Motion EMG showing ‘muscle guarding’ is courting personal injury wins for chiropractors and patients

The device that is securing practices with objective ‘muscle guarding’ data while providing ‘unimpeachable evidence’ for personal injury DCs

GROUNDBREAKING PRODUCTS THAT CHANGE THE INDUSTRY are few and far between in chiropractic. That has changed over the last few years in the personal injury realm with the growing popularity of Dynamic Surface Electromyography, a device that personal injury attorneys are calling “the lie detector for back pain.” The DynaROM Motion EMG measures both range of motion and the “muscle guarding” during motion, eliciting a pain response to detect the presence or absence of soft tissue injury.

“I was getting calls from chiropractors with worker’s comp and personal injury (PI) practices  that started the same way every time,” said designer David Marcarian, who developed his expertise in electrophysiology at NASA’s Ames Research Center. “It was like, ‘The attorney said they won’t work with me unless I get a DynaROM, period.’”

‘Muscles can’t lie’ in court

Soft tissue injuries and symptoms are magnified when you measure muscle guarding through range of motion. Muscle guarding is the body’s natural defense mechanism to pain in motion.

“Mine is a functional test, there’s motion,” Marcarian says. “The way I present it is, ‘Does it hurt when standing or when you go to bend over to pick up something?’ It’s always when you go to bend over that the muscles go into spasm. Unlike static tests like MRI, CT or endpoint ROM, sEMG through motion is functional, and elicits the abnormal muscle guarding response.”

The device has resulted in millions of dollars won in personal injury cases and has become the gold standard for personal injury attorneys who work with chiropractors.  This was exemplified in Merritt vs. the Florida Department of Health (DOH), one of the first big wins for the device.

“What makes it a landmark case is the fact that the State of Florida was joined by 300 insurers, and one of the largest insurers purchased my law firm a couple of months prior to trial, creating a conflict of interest,” Marcarian said. “It was clear that a statute approving of this tool for evaluating soft tissue injury would destroy their defense, that soft tissue injury was purely subjective. This meant having to actually pay out on soft tissue claims like never before. In my opinion, their actual goal was to prevent chiropractors from seeing PI patients, as the same year they eliminated massage therapists from seeing PI patients.

“When it is just yourself and one main attorney against  300 insurers, 75 attorneys and  nine expert witnesses, the probability of winning was so low,” he said. “We won all the way to the Florida Supreme Court, twice. My attorney said it was simple: We told the truth, and they did not.”

The case resulted in the American Medical Association adding the device to its medical text on Range of Motion Assessment and led to Florida green-lighting 100% CPT code reimbursement (96002, 96004) for personal injury protection in Florida, and reimbursement throughout the country.

“No jury ever wants to give money on a personal injury lawsuit when it’s resting upon the testimony of the very person who will gain from it,” said personal injury attorney Mike Maxwell regarding a lack of objective proof. “When a plaintiff attorney brings in the DynaROM, this machine, which can provide the Holy Grail, the objective finding, suddenly they don’t know what to do. Unlike MRI, CT or Endpoint ROM which are so often normal in soft tissue cases, it really eliminates all of the lack of objective findings. So that’s who I choose to refer my [personal injury] clients to.”

Courting winning results with muscle guarding proof

Marcarian has seen his share of dramatic court cases featuring wins for his muscle-guarding technology.

“One was the largest personal injury award in the history of that county, with $650,000 for a soft tissue case,” he said. “Then an attorney in Seattle started seeing that all of the cases were settling for large amounts of money. One of them was offered zero dollars, and they settled it after my deposition for around $260,000. If insurance defense attorneys don’t go to jury trial, the case doesn’t get recorded as a loss to them. By avoiding jury trial, the only way to keep the DynaROM from proliferating was through major out-of-court settlements, such as Youngblood vs. State Farm, where finally a young attorney wanted to test the DynaROM in court.

“In the 2018 jury trial in King County, Wash., [Case #16-2-29568] the defense was certain of a max jury award of $10K with the plaintiff hoping for $70K. I was the last to testify, and made clear this was about data, not my opinion. In a move never seen in any case in U.S. history, according to the attorney, the insurance expert quit, never rebutting  my testimony. The jury handed down an unprecedented $958K. In the next jury trial in Washington, the same insurance expert testified with me, not against me. The patient, who asked to not be named, said, ‘The decision changed his life forever.’”

Law and order

In another case, Marcarian was called to test an individual involved in a court case being filmed for the Law and Order reality series, ”You the Jury,” involving a live jury trial.

“I tested this individual named Kevin who was a cop and he had been kicked in the head during an arrest,” Marcarian said. “To establish unimpeachable credibility I double-blind the test: I refuse to see history or even hear what the patient experienced. This approach, learned at NASA, has been a crucial element in my success. Without seeing his medical records, I testified that I saw an old and new injury to his cervical spine, the old to the back and the new to the front. The insurer was claiming pre-existing condition, with his symptoms due to a motorcycle accident two years prior. My interpretation of the data exactly matched the ER reports for both injuries; the 2-year old-motorcycle injury to the back of his neck with the recent injury to the front of his neck. How could I tell? New injuries present as very random lines in the graphs (jitter) which correlates with muscle fibrillation. Old injuries may have an abnormal pattern of motor firing but have graphed lines which are smooth in appearance.

“The defense attorney went nuts on me, saying, ‘Who told you about the ER reports?’ And I said, ‘I have no idea what you’re talking about but the data speaks for itself.’ She kept yelling names, stating. “You have to have seen the ER reports.” I had not. Thus I successfully wiped out the pre-existing condition claim, and we won the case.

Data from the device also displays lack of injury and symptom magnification as well.

“Numerous insurance claims have been dropped by patients ‘faking’ their symptoms [with lack of muscle guarding shown],” he says. “This fact makes it further unimpeachable, as it has been used to defend both insurance and defense positions.”

Muscle guarding: old and new sEMG

The new range-of-motion technology that detects muscle guarding has had to separate itself from static EMG (performed in a neutral position with hand-held probes) and comparisons previously used in court rooms.

“The problem is, there’s two types of sEMGs,” Marcarian says. “People mix up the two tests and those attorneys sometimes literally have the wrong information in court – in one case my assistant was there and she saw their materials and she said, ‘Everything they had was on static EMG,’ so they could not even defend. They had nothing and I’ll never forget — one defense attorney walked up to me six times in the court room — walked up, looked right at me and turned around and went and sat down as her questions were all about static sEMG.”

Last year Marcarian was appointed as a clinical instructor at the University at Buffalo Jacobs School of Medicine and Medical Sciences, teaching radiology students how to utilize the technology.

“A professor in charge of one of their courses said, ‘You realize you’ve completely revolutionized how radiologists see the spine,” Marcarian said. “He said, ‘We have a hard time explaining this, and we have a class tomorrow, would you mind teaching?’ And I said no problem, and I didn’t know that the committee for nominating sat in on the class, then they asked me to teach the class, so I was officially made a clinical instructor in August and teach typically every two weeks. We already have over five published NIH Case Studies. The U.S. Patent office gave it a leg-up on the competition when concluding the device is, “A soft-tissue-injury diagnostic system for diagnosing soft tissue injury…” With such a difficult claim, it took nine years to grant the patent. Now there’s over 12,700 studies published on surface EMG in general. Surface EMG was able to establish that muscle-guarding pain was measurable, and we have the research to prove it. It’s a true win-win for insurers, doctors, and ultimately patients.”

sEMG and chiropractic objective data

A surface EMG tool that can identify true pain in patients via muscle guarding has changed the game for personal injury chiropractors, and chiropractors in practice seeking concrete data to protect themselves from lawsuits.

Marcarian tells the story of two Colorado chiropractors, one running a cash and Medicare practice who lacked objective data, and one who used range of motion and static EMG with patients. Both chiropractors utilized the same technique, but when Medicare came calling, the DC who could not show objective data was fined $150,000 including attorney fees and lost his license.

He likens the availability of objective data to B.J. Palmer’s desire to objectivity to validate chiropractic care.

“Chiropractors are not listening to what B.J. Palmer said back in 1938, that if you don’t have objective tools that are accepted by medicine to prove what you’re doing, you’re not going to be believed,” he says. “I’ve worked on this for 30 years and everyone thought I was crazy, but people remind me that the airplane took 30 years [to perfect], the MRI took 30 years. It takes time to move from fringe to mainstream, and we’re there right now. One of the coolest things about this device is, it tells the truth.”

RICK VACH is editor-in-chief of Chiropractic Economics.

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CBD comes from hemp, but is it the same as natural hemp oil?

While they both come from the hemp plant, CBD and natural hemp oil contain different compounds for different health benefits

Cannabidiol (CBD) and natural hemp oil are often used interchangeably. They both come from the hemp plant, so it’s understandable why people would assume they are the same thing. Yet, the reality is that they are not. Knowing the differences between the two can help patients decide the best option for them.

Plants vs. seeds

One of the first major differences is where, within the plant, each substance is extracted. CBD products are created using an extract that is taken from the entire hemp plant. It is a cannabinoid found in the plant’s stalk, leaves, and flowers.

Hemp oil is different in that it is made using only the seeds, hence the reason some products are labeled as hemp seed oils. These seeds do not contain any CBD. Thus, natural hemp oil and CBD oil are not the same products.

Product compounds

When purchasing a CBD product, consumers can choose between a full-spectrum CBD, a broad-spectrum CBD, and a CBD isolate. An isolate is the simplest as this refers to a product that contains just one cannabinoid: CBD.

Conversely, full-spectrum CBD products contain a variety of other cannabinoids extracted from the hemp plant. This includes cannabichromene (CBC), cannabinol (CBN), cannabigerol (CBG), and perhaps the most well-known cannabinoid, tetrahydrocannabinol (THC). To be legal, the CBD’s THC content must typically be below 0.3%, though some state laws do allow higher concentrations. For instance, under Texas’s Compassionate-Use Act, CBD users are allowed THC concentrations up to 0.5% if they are prescribed for medical purposes.

A full-spectrum CBD also contains other substances, namely flavonoids and terpenes. Flavonoids give the cannabidiol its color, much like they do for fruits and vegetables. Terpenes give the CBD its distinct scent. Though this substance isn’t often discussed, like flavonoids, it can also be found in everyday foods. Apples and citrus fruits contain terpenes. There are also terpenes in beer and some spices.

Broad-spectrum CBD products fall somewhere in between. Unlike isolates, they contain more of the compounds found within the hemp plant. But they don’t contain the THC found in full-spectrum CBD. That makes these products good options for people who want as many healthful effects of the hemp plant as possible but without the THC, whether due to its psychoactive properties or if they’re concerned about it potentially showing up on a drug test.

Hemp seeds, on the other hand, supply the body with different compounds. Among them are fatty acids — omega-3s, omega-6 fatty acids, and gamma-linolenic acid — and a variety of nutrients, some of which include vitamin D and some of the B vitamins.

CBD and natural hemp oil benefits

Another difference between CBD and hemp is the way each can potentially help improve health. On June 25, 2018, the U.S. Food and Drug Administration (FDA) issued an announcement that it had approved the first-ever CBD-containing product, Epidiolex, for two hard-to-treat forms of epilepsy: Lennox-Gastaut syndrome and Dravet syndrome. On July 31, 2020, the FDA expanded the use of Epidiolex for the treatment of tuberous sclerosis complex, a disease that causes non-cancerous tumors to grow on vital organs such as the brain, kidneys, and lungs.

The National Library of Medicine adds that, while many pieces of research are in the early stages, there does seem to be some evidence that CBD may aid in the treatment of schizophrenia. It goes on to say that there have also been positive findings in studies using CBD to help people diagnosed with substance use disorders. Research is continuously being conducted to learn more about CBD’s other potential benefits, some of which involve studying its effects on pain, anxiety, depression, and other medical conditions.

What about natural hemp oil? Research published in Comprehensive Reviews in Food Science and Food Safety reports that hemp seeds are 25-30% oil, 25-30% protein, 30-40% fiber, and 6-7% moisture. This makeup highlights the seeds’ high nutritional content.

Additionally, the seeds are more than 90% unsaturated fatty acids and contain a “desirable balance” of omega-3s and omega-6s. This makes them good for the heart and for reducing inflammation in the body. The seed’s two main proteins (edestin and albumin) further aid in healthy organ function and metabolism.

Putting it all together

While they both come from the hemp plant, CBD and natural hemp oil contain different compounds, each of which leads to different health benefits. Understanding these differences can help medical professionals better assist their patients when trying to choose the best type of product for them based on their condition and desired results.

For more on CBD and hemp oil products go to

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Prunes benefits make a patient food for the ages (not just the aged)

Prunes benefits include compounds that are known to enhance bone health such as resveratrol, ferulic acid, syringic acid, sulforaphane, anthocyanins, and polyphenols

A healthy skeleton is continually responsive to its internal and external environments.  During growth years, bones elongate, accrue mass, and increase their hardness via mineralization. Change is uninterrupted throughout adulthood with many factors that influence gains or losses. Genetics, gender, ethnicity, diet, exercise, medications, natural compounds, diseases, and hormonal status all effect bone. But prunes benefits can help halt poor rates of bone accrual or rapid bone losses that can yield a compromised skeleton — one that is at risk.

Approximately half of your adult patient population will experience one or more fractures due to osteoporosis in their lifetime.1,2 There are many scenarios whereby bone losses outpace bone gains. For example, a post-menopausal woman3 vs. an anorexic teenager4 vs. vitamin D deficiency5 vs. chronic use of corticosteroid medications6. The cause, and proper treatments, for each of these is not the same.

Prunes benefits: healthy diet and bone metabolism

Diet plays a vital role in skeletal health.

Hippocrates said, “Let food be thy medicine, and medicine be thy food.” This is often stated but not nearly as often believed nor acted upon. There is one fruit in particular that may change your mind.

Prunes benefits include compounds that are known to enhance bone health. These include resveratrol, ferulic acid, syringic acid, sulforaphane, anthocyanins, and polyphenols.7,8 Collectively, they increase bone formation, decrease bone resorption, and increase trabecular microstructure.9 These outcomes all decrease the risk of fracture.

In looking through a reductionist lens, prunes also contain generous amounts of magnesium, potassium, boron, copper, and vitamin K1.9 Each of these play a positive role in bone metabolism.

Prunes? Really?

Prunes are known for their laxative effect, sweet flavor, and for being an easy target of jokes. Prunes taste sweet yet they have a low glycemic index.  Their “sugariness” is due to sorbitol.9 Prunes are a low calorie, natural sweetener.

When a new drug is being studied, investigations are performed as to the specific pathways and effects. Several research teams have pursued these types of experiments with prunes.

The specific bone effects are:

Increase bone formation10,13 — This is unusual as nearly all of the currently available drugs act by decreasing bone resorption, not by increasing bone formation.Increase trabecular microstructure11,12 — This, too, is unusual. Typically bone quality declines over years. Prunes benefits include compounds that have have a unique capacity to benefit trabecular connectivity.Decrease osteoclastogenesis12 — Fewer osteoclasts mean less bone resorption. There is only one currently available drug that both enhance bone formation and decrease bone resorption.Decrease RANKL (receptor activator of nuclear factor kappa-Β liga)14 — RANKL leads to increases in bone resorption. Inhibiting RANKL is exactly the mechanism by which the prescription drug, Prolia, works.

The above prunes benefits are active in both men and women. Traditionally, osteoporosis was viewed as a disease affecting women, however, the numbers of fractures have been, and are, increasing in men.14,15

Fun facts:

The U.S. Food and Drug Administration approved the use of the name “dried plums” for prunes in 2001 after research showed that consumers responded to the term better than prunes (FDA).Agriculturist brothers Louis and Pierre Pellier brought the Petite d’Agen plum from France to California during the Gold Rush and grafted it onto wild American plum stock ( California, with approximately 46,000 acres of prune plum trees, primarily in the Sacramento and San Joaquin Valleys, produces 99% of the U.S. supply of prunes and 40% of the world’s supply ( pounds of fresh fruit yield one pound dried prunes.Results of a clinical trial discovered dried plums are effective than psyllium for mild to moderate constipation (Attaluri et al. 2011).Prunes benefits include high nutrient counts, containing more than 15 different vitamins and minerals, in addition to fiber and antioxidants ( have shown that regular consumption of prunes significantly lower blood pressure levels, total cholesterol and “bad” LDL cholesterol (

How much for improved bone health?

Researchers used 100 grams or 10-11 prunes per day.10,13,16,17 Given the known laxative effects, some patients may consider this dosage to be an edict that they live in a pasture. The way to overcome this is to begin with two prunes per day and slowly increase the number until reaching bowel tolerance.

Osteoporosis is a widespread and multifactorial disease. Steps need to be taken to inventory bone health (via a DXA test), understand the reason or reasons for your individual patient’s bone losses, and prescribe a program to enhance their skeletal health.

Prunes are low risk, high benefit when considering skeletal health. They should never be considered to be a complete treatment plan but prunes benefits should be included in the overall strategy for preventing or treating osteoporosis.

ALAN COOK, DC, has been in practice since 1989 and is currently working with EasyWebCE, an on-line provider of chiropractic continuing education, and can be reached at

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10 Piriformis Stretches To Get Rid Of Sciatica, Hip, And Lower Back Pain

Stretches for sciatic nerve pain

There’s a tiny muscle you’ve probably never heard of that has a big impact on your everyday activities and is also connected to sciatica. The piriformis is the muscle that allows you to lift your hips, upper legs, and feet away from your body. The sciatic nerve, which stretches from your lower back to your legs, is also protected by the piriformis.When the sciatic nerve is pinched, it causes the excruciating pain known as “sciatica.”The stresses of everyday life can put even more strain on the sciatic nerve, resulting in numbness, tingling, and even intense pain that can last for minutes to hours. Pain usually radiates from the lower back to the hip, buttocks, and legs. Sitting or shifting roles becomes complicated before you know it.Fortunately, there are a few easy and safe ways to stretch out the tiny piriformis muscle and relieve sciatica pain. Try out these 10 piriformis stretches, and don’t forget to watch the updates.t here…

1. Basic Seated Stretch

  • Start by crossing your sore leg over the knee of your other leg when sitting in a chair.
  • Bend your chest forward while holding your spine straight. Bend over a little more if you don’t feel any pain.
  • For about 30 seconds, stay in this place.
  • Carry on with the stretch with the other leg.

2. Piriformis Stretch (Standing)

For extra support, stand with your back against a wall and your feet about 24 inches from the wall if you’re having trouble balancing with this stretch.

  • Place the leg that is causing you pain over the knee of the other leg when standing. It should take the form of the number four.
  • Reduce the hips to a 45-degree angle and lower them to the ground. As required, bend the leg you’re standing on.
  • Swing your arms down to the ground while bending over at the waist and holding your back straight.
  • Hold the position for 30-60 seconds.

When you’re done, switch legs.

3. Piriformis Supine Stretch

  • Lie back with your legs bent upwards.
  • Bend the affected leg upwards toward your chin, crossing it over the other leg.
  • With one hand, grab your knee and the other, your ankle. Pull the glutes close by pulling the bent leg around your body.
  • Hold for 30 to 60 seconds before releasing.

4. Piriformis Stretch on the Outer Hip

  • Bend your sore leg upward and put your foot next to the back of your other knee when lying on your back.
  • Twist your leg to the opposite side by tucking your foot behind the knee. The bottom of your knee should be in contact with the ground (or as close as you can get).
  • Lift your opposite arm in the air and place your hand on your opposite knee.
  • Hold the place for 20 seconds.
  • Change to the opposite leg.

This is a stretch you’ll want to recover from! Lie down on your back and gently draw both knees toward your chest with your hands.

5. Stretch the groin and long adductor muscles.

  • Stretch your legs straight out in front of you, as far apart as possible, when sitting on the floor.
  • Place your hands next to each other on the concrete, torso angled down toward the deck.
  • Lean forward, the elbows resting on the deck. Stop immediately if you feel pain!
  • Hold the spot for 10 to 20 seconds.

6. Stretch the inner thigh and short adductors.

  • Place the soles of your feet together in front of your pelvis when sitting on the ground.
  • On the opposite hands, hold the ankles (left hand – right foot, and vice versa).
  • Gently press forward with your feet, aiming to make contact with the ground. Stop just until you feel any discomfort, which means if you feel pain, back up an inch or two and stay there.
  • Hold for 30 seconds, then release and flutter your legs in that position for another 30 seconds (like a butterfly).

If you want to go for a longer stretch? Bend your body forward while holding your back straight or push your knees down with your elbows.

7. Side Lying Clam

  • Lie down on the non-painful side of the body.
  • Bend your knees backwards, crossing one foot over the other and keeping your legs parallel. Make a “L” form with your hands.
  • Raise the top knee while holding the rest of the body in the original position, keeping your feet together.
  • Slowly return the knee to its starting spot.
  • Rep 15 times more.

8. Extension of the hips

  • Make sure your hands are in line with your shoulders when you get down on all fours.
  • Lift your affected leg toward the ceiling with your knee bent.
  • Lower the leg gradually until it is almost hitting the ground.
  • Rep 15 times more.

9. Piriformis Supine Side Stretch

  • Lie on your back with your legs flat on the ground.
  • Bend your sore leg upward and place your foot on the outside of the opposite leg, next to the knee.
  • On the opposite side, gently extend the knee of your affected leg around the center of your body until you feel a stretch, making sure to hold both your shoulders and hips on the ground.
  • Return to the starting spot and swap legs after 30 seconds.
  • Repeat the step two or three times more.

10. Stretching the Piriformis Muscle in the Buttocks

  • Get down on all fours by placing your hands and knees on the deck.
  • Bring the affected leg’s foot under your stomach and twist it to the opposite side near the thigh, while pointing the knee toward the elbow.
  • Lean your forearms on the ground for support while you lower your head until your forehead meets the ground.
  • Slowly extend the non-affected leg behind you while maintaining a straight pelvis.
  • Slightly lower your hips to the floor.
  • Hold for 30 seconds before slowly returning to the starting spot. Rep 2-3 times more.

It’s worth noting that while home remedies can help relieve pain, they don’t fix the underlying cause. A thorough chiropractic review pinpoints the cause of the discomfort, offers medication to alleviate the symptoms, and creates a personalized treatment plan to ensure you stay pain-free for the long haul.

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Average DC age jumps, retirements loom according to 2021 Chiropractic Economics Salary & Expense Survey

Chiropractors in the U.S. responding to the latest Chiropractic Economics Salary & Expense Survey, measuring the pandemic months from April 2020 to April 2021, reported the average age of doctors of chiropractic in the U.S. jumping from 48.6% to 52.1%, the first time the average age has crested 50% or above

“There is not a great deal of data on the aging of the chiropractic practitioner,” David S. O’Bryon, JD, CAE, and president of the Association of Chiropractic Colleges wrote earlier this year for Chiropractic Economics. “The National Board of Chiropractic Examiners provides some insights in their studies of the profession in broad areas by the number of years in practice.

“The medical professions projected a severe shortage of doctors to serve a growing population and increased enrollment in medical schools by 30%. In a similar fashion osteopathic schools increased enrollment by doubling the number of schools and growing graduation rates from 1,500 to 4,500 DOs per year … Are we adding the resources that are needed? Having a larger portion of our population retired will have an impact on the economy, with potentially slower growth … What we do know is that chiropractic care is growing. The Department of Veterans Affairs has had a steady growth of providers giving care. The baby boomer population is an active group. We can also learn about aging populations by studying Japan’s experience, for example … we need to continue to train future chiropractors mindful of the nation’s pending needs.”

The 2021 Chiropractic Economics Salary & Expense Survey will be released in mid-May of this year, but survey respondents and chiropractors who subscribe or re-subscribe for free (click here) to Chiropractic Economics will receive the survey results at the end of April, two weeks before it is released in print.

From the 2021 survey, pandemic conditions also saw solo chiropractic practitioners increase roughly 6% to 63%, group practitioners/partners and associates down slightly, franchise owners increasing to 1%, and urban practitioners up roughly 3% to 30% while suburban and rural practitioners were down slightly, as reported by U.S. chiropractors.

The 2021 Chiropractic Economics Salary & Expense Survey is the go-to source for annual salary data and trending information in the chiropractic industry.

To receive the full 2021 survey results before they are published in May, via email PDF, click here for a complimentary subscription (or to renew or add on to your subscription) to Chiropractic Economics.

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Absorb this: topicals effectiveness vs. the layers of epidermis

How much pain relief and penetration are patients getting from topicals through the layers of epidermis, and how can they get maximum relief?

Patients enjoy and take advantage of a wide variety of topical products in my office for pain relief. The results I see using topical creams on my patients has to do with the products physiochemical properties, the dose frequency patients apply, and the mechanism(s) of action to penetrate the layers of epidermis.

Sometimes I want something that has an anti-inflammatory effect, and sometimes I want something that decreases pain sensation levels — sometimes I need both!

Getting topical with pain

Topicals are easy to prescribe because they lack systemic side effects, are noninvasive, easily self-administered, and can be fast acting. Another big benefit of topical administration is no gastrointestinal (GI) tract issues.

People get focused on the site of their pain as if it’s the pain generator. Whether it’s placebo or not, the combination of having the patient rub a topical “something” with a cooling sensation or no sensation at all into a painful area and then having them move the painful body part (skin, fascia, muscle, joint, bone, etc.) is a true example of neuroplasticity in action.

In many of my patients the combination of a local stimulation with a topical concentration are greater than taking a pill with systemic effects and has allowed me to help patient’s lower oral analgesic consumption.

Topical + rubbing action + movement = mind changing brain structure

Hemp-derived cannabis topicals and menthol-based products fulfill all the above and have millions and millions of applications without adverse effects.

Topicals act locally in the layers of epidermis and dermis. Very little if any gets absorbed systemically into the bloodstream. Surprisingly, topical products, i.e. CBD, do not absorb very well, since the skin is not very permeable. If you want to use topical treatments to deliver pain relief that is localized to the affected area, then you must consider particle size. Particle size affects the degree to which the product may be physically irritating when applied; generally, smaller particles are less irritating.

Counterirritant and CBD

Counterirritants are the most commonly recommended topical for pain relief. Their ingredients (usually menthol or camphor) work by irritating the skin, causing the sensation of burning or tingling.

Most patients interpret this sensation as the topical working to relieve their pain, when in reality it is simply distracting them from the pain underneath. In order to optimize the performance of a topical pain analgesic, you need to ensure that the menthol and other ingredients are getting to the inflammation and pain site quickly. This is achieved by formulating a product with the correct ratio of quality ingredients that are designed to work in conjunction with each other.

As Robert Topp, et al, stated in the paper, “Topical Menthol Gel versus a Placebo Gel on Post-manipulation Pain and Range of Motion in Patients with Mechanical Neck Pain,” “Topical application of menthol may be effective in mitigating pain immediately post cervical manipulation and is accompanied by a low risk of adverse effects. Topical menthol application before manipulation may reduce neck pain, but it has no measurable effect on neck range of motion following cervical manipulation among patients with mechanical neck pain.”

Dose and frequency for layers of epidermis permeation

For topical products to have biologic effects, the active ingredients must first enter the body. I do that in the office by introducing the product and applying the first dose of the topical.

Next I need the patient to follow up with “on your own” applications to keep delivering another sensation (counterirritants such as warming effect or cooling effect) and/or to achieve an appropriate concentration of hemp-derived cannabis for an anti-inflammatory effect. I can’t get a topical to cross the stratum corneum of the skin unless the patient understands dose and frequency of application to do on their own.

Topical skin permeation rates have been measured in experimental models of human skin. Studies by Paudel, et al, and Lodzki, et al, demonstrate topical penetration of cannabinoids into the animal bloodstream. The Lodzki study describes the ability of a topical cannabinoid preparation to penetrate through the layers of epidermis all the way through and into the underlying muscle tissue. This is important to us because relief of muscles soreness is one of the most commonly reported effects of topical cannabinoids, including tetrahydrocannabinol (THC) and cannabidiol (CBD).

Some cannabinoids have higher barriers to penetration than others. In animal models, for example, CBD has been shown to cross the skin barrier much more easily than delta-8-THC does, by a 10-fold factor. Additionally, CBD is more easily absorbed through skin compared to cannabinol (CBN), another common cannabinoids.

Deep skin penetration and local tissue penetration

Carrier ingredients in a product, such as ethanol, can enhance topical penetration across the skin. Additionally, and importantly, in animal models, a more concentrated topical has yielded better experimental results than those with lower cannabinoid content, suggesting that topical effects are concentration dependent.

A topical behemoth brand in the retail sector (and chiropractic space) and a friend to all body workers across health care professions was sold recently to a large international company. This familiar company brand and others like it contain various levels of menthol.

We have all felt the cooling effects of menthol. Just get this product on the skin and the patient will feel some cooling or tingling effect (counterirritant). Other brands contain proprietary ingredients such as camphor, tumeric, arnica, Pycnogenol, glucosamine and MSM (methylsulfonylmethane).

If I need deeper penetration of the layers of epidermis, I need enhancers and other chemicals designed to promote ease of application. Without penetration we will not see the anti-inflammatory effect, i.e. CBD products.

Product smell and inactive ingredients

Attractiveness of the final product to my patients often depends on the smell of the product.

Complementary ingredients in topicals include terpenes. These are aromatic organic hydrocarbons found in the essential oils of plants. They produce the distinct aroma associated with each plant, which is not only thought to protect the plant, but to offer therapeutic benefits. Menthol and camphor are the two most widely used active pharmaceutical ingredients in topical pain management today.

The terpene molecules (C10H16) produce analgesic action in neuropathic pain by decreasing neuronal excitability through peripheral mechanisms. Terpenes like eucalyptus, clove and peppermint can be combined with the active ingredients to create a synergy effect with the other natural ingredients for optimal benefits.

Excipients are frequently called “inactive” ingredients — they ultimately affect the quality, safety, and potential effectiveness of a compounded preparation by affecting solubility, stability, release of the active ingredient, and skin penetration. Excipients also have the potential to interact with other ingredients.

Skin cannabinoid receptors

Approximately 90% of the skin cells (keratinocytes) contain cannabinoid (CB1 and CB2) receptors and transient receptor potential channel vanilloid-receptor (TRPV), expressed on central and peripheral terminals of primary sensory neurons. TRPV is a molecular pain target for analgesics.

When considering topicals:

Choose a topical that has non-toxic ingredients and additives. No parabens!No phthalates or other endocrine disrupting chemicals;Stick with healthy natural carrier oils (organic) to maximize CBD absorption;I like a topical with botanicals and terpenes that work synergistically with CBD;Choose topicals that are third-party tested for potency and purity.

Experience demonstrates that the feeling of menthol and camphor topical applications change with temperature of the skin when it is applied. Physical therapies that increase temperature (laser, TECAR (Transfer of Energy Capacitive and Resistive), etc.) versus those that decrease it (cold therapy, ice packs) may explain patient preference.

Pain within local tissue that has produced a wide range of inflammatory substances requires sensitizing the sensory nerves. On top of my multimodal treatment approach including hands-on therapy, powerful modalities like percussion massagers, shockwave, TECAR, laser, and electrical cupping devices, I need topicals for pain relief. The combination of using a topical with chiropractic and technology allows patients to feel better faster or recover faster than Mother Nature intended.

JEFFREY TUCKER, DC, is the current president of the ACA Rehabilitation Council and practices in West Los Angeles, Calif. He writes for Stopain Clinical and can be reached at

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DCs in the News: punk rock chiropractors and ‘space’ clinic space

Kyle Sprecher, DC, is ‘happy to be home’ and working to build his Space Center Chiropractic clinic space…

A 20th anniversary is also a marketing opportunity, and Back to Health Chiropractic Alliance in Klamath Basin, Ore., with a clinic space owned by Michael Shatto, DC, celebrated by offering $20 specials and a patient raffle, culminating in a $4,170 donation to the Assistance League of Klamath Basin. The donation was used for the league’s primary philanthropic program, Operation School Bell, which provides school-age children with clothing, supplies, and meets other challenges. “We feel very fortunate to practice in such a wonderful community,” Shatto told the local Herald and News. “We value our patients and consider it an honor to support the community when we can.”

Punk-rocker-turned-chiropractor Ricky Fishman of ChiroMedica in San Francisco is also the founder of the Musicians Chiropractic Project, “which offers special rates and treatments for musicians, who are prone to injury from carrying heavy equipment” according to the Jewish News of Northern California. The native New Yorker was also a public school teacher and law student before deciding to attend New York Chiropractic College. “If you can find something that is a vehicle to put you into the zone where you’re able to sort of transcend your sense of self, then that’s a good thing,” the 65-year-old says of punk rock and chiropractic. “And I found that in chiropractic, because it is both a science as well as an art, in many ways it brings me to a similar place of playing music. So, I figured if I can have a career, if I can do work that brings me to that place, then I’m happy with the choice.”

The Louisville, Ky., market learned about chiropractic and head injury safety when Patrick Lowe, DC, and his Lowe Chiropractic & Wellness hosted the 2nd annual Helmet Safety Day in March which is Brain Injury Awareness Month. His clinic distributed 500 bike helmets to 500 children, noting that doctors say 88% of head injuries can be avoided by wearing a helmet. “We know what happens, the helmet gets run over in the garage, the kids outgrow them, they lose them, they break them, so it’s pretty common kids need a new helmet,” Lowe told Louisville’s WDRB TV during their coverage. As part of a kid’s fair along with the event, children could participate in a gymnastics course while parents could receive free massages.

From working with NASA back to Lake Mills, Minn., Kyle Sprecher, DC, is “happy to be home” and working to build his Space Center Chiropractic clinic space in hopes of eventually making Minnesota a permanent home again. “The name of his business (its first location is in Webster, Texas, outside Houston) comes from the bulk of his professional experience as a contract chiropractor for NASA,” writes the Albert Lea Tribune. He began with NASA as a test subject while completing studies at Texas Chiropractic College, and completed all of the training required of astronauts. He earned a master’s degree in fitness and human performance and also studied business and public speaking. He also lectured at NASA, did contract work for public health groups and served on advisory boards. Good relationships are key, and he works with area providers Mayo and Mercy hospitals. “Everything’s integrated,” Sprecher says.

Sparks, Nevada-based DC Rick Swecker took advantage of the national “Random Acts of Kindness Day” on Feb. 17 to assist area girls in staying active and healthy. His Family First Chiropractic donated $4,500 to Girls on the Run, an organization with an “intentional life skills curriculum and highly trained coaches that positively impact girls’ lives by helping them increase their self-confidence, develop healthy relationships and feel good about themselves.” The donation will help sponsor girls who cannot afford the program. “We love the fact that Girls on the Run empowers and encourages people, and especially young women, in our community to have self-love,” Swecker told the Northern Nevada Business Weekly. “In our world right now, we really believe there’s a lack of love for ourselves and we believe that attribute alone, in addition to so many other wonderful things the organization does, is just so vital to the health of our community.”

The annual “Spread the Love for Love INC” event hosted by Huntington Chiropractic Center raised $1,155 and an additional $300 in groceries to support the Love INC Food Pantry in Huntington, Ind. The 20th year of the event saw patients, in exchange for chiropractic services provided by the clinic space, donate cash or groceries to assist local families, with food pantries experiencing a much greater need than usual for services during the COVID-19 pandemic. Drawings were also held, for a first-place $100 Visa gift card, a second-place wine and chocolate basket from local businesses, and a third-place basket included a $50 gift card to a local restaurant.

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Not dead yet, direct mail response rates still producing high ROI

‘Direct mail isn’t dead yet’ as direct mail response rates are high and can effectively target local patients combined with your digital marketing strategies

If you double-checked the headline — yes, we did say “direct mail.” Lots of mediums that we thought were dead are making a comeback, or they didn’t truly go away completely in the first place — vinyl records, retro furniture, and … direct mail. Direct mail response rates remain high and remain popular for reaching people to compliment your e-commerce and digital presence.

In 2019, marketers made direct mail fourth on their lists of what they spent money on by sending 53.7 billion pieces of postal mail.

“Direct mail isn’t dead yet,” says David Cusick, chief strategy officer of House Method, which is headquartered in Raleigh, N.C. “As they’ve become less common, the more they’ve become special and exciting for the recipients. Businesses should consider direct mail and combine it with their digital marketing strategies.”

Cusick answered our questions about direct mail, and what follows is our interview, edited for length and clarity.

Why are direct mail response rates still resonating with marketers?

Direct mail may feel outdated, but it’s still an effective way to reach your target audience and market your products and services. Direct mail response rates still have high ROI and it’s best paired with digital marketing strategies.

Chiropractors can take advantage of direct mail response rates as a marketing tool, especially as they target the local market.

What impact does direct mail have on recipients?

Direct mail feels more personal to people because fewer people or businesses send them. That makes direct mail more exciting.

It feels as if the sender cares enough to send you something tangible like a personal letter or post card.

What are some ways that chiropractors can use positive direct mail response rates to drive people to their e-commerce efforts?

Direct mail can help drive customers to your website and raise brand awareness. Chiropractors can send a card with educational information about what chiropractic care is, including answers to FAQs.

They can also include a discount code that the customer can use when they visit your website or your clinic. The informative mail can give them solutions to what they need, and the offer can encourage them to check you out.

Should there be specific offers that are only sent to patients via direct mail?

Yes, you can send special offers meant only to direct mail recipients. That makes it feel more personalized and exclusive.

How can chiropractors integrate their direct mail with their digital presence?

Chiropractors can use call-to-actions that prompt the recipients to go to the website or use social media to share about a challenge using a hashtag.

You can also add a QR code that they can scan, which sends them to your landing page.

For more on direct mail response rates and direct mail marketing see the Chiropractic Economics article archive at

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New Mediterranean diet study results show better memory, test scores in

Mediterranean diet study results also show it can lower the risk of heart disease, Type 2 diabetes, and decrease the risk of depression and dementia

The Mediterranean diet has been proven to have quite a wide range of physical and mental benefits for those switch, and now Mediterranean diet study results are showing better memory and test scores in older adults on the diet.

Less red meat and more healthy fats

The structure of this diet, as the Mayo Clinic states, is eating food usually consumed by people in countries bordering the Mediterranean Sea. This means, for example, eating whole grains, vegetables, fruits, nuts, beans, and herbs. It also means eating dairy, seafood, eggs, and poultry in moderation and eating red meat only occasionally. The most often-used fat in this diet tends to be olive oil, which is considered a “healthy fat.”

According to the Harvard School of Public Health, Mediterranean diet study results have shown that it can lower the risk of heart disease, reduce the risk of getting Type 2 diabetes, and decrease the risk of both depression as well as dementia.

Mediterranean diet study results

A study titled “Dietary patterns, cognitive function, and structural neuroimaging measures of brain aging” published by researchers at the University of Edinburg in the December issue of Experimental Gerontology determined that adhering to the Mediterranean diet can also improve test scores and promote higher memory in older adults.

Here’s how it worked: More than 500 individuals of the mean age of 79 years, who did not have dementia, and who were in the Lothian Birth Cohort 1936 (they all participated in the 1947 Scottish Mental Health survey) were asked questions about their diet in the previous year. The researchers then tested their thinking skills in areas such as memory, word knowledge, thinking speed, and problem solving. Afterwards, more than 350 participants had MRIs so that the researchers could look at their brain volumes and white matter microstructure.

In the Mediterranean diet study results, when researchers compared participants who ate the Mediterranean diet to those who didn’t (and who tended to eat more processed foods), they discovered that the Mediterranean diet consumers had better verbal ability as well as higher cognitive function. Their brain structural integrity, however, showed no differences, so the diets of their participants seemed to not matter.

Cognitive as well as neuroimaging outcomes together

One of the highlights of this particular set of Mediterranean diet study results is that it investigated dietary patterns with participants’ cognitive as well as neuroimaging outcomes. By and large, research studies don’t tend to study these together.

Of course, the most important conclusion was that the Mediterranean diet was seen to improve overall cognitive function.

International Mediterranean Diet Month

May is International Mediterranean Diet Month, celebrating the mostly plant-based diet.

In addition to the diet outlines, patients are encouraged to exercise at least 2-1/2 hours per week.

Patients should also make sure they’re getting enough protein.

“If you’re shifting over to a more plant-based diet, like I did when I started the diet, you need to be careful about getting enough nutrients, especially protein,” advised Jennifer Barton, writing for “I didn’t think about that enough in those early months and spent the first few weeks feeling really light-headed. But once I started consciously adding beans, lentils, eggs, and fish to my meals, I stopped feeling so hungry and dizzy all the time.”

Jennifer Fleming, assistant teaching professor of nutrition at Penn State, said healthy diets can include a wide variety of foods, such as red meat, and still be heart friendly.

“When you create a healthy diet built on fruits, vegetables, and other plant-based foods, it leaves room for moderate amounts of other foods like lean beef,” Fleming said. “There are still important nutrients in beef that you can benefit from by eating lean cuts like the loin or round, or 93% lean ground beef.”

Red meat has been associated with an increased risk for cardiovascular disease in many studies and should be limited. In a meta-analysis study of 17 prospective cohorts reported by, “One serving per day of red meat was associated with a 19% higher risk of cardiovascular disease mortality, and this risk was mostly associated with processed red meat.”

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Student DC: New patients welcome, but how to best examine and communicate with them?

Thorough consultation, X-rays, and more steps to a proper treatment plan when rolling out the new patients welcome mat

I can still clearly remember the first new patient I ever saw in “real” practice — that is, not in a chiropractic school clinic setting.  I walked into the exam room excited, with adrenaline flowing, ready to roll out my new patients welcome mat, and as soon as I saw the patient, I literally forgot everything that I was ever taught about taking a history and performing an exam.

It was terrifying. I’m sure many of my colleagues had similar experiences early in practice. No matter how well you did in chiropractic school, or how high you scored on board exams, there is no substitution for seeing a real patient, who is most likely in pain.

In order to successfully treat a patient, you must begin with a thorough “Day 1.” Although consultations, examinations and treatments can vary greatly between chiropractors, due to philosophy and technique, we will outline what a successful first visit looks like in my clinic. Following these steps will allow for proper diagnosis and successful treatment of that first nerve-racking patient, and every patient that follows.

The new patients welcome mat consultation

The first thing I always do when I see a new patient is a complete consultation. I will ask a number of questions designed to figure out exactly what may be causing the pain that brought them into the office. These questions follow the OPQRST (Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, and Time) we all learned in school and include:

How long have you experienced this pain?Have you ever had pain like this before?Is there any motion or activity that either helps or causes more pain?Have you seen any other doctors or tried anything at home to help with the pain?Is the pain constant or does it tend to come and go?Is the pain worse first thing in the morning or does it get worse as the day goes on?Does the pain radiate down your arms or legs?

A good consultation alone usually results in a proper diagnosis 90% of the time.

When rolling out the new patients welcome mat, a complete health history is also part of a solid consultation. This includes whether the patient has issues with any organ systems such as the digestive, respiratory, or renal systems. In addition, I will ask about any previous surgeries or medication that the patient is currently taking.

Finally, I ask about any past traumas, like falls or car accidents. Most of the patients I see have repetitive stress injuries, but I have found that even very minor traumas can cause issues years later.

The examination

After the consultation, if I still believe that I can help a patient, I move on to a thorough examination of the spine and nervous system. However, there are times when after taking the history, you absolutely know the patient is in the wrong spot.

I have seen patients come in with blood clots, broken bones and other issues that were out of my ability to treat. If you know you can’t help them at this point, stop and refer them to someone that can. Some of my most satisfied patients (like the patient that I suspected, and was later confirmed, had a blood clot) are the ones I didn’t even treat.

My examination includes range of motion, orthopedic, and neurologic tests. The orthopedic tests are pretty standard and include cervical compression/distraction, shoulder depression, Kemp’s, Straight Leg Raise, Yeoman’s and FABERE, as well as a few others. The neurologic tests include deep tendon reflexes, muscle testing and dermatomes, however, I do not perform all of these on every patient.

I do not limit my examination to only the area of complaint. Meaning if a patient comes in with lower back pain, I do not look at only their lower back, I also examine the neck and mid back. I have found that I get better results when I look at the spine in its entirety instead of just focusing on one area. “It’s all connected” may get a bad rap in some chiropractic circles these days, but rarely do I find that patients only have problems in one region of the spine.

Necessary X-rays

This section may be somewhat controversial, especially with recent chiropractic school graduates.

After the consultation and examination, if necessary, I then move on to take x-rays of the spine. Although many chiropractors are moving away from taking x-rays, I have found that in many cases they are essential for the safety of the patient. Not only do x-rays give me a picture of exactly what your spine looks like, they also keep me from performing any treatment that could be harmful to the patient. Every time I think that I can stop taking x-rays on patients, I find something on x-ray that I never would have suspected.

The most common condition that I find on x-ray that alters my treatment is a spondylolisthesis. Although a spondylolisthesis obviously does not keep me from treating a patient, I have learned over the years that patients with this condition do not respond well to traditional side posture adjusting, but instead do extremely well when being adjusted using a drop piece. If a patient has chronic lower back pain and has not responded well to chiropractic treatment in the past, I often find that they have an undiagnosed spondylolisthesis and the prior chiropractor was adjusting the lower back using side posture. In many cases, their pain level does not improve, and even gets worse. Most patients with a spondylolisthesis do not even know they have one until I review their x-rays with them.

X-rays and unknown medical conditions

In rare cases, X-rays have also allowed me to find severe medical conditions that a patient did not even know they had. In my career, I have discovered cancer in patients three times. In each case, the patient had absolutely no idea, and it allowed me to refer them to oncologists for proper treatment. Had I not taken X-rays, and adjusted these patients, I could have possibly fractured vertebra due to cancer weakening the bone structure.

There is an old saying, “To see is to know, to not see is to guess.” I think that this is true when it comes to X-rays. An X-ray allows me to be sure that there is absolutely nothing that would keep me from treating a patient and allows me to alter my treatment in order to get the best possible outcome for the patient.

Report of findings

The next step I take before treating a patient is explaining to them, in depth, what I have found based on the consultation, exam and X-rays, and how I believe that I can help them. During this time in making new patients welcome I also answer any and all questions from the patient about their diagnosis or treatment are answered. A specific treatment plan is also reviewed with the number of visits and time frame for these visits. The cost of care, and any insurance information, is also covered at this time.  I am shocked at how often I hear from patients that other doctors, even other chiropractors, never talked to them at all about their problem, or explained treatment options.

Finally, I give a patient a consent form which outlines any potential risks of chiropractic care, as well as the risk of going without treatment. However, with X-rays and a good consult and exam, we can eliminate almost all of these risk factors. I also explain exactly what the patient should expect before giving them their first adjustment.

Only after I have completed all of these steps do I move onto treating the patient. I firmly believe that skipping any of these steps is not in the best interest of the patient, and that is truly what our entire profession is about. Make your new patients welcome, take a detailed history, perform a thorough exam, take any necessary imaging, and explain your diagnosis and treatment plan before treating a patient. You will get better results and your patients will be happier.

KEVIN WAFER, DC, is a practicing chiropractor in Houston, Texas, and the clinic director at CORE Chiropractic in the Energy Corridor. He can be reached at

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