Evaluation & Management

Joint Trauma: Perspectives of a Chiropractic Family Physician

By Frank M. Painter|May 23, 2012|Chiropractic Care, Degenerative Joint Disease, Diagnosis, Evaluation & Management, Spinal Manipulation|

Joint Trauma:
Perspectives of a Chiropractic Family Physician

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Clinical Monograph 8

By R. C. Schafer, DC, PhD, FICC

INTRODUCTION

The general stability of synovial joints is established by action of surrounding muscles. Excessive joint stress results in strained muscles and tendons and sprained or ruptured ligaments and capsules. When stress is chronic, degenerative changes occur.

The lining of synovial joints is slightly phagocytic, is regenerative if damaged, and secretes synovial fluid that is a nutritive lubricant having bacteriostatic and anticoagulant characteristics. This anticoagulant effect may result in poor callus formation in intra-articular fractures where the fracture line is exposed to synovial fluid. Synovial versus mechanical causes of joint pain are shown in Table 1.

Table 1. Synovial vs Mechanical Causes of Joint Pain

Feature	Synovitic Lesions	Mechanical Lesions
Onset	Symptoms fairly consistent, during use and at rest.	Symptoms arise chiefly during use
Location	Any joint may be involved.	Primarily involves weight-bearing joints.
Course	Usually fluctuates. Episodic flares are common.	Persistently worsening progression. No acute exacerbations.
Stiffness	Prolonged in the morning.	Little morning stiffness.
Anti-inflammatory effect	Aided by cold and other anti-inflammatory therapies.	Anti-inflammatory therapy of only minimum value.
Major pathologic features	Negative radiographic signs or diffuse cartilage loss, marginal bony erosions, but no osteophytes.	Radiographic signs of cartilage loss and osteophyte developments

Periarticular Lesions

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Shoulder Girdle Trauma

By Frank M. Painter|May 16, 2012|Chiropractic Care, Diagnosis, Evaluation & Management, Rehabilitation, Shoulder, Spinal Manipulation, Sports|

Shoulder Girdle Trauma

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Clinical Monograph 16

By R. C. Schafer, DC, PhD, FICC

The articulations of the scapula, clavicle, and the humerus function as a biomechanical unit. Only when certain multiple segments are completely fixed can these parts possibly function independently in mechanical roles. Forces generated from or on one of the three segments influence the other two segments. Thus, they will be described here as a functional unit. Please underscore this point in your mind as you read this paper.

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Cervical Spine Trauma

By Frank M. Painter|May 15, 2012|Cervical Spine, Chiropractic Care, Evaluation & Management, Rehabilitation|

Cervical Spine Trauma

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Clinical Monograph 18

By R. C. Schafer, DC, PhD, FICC

As with most parts of the body, traumatic effects in the forearm or wrist may occur abruptly (eg, fracture, strain, sprain) or be the result of long-term microtrauma (eg, tunnel syndromes, arthritis, entrapment by scar tissue).

The cervical spine provides structural stability and support for the cranium, and a flexible and protective column for movement and balance adaptation, along with housing of the spinal cord and vertebral arteries. It also allows for directional orientation of the eyes and ears. Nowhere in the spine is the relationship between the osseous structures and the surrounding neurologic and vascular beds as intimate or subject to disturbance as it is in the cervical region.

BACKGROUND

Whether induced by trauma or not, cervical subluxation syndromes may be reflected in total body habitus. IVF insults, and the effects of articular fixations can manifest throughout the motor, sensory, and autonomic nervous systems. Many peripheral nerve symptoms in the shoulder, arm, and hand will find their origin in the cervical spine, as may numerous brainstem disorders.

Common Injuries and Disorders of the Cervical Spine

Cervical spine injuries can be classified as

(1) mild (eg, contusions, strains);

(2) moderate (eg, subluxations, sprains, occult fractures, nerve contusions, neurapraxias);

(3) severe (eg, axonotmesis, dislocation, stable fracture without neurologic deficit); and

(4) dangerous (eg, unstable fracture-dislocation, spinal cord or nerve root injury).

Spasm of the sternocleidomastoideus and trapezius can be due to strain or irritation of the sensory fibers of the spinal accessory nerves as they exit with the C2–C4 spinal nerves. The C1 and C2 nerves are especially vulnerable because they do not have the protection of an IVF. Radicular symptoms are rarely evident unless an IVD protrusion or rupture is present.

Prevalence

Because of its great mobility, relatively small structures, and weight-bearing role, the cervical spine is a frequent site of severe spinal nerve injury and subluxation/fixations. A large variety of cervical contusions, Grade 1–3 strains and sprains, subluxations, disc syndromes, dislocations, and fractures will be seen as the result of trauma.

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Soft-Tissue Neck Trauma

By Frank M. Painter|May 12, 2012|Chiropractic Care, Evaluation & Management, Rehabilitation, Spinal Manipulation|

Soft-Tissue Neck Trauma

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Clinical Monograph 15

By R. C. Schafer, DC, PhD, FICC

The mechanical relationship between the head and neck has been crudely compared to a brick attached to a flexible rod. As the structural mass of the head is so much greater than that of the neck, it is no wonder that injuries of the neck are so prevalent. Even the person with a short neck and well-developed neck muscles and ligaments is not free of potential injury.

BACKGROUND

The viscera of the neck serve as a channel for vital vessels and nerves, the trachea, esophagus, and spinal cord, and as a site for lymph and endocrine glands. When the head is in balance, a line drawn through the nasal spine and the superior border of the external auditory meatus will be perpendicular to the ground.

Anterior injuries are more common to the head and chest as they project further forward, but a blunt blow from the front on the head or chest may cause an indirect extension or flexion injury of the cervical spine and soft tissues of the neck. In any neck injury, the injury may not be the product of a single force. For example, while extension, flexion, and lateral flexion injuries are often described separately, rotational, compressive, tensile, and shearing forces are invariably part of the picture.

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The anterior and lateral aspects of the neck contain a variety of vital structures that have no bony protection. Partial protection is provided by the cervical muscles, the mandible, and the shoulder girdle.

After neck injury, a careful neurologic evaluation must be conducted, and every examination should begin with a thorough case history. See Table 1. Note any signs of impaired consciousness, inequality of pupils, or nystagmus. Do outstretched arms drift unilaterally when the eyes are closed? Standard coordination tests such as finger-to-nose, heel-to-toe, heel-to-knee, and for Romberg s sign should be conducted, along with superficial and tendon reflex tests.

Table 1 Typical Questions Asked During the Investigation of Joint Pain

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The Foundation of Biomechanical Evaluation Following Injury

By Frank M. Painter|May 11, 2012|Chiropractic Care, Clinical Pearl, Evaluation & Management, Rehabilitation|

The Foundation of Biomechanical Evaluation Following Injury

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Clinical Monograph 9

By R. C. Schafer, DC, PhD, FICC

INTRODUCTION

The study of human biomechanics includes the mechanical principles involved, the physiologic considerations of muscle length-tension relations, and an understanding of the controlling neuromotor mechanisms and the sensory feedback apparatus, reflecting both locomotor activity and cerebral function. Applied biomechanics is the application of the practical principles of mechanics (the study of forces and their effects) to the body in movement and at rest.

The more biomechanics are understood, the better musculoskeletal disorders in sports and the workplace can be appreciated. The same can be said of physical work and recreational activities. The athlete is constantly attempting to improve performance by applying biomechanical principles to specific movements. The same is true for ergonomics in the workplace. From the viewpoint of the doctor, knowledge of the mechanisms involved in an injury is necessary to evaluate an injury accurately.

PERTINENT BIOMECHANICS

From a pure musculoskeletal standpoint, the human body is a mechanical device. All mechanical devices are subject to wear during use that reflects their history of destructive forces. Unique to living tissue is its ability to heal, adapt, and strengthen, which provides a dialogue between catabolic and anabolic forces. While machines convert thermal or chemical energy into mechanical energy, muscle tissue transforms nutrients directly into mechanical energy without a thermal intermediary. Body energy enables it to overcome resistance to motion, to produce a physical effect, and to accomplish work.

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Practical Concepts

The body’s kinetic energy is reflected in its velocity, and its potential energy is reflected in its position. Work is the result of a force acting through a distance. Power relates to the time element and the work accomplished. There is a close association in the same unit of time between the work accomplished by a weight lifter and that of a sprinter. (more…)

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How To Use the Evaluation & Management (E&M) Codes Properly: Part III

By Frank M. Painter|September 11, 2011|Evaluation & Management, Guidelines|

How To Use the Evaluation & Management (E&M) Codes Properly:

Part III: Mastering the E/M Guidelines

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SOURCE: Chiropractic Economics

By Kathy Mills Chang, MCS-P

Part III: Mastering
the Evaluation & Management
(E&M) Guidelines

Jump to: Part 1 or Part 2

The medical decision making component ties it all together.

Welcome to part three this focus series on the evaluation and management (E/M) guidelines. This will wrap up what you need to know to stay compliant with E/M coding for the Centers for Medicare and Medicaid Services (CMS).

In the last installment, the elements of your patient’s examination were reviewed and you learned how it is the second of the three key elements of the patient’s E/M service. Now, the third part of this E/M documentation series will unravel the final component of the E/M code: medical decision making (MDM). For chiropractors, this is usually the diagnosis and treatment plan.

Three key components of the E/M guidelines:

Patient history
Examination
Medical Decision Making (MDM)

Remember that your patient’s medical record should establish a chronological record of exams, tests and results, and treatments and treatment plans (including the diagnosis and prognosis of the illness or disease). The medical record should corroborate the reimbursement request and is requisitioned by most payers for adjudication of claims when reimbursement is in question. (more…)

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