Lumbar Herniation

Current Knowledge On A Robust Low Back Pain Diagnosis

CF 125: Current Knowledge On A Robust Low Back Pain Diagnosis Today we’re going to talk about picking apart a Lumbar pain diagnosis. What’s the latest information according to research? But first, here’s that sweet sweet bumper music    
Chiropractic evidence-based products

Integrating Chiropractors

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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. Not the stuffy, high-brow 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.   Today, I want to use a current paper from November on low back pain and diagnosing it correctly. I’m going to use the paper as the main source of info here but I’m going to be peppering in my own learning as a Fellow of the International Academy of Neuromusculoskeletal Medicine. I’m a nerd when it comes to the low back for whatever reason. Maybe because its the best researched of the conditions we treat. I don’t know. But I nerd out of this stuff and, if you follow along, by the end of today’s episode, you should be able to raise your low back diagnosis game considerably.    Item #1 This one is called “Current evidence for the diagnosis of common conditions causing low back pain; systematic review and standardized terminology recommendations” by Robert Vining, et. al(Vining R 2019). and published in Journal of Manipulative and Physiological Therapeutics in November of 2019……hot enough, here we go.  Why They Did It The purpose of this systematic review was to evaluate and summarize current evidence for the diagnosis of common conditions causing low back pain and to propose standardized terminology use. How They Did It
  • A systematic review of the scientific literature was conducted from inception through December 2018
  • Electronic databases searched included PubMed, MEDLINE, CINAHL, Cochrane, and Index to Chiropractic Literature
  • Of the 3995 articles screened, 36 (8 systematic reviews and 28 individual studies) met final eligibility criteria
  • Diagnostic criteria for identifying likely discogenic, sacroiliac joint, and zygapophyseal (facet) joint pain are supported by clinical studies using injection-confirmed tissue provocation or anesthetic procedures
  • Diagnostic criteria for myofascial pain, sensitization (central and peripheral), and radicular pain are supported by expert consensus–level evidence
  • Criteria for radiculopathy and neurogenic claudication are supported by studies using combined expert-level consensus and imaging findings.
What They Found
  • The absence of high-quality, objective, gold-standard diagnostic methods limits the accuracy of current evidence-based criteria and results in few high-quality studies with a low risk of bias
  • These limitations suggest practitioners should use evidence-based criteria to inform working diagnoses rather than definitive diagnoses for low back pain
Let’s dive in a bit, shall we? Discogenic pain, they say provocation discography is the diagnostic reference standard test used to confirm discogenic pain but it costs a lot, it’s not well standardized and there are some pretty significant risks of adverse effects. So the authors are recommending the centralization phenomenon as an office-based test to try to confirm discogenic pain. I’d add a few other signs of the pain being disc in nature. Here are a few off the top of my head:
  • The patient locates their pain axially and at L5 or above, not laterally
  • You cannot typically provoke the pain when pressing P to A on the segment
  • Walking helps
  • The Slump Test is highly useful here
  • Pain on coughing or sneezing or going from seated to standing
  • Pain that is worse sitting and better when lying down
  • Pain that can be centralized or peripheralized
  • Diminished motor, sensory, or reflexes
  • About 40% of low back pain patients under the age of 50 are discs
  • And pain that radiates beyond the knee
Myofascial Pain – They recommend myofascial pain be defined as nociceptive signaling from within muscle or fascial tissues that may or may not include referred pain or the presence of trigger points. Diagnostic criteria consistent with this definition include tenderness within a muscle with or without referred pain and reproduction of familiar pain with palpation or use. SI Joint Pain – Despite the existence of numerous provocation tests designed to identify SI joint pain, current scientific evidence does not support the diagnostic utility of individual tests. I can agree with that. Therefore, they say that SI anesthetic injections or blocks are the current diagnostic standard but of course, we don’t do that do we? No, we test the SI joints in several different ways and try to have a consensus. 
  • SI joint pain prevalence is about 22.5% of your low back patients
  • Fortin’s finger test raises your suspicion considerably
  • Walking hurts
  • Seated to standing usually hurts
  • For a robust diagnosis of SI, you should have 3 of the following 5 positive tests. 
  • Sacroiliac compression test
  • Distraction / gapping test
  • FABER test
  • Gaenslen’s test
  • Thigh thrust
Facet Joint Pain – They point out a study by Laslett et. al. saying a reporting of 3 out of 5 findings is sufficient to make a facet dx. They are:
  • Patient over 50
  • Paraspinal pain
  • Relieved with walking
  • Relieved with sitting
  • Positive extension/rotation
I will add to that list that facet joints constitute roughly 30% of your low back patients. The extension/rotation test is important. If it’s positive, it can still be something other than facets. But, if it’s negative, it’s almost certainly NOT a facet. Get that again, if extension/rotation is NOT positive, it’s almost certainly NOT facet.  In addition, you can push paraspinal on the patient and provoke the pain whereas, as mentioned, with a disc, you cannot provoke it by palpation.  Typically, long-lever activities are bothersome. Things like vacuuming, doing the dishes, or folding laundry. Anything that involves being slightly bent forward for a period of time.  Stenosis – They say “Neurogenic claudication occurs when spinal stenosis is severe enough to cause symptoms from intermittent neural compression or ischemia, most commonly from degenerative changes within the spine.” They say they “recommend diagnostic criteria reported by Nadeau et al. Which are symptoms triggered with standing, relieved by sitting, symptoms above the knees, and positive shopping cart sign.” For me here in my clinic, I use the protocol Carmen Amendolia created and validated through research. It’s been highly effective for us and our patients.  Piriformis Syndrome Current diagnostic criteria are available only through a systematic review of clinical features reported in the scientific literature: 
  1. ipsilateral leg radiation, 
  2. (2) greater sciatic notch tenderness, 
  3. (3) buttock pain, 
  4. (4) positive SLR, and 
  5. (5) pain with sitting
I would add that resisted external rotation could give you a hint. Put your hands on the lateral sides of the patient’s knees bilaterally. Then tell the patient to try to spread their legs while you resist. It’s painful, you have another very simple hint that you may be dealing with a piriformis issue.  So there you have it with my own learning from the neuromusculoskeletal diplomate program salted and peppered in for a good robust discussion. Yes, there are other considerations like lumbar sprain strain and things like that but these are the biggies.  If you weren’t before, you should be well-equipped after this episode to kill it on a low back diagnosis.  Alright, that’s it. Y’all be safe. Continue taking care of yourselves and taking care of your neighbors. 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.  Key Takeaways Store Remember the evidence-informed brochures and posters at chiropracticforward.com.   
Chiropractic evidence-based products

Integrating Chiropractors

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  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. Website
Home
Social Media Links https://www.facebook.com/chiropracticforward/ Chiropractic Forward Podcast Facebook GROUP https://www.facebook.com/groups/1938461399501889/ Twitter YouTube https://www.youtube.com/channel/UCtc-IrhlK19hWlhaOGld76Q iTunes https://itunes.apple.com/us/podcast/chiropractic-forward-podcast-chiropractors-practicing/id1331554445?mt=2 Player FM Link https://player.fm/series/2291021 Stitcher: https://www.stitcher.com/podcast/the-chiropractic-forward-podcast-chiropractors-practicing-through TuneIn https://tunein.com/podcasts/Health–Wellness-Podcasts/The-Chiropractic-Forward-Podcast-Chiropractors-Pr-p1089415/ About the Author & Host Dr. Jeff Williams – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & VloggerBibliography Vining R, S. Z., Minkalis A, (2019). “Current evidence for diagnosis of common conditions causing low back pain; systematic review and standardized terminology recommendations.” J Man Manip Ther 42(9): P651-654.

Insurance Warming To Chiropractic in 2020 & Chiropractic For Lumbar Herniation and Sciatica

CF 107: Insurance Warming To Chiropractic in 2020 & Chiropractic For Lumbar Herniation and Sciatica

Today we’re going to talk about what to expect with Insurance coverage in 2020 and we’ll talk about some thoughts on chiropractic, lumbar herniation, and sciatica according to what the research tells us. 

But first, here’s that sweet sweet bumper music

Chiropractic evidence-based products
Integrating Chiropractors
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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. Not the stuffy, high-brow kind of research. We’re research talk over a couple of beers.

Welcome, 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. 

  • Like our facebook page, 
  • Join our private facebook group and interact, and then 
  • go review our podcast on iTunes and other podcast platforms. 
  • We also have an evidence-based brochure and poster store at chiropracticforward.com
  • While you’re there, join our weekly email newsletter. No spam, just a reminder when the newest episodes go live. Nothing special so don’t worry about signing up. Just one a week friends. 

Do it do it do it. 

You have collapsed into Episode #107

Now if you missed last week’s episode on joint replacement life spans, spinal infections, and vitamin D w/ calcium supplementation, then make sure you don’t miss that info. 

I think there were some good solid knowledge nuggets found there within so make sure you’re up to date and not falling behind the rest. Keep up with the class won’t you?

On the personal end of things I have to say that this has been one of the more challenging of Christmases if I’m being honest.  Beyond the disruption of normal schedules and normal business that goes on with the holidays…..we expect those things. The disruption stinks and it can make us lose money. That is frustrating. 

However this one was a bit different for me. If you’re a regular listener then you know that my Dad had a stroke on November 9th so that’s still a daily deal. Going out to the rehab hospital, working with his hand and wrist, elbow, and shoulder to see if I can spark any kind of sensation or movement. 

Then on Christmas Eve, my stepdad needs to go to the ER so I drive over to their house and drive my mom and Fred to the VA ER at about 10pm. 

Well, we end up sitting there until about 5am. Turns out he has appendicitis but no surgeons until the morning. We had a little time to go home and get a few hours of sleep before having to be back up at the hospital for surgery at about noon on Christmas Day. 

So, I got a few hours of sleep in, went by the rehab hospital to check on Dad, went back to pick my mom and family up, then off to the hospital. It only took them about 45 minutes and here’s the amazing thing. 

Fred had his appendix out at about 12:45 in the afternoon and was out of the hospital and at his house by 6:30pm. 

Outstanding!! And he’s done great. Hell, he said the worst part is where they shaved him and the hairs growing back in are wanting to catch on his clothing. Lol. 

So, as you can guess, it was a bit of a miserable Christmas. Back in my rascally days, 5am was nothing to me. In fact, I saw 5:00am pretty regularly after having been up all night hooting and hollering and acting a fool. But at 47, 5:00am is some mystical thing that I only hear about sometimes from my health freak friends that get up to work out in the mornings. 

I hope you holidays were more amazing than mine. I hope you got to spend some quality time with your loved ones and I hope the best for all of us in this new year. Upward onward and forward. 

Before we dive into the reason we’re here, it’s good to support the people that support you don’t you think? I’m about to throw you a deal and if you don’t take advantage of this deal, I just think you might be crazy.

If you’re a regular listener of our podcast, you know I’ve used ChiroUp since about June of 2018. Let me tell you about it because I’m about to give you a way to do a FREE TRIAL and, if you sign up, only pay $99/month for the first six months which is pennies compared to what it’s worth. So listen up!

ChiroUp is changing the way we practice by simplifying patient education and here’s what I mean: 

In a matter of seconds, you can send condition-specific reports to your patients with recommendations for treatment, for their activities of daily living, & for their exercises. 

You can see how this saves you time – no more explaining & re-explaining your patient’s care, because they have access to it at their fingertips. 

You can be confident that your patients are getting the best possible care, because the reports are populated based on what the literature recommends and isn’t that re-assuring? All of that work has been done FOR you. 

There are more than 1000 providers worldwide using ChiroUp to empower their treatments, patients, & practice – Including myself! **Short testimony**

If you don’t know what it’s all about or you’d like to check it out, do yourself a favor and go to Chiroup.com today to get started with your FREE TRIAL – Use code Williams99 to pay only $99/month for your first 6 months

That’s ChiroUp.com and super double secret code Williams99.

Item #1

Our first item of interest today is called “More Payers Backing Chiropractic Care in 2020” by Sherry McAllister(McCallister S 2019). It was published in the Managed Healthcare Executive on December 23, 2019. 

Hot potato, coming through….

Just taking this article point by interesting point:

She says research has shown private and government health plans may inadvertently be steering their members toward opioids by not covering, restricting benefits, or charging higher co-pays for chiropractic care. 

Indeed and we’ve covered that here as well. This was laid out particularly well in a White House report from 2017 or so I believe. They were actually very clear in pointing out that current Medicare and healthcare policies actually create barriers to conservative management rather than pharmaceutical modalities. 

Think about it; when a prescription of opioids cost $10-$20 but a visit to a PT or chiropractor can bust the bank…..well, what you going to pick if you’re not very educated on all of the options available?

She points out a recent study from Boston University showing that patients with a deductible greater than $1500 were less likely to choose a doctor of chiropractic as their entry-point provider. 

However, as she points out, United Healthcare has announced a certain employer-sponsored medical plan that will have zero out-of-pocket spending, which will include their deductible….if they opt to go to a chiropractor for treatment of low back pain first. Hell yeah. Hell yeah is what I have to say about that. 

We’ve been sitting here at the end of the tunnel waiting on this train that has been delayed for decades. I’m getting old waiting on this stupid POS but it looks like we might be seeing the light coming down the way and hearing the rumbling on the line. 

Medical doctors will never lead the charge when it comes to sending these patients to chiropractors. It must come from the payers and maybe we’re starting to see the push. Hell, we know we save the system money so why on Earth would they NOT lead the charge?

UHC estimates that by 2021 this design can reduce imaging by 22%…..good luck getting some chiros to scale back on x-rays UHC….good luck. They estimate it can reduce spinal surgeries by 21%….I’d guess more than that, reduce opioid use by 19%…..more than that I’d guess, and reduce total cost for members and employers. Agreed and agreed. 

McAllister goes on to discuss how other healthcare plans are coming on board by expanding or emphasizing coverage in 2020 for chiropractic including Tricare which handles the military folks here in America. Instead of just active duty troops, Tricare is expected to approve extending chiropractic coverage to family members, retirees, and family members!! 

Kowapow, people. Sha-freaking-zam to the bamalam. 

She points out this is most likely in response to a 10-year study of military members through 3 different clinical trials showing chiropractic was instrumental in increasing strength, endurance, and response time among service members with lower back pain. Again, we have covered these here on The Chiropractic Forward podcast if you’ve been following along. 

Chiropractic’s own Dr. Christine Goertz has been instrumental in some of those clinical trials. 

Mrs. McAllister points out that even non-military seniors in some part of America could be getting upgraded access to chiropractic through benefit expansions of Medicare Advantage plans. 

We know that insurance plans do not like wellness care because they’re stupid and short-sighted but Anthem Blue Cross in California expanded wellness benefits for its Medicare Advantage plans to include up to 24 visits per year with a chiropractor, massage therapist, and/or acupuncturist at no extra cost. Same goes for folks in Philadelphia. Good stuff here people. 

When you hear veteran chiropractors such as myself say there’s not been a better time to be a chiropractor in the last 30 years, since the Mercedes 80’s,  now you are seeing why. It’s happening before your eyes I believe. 

This is all excellent news for chiropractors, massage therapists, and acupuncturists. Now, when can we expect things to really change and translate into more patients in your doors and more money in the bank? Well, who the hell knows? But, I can tell you that the American College of Physicians started recommending spinal manipulation for back pain in 2016, the Journal of the American Medical Association supported that recommendation in a 2017 article, The Lancet’s series on Low Back Pain supported the recommendations in 2017, The White House Report we mentioned backed it all up, Consumer Reports, The Joint Commission, CDC, NIH, and the FDA all came in line with this new thinking. 

So, you see the more of these organizations and voices of authority that come on board, the more we’re going to see in our offices. But it is a snowball and the ball has just started rolling at the top of the hill. 

The trick is going to be to take advantage of it all by following research and evidence. By expanding and bringing chiropractic closer to the medical community rather than leaving it in some archaic form from 100+ years ago. 

Stick with it. It’s moving the right direction and it’s going to be OK. 

Item #2

The second paper is an older one. It’s from way back in 2006. Old man river…. that old man river…

It’s called “Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations.” It was authored by V Santilli et. al. and published in Spine Journal(Santilli V 2006). If it’s in Spine, it’s prolly muy bueno amigo. 

Why They Did It

The stated goal here was to assess the short and long-term effects of spinal manipulation on acute back pain and sciatica WITH disc protrusion. 

How They Did It

  • It was a randomized double-blind trial comparing active and simulated manipulations in rehabilitation medical centers in Rome and its suburbs
  • They had 102 ambulatory patients with at least moderate pain on a visual analog scale for local pain and/or radiating pain. 
  • They implemented appropriate outcome measurements
  • Manipulations or simulated manipulations were performed five days per week by chiropractors with a number of sessions which depended on pain relief or up to a max of 20 
  • They used a rapid thrust technique which I’m assuming is high-velocity low amplitude such as diversified 

What They Found

  • Manipulations appeared more effective on the basis of the percentage of 
  • pain-free cases
  • number of days with pain
  • number of days with moderate or severe pain
  • Patient receiving manipulations had a lower mean VAS score
  • There were no adverse events

Wrap It Up

“Active manipulations have more effect than simulated manipulations on pain relief for acute back pain and sciatica with disc protrusion.”

Pawya!!

Item #3

Our last one today is called “Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study” authored by McMorland et al and published in the Journal of Manipulative Physiological Therapeutics in October of 2010. Old man river….not quite that old though. 10 years isn’t fresh in the research world but that’s OK, it’s still a good one we should all know about. 

Why They Did It

They wanted to compare the clinical efficacy of spinal manipulation against microdiskectomy in patients with sciatica secondary to lumbar herniation

How They Did It

  • It was a randomized clinical study
  • 120 patients were included all of which were referred by a primary to neurosurgeons for lumbar herniation
  • All had unilateral lumbar radiculopathy secondary to lumbar disc her4niation 
  • The herniations were present at L3/4, L4/5, or L5/S1

What They Found

Significant improvement in both treatment groups compared to baseline scores over time was observed in all outcome measure

Wrap Up

“Sixty percent of patients with sciatica who had failed other medical management benefited from spinal manipulation to the same degree as if they underwent surgical intervention. 

Of 40% left unsatisfied, subsequent surgical intervention confers excellent outcomes. 

Patients with symptomatic lumbar herniation failing medical management should consider spinal manipulation followed by surgery if warranted.

Three syllables….one word, folks. Bamalam. Bam-a-lam, people….

It’s happening. It’s coming. Stay the course, make smart decisions. Be the expert. Use research and the Chiropractic Forward Podcast to do it. 

Chiropractic evidence-based products
Integrating Chiropractors
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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 instead of chemical treatments like pills and shots.

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

It’s safe and cost-effective. It can decrease surgeries & disability and we normally do it through conservative, non-surgical means with minimal hassle to 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 of the patient!

Key Point:

Patients should have the guarantee of having the best treatment offering 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 or tell us your suggestions for future episodes. Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on iTunes and other podcast services. Y’all know how this works by now so help if you don’t mind taking a few seconds to do so.

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

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

Bibliography

McCallister S (2019) “More Payers Backing Chiropractic Care in 2020.” Managed Healthcare Executing.

Santilli V, B. E., Finucci S, (2006). “Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations.” Spine J 6(2): 131-137.