November 2018 - chiropracticforward November 2018 - chiropracticforward

Month: November 2018

CF 050: Chiropractic Care – Text Neck, Headaches, Migraines

CF 050: Chiropractic Care – Text Neck, Headaches, Migraines

Today we’re going to talk about headaches, migraines, neck pain, and our favorite topic here at the Chiropractic Forward Podcast, yes….we’ll talk about Chiropractic care. Specifically, chiropractic care for the headaches, migraines, and neck pain. 

Hold on though, make way, get in the Soul Train dance line because here’s that bumper music

Integrating Chiropractors

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

You have skidded all fast and furiously into Episode #50

Let’s talk a bit about the DACO program. For those that don’t know, that’s the Diplomate of American Chiropractic Orthopedists program I’m slowly trudging through. 

I say slowly. You have 3 years to finish. But, I’m a doer if you can’t tell. I’m a worker bee if you will. When I start something, I want to finish. I don’t like unfinished bidness. I don’t like things flapping out in the wind. I want to start it and then I want to finish it quickly and move on to the next thing. 

Getting 300 hours is never going to get done quickly. Especially when you are the sole doctor in a busy practice not getting home until 7 pm or even later sometimes. Such is my life. A curse and a blessing depending on the day and my outlook on that particular day. 

However, I believe I’m on a path to finish it up in about a year from when I started. Probably much sooner. For example, I knocked out 12 hours last week. That’s pretty solid but, we had a snow day and I took advantage of being stuck at home. 

I crawled down into my basement man cave, got in my blankie and jammies with an iPad on my belly, leaned the recliner back and got some education. 

So far, I have 40 hours of the 250 online hours done and 40 hours of the 50 live hours required. In total, I’m 80 hours into a 300-hour course. Rocking and rolling folks. Rocking and rolling. 

Some of the more recent courses I’ve completed were hip pain in children, joint hypermobility disorders, TMJ, and thoracic outlet syndrome. These courses are fascinating. 

The offer is there. If you need help getting started on yours, send me an email at dr.williams@chiropracticforward.com I’ll be glad to get you on your way. 

Speaking of getting in touch, I want to ask you to go to chiropracticforward.com and sign up for our newsletter. It makes everything easier. 

Now onto a discussion that took place on our Facebook page a couple of weeks ago that I thought was particularly interesting. 

I will put it in the show notes for you if you’d like to see the meme….funny word. My son loves it when we mispronounce it. You should try it with your kids if they’re old enough to get embarrassed by their parents.  

Anyway, the picture I posted was of a contemplative Kermit the Frog and it said, “Me when a patient tells me another chiropractor wanted 5 sets of x-rays over 9 months of treatment to correct something research doesn’t support.”

Now, let me set the stage here. The impetus for this was that one of my patients moved down to Georgia. Her daughter started having some headaches and pain so she went and got an MRI. 

The results of the MRI showed the issue to be out of the scope of chiropractic. Regardless, you guessed it, she got a recommendation for 5 sets of x-rays over 9 months of treatment. 

Absolute scare care riduculosity. 

Here’s where it got a little sticky. A colleague got on that post and expressed some dissatisfaction that I would post something like that. I guess he didn’t like my airing dirty laundry. Which is cool. I don’t mind at all but here’s what happened for me on the deal. 

I sat down and crafted a very PC response I think and in doing so, I had an opportunity to reflect on the podcast, the reason for it, and what we’ve done in just the past year. 

Here are some highlights that came to mind for me:

  1. You don’t make an omelet without cracking some eggs and I think some difference of opinion is to be expected and it’s something I just need to get used to. 
  2. I think I created this podcast to do whatever I could to move this profession forward. 
  3. Forward to me means providing research like we do every week but also to educate others, to suggest new research avenues, to encourage specialization and higher education, to push for integration, and to call out and discourage the behavior I feel holds us back from moving forward. 

If you aren’t active on our Facebook page, I’d encourage you to stop in and say, “Hi.” Tell us if you’re digging the podcast. Share some research you’ve found. Maybe give us a suggestion for a future podcast. We’re here. We also have a private Facebook group if you’d like to join the private group. 

OK, research for this week, here we go with paper #1

This one is called “Characteristics of Chiropractic Patients Being Treated For Chronic Low Back and Neck Pain[1].” The lead author is PM Herman and the paper was published in August of 2018 in the Journal of Manipulative Physiological Therapeutics. 

https://www.ncbi.nlm.nih.gov/pubmed/30121129

Get your marketing hat on for this one people. 

Why They Did It

Since chronic low back and neck pain are so prevalent, and since spinal manipulation is a common non-pharma treatment for them, the authors wanted to determine the characteristics of the type of patient that visits the chiropractor. 

How They Did It

  • They collected data from chiropractic patients in regard to regions and states, sites, providers and clinics, and patients. 
  • The data was collected through an iPad questionnaire given at the chosen sites. 
  • They had 518 chronic low back pain patients complete it while 347 chronic neck pain patients finished theirs. They also had 1159 do both. 

What They Found

  • Most of the sample were highly-educated
  • Most were non-hispanic
  • White females were the dominant demographic for race and gender
  • Few used narcotics
  • Avoiding surgery was the most important reason they chose chiropractic care 
  • Over 90% of the patients reported high satisfaction with their care

That should give you some good ideas when trying to figure out who you should be marketing to. I can lead the horse to water but I cannot show the snout into the pond and make the horse drink it up. 

Text Neck

I picked this one out because I saw a discussion on Facebook last week about Text Neck. The question posed was, isn’t text neck just a new term for an old problem? Is text neck just a scare tactic?

That was the general gist of the post. 

While I did not respond, I do have an opinion on text neck. I do not think it’s an old problem. I mean, let’s back up a bit. Poor posture is most certainly an age-old problem. No doubt about it. 

However, at no other point in our time in history that I’m aware of, have little bitty children all the way up to mid-aged and elderly people had a reason to be sitting in one spot for hours with their head flexed forward, bent down almost into their laps. It pains me to see some of the kids these days. 

My poor son. Not so much my daughter right now but my son….my goodness. That kid…I’ll look at him sometimes and he has somehow balled himself up into what I can only describe as something resembling a roly-poly or an armadillo. His head bent at 90 degrees looking at his phone in his lap. Basically, the epitome of text neck.

It must really suck being a chiropractor’s kid. I’ve taken pictures of it before when he wasn’t looking. As you probably know, you can draw on pictures on your phones. So I took that picture then drew big red marks exploding out of his neck. Then, while he’s sitting there on his phone, he gets the picture in a text. 

It’s awesome. You all should try it sometime if for no other reason than to give yourselves a laugh. 

Next Paper

This paper is called, “Cervical Proprioception in a Young Population Who Spend Long Periods on Mobile Devices: A 2-Group Comparative Observational Study” and it was published in the Journal of Manipulative and Physiological Therapeutics as well[2]. The lead author was Andrew Portelli and it was published in February of 2018. 

https://www.jmptonline.org/article/S0161-4754(17)30010-6/fulltext?elsca1=etoc&elsca2=email&elsca3=0161-4754_201802_41_2_&elsca4=Physical%20Medicine%20and%20Rehabilitation%7CHealth%20Professions

Why They Did It

The purpose of this study was to evaluate if young people with insidious-onset neck pain who spend long periods on mobile electronic devices (known as “text neck”) have impaired cervical proprioception and if this is related to time on devices.

What They Found

“The participants with text neck had a greater proprioceptive error during cervical flexion compared with controls. This could be related to neck pain and time spent on electronic devices.”

This message has been brought to you by an uncool parent of a teenager. 

Paper #3

This one is called, “Dose-response and efficacy of spinal manipulation for care of cervicogenic headache: a dual-center randomized controlled trial[3].” and it was published in Spine journal in February of 2018. 

https://www.ncbi.nlm.nih.gov/pubmed/29481979/

Why They Did It

The optimal number of visits for the care of cervicogenic headache with spinal manipulative therapy is unknown so the authors hoped to identify the dose-response relationship between visits and chronic headache outcomes…. and to evaluate the efficacy of chiropractic by comparison with a light-massage control.

What They Found

The authors’ conclusion was as follows, “There was a linear dose-response relationship between SMT visits and days with CGH. For the highest and most effective dose of 18 SMT visits, CGH days were reduced by half and about 3 more days per month than for the light-massage control.”

So, you guys and gals that want to take evidence-based to the extreme and get people out of your office in only 3 or 4 visits, you may not be hitting the number of visits that work the best. Everyone is different right? Everyone heals differently. Here we have 18 visits being the most effective for chronic cervicogenic headache. 

Good info to keep in mind. 

Integrating Chiropractors

I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment instead of chemical treatments like pills and shots.

When compared to the traditional medical model, research and clinical experience show that many patients get good or excellent results through chiropractic for headaches, neck pain, back pain, joint pain, to name just a few.

Chiropractic care is safe and cost-effective. It can decrease instances of surgery & disability. Chiropractors normally do this through conservative, non-surgical means with minimal time requirements or hassle to the patient. 

And, if the patient develops a “preventative” mindset going forward from initial recovery, chiropractors can likely keep it that way while raising the general, overall level of health of the patient!

Key Point: Patients should have the guarantee of having the best treatment offering the least harm.

That’s Chiropractic!

Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show or tell us your suggestions for future episodes. Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on iTunes and other podcast services. Y’all know how this works by now so help if you don’t mind taking a few seconds to do so.

Help us get to the top of podcasts in our industry. That’s how we get the message out. 

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

Website

http://www.chiropracticforward.com

Social Media Links

Chiropractic Forward Podcast Facebook GROUP

Twitter

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Stitcher:

TuneIn

About the author:

Dr. Jeff Williams – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger

Bibliography

1. Herman PM, Characteristics of Chiropractic Patients Being Treated for Chronic Low Back and Neck Pain. J Manipulative Physiol Ther, 2018.

2. Portelli A, Cervical Proprioception in a Young Population Who Spend Long Periods on Mobile Devices: A 2-Group Comparative Observational Study. J Manipulative Physiol Ther, 2018. 41(2): p. 123-128.

3. Haas M, Dose-response and efficacy of spinal manipulation for care of cervicogenic headache: a dual-center randomized controlled trial. Spine, 2018: p. S1529-9430.

CF 012: Proven Means To Treat Neck Pain

CF 033: Did You Need Proof That Chiropractors Help Headaches?

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

 

 

CF 049: The Palmer/Gallup Poll 2018 Discussion On Chiropractic Marketing

CF 049: The Palmer/Gallup Poll 2018 Discussion On Chiropractic Marketing

Today we’re going to talk about the 2018 version of the Palmer Gallup poll that has some great info including some chiropractic marketing nuggets for your nugget pouch so stick around as we get into the details

But first, make way for that sweet sweet bumper music

Integrating Chiropractors

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

Introduction

You have crumpled into Episode #49. Info to help with your chiropractic marketing. We are moving in on a solid year of Chiropractic Forward episodes and that feels good. Every single week. We haven’t missed one week this past year. There is most certainly a sense of accomplishment and doesn’t it feel good to feel good? Of course, it does. 

The Diplomate of American Chiropractic Orthopedists (DACO)

Let’s talk a bit about the DACO program – Same as last week. Just trudging along. Last week I took classes on benign paroxysmal positional vertigo, poster canal, anterior and horizontal canals, Epley’s maneuver and all that goes along with that. I also had a class on Lumbar spinal stenosis that I learned some new tidbits on. Great stuff. My offer stands, if any of you want to start looking at it, I’d be glad to give you a little guidance in getting yourself started. 

Newsletter

How’s about youse guys head over to chiropracticforward.com and get yourself on our newsletter. I have some cool stuff coming down the pike and I want you to be the first to know about it and I want you to save money because you were cool enough to be on our email list. No more than once a week. That’s my guarantee. It’s just an email address folks. Not a big deal. 

Personal happenings

You have heard my woes and my front desk worries over the past month or two. I told you last week that it appears my wife has herself a new full-time gig and guess what? With her help, we had not only one of the best Octobers we have ever had, but we also had one of the best months (numbers-wise) that we have ever had in 20 years. 

I believe there’s something to this “wife working the front desk” idea people. Something to think about for sure. If you can work with your wife or husband that is. You may have to pee strategically around the office just to mark your territory and let it be known this is your domain but, nobody will work as hard for the office as someone that has a vested interest in it. I’m a firm believer in that. 

Into The Information

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.

This week I want to talk about the Palmer/Gallup poll that has been coming out annually for a couple of years now. I think it’s two years but cannot recall off the top of my head. 

Regardless, let’s talk about the 2018 version. I look forward to its release every year because you can get some chiropractic marketing ideas from it if you’re looking at it the right way. 

The Ideal Patient

Any time you start a new generic chiropractic marketing program, they have you create your ideal avatar or your ideal customer. The customer that not only comes in and you love to see them come through the door but the customer that is coming in and paying good money to see a good doctor. The people that love you and go out into the world to tell everyone every good thing they can about you and the ones that are the first to leave you a great Google review. 

THAT’S the ideal patient, isn’t it? If we could only fill up our offices with that specific, amazing person all day every day. We’d never even think about giving up our practices and moving to an exotic place with umbrellas and funny drinks. Chiropractic marketing would be non-existent. 

Well, we may still think about doing that but it wouldn’t occupy as much brain space if these people were all that ever came through our door. 

Don’t we just love seeing these perfect patients? Smiles, good vibes, and excitement. And sometimes food!! I have one bring us pumpkin spiced cake and sugar cookies last week. We need to work on a nutritional talk for sure but you get the point. 

On To The Poll

I am linking the poll in the show notes so go check it out Episode 49 at chiropracticforward.com

http://www.palmer.edu/uploadedFiles/Pages/Alumni/gallup/palmer-gallop-annual-report-2018.pdf

The first thing we really get into here is the Summary and I think that’s really where we are going to stay instead of going too deep in because we’ll wind up with a 4 hour episode and I don’t want that any more than you do so let’s hit the high spots and call it good. 

  1. Neck and back pain is common among adults in the US – yes, we knew that now didn’t we? They say about 2/3 of US adults (62% to be specific) have had neck or back pain that was significant enough that they saw a healthcare professional for care at some point in their lifetime, including 25% who did so in the last 12 months. 
  • 25% of the population sought care in the last year for pain. I bet 25% did not seek care for wellness. 

2. 80% of American adults prefer to see an expert in spine care for neck and back conditions rather than a general medicine professional who treats anything and everything. I think we all know who the experts are right? It’s us….

He’s a problem though, 67% of them prefer to see someone that can prescribe medication or surgery to treat neck or back pain.  Only 28% want to see someone that does not use prescription medication or surgery. That one is a bit of a kick to the nether region. I thought we were making more progress on that front. 

I can’t tell if the next point contradicts the previous one or not. You decide. They say that prescription pain meds aren’t preferred as first-line care for about 79%. I can only guess they are preferring a practitioner that can prescribe just in case it declines to the point of needing it but they don’t necessarily want to start with pills? Maybe…..

3. When it comes to healthcare providers, people say that chiropractic doctors and medical doctors are the top choices for neck or back pain care. In the last year, 62% say a medical doctor while 53% saw a chiropractic doctor. 

Peel Back The Layers

Going a little deeper there, 34% say a PT and 34% visited a massage therapist. 

I think it’s of important note here that half of the people that went to the chiropractor went because they said that chiropractors provide the most effective treatment for their pain. That’s pretty damn awesome right there. We’ll get to the other half here in just a minute. 

The overwhelming feeling in this subsection is the keyword is “EFFECTIVENESS.” Can you say, “Chiropractic Marketing Nugget?” How effectively can you relay your effectiveness? 

I would offer to you the idea that this podcast is an EXCELLENT way to speak about your effectiveness as well as to back up your effectiveness. You just have to listen and you have to take what you learn and turn that into kick-butt content and marketing material. 

Since not everyone is particularly gifted at chiropractic marketing or creating content, we are working on helping you out in that aspect. Stick with us. It’ll happen. Just go to  chiropracticforward.com and get on the email list to stay on top of that. 

Outside of ‘effectiveness,’ SAFETY was another reason people chose chiropractors and PTs for their back and neck pain. In fact, about half of those coming to the chiropractor said safety was why they chose chiropractic.

So, we have the big TWO reasons. Only two. That people go to chiropractors nationwide. They are Effectiveness and Safety. That should be useful information for you guys and gals to take and run with. Chiropractic marketing at its best. 

Next point

4. The fourth point of the summary was types of care. They found a lot of people utilizing self-management at home, as they should. They say 53% of American adults went to get massages to control pain. They say 47% had chiropractic care for their pain. And 42% went to a PT. 

That means we have a lot of people doing more than one thing right? It would make perfect sense to not be a one-trick pony in your practice. For instance, the subluxation guys and gals only adjust. They’ll see a patient 100 times a year and only adjust. Nothing else.

Oh wait, I lie. There’s a local guy here that will pray over each one before using the activator on them all so I guess it’s a little more than just the adjustment. 

I don’t want to make light of prayer. I’m a Christian and am well aware of the power of prayer but when it’s done after joining Body By God type management programs, well, it just seems a bit disingenuous doesn’t it? If we’re being honest?

Anyway, if you have to see someone that many times a year, you’re probably a terrible chiropractor and you’re probably doing more damage than you are doing good.

Diversifying

Back to doing more than one thing: it’s clear that patients are not looking for just an adjustment. It appears they’re looking for chiropractic, they’re looking for massage, they’re looking for some exercise/rehab considering 72% were looking into yoga. 

Although it’s not in this article, I believe many are looking for acupuncture these days. As discussed earlier, they may potentially be looking for meds so why couldn’t you offer anti-inflammatories like turmeric or Boswellia just to name a few. I say this because this poll showed that 73% of people took an over the counter medications like acetaminophen or ibuprofen. Definitely food for thought. 

5. Patient Experiences

Patients that visited a chiropractor, a PT, or an MD over the last year said they received a high level of care. That’s good news. 

For chiropractors specifically, 9 out of 10 patients said

  • The chiropractor listened to them
  • DCs provided convenient and quick care
  • We demonstrated caring and compassion
  • The chiropractor explained things well
  • And they spent the right amount of time with them

Approximately 90% of patients had all of that to say about chiropractic doctors. That’s outstanding news, folks. That means that we can fight amongst ourselves and, while I would argue the straights are keeping us from full integration, in the eyes of patients, almost ALL of us are doing a good job!

For Physical Therapists, overall, they were hitting around the 83%-86% area. 

For MD’s, they didn’t do too well honestly. But didn’t we expect that? Here’s how they fared:

  • 72% say their MD listens
  • 67% said they often explain things well
  • 66% said they demonstrate care and compassion
  • 53% said they have quick access and are convenient

No surprise there. In fact, the surprise comes when we see that so many are still going to the GP for non-complicated musculoskeletal pains. That’s the real surprise. 

Point 5 Discussion

When you consider that chiropractors hit around 90% for all of those and you see MDs around 64% for the same metrics, well…..that’s not so good, right?

I see A LOT of opportunities here. If you are of the marketing mind, I’m sure you see the same!

This podcast isn’t just for listening to some mindless drivel folks. I am trying to give you stuff that you can use immediately after you listen. If you pay attention to what I’m telling you every week, you can turn around and communicate FACTS to your patients, your staff, and to those in the medical field in your region. 

I’m friends with a neurosurgeon and a vascular surgeon because I’m not freaking crazy. I can communicate research to them in an effective way that they understand. I’ve taught them a ton they didn’t already know. Plus we all like a Cerveza here and there so that works out well for us. 

Research helps you communicate

What I’m saying is that you should be listening to this podcast to learn for sure. But you should also be listening to it with the mindset of, “How am I going to take this information and use it in either my marketing or in my communication with my community?”

Believe me or don’t. I hope you believe me. The information I am bringing to you is the information you should be using. Not the subluxation stuff. Not the philosophy stuff. Literally, straights in our profession are the only people on this Earth that give a damn about that stuff. 

Nobody else knows or cares. Nobody. 

But research, safety, and effectiveness, well…..when you’re talking in those terms, then you are getting somewhere. 

Integrating Chiropractors

The Message

I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is a mechanical pain and responds better to mechanical treatment instead of chemical treatments.

The literature is clear: research and experience show that, in 80%-90% of headaches, neck, and back pain, patients get good to excellent results when compared to usual medical care and it’s safe, less expensive, and decreases chances of surgery and disability. It’s done conservatively and non-surgically with little time requirement or hassle for the patient. If done preventatively going forward, we can likely keep it that way while raising overall health! At the end of the day, patients have the right to the best treatment that does the least harm and THAT’S Chiropractic, folks.

Contact

Send us an email at dr.williams@chiropracticforward.com and let us know what you think of our show or tell us your suggestions for future episodes. Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on iTunes and other podcast services. Y’all know how this works by now so help if you don’t mind taking a few seconds to do so.

Being the #1 Chiropractic podcast in the world would be pretty darn cool. 

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

Website

http://www.chiropracticforward.com

Social Media Links

https://www.facebook.com/groups/1938461399501889/

iTunes

Player FM Link

Stitcher:

TuneIn

About the author:

Dr. Jeff Williams – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger

http://www.palmer.edu/uploadedFiles/Pages/Alumni/gallup/palmer-gallop-annual-report-2018.pdf

CF 026: Chiropractic Better Than Physical Therapy and Usual Medical Care For Musculoskeletal Issues

 

CF 034: Chiropractic Information To Help You Form Your Practice

 

CF 032: How Evidence-Based Chiropractic Can Help Save The Day

 

CF 048: Do Disc Herniations On An MRI Worsen When Sitting Or Standing (PART TWO)?

CF 048: Do Disc Herniations On An MRI Worsen When Sitting Or Standing (Part TWO)?

Today we’re going to continue our talk from last week on whether or not a disc herniations change as you sit up, stand up, or move around. We went over some pretty good research last week. This week, it’s time for the cherry on the top. 

But first, here’s that bumper music

Integrating Chiropractors

 

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

You have scampered into Episode #48. I use scamper this week because, as my son was playing with his aunt and uncle’s dog named Rowdy down in Dallas last weekend, that was the way he described when the dog would take off after the tennis ball every time. Scamper. Great word that I plan on using more from here on out where appropriate. 

Diplomate of Chiropractic Orthopedists

The DACO this weekend down in Dallas. The class was with James Lehman. Dr. Lehman, in case you do not know, is with the University of Bridgeport Connecticut. His official title from their website is Associate Professor of Clinical Sciences, Health Sciences, College of Chiropractic. 

Dr. Lehman is also one of the main drivers of this DACO program. Through Univ. of Bridgeport Connecticut, he has teamed up with CDI out of Australia and their courses in neuromusculoskeletal online education. It is VERY well done. Very professional and very worthwhile. You can find that at https://cdi.edu.au

We talked a lot about some stuff that I want you to hear straight from him so we’ll do an interview with him very soon but the gist of it all is this: get certified in something other than simply having your doctor of chiropractic degree. 

FQHC

I’ve heard a couple of opinions. I’ve heard the Diplomate programs are worthless now and that people are moving away from them. But, I think that’s coming from people that don’t want to take the time or put in the effort. The real story is most likely that our system, for good or bad, is moving away from private practice and TOWARD integrating through the group offices and through the Federally Qualified Health Centers. 

There are chiropractors being reimbursed in the system up to $300 for a Medicaid visit and around $150 on the lower end. 

I have to thank Dr. Craig Benton once again for bringing this to my attention. Did you guys know that, given the right positioning, you could make that much per appointment from freaking Medicaid?

Here’s the deal though: you have to be a specialist. A Diplomate. So, is it really useless? I say it most certainly is not. 

Whiplash Section

Now the course, the course this weekend was on whiplash. I’ve been through Art Croft’s 4 part Advanced Certification on Whiplash Biomechanics and Traumatology so I can say with a lot of honesty that a good portion of the course was a refresher for me. 

But, I absolutely learned a solid amount of new stuff as well. Such as Axillary compression. Axillary compression was not a condition of the shoulder that was on my radar screen prior to this course. 

That is one simple little example but there was a gob of nuggets for the nugget pouch and as always, I really walked away feeling that I will be better at my job on Monday. But it’s always that way. Even after just a 2-hour online course. It’s phenomenal.

Personal

Continuing the ongoing saga of hiring a front desk staff member in the year 2018. Here’s what all I’m going to say about it. Looks like my wife has found a new full-time job. Lol. Get the picture?

It looks like I may have a cool speaking gig coming up in February. Nothing solid but, if I were to come to your state convention or to some sort of event you are at, what topic along the vein of Chiropractic Forward’s typical content would you like to learn more about? 

If you are a regular listener and familiar with what we have been doing here this last year, I’d really appreciate it if you would take just a minute and email me at dr.williams@chiropracticforward.com and give me a little guidance. What topics would you want to see in a presentation?

I’m glad you’re here and hopefully, I didn’t ramble too much before getting to the meat and taters. Here we go with some vital information that we think can build confidence and improve your practice which will improve your life overall.

On To The Research

Picking up from last week, we want to start in on the changes disc herniations undergo when axial pressure is placed on them. In other words, what happens to disc herniations from the time the MRI is taken laying down to the point where the person sits up. 

I have to preface it all by saying go listen to last week’s episode which is #47, please. It tells you how it is very common in the medical field amongst even radiologists to assume or guess that there is no change in the disc or in the herniation when axial pressure is applied. Research tells us differently. 

This week we want to start with a paper called “Evaluation of intervertebral disc herniation and hypermobile intersegmental instability in symptomatic adult patients undergoing recumbent and upright MRI of the cervical or lumbosacral spines.” It was done by Ferreiro Perez, et. al[1]. and published in the European Journal of Radiology

How they did it

  • 89 Patients studied
  • 45 of them had their low back imaged
  • 44 patients had their necks imaged
  • The images were done in both the lying down position as well as the sitting.

What They Found

  • The overall combined recumbent (lying down) miss rate in cases of pathology was 15%
  • Overall combined recumbent underestimation rate in cases of pathology was 62%
  • Overall combined upright-seated underestimation in cases of pathology was 16%.

Wrap It Up

Upright-seated MRIs were seen to be superior to recumbent MRIs in 52 of the patients studied for conditions of posterior disc herniations and spondylolisthesis. Recumbent MRIs were only superior in 12% of the patients.

Next, this one is titled, “Effect of intervertebral disk degeneration on spinal stenosis during magnetic resonance imaging with axial loading” by Ahn et al[2].

Why They Did It

The authors in this paper were wanting to determine if disc degeneration will increase the severity of spinal stenosis when the spine is loaded with axial pressure. 

How They Did It

They had 51 patients with symptoms of neurogenic intermittent claudication and/or sciatica that had their MRIs loaded as well as non-loaded. 

The foramen involved were all measured for changes in sizes.

Wrap It Up

Here’s what they found, “More accurate diagnosis of stenosis can be achieved using MR imaging with axial loading, especially if grade 2-4 disc degeneration is present.”

AKA:” Seated or loaded MRIs are superior for assessing lumbar stenosis. 

Next, this one is by Willen[3] and it’s called “Dynamic effects on the lumbar spinal canal: axially loaded CT-myelography and MRI in patients with sciatica and/or neurogenic claudication.” It appeared in Spine Journal in 1997. 

They had 50 people with CTs, 34 were imaged with MRI, the imaging was performed laying down as well as axially loaded. 

They closed it up by saying, “Axial loading of the lumbar spine in computed tomographic scanning and magnetic resonance imaging is recommended in patients with sciatica or neurogenic claudication when the dural sac cross-sectional area at any disc location is below 130 mm2 in conventional psoas-relaxed position and when there is a suspected narrowing of the dural sac or the nerve roots, especially in the ventrolateral part of the spinal canal in psoas-relaxed position”

Next Paper

This one is by Kanno, et. al[4]. called “Axial loading during magnetic resonance imaging in patients with lumbar spinal canal stenosis: does it reproduce the positional change of the dural sac detected by upright myelography?” It appeared in Spine Journal in 2012. 

44 patients, with imaging in the supine position and then with axial load added. The dural sack was measured 

“The size of the sack was significantly reduced in the axially loaded imaging and the axial loaded MRI detected severe constriction with a higher sensitivity (96.4%) and specificity (98%) than the conventional MRI.”

Next paper

This one is by Danielson et. al. from 2001 called, “Axially loaded magnetic resonance image of the lumbar spine in asymptomatic individuals.” This paper appeared in Spine Journal in 2001 as well. 

MRIs were performed lying down as well as with axial load on the participants. The axial loading was performed lying down, face up with a compression device built for this study specifically. The diameter of the dural sack was measured to check for the differences. 

The authors said, “A significant decrease in dural cross-sectional area from psoas-relaxed position to axial compression in extension was found in 24 individuals (56%), most frequently at L4-L5, and increasingly with age.”

Pretty cool stuff right there people. 

I want you to go forward this week knowing what you get from listening to this podcast every week. You get things you can absolutely use and implement immediately. Some of you may gain confidence now that you know some research that you maybe didn’t know previously. Some of you may now be able to tell a patient that has a 5mm central posterior herniation that 5mm isn’t telling us the whole story. 

It’s telling us part of the puzzle but that discs respond to positioning and various stresses we put on the discs through our activities. 

Use it or lose it

This can give you some extra guidance in your recommendations when you consider disc herniations change and get worse, stenosis gets worse when the patient sits up or bends forward. 

If you aren’t up on directional preference exercises, McKenzie, and CRISP protocols, it’s time to get there folks. It’s time to get there. The anatomy absolutely responds to movement and positioning. 

Integrating Chiropractors

I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is a mechanical pain and responds better to mechanical treatment instead of chemical treatments.

The literature is clear: research and experience show that, in 80%-90% of headaches, neck, and back pain, patients get good to excellent results when compared to usual medical care and it’s safe, less expensive, and decreases chances of surgery and disability.

It’s done conservatively and non-surgically with little time requirement or hassle for the patient. If done preventatively going forward, we can likely keep it that way while raising overall health! At the end of the day, patients have the right to the best treatment that does the least harm and THAT’S Chiropractic, folks.

Contact Us!

I want to ask you to go to chiropracticforward.com and sign up for our newsletter. We love to stay in touch and want to offer you discount specials when we get our educational products up and rolling. 

Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show or tell us your suggestions for future episodes. Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on iTunes and other podcast services.

Y’all know how this works by now so help if you don’t mind taking a few seconds to do so.

Being the #1 Chiropractic podcast in the world would be pretty darn cool. 

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

Website

http://www.chiropracticforward.com

Social Media Links

Chiropractic Forward Podcast Facebook GROUP

https://www.facebook.com/groups/1938461399501889/

iTunes

Player FM Link

Stitcher:

TuneIn

About the author:

Dr. Jeff Williams – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger

CF 047: Do Disc Herniations On An MRI Worsen When Sitting Or Standing (PART ONE)?

CF 035: Chiropractic & Disc Herniations

Bibliography

1. Ferreiro P, e.a., Evaluation of intervertebral disc herniation and hypermobile intersegmental instability in symptomatic adult patients undergoing recumbent and upright MRI of the cervical or lumbosacral spines. Eur J Radiol, 2007. 62(3): p. 444-8.

2. Ahn TJ, e.a., Effect of intervertebral disk degeneration on spinal stenosis during magnetic resonance imaging with axial loading. Neurol Med Chir (Tokyo), 2009. 49(6): p. 242-7.

3. Willen J, e.a., Dynamic effects on the lumbar spinal canal: axially loaded CT-myelography and MRI in patients with sciatica and/or neurogenic claudication. Spine (Phila Pa 1976), 1997. 22(24): p. 2968-76.

4. Kanno H, e.a., Axial loading during magnetic resonance imaging in patients with lumbar spinal canal stenosis: does it reproduce the positional change of the dural sac detected by upright myelography? Spine (Phila Pa 1976), 2012. 37(16): p. E985-92.

CF 047: Do Disc Herniations On An MRI Worsen When Sitting Or Standing (PART ONE)?

CF 047: Do Disc Herniations On An MRI Worsen When Sitting Or Standing (PART ONE)?

Today we’re going to talk about those MRI’s you get back that show 4mm disc herniations in the low back. OK, that doesn’t sound too bad right? But what happens to the number when a patient comes out of the MRI tube and sits up, stands up, or bends over and lifts something? Let’s talk about it. 

But first, here’s that bumper music

 

Integrating Chiropractors

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

Introduction

You have toppled into Episode #47 just like a big huge Jenga game. 

DACO Talk

Let’s talk a bit about the DACO program: this weekend, I will be headed back to Dallas, TX to attend another 10 hours of the DACO program. This class will again be with Dr. James Lehman, the man, the myth, the legend.

After this weekend, I’ll have 40 of the 50 live hours needed and I’ve been chipping away at the online hours in the meantime. I’ve got about 20 done so far so I’ll be sitting at roughly 60 of the 300 hours needed. 

Yes, that sucks when I look at it through one lens but is pretty dang cool when I look at it through another. It’s been an excellent journey so far. 

It’s not just orthopedics. Which I love. There is stuff I don’t love like the different forms of arthritis. I’m not a big fan of neurology-like refreshers on vestibular nuclei, spinothalamic, corticospinal tracts, and all of that stuff.

It’d be nice to separate that and leave it for the Neuro Diplomates but it doesn’t work that way. It’s a lot. And at only 60 hours in, I’m wondering how on Earth I’m going to be able to remember it all enough to pass a big ol’ hairy test on it but, I started it and I’m going to finish it pass or fail. 

Between you and me though, I have an A in the class so far so I plan on passing the thing!

At The Office

Front desk…..well…..it’s still a thing for us. If you’ve been following along, you know what’s up. If you haven’t, then you know that I was thinking we finally had the spot filled. That is until we didn’t. So, starting over. Boo…. What a tough time it is these days. 

I’d rather get a colonoscopy or have a joint drained than keep dealing with this but…. we keep on keepin’ on, don’t we? As if there is any other option outside of closing shop and going on the road as a speaker….. Hey, wait a minute….

Meat n’ Taters

Alright, enough of all that. Let’s get down to the nuts and bolts of what we do here. 

You either are a patient or you sent a patient to get an MRI on the low back because you think they are showing signs of having disc herniations pain is running out into the leg, and you want to take a look at it. We have enough here that I need to split this into a two-part podcast. 

We don’t want these dudes getting too long or you’ll look at the length and skip the whole damn thing. We’re busy after all aren’t we? You have to be really good to get me into a 45-minute podcast and I …..may not be that good. Lol. 

The Question

As I mentioned in the intro: what happens the measured herniation when a patient comes out of laying down in the tube for the MRI and then sits up, stands up, or bends over and lifts something?

Some of you probably think the answer is obvious but I’m going to suggest to you that it is not obvious. Here’s how I know for sure. I run in medical circles to some extent.

I’m friends with radiologists, two heart surgeons, a vascular surgeon, a cardiologist, several ER/Urgent care docs, and countless Nurse Pracs and PAs as well as PT’s. 

I haven’t asked them all because there’s no reason to but the radiologists for sure and a couple of the others…..I asked them the same question. What happens to disc herniations when the patient applied weight-bearing to the disc herniations?

I was told universally that, while they didn’t know for sure, they thought the disc was so strong that really nothing would happen. Certainly nothing significant. 

The radiologists felt this was too and I just wasn’t satisfied. I just knew something had to happen. And something important at that. So, what does a research nerd such as myself do when they don’t have solid answers? They start a search for research. 

The key was to find the right keywords. If I recall, they were “axial loaded MRI” or something very similar to that. I believe that was the key to the kingdom. 

Anyway, I want to go through some papers I found on disc herniations and axial loads and we’ll see what we find. 

The Research

Let’s start here, if you know a little anatomy and a little McKenzie stuff, you know the disc can be likened to a stout bag of water. Meaning, if I push one side down, the opposite side will “bulk up.” The gym rats call it “swole” I believe. 

If I push a different side down, the other will push up. It reminds me of why I can’t go camping. First, I require central heat and air and plumbing. Secondly, I’m 6’4” and 280 or so depending on how much fun I’ve been having lately. If my much smaller wife and I try to sleep on an air mattress, I go to the ground while she is sleeping on a mound of air. 

It just doesn’t work for us which works for me. I’m no camper people. 

Anyway, this knowledge, if you didn’t already have it, will come in handy here in a little bit. 

Also, I hope you’ll go to our show notes for the diagram demonstrating the different amounts of pressure on your low back depending on how you are positioned. For this study, I am told the researchers actually placed pressure sensors into the patients’ discs and had them do these moves to find the differenced. 

Can you even imagine doing that or volunteering to do that? Holy smokes. 

Anyway, laying down shows 25 kg of pressure in your low back discs. Standing places 100kg on them while sitting straight up is 140kg. Now, the big ‘no-no’s’….standing and bending forward with something of substance in your hands, 220kg and the daddy of them all, sitting bent forward with weights in the hands. 275 kg. 

No weights, bending forward at the waist and sitting slumped. How would they affect those discs? 

Now,  let’s get to the first paper, it’s paper #1 titled “Upright magnetic resonance imaging of the lumbar spine: Back and Pain Radiculopathy.” It was published in the Journal of Craniovertebral Junction & Spine in 2016[1].

They were testing MRI results lying down as well as when seated. 

How They Did It

  • 17 participants
  • 10 were asymptomatic
  • 7 had symptoms of radiculopathy
  • MRIs were done on each in the seated position

What They Found

  • Mid-disc width accounted for 56% of the maximum foramen with in the symptomatic group.
  • Mid-disc width was over 63% of the maximum foramen within asymptomatic volunteers.
  • Disc bulging was 48% larger in the symptomatic group.
  • The measurements of the foramen were smaller in the symptomatic group.

Wrap It Up

The information suggests that MRIs performed in the upright seated position can be useful in the diagnosis process because it is better able to distinguish important differences among the asymptomatic and symptomatic. Especially in regards to the size of the intervertebral foramen.

Then we have this study by Madsen, et. al[2]. called ““The effect of body position and axial load on spinal canal morphology: an MRI study of central spinal stenosis.”

http://www.ncbi.nlm.nih.gov/m/pubmed/18165750/?i=26&from=/9612180/related

In this paper, the authors say that axial loading of the spine does not necessarily cause any significant changes to the disc itself, but that the simple act of having more extension in the spine was a determining factor as to how much space remained in the dural sac surrounding the spinal cord or cauda equina.

I wanted to be fair so I included this study. It suggests the discs play a very small part in the process but, as you will see from approximately 10 other papers we’ll discuss, this sort of finding or thought process is very much in the minority.

See…..I’m fair. I don’t want to cherry-pick. 

Here we have one by Hansson et. al.[3] called “The narrowing of the lumbar spinal canal during loaded MRI: the effects of the disc and ligamentum flavum.” 

http://www.ncbi.nlm.nih.gov/m/pubmed/19277726/?i=10&from=axial%20loaded%20disc%20MRI

How They Did It

  • There were 24 participants in the study.
  • The lumbar (low back) spines were examined by MRI while lying down supine (face up).
  • Then the study was repeated with roughly half of their weight loaded to the spine axially.
  • The measurements were through the cross-sectional areas of the spinal canal as well as the ligamentum flavum, the thickness of the ligamentum flavum, the posterior bulge of the disc and the intervertebral angle.

What They Found

  • The axial loading did, in fact, decrease the cross-sectional size of the spinal canal.
  • Increased bulge or thickening of the ligamentum flavum was to blame for 50%-85% of the decrease in the spinal canal size.

Wrap It Up

The authors concluded that it appears the ligamentum flavum, not the disc, played a dominant role in reducing the size of the spinal canal on axially loaded spines for those with stenosis.

Next up is Choy et. al. called “Magnetic resonance imaging of the lumbosacral spine under compression.” This paper reveals that sitting MRI imagined exists at Harvard and Zurich. Since seated MRI is so limited in regards to availability, the authors were looking to be able to compress the spine in other ways to duplicate the pressures found in someone that is seated. 

http://www.ncbi.nlm.nih.gov/m/pubmed/9612180/?i=20&from=sitting%20disc%20herniation%20mri

They built a plywood contraption that had the ability to fit into a standard MRI machine and subject the patient to similar compressive forces. Interesting I thought. I’d love to see this contraption. 

What They Found

They were able to reproduce the symptoms in 50% of the patients through the compression machine and they were able to reproduce  “augmentation” or accentuation of the disc herniation when the compressive force was initiated. Meaning, simulated axial compression herniated the disc further. 

Man, we’re scootin now folks, 

This one is by Nowicki, et. al[4]. called “Occult lumbar lateral spinal stenosis in neural foramina subjected to physiologic loading,”

https://www.ncbi.nlm.nih.gov/m/pubmed/8896609/?i=20&from=axial%20loaded%20disc%20MRI

These authors wanted to see how different positioning of the trunk affects the relationships of the bones and discs in regards to the neural structures in the same anatomic region. They also wanted to find out how disc degeneration responds to axial loading.

What They Found

The average findings were that extension, flexion, lateral bending, and rotation show contact or compression of the spinal nerve by the ligamentum flavum or disc in 18% of the neural foramina. 

Extension loading produced the most cases of nerve root contact. Disc degeneration significantly increased the prevalence of pain stenosis.

Wrap It Up

The authors concluded, “The study supports the concept of dynamic spinal stenosis; that is, intermittent stenosis of the neural foramina. Flexion, extension, lateral bending, and axial rotation significantly changed the anatomic relationships of the ligamentum flavum and intervertebral disc to the spinal nerve roots.”

So, we’re starting to paint a picture here I think and starting to show that positioning and weight-bearing does indeed have an effect on the disc herniations, the ligamentum flavum, and the neural structures present at each level. 

Here’s the last one we’ll cover this week and it’s called “The diagnostic effect from axial loading of the lumbar spine during computed tomography and magnetic resonance imaging in patients with degenerative disorders.” It was authored by Willen et. al[5].

http://www.ncbi.nlm.nih.gov/m/pubmed/11725243/?i=14&from=axial%20loaded%20disc%20MRI

Why They Did It

The authors stated goal in this paper were to find out if there was any real value in imaging patients that had axial loads (simulated weight-bearing) applied in cases of degenerative spines.

How They Did It

  • A device was used to induce a load on the low back before imaging.
  • 172 patients were examined with compression applied.
  • 50 of those were imaged with CTs.
  • 122 of those subjects were imaged with MRIs.
  • Any changes in the major anatomy of the regions were noted.

What They Found

“Additional valuable information was found” in 50 of the original 172 participants. “A narrowing of the lateral recess causing compression of the nerve root was found at 42 levels in 35 patients at axial loading.”

Wrap It Up

There is certainly and frequently additional information that can be gathered for diagnostic purposes when the imaging is done with weight-bearing loads applied. This included those with neurogenic claudication as a result of stenosis but also sciatica.

We have a painting forming up here folks. I did the underpainting this week and we’ve got it ready for the finishing touches next week so stick around and make sure you’re connected with us. 

We do that through our weekly newsletter to let you know when the next episode goes live. You can get on that at chiropracticforward.com. 

You can also find us on Facebook on our Chiropractic Forward Page but, if you’d like to take it a step further, you can join us at our Chiropractic Forward Group where we post the papers from each episode and maybe even spark up a discussion about them if you like. 

The Message

Before you leave us today, I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is a mechanical pain and responds better to mechanical treatment instead of chemical treatments.

The literature is clear: research and experience show that, in 80%-90% of headaches, neck, and back pain, patients get good to excellent results when compared to usual medical care and it’s safe, less expensive, and decreases chances of surgery and disability.

It’s done conservatively and non-surgically with little time requirement or hassle for the patient. If done preventatively going forward, we can likely keep it that way while raising overall health! At the end of the day, patients have the right to the best treatment that does the least harm and THAT’S Chiropractic, folks.

Contact Us

Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show or tell us your suggestions for future episodes. Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on iTunes and other podcast services. Y’all know how this works by now so help if you don’t mind taking a few seconds to do so.

Being the #1 Chiropractic podcast in the world would be pretty darn cool. 

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

Website

http://www.chiropracticforward.com

Social Media Links

https://www.facebook.com/groups/1938461399501889/

iTunes

Player FM Link

Stitcher:

TuneIn

About the author:

Dr. Jeff Williams – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & VloggerBibliography

1. Nguyen HS, e.a., Upright magnetic resonance imaging of the lumbar spine: Back pain and radiculopathy. J Craniovertebr Junction Spine, 2016. 7(1): p. 31-7.

2. Madsen R, e.a., The effect of body position and axial load on spinal canal morphology: an MRI study of central spinal stenosis. Spine (Phila Pa 1976), 2008. 33(1): p. 61-7.

3. Hansson T, e.a., The narrowing of the lumbar spinal canal during loaded MRI: the effects of the disc and ligamentum flavum. Eur Spine J, 2009. 18(5): p. 679-86.

4. Nowicki BH, e.a., Occult lumbar lateral spinal stenosis in neural foramina subjected to physiologic loading. AJNR Am J Neuroraiol, 1996. 17(9): p. 1605-14.

5. Willen J, e.a., The diagnostic effect from axial loading of the lumbar spine during computed tomography and magnetic resonance imaging in patients with degenerative disorders. Spine (Phila Pa 1976), 2001. 26(23): p. 2607-14.

 

CF 046: Chiropractic Effectiveness – Chiropractic Integration – Chiropractic Future

Chiropractic Effectiveness – Chiropractic Integration – Chiropractic Future

Today we’re going to talk about what I think is some good news that bodes very well for the chiropractic future, for chiropractic integration, chiropractic effectiveness, and playing well with others. We’ll discuss a paper on non-pharma ways of treating pain and then we’ll discuss an article showing how roadblocks are set up to keep Americans from following those recommendations.

Stick with us as we shake it all out, but first, here’s that bumper music

Integrating Chiropractors

Welcome to the podcast today, I am still pretty new to the podcast game so, in case you don’t know me just yet,…I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.

You have gallivanted into Episode #46 and we are so glad you did.

DACO Program

Let’s talk a bit about the DACO program, I have gone through 30 hours live and have taken 12 hours online so far. That makes 42 of the 300 but hey, who’s counting right? The last one I took had to do with Cervical pain and neural tension. I’m man enough to admit that, while I have an A in the class, I missed a question on this one and here’s what I’m going to say…..STOP. Stop asking trick questions dammit.

Honestly, you can know the material cold but the way they ask some of the questions, there’s no telling what the hell the answer is. “Which statement makes the most clinical sound?” Fine…no problem. But, as you read through them, there is maybe one answer that is very thorough while the others are not technically incorrect but aren’t quite as comprehensive as the one answer. Then, yes…..the feared…..ALL OF THE ABOVE.

Uh huh….just ask the damn question and be fair about it. That’s all I’m saying. On one hand, one answer is most definitely more clinically sound than the others. On the other hand, all of them have some correct aspects. So, you’re bound to miss some here or there and, with only 5 questions, you miss one, you make an 80. An 80 is hard for me to swallow friends.

So….cut it out, people. Be fair in your questioning. Thank you very much

The material though, my goodness. I can’t even begin to tell you all how wonderful the material is. Of course, I like some of the classes more than others. The one on pain was not necessarily my favorite but I muddled through it and still know a ton more about pain than I did prior to. Pain is a difficult topic but they did an excellent job of lining it out for us.

Every class makes a difference. Without a doubt. Let me know if you need some guidance on getting started on your DACO. Which was the main thing for me….just getting started in the first place. It’s a bit confusing but once you get enrolled and get that first class under your belt, you’re good to go. Just email me at dr.williams@chiropracticforward.com

Sign up for our Chiropractic Forward Newsletter

If you haven’t yet, please go sign up for our Chiropractic Forward newsletter by going to chiropractic forward.com and it’ll pop up right there. You can’t miss it. It almost punches you right in the face. Help us keep pass along important stuff here by getting on that newsletter. Never any more than once per week. Promise.

Evidently, you and your colleagues are catching onto this here podcast. We appreciate it and we appreciate your continuing sharing it with you people. That’s the only way to grow.

Front Desk Woes

So far, we still have the front desk staff in place. So that’s been amazing to not be obsessing about. It is really hard to find the right person with the right qualities to fill that spot. I’m not spouting fake numbers when I tell you that we see an average of about 60 new patients per month by myself.

No associate. I had a colleague recently tell me they don’t think they could do that by their self. I have to admit, I didn’t realize it was an impressive amount. Lol. I was glad to hear it though. Here’s my deal though, I don’t hold onto them. I see them, get them better, and will have them again in a year or so when they re-injure something.

I have about 40 or so visits booked per day and that’s pretty manageable when you have great staff. I still work from 8-1 on Fridays too. The majority of my time is spent on new patients trying to figure them out. After we have a direction with a patient, however, we have a team of people that really help take the workload off of me other than the actual adjusting.

And, in case anyone is wondering out there, I adjust manually, Diversified with some drops here and there. Very little activator. Some muscle work when appropriate but there’s not a lot of fluff in a visit once we are rocking and rolling with a case.

I tell them that I can really drag this visit out and make it last a lot longer than it takes if they want me to but most are ready to get in and out and back to work. And that works well for us too.

Getting back on track

Anyway, back to the original point: it’s hard to find someone that is not intimidated by the insurance demands, new patients, existing patients, etc…but excited about chiropractic effectiveness….looking them in the eyes all day every day all day.

Plus, a third of the building is massage, day spa services so, the right person is key. They get intimidated and leave. Lol. I suppose it’s a good problem to have. But, so far so good with the new one!

As I’ve said before, I will certainly keep you updated.

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.

Let’s get into the papers

Let’s kick off the discussion today with one from McGregor, et. al. 2014 called “Differentiating intraprofessional attitudes toward paradigms in health care delivery among chiropractic factions: results from a randomly sampled survey.” It was published in BMC Complementary and Alternative Medicine[1].

In the background section of the abstract, the authors’ discuss how healthcare has increased in complexity and there has developed a need for interprofessional collaboration. Amen, brothers and sisters.

It goes on to talk about how different factions within the chiropractic profession are contrary to each other and how one faction holding unorthodox practice beliefs and behaviors may compromise interprofessional relations going forward.

We can have all of the research on our side but when you have one faction of the profession spouting chiropractic effectiveness for everything under the sun, well, the credibility of the profession as a whole really suffers.

The purpose of this paper was, “to quantify the professional stratification among Canadian chiropractic practitioners and evaluate the practice perceptions of those factions.”

How do you go about figuring this stuff out? Luckily, there are far more intelligent people out there in the world. They took a stratified random sample of 740 Canadian chiropractors and surveyed them in an attempt to determine faction membership and how professional stratification could be related to views that could be considered unorthodox to current evidence-based care and guides.

What they found

Out of 740 questionnaires, 503 came back.

Less than 18.8% of the chiropractors were in the faction considered to be unorthodox in the perceptions of the conditions they treat.

They also state that prediction models suggest that unorthodox perceptions of health practice related to treatment choices, x-ray use, and vaccinations were strongly associated with unorthodox group membership.

The conclusions reached here were as quoted, “Chiropractors holding unorthodox views may be identified based on response to specific beliefs that appear to align with unorthodox health practices.”

Despite continued concerns by mainstream medicine, only a minority of the profession has retained a perspective in contrast to current scientific paradigms. Understanding the profession’s factions is important to the anticipation of care delivery when considering interprofessional referral.”

Basically, what they’re saying is that, in Canada at least, there are 20% of you chiropractors walking around saying your nerve doctors, that you fix everything under the sun, and you’re releasing the innate and turning on the power. This isn’t chiropractic effectiveness. This is belief. Not research-based findings.

That 20 % is REALLY putting 80% of us that have busted our butts and learned the latest science and research….you’re putting us at risk of staying right where we’ve always been rather than expanding, integrating, and being the experts in what we do.

We are masters at what we do but there are 20% out there keeping anyone that matters from taking the rest of us seriously. When we are talking about legitimate chiropractic effectiveness, that 20% has taken away our credibility.

Parento’s principle proves to be a real thing once again. 20% of chiropractors do all of the work in discrediting the other 80% of the profession.

Next paper

Let’s go to the next paper before I lose my mind.

This one is called Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care[2]. It was published in June of 2018 in Explore: The Journal of Science and Healing and was written by Heather Tick MD along with a team of other medical doctor/PhDs.

Dr. Tick is a specialist in pain management in Seattle Washington. She even has her own website and blog. All that good stuff. You can check it out at heathertickmd.com if you are so inclined.

A little more about her: She co-founded and directed one of the first inter-disciplinary pain centers in Toronto from 1991 – 2008 and has been involved in research with the University of Waterloo at the Department of Kinesiology, the Canadian Memorial Chiropractic College (CMCC), the University of Washington, and the University of Arizona.

She served as the Director of the Integrative Pain Clinic at the University of Arizona in the Department of Family and Community Medicine until Dec 2011, when the University of Arizona Health Plan recruited her to start the integrative medicine pain clinic for Medicaid patients.

Dr. Tick currently serves at the forefront of research and teaching as a Clinical Associate Professor at the University of Washington in the departments of Family Medicine and Anesthesia & Pain Medicine and is also the first holder of the prestigious Gunn-Locke Endowed Professorship of Integrative Pain Medicine at the University of Washington.

In this paper, Dr. Tick starts by saying “Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths.”

I like that opening quote. I like it a lot, folks. She’s saying that the medical way of managing pain isn’t working and throwing more pills at it is a downward spiral. And I agree as I’m sure you do as well.

She goes on saying, “There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options.

“Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability.”

Conclusion

The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices.

Here’s what I hate to do: I hate quoting an abstract word for word. It’s usually dry and well….boring. But, what she says here is so spot-on, quoting it was the best way to get it across in an equal manner. Meaning that I couldn’t say it better myself. Chiropractic effectiveness is becoming undeniable at this point.

She nails it:

  1. It’s not working
  2. We need non-pharma options that are backed by evidence
  3. There are barriers set up to prevent non-pharma options from being utilized
  4. There is ignorance in regards to non-pharma options and that needs to be addressed through education
  5. Continued research is needed

Further down into the paper, the authors mention in one spot that chiropractic care is 60-70% less likely to be reimbursed. Is that accurate? We are typically covered by most insurance plans no?

When they are saying that there are barriers set up to prevent complementary options, this may fit her rhetoric or point but I just haven’t experienced it being that much less likely to have coverage.

They cite a paper by James Whedon, Et. al. where they found, for New Hampshire[3], there was 60%-70% less reimbursement. I wonder if that is consistent throughout the US or if it’s isolated to New Hampshire?

That’s a great question and if one of you out there in podcast listening land knows the answer, please email me at dr.williams@chiropracticforward.com and fill me in. I’m curious and I’m pretty sure the rest of us out there are too.

Under their Evidence-Based Non-pharm Therapies for Acute Pain, they point out that non-pharma therapists have shown effective in acute pain with opioid paring in the hospital setting as a result of their use and the therapies mentioned in the paper are acupuncture, chiropractic, osteopathic manipulative therapy, massage, physical therapy, relaxation, and cognitive behavioral therapy.

The authors also site spinal manipulative therapy as being effective for chronic pain including migraines, cervicogenic headache, neck pain, low back, hip pain, patellofemoral syndrome, and on and on. Of course, we chiropractors know this stuff but it’s great to see it in black and white and as part of a paper written exclusively by MDs and PhDs.

This is a long paper with a lot of excellent information. I highly encourage your checking it out. Just go to our show notes for links and citations.

Wrap it up

A great takeaway from this paper is this quote, “In general, the costs of evidence-based nonpharmacologic options are nominal compared to medical costs of treating chronic pain with risk mitigation and greater potential for engaging patients in ongoing self-care.”

This is exactly why we are discussing chiropractic effectiveness at length these days. It is paramount for the future of our patients as well as for the the chiropractic future for people to get this message.

Last Paper

The last paper I want to talk about is by our very own Dr. Christine Goertz, DC, Ph.D. with Steven George, PT, Ph.D. as her side-kick and is published in JAMA. It’s called “Insurer Coverage of Nonpharmacological Treatments for Low Back Pain—Time for a Change[4]” and published on October 5 of this year so, just this month. Brand new.

Dr. Goertz begins by relating low back pain with the obvious opioid crisis and goes into last year’s recommendation that you’ve heard here a million times.

The recommendations from the American College of Physicians for low back pain which recommended spinal manipulative therapy as a first-line therapy for chronic and acute low back pain.

We will talk about it in upcoming episodes but Dr. Goertz also mentions the new Gallup-Palmer Poll where they found that 78% of US adults prefer to use non-pharma options for back and neck pain.

In the article, she cites a paper by Heyward, et. al[5].  called “Coverage of Nonpharmacologic treatment for low back pain among US public and private insurers” that found coverage of some therapies (like chiropractic) was available in most health plans but that there are significant barriers to patient access identified.

Barriers such as visit limits, prior authorization requirements, and high out-of-pocket expenses. And that payment policies targeted toward coordination of pharmacological and nonpharmacological care were virtually nonexistent.

She says pretty clearly the following: In regards to most health plans surveyed, they did not have policies in place that:

  1. emphasize the use of nonpharmacological treatments at the forefront of the patient experience
  2. provide meaningful levels of coverage for care professionals who focus on guideline-adherent nondrug therapies like spinal manipulation, exercise, massage, acupuncture, and cognitive behavioral therapy
  3. us financial incentives that favor the use of nonpharmacological options over commonly prescribed pharmaceuticals, including opioids

Wrap it up

She also calls out healthcare executives quite effectively I thought by saying, “Relative to stigma, Heyward et al found that health care executives did not believe expanded coverage of nonpharmacological treatments is supported by the existing literature.

As outlined in the ACP guideline referenced earlier, in many cases nonpharmacological treatments offer equal benefit or even improved benefit, with lower risk, than commonly used pharmaceutical options.”

And by suggesting that future coverage policies should be based on unbiased reviews of the evidence appropriately balancing risk with benefit rather than prior dogma or biases.

Lastly, Dr. Goertz discusses cost-effectiveness and the need for future payment policies to decrease patient out-of-pocket expenses to strongly encourage earlier us of evidence-based non-harms options.

The Heyward paper demonstrated how trips to PTs or DCs are usually 6-12 visits with an out-of-pocket of $150-$720 or more. She then showed how Lin et. al. showed the median cost of a 30-day  supply of preferred generic opioid by commercial insurers is $10.

How does that add up for the Joe Blow citizen on the street?

It doesn’t.

I love how they sum it up by saying, “Restricting access to opioids without addressing the underlying problem of chronic care management for low back pain is unlikely to positively affect the opioid crisis. Well-conceived guidelines that encourage the use of evidence-based, nonpharmacological treatment options exist and must be enabled by changes in public health policies that better guide care delivery and reimbursement.”

Boom, Snap, kapow, Shazam…

Honestly, where would we be without Dr. Goertz? We’d still be moving the direction we’re moving in because of the opioid issue but she has done some amazing work that is putting us on the fast track where we hope to go rather than on the snail’s pace.

This week, I want you to go forward understanding that It’s happening folks. we are now able to cite papers in JAMA that are pro-chiropractic. Pro-complementary health care. Anti-pharma. This is big stuff. We are in the right place at the right time. And, it was in part, the failure of many in the medical kingdom that put us here. Integrating Chiropractors

The message

I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is a mechanical pain and responds better to mechanical treatment instead of chemical treatments.

The literature is clear: research and experience show that, in 80%-90% of headaches, neck, and back pain, patients get good to excellent results when compared to usual medical care and it’s safe, less expensive, and decreases chances of surgery and disability.

It’s done conservatively and non-surgically with little time requirement or hassle for the patient. If done preventatively going forward, we can likely keep it that way while raising overall health! At the end of the day, patients have the right to the best treatment that does the least harm and THAT’S Chiropractic, folks.

Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show or tell us your suggestions for future episodes. Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on iTunes and other podcast services. Y’all know how this works by now so help if you don’t mind taking a few seconds to do so.

Being the #1 Chiropractic podcast in the world would be pretty darn cool.

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

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About the author:

Dr. Jeff Williams – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger

Insurer Coverage of Nonpharmacological Treatments for Low Back Pain—Time for a Change | Complementary and Alternative Medicine | JAMA Network Open | JAMA Network

Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care – Explore: The Journal of Science and Healing

https://www.ncbi.nlm.nih.gov/pubmed/28304182?dopt=Abstract

Differentiating intraprofessional attitudes toward paradigms in health care delivery among chiropractic factions: results from a randomly sampled survey | BMC Complementary and Alternative Medicine | Full Text

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2705853

Bibliography

1. McGregor M, Differentiating intraprofessional attitudes toward paradigms in health care delivery among chiropractic factions: results from a randomly sampled survey. BMC Comp Altern Med, 2014. 14(51).

2. Tick H, Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care. Explore J Science Healing, 2018. 14(3): p. 177-211.

3. Whedon JM, e.a., Insurance Reimbursement for Complementary Healthcare Services. J Altern Complement Med, 2017. 23(4): p. 264-267.

4. C, G., Insurer Coverage of Nonpharmacological Treatments for Low Back Pain—Time for a Chang. JAMA, 2018. 1(6).

5. Heyward J, Coverage of Nonpharmacologic Treatments for Low Back Pain Among US Public and Private Insurers. JAMA, 2018. 1(6).

CF 020: Chiropractic Evolution or Extinction?

CF 027: WANTED – Safe, Nonpharmacological Means Of Treating Spinal Pain

CF 030: Integrating Chiropractors – What’s It Going To Take?