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Before and After Posted 11/27/15 by Dr. Miller

We have all seen ads for weight loss and beauty makeover programs that employ before and after photos of their clients’ success stories. Some of the photos are believable. For example, an ad may present pictures of an individual that show his size before and after weight loss. In many cases the person is wearing the same pair of pants in both pictures. The pants often appear to have enough room in the after picture for another person…or two.

However, for every believable set of before and after pictures there are several that are questionable. The person in the photos does look different but the pictures are not a one to one comparison.

In many cases the person in the pictures has changed in more than one way between the before and after photos.

Differences in hairstyles, tanning, types of clothing, degrees of dress and undress, make-up, facial expressions, weight loss and photo backgrounds can be seen. Obviously, the larger the change between pictures the more the recommended product appears to have helped the client.

I bring this up because I have attended a few license renewal seminars recently, seminars where before and after pictures of patients were used to depict the success of the techniques presented. Improvements in posture, leg length, range of motion, gait, muscle tone and other physical features were shown.

While the photos appeared to show remarkable patient progress there were problems with many of the photos. There was no consistency in the manner they were taken. Before and after pictures were taken in different rooms. The distances between the patient and the camera varied. The angles the pictures were taken from also varied. Lighting and the degree of dress were also issues. These are serious discrepancies. It is difficult to take the results of the techniques seriously with this lack of consistency.

Digital cameras and camera stands are inexpensive. Backgrounds with grid patterns are also inexpensive. These items can be placed in fixed positions for ready and consistent use. A pattern can also be placed on the floor as a guide for patient foot placement. Consistency in the placement of equipment and patient enhances the practitioner’s ability to detect results. It also enhances the practitioner’s ability to determine the accuracy of the results.

This is logical. It was surprising to me that the instructors in these courses did not utilize these principles and that the organizations granting postgraduate credit were not more scrutinizing. The largest surprise was the number of doctors in attendance who did not question the depiction of results or did not seem to care when the depictions of the results were questioned.

In this era of evidence based practice it is hard to understand how we can be evidence based when we cannot present evidence logically or interpret it objectively.

I'll Go Ahead and Be Embarrassed For All Of Us Posted 10/14/15 by Dr. Miller

I have doctors and management consultant calling me from all over the country in a panic.  It is kind of a second wave of panic associated with the ICD-10-CM conversion.  They are all concerned about how to justify the use of the new diagnosis codes.  In other words, if an insurance carrier asked them to prove a patient has the diagnosis rendered what clinical findings would the doctor need to list in order to convince the carrier the patient has the diagnosis. 

Really?  

Ok, I’ll go ahead and be embarrassed for all of us because; this is embarrassing.  

First, if a doctor renders a diagnosis, he is supposed to do so after identifying signs, symptoms, imaging results, test results etc., that indicate the presence of the diagnosis.  Proving the diagnosis is on the front end of the diagnostic process.  It isn’t on the back end of the diagnostic process. 

You can’t just write down a diagnosis because it sounds good, looks good or pays good and worry about the “proof” later. 

If a doctor renders a diagnosis but doesn’t know how to prove it exists, he should not have rendered it in the first place.  Additionally, if a doctor renders a diagnosis he cannot document, the care for that diagnosis is probably inappropriate. 

Second, only the codes changed.  The conditions didn’t.  A cervical disc with radiculopathy is still a cervical disc with radiculopathy.  The findings that support this or any other diagnosis did not change. 

Third, even with the addition of thousands of codes the principle is the same.  Most new codes only identify conditions that already existed.  The new codes are used to separate many of the diagnoses from the herd.  Conditions that were previously lumped together have been separated to allow for more specific identification in the new system.  Despite the existence of the additional codes the principles are still the same.  A doctor should not use a code/diagnosis he cannot prove exists (on the front end).  And, revising the codes did not create new conditions or alter the findings that prove the presence of any of the conditions. 

Fourth - buy Practical Assessment of the chiropractic Patient 2nd Edition (see our Products page).  It has a listing in one of the Appendices of common diagnoses and the orthopedic and neurological tests from the book that justify those diagnoses.

Miller's Law Posted 9/10/15 by Dr. Miller

In 1956 George A. Miller published a paper that would become one of the most cited works in the history of psychology.  The paper on cognitive psychology described the number of items a person can hold in their working memory at one time as 7, plus or minus 2.

The affects of the study had profound influence on developments in many fields.   For example, when the number of telephones in America increased to a point where all possible combinations of 3 and 4 digit phone numbers had been used, numbers had to be expanded in length.  When the decision to expand was made, Miller’s theory influenced the decision.  Phone numbers were increased to seven digits.  This worked until the combinations for seven digits where approaching maximization.  Area codes were incorporated at that point.

Miller’s theory also influenced neurological testing for mental status.  Asking a patient to memorize a seven-digit number early in an exam and repeat it back to the examiner later became a standard test for short-term memory.  Short-term memory is normal if seven digits can be learned quickly and repeated shortly after memorization. 

For this test, I use the primary seven digits of my office phone number.  The examiner can pick any seven-digit number.  However, a word of caution must be given prior to the selection of the number, do not use 867-5309.

Roaming Orthopedic Tests Posted 8/12/15 by Dr. Miller

I was speaking with a doctor recently about shoulder diagnostics. We were discussing orthopedic tests and I asked if he used O’Donoghues Maneuver as part of his exam protocol. He looked confused and asked, “Isn’t that a cervical test?”

I responded by saying, “It is traditionally described for cervical pathologies, mainly differentiation between sprains and strains. It can also aid in the of assessment range of motion. However, it can be used for other joints or regions.

O’Donoghues is performed by having the patient move a joint or series of joints actively through their ranges of motion. This is followed by the examiner passively moving the same joint(s) through their ranges of motion. Pain during active movement could be due to strain and/or sprain. Pain during passive movement is thought to be due to sprain since the muscles are not active and less likely to cause pain. It isn’t the most accurate of tests. Realistically, every movement hurts with bad sprains and strains.

In some texts books it is stated that if large differences in active and passive ranges of motion are noted, the patient should be assessed further for the possibility of malingering. The ranges should be reasonably close despite pain.

I refer to O’Donoghues test as a roaming orthopedic test. This means the test can be applied, in principle, to any joint or series of joints where active and passive range of motion is possible.

There are three other common tests in the roaming category; apprehension tests, valgus stress tests and varus stress tests.

Apprehension tests are described routinely for the shoulder and patellar joints. The tests are performed by “slowly” maneuvering a joint into a position that could reproduce a previous dislocation. When the patient feels the joint approach this position, he becomes apprehensive, and resists further movement in fear of another dislocation.

While the shoulder and patellar joints are common sites of dislocation, the test can be performed for any joint that has been dislocated and in a sense, for any joint that is unstable.

There are two keys to performing apprehension tests. The first, the doctor’s movements must be slow to prevent sudden dislocation. The second, the doctor must watch the patient’s face for apprehension. I have seen more than one book where the doctor depicted in the text is staring at the shoulder being tested.

Valgus and varus stress tests also roam. The tests can be performed for any joint where flexion and extension are the primary ranges of motion and the joint has collateral ligaments or ligaments that serve as collateral ligaments.

For valgus stress testing, the body part distal to the joint being tested is moved away from the midline of the body or laterally. This tests the medial collateral ligament for sprain.

For varus stress testing the body part distal to the joint being tested is moved toward the midline of the body or medially. This tests the lateral collateral ligament for sprain.

The tests can be performed with the joints in their fully extended position and with the joints in approximately 30 degrees of flexion. The fully extended position is considered less accurate as in this position other structures (the bony configuration of the joints) help stabilize the joint making it difficult to detect collateral instability.

Valgus and varus stress tests are associated with the knee and elbow where true collateral ligaments are found. The tests are also associated with the ankle where the deltoid (medial) ATFL, CFL and PTFL (lateral) ligaments serve as collateral ligaments. The tests can also be employed for digits (fingers and toes).


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