Which type of traction is best?
This is probably the most asked question and also the one for which I don't have a good answer. There is no research published at this time that would indicate any one type of traction is necessarily better than another.
Likewise there is no compelling evidence that any particular traction method is better than another for any particular cervical curve configuration in spite of much conjecture to the contrary. Many doctors feel that the counter stressing methods such as Stynchula and Pope Two Way traction are better for reversed and S-shaped curves.
It appears to many doctors (me included) that the counter stressing methods may have some advantage in terms of directing force into the more kyphotic portion of the cervical curve. Whether or not this is true remains to be proven. I personally have seen kyphotic and S shaped necks respond to any and all types of traction.
Likewise I have seen almost every form of traction fail at one time or another to produce the desired result on a given patient. Having said that, I will share with you how I personally decide which traction method is best for any given patient.
In my humble opinion, the pure compression methods (Payne, Dakota, Gambale-DeGeorge, Regainer, Target Traction etc) all tend to be fairly aggressive.
IF (you will notice that is a big IF), a patient can tolerate a compression method then that is what I prefer to use. If the patient can tolerate compression, I prefer to use the Dakota traction as my main method of providing home traction.
IF (there's that big IF again) a patient cannot tolerate a pure compression method then I switch to a method which is better tolerated. Usually a counter stressing method since these seem to be easier for many people. I use the Stynchula method (Seated compression combined with a counter stressing strap) a lot!
I use it as my main method of traction in the office and quite often will send patients home with a Stynchula unit. I also use the Pope 2 way traction in my office. It is a good method, extremely well tolerated by almost everyone, and even though it is a bit expensive I believe that every doctor should have one. Just so you know, I don't make one cent off of the sale of the Pope Traction device. I carry it in our catalog because I believe in it. Try it. You will too.
IF the patient cannot do any of the above methods, I will generally fall back to either a CET-1 unit used supine with a double wide wedge (see catalog,) OR the very gentle Fisk method of using the old medical type over door traction.
Occasionally I run into people who simply can't find a comfortable method of traction for one reason or the other. In these cases I generally have the patient rehab the neck for 4-6 weeks and then try again as long as there are no contraindications to proceeding. I believe that generally patients have to be able to traction pain free IF we expect to get good compliance.
I always tell my patients to work through discomfort and boredom but to stop traction if they feel pain. If pain persists I generally just try another method. Some doctors approach this differently. Some highly charismatic doctors will encourage their patients to tough it out through spinal pain and discomfort. (NOTE: we are talking about simple spinal discomfort here, NOT radiating or radicular pain or any of the other serious symptoms described as contraindications in the Extension Traction Testing Protocol. If you aren't familiar with the protocol we will be glad to send you a FREE COPY.)
This is largely a function of the doctor's personality and ability to get people to comply. Let's face it. Some doctors have so much personal charisma that they could get their patients to walk on hot coals. That approach doesn't work very well for my personality. Maybe I am just a little bit more laid back than that! Work with the various methods a while.
Support and encourage your patients and remember, each method is just a tool. The more tools you have in your bag of tricks the more likely you are to find one that will work for any given individual.
Can patients get themselves into and out of traction in the office?
Patients can easily get themselves into and out of the traction units. They generally need a bit of help the first few times and then they can do it without problems.
There is no need for your staff to be tied down with this other than showing them the first few times. It does help if the traction area is within view of your staff so that they can quickly come to the aid of any patient who is confused or having a bit of difficulty.
How long should the patient traction?
Suggested treatment protocols are as follows:
Once I have screened my patients using the Extension Traction Testing Protocol and determined that there are no contraindications, I generally start my patients with in office traction at about three minutes.
I generally increase the treatment TIME by about one or two minute (s) per session until the patient can comfortably tolerate 10-12 minutes of traction. This generally takes a couple of weeks if the patient is being seen 3X weekly.
Once the patient has demonstrated in the office a good tolerance for the procedure as well as a familiarity with getting into and out of the traction unit, a home unit is prescribed. I recommend that patients increase their traction times at home to approximately 30 minutes. Thirty minutes gives an optimum amount of tissue stretch for the time invested.
There are various folks out there teaching 5, 7, or 10 minutes but I do not believe these times are going to yield ideal results. The exception to this is in-office traction where I generally limit my traction times to 10-12 minutes. I (as well as most other doctors) often compromise on traction time in order to better expedite the flow of patients through the office. It is simply not practical to keep patients in traction for 30 minutes on each office visit so we rely on the patient to do longer session when tractioning at home.
I do feel that the longer session times are VERY important during home treatment. Once the patient can tolerate 30 minutes they should return the traction unit to your office and have your staff add one lb of lead shot into the unit or in the case of the Dakota traction, show them how to increase the tension on the unit.
On the next session the patient should do as close to 30 minutes as they con comfortably tolerate. When the thirty-minute goal is achieved again then another pound of weight is added or the force in increased. This will generally be done two or three times and then most patients will find that the increased weight makes it difficult to traction for much more than 25-30 minutes.
In my humble opinion, this is the combination of weight and time that will produce the most tissue stretch in the least amount of time. I do not recommend that any weight or force be added to the traction device until the patient had reached the doctors recommended target times for treatment. Some doctors prefer to add weight sooner in the process but I believe it is counterproductive as longer treatment times are necessary to effect viscoelastic deformation of soft tissues.
How much correction should I expect at the time of Re-Xray?
Results vary from patient to patient, however in the one study to date, which looked at cervical extension traction (compression type traction) combined with adjustments, the results averaged about 13 degrees over approximately a twelve week period.
This is consistent with what I have personally observed in my own office. Occasionally you will have a patient who makes very rapid progress; however, on average if you are gaining about a degree per week, I personally think that is pretty good.
How should I position the patient on the Dakota Traction?
The important thing about positioning is that the patient's head be "free hanging". By that I mean that the head should NOT touch either the foam wedge of the Dakota Traction or the floor. Usually this positioning is best achieved with the apex of the wedge at about T-2-3 or so.
If the head touches the foam, the patient will need to position the wedge just a bit lower into the thoracic spine.
If the head should touch the floor you (fairly unusual except with the most flexible of individuals) you will need to place a small book beneath the Dakota traction so as to "lift" or elevate the wedge slightly above the surface of the floor.
Remember that the ideal position may vary a bit from patient to patient. Once you have helped the patient find the proper positioning, he/she will usually be able to replicate that position after being coached only a few times. A few moments spent coaching on successive visits before actually sending the patient home with the unit will pay off handsomely in terms of patient compliance.
What is the best set up for my weight bags?
The best method I have found,if using the Stynchula method, is to have three weighted bags and one CETPRO with Counter Stressing Strap at each traction station.
One bag is weighted with two lbs of lead, one bag is weighted with three lbs, and the third bag is weighted with four lbs. I clearly mark the weight on each bag with a piece of tape. This bag set up allows me to easily change bags/weights in order to add or subtract weight for each patient.
With only these three bags I can have weights of 2, 3, 4, 5 (2 +3), 6 (4 + 2), 7 (3 + 4), and 9 lbs (2 + 3 + 4). In the unlikely event I need more weight there is always an extra bag or two lying nearby.
Why use weight bags instead of lead balls?
I prefer weight bags to the old style lead balls for several reasons. Most importantly, they are a "soft" weight. If accidentally dropped, or if some passing kid picks up the weight and conks his brother on the head, there is unlikely to be a serious injury. The same cannot be said for the lead ball weights.
The second reason has to do with lead to skin contact. Lead can be absorbed through the skin by repeatedly handling un-coated lead balls. Lead is both toxic and cumulative in the system. Our bag system triple seals the lead shot into the weight bag so there is very little chance of the lead actually contacting my staff, my patients, or myself.
The third reason is purely cosmetic. The old lead ball weights have a "medieval" look to them that is emotionally intimidating to a lot of patients. If you have used the lead balls you will notice that your patients cringe a bit when first introduced to the method. You may also hear vague mutterings around your office about “torture devices” and the like.
I rarely get that reaction about the beanbag style weights. It always seemed to me that patients are more likely to comply with methods that are not intimidating. The truth is that both style weights work equally well. I know the lead balls are a buck or two cheaper but it just seems like a false economy to me. These devices are so cheap anyway! Why sacrifice safety or patient compliance to save one or two dollars.
Is traction ever contraindicated?
Basically you should never traction any patient for whom extension of the neck is contraindicated. Another way to put it is...Never traction anyone for whom adjustment (manipulation) of the cervical spine is contraindicated.
We have put together a testing protocol to help simplify the process of screening out patients for whom extension traction might be contraindicated. Please follow the testing protocol with every patient.
A printed copy is free upon request. Please refer to the Guest article section of the website and review the articles "Who Shouldn't Traction" and "A Suggested Screening Procedure for Patient Safety."
One Doctor's Letter...
Here is a very typical letter from a doctor having some common problems. Perhaps my answers (at the end) here might be helpful to some of you just getting started.
Mark R. Payne, D.C.
Dear Dr. Payne,
First I want to say I love your products and I am now starting to see awesome spinal corrections. I've only been in practice for just about 1 year and already I've seen some awesome changes in cervical curves. I have a question regarding a patient.
She has been on traction for approx 15 weeks, I've re-x-rayed her and I'm starting to see an improvement. She went for a straight c/s to +10 degrees. My problem was I used a different company's block and it was too soft. So I switched her to the Dakota block but the head strap keeps slipping off her head. I even tried changing the angle and that didn't work either. I would really like to use the Dakota block because her thoracic cage has translated posteriorly.
I believe that if I can work more on reducing the post translation of the thoracic cage here c/s will respond more rapidly. Here is some more info. Patients 20 y.o.a., good health, fit, good bone structure and disc space. So if you could help me with some options that would be great. Oh, I did try the Dakota block with a weighted head harness and that worked great on my rehab table, but my thought is a bed will be too soft to get proper pressure on the T/S.
Another question I have is at what point of spinal degeneration do you chose not to use traction to restore the cervical curve and is there any other procedure or treatment option to offer these patients in terms of at home care. For example I've been using cervical traction on people with good bone structure and discs (phase I) and even some people with very mild (thinning disc and sharpening of bone edges) degenerative changes. However with moderate to severe arthritis or arthritis at multiple levels I use a cervical roll and pillow for relief and I haven't been addressing the use of traction.
My training has taught me that if the C5, C6 disc is very thin and the bone shows spurring, that the restoration of the curve is unlikely. I was just wondering your thoughts. I appreciate any help. I know you are a very busy doctor and business man.
Dr. J V
Dear Dr. V,
First off, thanks for your interest in our products and congratulations on the positive changes you are seeing in your patients. It sounds like your practice is off to a great start.
Regarding the ten degrees of improvement, actually, this is not a terrible amount of change. Yes we would hope for a bit more, but my average is around 12-13 degrees in 12-14 weeks, so this patient isn't doing terribly to begin with.
Regarding the foam being too soft on the knock off Dakota tractions you purchased (SHAME SHAME SHAME on you Dr. V!) Seriously, this is a problem with a lot of the knock off products. They use a much lower grade of foam to keep costs down but of course it doesn't hold up very well. The result is poor product performance as you are seeing and when the foam breaks down it allows the thorax to translate posteriorly...not good.
The strap slipping off the forehead is USUALLY related to one of two problems:
1. The patient is placing the apex of the foam wedge too high in the thoracic spine. This prevents the head from extending fully because the occiput is striking the foam wedge at the posterior. And of course traction isn't particularly uncomfortable as long as the head never extends fully, so the patient, now able to easily traction for 20-30 minutes, begins to tighten the bungee cord tighter and tighter until finally it will just roll off of the forehead due to all the pressure. The proper placement for the wedge is with the apex at approximately T-3. Just make sure the head is "Free-hanging" and not touching the foam rubber or the floor. Once this position is achieved most patients will find compression traction to be considerable more difficult and will have to loosen the tension on the elastic cord allowing the "rolling" problem to disappear.
2. The second possibility is one which very common with younger females. Many young women are just so flexible (estrogens make soft tissues very pliable) that the neck will extend so far as to make it impossible to keep the band over the forehead. If you think this is the problem, here are two possible solutions. First you can try placing the foam pad over the bridge of the nose, just below the glabella. Since only light force is required, this is usually not something which is overly uncomfortable. A second possible solution is as you mention below, to use the Dakota Type Block (Item # LE-8 sells for $9.00) and allow the patient to traction with a traditional weight harness (Item # CET-1) off of the bed.. You mentioned that you thought her C Spine problems might be due to thoracic translations and my thought is that you are probably on the right track here with this patient. Many of these problems with straight necks in young females have more to do with other imbalances lower in the spine than they do with soft tissue contracture in the C spine. This is especially true with cases where the neck is hyper flexible. It is intuitively obvious that the patient who is HYPER mobile in cervical extension is not in particular need of stretching the soft tissues on the anterior spine...therefore the cervical hypolordosis is almost a compensation for underlying thoracic and/or pelvic postural distortion. Check these areas well.
Regarding your idea of using a harness with the Dakota type block (item LE-8) off of the bed:. A bit of softness in the bed will not necessarily prevent you from getting a decent correction provided it is not excessive. You may wish to give this a try if you are sure the patient actually requires more cervical traction. As long as the thorax is held in forward translation/flexion relative to the pelvis, even if the bed sags just a bit, she should do fine.
Regarding what types of patients I might NOT use traction on...I generally never traction young children...usually just laying off the bed with the head in extension is very adequate. (And do not even do this with infants..they should develop their curves naturally as they assume upright postures) And I personally have a problem recommending an extensive and difficult program of traction for the very elderly and severely degenerated patient who IN MY PROFESSIONAL OPINION will probably achieve little to no spinal improvement. I just don't have it in my heart to strong arm Gramps into tractioning for the next eight months, when he could be enjoying his Bonanza re-runs, UNLESS I really think there is a real and legitimate chance of improvement. Use your own judgment here.
Regarding degenerated patients, well...I certainly do traction patients with disc thinning and evidence of spurring, even well into phase two and sometimes phase three, but I try to temper my desire to help with some common sense. For instance, a degenerated 48 year old is a very different proposition from a degenerated 78 year old in my opinion.
Again...Every doctor has to make these decisions according to his/her own dictates as to what is possible and proper for each case. I can only try to share how I might come to those decisions. Not sure if I am clearing the waters here or muddying them further. (Hope this helps! Call me if you need to talk in person. I will look forward to hearing how this young lady does.)
Mark R Payne DC
Matlin Mfg Inc
Trouble shooting common problems with the Dakota Traction.
A. Torn foam head pads
Generally, this is due to patients pinching the foam rubber portion of the head pad as they “pull” it up and over the head. This can be easily remedied by instructing your patients to place their fingers underneath the headband and gently press or “lift” the head pad up and over the forehead.
Replacement pads are available at a very low cost.
B. Broken elastic bands (bungee cords)
This one is a bit more serious since it indicates a common misuse of the unit.
If your patient should actually break a bungee cord (very hard to do), it indicates that your patients may be using the units in a way that will not only damage the unit but almost surely will result in a very poor correction. Allow me to explain.
It is vital that when the patient is using the unit, they be positioned so as to have the head hanging completely free from the foam wedge. Please be sure the back of the patient's head is not touching the foam wedge when traction force is being applied.
We have found a number of doctors positioning the patients so that the uppermost edge of the foam wedge strikes the patient in the mid cervical area. THIS IS INCORRECT. This incorrect use of the unit has been taught and promoted primarily by some of our competitors who chose to “knock off “ our original Dakota Traction.
I guess it just indicates that people who are so lazy as to steal other folk’s ideas are probably also too lazy to put much work into learning how to do things right. If you've been taught to place the fulcrum into the mid cervical area we need to cover proper placement in order to better your clinical results.
When properly positioned, the uppermost edge of the foam wedge should strike the patient at around the T3 or T4 area. This will allow the head to "free hang" from the wedge and extend into a much more pronounced cervical arc.
If improperly positioned, the back of the head will merely rest against the foam fully. In this position, many patients will mistakenly keep tightening the elastic band thinking they are getting a more pronounced and effective traction effect. In reality, since the head cannot extend any further backward, all they are doing is pressing harder against the forehead.
While this is very effective for putting a most attractive groove into the patient’s forehead, it actually does very little in terms of cervical correction!
Some patients have tensioned the elastic bands so tightly as to break the elastic bands and tear the foam head pads. If this occurs with a patient you should immediately suspect improper positioning on the unit Please take a few moments and check your patients for proper form and use of the units.
When the head is "free hanging" and not supported by the foam wedge, you will find that very little tension is needed on the elastic band in order to produce a profound sensation of traction. If you find that some of your patients need to be re- coached on proper positioning, they will also need to relax the tension on the elastic bands considerable in order to accommodate the new and correct position.
What about patient retention?
You spoke with me a month or two ago on the phone. Then you sent me your letter regarding retention, thank you and I have been receiving your newsletter. Here are some additional questions. What retention do you expect from a patient, if the traction and exercises are done at home?
Other then the initial training and occasional follow-up, what are they coming into the office for? If it is the adjustment how long do you keep that up and when do you determine that need is accomplished?
Thanks for your time,
PS: What do you think about what Dr Woggan is doing with his scoliosis treatment?
We are practicing in interesting times. Years ago (during the good years of insurance) I averaged around 65 visits per patient. That's probably not realistic in today’s market. More importantly, it may not even be necessary.
Consider the following. In the earlier years of my practice, I (like almost every other high volume practitioner), put patients on VERY long programs of adjustments. You know the kind I'm talking about... 3 x weekly for 10-12 weeks, then 2 x weekly for 10 weeks, then 1 x weekly for just about forever, then once every two weeks..... Well, you get the idea. That made for a heck of a lot of adjustments and consequently, a high patient visit average (PVA) or "retention".
Only problem is, it probably didn't really benefit the patients very much. Oh sure, we were getting pretty good corrections. In fact, we were averaging just about what we do now...12-14 degrees of correction over the first three months or so of care.
The difference is that now we do the same thing with a lot less in the way of office visits. I don't really have any defense for why I placed so many patients on long "corrective care " programs other than that was what I had been told to do by my practice management gurus at the time.
We now know several things that make such long programs of adjustments highly questionable.
1. Any type of treatment program is rarely linear in the results it produces.
If three months of care produces ten degrees of correction, that is certainly no indication that nine months of care will confer thirty degrees of improvement. There is a point of diminishing returns for every patient. It's our job to try to figure out when the patient is approaching that point if possible.
2. The adjustments don't appear to be responsible for much of the correction any way.
We now have about a half dozen studies indicating that adjustments probably account for only about a third of the correction we typically see...possibly less.
It appears that exercise and traction are much more effective at restoring the cervical lordosis and this most likely applies to other postural imbalances as well. At least there is no evidence to believe otherwise. So...if adjustments only account for a small portion of the improvement, why then do some doctors continue to sell patients on long term programs of repetitive adjustments. Unfortunately, I think the answer to that is pretty obvious.
In my humble opinion, it is our responsibility to only render that care which appears to be most effective. Without such consideration, valuable resources are wasted. For years the profession, myself included, practiced with giving any consideration to being cost efficient.
It was wrong and now we see the results of our folly. It is unlikely that the profession will ever recover from the fallout of our excesses during my lifetime.
3. Patients generally do much better when they are responsible for some portion of their own outcome.
It is the responsibility of the doctor to get patients involved and accountable for some portion of their care. If a patient can exercise or traction at home and get an equal result, there is absolutely no justification for me to have the patient come in just so I can collect on another office visit charge.
Instead, I prefer to schedule patients for adjustments as I determine they are needed,and to have them do everything possible for themselves on a daily basis at home. My results are just as good and patients end up spending a lot less time and yes, money, in my office. That may sting financially in the short term, but in the long run it's much better for the people we serve and for our profession.
RETENTION: We did start this conversation about retention didn't we? Here's a rough approximation of how a typical treatment plan my go in my office.
- Daily care for acute, severe, symptoms for a two or three days until they are calmed down a bit.
- 3 X weekly for 2-4 weeks. (Begin in-office active care and training for home care program. )
- 2 X weekly 1 week. (Start reducing visit frequency when they appear symptomatically stable. Begin home care program)
- 1 X weekly for 3-6 weeks ( Home care continues to be done daily)
- 2 X monthly until post care films are taken. (Patients are adjusted as and if needed. I think the real value is when these twice monthly visits are used to follow up on patient compliance, re-coach on home care as needed, and to observe for anything that would indicate a pending exacerbation.)
- POST care films generally around 12 weeks of care. If patient appears to be compliant with home care.
- 1 X monthly or occasionally less in order to keep patient working toward maximum correction.
- In rare cases I might take a second set of post care films but generally not.
- Once I feel the patient's posture is sufficiently improved, I will typically cut them loose to return PRN and to continue their home care at least 1-2 X weekly to maintain their correction. (No...they don't always do it, but it's my job to give them the tools and the opportunity. If they don't follow through, I'll discuss it next time they have a flareup.)
Patients appreciate that you aren't trying to keep them coming forever and that you are giving them real tools to help themselves. It's been a while since I checked my PVA, but it's probably in the mid twenties or so now. Not as good as during the heydays, but still enough to make a living.
Dr. Patton...In my opinion, patients do need to be adjusted regularly during the early portion of care. The adjustment is a very effective tool at helping patients to get well. But the logic breaks down when doctors take a tool that is proven effective at helping patients to feel better (the adjustment) and blithely assumes the same tool will result in real spinal correction if applied over a long period of time. There's just no evidence to support that and a lot to indicate it just isn’t so.
Hope this helps,
Mark R Payne DC
Matlin Mfg Inc.
PS: I really don't know anything about Dr. Woggon's scoliosis methods, but he is a smart and creative guy. I took a couple of his seminars back in the late seventies and learned a lot. I'm sure I could learn a lot today as well.
What do you do in the way of ACUTE Care?
This is an answer to an email from a doctor interested in knowing more about what procedures we use during the acute phase of care.
Dear Dr. Payne,
I read in your bulletin that one should not start extension traction until the patient is asymptomatic, which in your office generally takes about one to two weeks. Could you please tell me what you do in general to get the patient to be asymptomatic?
Dear Dr. P.R.,
I hope I haven't inadvertently overstated my success in helping patients to feel better. I certainly have difficult cases who take much longer than two weeks, and occasionally I have cases I can't help at all. I think we all have some of those from time to time. That being said, I think it's fair to say the average patient is feeling considerably better in a couple of weeks or so. Maybe not 100% asymptomatic, but certainly much improved. I don't think our office is much different than most others in this respect. Most doctors in the field are remarkably good at providing symptomatic relief. I think I have seen a study on this indicating most patients receive in the neighborhood of 5-7 adjustments before they are feeling considerably better. The bottom line is that whenever possible, I prefer patients to be pretty much pain free before starting extension traction and/or rehab. Occasionally that isn't possible, and it is necessary to go ahead and initiate rehab in order to help the patient, even though they are still symptomatic. The typical things we do in the way of Acute Care are as follows;
ICE: to affected area generally 15-20 minutes every 1-2 hours a minimum of 5-6 times daily. Patients are given a gel type ice pack and instructed to take it to work with them. (Most work areas have a freezer they can use to re freeze the pack.)
REST: We generally try to get the patient to avoid as much as possible those activities which appear to be culpable in producing their pain. That being said, we also encourage patients to get up and simply walk around the house, or workspace for 5-10 minutes every hour. Gentle movement is important even at this early stage. Complete bed rest is only recommended in the most extreme cases.
MANIPULATION: We will generally adjust the involved areas at least once daily. Occasionally twice daily if the pain is severe. More on this in a moment…
TRIGGER POINT THERAPY: If the pain appears to be myofascial in origin, we will start trigger point therapy immediately as well. Some of the various methods we use might include direct pressure, ice massage, transverse frictional massage, active release, or PNF stretching.
ELECTRO THERAPIES: I don't personally use any electro-therapies, mostly because I am fairly ignorant of their proper use and mechanisms of action. However, my partner does use some muscle stim and interferential occasionally, and it seems to be effective for some folks. I will confess to sending some of my acutely painful patients to Dr. Gordon so that he can do his electrical wizardry if they are at all slow in responding.
SCHEDULING: As you can see, these above items really aren't much different from what most chiropractors do in the way of acute care. One thing I do that seems to be different from a lot of doctors, has to do with how I schedule patients who are in severe pain. When patients are hurting severely (unable to work or perform most of their normal activities of daily living), I prefer to see them very frequently until the pain begins to improve. That generally means DAILY care at a minimum but very often, I will schedule them to be seen both morning and afternoon. This is something that was recommended to me during chiropractic college when I was fortunate enough to speak personally with Dr. Clarence Gonstead. Dr. Gonstead related to me that he felt like one of the reasons he got such wonderful symptomatic results with so many difficult patients was that he would treat the patients sometimes up to three or four times daily if they were in severe pain. The famous Gonstead clinic had a motel on the grounds where patients could stay and get their treatment as often as recommended. This allowed Dr. Gonstead to see the patients as often as needed. Of course I don't have a motel attached to my clinic, so it would be difficult to treat a patient three or four times daily, but it isn't unusual at all for me to see severe cases in the morning and then again in the afternoon. As a side note, I never charge patients for the second visit on a given day. That's just my preference. I always figured if they were hurting that badly, the last thing they needed was for me to be beating up their checkbook! Typical patients of course, don't generally need that type of intense care, and will be adjusted three times weekly for the first two to four weeks. Once the pain is subsided, and the patient appears to be stable, I may see them twice weekly for another week or two and then as quickly as possible try to get them on a once weekly program. I personally think that a weekly adjustment is ample for most patients who are participating in "Corrective Care" programs. In my opinion, most of the real work such as traction, rehab, etc, can be done equally well at home. The once weekly visit allows me to not only adjust the patient but to follow up how well they are doing their home care programs. More importantly, the office visit provides an opportunity to observe them performing their exercise and traction procedures and to RE COACH them if needed.
CASE HISTORY: You already know this part, but I just thought I would throw it in anyway. In my experience, a very careful case history goes a long way toward helping you determine what actually caused the injury and in turn being able to figure out what type of tissue is generating the pain. Once you do that, the rest should come pretty easily. The most common mistake I see chiropractors making is failing to make a "tissue specific diagnosis" and then just adjusting away on the patient. As chiropractors, we often have a tendency to see everything in terms of subluxation (joint dysfunction). Consequently, we need to guard against overlooking obvious signs that might indicate the pain is coming from somewhere else. I cannot tell you how many patients I have seen in my career who spent months being adjusted by their chiropractor to no avail, only to end up in my office where I determine that the pain is myofascial in origin. A week or two of muscle work and they they think I hung the moon.
So why didn't the other guy see it? Most likely because he never looked for it to begin with. The old cliché "When the only tool you have is a hammer, everything starts to look like a nail" comes to mind here. And it's really true for chiropractors. The nature of our training, at least in many chiropractic colleges, is to look at everything as "subluxation". "One Cause. One Cure". "Find it, adjust it, leave it alone". We get all that stuff drilled into our heads in chiropractic college. At least we did at Life College in the seventies. And from what I can see in talking to new graduates, it isn't all that much different today. I personally have made the same mistake many, many, times. Old habits of thought can be hard to break! Anyway...I hope this helps. If for no other reason than to let you know that we don't do anything particularly new or revolutionary in terms of acute care. I am sure that many other doctors proceed quite differently and get equally good symptomatic results. However you do it is pretty much fine with me. The important part, the thing that is really going to make a difference for the patient in the long run, is what we do for the patient AFTER the pain goes away. Good corrective care programs which implement corrective postural care and functional rehabilitation are what separate the doctors who "walk the walk" from those only "talk the talk." Once again, thanks for your interest.
Hope this helps!
Mark R Payne DC
Matlin Mfg Inc
What is the best setup to use for traction in my office?
My personal favorite and the one I recommend for doctors who are just getting started using extension traction methods is the Stynchula Method. The method only needs one of our CETPRO units and one Counter Stressing Strap (Item # CSSPRO).
I have described a simple and inexpensive method for installing these units in your office. Please see our technical bulletin "Everything you ever wanted to know about Stynchula Traction."
When should I add weight or increase the traction force?
I recommend that you do NOT add force or weight to the traction unit until the patient has attained the ability to traction for at least 20 minutes…. 30 minutes is probably optimum.
When should I Re-X-ray?
Use your own judgment, however, bear in mind that rehabilitating the cervical lordosis is a slow, gradual, process for most patients. I generally don't think about taking another film for at least three months.
How much weight/force should I use to start?
When using the CET-1, SET-1 or Stynchula methods, I generally start most adults out with three pounds of weight in the traction unit.
When using the Dakota Traction I tighten the elastic band until it will just barely stay on the forehead (probably only a couple of ounces of force).
When using the over the door type traction (Fisk Method) I typically start adults with about 14 lbs of water in the weight bag.
With all types of extension traction, I do not generally recommend that any weight or force be added to the traction device until the patient has reached the doctors recommended target times for treatment. Some doctors prefer to add weight sooner in the process to try to hurry the correction process along. I believe this to be counterproductive.
Adding more weight DEFINITELY makes it harder for the patient to traction for extended periods of time. We know that longer treatment times are necessary to effect viscose elastic deformation of soft tissues. It makes since to me to only add weight AFTER we have the issue of time compliance handled.
How often should the patient traction?
Once a day, EVERY day until the desired correction is achieved. Afterwards you may want to have the patient traction once every 7-10 days to help maintain correction.
Dear Dr. Payne,
My name is #### and I work for ##### Healthcare. We are having difficulties being paid on our Dakota wedges because the insurance companies are saying they are "experimental". I was wondering if you had any scientific evidence that says otherwise so that we can send that information into the insurance companies. If you could help us out in anyway I would greatly appreciate it.
I have attached a copy of my report with literature support for various aspects of a postural approach to chiropractic. The section which may contain some helpful material for you is entitled " Evidence supporting the use of extension traction/exercise as a means of correcting sagittal spinal curves and/or improving therapeutic outcomes." You can go to pubmed.gov to download the actual abstracts of the articles. Copyright laws prohibit me from publishing the abstracts or articles in full.
One additional item that may be of help to you. Most doctors will file the units simply as E0941 (Gravity Assisted Traction) without making any mention of the item's brand name...i.e. "Dakota Traction". This is probably the most accurate coding of which I am aware, and one which many companies will pay without question since they are familiar with a relatively wide range of devices on the market which may fall under this designation. Calling attention to the fact that this is a different device, one with which they probably aren't familiar, probably isn't the best way to go....UNLESS of course the company asks you to identify the specific device the doctor is recommending in which case you should of course be truthful.
Many doctors continue to get reimbursed for these devices without complication, but of course each company is different in what they will or won't pay for. Some further points for your consideration relative to getting paid are as follows.
• The Dakota Traction is a device which costs the doctor about 22-25 dollars on average to purchase.
• Suggested retail for the device is roughly twice your actual cost to get the device into your office...$55-60 is officially our suggested retail price. Some doctors will actually triple their cost and still seem to get paid without drawing a lot of unwanted attention to the claim.
• In the past couple of years we have become aware that a number of doctors are charging the insurance companies $300-400 or sometimes even more in an attempt to maximize reimbursement. Although your fees are your business, I cannot help but feel that such large markups for durable medical equipment are likely to draw more scrutiny to a claim, and consequently start the insurer on a quest to find a reason to deny the claim.
• As an alternative to itemizing the charge for any needed traction/rehab equipment likely to be needed by the patient, many doctors are simply "building in" the charges to their case management fee schedule.
• Finally, our job is to provide you with a sound quality item, which hopefully is reasonably affordable for your patients should their insurer happen to deny the claim. We continue to recommend that you get paid for the units before allowing them to leave your office with the patient. Doing so should help to reduce any potential loss for the clinic.
I hope this is helpful. Please don't hesitate to write back if you have any further questions.
Mark R Payne DC
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