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Treatment Considerations for Myofascial Trigger Points

 

 

So we’re gonna be discussing some treatment considerations for myofascial trigger points, how to incorporate them into the treatment, a little bit of comparison between those and motor points.

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Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

Hello. Thanks for joining us everyone. And thanks to American Acupuncture Council for having us back. I say us, but Matt Callison is not joining us today. So it’s just me and our guest, Joe Bickle, Joseph Bickle, and I’ll introduce him in a second. Sorry, Matt’s not here. He had a little incident with food poisoning, so he will feel better soon, hopefully.

But didn’t really feel up to being in on the webinar today. So we’re gonna be discussing some treatment considerations for myofascial trigger points, how to incorporate ’em into the treatment, a little bit of comparison between those and motor points. So it’ll be a really nice discussion that Joe and myself have.

So let me introduce Joseph Bickle. He is graduate of the SMAC program, Sports Medicine Acupuncture certification. So he’s a C.SMA. He also took classes as I did in Myo pain which goes through some various trigger point protocols. I haven’t taken all the classes. Joe did take all the classes, so he certified through Myop pain.

So we’ll have a little common language we can discuss and maybe talk a little bit about that training also. Joe, do you wanna give any background of how you, we can get more into specifics in a bit, but how you incorporate or what you do and where you work and Yeah. So I work primarily in two different locations in Minneapolis, St.

Paul area. I work as part of an outpatient program attached to the Allina Health and Abbott Northwestern. And then I also do supervise at the local school Northwestern Health Sciences, their human performance center, where we focus primarily on treating athletic conditions. Obviously treating there.

But my patient population tends to be more of the chronic pain and or chronic orthopedic conditions throug

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h the Allina Health System. Great. All right. So we’ll jump right into the discussion. We’ll start with a PowerPoint. We’re not gonna have a PowerPoint for the whole whole webinar. But we wanted to start with just a little brief discussion on A comparison of motor points and trigger points.

These are not such a black and white, easy comparison to make cuz there’s a lot of crossover. And on top of that, there’s a lot of discrepancy on how people describe a lot of these things. So they’re not even always clear delineations between the two. But just since a lot of people use motor points, a lot of people use trigger points, some people use both.

It’s nice to of get a little. Into the the different slash similarity comparison. So let’s go to the first slide. Gimme just a second.

All right. There we go. Sorry about that. So we’ll start, like I said, this comparison, but then once we get through the. The PowerPoint, we’ll start talking about some key kind of areas referral patterns, a little bit about how to assess for trigger points, including them into the treatment. And then one of the main things we wanna talk about today is is dosage.

So how much stimulation do you give? Are you looking for a ation, the duration of treatment? So I know I’ve had a problem and I talked to Joe about this. Sometimes I’ve overtreated people and they come back and, Oh, they were so sore, And it’s little soreness is one thing but you can definitely overtreat.

So being able to judge how much that person can tolerate is really important. And I know all of us know that from Chinese medicine, but looking at it from this little more my myofascial stimulation is really an important topic. Let’s go into this. Joe, if you have anything to add, we’ll just talk about it, but we’ll just get through these like early slides to start off with.

Anything to add to that now or we’ll get, I guess we’ll probably getting into it as we go. Yeah, I just guess would just like to emphasize that it really, it can get a little confusing motor points versus trigger points. And so for anyone listening who has feel that way, you’re in good company.

Yeah. Excellent. So what is a, let’s start with a motor point. I’m gonna use the term motor entry point. So motor points are described not consistently inco inconsistent descriptions of. A lot of the more precise language is using motor entry points, cuz this specifically tells you it’s where the motor nerve enters or penetrates the muscle.

So what you’re seeing in this image here is a picture of the flexor carpials. So what’s being held there with the gloved hand is the ulnar nerve, which is traversing down the for. But then you see that little collateral branch that the hemostats are pointing to. That, that collateral branch is going entering right into the flexor carpials.

That’s gonna be about a third. If you drew a line from heart from s si eight to heart seven, and made that line divided in thirds, that’s gonna be the proximal and middle third junction. Thereabouts. It’s slight variability on pe, person to person, but it’s pretty consistent. It’s a pretty consistent location.

So that’s gonna be the motor entry point, and we’ll talk about other terminology here in a second. So not really all always agreed upon, but that’s the definition that I like and that I wanna use and that we tend to use in the sports medicine and acupuncture program. Whoops, let’s get. All right, so once the motor nerve enters the muscle though, then it bifurcates and sends branches out, usually approximately in distally, and those branches terminate somewhere in the muscle and some languages some descriptions.

If you look at research, we’ll talk about those as being intramuscular motor points, so areas where the motor nerve after it bifurcates and travels for. Depending on the muscle and the person and all that, it’s gonna D terminate at that intramuscular motor point. So that’s a motor point also. But that would be an intramuscular motor point versus the motor entry point.

So in this image, if you can look somewhere in the center, this is the hamstrings. Somewhere in the center you’ll see me P. That’s the motor entry point. That’s where the sciatic nerve sends off. A branch enters the muscle, penetrates in the muscle. Then dlp, plp, I forget what those stand for.

Proximal and dis. But basically they’re talking about the termination place within the those branches that go distally and proximally and then terminate at the intramuscular motor point. So that’s something that we can talk about and maybe from there, make a comparison to trigger points. And Joe, I don’t know if you wanna jump in here and add any thoughts to this.

Yeah, I think that’s, that sums it up pretty well as far as the main differences that I’ve seen and that I work with where the motor point is, motor entry point tends to be a lot more predictable. Like you were saying, how you’re mapping out the flexi, carpal nas whereas the end plates can be a little bit less predictable and therefore more palpation based.

But otherwise I would agree. So would you say, and this is the way I see it trigger point. When we define a trigger point here in a second, trigger points can exist anywhere in the muscle. So this is showing the biceps for Morris Longhead motor entry points somewhere in the center. The muscle, it’s pretty close to UV 37, just lateral to UV 37.

There’s another one too, the couple different motor entry points, but this is the main one. And then those junctions that send out intra muscularity and terminate at where it says PLP and dlp. Those would be the area where there’s motor in plates where there’s receptors for acetylcholine.

That’s the neuromuscular junction. You can describe it in structure. You describe it in function. That’s where the discrepancy between neuromuscular junction and motor in plates comes in. But in trigger point language, they mention that trigger points tend to form at the highest concentration of motor implants.

So in my mind, that would be at these intramuscular motor points, even though they don’t have these mapped. I don’t know how variability, how much variability it is. Maybe someday there’ll be all these maps that say, Oh, okay, here’s where the distal intramuscular motor point is of the biceps, or more.

I doubt it. It’s probably much more variable than that. But this would be the relationship in my mind is there’s the motor entry point where the muscle, where the motor nerve enters the muscle and then the intramuscular motor points that terminate somewhere that’s probably less predictable in each.

And those would be sites where the trigger points tend to form. They could also form really at the motor entry point. It could form anywhere in the muscle, but those are gonna be the key areas. Yeah, I would definitely agree. It definitely seems like there is some predictability to those, to the end plates.

, but I don’t, obviously I’m, I would assume things like activity, how athletic the person is, their movement patterns would have an impact on those locations. So Yes. Yeah, I would. It is interesting that you mentioned predictability cuz for those who used trigger points and have looked at Janet Trevell and David Simon’s book Myofascial Pain and Dysfunction Trigger Point Manual.

In her early additions, up until just recently into the recent edition, she had Xs not because they were definitive locations for trigger points, she made it clear that they could exist anywhere in the muscle, but she had Xs just clinically being a very skilled palpate and c. Of areas where you tend to find trigger points, it tends to form here in the muscle.

The kind of go-to areas that that wasn’t trying to imply that they would always be there, but they were go-to based on clinical experience and just seeing a whole ton of patients. In the recent addition of that, they took those x’s out, which I don’t know, I could see an argument for it.

Cause you have to palpate all through the muscle and. But I kinda like the X’s. I don’t know. . How do you feel about that, Joe? I see two sides to that argument. I actually like them not there because it does force the practitioner to palpate , as opposed to one, I think one thing acupuncture specifically can fall into a trap on is they’re used to that precise location.

Tell me the measurements and then I can find. And they can lose that ability to palpate exactly what they’re feeling for. Yeah, for sure. And that’s, I think the reason, not for acupuncturists per se, but that’s the reason they weren’t taken out. Yeah. But yeah, as I understand that is why yeah.

If you do work with trigger points a lot that you will find that they tend to be not, I wouldn’t say predictable. Yeah. It tends to be go-to areas. You tend to find some consistency. But, that’s the trap. You’re right. Is. Can then start to force yourself to think, there should be a trigger point here cuz the pain referral or whatever.

And you don’t palpate carefully and end up missing something that if you were to be more open minded, open, open possibility about it, I think you would just not get Huang up on trying to force it into that location. Yeah. All right, so then motor entry points, intramuscular motor points.

Trigger point is a hyper irritable spot in skeletal muscles associated with hypersensitive, palpable nodules and a taught band. So when you’re palpating for a trigger point, we can talk about what that refers to. The spot is painful on compression and can give rise to characteristic referral, pain referred tenderness, motor dysfunction, and autonomic phenomena.

So that’s the definition from Trave and Simon’s book. And it’s a mouthful in and of. . But that tells you that there’s a hypersensitive, palpable nodule there. So whereas a motor point is, or especially motor entry point is an anatomical thing, you have that, whether there’s dysfunction in the muscle or no dysfunction.

It’s there. It’s, it might be slightly there, variable from person to person, but it’s in a relatively consistent location that the muscle’s in dysfunction, the motor point’s there. If the muscle’s healthy, the motor point’s there. It’s just part of your anatomy. Whereas trigger points are talking more specifically about dysfunction, they could form at a motor entry point.

They could form at the intramuscular motor points, They could form somewhere else in the muscle, probably most likely at the intramuscular motor points. But they’re they’re a sign of dysfunction where there’s hyper irritability and there’s characteristic referral patterns and other phenomena that you see with it.

Good. Joe, I’m gonna move on unless you wanna add something to that. No, I think that summed it up pretty well. All right, so we’ll come back to this we’ll take the PowerPoint away for now. We’re gonna come back to this when we use an example later and discuss the Quadra Lium. But just glancing at it for now, you can see these characteristic referral patterns that are mapped out when you’re looking at these referral patterns.

You. If you don’t know the mapping, there’s something that you wanna know about ’em is that dark red doesn’t indicate more intensity of pain. The dark red indicates more of the Tendency of where those muscles refer to. And this one is from an old edition. It has the X’s in there. Modern ones don’t have the newer edition doesn’t have that X, but don’t worry about that so much.

But that characteristic darker red area is where you’re gonna more commonly see that referral. And then there’s the spillover, speckly red that could be just as severe pain at those spillover areas, but they’re less frequent, less frequently gonna be experienced there. So that’s what the mapping is.

So let’s bring the PowerPoint away and we can come back to that in a. All right, so exit this out so I can see Joe. There we go. Good. So we talked a little bit about that difference between motor points and trigger points. So let’s look at how you would incorporate, if you’re using motor points, how you would incorporate trigger points in or even if you’re not using trigger points.

How would you incorporate, what would you be doing? What would lead you to think trigger points and how would you make that a part of your treatment? Sure. Just looking at the mapping that Traves done, I think. L thinking about it from someone who is new to orthopedics or new, certainly new to trigger points.

I think that’s your first go to is based on patient symptom presentation. And then that’s gonna narrow it down. So if we’re looking at the QL as an example, it’s lighting up parts of the hip, parts of the si. There are gonna be multiple muscles that do but it does give you a way of zooming in relatively quickly to Alright, I’m gonna start thinking about glutes.

I’m gonna start thinking about ql. And then you can also, if you’re more orthopedically inclined, you can start thinking about. The spine and other things as well. So that’s a good first step. I think a good second step would be reading some of the traves information. She gives a lot of more specific symptom presentation and as well as other ways to incorporate.

So talking about the relationship between glued trigger points and their effect on QL as well. And. Another good way of starting would be active and passive ranges of motion. I know when I first started of getting into this, that was a very nice, like just memorize how the body can move and then have a patient see what they can and cannot do and incorporate that into a pre and post exam.

And then lastly, I’d. What I’ve been talking about before, help patient, the more you can get a feel for the tissue, it’s gonna lead you in a direction. . Yeah. This is the trick with those who use motor points. The trick cuz there is crossover cuz in sports medicine, acupuncture in the certification program we tend to use more discussion of motor points and we use a lot of the same thing, range of motion.

Looking at muscle inhibition, that could be something. I know trave talks about muscles becoming inhibited when there’s trigger point formation in there, so there’s definitely a lot of crossover. Yeah, in the sense that, if somebody has limited range of motion in the upper trapezus, for instance, so I go with the motor point, or do I go with the trigger point?

What’s my. What’s what’s going to be the thing that leads me to one or the other. And they can be the same thing cuz the trigger point might form at the motor entry point location. But let’s assume it’s a little off the motor entry point location. Which one do I use? So what’s your way of differentiating those, even though there is so much crossover?

What’s your way of differentiating those usage? Sure. I guess I tend to look at it and especially this is gonna. Feed off of my smack background, but motor points tend to, or I use them more so for global aspects of treatment. So looking at the posture, like if we’re talking about bet trapezius, upper cross syndrome, know, I’m definitely gonna be thinking more motor entry point.

Whereas if the patient’s coming in for. That temporal rams horn headache I’m gonna be specifically thinking, All right, I need to feel the upper trapezius, find some trigger points in that region or not advanced that, that are almost recreating those symptoms. That’s a good bet.

If you’re finding a 10 point that’s saying, Oh, wow, yeah, that, that goes right to where my, I typically have a headache. , That’s why I’ll tend to lean in on treating the trigger point specifically over the motor point. Yeah, I gotcha. Let me say it. Tell me this is because I, this is what I heard, and this is how I think about it too.

But let’s use back to the Upper cross syndrome patients coming in with headache neck pain, maybe cervical type headaches, tension headaches that are coming up the cervical spine, and then radiating along the gallbladder channel to the temple. So knowing the trigger point referrals, upper traps would be one of the key structures that I’d wanna look at for that.

However, they have upper curl syndrome. So once I’ve diagnosed and assessed that, that posture and I can see that posture’s part of that pain pattern, I could choose motor points such as the OIDs, lower traps to help re return some. Awareness to that area so that the person’s able to engage them, especially if I give ’em some exercises afterwards to help engage that.

I might include Peck minor as a way to let that peck minor soften. It’s not what’s causing the pain, it’s not the direct cause of the pain, but it’s part of that that postural symptomology and then the upper trap sugar point to speak almost directly to that pain referral. Yeah. Yeah, I definitely consider it like trigger points to be like the branch treatment of to use a Chinese medicine term, the branch treatment of kind of assessing those like postural and mobility issues where the trigger point itself is a symptom of what, what’s going on underneath.

But it still needs to be treated, and Thank you. So you’re incorporating, I need. This trigger point, this exact one part of the region of that muscle. But I also need to balance that with motor entry points to create a more global effect. , I know. And leading up to this webinar on Facebook there was a question about needling motor points.

Will that release the trigger point or will that have a clinical effect on the trigger point? So should there be, and I think this is gonna be very opinionated by the way, but should there. If you find that trigger point in the upper traps, should I needle the motor point, assuming the trigger points at a different location?

Should I needle the motor point to release that trigger point in the upper traps or should I go right to the trigger point? Sure. Any thoughts on that? I think this would actually this would lead into our conversation about dosage because needling into that trigger point is gonna have a certain level of sens.

Versus needling into the motor point. . And to me that becomes a question about who’s sitting in front of me. I think there are times where I would say needling the trigger point is exactly what you need to do. And there are other times where I don’t think that’s a great idea. I think just balancing the treat, focusing more so on the bilateral trigger point or bilateral motor points, and then postural issues might be a better approach depending on who’s sitting in front of you. Yeah. Gotcha. It’s interesting the idea of trigger points. I’m gonna make a comparison to something. I do, I’m in Florida, so I can do injection and I use.

Modified like buffer, D five W 5% dextrose and sterile water, which could be great for trigger points. I use it for trigger points. It’s also used for ural injection. So when you’re working with cutaneous nerves, so a lot of pain syndromes, you can palpate these cutaneous nerves and do very superficial injection.

And using the D five W to desensitize some of the nerves because the idea is that when nerves are absent when there’s glucose, oxygen deprivation, when there’s pressure on the nerves, they, they’re not getting oxygen. They’re not getting glucose. Dextro is about the same thing. You can desensitize them with this dextrose solution, bathing that area and this Dex solution.

And the person who who really spearheaded a lot of this work is MD and New Zealand. And he uses it really comprehensively for a lot of different things, even like sciatica. And it’s like you’re desensitizing that most distal portion. Of the nerve. It reminds me a little bit of distal points in acupuncture, even though they’re, these aren’t, know, it might be around the knee or wherever the pain presentation is, but it’s almost like desensitizing that end of the nerve kind of, refers back to that neurologically back to the main unit.

I of feel like trigger points are a little bit like that too, versus motor points is sometimes you wanna use the motor point, which is gonna affect all the branche. Distal from that, all the intramuscular motor points. But I wonder if it has like a little dispersed effect. It’s effect is dispersed among all of those, which is very regulatory versus sometimes you need to zoom in right at that most distal branch that’s irritated.

Yeah, exactly. And I to play off of that, I don’t think there’s anything wrong with saying, All right, let’s try the, let’s try the motor entry point. , and then reassessing the trigger point and saying, Howard, how’s that feeling? Now that I’ve done. I think that’s a good thought process to be going.

Yeah. Gotcha. On that topic, and you already started getting into dosage, I think we should probably go into that. Could you define dosage again, cuz it’s a term I hear in acupuncture world, often when people hear dosage they think medicine, which is medicine.

Medicine can. Yeah, it can be a little tricky. I’ve broadened my definition quite a lot in the last year. So I considered anything that’s, Going into the treatment. I think the way it gets talked about and has been researched the most is number of, treatments within proximity one another.

So number of treatments per week but needle retention time, we talk about it in school, like the 23 some minutes and talking about cheese cycling. You can of get locked into that and stop thinking about it, but there’s definitely a difference between needling. Leaving a needle in for a minute, to five minutes, to 15 to 35 those are all gonna have a different effect on particular patients.

The amount of needles and then the amount of stimulation like we’re with, talking about trigger points, the local twitch response doing some type of manual technique on the needle. Eim, I think these all have a level of stimulation, a level of dosage. And they all do slightly different things. As an example, there are times where.

What you want to do is to get multiple local twitches versus another patient who’s gonna have a really bad reaction to that. And maybe Easton was a better way to go. But then even then you can of start building off of that. Or what are the accessory techniques you’re doing? What effect is that gonna have on your treatment and how often you need to be treating and how much needling you do.

If you’re doing a ton of mild fascial work, like we learn, like we learn in smack, how much needling do you really. I know going through the program we’d spend you’re spending like five minutes doing a tech a mile fascial release technique, and then you’d have you or Matt just being like, I just remind everybody you’ve already done the needling at this point, so you don’t have to do all that.

A ton of mild fascial work. And that’s an just an example of moderating the dosage and then what you’re giving ’em, what you’re giving them. As far as herbs or homework assignments I know there’s some interesting research that talks about using exercise to minimize that post-treatment soreness.

I certainly think if you’re incorporating that, you need to be thinking, how much work can I do with the needle versus how much work am I gonna have the patient do when they’re at. And yeah, I just think those are all different examples of what you could term dosage. Yeah. I also add a thought to that is that upper cross syndrome would be an example of this.

Somebody can’t tolerate a lot of needle stimulation. That’s a lot of needles to do. The rom boy major rom boy, minor, middle traps, lower traps, tech minor. Especially if you’re doing this bilateral. There’s a lot that goes. So I start to think distal points sometimes too. And think which channels are those, if those muscles are part of a sinia channel and maybe I can affect differently, maybe not as direct, but maybe I can affect those lower traps with the urinary bladder channel, a distal point that I might be using anyways. And I can have that have some regulatory effect.

I think its effect is gonna be a little bit more dispersed and its effect is gonna be stronger if that distal points there. Plus the local point. But, the person can’t tolerate, I can still of build energy in the channel to help that, relate to the lower traps in that case without having to needle ’em directly.

If I do need to minimize, or maybe to release the Peck minor, I’m gonna use a lung channel point that’s gonna have a little less less , impact. It’s not gonna be as strong of a needle sensation as going into the Peck minor with a, with a. Yeah. And I agree. You can have two, you can have one patient and then 30 minutes a nut later, another patient, same condition.

If we’re doing upper cross, you’re doing the upper trapezius trigger point and you’re gonna make it worse. Or someone else, you, if you do the upper cross, trigger point, you’re gonna make ’em way better. . And it’s just, I think the trick is learning how and when to do that. I do think there are some tales, but ultimately just building your clinical experience around how you’re, how patients are gonna respond to that.

But yeah, it’s a thing I love about Chinese medicine is that gives us, it gives us those options. If I can’t treat the trigger point directly, I can use lung seven. Yeah. It’s funny, I think when I’ve overtreated people, it comes down to this one thing. And I’m gonna use a phrase that I heard this in context from another educator used to teach with sports medicine, acupuncture Patrick Cunningham.

He discussion, he reminded it was, this was an online discussion, but it reminded folks about a saying they have in chiropractic, which is being addicted to the audible. So that case is trying to adjust and get that pop, and sometimes the joints move, but you’re like, I’m looking for that audible.

I feel like face situations are that, and this was his point, the fasiculations are that in the acupuncture world especially more sports acupuncture based world is getting addicted to that big muscle twitch. And sometimes that you put the needle in and boom, it’s right there. But other times not and, maybe you over overstimulate looking for that big muscle twitch because that’s what’s driving, that’s what you judge as being what’s important for the treatment.

Maybe their body’s telling you something different. I dunno. So when I have over, when dosage has been wrong, it’s for me, that’s what it’s been. Yeah. I’m guilty of that too. Certainly. Who doesn’t love just getting that like nice big pop of the muscle? Yeah. What was I gonna say based off of that?

Oh shoot. Escape me. But you said something that reminded me of that, but Yeah. I think. Certainly knowing when and how much and knowing that, I also like to say it’s like it’s not the worst thing in the world to over treat somebody. As long as you’re communicating with them like, Hey, I’m gonna do this thing, you’re probably gonna be sore one to two days.

Anything over that. I consider to be too strong. I’ve definitely had patients be like, Oh yeah, I think we did a little too much and then it’s, and then we move on. We know to treat, do a little less stem. But the point, I need to close with this cuz we’re running a little short on time, but the ations I do think is where it’s spending a minute or so on and I’ll mention my thoughts on it.

I don’t think there’s an answer to if you need a ion or not. I feel like the ion is, I. . But I think oftentimes we miss these very small background, quiet fasiculations, which is maybe what that person’s body needs. And I have some ways that I sometimes, like I, for Summit 36, if I’m using that for the tibialis anterior or just any tib anterior or motor motor point or trigger point, I’ll go down distally to about the liver four area and just go a little lateral, which would be right on the tibialis anterior tend.

Yeah. Sometimes you need all that region of oft anterior and you can clearly see and feel of ion, but sometimes you can’t. But you can fairly clearly feel like a little pull on the tendon and it’s I might have missed that on the needle and kept on looking for a ion. . And I think for some people that their body is that was the therapeutic outcome and I got it and I missed it if I don’t have a way of assessing it.

So sometimes I think when we talk about fasiculations, we’re not talking. , the spectrum of that muscle ion that can happen, that can be from almost imperceptible to you can physically see it. Yeah, sometimes we talk about fasiculations as it being that part of the spectrum is the parts you can physically see or right there you see it.

Yeah. Yeah. No, I think it’s important to understand that. Even the research is gonna tell you. Oh, like getting a twitch, it does have a response. It has a local response, has a global response. But searching for it can actually recreate a lot of the, in nociceptive increase the presentation of a lot of the nociceptive chemicals that you’re actually trying to get rid of.

Yes, getting the twitch can matter to a degree. , but it’s very easy to overdo if you go hunting for it. And I do think, like you’re saying, like trying to look further, like further distally or approximately along the muscle, looking for those small littler twitches is probably a smarter way to go.

Yeah. And also I think when it’s like that and it’s assuming you’re in the right location, sometimes you take the needle out, Repa. Oh yeah. I think I was just a little off. And you put it in, you get it right away, but sometimes you’re right on the right spot. And then sometimes you just have to use good needle technique instead of just banging away at the muscle.

You just coax Yeah. Little English on it. Yeah. . So I think that’s that’s been the change for me in treatment is not just assuming. I didn’t get the twitch because I’m in the wrong location and just keep on wailing away at it. But just to see that as the body needs a little bit more a little more mechanical stimulation, quiet stimulation in that area and let it come to the needle.

In those cases where it’s probably more of a deficiency case, know, Cause the excess portions you put the needle in and know, it’s, Yeah. It’s there. Yep. Yeah, I would agree. All right. Joe’s gonna be presenting at the 2023 specific sports in an orthopedic acupuncture symposium.

Maybe you’ll get a little more into some of this at the symposium. I know the dosage thing is a really interesting thing, and you’ve talked a lot about various research that, that discusses this, and I think that’s useful to hear it from that perspective. Hopefully more on that topic later.

Yes, that is the point. Oh, we were gonna talk about ql, but I think we’re probably a little short on time, so maybe we’ll leave it at that. We got a lot of good information discussed in this. All right. So thank you, Joe. Thanks for being the guest. Sorry Matt couldn’t join us. Thanks again to the American Acupuncture Council for having us.

It’s always great to, to be available for these webinar. And I didn’t get who is here next week, but I think it’s usually put up on the screen, so there we go. Awesome. So hopefully you guys can join next week and thanks again and see you guys another time. Thank you, Joe. All right. Yeah, Thanks Brian.

 

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Facial Fascia: Appearance and Function

 

 

And I am going to talk to you today about facial fascia and what it is and how it can affect your facial acupuncture treatments and how it can affect your patient’s appear.

Click here to download the transcript.

Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

Hi, my name’s Michelle Gillis. I am an acupuncture physician and I teach facial and cosmetic acupuncture classes internationally. And I am going to talk to you today about facial fascia and what it is and how it can affect your facial acupuncture treatments and how it can affect your patient’s appear.

So I wanna thank the American Acupuncture Council for this opportunity, and I need to see the first slide.

So what is facial fascia? That is going to be the first thing we talk about today, and after that we will discuss how it affects your facial appearance. and the movement of your face. So it’s not just about cosmetic, but also how your face functions, and then some treatment modalities, things we can do in order to affect the function of the face by treating the fascia.

So facial fascia is composed of two layers, and the first is the superficial facial fascia, and that is On the outer layer, and that is, it’s right underneath your skin and it helps to support your face and hold everything up, and it’s responsible for giving you a youthful appearance and. It also can carry a lot of tension in it and restrict circulation to the face so things can get trapped, whether it’s lymphatic fluid or blood.

And even some of the superficial nerves. Then we have the deep fascia layer, and that kind of forms a girdle and it is called the mass layer, the superficial muscular epi neurotic system. So the superficial layer itself. Has the superficial fascia itself has two layers. It has the outer layer, which is this kind of fatty layer, and then we have the mass layer, which is right here and.

That is what allows us to make facial expressions. It takes the nerve impulses from deep and sends them out to the muscle, which then translates out to our skin.

So the superficial. Fasha layer is what is responsible for our facial expressions. And the deep fascia layer, which includes the fascia of the temporalis because the temporalis is connected to the face the parotid fascia, which goes down into the neck. The periosteum, which works around the part of the skull that connects to the face.

and the septum, the area around the orbit or the eye area. And this is where the deep fascia exists on the face. So here’s a. Pictorial representation of a piece of bone and a muscle and the skin. And the reason why this is important is because our face is the only part of our body where the skin is connected.

To the skin layer is connected to the bone through muscle, which is why you can move the skin on your face without having to move. Any part of your face so you don’t have to move joint in order to move the skin on your face, everywhere else on your body, if you wanna move the skin, one of your body parts has to move.

The skin can’t move Separate from the the body part.

So one of the things that can happen is, so here’s the bone and here’s the fat and the muscle and the skin. And what can happen is, so as the muscle contracts, the skin gets pulled towards the bone and we can get. Kind of wrinkling of the skin, right? If you smile, if you raise your eyebrows, if you pull your eyebrows together, if you purse your lips right, you can purse your lips without having to move any bone at all.

Just by moving the muscle, the ais ORs, and what can happen is, We can get these fossil adhesions, which are like scar tissue. They can happen as we age. They can happen through injury, they can happen through overuse or underuse. And it’s this very fibrous collagen fibers. It’s like if you think about, if you have like a chicken.

And you pull the chicken away from the bone. There’s that layer. It almost looks like really a strong cobwebs, and those fibers can. Trap nerves and blood and other things. And they can cause these adhesions where it can prevent the full expression on our face of different facial expressions, the full movement and.

Like if an individual perhaps had a stroke and things, or Bell’s palsy and things don’t move for a long time, then you have to physically get this area moving because of these muscle adhesions that can form. So here’s the bone. Here’s a piece of bone, and here’s the fascia, and here is a nerve, which as you could see, could get trapped in the fascia and it could prevent the signaling so the muscle won’t even.

The signal that it needs to move because the nerve is trapped or it can reduce. The ability of the muscle to move well, and it can also restrict blood flow. You can see there’s veins that could also get trapped. So here’s a picture of someone with Bell’s Palsy. They’re making a facial expression with the right side of their face, but the left side of their face isn’t moving.

At all, and part of this is due to nerve damage, but it can also be from entrapment

and wrinkles. When we think of wrinkles, we think of something that happens as we age, and in many cases it can be from sun damage, it can be from just the skin getting older, but also if you habitually make an expression and the skin is attached to the fascia. If that fascia is restricted at all, then you can end up with these deep wrinkles.

We see it a lot in people’s far heads and even sometimes around the eyes with crow’s feet or the lips. And also with jowling. , and I’m gonna talk about a couple of ways that we can help with this, but sometimes wrinkles and sagging are reversible just by doing things to the fascia layer. So here we have an example of forehead wrinkles.

Perhaps this person made the expression where they raised their eyebrows a lot. Also, this is when I said jowling. This is what is referred to as a jowl, and it can happen through the aging process. Things loosen and they become a fixed into a new position. Sometimes it’s from excess weight on the face, sometimes it’s from habitually frowning.

And When I was young, my mother used to say to me, Don’t make that face. It’s going to stay that way. And there was actually a lot of truth to that. A lot of our facial expressions get etched on our face over time.

So what are some of the treatment modalities that we can use in order to affect this fascia? On the face. One very effective treatment is facial cupping. Now, facial cupping is something it’s a skill that you would need to learn. It’s not like cupping on the back. You don’t want to try to use your glass cups and cup the face the way you would’ve back, or a neck or a shoulder or a.

Facial cupping uses small cups. and they look like this. And you would use these small cups and oil and you would glide these cups across the skin. You don’t park the cups and you do it in such a way that encourages lymphatic drainage. And works with the anatomy of the face. And this is a cupping set that is made by Oculus Skincare.

And so there’s a slightly larger cup and a smaller cup for different types of wrinkles and. Rubber part is very easy to squeeze so you can squeeze and move and release and squeeze and move and release, and really keep that chi and energy going. Facial Guha is also another technique that we can use.

And here are some facial guha tools. You can see that they are these are made out of Jade and they’re specially shaped to work around the gel. The cheeks to work along the temporalis and underneath the chin, across the clavicle. Lots of places where we can get these adhesions and by. This kind of physical movement of doing the cupping and then the guha afterwards.

You help to keep the lymphatic system of the face moving, the blood and the chi moving, and also to really get in there and break up those fas adhesions, especially with the guha tool on the forehead. You can spread the wrinkles and you can really get in there and break up a lot of that tension and that tight fascia.

So this is a picture of me just doing some gua along the jaw, jawline, sculpting the face, helping to lift everything up.

And the next technique that we can use, which is very beneficial for submuscular needle, for treating facial fascia is submuscular needling. and this is a technique where you would work on different areas of the face. And I teach a whole class just on submuscular needling, and it involves taking your needles and getting.

Underneath the muscle. So you’re really getting underneath these memetic muscles. I’ve lost my mouse. Where’d they go? You get underneath the memetic muscles. And you’re going to needle right through and down. And this can help get into the superficial fascia and then into some of the deeper fascia depending on which part of the face you’re working on.

And you would insert a few needles. Underneath the muscle, depending on what part of the face you’re working on. So I have a quick video that I’ll show in a moment, but you can use this to work. Underneath the mace here, you can use this to work along the attachment points for the pla. You can work into and underneath the anterior digastric.

You can work underneath the corrugator muscles. You can work underneath the frontals muscle. Pretty much any muscle were on the face where you have access to the margins of the muscle you can get underneath there. And this can really effectively break up some of those fossil adhesions, which is really quite wonderful.

And let’s see. I don’t know if you’ll be able to hear this, but you can see it and I can talk through it.

In needling, the frontalis muscle, the. Way that you isolate the muscle is you ask your patient to raise their eyebrows. Go ahead and raise your eyebrows. Okay? And then, so this is the frontals muscle and you can find the border of the frontals muscle. And the way that you needle is you’re going to go.

From the origin to the insertion, so you find the borders up here in the insertion is here. And typically what I do is I will put in usually three needles, and then you get right underneath the muscle lateral on either side and. I will put in two needles on the medial side, and when you’re needling, what’s important is that the angle of the tube is the angle that the needle’s gonna go in.

So if you go like this, it’s gonna go too deep. If you go like this, it’s going to be too shallow. I use. My thumb or a finger to help to guide the needle. So you wanna keep your fingers out of the way when you’re actually inserting. That way you can get to the correct depth right underneath the muscle.

That’s lateral side. Then you’re going to do the medial side, and usually two needles. Suffice. And I do the one side and then I do the other side and I’m using half inch noodles. You can use one inch noodles depending on how big your patient forehead is, so you just get all the way down underneath the muscle.

And isolate the muscle and needle right underneath it, and this, you would just leave the needles in for anywhere from 15 minutes to a half an hour. And this is especially helpful. Let’s say your patient has Bell’s Palsy or some sort of facial paralysis. You can do it on both sides. You can do it on one side, wherever the muscles are affected.

This is just a list of some of the classes that I teach facial and cosmetic acupuncture, facial cupping. A lot of what we talked about today is from my treating neuromuscular facial neuromuscular facial conditions class. I do some self care for acupuncturists safety ethics, microneedling. And a lot of the techniques that we use for cosmetic acupuncture can also be beneficial for treating neuromuscular facial conditions like osis.

Or if someone’s had a stroke, TMJ and vice versa. A lot of times when you’re working with a neuromuscular facial condition that your patient might have, it also helps to benefit the Movement of their face and therefore their skin will look healthier and more vibrant. So I think that’s everything.

I wanted to thank the American Acupuncture Council again, and next week we have Matt Callison and Brian Lao, and I hope to see you again next.

 

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Best Practices for Structuring a Virtual Visit

 

 

So there are two types of virtual visits…

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Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

Would you like to have a virtual practice but you’re not sure how to structure your visits? Or you currently already have a virtual practice, if would like, is to flow better and help your ideal patients or clients get the best outcomes possible. Welcome, this is Chen Yen, your six and seven figure practice makeover mentor at introvertedvisionary.com. So there are two types of virtual visit. Number one is that you might be treating them in more of a practitioner patient kind of a relationship.

And then so they are considered your patient and maybe you have seen them in person before. And then you’re just having the virtual side of the connecting, going done virtual. And then and then some of you may be completely telehealth, and of course you need to check with the loss of your state and profession about that and how it’s kosher or not.

And then the second possibility of virtual visit is that you are type of virtual visit is that you are coaching them on more and educating them on mindset and health kind of education. So there is no. Provider patient kind of relationship here, it’s strictly on educating, it’s strictly on teaching and perhaps coaching.

And those are the two types of virtual visits that, that I see are most common. And so what, how can you structure the flow of these visits? So the first hot tip is to. At the beginning of a visit set a strong intention for for the visit and what to expect. So certainly some of the PR principles that if you’ve had a brick and mortar practice apply if it’s virtual, but sometimes because you’re not used to what a virtual flow would look like, then you’re wondering how best to.

Communicate it and communication becomes, and setting expectations and inspiring becomes even more important because that dimension of being with you in person isn’t there. So the. First is setting the intention of the visit and letting them know what to expect today. So that way your patient or client feels really grounded in what to expect instead of just starting off in a visit and talking about things.

One important thing is to set the intention and expectations for today, and then at the end of the visit summarize what’s been covered. Many times in a treatment, in person what has happened, they can experience it and feel it. And and maybe sometimes you, for you don’t always think to summarize what you did to today.

But it’s even more important if it’s in a virtual relationship to, to summarize what happened, acknowledge the progress that’s been made, and then ask them. So this is really key. So this is something that, this next thing I’m about to share is something that is often overlooked because as a clinician, it’s easy.

Just bring up what you saw was had shifted for them or what to ex, what to expect perhaps next time and that kind of thing. But even before then, if you’re able to ask them to share what stood out for them and then solidify your next step recommendations, then it helps the, your.

Patient or client be able to verbalize that and settle into another level of owning that and feeling that from the visit instead of you just bring up what, what stood out for you about that session for them and the Also using powerful questions throughout your visit. So this is a second hot tip.

What, how do you structure the visit? So I shared with you this overarching idea of structuring and what to say at different moments in time, beginning and then at the end of your visit. But then what are some powerful kinds of things to ask or say during your visit? Consider asking questions that might be powerful questions, for example, saying things like, what will having that do for you?

What’s important to you about that? So these are kinds of questions that can help your patient or client. Reflect on things more especially if a virtual visit may not be as quite experiential as in person in the way that you have imagined, in the way that you’re used to in person. So certainly a virtual visit doesn’t mean that, that people don’t have an experiential shift.

It’s just that the shift typically is a little bit different than an in person experience. Another kind of a phrase would be saying, Oh, something like this. Imagine if X, Y, Z. So when you are sparking belief changes, how can you weave in words that paint a picture of that for them? One of the things about virtual visit many times in terms of the practitioner’s role and how it shifts compared to a brick and mortar in person role is that there’s likely even more within a virtual visit where you are able to like that the.

Part of the value is sparking belief change or inhabit kind of change. And so what you can, whatever you could say to inspire to also hold them accountable for those shifts can really make a difference for a patient or client. Cuz how many of you have ever thought, especially if you don’t have a virtual practice, ci, you’ve thought.

What can I actually do in a virtual visit that people would find beneficial? Cause I just, I, I need to see them in person. There’s, I don’t see that I can really give much value in a virtual visit. And sometimes we don’t think about how some, the most significant shifts that a patient or client can make has to do with the lifestyle changes that they’re making in between your visits and.

So it, but sometimes those are the hardest things for a patient or client. So how can you help them ha have better outcomes Because they’re actually motivated, inspired, and they are sticking with the lifestyle changes that you are recommending for them. And Also the, Have you ever had a, discussing the, at the begin, also at the Beginning of each visit, like at the next visit, always discuss the commitment.

So what was the previous commitment that your patient or client made? What and verbalize that. So last time we discussed you X, Y, Z. And then talk about the progress with that commitment. And this accountability piece might seem so trivial but still crucial because have you ever had that experience or maybe either you had a coach before, like in sports or something or a teacher in school where you had to be accountable to whether it was just even turning homework in.

Then did you notice you, you then worked on the homework and turned it in. Whereas if you didn’t have homework to turn and you probably wouldn’t turn it in, or if you have had a coach you were responding to, or a coach, sports coach who made you do 10 pushups every morning then you did do those pushups.

Whereas if you, and maybe someone watching you right, doing the pushups, then you were more likely to do it. Same thing with your patients or clients when you can hold them accountable. There’s huge value to that. That way your patients or clients are held accountable even if they didn’t feel like it.

Final couple hot tips is are this, so remember that. Because I think one of the things about a virtual practice and virtual visit situation is especially at first feeling like, Oh, I’m not sure if I’m really giving enough value here because I’m so used to treating and then they’re feeling the treatments being having shifted.

And and so is this feeling. We need to give in, in, in each visit. So we need to educate them about as much as possible because we’ve got this time allotted. So we need to put everything in that visit as much as possible. And guess what happens? Patient or client gets into information overload and feels so overwhelmed.

And then sometimes then they don’t end up rebooking or, have this that ever happened to you before where you if you’ve had a virtual Practice, you’ve noticed that, oh, maybe I said too much in that visit. , right? And so remember that information overload is not helpful. It’s actually the right balance of, because it can overwhelm people and people can tend to only absorb so much each time, even though we wanna give so much each time.

And so it’s helpful to, it’s an art and a skill. To be conveying what is important to convey in that container and enough to help them move forward with an important shift. So when shifting from a model of treating people to helping people online and perhaps missing the treat treating component, remember that the value of the visit is not just in fixing people.

So think about what are the most significant things that will spark lasting transformation and focus on that in, in your visits. If you are in a place where you already have a virtual practice or thinking about getting it, shifting into more of a virtual practice, either hybrid brick and mortar and virtual practice model, or maybe even a hundred percent virtual so that you have that flexibility to travel anywhere or work from home and not have to.

Be tied down to renting office space and being tied to having staff and that kind of thing as much, then I, but you’re not really sure how to go about it. You’re welcome to, to check out our website and reach out to us at introvertedvisionary.com. So introverted visionary.com and till next time.

 

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Getting Ideal Patient Referrals

 

 

“How do I Get Ideal Referrals into my Practice?”

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Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

Hi everyone, and welcome. I’m so excited to be here. I’m Dr. Nell and I just wanna thank the American Acupuncture Council for the opportunity to be here and talk about one of the most common things that I get asked questions about, and that is, how do I Get Ideal Referrals into my Practice? Let. What are the slides?

So this is what we’re gonna be going over today. We have a lot of information we’re gonna get in a short period of time, so value packed. We’re gonna talk about those ideal patient referrals. Not just a Luke warm person who might be interested, but really, truly deep dive into how are we getting those ideal people into our practice?

We’re gonna go through what’s your current referral strategy. Three key questions that you really need to be asking before you even seek out referrals, and then what those next steps are. So let’s get right into it. What is your current referral strategy? And I will say a lot of times I get a blank stare when I ask practitioners this question.

Sometimes if it’s current patients, Oh, I rely on the patients who are already coming into my practice. They like my treatments, so of course they’re going to refer to me. Maybe it’s m. If you work in an integrative setting, if you are working with patients who have other health concerns other people on their care team, that could be MDs, that could be other integrative providers it could be maybe friends and family.

Are you thinking my friends and family know that I’m well educated in this medicine, They know that I can do to help so my friends and family can refer to me. That’s my strategy, That’s my plan. Maybe you enjoy public speaking. You might do continuing education. Perhaps you are a leader in a certain area of this medicine, and so other practitioners might see you as a thought leader, an expert in a certain space like fertility, for example, and then say, Oh, that’s the person who I’m gonna send referrals to.

I will say though, that when I ask this question, , it’s usually met with, I’m still looking for a strategy or I, I do rely on patients to refer to me, but I don’t really have a strategy around that. I don’t know how to ask people for referrals. And a lot of times we get stuck in this, what I call the.

The one man, one woman, one person referral machine. And that means that getting referrals into my practice is directly related to me being there personally. So I meet someone on the street and get them in or I am, at an event and I talk to someone and they become a patient. And really the goal of a referral strategy should be to get you out of a place where it has to be you telling people to come into your.

And there’s another trusted person funneling people in. And ideally, you want these to be ideal people for you. So that means people who geographically are in the right place, are the right fit for your practice. And we’re gonna go over some of those really key things and how do we make this a seamless transition.

So let’s go to the next one. First step. You’re gonna have three questions here, and the first thing you wanna ask yourself before embarking upon this journey to getting ideal referrals, who do I even want to attract into my practice? Let’s take a pause for a second because I know so many of you, including myself, wanna say anyone acupuncture can help.

So many things. Why would I turn anybody down? Why would I not seek out as many patients as. Having a targeted referral strategy does not mean that you have to turn down patients that walk in your door. It just means that you get really clear with what your ideal patient is so that your bandwidth, your energy, your time, your money.

All of it gets funneled to the right place to bring as many people in that are ideal for you and for your practice. We can’t be the be all, end all for everyone. But you wanna look at, okay, who am I attracting? Is it people with specific health issues? Do I like working in the fertility space?

I do a lot. Men’s health and post-surgical work specific health issues can be a great way to start narrowing down that target for you of who you wanna attract in if you have a specialty. Makes a lot of sense. But if you don’t, there are other ways to lean into that too. So you can look at age, location, obviously, financial status, occupational demographics.

Who is it going to be? Seamless and easy to get in and maybe past experiences with medicine. So I know that some practitioners. Are the person that people come to once they’ve exhausted a lot of other treatment options. They’ve tried particular things in western medicine, or they’ve gone for another type of care they need an additional provider on their care team or something didn’t work for them.

With my postsurgical patients, I have patients who have a history of addiction. And so when they’re having a surgery, they’re very concerned about avoiding pain medication after the surgery. And so that’s a real consideration. So someone is seeking me out because they know that they need that specialized care so that they don’t only have standard of care as their option.

Even looking at what interests do these particular people who you’re hoping to welcome into your practice as patients, what interests do they have? Do they travel a lot? Are they, really high performing, hardworking, stressed out individuals and their favorite downtime is to. Be a foodie and go to restaurants.

These are all things that you wanna consider when you’re looking at who is ideal. How do I come up with that ideal patient avatar? And we’re not gonna go into this a lot, but I wanna show you how granular this can truly get. So again, not reading all of this to you, but when you’re thinking of that ideal person who you wanna welcome in, you wanna name them, you wanna think about their age, What is their family life like?

What’s their occupation? Where are they living? Where are they traveling? What’s their personality type? Where do they go to eat? What do they wear? Where do they shop? Really thinking about what are their values, and that’s gonna bring us to this next very key question. So the first question was, who am I looking to attract into my practice?

Second question is, who does this person already value? Quick note here, not who we value as a practitioner, who does that person value? So we’ll go with my example of Craig who does Craig value? What’s important to him? And so when you’re thinking about who they value, you wanna think, All right, they already invest in this person.

And what I mean by invest we mean financially or with their time. They trust them. They rely on this person’s council, and they’re influenced by this person. So that’s how you can get a little bit of an idea about who they truly value. This person could be a personal trainer, it could be another healthcare provider that they have.

It could be the leader of their business, networking. Let’s go with personal trainers as an example. Let’s say Craig is religious about going to his personal trainer. And I’m speaking from experience here because I have done this and I know you all can do this very effectively. When I had was first starting out in Beverly Hills.

I had my practice and there was a. Equinox, I’m sure you all are very familiar with, and I started looking at the personal trainers there because all of those personal trainers had clients who were paying a very high amount for personal training. So I knew they were in close proximity to my office.

These clients, I knew that they could afford my services. I knew that they were already invested in their health and I knew they already trusted their. So when you get through that, you say, Oh, okay, so we’ll keep with the personal trainer example. I know that. So now that’s gonna lead us to our next question, and this is the big one.

Now how do I become the trusted source? And really the strong point behind that is, How can I provide value? We know you’re going to provide value for your patients, but it’s about getting them in the door. It’s about getting that buy-in. It’s about it not having to be you convincing that person to come in.

Following this example of Craig and the personal trainer, I want the personal trainer to start convincing people. To come in because then it’s not dependent on me to stumble upon Craig at a restaurant and convince him to get acupuncture. You have someone who is out there who believes in what you do, who can tell their clients, the people who value them, and their opinion that they should be coming to you.

And so when you’re thinking about how do you become the trusted. In this example for the personal trainer at Equinox thinking about how can you provide value, I always have loved to think that it’s enough to say. I can help your people. That’s true, but it’s not specific enough. And so when you’re looking for getting these ideal patients into your practice, you need to solve a specific problem for that personal trainer, for the person who has those ideal clients that you wanna bring into your practices.

So what could this look like for a personal trainer? What type of problems are they experiencing that you can solve? Perhaps if their clients are in pain, they’re not coming to train as often. Perhaps if they’re training athletes who want to get to a higher level of performance and be excited about continuing to train they wanna recover better, they wanna perform better, we need to be able to speak to those key areas where we can add value.

To that person who can influence their clients to then come into our practice as patients. So let’s just, That was a lot of information in a short period of time. Let’s look at it from big picture again. So when you’re looking for ideal patients to come into your practice, not just anybody, because you know you do well for your patients, people will refer to you, but this is about having that strategy that doesn’t take a lot of work.

That doesn’t require you being the person who always has to meet somebody for them to become a patient. You wanna ask these three key questions, and this is what is going to narrow. Focus, it’s going to allow you to use less bandwidth, less energy less money targeting people. So you’re gonna ask these three questions first, Who do I wanna attract?

Remember, get very specific with this. It doesn’t mean that these are the only people you are going to see in your practice. It simply means this is who I am going to put my energy towards. I’m gonna look for. Second question, who does this person value? And again, Not who we value, but who that ideal future patient values, who they invest in financially time-wise, rely on for their council.

So that’s really important cuz it’s that patient centered care. So we need to be thinking about what is this perspective patient care about. And then lastly, how do I become the trusted source? The trusted source? No, not only for the future patient, the trusted source for the person that future patient values.

So the personal trainer in this example, and that’s really about. How do you as a provider, as a business person, as an owner of a private practice, who wants to do right by your patients, how do you add value to that person’s life? How do you solve a problem for them? What is a specific thing that you can do that would make their job easier, that would make their life easier, that would help support their.

And I know you all, I know we come from a very genuine place with wanting to help patients with wanting to help people in general. So this is not a an unfamiliar area for us, right? We want to provide value that is very innate in this profession. So this is just an additional, more strategic step when it comes to referral.

How are you gonna add value to someone who has already the client base that you want to bring into your practice? And these are really the benefits of having a strategy, right? Because your skills, your time are so valuable if you are spending time and energy doing things. You didn’t go to school for, you’re not interested in, you’re spinning your wheels.

Just trying to make sure you have enough patience in your practice that you can help. That does a lot to your energy, and we don’t want that. We want to have more energy. We want to be really intentional with our energy, and it’s the same thing. You’re being intentional here with who you can add value to.

This also helps bring the right people to you. So once you identify these people, Sticking with that personal trainer example, they understand how your practice works. They understand the results that you can get for their clients. They understand the value that you bring to the table, and so you don’t have to reinvent the wheel every time explaining to someone, This is the way the process works, this, they’re gonna do a lot of that for you and make your job so much easier so you can focus on treating and getting great.

Which you can do. It also was time and energy saving, right? So again, it takes you out of that, Oh, I need to always be there to convince someone to come in. I need to be there to explain how acupuncture works and what it does. No, you train somebody else to do that, and then they’re doing that for you, and that effect multiplies, and that is so key.

So important and it’s very tangible, like you will get tangible results from this. And lastly, here are your next steps for these three key areas. You first and foremost, wanna identify your ideal patient. Being as specific as possible, knowing that being specific does not exclude anyone from coming in. It just means you’re gonna get the right people coming in for you and for your practice.

Determine who their trusted resources are, so the trusted resources. For your ideal patient, and then you just really importantly, need to think about that value add. How are you going to offer value to those trusted sources? I love talking through this with people. I’m happy to answer any comments moving forward and.

This is an exciting thing because we need more people who are familiar with our medicine. We are great practitioners. More people need to know about us, and this is a way to help people in your community send you the ideal people for your practice. So hope you all enjoyed that. I’m excited that I got to be here and talk through this proven strategy with you.

Please don’t miss another episode of To The Point. We next week are going to have Chen Yen, and I believe, I mean she, she is all about referrals as well, so she’ll be adding value for you next week. I hope you all enjoy it and I will see you next time on Two the Point.

 

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The Pros and Cons of Joining an Insurance Plan

 

 

Hey, should I join this plan?  Is it worth it? What are the good ones? Which are the bad ones?

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Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

All right everyone, and welcome to another edition of To The Point with the American Acupuncture Council, and thank you to the American Acupuncture Council for this opportunity, but also as an opportunity for you to get more information about how to make sure you can run a well run, well-rounded practice, one that you enjoy doing, one that can also be profitable.

On today’s topic, what I’d like to discuss is manage care, joining an insurance. Let’s go to the slides. Let’s talk a little bit about that. Cause it’s a very common question I get as a coding and billing expert and doing this for a number of years with seminars, one of the main questions I get for members is, Hey, should I join this plan?

Is it worth it? What are the good ones? Which are the bad ones? And what I wanna do with this is try to give you a little bit of a primer on what you should do or understand when you join or think of joining, what are the things that you must consider? So managed care plans, I like to think. Is it worth it?

Is there a value to join or not to join, if you will, is the question. So let’s focus in, Let’s really talk about what we mean by the term managed care. Often, I think we misunderstand it, but in many ways managed care just means that the insurance company is truly managing the providers you’re joining.

And you’ll often hear these terms like a preferred provider or a member provider. And these are often what we call ppo, preferred provider organizations or HMOs. And these are plans that the patient is given incentive. To see the doctors within the plan, generally with lesser copays, deductibles, or within hmo.

Of course, it means if they go someplace that’s not in the hmo, there’s literally no benefits, so we have to look whether or not this is worth it. So here it says, insurance plans that provide or that have the provider acupunctures to join in order to gain access to get the insurance payment. Sometimes remember, You can be outta network, and this is one of the things to consider.

Do you have to join an insurance to be paid by it? And let’s make this clear on a regular insurance plan. Once you are licensed, you may bill and access benefits. Unless the plan has a provision that they only pay for providers in network. Be very careful. A lot of people when they first start will think, Ooh, I have to join.

In order to gain access and you don’t. So first thing is make sure, does the plan have benefits that are out of network? Meaning any willing provider or do they require in network by example? Some of you’ve probably have seen these Medicare Advantage plans, Part C plans. They’re advertised quite heavily right now.

Pay attention to on television commercials, and you’ll see companies like United and Cigna and others advertising that there’s acupuncture benefit. Bear in mind, many of these plans don’t require that you join as a provider. Just be willing to accept the patient. Now, when you do accept the patient, you’re gonna be limited to their fee schedule, but at least that way gains access without joining.

Now, the other side would be, if I join, would it be more likely for the patient to come to me? Does it incentivize them enough to choose me as the provider? So again, the provider gains access. But we have to make sure, is that access we could have already had. The real issue here, I think that we want to consider is your business is that it’s a business.

I know it’s a practice and you’re there to help and all do all the good things to care for someone, but at the end of the day, it’s still a business. So like with any business, we have to make a business decision on this type of plan. There is a trade off. What is the trade off? The trade off is if you join, you gain access.

In other words, the patient has incentive to see you. Now, for me, the big issue is does the patient have complete access or is it one that they could still go anywhere? So the bottom line though, it gives you access. It allows the patient to come and see you and have a benefit. And let’s face it, people who have insurance are more likely to go to the doctor than those that don’t.

I’m sure you’ve all witnessed that. You all probably know someone right now, maybe even a family member that needs to go to the doctor but is not going because affordability, they have no insurance, no benefits. They’re not going. So this often is why people with insurance generally go to the doctor more because frankly they have access.

Always think of what’s the barrier to care. Often money. So this may help with that. However, talking about money, the trade off is yes, you may get more patients or at least more access. , But do you get paid? You’re saying money. No, you don’t. Mostly, and I’ll say every time you join a plan, there’s always a reduced or limited reimbursement you can collect.

Now, that reimbursement could be decent enough that it’s worth it, but it may be too low. So one of the things to consider is there enough value for me to do it? In other words, the choices can, the volume. Make up the difference, and in some ways, think of managed care, and this sounds awful, but Managed Care, in my opinion, in some ways is the 99 cents store.

The 99 cents store is a very popular store, but how does that store really function? They have to sell a very high volume of goods because they’re only 99 cents. So you have to think of it when you’re getting reduced payment. Your volume has to go up. Now, this is something that’s a little more complicated for an acupuncturist.

Say, compared to a chiropractor, you have to provide all the services that you deliver in a acupuncture, excuse me, in a chiropractic or physical therapy setting, they can have assistance. Acupuncturists are pretty much out of the loop on that, so it means, for the most part, you have to do everything, all the care, and of course, your care is very time.

I. , Let’s face it. Each set of needles is 15 minutes. And while the eight minute rule does apply, even if you’re doing three units, you’re spending close to 40 minutes, maybe 45 minutes with that patient in your. That’s a lot of time if you’re only getting a very minimal amount of reimbursement. So you’ve really gotta kinda weigh out the pluses and minuses.

And what I think you should do is start to really to look at these plans from a true business standpoint. Like just when you take your first business course in college, one of the things you learn is, Hey, can you make a widget? How much does it cost to make the widget? How much can you sell it for? And how many can you sell?

That depends on how profitable the business can be. So what I’d like you to do is keep it relatively simple. Get a piece of paper, draw a line down the center on one side, put yes, one side, put no, this is exactly what I do with my network members. It can be a little bit more detailed. Obviously in this form we’re limited, but this can give you a good starting point.

Am I gonna join something? The yes would be if it’s exclusive. If the patient has no benefits at. Without you being in the plan. To me, that’s a big yes to join because otherwise there’s no access. What if you’re in an area where there’s a group where a lot of people in your area belong to it?

Would you likely wanna join? Because if they can’t come to you with their insurance, are they still gonna come in or are they gonna choose elsewhere? So an exclusive plan to me is a big yes. However, keep in mind, what if it’s non exclusive? And be careful. A lot of PPOs prefer provider organiz. Are not actually as exclusive as people think.

An HMO is one where the patient has to go within the plan, but a PPO is one where the patient can still choose to go outside of it, and you want to check to see if I join, could the patient still come to me? One of the things I will be concerned with is often people join these plans and all of a sudden realize, Hey, I’m getting less money.

I’ll give an example. Sigma Insurance has done this. There’s a group with a SH that if you join. You get a limited reimbursement, but if you’re out of network, your reimbursement’s the same but or is higher actually. So from that standpoint, often you really wanna look to see if it’s not exclusive, what type of access does a patient have?

And here’s another example. United Healthcare generally will pay providers better that are out of network. And you’re thinking that doesn’t make sense. That’s how the plan works. It just pays more. Now, the difference could be though, maybe they don’t find you because you’re not in the network, or sometimes their deductible could be higher for out of network providers.

So I look first, if the patient could come to me anyway, what’s the incentive here? So you have to look at what’s the balance and how’s it gonna draw someone in, because at the end of the day, it comes down to if I’m gonna join, even if it’s exclusive, is the pay reason. Does it pay me enough to really make it work?

Bear in mind, there are some plans for acupuncture that I kid you not pay as little as about $40 per visit, and that’s all inclusive. I don’t care what you do, you can do five sets of needles in a therapy or two sets of needles. You’re still getting, the $40. And also keep in mind, this is something that surprised someone the other day.

They had a plan that pays 63 42 with a $25 copay. And they had the mindset that the plan was gonna pay 63 42, and then you charge the patient 25 on top of it thinking they were gonna get close to $90. The reality is, in a plan like that, when it says it pays 63 42 with a $25 copay, they’re going to allow 63, 42 minus the 25 that the patient pays.

So the total you. Is 63 42 with 25 of it coming from the patient. So we have to look even at that amount. Is that reasonable? Is it enough for me to really make my office work? What if it just simply pays too little? know, You look and go, I can’t do that. Work for it. You know yourself as a practitioner, some of you could spend maybe 20, 30 minutes with a patient.

Some of you might spend an hour or. The more time you spend, the more value to the service. You can’t really survive. If you’re seeing a patient for 40 bucks and spending an hour or plus, I don’t think you can keep your practice helping. Let’s face it, that means you can make a max of maybe 300 a day, and I’m not sure $300 a day is gonna keep enough for your office as well as your home expenses.

The other fact to think of though is what if I joined? Does it bring me many new patients? Would it give me access to people who otherwise wouldn’t? That’s something to consider. What if all of a sudden you can get many more patients? Realize if an increase in volume happens, then that could still increase the bottom line cuz you’re seeing more people.

The limitation as an acupuncturist though, is how many people can I see per day? There’s limits there. There’s only so much time in the day. If you spend an hour with every patient, all you can see is eight and eight hour day anyway. So something to think of. But if it brings a new patient, I think.

That’s not a bad thing. You know what? If this is a new patient that you wouldn’t I otherwise see? And bear in mind, I had an office once that said, Sam, I’ve joined these plans because when I join, these people come in. But they often refer me people that aren’t part of the managed care plan because they have friends.

And so I thought, Okay, tangent. Generally I can see where there may be a benefit there, but those are all the things to weigh out because bottom line, what if they’re already a current patient? And this has happened to me. I had an office that they joined. And they were getting a hundred plus per visit.

When they joined, they got dropped to 60 and I thought, didn’t you find that out before joining? So before you join, really ask the hard question, What does it pay? Realize, because of the no surprise act, the insurance company have to be forthcoming with what they’re going to allow. So be careful before you join, really start to weigh out all these factors, and you may look at some other things as well.

Sometimes these plans, as America Specialty Health, may request that you send pretreatment author. After a certain number of visits. Now, I won’t say those are very hard, but that’s a lot of extra work or at least extra work that you have to do after five visits. Is that worth it when you consider the time that it takes to do it Now, what if it even only takes 15, 20 minutes?

That’s still time. So again, we have to weigh all those factors in. Now, if it has a lot of things that you’re required to do, maybe. If it’s relatively simple, and again, you have to learn to make it work and understand what they’re looking for. But you can see here this lens toward be a little bit more scrupulous.

Don’t be afraid to be a little bit more focused on is there enough value here? Now, the good news is, let’s say you join something and it turns out to be horrible, and you’re like, Oh my God. You can always drop out, but bear in mind, dropping out is not immediate and be also conscientious that when you join something, always ask.

What other plans will this join me to? By example? If you join a group like multi plan, it’s not just one. It often attaches itself to several things and be conscious that you can sometimes opt out of these types of plan. You can say, Okay, I wanna belong to this one, but not that. So by example, with some as H policies, you can choose to opt into Blue Cross, but not Blue Shield or Cigna and not Aetna.

So before, always look at what do I really want to join? What’s good for me or what’s not so good and see about opting out. At the end of the day, it’s all about the value, The business value, I would say. Think of what your cash rate. Cash rate is meant to be simpler, less because there’s less work. I’m not saying insurance coding and billing is hard, but there’s more time.

So often for cash patients, we’ll offer like 10% off because know, we don’t have all the other background paperwork. Okay? So think of that rate. In my opinion, I need at least that to be darn close to what my cash rate is. Now, obviously I don’t think anyone has a cash rate as little as. So I’m looking at 60 or 70.

So a lot of these plans I look at and go, I’m not so sure unless I can really make it up in the volume. But I wanna look at does it match that, or at least this, Have you ever thought of, what does it cost to treat a patient in your office? Really, know, what’s your bottom line? What does it take for me to just keep my office open?

Now how do we do that? What I’d like you to do is to take your office over. What does it cost for your office? And that includes your rent, your lease, cost of needles, table paper, everything to rent in your office. You know what I’d actually include with that? I’d include student loans. I really think that’s part of your office cost.

But anyway, take your overhead, then divide that by the average number of patients per month. Notice I didn’t say, or excuse me, patient visits per month. Not patients, but patient visits. So by example, let’s say your overhead cost is $4,000. That’s what it costs to run the office, and 25 visits per week or a hundred per month.

That means in order for you just to break even and pay for the office, you have to get at least $40 per patient. So when you’re looking at a plan like an ASF that’s paying 40, you’re making nothing. So unless you can increase the volume, this really doesn’t help. So be careful before you decide to choose.

You cannot do this at a loss. It’s gotta be with some level of profit. Now, maybe you can have an office cost that’s only $15 or $20 a patient. So some things to consider, but I really want you to look at the business side of it, and this is the part maybe we don’t like doing. You want the school to be an acupuncturist.

You are good at what you do. You help people. The part we don’t like is, What do you mean I gotta deal with the business end? And that is an important part because unfortunately a lot of acupunc. Within three to five years of graduation, don’t practice because they simply couldn’t deal with the business side of it.

And I want to help you with that to say, could this make a difference? Now what if you join this plan and though it doesn’t pay very much and that doesn’t meet the overhead expense, but what if you have an office, you’re not very busy, and you have openings for another 20 visits per week or more.

I would rather fill them with these than not have them at. And then maybe you can build the practice from there on other referrals and get them sold on maybe maintenance care. So there’s some things to consider here, but I want to be careful that if it’s gonna take away an existing patient and all of a sudden now you’re replacing a hundred dollars patient with a $40 patient, not a good idea.

Realize that under ash, depending on the plan you join, whether it’s Cigna or others, the reimbursement can be as little as 40 to about $90, which means in this aspect, you could be making $0. Actual profit to maybe 45 per patient. Now that’s not awful, to get 45. In fact, I think we can make overhead a little bit lower.

So let’s take a look at like Ash with Cigna. And I’m gonna say this varies from state to state. I’m giving you just one state here, and you’ll see here they allow 51 for the first set, 38 for the second, but it’s just a maximum of two. Means you’re gonna get $89, you’re not gonna build multiple sets or therapies.

They’ll either pay two codes and the max is 89 per day. Now is that. No, I think that’s reasonable. I think that fits a lot of people’s cashes too. Two sets, meaning you can do it 30 minutes, they do pay separately for exams. But let’s be honest, notice the exam price are only 20 to $40. So when you’re getting managed care, you gotta know that I’m gonna get probably less than a hundred dollars per visit.

Can I make that work? Does the volume hit it? And remember, this is an ash tier. When you join Ash, and I’m not saying this is negative for ash, I just wish they paid more. Most acupuncturists when you join is gonna be put at a tier three, which means when you’re a tier three, after five visits, you have to send more information about the need for care from the patient.

Now, as you’re in the plan for a length of time, you may reach a tier six where you don’t have to do that because they know that you’re trustworthy. You’re not over utilizing. But you can see here, there’s extra work. Now, again, I’m not against it, and there’s ways to work with that. That’s one of the things I do with our network services to help you with that.

But I want you to also look at this overall and know yourself. If you know that you spend more time, if you know that you do not like to do extra reports, this may not be for you. You’ve really gotta make the hard choice of is there enough value for me? I’m not against joining, but take a look at the plans and what the incentives.

How does it increase the volume of patients? Does it bring in 10 general patients? So let me give you a kind of a quick primer about what must or should you join. I’ll never say must, but these are just my opinion. I will certainly say if you’re joining the va, that’s a win-win, meaning there’s no negative to that, in my opinion.

If you join the va, whether you’re on, Texas or west of Texas or East with Optum, Tri West, or Optum, when you join, there’s no cost to join. And the only access is to VA patients. Now, if you get a VA patient, it’s great that VA patient’s probably gonna equal 1500 to $2,000 of reimbursement for the amount of services they offer.

So I’d say, Okay, there’s a value there. There’s no downside, because if you join the worst thing that happens, you don’t get a patient. If I get just one or two a month, that certainly could be worth it. So I think for me, there’s no issue there. I think HMO plans like Medicare Part C. Now notice I’m saying Medicare Part C, I’m not talking regular Medicare.

I’m talking the Part C policies with the additional acupuncture benefit, those I have no problem joining because again, this is exclusive. If you’re in, you can see the patient and these can actually decently reimburse. They give access not only to acupuncture, but to exams and therapies as well. So those I have no problem.

Again, no cost to joining. What about optional plans? You know what? If I wanna join an a sh or Primera or Blue Cross Blue Shield look to see what does it do, what else does it join you to? I would start with, is it exclusive? Is my number one issue. Cause I think if I wanna bring people in, think of how many times you’ve had a patient come in and has this ever happened to you?

Have you ever had a patient that you gave a hardship? that you hardly charge ’em anything, but you wanna be helpful. That’s what you do. And in turn, that patient wound up referring you many patients. So realize there’s more benefits that could be there, but you wanna start to weigh that out. Is there enough value outside of this?

I’d really have to work with the individually to say, Okay, let’s talk about what area you in, What part of the country, what county, what city? Who is insured there? What type of plans are you seeing? Is there enough a benefit to do it? Does it pay enough? Now, as you can tell, this is complicated. The good news is you’re never stuck, but you do wanna make some choices and decide whether or not it works for you as a business provider.

At the end of the day, you are providing a service that has a value, and that value has to be enough to pay for you and your office, but just your home cost as well. So it’s something to consider. I would say certainly take some time to look through it. Don’t be afraid to be a little scrutinizing, and if you jump in one.

Don’t like it. You can always jump out. Keep in mind though, one thing, you can join one plan and not necessarily have to join the other. So when you join like a sh, make sure you know that. Can I opt into one plan? Maybe I belong for Cigna, but not for Ner or some of the others. So keep in mind to always look at all the aspects of whether or not, what do I have to be in?

What am I automatic or what are optional? Cause I would certainly not wanna be part of personal injury or some of these other things that may be involved with them. And that’s what we do at the American Acupuncture Council Network. For some of you, You may have already been familiar with this, but it’s a chance for me to be part of your staff.

Give me a call, send me an email, do a Zoom meeting with me, and we help your office. Take a look here. Just go to our website or do this QR code. We’re here to help. We always want to have you to have the best possible practice you can. That’s really our goal. So we’re always here to serve American Acupuncture Council Network.

Here’s our phone number. Go to our website. I will say to all of you, best wishes, and don’t be afraid. Make that choice. Decide what works for your business. We’re here to support you. Until next time, everyone take care.

 

acupuncture malpractice liability insurance, acupuncture malpractice insurance, acupuncturist business insurance company

Malpractice Insurance For Acupuncturists

We cannot emphasize enough the importance of malpractice insurance for acupuncturists. If you have been following us for quite some time, then it is highly likely you are already aware it is one of our recommendations to add to your business checklist. With that said, it is also imperative that you are careful when choosing insurance, as providers are not the same.

When shopping for malpractice insurance for acupuncturists, it is crucial to ask the following questions to help narrow your choices to the most qualified providers.

How long have you been in business?

Asking your prospect this question will provide insights into the company’s strength as an acupuncture insurance provider. If they have been around for a decade or two, it means they have weathered the ups and downs of the industry. That also means they have polished their expertise and can offer insurance products that are top-notch in the market.

What is the scope of your insurance coverage?

You must know how extensive the level of protection they can provide so that you can weigh the benefits relative to the amount of money you are paying for the premium. The coverage may include malpractice insurance, business insurance, worker’s compensation, etc.

Can you give us some figures about your company?

Figures/statistics give you a snapshot yet a holistic view of the company. Figures worth taking note of are the number of clients they are currently serving, amount of insurance claims, amount limits of liability, and the premium.

Are you a licensed service provider?

In California, domestic and foreign insurers are subject to licensing, control, and supervision by the California Department of Insurance, as prescribed by law. If an insurance provider cannot provide proof of their license, you have a compelling reason to cross that company out from your list of prospects.

Online looking for a reputable company that offers malpractice insurance for acupuncturists? Contact the American Acupuncture Council today at (800) 838-0383.