Knee Pain

CF 167: My Insane Life, Hip & Knee Osteoarthritis, Risks For Acute to Chronic Pain Today we’re going to talk about hip and knee osteoarthritis and we’ll talk about the risks for back pain going from acute to chronic pain. Interesting couple of papers. Plus all my current ongoings.  But first, here’s that sweet sweet bumper music

OK, we are back and you have found the Chiropractic Forward Podcast where we are making evidence-based chiropractic fun, profitable, and accessible while we make you and your patients better all the way around.   We’re the fun kind of research. The Bon Jovi and Def Leppard kind of research.  Not the stuffy, high-brow, high and mighty, better than you kind of research.  We’re research talk over a couple of beers.

I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.   If you haven’t yet I have a few things you should do. 

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You have found yourself smack dab in the middle of Episode #167  Now if you missed last week’s episode, we talked about dry needling, types of exercises that count, motor skills for chronic low back, and the relationship between high blood pressure and dementia. Keeping you folks smart! Check it out.  Keep up with the class.  

On the personal end of things…..

Alright, you wanna talk about juggling a bunch of balls in the air, I’m here to tell you about having balls in the air. Let’s go through it a bit, shall we? Then you can find yourself and your situation and maybe my path helps you on yours. 

• • I lost my office manager of over 11 years – here’s what I’m doing about that. 
  • Setting up a medical entity – what’s that about?
  • Looking at RHC’s – explanation to follow
  • I have finished my book – The Remarkable Truth About Chiropractic: A Unique Journey Into The Research.  – What’s that process like so far?
  • I have a virtual Assistant helping me build a website to help you all succeed – what’s the timeline? 
  • I started my second Fellowship/Diplomate program last week. Maybe I’ve lost my mind
  • Here in Texas, we went through SNOWVID 19
  • We are switching CPAs. Maybe this group gets it right. 
  • The Voice Over career has started going a little crazy here lately – I’ll explain
  • I’m about to head to Florida because…..well….because my life.
  • My main computer that holds my life has been dead for two weeks now. 

Hell yeah, folks. Lol. It’s a wonderful life, right? Let’s start at the top. As I’ve mentioned a time or two, my main employee, my OG staffer, over 11 years, and basically almost family member actually quit me and went to work elsewhere making a little more money with the change of making even a bit more next year. 

So, my main right-hand wo-man is adios but Jiminy crickets people….do you have a clue how much money I’m saving on this? She got raises every year for 11 years in her normal capacity and we created an extra marketing position for her as well at a considerable amount monthly as well.  Now, that means I’m out a marketing position but it also means I can take that money and try some different marketing for a while. Because, if I’m being honest, I’m not sure how much what we were doing was actually helping.  Plus, with the money I’m saving here, I can transition.

With the closing of doors, we usually get to experience the opening of other doors. And that’s what we’re doing. As mentioned, we are using some of the funds we are now saving to move our practice into a medical entity, hire a nurse practitioner, and move toward being finally truly integrated.  This has been a goal for years but I’ve just never pulled the trigger. Now, with PPP in place to help us pay for our payroll, it makes sense to use our existing resources, in addition to what we are now saving, to go ahead and get it done.  I’ll update you on the process as I make my way.

So far, we’ve signed paperwork with the attorneys to create the entity, we have our attorney in communication with our new CPA, which I’ll talk about later, and I’ve started reaching out. I’ve also signed up with a consulting firm on it to try to make sure I have a head start and I’m not trying to re-invent the damn wheel. I don’t like making costly mistakes. My wife and I call them ‘dummy taxes.’

If you’ve been a regular listener here, you know I’ve paid some MONSTROUS, CATACLYSMIC dummy taxes.  First, I have some fairly close relationships in the medical community. So, not only to put them all on notice of what we have planned but also to test the waters of who may be interested in being a part of it….I started reaching out. Here’s how: Hey Friend! I’m in the process of transitioning to a medical entity and hiring a nurse practitioner eventually. I’ll need to have a medical director (MD/DO) to serve in that capacity.

As I go through the process of finding one, would you be willing or able to serve as a potential character witness on my behalf if the MD or DO wants to talk to people in healthcare that know me, have experience with me and my clinic, and can speak to how I approach healthcare? I just want to be sure and ask first before I get too much further into the process. Hope you’re doing well and having a good Monday. Now, my MD/DO friends may just step up and say, “Hey I’ll be your medical director!” They may not. We’ll see. I have one in mind but it’s always good to have more than one or two options, me thinks. Also, when I reach out to my NP friends, one may raise their hands to sign up. Either way, I’m being polite, I’m putting all my friends and network on notice of intentions, and who knows, maybe it serves as some sort of guerrilla marketing. I don’t see a downside.  So, that’s the process there so far.

We almost looked at a Rural Healthcare Clinic before we decided on going the NP route. And we may still eventually. We had a call with a consulting and management firm for the RHCs and it was alright but it was also clear that the ROI wasn’t where we had heard it was and it was clear that it’s quite an endeavor and even more regulated than the medical entity endeavor would be.  It made sense to go with what my colleagues and network is the most familiar with and potentially stray off into the RHC thing if the interest is still kicking around our brains in a couple of years. 

Next on my list, the book. Being an author has always been a big goal of mine.

I love books, I love reading, and I love the idea of facilitating learning. It’s a natural progression for me. As mentioned, it’s called ‘The Remarkable Truth About Chiropractic: A Unique Journey Through The Research’. It’s essentially all of these papers I go through every week organized into their relevant categories so that they’re all in one resource and are easy to find for quick reference. Some just have the Why They Did It, How They Did It, What They Found, and The Wrap It Up sections for each paper. Some topics go further into discussion and talking points.  I believe the way to do it these days is to self-publish. I’m still figuring it out right now while it is off being edited. You wanna know who’s editing it? It’s my good friend, literary scholar, and inventor of the Drop Release tool, and hospitalist chiropractor extraordinaire from the frozen tundra of North Dakota, Dr. Chris Howson! Thank you sir. This will give you all something to look forward to in the near future. I hope you’ll all need your very own copy! So…..that’s exciting. 

On top of that, I’ve had a virtual Assistant helping me build something I think some of you will be interested in. I don’t want to give to say too much until it’s built. First, I don’t want anyone beating me to the idea, and second, I don’t want to move in that direction and then figure out I can’t make it work and then it was for nothing. Nobody wants their failure in the shop’s front window….right there on Main Street! Lol. So I’ll just say that it is something that if you need it and haven’t used it before, will 100% help you be more successful and more cognizant of what’s going on with your business from day to day. So….that’s exciting as well. 

I started my second Fellowship/Diplomate program last week. Maybe I’ve lost my mind. I probably have. Or….I’m secretly a genius. Here’s what I’ve always said; I may get beat. I may not be the best ever. And that’s OK. But I can damn sure guarantee you that it will not be due to a lack of effort. It most certainly won’t be because someone else out-worked me. Maybe they were unethical. Maybe they were lucky. Maybe they inherited something I did not. But it won’t be because I got outworked or because I didn’t try hard enough. Maybe that’s just me. Maybe it’s totally Gen-X. I don’t know. But that’s the way it is in my life. 

Here in Texas, we went through SNOWVID 21. First, you have to know that my area of Texas is very used to snow and ice and blizzards and all of that good stuff. I grew up in it. What South Texas is not used to is the ice and blizzards and snow. That was rough on them but the real kicker was losing power for not only hours but for days. Losing electricity led to losing water. Then water pipes busting and homes and offices ruined. It’s a mess. Chiropractors and Texans, in general, are trying to recover but it wasn’t any little thing. It was the worst Winter Weather event since 1890 or something like that. People can figure out -30 degree wind chill. What they can’t figure out is no power, no water, and no food. It was that real for some folks. 

We are still going through the intro phases of the Wealthability program with the Tom Wheelright group, new CPAs, the whole thing. Part of that was figuring out that our previous CPAs have been wrong and we have to figure out how to get right and part of that answer is money so…..fun fun fun.

What a wonderful life.

I’ve been without my main computer for about two weeks due to Snowvid but it’s getting up and running today which means my life is going to be up and running just a bit smoother within a day or two. Yay!! The voice-over side gig is going a little crazy at the moment. I’ve found a way to get another full-time job I think. I’ll keep you updated as that goes along but, in short, I signed with a talent agency called Heyman Talent in Cincinnati Ohio and they cover Ohio, Indiana, and Kentucky. I signed with Crown North out of San Francisco some time back as well so it’s an interesting adventure. I’m 48 years old and signing with talent agents. What the hell is that about exactly? Who knows but I’m a do-er. Let’s see what happens. 

OK, let’s get to the papers.

Only two this week because the personal side of things took a little longer than usual. Before we get to the papers though, let’s recognize my friends and this show’s amazing sponsors. 

CHIROUP 

Item #1 This first one is called “Diagnosis and Treatment of Hip and Knee Osteoarthritis – A Review” by Katz et. al. (1) and published in JAMA on February 9 of 2021, Hot off the press, smokin’ stack of steam.  What we have here on our hands…..on our meaty little mitts….is a good ol fashioned learnin’ sesh on Osteoarthritis. This is truly some good stuff, folks. Where in here can you find an opportunity to help patients and, in turn, make a living and be the expert in your community?

• Osteoarthritis (OA) is the most common joint disease, affecting an estimated more than 240 million people worldwide, including an estimated more than 32 million in the US. Osteoarthritis is the most frequent reason for activity limitation in adults. This Review focuses on hip and knee OA.
• Patients with OA typically present with pain and stiffness in the affected joint(s). Stiffness is worse in the morning or on arising after prolonged sitting and improves within 30 minutes. Pain is use related early in the course but can become less predictable over time. Although OA is sometimes viewed as a disease of inexorable worsening, natural history studies show that most patients report little change in symptoms over 6 years of observation.
• Nearly 30% of individuals older than 45 years have radiographic evidence of knee OA, about half of whom have knee symptoms.
• Osteoarthritis leads to substantial cost and mortality. Forty-three percent of the 54 million individuals in the US living with arthritis (most of whom have OA) experience arthritis-related limitations in daily activities
• Persons with knee OA spend an average of about $15 000 (discounted) over their lifetimes on the direct medical costs of OA.
• Osteoarthritis can involve almost any joint but typically affects the hands, knees, hips, and feet. It is characterized by pathologic changes in cartilage, bone, synovium, ligament, muscle, and periarticular fat, leading to joint dysfunction, pain, stiffness, functional limitation, and loss of valued activities, such as walking for exercise and dancing
• Risk factors include age (33% of individuals older than 75 years have symptomatic and radiographic knee OA), female sex, obesity, genetics, and major joint injury.
• Persons with OA have more comorbidities and are more sedentary than those without OA. It has been estimated that 31% of persons with OA have at least 5 comorbid conditions.² Persons with hip and knee OA have approximately 20% excess mortality compared with age-matched controls, in part because of lower levels of physical activity. They become sedentary
• The reduced physical activity leads to a 20% higher age-adjusted mortality. 
• Several physical examination findings are useful diagnostically, including bony enlargement in knee OA and pain elicited with internal hip rotation in hip OA. 
• Radiographic indicators include marginal osteophytes and joint space narrowing. 
• The cornerstones of OA management include exercises, weight loss if appropriate, and education—complemented by topical or oral nonsteroidal anti-inflammatory drugs (NSAIDs) in those without contraindications. 
• Intra-articular steroid injections provide short-term pain relief and duloxetine has demonstrated efficacy. 
• Opiates should be avoided. 
• Clinical trials have shown promising results for compounds that arrest structural progression (eg, cathepsin K inhibitors, anabolic growth factors) or reduce OA pain (eg, nerve growth factor inhibitors). 
• Persons with advanced symptoms and structural damage are candidates for total joint replacement. 

Conclusions and Relevance  

• Education, exercise and weight loss are cornerstones of management, complemented by NSAIDs for the right patients, corticosteroid injections, and several adjunctive medications. 
• For persons with advanced symptoms and structural damage, total joint replacement effectively relieves pain.

Item #2

Our second and last one today is called “Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care” by Stevans et. al. (2) and published in JAMA Network Open on February 16, 2021. Pop goes the weasel it’s fresh outta the oven!

Why They Did It To figure out the transition from acute to chronic low back pain using a tool to assess and predict the transition; demographic, clinical, and practice characteristics; and whether treatments that did not fit within common guidelines were partly to blame. 

They termed these treatments as nonconcordant. Treatments like opioids. Additionally, prescriptions that included benzodiazepines and/or systemic corticosteroids alone without the presence of nonsteroidal anti-inflammatory drugs or short-term skeletal muscle relaxants were considered nonconcordant. Nonconcordant diagnostic imaging consisted of an order for lumbar radiograph or computed tomography/magnetic resonance imaging (CT/MRI) scan. Nonconcordant medical subspecialty referral included referrals to nonsurgical or surgical specialties (eg, PTs, orthopedists, neurologists, neurosurgeons, or pain specialists). That was all considered nonconcordant care

How They Did It It was a cohort study with 5233 patients having acute low back pain Nearly half of the patients were exposed to at least one treatment recommendation that was not actually recommended within the first 21 days after the first visit   

What They Found

• Patients were significantly more likely to transition to chronic low back pain as their risk on the prognostic tool increased and as they were exposed to more bad recommendations
• Overall transition rate to chronic LBP at six months was 32%
• Patient and clinical characteristics associated with the transition to chronic LBP included obesity, smoking, severe baseline disability, and depression/anxiety.
• Patients exposed to 1, 2, or 3, bad recommendations in the first 21 days of pain were about 2 times more likely to develop chronic low back pain

Wrap It Up

This large inception cohort study found that the transition from acute to chronic LBP was substantial and the SBT was a robust prognostic tool. Early exposure to guideline nonconcordant care was significantly and independently associated with the transition to chronic LBP after accounting for patient demographic and clinical characteristics, such as obesity, smoking, baseline disability, and psychological comorbidities.

Boom. Instantly you’re smarter.  Alright, that’s it. Y’all be safe. Keep changing our profession from your little corner of the world. Keep taking care of yourselves and everyone around you. Tough times are upon us but, the sun will shine again. Trust it, believe it, count on it. Let’s get to the message. Same as it is every week. 

Store  Remember the evidence-informed brochures and posters at chiropracticforward.com.     

The Message 

I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment rather than chemical treatments like pills and shots. When compared to the traditional medical model, research and clinical experience show us patients can get good to excellent results for headaches, neck pain, back pain, and joint pain to name just a few. It’s safe and cost-effective can decrease surgeries & disability and we do it through conservative, non-surgical means with minimal hassle to the patient. And, if the patient treats preventatively after initial recovery, we can usually keep it that way while raising the overall level of health!

Key Point:  At the end of the day, patients should have the guarantee of having the best treatment that offers the least harm. When it comes to non-complicated musculoskeletal complaints…. That’s Chiropractic!

Contact  Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show and tell us your suggestions for future episodes.  Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on podcast platforms.  We know how this works by now. If you value something, you have to share it, interact with it, review it, talk about it from time to time, and actively hit a few buttons to support it here and there when asked. It really does make a big difference. 

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

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About the Author & Host  Dr. Jeff Williams – Fellow of the International Academy of Neuromusculoskeletal Medicine – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger    

Bibliography

1. Katz JN, Arant KR, Loeser RF. Diagnosis and Treatment of Hip and Knee Osteoarthritis: A Review. JAMA. 2021;325(6):568–578. doi:10.1001/jama.2020.22171
2. Stevans JM, Delitto A, Khoja SS, et al. Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care. JAMA Netw Open. 2021;4(2):e2037371. doi:10.1001/jamanetworkopen.2020.37371