FCA ANNOUNCEMENTS

1. FCA ANNOUNCEMENTS BEFORE CLASS BEGINS:“As many of you are already aware, per rules of the Florida Board of Chiropractic Medicine, each attendee is now required to have his/her badge scanned 4 times a day at the “attendance desk” regardless of which classes you attend. If you have not scanned your badge at the attendance desk BEFORE you came into class, please do so now and return promptly, so that class may begin. Also, be prepared to scan your badge, with photo ID. If you already scanned your badge at the attendance desk, you are good to go.” “Please pick up a lecture handout located in the back of the room. In order to retrieve an expandable version of our class notes, you will need the access code located at the end of your lecture handout. You WILL NOT be able to access the expanded version of these notes without this code. Thank you.” ATTENDEES. PLEASE NOTE THAT THERE SHOULD BE NO PERSONAL, PRODUCT, OR COMPANY PROMOTION IN THIS LECTURE AFTER THE INTRODUCTION OF THE SPEAKER/LECTURE.

2. Durable Medical Equipment…the Use of Lumbar Bracing in Chiropractic Practice. James C. Antos D.C., DABCO Florida Chiropractic Association National Convention, Orlando, Florida 2011

3. Two Reasons to consider using lumbar braces (LSOs) 1. Improved Clinical Results for Patients 2. Sound Practice Procedures for Chiropractic Physicians

4. Improved clinical outcomes • In this presentation I will provide you with examples of patients who can benefit from lumbar bracing. Patients that we, as chiropractors, see every day. • First, I will give you some literature examples of the opinions about lumbar bracing in the medical world.

5. ….Some literature notes University of Maryland Spine Program: A lumbar support orthotic, also termed a LSO, offers core or thoracic/lumbar/sacral stability to a person. The LSO will hinder the person from normal or excess movement in flexion, extension, rotation, lateral flexion, or combinations of these movements. The LSO will also add core trunk compression, similar but not quite the same as, strong abdominal muscles. Braces offer a safe, non-invasive way to help you heal from current conditions or prevent future problems

6. DuPry Spine, Inc. Spinal braces are commonly used for low back pain, trauma, infections, muscular weakness, and osteoporosis. Spinal instability is a common indication in conditions such as chronic facet syndrome, herniated disc syndrome, sciatica, spondylolithesis, and lumbar spinal stenosis. Braces are also used for a variety of reasons such as controlling pain, lessening the chance of further injury, allowing healing to take place, to compensate for muscular weakness, and to prevent or correct and deformity.

7. Shan TaniKulkaine D.O. Parkview and Lutheran Hospitals August 25, 2008 • Successful use of braces such as LSOs may led to decreased pain, increased strength, improved function, increased proprioception, improved posture, corrections of spinal deformity, protections against spinal instability, minimize spinal problem complications, and improve healing of ligaments and bones.

8. Andrew Morton M.D., Orthopedic Surgeon University Orthopedics It is estimated that more than 99% of all orthopedic physicians use back braces

9. Colorado Comprehensive Spine Institute Hard braces offer both immobilization and support

10. Million R Haavik, Nilsen K, Jason MIV, Baker RD • Compared two types of lumbar corsets….one with lumbar support and one without lumbar support • The patients in the study all had low back pain longer than 6 months • “this study found considerable and significant improvement in symptoms in the group with lumbar support” • Clinical Practice Guidelines, Number 14 • U.S. Department of Health & Human Services • Agency for Health Care Policy and Research, Rockville, Maryland • AHCPR Publication No 95-0642, December 1994

11. Wikpedia • The two types of braces commonly used in an out- patient office are: • The soft brace which limits some movement and is used for lifting occasions such as employment requiring the lifting of heavy loads and… • The other is a rigid form fitting plastic type mold that restricts motion by as much as 50% and is used for low back pain and instability when non-rigid (soft) bracing is not enough

12. What does a lumbar brace really do? Answer: the support needs to be an anterior and posterior and lateral control custom fitted brace that limits excessive rotatory movement.

13. For example • Injury or increased stress to the facet joint and surrounding structures creates inflammation • When the patient moves an inflamed area, this motion creates more inflammation • By wearing the brace appropriately, the patient limits the anterior and posterior lateral rotatory movement • This allows the inflammation to be decreased

14. A GENERAL EXAMPLE: • The patient’s current chief complaint (CCC). • Chronic , exacerbating lower back pain • How common is this is our chiropractic offices?

15. Past history of medical treatment: • The patient has………. • taken meds from family physician • taken many over the counter medications (OTCs) • undergone physical therapy • tried rehab • been given pain management( epidurals, trigger points, etc.) • chiropractic (helps for a while but problem returns, now returning more frequently for care) • Perhaps other diverse treatments such as acupuncture, massage, etc. • ……….or others

16. Clinical presentation • Patient shows some of the following: • Antalgia • muscle spasm • decreased range of motion • increased range of motion • motor weakness in the lower extremities • balance difficulties (weak core) • problems with heel and toe walking • poor functional testing such as the “get up and go test” • Hyperlordosis • hypolordosis instability (back “pops” on it’s own, or has sudden “catches’ often) • hypermobility of joints on motion palpation • ..and many others..

17. Testing shows some or all of the following: • Disc degeneration……..Disc bulging……..Disc prolapse • Disc herniation………….Stenosis (central or foraminal) • Spondylolisthesis (with or without pars defect) • Misalignment…………….Osteoporosis…….Spurs • Facet hypertrophy………Instability on motion studies • Past spinal surgery………Sciatic nerve involvement • …..and others

18. Diagnosis possibilities • 729.20 Neuralgia, Neuritis and Radiculitis, Unspecified • 724.30 Sciatica • 729.10 Myalgia and Myositis • 724.50 Backache, unspecified • 847.2 Sprain and strain of the lumbar spine • 724.20 Lumbago • 724.02 Stenosis • 722.2 Lumbar or lumbosacral intervertebral disc • 722.52 Post-laminectomy syndrome – lumbar region • 738.40 Acquired Spondylolithesis • 720.00 Ankylosing Spondylitis • 721.30 Lumbosacral spondylosis w/o myelopathy • 724.40 Lumbosacral neuritis or radiculitis, unspecified • 722.93 Unspecified lumbar disc disorder • 724.90 Other unspecified back disorders • Lumbar instability syndrome • Chronic facet syndrome • ……………And others that may justify the use of bracing for stabilization

19. “get up and go” test • Medicare loves to see functional deficiencies and loves to see improvement of functional deficiencies to justify continuing care or results of care delivered • The “get up and go test” is a great test to establish a baseline and monitor progress in documentation • I use this every day in my practice with all low back patients, not just Medicare enrollees

20. “get up and go” test • First…………. have the patient sitting down • Second………instruct the patient how to perform the test • Third………...have the patient get up from the chair on their own power • Fourth……….have the patient walk 10-12 feet, turn around, walk back to the chair, and sit down again • In my opinion, a normal time period for doing this functional test is 10 seconds or less

21. Try putting on a brace • I often see patients improve immediately when applying a lumbar brace to a positive “get up and go” test • Improvement from a 25 second test result before the brace in applied to a 15 second test result after the brace is applied is often seen • I will see greater improvements over time with brace use, conservative care such as chiropractic adjustments, core strengthening, and/or endurance factor improvements

22. Also, patient feedback commonly is: • “I feel safer” • “I am more stable” • “The pain is less” • “I am able to move better” • “I don’t worry if I am moving too much” • “I now am walking better and more!” • “I am stronger”

23. Why does Medicare approve back braces? • Back braces have been in continuous use for hundreds of years with so much success that their validity is not even questioned anymore • The only questions are when to use a back brace on a patient, which back brace is best suited for the patients needs, and which back brace is appropriate (best use of public dollars)

24. The DME department of Medicare will… • (DME means Durable Medical Equipment) • 1. Allow a chiropractor to become certified to be a DME provider. • 2. The chiropractor must apply honestly using proper forms, applications, and documentation. • 3. When approved, the chiropractor then must follow exact and proper procedures to be paid for applying a lumbar brace on a qualified patient

25. HOW CAN THIS BE? • We all know about Medicare and that they pay for chiropractic adjustments under certain circumstances: • 1. demonstrable subluxation • 2. proper documentation • 3. 98940, 98941, 98942, and no others…… • BUT, WHAT NO ONE HAS TOLD YOU BEFORE IS……………

26. Medicare Re-imbursement • At this time (2010-2011) Medicare will reimburse a chiropractor $1235.00 for a lumbar brace that costs the doctor about $220.00 • YES, that is right! • If the chiropractor is properly certified (as I am and you can be too) and the patient qualifies (as many of our patients do) you can receive from Medicare payments for providing DME products such as back braces.

28. Are there any questions about what we have talked about so far?

29. FCA ANNOUNCEMENTS AT THE CONCLUSION OF YOUR LECTURE: “We are getting ready for our break. Please note that you will NOT need to have your badge scanned at the “attendance desk” during the break.” “This is the last opportunity for you to pick up the handout located in the back of the classroom. You will find an expanded and printable version of these notes are available on the FCA website with the pass code ANT8288; simply follow the directions listed at the bottom of the handout to access an expandable version of our class notes. We will dismiss now and a new class will resume in 40 minutes at 10:20am.”