May 2018 - chiropracticforward

Month: May 2018

CF 024: They Laughed When I Said I Could Still Help After Back Surgery

They Laughed When I Said I Could Still Help After Back Surgery

Today, we’re going to talk about people coming into our office after having had back surgery wanting us to perform miracles. Well, why didn’t they come to us BEFORE the surgery would be my big question. We’ll toss all that stuff around today on the Chiropractic Forward Podcast. 

But first, here’s that bumper music!

OK, we are back. Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.  

Before we get started, I want to ask you to go to chiropracticforward.com and sign up for our newsletter. On another note, do you need an hour or two for your Continuing Education seminar on low back pain guidelines or on Debunking the myth that chiropractors cause strokes? 

Go no further, you have found your man. Just send me an email at dr.williams@chiropracticforward.com and we will get it done.

We are honored to have you listening. Now, here we go with some vital information that we think can build confidence and improve your practice which will improve your life overall. That’s a tall order but that is the goal

You have done the electric slide right into Episode #24 and that’s exciting

Now, as I mentioned previously, how many times do chiropractors have new patients come through the doors but they’ve already had back surgery? They’ve had back surgery they hoped would be a quick fix usually. But it wasn’t. 

Now, they’re sitting in your office, looking at you with a very scared and concerned face, and it’s up to you to lead the way and, hopefully, be able to provide them some sort of relief with your magical abilities. 

I can tell you from 20 plus years of experience that it happens all of the time. At least a time or two per month for a busy practice. That’s what I would guess. 

The truth is, sometimes we can help these back surgery people and sometimes we just can’t. I tell patients that surgery, many times, is permanent and anything we do toward trying to get some relief can be a little bit like pushing a wheelbarrow uphill. Depending on the weight in the wheelbarrow, we may get it to the top and we may not get it to the top but we’re sure as hell going to try while making sure we keep them safe from further damage. 

At first glance, when you’re looking at an x-ray of a post-surgical patient, many times I find myself thinking, “What in the heck can I possibly do with this trainwreck.” I’m sure I’m not the only one to ever feel like that. It’s a little bit of a helpless feeling sometimes. Especially when you see parts missing like you’ll see in a laminectomy. Or when you see parts added like boney fusions or fusions with hardware. I get a sinking feeling in my stomach for patients like that. Back surgery is no joke.

Especially when we know for a researched-fact that these patients most likely did not have to endure those procedures. For any reason. If you aren’t sure about that statement, please review our podcast episodes we did no The Lancet low back series. Episodes #16, #17, and #18 dealt with this very issue. 

Back surgery is gaining in popularity while the outcomes show no change. They are no longer recommending surgery for acute or chronic low back pain. Period. Sure, cauda equina syndrome, foot drop, and severe symptoms like that may indicate surgical intervention but, otherwise, they say no shots, no surgery, no bed rest, and no medications. 

We will be hammering these things consistently until we start seeing some change. I can guarantee it. 

OK, but…..what if nobody listened to the experts and they just did the surgery with no relief? Can we do anything about it? 

Let’s look at a couple of possiblities:

  1. The spine was fused years ago and now, due to the immobilization and increased workload on the segments above and below, the segments above and/or below begin to show signs of wear and tear. 
  2. The spine was not fused but the complaint never improved. This may be the case in people that have the microdiscectomies or epidural spinal injections. 

Of course there are a lot of different, very specific outcomes that don’t fit in those two categories but I’d say these are the ones I commonly see. 

Let’s take the first one: a fusion that caused issues above and below the fused segment. If you go through nonsurgical spinal decompression certification through the Kennedy Decompression Technique, you’ll be taught that a fusion with hardware is a hard contraindication. At least it was 6 years ago. 

Assuming these people develop disc issues above or below the fusion, that would mean you can’t do any decompression on the site. An orthopedic surgeon that is familiar with non-surgical decompression however, may tell you that the segment is more solid after the fusion than it ever was before and decompression won’t cause any issues with the fusion itself. 

OK, so, we’re stuck between two worlds on that and, honestly, if you’re an expert on this and you’re listening, email me at dr.williams@chiropracticforward.com and tell me your experience and understanding. 

After bouncing the problem off of several highly trusted colleagues, I think a light pull on decompression is tolerated just fine and does in fact provide relief to fusion patients. No, you cannot pull them at 1/3 or 1/2 of their body weight. We’re talking a LIGHT pull. This combined with gentle McKenzie and Core exercises as well as self-management recommendations at home will go toward getting them back on their feet and getting back after it. 

If any of you disagree, I’d love to talk about it. My first question would be, “What would the alternative be?” 

I am by no means the final and ultimate opinion on this. We have to depend on trusted advice and clinical experience, don’t we? That’s just what I do and what I’ve found is that about 80% of patients just get better. There’s about 10% that gets better but not quite what we hoped for. Then there’s that 10% that …”Hey, we tried and it looks like I’m not your homey on this deal.”

Now, what about the second option? Let’s say that they had a discetomy back surgery but it was a failure (surprise surprise) and now it’s up to us to help the patient and attempt to keep them from enduring any more back surgery or shots. What do you do? Maybe I should say, “What do WE do?”

I say adjust them!! After a certain healing time has passed, of course. 

I say we do all the other stuff I mentioned previously for them as well. We may do decmopression. We may do laser. We certainly do McKenzies, Core Building, McGill’s Big Three, no bed rest, and home self-management.

If you have paid much attention to our previous episodes then you know the American College of Physicians and the global panel of experts on low back pain that published the low back pain papers in The Lancet back in March of 2018 say that spinal mobilization is a researched and recommended first-line therapy for acute and chronic low back pain. 

In my opinion, a discetomy doesn’t change these recommendations much. Sometimes, cases are so specific, that they just don’t get researched in depth for that certain instance. 

However, I CAN offer a case study if you’re willing to listen. 

It was titled, “Chiropractic/Rehabilitative Management of Post-Surgical Disc Herniation: A Retrospective Case Report” and was published in the Journal of Chiropractic Medicine in the Summer edition of 2004(Estadt G 2004).  

Why They Did It

To explore management of lumbar disc herniation following sugery using a regimen of chiropractic manipulation and exercise/rehab. 

How They Did It

  • The patient was a 54 yr old male
  • The patient had a history of acute low back pain with left sciatic pain down the left posterior thigh and lateral calf as well as numbness inthe bottom of the left foot. 
  • The patient previously had steroid anti-inflammatory drugs and lumbar microdiscectomy surgery. 
  • The patient did not recover completely.
  • The patient couldn’t walk without hurting and was unable to return to activities of daily living. 
  • He was antalgic in flexion. 
  • His lumbar range of motion was restricted in flexion as well as in extension. 
  • He had a positive SLR as well as foot drop on the left. 
  • Intervention consisted of patient education on posture, bending, and lifting. 
  • Exercise/Rehab was started in-office progressing to at-home based exercise/rehab. 
  • Active rehab was continued after early improvement (7 visits) in order to return lumbar spinal extensor strength. 
  • The patient was ultimately released to home therapy and supportive chiropractic care and continued to show improvement. 

Wrap It Up

The author concluded, “Management of postsurgical lumbar disc herniation with chiropractic and active rehabilitation is discussed. Spinal deconditioning and weakness of the lumbar spinal extensor muscles appeared to be related to the patient’s symptoms. Patient education on proper posture, proper lifting techniques, core stabilization exercises, active strengthening exercise and chiropractic manipulation appeared effective in this case.”

OK, a case study with one subject. What does that tell us as far as research goes? Very little. What is the impact of the Journal of Chiropractic Medicine? It’s  peer-reviewed and it has an impact factor of 0.74 and has climbed significantly since 0.36 in 2011. 

Although this case study is only one patient’s experience, from my own anecdotal evidence, I would come very close to guaranteeing you and betting the farm that these post back surgery results can be repeated time and time again.

I’ve seen it time and time again. My experience tells me we can help these people. YOU can help these people. Back surgery doesn’t always mean we are helpless to pull out the power of chiropractic. 

I want you to know with absolute certainty that 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.

When you look at the body of literature, it is clear: research and clinical experience shows that, in about 80%-90% of headaches, neck, and back pain, compared to the traditional medical model, patients get good to excellent results with Chiropractic. It’s safe, more cost-effective, decreases chances of surgery, and reduces chances of becoming disabled. We do this conservatively and non-surgically with minimal time requirements and hassle on the part of the patient. And, if the patient develops a “preventative” mindset going forward, we can likely keep it that way while raising the general, overall level of health! And patients have the right to the best treatment that does the least harm. THAT’S Chiropractic folks.

Please feel free to send us an email at dr dot williams at chiropracticforward.com and let us know what you think or what suggestions you may have for us for future episodes. Feedback and constructive criticism is a blessing and we want to hear from you on a range of topics so bring it on folks!

If you love what you hear, be sure to check out www.chiropracticforward.com. We want to ask you to share us with you network and help us build this podcast into the #1 Chiropractic evidence-based podcast in the world. 

We cannot wait to connect again with you next week. From Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward. 

Social Media Links

iTunes

Bibliography

Estadt G (2004). “Chiropractic/Rehabilitative Management of Post-Surgical Disc Herniation: A Retrospective Case Report.” Journal of Chiropractic Medicine 3(3): 108-115.

CF 020: Chiropractic Evolution or Extinction?

CF 008: With Dr. Craig Benton – Brand New Information Based on Results Chiropractic Proven Effective For Low Back Pain

CF 023: How Can Research Help You Talk To The Medical Profession?

How Can Research Help You Talk To The Medical Profession?

This week we’re going to be discussing Chiropractic integration and how can research help you. Getting closer to the center of healthcare rather than being far out on the outer ring about to be spun into the cold dark void of space. 

First though, bring on that bumper music to get the party started. 

Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast. You have beamed yourself right into Episode #23. 

We are honored to have you listening. Now, here we go with some vital information that we think can build confidence and improve your practice which will improve your life overall. That’s a tall order but that is the goal.

Before we get started, I want to draw your attention our website at chiropracticforward.com. Just below the area where you can listen to the latest episode, you’ll see an area where you can sign up for our newsletter. 

I’d also like to let you know that I am starting to accept bookings for public talks. Do you need an hour or two for your Continuing Education seminar on low back pain guidelines or on Debunking the myth that chiropractors cause strokes? Go no further, you have found your man. Just send me an email at dr.williams@chiropracticforward.com and we will get it done. 

Part of my function is to show where we can fit more and more into mainstream health and why we fit. That’s where the research continues to smile on Doctors of Chiropractic. What does research tell us on this journey to expand and integrate?

Let us be honest with one another here when we say that there is a reason our profession is misunderstood. There is a reason that we have been treated unfairly for generations; since our inception. 

I would say the number one reason is that several in our profession over the years have professed chiropractic to be a miracle cure for any and all ills. Let me give you an example to demonstrate my point. I remember sitting in a seminar and the speaker who will remain unnamed was telling us that their patient had cancer and several adjustments caused it to encapsulate and then work out of the body into a large skin tag looking sort of thing before it finally just fell off. Cancer free!! Thanks to chiropractic!!

Young impressionable chiropractors-to-be lapped that speech right up and likely went on to tell scores of colleagues and patients all about this. And, this person is still out giving seminars and speaking to impressionable minds. 

Is it true? Who knows? I hate to denigrate something I truly don’t understand, but, I admit, I doubt it. And, if it were repeatable, this person would be in some hall of fame and would be the most famous person in healthcare because he discovered the cure for cancer. I mean, it gets no bigger than curing cancer does it?

Honestly though, it doesn’t matter what I think about it. What matters is whether or not boasts like this serve to further progress this profession or serve to make us walk the proverbial professional plank. If chiropractors can do clinical studies on such a thing, then get it done and quit talking about it. Prove what you say. You saw cancer work itself out of the body after your treatment? That is amazing, but in this day and age, it should be documented. You can get with a cancer research center and attempt to repeat your findings and prove what you think to be true. 

I’m being dramatic here but you get my point. I’m not trying to pick fights with this podcast. I’m trying to be honest and make sense. I realize that turns some off and I hate that because I truly feel civil discourse is in short supply in 2018. 

You find some claims in our profession that just lack any backing as far as research goes and I’d like to see our profession either put up or shut up basically. If you say you can do it, prove it and show us all through accepted research protocols and studies. “Because I said so,” no longer works.

Reason #2: I’d say, if you listened to episode #9, referenced and linked in the show notes, then you know that the American Medical Association and the state medical associations have done quite a job over the generations in de-valuing the chiropractic profession. 

Take the idea that chiropractors cause strokes in their patients. We spent three episodes of this podcast methodically dismantlying this crazy myth. I am referring to Episodes #13, #14, and #15 referenced and linked in the show notes along with the associated blog we posted on the matter called, “DEBUNKED: The Odd Myth That Chiropractors Cause Strokes.”  You can read the blog here: https://www.chiropracticforward.com/blog-post/chiropractic-forward-podcast-introduction-and-welcome/

The myth has no basis in fact and research clearly demonstrates this. Yet, you will still get arguments about how Doctors of Chiropractic cause strokes. The Chiropractic Forward Facebook page is proof enough of this. Fighting against long-held beliefs is a hard thing to do and all of the research in the world will never change some minds. However, that doesn’t mean we stop showing it to everyone! 

I will say with some sense of satisfaction that networking and forming relationships with medical providers has never been easier than it has become within the last several years and that is a stepping stone and absolutely welcome and a blessing. 

One thing I hear from straight chiropractors from time to time is that guys and girls like me are “Medi-Practors.” What does that mean exactly? Well, I would say it implies that we want to be medical doctors. But, they use the term for any chiropractor that even uses therapies like electric stim, ultrasound, or any other modality outside of just an adjustment. 

I would simply say that I personally have no desire to prescribe medications. In fact, when I have a car wreck patient, I’m actually glad I can just say, “I’m sorry, I can’t prescribe you anything since chiropractors treat conservatively and naturally and do not prescribe medications.” It’s liberating. I love that we do not treat that way. 

On the other hand, I certainly recognize the use of medicine and the benefits of some medicine. I’m not necessarily against medication. I’m certainly against long-term medication when lifestyle change could prevent being on medication. I’m absolutely against a mentality that simply treats the symptom with pharmaceuticals rather than addressing the cause or the source. 

As I say in almost every episode, spinal pain is a mechanical pain and it makes sense that mechanical pain responds better to mechanical treatment rather than chemical treatment. In addition, patients should have the guarantee of the best treatment that causes the least harm and, folks, when it comes to non-complicated spinal pain, that’s exactly what chiropractic is. How can research help you relay this message is powerful.

This podcast, in case you’ve wondered, is a bit cathartic for me. And, I will admit, doesn’t seem to stir as much fussing as I originally expected. In fact, most chiropractors listening are in agreement with me so I certainly feel a sense of validation there and I appreciate the support. 

As you should know by now, I enjoy covering research papers so let’s get to that now that my grumpier side decided to show itself. Back to our regularly scheduled program. 

Here’s one called “Can chiropractors contribute to work disability prevention through sickness absence management for musculoskeletal disorders? – a comparative qualitative case study in the Scandinavian context” by Stochkendahl et. al. published in Chiropractic & Manual Therapies on April 26th of 2018. Brand new stuff. 

Why They Did It

Even thought the guidelines are there for managing non-complicated musculoskeletal pain, there has been little to no decrease in work disability. Right now, Norwegian chiropractors have legislated sickness certification rights but the Danes and the Swedes do not. The authors were looking to describe, compare, and contrast the views and experiences of Scandinavian chiropractors when engaged in the prevention of work disability and sickness absence. 

How They Did It

The study was a two-phased sequential exploratory mixed-methods design. 

In a comparative qualitative case study design, the authors explored the different experiences amongst chiropractors in regards to sickness absence from face-to-face interviews.

What They Found

  • 12 interviews conducted
  • The chiropractors’ ability to manage sickness absence depended on four key factors:
  1. legislation & politics
  2. the rationale for being a sickness absence mangement partner
  3. whether an integrated sickness management pathway existed or could be created
  4. the barriers to service provision for sickness absence management. 

Wrap It Up

The authors concluded, “Allied health providers, in this instance chiropractors, with patient management expertise can fulfill a key role in sickness absence management and by extension work disability prevention when these practices are legislatively supported. In cases where these practices occur informally, however, practitioners face systemic-related issues and professional self-image challenges that tend to hamper them in fulfilling a more integrated role as providers of work disability prevention practices(Stochkendahl M 2018).”

And then this paper by F. Gedin, et. al. called “Patient-reported improvements of pain, disability and health-related quality of life following chiropractic care for back pain – A national observational study in Sweden” published in Journal of Bodywork and Movement Therapies in February of 2018

Again, pretty recent stuff. 

Why They Did It

The authors were simply trying to get patient reported feedback from those patients in Sweden seeking treatment via chiropractic for their back pain. 

How They Did It

  • The study was a prospective observational study
  • It included those 18 years and older having back pain of any duration 
  • It included 23 chiropractic clinics
  • The patient questionnaire was performed at baseline, and at 4 weeks
  • Questionnaires used were the Numerical Rating Scale, Oswestry Disability Index, health-related quality of life (EQ-5D index)
  • Visual Analog Scale or VAS

What They Found

There were statistical improvements over the 4 weeks for all patient reported outcomes. 

Wrap It Up

The authors’ conclusion was, “Patients with acute and chronic back pain reported statistically significant improvements in PRO four weeks after initiated chiropractic care. Albeit the observational study design limits causal inference, the relatively rapid improvements of PRO scores warrant further clinical investigations(Gedin F 2018).”

I want you to know with absolute certainty that 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.

When you look at the body of literature, it is clear: research and clinical experience shows that, in about 80%-90% of headaches, neck, and back pain, compared to the traditional medical model, patients get good to excellent results with Chiropractic. It’s safe, more cost-effective, decreases chances of surgery, and reduces chances of becoming disabled. We do this conservatively and non-surgically with minimal time requirements and hassle on the part of the patient. And, if the patient develops a “preventative” mindset going forward, we can likely keep it that way while raising the general, overall level of health! And patients have the right to the best treatment that does the least harm. THAT’S Chiropractic folks.

Please feel free to send us an email at dr dot williams at chiropracticforward.com and let us know what you think or what suggestions you may have for us for future episodes. Feedback and constructive criticism is a blessing and we want to hear from you on a range of topics so bring it on folks!

If you love what you hear, be sure to check out www.chiropracticforward.com. We want to ask you to share us with you network and help us build this podcast into the #1 Chiropractic evidence-based podcast in the world. 

We cannot wait to connect again with you next week. From Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward. 

Social Media Links

iTunes

REFERENCES

Episode #9 with Dr. Tom Hollingswortth: The Case Against Chiropractic in Texas

https://www.chiropracticforward.com/2018/02/15/episode-9-dr-tom-hollingsworth-case-chiropractic-texas/

Episode #13: Debunked: The Odd Myth That Chiropractors Cause Strokes (Part 1)

https://www.chiropracticforward.com/2018/03/15/debunked-the-odd-myth-that-chiropractors-cause-strokes/

Episode #14: Debunked: The Odd Myth That Chiropractors Cause Strokes (Part 2)

https://www.chiropracticforward.com/2018/03/22/cf-episode-14-debunked-the-odd-myth-that-chiropractors-cause-strokes-part-2-of-3/

Episode #15: Debunked: The Odd Myth That Chiropractors Cause Strokes (Part 3)

https://www.chiropracticforward.com/2018/03/29/cf-015-debunked-the-odd-myth-that-chiropractors-cause-strokes-part-3-of-3/

“DEBUNKED: The Odd Myth That Chiropractors Cause Strokes.”  You can read the blog here: https://www.chiropracticforward.com/blog-post/chiropractic-forward-podcast-introduction-and-welcome/Bibliography

  • Gedin F (2018). “Patient-reported improvements of pain, disability and health-related quality of life following chiropractic care for back pain – A national observational study in Sweden.” Jounral of Bodywork & Movement Therapies.
  • Stochkendahl M (2018). “Can chiropractors contribute to work disability prevention through sickness absence management for musculoskeletal disorders? – a comparative qualitative case study in the Scandinavian context.” Chiropractic & Manual Therapies 26(15).

CF 013: DEBUNKED: The Odd Myth That Chiropractors Cause Strokes (Part 1 of 3)

CF 022: Cold Laser Research You Should Know About

 

This week, I have some brand new research concerning spinal manipulation with laser therapy added as well as cold laser research looking at laser therapy in general. We concentrate heavily on research having to do with musculoskeletal conditions and I think this week gives us an opportunity to look at spinal manipulation but to also look at a modality many Doctors of Chiropractic implement regularly in their day-to-day lives. 

Before we get started with the cold laser research, I want to draw your attention our website at chiropracticforward.com. Just below the area where you can listen to the latest episode, you’ll see an area where you can sign up for our newsletter. I’d like to encourage you to sign up. It’s just an email about once a week to let you know when the episode is updated and what it’s about.

 

Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast. We are honored to have you listening. Now, here we go with some vital information that we think can build confidence and improve your practice which will improve your life overall. That’s a tall order but that is the goal.

You have boogied right on into Episode #22

But first, my week has been mixed man. Being a small business owner isn’t all peaches and cream is it? I tell you, sometimes you’re up….sometimes you’re down but we keep soldiering on. I’ve been in practice for 20 years and it can still be stressful. I found something that helps me though. Some of you already know this. It’s music. You can have elevator music on in your office if you like but I say NO. 

First, your patients don’t really like that stuff. Just in case you didn’t know that, I’m telling you now. I spent the time last week to make a couple of playlists. One is called Memphis/Motown/Muscle Shoals and one is called Rat Pack. Now, I’m a former traveling musician. In fact, the bumper music you just listened to….I wrote that and recorded all of the parts on it from the guitars, bass, piano, everything. 

My personal preference is Americana/Texas Country style music. If you have iTunes, you can find my old touring band called Copperhead and the album is called Remedy. That was us! 

Anyway, Texas Country is my preference but, for my office, I and my patients are loving the older boogie and soulful stuff like Otis Redding, Wilson Pickett, The Temptations, Ray Charles, and anything that fits that style whether it’s old or new. Doesn’t matter. In fact, a lot of the newer artists are sounding like the great stuff from the older days. I love it. Then, to mix it up a bit, I throw in the Rat Pack list here and there with Sinatra, Harry Connick Jr, Michael Buble, Dean Martin, and guys like Wayne Newton. It’s great. Classy and cool. Anyway, the days have just started flying by. When you boogie all day, and your patients boogie all day, well…..it makes for an awesome place with an awesome experience. 

If any of you have any interest in the playlists, send me an email or Facebook message and let’s talk about it. I love talking music!!!

Now, what we are REALLY here for. 

Let’s start by saying that Low Level Laser has been around for many years in one for or another at this point in time. But, how many actually know where it came from, how it was discovered, and what research is there showing its effectiveness? 

I would hope that, if you include a modality in your office, you have done some background work to show yourself and to demonstrate to your patients that there is backing research for the modality and they don’t just simply need to take your word for it. And, if you can find little to no evidence of effectiveness for a modality, my suggestion is that it should play no part in your services. Of course, that is my opinion and can be taken or dropped as may opinions commonly are. 

Let’s start with the newest paper that mentions cold laser but does not really do anything to address effectiveness of cold laser. I think you can anticipate the outcome once you learn the basis but, it is new so we are talking about it. 

This paper is called, “Spinal manipulation combined with laser therapy is more beneficial than laser therapy alone in chronic non-specific low back pain. A randomized controlled study,” and it was published in the European Journal of Physical Rehabilitation Medicine on April 24, 2018 and was authored by Subash Chandra Bose, et. al(Subash Chandra Bose GN 2018). 

 

Why They Did It

The authors were looking to compare treatment regimens for exercise/cold laser/spinal manipulation vs. exercise/cold laser alone for patients suffering from chronic non-specific low back pain.

How They Did It

  • Three hundred and thirty patients were included
  • Study was randomized control
  • Outcome measurements used were Visual Analog Scale, Roland and Morris Disability Questionnaire, Physical Health Questionnaire, and Health Related Quality of Life-4.
  • Outcome measurements were taken at the beginning to measure the baseline total, at the 4-week mark, at the 6-week mark, and at the year mark. 
  • A blinded assessor was used to evaluate the Outcome Measures

What They Found

  • 326 patients finished the program
  • 304 patients finished through the 1-year mark
  • ANOVA analyses proved statistically significant improvement in regards to the lessening of pain, in regards to increased range of motion, functional disability, depression, and Quality of Life. 
  • All of these significant improvements were seen in the Spinal Manipulation/Exercise/Laser Therapy group. 

Wrap It Up

The authors conclusion was, “Spinal manipulation combined with laser therapy and conventional exercise is more effective than laser therapy and conventional exercise alone in chronic non-specific low back pain. Spinal manipulation is an adjuvant intervention and it can be applied in every day clinical practice.”

If you have paid attention to research, you probably predicted the outcome on this. Spinal manipulation appears to be the most effective means of treating non-complicated low back pain bar none. It just is. On top of laser plus exercise, on top of exercise, equal to more effective than NSAIDs…..it just is and research backs it time and time again. 

But, this paper does nothing to look at cold laser specifically. It just shows us that spinal manipulation gets better results. 

Let us say up front: low level laser, also known as cold laser, is not covered under insurance plans. As they explain it, the modality is experimental and investigational. I have a ton of experience and anecdotal evidence I could relay to you but, in the end, it’s cold laser research that you need for validation. 

First, let’s go through a brief history on cold laser before we get to the cold laser research. 

In 1967 a few years after the first working laser was invented, Endre Mester in Semmelweis University in Budapest, Hungary experimented with the effects of lasers on skin cancer. While applying lasers to the backs of shaven mice, he noticed that the shaved hair grew back more quickly on the treated group than the untreated group. It’s use wide array of uses have been explored since then and they had no idea where it would lead them.

When we think of lasers, we think of burning or cutting lasers. Cold laser is actually called low level laser. It’s different. You really don’t feel it during the treatment and It works by stimulating cell function. The second paper below by Cotler et. al. states “LLLT at low doses has been shown to enhance cell proliferation of fibroblasts, keratinocytes, endothelial cells, and lymphocytes. The mechanism of proliferation is thought to result from photo-stimulation of the mitochondria leading to activation of signaling pathways and up regulation of transcription factors eventually giving rise to increases in growth factors.”

Here is a paper from 2014 published in the International Journal of Oral and Maxillofacial Surgery called “Does low-level laser therapy decrease swelling and pain resulting from orthognathic surgery?” and authored by G. Gasperini, et. al(Gasperini G 2014). 

Why They Did It

Hoping for alternatives to treating swelling and inflammation following orhognatic surgery, and noticing there was a lack of research for or against cold laser, the authors wanted to further investigate it’s effectiveness in that capacity. 

How They Did It

  • 10 patients having undergone bilateral sagittal split with Le Fort I osteotomy were randomly selected. 
  • The treatment protocol consisted of intraoral and extraoral treatment with the laser on one side of the face following surgery 
  • Fake application was performed on the other of the face. Remember that surgery was done on both sides. 
  • The two sides were compared for pain using the visual analog scale and for swelling.

What They Found

  • Immediately after surgery, there was little to no difference for inflammation and pain in the two sides.
  • On the side treated with cold laser, inflammation and swelling decreased significantly on day three, day seven, day fifteen, and day thirty. 
  • Self-reported pain was reduced on the treatment side at the one-day mark and at the three-day mark. 
  • After seven days, however, no pain was present on either side. 

Wrap It Up

The authors of this paper concluded, “This LLLT protocol can improve the tissue response and reduce the pain and swelling resulting from orthognathic surgery.”

Here’s one from Dr. Roberta Chow, et. al, published in The Lancet in 2009 called “Efficacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomized placebo or active-treatment controlled trials.(Chow R 2009)”

You should know the reputation of The Lancet. If not, it is one of the world’s oldest medical journals dating back to 1823. Being published in The Lancet is notable to say the least. 

Why They Did It

The point was to perform a systematic review of the literature proving or disproving the effectiveness of cold laser in the treatment of neck pain. 

How They Did It

The authors did an exhaustive search of the databases holding information comparing efficacy of cold laser implementing any wavelength vs placebo or active control for acute or chronic neck pain. 

What They Found

  • 16 Randomized Controlled Trials were identified
  • 820 patients

Wrap It Up

“We show that LLLT reduces pain immediately after treatment in acute neck pain and up to 22 weeks after completion of treatment in patients with chronic neck pain.”

Powerful in my opinion, folks.

This paper is called “The Use of Low Level Laser Therapy For Musculoskeletal Pain” by Howard Cotler et. al. and was published in 2015 in MedCrave Online Journal of Orthopaedics & Rheumatology(Cotler H 2015).

Why They Did It

With the current treatment options for chronic musculoskeletal pain consisting of NSAIDs, steroid injections, opiates, and surgery, the authors recognized a need to further treat chronic pain in a more effective manner as chronic pain continues to become more and more prevalent globally. Particularly chronic low back pain. 

What They Found

The authors state that over 4000 papers found on pubmed show that cold laser does indeed show effectiveness on acute and chronic musculoskeletal pain. They state that heterogeneity of populations, treatments, and groupings means that not every single study was positive but the majority are positive. They also state that the overall positive studies should provide the practitioner with a certain level of confidence in implementing the modality in their treatment protocols. 

Wrap It Up

The authors concluded the following, “One has to be realistic about the therapeutic use of LLLT. The previous discussion has shown that LLLT is beneficial for pain relief and can accelerate the body’s ability to heal itself. LLLT has a long history and strong basic science evidence, which supports its use in pain management. It has few side effects and is well tolerated by the elderly. A laser or LED does not correct situations involving structural deficits or instabilities whether in bone or in soft tissue. Also, LLLT should only be used as an adjuvant therapy for pain relief in patients with neuropathic pain and neurologic deficits. Successful outcomes, like all medical management, depend on good clinical skills linked with an understanding of the nature of injury, inflammation, repair, pain, and the mechanism of laser and LED effects.”

That’s good stuff I think you’d all agree. 

And then there’s this paper from 2003 we will cover quickly. It’s called “Efficacy of low power laser therapy and exercise on pain and functions in chronic low back pain” and written by A. Gur, et. al.. It was published in Lasers in Surgery and Medicine(Gur A 2003).  I do dislike including papers from 15 years ago since lasers and technology change rapidly  these days, however, my thought process is that, hopefully, treatments become even more effective over the course of 15 years rather than less effective. 

Why They Did It

The authors were trying to decided whether cold laser was effective (or was not effective) for treating chronic low back pain. 

How They Did It

  • 75 patients
  • The outcome assessments were done through the visual analogue scale, the Schober test, through flexion and lateral flexion measures, through the Roland Disability Questionnaire, and through the Oswestry Disability Questionnaire. 
  • The measures were taken pre- and post-treatment. 

What They Found

Except for lateral flexion specifically, significant improvement was noted in all groups and in all outcome measures taken. 

Wrap It Up

The conclusion by the authors was, “Low power laser therapy seemed to be an effective method in reducing pain and functional disability in the therapy of chronic LBP.”

Key Takeaways this week:

I don’t care what the insurance companies say about cold laser research and cold laser being experimental and investigational. Cold laser is not a “chiropractic thing” and practitioners of all shapes, sizes, and professions are using it including dentists and surgeons. While there are some papers that aren’t positive, heterogeneity and styles and techniques make it difficult. However, the majority of papers on cold laser are very much positive and show effectiveness including those published in The Lancet. 

Walk forward in your practice knowing that you are getting your patients better with cold laser and you are helping make a difference in their lives. 

Going forward this week, Retweet us, like our page on Facebook, and SHARE us on Facebook so we can get those likes up and increase listenership and involvement. We need every bit of your help to do that. I can’t do it alone. 

I want you to know with absolute certainty that 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.

When you look at the body of literature, it is clear: research and clinical experience shows that, in about 80%-90% of headaches, neck, and back pain, compared to the traditional medical model, patients get good to excellent results with Chiropractic. It’s safe, more cost-effective, decreases chances of surgery, and reduces chances of becoming disabled. We do this conservatively and non-surgically with minimal time requirements and hassle on the part of the patient. And, if the patient develops a “preventative” mindset going forward, we can likely keep it that way while raising the general, overall level of health! And patients have the right to the best treatment that does the least harm. THAT’S Chiropractic folks.

Please feel free to send us an email at dr dot williams at chiropracticforward.com and let us know what you think or what suggestions you may have for us for future episodes. Feedback and constructive criticism is a blessing and we want to hear from you on a range of topics so bring it on folks!

If you love what you hear, be sure to check out www.chiropracticforward.com. We want to ask you to share us with you network and help us build this podcast into the #1 Chiropractic evidence-based podcast in the world. 

We cannot wait to connect again with you next week. From Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward. 

Social Media Links

iTunes

CF 016: Review of The Lancet Article on Low Back Pain (Pt. 1)

CF 014: DEBUNKED: The Odd Myth That Chiropractors Cause Strokes (Part 2 of 3)

 

Bibliography

  1. Chow R (2009). “Efficacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomised placebo or active-treatment controlled trials.” Lancet 374(9705): 1897-1908.
  2. Cotler H (2015). “The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain.” MOJ Orthop Rheumatol 2(15).
  3. Gasperini G (2014). “Does low-level laser therapy decrease swelling and pain resulting from orthognathic surgery?” Int J Oral Maxillofac Surg 43(7): 868-873.
  4. Gur A (2003). “Efficacy of low power laser therapy and exercise on pain and functions in chronic low back pain.” Lasers Surg Med 32(3): 233-238.
  5. Subash Chandra Bose GN (2018). “Spinal manipulation combined with laser therapy is more beneficial than laser therapy alone in chronic non-specific low back pain. A randomized controlled study.” Euro J Phys Rehabil Med.

CF 021: Crazy Update On Run-Away Healthcare Spending in America

Crazy Update On Run-Away Healthcare Spending in America

In today’s podcast, we are going to talk about the crazy, run-away healthcare spending in America and we’re going to use an article straight from the leading authority, the Journal of the American Medical Association, to help us out.

Before we get started, I want to share with you how much have enjoyed getting this podcast up and running. I strongly doubt it’s as popular as the other great chiropractic podcasts that have been up and going for a couple of years now. Heck, Chiropractic Forward has just been going since December so, at this point, one would expect for us to still be trying to gain attention and trying to gain some ears. And…..we are. No doubt.

But I can say that is has been pure joy to look up the downloads for each episode and seeing that, no…..its not just me that finds this stuff fascinating. Lol. You guys and gals are starting to listen and starting to pay attention.

We’re still struggling for those like and retweets on Twitter.

That’s the frustrating part if I’m being honest. To KNOW that you have put together an effective article on how chiropractors do not cause strokes and then to have such a hard time getting the word out. It’s frustrating to be sure but it’s also part of building something new and exciting.

So, I will simply continue to remind you that we need your help if we are to make a difference and I will keep reminding you to like our Facebook page, follow us on Twitter, sign up for our weekly reminder newsletter through the form on our homepage, and share us with your network.

We would certainly appreciate that help. Some of you may have actually gotten to see me arguing the stroke issue on our Facebook page. My gosh, some people, you could hit them with a research book full of papers in your favor and some would still argue just to try to prevent being wrong.

Not only do I get to argue about stroke or whatever the topic may be, it always strays into generalized ignorant statements like, “Chiropractic is bunk.”

I can use research to absolutely wipe the floor with people like that. And, the irritating thing is that the people, or trolls spouting off like that are usually computer majors, musicians, or something else completely removed from healthcare.

It is enough to make a man insane if you allow it. So I don’t.

Anyway, check us on Twitter and Facebook. Every now and then, you may find an enthusiastic discussion. lol. To say the least.

Since I haven’t yet, I’ll introduce myself, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast. We are honored to have you listening. Now, here we go with some vital information that we think can build confidence and improve your practice which will improve your life overall. That’s a tall order but that is the goal.

You have shaked, shimmied, and rolled into Episode #21

I’d like to start by saying that it is good to see the medical world beginning to examine itself with a clear lens. We have seen them turn blind eyes to many things we notice and research notices. As we have mentioned, there has been little attention given to the updated recommendations in favor of chiropractic, massage, and acupuncture in February of 2017. It is yet to be known what, or if anything, will change following the series of low back pain papers recently published in The Lancet (March21, 2018).

I have been mentioning how I feel that the opioid crisis has opened many many doors recently in regards to the medical field, clinical pathways, and in they way they are starting to look at the costs. Kudos to those in the medical field for beginning to call out their own protocols and questions them for effectiveness vs. risk. Some procedures may be effective here and there but, in general, if the squeeze is not worth the push, then there is little to zero return on investment and it should be abandoned. Obviously, one’s health is different than a business stat sheet but the metaphor is a valid one I believe.

Obamacare was supposed to heal all of our healthcare woes, right? From what I can tell, all it did was squeeze out the middle class. The folks that make too much to be subsidized but do not make enough to not really care about the new jacked health insurance rates.

For example, the premiums here in Texas have doubled or tripled in many cases while the insurance companies cover less and less. The co-payments have gone from $15-$20 all the way up to $50 and even $100. The deductibles have gone from $250 or $1,000 all the way up to $5000 or $10,000. In addition, the insurance companies are now reimbursing healthcare providers less. in many cases, 3/4 less.

Did you know that here in Texas, where a medical radiologist was once reimbursed up to $28+ or so for reading a neck series, they now get paid in the ballpark of $7 for the same series? I promise the doctors are not living less of a life than they were prior to Obamacare. Not at all. But, what is likely happening unconsciously is they are probably reading more x-rays more quickly to attempt to make up for the reduction in their pay.

Would you agree that this may put patients at more risk? I’m not saying doctors make a conscious decision to put patients at risk but, if a professional in ANY industry has a house in town, a house and boat on the lake, 3 cars, time share on a private plane, and things of that nature, when their income is cut by 3/4 in some cases, they will tend to find ways to make that up in ways that make sense to them. Regardless of profession or industry.

Maybe Obamacare just makes them more efficient rather than raising the patient risk. I do not have the answer on this but I do know that radiologists are responsible for everything on a film and their license is at risk on each and every film. When the government cut their pay that dramatically, the government began putting people at more risk. In my opinion of course.

I am firmly on the side of the medical field on this issue. The same type of thing is currently happening with the chiropractic industry as well. We are being reimbursed at smaller and smaller rates. We are seeing our covered patients being turned into cash patients whether we like it or not. The co-pays and deductibles are so high, the could just as easily be cash patients for our purposes. For this very reason, you are seeing more and more chiropractors in America begin to look at changing over to a cash-based practice model and drop insurance contracts all together.

I’m not certain every bit of this discussion is completely on topic but let me tie it up and bring it home through the use of this research paper. This paper appeared in the Journal of the American Medical Association (JAMA) on March 23, 2018. It was titled “Health Care Spending in the United States and Other High-Income Countries” and was authored by Irene Papanicolas, PhD (Papanicolas I 2018).

Why They Did It
Healthcare spending in America is a long-time hot topic and issue that has never been adequately addressed. Part of the problem is that we Americans spend more than other high-income countries with little information that shows that any efforts to control expenses has done anything to help the problem.

These authors attempted to compare the big ticket items in healthcare in America with the same items in ten other high-income countries in an attempt to learn where improvement might be made here at home.

How They Did It
Information was mostly gained from the Organization for Economic Cooperation and Development (OECD) from 2013-16. The OECD is an international organization comparing underlying differences in structural features, types of health care and social spending, and performance for several high-income countries.

What They Found
In 2016, America spent 17.8% of its gross domestic product on healthcare while the other 10 nations spent from 9.6%-12.4%.
Surprise, surprise….pharmaceutical costs spending per capita in America was $1443 vs. from $466-$939 in the other 10 countries. American doctors and patients love those pills. That is healthcare spending in America at its best.
90% of Americans are insured while 99%-100% were insured in the other 10 countries.
The U.S. has the highest proportion of private insurance when compared to the other 10 countries, which is 55.3%.
When it comes to smoking, Americans actually have the second lowest rate sitting at 11.4%
When we talk about obesity, the US has the highest proportion at 70.1%. Others range from 23.8%-63.4% for comparison purposes.
The US life expectancy was the lowest at 78.8 years.
US infant mortality was the highest rate of the 11 countries.
There was no real difference in the American physician workforce, nurse workforce, etc., when compared to the other 10 countries.
America has comparable numbers of hospital beds
Americans use MRIs and CTs when compared to the other 10 countries.
The US had similar rates of utilization for acute myocardial infarction, pneumonia, chronic obstructive pulmonary disease, hip replacements, knee replacements, and coronary artery bypass graft surgery.
Administrative costs of care in American stood at 8% while the same measure in the other 10 countries ranged from 1%-3%.
Salaries of physicians and nurses were higher in the US; for example, generalist physicians salaries were $218 173 in the US compared with a range of $86 607 to $154 126 in the other countries.

Wrap It Up
The authors of the paper concluded that, “The United States spent approximately twice as much as other high-income countries on medical care, yet utilization rates in the United States were largely similar to those in other nations.

Prices of labor and goods, including pharmaceuticals, and administrative costs appeared to be the major drivers of the difference in overall cost between the United States and other high-income countries”

My own wrap up would be that America spends twice as much money on healthcare while we have the highest rate of obesity, double the amount of pharmaceuticals, lower life expectancy, higher infant mortality, and higher administrative costs when we are compared to 10 other countries of similar income. Healthcare spending in America is out of hand.

That’s not good, folks. Not good at all. When do the pharmaceutical companies stop controlling the medical profession and the medical profession turn it around to control the pharmaceutical companies? When does that happen exactly?

Did you know that, from 1948 until 1996, there was a TV ban on running liquor ads? You may see beer or wine ads but you would never see Jim Beam running a commercial between Alf and Different Strokes. But, how often do we see pharmaceutical ads on TV these days? It’s a shame to be honest. Shouldn’t the doctor be the one that is informed on medications rather than a 320 million people that are almost completely uneducated on pharmaceuticals? Should patients be going into doctors’ offices ready to pressure them into a certain medication because they saw it on TV?

It is absolutely insane and should have been stopped at the first mention of it. To make it fair or legal or whatever may be the case, they state a long laundry list of all of the things that may happen to you if you take it. But, the information is delivered and people are influenced.

If a patient goes in for something like erectile dysfunction, the doctor tells them what they need. They don’t tell the doctor!! Do you see the problem here? If the patient goes in for potential blood clots, the doctor should be telling them they need a certain type of thinner. That is not the patient’s place in any country on the entire planet.

Not only do the pharma companies control patient mentality in this way but they attempt control of the physicians. Pharma reps are skilled at what they do. They are highly trained and very well-paid to effect influence in their market’s physicians. They take them on dinners, bring the office lunches, pay for trips, etc. You can spot them at any doctor’s office you go to. Just look for the well-dressed person in the waiting room with a clip board and a bag of goodies. That’s them!

I had a general practitioner that I had to finally fire. I had been living a bit unhealthy for several months when I went for a yearly checkup. My blood pressure was high. He immediately tried to put me on life-long meds. I was overweight and drank a 12-pack of Bud Light here and there while traveling in a band playing music. You might say that I used to be a little bit ornery. Again, I was admittedly behaving badly. His diagnosis was that I was depressed and needed an anti-depressant. Really?

Instead of trying some behavior modification, according to him, I needed life-long blood pressure meds and life-long antidepressant meds. Where does this mentality come from? What if we treat the CAUSE rather than the SYMPTOM?

First, I lost weight and started to behave. Guess what? My blood pressure returned to normal. As a result of ceasing traveling in a band, I basically quit drinking beer outside of social events. Boom! I was no longer depressed according to his definition.

This may seem like an extreme example to some but, it is my estimation that this sort of “doctoring” and “pill pushing” is far more common than one may even dream.

I am in no way against the medical field or against surgery or against medicine. I am against simple pill fixes. I’m against long-term meds when not needed. There are some conditions like diabetes or genetic high blood pressure that require long-term meds but, in many cases, they should be avoided. I’m against the medical field performing shots and surgeries and using opioids for musculoskeletal pains when the research is clear when it recommends chiropractic, massage, etc.. for those pains.

Basically, the medical field needs to stop thinking the pills are the be all – end all of healthcare and start looking more to the cause rather than just treating the symptoms. The physicians need to take the reins of their profession away from the pharmaceutical companies and wield the power over pharma that they attempt to wield over chiropractic and other alternative means of healthcare.

Enough about them for this episode. I want you to know with absolute certainty that 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.

When you look at the body of literature, it is clear: research and clinical experience shows that, in about 80%-90% of headaches, neck, and back pain, compared to the traditional medical model, patients get good to excellent results with Chiropractic. It’s safe, more cost-effective, decreases chances of surgery, and reduces chances of becoming disabled. We do this conservatively and non-surgically with minimal time requirements and hassle on the part of the patient. And, if the patient develops a “preventative” mindset going forward, we can likely keep it that way while raising the general, overall level of health! And patients have the right to the best treatment that does the least harm. THAT’S Chiropractic folks.

Please feel free to send us an email at dr dot williams at chiropracticforward.com and let us know what you think or what suggestions you may have for us for future episodes. Feedback and constructive criticism is a blessing and we want to hear from you on a range of topics so bring it on folks!

If you love what you hear, be sure to check out www.chiropracticforward.com. We want to ask you to share us with you network and help us build this podcast into the #1 Chiropractic evidence-based podcast in the world.

We cannot wait to connect again with you next week. From Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.

CF 013: DEBUNKED: The Odd Myth That Chiropractors Cause Strokes (Part 1 of 3)

CF 016: Review of The Lancet Article on Low Back Pain (Pt. 1)

Bibliography
Papanicolas I (2018). “Health Care Spending in the United States and Other High-Income Countries.” JAMA 319(10): 1024-1039.

CF 020: Chiropractic Evolution or Extinction?

Chiropractic Evolution or Extinction?

This week on the Chiropractic Forward Podcast we are talking about Chiropractic Evolution and hopefully NOT extinction. I want to continue with discussions on low back pain (LBP) because that is the topic that is on fire at the moment. Not only that but I will go into some of the inter-professional feuding we find in the chiropractic industry and we will touch on some admittedly uncomfortable topics for some chiropractors.

First, bring on that bumper music!

Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast where we talk about issues related to health, chiropractic, evidence, chiropractic advocacy, and research. Thank you for taking time out of your day I know your time is valuable and I want to fill it with value so here we go with some vital information that we think can build confidence and improve your practice which will improve your life overall.

You have shimmied right into Episode #20. It’s hard to believe all of this craziness started 20 weeks ago. It feels like I’m still trying to get it figured out. That’s for sure.

I just returned from a trip to New Orleans. Did you know that New Orleans is actually good for you?

The momentum low back pain has picked up recently is a once in a lifetime re-booting of an entire thought process, of long-held clinical pathways, and of stubborn practitioner mentality and dogmatic beliefs.

I blame the national emergency we know as the “Opioid Crisis” for starting a more focused attack on low back pain. The statistics on low back pain are some incredible numbers. It’s the number one reason for disability in the world. That is truly impressive. However, low back pain as a global issue did not crop up in only the last several years. Granted, due to an older, aging population, it has increased but low back pain has been a serious concern for many years at this point.

Yet, there were no global papers on low back pain. There were no articles in the journals for the American Medical Association and for the American College of Physicians recommending spinal manipulation (chiropractic adjustments) as an effective, first-line treatment for low back pain. We have simply never seen the attention based on the research that we have seen since the onset of the opioid crisis.

One must give kudos to the medical field in the sense that they recognize they have been partly the cause of the opioid crisis and, in turn, are taking steps to address the problem through new thinking and alternative means. Even if that means going against old dogmatic beliefs and against the common grain.

I applaud the new directions. Although, there is still a very clear gap that will take time to fill in regards to what the practitioner is doing and what they SHOULD be doing.

We recently discussed a series of papers in The Lancet from March 21, 2018 that dealt with low back pain. The Lancet is one of the oldest and most respected medical journals in the world dating back to 1823 and the series of papers was compiled by an international, interdisciplinary group of experts. It is considered the best current information we have dealing with low back pain, it’s prevention, and going forward. I highly encourage you to read through the papers.

Since it would get a little boring going over the same three papers over and over, I am going to move along with other research and other information concerning low back pain.

I want to start with a paper that echoes the sentiments of The Lancet series in regards to the gap in what the evidence suggests and in what is actually happening in the real world. In all actuality, from here forward, I believe most of what we discuss on the topic of low back pain will somewhat echo the sentiments found in the recent Lancet papers.

Moving on, the papers we will discuss are arranged strategically and tell a story if you follow along.

To start, here is a paper from 2010 titled “Managing low back pain in the primary care setting: the know-do gap.” It was published in Pain Research & Management and authored by NA Scott, et. al. with the Institute of Health Economics in Edmonton, Alberta, Canada.

Why They Did It
The goals for these authors were to identify gaps in knowledge in regards to diagnosis of acute and chronic low back pain in a primary care clinical setting for primary practitioners in Alberta, Canada in order to further determine what barriers lie in the way of the primary practitioners adopting a multidisciplinary approach in the treatment process.

How They Did It
• The authors accepted papers from 1996-2008
• The papers compared clinical pathway patterns found in the primary practices and in the guides and recommendations found through searching literature databases, websites of various health technology assessment agencies, and libraries.
• The data was organized qualitatively.

What They Found
The search for quality papers yielded 14 that were considered relevant.
Knowledge gaps were identified in the primary practices for red flags, imaging use, advice for bed rest and sick leave for low back pain, medications, and recommendations of alternative treatment means such as chiropractic, acupuncture, physiotherapy, etc.)

Wrap It Up

The authors stated that a “know-do” gap certainly exists. Meaning, there is a difference in what the research is telling primary practices to do for low back pain and in what they are actually doing in the real world.

The authors plan to use this information to develop a plan to implement more multidisciplinary protocols for low back pain by educating the primary practitioners on the guides and recommendations[1].

If we are to talk about the “Know-do” gap, what a common result of there being a gap in knowledge of diagnosis and treatment when compared to actual researched guides?

To help shed some light on this, let us look at a paper from March of 2018 by Richard Deyo, et. al. at the Department of Family Medicine at Oregon Health Science University in Portland, Oregon. This paper is titled “Use of prescription opioids before and after an operation for chronic pain (lumbar fusion surgery)”

Why They Did It
Considering low back fusion surgery is typically performed to treat chronic low back pain, and considering that patients have the expectation of no longer needing opioids after a surgery, the authors were looking to discover three things:
• What amount of patients having long-term preoperative opioid use discontinued or reduced dosage after surgery?
• What amount of patients having had a smaller amount of preoperative opioid use initiated long-term use?
• What predicts whether a patient goes on to use opioids in the long-term after surgery?

How They Did It
• This was a retrospective cohort study
• There were 2491 participants that had undergone lumbar fusion surgery to treat degenerative conditions.
• The researchers used Oregon’s prescription drug monitoring program to determine pre-op and post-op use of opioids by the test subjects.
• Long-term use was defined as more than 4 prescription refills 7 months after hospitalization. At least 3 occurring more than 30 days after hospitalization.

What They Found
• 1045 patients were identified as having long-term opioid use PRE-operatively
• 1094 were determined to have had long-term opioid us POST-operatively.
• From the long-term PRE-op patients, 71% continued long-term in POST-op use and 13.8% experienced episodic opioid use.
• A mere 9.1% of the long-term PRE-op patients had short-term use POST-op.
• In the group of patients that received no preoperative opioids, 12.8% went on to use opioids long-term.

Wrap It Up
This paper suggests that the strongest predictor of whether a patient would use opioids long-term was the cumulative effect of PRE-op opioid doses. The paper also suggests that lumbar fusion surgery commonly had no effect on eliminating long-term opioid use so patients that are unaware of the risks of opioid use run a risk of long-term use[2].

While I’m no orthopedic surgeon, I would ask, “Why are they doing lumbar fusions on stable segments in the first place considering the research showing that it should be a treatment of last resort?”

It should come after spinal manipulation, acupuncture, massage, exercise rehab, physiotherapy, cognitive behavior therapy, yoga, etc….. That is A LOT any sort of surgery should typically follow so why? Of course, I’m not making the money those folks make so, that may be the decision maker for some of them at least.

Moving from things going wrong to ways they can go right, there is this paper from the journal Pain from March 27, 2018 titled, “Spinal Manipulation and Exercise for Low Back Pain in Adolescents: A Randomized Trial by R. Evans, et. al. with the University of Minnesota’s Integrative Health and Wellbeing Research Program. As a side note, Gert Bronfort was also listed as an author in this paper. If you are unfamiliar with Bronfort, he has authored several key papers previously.

Why They Did It
The authors state that there is a “paucity” in high quality research on the matter of exercise vs. spinal manipulative therapy in the treatment of low back pain.

How They Did It
• The research was a multicenter, randomized trial
• 185 adolescent were included
• The participants ranged in age from 12-18 years old
• All had chronic low back pain
• Outcome assessments were measured at 12 weeks, 26 weeks, and at 52 weeks

What They Found
• The inclusion of spinal manipulative therapy (chiropractic adjustments) to exercise therapy had a greater effect on the reduction of low back pain severity over the course of a year.
• At the 26-week mark, the spinal manipulative therapy with exercise group had better effectiveness for disability and improvement over the exercise alone group.

Wrap It Up
The spinal manipulative therapy with exercise group had a significantly greater satisfaction with care at all time points. “There were no serious treatment-related adverse events. For adolescents with chronic LBP, spinal manipulation combined with exercise was more effective than exercise alone over a one-year period, with the largest differences occurring at six months. These findings warrant replication and evaluation of cost-effectiveness[3].”

We chiropractors have to love that paper now, don’t we?

Next, let’s look at a different level of recovery that deals with the way patients think as much as the treatment they undergo. Here is an article that appeared in HealthDay called “Overcoming Fear of Back Pain May Spur Recovery” by Steven Reinberg. The article was based on a recent paper that appeared in JAMA Neurology in April 16, 2018 published by lead researcher Anneleen Malfliet. It is usually wise to at least listen up when it’s in journals such as The Lancet or in the Journal of American Medical Association.

The research paper being cited once again echoes much of the sentiment laid forth in The Lancet low back series. Basically, their recommendations were as follows:
• We need to help patients think differently about their pain.
• We need to encourage patients to move in ways they had been afraid of.
• We need to teach patients with neck and back pain to remain active and/or increase their activity level gradually.
• We should avoid the use of scary or un-reassuring labels or diagnoses.
• We should not use pain levels as a reliable symptom or guideline to limit activity.

In short, research proved that patients following these guidelines showed less disability, a reduced fear of moving, and improvement in mental and physical outlook.

“Pain neuroscience education aims to change patients’ beliefs about pain, to increase their knowledge of pain and to decrease its threat,” Malfliet said[4].

Be sure to read the full article at: https://consumer.healthday.com/bone-and-joint-information-4/backache-news-53/overcoming-fear-of-back-pain-may-spur-recovery-732970.html

Now that we chiropractors are taking the step more and more into the spotlight as the experts in the treatment of biomechanical issues, what can we do on our end to ensure our colleagues can confidently refer to us and see us as peers for these issues?

I can tell you that, being in the ER one night as a result of a viral infection, not only was the virus running crazy through me but my neck was killing me as well. I thought I would ask the ER doc if he had any orthopedic exam up his sleeve that could determine what on Earth was hurting me so bad. Between you, me, and the light post, I already had a good idea but was curious as to what he knew and I thought it may be something that both of us could learn from.

It was. He did a Spurling’s move and that was about it before he gave up and said, “Honestly man, you probably know what’s going on better than I do.” And he was right. I did. But, it showed me that he was honest and that he saw me as an expert in my field and I appreciated it. Of course, he’s more of an expert in his field which is why I was there in the first place. We all have our part to play in the treatment of patients. Don’t we?

Back to my original point: how do we increase our profile as spinal, biomechanical experts. How do we increase interdisciplinary, inter-professional trust in who we are and what we can do for our patients?

I can tell you what NOT to do if that helps anything. I do not see any use chiropractic terminology that our colleagues do not understand. I personally do not use the term subluxation. In the dictionary, it is described as a partial dislocation. What does that mean in the medical mentality? It means a shoulder that was almost dislocated but reduced naturally. It means something along those lines. It does not mean a slight misalignment of a vertebra that causes cancer or whatever other conditions some describe.

I understand chiropractors wanting to stay separate and distinct. I get it. But, there is a difference between being separate and distinct and putting yourself in a category nobody understands, that everyone thinks is out on the fringe, and that nobody knows exactly how to utilize.

If our profession is not careful, it will separate itself into oblivion now that physical therapist, physiotherapists, and the medical world in general have discovered something we have known all along. That is that spinal manipulation and mobilization is one of the best and most effective means of treating neck and back pain.

What has kept us safe from them taking our business all of these years is that they all thought we were crazy! For some, they were right but the basic principle our profession is based on was one that evidence eventually backed up and proved. Now we are in danger of losing it if we do not learn that separate and distinct may not be the most effective means of conducting our business.

The last paper I want to discuss is one called “How frequent are non-evidence-based health care beliefs in chiropractic students and do they vary across the pre-professional educational years” by Stanley Innes, et. al. It was published in Chiropractic & Manual Therapies in March 15, 2018.

Why They Did It
The authors wanted to determine what proportion of chiropractic students in Australia hold non-evidence-based beliefs from the start and what their beliefs are in the treatment of non-musculoskeletal health condition. In addition, the authors wanted to determine if the beliefs changed any over the course of their education.

How They Did It
• The study was performed in 2016
• The information was taken from two chiropractic schools in Australia
• The students answered a questionnaire with the following questions
1. How often would they give advice on five common health conditions in their future practices
2. What was their opinion about if chiropractic spinal adjustments could prevent or help seven health-related conditions.
• There were 444 responses to the questionnaire

What They Found
• Students were highly likely to offer advice on non-musculoskeletal health conditions.
• The chances of a student doing so rose to the highest level in the last year of their education.
• High numbers of students held non-evidence-based ideas of the capabilities of chiropractic spinal adjustments in beginning which then tended to decrease in proportion until the last year. In the last year, the pattern reversed.

Wrap It Up
The authors were quoted as saying, “New strategies are required for chiropractic educators if they are to produce graduates who understand and deliver evidence-based health care and able to be part of the mainstream health care system[5].”

I want you to know that I am a chiropractic advocate. I want chiropractors to practice how they wish. I want the minimal practices to be comfortable and be as stripped down and as effective as they can be. I want the interdisciplinary doctors to do everything they can do to get people well and make a difference in lives. But I want them to do things in a way that is backed by science, that brings us to the center of healthcare rather than the fringes, I want us using terminology and ideas that garner confidence and respect rather than ridicule and scorn, and I want us all to thrive and prosper while we grow our incredible profession.

There will always be an internal feud amongst chiropractors. Likely, some of my close colleagues whom I respect immensely will take offense to what I am saying and to them, I can only say, “I’m sorry but it’s the way I feel about it and it’s the way I see it.” Thank God we are all different. The same would be boring.

A colleague of mine told me he feels that philosophy and science can live hand in hand. I want to believe that too. I hope it is true. But, what I do know for a fact is that, if we do not take this once-in-a-lifetime opportunity that opioids and low back pain has presented us, and move toward better integrating ourselves with the medical profession, I fully believe we will have our techniques and treatment stolen from us and we will cease to exist in our current form.

One constant you can always count on in life is change. I hope the inner-professional feuding does not keep change from happening quickly and in the right direction.

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.

Did you know that 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 what suggestions you may have for us for future episodes.

If you love what you hear, be sure to check out www.chiropracticforward.com. We want to ask you to share us with you network and help us build this podcast into the #1 Chiropractic evidence-based podcast in the world.

We cannot wait to connect again with you next week. From Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.

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CF 011: With Dr. Tyce Hergert: It’s Here. New Guides For Low Back Pain That Medical Doctors Are Ignoring

CF 013: DEBUNKED: The Odd Myth That Chiropractors Cause Strokes (Part 1 of 3)

CF 016: Review of The Lancet Article on Low Back Pain (Pt. 1)

 

 

References

1. Scott NA, Managing low back pain in the primary care setting: the know-do gap. Pain Res Manag, 2010. 15(6): p. 392-400.
2. Deyo R, Use of prescription opioids before and after an operation for chronic pain (lumbar fusion surgery). Pain, 2018.
3. Evans R, Spinal Manipulation and Exercise for Low Back Pain in Adolescents: A Randomized Trial. Pain, 2018.
4. Malfliet A, Effect of Pain Neuroscience Education Combined With Cognition-Targeted Motor Control Training on Chronic Spinal Pain
A Randomized Clinical Trial. JAMA Neurology, 2018.
5. Innes S, How frequent are non-evidence-based health care beliefs in chiropractic students and do they vary across the pre-professional educational years. Chiropr Man Therap, 2018. 26(8).