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Dynamic Chiropractic Canada – April 1, 2013, Vol. 06, Issue 04
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Training Staff to Perform Ancillary Procedures: Three Topics to Cover

By K. Jeffrey Miller, DC, MBA

The majority of ancillary treatments performed in chiropractic practices are performed by staff members. This has been the norm in chiropractic for many years. Unfortunately, it is also the norm for staff members to have limited clinical training.

There are exceptions to limited training; however, the majority of training for chiropractic assistants performing ancillary treatments is limited to on-the-job training. Some doctors provide excellent training, but others do not.

It is best to have a plan for staff training. The plan should include basic information on the equipment being used, indications and therapeutic effects for each procedure, contraindications for the use of each procedure and general safety concerns for each procedure.

Let's focus on three components of the recommended plan: therapeutic effects, contraindications and safety concerns. Basic information about the equipment utilized will not be discussed, as there are too many types and brands of equipment out there. Indications for use also will not be discussed, as use of ancillary procedures is primarily determined by the individual doctor and the individual patient case.

nurse with patient - Copyright – Stock Photo / Register Mark Therapeutic Effects

A frequent question from patients receiving an ancillary procedure is, "What's this for?" The question concerns the indications and therapeutic effects of the procedure. This is a common question that can bring to light several important points. In order for the patient to have this question in the first place, they probably did not understand the explanation provided by the doctor during the report of findings. To determine if this is a problem, staff should first be instructed to alert the doctor to the frequency of the question. If the question is frequent, the doctor may wish to review the method they use for describing some procedures. The problem is usually due to the doctor explaining the procedure in complicated terms and confusing the patient. If the frequency of the question is low, the question is probably localized to the individual patient.

Staff members can answer the question if they have been taught the general therapeutic effects for the procedures they provide. Short, concise answers are easy to develop. For example, if a patient asks a staff member why ice is being used, the response could be, "It reduces swelling and pain." (Table 1) This describes the overall intentions for the procedure. The staff member should not have to answer further. If the patient is not satisfied with the simple answer, staff should be instructed to direct additional questions to the doctor.

Table 1: Primary and Secondary Effects of Common Ancillary Procedures With Patient Explanations

ProcedurePrimary Effect(s)Secondary Effect(s)Suggested Answers to Patient Question; "What's this for?"
Interferential CurrentElectro-kineticMuscle stimulation, increase venous and lymph flow, reflex stimulation"It helps reduce pain and swelling"
Cellular massage, heat, sedation"It creates deep heat and promotes healing"
IceHypothermalSedation, decongestion"It decreases swelling and pain"
TractionDecompressionTissue stretch"It helps decompress joints"
VibrationKineticMuscle stimulation, increase venous and lymph flow, tissue stretch, reflex stimulation"It relaxes muscles and helps circulation"
StretchingTissue stretchIncreases flexibility"It increases your flexibility"
Strength TrainingIncreases
muscle strength
 "It helps strengthen muscles to support joints"


Contraindications and safety issues are considered by the doctor when formulating the treatment plan. Despite this, the topics should be stressed to staff for safety purposes. This will serve as a back-up for patient safety, particularly in instances when the patient's clinical situation changes.

While it is probably rare, a doctor may recommend a procedure for a patient who has a relative or frank contraindication to that procedure. A staff member with basic knowledge of contraindications may be able to alert the doctor to the oversight. (Table 2)

Table 2: General Contraindications for Selected Ancillary Procedures*

Ancillary ProcedureContraindication(s)
Interferential CurrentAreas of skin with decreased sensation, over skin lesions, over a pregnant uterus, on patients with pacemakers/defibrillators, transcerebral application, over the heart, hyperanxious patients, over an area of metastasis, over an abscess
UltrasoundNear hearing aids, malignant lesions, metallic implants, pacemaker and defibrillators.  Over growth plates in children, the eyes, the heart, the spine, the head, pregnant uterus, nerve plexuses, embolus, reproductive organs, radiculitis
IceAreas of skin with decreased sensation, areas of poor circulation, Raynaud's disease, rheumatoid and gouty arthritis
TractionUnstable joints, areas of skin that could be irritated by the harnesses, tendonitis, rheumatoid arthritis, severe spams, acute inflammation, osteoporosis, acute trauma, osteomalacia osseous infection
VibrationAcute local inflammation, advanced heart disease, cervical spondylosis, hemorrhaging areas, taking blood thinners, malignant lesions, oversensitive skin, over any skin lesions, over the eyes, chest wall pathology, tuberculosis
StretchingUnstable joints, balance problems, certain heart and lung conditions, the severe deconditioning, acute injuries, acute inflammation, acute pain, fractures, tendonitis
Strength Training

*This table does not represent a complete list of contraindications.

Patients have been known to request that staff change a procedure. Staff knowledge of a contraindication to the request may prevent a change that could have a negative impact on the patient's condition. Appropriate training along this line would consist of staff having the understanding to know not to make changes in procedures unless the doctor is consulted.

Many doctors do not adjust "skin on skin." This can leave staff members as the only people who may see the patient's skin during the majority of the patient's care. Staff may notice skin rashes, abrasions, infections and other conditions that may develop during the course of care. A patient could burn their skin or cause frostbite with improper use of heat or ice at home. Depending upon the procedures being used in the office, these conditions may be contraindications to their continued use.

Contraindications can also arise when a patient develops new symptoms, experiences a new trauma or encounters other situations. These situations should be brought to light when the patient sees the doctor. Unfortunately, there are often times when patients speak more freely with staff members than they do with the doctor.

Staff members often work with patients prior to the patient seeing the doctor. If new circumstances contraindicate continued use of a procedure and the staff does not realized this, it may be too late by the time the patient sees the doctor. Staff may have already performed the now-contraindicated procedure. If the patient does see the staff before the doctor, staff should always ask the patient if their condition / situation has changed since the last visit.

Doctors sometimes fear this last scenario (staff questioning the patient), especially within listening distance of other patients. They do not want a patient blurting out statements like, "I feel worse" or "I have been sore since the last adjustment." If this occurs, staff should respond to the patient by saying, "We don't hear this very often, but I will be sure to let the doctor know."

General Safety Concerns

Contraindications and general safety concerns are separate, but equally important issues. Safety concerns deal with use and condition of equipment, cleanliness, and following protocols. Staff should always be alert to frayed wires, sticky pads that don't stick, rubber tubing that has lost its elasticity, and similar upkeep and repair issues. They should know when to discontinue use of equipment and replace parts / supplies.

Tables, electrodes, chairs, exercise equipment, etc., should all be on maintenance and cleaning schedules. Gloves, disinfectants and OSHA spill kits should be readily available. In some cases, equipment should be cleaned after every use.

Following protocols is vital in order to provide consistent care from patient to patient. Proper application of procedures and sticking to straightforward answers are very important.

There are also times when staff should be instructed not to respond to questions and avoid commenting. Nothing could be worse than a staff member saying, "I wouldn't let them use this on me" if asked by the patient, "Have you ever used this?" Likewise, saying, "That isn't supposed to happen," in the middle of a procedure is not wise.

Staff members also should not discuss negative personal events. If something is not working correctly, the procedure should be stopped immediately and the doctor alerted. The staff member should simply say to the patient, "We are going to stop for a moment, I'll be right back."

The information offered here is intended to motivate doctors to improve or implement training to increase the skills of their clinical support staff. The information is not comprehensive; it is intended as a starting point for the process. The information inTables 1 and 2 is generalized and may not apply to procedures used in every office. Doctors should use the tables as examples and consult the references below to formulate staff responses to patients' questions, identify contraindications to procedures and address common safety issues.


  • Jaskoviak P, Schafer RC. Applied Physiotherapy. American Chiropractic Association, Arlington, VA, 1993.
  • Be'langer AY. Evidence Based Guide to Therapeutic Physical Agents. Lippincott Williams and Wilkins, Philadelphia, 2003.

Click here for more information about K. Jeffrey Miller, DC, MBA.

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