January 2018 - chiropracticforward

Month: January 2018

CF 006: With Dr. Tyce Hergert: Astounding Expert Information On Immediate Headache Relief

This episode is all about headaches, it highlights one service dressed up and parading around as another sort of like it’s Halloween or something, and we’ll tell some personal stories about what we have seen in practice during our years of service to our patients. It should be a good one.

We are excited to welcome Dr. Tyce Hergert to the Chiropractic Forward podcast. Dr. Hergert has the distinct privilege of being the very first guest that we’ve ever had. Dr. Hergert was the Texas Chiropractic Association President, the head honcho, for 2016/2017 and, under his leadership the TCA was able to get 5 Chiropractic friendly bills through the legislation whereas we had failed to get even one through in all the years prior to that as far back as I had paid any attention so that was quite a feat.

Dr. Hergert is the owner/operator of Chiropractic Care Center of Southlake as well as the owner/operator of Southlake Physical Medicine in Southlake, TX

In addition, Dr. Hergert and myself both grew up in Perryton, TX. He was a couple of years younger than myself but we grew up on the same neighborhood, went to chiropractic school at the same time roughly, and have both served in the Texas Chiropractic Association at the same time. You could say that we know each other.

Welcome to the Chiropractic Forward Podcast Dr. Hergert. How do you feel about being the very first guest that we have ever had?

In this episode, I promise that we’re going to have more fun than being on the receiving end of a purple nurple.

This week, I want to discuss headaches and conservative, alternative headache treatment. It’s common for people to look at chiropractors as “spine people” and “back doctors”.

Is that your experience as well, Dr. Hergert?

What people don’t commonly know is that chiropractors can knock it straight out of the park when it comes to treating headaches. Yes, I said, “Knock it out of the park.” That’s an old metaphor comparing baseball players hitting home runs and I’m telling you, chiropractors mostly hit home runs on headache cases.

I have to admit that I was a terrible baseball player. I played college football and I’m Texan born and raised where football is King so I should probably put it in football terms.  In football terms, you might say that we chiropractors have a record of 80-yd touchdown passes when it comes to headaches. We return headache punts for a score almost every time. We pick-six those suckers. That’s probably enough to drive the point home.

Not every single headache of course. I’ve met my match several times over my 20 years in practice. But I don’t think it’s too bold to say that about 80%-90% of headache patients just improve. And not just improve, but DRAMATICALLY improve.

Before we get into the research, let me take a minute to give you just a couple of personal experiences in treating headache patients in my practice here in Amarillo.

Case #1: We will call this patient Andy McFuddlesticks just because I’m feeling a little goofy today. That sounds a little like a Harry Potter character, doesn’t it?

Andy had experienced migraines his whole life and was around 40 years old at the time we crossed paths. He had been to all of the medical doctors. He had endured injections if his suboccipital region. I don’t recall what the injection was exactly because this was about 18 years ago. I don’t believe they did botox for migraines at that point in time. He had gone through nuclear bones scans as well. Andy McFuddlesticks had been through it you might say.

He came to see me only a few times. It was frustrating that he didn’t finish his treatment plan but the reason he didn’t finish is satisfying. Andy only came a handful of times because the headaches were gone. After all of the years and procedures, just a few visits to a very new and green chiropractor made them vanish. How do I know? Well, I was in a civic organization with his brother who confirmed months later that his brother was doing great and had not had a headaches since seeing me. How is Andy 18 years later? I have no idea. I switched towns but I know he did great for a long time and we are putting that one in the “win” column.

Dr. Hergert, would you like to share one of your more memorable headache case stories with us?

Case #2: Sally McGullicutty I believe was her name. Red hair. Irish. Anyway, Sally had migraines for years. I actually knew Sally personally and had been friends for some time. Evidently I was not skilled at getting my message out on how successfully we can deal with headaches because it took Sally way longer than it should have taken her to make an appointment with us.

Sally shared with me that she had migraines, on average, several times a week and once or twice every month would find herself in a dark bathroom floor sitting my the toilet throwing up. How awful of an existence is that? I cannot even imagine being forced to live that way. I say it often but it bears repeating, “Pain can absolutely change a person.” Not only the person but it can change everyone around the person that is consistently in and out of contact with them.

After approximately 2-4 weeks of working with Sally, she just started to not have the migraines anymore! I would say she “magically” recovered but chiropractors know this isn’t accurate. We got the right joints moving, we got the right muscles to relax, and we got out of the way and let the body do the rest. There’s no magic in that. It’s just common sense to chiropractors.

Fast forward a few years and Sally is still a patient and Sally comes here for other reasons and conditions from time to time but she doesn’t visit because of migraines anymore. She just doesn’t have them.

How about one more story Dr. Hergert?

I’m pretty sure we could both absolutely go on and on with examples from personal experience in practice. I have 20 years of dealing with headaches and I can tell you, Chiropractors are modern day headache whisperers.

Let’s dive into a little research just to show you what I’m talking about. There are more we will go over in the future episodes but I want to touch on two this week. One new study and one older.

The first one is the more recent research paper and comes to us from a group in Spain. The lead author was Miguel Malo-Urries, PT, PhD with the University of Zaragoza Aragon Spain and it was published in Journal of Manipulative and Physiological Therapeutics in the November-December 2017 issue, Volume 40, Issue 9, Pages 649-658. The study was titled “Immediate Effects of Upper Cervical Translatoric Mobilization on Cervical Mobility and Pressure Pain Threshold in Patients With Cervicogenic Headache: A Randomized Controlled Trial.” What a name.

Did you catch that word, “Translatoric?” Dr. Hergert, have you run across this term prior to this interview?

I’m going to define that word for everyone. Translatoric is not commonly in the Chiropractic verbiage or vernacular. At least I don’t recall it from my education at Parker University in Dallas but that was eons ago. I have gray sideburns now. It has been a while. The authors of the paper all have PT behind their names so we have physical therapists setting the terms for the research project. Understanding this, then the use of translatoric makes more sense.

I found a site that gives a pretty good definition of Translatoric Spinal Manipulation. The term Translatoric Spinal Manipulation or TSM “consists of a series of high and low-velocity manipulative spinal techniques, which emphasize the use of small amplitude, straight-line (or translatoric) traction and gliding impulses delivered parallel or perpendicular to an individual vertebral joint or movement segment. Furthermore, TSM emphasizes the use of either direct manual stabilization or the use of spinal pre-positioning to restrict the amount of motion occurring at adjacent spinal segments during the translatoric impulse.” The website goes on to say, “Delivering translatoric impulses (in the form of disc traction, disc glides, facet traction and facet gliding) to an individual joint or spinal motion segment while using stabilization provides the manual therapist with a manipulative tool that has a predictable effect in terms of pain reduction and motion restoration with minimal potential risk of patient injury.”

Do you know what that sounds like to me? Dr. Hergert, what does it sound like it’s describing to you?

It sounds like a “Chiropractic Adjustment.” Another term it sounds like is “Spinal Manipulative Treatment/Therapy.” Something we chiropractors have been doing for over 100 years and have been called crazies and quacks for doing. It sounds like the exact thing that the medical world has touted as being responsible for strokes for years and years. Of course, research proves that they don’t have a clue what they’re talking about on the storke issue but translatoric spinal manipulation is nothing more than a Chiropractic Adjustment.

Now that that is clear, let’s get back into the research.

Why They Did It

The good folks in Spain performing Translatoric Spinal Manipulation rather than Chiropractic Adjustments wished to assess the response in terms of range of motion and pain in patients suffering cervicogenic headaches.

How They Did It

  • It was a randomized controlled trial
  • The paper included 82 patients.
  • The patients ranged in age from about 25-55 or so.
  • All patients suffered from cervicogenic headaches.
  • The patients were randomly split up into two groups. One was a control group and one was a treatment group.
  • The treatment group received Chiropractic Adjustments…..I’m sorry…Translatoric Spinal Manipulation.
  • The control group received no treatment or sham treatment.
  • The researchers tested Cervical range of motion, they tested the pressure pain thresholds over the upper trapezius muscles, the C2-3 zygapophyseal joints and sub occipital muscles were tested, and the current headache intensity were all measured on the Visual Analog Scale prior to the Chiropractic adjustment and right after.
  • The testing was done by two blinded investigators

What They Found

  • Afterward, the Chiropractic Adjustment group had significantly increased range of motion in the neck region overall as well as in the flexion-rotation test.
  • And, while there was no changes in the pain thresholds, patients reported significantly lower intensity in their headaches!

Wrap It Up

The quote from the authors themselves reads as follows, “Upper cervical translatoric spinal mobilization intervention increased upper, and exhibited a tendency to improve general, cervical range of motion and induce immediate headache relief in subjects with cervicogenic headache.”

Dr. Hergert….do the findings in the study surprise you at all?

What are your initial impressions of the study?

I’d say that, if you have issues with chiropractors, now you can just take it straight from physical therapists with PhD’s that are performing chiropractic adjustments but calling it something else.

I want to be honest here: the frustrating part of this for me isn’t necessarily the fact that PTs are doing cervical chiropractic adjustments. Heck, chiropractors have been doing PT for years but the physical therapists claim ownership of the term so the chiropractic industry just call it exercise rehab.

Although, their doing adjustments may be irritating on some level, the most irritating thing is that a certain aspect of the physical therapy community and a larger aspect of the medical community have spent years ridiculing, mocking, and belittling generations of chiropractors. And now, doctors of osteopathy and physical therapists are trying to do the exact same thing without going through any chiropractic training. You would think they would at least release a statement saying, “You know, we have thrown rocks at chiropractors for years but it turns out they were right all along so, since we can’t beat them, we’re going to just join them.”

Wouldn’t that be refreshing?

Can I get an amen on that Dr. Hergert? Do you have any other thoughts on that?

I’m geting all bothered over here so let’s go over the older study before I start getting too ugly about the whole deal.

This one is by GV Espi-Lopez et. al. and is called, “Do manual therapy techniques have a positive effect on quality of life in people with tension-type headache? A randomized controlled trial.” It was published in the European Journal of Physical and Rehabilitation Medicine  on February 29th of 2016.

Why They Did It

Although there have been lots of studies that prove the impact of manual therapy and spinal mobilization for frequency and intensity of pain suffered from tension type headaches, there have been no studies in regards to the effectiveness of the same therapies for the quality of life for the people suffering from them.

The authors of this paper wished to focus on patient quality of life.

How They Did It

•The study was again, a randomized, single blinded, controlled clinical trial.

•Comprised of 62 women and 14 men.

•Aged between 65 years old all the way down to 18 years old.

•All subjects suffered from chronic tension type headaches or episodic tension type headaches.

•The subjects were categorized into four separate groups: suboccipital inhibitory pressure, suboccipital spinal manipulation, a combination of the two together, and then a control group.

•An SF–12 questionnaire was used to help assess the subjects’ quality of life at both the beginning of treatment, the ending of the treatment, as well as at the one month follow-up.

What They Found

•The suboccipital inhibition group improved significantly in their quality of life at the one month mark as well as improvements in moderate physical activities.

•Not the control group, but all other treatment groups had an improvement in physical activities, pain, and social functioning at the one month mark.

•After treatment, as well as that the one month mark, the combined treatment category had improved vitality.

•Following treatment and at the one-month mark, both groups that had manipulation to the sub occipital region also showed improved mental health.

Wrap It Up
All three therapy approaches showed significant effectiveness toward improving the quality of life, however the combined treatment therapy had the most dramatic change for the good.
In short, manual therapy techniques and manipulation applied to the sub occipital region for four weeks or more showed great improvement and in effectiveness for several aspects that measure the quality of life of a patient having suffered from tension type headaches.

Dr. Hergert…you like apples? Lol Do these findings reflect what you have seen over the years there in Southlake, TX?

These are just a couple of studies to get us started off on the right foot for headache discussions on the Chiropractic Forward Podcast. There are several more I will be sharing in the future so stay tuned.

When Chiropractic is at its best, you cannot beat the risk vs reward ratio. Plain and simple. Spinal pain is a mechanical pain and responds better to mechanical treatment rather than chemical treatment such as pain killers, muscle relaxants, and anti-inflammatories.

I mentioned this in episode #1 but Dr. Hergert and myself spend some time trying to generate a concise, responsible statement regarding chiropractic care in general. A statement that could easily be shared. An elevator speech for the profession if you will. You will find it at the end of every blog, every video, and every chiropractic forward podcast. It is as follows:
Research and clinical experience shows that, in about 80%-90% of headaches, neck, and back pain, in comparison to the traditional medical model, patients get good or excellent results with Chiropractic. Chiropractic care is safe, more cost-effective, it decreases your chances of having surgery, and it reduces your chances of becoming disabled. We do this conservatively and non-surgically. In addition, we can do it with minimal time requirements and minimal hassle on the part of the patient. And, if the patient develops a “preventative” mindset going forward from initial recovery, we can likely keep it that way while raising the general, overall level of health!

Thank you to Dr. Hergert for spending his valuable time with us today. We look forward to many more guest appearances.

Please feel free to send us an email at dr dot williams at chiropracticforward.com and let us know what you think or if you have any suggestions for future episodes.

From Creek Stone in Amarillo, TX and the flight deck of the Chiropractic Forward podcast, this is Dr. Jeff Williams saying upward, onward, & forward.

https://www.jmptonline.org/article/S0161-4754(16)30281-0/fulltext?elsca1=etoc&elsca2=email&elsca3=0161-4754_201711_40_9_&elsca4=Physical%20Medicine%20and%20Rehabilitation%7CHealth%20Professions

https://www.optp.com/Translatoric-Spinal-Manipulation-for-Physical-Therapists-Book-and-DVD

https://www.amarillochiropractor.com/get-rid-of-migraines-and-headaches-once-and-for-all/

CF 005: Valuable & Reliable Expert Advice On Clinical Guides For Your Practice

This weeks’s entry is going to be a little long and it’s definitly more geared to chiropractic practitioners rather than patients or potential patients. Unless you are a patient that is just a little bent toward practice protocols and I just don’t know very many of those types of patients. I can see where a patient may be interested in this week’s edition if they feel they have received poor treatment in the past I suppose but most patients likely won’t be interested this week.

Welcome to episode #5. We’re on a roll folks. We’re going to have more fun than walking on hot coals today.

Have you ever been in practice, especially in the early years, wondering if you’re doing things right? I mean, they taught you how to diagnose. The taught you how to evaluate and adjust. But what about all of the gaps in between? Did you get it all and, if you got it, did it stick? Did you retain it? We all have questions about certain issues. If you aren’t always learning and asking yourselves questions, then I would suggest that you do. I believe that’s how we grow.

In this episode we are going to try to help answer some age-old questions that many chiropractors get out of school not necessarily knowing the answers to. We are going to cover recommendations on how often, what, why, and how for your practices. It should be interesting for most of you. That’s my hope anyway. So buckle up.

Many of us in the chiropractic profession tend to wonder around on our own islands for years without any sort of mentorship or guidance. If I’m being honest, and I am, I was that way myself until about 11 or so years ago when I decided to start paying attention. In fact, there are still times I find myself researching the latest standards of practice and guidelines to make sure that I am not an outlier in my profession without even realizing that I’m an outlier. Healthcare tends to change so quickly that it is a scenario I would assume occurs more often than we think.

This sort of information can admittedly be monotonous and can make your eyes bleed if you allow. Some LOVE to dive into long text and technical terms but I’m guessing most do not. That is why I am offering it in different forms.

Different people communicate in different ways. Some prefer email. Some prefer texts. I like videos while others prefer blogs. Podcasts, Reddit, etc… It’s all a part of communicating in the best, most effective way possible. With this in mind, I offer you this information in blog form, on YouTube in a video, and in Podcast form in the hopes that you guys and gals out there can digest it and maybe even RECEIVE it rather than just simply take note of it, before moving on to something else.

The impetus for this week’s information comes from a blog I read that was recently published on the American Chiropractic Association’s blog. You can find this at www.ACAtoday.org/blog. The blog was posted December 28, 2017. It was titled “Research Review: Clinical Practice Guideline: Chiropractic Care for Low Back Pain,” and was submitted by Dr. Shawn Thistle(1). Dr. Thistle is the founder of RRS Education which is a continuing education company providing weekly research reviews. Much like we do right here on my blog, on YouTube, or as part of the Chiropractic Forward Podcast.

I have used Dr. Thistle’s article here as the template and simply “overdubbed” and commented on it as I went through it.

In this article, Dr. Thistle reviews a research paper called “Clinical Practice Guideline: Chiropractic Care for Low Back Pain,” The lead author and researcher for the paper was Dr. Gary Globe who has a Masters in Business, a Doctor of Chiropractic, and a PhD.  The paper was published in the Journal of Manipulative & Physiological Therapeutics in Volume 30, Issue 1, in 2016(2).

Basically, we are doing a review of a review. You may wonder why this is even necessary to do on my part. I feel it’s necessary because I believe my calling is to take more difficult or more boring concepts, terms, and ideas and to then strip them down into a very understandable and more palatable form. A transfer of information, if you will. Hopefully I can get that information distributed to folks that need it. If we just left it at this blog, it is my assumption that the people that really need the information may not get it. In other words the people that read the American Chiropractic Association’s blog probably have already familiarized themselves with much of this information. However, people that do not read their blog likely do not keep up with Chiropractic research either. If they’re not involved, then they’re just not involved usually. They may be outliers in the profession because they have likely never been exposed to this sort of evidence-based information.

I’m hoping that’s where I come into the picture.

First, why would chiropractors be interested in guidelines of any sort? I would share with you that a frustrating part of our profession for me personally is that there seems to be no standardization that is widely followed or respected by chiropractors as a population. Some practitioners in Chiropractic may think that’s a great thing and that that’s what is unique about Chiropractic. I am of the thought that it’s a good thing when you go to a practitioner of any style and you can feel comfortable knowing there are professional standards of care being followed by your caregiver. It’s when practitioners have not educated themselves or have not at least been somewhat in tune to what’s going on in their profession that they may start to be considered outliers and can run the risk of getting themselves into some sort of trouble professionally. Nobody wants that.

Let’s be clear; following guidelines don’t mean that the practitioner has no autonomy or that there is no professional decision-making going on. They are just that: guidelines. General guidelines that not only help your decision-making process, but also give you something to refer to should there be any questions down the road about your treatment plans or protocols. I call that “standing on solid ground.”

When you have so many webinar and seminar folks trying to scare chiropractors into buying their courses and marketing to them by triggering the fear of either being sued or jailed if they don’t buy, well….standing on solid ground is always a bit liberating.

Be honest here, how does it look when one chiropractor tells the patient they need to be seen 55 times this year and this happens just one or two weeks before a doctor with the second opinion says the standards of practice require 18 visits over the next 2 months or so for the same issue? Of course, that reflects poorly on the first chiropractor but wouldn’t you agree that it also reflects poorly on Chiropractic in general?

I am in no way saying that there are not conditions requiring 55 visits so don’t send me any hate email. I’m simply using a generalized example here. I’ve always felt that treatment should have a start, it should have a finish, it should be responsible and smart recommendations, and upon completion should enter the maintenance phase. If we aren’t giving good recommendations, Then we simply are not doing our job. But it’s also my opinion that if you’re not staying on top of research and current standards of practice, then that also means you’re not doing your job.

Now that we talked about standards of practice and guidelines, let’s dive into this research and guideline summary.

Why They Did It

Everyone should know by now that low back pain is the leading cause of disability around the world. Research has continued to show over and over that chiropractors are highly effective when it comes to low back pain. Even traditional chiropractic haters, at this point, mostly concede the fact. The goal of this research project seems to be focused on providing some sort of standardization and guideline protocol for an easier and smoother transition into an integrated setting in the medical world. The project focused on nonspecific low back pain.

How They Did It

The authors underwent a comprehensive search of the literature. They found 270 relevant articles. After screening the 270 articles, only 18 where accepted for the paper. Of those 18, sixteen of the papers were accepted as high-quality.

Here’s where we get into the thick of it. They break their points down into the following categories: general considerations, informed consent, severity and duration of conditions, examination procedures for lower back pain, treatment frequency and duration, initial course of care for low back disorders, re-evaluation and re-examination, benefit vs. risk, contraindications and cautions, and chronic pain management for spinal disorders.

Let’s dive into those sections a little further point by point and try to make some sense of it all.

General Considerations. 

  • If a patient gets chiropractic treatment in the acute pain phase, they usually have full recovery of the complaint. Even though they may have full recovery, recurrence of the pain can be common.
  • If not treated properly in the beginning, it could turn chronic with increased disability.
  • Practitioners, at all times, should be mindful of red flags and yellow flags. In case you don’t know, yellow flags are usually associated with chronic pain or disability. Some examples may be negative coping strategies, poor self efficacy beliefs, fear of avoidance behavior, and distress. That’s according to Dynamic Chiropractic, Nov. 30, 2002, Vol. 20, Issue 25 by Craig Liebenson, DC. Patients with high yellow flag scores should not be labeled with an injured back. For example, telling the patient they have a ruptured disc may not be the best idea. Your treatment should reduce dependency on medication and encourage active treatment rather than passive treatment and should include self-treatment protocols(3).
  • The authors of this paper feel that the goal of chiropractic should be improving the patients’ functional capacity as well as educating them to accept responsibility for their own health.

Informed Consent: Chiropractors often get into trouble because they lack a proper informed consent procedure.

  • Basically, informed consent is communication between your office and a patient that results in the patient giving you authorization for treatment.
  • An informed consent should include a clear explanation of the diagnosis, of your examination, and what you propose to do as far as treatment. This should include treatment options and possible risks involved.
  • If the person appears to be of sound mind to perform an informed consent, you have satisfied recommendations, assuming they have no further questions.

Examination Procedures for Low Back Pain:

  • While there is no limit to what the examination includes, there should at minimum be a health history, an examination that includes range of motion, orthopedic tests, and/or neurological testing, and further diagnostics when indicated. These may include lab tests or imaging.
  • This report says that range of motion should not be used to determine a person’s functional status but can be used as part of the exam to assess regional mobility.
  • As part of the exam process, they don’t recommend routine imaging for diagnostic tests in cases of nonspecific low back pain.
  • With that being said, if serious pathology is suspected or if someone is having neurological issues associated with it, then of course further diagnostics would be appropriate.
  • While the authors are not proponents of regular imaging, MRIs are indicated when the low back complaint is associated with symptoms of stenosis or radiculopathy.
  • Another condition in which a practitioner may consider getting imaging would be when the patient has not responded to a reasonable, responsible short-term conservative protocol or if you have reason to suspect something else is going on such as spondylolisthesis.

Severity & Duration of Conditions: this is a really simple section that can cause confusion by those that have just never had the information or have forgotten it.

  • An acute complaint refers to something that has been experienced for less than six weeks (1.5 months).
  • A subacute symptom has lasted between six and 12 week (1.5 months to just under 3 months).
  • A chronic condition is something that has lasted 12 weeks minimum (3 months).
  • A recurrence means the return of the symptom that is suspected to be similar to their original complaint.

Treatment Frequency & Duration:

  • The authors indicate that most patients respond to your care but that the treatment frequency and duration may change depending on the patient themselves. They may have other issues including red and yellow flags that extend, or alter in some way, the duration or the frequency of treatment. Again, the practitioner must always be mindful of the red and yellow flags.
  • The paper suggests that the effectiveness of care should be evaluated both subjectively and objectively during or after each course of care. In our office we use the Functional Rating Index (FRI) every single day upon the patient’s arrival. We also use outcome assessment questionnaires fairly often. We use them for a baseline during the initial treatment, again at each re-examination, and then again upon the conclusion of the treatment schedule. In addition to that, our patients are asked to rate their pain on the Visual Analog Scale (VAS) for each complaint at each visit. It takes seconds. Yes, it’s subjective and can have a wide variance from day to day for the same person but, when you are keeping these types of records, you are standing on more solid ground if anything about you or your treatment ever comes into question. Not to mention, it’s just better for the patient to be kept track of in this manner.
  • Here is a quasi-answer to a big question. The question I’m referring to is, “How often should I see someone?” Well, the full answer is not in this paper but there are hints at it. The researchers here suggest that a therapeutic trial of chiropractic is usually between 6 and 12 visits that takes anywhere from 2 to 4 weeks to complete. That seems to be about the average. For further insight into generally accepted treatment protocols, you may try looking at the Council on Chiropractic Guidelines & Practice Parameters (CCGPP) guidelines(4).

Initial Course of Care for Low Back Disorders

  • The best evidence of efficacy is in High Velocity/Low Amplitude manipulation and in mobilization. 
  • A good starting point in care is passive physiotherapy like electric stim, cold laser, ultrasound, etc for pain. Additionally a practitioner should attempt to educate the patient about their complaint and set in place recommendations for self-management of the complaint.
  • As the authors state, physiotherapy shouldn’t be used individually or isolated as the lone means of treatment. As I tell my patients, “There is a mountain of evidence for manipulation/mobilization, for certain physiotherapies, and for exercise/rehab but the best evidence show the greatest effectiveness comes from the three being combined and integrated into a treatment protocol that is reasonable and makes sense.” How it is used will come down to practitioner judgement and patient preference.
  • The authors here state that they cannot recommend the use of lumbar supports like bracing, taping, or orthoses because the research just isn’t there to support it at this time.
  • Active care, otherwise known as exercise/rehab, should become a bigger and bigger part of all chiropractic clinical protocols. I often will try to relate this to patients in a way that make sense in the medical world. When appropriate I may say something like, “What happens on the day after someone has a knee replacement, appendectomy, or a C-section? They have them up walking, which may seem counterproductive to do so soon after a surgery. In fact, for low back pain, a common recommendation used to be to go home, get in bed, and wait it out. But, they realized that movement is healing. Part of the healing is getting the joints moving properly through manipulation and joint mobilization but that’s just part of it. Another big aspect of it is exercise/rehab; both here in the office and at home.” Chiropractic practitoners need to stress it.
  • The more you explain why you want them performing exercise/rehab and the more you stress that exercise/rehab is part of the protocol from the very start, the less resistance you tend to run into later down the road.

Re-examination & Re-evaluation

  • After your initial recommendations are fulfilled, then what? You need to determine whether any further treatment is indicated and why it’s indicated. What was the patient’s response to your care?
  • If you threw everything in your office including the kitchen sink at someone for 2-4 weeks for 6-12 visits and saw little to no improvement, do you think any further treatment is likely to bring about positive change? Not very likely. It’s times like these that I swallow my pride and, in the best interest of the patient and my reputation, I find them a referral to a reputable practitioner that may be better-suited to address the complaint. I wouldn’t want a family member of mine treated any differently so I don’t treat patients any differently.
  • On the other hand, if the patient’s complaint is resolved, you should perform a final exam and outcome assessment questionnaire, make sure the patient is adequately educated on your recommendations going forward (exercise, maintenance care, etc.), and then release the patient from the active care protocol.

Benefit vs. Risk

  • The authors state that chiropractic care is remarkably safe and effective. Certainly when compared to our medical counterparts. Even though we all know this already, it never hurts to re-state the obvious. I hope you don’t mind.
  • The paper says that serious adverse reactions to chiropractic care tend to only happen to the tune of 1 in 1 million patient visits when referring to treatment for low back pain.
  • The authors went a little further by saying that, while adverse reactions were very rare, other more mild-moderate events were noticed like muscle soreness or stiffness. We see this in my office here and there as well. If they have never been to a chiropractor and then get sore after the first one or two visits, one could compare that to going to the gym after laying off for an extended time. You are doing something new and something different with the body. It makes sense for people to get a little sore sometimes.

Contraindications & Cautions: have you always been completely aware and knowledgeable on what constitutes a hard contraindication to chiropractic care? The authors try to help us all out here so listen up. This is a biggie. Since I feel the importance of knowing these are paramount to your longevity in practice, I am going to quote these conditions directly from the source(1) for accuracy. Don’t be caught having treated these conditions. 

  • General Conditions: severe osteoporosis, multiple myeloma, osteomyelitis, local primary bone tumors where osseous integrity is questionable, local metastatic bone tumors, Paget’s disease.
  • Neurological Conditions: progressive or sudden neurological deficit (including cauda equina syndrome) or spinal cord tumors demonstrating neurological compromise (care may be appropriate after specialist investigation and clearance)
  • Inflammatory Conditions: rheumatoid arthritis in active systemic stage (or locally in the presence of inflammation or atlantoaxial instability), inflammatory phase of ankylosing spondylitis or psoriatic arthritis, or Reiter’s syndrome (reactive arthritis).
  • Bleeding Disorders: congenital or acquired, unstable aortic aneurysm, etc.
  • Other: structural instability, inadequate physical exam, or inadequate SMT training/skills

Chronic Pain Management for Spinal Disorders:

These conditions can no longer be referred to as “acute” or “uncomplicated” as they are beyond 3 months in duration at the point of being labeled “chronic” and other factors must be considered in a robust treatment protocol. Some complications may include:

  • Work environment, including ergonomics
  • Work requirements
  • Comorbidities. Some may wonder, “What the heck is that?!?” Well, that is when you have two or more other conditions occurring in addition to the initial diagnosis. Low back pain in addition to arthritis and diabetes is an example. Low back pain in addition to obesity and depression could be another.
  • The history of the condition’s prior treatments
  • Lifestyle factors including bad habits
  • Other psychological factors which may include depression, anxiety, etc….

Whew….that was a lot, right?

With such an amount of information to wade through, I would say, that Dr. Thistle did a great job of reviewing this paper for the American Chiropractic Association’s blog and I hope, in turn, that I have been able to bring even more clarity and maybe even relate it to my personal practice and your practice in a way that really drives home the need for more regulation and practice standards in our profession.

As the internet and the “Age of Information” has brought the world together, I believe the days of being a lone wolf and/or being an outlier may be numbered. When they say that ignorance is not a defense, that especially rings true now that information is at our very fingertips at all times of the day no matter where we may be.

You may agree with me that this is a good thing. You may disagree and think I’m off my rocker for wanting some standards in the profession. Chiropractic practitioners differ from one to the other. That’s OK. Differences in opinions is American to the core. Usually what triumphs is reason and, if you find these guidelines or those of the CCGPP to be reasonable guides, I hope you will consider giving them more thought and maybe even implement them into your regular treatment protocols.

Regardless of how you go about practicing, I’m a firm believer that we chiropractors can absolutely change the world when it comes to the treatment of non-complicated neuromusculoskeletal conditions of the body. Not just low back pain either, but the whole shibang. As I said last week, if we were wrong in what we do as a profession, we would have been wiped off the face of the Earth years ago. Lord knows they tried and keep trying.

We are still here because we are naturally right but, we give our detractors ammunition for the battle when we are not holding ourselves and our profession to certain reasonable and responsible standards.

I hope you will stop by our websites and get involved with what we are doing. chiropracticforward.com is our podcast site. We have years of research-based blogs available right now at amarillochiropractor.com/blog as well. Not to mention our YouTube channel which can be found by searching Creek Stone Integrated Care Jeff Williams in a YouTube search. Find Chiropractic Forward on Facebook as well as Twitter which is @Chiro_Forward. Subscribe, share, and do all the things that help us grow and spread our message.

When Chiropractic is at its best, you cannot beat the risk vs reward ratio. Plain and simple. Spinal pain is a mechanical pain and responds better to mechanical treatment rather than chemical treatment such as pain killers, muscle relaxants, and anti-inflammatories.

Just another reason to call a chiropractor TODAY!
Research and clinical experience shows that, in about 80%-90% of headaches, neck, and back pain, in comparison to the traditional medical model, patients get good or excellent results with Chiropractic. Chiropractic care is safe, more cost-effective, it decreases your chances of having surgery, and it reduces your chances of becoming disabled. We do this conservatively and non-surgically. In addition, we can do it with minimal time requirements and minimal hassle on the part of the patient. And, if the patient develops a “preventative” mindset going forward from initial recovery, we can likely keep it that way while raising the general, overall level of health!

Please feel free to send us an email at dr dot williams at chiropracticforward.com and let us know what you think or if you have any suggestions for future episodes.

From Creek Stone in Amarillo, TX and the flight deck of the Chiropractic Forward podcast, this is Dr. Jeff Williams saying upward, onward, & forward.

  1. https://www.acatoday.org/News-Publications/ACA-Blogs/ArtMID/6925/ArticleID/315/Research-Review-Clinical-Practice-Guideline-Chiropractic-Care-for-Low-Back-Pain
  2. https://www.ncbi.nlm.nih.gov/pubmed/26804581
  3. https://www.dynamicchiropractic.com/mpacms/dc/article.php?id=15493
  4. https://clinicalcompass.org

CF 004: And Instantly, Treatment of Back Pain Changes Due To Increase In Opioid-Related Deaths

This week we’re going to discuss some attacks on the profession in the not-so-distant past, we’ll talk about the current state of the opioid epidemic, and we’ll talk about why right now is such a good time for what is going on with Chiropractic research.

Before we get to the meat of the subject this week, I want to say that I hope you all had a Merry Christmas and a Happy New Year. My family brought it in sitting on the couch drinking decaf coffee. It was very uneventful but pleasant. I used to be a traveling musician in what seems like a former life now and…if you’d have told me 10 years ago that I’d be bringing in the new year sitting on the couch drinking coffee, I would have laughed at you in a dismissive way and probably had given you a look that you would not have taken as being positive. But, jobs and kids and family have a way of forcing the needed changes and that’s OK with me. It’s all a part of life and you better believe I’m living it.

Here’s wishing you all a happy and prosperous 2018.

Now, back to our regularly scheduled programming. This week, we’re going to have more fun that Chinese algebra. Just sit back and watch. I tell you the truth.

Seriously though, this is the place where we talk about some pretty cool stuff going on in the Chiropractic field that is based on research and evidence. How cool is that? When you can just sit back and let all the super smart guys and gals validate everything you do? What a blessing. Of course, we chiropractors have always known we were right about how to go about treating our patients. Think about it. Think about the generations of attacks this profession has endured through the years from extremely powerful people in the legislative and in the healthcare world. The American Medical Association. I’m not sure it gets more powerful than that. Heck, they even lost an anti-trust case in the Supreme Court when chiropractors sued them. In short, chiropractors proved in Federal Court that the American Medical Association did the following or encouraged their members in the following manner:

  • They encouraged ethical complaints against doctors of chiropractic;
  • They opposed chiropractic inroads in health insurance;
  • They Opposed chiropractic inroads in workmen’s compensation;
  • They opposed chiropractic inroads into labor unions;
  • They opposed chiropractic inroads into hospitals; and
  • They attempted to contain chiropractic schools.
  • They conducted nationwide conferences on chiropractic;
  • They distributed publications critical of chiropractic;
  • They assisted others in preparation of anti-chiropractic literature;
  • They warned medical doctors and their underlings that professional association between medical physicians and chiropractors was unethical; and
  • They discouraged colleges, universities and faculty from cooperating with chiropractic schools.

If you hear all of this ridiculousness and you say to yourself, “There’s no way that’s true,” then please do us both a big favor and Google the term Wilk vs. AMA and that should tell you all you need to know about the matter.

Anyway, to my original point, if we weren’t right, we would have been destroyed years ago by the machine. I want you to listen to me here. Let me say it again, if we chiropractors were not right, we would have been wiped off the map years ago. It certainly wasn’t from a lack of effort on the part of the powers that be.

The best part about the blogs and podcasts and videos I share every week is that most everything we talk about has its roots in research. How do you generate facts? I’d argue it’s through research. I hear it all the time: “I believe in chiropractics.” My response is pretty simple. We’re not a church. You don’t have to believe. We have mountains of research. The problem is, few people know about it.

I don’t like the fact that our national debt and deficit is what it is. But, they’re just facts and we have to learn to live with it. Well, the medical field is starting to learn to live with some new facts. In fact, they’re getting smacked down like a red-headed step kid by these facts!

Facts like this…the opioid crisis cost the US economy $504 billion dollars in 2015 according to an article from Reuters this year written by Lucia Mutikani and Ginger Gibson. There authors of the article were relaying information taken from the White House Council of Economic Advisers (CEA).

There is no reason to expect this number to improve any time soon either. If indicators are correct, as numbers become more available for 2016 and 2017, you’ll see this amount explode.

The opioid crisis has reached the point that President Trump was forced to declare it a public health emergency.

The article goes on to discuss the fact that there was a total of $221 billion to $431 billion in lost economic output due to there being 33,000 opioid-related deaths in 2015. The wide range in dollar amounts is to take into account the fact that there are several different models but, I think you get the idea. It’s incredibly significant.

“The crisis has worsened, especially in terms of overdose deaths which have doubled in the past ten years,” the CEA said. Wow. And, if I’m correct, yo u can compare the crisis to a fire. While it may have taken 10 years to double (which is bad), I believe the rate of expansion of the problem has increased exponentially.

The article wraps up by citing the U.S. Centers for Disease Control and Prevention as saying more than 100 Americans die daily from related overdoses. On top of that, new information is out that opioid-related deaths have now surpassed breast cancer. I love that the NFL does the pink uniforms during October which is Breast Cancer Awareness Month but I’m wondering if now we’ll start seeing a specific color and more awareness for the Opioid Addiction Awareness Month or something of that nature. It’s bad, y’all.

https://www.reuters.com/article/legal-us-usa-opioids-cost/opioid-crisis-cost-u-s-economy-504-billion-in-2015-white-house-idUSKBN1DL2Q0

How bad is it? It’s so bad that a recent article in The Guardian says that overall life expectancy in the US has declined for the second year in a row as a result of the opioid crisis. Can you imagine? It’s the first time in 50 years that the US life expectancy has gone down for 2 years in a row. The last time was the year of our Lord, nineteen hundred and sixty-three!

The article in The Guardian was written by Jessica Glenza and was published on December 21, 2017. In the article, she shares that there were 63,600 opioid-related deaths in 2016 which was an increase of 21% from the 2015. These numbers came from the National Center for Health Statistics.

As I hinted in the beginning of this blog, early indications for 2017 aren’t looking very bright. Robert Anderson of the National Center for Health Statistics says of 2017, “It doesn’t look any better.” Anderson goes on to say, “We haven’t seen more than two years in a row in declining life expectancy since the Spanish flu100 years ago,” said Anderson. “We would be entering that sort of territory, which is extremely concerning.”

There are guesstimates that this crisis is going to take a good 10-20 years to turn around now that multiple generations are already hooked.

https://www.theguardian.com/us-news/2017/dec/21/us-life-expectancy-down-for-second-year-in-a-row-amid-opioid-crisis

Realizing that the first phase of the opioid crisis was started by physicians over-prescribing these opioids, the American Medical Association and the American College of Physicians have really stepped up in a way that I would believe most alternative caregivers would describe as rather unexpected considering the history of these organizations. They have consistently and constantly attacked – verbally, in the courts, and legislatively – just about any and all alternative healthcare protocols up to this point in history.

However, in new recommendations put out in February of 2017, the American College of Physicians have now started recommending Chiropractic, Massage, and/or Acupuncture as first-line treatment for acute and chronic low back pain before even taking an over-the-counter anti-inflammatory such as Aspirin, Tylenol, or Ibuprofen.

Quickly thereafter (2 months), the American Medical Association published an article in its journal called Journal of the American Medical Association (JAMA) in support of the updated recommendations made by the American College of Physicians.

I would say they need to go ahead and expand it to the entire musculoskeletal system but acute and chronic low back pain is a good starting point I suppose.

In the end, it is my firm belief that patients are entitled to the best treatments that do the least harm. There is nothing out there safer and more effective than chiropractic, massage, and/or acupuncture.

Through the years, I have carried with me a wonderful quote by Dr. Lee Green, a Professor of Family Medicine at the University of Michigan. He said, ”Neck pain is a mechanical problem, and it makes sense that mechanical treatment works better than a chemical one.”

Doesn’t it?

Just another reason to call a chiropractor TODAY!

  • Research and clinical experience shows that, in about 80%-90% of headaches, neck, and back pain, in comparison to the traditional medical model, patients get good or excellent results with Chiropractic. Chiropractic care is safe, more cost-effective, it decreases your chances of having surgery, and it reduces your chances of becoming disabled. We do this conservatively and non-surgically. In addition, we can do it with minimal time requirements and minimal hassle on the part of the patient. And, if the patient develops a “preventative” mindset going forward from initial recovery, we can likely keep it that way while raising the general, overall level of health!

https://www.amarillochiropractor.com/evidence-backed-reason-add-chiropractic/

I want you to be sure you know all about our blog and our YouTube channel. Currently, we have these entities set up under Creek Stone Integrated Care. Now, with the building of the Chiropractic Forward podcast site, how’s that going to change and how’s that going to look? I haven’t figured that part out just yet but know this, you can get your fix on all things chiropractically researched by going to amarillochiropractor.com and clicking on the blog button. Or, you can visit our youtube channel by searching Creek Stone Integrated Care in the YouTube search

Be looking for our upcoming website at chiropracticforward.com. It is not ready but it will be soon enough. It’s closer every week. I don’t know if you know this but I am all over social media in a whole bunch of areas. For a list of links, see the show notes and we’ll see you somewhere in that list I hope.

Thank you for listening. You know, sharing is caring and that’s how we get to more and more ears. If you like what you hear and you know other chiropractors or medical field professionals…..or even potential chiropractic patients….make sure you share our podcast with them. Together we can make a difference and help people get off of medication, get out of pain, and get healthier overall.

I’m Dr. Jeff Williams from the Chiropractic Forward Flight deck saying upward, onward, and forward .

CF 003: Great News: Chiropractic Outpaces Muscle Relaxants

Great News: Chiropractic Outpaces Muscle Relaxants

Hey hey, Dr. Jeff Williams with the Chiropractic Forward podcast coming to you directly from the flight deck at Creek Stone Care in icey Amarillo, TX and you have stumbled head first into Episode numero 3.

Welcome welcome, this week we’re going to be talking about people that I believe may be related to unicorns because I can’t hardly believe they exist, we’ll talk about something I pondered while in the shower, and we’ll talk about what research has to say about low back pain, muscle relaxants, and chiropractic care.

I like to be an honest person so I’m just going to speak directly here and say that….I have yet to get the hang of the whole podcast thing but, I’m at least screwing it up regularly and consistency is half the battle I’m told. We’re going to have more fun than chopping wood and I firmly believe it. If you believe it, it must be true. What’s the saying? Perception is reality? I sometimes enjoy living in my own reality to tell the truth. Who doesn’t?

Speaking of unbelievable, Did yo u know that you are 75% to 85% likely to experience low back pain in your lifetime? Those are some pretty good odds. Or, bad, odds depending on how you look at it. That’s where the unicorn reference comes in here. I have a hard time believing these people exist.

By the way, I’d like to meet the 15%-25% that don’t have back pain. Wouldn’t you? Maybe these folks have been marked by God for greatness that just can’t be achieved if they’re suffering from back pain. They’re the ones looking at everyone else like, “What the heck is wrong with you people?”

How do you make it through a lifetime without back pain? That just doesn’t seem right to me. Someday, I plan on having a talk with God about this deal. I’m kind of mad about it.

Believe it or not, I remember life without back pain. I specifically remember being a kid, taking a hot shower, and thinking about adults that always gripe about back pain. I had recently heard an adult talking about how standing in a hot shower made their back feel better so that’s what made me think about it.

I thought, “That must really stink to always be hurting like that.” Well then I was smart enough to play college football and go to chiropractic school where chiropractors get to use each other as guinea pigs to learn how to help others. Yes, you could say I donated my body to science in a way. Regardless of the reasons, I am well-acquainted with the occasional back  pain. It has been intense a few times. To the point of crawling to the bathroom because I couldn’t walk to get there. It’s been years since that was the case but I certainly have empathy for my patients that come through the doors like that. It can be pure misery and it’s no wonder at all why people would look to medication for a quick fix for such intense, non-stop pain. If I’m being honest, when I remember that pain, I would be be looking for anything and everything to make it stop too.

Here’s the problem though: there arebut a few things that can help immediately. The good news here is that Chiropractic is one of the very BEST answers for this issue. The even better news is that the American Medical Association and the American College of Physicians now agree with me on this as of 2017.

That leads us into this article’s source material which is a research paper by KT Hoiriis called “A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain.” It was published in the Journal of Manipulative Physiological Therapeutics in July-August issue in 2004 and can be found on pages 388-398.

Why They Did It

Considering the fact that we are almost all going to suffer from low back pain at some point in our lives and considering the fact that acute pain will generally resolve and chronic pain is tough to treat, the authors of this paper were interested in trying to assess the reponsiveness of SUBacute low back pain to different treatments available. The treatment the authors chose to compare were Chiropractic treatments vs. muscle relaxants and placebo.

How They Did It

  • The platform chosen by the researchers was a randomized, double-blind clinical trial. It is high-quality information when done with this sort of design.
  • They chose 192 patients that had suffered low back pain for a time period of between 2 and 6 weeks in duration.
  • The patients were randomly split into three different groups for the purpose of the project.
  • They each underwent 2 weeks of treatment. One group with Chiropractic, one with muscle relaxants, and one with placebo.
  • The Outcome Assessments were performed through the use of the Visual Analog Scale (VAS), the Oswestry Disability Questionnaire, and the Modified Zung Depression Scale.
  • These assessments were performed at the beginning of treatment (baseline), at two weeks, and at the conclusion of the treatment which was at the four week mark.
  • In addition to the Assessments previously mentioned, Schobers’s flexibility test, acetaminophen usage, and the Global Impression of Severity Scale (GIS) were assessed at the 2 week mark and at the 4 week mark.

What They Found

  • The baselines were essentially the same in all of the Outcome Assessments except for in the Global Impression of Severity Scale.
  • The subjects that actually finished the trial, 146 in all, had their data combined revealing pain, disability, depression, and the Global Impression of Severity Scale had ALL decreased significantly while flexibility for the low back was not altered.
  • Statistical differences through the groups showed that the chiropractic patients improved more than the control group and in terms of the Global Impression of Severity Scale, the chiropractic patients also improved more than the placebo group AS WELL AS the muscle relaxants group.

Wrap It Up

Chiropractic was more beneficial than placebo in reducing pain and more beneficial than either placebo or muscle relaxants in reducing GIS.

While this is good news from 2004, there are studies subsequent to this one showing how Chiropractic outpaces medication in the treatment of low back pain. These are part of the reason that they American Medical Association and the American College of Physicians recently published articles and papers recommending Chiropractic as first-line treatment for acute and chronic low back pain before even taking acetaminophen or aspirin. That’s huge folks.

Source Material

Hoiriis KT, et. al., “A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain.” J Manip Physiol Ther. 2004 Jul-Aug;27(6):388-98.

https://www.ncbi.nlm.nih.gov/pubmed/15319761

Just another reason to call a chiropractor TODAY!

https://www.amarillochiropractor.com/evidence-backed-reason-add-chiropractic/

 

I want you to be sure you know all about our blog and our YouTube channel. Currently, we have these entities set up under Creek Stone Integrated Care. Now, with the building of the Chiropractic Forward podcast site, how’s that going to change and how’s that going to look? I haven’t figured that part out just yet but know this, you can get your fix on all things chiropractically researched by going to amarillochiropractor.com and clicking on the blog button. Or, you can visit our youtube channel by searching Creek Stone Integrated Care in the YouTube search

Be looking for our upcoming website at chiropracticforward.com. It is not ready but it will be soon enough.

Thank you for listening. You know, sharing is caring and that’s how we get to more and more ears. If you like what you hear and you know other chiropractors or medical field professionals…..or even potential chiropractic patients….make sure  you share our podcast with them. Together we can make a difference and help people get off of medication, get out of pain, and get healthier overall.

I’m Dr. Jeff Williams from the Chiropractic Forward Flight deck saying upward, onward, and forward  .