By: Joshua Swart, Dipl. Ac.

Here are the top 3 most important aspects of treating MSK patients, based on my experience as a practitioner and continuing education provider. Utilize these as guiding principles and you will be a force in treating MSK and pain!

1.  Learn skills that deliver results

As acupuncturists, we all know that many patients have unrealistic expectations for us. Oftentimes patients have gone to other specialties like PT or chiro for months or even YEARS, and after wasting all that time and money, decide that when they see us they are going to then be frugal and skeptical. We are their last resort, yet they give us the least amount of commitment and expect us to “fix” them right away. This will always be a thorn in our side, and while there are many reasons for this, at the end of the day we just need to deal with it.

There are many practice management “techniques” to help with this part of the patient experience (for example, getting patients on board and committed to a plan of care, effective communication, etc.) and while these are helpful, the number one way to handle this is to simply show the power of acupuncture. We need to make clear, noticeable changes on the first visit. I don’t mean just, “Oh I’m so relaxed”, or “I had a great nap”. I mean real, measurable changes. After all, acupuncture is the best treatment for MSK conditions, and we can easily deliver immediate, profound results. We should all push the limits of what acupuncture is capable of and have high expectations of our outcomes accordingly. You just need the right techniques and confidence.

When my practice turned around, it was a combination of results and confidence that made it possible. After all, RESULTS RULE. The patient feeling relaxed and taking a nap were not considered results to me. I required objective and subjective results, and when the patient experienced those, their confidence in me was immediately secured. They adhered to my treatment plans, referred friends and family, and oftentimes became not just loyal referral sources but actual advocates for me.

Here are some questions to seriously consider when it comes to self-assessment of clinical aptitude: What are your expectations of outcomes from your treatments? What do you expect to see as far as results, and how soon? Are you consistently getting improvements after your first visit? Having a solid idea of this will help you develop how you communicate with patients and develop treatment plans.

Here are the top skills I recommend learning to become a well-rounded MSK practitioner:

Assessment: EXSTORE physical assessment is part of the overall EXTORE system developed by Dr. Anthony Lombardi. EXSTORE streamlines your assessment, making it more precise and faster. The EXSTORE system dispels the myth that doing assessment takes too long, while also giving clarity to the confusion that comes with just single, seemingly random orthopedic tests. EXSTORE provides the practitioner with a blueprint of what to treat so results are felt (subjective) and seen/measured (objective) quickly.

Motor Points: Motor points are an integral part of regaining function and treating the root cause of kinetic chain dysfunction. Knowing when to use motor points is key since if they are not used correctly, the patient’s condition can be exacerbated. Oftentimes many more motor points are needled than necessary. Motor points are included in the EXSTORE system, including when to use them and which ones to select.

Electro-Acupuncture (EA): Includes techniques that treat inhibited muscles, reduce pain, treat peripheral nerves, joints, improve blood flow, and treat mechanical as well as chronic systemic conditions. As with other techniques, knowing which EA techniques to use and when is important for optimum results and to not aggravate the patient’s condition. EA is an important part of the EXSTORE system.

Trigger Points: Trigger points can be very helpful in treating symptoms of myofascial pain and dysfunction. Treating trigger points can be fun and very effective but should be part of the overall treatment that focuses on the causes of their formation. Treating trigger points alone may not be enough, but there are exceptions to this.

Distal acupuncture: Distal acupuncture is great for treating chronic systemic patients. Points below the elbow and knees are often the best, and adding in even just a few can add a lot of relief to the patient, particularly when used in combination with other techniques such as the perfusion treatment. Auricular acupuncture and stimulation of the vagus nerve is another powerful adjunct when regulating autonomic nervous system dysfunction seen in the chronic systemic patient.

When looking at a complete system of distal acupuncture, in my opinion Dr. Tan has the most powerful, straightforward, and simple system which you can learn in his book Acupuncture 1,2,3. I am very much aware of the other awesome systems/teachings out there, but I think Dr. Tan’s book alone can provide you with almost everything you need to get excellent results, particularly for chronic systemic conditions in conjunction with EA. Prior to learning motor points and the EXSTORE system, I read Dr. Tan’s book and in two weeks was using distal almost exclusively in my clinic. However, as many practitioners find out, distal is not the end all say all. Again, this is because distal acupuncture works very well in specific conditions and not so well in others. And while immediate reductions in pain are easy to get, long lasting results can be challenging. Other shortcomings can include using be high number of needles and needing a lot of treatments.

While certain practitioners swear that you only need to rely on a single system, either distal or orthopedic, the reality is that skills from BOTH orthopedic and distal perspectives provide you with the best set of skills needed to transform your practice. The trick is knowing WHEN to use each, and that brings up the 2nd most important aspect of treatment.

2.  Take a correct MSK patient intake

This could be number 1 since it is so important. Taking a correct MSK patient intake accomplishes many important goals and sets the tone for future care:

a. To determine what techniques to use: it is critical to first determine if the patient’s root cause of their MSK/pain condition is chronic systemic or mechanical. This helps you determine which technique should be used – motor points, electro-acupuncture, or distal acupuncture. This in turn assures optimal results and avoiding flaring up the patient’s condition.

b. To rule out red flags

c. To organize & document results of your physical assessment

d. Develop a treatment plan with documented findings and benchmarks

e. To accomplish the above in a very efficient manner

For the purpose of this blog, I will not go into each one of the above, since there are plenty of resources (keep reading!). I will however address one of the most common pitfalls of the intake – taking too much time.

In my opinion and experience, it is imperative that acupuncturists do not take excessive amounts of time during the patient intake. It is not necessary. Practitioners are most effective when they are actually treating the patient. That is their wheelhouse. Excessive talking or “venting”, while expected in some situations, is ultimately not productive. Of course, this doesn’t mean being rude or dismissive, but the focus must always go back to the intake and treatment as soon as possible.  A very efficient intake allows you to go right into treating so you can help the patient as soon as possible, as well as manage your time better and see more patients.

The biggest reason for taking too much time is just not knowing what needs to be included in the intake and what needs to be accomplished. But another reason that pervades the profession is this idea in which the acupuncturist equates time with the degree of their compassion and care. I highly recommend against the practitioner gauging the quality of their care by how much time they spend with the patient during their treatments. This is a recipe for disaster and follows no real beneficial purpose for the patient. It also equates amount of time spent with value or effectiveness of the treatment, which is not related at all.

I write more about the above in my free Ebook, Dos and Dont’s in Private Practice, which can be found HERE.  Therefore, I won’t take any more time on this topic. But in summary, if the practitioner includes physical assessment in their intake/initial visit, they are already doing something that the great majority of medical practitioners and other acupuncturists are not doing. Even many MSK and pain specialists will not put their hands on their patients, they won’t palpate, let alone go through an assessment. Yet completing an assessment shows much more care and attention and the patient definitely notices it. Many times patients will comment that their doctor or last acupuncturist “didn’t do that”. Already you have set yourself apart and are providing superior care.

Taking a correct patient intake is an integral part of the EXSTORE system. For more information on this topic, watch Dr. Lombardi’s webinar How to Take a Correct Patient Intake, free for the month of February! Click HERE to access.

3.  Treatment plan with follow up and benchmarks

After you complete the patient intake and first treatment, you have then provided the proof the patient needs to believe that you can help them. At this time, it is critical that you set a course of care that will progress the patient along on the road to recovery. You do not want setbacks! Too often there is too much time between visits, and patients will regress. One step forward, one step back. Are you really doing the patient any favors by having them come in once a week or even less often for a condition that requires more frequent treatment? What happens is, you end up causing the patient to come in for more overall treatments AND you drag out their treatment plan for months instead of weeks, while getting constant setbacks and ultimately little to no results. Many times the patient ends up frustrated and just drops out of care. This has helped no one. I got to the point in my clinic where for the great majority of patients, I would not see them if they didn’t come in at my recommendation. This isn’t an ego thing. It’s an ethical matter. I was not going to waste the patient’s time and money only to have them not get the results they could and then drop out of care – And then go back to friends and family and tell them, “I tried acupuncture, it didn’t work”. If I put the treatment plan on them and they didn’t follow it, then it wasn’t “Acupuncture” that failed, it was their commitment. I cannot be more committed to their care then they are. That never works.

Of course the above doesn’t apply to all patients, and you will have patients that come in as needed or for maintenance/preventative. Generally though that is not the norm for most patients.

Why you need treatment plans!

There are two main reasons why you develop a treatment plan. One, to help keep yourself organized and have a plan to get the patient better in an expected trajectory and reasonable amount of time and number of visits, and number two, to communicate these expectations to the patient so there is no ambiguity. The patient will know you have a plan and feel confident in your care.

How to create the treatment plan requires skills, taking a correct intake and assessment, and confidence. A treatment plan should include:

  1. Assessment results: Inhibited muscles that tested weak on the initial intake should test stronger in subsequent visits, showing solid improvement. ROM and mechanics should have improved as well
  2. Basic VAS pain scale reduction
  3. Documentation of what ADLs or other activities the patient was not able to do and can do now, e.g. playing sports, running, gardening, improved sleep, etc.
  4. Other test results with improvement; functional benchmarks included
  5. Percentage improvements and estimated continued improvement based on prior results.

Documenting is key since the patient can lose track of their progress. Having them see the documentation, feel their improved strength, and see their increased ROM has profound effects and serve as proof that they are improving. Believe it or not, that is not always clear to the patient.

More on the topic of treatment plans can be found in various webinars on aseseminarsll.com and dranthonylombardi.locals.com.

Confidence

I wasn’t planning on writing about this, but it’s such an important part of being a successful practitioner that I’ll take a moment to mention it. Most of us graduated acupuncture school with little to no confidence. I won’t get into the why and instead would like to focus on how to change it.

Repetition builds confidence

No matter what the skill, repetition is always the path to competence and confidence. When it comes to being a confident practitioner, you need to see a lot of patients and get a decent number of treatments under your belt. If you are recent graduate/new practitioner and only rely on what you learned in school, that will not be enough to give you confidence. And while continuing education definitely speeds up this process and delivers confidence for many practitioners, you will still need to practice what you learned.

So how do you do this? After all, if you are building your clinic, have a slow clinic, are just starting out, etc., then you can’t sit around waiting for patients to come in to practice your skill set. There are two effective ways at getting these hours in: Volunteering and holding or attending event.

Volunteering can provide you with a low stress environment that allows you to see a lot of people and try out your techniques and communication. Don’t worry about the perfect environment – treat patients in chairs. Or have a couple tables. Use whatever techniques you can to wow them. When I volunteered, I had a room full of chairs and another with two tables. I would use distal, perfusion, motor points, trigger points, whatever I wanted to practice.

So go find people to put needles in. Run an open free clinic such as a ‘Bring Your Pain’ clinic in your office. Bring in people and show them. Or go to a CROSSFIT gym and offer a free talk and demo. Go to CROSSFIT or other competitions and offer treatments to competitors. Volunteer during a fund-raising event such as a bike race or Triathlon. Can it be nerve wracking being put on the spot like that? It can be. But it only gets better. When I would hold these events, I would have room of prospective patients watching me work. When the person I was treating got profound, immediate results, you can imagine the effect that had on everyone in the room. You can’t be afraid of “failure”. You need to learn how to handle that as well, since sometimes your treatments won’t deliver as expected.

Summary:

I firmly believe that utilizing the above will help you become great at treating MSK patients. If you focus on getting results and building confidence, the rest will come much easier. To get results, you need to learn real world skills taught by practitioners who use these techniques day in and day out. At ASE Seminars LLC, we offer continuing education that you can go back to your clinic and use right away and get superior results. We provide a full support network for all aspects of practicing through webinars, live seminars, on-line courses, and our mentorship community. Visit us as aseseminarsllc.com and dranthonylombardi.locals.com to learn more!


Joshua Swart, Dipl. Ac. practiced from 2002-2019. He founded Chinese Medicine That Works Ltd. in 2015 and ASE Seminars LLC in 2020, and runs ASE Seminars full time now. Joshua has always focused on providing only the most clinically relevant, results-driven courses and content, and currently offers continuing education from Dr. Anthony Lombardi and Dr. Jamie Hampton. Joshua can be reached at aseseminars@gmail.com.