By Annette Bernat
Since the beginning of the COVID-19 outbreak in the United States, the American Chiropractic Association (ACA) has advocated on behalf of doctors of chiropractic and their role as essential healthcare providers who support many front-line workers by helping them to function under strenuous physical conditions and increased stress. ACA appealed directly to the White House and the Department of Homeland Security, which released a memorandum in March that included chiropractors on the list of essential healthcare workers distributed to state and local governments.
Below, ACA Blogs talks to one of those essential workers, Hawaii delegate Joseph Morelli, DC, of Waipahu, Hawaii (pictured), who has been treating not only healthcare workers but also teachers and others who continue to provide essential services to the citizens of Hawaii.
Do you see a lot of front-line workers in your practice?
Hawaii is a very unionized state, and most essential workers in the state belong to unions. Pretty much of all the unions have contracts with various IPAs to provide medical services to their membership, and these all include some form of chiropractic coverage. So, many of the DCs here are contracted providers with these IPAs and see nurses, police, firefighters, ambulance drivers/EMTs and hospital workers, etc.
As the COVID-19 outbreak emerged, was there any delay in Hawaii determining that chiropractors were essential workers?
Hawaii was one of the states to invoke early “stay-at-home orders” and quarantine of travelers into the state and stop all non-essential travel between islands. Our governor put his lieutenant governor, Josh Green, M.D., in charge of the COVID-19 policy taskforce. Our lieutenant governor is a practicing ER doctor, so this was right up his alley.
Initially, they were seriously considering not listing chiropractic services as essential because of our “high touch” type of patient interaction. For this reason, they did NOT designate massage therapy or acupuncture as essential, right from the beginning.
We discussed the situation with Lt. Gov. Green, and he was concerned about us possibly being a source of community spread. One of the first things we pointed out to Dr. Green is that studies show that one of the primary reasons people go to see their PCP, or acute care clinic, is for musculoskeletal pain conditions. Being an ER doctor, he agreed with this. He also agreed that chiropractic is very effective in diagnosing and treating these types of conditions.
So, it stands to reason that by making chiropractic essential, we can keep many people out of the ER and acute care clinics. This prevents such facilities from getting overwhelmed by a large segment of patients that can be treated elsewhere, leaving services available for the unknown numbers who may need to be attended in a large outbreak.
This was an “aha” moment for Lt. Gov. Green in the discussion. One of the things we pledged that we would pass on was his requirement of face masks for doctors and staff and all who enter our clinics. He also emphasized cleaning and sanitizing between every patient encounter. Open bay treatment areas would also be limited to one patient at a time (unless a family sheltering together was being treated). Also, we were asked to keep the patient visits to the more acute cases or flair ups of chronic cases and hold off on scheduling “maintenance” type patients for the future when restrictions were removed. Apparently, Dr. Green was well acquainted with the various forms of chiropractic practice styles, and he made it clear that being essential was all about treating and protecting the public and assisting in this crisis. So, he put DCs on the essential list right at the start.
It was also agreed that some therapeutic massage services be allowed if performed in a clinical setting. Spas and non-clinical settings are not allowed for the duration of the lockdown. So, massage therapists working in a doctor’s office may continue, of course, following strict sanitary practices.
The outcome of all of this was that about 80 percent of Hawaii DCs stayed open, following the directives, and the rest closed, out of fear, or not wanting to change practice style.
What sort of musculoskeletal conditions are you seeing among healthcare workers in particular?
Besides the usual back and neck problems that are common in nursing and hospital workers, who often do heavy lifting as part of regular patient care, an emerging problem in this group is foot problems. Standing on their feet for 10 or 12 hours or extended double shifts is taking its toll on feet and ankles. Plantar fasciitis seems to be a more common complaint lately. This can cause a change in gait and posture, putting additional stress on the knees, hips and back, in addition to foot and ankle pain.
I am also seeing a flair up of the more chronic underlying back and neck problems due to a change in sleeping habits. Many nurses and other frontline healthcare workers are trying to protect their families by sleeping on makeshift beds, mattresses, sofas, the floor, etc., to minimize contact via a sort of self-quarantine. Sleeping on unfamiliar beds and different surfaces are causing many to end up in unusual sleeping postures that are adding stress to the spine, shoulders and hips.
Is it important that these workers do not take unnecessary pain medications during this challenging time?
Besides the obvious possibility of becoming dependent/addicted to pain medications, some of these medications can cloud thinking, judgement, and slow reaction time. This is not a good thing when these front-line healthcare workers need to be at the top of their game when working in life-and-death situations.
Another thing to consider is that the very nature of these medications is to minimize or stop pain. Well, pain is also a protective mechanism. So, by not feeling pain in their back, etc., one can make a condition worse by overdoing or overstressing an injured or chronic condition.
What other types of patients are you seeing?
There are the teachers! So many of them are experiencing increased musculoskeletal stress (on top of the emotional stress). They all have been working with their students via electronic means. Sitting hours in front of their computers trying their best to engage their students under all kinds of conditions. I have been using the phrases “Zoom neck,” “Laptop neck” and “Tablet neck”! I have been encouraging patients to try to take regular breaks and do some simple stretches or postural changes to give their bodies a break.
I have taken ACA's recommendations for teleworkers and customized them as a handout for my patients.
Has your patient load of essential workers increased since the pandemic started?
Initially, all practice visit numbers were down by on average 50 percent to 60 percent. Recently patient visits have slowly been increasing. In the beginning, many of the essential worker group did not come in as they were just exhausted, or they were not sure that we were open. Little by little, they started to come in, and now there is a large group of them. I think that some of them are networking amongst themselves, as they are very satisfied with our services.
In general, how are you and other Hawaii chiropractors coping? Are you supporting each other in some way?
I am currently serving as the secretary of the Hawaii State Chiropractic Association (HSCA) and its executive director. I am the past president of the HSCA and am trying to help keep things together in this crazy time. We are a small volunteer organization, with no paid staff—in fact, the association phone line rings on my desk!
We are regularly advising our doctors on the various federal, state and county COVID mandates related to our practice and businesses, and going over social distancing, sanitation protocols, etc.
I get several calls per day from the doctors who just seem to need some reassurance. I guess I sometimes feel like the “father-confessor” just listening to their troubles. I really don’t mind at all, having been here in practice for more than 43 years, and having seen a lot go down in all that time. I do have a lot that I can relate to them. My experience on the ACA Board of Governors has also come in handy, having had some firsthand experience on how the politics in Washington, D.C. and in the profession goes.
This COVID-19 pandemic experience has been extremely hard on us all. Many of us have had to take advantage of some of the federal programs to survive. I personally did the Paycheck Protection Program and got some funds toward my employee payroll. As soon as CARES Act small business loans, etc., were announced, we encouraged our colleagues to apply if they qualified. Many did, and this has helped keep the lights on for many of us.
The overall social/professional atmosphere here in Hawaii has always been very supportive. The Hawaiian people are generally very social, caring and compassionate. This has made the stay-at-home orders very interesting. I have had many patients tell me that I am the only outside person they have seen or had in-person contact with, other than the pizza delivery guy!
Now, as things are opening, there is a lot of pent-up energy. People are ready to get out to the beach, or surf, or go fishing, golfing, hiking, etc. I am sure I will probably see some uptick in overuse syndromes, as people will most likely overdo it! I look forward to being the help they can depend on.
Prevention Strategies in the Clinic
Dr. Morelli shared some of the COVID-19 prevention strategies he has incorporated into his clinic since the pandemic started:
- We are currently keeping our regular clinic hours but have ramped up our sanitary measures throughout the clinic and after each patient visit.
- We are sanitizing our treatment tables (head pieces, arm rests, etc.) and all surfaces that touch the patient after every patient use.
- I am of course regularly washing my hands and using a hand sanitizer before and after each patient encounter.
- Face masks are the requirement of all essential services by local government decree, to be worn by all staff and patients.
- I have posted signs on the front of my office door and throughout the clinic notifying that a patient can wait in their car after they have checked in at our front desk, and we will call them on their mobile phone when it is their turn to be seen. This is optional and mainly for those who want to practice social distancing, since my office reception area is very compact.
- My office design has been amenable to social distancing since the treatment rooms are all separate. The Hawaii State Chiropractic Association has sent out directives to all the DCs in Hawaii, especially those who practice in “open bay” adjusting rooms (rooms with multiple adjusting tables in the same room). We recommended that the doctors either take out some of the equipment or move the tables far apart, bring in only one patient at a time into a treatment area, and then sanitize after each patient encounter.
- I have posted a message on the landing page of my website, www.WaipahuChiro.Net, so patients can know that we are still open and are taking proper measures to protect them.
For CDC guidance on COVID-19 for healthcare providers, as well as important news and updates on relief programs for small businesses, visit the ACA website at www.acatoday.org/COVID19.
Annette Bernat is ACA vice president of branding and communications. She can be reached at email@example.com.