Documenting Patient Care Part 2 – Don Capoferri DC

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Good afternoon everybody. This is Don Capoferri coming to you this afternoon. I wanna thank ChiroSecure for the opportunity to bring you part two of documenting patient care. So let’s go to the slides. We’re going to do a quick review of part one. And I’m gonna blow through these pretty quick. I believe you have the opportunity to go back and look at the video for part one.

If you see some information on part two that maybe you missed on part one, or maybe you weren’t attending part one, and you can Go back and run that replay if there’s information that you missed. And go ahead and get that. Just real quick on this homepage, the title, documenting Patient Care, I also want you to notice that I am a clinical instructor at a medical school state, university of.

Buffalo School of Medicine in New York, and also adjunct faculty of Cleveland University in Kansas City. So what I’m teaching you is what gets taught in those institutions. So it’s not something that we’re just making up. This is also brought to you by ChiroSecure and Symverta. Symverta, in my opinion, is the number one patient care documentation tool for a chiropractor.

This may be even a new concept for you, but every specialty has to document patient care. If you’re a primary care physician and you’re working with a patient for hypertension, obviously the blood pressure readings are how you document the effectiveness of your care and whether the person needs continuing care.

If you’re working with diabetics, of course the blood tests the glucose tests, if you’re a rheumatologist, the biomarkers for inflammation are how you judge the effectiveness of what you’re doing and the need or not of ongoing care. So for chiropractic, in the past we’ve used range of motion reviews, different things, but I reviewed in part one that Contrary to what the scuttlebutt is and actually contrary to even our national organization’s stated policy, there is absolutely no evidence.

That anyone is harmed by diagnostic X-rays, particularly in a chiropractic office, and we went through that, that you’d have to take thousands of x-rays, about 5,000 cervical x-rays to come close. To the harmful threshold for radiation exposure. Now I’m in practice 41 years, still in active practice. Part of the reason we started a few minutes late today is traffic on my way home from seeing patients this morning.

So I’m not a consultant, I’m not disengaged from what happens on a day-to-day basis in a chiropractic office. So we review, let me click on.

We’re moving. Okay.

All right. We’re not moving.

Your slides are changing on my end. I don’t if you’re seeing slide. Do you see that? It says safe use of x-ray right now. Then it’s automated de demonstrative. I don’t know where you’re going with this. Okay. Okay. They’re starting to move now. Actually they’re moving without me controlling it.

That’s frightening . Yeah. So what slide do you see now? Automated. Automated demonstrated validation of comorbidity. Okay. So what you’re looking at is a report from Symverta. That is able, you’re able to produce a disc height analysis report. One of the reasons I put this slide in there is because disc degeneration is a comorbidity that prolongs the expected a patient response to treatment.

So how do you do that? You can actually take upright standing lateral cervical x-ray measure central disc height. And then measure the height of the vertebral body below and anything. If the ratio is 33% or higher, that’s a healthy disc. 33% or lower is a pathologic disc, or you could just digitize the patient’s x-rays and get this report, which shows that C six C seven, a disc with loss of disc height, which is a primary indicator of disc degeneration.

Pathology. So that becomes now a comorbidity and there are others. But this is objective documentation of degenerative disc disease, which can prolong your care. Traditionally, we’ve used range of motion studies or motion palpation, and what you’re looking at now is the poor. Interrater reliability of motion palpation, and then x-ray analysis, particularly from Symverta.

That next page shows very high scores of interrater reliability using x-ray digitization. So this is something that’s accepted in the community and is duplicatable. From provider to provider, from patient visit, or transitioning patient care from one frequency to another. And as you document that, there’s less carrier resistance in paying you for your care cuz you have the documented need for it.

Now, how traditionally we would manage the success or failure of our care. Most chiropractors would not admit this, but they do it based on pain. So we have a pseudo pain management profession, chiropractors, and a pain management profession, which obviously uses medication and injection therapy to manage patients pain.

Where what I’m excited about is taking the subjectivity out of that and entering the objectivity into it by using. Digital x-ray biomechanical analysis as definitive diagnosis. It’s reproducible from one provider to another. It’s demonstrable to the patient. It’s demonstrable to the carrier or in the medical legal community.

It’s demonstrable. We do it all the time. That’s just so you know. That’s pretty much where I live in the medical legal world. It’s legally defensible. It also prevents you from being accused of predetermined treatment plans cuz your treatment plan is not predetermined, it’s determined based on your testing and eval and x-ray biomechanical analysis.

Okay, so I believe this is where I stopped last time. One of the relatively misunderstood. Tissues that get into issues in our spine are the ligaments. So you’re looking at actually the Golden Gate Bridge. There ligaments are suspension cables of the spine, just like the bridge has suspension cables.

Now, those suspension cables allow for a certain amount of movement of the bridge, particularly in weather. But they secure the bridge from too much movement. That’s exactly what ligaments do in the body. The microstructure of ligaments. They’re made of three things, elastin, collagen, and fibroblasts. Up until the time someone hits puberty, the fibroblasts, I’m sorry, produce both collagen and elastin, and each joint has a unique percentage of collagen and elastin, depending upon.

The amount of movement, like your shoulder would have a lot more elastin than your spine. I don’t know what the percentages are exactly, but collagen is more or less concrete. Elastin, just like it says, is stretchy, but once the person hits the age of puberty where the skeleton is matured, usually that’s 14, 15, 16, something like that.

Fibroblasts never produce elastin again. So when the ligament is compromised, that. Compromise in the beginning allows for hypermobility of the individual segments that it was securing and is permanent. As I’m gonna show you in just a minute, we’re talking about sprains. That’s the compromise of a ligament.

And there’s three grades of sprain. Grade one, which is a, basically an overstretch past the para physiological limit, grade two with a partial tear, and grade three with a full thickness tear. And at 41 years of practice, I’ve never seen a grade three walk into my office most likely. Cuz they couldn’t, if it was in the neck, they wouldn’t be able to hold their head up.

If it was in their back, they most likely would be able to walk. So they’d go right from the scene of the injury to the hospital and have orthopedic stabilization surgery. So ligaments are pretension. They allow some movements. Compromise allows too much motion initially. Eventually, anky leads to too little motion, but all of our range of motion studies are focused on restricted motion, when actually hypermobility is far more egregious to the spine long-term than restricted mobility.

What on the screen now is a report of. Inter segmental translation. Now translation is one vertebrae sliding on the other. There’s a certain amount of that’s allowable and that’s measured by the green vertical line You see there anything to the left, to that green line or to the left of that line is normal, but you also see here at C five.

That movement of C5 goes way past the green line, which is the pathologic threshold and past the red line, which is an administrative line for full whole person impairment according to the AMA and the. Software, which if you’re interested, you can go to and look around, walk around, see what it looks like to you.

But you can select fifth edition of the AMA Guides if you’re in a fifth edition state, and you can select Sixth Edition because those two guides, fifth and sixth edition, treat this condition, which is called A O M S I, alteration of Motor segment integrity. Differently. So you wanna definitely know which state you’re in, if you’re gonna do an impairment rating and which addition of the AMA guides they use.

Now, some states don’t. Mandate. My state, Georgia is a fifth edition state and there are six edition states. There are Oregon, I believe, still back in the third edition, so that might be something you wanna find out. You can go to ama, click on the button that says, guides by State. Another thing from a clinical standpoint, not just a personal injury standpoint, this hypermobility of C5 is a contraindication.

To manipulation, if that’s what you call what you do, or chiropractic adjustment, there’s no such thing as an adjustment that can make a vertebrae move less. Only more so it behooves you to know if there’s hypermobility in your patient’s spine and take appropriate action. In my case, this would call for a different treatment approach than an adjustment.

And also same in the lumbar spine. Now, if you were to look at these x-rays on the left, you have a lumbar flexion. On the right you have a lumbar extension. If you look carefully, L four is displaced anterior to L five pretty significantly. That would be a grade one spondylolisthesis of L four. If you look.

To the pars, just posterior. You can see the lysis back there, and there’s definitely some pathology there that would be diagnosed as a spondylothesis. And then if you look at the extension X-ray on the right, there’s some retraction that we see of L four, and that movement is depicted on the report from sim in translation at L 45.

As movement, but we have more significant movement at L five S one past the pathology threshold and past the impairment threshold. So actually, the biomechanical pathology is worse at L five than it is at L four, which is why we say you cannot eyeball this. I have seen radiology reports on M R I that say no indication of ligamentous instability.

First of all, that’s absurd for a radiologist to comment on that, mainly because ligamentous instability would have to be. Evaluated by moving, like we do here, flexing and extending. Evaluating ligamentous instability while someone’s laying in an MRI machine is ludicrous, yet I see it all the time. I probably read a thousand m radiology reports a week, so it cannot be eyeballed.

It has to be tested. So we just talked about translation. Now, translation is one segment sliding upon another, which is a compromise of the facet joint. The facet joint capsule is what restrains the gliding action of the superior surface and the inferior surface of the facet. If that capsule is breached, it will allow too much motion and in an injury, sports injury, car crash, or whatever.

What injures, what tears that capsule is when the facet joint retracts, not the extension of it, but when it retracts, it often tears that capsule. The facet joints are wired directly, the. To the dorsal horn of the spinal cord and up to the brain and that biomechanical malfunction, along with the ensuing pain ping pongs around the brain, setting off pain signals.

So a facet, although not paid much attention to the redheaded stepchild of the spine is often the sight of painful. Especially referred pain. What on your screen now, I believe is the pain patterns for cervical facet problems. Yeah. Big delay in moving of the slides yeah. Okay. From suboccipital, mid cervical, lower cervical, and then scapular pain often generated by the facet joints.

And you could take a, actually if you wanted to take a screenshot of that. In fact, you could Google facet pain patterns too. Now this is a pain pattern in the absence of clinical indications of radiculopathy or myelopathy. This is from the facet joint, so it’s a little bit of a diagnosis of exclusion, but when you have Symverta, you correlate.

The inverter report of biomechanical compromise of the facet with the patient’s reported pain pattern, and that’s a lock and key fit. Same true in the lumbar spine. You have the pain patterns there correlated to the translation pathology in the lumbar spine, in this case, L five facet compromise. Also, there’s a compromise of the ligamentum also, which allows for too much motion of the L five.

Segment and then you have the patient reported pain patterns. A lot of docs jump to the conclusion of if someone has lower back pain and leg pain, that it’s radiculopathy, but more commonly it’s the facet joint. Okay, now this is what I talked about before. This is the actions, the biomechanical actions of a ligament.

There are four creep, which is a long stretch of the ligament. Tension, relaxation, which is stretch and relax. That is what you see a lot of athletes do prior to competition. Then you have strain rate. Slow or fast, but no time to stretch athletes stretch before they compete. Chances are people in a car crash did not stretch that morning to prepare their ligaments for the impact that they are unaware is gonna happen later in the day.

And then you have hysteresis. So the most common cause of ligament damage is. Rapid acceleration deceleration. We also know that as whiplash, the ligaments are not prepared and there’s a sudden movement and the tissue pulls apart. Only when you have a grade two sprain, which is a partial avulsion, do you get hypermobility at the end?

There is a chronic cause of facet syndrome, and that is a side effect of disc height loss, or disc degeneration in the normal. Spine, the vertebral body disc. Nucleus vertebral body combination or motor unit we call that is supposed to accept 70% of the biomechanical strain of the spine in any given day, and 30% is on the facet.

But those ratios change as the disc degenerates strain and biomechanical forces now shift more to the facet so you can get facet arthropathy. A R t h r o p a t h y. I was once doing a talk and in attendance was a neuroradiologist, and I kept using the word that arthritis comes about as a.

Mechanical degeneration of the joint. I don’t know where that slide came from. Don, you had a, you actually froze for a second okay. We lost about 10 seconds of what you were just saying. I apologize. Okay. So I’ll repeat that. There’s a difference between arthritis and arthropathy. Arthritis.

Don’t bandy about that word too much because arthritis needs to be conf.

Ligament sprain. A common cause of it are falls or sports injuries. Motor vehicle crashes a ligament, partially tears, and it results in hypermobility of the segments. There are three grades of sprain. I mentioned them before. Grade one is an overstretching. Grade two is partial tear. Grade three is full thickness tear, and you may have seen that on a radiology report oftentimes in the shoulder or knee, full thickness tear of blah, blah, blah ligament in the spine.

Grade two and grade three will definitely result at the acute phase in hypermobility. But chances are you won’t see a grade three come into your office. 41 years. I’ve not seen one. Hauser and Dolan wrote the kinda landmark paper in 2013 that ligaments once compromised, replace the damaged tissue with inherently inferior tissue, especially after Puberty after puberty.

So ligament damage is permanent. That’s another reason. To manage your patients ongoing cause there is no bring the ligament back to pre-injury status or pre compromises status. You might wanna take a screenshot of this. This study by Leahy in 2012 talks about partial tears of ligaments having the equivalent.

Compromise of the biomechanics as full thickness tears, so they just don’t have the acute symptoms of a full thickness tear. Davis’ law is what we’re talking about. A lot of, you’ve probably heard of Wolf’s Law, we’re gonna talk about that in just a second, but Davis’ law is Wolf’s law. For connective tissue, I don’t wanna say soft tissue because soft tissue has become unimportant, but it is important and how soft tissue deteriorates over time through the trauma, the inflammation phase, the muscle spasm, the adhesions, which adhesions of scar tissue altered neuromuscular control and muscle imbalance.

Is the vicious cycle that patients go through when their ligaments are compromised. When the connective tissue’s compromised Wolf’s law, which originally I thought was a biomechanical result, a biomechanical degeneration, but it actually is biochemical, when tissues damaged, they lose the positive negative ion balance.

Positive ions are flushed out of damaged ligaments and muscles negatives remain, and then the negatives attract the most easily accessible source. Of positive ions, which is calcium, which exist in the body as ca plus. So it’s very positive and that’s how you start to get bone spurs. Bone spurs deteriorate.

Nplate sclerosis, all is part of Wolf’s law. Wolf’s law was written in 1858 and it says that bone remodels, according to the pressure applied to it. So go to Check it out. It’s a way to document your patient comorbidity and your patient’s need for ongoing care. What in front of you here on your left is a angular motion report with C4 five and C5 six.

Pass the pathology threshold and pass the impairment threshold at C five. six. That is a. Helps me determine my treatment plan. Number one, not gonna adjust those segments. They’re already moving too much. Then for translation on the right hand side, that report is showing at the very top pathologic motion of c1.

On c2 three millimeters is the threshold for pathology there. Five millimeters is the threshold for severe instability. Clinically, I need to know that C1 on C2 is unstable and we make other treatment plans as a result. You see what I’m saying? No predetermined treatment plans. It’s all based on the clinical findings of this patient.

Also, we have runaway translation at c2, c3, c5, and c7. All of that clinically pays into my. Treatment planning and also if it’s a medical, legal world, those are significant ligamentous injuries that are demonstrable. So what are some of the comorbidities you need to pay attention to? Let me get back.

Okay, so we need to talk. Number one, diabetes. Diabetes pretty much throws all the age dating. Out the window. Someone with, I’ve seen someone with diabetes have high signal edema in the annulus of a disc over a year after the injury. Normally, it dissipates in four to six weeks, maybe eight weeks, but in a diabetic it can last a long time, especially if that diabetes is uncontrolled.

High blood pressure is a comorbidity. Smoking modic, bone marrow changes, type one, two, and three. All. Suffice to prolong a patient’s expected recovery, documented disc degeneration. And what you see just to the side of that is a disc height analysis report from Cmta facet arthropathy, ankylosing spondylitis, prior spine surgery, with or without hardware and morbid obesity.

These things need to be documented and then you’re explaining to the carrier and to the patient the need for your treatment plan. What in front of you here is a biomechanical analysis from Symverta demonstrating both primary lesions and compensations. The black lines that you see emanating from center reflect spinus process rotation.

There’s a primary lesion cervical. There’s one midthoracic and 1, 2, 3, 4 in the lumbar spine. That’s the pre. Now, this person had a 12 visit. Treatment plan over 30 days. At the end of 30 days, we redo the biomechanical analysis, and this is the post that we see significant reduction of the rotation pathology significant.

Now, this person had such a great response. This is not common, but they had such a great response. The pain went down from a nine over 10 to a two over 10, so they were basically discharged and told to return as needed. But see, there’s no predetermination here. This is based on the actual clinical findings.

Let me scoot ahead so I can get finished this time. And we don’t have to have a Part three wolf. Most of you have seen this poster before. You might even hang it in your office. This is Wolf’s Law Pictorial. It shows cervical, thoracic, and lumbar and the gradual change in the bone and the disc space from narrowing discs, nplate sclerosis, disc height degeneration.

So we’re at right at one 30. Let me just scoot ahead here and get to my contact information. So again, I wanna thank ChiroSecure. For allowing me to bring you this information, both part one and part two. You can review part one and now you have part two to try to put all this together. If you need me, let me suggest a text message to my cell phone or an email to that email address so I’m gonna turn this back over and I appreciate your time today.