Blog, Chirosecure Live Event April 23, 2023

Documenting Patient Care – Don Capoferri DC

Click here to download the transcript.

Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  We suggest you watch the video while reading the transcript.

Hello everybody. My name is Don Capoferri. Good afternoon if you’re in the Eastern time zone. Happy lunchtime if you’re in the central, or good morning if you’re on the West Coast. My name is Don Capoferri, I’m a chiropractor. I’ve been in practice for 41 years, and I wanna thank ChiroSecure for the opportunity to meet with you today and chat about documenting your care.

Let’s go to the slides, if that’s okay. Little bit about me. Some of the credentials that you see up there. I’m fellowship trained in spinal biomechanics and trauma. That was my first fellowship from 2016 to 20 18, 2 year fellowship. And then I just finished a fellowship in primary spine care.

From 2021 to 2023 I am a clinical instructor at the State University of Buffalo School of Medicine, and also I’m on the adjunct faculty at Cleveland University, Kansas City College of Chiropractic. The whole point of saying all that is what I’m gonna present to you today is what I present at those institutions.

So it’s the state of the art of. Care as far as documentation is concerned, and hopefully, I have 30 minutes, so hopefully I’m just going to get you thinking about something, getting it, thinking about how you’re documenting the need for your patient’s care, both in the immediate and in the long term care.

And hopefully be able to present to you a vision of what chiropractic can accomplish in the next. Five to 10 years. So let’s get into it. If I happen to run out of time, we’re just gonna zip to the end. I’ll go through the slides to the end where my contact information is, and we’ll schedule another time to finish.

If you’ve never heard of Sim Verta is a mechanically assessing software that allows you to digitize static and motion x-rays. To determine biomechanical lesions. We’re gonna show you some of those this morning as well as determining A O M S I. Now just a caveat I live in the personal injury space, but subvert is not just for personal injury.

It does however allow you to diagnose A O M S I alteration of motor segment integrity, and then apply that to the AMA Guides, which is very helpful if you have a personal injury practice. But it’s beyond that. It also measures disc height for you and quantifies the level of disc degeneration based on current research.

The slides are pretty heavily researched, if you can, if you need to take a screenshot or whatever and look up the citation that we have for the literature on there. But if you have not heard us inverter, go to Look around, see what you think. It is an incredible tool whether you’re in the personal injury space or not.

Okay, so the first thing I wanna address since Sim Verta is a X-ray digitizing software. There’s been a lot of buzz recently. About state boards possibly pulling our right to accurately diagnose our patients using radiographs. The ACA has adopted the American Academy of Family Practice Philosophy as far as x-raying people, which.

The people that know the least about the spine are in the primary care space. Why would we go there? I have no idea. But I wanted to start out with mentioning this. This is actually a macro that you can acquire to put in your notes based on Mr. Jones’ history and clinical findings, the following.

Cervical X-rays are ordered to rule out anatomical and biomechanical pathology. If you’re not doing this, you really need to start doing this now for compliance purposes. Everything that happens in your office, be it a treatment, being a test, being a x-ray, range of motion, study mg, whatever, whether it’s in your office or referred out, needs to have an order associated with that.

If there isn’t an order. That could create havoc for you among the carriers. If they do an audit and pretty much the way it’s going with the carriers, it’s not if you’re gonna be audited, it’s when, so I want you to have all your Ts crossed and I dotted cuz it really doesn’t matter how much money you make if you have to give it all back.

But let’s look at number one. And it has the citation right below it. Among humans, there’s no evidence of carcinogenic effect of acute for acute radiation. Diagnostic X-rays had a virtually zero negative adverse health sequelae based on this and the total totality of other literature. And then you have the.

Citation behind that, the use of x-ray is found to be significantly consistent in accuracy, repeatability in accessing osseous pathology when utilizing x-ray digitization and measurement protocols in conjunction with coordinate systems created by Panjabi et al, and digitize directly into a computer. , it assures accuracy in reporting biomechanics and st and stability or instability, depending upon what you’re looking for.

But I wanted to get that off the table. Whether you take your own x-rays or whether you refer them out to an imaging center, either way is fine with me. SIM Verta is an x-ray digitizing software, so I wanted to address this issue right up front and get it out of the way. Again, general public health risks of not taking x-rays.

So I’m not gonna just read to you today, but I’ll tell you about a couple of examples. Real life from my office that. Situations that are basically impossible to palpate unless you can visualize in 41 years, this has only happened to me twice, but I’ve had two patients with a condition called agen of the posterior arch.

That is the whole posterior portion of the C one vertebrae was not there from birth. Now, imagine putting a high intensity force. Into that area, there’s nothing between your hand and the brainstem. So both of those patients, we avoided catastrophe. They didn’t know they had the problem, and I wouldn’t have known it either had I not x-rayed them.

There’s another condition called Belotti syndrome where basically the transverse process, Of the L five vertebrae, one or both sides, hypertrophies and affixes itself to the S one segment. Now, if you don’t know that’s there and you’re adjusting the L five vertebrae, all you’re creating is pain for your patient because it won’t move it’s congenitally fused.

That’s just two examples. There are many others to certainly justify the X-raying of your patients. This is a table, the safe use of x-ray. It comes from the American College of Radiology, and so radiation exposure to a patient in plain film examinations of the spine involves an estimated 0.2, that’s cervical 1.0 and thoracic and 1.5 milli serves of radiation.

It takes. Any dose less than a hundred milli serves for protected irradiation does not does less than 500 miler. So anything less than 500 milli serves is safe. What that means is you would need to take 5,000 cervical x-rays on one patient. At one time in order to exceed the dose limitation, 100 thoracic x-rays and 67 lumbar x-rays to come even close to the dose limitations.

So there’s no evidence that X-raying. Causes any health concerns. One of the other things that subverted does, I mentioned before, is it measures disc height as you digitize the vertebrae. The algorithm will measure center disk at the nplate above center disk at the NPA below, and it produces a report for you.

What is a green line going vertically up and down this report, and then the black lines extending from left to right is the percentage of the disc height at center compared to the height of the vertebrae immediately below the disc. So top one C2 c3. It measures the center disc height of C2 c3 compared to the.

Vertebral body height, posterior of c3, and it gives us a percentage, any percentage. Over 33% is a healthy disc. Anything under 33% is pathologic loss of disc height. So on this report that every disc meets the healthy disc criteria of over 33% except C 67. That’s degenerative disc disease. And the way you help document to a carrier or to a patient, the need for care beyond the immediate pain relief is to report comorbidities, if you will.

Now, maybe you’re doing that now, maybe you’re not. But disc degeneration is definitely a comorbidity, so this is automated demonstrative validation of a comorbidity degenerative disc disease C six C seven. This person will need longer time to stabilize, and this is what this says, Johnny tests. Cervical x-rays reveal disc height of C2 c3, and then it goes through all the numbers.

The results there is a pathologic disc height or pre-existing degeneration at c6, c7. So that is the need for prolonged care beyond just the initial Yes. Let’s go to the next slide. Okay. Comorbidities, degenerative disc disease. Many times a radiologist will just eyeball it and the paper you might want.

Take a screenshot of this. There’s three references there. They’re current, the top papers reference 2021 gives you the formula for determining disc height and in sim Verta. We just automated it. So Mrs. Jones demonstrates radiographic evidence of cervical degenerative disc disease based on the digital analysis.

C. Attached the C6 C7 disc is permanently degenerated. Preventing the motor unit from functioning normally and changing the biomechanics of the entire spine. The evidence in the literature reveals that this is significantly lengthens the time for stabilization. What literature? The literature we’ve listed on the bottom of the page.

So when you accurately communicate both to a patient and to the carrier, they will understand that this is not just. A muscle strain. This person has degenerative disc disease and it’s independently validated by the software. So how do you determine. When, where, and how to adjust your patients. Now and I just put this up cuz this is common that people use motion palpation or muscle palpation or something like that.

The interrater reliability of muscle. Is worse than motion palpation, but let’s look at what the literature says. Passive intervertebral tests had lower CAPA values suggesting poor reliability. That’s for motion palpation. The means stiffness detection threshold for clinicians was 8%. That means 92%.

Got it wrong or disagreed. When two examiners access a patient with musculoskeletal complaint, we would clearly distinguish the cases in which they completely disagree on the location of the punitive vertebral level that is relevant. The K values for palpation of segmental motion restriction were poor Evidence suggests the re reliability of soft tissue structure palpation is inconsistent and the reliability of bony structures of joint mobility palpation is poor.

So motion palpation has poor grades on reliability unlike x-ray analysis. Now what you’re looking at there is what we call with sim Verta a biomechanical study. That A to P lower cervical x-ray on the right hand side there. Then on the far left side, bar graphs. Now what those graphs are telling me is the level of an extent to which the spinus process has rotated at that segment, any of the ver horizontal lines.

That cross more than two of the vertical lines is pathologic. And then also this report tells me what the prime lesions are like. If you look right in the middle, right in the middle of thoracic area, we have 1, 2, 3, 4 rotated vertebrae. Chances are the longest one is the prime lesion and the others are compensations for that.

Up at the upper thoracic, we’ve got a lot of rotation at t1. At the bottom part of the information on the far right, the adjustment. Report will also give you line of drive, it’s I to s or S to I, inferior to superior to inferior. And then over here on the left hand side, bottom of the page, it gives you the flexion and extension data for each of the levels in the cervical spine.

And basically you should have balance on either side. If you’ll get the very top line there, you see a lot of extension and no flexion whatsoever. So that’s a baseline in my office. Every patient is digitized, is x-rayed and digitized, and this becomes the initial blueprint for the chiropractic adjustments.

We adjust the longest lines in each area. So here’s what the literature says about X-ray reliability. The reliability of x-rays in morphology measurements and spinal biomechanics has been determined as accurate reproducible in both chiropractic and medical specialties. So one of the other things that inverted allows me to do is communicate.

With the medical profession. And I do that extensively. In my office, patients basically fall into one of three categories. If they come in with evidence of myelopathy or radiculopathy usually they’re ordered an mri. And if we see the extent of that, They would be referred for a neurosurgical consultation.

So that’s one is people we have to refer out for surgery. Number two is there’s a biomechanical component, maybe also with a disc lesion that’s not surgical. And we will co-manage those patients with pain management typically. And when I send a patient to pain management, I always send my subverted reports cuz it helps them identify the level of facet or the level of disc.

They’re going to treat. So it in fosters interprofessional communication. Okay. Reliability was excellent for all parameters. Based on X-ray reliability. High interclass correlation coefficients verified the reliability of labeling process, vertebral motion analysis. That’s what CTA does. Measurements demonstrated substantially more precision compared to manual techniques like.

Motion palpation. X-ray findings provide good interrater reliability for the of the back mapper in healthy subjects I, one of my visions is that people will, Come prey. I know that’s been a dream of in the chiropractic world for such a long period of time, since almost everybody’s motivated by pain when they come into our office.

But let’s not fall into the trap of saying, okay, you feel better. Everything’s good. Cuz that’s not necessarily Lower back pain particularly is a worldwide epidemic. It is the number one cause of disability and the number two cause of visits to physicians. So we’ve lost ground. When I started in practice in 1982, the pain management pr specialty was just gaining ground.

Now it’s full blown and we have more people in pain than ever. I’m suggesting to you that basing your patient’s progress purely on relief. Now that’s how we’ve survived since 1895, cuz what we do works. But basing it purely on that is going to make the doors of your office spin. Cuz as soon as people feel better, they’re gonna go away.

Now I made a deal with my dentist many years ago. I said I will do whatever hygiene things schedule you tell me I need to do, but I wanna make sure I keep my teeth in my mouth and not in a glass on the nightstand next to my bed. So I would like to see people treat their spines that way and the way we cure this epidemic.

Is not coming up with special new treatments. There’s no lack of treatments for spine pain. There’s lack of diagnosis for spine pain. What tends to happen is silo care in the medical world, and the reason why I talk about the medical world is if you’re an optimist, chiropractors deal with 10% of the population.

That’s a, an optimist. If you’re a pessimist, you’d say 5%. If you’re a realist, probably seven. So that means 93 out of every a hundred people with spine pain, it doesn’t even dawn on them to go to a chiropractor. And the reason is silo care, which means whatever you do, if you inject people, Then that’s your hammer and everything looks like a nail.

If you are a surgeon, when you evaluate people, typically, and this is not true for everybody, there are clinically great surgeons, but if that’s your only tool, Then you just screen people to see who you can justify for surgery. What we need is highly trained spine diagnosticians, and we as chiropractors, the chiropractic profession, in my opinion, need to own spinal biomechanics for two reasons.

The worldwide epidemic of spine pain and 85% of them are labeled by the medical profession. Non-specific spine pain. Now, non-specific spine pain is a myth. It doesn’t exist, but what they label people, non-specific spine pain is spine pain in the absence of fracture, tumor and infection, cuz that’s what they look for, right?

85% of spine pain is biomechanical. So the world’s out there for us. If we get it known that we are the diagnostic portal of entry for spine, it’s all over. And the way we do that is own spinal biomechanics. So let’s look at this real quick. On an initial visit, Ms. Jones presented with cervical pain on 1 1 23.

A demonstrative biomechanical X-ray study showed lesions at c2, C4, t1, T seven, T eight, T nine, L two, L four, and L five based on the demonstrative literature based evidence. Mrs. Jones spinal pain is a combination of the spinal cord. And super spinal brain mediated mechanisms. This requires the management of all patho, biomechanical spinal motor units at three times a week for four weeks with a reevaluation to determine if future care is clinically indicated.

So that’s a macro, and you see the citations below it to back it up. And in my office in 30 days exactly, we will do a reevaluation and depending upon symptomatic progress with motor deficits if they had them, global range of motion. This is not global range of motion. This is intersegmental, but we also do global range of motion because it’s expected of us.

We will do a 30 day reval, and this sounds like this after a 30 day course of chiropractic care. A follow up, demonstrative biomechanical x-ray study showed, and it reports on that based on the demonstrative lit literature based evidence. Mrs. Jones spinal pain is a combination, as I mentioned before.

This requires a management of all patho, biomechanic spinal units two times a week for four weeks. Why? What’s the evidence of the need for prolonged care? The report right next to that paragraph, it’s still showing pathological. Rotational segments. And by the way, when a segment rotates like that, it’s a compromise most of the time of the inter transverse ligament.

And once ligaments are compromised, they stay that way. But X-ray digital biomechanical analysis gives you definitive diagnosis. Your operating basis. In my opinion, this is how we operate in my office. It is accurate diagnosis, prognosis and treatment plan. We never treat until we know what’s wrong with the person, and then they fall into one of those three categories that I mentioned before.

It is reproducible, it’s demonstrative, it’s legally defensible, and it has no adverse health concerns as we addressed before. That’s x-ray, digitizing. So real quick about ligaments, cause in our human body, every joint basically works the same way. Ligaments are movers, I’m sorry, muscles are movers, ligaments are restraining bolts and just like the supports and you see the picture of the Golden Gate bridge right there.

Those cables, those suspension cables keep that bridge from falling. But they also allow a certain degree of movement too, cuz if they were so stiff, they would just snap. So ligaments or suspension cables of the spine, their pretension, they allow for some movements. Compromise allows too much movements.

One of the big errors. And it’s true in physical therapy too. Is when you do range of motion studies, let’s say, and we do digital range of motion on a J Tech system, it’s very accurate. But the results tend to, people tend to focus on restriction of a joint where actually hypermobility is far more injurious to the spine than restricted range of motion.

Eventually anky two little movements. So initially you get too much. And then because that joint is moving more than it was programmed to do or built to do, it starts to wear out. Bone spurs start to occur, disc height starts to narrow, and it eventually fuses to the vertebrae below if the or above, if the patient lives long enough for that to happen.

This A O M S I diagnosis cannot be eyeballed. It is a function of how inflection the vertebrae slides forward and extension the vertebrae slides back and those two are summed together or added together to come up with the amount of motion each segment is realizing. Compared to the ones above and below on the reports from inverter, you’ll get a green line.

That’s the pathology threshold. Clinically, that’s the important one. Any of the black lines that surpass that green line is pathological, hypermobility. The red line really is for academic purposes and medical legal purposes. There are thresholds published in the AMA Guides fourth, fifth, sixth edition.

that give you the threshold for movement. And if you can see this, the C5 vertebrae is translating, which means it’s sliding 6.037 millimeters. Pathology is at 3.5, so that’s almost twice as much as the motion necessary for full. AMA guide impairment. That’s important if you’re in the medical legal world.

It’s not if you don’t, but you may wanna consider. What types of treatment you’ll give to a segment that’s moving too much. As far as I know, there’s no such thing as an adjustment to make a vertebrae move less, only more. So this is an A O M S I report for translation, which is Compromise of the Facet capsule.

Also, this is translation for lumbar spine. And if you look at these two pictures, most people that take X-rays or analyze x-rays would say the obvious pathology there is at L four. L four has slid forward over L five. And so I, in the static world, that is the primary pathology. Probably that’s all you would get on a radiology report.

But if you look at the report, The translation is way worse at L five S one than it is at L four L five, which means if you look at the L five vertebrae compared to S one inflection, you see how it’s forward of it. And if you li almost lines perfectly back up, that means L five is unstable. I would think you would wanna know that when you are doing your treatment planning.

I mentioned that. Translation comes as a result of facet capsule compromise. You have a picture of a facet capsule there that is restraining the sliding of the superior surface and the inferior surface on each other. And if that capsule is partially torn or completely torn you’ll get excessive motion at that facet.

And that’s a translation is about the facets are hardwired to the spinal cord and then the, to the Dorsal root of the spinal cord and then to the brain so they can be exquisitely painful. This is the pain pattern for cervical spine facets. You can find this pretty much anywhere. And again, this report goes to the pain management doc that I co-managing with.

So they’re gonna look at C4 most likely for injection and possibly medial branch block lumbar spine. Here’s the pain pattern in lumbar spine and I’m gonna skip through that a little bit cause I’m running out of time. We can go back and visit, make sure you’re communicating with the attorneys you’re working with and with the carriers.

When you have a sprain of a ligament, it’s not just a sprain. There are three levels of sprain. That’s what in front of you. Grade one sprain means it’s stretched grade two, partially torn grade three complete avulsion. Most of the time you won’t see a grade three if it’s a sports injury or a car crash.

They’ll go right to the hospital and have orthopedic surgery. If it’s in their neck, they won’t be able to hold their head up, and if it’s in their back, they won’t be able to walk. Every study that’s been performed on ligament injury or ligament tears says that the ligament does not return to pre-injury status.

So ligament damage is permanent. There’s some, you might wanna take a picture of this research paper it goes on to say, Once ligaments are compromised, they provide negligible support to the spine as if there was no ligamentous support. It is one 30. My time is up. We will definitely reschedule to come back and finish what I started here.

But I wanna thank ChiroSecure for allowing me to present to you today. Let me flip through really fast and get to my. Contact information, you have it right there. If you need to get in touch with me, text is probably the best way. Second best way is an email, my office number. It’s difficult to get me on the phone there cuz we’re running like you guys are running, seeing patients every day.

So I’m still at the game. I have definitely enjoyed this and not sure how to end right now, but let’s. Go back.