Evidence Based Chiropractic Archives - chiropracticforward

Evidence Based Chiropractic

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 fulfil 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 018: Pt. 3 – Review of The Lancet Article: Low back pain a call to action

Review of The Lancet Article: Low back pain a call to action (Part Three)

On the Chiropractic Forward podcast this week, we are going continue a review of a recent paper published on low back pain that we hope will have a powerful impact in the months and years to follow. This week it will be a review of paper #3 from the Lancet series – low back pain a call to action.

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 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. Also, if something brand new pops up, we’ll be able to tell you about it quickly and easily.

Welcome to the podcast today, you have strolled right into episode 17. 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. And this week it’s low back pain a call to action.

As I mentioned at the top of the show, this week, I want to continue with the series published in The Lancet on March 21, 2018. For a quick re-cap this week…. The Lancet is one of the oldest and most respected medical journals in the world. It has been around since 1823. In addition to the credibility of the journal, this series of papers dealing with Low Back Pain was compiled and authored by the leading experts on the matter globally. On top of that, the experts were a group of interdisciplinary practitioners which meant they ranged from medical doctors and PhD’s, to physical therapists and chiropractors.

Essentially, EVERYONE had a seat at the table so, it is the general consensus at this point that this series of papers is as current, as credible, and as accurate as can be had at this point in time and in our understanding of Low Back Pain.

The three papers were broken down as follows:

  1. What low back pain is and why we need to pay attention.
  2. Prevention and treatment of low back pain: evidence, challenges, and promising directions.
  3. Low back pain a call to action.

Last week, we reviewed the first of the three papers which was titled, “What low back pain is and why we need to pay attention.” We went through it note by note and section by section trying to strip away the embellishments to simply boil it down to a leisure read and, hopefully, an enjoyable learning process.

We will do the same this week with the third paper of the series titled, “Low back pain a call to action.”

I want to start this week in the same way we started last week: by discussing how the papers were accomplished.

How They Did It

For this paper, again titled “What low back pain is and why we need to pay attention,” the researchers identified scientific studies through searches of databases:

•MEDLINE (PubMed)

•Scopus

•Google Scholar

•African Index Medicus Database

In order to ensure a high-quality standard, systematic reviews were shown preference for inclusion.

This week, we’re going to review the last of the three papers from a recent series published in The Lancet on March 21, 2018. If you don’t know the impact or why this series is so important, please review the last two episodes of the Chiropractic Forward Podcast at www.chiropracticforward.com or the last two articles of my blog over at amarillochiropractor.com/blog. That will get you up to speed. In short, the series on low back pain was compiled and authored by an international panel of experts on the matter. Essentially, the best of the best.

This last of the three papers is titled “Low Back Pain A Call To Action.”

Summary

We have already covered several times that low back pain is now the leading cause of disability globally and is only growing in significance because the global population is living longer. The issue may be more profound in low to middle-income countries. In addition, most low back pain doesn’t even appear to be directly related to any specific trigger or origin.

In many cases, patients are being restricted from attempting resolution of the back pain via conservative approaches such as self-management support, specialized interventions like spinal manipulations (I added that part) and multidisciplinary rehab.

The panel suggests the following:

  1. Address the political aspect. They recommend calling on the World Health Organization to make low back pain one of its priorities by putting it on the target list in an effort to increase attention and decrease treatment that is not recommended initially. They recommend calling on political, medical, and social leaders to make sure public health initiatives are properly funded and geared toward the prevention of low back pain and treatment.
  2. Public health challenge.
    • Change priorities – Make low back pain a priority. Create and implement ways to prevent it and combine these strategies with other strategies that are chronic and somewhat related. Strategies such as weighing the right amount, being active physically, and maintaining good mental health as well. These tactics treat more than simply low back pain. The panel also recommends strategies that can modify the factors putting the population at risk of developing low back pain.
    • Change systems and change practice – Provide early recommendations for maintaining work load as much as possible and/or return to work as quickly as possible. Attempt to ensure early ID of people that are at risk of developing long-term, chronic disability as a result of low back pain. Address co-morbidities raising a person’s risk of developing low back pain and promote a healthier lifestyle in addition to altering disability benefits and get people back to work as soon as possible. And lastly, address low back pain through multidisciplinary rehabilitation in an effort to return the patient to work quickly.
  3. Healthcare challenge –
  • Change culture – The panel appears to me to be promoting the use of a Public Relations campaign to focus and promote living well with low back pain, self-management, staying healthy, and to change the public perception of low back pain.
  • Change clinician behavior – After developing the best evidence-based systems, there will be a need togged everyone on the same team in regards to the way clinicians refer and treat, the patients, as well as the professional journals.
  • Change systems – There is a need to develop and implement systems allowing a patient to receive the right care at the right time. Clinical pathways will need a re-boot and will need to become consistent across interdisciplinary lines and differing clinical settings.
  • Tackle Vested Interests – The panel discusses the fact that governments and insurance companies need to regulate in a manner consistent with evidence-based treatment for low back pain and eliminate conflicts of interest. Regulation through contracts, and payment schedules for treatments with little to no evidence for effectiveness.

The idea that a healthy weight and regular physical activity will help reduce low back pain must enter the global subconscious through public programs, especially in low to middle-income countries.

An assertion I fully agree with the authors on is that, thus far, healthcare dollars have been wasted on treatments that are ineffective and, many times, downright dangerous. The risk vs. reward ration just doesn’t make sense more times than not currently. No too mention the issue of opioid addiction which we all should know the stats on by now.

Boiling it down, the panel aims to get rid of practices that harm and create waste while, at the same time, opening the door to effective and affordable means of treating low back pain to patients in need. The authors are quoted here as saying,”Protection of the public from unproven or harmful approaches to managing low back pain requires that governments and health-care leaders tackle entrenched and counterproductive reimbursement strategies, vested interests, and financial and professional incentives that maintain the status quo.”

The authors promote the idea of implementing a positive health concept as the umbrella idea aiming for prevention of long-term disability. This includes alternative to treatments and cures and promotes more meaningful lives. This truly is a low back pain a call to action recommendation.

Another great quote from this third paper is as follows, “Improved training and support of primary care doctors and other professionals engaged in activity and lifestyle facilitation, such as physiotherapists, chiropractors, nurses, and community workers, could minimize the use of unnecessary medical care.”

The panel also calls for an active monitoring system in order to assess and keep an eye on the recommendations implementation as well as the outcomes of the changes.

To read more for yourself, follow this link to the third paper:

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30488-4/fulltext

If access is unavailable, just simply register at The Lancet. It is completely free of charge.

If you are research minded, if you are a low back pain patient, or if you are a practitioner regularly coming in contact with low back pain patients, it is my opinion that taking the time to read these three papers yourself is of utmost importance.

Please find the links to the papers in the “References” section and get it done. Together, we can make a big, big difference in the lives of our low back pain patients. Without a doubt.

For this week’s next step, go register with The Lancet and get this paper for free! You just have to register. That’s it.

We hope you enjoyed this week’s paper called “Low back pain a call to action.” We’ll go through it bit by bit and hit the highlights for those of you that aren’t into reading research papers and things of that sort. Don’t miss it!

If you love what you hear, be sure to check out www.chiropracticforward.com. As this podcast builds, so will the website with more content, products, and chances to learn.

We cannot wait to connect again with you next week. From Creek Stone, my office here in Amarillo, TX, home of the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.

 

Other episodes you may enjoy:

CF 003: Great News: Chiropractic Outpaces Muscle Relaxants

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

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

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

CF 017: Pt. 2 – Review of The Lancet Article on Treatment of Low Back Pain

 

 

References:

Paper 1 – “What low back pain is and why we need to pay attention: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30480-X/fulltext

Paper 2 “Prevention and treatment of low back pain: evidence, challenges, and promising directions.”: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30489-6/fulltext

Paper 3 – “Low back pain: a call for action”: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30488-4/fulltext

 

CF 017: Pt. 2 – Review of The Lancet Article on Treatment of Low Back Pain

Review of The Lancet Article: Prevention and treatment of low back pain: evidence, challenges, and promising directions (Part Two)

On the Chiropractic Forward podcast this week, we are going continue a review of a recent paper published on low back pain that we hope will have a powerful impact in the months and years to follow. This week it will be a review of paper #2 from the Lancet series called Prevention and treatment of low back pain: evidence, challenges, and promising directions. 

Before we get started, I want to draw your attention our website at http://www.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. Also, if something brand  new pops up, we’ll be able to tell you about it quickly and easily.

Welcome to the podcast today, you have strolled right into episode 17. 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.

As I mentioned at the top of the show, this week, I want to continue with the series published in The Lancet on March 21, 2018. For a quick re-cap this week…. The Lancet is one of the oldest and most respected medical journals in the world. It has been around since 1823. In addition to the credibility of the journal, this series of papers dealing with Low Back Pain, prevention of low back pain, and treatment of low back pain was compiled and authored by the leading experts on the matter globally. On top of that, the experts were a group of interdisciplinary practitioners which meant they ranged from medical doctors and PhD’s, to physical therapists and chiropractors. 

The three papers were broken down as follows:

  1. What low back pain is and why we need to pay attention.
  2. Prevention and treatment of low back pain: evidence, challenges, and promising directions.
  3. Low back pain: a call for action.

Last week, we reviewed the first of the three papers which was titled, “What low back pain is and why we need to pay attention.” We went through it note by note and section by section trying to strip away the embellishments to simply boil it down to a leisure read and, hopefully, an enjoyable learning process. 

We will do the same this week with the second paper of the series titled, “Prevention and treatment of low back pain: evidence, challenges, and promising directions.”

I want to start this week in the same way we started last week: by discussing how the papers were accomplished. 

How They Did It

For this paper, again titled “Prevention and treatment of low back pain,” the researchers identified scientific studies through searches of databases:

•MEDLINE (PubMed)

•Scopus

•Google Scholar

•African Index Medicus Database

In order to ensure a high-quality standard, systematic reviews were shown preference for inclusion.

Paper 2 Summary:

Recommendations commonly offered for those with low back pain include:

  • Pharmacologic implementation is not typically a first line choice
  • Education supporting self-management
  • Resumption of regular daily activities
  • Resumption of exercise
  • Psychological programs for those with low back pain that tends to linger
  • Limited or non-use of medication
  • Limited or non-use of imaging
  • Limited or non-use of surgery

The authors state that these recommendations for prevention and treatment of low back pain are derived from high-income countries and that they are concentrated on treatment rather than preventative recommendations. 

The authors state there is an inappropriate high usage of the following treatments for low back pain:

  • Spinal injections
  • Imaging
  • Opioids
  • Surgery
  • Rest

In the rest of the paper, the authors identify some promising directions and solutions for treatment of low back pain including the redesign of clinical pathways, an integrated health partnership, and occupational interventions to get workers back when possible.

Prevention

  • A 2016 systematic review with 30,850 adults showed that there was moderate quality evidence that exercise alone, or in combination with education, is effective for prevention of low back pain. 
  • However, the review was mainly for secondary prevention and the exercise program required an intense schedule of twenty 1-hour supervised sessions.
  • A 2014 systematic review with 2700 children that found moderate quality evidence that education is not effective. They also found that ergonomic furniture was likely no more help in preventing low back pain than regular furniture. 

Treatment

The authors cite three studies. The studies come from Denmark, the UK, and the USA. 

  • All three of the studies (Danish, UK and USA) recommend spinal manipulation as an effective treatment of low back pain. The UK study specifically recommends spinal manipulation in conjunction with an exercise protocol. 
  • As my own side note, in America, chiropractors perform 90% of all spinal manipulations. When we are discussing spinal manipulation and it’s role in treating low back pain, it is important to keep in mind which profession is the one being recommended. Although the authors do not come out and recommend chiropractic specifically, when spinal manipulations are recommended, it is a well-known fact that chiropractors are the doctors that are best-equipped to perform the treatment. 
  • Also in the US guidelines, there is a recommendations for the marked reduction of pharmacologic care. 
  • Some key advice coming from these updated recommendations (besides the use of spinal manipulation) is to assure patients they are not suffering from serious disease, that they will indeed improve in time, that they should continue as much movement and exercise as can be tolerated, they should avoid bed rest, and they should get back to work as soon as possible. 
  • The authors recommend physical treatments. Certainly for chronic low back pain which refers to pain lasting longer than 12 weeks. Physical treatments included exercise programs targeting the patients’ abilities, preferences, etc. 
  • The authors stated that passive therapies such as electric stim, interferential, traction, diathermy, and back supports seem to be ineffective. As a side note, it’s strictly anecdotal but this panel of experts are going to have a hard time convincing me traction, when done correctly, is not effective. I’ve seen patients avoid surgery from traction therapy alone.
  • They say new recommendations encourage doctors consider psychological therapies such as cognitive behavior therapies, progressive relaxation therapy, and mindfulness-based stress reduction alone or in combination with other physical and psychological treatment for chronic low back pain with or without radiculopathy having not responded to other treatments. 
  • If the condition persists and the patient is functionally disabled, the authors then recommend multidisciplinary rehab with supervised exercise, cognitive behavior, and medication. 
  • Of course, routine use of opioids is not advised.
  • Recommend no spinal epidural injections or facet joint injections for low back pain
  • Do recommend epidural injections of local anesthetic & steroid for radicular pain, however, as we have discussed before, epidural steroid injections show short-term effectiveness only if they are effective at all and have no influence at all on long-term disability or future need for surgery. In my own research, epidural steroid injections have shown to increase risk of spinal fracture up to 21% after each subsequent injection. 
  • Surgery – the benefits for spinal fusion when the back pain was thought to be due to degenerated discs were about equal to the results gained with intensive multidisciplinary rehab and only a modest improvement over non-surgical treatment. In addition, surgery has obvious downsides like expense, recovery, medication, and the risk of adverse events. However, surgery may be indicated when the patient is suffering severe or progressive neurological symptoms and surgery may be indicated when patients suffer radicular pain, have failed first line treatment, and the symptoms can be traced to via imaging to a disc or stenosis origin. 
  • Ultimately, the authors say, low back pain patients have a tendency to resolve with out without surgical intervention so waiting and trying to avoid surgery is certainly appropriate. 
  • Research dealing with low back pain in children or in low and middle income countries is limited so a lot is unknown for those categories, however, the two studies that actually have been done in low and middle income countries (Brazil and Philippines) have similar results as those in high income countries. 

The global gap between evidence and practice

This section masterfully demonstrates the difference between evidence-based medicine and what is really happening in the real world.

  • They start by stating that low back pain should be managed by primary care practitioners and then go on to list studies showing how it is being managed, in many cases, by emergency rooms, hospitals, and surgeons. 
  • Their next directive is to provide low back pain patients with education and advice on self management and then show how, in the real world, roughly only 20%-23% of practitioners seem to actually do so. 
  • The next directive is for low back pain patients to stay active and get to work or stay at work if possible. They go on to cite research showing how, in the real world, medical professionals are recommending rest and time off work. In India, for example, 46% of physiotherapists recommended rest to low back pain patients and in Brazil, rheumatologist recommended rest. 
  • The next comparison was for the guideline that imaging should only be ordered if the practitioner suspects a specific cause that would guide treatment and case management differing from normal care recommendations. In the USA, for example, from 2010-2013 the rate of imaging the low back with no red flags stayed consistent at 53.7%.  If we thought that was excessive, the authors go on to cite information from India showing 100% of chronic low back pain patients in an orthopedic clinic underwent imaging for non-specific low back pain. Similar results were found through the other studies cited for low and middle income countries. 
  • The next comparison was for the guideline that the first line treatments should be non-pharmacologic. They found that this guideline is not commonly followed citing research for high income countries demonstrating that 64.5% of low back pain patients in Australia from 2000-2010 were prescribed meds on the first visit and, on a personal note, I had a patient here in the USA just this morning with acute low back pain that was prescribed pain meds on the first day. To be fair, his pain is severe but, they are not following guidelines and the meds have had no impact on his level of pain still he continues to take them as ordered. Medication for no effect essentially. In the lower and middle-income countries, the authors cite research showing that in South Africa, 90% of the low back pain patients going to a primary care physician received medication. 
  • The next guideline was that many times, there was advice to avoid electrical physical modalities such as diathermy, etc. In the high-income setting, Swedish physiotherapists recommend transcutaneous stim for low back pain to the tune of 38%, 75% of American PTs use lumbar traction, and a Spanish National Health Service study suggested 38.6% of physical therapy costs were for treatments known to have no effectiveness.
  • The next guide comparison was that the use of opioids is discouraged. The authors go on to cite prescription rates from 2004-2009 and, to be honest, I think the opioid epidemic has likely caused the numbers cited to actually drop. Although opioid addiction is on the rise, it’s my opinion that it is now at the forefront of the national story. With the sort of attention it has demanded, I cannot imagine the numbers staying the same. That is my opinion, of course. 
  • Next guide was that surgery and interventional treatment should be very limited or possibly eliminated for low back pain. In the real world, this is not occurring. In the USA in 2011, spinal fusion was the reason for the most costs of any surgical procedure in the nation. US Medicare covered 2,023,481 epidural injections (a substantial increase from 2000-2011), 990,449 lumbar or sacral facet injections as well as 406,378 lumbar or sacral facet neurotomy treatments, Medicare funded 252,654 sacroiliac joint injections. Two-thirds of Dutch spinal surgeons perform spinal fusion surgeries. 
  • The next guide comparison was that exercise is now recommended for the treatment of chronic low back pain. A 2009 paper the authors cited showed that 54% of Americans with chronic low back pain were not prescribed any exercise as treatment. 
  • The final guide comparison was done for the recommendation that a biopsychosocial framework guide the management for low back pain patients. In the USA, only 12% of chronic low back pain patients had been treated for their diagnosed depression in the year prior and only 8.4% were recommended cognitive behavioral treatment. 

Promising Directions

implementation of the best available evidence

The authors state here that some of the biggest issues toward implementation of new low back guidelines may be short consultation times, the practitioners having a decreased amount of knowledge on the guides, fear of being sued if missing serious pathology, and an effort to appease patients’ desires and, in my opinion, be the “good guy” in the patients’ eyes. However, the authors explain that there are some examples of successful implementation and that widespread use may be achieved through dispelling existing established practice patterns, repetition of the guides, and finding out what is the most effective and cost-effective treatments. 

The authors suggest integrated education of health-care professionals surmising that such a thing could not only educate & innovate but also break through professional barriers that exist. Professional barriers such as exist between many in the medical field and the chiropractic field. 

Clinical systems and pathways

The authors say that one solution in the treatment of low back pain could be a radical departure from current procedure and move toward a stratified primary care model known as STarT Back. This model is a two-part model with the first part consisting of a questionnaire to help the practitioner identify the patient’s risk of persistent disabling pain. The second part consists of treatments tailored to the patients level of risk according to the first part questionnaire. 

Another option along these lines would be to redesign the entire case management paths from first contact all the way through to the specialized care practitioner. They argue that a current barrier to doing this is the fact that healthcare reimbursements are currently geared toward quantity rather than quality. Two programs the authors cited for examples of promising pathways are Canada’s Saskatchewan Spine Pathway as well as NHS England’s program. 

Integrate health and occupational interventions

The authors argue in this section that healthcare and occupational health interventions need to be considered simultaneously when it comes to patients with low back pain and work disability issues. Return to work commonly happens before the absence of pain. Even hurting, people can still return to work. The authors tend to have a very strong recommendation on never leaving work or returning as quickly as possible. 

Due to very specific examples, I have admittedly glossed over this section to avoid inaccuracies and unintended generalizations. I highly encourage your reading the paper on your own time for accuracy. 

Public health interventions

In this section, the authors are discussing public relations: how to get the word out. How to change public perception of back pain and the treatment of low back pain. They cite a successful campaign in Australia that used television ads with prominent public figures serving as the spokespeople. They felt it was well-funded and was successful in part due to the proper messaging but also due to laws and public policies that supported the campaign. 

Conclusions

The authors admit that even the solutions put forth in this paper are based on relatively limited evidence. The following are quotes from the conclusion:

  • “Focusing on key principles, such as the need to reduce unnecessary health care for low back pain, support people to be active and stay at work, and reform unhelpful patient clinical pathways and reimbursement models, could guide next steps.”
  • “No single solution will be effective, and a collective, global effort will take time, determination, and organization. Without the collaborative efforts of people with low back pain, policy makers, clinicians, and researchers necessary to develop and implement effective solutions, disability rates, and expenditure for low back pain will continue to rise.”

Key Takeaways:

A paper of this size and of this magnitude, and with the level of education of contributors honestly cannot be done complete justice by a review such as this. I admittedly hit the high spots on the treatment of low back pain. I am more focused in some areas than in others. More specific for some topics and more general in others. That is the nature of a summarization and I hope I am allowed that latitude. 

If you are research minded, if you are a low back pain patient, or if you are a practitioner regularly coming in contact with low back pain patients and interested in treatment of low back pain, it is my opinion that taking the time to read these three papers yourself is of utmost importance. 

Please find the links to the papers in the “References” section and get it done. Together, we can make a big, big difference in the lives of our low back pain patients. Without a doubt. 

For this week’s next step, go register with The Lancet and get this paper for free! You just have to register. That’s it. 

Next week we will review the third and final paper of this three paper series. Next week’s paper is called “Low back pain: a call to action.” It will continue with ideas toward treatment of low back pain. We’ll go through it bit by bit and hit the highlights for those of you that aren’t into reading research papers and things of that sort. Don’t miss it!

If you love what you hear, be sure to check out https://www.chiropracticforward.com

As this podcast builds, so will the website with more content, products, and chances to learn.

 

We cannot wait to connect again with you next week. From Creek Stone, my office here in Amarillo, TX, home of the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward. 

 

Here is the link for Part One of The Lancet Review from last week:

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)

 

 

References:

Paper 1 – “What low back pain is and why we need to pay attention: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30480-X/fulltext

Paper 2 “Prevention and treatment of low back pain: evidence, challenges, and promising directions.”: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30489-6/fulltext

Paper 3 – “Low back pain: a call for action”: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30488-4/fulltext

 

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

Low Back Pain: A Major Global Challenge

On the Chiropractic Forward podcast this week, we are going to do a review of The Lancet article on Low Back Pain. It is a recent paper published in march 2018 that we hope will have a powerful impact in the months and years to follow. 

Before we get started with this review of The Lancet article on Low Back Pain, I want to draw your attention our website at https://www.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. Also, if something brand new pops up, we’ll be able to tell you about it quickly and easily.

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 illegally u-turned into Episode #16 and criminals are welcome so make yourself at home. Again, we are doing a review of The Lancet article on Low Back Pain.

I’ve been battling a head cold and depending on the day, the head cold is winning. I hope you’ll excuse my graveled voice and my nasal presentation. I’ll do my best on this review of The Lancet article on Low Back Pain. 

Those of us that are hungry for new research and the recommendations that arise from the body of literature being constantly created were excited last week about the release of significant reports coming out in a highly respected research journal called The Lancet. 

Founded in 1823, The Lancet is published weekly is is one of the oldest, most respected, and most well-known medical journals in the world so when it was announced a series of papers were to be published in The Lancet having to do with low back pain, as you may imagine, those of us interested in the research world and musculoskeletal complaints were all ears. 

Not only was the article noteworthy due to its being published in The Lancet, but it was also exciting for those of us in the so-called alternative healthcare world because there were several Doctors of Chiropractic sitting on the steering committee for the series of reports. For some reason, chiropractors are still considered by many to be alternative while this group of papers suggest chiropractic may be a lot more than simply “alternative.”

There are a couple of things in my mind that stand out as reasons for such a series of papers. The first being that low back pain has become a major problem globally and show no sign of stopping the growth of it impact. The second reason would be the ineffectiveness of the treatments commonly used or recommended. This includes surgery, epidural steroid injections, and, the most notable of failed treatments, opioids.

The series of Low Back Pain papers were compiled by a team of leading experts on back pain. The team was made up of an international spectrum  of varied backgrounds. They met for a workshop in Buxton, UK, in June, 2016, to start the journey and the process of setting the outline and some sort of structure for each paper. 

It was quite an undertaking from quite the group of experts. This is not a group of papers to be ignored since these authors and researchers are among the best of the best globally. 

The papers were broken down as follows:

      1. What low back pain is and why we need to pay attention.
      2. Prevention and treatment of low back pain: evidence, challenges, and promising directions. 
      3. Low back pain: a call for action

In this article, I will cover the first of the three papers with plans to highlight the next two papers in the coming weeks so be sure to return for those important discussions. 

How They Did It

For this paper, again titled “What low back pain is and why we need to pay attention,” the researchers identified scientific studies through searches of databases:

  • MEDLINE (PubMed)
  • Scopus. 
  • Google Scholar
  • African Index Medicus Database

In this review of The Lancet article on Low Back Pain I think it’s important to re-iterate the authors assertion that, in order to ensure a high-quality standard, systematic reviews were shown preference for inclusion.

Summary of the introduction of the first paper. 

  • Low back pain is now the leading cause of disability worldwide.
  • Only a small percentage have a well-understood, definite cause for their low back pain. Examples of well-known and udnerstood causes are things like a vertebral fracture, malignancy, or infection.
  • Things that seem to raise the risk of having low back pain complaints would be populations that smoke regulary, people that have physically demanding jobs or routine jobs or jobs that keep them mostly sedentary throughout the day and throughout the work week, people with physical and mental issues that add to a low back complaint or contribute to a low back complaint, and overweight/obese people. These populations are all at risk for developing low back pain.
  • 540 million people were affected at any one time globally.
  • A systematic review (3097 participants) found several MRI findings had a reasonably strong association with low back pain, including Modic type 1 change, disc bulge, disc extrusion, and spondylolysis. To further define Modic 1 changes, in regular vertebral endplate bone, the trabeculae shoud be like a type of scaffolding. Within the trabeculae there is red bone marrow producing blood cells. In a Modic type 1, the trabeculae are fractured intermittently and the patterns are more erratic and the marrow is absent. In the marrow’s place now is serum which is the same substance one can find in a blister. 

Symptoms associated with low back pain

Radicular Pain and Radiculopathy

  • Radiculopathy is usually called sciatica and mostly occurs when there is involvement where the nerve root exits the spine.
  • The authors noted that the term sciatica is used inconsistently by doctors and the public in general and should probably be avoided all together. 
  • The diagnosis of radicular pain relies on clinical findings, such as history of dermatomal leg pain, leg pain that is actually worse than the back pain, aggravation of the symptom when bearing down such as in coughing, sneezing, lying on your back and raising heels off of the table or in going from seated to standing, and straight leg raise test. General rule of thumb for an SLR is that pain in the first 30 degrees of leg elevation hints at a disc origin since that is the movement that first starts to tension the nerve at the root.
  • Patients presenting with low back pain in addition to radicular pain or radiculopathy tend to have worse outcomes than those presenting with low back pain alone.

Lumbar Spinal Stenosis

  • I tell my patients that the simplest way to explain stenosis is to say that a hole that nerves run through has become smaller and, as a result, the nerves sometimes have pressure on them that can cause them to be somewhat dysfunctional. 
  • Lumbar spinal stenosis is clinically characterized by pain or discomfort with walking or standing that radiates into one or both legs and can be eased resting and almost always by lumbar flexion (neurogenic claudication). They call this the shopping cart sign. Meaning, if a person gets relief from leaning on a shopping cart, it sure may be stenosis. If it is aggravated by leaning back or by inducing a “swayback” type of movement, that sure may be stenosis. As a sidenote and from my own studies, if lumbar extension (or swayback) does not hurt, but then rotation in either direction at the endpoint of lumbar extenstion actually does increase the pain, then the patient is likely suffering from a lumbar facet complaint. 
  • Lumbar stenosis is commonly caused by narrowing of the spinal canal or intervertebral foramina as a result of a combination of degeneration such as facet osteoarthritis, ligamentum flavum hypertrophy, and bulging discs. Two or three of these factors can combine to reduce the size and space available for the neural structures to pass through. Obviously that can create issues.
  • Experts tend to agree that the diagnosis of stenosis requires both the presence of the symptoms in addition to imaging findings demonstrating stenosis.

Other causes of Low Back Pain

  • Vertebral fracture, inflammatory disorders, malignancy, infections, intra-abdominal causes.
  • The US guideline for imaging advises deferral of imaging pending a trial of therapy when there are weak risk factors for cancer or axial spondyloarthritis. What does that mean exactly? That means a trial of conservative care. The authors will delve further into this in the second paper from the Lancet series but I will butt my head in here with the opinion of the American College of Physicians. Their updated recommendations from February of 2017 reflect that doctors should be recommending Chiropractic, massage, and/or ice for acute low back pain and should recommend Chirorpactic, acupuncture, and/or exercise/rehab for chronic low back pain. These recommendations are to precede taking even ibuprofen. 

Prevalence

  • Approximately 40% of 9-18-year olds in high-income, medium-income, and low-income countries report having had low back pain.
  • Low back pain prevalence increased 54% since 1990.
  • It is the number one cause of disability globally

Work Disability

Social Identity & Inequality

  • MacNeela and colleagues reviewed 38 separate qualitative studies in high-income countries. They showed found common traits, including: worry and fear about the social consequences of chronic low back pain, hopelessness, family strain, social withdrawal, loss of job and lack of money, disappointment with health-care encounters (in particular with general practitioners), coming to terms with the pain, and learning self-management strategies.
  • Froud and colleagues reviewed 42 qualitative studies from high-income countries, and found that many people living with low back pain struggled to meet their social expectations and obligations and that achieving them might then threaten the credibility of their suffering, with disability claims being endangered. Sometimes we have to almost force low back patients back into the workforce and, did you know that studies show in general that the sooner people are returned to work, the better they tend to recover from the low back pain complaint?
  • Schofield and colleagues found that individuals who exit the workforce early as a result of their low back pain have substantially less wealth by age 65 years, even after adjustment for education. This is just an obvious statement. It makes sense that people that quit working earlier than 65 end up making less money by the time they reach 65. You can also throw the expense of dealing with a back pain complaint in on top of the loss of wages. 
  • Globally, low back pain contributes to inequality. At first, when I read this, it struck me as being silly. Everything’s about inequality these days isn’t it? Certainlly in America it seems. But, this is a little different when you read through the explanation. The authors go on to say that in low-income and middle-income countries, poverty and inequality might increase as participation in work is affected. In addition, regulations on how to properly re-introduce a person into the workforce are absent, and workers are likely to be placed right back into the job they were originally injured without proper re-introduction. The authors felt this might place more strain on family and community livelihoods.

Cost of Low Back Pain

  • Costs associated with low back pain are commonly tallied as direct medical costs, meaning the cost of the doctor’s bill. They are also tallied in terms of indirect costs; meaning the cost of being out of work and the loss of productivity at the work place.
  • Most studies underestimate the total costs of low back pain
  • Although we do not think of low back pain in these terms yet, the truth is that low back pain, in terms of a real problem as far at the cost to treat and the overall indirect costs, are right up there with the biggest issues the global pupulation faces. Issues such as cardiovascular disease, cancer, mental health, and autoimmune diseases. That’s huge. 
  • In the USA, 44% of the population used at least one complementary or alternative health-care therapy in 1997; and the most common reason was low back pain. with 70,000 plus chiropractors in the United States, I can tell you with some confidence the profession most associated with alternative treatment for low back pain or spinal pain of any sort is chiropractic care. 
  • The USA has the highest costs, attributable to a more medically intensive approach as well as higher rates of surgery compared with other high-income countries. We see patients every week that have gone through needless surgeries. Surgeries for which there is plenty of high-level research proving its ineffectiveness yet you see the popularity for these surgeries continuing to rise. 

Natural History

  • A systematic review (33 cohorts; 11 166 participants) provides strong evidence that most episodes of low back pain improve substantially within 6 weeks, and by 12 months average pain levels are low. However, two-thirds of patients still report some pain at 3 months and 12 months
  • The best evidence suggests around 33% of people will have a recurrence within 1 year of recovering from a previous episode.

Risk Factors and Triggers for Low Back Pain Episodes

      • A systematic review (5165 participants) found consistent evidence that people who have had previous episodes of low back pain are at increased risk of a new episode. Likewise, people with other chronic conditions, including asthma, headache, and diabetes, are more likely to report low back pain than people in good health
      • a UK cohort study found psychological distress at age 23 years predicted incident low back pain 10 years later. The Canadian National Population Health Survey with 9909 participants found that pain-free individuals with depression were more likely to develop low back pain within 2 years than were people without depression
      • systematic reviews of cohort studies indicate that lifestyle factors such as smoking, obesity, and low levels of physical activity that relate to poorer general health are also associated with occurrence of low back pain episodes. We know that obesity and lack of exercise has become an American trait that needs to be reversed. 
      • A systematic review found the genetic influence on the liability to develop low back pain ranged from 21% to 67%, with the genetic component being higher for more chronic and disabling low back pain than for inconsequential low back pain.Don’t we all have patients that present to us claimng that their bad back just runs in the family? Mom and Grandma had a bad back so that must be why they have a bad back is the common sentiment. It seems there may be a bit of validity there. 
      • An Australian case-crossover study (999 participants) showed that awkward postures, heavy manual tasks, feeling tired, or being distracted during an activity were all associated with increased risk of a new episode of low back pain. Similarly, work exposures of lifting, bending, awkward postures, and tasks considered physically demanding were also associated with an increased risk of developing low back pain in low-income and middle-income countries

Psychological Factors

For this review of The Lancet article on Low Back Pain, the presence of psychological factors in people who present with low back pain is associated with increased risk of developing disability even though the mechanisms are not fully understood

Social and Societal Factors

      • Cross-sectional data from the USA (National Health Interview Survey 2009–10, 5103 people) found that those with persistent low back pain were more likely to have had less than high-school education and had an annual household income of less than US$20,000. 
      • Suggested mechanisms for the effect of low education on back pain include environmental and lifestyle exposures in lower socioeconomic groups, lower health literacy, and health care not being available or adequately targeted to people with low education.
      • To go along with lower wages, the lower socioeconomic groups are commonly in routine and manual occupations and ahve increased physical workloads is associated with disabling low back pain

Conclusion

In this review of The Lancet article on Low Back Pain, the authors concluded, “Low back pain is now the number one cause of disability globally. The burden from low back pain is increasing, particularly in low-income and middle-income countries, which is straining health-care and social systems that are already overburdened. Low back pain is most prevalent and burdensome in working populations, and in older people low back pain is associated with increased activity limitation. Most cases of low back pain are short-lasting and a specific nociceptive source cannot be identified. Recurrences are, however, common and a few people end up with persistent disabling pain affected by a range of biophysical, psychological, and social factors. Costs associated with health care and work disability attributed to low back pain are enormous but vary substantially between countries, and are related to social norms, health-care approaches, and legislation. Although there are several global initiatives to address the global burden of low back pain as a public health problem, there is a need to identify cost-effective and context-specific strategies for managing low back pain to mitigate the consequences of the current and projected future burden.”

Key Takeaway:

Obviously, if you followed us all the way through on this review of The Lancet article on Low Back Pain, low back pain is an issue that must be addressed in a more effective way globally and irregardless of national ranking in terms of the economy. Just because it’s musculoskeletal doesn’t mean it can be ignored and kicked to the curb while the big stuff like heart disease, diabetes, and cancer are treated. The research for the big stuff is adequately funded but, honestly, in general, most general practitioners don’t have the first clue of what to do for low back pain. I personally suggest they turn to their own American College of Physicians for updated recommendations on chronic and acute low back conditions if I were them. 

Authors

Steering Committee

Rachelle Buchbinder – Australia

Jan Hartvigsen – Denmark

Dan Cherkin – United States

Nadine Foster – UK

Chris Maher – Australia

Martin Underwood – UK

Maruits van Tulder – Netherlands

For this week’s Next Steps in this review of The Lancet article on Low Back Pain, be sure to send us an email at dr.williams@chiropracticforward.com and let us know what you thought or contribute to the show for next week. We love hearing from you all. Also, go and follow Jan Hartvigsen https://twitter.com/JanHartvigsen, and Chris Maher https://twitter.com/CGMMaher on Twitter. 

Next week we will review the second paper of this three paper series. Next week’s paper is called “Prevention and treatment of low back pain: evidence, challenges, and promising directions.” We’ll go through it bit by bit and hit the highlights for those of you that aren’t into reading research papers and things of that sort. Don’t miss it!

If you love what you hear, be sure to check out www.chiropracticforward.com. As this podcast builds, so will the website with more content, products, and chances to learn. This review of The Lancet article on Low Back Pain is just an example of what you can look forward to.

We cannot wait to connect again with you next week for review of The Lancet article on Low Back Pain Part Two. From Creek Stone, my office here in Amarillo, TX, home of the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward. 

Be sure to check out part of our Chiropracrtors Cause Strokes Myth. This is a link to Part Two:

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

References:

CF 015: DEBUNKED: The Odd Myth That Chiropractors Cause Strokes (Part 3 of 3)

Debunking the odd myth that chiropractors cause strokes. I’m almost done with this y’all. In this final episode of this series, we will discuss risky interventions, papers having to do with the risk, or lack thereof, of chiropractic adjustments to the cervical region specifically, and then a wrap up of the information.

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

DEBUNKED: The Odd Myth That Chiropractors Cause Strokes Revisited

Part 2 of 3

Chirorpactic Forward Podcast Subscribe Link

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This week we are in Episode #2 of the 3 episodes where we are systematically debunking the odd myth that chiropractors cause strokes. I’m not having it folks. The chiropractors cause strokes myth is old and tired and in need of retirement. In this episode, we will discuss research papers demonstrating and validating benefits of having cervical manipulation treatments. Or chiropractic adjustments to the neck. We will talk about the benefits, according to research, for neck pain as well as for headaches. And we’ll also talk a little about where this chiropractors cause strokes myth came from and why it perpetuates to this day.

Before we get started, I want to draw your attention to the reviews over at iTunes. If you would be kind enough to leave us a great review we sure would appreciate you! This is a new podcast and we need all the help we can get!

Right now though, it’s time for 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. I can’t think of a more valuable way to spend you time if you’re a chiropractor than to learn how to debunk the chiropractors cause strokes myth and shut people down on it.

Let’s begin this episode by thanking those of you that sent emails to me after this chiropractors cause strokes myth series kicked off last week. You guys are great. The best way you can help is to share these episodes with as many people as you can. We can get this myth debunked and we can put it to rest right here, right now. But, obviously, I can’t do it myself. I need your help to do it.

I also want to remind you that this is part 2 of a three part series on the chiropractors cause strokes myth. Last week was part one of the chiropractors cause strokes myth where we discussed some risky odds, some case specific discussion, some signs and symptoms of vertebral artery dissection, and some research dealing with common treatments within the medical profession.

Be sure to go back and listen to it if you have not. It’s essential.

Then next week we will discuss other risky interventions, papers having to do with the risk, or lack thereof, of chiropractic adjustments to the cervical region specifically, and then a wrap up of the information putting the chiropractors cause strokes myth to bed once and for all.

Don’t miss it folks.

Now, let’s get on with our risk vs. reward discussion with the BENEFITS of cervical manipulation therapy.

I want to start off with the benefits of cervical manipulation for neck pain specifically. Each paper mentioned includes a short description of the conclusion for each paper cited. Also each of these papers is referenced in the show notes and can be very easily reviewed independently. You have to know that I am going to absolutely murder some of these names and I don’t even care. I’m small town South y’all. I’m not fancy at all. All I can is do my best but I assure you I’m not going to do backflips trying to figure out the correct pronunciation of each of these names. Be sure though, the days of Dr. Smith or Dr. Jones doing all of the research are no longer Take this first name as an example.

  1. Korthalis-de Bos IB, et. al. – “Manual therapy (spinal mobilization) is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner[1].”
  2. Dewitte V, et. al. – “Based on key features in subjective and clinical examination, patients with mechanical nociceptive pain probably arising from articular structures can be categorized into specific articular dysfunction patterns. Pending on these patterns, specific mobilization and manipulation techniques are warranted. The proposed patterns are illustrated in 3 case studies. This clinical algorithm is the corollary of empirical expertise and is complemented by in-depth discussions and knowledge exchange with international colleagues. Consequently, it is intended that a carefully targeted approach contributes to an increase in specificity and safety in the use of cervical mobilizations and manipulation techniques as valuable adjuncts to other manual therapy modalities[2].”
  3. Dunning JR, et. al. – “The combination of upper cervical and upper thoracic HVLA thrust manipulation is appreciably more effective in the short term than nonthrust mobilization in patients with mechanical neck pain[3].”
  4. Brontfort G, et. al. – “For participants with acute and subacute neck pain, SMT was more effective than medication in both the short and long term. However, a few instructional sessions of HEA resulted in similar outcomes at most time points[4].”
  5. Puentedura EJ, et. al. – The objective of the paper was as follows: “Thrust joint manipulation to the cervical spine has been shown to be effective in patients presenting with a primary report of neck pain. It would be useful for clinicians to have a decision-making tool, such as a clinical prediction rule, that could accurately identify which subgroup of patients would respond positively to cervical thrust joint manipulation.” In the results, they showed if 3 or more of the 4 attributes were present,” the probability of experiencing a successful outcome improved from 39% to 90%[5].”
  6. Yu H, et. al. – “Chiropractic management of atlantoaxial osteoarthritis yielded favorable outcomes for these 10 patients[6].”
  7. Puentedura EJ, et. al. – “Patients with neck pain who met 4 of 6 of the CPR criteria for successful treatment of neck pain with a thoracic spine thrust joint manipulation demonstrated a more favorable response when the thrust joint manipulation was directed to the cervical spine rather than the thoracic spine. Patients receiving cervical thrust joint manipulation also demonstrated fewer transient side-effects[7].”
  8. Miller J, et. al. – “Moderate quality evidence supports this treatment combination (cervical manual therapy combined with exercise) for pain reduction and improved quality of life over manual therapy alone for chronic neck pain; and suggests greater short-term pain reduction when compared to traditional care for acute whiplash[8].”
  9. Hurwitz EL, et. al. – “Our best evidence synthesis suggests that therapies involving manual therapy and exercise are more effective than alternative strategies for patients with neck pain[9].”
  10. Muller R, et. al. – “In patients with chronic spinal pain syndromes, spinal manipulation, if not contraindicated, may be the only treatment modality of the assessed regimens that provides broad and significant long-term benefit[10].”
  11. Zhu L, et. al. – “There was moderate level evidence to support the immediate effectiveness of cervical spine manipulation in treating people with cervical radiculopathy[11].”
  12. Giles LG, et. al. – “The consistency of the results provides, despite some discussed shortcomings of this study, evidence that in patients with chronic spinal pain, manipulation, if not contraindicated, results in greater short-term improvement than acupuncture or medication[12].”
  13. Bronfort G, et. al. – “Our data synthesis suggests that recommendations can be made with some confidence regarding the use of spinal manipulative therapy and/or mobilization as a viable option for the treatment of both low back pain and neck pain[13].”

There you have a fairly thick list of research papers demonstrating the effectiveness of chiropractic adjustments for uncomplicated neck pain but neck pain is not the only reason to have a chiropractic adjustment delivered to the cervical region. Another very common reason for neck adjustments would be for the treatment of acute and chronic headaches.

In fact, I have an episode of this podcast that dealt with a paper showing the effectiveness of chiropractic for headaches. Episode #6 to be exact.

Here is a listing of papers demonstrating the benefits of cervical manipulation for headaches. Each paper mentioned includes a short description of the conclusion for each paper cited. Also each of these papers is referenced in the show notes and can be very easily reviewed independently

  1. Malo-Urries M, et. al. – “Upper cervical translatoric spinal mobilization intervention increased upper, and exhibited a tendency to improve general, cervical range of motion and induce immediate headache relief in subjects with cervicogenic headache[14].”
  2. Espi-Lopez GV, et. al. – “In short, manual therapy techniques and manipulation applied to the suboccipital region for four weeks or more showed great improvement and in effectiveness for several aspects that measure the quality of life of a patient having suffered from tension type headaches[15].”
  3. Dunning J, et. al. – “Six to eight sessions of upper cervical and upper thoracic manipulation were shown to be more effective than mobilization and exercise in patients with cervicogenic headache, and the effects were maintained at 3 months[3].”
  4. Hurwitz EL, et. al. – “Utilization and expenditures for headache treatment increased from 2000 to 2009 across all provider groups. MD care represented the majority of total allowed charges in this study. MD care and DC care, alone or in combination, were overall the least expensive patterns of headache care. Risk-adjusted charges were significantly less for DC-only care[16].”
  5. Bronfort G, et. al. – “SMT appears to have a better effect than massage for cervicogenic headache. It also appears that SMT has an effect comparable to commonly used first-line prophylactic prescription medications for tension-type headache and migraine headache[17].”
  6. Bronfort G, et. al. – “Chiropractic is effective in acute, subacute, and chronic low back pain, migraines and headaches originating from the neck, for the treatment of some forms of dizziness, extremity and joint issues, as well as mid back and acute and subacute neck pain[18].
  7. Tuchin PJ, et. al. – “The results of this study support previous results showing that some people report significant improvement in migraines after chiropractic spinal manipulative therapy. A high percentage (>80%) of participants reported stress as a major factor for their migraines. It appears probable that chiropractic care has an effect on the physical conditions related to stress and that in these people the effects of the migraine are reduced[19].”
  8. McCrory D, et. al. – “Cervical spinal manipulation was associated with improvement in headache outcomes in two trials involving patients with neck pain and/or neck dysfunction and headache. Manipulation appeared to result in immediate improvement in headache severity when used to treat episodes of cervicogenic headache when compared with an attention-placebo control. Furthermore, when compared to soft-tissue therapies (massage), a course of manipulation treatments resulted in sustained improvement in headache frequency and severity[20].”

Many headache patients present to chiropractors after a considerable amount of time spent taking headache and migraine medications. Medications do not come without consequences. Certainly when taking long-term. Not only have they spent a considerable amount of time on medication, they often have had botox injections, steroid injections, and worse before finally going to the chiropractor.

It is a fact that patients should have the GUARANTEED of the best treatment that does the LEAST amount of harm. In that spirit, and considering that chiropractic is safe, effective, and non-pharmacologic, it makes sense that the medical field should actually PROMOTE chiropractic as a viable and valuable treatment for headaches and migraines rather than dismiss it as ineffectual and dangerous.

Having demonstrated study upon study validating the effectiveness and benefit of cervical manipulation for neck pain (acute, subacute, and chronic) and headaches (chronic, acute, subacute, tension-type, cervicogenic, and migraines), we can now focus attention on research papers and abstracts having to do with the risk of stroke instance (lack of risk) as a direct result of cervical chiropractic adjustments. Hopefully, you are getting a more clear picture of the chiropractors cause strokes myth and its absolutely foolishness.

But first, where would you think the idea of chiropractors running around stroking everyone out might come from? I believe there are at least a few root sources.

  • You guessed it: our old friend the American Medical Association and their state association underlings. This group deemed it unethical to refer to chiropractors or accept referrals FROM They tried to run us out of business by conducting conferences about chiropractic and generating literature that was anti-chiropractic. They then dispersed the misinformation down through the channels of the state medical associations all the way out to the medical doctors, nurses, and medical field profession out in the field, and then ultimately to their patient bases. The “Chiropractors Cause Strokes” myth was well within their ability to propagate. When your initiative is to rid the Earth of the chiropractic profession, you take advantage of what you can. The Federal Court decision in Wilk vs. AMA shows the AMA did just that.
  • The other likely culprit for the chiropractors cause strokes myth in my estimation would be patients visiting medical professionals after having been to a chiropractor and having suffering a stroke sometime afterward. I did not say chiropractors “causing” strokes. Research shows us that people are going to chiropractors already suffering arterial tears that are sometimes spontaneous in nature. While chiropractors have a high level of education, there are many out there that are simply untrained at catching red flags and making the proper referral. Other times, patients present with very common symptoms and there are no red flags present whatsoever. The chiropractor treats the patient thinking they are going to help improve a neck complaint or a headache while in reality they may be exacerbating a tear. When the patient reaches the medical professional, the link is easy to make for the uninformed: chiropractor causes stroke.
  • Ignorance – The simple lack of knowledge regarding the body of evidence and research that is available dealing with the chiropractors cause strokes myth perpetuates the myth. It is clear the benefits are present. It is clear the risks are not. End of story. But if one is ignorant of the literature,

This is where we are going to stop for this second episode of the chiropractors cause strokes series. Remember, it is a three part series.

KEY TAKEAWAY:

The benefit is researched and it’s real. There is no denial possible.

Be sure to tune in next week for the third and final part of the three part series. Next week, we will discuss risky interventions, papers having to do with the risk, or lack thereof, of chiropractic adjustments to the cervical region specifically, and then a wrap up of the information.

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. As this podcast builds, so will the website with more content, products, and chances to learn.

We cannot wait to connect again with you next week for third and final part of the debunking of the chiropractors cause strokes myth. From Creek Stone, my office here in Amarillo, TX, home of the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.

Other episodes of interest include:

CF Episode #13: DEBUNKED: The Odd Myth That Chiropractors Cause Strokes (Part 1 of 3)

Source Material

  1. Korthals-de Bos IB, Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial. British Medical Journal, 2003. 326(7395): p. 911.
  2. Dewitte V, Articular dysfunction patterns in patients with mechanical neck pain: a clinical algorithm to guide specific mobilization and manipulation techniques. Man Ther, 2014. 19(2-9).
  3. Dunning J, Upper cervical and upper thoracic manipulation versus mobilization and exercise in patients with cervicogenic headache: a multi-center randomized clinical trial. BMC Musculoskeletal Disorders, 2016. 16(64).
  4. Bronfort G, Spinal Manipulation, Medication, or Home Exercise With Advice for Acute and Subacute Neck Pain: A Randomized Trial. Annals of Internal Medicine 2012. Ann Intern Med, 2012. 156(1): p. 1-10.
  5. Puentedura EJ, Development of a clinical prediction rule to identify patients with neck pain likely to benefit from thrust joint manipulation to the cervical spine. J Orthop Sports Phys Ther, 2012. 42(7): p. 577-92.
  6. Yu H, Upper cervical manipulation combined with mobilization for the treatment of atlantoaxial osteoarthritis: a report of 10 cases. J Manipulative Physiol Ther, 2011. 34(2): p. 131-7.
  7. Puentedura EJ, Thoracic spine thrust manipulation versus cervical spine thrust manipulation in patients with acute neck pain: a randomized clinical trial. J Orthop Sports Phys Ther, 2011. 41(4): p. 208-20.
  8. Miller J, Manual therapy and exercise for neck pain: a systematic review. Man Ther, 2010. 15(4): p. 334-54.
  9. Hurwitz EL, e.a., Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine, 2008. 33(4 Suppl): p. S123-52.
  10. Muller R, G.L., Long-term follow-up of a randomized clinical trial assessing the efficacy of medication, acupuncture, and spinal manipulation for chronic mechanical spinal pain syndromes. J Manipulative Physiol Ther., 2005. 28(1): p. 3-11.
  11. Zhu L, Does cervical spine manipulation reduce pain in people with degenerative cervical radiculopathy? A systematic review of the evidence, and a meta-analysis. Clin Rehabil, 2015.
  12. Giles LGF, M.R., Chronic spinal pain syndromes: a clinical pilot trial comparing acupuncture, a nonsteroidal anti-inflammatory drug, and spinal manipulation. J Manipulative Physiol Ther, 1999. 22(6): p. 376-81.
  13. Bronfort G, Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine, 2004. May-Jun 4(3): p. 335-56.
  14. Malo-Urries M, Immediate Effects of Upper Cervical Translatoric Mobilization on Cervical Mobility and Pressure Pain Threshold in Patients With Cervicogenic Headache: A Randomized Controlled Trial. J Manipulative Physiol Ther, 2017. 40(9): p. 649-658.
  15. Espi-Lopez G, e.a., Do manual therapy techniques have a positive effect on quality of life in people with tension-type headache? A randomized controlled trial. Eur J Phys Rehabil Med, 2016. 13(1): p. 4-13.
  16. Hurwitz EL, e.a., Variations in Patterns of Utilization and Charges for the Care of Neck Pain in North Carolina, 2000 to 2009: A Statewide Claims’ Data Analysis. J Manipulative Physiol Ther, 2016. May 39(4): p. 240-51.
  17. Bronfort G, Efficacy of spinal manipulation for chronic headache: a systematic review. J Manipulative Physiol Ther, 2001. 24(7): p. 457-466.
  18. Bronfort G, Effectiveness of manual therapies: The UK evidence report. Chiropr Osteopat, 2010. 18(3).
  19. Tuchin PJ, e.a., A randomized controlled trial of chiropractic spinal manipulative therapy for migraine. J Manipulative Physiol Ther, 2000. 23(2): p. 91-95.
  20. McCrory D, Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache. Duke University Evidence-based Practice Center, Center for Clinical Health Policy Research.


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

This week, we are going to start tackling the chiropractors cause strokes myth that has run rampant for years and I hope to once and for all dispel it. The information could not be clearer on the chiropractors cause strokes myth and we’re gonna to show it to you in a way that you can understand and in a way that allows you to show it to others. I’m done with this myth, folks!

Before we get started, I want to draw your attention to the reviews over at iTunes. If you would be kind enough to leave us a great review we sure would appreciate you! This is a new podcast and we need all the help we can get!

Right now though, it’s time for 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.

Unfortunately, you have often read, watched, or heard me complaining about how our profession has been historically attacked by those organizations in charge of the medical profession. I hope those paying attention understand it is not just sour grapes.

It is education.

I continually bring these facts up in my articles, videos, and podcast because many of the things we talk about have their roots in our history, in the attacks our profession has sustained, and in the attacks our profession is currently battling.

From the start, let me state that research simply does NOT support the chiropractors cause strokes myth.

If you have seen the TV series called “Mythbusters,” then you know the smart red-headed guy and the bald bespectacled serious guy both, along with their rascally cohorts, took a common myth and tested its validity.

Some of the myths were outrageous and some seemed like they may actually be plausible. The show, whenever I watched it was highly entertaining and extremely educational. The entertaining part always came toward the end of the show when they would blow something to smithereens. That’s the part where the inner child in me would leap with glee. Internally of course, not externally.

This mythbusting process has already been carried out for the chiropractors cause strokes myth. Several times, in fact. Without the show-ending explosion of course. Although, at the end of this Mythbusting series, I may walk away with a mic drop if you’re all OK with that.

I say mythbusting series because there is SO MUCH information here that I have to split it into 3 different episodes for the chiropractors cause strokes podcast series. I’m pumping my own tires and I am completely full of myself on what I’m about to say here and I’m well-aware of the fact but, from what I have seen out there on the interwebs, I feel like this is, or at least CAN be, the definitive article, the definitive podcast, the definitive gathering of the information for this topic. If that is indeed the lofty goal I’m aiming for, it has to be comprehensive and somewhat exhaustive and I don’t think I can maintain your focus and interest for the entire amount of the information to be compiled into one super long episode. Dispelling the chiropractors cause strokes myth is too important to lose your attention.

I have split it into three episodes that will break up like this

The first episode, the one you’re currently listening to will include some risky odds, some case specific discussion, some signs and symptoms of vertebral artery dissection, and some research dealing with common treatments within the medical profession.

In the second episode coming next Thursday we will discuss research papers demonstrating and validating benefits of having cervical manipulation treatments. Or chiropractic adjustments to the neck. We will talk about the benefits, according to research, for neck pain as well as for headaches. And we’ll also talk a little about where this chiropractors cause strokes myth came from and why it perpetuates to this day.

In the third and final episode we will discuss risky interventions, papers having to do with the risk, or lack thereof, of chiropractic adjustments to the cervical region specifically, and then a wrap up of the information on this chiropractors cause strokes myth.

Stick with us on this.

Now, let’s dive into this first episode of the chiropractors cause stroke series.

Through the RAND institute, it is estimated that a serious, adverse reaction (such as stroke as a result to a chiropractic adjustment alone) happens in approximately 1 out of every 1 million treatments?

Let’s put that finding into perspective by comparing it to some other odds.

  • The odds of being struck and killed by lightning is 1 in 174,426 according to the National Safety Council.
  • The odds of being told to “Come on down,” on The Price Is Right is 1 in 36!
  • The odds of being born with 11 fingers or toes is 1 in 500.
  • The odds of dying from a firearms assault is 1 in 113.
  • How about this one: the odds of winning an Oscars are 1 in 11,500.

I think it’s time to move to LA!

Consider that there are 70,000+ chiropractors in the United States of America. If Doctors of Chiropractic were out in the world causing strokes “all of the time,” it would be apparent, it would be obvious, and our malpractice insurance would reflect the fact that a visit to the chiropractor comes with a considerable amount of risk. To the contrary, we chiropractors have malpractice insurance that costs chiropractors approximately 1/10th of what it costs our medical counterparts. This fact alone should dispel the chiropractors cause strokes myth.

Before we start diving off into the research too deeply, I want to talk about a case that happened within the last couple of years (February 2016) that brought the “Chiropractors Cause Strokes” myth back to the forefront. It had to do with the “Queen of Snapchat” Katie May. Katie died of a stroke at the age of 34 and, by many, it was immediately assumed the stroke was caused by her two visits to a chiropractor to treat her recent onset of neck pain.

I actually wrote about this case shortly after it originally happened. Initial reports stated that she had a horrible fall while on the set of a photoshoot, which resulted in her neck pain. Then, for some reason, this fact seemed to disappear from further reports.

Also, initial reports stated that Katie visited either the ER or a medical professional prior to her visits with a chiropractor. The family later denies this so, admittedly, there is some confusion on the matter. With this information brought back into the reporting, let’s begin breaking it all down.

Katie posted this message to Twitter: “Pinched a nerve in my neck on a photoshoot and got adjusted this morning. It really hurts! Any home remedy suggestions loves? XOXO.”

Keep that in mind as we run through things that can cause a vertebral artery dissection such as Katie May suffered. They are as follows:

  • Physical Trauma (direct blow to the neck, traffic collision, etc.)
  • Strangulation
  • Spontaneous (from underlying connective tissue disorder)

According to one paper by Debette et. al., “Trauma has been reported to have occurred within a month of dissection in 40% with nearly 90% of this time the trauma being minor[1]. “

Vertebral artery dissection (VAD) can be particularly difficult to diagnose without the use of a CT Angiogram. For instance, some common symptoms of VAD are as follows:

  • Pain and/or numbness in the same side of the face.
  • Head pain/Headache that develops gradually and can be dull or throbbing
  • In less than 1/5th of the cases of VAD, people suffer difficulty speaking or swallowing.
  • Possible unsteadiness or lack of coordination
  • Visual abnormalities
  • Hiccups
  • Nausea/Vomiting
  • Hearing loss

When one reads this list, it is easy to diagnose a VAD, right?

It rarely presents with these classic signs.

Is a medical professional or chiropractor going to refer every single one of these patients for a CT Angiogram or an MRI? Not very likely. It is simply not economically feasible to do so and good luck getting insurance companies to cover the costs of the CT Angiograms!

If Katie did indeed visit a medical professional after her fall, they missed it. Unfortunately, it seems obvious that the chiropractor missed it as well. That does not, however, mean the two professionals are inept. As the website for emedicine.com states, “The focal signs may not appear until after a latent period lasting as long as three days, however, and delays of weeks and years also have been reported[2].”

With that being said, I don’t want to be completely biased here. If a healthy person shows up with a headache and neck pain BUT has a history of recent trauma, more exploration is advised, without question. Knowing this, I can relay countless stories of medical doctors having made bad decisions as well. I have heard countless stories throughout my twenty years of practice. Ultimately, we are all human which is why chiropractors and medical doctors both carry malpractice insurance. But, as I mentioned before, chiropractors’ malpractice is approximately 1/10th that of their medical counterparts because, basically, we do not typically cause any harms in our patients.

As we go through more and more papers, it should be clear that Katie likely suffered the VAD as a result of the fall during the photo shoot and the VAD was missed by the medical professionals (if she did indeed go) and then certainly missed by the chiropractor BUT, the chiropractor almost certainly did not CAUSE the VAD. There’s no we he helped it and could have even potentially exacerbated it, but it is highly doubtful and exceedingly rare that he could have been the CAUSE of it.

Some time later, the Los Angeles coroner reported that the chiropractor was responsible for Katie’s death. This finding really opened the door to all of the chiropractic haters to bash away at the profession.

The LA coroner’s office is an appointed position that, in some states, requires little training, to be quite honest. While I am unaware of this particular coroner’s level of training and expertise, this coroner has been under scrutiny for being understaffed and underfunded to mention just a couple of issues. In addition, I would argue that simply because a man or a woman is a county coroner, does not mean they are above being affected by bias or by their profession’s long-held beliefs and teachings. I would say they most certainly are not above influence and, in my opinion, are highly likely to be affected by them. When they are told by their schools, their national and state associations, and their mentors that chiropractors cause strokes, don’t you think they probably believe it?

I would also argue that the coroner likely has little to zero knowledge of the current body of research regarding cervical manipulation and the instance of stroke. How could an educated person aware of the body of literature on the matter decide otherwise?

For years, I have experienced nurses, physician assistants, medical doctors, and others in an online setting claiming that chiropractic adjustments are dangerous and ineffective. A common theme amongst them is, “It happens all of the time.” We see it “all of the time.” Research proves the notion is a lie.

I would like to be less dramatic or inflammatory in my wording but I do not know of another way to describe it.

Let’s assume that this myth has its base rooted in some sort of fact. Let us be clear. It does not. But, for argument sake, let us say that it does. At that point, we would need to assess the benefits of chiropractic treatment vs. the risks of chiropractic treatment.

In Southern terms, “Is the squeeze worth the push?”

Is there a return on the investment?

Again, this is purely for argument sake because the chiropractors cause strokes myth is not real to start with but playing the devil’s advocate can be of use and is almost always entertaining.

Before we step into deeper water with the research papers, let us discuss benefits & effectiveness vs. risk for some common treatments for spinal complaints in the medical world. If the discussion is focused on doing away with cervical adjustments, what then would be the alternatives and how effective are they? Basically, if the medical field is looking in OUR backyard, maybe we should take a peek into theirs as well.

Keep in mind that all of the research we discuss will be cited in the show notes so that those of you that wish can easily research these independently on your own.

  • The opioid crisis cost the US economy $504 billion dollars in 2015 and a total of $221 billion to $431 billion in lost economic output due to there being 33,000 opioid-related deaths in 2015[3].
  • There were 63,600 opioid-related deaths in 2016, which was an increase of 21% from the 2015.[4].
  • Chou R, et. al. – Although the steroid injections for radiculopathy showed some short-term relief in pain and short-term increase in function, the benefits seen in the patients were only small and short-term only. There was no effect long-term and no affect on whether or not the person had surgery eventually. The evidence in this paper suggested there was no effectiveness at all for the treatment of spinal stenosis[5].
  • Epstein N, et. al. – “Although not approved by the Food and Drug Administration (FDA), injections are being performed with an increased frequency (160%), are typically short-acting and ineffectiveover the longer-term, while exposing patients to major risks/complications[6].”
  • Peterson CK, et. al. – ““Subacute/chronic patients treated with SMT (spinal manipulative therapy) were significantly more likely to report relevant “improvement” compared with CNRI (CERVICAL NERVE ROOT INJECTION) patients.There was no difference in outcomes when comparing acute patients only[7].”
  • Chou R, et. al. – “Epidural corticosteroid injections for radiculopathy were associated with immediate improvements in pain and might be associated with immediate improvements in function, but benefits were small and not sustained, and there was no effect on long-term risk of surgery. Evidence did not suggest that effectiveness varies based on injection technique, corticosteroid, dose, or comparator. Limited evidence suggested that epidural corticosteroid injections are not effective for spinal stenosis or nonradicular back pain and that facet joint corticosteroid injections are not effective for presumed facet joint pain[5].”
  • Chou R, et. al – “Surgery for radiculopathy with herniated lumbar disc and symptomatic spinal stenosis is associated with short-term benefits compared to nonsurgical therapy, though benefits diminish with long-term follow-up in some trials. For nonradicular back pain with common degenerative changes, fusion is no more effective than intensive rehabilitation, but associated with small to moderate benefits compared to standard nonsurgical therapy[8].”
  • Maghout J, et. al. – “Use of intervertebral fusion devices rose rapidly after their introduction in 1996. This increased use was associated with an increased complication risk without improving disability or reoperation rates[9].”

 

At this point, it is clear the medical field has its own issues to concentrate on and improve upon when it comes to spinal pain and the treatment of it. It is my opinion these facts are but only a few of the concerns in the medical field and, if taken individually, are much more concerning than any one single issue that can be found within the chiropractic profession.

This is where we are going to stop for this first episode of the Chiropractors cause strokes series. Remember, our” chiropractors cause strokes” series is a three part series.

Be sure to tune in next week for the second part of the three part series. Next week, we will be talking about the benefits, according to research, for neck pain as well as for headaches. And we’ll also talk a little about where this myth came from and why it perpetuates to this day.

You may also consider listening to a recent episode in which we covered some great new research on treating neck pain conservatively through chiropractic care. Check it out at https://www.chiropracticforward.com/2018/03/08/proven-means-to-treat-neck-pain/

­­­­­­­­Please feel free to send us an email at dr dot williams at chiropracticforward.com and let us know what you think about the chiropractors cause strokes myth 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. As this podcast builds, so will the website with more content, products, and chances to learn.

We cannot wait to connect again with you next week. From Creek Stone, my office here in Amarillo, TX, home of the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.

 

References

  1. Debette S, “Pathophysiology and risk factors of cervical artery dissection: what have we learnt from large hospital-based cohorts?”. . Current Opinion in Neurology, 2014. 27(1): p. 20-8.
  2. Lang E. Vertebral Artery Dissection. Emergency Medicine 2017 January 18]; Available from: https://emedicine.medscape.com/article/761451-overview.
  3. Mutikani L. Opioid crisis cost U.S. economy $504 billion in 2015: White House. 2017; Available from: https://www.reuters.com/article/legal-us-usa-opioids-cost/opioid-crisis-cost-u-s-economy-504-billion-in-2015-white-house-idUSKBN1DL2Q0.
  4. Glenza J. Life expectancy in US down for second year in a row as opioid crisis deepens. 2017 December 21; Available from: https://www.theguardian.com/us-news/2017/dec/21/us-life-expectancy-down-for-second-year-in-a-row-amid-opioid-crisis.
  5. Chou R, Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis. Ann Intern Med, 2015. 163(5): p. 373-81.
  6. Epstein N, The risks of epidural and transforaminal steroid injections in the Spine: Commentary and a comprehensive review of the literature. Surg Neurol Int, 2013. 4(Suppl 2): p. S74-93.
  7. Peterson CK, Symptomatic, Magnetic Resonance Imaging-Confirmed Cervical Disk Herniation Patients: A Comparative-Effectiveness Prospective Observational Study of 2 Age- and Sex-Matched Cohorts Treated With Either Imaging-Guided Indirect Cervical Nerve Root Injections or Spinal Manipulative Therapy. J Manipulative Physiol Ther, 2016. 39(3): p. 210-7.
  8. Chou R, Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine, 2009. 34(10): p. 1094-109.
  9. Maghout J, e.e., Lumbar fusion outcomes in Washington State workers’ compensation. Spine (Phila Pa 1976), 2006. 31(23): p. 2715-23.

CF 012: Proven Means To Treat Neck Pain

Proven Means To Treat Neck Pain

In today’s podcast, we are going to talk about research on how to treat neck pain but hopefully in a fun way. We like to have fun on the Chiropractic Forward podcast. Let’s face it, research can be a bit boring so why not try to have some fun with it?

Before we get started, I want to draw your attention to the reviews over at iTunes. If you would be kind enough to leave us a great review, that tells iTunes that people are finding value in what we are sharing and it will help us grow this podcast. We sure would appreciate you!

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, and research and how those things all fit into a comprehensive approach for treating different conditions. Thank you for taking time out of your day to give us a listen. I know your time is valuable and I will always try hard to fill our time with valuable content.

In the words of Chris Berman, you have back back back backed into Episode #12 and this week we’re going to have more fun than having your teenage son spank you in video games that you’ve always beat him at. Yes, this recently happened to yours truly. Not only that but he did it with a pistol and I’m asham   ed. Call of Duty was my safe space y’all…..

So, I’ll just bury myself into my work, stuff it deep down inside to explode at a later date.

Now, If you have spent any significant amount of time with our videos, podcasts, or blogs, you are probably aware that there is an excess of research regarding chiropractic’s effectiveness in patients suffering from low back pain.

Although there are some excellent research papers having to do with chiropractic and neck pain, I would argue that it demands more attention. Without question. The first reason being that neck pain is as important or more so than low back pain. In the paper we will be discussing this week, they cite research suggesting that neck pain is responsible for up to 25% of the patients seen in outpatient orthopedic practices and 50% of the general population will have neck pain at some point in their lives.

The second reason I believe neck pain demands more attention from our industry is that we have been unfairly labeled as the profession out there in the world causing strokes every day. There needs to be a clear, factual representation of the risk vs. reward ratio and, if there is a small body of evidence, our case doesn’t stand up quite as strongly.

To be more clear, there is an abundance of evidence that Chiropractic is not linked to strokes any more than going to the primary practitioner. However, there is scant evidence of Chiropractic’s effectiveness to treat neck pain WHEM COMPRAED to the research available to treat low back pain.

This does not mean there isn’t great research in our favor on hwo to treat neck pain. That is not what I’m saying at all. It just means we have not documented it through research in the amounts that we have for the low back pain and I would like to see more. If I were a researcher myself, it is the condition I would be targeting without question.

Now, with that being said, this week’s paper is titled “The Immediate Effects of Upper Thoracic Translatoric Spinal Manipulation on Cervical Pain and Range of Motion: A Randomized Clinical Trial” published in the Journal of Manual Manipulative Therapeutics in 2008 that shows the effectiveness of spinal manipulative therapy. Here’s the catch, it was performed by physical therapists, not chiropractors. It was done by John Krauss, PT, PhD, OCS, FAAOMPT, et. al. Look at all of those letters.

At this point, I would like to diverge from the original path for a few moments. If chiropractors are unaware, along with research validating the chiropractic adjustment to treat neck pain, low back pain, and other maladies comes more competition for the service. Physical therapists were restricted to muscles and exercise essentially. Now, they are adjusting. This is going to become a turf war between chiropractors doing what we have always done and physical therapists adopting our treatments as their own. Of course, physical therapists can’t call what they do “chiropractic adjustments” so they have changed the term to “translatoric spinal manipulation.” It’s irritating to the chiropractic profession but it is a fact the profession will be facing more and more in the years to come so be prepared for it. It is particularly irritating when you consider that physical therapists have been part of the medical machine that have torn down the chiropractic profession for generations prior to adopting its techniques as their own.

Now, back to the research paper.

Why They Did It

The authors of the paper wanted to determine the effectiveness of thoracic (upper back) adjustments to treat neck pain and neck range of motion.

How They Did It

  • The active range of motion of the neck in each subject was measured before and after the manipulation. The term “active range of motion” means the patient turned their neck as far as possible in rotation both ways without the assistance of the researcher.
  • The range of motion was measured with a cervical inclinometer.
  • The patient’s neck pain was measured prior to and after treatment with the Faces Pain Scale. A quick trip to Wikipedia tells us that the Wong-Baker Faces Pain Rating Scale is a pain scale that was developed by Donna Wong and Connie Baker. The scale shows a series of faces ranging from a happy face at 0 which represents “no hurt” to a crying face at 10 which represents “hurts worst.”
  • The study included 32 patients having pain in the cervical region and limited range of motion.
  • 22 of these were randomly split into an experimental group while the other ten were randomly placed into a control group.
  • The evaluator measuring the pre- and post-manipulation outcomes was a blinded evaluator to reduce risk of bias.
  • The experimental (treatment) group received the manipulation treatment to the areas of the upper back region that had been determined to be hypomobile. In simpler terms, they delivered the adjustment to the areas of the upper back that were stiff or not moving like they should.
  • The control group had no treatment.
  • Paired t-tests were used to determine the changes within the group for cervical rotation and pain. A paired t-test is used to compare two population means where you have two samples in which observations in one sample can be paired with observations in the other sample.
  • A 2-way repeated-measure ANOVA was used to analyze between-group differences in cervical rotation and pain. A two-way repeated measures ANOVA is often used in studies where you have measured a dependent variable over two or more time points, or when subjects have undergone two or more conditions. The primary purpose of a two-way repeated measures ANOVA is to understand if there is an interaction between these two factors on the dependent variable.

What They Found

  • Significant changes were found for neck rotation within the group as well as between the groups.
  • The translatoric spinal manipulative group showed more range of motion in right rotation as well as in left rotation.
  • The levels of pain the subjects experienced after the manipulation were significantly reduced.

Wrap It Up

The authors of the paper concluded by saying, “This study supports the hypothesis that spinal manipulation applied to the upper thoracic spine (T1-T4 motion segments) significantly increases cervical rotation ROM and may reduce cervical pain at end range rotation for patients experiencing pain during bilateral cervical rotation.”

Did you know that 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! What better way to treat neck pain?

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. As this podcast builds, so will the website as we add more content, educational products, and a little further down the road, webinars, seminars, and speaking dates as they get added.

We cannot wait to connect again with you next week. From Creek Stone here in Amarillo, TX, home of the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.

Source Material

Krauss J, et. al., “The Immediate Effects of Upper Thoracic Translatoric Spinal Manipulation on Cervical Pain and Range of Motion: A Randomized Clinical Trial.” J Man Manip Ther. 2008; 16(2): 93–99.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2565124/

 

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

This week, we are talking about acute and non-acute low back pain. What are current healthcare guidelines? Why does it matter to chiropractic patients and non-chiropractic patients and are those in the medical field getting (and implementing) the information?

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, and research and how those things all fit into a comprehensive approach for treating different conditions. Thank you for taking time out of your day to give us a listen. I know your time is valuable and I will always try hard to fill our time with valuable content.

We’re going to have more fun this week than stepping on a nail. Which I have done.

Before we dive in, it was so nice we had to do it twice. What am I talking about? I’m talking about bringing on Tyce. Tyce Hergert that is down in Southlake, TX. Owner and operator of Chiropractic Care Center of Southlake as well as Southlake Physical Medicine where he oversees an integrated practice. Dr. Hergert is also the immediate former President of the Texas Chiropractic Association so now he can say what he really thinks. He was the big cheese, the illustrious potentate of chiropractic in Texas.

Although it’s highly unlikely, should you enjoy what Tyce shares with us here today, go and listen to his other guest spot which can be found in Episode #6. You can find episode #6 at the following link:

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

Welcome to the show Tyce. Nice to have you back.

I would say that a chiropractor would be completely oblivious to not understand that Chiropractic is considered to be on the fringe of healthcare by many to most in the medical field. It’s just a fact and chiropractors deal with this daily. We Chiropractors are used to feeling like the black sheep of the healthcare family off in a corner keeping all to ourselves.

In other articles, podcasts, and videos of mine, you’ll notice I have covered the Wilk vs. AMA case. I’ve covered the Doctored film by Jeff Hayes spotlighting mistreatment of chiropractors. I’ve also covered current attacks on Texas Chiropractors by the Texas Medical Association. It is all very well-documented at this point.

Chiropractic is currently undergoing an amazing renaissance. This is due to a couple of key factors. The first being the need to develop non-pharmacological treatment recommendations in the midst of a national opioid addiction crisis. A crisis that has killed thousands and thousands in the last several years. The second reason being the body of high-quality research that is consistently coming to light almost every month showing the effectiveness of Chiropractic and evidence-based chiropractors.

Do you feel this renaissance, Tyce, or is it just me living inside my head?

With all of the new information and new healthcare laws emerging, the questions going forward SHOULD be, “Is the medical field and is the insurance industry listening and implementing?” We shall see. So far, the answer is, “Absolutely not.” In fact, it’s almost defiant.

Is that an accurate statement Tyce? You’re my checks and balance guy on everything.

Let’s begin with the most glaring denial of Federal Law by the insurance companies right now. It has to do with Section 2706 of the Patient Protection and Affordable Care Act. Also commonly known as “Obamacare.” Section 2706 of the PPACA is entitled the nondiscrimination In Health Care section of the Federal Law and is intended to keep insurance companies and health plans from keeping chiropractors and the services they provide out of the system.

It reads as follows, “A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.”

On the American Chiropractic Association’s FAQ site for 2706, they state, “It is important to understand that Section 2706 and its assurance of non-discrimination in terms of participation and coverage requires that doctors of chiropractic not be discriminated against in the provision of any “essential benefit” that is within their scope of practice.”

Here’s the rub on 2706: part of its purpose is to reimburse chiropractors performing the same services under their scope and license at the same level financially as any other profession that provides that service.

For instance, under the PPACA Section 2706 Federal Law, chiropractors are to be paid the exact same for an 99203 exam code as a doctor of medicine or osteopathy is paid.

Would you agree with that assessment Dr. Hergert? Is this your understanding of the law?

Plain and simple. This is not happening. With so many chiropractors now integrating their practices with medical directors, physician assistants, nurse practitioners, and physical therapists like Dr. Hergert has in Southlake, it’s painfully clear that doctors of chiropractic are being discriminated against when it comes to reimbursements for the same codes performed.

In fact, chiropractors are integrating with these other professions just so that they can finally GET the reimbursements that the other practitioners are allowed! It is madness and clearly violates Section 2706 of PPACA.

Dr. Hergert, you are a great resource here since you’re in the middle of the two professions. What is your experience on this?
Tyce: The carriers will come right out and tell you they don’t think they have to play by this rule.

Also, there is violation of the law if an insurer does something such as applying caps on specific services provided by one healthcare provider whereas the cap does not apply to another type of provider. It is my understanding that United Healthcare has moved to a $65 visit cap on chiropractic care here in Texas.

Am I misinformed here Tyce? Does United Healthcare only put caps on Chiropractors or are they capping services with all providers?
Tyce: That gets very frustrating for those patients with a $50-70 copay.

It is the American Chiropractic Association’s opinion that a violation exists if the insurer or plan denies specific forms of care that is otherwise covered if it is a chiropractor providing the service and it is within their scope and licensing. I would suggest that a medical doctor probably gets services such as non-surgical decompression covered under insurance but chiropractors are routinely denied coverage.

Are there any better examples of this disparity, Tyce, since I don’t know any medical doctors that have their patients perform decompression?

There is also a possible violation when doctors of Chiropractic are denied inclusion into a plan or group purely based on the profession. For example, it is my understanding that FirstCare won’t cover Chiropractic. Is that a violation? I suppose I could offer an opinion if I were a lawyer. I’m not sure why exactly other providers are allowed coverage while chiropractors are left out in the cold. Here is a great example though that I’m aware of here locally. there is a local insurance network that will remained un-named that charges $200 per year for chiropractors to be included for coverage however, medical professionals pay nothing to be included. Could that be a violation of the nondiscrimination law? I would say it smells a little fishy.

In my opinion, Federal Law is being violated all over the place in regards to Section 2706 of PPACA. I’m not sure how it can be perceived any other way.

What can you add here Tyce that I may have left out?
Tyce: What this means for patients is you can’t use that shiny new insurance policy that is costing you more than a $250k house payment would. You have to fork over the more money to pay for your chiropractic care.

Moving on from Section 2706…..I love talking about the New Recommendations For Acute and Chronic Low Back Pain.
It is becoming more and more aggravating that we chiropractors are not seeing a flood of acute and chronic low back pain patients. If you read my articles, watch my videos, or listen to my podcast with any regularity, you have no doubt been informed several times over of these new recommendations which, at this point aren’t that new anymore. They have been around for about a year now.

It is my opinion that no long-held beliefs or protocols will change if new information isn’t continually pounded and yelled about from the top of the roofs with megaphones. In marketing, experts have said that it takes a target 7 times of being exposed to information before it is finally received and, hopefully, acted upon.

I know that the medical field has NOT been exposed to this information at least 7 times because of two factors:
1. I have spoken to several medical practitioners here locally and not a single one of them has heard of or were aware of these new recommendations.
2. I am not seeing an incredible, overwhelming influx of acute and chronic low back pain new patients coming through my doors as a result of medical referrals.

Tyce, are you seeing an incredible influx of new low back patients from the medical field these days?

Is this willful disregard for the changing recommendations and a “clinging on” to old dogmatic beliefs passed down from the AMA years ago? I think some of it most certainly is.

Is it that a few bad seeds in the Chiropractic profession are giving the rest of us a bad image? I would say some of it most certainly is.

What I think it is mostly based on, however, is the fact that medical professionals are busy, they’re stressed, and many times over-worked and they simply don’t always have the time or opportunity to stay completely up on every new recommendation or updated protocol.

What do you think about it, Tyce?
Tyce: “You’re not down with, what you’re not up on.” Most don’t know. They didn’t get this info in school, and the pharma reps aren’t out spreading the good news.

With that being said, let’s be clear; the issues of low back pain, its economic impact, and the national opioid epidemic crisis in America combine to make these new recommendations that much more important.

Let’s start with the American College of Physicians. Remember, the American College of Physicians was proven in the Wilk vs. AMA case to have played a part in collaborating with the AMA in an attempt to rid the Earth of Chiropractic. I think that’s important to note as we go through the information because the ACP is historically known as a detractor or the chiropractic profession to put it mildly.

In response to the opioid epidemic gripping the nation currently, the American College of Physicians developed new recommendations for treating acute and chronic low back pain.

Why They Did It
• The American College of Physicians developed this guideline in order to provide updated recommendations on treatment of low back pain.
• With these recommendations, the ACP hoped to influence clinicians AND patients to make the correct decision for care in acute, subacute, or chronic low back pain conditions.

How They Did It
• They based their recommendations on a systematic review of randomized controlled trials and other systematic reviews.
• The research they reviewed included those papers available through April of 2015.
• The research included only those on noninvasive pharmacologic and nonpharmacologic treatments.

What They Found
• Recommendation #1: patients with subacute or acute low back pain should seek nonpharmacologic treatments such as Chiropractic, Massage, Acupuncture, and superficial heat BEFORE resorting to non-steroidal anti-inflammatories such as Ibuprofen, Tylenol, Aleve, etc… (Graded as a strong recommendation)
• Recommendation #2: patients with chronic low back pain should seek nonpharmacologic treatments such as Chiropractic, Exercise/Rehabilitation, Acupuncture, & Cold Laser Therapy BEFORE resorting to non-steroidal anti-inflammatories such as Ibuprofen, Tylenol, Aleve, etc… (Graded as a strong recommendation)
• Recommendation #3: In patients with chronic low back pain that have had no relief from nonpharmacological means, the first line of treatment would consist of NSAIDs like Aleve, Tylenol, Ibuprofen, etc.. As a second-line treatment, the clinician may consider tramadol or duloxetine. Opioids would be a last option and only if all other treatments have been exhausted and failed and even then with lengthy discussion with the patient in regards to the risks and benefits of using opioids. (Graded as weak recommendation)

Let’s recap: in February of 2017, the American College of Physicians, historically a Chiropractic profession detractor and attacker, now recommends Chiropractic as a first-line treatment for acute and chronic low back pain.

Dr. Hergert, does that make you feel warm and fuzzy inside because it does me?

Next, let us discuss the American Medical Association. If you thought the American College of Physicians was guilty of Chiropractic-hating, the American Medical Association is, or was, “Pablo Escobar” or the “El Chapo” of the attacks on the Chiropractic profession. The “El Jefe” of the Chiropractic haters, and the group that not only sat in the driver’s seat but also OWNED the entire truck of destruction back before Wilk vs. AMA came along. I believe I have been watching too much Netflix.

As a side note, I have realized that I have a wife, a daughter, and an all female staff at my office and…..I’m not the El Chapo or El Jefe of really anything. My son and I just walk around following orders pretty much. Tyce, you’re married with two daughters right?

On April 11, 2017, the Journal of the American Medical Association published a study on their website titled “Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain Systematic Review and Meta-analysis,” authored by Neil Page, MD et. al. In the format of this research paper, they refer to chiropractic treatment as spinal manipulative treatment or SMT. But, because spinal manipulative therapy is what we chiropractors do the most and what we are most identified with, I’m replacing the term “SMT” with “chiropractic adjustment.”

Is that fair, Tyce? I think it’s fair.

Why They Did It
Considering that spinal manipulation, or the chiropractic adjustment, is a treatment option for acute low back pain, and that acute low back pain is one of the most common reasons for visits to the doctor’s office, the authors wanted to systematically review the studies that have been done in the past dealing with the effectiveness as well as the harms of chiropractic adjustments in the treatment of acute low back pain.

How They Did It
• The researchers used searches of MEDLINE, Cochrane Database of Systematic Reviews, EMBASE, and Current Nursing and Allied Health Literature.
• The search spanned 6 years from January 2011 through February 2017 for randomized controlled trials of adults with low back pain comparing spinal manipulative therapy with no treatment or with alternative treatments.
• The accepted papers also had to measure pain or functional outcomes for up to 6 weeks.
• The data extraction was done in duplicate.
• The quality of the study was assessed through use of the Cochrane Back and Neck Risk of Bias tool.
• Finally, the evidence was assessed using the GRADE criteria which stands for Grading of Recommendations Assessment, Development, and Evaluation.
• 26 eligible randomized controlled trials were identified and accepted

What They Found
• 15 of the RCTs, totaling 1699 patients, showed moderate-quality evidence that chiropractic adjustments had a statistically significant association with improvements in PAIN.
• 12 of the RCTs, totaling 1381 patients, showed moderate-quality evidence that chiropractic adjustments have a statistically significant association with improvements in FUNCTION.
• NO RCTs reported any serious harms or adverse event as a result of undergoing chiropractic adjustments.
• There were only minor events reported like some increased pain, muscle stiffness, and headache in roughly 50%-67% of those treated in the large case series. I would be interested to hear more about this statement by the authors. That is not what we commonly see in our practice. Sometimes, if the patient is new and is not accustomed to chiropractic adjustments, they may experience some soreness or stiffness the next day which is to be expected following a change in the body.
• I want to be as thorough as I can here….Tyce, do you see 50%-67% minor harms in your daily practice?

Wrap It Up
In true AMA fashion, instead of just coming out and saying, “Chiropractic adjustments showed moderate quality evidence for effectiveness in pain as well as in function,” the authors instead stated in conclusion, “Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. However, heterogeneity in study results was large.” Heterogeneity is defined as, “The quality or state of being diverse in character or content.” In my opinion, this is to give themselves and “out” by implying there was not enough focus to the RCTs to truly state their findings as fact.

Nonetheless, when the AMA comes even remotely close to endorsing anything having to do with Chiropractic, I’ll take it. And so should those in the medical field that commonly come in contact with those seeking help for their acute and chronic low back pain.

So…….We Should Be All Set For Success Now Right? Maybe they’re about to open up a chiropractic low back pain wing of the hospital, right?

That is what you’ think but there is new information from the White House that this simply is not the case despite the obvious ramifications. You can find the link in the show notes but on page 57 of The President’s Commission On Combating Drug Addiction and The Opioid Crisis report, the authors say, “A key contributor to the opioid epidemic has been the excess prescribing of opioids for common pain complaints and for postsurgical pain. Although in some conditions, behavioral programs, acupuncture, chiropractic, surgery, as well as FDA-approved multimodal pain strategies have been proven to reduce the use of opioids, while providing effective pain management, current CMS reimbursement policies, as well as health insurance providers and other payers, create barriers to the adoption of these strategies.” This is straight from the White House.

At the bottom of page 57, you will also see that it says, “The Commission recommends CMS review and modify rate-setting policies that discourage the use of non-opioid treatments for pain, such as certain bundled payments that make alternative treatment options cost prohibitive for hospitals and doctors, particularly those options for treating immediate post-surgical pain.”

What say you Tyce?
Tyce: You mean like a specialist copay for chiro care and a lower copay for primary care? Or covering surgery 100% and NOT covering non-surgical means.

Essentially, the United States Government is admitting there is professional discrimination at the highest levels…..hello Medicare and Health Insurance plans….I’m talking to you….this discrimination creates barriers to doing the smart thing.

The smart thing is seeing a chiropractor for your back pain. The “Big Guys” (AKA: American College of Physicians and the American Medical Association) recommend it and the government says policies are in place to prevent patients from following those recommendations.

In addition, policies that discriminate against chiropractic or chiropractors run in violation of Section 2706 of PPACA. It comes full circle.
I know you have something good to say here Tyce…
Tyce: The beautiful thing we get to see in our office, since we have both medicine and chiropractic working together, is the end of the story…people getting off the mind altering drugs, healing, and getting their lives back. All we do is follow these simple guidelines.

I have a question to pose to the entire Chiropractic profession: How in the heck do we deal with this?

It has to be through either the legislature at the state and federal levels or it has to be through the legal system. A guarantee I feel comfortable making is that the insurance companies won’t begin enforcing it on their own.

Mobilization and unification of the Chiropractic profession is probably where it starts.

Some steps toward that end include:
• Join or get involved with your state association. They’re the only ones effectively fighting for you and your rights on the state level.
• Join or get involved with your national association. They’re the only ones effectively fighting for you and your rights on the national level.
• If possible, build relationships with your state and national legislators.
• Donate to all of the above in the largest amounts you are comfortable with.
• Tell your friends and your colleagues about what is going on and help them get involved if they’re so inclined.
• Follow the news of your industry closely and stay knowledgeable about your profession. Both the good AND the bad.

Tyce, you have served for years and you’re still serving your profession. What you got on this?
Tyce: “Be part of the solution. You don’t have to dedicate 24/7 to the crusade….but you could do a little more. Right?”

A Chiropractic profession that is unified and playing offense instead of defense is powerful and is one of the worst nightmares of some folks I know out there in the world. Personally, as a side note, I like to see people like that squirm just a little don’t you? It just feels good. Makes what’s left of my hair stand up.

So won’t you consider helping if you haven’t before? If you don’t know where to start, email me at dr.williams@chiropracticforward.com and I will help you get on your way.

Tyce, I want to thank you for taking the time to come on the podcast and share your genius with us. With our history, I’m sure that Chiropractic Forward podcast listeners can count on your being a guest many many times. And, the next time will be the third time and I can say something like, “It was so nice, we had to do it thrice, with Tyce….or something stupid but entertaining like that.” Thanks for joining us today.

When Chiropractic is at its best, you cannot beat the risk vs reward ratio.

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. As this podcast builds, so will the website as we add more content, educational products, and a little further down the road, webinars, seminars, and speaking dates as they get added.

 

In the meantime, here are some of our recent podcasts that may be of interest:

CF 012: Proven Means To Treat Neck Pain

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

CF 010: Surprise Unique Information Shows Chiropractic May Work On The Brain Too

 

 

 

 

We cannot wait to connect again with you next week. From Creek Stone here in Amarillo, TX, home of the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.

References and Source Material
1. https://www.amarillochiropractor.com/startling-medical-professional-attacks-chiropractic/
2. https://www.amarillochiropractor.com/healthcare-in-texas-the-battle-against-a-monopoly-a-true-story-about-david-goliath-3/
3. https://www.whitehouse.gov/sites/whitehouse.gov/files/images/The%20Underestimated%20Cost%20of%20the%20Opioid%20Crisis.pdf
4. https://www.acatoday.org/Portals/60/Docs/Advocacy%20and%20Reimbursement/2706/2706-FAQs.pdf?ver=2015-12-23-125425-503
5. https://annals.org/aim/fullarticle/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice
6. https://jamanetwork.com/journals/jama/article-abstract/2616395?widget=personalizedcontent&previousarticle=2616379
7. https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Final_Report_Draft_11-3-2017.pdf