The Wisconsin Chiropractor_Fall 2024

TABLE OF CONTENTS

Cristiana Paul, MS, and Danielle Male, MS, CNS, LDN

BOARD

President CHRIS

DC

Secretary

WILLIAM SPONTAK, DC

Directors

BRUCE DAVIS, DC

MARTIN JACOBSON, DC

JENNIFER WAIDELICH, DC

JASON MACKEY, DC

Executive

Membership

Membership

Introduction to Collagen Peptides

By Cristiana Paul, MS, and Danielle Male, MS, CNS, LDN

Collagen makes up as much as 30% of the body’s total protein and is the primary structural protein in connective tissue.1,2 It plays a crucial role in organ development, wound healing, skin elasticity, and the health and function of tendons, ligaments, bones, and skeletal muscles.3 The turnover of collagen is influenced by nutritional status, physical stimulus (exercise, stretching), and hormones.4–6 Incorporating collagen peptides into the diet can complement a balanced daily protein intake.7 While collagen protein is considered an incomplete protein due to lacking tryptophan (an essential amino acid), it contributes to the overall amino acid status, similar to vegetarian proteins.7

The clinical benefits of collagen are due to its absorption and transport to cells in various amino acid sequences and lengths.6,7 These peptides, similar to those produced naturally in the body, help to promote the body’s natural repair and renewal of collagen tissues. Diet-derived collagen peptides help promote this signaling and provide building blocks for new collagen synthesis.7

Bone Health

Collagen helps contribute to bone elasticity and resilience by acting as connecting coils that bind the bone mineral crystals of calcium and phosphate.8 Collagen content, fibril diameter, and organization are all important determinants of bone quality and, thus, fracture risk.9,10 In vitro studies suggest collagen peptides provide amino acids for bone collagen, stimulate bone cell activity, increase osteocalcin synthesis, reduce osteoblast differentiation, and help reduce inflammatory cytokines meditators.9,11,12

Clinical Evidence: Postmenopausal women with osteopenia or osteoporosis (n = 131) who received Fortibone® collagen peptides (5 g/day for 12 months) experienced an improvement in bone mineral density (BMD) in the femoral neck and spine, along with increased markers of bone formation with no change in markers of bone breakdown.13 Similarly, in a small follow-up observational study (n = 31) of postmenopausal women with reduced BMD, a daily intake of 5 g of Fortibone® resulted in a steady increase in BMD and the T-score in the spine and femoral neck after four years.14

Muscle Health

Collagen may benefit body composition and muscle health especially when combined with

exercise, such as increasing fat-free mass and improving muscle strength.15,16 Collagen dipeptides and tripeptides may activate the mammalian target of rapamycin (mTOR) pathway, which is crucial in muscle protein synthesis.17 Research suggests collagen peptides may also support healthy muscle recovery, help mitigate muscle soreness post-exercise, and help to upregulate the gene expressions involved in skeletal muscle signal transduction.2,18,19

Clinical Evidence: In studies involving untrained, middle-aged men (n = 97) or elderly men with sarcopenia (n = 53), the subjects receiving collagen peptides combined with resistance training had greater increases in fat-free mass, muscle strength, and fat loss compared to a placebo.15,16 Similarly, recreationally active young men (n = 25) and young, healthy men (n = 39) who took collagen supplements with resistance training saw more pronounced increases in body mass, muscle strength, and muscle volume compared to those who performed resistance training exercises alone.1,20 Among premenopausal women (n = 77, aged 18 to 50), the women who received collagen peptides, plus followed a resistance training program, displayed a significant increase in hand-grip strength and fat-free mass compared to the placebo.17

Joint Health

Alterations in collagen may also affect joint health, as collagen damage is associated with osteoarthritis (OA).21,22 Specific collagen peptides have also been shown to support ankle stability and perceived function, pain, and swelling during physical activity, and help attenuate relapsing-remitting ankle trauma in subjects with chronic ankle instability.23 A meta-analysis of randomized, placebo-controlled trials found that oral supplementation of collagen led to a significant improvement in both the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and Visual Analog Scale (VAS) score in patients with osteoarthritis.22

Clinical Evidence: In one study (n = 139), athletes with functional knee problems during sports experienced a statistically significant improvement in activity-related pain intensity following Fortigel® collagen peptides intake (5 g/day for 12 weeks).24 Another trial with young adults (n = 180, aged 18 to 30) suffering knee joint discomfort reported a significant reduction in exercise-related knee pain with the same Fortigel® supplementation routine compared to placebo.25

continued on page 71 (references)

Advocating in Action for Wisconsin Chiropractic

Dr. Gene Yellen Shiring talks Medicare legislation with Congressman Mark Pocan (D-WI 2) at a recent fundraising event in Madison.

and

L-R: Mike Rogwoski - Husch Blackwell partner, Speaker Robin Vos, Zach Kasun and John Murray at a recent event.

L-R: WCA Membership Director Zach Kasun, Sarah Keyeski - candidate for State Senate, Senate Minority Leader Diane Hesselbien (D-WI 27) and WCA Executive Director John Murray at a recent event.

L-R:

L-R: Dr. Ben Mikla, Senator Tammy Baldwin (D-WI)

Dr. Gene Yellen Shiring at a recent event.

Executive Director’s Message

John Murray, Executive Director & CEO | jmurray@wichiro.org

Campaign Update 2024

Our top campaign priority is helping Rep. Clint Moses, the first chiropractor elected to the Wisconsin Legislature, get reelected in November.

Rep. Moses is the current Chair of the Assembly Health Committee. He has been a leader in health care policy and a champion for chiropractic issues during his two sessions in the Legislature. His district was previously a solid Republican one, but the new maps have made it more competitive, particularly in a high turnout Presidential year. It is critical that we help Rep. Moses get re-elected.

His campaign recently released its first campaign commercial (right). You can help fund his advertising campaign by making a contribution today. Even a small contribution of $25 or $50 will help Rep. Moses get his pro chiropractic reelection message out to voters in his district.

How to Support Pro-Chiropractic Candidates

ChiroStrong is a state political conduit fund administered by the Wisconsin Chiropractic Association on behalf of WCA members who elect to contribute to it. WCA members can support elected officials and candidates who are true advocates of the chiropractic profession in Wisconsin. Every dollar you contribute goes to your personal ChiroStrong account, which you control.

• If you are currently giving to ChiroStrong, please consider increasing your contribution so we can increase our political influence.

• If you are not giving to ChiroStrong, please consider contributing today so we can support pro-chiropractic candidates like Rep. Moses.

You can view other key Legislative races that will determine partisan control of the Wisconsin Legislature in 2025 at WisPolitics.com.

Thank you for your dedication to the profession and your contributions to ChiroStrong!

Why Support Pro-Chiropractic Candidates Like Rep. Moses?

Because the Wisconsin Legislature makes critical decisions that affect patient access to chiropractic care. Legislation affecting access to and reimbursement for chiropractic through the Wisconsin Worker’s Compensation system and State Medicaid program are considered every legislative session.

This last legislative session, the WCA worked with Rep. Moses to include a payment parity provision in the state budget that required the Wisconsin Medicaid program to pay chiropractors the same reimbursement rates as MDs for the same procedures. This provision increased Medicaid reimbursement for chiropractors by $1.5 million annually.

Having a strong state association like the WCA and legislative champions like Rep. Moses gives us a seat at the table to protect your rights as a provider and the rights of your patients. But we also need to actively support our champions when they are running for office through the WCA political fund known as ChiroStrong.

Rep. Moses has proven himself to be a serious policymaker in Madison as evidenced by the fact that in just his second term in office, he was appointed as Chair of the Assembly Committee on Health, Aging and Long Term Care." ~ John Murray, WCA Executive Director & CEO

Help Rep. Moses Get Re-elected through ChiroStrong >>

Attending WCA’s Fall Convention?

BTL staff will be waiting to meet you at WCA’s Fall Convention – please stop by our booth to experience BTL’s Emsculpt Neo and Emsella treatment.

BTL will be joined with Dr. Amyas Kabir (below), a practicing DC who averages $600,000+ yearly revenue in BTL treatment sales at his clinic in Illinois! Learn more about Dr. Kabir's experience (below) after his Emsculpt Neo arrived at his clinic!

Meet Tony Reeder Wisconsin BTL District Sales Manager

Dr. Amyas Kabir

Practicing DC

CORE TO FLOOR STUDY: IMPROVED QUALITY OF LIFE IN ELDERLY PATIENTS

THE IMPROVEMENT IN QUALITY OF LIFE AND CORE MUSCLE STRENGTH IN ELDERLY PATIENTS BY SIMULTANEOUS APPLICATION OF HIFEM WITH SYNCHRONIZED RADIOFREQUENCY

Diane Duncan, M.D., FACS1, David Kent, MD2, Evan Appelbaum, M.D., FAAC3

1. Plastic Surgery Associates, Fort Collins, CO, USA

2. Skin Care Physicians of Georgia, Macon, Georgia, GA, USA

3. Men’s Health Boston, 200 Boylston St a309, Chestnut Hill, MA, USA

Presented at IMCAS World Congress 2023, Paris

HIGHLIGHTS

• 39 patients were enrolled (60 –79 years, 19.7–33.9 kg/m2, skin type I-V)

• Four HIFEM+RF procedures (once a week over abdomen) and six standalone HIFEM procedures (twice a week over pelvic floor) were administered

• The biofeedback pressure measurements showed an increase in core muscle strength by +33.7% at a 3-month follow-up

• Three months after the last treatment, on average:

92% of patients were satisfied with the treatment outcomes

89% of patients could get up easily from a sedentary position

89% of patients felt that their core is stronger

89% of patients felt improvement in overall body movement

76% of patients were able to perform their daily activities better

68% of patients felt that they are at a lesser risk of falling

Celebrating Chiropractic at Fall Convention

The 2024 WCA Fall Convention is All About Honoring the Chiropractic Profession!

We're excited to recognize your hard work and commemorate our unique legacy together at the WCA Fall Convention! Wisconsin holds a prominent position nationwide as a chiropractic-friendly state, thanks to the strong leadership of the WCA, as confirmed by our national and regional leaders.

The 'Back to Basics' Podcasts Series

Hosted by WCA President Dr. Chris Resch

The Wisconsin Chiropractic Association podcast “Back to Basics” brings you conversations with leaders in the chiropractic profession hosted by WCA President Dr. Chris Resch. This month, we are featuring long-time WCA member, Dr. Kent Belville, WCA's 2024 Lifetime Achievement Award recipient. Did you miss an episode? Check out our podcast library on youtube!

Episode 7 Featuring Dr. Kent Belville

In this episode, I had the pleasure of speaking with Dr. Kent Belville, a 1984 graduate of Palmer College of Chiropractic, who has been practicing in Oshkosh for the last 40 years. As you listen in to our conversation, it’s clear that Dr. Belville’s passion for helping patients and his commitment to his business is as strong as when he first began. His enthusiasm for chiropractic care continues to drive him each day.

Throughout this interview, you will gain valuable insight into what it takes to build and maintain a successful practice that is still going strong after 40 years. You'll also hear how excited Dr. Kent is to keep moving forward with the same energy and passion he's always had.

I hope you enjoy my conversation with the 2024 recipient of the Wisconsin Chiropractic Association Lifetime Achievement Award, Dr. Kent Belville.

Reclaim Your Treatment Time: The Power of Online Intake Forms

Paper forms have been the go-to for medical clinics, businesses, and other organizations for decades, but as technology has evolved, so have the benefits of switching to digital forms. Online intake forms are a secure and efficient way to collect vital patient data, while saving your clinic time and money.

Why make the switch to digital?

Natasha Wilch is a physiotherapist and the owner of Symphony Rehabilitation. She is also the founder of Concussion Nerds — an online virtual program that mentors clinicians. Natasha shares that using online intake forms saves precious time for both her and her clinic staff.

“When forms get filled out beforehand, it saves me intake time. It means they have already put their past medical history in there. This means I have an initial idea of what their symptomatology is, so I can start to dig deeper faster. The higher-level stuff has been covered. And it also saves them brain power so they can get through more of the assessment in their session time,” Natasha shares.

Less admin time: good for you, good for your patients

Reducing admin time isn’t just a win for clinics, it’s beneficial for patients too. Automating the intake process cuts down waiting times, simplifies check-ins, and keeps everything running smoothly. For small practices with limited waiting areas, online forms can help prevent overcrowding and create a smooth patient experience.

“Our whole job as clinicians and as business owners is to create the most optimal, welcoming, warming customer experience we can create,” Natasha says.

The ability to take your practice on the go

Online intake forms enable clinic owners, practitioners, and admin staff to access patient information and work remotely.

Natasha explains: “It’s cloud-based, we can access anything anywhere, and we have the freedom to do our work from any device… that’s huge. Being able to access anything from anywhere gives me the freedom to support my team and my clients. I think in this day and age, that is crucial to success in business.”

Building better practices for a better practice

People are often in a hurry, and forgetting to collect important information can mean a payment goes uncollected or an insurer goes unbilled. Securely collecting all of that information from your patients before they even step through the doors of your practice lets patients be prepared and gives them accountability, which leads to fewer no-shows. It also keeps the focus of clinic visits on healing, rather than transactions.

First visits without the jitters

If patients can also conveniently access their intake forms on their own schedule, whether that’s at the time of booking online, through a secure patient portal, or via a secure link from their email, they won’t need to worry about the inconvenience of printing, scanning, and emailing their forms. This ensures the forms are submitted on time, so practitioners and patients don’t have to worry about form-filling taking up appointment time.

Giving patients the opportunity to complete forms from the comfort of their own home can also help reduce anxiety or nervousness associated with seeing a new practitioner or starting a new type of treatment for the first time.

Better security, without a padlock

Electronic forms help reduce the possibility of data loss or damage by securely storing and backing up clinic data. Businesses don’t have to worr y about their confidential information falling into the wrong hands, as it’s safely stored in the cloud.

At the end of the day, digital forms offer a secure and efficient way to collect vital patient data, while saving your practice time and money.

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The WCA has four distinguished awards for outstanding service and dedication and is honored to recognize these leaders in the profession at the Achievement Awards Luncheon at the WCA Fall Convention on September 21. The WCA is grateful to these professionals for demonstrating exceptional leadership and inspiring us to serve.

Chiropractor of the Year

Dr. Leo Bronston

Bronston Chiropractic Clinics

Leo Bronston, DC, MAppSc, is the owner and operator of Bronston Chiropractic Clinics in Onalaska, WI where he fosters a collaborative, multidisciplinary approach to patient care by integrating other healthcare professionals, such as physical therapists and nurse practitioners, into his practice. Dr. Bronston has served on the American Chiropractic Association (ACA) Board of Governors since 2019. He was elected ACA president in 2024. Over the years, he has been an active volunteer on key ACA committees and advisory boards in the areas of coding and reimbursement, integrative practice, and strategic planning. He has also represented ACA on AMA’s Current Procedural Terminology (CPT®) Advisory Panel and was later appointed by AMA to serve on its CPT® Editorial Panel. He is an active member of the Wisconsin Chiropractic Association, where he served on the organization’s Board of Directors for 15 years. A certified chiropractic sports physician, Dr. Bronston has treated Olympic athletes as a sports medicine clinician at the U.S. Olympic Training Center.

Lifetime Achievement

Dr. Kent Belville

Belville & Associates Chiropractic Clinic

Dr. Kent Belville has dedicated over 40 years to practicing chiropractic care in Oshkosh, WI. With a profound commitment to the healing arts, he views his role in the chiropractic profession as both a privilege and an honor. A 1984 graduate of Palmer College of Chiropractic in Davenport, Iowa, Dr. Belville is renowned among his patients for his unwavering dedication to delivering exceptional care and achieving optimal outcomes through chiropractic and natural methods. His extensive experience has allowed him to build lasting relationships with his patients, who have come to be regarded as an extended family. Dr. Belville’s practice has evolved into a family-centered clinic, now including his three sons: two of whom are chiropractors, and one who specializes in exercise rehabilitation. Other family members are also on staff who support the 40 years of experience Dr. Belville has given to the chiropractic profession.

Nels Bakke Award for Young Practitioner

Dr.

Madison Hopfensperger

Resch Chiropractic & Physical Therapy

Dr. Madi Hopfensperger is a chiropractor in Grand Chute, Wisconsin. She graduated from UW Madison with her undergraduate degree in Athletic Training and then went to Palmer College of Chiropractic in Davenport, IA. Dr. Madi earned her CCSP (certified chiropractic sports practitioner) certification in 2023 and has extensive experience working with athletes of all ages. Dr. Madi has also been a member of the volunteer Dale Fire Department as an emergency medical responder for the past two years. She finds great joy in giving back to her community.

Chiropractic Technician of the Year

Christine Perez, CT

Aurora Health Care

Christine always knew she wanted to work in the chiropractic field and started out by earning her Bachelors of Science degree in Human Biology from UW- Green Bay in 1999. Christine has been a Chiropractic Technician since graduating from Moraine Park in 2001. She has worked in multiple chiropractic clinics since graduating, and for the last 11 years has been with Aurora Health Care. Christine enjoys working in an environment where she can help her patients achieve wellness to improve their quality of life.

New! WCA Legacy Award Recipients 2024

This year, the WCA Board, in collaboration with our Membership and Education Committees, has introduced a Legacy award. This award aims to honor longstanding WCA members who have recently retired from their practice, acknowledging their 25 years or more of dedication and commitment to our organization. We are proud to celebrate the legacy of these WCA members!

Patrick Andersen, DC

Robert Carpenter, DC

Mark Cassellius, DC

Marc Gilerovich, DC

Russell Hauser, DC

Matthew Johns, DC

Joel Logelin, DC

Ross Royster, DC

Michael Polito, DC

Jennifer Waidelich, DC

Jeff Wilder, DC

Comprehensive Insights into Bone Health:

Nutrition, Minerals, Vitamins, and Herbs

Bones are dynamic living organs integral to the body's structure, protection, and function, and are composed of a protein matrix and mineral deposits. The matrix provides a framework, and the mineral deposits provide hardness and strength. Over time remodeling takes place, a process which removes old bone and rebuilds new bone.

Protein's Crucial Role: Collagen for Bone Formation

Collagen, the body's most abundant protein, forms the essential framework for bone formation. Synthesized from specific amino acids, collagen's triple helix structure relies on adequate dietary protein intake and cofactors such as zinc, copper, iron, manganese, and vitamin C.1 These elements contribute to the synthesis of collagen, pivotal for building the protein matrix.

Minerals: Calcium, Phosphorus, Magnesium, Manganese, & More

Calcium, phosphorus, magnesium, manganese, and other minerals play important roles in bone formation and growth. These minerals provide essential structural components for bone matrix, contribute to bone density, and participate in enzymatic reactions that regulate bone mineralization, ensuring the overall strength and integrity of the skeletal system.

- CALCIUM

Known for providing strength to bones, calcium's role extends beyond structural support. Acting as a storage reserve, bone releases calcium when serum levels start to fall too low. Adequate dietary calcium prevents the excavation of bone for other bodily needs.

- PHOSPHORUS

Partnering with calcium in the formation of hydroxyapatite, the bone's mineral complex, phosphorus, is crucial for balanced bone health. Phosphorus and calcium need to be consumed in a balanced way for optimum bone health. Studies suggest that low calcium and/or high phosphorus diets can adversely affect bone homeostasis.2

- MAGNESIUM

Magnesium takes part directly in mineralizing the protein matrix. When serum magnesium levels fall too low, magnesium from the bone is mobilized to buffer the effect. Indirectly, magnesium deficiency leads to inflammation and oxidative stress – both associated with bone loss. Its indirect role in parathyroid hormone secretion and vitamin D activation further emphasizes its significance.

- MANGANESE

Often overlooked, manganese acts as a cofactor in enzymatic reactions essential for collagen, cartilage, and bone mineralization. One study reported that those with osteoporosis had low serum manganese levels, and another study found that a supplement containing a combination of manganese, copper, and zinc, along with calcium, prevented bone loss more effectively than supplementing calcium alone.3

- ADDITIONAL MINERALS (BORON, SELENIUM, SILICON)

While their mechanisms are not entirely clear, boron, selenium, and silicon play roles in bone composition, function, and mineralization. The role of selenium seems related to the antioxidant capacity of selenium-containing proteins. Silicon appears to activate osteoblasts and play a role in collagen synthesis.4

Vitamins:

D and K – Key Vitamins for Bone Wellness

Beyond its well-known roles, vitamin D stimulates calcium absorption and regulates phosphorus. Vitamin D is synthesized in the skin when exposed to ultraviolet (UV) radiation from the sun. Often overshadowed, vitamin K is vital for calcium transportation and bone remodeling protein activation. Adequate intake, particularly of menaquinone MK7, is associated with reduced fracture risks.

Herbs: A Supportive Role in Promoting Bone Health

Dietary herbs and herbal extracts, such as black cohosh, red clover, kudzu, and Epimedium, show potential associations with lower rates of osteoporosis. Their diverse mechanisms, from influencing osteoblasts to preventing cartilage degradation, enrich the spectrum of bonesupportive options.5, 6, 7

References

1. Wu M, Cronin K, Crane JS. Biochemistry, Collagen Synthesis. [Updated 2020 Sep 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507709/

2. Calvo MS, Kumar R, Heath H. Persistently elevated parathyroid hormone secretion and action in young women after four weeks of ingesting high phosphorus, low calcium diets. J Clin Endocrinol Metab. 1990 May;70(5):1334-40. doi: 10.1210/jcem-70-5-1334. PMID: 2335575.

3. Pepa GD, Brandi ML. Microelements for bone boost: the last but not the least. Clin Cases Miner Bone Metab. 2016;13(3):181-185. doi:10.11138/ccmbm/2016.13.3.181

4. NHS News. The Nurse’s health study annual newsletter. 2004 (11). https://www. nurseshealthstudy.org/sites/default/files/pdfs/n2004.pdf

5. Pan Wei, Ming Liu, Yan Chen, De-Cai Chen. Systematic review of soy isoflavone supplements on osteoporosis in women, Asian Pacific Journal of Tropical Medicine, Volume 5, Issue 3, 2012, Pages 243-248, ISSN 1995-7645, https://doi.org/10.1016/S19957645(12)60033-9.

6. Thorup AC, Lambert MN, Kahr HS, Bjerre M, Jeppesen PB. Intake of Novel Red Clover Supplementation for 12 Weeks Improves Bone Status in Healthy Menopausal Women. Evid Based Complement Alternat Med. 2015;2015:689138. doi:10.1155/2015/689138

7. Luo Y, Zheng S, Ding Y, et al. Preventive effects of kudzu root on bone loss and cartilage degradation in ovariectomized rats [corrected] [published correction appears in Am J Transl Res. 2017 Nov 15;9(11):5180]. Am J Transl Res. 2017;9(7):3517-3527. Published 2017 Jul 15.

An Opportunity Like No Other Aurora Health Care’s

Integrated Clinical Practice Chiropractic Residency Program

It’s the first day of resident orientation at Aurora Health Care, now part of Advocate Health, and dozens of new residents sit waiting to begin the next phase of their healthcare careers. Amid the tables of medical residents are two chiropractic residents, Dr. Camila Irizarry Porrata and Dr. Joshua Nisler, ready to embark on a one-of-kind integrated chiropractic residency that will expose them to observational rotations in specialties across the Aurora system.

Aurora Health Care’s year-long Integrated Clinical Practice Chiropractic Residency Program offers chiropractors the only such private sector opportunity in the country. How did this unique program come about, and how do chiropractors—and patients—benefit?

History

The residency was conceived in 2019 by Dr. Eric Kirk, who at the time served as Clinical Director of Chiropractic Services for Aurora Health Care and now serves as Medical Director of Chiropractic Services for Aurora and Advocate Health Care and Program Director of Aurora's Integrated Clinical Practice Chiropractic Residency Program. Inspired by a similar public-sector program through the VA, Kirk said, “I thought about the resources we have here within Aurora Health Care and the relationships I’ve built over the years, and I felt a responsibility to create something like this.”

Kirk began by learning about residency programs in other organizations and researching available resources within Aurora. He met with the Aurora Orthopedics leadership team, which oversees chiropractic, and found support for the idea.

He then met with Dr. Jake Bidwell, Vice President for Academic Affairs and Designated Institutional Official for Aurora's Graduate Medical Education. Bidwell was also supportive. “It was a matter of, OK, let’s make it happen!” Kirk said.

The VA’s already-established public program helped set the ground work, but the opportunity for Aurora to create the nation’s first private program was a unique nuance, said Kirk. A step-by-step process of approvals followed.

Even with leadership support, creating this type of program is not possible without established relationships and success in delivering chiropractic services, Kirk pointed out.

Aurora had already developed the largest chiropractic workforce within a large integrated healthcare system in the United States. The existing interdisciplinary and administrative relationships laid the foundation.

With the VA residency as a guide, Aurora developed a private sector curriculum suited to its own resources and patient population.

Accreditation

Aurora pursued accreditation through CCE (The Council on Chiropractic Education). ACGME, the accreditation agency for graduate medical education, does not accredit chiropractic programs.

Accreditation is an arduous process, Kirk noted, including an initial application, program self-study and site visit from CCE.

“We are the first private sector program in the country to receive accreditation through CCE. We believe accreditation is important to validate our program, consistent with the VA programs and other graduate medical education programs,” Kirk said.

The chiropractic residency program at Aurora Health Care is awarded programmatic accreditation by The Council on Chiropractic Education. For further information visit http://www.cce-usa.org.

Pictured: Dr. Braden Sims, Program Coordinator Ellie McCarrier, Dr. Camila Irizarry Porrata and Dr. Eric Kirk

Program Curriculum

Once the pieces were in place, the program welcomed its first chiropractic residents for the 2022-2023 academic year, Dr. Braden Sims and Dr. Kendal Hoard.

The program is organized into three main categories:

• patient care

• interdisciplinary education

• scholarly activity

Each resident delivers supervised patient care three days per week in a clinic environment. Residents are observed for competency and become familiar with the Aurora system, including the EHR (electronic health record), advanced diagnostic imaging system and more.

Two days per week, residents have clinical observational rotations in core disciplines, including primary care, orthopedics, neurosurgery, radiology and more. Electives include specialties such as pediatrics, acupuncture, integrative medicine, rheumatology and others.

“These rotational experiences are what people really value about the program—the ability to see how another professional looks at a patient. They can build relationships and understand that the other doctor is a person, and you can talk to them. It’s not us versus them,” Kirk said.

“That’s what I think is the biggest value of our program.”

The third element of the program is scholarly activity, including developing case studies, quality improvement projects, and research. All residents have published and participated in ACCRAC, the Association of Chiropractic Colleges Annual Educational & Research Agenda Conference.

Life as a Resident

“This is an opportunity unlike any other,” Dr. Braden Sims said. “Most chiropractors don’t get the opportunity to do interprofessional rotations, observe surgeries, or shadow different providers. That experience is invaluable,” he said.

Among the biggest benefits Sims sees to working in a large integrated healthcare setting are the opportunities to build relationships and the ability to collaborate with other providers on a patient’s care. Having access to the patient’s electronic health record is crucial. “It’s all right there in the chart, and you have all their imaging. There’s a lot more information available to provide the best patient care,” Sims said.

In the Aurora system, “Our sole focus is patient care,” he said. “That’s what I went to school for, and that’s what I’ve always wanted to do.”

Two months into her residency in the 2024-2025 program, Dr. Camila Irizarry Porrata agrees that the ability to build relationships and have access to a patient’s history are major benefits.

Electronic health records allow for better patient follow-up, she said. When a patient gets care from another provider, “We can ask, how did it go? What are the implications for the patient’s health and chiropractic care?”

“What we do sets the pathway for other professionals, and what other professionals do sets the pathway for our care,” she said. She appreciates the opportunity to interact with other medical professionals.

“I’ve already gotten to know a big part of the team here. Historically, you hear about the dissonance between medical doctors and chiropractors.” Working alongside each other helps breaks down those barriers, she said.

Support System

New chiropractic residents receive guidance and support from program coordinator Ellie McCarrier. She assists the Program Director in meeting accreditation requirements and educational programming, and supports the residents and faculty.

“Ellie is one of the best,” Kirk says. “She loves to make the on-boarding process easier and considers the incoming residents like family.”

Career Opportunities

All program graduates to date have been offered, and accepted, positions within the Aurora system.

“That’s something I’m very proud of, because I created this program to create professional opportunities,” Kirk said. “I feel blessed to have been in this position for 24 years. The ability to share that opportunity and create this professional pathway is very important.”

The program welcomes applications from chiropractors of any age, not just recent graduates.

continued on page 23

“Most chiropractors don’t get the opportunity to do interprofessional rotations, observe surgeries, or shadow different providers. That experience is invaluable.”

~ Dr. Braden Sims, graduate of the Aurora Chiropractic Residency program

Dr. Kendal Hoard and Dr. Braden Sims were the first two graduates of the Aurora Chiropractic Residency program in 2022-23.

“This program prepares residents for success within our chiropractic department, and in effect makes them ready for hire”

~ Dr. Eric Kirk, Clinical Director of Chiropractic for Aurora Healthcare and Program Director for the Chiropractic Residency Program

Chiropractic Residency

The residency is a well-paid position with benefits, Kirk pointed out. “This is not us taking advantage just to have people in our workforce, but it is one way we build our workforce.”

Outside the residency program, Aurora usually only hires chiropractors with more than five years’ experience, Kirk said. But even experienced hires are often new to reading advanced imaging or navigating an integrated delivery healthcare system—skills residents learn in the program.

“This program prepares residents for success within our chiropractic department, and in effect makes them ready for hire,” he said.

Collaborative Vibes Only

A willingness to collaborate is critical for chiropractors interested in the program.

“People who enjoy working collaboratively and have a desire to deliver patient-centered care fit into a system like ours nicely. Those who bash other health care professionals would not be a good fit,” Kirk said.

Kirk has heard the rumblings that collaborating with medical doctors means chiropractors aren’t staying true to their principles. He disagrees, believing everyone benefits when chiropractors are knowledgeable about advancements in healthcare options.

“I think any patient would value a healthcare provider who is willing to go out and learn more, see more, collaborate more, all for the patient’s benefit,” Kirk said.

"In the past, I have had other medical professionals say, ' I didn't know what you did! ' because they were not exposed to a chiropractor's knowledge or clinical skill set through their medical education and training."

“That is why I developed this program. I wanted to create more opportunity for chiropractors to build collaborative relationships and generate professional opportunity,” Kirk said.

Looking Ahead

The Aurora Integrated Chiropractic Residency Program is becoming more competitive, more structured and more reproducible, Kirk said. He hopes other organizations follow Aurora’s lead and create similar programs.

Meanwhile, Aurora plans to remain at two residents per year based on resources and space. The residency will continue to evolve over time in response to feedback and needs.

“We developed a great experiential program that advances the learning opportunities for chiropractors,” Kirk said. “We have a strong foundation. Now we’re going to build upon that.”

Dr. Eric Kirk and Dr. Gina Budjak pictured in 2023-2024 with Dr. Budjak's research.

Dr. Eric Kirk and Dr. Jessy Johnson pictured in 2023-2024 with Dr. Johnson's research.

Dr. Camila Irizarry Porrata and Dr. Joshua Nisler are current residents of the Aurora Health Care Integrated Chiropractic Residency program.

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White glove service to meet all of your diagnostic laboratory needs.

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Unlock the Power of Diagnostic Testing with Evexia Diagnostics

As a chiropractor, you understand the critical role that diagnostic testing plays in delivering personalized, effective patient care. The right tests can provide invaluable insights, guiding wellness plans and helping patients achieve optimal health. If you’re a member of the Wisconsin Chiropractic Association, there’s fantastic news: you now have access to a comprehensive diagnostic test ordering service through Evexia Diagnostics.

Access to Over 30 Industry-Leading Lab Partners

One of the standout features of Evexia Diagnostics is the access it provides to over 30 of the industry’s top lab partners. This means you can order a wide variety of tests from a single platform, ensuring you have the tools you need to support your patients’ health journeys. Whether you’re looking for specialized panels or routine screenings, Evexia has you covered.

Comprehensive White-Glove Support

Navigating the complexities of diagnostic test ordering and interpretation can be challenging. That’s why Evexia Diagnostics offers white-glove support for all aspects of the process. There is always a live client success team member there to help. From ordering tests and receiving results to managing logistical details, Evexia’s dedicated team is there to assist you every step of the way. This high level of support ensures that you can deliver the best possible care to your patients without getting bogged down by administrative hurdles.

Expert Diagnostic Lab Interpretation Guidance

Interpreting diagnostic lab results can be a daunting task, especially when dealing with complex cases. Evexia Diagnostics provides expert guidance to help you make sense of the data. This support is invaluable in ensuring that you can accurately assess and effectively help your patient’s health outlook, and enhance the overall success of your practice.

Convenience and Affordability

Evexia Diagnostics is designed to make diagnostic labs impossibly convenient and affordable. By consolidating services and offering comprehensive support, Evexia reduces the time and cost associated with traditional diagnostic testing methods. This efficiency not only benefits your practice but also translates into better care for your patients.

The Bottom Line

With Evexia Diagnostics you have a powerful tool at your fingertips. Take advantage of this incredible resource to enhance your practice, improve patient outcomes, and streamline your workflow. Simply register for the type of account that works best for your needs. You will unlock the full potential of your practice with Evexia Diagnostics today and experience the difference that comprehensive, convenient, and affordable diagnostic testing can make.

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WCA Continuing Education

License Renewal Deadline: DECEMBER 14, 2024

Continuing Education Requirements

If you received your license AFTER December 15, 2022, you do NOT need to take continuing education hours for renewal. You still need to submit the forms/payment for renewal to DSPS.

If you earned your license BEFORE December 15, 2022, you need to complete the following continuing education hours:

DCs

40 hours of approved continuing education each biennium. Up to 8 of those 40 hours can be done online.

4 hours Nutrition CE every two years for those holding Chiropractic Nutrition Certification.

Find more CE information at DSPS

CTs

6 hours of state-approved CT continuing education each biennium. Up to 2 of those 6 hours can be done online. Find more CE information at DSPS

CRTs

12 hours of state-approved CRT continuing education each biennium. Up to 2 of those 12 hours can be done online.

Find more CE information at DSPS

Online CE Hours

DCs, CTs and CRTs may earn a portion of their required CE Hours by taking online courses.

• DCs: 8 Hours Online CE per biennium

• CTs & CRTs: 2 Hours Online CE per biennium

Earn CE from your Home or Office!

DCs, CTs and CRTs may earn a portion of their required CE hours by taking online courses with the Wisconsin Chiropractic Association.

View our 2024 Online CE Schedule

CE SPOTLIGHT

"The

Role of Chiropractic in the Opioid and Mental Health Epidemics"

This course will give you an overview of the crises in addiction and mental health and the role of the chiropractic clinic in making a difference!

John Rosa, CEO of Integrative Medicine clinics, addresses opioid and mental health crises by reviewing statistical data, and discussing addiction risk factors, societal influences, historical perspectives, and key strategies for awareness, prevention, and treatment. He emphasizes the role of chiropractic and integrative medicine in tackling these crises. Let's dive into this whirlwind of awareness, prevention, and solutions!

Saturday, October 5 | 8:00 am - 5:00 pm

Location: Holiday Inn American Center, Madison

CE: 8 CE DC/CT/CRT

Presenter: Dr. John Rosa

Sponsored by: NCMIC

CE CALENDAR

BUILD AND GROW YOUR PRACTICE with the Wisconsin Chiropractic Association

At the WCA, we understand the unique challenges you face as a chiropractic professional – and we’re dedicated to helping you overcome them. From comprehensive educational programs to invaluable networking opportunities, we offer a full suite of services designed to propel your practice forward.

With over 100 years of experience in supporting chiropractors, the WCA is here to provide the tools, resources, and guidance you need to thrive at every stage of your career. Join our community of successful chiropractors and unlock the potential of your practice!

WELCOME

WCA Membership Update

Zach Kasun, Membership Director | zkasun@wichiro.org | 608-292-1805

New DC Members

Kyle D Anderson

Grayson Cline

Eric E Davidson

Judith Davis

Antonio Duardo

Tucker Emerson

Elizabeth A Emerson

Lucas Gindl

Amy Gunderson-McNeil

Cody Gust

Olivia Healey

Seth Huber

Joshua Kary

Bailey Knautz (Redfearn)

Breanna Lambach

Mark Nemetz

Matthew Nikolay

Halima Phelps

David P Schmitz

Travis Tann

Bethany Van Rooy

New Student Members

Michaela Avila

Bryce Fischer

Jeslyn Kolasa

Benjamin Soborowicz

Brandon Swantz

Kodye Tangwall

Not a Member Yet?

Now is the best time for you to join the WCA, and we have a special offer when you sign up at Fall Convention. You will receive the Early Bird rate on your Fall Convention registration fees (if you haven't registered yet, there's still time!). Additionally, when you register in September, your 2024 Annual Dues will be prorated (75% off), and you’ll earn a $50 credit towards the 2025 WCA Fall Convention when you agree to become an autorenewing member in 2025.

Join today at the WCA Registration Desk or visit wichiro.org/join-now

YOUR PARTNER IN HEALTH

The specialists at Orthopedics & Sports Medicine

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Our goal is to minimize pain, improve function, and get patients back to their normal activities.

BayCare Clinic is proud to partner with the Wisconsin Chiropractic Association and more than 100 chiropractors in northeastern Wisconsin to provide top-level musculoskeletal care to their shared patients

Learn more about how we can help.

Laser Focus: Boosting Athletic Performance with Laser Light Therapy

Dr. Michael S. Trayford, Founder/Director of Operations at APEX Brain Centers

The use of laser therapy in sports medicine is nothing new, although progressive applications for peak athletic performance are now going far beyond joint, muscle, tendon, and ligament repair.

As no two lasers or sources of light are created equal, this discussion will focus on Class 2 low-level laser therapy (i.e. low power and visible spectrum light). These lasers are non-thermal (no heat production), safe for applications beyond the aforementioned connective tissues, and their positive benefits can be found across the literature in the areas of traumatic brain injury, cognitive decline, neurodegenerative diseases, learning and behavioral disorders, organic diseases, and peak brain and athletic performance.

Cellular Energy Production and Benefits of Class 2 Lasers

At their core, Class 2 lasers are proven to stimulate/enhance cellular energy production through their effects on the electron transport chain (ETC) in the metabolic pathway of oxidative phosphorylation. When interacting with protein and coenzymes complexes within the ETC, such as NADH and succinate dehydrogenase and various cytochromes, visible spectrum light at low power can drive the production of adenosine triphosphate (ATP) and provide needed energy for all cellular processes, including muscle contraction, nerve transmission, and countless chemical reactions.

While most are familiar with “red light” therapy, new research and applications with shorter wavelengths such as violet and green light are emerging that demonstrate the holistic impact on cellular energy production that red light alone cannot provide. Red light stimulates only one of 4 key complexes in the ETC, whereas violet and green now allow for stimulation of all 4. This is a fundamental change in the clinical toolbox that will allow healthcare providers to deliver a higher level of service, and enhanced clinical outcomes, to their patient populations.

At APEX Brain Centers we harness the power of all 3 light sources and are realizing the treatment times for both injury and peak athletic performance being dramatically reduced. This is particularly important in cases where we need to get athletes back on the track, field, court, etc. as quickly as possible!

A Patient's Journey with Laser Therapy

Manteo Mitchell, a long-time patient and friend of ours at APEX has built low-level laser therapy into his training and treatment arsenal with the highest of returns. Many may know Manteo as the track and field phenom that famously fractured his fibula during the men’s 4x400m relay while representing the United States during the 2012 Summer Olympics in London in 2012. And they were still able to secure a silver medal!

Subsequent to the London Olympics, we began to work with Manteo on the physical challenges related to the injury, as well as the cognitive and mental challenges that sport at the highest of levels brings with it. He was not finished and relied on changes in research and training

methodology that would continue to help him perform at his peak level, even after injury and age concerns crept in. Fast forward to 2024 and Manteo is now training to compete in the 2026 Winter Olympics in Italy in men’s bobsled – and standing on the podium there would make him one of only 7 individuals in the world to have medaled in both the summer and winter games!

Over the past years working with Manteo, we have employed low-level laser therapy as a core strategy to facilitate his ongoing cognitive, physical, neurological, and metabolic enhancement training regimen. Applications with cold laser therapy delivered simultaneously with physical and cognitive tasks on an ongoing basis have allowed him to not only to maintain levels of peak physical and cognitive fitness, but to continue to crush his goals on a regular basis. In many ways, he is stronger than he ever was at 37 years of age when so many are beyond their Olympic careers and dreams. We can’t wait to see what he does in 2026!

Applications of Low-Level Laser Therapy

As with Manteo and other athletes we treat, we deliver the same clinical thought processes and treatment approaches to our complex brain injury cases, those with cognitive impairments, learning and behavioral disorders, etc. Energy is energy – whether it is fueling the metabolic demands of a high-level athlete, or helping someone walk who has suffered a traumatic brain injury (oftentimes more important in the latter as energy demands are higher in those that have lost proper control over their bodily functions).

Harnessing the power of various wavelengths of light (red, green, violet), coupled with balance and vestibular therapies, visual/eye movement rehabilitation, training of motor timing and complex motor skills, neurofeedback/biofeedback, audio-visual entrainment, frequency-based therapies (electrical, vibratory, sound, light), hyperbaric oxygen therapy, and metabolic and nutritional therapies, is a recipe for success with any patient population!

Light therapy, particularly low-level laser therapy, is the future of brain-body medicine and Erchonia® lasers stand at the forefront of this healthcare revolution with their wide array of clinical devices, research, and device clearances.

Dr. Michael S. Trayford is Board Certified in Chiropractic Neurology and Neurofeedback. He is the Founder/Director of Operations at APEX Brain Centers in Asheville, NC. He sits on the board of The International Society for Neuro Regulation and Research and is, Board Advisor for the Dementia Society of America. www.apexbraincenters.com, IG - @apexbraincenters | erchoniagvl.com

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The Four Step Formula Every DC Should Know About Billing for Chiropractic Manipulative Treatment

By Evan M. Gwilliam, DC MBA QCC CPC CCPC CPMA CPCO AAPC Fellow | Practisync Senior Vice President

Chiropractic Manipulative Treatment (CMT) is the life blood of most chiropractic clinics. And Medicare (CMS) is the gold standard when it comes to rules and regulations. If a provider is able to satisfy Medicare guidelines, odds are good that he/she can satisfy any third party. CMS only pays chiropractors for Chiropractic Manipulative Treatment (CMT), but fortunately they have outlined all that a provider needs to know to make sure the service is reimbursable.

STEP ONE: P.A.R.T.

It all starts with documenting the existence of a condition that would respond to CMT, or the chiropractic adjustment. While most chiropractors would agree that the condition should be a problem with the spine, CMS tells us that the primary diagnosis must be a spinal subluxation. Fortunately, CMS has outlined a way to document that a subluxation exists. The acronym P.A.R.T. identifies diagnostic criteria for spinal dysfunction (subluxation). Per MLN Matters Number SE1601, Medicare Coverage for Chiropractic Services – Medical Record Documentation Requirements for Initial and Subsequent Visits, it is laid out as follows:

P - Pain/Tenderness:

The perception of pain and tenderness is evaluated in terms of location, quality, and intensity. Most primary neuromusculoskeletal disorders manifest with a painful response. Pain and tenderness findings may be identified through one or more of the following: observation, percussion, palpation, provocation, and so forth. Furthermore, pain intensity may be assessed using one or more of the following; visual analog scales, algometers, pain questionnaires, and so forth.

A - Asymmetry/Misalignment:

Asymmetry/misalignment may be identified on a sectional or segmental level through one or more of the following: observation (such as posture and heat analysis), static palpation for misalignment of vertebral segments, and/or diagnostic imaging.

R - Range of motion abnormality:

Changes in active, passive, and accessory joint movements may result in an increase or a decrease of sectional or segmental mobility. Range of motion abnormalities may be identified through one or more of the following: motion palpation, observation, stress diagnostic imaging, range of motion, and/or other measurement(s).

T

-Tissue Tone, Texture, and Temperature

Abnormality

Changes in the characteristics of contiguous and associated soft tissue including skin, fascia, muscle, and ligament may be identified through one or more of the following procedures: observation, palpation, use of instrumentation, and/or test of length and/or strength.

The guidelines go on to tell us that CMS only requires that two of these four elements be documented in the record, one of which must be Asymmetry or Range of Motion.

This exam is refreshingly simple. It is a fast and easy way to show that a patient has spinal segmental dysfunction. And this condition is perhaps the best one to justify the need for CMT, or the chiropractic adjustment. Therefore, consider documenting P.A.R.T. in every region that receives billable CMT, regardless of payer. Records for patients with private insurance, worker’s compensation, personal injury, and cash can all easily meet this standard. And all of these payers would have a hard time disagreeing with the record that clearly documents the segmental dysfunction this way, meeting the guidelines of Medicare.

STEP TWO: Diagnose

Once the objective findings support the existence of a problem that is known to respond to the chiropractic adjustment, the next step is to assign the right diagnosis code. Medicare has told us that the treatment they will pay for must be intended to correct a subluxation and that this must be diagnosed. Even though the word “subluxation” is not used with the codes found at M99.0- in the ICD-10 tabular list, they are the codes that CMS have identified for describing it.

If the M99.0- segmental and somatic dysfunction codes are good enough for Medicare, they are likely sufficient for any payer or third party who is looking for a reason that someone was adjusted. Make sure that every region that is adjusted has the appropriate M99.0code, and that each of these regions has clearly documented P.A.R.T. Medicare specifically requires that M99.0- be primary and that each region has a secondary diagnosis as well, but other payers may be more flexible on the secondary diagnosis requirement.

STEP THREE: CMT

Now that the objective findings show that there is spinal dysfunction, and the ICD-10 code is appropriately assigned, Chiropractic Manipulative Treatment (CMT) can easily be justified. The records should show a clear link as follows:

P.A.R.T.

M99.0- CMT

A simple self-audit might include a review of each record to make sure that all the links in this chain are easily identifiable. The three spinal CMT codes vary depending on the number of regions addressed. 1-2 regions for 98940, 3-4 regions for 98941, and 5 regions for 98942. Therefore, if billing for 98941, an auditor would look for 3 or 4 regions, each with P.A.R.T., and 3 or 4 M99.0- diagnosis codes.

This would work for 98943 extraspinal CMT as well. The records can show that the area was examined, that there are at least two elements

continued on page 45

Four Step Formula - Cont. from page 43

of P.A.R.T., and that a code like M99.06 Segmental and somatic dysfunction of lower extremity or M99.07 Segmental and somatic dysfunction of upper extremity is linked to the 98943.

STEP FOUR: MEDICAL NECESSITY

But the bigger picture must also be considered. Even if all these other things are documented, medical necessity needs to be established. This can be accomplished by adding a few more pieces to either end of the formula. Before P.A.R.T., in the subjective part of the record, the patient should have identified a problem that he/she wants help with. It is difficult to establish medical necessity if the provider treats areas that are not identified by the patient as part of the problem they came in for. For example, treating an asymptomatic knee just because the provider decided to adjust it, would not be considered medically necessary.

At the other end of the formula, each procedure delivered must have a purpose or rationale. For example, if limited range of motion was found in the exam, and increased range of motion is expected as a result of the chiropractic manipulation, then that can be documented to explain why the service is necessary. And, in the bigger picture, the whole episode of care can be rationalized with documented functional loss, and goals focused on functional gains that are a direct result of the service rendered. Ongoing progress is critical to supporting medical necessity, but that is another discussion for another time.

If these four steps are used, a chiropractor can clearly and easily support CMT services in such a way that any third party should be satisfied that it was necessary and billed appropriately.

Dr. Gwilliam, Senior Vice President of Practisync, brings a wealth of expertise to the healthcare industry. Graduating as Valedictorian from Palmer College of Chiropractic, Dr. Gwilliam holds credentials as a Certified Professional Coder, Medical Auditor, and Compliance Officer. With a unique background combining clinical experience with

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WCA Help Desk Updates

Tammy McKeown, C.T. | Membership Services Director | wcahelp@wichiro.org | 608-292-1804

United Healthcare-AARP Medicare Advantage Plans

The WCA Help Desk has been made aware that in-network providers for United Health Care-Optum received a letter dated July 31,2024 outlining changes that will be effective as of September 1, 2024.

We have also learned that Humana Medicare is partnering with Cohere Health and Evolent to facilitate Utilization Management process for certain codes including Spinal Manipulation. This policy is outlined in a letter dated June 10, 2024. This is effective as of August 29, 2024 (does not apply to out of network providers).

This will require online clinical submission of a Patient Summary Form (PSF), for certain United Healthcare and AARP Medicare Advantage members. A PSF is not required for the initial evaluation. A PSF submission is required for subsequent visits. This will include treatment in progress after the effective date. This change will be required for all in-network DC providers, no matter your Tier status with Commercial United Healthcare plans.

Resources that Can Help with this Change

The Help Desk has reviewed myoptumhealthphysicalhealth.com, the Resource Library section and Clinical Submission Forms.

• View Patient Summary Form (PSF)

• PSF Tutorial & Instructions

• Clinical Forms Instruction Manual

• Prior Authorization Changes for Outpatient Therapy Services

Get Involved:

ChiroCongress Patient Campaign

Chiro Congress has created a Template Letter for providers to send to United Healthcare to oppose the PSF-Clinical Submissions.

They also developed a Patient Campaign to educate chiropractic patients about Advantage Plans and this should prompt patients to contact their carrier and oppose. They added both United Healthcare and Humana Medicare to the patient campaign handout, this is a nationwide campaign.

Clarification from Fulcrum on Minnesota Medicaid Enrollment

The WCA Help Desk received clarification from the Senior Manager of Provider Network Development and Fulcrum’s Compliance Officer. Fulcrum did confirm, they will require Providers in bordering counties to Minnesota to be enrolled in MHCP (Minnesota Health Care Programs).

You do not want to start receiving claim denials as of October 1, 2024, if the requirement is not met by the deadline of September 16, 2024, for In-Network Fulcrum Providers. The WCA Help Desk received clarification from the Senior Manager of Provider Network Development and Fulcrum’s Compliance Officer. Fulcrum did confirm, they will require Providers in bordering counties to Minnesota to be enrolled in MHCP (Minnesota Health Care Programs).

Network Health Cultural Competency Training

The Manager of Provider Integration at Network Health has informed WCA that this is a yearly requirement for In-Network Providers. Providers have received notice from Network Health regarding this requirement.

Check out the WCA Help Desk Webinars On Demand for the May 8, 2024 recording of "Recognizing Cultural Diversity and Implicit Bias" featuring Dr. Mario Fucinari.

$1,000+ annually

Longtime givers who make significant annual commitments in support of WCA’s pro-chiropractic political advocacy efforts. Chiropractic Champions will be recognized at the WCA Fall Convention and will receive complimentary invitations to every exclusive WCA-ChiroStrong event.

$500 - $999 annually

Consistent ChiroStrong supporters who are committed to WCA pro-chiropractic advocacy efforts and are considering an increase in their investment.

Chiropractic Defenders will be recognized at the WCA Fall Convention and receive complimentary invitations to select WCA political special events throughout the year.

Up to $499 annually

New ChiroStrong givers, or members interested in making a more modest investment in pro-chiropractic political advocacy efforts. Chiropractic Advocates will be recognized at the WCA Fall Convention and will receive invitations to select WCA political events throughout the year.

Up to $250 annually

Those who are just getting started in the profession who wish to have their voices heard in the political process. Enthusiasts will be recognized at WCA Fall Convention.

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Using Timed Therapy Codes Appropriately

Dr. Ray Foxworth, DC, FICC | Founder and CEO of ChiroHealthUSA

I

n chiropractic care, accurate and appropriate use of timed therapy codes is essential for ensuring compliance with federal regulations and avoiding legal pitfalls. Recent legal actions against The Grand Health Care System and its affiliates highlight the importance of understanding and correctly applying these codes. Here’s a detailed look into how chiropractors can use timed therapy codes appropriately and avoid common mistakes.

Understanding the Legal Context

Strauss Ventures LLC, doing business as The Grand Health Care System and 12 affiliated skilled nursing facilities will pay $21.3M after recently settling allegations of violating the False Claims Act. The allegations included billing federal health care programs for unreasonable, unnecessary, or unskilled therapy services or services that did not occur as billed. The case emphasizes the need for strict adherence to billing guidelines to protect both patients and taxpayers. (US Department of Justice, 2024)

The Importance of Timed Therapy Codes

Timed therapy codes are used to bill for services based on direct, one-on-one patient care duration. Common codes include those for manual therapy, therapeutic exercises, and other skilled rehabilitation services. Medicare’s “eight-minute rule” is a crucial guideline for determining the billable units of service.

The Eight-Minute Rule

For time-based codes, Medicare requires a minimum of eight minutes of direct patient care to bill for one unit of service. The total time spent on therapy is divided by 15 to determine the number of billable units. An additional unit can be billed if eight or more minutes remain after dividing. (Collins, 2016)

For instance:

1 unit: 8-22 minutes

2 units: 23-37 minutes

3 units: 38-52 minutes

4 units: 53-67 minutes

Commonly used codes in chiropractic practices include:

97110: Therapeutic exercises

97112: Neuromuscular re-education

97124: Massage therapy

97140: Manual therapy techniques

Each code requires accurate documentation of the time spent on each procedure to ensure compliance and proper reimbursement.

Proper Documentation

To maximize revenue and avoid legal issues, chiropractors must:

Clearly Document Techniques and Time: Record the specific techniques, therapeutic goals, and time spent on each procedure. Documentation should reflect direct, face-to-face time with the patient, including pre-service, intra-service, and post-service activities. (Kathleen D. Weissberg, 2018)

Accurately Calculate Total Time: The total time is cumulative when multiple services are provided. For example, if you provide 10 minutes of therapeutic exercise (97110) and 10 minutes of manual therapy (97140), you have 20 minutes. This time only qualifies for one unit, which falls below the 23-minute threshold for two units.

Ensure Consistency with Clinical Condition: Therapy services should be based on the individual patient’s clinical needs, not arbitrary quotas, or financial incentives. Overbilling or providing unnecessary services can lead to severe penalties, as seen in the Grand Health Care System case.

Example of Proper Billing

24 minutes of neuromuscular re-education (97112)

23 minutes of therapeutic exercise (97110)

Total time: 47 minutes

This falls within the range for three units (38-52 minutes). The correct coding would be two units of 97112 and one unit of 97110.

Since each service was performed for at least 15 minutes, you can bill either code for two units and the other for one unit.

Timed therapy codes are critical for compliance and ethical practice in chiropractic care. By understanding and applying the eight-minute rule, accurately documenting services, and ensuring that therapy is clinically justified, chiropractors can avoid the pitfalls that led to legal action against The Grand Health Care System. Always prioritize patient needs over financial incentives to uphold the integrity of your practice and protect your patients.

Dr. Ray Foxworth, DC, FICC, is the visionary behind ChiroHealthUSA, serving as its esteemed founder and CEO. With over 39 years of dedicated service in chiropractic care, Dr. Foxworth has navigated the complexities of billing, coding, documentation, and compliance firsthand. His rich experience includes roles as the former Staff Chiropractor at the G.V. Sonny Montgomery VA Medical Center and past chairman of the Chiropractic Summit and Mississippi Department of Health.

Dr. Foxworth is deeply committed to advancing the chiropractic profession, which is evident through his leadership roles. He is an at-large board member of the Chiropractic Future Strategic Plan and holds an executive board position with the Foundation for Chiropractic Progress.

BUILDING CHIROPRACTIC'S POSITIONING DURING

Drug-Free Pain Management Awareness Month

Resources for Your Clinic to Support September’s Campaign

As a Group Member of the Foundation for Chiropractic Progress (F4CP), you have access to a variety of resources such as eBooks, posters, tip sheets, webinars and so much more to support the messaging of choosing drug-free pain management options such as chiropractic care!

Follow the steps below to get started

OUR DEEPEST Sympathy

Dr. Matthew Dejanovich

July 2, 1926 - April 28, 2024

Born to eternal life early on Sunday morning. April 28, Doc is survived by his loving wife of 44 years, Deanna (nee Majeski). He is further survived by his sisters, Rose Mary (late Chuck) Pook and Catherine (Late Timothy) DuFresne of California. Matt was born at home in Mayville, WI, His half brothers and sisters {all deceased) were Nick (Mary) Hecimovich, Clara (Fred) Hecimovich, Beck, Peter (Eleanor) and Louie (Mara) Dejanovich and Mary Dejanovich, Polsen, Sartich. He will be missed by numerous nieces and nephews, as well as other relatives, friends, neighbors and colleagues.

As a child, Matt attended Gesu Grade School and Little Flower Grade School, then Pius XI High School where he graduated in 1944. High school graduation meant registration for the draft and all the young men knew their future was WWII service The day he registered, he was immediately drafted into WWII U S Naval Service and wasn't able to go home. {He was prepared to go into the Army because his brother Pete had kept him supplied with Army rules and regulations and complete information on all the weaponry and ammunition.} His dad came down to the induction center with $5 for him and his mother accused him of doing it on purpose. After Boot Camp at Great Lakes he was shipped to San Francisco and assigned to the Amphibious Division at US Naval Base. Subic Bay, Philippine Islands. He was discharged in 1946. Several years after this he joined the Subic Bay Association Group and enjoyed the travel and camaraderie. He eventually became President of the Group., which unfortunately disbanded when the members were no longer able to travel.

After the War, taking advantage of the GI Bill of Rights, Matt studied at Palmer Chiropractic College in Des Moines, Iowa. After graduation, Matt started his practice in Milwaukee, WI and eventually purchased Land in New Berlin, WI, where he built his home and Chiropractic office.

Together with his friend and Chiropractic colleague, Dr. Dick Klein, they became involved in Wisconsin legislative action as it related to the practice of Chiropractic service, They spent many years traveling to and from Madison to attend Legislative meetings.

When vacationing in Croatia, his parents homeland, Matt became acquainted with several Orthopedic practitioners and surgeons. He was invited to lecture and discuss Chiropractic procedures with this group and, in 1984, was invited to treat Yugoslav athletes during the 1984 Olympics. Regrettably, he was unable to view any of the live Olympics.

Matt became affiliated with the National College of Chiropractic in setting up continuing education courses in the Milwaukee and Southeastern Wisconsin area. Some of the courses included: Orthopedics, radiology, neurology, physical therapy, pain management and clinical diagnostics. He also specialized in independent consultations and impairment evaluations. He became a board member of ChiroCare of Wisconsin, and after retirement in 2000, he continued to remain active in various aspects of

During all his work related activities, Matt took time to enjoy his hunting, traveling and appreciating the “out of doors”. His hunting specialties were raccoon, geese, deer and rabbit. He hosted a few wild game dinners. Doc became involved in the Bob and Rocco Gun shows, eventually becoming a Member of the Board.. It is now the “Take a Kid Hunting Foundation” promoting recreation, hunting and fishing for Wounded/Disabled Military Veterans and Kids with disabilities.

The last few years have seen Doc slow down with mobility problems, but he has continued to remain active, especially with the Gun Shows. Throughout his life he enjoyed family and friends and cherished his Croatian heritage. Doc will be missed by all who knew him.

We would like to give special thanks to the 911 Police Emergency team.

OUR DEEPEST Sympathy

Dr. Jeffery S. Wierichs

August 26, 1956 - June 7, 2024

“When I lay my head on my pillow at night, I ask myself “Did I do good in the world today?” (Dr. Jeff)

The answer to your question unequivocally Dr. Jeff is “YES! YOU did an ABUNDANCE of good in the world today and EVERY SINGLE DAY!”

While Dr. Jeff had kicked cancer’s %$# since 2015, a freak accident at home over Labor Day weekend significantly impaired his physical being. When asked how he was doing he would respond “I’m still in the fight.”

Although he was a warrior, a “force” who optimistically and faithfully fought with dignity and grace, never once complaining, Dr. Jeffery S. Wierichs (LTC (RET) USArmy, passed at the Zablocki VA Hospital after a 9 month complicated, “1 step forward, 2 steps back “ordeal. He left this world with the pride, admiration, love and respect of his family and all who knew him. Jeffery did everything humanly possible to recover, but modern medicine didn’t hold up its end of the deal. Jeffery said “Don’t be sorry for me. I’ve lived a great life and God is in charge. I’m at peace with it and just want my family and those around me to be at peace too.” Still putting others before him until the end.

How does one describe Jeffery’s huge heart, and his large presence which filled a room? You can’t possibly capture it all. Instead, you share an overview of the amazing person he was and trust that those whose lives he positively impacted are changed for the better and will pay it forward and share Jeffery’s legacy so he lives on. We will tell you this: When Jeffery was in a room of people, if you didn’t know him beforehand, you knew who Dr. Jeffery Wierichs was thereafter, because he made you feel like you had known him forever. Jeffery remembered you from that day forward and you too look forward to the day you would see and talk to him again.

Jeffery had a quick and witty sense of humor, was grateful, optimistic, humble, compassionate, selfless, loyal and of unwavering dedicated service to our country, his patients, community, numerous nonprofit organizations and his friends and family. He was an outstanding provider and protector who loved his son Zachary, and his late wife Dr. Sandra Wierichs.

Lieutenant Colonel (LTC) Jeff retired from the US Military after 26 total years of service in both the United States Marine Corps and Army/ Army Reserve. He received multiple awards during his military service including, but not limited to The Army Achievement medal and the Army Commendation medal while serving as an Executive Officer. LTC Jeff’s most coveted military award however is The de Fleury Award for professional excellence in the Engineer Regiment.

After his miliary retirement, to continue in service to his fellow veterans, Jeffery was instrumental in founding the Fox Valley Veterans Council and the AMVETS Post 1212. He also took an active role in the American Legion, PLAV, (Polish Legion American Vets), as he was of

proud Polish decent and the Military Veterans Museum. In addition to his service in veteran organizations, he co-founded the Fox River Lions club with his late big brother Lou. Together they created and organized unique events for fundraising such as the (NCAA) Final Four and (WI) Badger Bash to raise funds for the overall good of the Lions organization which in turn helped others in our community. Jeffery was a longtime supporter of the Greenville Lions and their Catfish Races/Concert Security team during concert festivities. (Although not a member of the Greenville club, they previously recognized his dedicated service with an award) This past year he was asked to introduce the bands during the Catfish Concert kick off. He was honored to do so and even more so when he was able to use the stage to give honor to his son Zachary who was celebrating his 33rd birthday that same day. Jeffery would beam saying he always told Zachary he wanted to throw him a big birthday party and with 10,000 concert goers singing Happy Birthday to his son, Jeffery did just that.

The Fox River Lions annual rose sale was an event Jeffery held near and dear to his heart. He dedicated an incredible amount of time and effort toward its success. One of Jeffery’s most heralded fund raisers, for obvious reasons, was his hosting of The Army/Navy Game fundraising event at the local Legion Club to raise money for Veterans and their families in need. Jeffery was a dedicated servant and relentless Warrior.

While on Active Duty at Fort Leonardwood, Missouri in the United States Army Jeffery also attended National College of Chiropractic in Illinois to pursue his Doctorate of Chiropractic degree before online classes were an option. He was simultaneously dedicated to his full-time military service, full-time chiropractic studies and home life obligations. He would often arise at the crack of dawn to travel 10 hours in a weekend roundtrip to visit his newborn son and wife, his one love Dr. Sandra (Kalies) Wierichs. His perseverance and dedication culminated in yet another achievement and in 1990 Dr. Jeff graduated with honors from National College of Chiropractic, also serving as President of his class and Graduation Speaker. He could add this to his list of educational achievements, which included his Masters of Business Administration degree and also having graduated 2nd in his Army class of Engineers despite having no formal Engineering degree.

Upon his graduation from National College of Chiropractic, Jeffery began Packerland Chiropractic in Green Bay, WI. Because he ideally cared about his patients Dr. Jeff’s practice grew quickly and thrived. Packerland Chiropractic, because of its well known reputation and namesake was even mentioned in an issue of Sports Illustrated when an article about Green Bay and the Packers was published. In later years Jeffery took on an Associate who would subsequently take over Packerland Chiropractic while Jeffery took over Kalies Chiropractic in Brillion, WI.

Read the full Obituary

OUR DEEPEST Sympathy

Dr William"Bill" Haanen

April 10, 1935 - August 2, 2024

On August 2, 2024, the world lost a bright and compassionate soul. Dr. Bill Haanen, a beloved chiropractor whose healing hands and kind heart touched the lives of many, died at the age of 89.

Bill was born in Green Bay on April 10, 1935, to the late Louis and Gertrude (Schnetzer) Haanen. He attended UW-Madison, earned a Doctor of Chiropractic degree from Logan College of Chiropractic in St. Louis, and was certified as a Diplomate of Chiropractic Orthopedists. In 1959, Dr. Haanen established a successful chiropractic clinic in Kaukauna, where he served the community for 46 years. His practice brought him joy, and he loved his patients. Bill was an ardent adventurer who traveled the world. He had a big personality and a competitive nature, and he spread joy by making people laugh with pranks and jokes. Bill loved his family, sports (go Pack!), food, books, and classical music. He continued boating into his 80’s, including daily turtle-spotting canoe trips and tubing behind the pontoon boat.

Bill will be sadly missed by his wife of 41 years, Peggy (Miller) Haanen and his large blended family, including his children: Mike (Ann Galley) Haanen, Shelley (John) Snyder, Julie Gerow, Tom (Karee) Haanen, Mary Fink, Karen Sieler, Krista Haanen, Nicole (David) Schram, Justin Simpson; former spouse Marianne (Haanen) Lechler; sisters and brothers-in-law: Linda (Larry) Mitchell, James (Sally) Miller, Susan Rooyakkers, Vickey (Rob Martzahl) Miller, Jan Vosters, Mary (Renee) Petit, Margie (Kurt Meyer) Bartels, Tom (Julie) Miller, Karla (Scott) Paulan, Kim (Ben) Charles; and numerous nieces, nephews, grandchildren and great-grandchildren. Bill was preceded in death by his parents Louis and Gertrude; father-in-law Jerome Miller; children Catherine and David; grandchildren Danielle and William Beyer; sisters and brothers-in-law Marguerite “Peg” (John) Kitslaar, Joyce (William) Gehr, and Terry (Linda) Miller.

The funeral service for Bill will be held on Monday, August 12, 2024 at 11:00 a.m. at the Verkuilen Van Deurzen Family Funeral Home, 2401 Fieldcrest Dr., Kaukauna. A time of visitation will be held on Sunday, August 11, 2024 from 4:00 until 7:00 p.m. at the funeral home and will continue on Monday morning from 9:00 a.m. until the time of the service at the funeral home. For online condolences please visit www.verkuilenfh.com. In lieu of flowers, the family requests that donations be made to Bristol hospice or the Chute Lake District in Bill's memory.

Every tear is a prism through which I see, a rainbow of emotions and memories, though fate has led you to another place, true moments hold meaning time can never erase.

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Perimenopause and Gut Health: Decoding the Connection

Dr. Rob Silverman, DC, MS, CNS, CCN, CSCS, CKTP, CES, CIISN, DACBN, DCBCN, HKC, FAKTR

Re-published from Chiropractic Economics, published July 5, 2024 | www.chiroeco.com

Gut health during perimenopause (the months and years of a woman’s life leading up to menopause) can be essential to a woman’s ongoing and future health.

Perimenopause usually begins when a woman reaches her mid-40s and ends when she reaches menopause, on average, at age 51.

Hormonal Changes & the Gut Microbiome

Gradually diminishing levels of estrogen are the hallmark of perimenopause. The body also produces less progesterone. During this time, declining ovarian function leads to irregular menstruation and symptoms, such as hot flashes. At the same time, the number of follicles and the number of viable eggs in the ovaries decreases, leading to fewer ovulations. By the time a woman is in her 40s, her estrogen levels become less predictable. Especially in the early years of perimenopause, they may spike higher than normal as the body tries to stimulate ovulation. Later, estrogen levels may drop very low. These hormonal changes result in irregular menstrual periods that eventually stop.1 Perimenopause officially ends a year after a woman has her last menstrual period. On average, this time lasts about four years.

Estrogen Metabolism

The body makes three main types of estrogen: estrone (E1), estradiol (E2) and estriol (E3). Before perimenopause, estradiol, produced primarily in the ovaries, is the most potent form of estrogen and the most abundant in the body. Estriol (E3) is the weakest estrogen; it’s made primarily during pregnancy.

Estrone is made in both the ovaries and in adipose tissue. It’s sometimes called menopause estrogen because it continues to be produced in fat tissue and from endogenous testosterone, even after the ovaries have stopped making it. Higher levels of blood estrogen from estrone after menopause are linked to an increased risk of breast cancer.2

All forms of estrogen are metabolized in the liver. In phase 1, the cytochrome P450 enzyme system converts all forms of estrogen into three possible metabolites: 2-hydroxy estrone (2-OH), 4-hydroxy estrone (4-OH) and 16-hydroxy estrone (16-OH).3

• 2-OH (2-hydroxyestradiol) is the weakest metabolite in terms of estrogenic activity in the body. It blocks more potent estrogens that

promote cell proliferation. Because the stronger estrogens may promote cancer in the breast, ovary or uterus, all tissues high in estrogen receptors, 2-OH is the safest estrogen metabolite. About 80% of estrogen is converted to 2-OH.

• 4-OH (4-hydroxyestradiol) is a much stronger estrogen metabolite. It has been shown to alter DNA, which can promote cancer in estrogensensitive tissues. About 20% of estrogen is converted to 4-OH.

• 16-OH (16-hydroxyestradiol) has also been shown to promote cancer in estrogen-sensitive tissues, particularly in the breast. This metabolite is also associated with inflammation and obesity in perimenopause and menopause. Small amounts of estrogen are converted to this form.

During phase 2 conjugation and detoxification, estrogen metabolites are further transformed through methylation, glucuronidation and sulfation. These processes inactivate estrogen and make the metabolites water-soluble so they can be excreted through the bile into the gut for elimination in the stool. The methylation process activates the beneficial properties of the 2-OH metabolite and decreases the harmful properties of the dangerous 4-OH metabolite.

A healthy estrogen balance favoring the production of 2-OH is vital for a woman’s health. Efficient liver detoxification pathways are needed to influence estrogen metabolism toward 2-OH production and away from 4-OH and 16-OH production.

Gut Health and Estrogen Metabolism

Once the conjugated estrogen metabolites reach the gut, more than half are deconjugated and returned to circulation by the estrobolome bacteria. These are a suite of 60 gut bacteria genera4 that produce the enzyme beta-glucuronidase, which cleaves the conjugated estrogen metabolites and reactivates them. Most deconjugated estrogen is released back into the enterohepatic circulation in biologically active form. The estrobolome helps balance estrogen in the body, regulating the levels during the regular increases and decreases of the menstrual cycle.

At the start of the perimenopause years, estrogen levels naturally fluctuate more between high and low levels. The estrobolome helps even out the estrogen levels during this time, but dysbiosis can disrupt balance and reduce beta-glucuronidase production. This keeps estrogen from recirculating and reduces overall estrogen levels.

continued on page 63

Perimenopause

Many researchers believe dysbiosis affecting the estrobolome plays a role in perimenopausal and menopausal symptoms, such as hot flashes, vaginal dryness, insomnia and emotional disturbances, such as depression. Alterations in the estrobolome may also accelerate osteoporosis.5

Support Estrogen Metabolism in the Liver

Helping the liver metabolize estradiol and estrone more efficiently minimizes the time the OH-4 and OH-16 metabolites spend in circulation, giving them less opportunity to damage estrogen-sensitive tissues. One way to improve the process is by ensuring the liver has plenty of the cofactors needed to conjugate the estrogen metabolites. Essential cofactors for estrogen conjugation include N-acetyl cysteine (NAC), choline, folate and vitamin B12.

To support the methylation and glucuronidation pathways, women in the perimenopause years should consume a high-fiber diet rich in cruciferous vegetables, particularly brassica vegetables, such as broccoli, Brussels sprouts, cabbage, cauliflower, collards, kale and turnips. The brassicas are high in fiber, and fiber alone positively affects estrogen metabolism.6 These vegetables are also high in indoles, including indole-3-carbinol, which help shift estrogen metabolism away from the dangerous forms.7 Brassicas are also an excellent dietary source of diindolylmethane (DIM), a compound shown to affect estrogen metabolism and shift it toward 2-OH production positively.8

Other foods that support estrogen metabolism in the liver include dandelion leaves, rooibos tea, rosemary, curcumin (turmeric) and ellagic acid from berries, pomegranates, grapes and walnuts. Supplements of resveratrol, a phenol found in the skin of grapes, blueberries, raspberries, mulberries and peanuts, can be helpful. Supplements of astaxanthin, a xanthophyll carotenoid found in some kinds of algae and salmon, trout, krill and shrimp, may also help. Isoflavones, such as soy and flaxseed, omega-3 fatty acids and green tea polyphenols, may also help shift estrogen metabolism toward 2-OH.

Aerobic exercise can help reduce high circulating estrogen levels and shift the estrogen pathways in the liver toward a healthier ratio. For example, exercise has improved healthy premenopausal women’s 2-OH/16-OH ratio.9

Accumulated toxins from common drugs, including statins, steroids, some antibiotics, some arthritis drugs, acetaminophen and antifungal drugs, can also slow liver pathways. Alcohol, food additives and environmental toxins (pesticides, agricultural chemicals, household chemicals, personal care products and many other sources) can also slow the estrogen metabolism pathways by competing for the same detoxification enzymes.

Support Estrogen Metabolism in the Gut

During the perimenopause years, decreasing estrogen and progesterone gradually reduce the diversity of the gut microbiome. The microbiome composition starts to become similar to that of a man of the same age. Because beneficial bacteria thrive in environments with estrogen, declining hormone levels mean the microbiome community may shift toward containing more harmful bacteria.

The decline in estrogen and progesterone and the associated shift in the gut microbiome composition may lead to increased gut barrier permeability, allowing microbial translocation. This may be an underlying cause of the increased frequency of bacterial vaginosis, yeast infections and urinary tract infections during the perimenopausal years.

Continuing a diet with the same food components that lead to a healthy gut microbiome will help modulate the natural shift in the gut microbiome and support gut barrier integrity. It will also lead to a healthy estrobolome and safer circulating estrogen levels.

Fiber is essential for gut health and supporting the microbiome. Many studies suggest dietary fiber may be even more important for the estrobolome bacteria than the overall microbiota.10 Similarly, higher fiber intake may naturally lower estrogen levels, particularly estrone levels, in postmenopausal women by as much as 47%.11

Adding prebiotic dietary fiber provides the most support for the estrobolome bacteria. Good dietary sources of prebiotic fiber include almonds, bananas, beans, whole grains, oats, flaxseed, peas, artichokes, soy foods, leafy greens and cabbage. These foods are all high in inulin, a prebiotic soluble fiber. Inulin supplements can help increase prebiotic intake.

Phytoestrogens are plant nutrients found in many foods, including soy products, whole grains, beans and some fruits and vegetables. These phenolic compounds, including isoflavones and lignans,12 are structurally similar to estrogen and can bind to estrogen receptors throughout the body, mimicking the effects of estrogen. By blocking estrogen metabolites from estrogen-sensitive tissues, phytoestrogens may help prevent some cancers.

The efficacy of phytoestrogens for relieving perimenopause and menopause symptoms has been extensively studied. Overall, the research finds a plant-based approach is helpful for mild to moderate symptoms.13

Some women find a diet high in phytoestrogens, especially lignans, helps relieve perimenopause symptoms, such as hot flashes. Good phytoestrogen food choices include beans and legumes, soy foods (tofu, soy milk, soy protein powder), flaxseed, oats, pears, broccoli and carrots. Foods rich in lignans include flaxseeds (the most concentrated dietary source), cashew nuts, vegetables and fruits, legumes and whole grains.14 Dark chocolate contains phytoestrogen compounds in the form of catechins. All these foods are also high in prebiotic fiber that support the estrobolome and the rest of the gut microbiome.

Perimenopause - Cont. from page 63

Phytoestrogens in supplement form are usually sourced from soy, red clover, flaxseed and hops. Soy and red clover supplements contain large amounts of the isoflavones genistein and daidzein, which may have estrogen-like effects. Vitamin D, DHEA and garlic oil supplements also help support estrogen.

Constipation is a common problem that can develop in the perimenopause years. It’s partly caused by decreased estrogen and progesterone, which can slow down the passage of food through the digestive system and cause more water reabsorptions, leading to constipation.

The perimenopausal years are also when many women start needing medication for health issues, such as high blood pressure and low thyroid function. Some of these drugs, such as calcium channel blockers for hypertension, can cause constipation.

An additional factor is the natural weakening of the pelvic floor muscles, which comes from childbearing and simply from age. Weakened pelvic floor muscles make passing stool more difficult.

Increasing fiber and fluid intake is essential to help relieve frequent constipation during this time. Plain water or water with lemon is a good, simple choice. Drinking coffee can help; aloe vera juice is also helpful. Increasing physical activity helps increase colon activity and strengthens pelvic and abdominal muscles. If the pelvic floor muscles are weak, exercises designed to improve bowel function can be beneficial.

Heal the Gut

A healthy gut microbiome is vital for efficient estrogen metabolism. If the gut wall is damaged and has increased permeability, conjugated estrogens can escape into the circulation before the estrobolome can recycle them. In addition, decreasing estrogen levels cause changes in the composition of the gut microbiome associated with weight gain in the perimenopause and menopause years.15 In addition, estrogen-related microbiome changes are related to metabolic syndrome, non-alcoholic fatty liver disease (NAFLD), osteoporosis and coronary artery disease.16

To help make sure the gut microbiome is balanced and reduce gut permeability, I recommend following my Super 7(R) Action Plan:

1. Reset diet/lifestyle/mindset

2. Remove triggers, such as food sensitivities and pathogens

3. Replace digestive enzymes and stomach acid

4. Regenerate damaged intestinal mucosa

5. Re-inoculate with quality pre- and probiotics

6. Reintroduce certain foods removed in step 2

7. Retain your health and GI integrity

The recently introduced supplement BPC 157 can be beneficial for treating leaky gut syndrome. This peptide, found naturally in gastric secretions, helps regenerate cells in the intestinal walls and helps seal up damaged areas. It also helps stabilize the microbiome and helps treat dysbiosis.17

Final thoughts

In wrapping up our exploration of the nuanced relationship between perimenopause and gut health, it’s clear this is a dynamic and complex interaction with significant implications for women’s health. The shifts in gut microbiota composition and function during perimenopause underscore the physiological changes women experience and highlight the connection between gut health and prevalent symptoms, from mood swings to weight shifts. Most natural changes during the perimenopause transitional time can be efficiently and effectively managed by maintaining a healthy lifestyle and a healthy gut.

Understanding the bidirectional nature of this relationship holds the key to unlocking targeted, effective interventions that can support women through perimenopause.

Robert G. Silverman, DC, DACBN, DCBCN, MS, CCN, CNS, CSCS, CIISN, CKTP, CES, HKC, FAKTR, is a doctor of chiropractic, clinical nutritionist, national/international speaker, author of Amazon’s #1 bestseller Inside-Out Health and founder and CEO of Westchester Integrative Health Center. He graduated magna cum laude from the University of Bridgeport College of Chiropractic and has a master’s degree in human nutrition. The American Chiropractic Association Sports Council named Silverman Sports Chiropractor of the Year in 2015. He is on the advisory board for Functional Medicine University and is a seasoned health and wellness expert on the speaking circuits and in the media. A thought leader in his field and practice, he is a frequently published author in peer-reviewed journals and other mainstream publications and was the principal investigator in two Level 1 FDA laser studies. His book, Amazon best-seller Immune Reboot, was released in December 2022. For more information, visit drrobertsilverman.com

For a complete list of article references, click here.

At Foot Levelers, our support extends to your business health. From the latest technology, to top-notch educational materials, to live workshops run by pros, we’re here to help you build a successful practice every step of the way.

Buying or Selling a Practice?

Current Wisconsin Practices For Sale

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Contact Loren Martin www.practiceop.com

Phone: (952) 322-1177 www.practiceop.com

Email: martin@practiceop.com

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WINDING DOWN?

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BUYING OR SELLING A CHIROPRACTIC PRACTICE?

Current Wisconsin Practices for Sale:

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Bauer Chiropractic is an efficient and growing practice serving the Fond du Lac area for over 26 years. Current associate doctor is retiring, and new doctor will take over and continue to grow that patient base. We offer traditional chiropractic care which includes a team of certified chiro techs working alongside the doctors to provide the optimal patient experience. Competitive base salary plus bonuses based on performance. 401K, paid holiday/vacation & profit sharing. Potential health insurance. If you strive for personal & professional growth and are looking for a long-term opportunity, e-mail your resume to: drbauer@bauerchirofdl.com

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At the Howard Chiropractic Clinic, we are committed to providing our patients with skilled and reliable treatment while offering unparalleled customer service. Our State-of-the-Art Clinic currently has a Full or Part-Time Associate position available. Associate would have full access to the use of Physiotherapy and X-Ray. Chiropractic License Required. Salary and benefits are negotiable. If interested, please Email: drdjk@ hccgb.com

ASSOCIATE WANTED – WESTFIELD, WI

Opportunity for ambitious, up-beat, full-time Doctor to join our clinic in central Wisconsin. Well established family-based wellness practice with opportunity for future partnership potential. Looking for caring, self-motivated, energetic, and ethical doctor. EMR and electronic billing in state-of-art modern staffed facility. Digital x-rays and multiple physiotherapies. Activator certification, diversified, and drop piece adjusting skills preferred. Nutrition certification recommended.

Salary based on collections with opportunity to earn a very competitive income. Benefits include retirement, insurance, group practice, and continuing education.

Please submit your resume to: westfieldchiros@hotmail.com

ASSOCIATE WANTED - WAUWATOSA, WI

Front Runner Chiropractic is currently seeking a Full-Time associate chiropractor in the amazing Village of Wauwatosa. We utilize Active Release Techniques (will get you certified if needed) & high-tech therapies such as Shockwave Therapy. This position offers the opportunity to work in a dynamic, patient-centered environment focused on providing top-notch care to athletes, active individuals, and families. Prior experience is preferred by not required.

• Starting Pay: $70k+ OR Competitive Percentage Based Pay and negotiable benefits.

• Send CV & Resume to Dr. Beth Ringwelski: hello@ frontrunnerchiro.com

PRACTICE FOR SALE - DODGEVILLE, WI

Semi-retired, doctor owned, 1320 sq ft building with 4 treatment rooms - open to selling building or renting. Currently half of patient volume is maintenance cash patients. 85K receipts the past 12 months. Integrated techniques mostly with a mix of manual adjusting and the use of drop pieces and therapeutic exercises. Also, low-level laser, ultrasound and electrical stimulation used for treating acute pain. Asking $42,500 for practice. Text or Call: 608-553-3540 for more information

Equipment available for purchase:

• Zenith 440 Hi-Lo table w/ pneumatic drops & quiet air compressor

• Barnes Flexion-distraction table

ASSOCIATE WANTED - SOUTH CENTRAL, WI

Join a phenomenal team with over 40 years serving in a rural community located in the Johnson Creek area - we are expanding! Seeking a professional willing to learn techniques and contribute their own. Practice honestly. Compensation is a base salary with a percentage of collections. Provider for most insurances. Excellent opportunity to transition into ownership in a few years. I will do a lot to make this a great relationship. We strive to give each patient their personal best, complete adjustment. Patients and team members are encouraged to thrive. Please email resumes and inquiries to: southcentralwichiro@ gmail.com

SUPPORTS DISC AND CONNECTIVE TISSUE HEALTH

• A SPECIAL BLEND OF INGREDIENTS DESIGNED TO NATURALLY REDUCE INFLAMMATION

• PROMOTES THE PRODUCTION OF COLLAGEN

• SUPPORTS THE REBUILDING OF CARTILAGE

PRACTICE FOR SALE - MONROE, WI

Busy family practice for sale located in historic Monroe WI. This practice has served the town of Monroe and many surrounding communities for 34 years. Included in sale are three zenith hi-lo's, digital xrays, cervical and lumbar decompression, knee decompression, flexion/distraction, interferential, ultrasound, digital notes and much more. Must sell. Please contact: 608-558-8355 for more information.

OFFICE SHARING / PRACTICE BUYOUT OPPORTUNITY

Well established chiropractic office located in Fond du Lac has an office sharing opportunity for a self-motivated doctor to establish and build their independent practice. Current doctor is beginning to explore / implement their retirement path / exit strategy. I am NOT looking for an associate doctor / employee - my goal is to find a self-motivated doctor (or doctors) to establish themselves and absorb my practice when I retire in the next 3-5 years.

The office is a 3200 sq. ft. business condo located on one of the busiest thoroughfares in Fond du Lac. The office is fully furnished and equipped – including digital x-ray system as well as practice management & clinical documentation software. There is a large parking lot with ample spots for patient and staff parking. Signage for your practice on the building exterior as well as in a large lighted sign bank near the road.

All of the above plus limited staff support for billing and patient scheduling included for a monthly rent. This is a great opportunity to develop and grow your practice without the costs or burden of establishing your own office space. For more details, seriously

Dr. Jeff Walters - Preferred Chiropractic

OFFICE SPACE AVAILABLE - MILWAUKEE, WI

Office space available for an independent contractor or an office share for an experienced chiropractor. I am ready to reduce my practice after 42 years of practice in a well-respected clinic. The clinic is located in the Bayview neighborhood of Milwaukee. My goal is to find someone to join me in my low tech, client centered office. An option to purchase in the future is also available. Serious inquiries only. Multiple Contact

EQUIPMENT FOR SALE - KENOSHA, WI

Zenith HYLO Table w/ drops. ** In Great Condition - Recently reupholstered w/ black Naugahyde ** 71" L x 22" W x 23" H, Holds 8.5" x 125" face paper roll, No

Zenith Cox Table ** In Great Condition - Recently reupholstered w/ black Naugahyde ** - 73" L x 23" W, Holds 12" x 125" face paper roll, No mechanical issues, Asking $3,000

Contact Lockhart Chiropractic if interested: View Photos. lockhartchiropractic.kenosha@gmail.com | 262-657-8434

ASSOCIATE WANTED - APPLETON, WI

** Wagner Family Chiropractic **

We are looking for a motivated chiropractor interested in helping patients of all ages in the Fox Cities. We are a fast-paced clinic that has been helping patients for 20 years. Join 3 other compassionate doctors in helping others with high-quality chiropractic care. The position includes base plus generous bonus, PTO, 401K, paid malpractice/CEU and health insurance. Please call Dr. Jody or Dr. Mike as we want to hear from you! Text or Call at: 920-209-9137 OR Email your resume to: resume@wagnerchiropractic.net

JOIN OUR TEAM AT THE CENTER FOR HUMAN RESTORATION IN CRANDON, WI

Established in 2010 by Dr. Laura Connor, The Center for Human Restoration is dedicated to uncovering the root causes of illness. We are currently seeking an associate DC who prioritizes patient care over numbers and views their chiropractic techniques as an artform capable of deep healing. Our clinic is nestled in the serene Northwoods of Wisconsin and is flourishing. This opportunity is ideal for those seeking a slower-paced practice with a focus on holistic health and patient-centered care. Please send your Resume to: laura@ connorrestoration.com

PRACTICE FOR SALE - ADAMS, WI

Practice for Sale by sole proprietor. Close to Northern Bay Condominiums/Golf Resort, Sand Valley Golf Resort, and the Wisconsin Dells. Located in the city of Adams. This area has a great school district, small-town feel for raising a family, and local hospital to partner with for PT and X-Rays. 29-year established family referral practice. Balanced mix cash and insurance. Clinic is fully furnished in a great location with good visibility within a professional building with low overhead. Great for someone starting out that wants to have their own practice. Doctor is retiring. Asking $50,000. Click here to view clinic photos

Contact Information if interested, drslea@yahoo.com Cell #: 608-548-1277 | Clinic #: 608-339-9225

CLINIC WANTED FOR PURCHASE - GREATER MILWAUKEE AREA

Chiropractic Company is currently looking to purchase a clinic in the Greater Milwaukee area. If you have interest in selling, a merger or are contemplating retirement and need an exit strategy: Please contact Kent McLeod at 414-213-4808 or drmcleod@chiropracticco.com or visit chiropracticbuyers.com for additional information.

ASSOCIATE WANTED - GREATER MILWAUKEE AREA

Chiropractic Company is a rapidly expanding group of clinics in the greater Milwaukee area, and we are currently looking for associate doctors. We are unique in the profession in that doctors have the opportunity to advance from associate to clinic director, to shareholder in the corporation all based on their personal performance.

In addition to a salary and bonus structure we also offer health

insurance, short term and long-term disability insurance, and a matching 401k plan. Continuing education, chiropractic coaching, 50% off a gym membership, license, CPR training, and malpractice insurance are also covered benefits of working with the Chiropractic Company.

For more information go to: www.chiropracticco.com/careers OR Email: drmcleod@chiropracticco.com

NOW HIRING MULTIPLE ASSOCIATE POSITIONSNORTHEAST WISCONSIN

Associate DC position(s) available in an award-winning practice based out of Northeast Wisconsin. Ability to potentially run your own practice someday if you are the right candidate. Starting pay range is $70,000 - $150,000, company paid malpractice insurance and continuing education after 2 years, $5000 Student Loan forgiveness every 5 years, IRA match, health insurance reimbursement, PTO, and paid maternity/ paternity leave.

• Job Type: Full-time

• Pay: $70,000 - $150,000 per year

• Benefits: Employee Discount, Health Insurance, PTO, Professional Development assistance, Retirement Plan, and Tuition reimbursement.

*** If you're someone motivated and willing to grow with a passion for chiropractic; please apply! *** https://www.thechiroadvantage.com/ https://www.linzmeierchiropracticsc.com/ Email: drbuss@thechiroadvantage.com

References: Introduction to Collagen Peptides -

Cont. from page 5

References

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2. Khatri M, Naughton RJ, Clifford T, Harper LD, Corr L. The effects of collagen peptide supplementation on body composition, collagen synthesis, and recovery from joint injury and exercise: a systematic review. Amino Acids. 2021;53(10):1493. doi:10.1007/s00726-02103072-x

3. León-López A, Morales-Peñaloza A, Martínez-Juárez VM, Vargas-Torres A, Zeugolis DI, Aguirre-Álvarez G. Hydrolyzed collagen — sources and applications. Molecules. 2019;24(22). doi:10.3390/molecules24224031

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5. Wallace JD, Cuneo RC, Lundberg PA, et al. Responses of markers of bone and collagen turnover to exercise, growth hormone (GH) administration, and GH withdrawal in trained adult males. J Clin Endocrinol Metab. 2000;85(1):124133. doi:10.1210/jcem.85.1.6262

6. Holwerda AM, van Loon LJC. The impact of collagen protein ingestion on musculoskeletal connective tissue remodeling: a narrative review. Nutr Rev. 2022;80(6):1497-1514. doi:10.1093/nutrit/ nuab083

7. Paul C, Leser S, Oesser S. Significant amounts of functional collagen peptides can be incorporated in the diet while maintaining indispensable amino acid balance. Nutrients. 2019;11(5):1079. doi:10.3390/nu11051079

8. Bala Y, Seeman E. Bone’s material constituents and their contribution to bone strength in health, disease, and treatment. Calcif Tissue Int. 2015;97(3):308-326. doi:10.1007/s00223-0159971-y

9. Daneault A, Prawitt J, Fabien Soulé V, Coxam V, Wittrant Y. Biological effect of hydrolyzed collagen on bone metabolism. Crit Rev Food Sci Nutr. 2017;57(9):1922-1937. doi:10.1080/10408398.

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11. Liu J, Zhang B, Song S, et al. Bovine collagen peptides compounds promote the proliferation and differentiation of MC3T3-E1 pre-osteoblasts. PLoS One. 2014;9(6):e99920. doi:10.1371/journal.pone.0099920

12. Kim HK, Kim MG, Leem KH. Osteogenic activity of collagen peptide via ERK/MAPK pathway mediated boosting of collagen synthesis and its therapeutic efficacy in osteoporotic bone by backscattered electron imaging and microarchitecture analysis. Molecules. 2013;18(12):15474-15489. doi:10.3390/molecules181215474

13. König D, Oesser S, Scharla S, Zdzieblik D, Gollhofer A. Specific collagen peptides improve bone mineral density and bone markers in postmenopausal women — a randomized controlled study. Nutrients. 2018;10(1):97. doi:10.3390/nu10010097

14. Zdzieblik D, Oesser S, König D. Specific bioactive collagen peptides in osteopenia and osteoporosis: long-term observation in postmenopausal women. J Bone Metab. 2021;28(3):207-213. doi:10.11005/ jbm.2021.28.3.207

15. Zdzieblik D, Oesser S, Baumstark MW, Gollhofer A, König D. Collagen peptide supplementation in combination with resistance training improves body composition and increases muscle strength in elderly sarcopenic men: a randomised controlled trial. Br J Nutr. 2015;114(8):1237-1245. doi:10.1017/ S0007114515002810

16. Zdzieblik D, Jendricke P, Oesser S, Gollhofer A, König D. The influence of specific bioactive collagen peptides on body composition and muscle strength in middle-aged, untrained men: a randomized controlled trial. Int J Environ Res Public Health. 2021;18(9):4837. doi:10.3390/ ijerph18094837

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19. Centner C, Jerger S, Mallard A, et al. Supplementation of specific collagen peptides following high-load resistance exercise upregulates gene expression in pathways involved in skeletal muscle signal transduction. Front Physiol. 2022;13:838004. doi:10.3389/fphys.2022.838004

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23. Dressler P, Gehring D, Zdzieblik D, Oesser S, Gollhofer A, König D. Improvement of functional ankle properties following supplementation with specific collagen peptides in athletes with chronic ankle instability. J Sports Sci Med. 2018;17(2):298304.

24. Zdzieblik D, Oesser S, Gollhofer A, König D. Improvement of activity-related knee joint discomfort following supplementation of specific collagen peptides. Appl Physiol Nutr Metab. 2017;42(6):588-595. doi:10.1139/apnm-2016-0390

25. Zdzieblik D, Brame J, Oesser S, Gollhofer A, König D. The influence of specific bioactive collagen peptides on knee joint discomfort in young physically active adults: a randomized controlled trial. Nutrients. 2021;13(2):523. doi:10.3390/nu13020523

YOUR PARTNER IN HEALTH

BayCare Clinic is a physician-owned specialty care clinic headquartered in Green Bay, Wisconsin.

We pride ourselves on our commitment to excellence and our collaborative approach to care for patients throughout the region.

To best serve WCA members, BayCare Clinic offers an Online Referral Portal which allows providers to seamlessly send referral or consultation requests to the BayCare Clinic specialists of your choice.

The site is secure, allowing you to add medical information about a specific patient and send images with confidence.

BayCare Clinic is committed to this dual care process and will maintain strong communication with each WCA member until your patient returns to your care.