Alright, Gerard, welcome to the ChiroPractice Pro podcast. This is my good buddy Gerard. We’ve been friends for a few years now. He actually was instrumental in helping me get my diplomate. Gerard, welcome and thanks for joining me.
Dr. Gerard Bogin: Thanks for having me, Josh.
Dr. Joshua Eldridge: Tell me about your journey into healthcare and chiropractic.
Dr. Gerard Bogin: My mother worked at a chiropractor’s office growing up, and I had a lot of issues with asthma. I spent a lot of quality time at Dr. Gregory’s office. As I got into college, I was looking for something to do with my life, it seemed like a pretty neat way to make a living. We just kind of follow along the path there and just kept working at it, and guess that’s where we are now. Yeah, pretty much goes back to Dr. Gregory and some pretty bad asthma attack.
Dr. Joshua Eldridge: What do you do in the industry now? Tell us the cool stuff you do.
Dr. Gerard Bogin: Sure. I’m very fortunate I had the opportunity to sort of surge towards sports medicine, sports chiropractic a couple years back. It was partly intentional, partly fortunate. I started pursuing all the things that you needed to be to be a successful sports chiropractor. Diplomates and additional certifications, and little by little, I started having the opportunity to kind of travel with different groups. These days, when I’m at home, I work for a large practice. Couple days a week, I see my own patients who tend to be athletes, and then a couple days a week, I see the other practice patients which gives me the opportunity to travel.
Now, these days, I get to travel with a group that provides chiropractic services for the PGA Tour and for the Champions Tour, that’s kind of a neat experience. I also travel, I’m a qualified healthcare provider, meaning I’m a sports chiropractor. I travel with USA Fencing, and I also do some traveling with USA Archers. When some of the senior national squads travel overseas, I get the opportunity to go with them, so I’m very fortunate with that. A lot of people don’t get to do that, and I really enjoy it.
Dr. Joshua Eldridge: Also USA rowing, you’ve done some work with them as well.
Dr. Gerard Bogin: Yes, I have, I had the chance, I had the opportunity to work with women’s rowing at the Olympic Training Center before in London, and spent three months out there and getting them ready. That was a great experience.
Dr. Joshua Eldridge: That’s very cool. Sometimes, when I think about growing up, I think about the stuff that you’re doing, it just sounds like such a great experience and kind of what I wanna do as we get going. You got great stories and you’ve been all over the world doing really cool stuff.
Dr. Gerard Bogin: Yeah, I’ve been very, very fortunate.
Dr. Joshua Eldridge: The other thing. I kind of alluded to it earlier. When I was taking my diplomate exam, I hung out with Gerard and he set up mock exams for me to go through. One of the things that he did was he had a format for exams. That’s what I wanna get into today with you Gerard, is talk about this exam format that you’ve developed. Tell me a little bit about this, how you came up with it, and what you call it.
Dr. Gerard Bogin: Sure. I can’t actually take credit for it, Josh, it was when I was taking classes for my sports diplomate. One of the instructors, gosh, I can’t recall who now. One of the instructors was going over basic exams and couple different things. The way he introduced it to the class was basically that it was the legal minimum to be considered an exam was to hit all these different categories. It didn’t sort of sink in at the time, because it seems like stuff everything that we would normally do anyway. But when you’re out on the field, or when you’re at a sporting event, it’s a very different experience from when you’re in your office.
When you’re in your office, you have paperwork, you have everything set exactly how you like it, you just have to do it, you don’t have to really think. When you’re on the field, and someone runs up to you and their leg’s pointing the wrong way, things kind of get hectic fast. You tend to skip over parts, which isn’t really ideal when you think about in terms of a legal minimum. When I was studying for my test, what I did was, I condensed that doc’s information into an acronym that I call VIP NORO. Each letter is a category that lets you fulfill a basic standard for an exam.
Dr. Joshua Eldridge: What are some of the expectations for the exam from your standpoint? As a diplomate, why are they so important?
Dr. Gerard Bogin: There’s two ways to look at it, right? The basic way to look at it is the expectations for an exam is to get an answer to whatever the problem is at hand. Usually, athletes are presenting with something, your job is to find out what that is and what the next proper step is. The other side, the legal side, liability side is that truth is, you don’t get everything 100% correct. You need to hit legal minimums, a bare minimum for an exam. The way it was presented to me is if you cover each one of these categories in exam, you might not get the right answer, but you performed the bare minimum to fulfill your legal obligation.
Dr. Joshua Eldridge: Gotcha. Do you think this is important, a format like this just for diplomates, or do you think it throughout the chiropractic healthcare?
Dr. Gerard Bogin: Yeah, during the course, this was not presented as a diplomate specific requirement. This is basic legal requirement. Again, in your office, it’s easy because you just follow the paperwork. In the field, and you’ve been there, we worked in half-pipes together, and we worked on cold mountain when it’s negative 30 degrees. You know what? You don’t feel like taking a blood pressure or a pulse, but you know what, you don’t know what’s going on underneath that ski jacket, either. It’s important to have something to rely on, that you can count on when things are kind of going south quickly. That’s what this was designed to do. As long as you covered each letter, you’re gonna get a correct answer, and you’re gonna be protected, and the athlete’s gonna be protected.
Dr. Joshua Eldridge: Great, let’s go through each one of these, of our acronym of VIP NORO. What we’re looking for, and what we could consider normal, and what you document. Starting off with vitals.
Dr. Gerard Bogin: Okay. I’m just gonna prep this discussion with the fact that each category, each letter has an acronym to itself too. I know you love more military stuff. Each one has an acronym too. I’ll go down the list, and then I’ll give you each acronym, how about that?
Dr. Joshua Eldridge: Sounds perfect.
Dr. Gerard Bogin: Alright, so vitals. Vitals is easy, height, weight, blood pressure and pulse. That’s considered bare minimum for an exam. That one’s easy. Inspection, is visually inspecting the area of complaint whether if that’s a shoulder or knee, up the leg, the back, whatever it is. For that, I use the acronym ADD HAS which sounds kind of crazy, but it makes sense, I promise, because it’s easy to remember. ADD HAS means the way I view it is the problem sides should look similar to the non-problem side. As long as they match, you’re probably gonna be okay. But if not, you’re looking for the ADD HAS stands for A is asymmetry, D is deformity, D is discoloration, H is hypertrophy, anything like that. A is for atrophy, scars, swelling and other. As long as you go down that list, and you don’t notice any of those, you’re probably gonna be okay.
Dr. Joshua Eldridge: I like it. It’s too easy.
Dr. Gerard Bogin: Yeah, for the next piece, for palpation. For that, I use MAG+. Palpation is anything you can feel that might be going wrong. If it’s a fracture, chances are that’s gonna be pretty evident, and there’s gonna be so much screaming as you’re palpating or touching. MAG+ stands for Muscles, Attachments, Growth plates and other. Especially in younger athletes where you’re gonna have sometimes it’s hard, they’re more flexible, it’s hard to find something going on. Those are the areas you wanna test, especially with the younger athlete, you wanna make sure you palpate growth plates because that’s where they tend to have a lot of problems. Palpation is MAG+. All right, then N stands for neurovascular which I break down to ABCs and MRS.
All right, for neurovascular, A was for arterial, means peripheral pulses, got to make sure blood’s still go to whatever’s distal. B was for Babinski or Hoffmann’s, which is upper motor neuron lesion reflexes. Then C was cerebellar, because you never know what you’re gonna see out on the field, or even in your office. For cerebellar I always use Romberg. MRS is your classic muscle testing, reflex and sensory. Everyone knows that one, that was easy.
The one I did add, which I’m not even sure was in the original course was other, which I think was one of the ones that surprised me when I took the course, because maybe I never really thought of it this way, but truthfully whenever you’re dealing with a chief complaint in a certain region or joint, you really do need to test the joint or region above and a joint or region below, especially with younger athletes, because they do have certain things where you can have a hip issue that’s presenting as knee pain, or different things like that. That’s just a reminder that hey, just because they’re laying, their grabbing their knee, doesn’t mean they also didn’t hurt their hip or their ankle.
Dr. Joshua Eldridge: One of the things that you always told me is do a quick VIP NORO with the other two. Let’s say you’ve got a knee complaint, when you go to the hip, you’re doing a quick inspection, palpation, neurovascular, range of motion or a special test.
Dr. Gerard Bogin: Exactly, and then next is range of motion which everybody knows how to do, your classic range of motion that everyone learned in school or whatever the chief complaint is. The last one is orthopedic or special test which is, of course, everybody love to study and learn all the names, and all the specific tests which I guess nowadays everyone’s showing that don’t really work that as well as we were taught in school but just have to do it.
Dr. Joshua Eldridge: Right, and even now, they’ve even talked a lot about instead of coming up with these fancy names after somebody, the Gerard test or the Josh test, it’s more descriptive of what you’re doing.
Dr. Gerard Bogin: Which is the way it should be. However, I would totally be behind the Josh test, just so you know.
Dr. Joshua Eldridge: Going back through, we got vitals, inspection, palpation, neurovascular, other, range of motion, orthopedic, or special test.
Dr. Gerard Bogin: That’s it, VIP NORO.
Dr. Joshua Eldridge: It’s pretty versatile, this format. What body regions do you apply it to? In your daily practice, how does it look?
Dr. Gerard Bogin: Actually, you know what, it’s whatever the region or chief complaint is, I apply VIP NORO. If it’s a cervical spine, if it’s a shoulder, whatever it is, I think if you hit those categories, you’ve done a pretty thorough exam, you’re gonna have a pretty good idea what’s going on.
Dr. Joshua Eldridge: How do you link it? Do you use SFMA through your practice as well?
Dr. Gerard Bogin: Yes, I do.
Dr. Joshua Eldridge: Okay, how do you link it through that?
Dr. Gerard Bogin: It’s more like an additional add-on. Not that it’s not important, but SFMA gets more important with the level of athlete you’re dealing with. It is important that everyone I see gets some functional testing, but I don’t consider it part of the core VIP NORO because it’s an additional add-on, it’s not a legal minimum, how’s that?
Dr. Joshua Eldridge: Right, and I’ll add it in on range of motion. I’ll go through all the rest, and then I’ll add it in as my range of motion, and then look for the area, if there might be an area that’s causing the issue, the actual area of pain. That way, I know to go there and look after. That’s one thing I do.
Dr. Gerard Bogin: Actually, I kind of do that too because what I’ll do is if I’m doing range of motion, I will go through a full body weight bearing range of motion. I do mix in some of the SFMA. But you’re right, because I’m looking for where the problem might be coming from.
Dr. Joshua Eldridge: Right.
Dr. Gerard Bogin: But that’s also different from like if you have someone presenting with more of a gradual onset issue versus someone laying in front of you on the half-pipe that just bit it.
Dr. Joshua Eldridge: Absolutely.
Dr. Gerard Bogin: How tight their hips are when their ankle’s bent the wrong way.
Dr. Joshua Eldridge: Make them do a squat.
Dr. Gerard Bogin: That’s right. I need to see a we’re just gonna lift your leg here for a second.
Dr. Joshua Eldridge: When you’re linking these together with your history, talk to me a little bit about that. How you link it, how do you think they interact? What’s your kind of flow maybe?
Dr. Gerard Bogin: That’s a great question. To me, I think the history is the most important part of any exam. That’s where you’re getting a feel for what’s going on, how long it’s going on and what kind of patient is. To me, I think VIP NORO it stops me from skipping ahead. I tend to take pretty long histories because again, I think they’re the most important part.
Generally, you always thought you should have a good idea what you think’s going on by the end of the history, but sometimes I think as we’re busy in practice, or in the field or whatever you’re doing, you tend to think okay, well this has to be such and such. Let me just confirm it and we’ll move on. To me, VIP NORO makes me go through the steps to avoid skipping ahead. Does that make sense?
Dr. Joshua Eldridge: Absolutely.
Dr. Gerard Bogin: What’s on the air brakes for my enthusiasm for my chief complaint.
Dr. Joshua Eldridge: When I’m getting excited and I’m like working ahead, I always have Gerard’s voice in my head like, “Hey, VIP NORO. Get back to it, get back to the basics.”
Dr. Gerard Bogin: Yeah, that’s how I look at it too, it’s the basics. It prevents you from making mistakes.
Dr. Joshua Eldridge: Absolutely, and how do you work this into your documentation? What does your documentation look like when you get through this?
Dr. Gerard Bogin: Sure, actually, if you imagine a SOAP note for a regular treatment, subjective objective assessment. My exam is actually just blocks all the way down to VIP NORO. Vitals and then like I said, I have the different acronyms under each category. Inspection, I just have a whole list, ADD HAS, and then I make any notes in there. It actually is my exam.
Dr. Joshua Eldridge: In my system, when I work outside of the hospital, when I’m doing the work with my athletes, I have it set up in my system just like that. It makes it really nice for me as I’ve applied the VIP NORO to my documentation, so it makes it easy.
Dr. Gerard Bogin: You know what, it travels pretty well.
Dr. Joshua Eldridge: It does. Even you’ve had some quick tip sheets that you shared with me. I still take them with me when I go, and especially one of the habits that Gerard taught me was when you’re on the plane traveling to an event, they take your notes and go through it and refresh everything you do. That’s part of my refresher packet.
Dr. Gerard Bogin: I still do that every time.
Dr. Joshua Eldridge: You’ve given me a lot of great habits that hopefully we can share with other people. I think too, part of it was when you were helping me prepare for my diplomate exam, you grilled me pretty good. It was good information and it’s just stuck with me. Hopefully, we can pass this on to people, so they can have some of the things that they can do. We’ve kind of went over this before, but just tell us again why you think it’s so important for a thorough exam. Just hit some of those key points that you hit before.
Dr. Gerard Bogin: I think a thorough exam prevents you from overlooking some less obvious problems which could be a real complication. I mean, everything in your office is generally controlled. The chances of having a problem are a lot less. But in the field, no one says you have to have just one problem, right? You could have a knee injury with an internal bleed. You came over onto somebody and they’re grabbing their knee, and they said they twisted wrong and they’re pointing to the outsides. All right well, ligamentous injury or something along the line. If you don’t take the time and check the distal pulse, you might not realize, there’s a torn artery inside, too. What could have been just a quick life-saving trip to the hospital, now gets delayed and now there’s some real complications. I think a thorough exam helps you avoid overlooking things.
Dr. Joshua Eldridge: Do you mind if we do a practical exam? We’re gonna put you on the spot, no big deal. We’re at a basketball game, and we have a FOOSH injury and let’s just say an AC joint injury. Walk us through even if we bring them over the bench and you’re on the sideline, how would you go through this exam with this person?
Dr. Gerard Bogin: Since it’s a traumatic injury, first I’m just gonna check your basic EMT things. We’re gonna go through some A&O X3, did he also hit his head? Is he alert, oriented X3, just clear out any problems there, You don’t know why did he fall, did he get hit and then fall, what’s going on? That’s one of the things the exam does for you is it kind of steers you away from just isolating on a certain problem. Say he’s alert X3, no problems, you know, PERRLA, everything’s checking out neurologically. Okay, he’s pointing to the spot, if you wanna follow the exam, now I don’t have a technical question. Are you and I officially there, or did we jump onto health?
Dr. Joshua Eldridge: We’re officially there.
Dr. Gerard Bogin: We’re officially there, all right. That means I know that I’m gonna be able to do a couple things back in the locker room in a few minutes. I might do sort of a more cursory timeline exam, but I’m still gonna follow VIP NORO. I’m gonna get the vitals eventually, I might not just get them right there on the bench because of what’s going on.
I would inspect it and chances are if it’s an AC separation, we’re gonna see a bump, he’s gonna be pointing right to where it hurt. But inspection, one of the important things that I was always taught was amazing how many people don’t visualize the actual area with skin. They’ll just assume what’s going on underneath the shirt. I was always taught you have to get down and you have to visualize the actual joint, or whatever’s going on.
Basketball should be a big deal because they wear a basketball jersey. Inspection, I’m gonna look for all the things we talked about. Asymmetry, we’re gonna see a difference side to side, deformity, we’re gonna see an elevated AC joint, discoloration, we might start to see some swelling. Hypertrophy, we’re probably gonna see a little bit of that by now, and then probably a little bit of swelling going on. Then palpation, I’m gonna palpate a little bit. What I’m gonna do is it’s pretty obvious to what might be going on, but I’m gonna palpate that, but then I’m gonna start working my way north and south from there. I’m gonna palpate up, any of the musculature up to the cervical spine, although we’re gonna hold that off for other, but I’m just gonna palpate up. I’m gonna palpate down. I’m gonna check out what else might be going in the shoulder. Neurovascular, okay so now, we have a good idea what might be going on. Now I’m gonna check the distal pulse just to make sure that there’s still blood going where it needs to.
We’re gonna do Hoffmann’s just to make sure that when there is a fall, there’s not an upper motor neuron lesion or something more serious near the spine, and then Bromberg’s fast. We already have an idea because we sort of gave him a bench side neuro test, so I have a pretty good idea that those are gonna be okay. Then we go to range of motion, we’re gonna be really careful because we suspect what might be going on. I’m gonna probably just walk him through some real simple stuff. I’m just gonna do whatever I can to the point of tolerance just to see what we have. But most likely, I’m gonna be really careful because it’s traumatic and we don’t wanna make anything worse.
Then we’re gonna go to other. That’s where you avoid missing something else that might have happened. Now, I’m gonna do a quick range of motion, a couple of tests in the cervical spine, and then probably down on the elbow too, maybe even the wrist, because it was a FOOSH, right? You don’t wanna miss a possible fracture that he hasn’t even really kind of noticed yet in the wrist because he fell on it. We might even expand that out a little bit further.
Then range of motion we already talked about and then orthopedic special tests, I mean there’s gonna be some more of those that are probably gonna confirm what we’re thinking, If I’ve already felt a deformity and we have a pretty good idea what’s going on, I’m probably just gonna do some confirmatory test just to make sure. I’m gonna try not to piss him off too much because we’re probably gonna have to go get this athlete to the ortho and get some bracing, at least probably go to the hospital and get some x-rays.
Dr. Joshua Eldridge: Alright, and once you get up in the cervical spine, how in-depth do you get there? What would you do for your quick VIP NORO there?
Dr. Gerard Bogin: Same thing, it’s a little harder to do other in the lower extremity because the distance is greater but the shoulder’s so close because it’s the upper quarter. You’ve already pretty much visualized the cervical spine, but maybe I’m gonna take a closer look, make sure there’s no bruising developing, no swelling anything like that, that’s inspection.
Palpation, I’m actually gonna feel in there. I’m gonna see if there’s any tenderness, any difference side to side, we’re just gonna work our way down, make sure we’re not missing anything from the fall. Then we’re gonna do some range of motions. The cervical range of motion really shouldn’t affect the injury site, so I gotta be pretty thorough about that. I’m just gonna check through and make sure a young athlete like that as long as there’s nothing going on should have a pretty full range of motion cervical spine.
Dr. Joshua Eldridge: A quick example of some of this stuff was I was treating at a gymnastics meet and a girl went off the floor, overshot her landing. She came over the table with her coach and coach was like, “Yeah, she just kind of slid off the floor. Her shoulder hurts.” First thing I did was I took her vitals and her blood pressure was just crazy high, and her pulse was high. I’m like “What happened when you went off the floor?” She’s like, “I don’t know, I don’t remember.” So then we got into it a little bit more, and then it came out that she had a concussion.
Her vitals, after they went high, they just started to tank. There were actually EMTs at the meet. We did a seated to standing to backboard stabilization of the cervical spine. It was really cool. I’ve never done it before. She was sitting in a chair, so we stabilized her head and neck. As we were doing that, the fire department was coming in. That’s who ran the paramedics and the other EMTs. They were actually impressed with what we did. Once her vitals started tanking again, then we backboarded her and they transferred her.
Dr. Gerard Bogin: Did you put the collar on while she was in the chair?
Dr. Joshua Eldridge: We did. When it was in the chair, from there, we stabilized and stood her up and then we laid her back onto the backboard. It was like a standing to straight to laying down on the backboard. Those EMTs were high-speed, they’re great people.
Dr. Gerard Bogin: Yeah, EMTs are great. They don’t fool around. They’ve got a protocol and they follow it.
Dr. Joshua Eldridge: Yes, and that was one of the best meets that I worked at with EMTs, because they were like, hey that’s a sprained ankle. We don’t know what to do with it. We’re gonna put it in a boot and put them in the ambulance and that’s not necessary, you take care of that and then we had two or three actually where we had to call fire department to come in that meet, but they were great people.
Dr. Gerard Bogin: How many transports do you average at a gymnastics meet?
Dr. Joshua Eldridge: That one was rare. I don’t know if it was the time of the year or what the problem was, but that one seemed to be more often we’d have three or four almost every time on that meet. Usually, even on big meets, I was out at one in Las Vegas that had 5,000 athletes come. I think we had two where we called the EMTs to actually come in the ambulance. One girl, she was an elite girl. She went to a double back, so she did two backflips off a tumbling pass and landed off the floor, it was carpet, but it sat right on cement. She landed on that. I think we had to call the EMTs for her just because it was such a serious bilateral calcaneal fracture.
Just for her comfort, we did that. The other one was an awkward one where a girl had fallen and hit her head. She was just acting very unusual, so we called EMTs and they got there. As soon as the EMTs got there, she hopped off the table and was like, “There’s nothing wrong with me, there’s nothing wrong with me.” That was the weirdest encounter that I’d had up to that point with an athlete.
Dr. Gerard Bogin: I’ve had a couple of those. It’s amazing what change of attitude someone in a uniform will make, right?
Dr. Joshua Eldridge: Yeah, and the problem was, she started to hyperventilate and she wasn’t able to calm down. But then once they got there, her parents were not happy, to say the least.
Dr. Gerard Bogin: At you or at her?
Dr. Joshua Eldridge: No, at her. They were very upset at her just because of the way she was acting.
Dr. Gerard Bogin: That’s really strange. You know what, getting back to our basketball example which is actually perfect because again you and I, we’re at the game. We’re watching the athlete, so we have a good idea what’s going on. It’s not like we walked up onto a trauma. In the example, I would have gone through that bench side and I would have determined if it was an emergency case that had to be rushed off or something that was gonna be treated in-house, in which case then I would take them back to the locker room, then I would be a little more thorough where I would take the vitals. I would go through everything a little bit more as opposed to just the bench side where you had to determine if it was gonna be a transport or not.
That’s what VIP NORO does because I wouldn’t let that athlete leave my care until I had all those categories still. I might not have gone in the exact order because of the situation, but I definitely would have gotten, and technically you would normally take them every 15 minutes. If it was a transport, we would go back to locker room and I would be taking them in every 15 minutes until the EMT showed up.
Dr. Joshua Eldridge: Well, that’s pretty cool, Gerard. I think that’s pretty solid what we got.
Dr. Gerard Bogin: We did okay, Josh?
Dr. Joshua Eldridge: Yeah, I think so. Thanks for joining us. Any last thoughts you wanna leave with us?
Dr. Gerard Bogin: No, I wish I did. I wish I had some original thoughts, but pretty much everything I’ve got is from somebody else that I just condensed to my own need. You gotta kind of thank everyone that went before you.
Dr. Joshua Eldridge: And just like that, I got it from Gerard. He’s been instrumental in just helping me develop those protocols that I use today and even out on the field and with athletes. Every time I talk to him, it’s amazing because it just gets me back to the basics, and that’s so important for us as docs is to get back to the basics and don’t forget these things every day.
Dr. Gerard Bogin: I agree, basics are important.
Dr. Joshua Eldridge: Yes, do you have a place where people can get in touch with you, or do you have any social media for anything you do?
Dr. Gerard Bogin: You mock me, Josh. I do not have any social media Josh, but I do have all my contact infos on my website, athletesonlyperformancetherapies.com. Anyone wants to get ahold of me or any of you doc’s who want this information, I’m always happy to share, by all means, shoot me an email, I’ll give you whatever we have.
Dr. Joshua Eldridge: All right, thanks Gerard for joining us.
Dr. Gerard Bogin: All right, Josh.
Dr. Joshua Eldridge: Getting your exam right is important to make sure you properly diagnose your patients and reach the legal standard for exam completion. Dr. Gerard Bogin laid out an easy-to-use format with the acronym VIP NORO. We’ve created a resource of three exams, upper extremity, lower extremity and torso that you can download at chiropracticepro.com/episode4.
Again, that’s chiropracticepro.com/episode4. Thank you again for joining us. My name is Dr. Joshua Eldridge, and I’ve been your host for this episode of the ChiroPractice Pro podcast. We’re looking forward to seeing you next time right here. Have a great day and enjoy being a leader in your practice and in your community.