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Evidence Based Chiropractic

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 a possible violation of Federal Law when Chiropractors 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 of 2706?

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

 

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

Surprise Unique Information Shows Chiropractic May Work On The Brain Too

Welcome to the Chiropractic Forward podcast. I am your host Dr. Jeff Williams and we’re exctied to have you along for the ride. In today’s show, we’re going to talk about how chiropractic may work in the brain itself rather than how it affects just the musculoskeletal system.  We include some intriguing stuff from New Zealand that will make you think, hmmmm, that’s interesting, and we’ll have a little fun along the way

Bring on the bumper music

Again, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast This is 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.

You have bobbed and weaved your way into episode #9 of the Chiropractic Forward podcast.

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!

For anyone that has paid any amount of attention to chiropractic, it’s clear that chiropractic treats muscles, bones, and the biomechanics overall. But what some people don’t commonly consider is the fact that chiropractic is effective when treating the nerves that make it all work together.

For instance, what do you think about when you think of chiropractic? More than likely, you think about back pain, neck pain, athletes, and headaches and migraines. It is unlikely that phrases like “cortical drive” or “movement related cortical potential” comes to mind.

According to the author of the paper we’re going to be talking about today, “Scientists use to believe spinal manipulation was a biomechanical treatment option for spinal pain conditions. However, the growing basic science evidence suggests there may be more of a neurophysiological effect following spinal manipulation than previously realized.”

When we begin to talk about the brain, physiology, neurology, and neurological processes, you can get into some highly complicated terms and ideas. I’m going to do everything I can to put it into terms that anyone and everyone can easily process without having a year of neurology classes.

And let’s be crystal clear, I’m not a neurologist or a chiropractic neurology diplomate either with tons of extra education on the brain and nervous system specifically. Many of these terms go above MOST of our heads and MOST of the heads in the medical field as well. That is just a matter of fact. But that doesn’t mean we can’t read, comprehend, and relay the overall pertinent information, which is what we are doing here.

Basically, “What’s the big idea?” That’s what I’m trying to bring to you here without making your eyes glaze over and making you fall into a deep state of hibernation.

Now, with all of that being said, there is some potentially fascinating research coming out of New Zealand we’re going to be talking about here having to do with the dact that chiropractic may work on the brain itself. We are going to talk about two papers that have been done by roughly the same group at the Centre for Chiropractic Research at the New Zealand College of Chiropractic in Auckland New Zealand. Just the name “Auckland” makes me want to go visit. I hear New Zealand is fantastic and the Lord Of The Rings was filmed there so you know it’s stunning. If an epic is filmed in your country, then you know it must be truly epic.

Here is a bit of a disclaimer to start off with. I have seen some dispute from other evidence-based chiropractors online of a different study from Dr. Haavick so I want you to understand that this sort of research cannot be accepted as the gospel. Not just yet anyway. I’d say it’s promising to an extent but there needs to be A LOT more exploration here before we hold it up as the gospel truth. Today’s podcast is more of a, “Hey, look what they’re studying, look what their findings are, and look what the potential for this sort of study could be.” rather than drawing any firm conclusions at this time.

The first study is titled, “Impact of Spinal Manipulation on Cortical Drive to Upper and lower Limb Muscles,” and was published in the journal ‘Brain Sciences’ in December of 2016(1).

Why They Did It

The researcher wanted to find out whether chiropractic care changes motor control. Motor control is basically the messages your brain sends your body in order make it move. Bending your arm, writing on a piece of paper, kicking your leg, or walking are examples of motor control. They assessed whether chiropractic care affected motor control for the arms as well as the legs and tried to find out if the changes may partly happen in the cortical part of the brain, which   is the part that issues motor commands. Although the researchers couldn’t completely rule out the idea that chiropractic adjustments can help motor function at the actual spinal level manipulated, the theory was that some of the changes must happen in the brain itself.  Basically, do chiropractors change how the brain controls muscles(2)? 

How They Did It

  • They conducted two experiments to test their theory. One for the arm and one for the leg.
  • In the first, transcranial magnetic stimulation input-output curves for an upper limb muscle known as the abductor pollicis brevis were recorded.
  • They also recorded F-waves before and after spinal manipulation or the control intervention for the control group on the same subjects on two different days.
  • The researchers did the same in a separate experiment for the lower limb using the tibialis anterior muscle.

What They Found

Before getting into what they found, let’s define the term motor evoked potential.”  According to Medscape, the definition is, “Single- or repetitive-pulse stimulation of the brain causes the spinal cord and peripheral muscles to produce neuroelectrical signals known as motor evoked potentia ls. Clinical uses of motor evoked potential include as a tool for the diagnosis and evaluation of multiple sclerosis and as a prognostic indicator for stroke motor recovery(3).”

With that knowledge the following was noted:

  • Spinal manipulation caused an increase in maximum motor evoked potential in both muscles tested.

Wrap It Up

In a quote from the research abstract, the authors conclude, “Spinal manipulation may therefore be indicated for the patients who have lost tonus of their muscle and or are recovering from muscle degrading dysfunctions such as stroke or orthopaedic operations. These results may also be of interest to sports performers. We suggest these findings should be followed up in the relevant populations.”

In another quote from the lead author, she said, “This research has big implications,says an enthusiastic Heidi Haavik. “It is possible that patients who have lost muscle tonus and/or are recovering from muscle degrading dysfunctions such as stroke or orthopaedic operations could also benefit from chiropractic care. These findings are also very relevant to sports performers (although this too must also be followed up with more research), because it indicates that chiropractic care may help their brains to more efficiently produce greater outputs. So all in all a very exciting study!”

Guess what? They took their own advice in their conclusion and followed up this paper with another similar paper focused more specifically on athletic performance. Here’s the last paper we will discuss called, “The Effects of a Single Session of Spinal Manipulation on Strength and Cortical Drive in Athletes” published in the European Journal of Applied Physiology in January of 2018. Brand new information(5).

Why The Did It

Of course, they did it because they suggested the need for the paper in the conclusion of the previous study but more specifically, they did it because they wanted to test if a single chiropractic adjustment could change things in the muscles of the lower leg for an elite Taekwondo athlete.

How They Did It

  • The muscle measured was the soleus muscle, which lies just under what is commonly known as the calf muscle or the gastrocnemius.
  • Soleus evoked V-waves, H-reflex and maximum voluntary contraction of the plantar flexors were recorded from 11 elite Taekwondo athletes
  • A randomized controlled crossover design was utilized.
  • Treatments used consisted of either spinal manipulation in the treatment group or passive movement control in the control group.
  • Outcome measurements were noted prior to treatment, immediately after treatment, 30 minutes after treatment, and an hour after treatment.

What They Found

  • Spinal manipulation was responsible for increasing each factor measured when compared to the control group.
  • The differences were considered significant through each time interval.

Wrap It Up

The authors are quoted in the conclusion of the paper as saying, “A single session of spinal manipulation increased muscle strength and corticospinal excitability to ankle plantar flexor muscles in elite Taekwondo athletes. The increased maximum voluntary contraction force lasted for 30 minutes and the corticospinal excitability increase persisted for at least 60 minutes.“

As I said in the beginning, I feel that this sort of research is really just beginning and consider it in its infancy but I also think that the results are enough to demand more exploration into this area of how chiropractic can affect neurology.

There is actually a court case in Texas this very minute. The appeals argument starts on February 28th down in Austin. The Texas Medical Association is attacking Texas Chiropractors’ rights to treat the “neuromusculoskeletal” system. They argue that chiropractors do not (and cannot) treat anything further than the “musculoskeletal”system. Certainly, NOT the “neuromusculoskeletal” system.

Regardless of the opinions held by those in the leadership of the Texas Medical Association and their legal team, both of these papers (and many other by the way), in my opinion, render their arguments ignorant, nit-picky, archaic, and obsolete. It’s not a question of what research is out there. It’s a question of if they can understand it or will let their pride go. My guess is, “No.” They have to prevent Chiropractic from moving into their territory at any and all costs. It is NOT about patient safety. It never has been and it never will be. It’s purely based on power and the threat of losing it.

What’s your opinion. We would love to hear it.

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 or 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 and do it 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, of course now, we see that chiropractic may work on the brain too!

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.

Sources:

  1. Haavik H, Niazi IK, Jochumsen M, Sherwin D, Flavel S, Türker KS. Impact of Spinal Manipulation on Cortical Drive to Upper and Lower Limb Muscles. Brain Sci. 2016 Dec 23;7(1).https://chiropracticscience.com/increase-cortical-drive-following-spinal-manipulation/

2) https://spinalresearch.com.au/new-study-reveals-impact-spinal-manipulation-cortical-drive-limb-muscles/

3) https://emedicine.medscape.com/article/1139085-overview

4) https://www.researchgate.net/publication/322199907_The_Effects_of_a_Single_Session_of_Spinal_Manipulation_on_Strength_and_Cortical_Drive_in_Athletes

5) Christiansen L, et. al. (2018). The Effects of a Single Session of Spinal Manipulation on Strength and Cortical Drive in Athletes. European Journal of Applied Physiology. . 10.1007/s00421-018-3799-x/fulltext.html.

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

Today’s episode is all about chronic low back pain and some great, brand new research. By now, as I’ve said in the past, even traditional Chiropractor-hating, torch-wielding, quasi-scholastic chiropractic detractors are admitting that, yes, Chiropractic is indeed helpful for low back pain.

If you love what you hear, be sure to check out www.chiropracticforward.com. As the podcast builds, so too will the website content, educational products, webinars, seminars, and speaking dates as they get added.

For now though, it’s time for bumper music!

We will dive into the research in a few minutes but first, I have to introduce my guest this week. His name is Dr. Craig Benton. Dr. Benton is the owner/operator of Benton Chiropractic down in Lampassas, Texas but that’s not where the intro stops. Dr. Benton is the chair of Scientific Affairs for the Texas Chiropractic Association. He is where I have found a healthy percentage of the material that I have covered over the years for my blog, my YouTube videos, and now for the Chiropractic Forward podcast. Dr. Benton has been unknowingly instrumental in keeping me in business and making my life easier.

Welcome to the show Dr. Benton, how is life in Lampassas this week? My first question today is, have you been playing any guitar lately?

Dr. Benton and I are both in active practice. In fact, there’s a chance we may both have a patient show up at any time. That’s how actively we are practicing. I think that’s incredibly important to note because, so many times, you hear podcasts and attend seminars where the guys and gals speaking don’t really know a thing about actively practicing for 20 plus years. I’ve always felt that experience matters. Even when I was young and green. I was well-aware that I didn’t know it all and I’m even more aware of that today than ever.

So Dr. Benton, I’m looking forward to hearing your opinions and insight today.

Since the podcast today is about chronic pain, I think we should begin with a definition of what Chronic really is. When we define “chronic” in the context of neuromusculoskeletal complaints, we define it as being a complaint that is greater than 12 weeks in duration. Right at 3 months. Some patients will come into the office having had a condition for 15-20 years. I tell them that they are more than a little stubborn to have put up with something for so long.

It is common sense that a condition that is chronic will be more difficult to treat. Also, most chronic conditions can be traced back to a biomechanical, neuromusculoskeletal origin. One of my favorite quotes is from Dr. Lee Green, Professor of Family Medicine at the University of Michigan. He said, “Neck pain is a mechanical problem, and it makes sense that mechanical treatment works better than a chemical one.” Although Dr. Green is referring to neck pain in this instance, “low back pain” can easily be substituted. What he says could not make more sense. It’s an easy and very concise way to understand why Chiropractic, manipulation, mobilization is so incredibly effective above and beyond anything else for this sort or issue, including medication.

Do you have a quote or quotes that you love sharing that make sense to you and that help you boil down what it is we chiropractors are doing to help our patients?

I have overhead medical doctors (more than once) talking about having back pain and just injecting themselves with something to try to get over it. If they asked me, I’d tell them that they’re just covering up an underlying trigger or cause and ignoring it is to their detriment.

A good metaphor I came across for using medication for neuromusculoskeletal complaints is that it’s like unplugging a smoke alarm because you don’t like the noise. But, the fire is still slowly growing. What have they done to treat anything in a responsible and effective way? Nothing at all. We tend to live in a society that wants a pill for this and a potion for that so they can get over it and get on with life. But it doesn’t work that way.

Dr. Benton, has this been your experience as well?

Dr. Benton, don’t you treat soldiers through the VA program? Can you tell us all a little bit about that?

Let’s go over some low back pain statistics just we can try to stress the importance of what we’re talking about here. Dr. Benton, please feel free to jump in with anything you’d like to add:

  • Low back pain is the single leading cause of disability worldwide.
  • 8 out of every ten people will experience back pain. I will admit that I have never met anyone in 45 years of life on this Earth that fit’s into the 20% that apparently never suffers from any low back pain. Dr. Benton….have you ever met anyone that has never had back pain? Is it just me?
  • Back pain is the second most common reason for visits to the doctor’s office right behind upper-respiratory infections.
  • With such gains and leaps in the medical industry as far as treatment goes, low back pain is stubbornly on the rise.
  • More than half of Americans who experience low back pain spend the majority of the work day sitting. 54% to be exact. It’s good to be a chiropractor I guess. Our patients keep us up and moving most of the day.
  • Dr. Benton, did you know that….now…an equal number of patients seek help with a chiropractor first as seek help with a medical practitioner first for back pain? That’s new information to me that I found interesting.
  • Back pain in general costs $100 billion dollars every year when you factor in lost wages, productivity as well as legal and insurance overheads.

Now that we all know more about low back pain, let’s go through some things that may put you at greater risk of suffering from the condition. Dr. Benton, with your experience on the research, stop me if you have anything to add to any of these:

  • Age: as the spine and supporting structures begin to age and decline, the rate of low back pain will understandably increase.
  • Fitness Level: physically active people do not suffer low back pain to at the rate inactive people suffer. A healthy exercise and core building protocol can help reduce symptoms or instances of low back pain.
  • Weight Gain: Being overweight or obese and gaining weight quickly places increased strain on the low back.
  • Pregnancy: This one goes without saying. Pelvic changes and weight gain both contribute.
  • Genetics: Some forms of arthritis or other systemic conditions are genetic in nature
  • Work: Jobs that include heavy labor and or twisting or expose people to vibration consistently can be problematic. Jobs that require long periods of sitting in a chair can be equally problematic.
  • Mental health factors: Many people are able to deal with chronic pain but anxiety and depression are conditions that can cause a person to focus on the pain which tends to raise the perceived severity and significance for the person suffering from the condition. Dr. Benton, have you come across any patients that fit this description in your practice?
  • Improper backpack use: Kids suffer back pain needlessly since they are not traditionally in an age range we would consider to be a risk factor. However, backpacks used improperly are a common culprit. A backpack should never be more than 15%-20% of a child’s weight and should be carried on both shoulders with the bottom being at or about waste level.

What does the research say?

As I’m sure Dr. Benton will agree…..the research says a lot, to be honest. In fact, I’d say that there’s more research for the effectiveness of manipulation/mobilization in low back pain than for any other conditions chiropractors commonly treat. Am I out of bounds here Dr. Benton?

The research shows Chiropractic beating general practitioners in effectiveness as well as cost. The research shows Chiropractic beating common medications prescribed for low back pain. The research shows Chiropractic beating physical therapy and exercise alone. The research shows Chiropractic beating epidural spinal injections for low back pain. And the two of us can point you to randomized controlled trials proving it. Basically, the research is clear.

In January of 2018, a brand new research paper dealing with manipulation and mobilization was published in Spine Journal by Ian Coulter, PhD et. al. titled “Manipulation and mobilization for treating chronic low back pain: a systematic review” and funded by the National Center for Complementary and Integrative Health.

Now, to be clear, Spine Journal sounds a little bit like it may be a Chiropractic publication for those of you that don’t commonly read research abstracts…… but it is not.

Dr. Benton, can you describe Spine Journal for us?

Here’s why the authors took this project on.

The authors of the paper stated that there remained questions about manipulation and mobilization efficacy, the proper dosing of the techniques, how safe they are, as well as how they compare to other treatment protocols commonly used for chronic low back pain.

I have to say that I had no remaining questions regarding really ANY of those topics but it seems that these authors did.

Dr. Benton, again, please feel free to jump in anywhere you’d like as we go through the hows, why’s and the what’s here.

Here’s How They Did It

  • This paper was a systematic review and meta-analysis.
  • They searched databases for relevant studies from January 2000-March 2017
  • They chose randomized controlled trials that compared manipulation or mobilization to sham treatment, no treatment, other therapies, and multimodal therapeutic approaches.
  • They assessed the risk of bias using the Scottish Intercollegiate Guidelines Network.
  • Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was applied to determine the confidence in effect estimates.
  • 51 trials were included

What They Found

  • Within 7 of those trials on manipulation and/or mobilization there was reduction of disability when compared to other forms of therapy.
  • Further analyses showed that manipulation specifically was responsible for significant reduction in pain and disability when put up against therapies such as exercise and physical therapy.
  • Mobilization was also was significantly more effective when compared to exercise regimens for pain reduction but not for disability.

Wrap It Up

In the conclusion of the paper abstract, the authors say, “There is moderate-quality evidence that manipulation and mobilization are likely to reduce pain and improve function for patients with chronic low back pain; manipulation appears to produce a larger effect than mobilization. Both therapies appear safe.”

As I’ve said many times, “a lot of research in your favor becomes fact.” Chiropractic has A LOT of research in its favor.

Dr. Benton, would you like to add any final thoughts?

I’d like to thank Dr. Benton for taking the time to be with us today. He really is one of the guys out here in the real world trying his best to help change things for Chiropractors in Texas and in the world.

I want to finish off by saying that when Chiropractic is at its best, you cannot beat the risk vs reward ratio. Plain and simple.

Just another reason to call a chiropractor TODAY!

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 or 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 and do it 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!

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. Please remember, we need your help to spread the word and grow this podcast. If you would help us out by sharing our podcast information, our website, and social media entities, we would greatly appreciate your help.

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.

Research Citation:

Coulter I, et. al. “Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis” The Spine Journal, Volume 0 , Issue 0 ,

https://www.thespinejournalonline.com/article/S1529-9430(18)30016-0/fulltext

CF 001: The Chiropractic Forward Podcast Introduction – Evidence-Based,

Hey world. Welcome to our very first episode of Chiropractic Forward Podcast! It’s going to be better than stepping on Legos barefooted. Here in episode number one, we’re going to speak a little bit about what Chiro Forward means to me, why a podcast dealing with this is necessary, and why right now is the best time for the information we will be sharing here.

My very first Chiropractic Forward Podcast. Will Eventually have a dedicated website with material available but for now, you’re stuck with the newbie. But it’s good to be on the ground floor. It’s fun to watch things run their course and see where they go.

Stats On Veterans, Pain, And Medication Are Shocking And Require Urgent Action

going to revolve around a new article that came out on Observer this week and graciously shared via one of my favorite colleagues with Benton Chiropractic in Lampasas, TX, Dr. Craig Benton. The article was written by Ken Blaker, published on November 16, 2017, and called Bandaging Veterans’ Pain With Opioids Is Proving Deadly, Must Stop.”

As a portal-of-entry practitioner, I believe that ANY chiropractor will quickly agree that the veterans we see are hurt. And I do not mean just a little hurt. I have a couple of patients that have fallen out of helicopters for example. That’s the kind of hurt I am referring to. These men and women have not only risked their lives, they (in many cases) have ruined their lives.

In the article, Mr. Blaker mentions an “overburdened VA health System.” I cannot tell you how many times I have mentioned getting x-rays at the VA. Or how many times I have said something similar to, “Have you seen your VA doctor about this yet?” These types of comments and questions are ALWAYS met with an eye roll and a dismissive, “Pffft.” They don’t like going to the VA because they don’t like waiting forever to be seen and they don’t normally like the treatment they receive when they finally DO get seen by the doctor.

Combine the increased trauma and stress they put on their body with sometimes very traumatic experiences related to combat and service, and you have a volatile combination. It is easy to see why our veterans are at an increased risk of abusing (and overdosing on) opioids. Now that the United States is in an opioid epidemic, we had ALL better start paying close attention to this group of people. Especially considering the fact that this article is quoted as saying, “Veterans succumb to opioid overdose-related deaths at twice the rate of the general population.” WOW!

Mr. Blaker has a comment in this article that I will likely carry with me for the rest of my career. The quote is, “Patients are entitled to the best treatments that do the least harm.” How lovely is that? It’s perfect when we are discussing weighing the risk vs. reward ratios for chiropractic protocols and medical protocols in regards to uncomplicated neuromusculoskeletal complaints.

As the article goes on to discuss, there is a wave in the medical community as a result of the opioid epidemic. The wave is more and more in favor of not only making it harder to get hold of opioids, but also identifying alternative, non-pharmacological treatments for pain.

The current President of Parker College in Dallas and former chiropractor to the US Capitol in Washington, D.C. was quoted in the article as saying, “Non-pharmaceutical approaches to pain should always precede pharmaceutical interventions. Chiropractic, acupuncture, physiotherapy, exercise and psychosocial counseling are all preferable starting points in treating pain.”

He is standing on tall shoulders when he makes this statement. As I have discussed recently on my blog, The American College of Physicians and the American Medical Association have BOTH recently published papers and articles supporting the use of Chiropractic, Massage, and Acupuncture FIRST for chronic and low back pain before turning to any anti-inflammatories such as Ipuprofen, Tylenol, or Aspirin. One more time just for good measure: two of the biggest entities in the American medical profession now recommend seeking help from a chiropractor, massage therapist, and/or acupuncturist before taking any pills of any kind.

A collegue of mine and former President of the Texas Chiropractic Association, Dr. Tyce Hergert in Southlake, TX worked back and forth for quite some time to attempt to formulate a very concise and repeatable script for how we could accurately describe what it is we do. Here’s what we came up with.

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 oru patients’ health!

If you are a Chiropractor, feel free to use it. In fact, I HOPE you’ll use it! If you are a heatlhcare practioner of a different discipline, I hope it helps you further understand what we are doing and bringing to the table. If you are a patient or potential chiropractic patient, I hope it encourages you to keep on your path and spread the word about the Chiropractic Forward Podcast.

That’s it for episode one. Thank for listening to me. The first one is always the challenge and they say the rest is all downhill. I’m looking forward to where this can take us and take the profession.

I’d like to invite you, until the separate website is built and running, to visit my blog at www.amarillochiropractor.com/blog  There are LOTS of research-based blogs, articles, and papers we will be discussing over time. Don’t get in a hurry though….I don’t want you to get TOO far ahead of me. If you have ideas for future shows or have come across some great research that you think we should talk about, shoot us the information at dr dot williams at chiropracticforward.com We will also have future segments highlighting some of the email we get so send us emails and let us know what you think. As always, join us for more information at our home on the web, https://www.chiropracticforward.com

I’m Dr. Jeff Williams from the Chiropractic Forward Podcast flight deck, thanks again,

Upward, Onward, and Forward.