October, 2013

Effective Business Building Strategy

By Mitch Carter, DC

As Tom Necela, DC so clearly stated in the June 1, 2013, issue of Dynamic Chiropractic ("Business Building: What's Your Strategy?"), the old revenue models in practice just aren't working like they used to. In fact, several of them are not working at all for too many good doctors out there. As I write this, I'm thinking of the young female chiropractor in Georgia I spoke to yesterday. She had just sold her practice after two years and was already throwing in the towel. I have no idea how much this doctor's business acumen (or lack of same) contributed to her so rapidly reaching that point where there was just too much debt and not enough income to continue but I do know ... it's tough out there. Costs continue to rise while revenues for so many remain flat or in decline. New graduates are coming out into this environment with unprecedented student loan debt.

As many of you already know, a scatter shot approach of adopting the "Next Big Thing" rarely works. It may (or may not) provide a short-lived cash infusion and ... then what? What has worked for us and for our doctors for the last seventeen years is dispensing and billing durable medical equipment, particularly TENS (transcutaneous electrical neurostimlation) units.

building a plan - Copyright – Stock Photo / Register Mark To our thinking, TENS units dovetail perfectly with the chiropractic philosophy of drug-free health care. With the growing epidemic of prescription drug abuse and the constantly increasing list of complications associated with both prescription and over-the-counter medications, why wouldn't a chiropractor want to give their patients with chronic pain a TENS unit?

It is important to understand that the recent systematic review done by Dubinsky and Miyasaki1 that resulted in a stated position that "TENS is not recommended for the treatment of chronic low back pain due to lack of proven efficacy" was based only on two studies. The Warke et al study,2 assessed TENS efficacy in patients with multiple sclerosis; results from this study cannot have universal application to the entire population of chronic low back pain patients. The other study by Deyo et al,3 is flawed in that there is no reportage of the intensity of stimulation used with the test subjects. Rakel4 and Bjordal5 have both found that stimulation intensity and adequate dosing are critical for TENS to be effective.

On the other hand, a rigorous meta-analysis by Johnson and Martinson6 of data collected from 38 randomized trials reported superior results from TENS as compared to placebo for chronic pain in various anatomical areas, including back, neck, hip and knee. A study by Melzack et al,7 showed a participant-reported pain reduction of 70% to 80% with the use of TENS as compared to massage. Grant et al,8 found an approximate 50% reduction in pain and a reduction in the utilization of pain medication in subject adults over 60 years of age as compared to those using acupuncture. Studies by Chabal and Fishbain9,10 found statistically significant reductions in the use of opiate analgesics, tranquilizers, muscle relaxants, NSAIDS and steroids with the utilization of TENS. Cost simulation data suggested that TENS use could reduce medication costs by 55%.

There is more supportive evidence for TENS out there but most important to us is what we hear on a regular basis from patients. Gratitude, appreciation, reports of decreasing or discontinuing pain medications, returning to work, returning to activity, sleeping better and just having a better quality of life. With all of that, we have to ask once more, why wouldn't you give this service, this gift to patients? It's a wonderful way to provide additional care and add a significant source of revenue to your practice.


  1. Dubinsky RM, Miyasaki J. Assessment: efficacy of transcutaneous electric nerve stimulation in the treatment of pain in neurologic disorders (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2010; 74:173-176.
  2. Warke K, Al-Smadi J, Baxter D, Walsh D, Lowe-Strong A. Efficacy of transcutaneous electrical nerve stimulation (TENS) for chronic low-back pain in a multiple sclerosis population: a randomized, placebo-controlled clinical trial, Clin J Pain 2006;22:812-819.
  3. Deyo RA, Walsh NE, Martin DC, Schoenfeld LS, Ramamurthy S. A controlled trial of transcutaneous electrical nerve stimulation (TENS) and exercise for chronic low back pain. N Engl J Med 1990;322:1627-1634.
  4. Rakel B and Frantz R. Effectiveness of transcutaneous electrical nerve stimulation on postoperative pain with movement. J Pain 2003;4(8):455-464.
  5. Bjordal JM, Johnson MI, Ljunngreen AE. Transcutaneous electrical nerve stimulation (TENS) can reduce postoperative analgesic consumption. A meta-analysis with assessment of optimal treatment parameters for postoperative pain. Eur J Pain 2003;7:181-188.
  6. Johnson M, Martinson M. Efficacy of electrical nerve stimulation for chronic musculoskeletal pain: a meta-analysis of randomized controlled trials, Pain 2007;130:157-165.
  7. Melzack R, Vetere P, Finch L. Transcutaneous electrical nerve stimulation for low back pain, Phys Ther 1983;63:489-493.
  8. Grant DJ, Bishop-Miller J, Winchester DM, Anderson M, Faulkner S. A randomized comparative trial of acupuncture versus transcutaneous electrical nerve stimulation for chronic back pain in the elderly, Pain 1999;82:9-13.
  9. Chabal C, Fishbain DA, Weaver M, Heine LW. Long-term transcutaneous electrical nerve stimulation (TENS) use; impact on medication utilization and physical therapy costs, Clin J Pain 1998 Mar;14(1):66-73.
  10. Fishbain DA, Chabal C, Abbott A, et al. Transcutaneous electrical nerve stimulation (TENS) treatment outcome in long-term users, Clin J Pain Sep; 12(3):201-214.

Dr. Mitch Carter practices in West Hills, Calif. He can be reached at .

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