For many chiropractic patients, seeking the elimination of pain is what first brings them into a chiropractor's office. And for most, it works—for a while. Terry W. Shaw, DC, DACRB, has gone one extra step toward treating pain: He adopts a rehabilitation model that has patients using various modalities and techniques to strengthen their bodies. This is so pain becomes a thing of the past, enabling patients to lead fully functional lives again.

Shaw uses an active care approach, which he describes as being evidence-based and tailored to the unique needs of each patient. This means that he uses devices such as interferential electrotherapy from LSI International, ultrasound units from Amrex Electrotherapy Equipment, and traction devices from Chattanooga Group.

Passive Treatment

Shaw says he chose the LSI inferential electrotherapy units because they are easy to use and reasonably priced. He says he uses the LSI units for various types of treatment. "It can be used with acute patients to reduce inflammation and pain," he says. "For less acute patients, it will also offer a little muscle reactivation. For those who need strengthening, it really contracts the muscle and tends to strengthen it."

Shaw decided to purchase the LSI machines outright, paying for them within the first year. Purchasing them made sense, he explains, to keep overhead low and eliminate the monthly payment. "You can also write it off [your taxes] after the first year, if you pay cash for it," he says.

Shaw also chose to purchase his Amrex ultrasound machine instead of leasing it. He says that like the LSI units, the Amrex-model ultrasound is reasonably priced and extremely reliable. Shaw had his first Amrex ultrasound unit for more than 20 years, and during that time, repairs were inexpensive and handled in a timely manner. "It's a good company to work with," he says.

Shaw uses the Amrex machine to treat edema, strains, and sprains. The machine is also useful in treating chronic conditions and is effective in breaking up scar tissue from old injuries.

While the modalities are effective, they are only first steps in Shaw's active care rubric. They serve as a crucial first step, helping patients to overcome the hurdle of inactivity caused by the pain and lack of motion related to their injury or condition. "The biggest problem most patients have is deconditioning syndrome, with their body getting weaker," he says.

The modalities help patients to a point that they can become more involved in active care, and this is motivating. Shaw says that positive results keep patients coming back for more treatment, which furthers their progress. "We complete activities of daily living forms with the patients," he says. "With that we determine what they want and need to accomplish. And even if they want temporary relief of pain, we adjust their treatment to get results. If a patient wants more permanent correction, then we determine, with the various pain indexes, what is their loss of function. With treatment, we see function return. Sometimes there is still some pain, but if the function is 100% then we give them home exercises to help overcome that but may not continue care. On the other hand, sometimes the patient's pain is significantly reduced but they are still very limited in their daily activities. Then we may continue care to improve that." Once the modalities have helped to reduce pain, inflammation, and/or scar tissue, patients are then able to move to more active therapy.

Tracy McDonald, DC, who practices with Shaw, performs ultrasound therapy on a patient.

Strength Training

A key component of Shaw's active care approach is strength training, which is designed to solidify what has been accomplished with an adjustment. "You can adjust until the cows come home, but if you don't have flexibility and [muscle] strength, it won't hold," he says. "You need flexibility and strength for the adjustment to last."

To this end, Shaw has his patients go through a strengthening regimen. His 6,000-square-foot facility boasts a full gym with free weights and Quantum Fitness exercise machines. But one of the most potent tools in his arsenal are wall tubing units from Synergy Therapeutic Systems. These are particularly useful for proprioception, strength training, and core stabilization.

The Synergy Therapeutics tubing is not the only tubing Shaw uses, but these units are beneficial because they can be used for a variety of applications and positions. "I chose this tubing partly because of cost and partly because of ease of use," he says. "With older patients, it's good both for strength training and balance training, which is a problem a lot of these patients have."

All of Shaw's treatments are modified to fit the patients' needs. The tubing is ideal for individualization, and it helps to net good results. "Senior patients are very compliant, and they have an amazing recovery," he says. "They really can do anything as long as you modify the rehab. The tubing is also easy for all ages, with ease and duplication of an exercise being very important."

Terry W. Shaw, DC, DACRB, says the Synergy wall tubing system is excellent for stabilizing the lower back and also for core stabilization.

With all of his treatments, Shaw takes particular care to get his patients involved. He says that he never simply sends his patients home with a piece of equipment without showing them how to use it—again another instance of motivating the patient to follow the treatment.

The clinic has an open treatment arrangement of six bays—each separated by curtains for patient privacy. Shaw uses a variety of imaging modalities in addition to traditional x-ray. He has a dual-energy x-ray absorptiometry (DEXA) unit for bone-density studies, a diagnostic ultrasound machine from Fukuda Denshi, Seattle, and he is certified to perform nerve-conduction and needle EMG studies.

Shaw says the Fukuda Denshi model "is excellent in diagnosing muscle and rotator cuff injuries, carpal tunnel syndrome, and other joint soft-tissue sprains/strains."

For the EMG studies, Shaw uses a machine from Cadwell Laboratories Inc. "They have a very good price on their units and have been fantastic in telephone support and for any repairs," Shaw says.

Success Story

Though not a "miracle cure" by any means, Shaw's methods have had their almost miraculous successes. He recently had a patient who is back at work because he followed the active care approach.

The young patient had fallen and injured himself at work. To relieve his pain, he had sought traditional medical care, which included epidural pain injections. These injections proved to be ineffective, and the patient sought treatment from Shaw.

By the time he came to Shaw, the patient had been off from work for 6 months and was in moderate to severe distress. Shaw followed a holistic approach, beginning—as he always does—with an evaluation, x-rays, then an adjustment. He then prescribed modalities and core-stabilizing and eventually strength-training exercises. Within 2 weeks, the patient was back on the job, working in a limited capacity. Four weeks later, he was back to work full-time and at full capacity.

Shaw notes that other approaches—including those of physical therapists, medical doctors, and chiropractors—are not enough. For instance, he says chiropractors who rely only on adjusting without strength training cannot expect the adjustment to hold.

Evidence-Based Practice

The active rehab approach is the foundation of Shaw's business success. It is an evidence-based approach that uses results to back it up. Shaw does various outcomes assessments on his patients. And this is the kind of thing insurance companies and other payors are looking for when determining whether to reimburse a treatment. "When insurance companies are looking at reimbursing your services, they look at your diagnostic approach and the functional loss evaluation you have made, and your plan for rehab—doing this will get you a reimbursement at the highest level," he says. It also defines what he does with active rehab.

Monitoring patients allows Shaw to decide how acute or chronic an injury is, what the functional losses are, and what modalities should be used—tailoring care to meet the patients' needs and expectations. The initial evaluations track the loss of function to how that function is gradually restored. This data is shared with the patient as well as the payor. Once the function is restored, the patient will be put on a home program—even if there is some pain. If pain persists or function is not fully restored, Shaw will continue to treat the patient. And though modalities are part of the toolbox he uses, Shaw says that they are not the primary means by which treatment is given—they are simply tools to help restore function. This is one of the reasons he is successful at getting reimbursed at a good rate. "Medicare and all insurers want to see a reasonable treatment plan and the results from that plan with an end point of care," he says. "They don't want to see you only using modalities."

Shaw says that attaining his certification in active rehab altered his practice, adding that this chiropractic specialization is the one that will change a practitioner's practice the most and for the best. "What's more natural than stretching and exercising? There's really no stability without exercise," he says.

C.A. Wolski is a contributing writer for Chiropractic Products. For more information, contact .

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