Adjustments, massage, exercise, stretches, electro-stim, ultrasound. These are all part and parcel of the chiropractic tool kit. Another tool that is growing in use and proving its effectiveness is nutritional supplements.

And while these pills might not be "miracle" cures and do not look much different than what is available on supermarket shelves, the high-grade supplements provided during and after chiropractic treatments may be the key factor in helping a patient not only to continue to feel better after their adjustment, but also to maintain and improve their health beyond their course of chiropractic treatment.

Though they may not be drugs in the conventional sense, these supplements are manufactured and handled as if they are.

Manufacturer's Guarantee

Biotics Research Corp, Rosenberg, Tex, manufactures a number of nutritional supplements under strict conditions designed to guarantee the quality and, most of all, potency of its products. According to Rachel Olivier, MS, ND, PhD, a physician adviser for the company, all of its products are manufactured and tested in-house to make sure that they are of the highest quality.

According to the Biotics Research Web site, all of its products are manufactured in separate rooms to prevent cross contamination.

Olivier says that the company does not wait until the supplements are finished to worry about the quality of its product. This concern starts from the very beginning with the raw materials, which are closely scrutinized by the company. She notes that a supplier once provided a shipment of herbs that was found to be laden with heavy metals. The herbs were rejected by Biotics Research and returned to the supplier.

Reflecting the pharmaceutical quality of its products, Biotics Research sells its various supplements only to licensed medical professionals.

But having high-quality products available is only the first step in helping patients. Using them in a way that is effective is even more important.

Patient Loyalty

It can be said that G. Douglas Andersen, DC, DACBSP, CCN, is a supplements guru. The Brea, Calif-based chiropractor has built a large part of his practice on helping his patients with their nutritional needs. It is a niche that he commands so expertly that he is routinely called on by other chiropractors to consult with their patients.

Andersen also lends his knowledge about nutrition to a monthly column that he writes and posts on his Web site, www.andersenchiro.com.

In both his practice and his writing, Andersen's enthusiasm for using nutritional supplements is obvious. But Andersen stresses that practicing nutrition does not equate to selling supplements.

"There is a surprising number of people who, when they hear 'chiropractor and nutrition,' immediately think ‘many bottles of expensive supplements,' which is an impression I immediately correct whenever I hear or even sense it," Andersen says.

And that translates into a seemingly contradictory result, because he carries a laundry list of products from a number of suppliers. Supplements from Nutriguard, Progressive Laboratories, Karuna, Metagenics, Marlyn, Pure Encapsulations, NF Formulas, Anabolic, Thorne Research, Dee Cee Laboratories, Physiologics, and Ortho Molecular Products currently sit on his shelf.

"In the event I need a specialty product for a specific problem, having a quality bio-available formula at my disposal makes my job easier," Andersen says.

Conversely, because most people already own nutritional supplements, reviewing them in detail is part of his workup.

"If I am seeing the patient in person, I have them bring every vitamin, mineral, enzyme, herb, protein, or nutraceutical they own to the appointment, whether they are currently using them or not. It is not uncommon for a person to own the correct product, not use it, and take an incorrect product instead. If it's a phone consultation, they get out their reading glasses because I want to know every ingredient on every label."

He then analyzes the supplements and finds out everything from who recommended them and where they are stored, to how many pills from which products are being used. But Andersen doesn't stop there. How many times per day and how many days per week doses are both skipped and taken is also uncovered. He even finds out how long the patient waits to buy more when they run out. This attention to detail reduces supplement sales drastically.

"If a patient is seen for low bone density and already takes supplements, before I sell them another bottle of pills, I make sure the product that is apparently failing really is. For example, in easy-to-read print, the label may state, ‘1,200 mg of calcium,' and in fine print, ‘provided by six capsules.' If the patient had been only taking one to two a day, it would take 3 to 6 days for them to get 1,200 mg of calcium. The next person with the same product may have been taking six with one meal. They didn't realize 500 mg of calcium is all most people can absorb at one time. Like the first patient, but in a different way, it was taking 3 days to get 1,200 mg of calcium."

Andersen then went on to say, "It's not just the public who equate chiropractic and nutrition with supplement sales. Chiropractors make the same assumption. Doctors of chiropractic who don't specialize in nutrition still shy away from a referral because they don't want to be indirectly responsible for a $300-per-month supplement bill their patient gets hit with. And I don't blame them."

So when will Andersen sell a supplement?

"Using the example above, if a patient has been taking the product correctly, storing it properly, only missing a dose or two a week, and the length of use is long enough to (in this case) stop bone loss and it doesn't, I would recommend a different product and sell them one of mine."

Individual Approach

The report Andersen generates is detailed, addressed to the referring doctor, and cc'd to the patient. The thought of a different chiropractor talking to your patient on the phone for an hour or 2 is only topped by having that DC do so in your office as an obvious practice buster. But Andersen isn't there to make the doctor look bad or to steal a patient. His goal is to help the doctor help the patient and look good in the process. The credit goes to the referring DC, and the management remains in his or her hands. This, too, reduces supplement sales for Andersen because he always gives the referring DC first chance to sell a product if one is needed.

From a health perspective, Andersen believes most nutrition-related problems are not only caused by diet, they are solved by diet. And that means it is critical to determine the diet.

The availability of high-quality supplements is the first step in helping patients. More important is that patients use the supplements in a way that is effective.

"I can't tell you how often I see patients taking the wrong supplements simply because no one took the time to discover what they really eat. And time is how I find out what others overlook or miss. It is a true long shot to believe a food questionnaire or a 24-hour patient recall will yield accurate dietary information," says Andersen, who also notes, "I guess the best way to describe what I do would be that I cross-examine the patient like an attorney in open court. Each answer prompts three more questions until both parties are really satisfied we have a real summary of where they get 90% of their calories."

With this approach, it is not uncommon for Andersen to have patients discontinue supplements such as calcium or fish oil, two of the "everybody needs these" types of products. He explains, "If a patient averages 1,500 mg a day in dietary calcium, guess what they don't need to take? Another 1,200 mg!" Or, "I recently had a patient whose family doctor told him to take fish oil capsules. But the man ate seafood at least 10 meals a week, four of which included salmon. And in the course of his history I discovered when he cuts himself shaving he bleeds a lot longer than he used to."

Andersen concludes by commenting, "I told him if he ever tells someone a chiropractor took him off the fish oil, remember to explain why."

Each consultation and result are completely different. This is not only due to the history of complaints, disorders, diet, and supplements, but it also employs the same type of attention to medications, sleep, exercise, psychosocial, alcohol, tobacco, caffeine, and anything pertaining to unique hobbies, lifestyles, or habits. With a wealth of information, the patient interview is concluded and Andersen can begin to put things together and generate a "hand-crafted" report with patient-specific information that computer- or questionnaire-generated generic reports simply cannot touch. But that also means Andersen can't push a button to create a report that will take no less than the hour he spends with a patient to write. Couple that with very moderate supplement sales, and the question is, how does he pay the bills?

"By charging for my time," Andersen says. And what about his programs?

"My patient-centered approach allows me to easily determine what level of recommendations can be realistically and consistently followed." And consistency over time is the key to Andersen's extremely high rate of clinical success.

"One piece of fresh fruit a day may not sound like much until you realize the 'one piece a week' patients' annual intake goes from 50 to 360," says Andersen, who uses the same approach to exercise.

"Two workouts doesn't sound like much until you consider that is 100 a year. I then ask the patient who (for example) hasn't exercised for 3 years, because twice a week isn't enough, if 300 over the last 3 years would have made a difference."

This is not to imply that Andersen will not make aggressive recommendations. "A professional athlete will obviously be asked to do more than eat one piece of fruit a day. But they are still human. Some need more pushing than others, and each has his or her own unique history. The bottom line is recommendations that are easy to follow make it easy to progress and difficult to fail."

A Chiropractic Practice

In addition to carving out his niche as a nutritional expert, Andersen has a chiropractic practice that is not limited to the spine. As the 2003 American Board of Chiropractic Sports Physicians Sports Chiropractor of the Year, he primarily uses diversified technique to treat his patients, but, like his approach to supplements, he is not loyal to a single technique.

"I do whatever will get the patient better fast, from manipulation to modalities, to a wide array of manual techniques," he says. "I always ask the patient if he or she is better, worse, or unchanged. If they are in more pain or their condition is unchanged, the cross-examination begins. Did they follow my instructions? Did they do something to irritate it? Since I won't end a treatment until they feel better than when they entered, I will ask how long the improvement lasted. If they really are unchanged or worse for no explanation, I gladly take the blame," Andersen states.

If that sounds different, to most doctors of chiropractic it is. "Patients like honesty. I'll come right out and say if I fail today it won't be with the approach that didn't work last time."

Andersen goes on to say he keeps trying different things until something works, and if he isn't getting results he will bring up the subject of a second opinion before the patient does. He then makes it clear that his job includes helping them select the best alternative.

"I refer to orthos, neuros, GPs, PTs, rheumatologists, dermatologists, endocrinologists, gynecologists, internists, acupuncturists, psychologists, massage therapists, and I'm probably forgetting a discipline or two." What about chiropractors?

"Absolutely. My associate, Dr Dave Velasquez, is a soft tissue specialist, a CSCS, and probably gets more referrals than any other person I use."

Chiropractic Plus Nutrition

Even though Andersen does not combine a nutritional appointment with a chiropractic treatment, he will remind patients that just because pain may temporarily prevent some activities, it is no reason to skip their vitamins or eat unhealthy foods. He ensures that his patients get enough protein because injuries raise the requirements, and gives them easy-to-remember pearls such as increasing vitamin C intake to "10 mg per pound of body weight" when healing or "get sleep to get better," since repair, recovery, and regeneration occur during sleep.

Andersen's overriding principle in treating his patients is to make himself unnecessary. "My goal is to get them out of pain. I tell them that I want them to try to avoid me. To me, this is common sense and honesty. People like honesty," he says.

Supplement your knowledge by going to the May 2007 Archive.

And while Andersen is always looking at what is best for the patient, while taking himself out of the equation, it is Biotics' Olivier who notes that many chiropractors might be influenced by their own treatment philosophy and background. In general, many chiropractors who use supplements while treating their patients will be very specific in terms of what they prescribe, including a multivitamin, a fatty acid, and a chondro-protective supplement.

Indeed, it is eventually up to the doctor himself to determine the mix of chiropractic and nutrition that is "healthy" for the patients and practice alike.

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