Blog, Chirosecure Live Event September 24, 2023

Spinal Biomechanics and Treatment Planning

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Good afternoon everybody. My name is Don Capoferri, and for those of you who are tuning into this show, expecting to see Dr. Mark Studin. I am not him, but I am excited to be able to fill in for him today and discuss what I consider a very important topic, and that is the use of biomechanical studies in your practice for treatment planning for accurate diagnosis, for prognosis.

Even for working with other medical professionals. So if we can go to the slides, that would be great. Awesome. Whenever I attend a lecture, watch a video that’s teaching me something, one of the first things I wanna know is who is teaching me? So that’s what this slide is about. It’s got my name at the top.

Of course, DC stands for Doctor of Chiropractic. F S B T stands for Fellow in Spinal Biomechanics and Trauma. I completed that fellowship in 2018 F P S C Fellowship in Primary Spine Care. I completed that in 2022 and then BO certified neurofeedback. That was I. Back in the nineties I have fellowships in neuroradiology for spine.

I have fellowships in spinal biomechanics. As I mentioned, I’m a clinical instructor at a medical school state University of New York at Buffalo School of Medicine. And I’m an adjunct professor at Cleveland University, Kansas City College of Chiropractic. So what I’m teaching you is what’s taught in medical and chiropractic, academia.

It’s not something I made up on my own. And most of the slides you’re going to see in just a second are referenced. So if you have a cell phone with you and want to record that reference, feel free to take a picture of it. I am heavily involved with Symverta for my biomechanical assessment of the patients in my practice.

It is the premier chiropractic tool for objectifying spinal function. If you have never heard of it, I suggest, and even if you have heard of it but aren’t a subscriber, I strongly suggest that you go to Look around. There’s some videos on there you can watch, and at the end of this, I’ll give you my.

Contact information should you have any questions. Okay. Let’s talk about lower back pain. If there’s anything that chiropractic is associated with in the general public, it’s spine pain and more specifically, Lower back pain. So you see the reference down there on the bottom. The abstract of this paper states non-specific lower back pain has become a major public health problem worldwide.

The lifetime prevalence of lower back pain is reported to be as high as 84%. And the prevalence of chronic lower back pain. By the way, chronic lower back pain is consistent low back pain over a three month period of time or more. So chronic lower back pain is 23% of the population and disabling lower back pain, 11 to 12% of the population.

The economic cost of lower back pain is through the roof, and other than the common cold, lower back pain is the number one cause of visits. To a doctor just on and on in this? Yes. Okay. This is what I wanna talk about. History taking clinical examination are included in most diagnostic guidelines, but the use of clinical imaging for diagnosis should be restricted.

So the stance that our colleagues in the medical profession are taking is that, Efforts to actually accurately diagnose the reason this person is in pain. Are restricted because I’ve done, I’ve been in practice 41 years. I’ve done tens of thousands, hundreds of thousands of clinical exams, and all those clinical exams tell me is what imaging I need to order.

You cannot have a definitive spine diagnosis without imaging. Yes. That is what this says. Also, I want you to think about this. 84% of the population that’s 84% are going to experience lower back pain. So if you are an optimistic individual, you would say that chiropractic deals with 10% of the population.

If you’re a pessimistic individual, you would say that chiropractic deals with 5% of the population. So let’s just go in the middle. Let’s say we work with 7% of the population. So of this 84% of the people that are going to experience lower back pain, only 7% of them are going to visit us. Where are the rest of them going?

Yeah, you got it. They’re going to the medical profession and the next few slides will show you what their approach is. So we have one or more of the following tests might pinpoint the cause of lower back pain x-rays. So here they’re talking about imaging. Yet on the other policy statement, they say imaging should be restricted, M r I or ct.

Blood tests, see if there’s an infection and nerve conduction studies. Then Harvard Medical School published What treatments should be considered after running these tests? Medications depend on the type of lower back pain they might include. So there’s pain medications, pain relievers, there is muscle relaxants, topical pain relievers, narcotics and antidepressants.

All come before chiropractic care. Mentioned not even in the ball game, but a lot of times when most of the tests are negative. For anatomical pathology, tumor, or infection, they’re sent to a physical therapist. A physical therapist can teach exercises to increase flexibility, strengthen back and abdominal muscles improve posture.

Regular use of this techniques can help. Keep pain from returning physical therapists will also provide educational on how to modify movements during the episode of lower back pain and avoid lifting pain and symptoms continuing to be active. So here’s the point. That’s what a physical therapist does. I think that’s a very accurate description of what a physical therapist does.

And regardless of the diagnosis, that’s what a physical therapist is gonna do. And so oftentimes a physician. Training in diagnosis like a primary care doctor for the primary care. Scored lower than first quarter chiropractic students when it comes to musculoskeletal conditions. So you have a P C P that has no idea what’s wrong with this person, sending them to physical therapy, getting those kind of.

Physical therapy exercises and other therapies done, this can be dangerous. We had one patient that went through that exact same process, and when they came to me, it turned out that they had spinal cord compression and myelopathy, and the last thing you wanna do is exercise that. This is the stance they a medical profession has taken.

Why? Because chiropractic has not stepped up to the plate yet. Here’s the research. You can take a picture of that. Citation on the bottom. Physical therapy as a number one line treatment for spine. In 2016, this paper reported that physical therapy care required 239% more off work time to end full compensation.

Obviously, that’s a workers’ comp stat. Physical therapy, 313%. More time versus chiropractic regarding partial compensation. So 239% longer, completely outta work, 313% longer versus chiropractic care, partially out of work. Physical therapy is great for extremities, has failed miserably for the spine. Has continued to be used by the meds, and I’ve sent people for physical therapy, but mainly for extremities conclusions as documented by the growing number of scientific papers concerning chiropractic therapy in PubMed over the past 20 years, complimentary and alternative me medicine and chiropractic in particular are becoming close to traditional medicine especially, but not only in the treatment of chronic pain.

And there’s your reference. So many of you probably have heard this rhetoric before. Non-specific back pain, non-specific back pain. I’m gonna repeat this twice here and on the next slide, does not exist. When a medical doctor gives that diagnosis to a patient, it, he’s essentially saying, I can’t find anything wrong with you.

That’s why on the other slide, they talked about using antidepressants ’cause it’s all in their head, right? I can’t find anything wrong with you, so we’re going to send you to physical therapy or, and we’re gonna label you with non-specific spine pain. So this is small, so I’m going to make it a little bit bigger for myself to read.

You have the name of the paper. At Al reported that over 96% of the survey respondents with spine related problems who said they used chiropractic manipulation Stated. Stated that the therapy helped them with their condition with approximately 46% increased odds that it helped when compared to osteopathic manipulation compared these statistics to medicine which persists in diagnosing 90 to 95% of the population with non-specific lower back pain, which is significant evidence of a failed care path.

And boy, that’s an understatement. Okay. Non-specific spine pain doesn’t exist. Told you, I would repeat that. What you’re seeing here is biomechanical studies. These two studies are for what’s called A O M S I, if you’re unfamiliar. Look it up. It stands for alteration of motor segment integrity, and it’s the premier way of testing for ligament compromise.

On the left hand side, written in red. At the top it says Vertebral angular segmental motion analysis. So when you compromise the interspinous, Ligament and the supraspinous ligament, you get too much angular deviation like we see here at C two C three. It’s not only past the green pathology line, but it’s past the red full impairment line.

11.9 degrees of angular deviation. Now that same patient has translation pathology. This is a compromise of the facet capsule and the ligament.

2.69 millimeters of translation at C two and even worse, 3.44 millimeters of translation of C one on C two. So this would be alar ligament and transverse ligament compromise. And C two, we have the facet capsule and ligamentum flava compromise. Now for those of you who. Are in the medical legal space.

That’s where I do most of my work every day. So I’m regularly in court. If this patient that you’re seeing here, the M R I report came back every level was either normal or had a disc bulge. Now, a disc bulge is a degenerative finding. It’s not a traumatic finding. So if you were dependent or if I was dependent upon the M R I proving causality of injury in this person’s case, and that’s all I had, I would’ve nothing.

Absolutely nothing but a person feels worse which carries absolutely no weight in the medical legal world. Instead, we have C two C three passed the full threshold. According to the fifth edition of the A M A Guides, that injury is worth 25% whole person impairment. Now, that’s something that the attorneys you work with can sink their teeth in, but if you don’t have these studies, then you don’t have that data for the attorney.

Then the other thing I wanna point out is C one C two is unstable, 3.44 millimeters of translation. This tool, Symverta is the only one that does this, and it’s worth. What you have to pay every month to be a subscriber, just to know that this person’s C one is moving too much. Listen to me carefully. There’s no such thing as an adjustment that can make a bone move less.

Only more. So this is a stay away from when it comes to high velocity, low amplitude thrust. We have other methods that we use to strengthen the muscle tissue around this area to reduce that hypermobility. But you need to know that your insur, your professional liability insurance carrier wants you to know that for sure, because this is a disaster waiting to happen for somebody who does no imaging, lays a person down and does a rotary break left and a rotary break.

That’s a disaster. Not only. Are you gonna hurt this person? You’re probably gonna lose your license or have it suspended. And I just read a case not too long ago that a chiropractor failing to diagnose cost him $8 million and his insurance policy only had three. They were probably negotiate that down, but he could lose his home, his cars and have his practice income.

Taken from him to meet the court’s decision. So this is an important topic. Then we have what also Symverta gives us biomechanical studies. This is how I determine when, where, and how I adjust combined with this. So if I get an indication like we have up here at the very top for C two to be adjusted, but when I look at.

I see C two is hypermobile. I’m staying away. But down here we have T one spinous process rotated, right? A number of them. T six, T seven, T eight, T nine rotated, right? Spinous process in the middle thoracic. Any of these lines that represent rotational pathology, which just as an aside, is a compromise of the inter transverse ligament.

As long as they’re not hypermobile, then it’s fine to adjust those. The report also gives us a motion analysis. If you look straight down where we have flexion and extension at the bottom of the page. Look at occiput C one, you’ll see a line that shows a fairly good amount of extension, but zero flexion.

That’s biomechanical pathology 1 0 1. And then on the far right where it says adjustment, it will actually give you line of drive, which this is easy for me ’cause I’m an instrument adjuster, but superior to inferior at occiput. C one, superior to inferior at C one C two. And we have inferior to superior C six C seven.

So as long as you’ve looked at A O M S I and you have the biomechanical analysis, this tells you where to adjust and how. It also allows me to accurately determine a person’s treatment plan other than. A suit over hurting someone. Malpractice, the number one reason chiropractors are being hauled into court is predetermined.

Treatment plans. Not too long ago I read the case against one particular chiropractor. They pulled a hundred files, and of those files, 95% of the patients all had the same diagnosis, all had the same treatment plan, all got the same adjustment. Two modalities every time they come in. That’s predetermined treatment plans and it will cost you your license at some point in time if you persist.

When you use a tool like Symverta, the treatment plans are customized to that individual. So we always start out the same way, just like any other physician. We start a patient at it three times a week, so this is their initial. Biomechanical study a seven year history of spine pain. Been to two other chiropractors.

Physical therapists got injections. Nothing worked for her. I expected a prolonged treatment plan because seven years we’re now in chronic pain. A lot of times people like that. Once the problem’s fixed, the pain persists because it’s gone chronic. So there are little xs on the grid there. That’s where I intend to adjust the, this patient.

So we started out on a course of treatment, 12 treatments over four weeks, and then we retest to see if what we’re doing is having a. The designated effect or the expected effect, just like an endocrinologist treating somebody with diabetes, they’re gonna put ’em on a certain amount of insulin, then retest their blood sugar.

Why? To see if it’s right. I retested this individual now look how small these rotational measurements are now after 12 adjustments in four weeks, here’s the first. Anything over two lines is clinically significant. And then here’s the post study. Her pain was a zero and at the end of four weeks we discharged her ’cause there was no reason to continue seeing her.

One other thing I wanted to mention too. Symverta helps you determine a primary lesion versus a compensation. So if we look at the very top of this page at C seven, we’ll see in the cervical spine there’s right spinous process, rotation, extending over 1, 2, 3, 4. Standard deviations. That’s my primary lesion for the cervical spine.

In the thoracic spine, my primary lesion is T nine spinous rotation left, and the lumbar spine is L four spinous process rotation left. This tells me that assessment of what was a primary lesion and what was compensation was correct. ’cause you can see the other areas that we did not adjust, still improved ’cause they were being caused by those primary lesions that I mentioned before.

Okay. In this study we reveal that unstable mechanical loading in the spine induces endplate hypertrophy. The endplate, for those of you not familiar, is the interface between disc and bone. So you have a vertebral body. You have the endplate, which is a mixture of cartilage and bone, and is specifically designed to withstand compressive forces.

When you have abnormal me biomechanical loading on a joint, the endplate thickens almost like scar tissue formation, which in turn starts narrowing the intervertebral disc at four weeks, especially if you’re in the medical legal world measuring disc height. Is absolutely critical to establishing causality.

So this is a little bit about disc kite. Disc kite analysis must be performed on upright weightbearing quality X-ray studies. I probably read. 500 radiology reports a week, and I’ll see a, I’ll read that a radiologist is commenting on disc height from an M R I or a ct. The neutral lateral, cervical, or lumbar x-ray should be used.

CT and M R I should not be used to measure disc heights due to the recumbent position of the patient. It’s gonna make the disc height space look bigger. Abnormally. It is critical to work with doctors who not only understand the effects of trauma on the human spine, but also. What to look for to determine causation and identify the cause of persistent functional losses.

That is the citation. If you wanna take a picture of it, published 2021. This is a subverted disc height analysis. Now doing the same work. Plotting of the points on an X-ray that I use to get my A O M S I analysis. It also gives me disc height analysis. The green line cutting down the center of the page to the left of it is pathology, and to the right of it is normal.

So you see the disc at C two three is normal, C three four normal, C4 five is somewhat diminished. That number should be 33. C five C six, 18 percent, and then 25%. So we’ve got three pre-existing levels with disc degeneration and two that are healthy. Let’s see. I think I’m missing a page here. No.

Okay. So this is done automatically for you, and especially if you’re in the medical legal world. It helps you establish causality, but it also helps you in getting. Your patient’s treatment plan covered by their carrier. These are called comorbidities. A comorbidity is like diabetes, hypertension, C O P D.

Those are diseases that prolong healing time. Degenerative disc disease is a comorbidity for us. If a patient has it, you’ve now proved it and they should expect this pressure to require more care to stabilize, not less. Okay, when are we getting into M R I world here? Alright, so on the left we’re looking at an axial view of lumbar spine, normal axial view, lumbar disc level.

What I want you to see, if you’re not familiar with MRIs, just follow my cursor. Here’s the facet. There’s the lamina into the spinous process. On the side of each one of those are these thick, kind of dark gray tissue. That’s the multifidus muscle, and that’s the primary. Lower back spine stabilizer is the multifidus muscle, and it should abut right up to the lamina and the spinous process to secure it.

Now if you look at the picture on the right, you’ll see pretty substantial white where it should be dark. Muscle tissue. Instead, we have white, and that white represents fat. This is multifidus muscle atrophy. Moving back just a little bit, really where the arrows are, that’s the erector spine eye muscle that’s pretty healthy, but the multifidus muscle has atrophied pretty significantly.

I mentioned this because. I’ve been in practice 41 years and up until Covid in 2020, I probably would see one of these a year and now post Covid I see one or two a week. I assume, because there’s so much I. Decrease in activity during that period of time. You can also have muscle atrophy from a denervation.

If the nerve is being compressed, say by a disc or they’ve had medial branch block of that nerve that comes out of the facet. All of those can lead to multifidus atrophy, and that would prolong your treatment plan. So I want you to think about these. When you’re diagnosing your patient, you want to put in every diagnosis that you see including muscle atrophy, including disc degeneration, loss of disc height, nplate sclerosis, all of those, whether you do medical legal world or not.

Now, if I see nplate sclerosis, I know that. Level is at least four weeks old. If I see a bone spur, particularly a posterior bone spur at the same level. There’s a disc herniation. I know that’s been there at least six months. So age dating the pathology helps the attorney with proving causation. Also, those factors will prolong the care.

Needed for whatever kind of patient you have, whether it’s a personal injury patient, whether it’s a regular, major medical patient, doesn’t matter. I guess that term’s not used much anymore major medical, but What’s important is that you have a complete and accurate diagnosis. I’m not suggesting any particular form of treatment, but I am suggesting that anybody you look let into your office, once they walk through that front door, I feel this is how I feel.

You don’t have to feel this way, but I think you should. I feel I owe them an accurate diagnosis, should they choose to treat in my office. If it doesn’t turn out that it’s something that needs surgery relatively immediately then the treatment can vary, right? The treatment is, can be time consuming, can be expensive, especially if insurance doesn’t cover it.

And many of the things we do in my office, insurance does not cover. But we are uniquely positioned. To solve the epidemic that I mentioned in the very beginning of 84% of the people suffering with lower back point at some point in their life, and some allowing it to get to a chronic stage which ruined the rest of their life.

So here’s what we need to do that. Step number one, accurate diagnostic workup. Never treat without a diagnosis. Now, this may ruffle some of your feathers. Pain is not a diagnosis. It’s a description of why they came to your office. The diagnosis is what’s causing that pain, and if you let ’em in your office, guess what?

It’s up to you to find it. The only rare occurrence, most state scope of practices are the same. They command you to arrive at a diagnosis, see if this patient needs you as a treater. Needs. To be referred to a medical provider solely or can you co-manage this with the medical profession, one of they have to fall into one of those three categories and it’s all diagnostic dependent.

Triage to appropriate provider, treat those you can help, have all the tools for treatment that your state scope would allow you to have. So in our office we have decompression, ultrasound, lasers, electrical stem, all those things that, ’cause they’re all allowed by my state scope. Okay, there is my contact information.

If you have any question, particularly about Symverta, go to, check it out, tool around, see what you think. If you have questions, you can text me, which is actually the best way. You have my cell phone number there. (770) 595-9314. Because I’m still an active practice, I’m not a consultant. I do teach at a chiropractic school and at a medical school.

But that’s not full-time. And so I just came from work to do this. So I’m at, in active practice like most of you. So a text and I’ll get back to you. Okay. I hope you’re all having a great day. Looks like we’re just about finished one minute early. .