1. TENS OR E- STIM with HEAT PORTION OF THERAPY

Set time to 6-7 MINUTES. This is for clinical, business, and insurance purpose. Medicare and insurance guidelines say that therapy has to be given for 7 minutes and 30 seconds. Therefore by the time we set the therapy it has taken us about 2 minutes to do so ( time it if you do not believe it) and therefore, we set the timer for 6 minutes then it has been 8 minutes since they have had therapy.

Research shows that clinical data effectiveness is between 5 and 20 minutes.

ASIDE: set the small separate timer to increase in time instead of counting down and the buzzer going off because we can look at how long it takes to do soft tissue work as well as how long it takes for each patients total treatment.

2. When setting machine to patients comfort on the first treatment. . . . . explain what the unit does this would be applicable for first time patients:

"John, this is a muscles stimulation machine (we do not want to use the term electric stimulation because it scares people); it helps relax the muscles, increase circulation, and speeds the healing process. It is going to feel like a tingling massage and most patients really like it. Tell me when you feel it . . . . . (we do this because we wants to make sure the machine is working properly and once they feel it,) then say "NOW, when it is COMFORTABLE BUT STRONG. WE WANT IT TO BE STRONG BUT NOT UNCOMFORTABLE. Right there is comfortable? Great I will leave it there. Now John your body will start to get use to it. This is normal and it is working at the same intensity as it was in the beginning." (This so they do not keep asking to turn it up and we do no end up going extremely high.)

APPLICABLE FOR THE PATIENTS ON REPEAT VIVITS:

"Okay john let me know when you feel it . . . . . . . let me know when it is strong but comfortable"

We refrain from asking patients throughout the treatment, if they want the TENS machine increased. On the first visit we have set the tone that they can expect to use to it and if they ask on a subsequent visit that they cannot feel it anymore than we just remind them. . . .

"Remember you will start to get used to it but it is still working at that same high intensity and we do not want to bring up to high" It also does not give the patient control over changing the machine or their treatments. We condition patients expect the same type of service every time they come in for a treatment.

3. Once patient is sitting or lying receiving the TENS: We are careful with our verbage to not elicit a response from the patient to change the machine settings.

Ask "are you comfortable?" or "let them know if the moist heat gets to warm"

This will focus on the condition patients to let the doctor determine the care that is needed AND will reaffirm that they are very comfortable and are very relaxed and happy with the care.

Note: if there is some silence that is a good thing. The more time the patient has to concentrate on their condition with less talking than the greater the perceived time is and it gives patients a break everyday stress. At this point you can also add,

"John, just lay back and relax because this is also your rest, relaxation, and healing time"

When we do talk we try to focus on their condition instead of the

Weather or movies or etc. this silence allows us to finish notes and concentrate on other patients as well.

FOR EXAMPLE: if we sit and a room silence for three minutes it seem like a much longer time. This means a portion of all treatments should be available for the patient to concentrate on their condition. This also frees up the practitioner to multitask better.

MYOFASCIAL PORTION OF THERAPY

4. When working on patient after taking them off of the TEN/ E-stim: (Manual therapy and vibratory massage)

We let patients know briefly what type of therapy, clarify parts of the body we will focus on, and give them a timeline of what expect so every visit they know what to expect.

If the person know what to expect, they will perceive that the time spent was well worth it and more, likely to continue care

First visit of treatment for manual therapy vibratory massage:

a. (As the pads are taking off) . . . . . . . . . "That will help relax the (low back) area and speed the healing process... Now we are going to do some more work to further help relax the low back region. This will help take some of the pressure off of the nerves and muscles in the area. (As we do the manual therapy portion of the treatment) remember that your condition has been going on for a long time so we do expect this to take time.

b. As we treat the area ( for example we know the patients biggest area is left low back) we are constantly confirming and focusing on it by stating

"I know right here is your main spot"

The patient will give nice body language or verbal cues that we are right on it and we use rule of 3's to confirm it and we state. . . .

"This is it right there; this is spot, I GOT IT, right here."

As we treat the area of the biggest concern, we spend the most time focusing on their main compliant and the perceived quality of knowledge and service sky rockets and by letting them know 3 times there is no question in their mind that we understand there problem and exactly where it is. Many patients do not feel that other doctors have located or understand exactly where the pain is. WE DO!!

ALSO, BY FOCUSING ON WHAT THE PATIENT PERCEIVES TO BE THE MOST PAINFUL AREAS, THE PATIENT WILL PERECIEVE THE TIME SPENT ON THE TREATMENT A BEING LONGER AND WELL WORTH THE TIME.

When the patient has a couple areas of concerns we go through the same process but add. . . .

"This is the spot, right here in your neck, got it. Now I will concentrate a little more it on your low back since it bothers you the most." And repeat for low back

We are emphasizing that we will concentrate on the low back and increasing perceived value by just starting it

c. When performing hands on therapies on patients, it is helpful to periodically check with patients to see how they perceive the therapy. We will use close ended question or statements, to let them know it is all right to let us know but keeping the conversation short and focused.

John let me know if this is too much or not enough pressure. Is the pressure ok there. Great."

d. When performing therapies on patients (myofascial release, portable hand massager etc) we try to keep conversation focused around chief compliant, try to bring the talk back to the chief compliant, EX: patients say that they went to a great movie to other night. As much as we are interested in how it was and what movie it was. . . . it takes us off of our mission and focus of helping that patients neck or back

EX: "WOW HOHN, MOVIES ARE A LONG TIME TO BE SITTING. I AM SURE SITTING FOR 2 HOURS WASN'T THE BEST FOR THE LOW BACK. THAT IS WHY THE EXERCISES AND THERAPY WE DO HERE ARE SO IMPORTANT. MAKE SURE YOU CONTINUE TO DO THOSE EXEERCISES WE TALKED ABOUT."

This will increase patient's perception of time being spent on therapies.

e. When doing soft tissue work we will save the potable hand massager as the last therapy OR if the patient gets an adjustment then this will be last procedure. Side note: 1.5 minutes of hand massager will be whatever we keep consistent as the last therapy/ procedure will cue and condition the patient that when the hand massager OR adjustment is done then they are done

After TX:

"All right, that is it for today. You are all set. You are doing a great job and keep up the good work with doing the exercises/ stretches. So . . . we will see you on Friday.