In our office, 95% of our patients are fitted with custom orthotics to begin their programs. This number took years to reach, but once an office understands the global benefits and commits to making patients understand the value, this number becomes easy to achieve.

Raise the Percentage

The following are five steps to raise the percentage of custom orthotic recommendations:

1. The patient must understand "Crooked Man."

   Figure 1. The “Crooked Man” helps patients visualize biomechanical imbalances.

   In our office, assuming the patient is not there for an acute injury, we explain "Crooked Man" (Figure 1) at the end of each consult to help the patient have a visual of what biomechanical imbalances look like. This also makes the patient understand that it all begins with the feet, and if the feet aren't balanced, the structure will have a reduced potential for optimal balancing. We tell the patient we'll be checking their feet in a variety of ways to determine if their imbalances originate there.

2. The examination must involve more than tests at the site of injury.

   We perform a comprehensive biomechanical exam that tests feet, knees, leg length, joint mobility, muscle compliance, center of gravity, digital foot scan, and standing biomechanical x-rays. This lets the patient know that structural imbalances—which, again, originate in the feet—can be seen in many forms throughout their entire structure.

3. On the report of findings, there must be visual evidence to support what you've been saying.

   Any chiropractor who does a limited exam with no visual evidence will likely not do well at making people understand the need for custom orthotics or long-term care. The public has been miseducated with regard to musculo-skeletal care and health, and has a hard time trusting anyone's word. They need visual evidence to understand and believe what is being said.

   Figure 2. Reports of findings should start by showing patients their digital foot scans.

   We'll begin our report by showing a patient their digital foot scan (Figure 2), showing more weight-bearing on the left side of the body, compared with the right. We'll then show the patient the biomechanical information on the x-rays, showing a 55° sacral base angle with an anterior Ferguson's gravity line and degenerative changes already occurring in the L5 disk space (Figure 3). This is followed by their A-P open-mouth view (Figure 4), showing an imbalance between the right and left atlanto-odontoid spaces. We conclude by showing the patient's centers of gravity, from the side (Figure 5) and from the front (Figure 6). The red represents "eyes open," and the blue represents "eyes closed." The width of the graph shows the amount of instability in the patient's nervous system and core strength.

   When a patient sees all this visual evidence of imbalance, wear and tear, and nervous system weakness—and is doing nothing about it—it makes a huge impact on his or her decision.

4. There must be good communication between the doctor and the patient.

   The doctor must convey through not only visuals, but also through words, what these visuals mean. He or she must not only interpret this information correctly, but must then communicate it to the patient. This is where many lose the patient, as they are unable to convey the significance of structural imbalances, correction, and wellness. In our office, we have a very standardized report that reviews all of these findings, and makes the patient understand the gravity of the information discussed.

   Figure 3. A patient’s biomechanical information, shown on an x-ray.

   Second, the patient clearly understands that if no action is taken, this is the best that he or she will ever be. The aging process, combined with future structural stresses and gravity, will predictably make this condition only worsen over time. We let the patient know how to strategically work to improve these findings, but it takes time, money, and energy on their part for a long enough period of time to get results.

   The patient also must know that periodic reevaluations will be done to assess the progress made during this program. Finally, all of this must begin with custom orthotics, as the structure must go through a reeducation program to im­prove structural balance, joint mobility, and muscular flexibility. If custom orthotics are not part of the program from the very beginning, the patient will default into their current structural imbalances every time they stand. This will drastically reduce the potential biomechanical improvement for this patient.

   Custom orthotics are preferred for two reasons: they are flexible, and they provide additional shock absorption. These two features make sense, and only confirm to a patient that they are making the correct decision by saying yes to the orthotics and yes to your recommendations for a corrective program.

5. Give the patient a way to pay for them.

   Figure 4. A-P open mouth view reveals imbalance between the atlanto-odontoid spaces.

   This is one of the biggest stumbling blocks that doctors have. When new in practice, young doctors can't imagine anyone paying $360 for orthotics. Over time, this insecurity on the doctor's part creates the habit of not recommending custom orthotics. Therefore, they never embrace the huge benefits that orthotics will make in their patients' lives as well as the improved clinical results they'll get in their practice.

   Once people can see the need, understand the need, and "want" custom orthotics, they now need a means to pay for them. Everyone's financial situation is unique. Some people have money and don't want to spend it, while others may not have it and want to buy everything they see. It's not the doctor's job to figure out the patient's financial situation, only to give options so everyone has the ability to buy orthotics. In our office, we generally offer multiple options, from paying up front to setting up a payment plan. Once the patient believes they have a choice that fits their circumstances, the acceptance rate goes way up.

Becoming a Better Doctor

These five recommendations truly make a doctor become a better doctor. Anytime you can help the patient understand better, as with "Crooked Man," you're doing a good job. With structural imbalances and the aging process alone, people must understand that they either will be working on improving or will be getting worse every day. They are not staying static. Pay now or pay later is the basic concept patients need to be reminded of.

Figures 5 and 6. The patient’s center of gravity, as seen from the side (Figure 5) and the front (Figure 6).

Doing more tests than just at the site of injury will make all chiropractors more effective, as the kinetic chain should be looked at in its entirety with all patients. A forward head carriage has a dramatic effect on shin splints. The more you begin looking at all parts of the structure upon examination, the more you realize the many contributors to any localized symptomatology. And, if corrections aren't made on the secondary sites of imbalance and fixation, the potential benefits will be greatly reduced.

Providing visual evidence only makes sense. It's been said that human beings make decisions based on many factors, but visual evidence contributes 85% to that decision-making process. As one patient once said to me, "Seeing is believing." If you don't use visuals, there is no way you'll convey the message, degree of injury, or areas that need work.

Get the orthotics lowdown by checking out our December 2007 issue archive.

Communication is the very foundation of human interaction. If you are not a good communicator, you'll have a very difficult time in practice, as people come in with preconceived ideas of what you do. Unless you can redirect them effectively, you'll always end up being what the world thought you were. If you can't communicate during the journey of a program with a patient, you'll never succeed, because they forget what you showed them the first day on their report. Good communication can never end. You must continue to remind people during each and every visit, as all stimuli outside your office is pushing medications, "You haven't got time for the pain" concepts, and traditional medical values. This works against everything you're trying to do.

Finally, be willing to talk money with patients. If you've done all of the above, and fail to understand that all patients have different financial situations as well as money values, you'll fall far short of giving people enough options for them to say yes to your recommendations.

In the end, it's totally up to the doctor as to what percentage of patients buy orthotics and pay more money to actually get well and have a better life. If you don't elect to continue improving your skills, many patients will come and go, but fewer of them will get well.

Timothy J. Maggs, DC, is the developer of The Structural Management® Program and travels the country teaching. He also will be heard live on his Internet radio show, Thursdays 3 pm to 4 pm EST at www.StructuralManagement.com, beginning March 1, 2008.