re seated while doing this, I also use the time to talk about proper sitting ergonomics and the importance of getting up for micro-breaks.)
We then proceed to a standing posture evaluation, followed by gait observations. Although I’m on a time schedule, I let the patient set the pace. My goal is that I am able to complete the examination and provide an initial treatment (and also teach an exercise or two if that’s something I believe will be helpful on the first day).
Along the way or at follow-up visits, we talk about eating healthy foods. I educate them on low carb, whole foods, lots of fresh produce and veggies so they can understand and implement an anti-inflammatory diet. I encourage that inner chef. I may have them schedule a consultation with my office nutritionist if I think a loss of 5-10% or more body fat is indicated.
For the past year we are focusing on the ketogenic diet. Our average fat loss for females is 2 lbs. per week and men lose 2.5 lbs. of fat per week. It definitely helps decrease chronic inflammation and ease joint pain. I get them to eat a healthy diet, but not a deprived diet. (Hey, I still enjoy a glass of wine or cocktail from time to time.)
I integrate the examination with standard orthopedic tests and functional movement tests. My plan is to figure out how to make it obvious to the patient that they need flexibility work and/or strength/stability training. It’s easy to demonstrate both using standard range of motion and isometric “holds” in various plank poses. Then I guide the patient into what they can do at the gym or at home. I explain that our body can do the following movements, and I ask them to demonstrate these for me:
- Lift from the ground (hip hinge)
- Push overhead (vertical press)
- Push away from the body (horizontal press)
- Pull a band or weight from overhead (vertical pull)
- Pull a band or weight towards the body (horizontal pull)
- Step (lunges or step-ups)
- Twist (rotational drills)
I feel like I did a good examination if I can translate the findings into floor exercises and bodyweight exercises that improve posture and reduce pain. I like to demonstrate the movements, watch them do it, correct obvious mistakes and then help them download proper technique until it’s imprinted in their muscle memory.
For some patients, my exercises are a complete workout; for others it’s part of the warmup. Either way, we start out easy, then increase intensity from week to week, incorporating sessions of bodyweight, CLX bands, free weights or kettlebells, and cardio (power walking), none longer than 40-45 minutes (unless they personally choose to extend the cardio).
I have patients who run marathons and do triathlons and crazy other high level athletics. I really enjoy seeing them feel their progress from week to week, and I want them to be as excited as I am about regaining their lost range of motion, and improving their fitness and health. I often say to patients, “Once we regain lost range of motion, I never want you to lose it again!” The same goes for weight loss.
I’m able to keep patients engaged in exercise because I have the ability to vary the workout types – from body weight and light weights with lots of reps and sets, to heavier weight and less reps, to new combinations of exercises, all mixed in with cardio variations. The goal is slow, steady gains – whether that’s in flexibility, stability/ strength or something else.
I do require that patients provide a detailed workout log and/or a food diary. When people know that they will be weighed in and have a body composition analysis on a weekly basis, it increases accountability and keeps them motivated to complete that week’s program. My goal is to allow my patient’s body to adjust and adapt to the process without injury.
When it comes to getting patients out of pain, I look for something that will provide fast relief – while acknowledging that weight loss or improved posture has no “quick fix” solution. These are truly lifestyle changes and adaptive choices that come along with education.
My current treatment includes manipulation, shockwave, laser, Rapid Release, Deep Muscle Stimulator, IASTM, Lymph therapy, taping and more. If one therapy plateaus I have another to try. Doing manual therapy and adjustments is still a favorite. I recognize the range of motion gains from manipulation and appreciate the amount of re-awakened muscle that manipulation provides! My pulse rate still goes up with a good “crack.”
How did I become such a modality guy? I think the answer is that I embrace technology and as my practice became more filled with chronic pain patients, I was willing to try and buy new technology. It just seemed to happen – chronic neck and back pain was improving with my exercise recommendations. But new plateaus occurred. I started mixing some of the modalities.
For example, I found Class 4 laser to be effective, safe, and cost-effective compared to injection treatments. When I added a Class 3B laser and the Deep Muscle Stimulator together, I saw intensity of pain, disability, quality of life problems, medication use, and costs go down.
I did my own experiments – I assigned chronic neck pain patients to laser; chronic low back patients to laser and deep muscle stimulator; chronic hip patients to shockwave; elbow to shockwave and laser. (Everyone got manipulation and exercise as indicated.) I figured out that three sessions was a start to see if anything would improve. If it did, then six sessions over 2 to 3 weeks was a good trial.
My components of Chiropractic involve releasing fascial tissue and tight connective tissue and addressing joint dysfunction. I touch points throughout the body. I push and grasp manually. I found that fascia likes heat, so laser before soft tissue manipulation is easier.
Since my therapeutic approach involves manual manipulation of the soft tissue and joints, it was logical to apply a layered approach: IASTM and Rapid Release for the superficial layer; and Deep Muscle Stimulation for a little more depth.
For the deepest layers, I go with shockwave therapy in which a device produces simultaneous kneading and drumming techniques to soften fibrotic tissue. My patients sometimes call it the “jackhammer.” Shockwave is a rather unknown type of soft tissue therapy that is becoming popular for both practitioners and patients. It’s a powerful modality that addresses specific patterns of tendinopathy in the body.
The POLITE Method™ is the name I created to describe how I care for patients. It’s not a comprehensive system, but each letter helps remind me of something I can address or offer for the patient. The list includes: Posture, Pain, Plan, Outcome assessments, Optimal Loading, Instruments, Technology, Taping, Exercise, Energy, and Ergonomics.
If your form of bodywork is based on Chiropractic principles – using flexibility training, stability exercises, stretches, (self) myofascial release, pressure point therapy, posture education, joint movements, diet and nutrition, etc. to balance the body – I’m curious as to what you call this combination of practice. Does it have a name?
Learning From And With Others
Whether you’re an experienced rehab Chiropractor or totally new to the rehab Chiropractic path, I highly recommend that you allow yourself to be guided by mentors.
On April 6-8, 2018, the ACA Rehab Council is having its annual symposium in Las Vegas at the Flamingo Hotel. Come and meet some of the best and brightest minds in cutting edge Chiropractic care. Registration is available at https://ccptr.org/next-annual-symposium
ACA Rehab Council 2018 Symposium Schedule
Friday, April 6
- Registration 11:30 am – 12:00 pm
- Dr. Michelle Maiers (Sponsored by Back-A-Line) 12:00 – 2:00 pm
Topic :“The Optimal Evidence-Based Exercise Regimen”
- Vendor Break 2:00 – 2:30 pm
- Dr. Michelle Maiers (continued) 2:30 – 4:20 pm
- Short Break 4:20 – 4:30 pm
- Dr. Jeffrey Tucker (Sponsored by ACA Rehab Council) 4:30 – 6:30 pm
Topic: “Utilizing CLX Rehab Bands”
- Vendor/Member Social Hour (Sponsored by Aline) 6:30 – 7:30 pm Complimentary drink for Rehab Council Members
Saturday, April 7
- Registration 07:30 – 08:00 am
- Dr. Mitch Mally (Sponsored by Multi Radiance and Rapid Release) 8:00 – 10:00 am
Topic: “Expertise in Extremity Adjusting”
- Vendor Break 10:00 – 10:30 am
- Dr. Mitch Mally (continued) 10:30 am – 12:30 pm
- ACA Rehab Council and ACRB meeting/lunch – All attendees/vendors 12:30 – 02:30 pm
- Eric Cressey, MA, CSCS (Sponsored by MARC PRO) 02:30 – 04:30 pm
Topic: “Strength, Conditioning and Sports Performance”
- Vendor Break 4:30 – 5:00 pm
- Eric Cressey, MA, CSCS (continued) 5:00 – 07:00 pm
Sunday, April 8th
- Dr. Steven Weiniger (Sponsored by Performance Health) 8:00 – 10:00 am
Topic: “Strengthening Posture & Balance”
- Vendor Break 10:00 – 10:30 am
- Dr. William Morgan (Sponsored by Parker College) 10:30 am – 12:30 pm
Topic: “Treatment Protocol for Lumbar Disc Disorders”
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