Primary Spine Care, Frozen Shoulder, & Evidence-Based Chiropractic & Cost
CF 158: Primary Spine Care, Frozen Shoulder, & Evidence-Based Chiropractic & Cost
Today weāre going to talk aboutĀ Evidence-Based Chiropractic, We talk aboutĀ the primary spine care model integrated into a primary care setting. What happens when thatās the mode of treatment? Then weāre going to talk about some Frozen Shoulder (adhesive capsulitis) research in JAMA recently. Ā But first, hereās that sweet sweet bumper music Ā
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.Ā Weāre the fun kind of research. Not the stuffy, high-brow kind of research. Weāre research talk over a couple of beers. Iām Dr. Jeff Williams and Iām your host for the Chiropractic Forward podcast. Ā If you havenāt yet I have a few things you should do.Ā
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You have found yourself smack dab in the middle of Episode #158 Now if you missed last weekās episode, we talked about chiropractors that spread misinformation, we talked about patients needing movement, and we talked about love. Iām a softy at heart believe it or not. Make sure you donāt miss that info. Keep up with the class. Evidence-Based Chiropractic is catching on!
On the personal end of thingsā¦.. We are sitting here on a Monday 12/21 as of the typing up of this episode. Christmas is upon us. Nothing crazy special going on beyond that.Ā There are a couple of things Iāll mention. The first is that I got the Mirror gym you hang on a wall. Itās basically like having a trainer in your living room. Lots of you are already used to this sort of a deal with products like Peloton but itās new to me and itās pretty awesome. Iām doing stuff like Tai Chi, yoga, boxing, kickboxing, and stuff like that.
Stuff Iād never do otherwise and itās pretty darn cool.Ā We turned what used to basically be a dog room into a small gym and itās been pretty cool so far. Iām enjoying it. Iāve always been a skinny dude stuck in a big dudeās body. So, now that Iām down 33 lbs on weight watchers, and Iāve added the home gym to the mix, I feel like Iām on the way to realizing the skinny dude. Eventually. Lots of work left to do first though.Ā
Secondly, Iām getting the vaccine in a day or two if everything works out. I have mentioned several times on the podcast that I have very positive relationships with a lot of folks in my local medical community. Through that network, my wife and I will be getting ours this week. Iām ready to get that dude and start moving on with life.Ā
No, Iām not worried about it. Understanding I have some level of influence and some level of leadership with my friends, family, and patients, I feel itās important to get out front and set an example on this deal.Ā Especially being a chiropractor. When you see so many of us disenfranchised because of the vitalists in our profession out there preaching the harms of vaccines when they wouldnāt know how to make it through a research paper on the vaccine to save their livesā¦..well, wouldnāt it be refreshing to see evidence-based chiropractors stepping up and leading the way on this vaccine? Hereās my stance on it. Maybe it helps you if youāre on the fence. Maybe it doesnāt but here it is anyway.Ā Iām not an epidemiologist or a maker of vaccines. I have researched masks, COVID, the transmission of Covid, and things like that. Not as much on the vaccine on the vaccine itself though.Ā
Scientists understand so much more about that sort of research than Iāll ever know. A Fox Poll says 61% of Americans will get the shots while only 23% are strictly against taking it. There were 16% unsure. Probably the ones waiting to see if everyone does OK with it before they step up. And I donāt think thatās unreasonable.Ā The point is, those getting it like meā¦..Iām not the minority on it. For me, itās not only about life or death. I have a 20-something-year-old patient that canāt go back to work because sheās still positive 6 weeks later. I know a nurse that was positive for over nine weeks. I know Patients that had to go to physical therapy for weeks. Long haulers is a real deal. In the end, itās an easy decision for me. Iām not worried at all really.
Thereās risk crossing the road. If I get sick, I have to close my office for at least 2 weeks if not more. That means I lose a lot of money, there will be patients drop off of the schedule, weāll miss new patients, and Iāll be sick AND anxious the entire time. If COVID doesnāt make me nauseous, the destruction of my business while Iām out sick will.Ā Besides myself, I have 13 or so other employees and their families depending on my presence. My business depends on my presence and does not run when Iām not there. Thatās a little different than a lot of other folks. Iām not doing that if I can prevent it. If a vaccine allows me to prevent it, well then, a vaccine it is.
We chiropractors work within inches of peopleās faces and in close contact with them. That puts us at more risk than the average Joe and, if we have it, puts our patients at serious risk of getting it from us.Ā If youāre like me, we work with a lot of elderly and immunocompromised patients. Iām not willing to put them at risk like that when all I had to do was trust in science and just get the damn vaccine. They ran human trials on 35000-45000 or so people with no unacceptable issues. Thatās a huge sample size. Iāve seen this thought on the FTCA group before. Itās probably a Bobby Maybee special quote but, back before Facebook, people would have just taken the vaccine.
They werenāt worried about this stuff back before Facebook told them to worry about it.Ā No matter whatās out there these days, you have people castingĀ doubt on it for zero reasons. Maybe itās a call for attention at all costs. Who knows? But itās to the point now where science and experts are constantly doubted and discounted. And thatās about as dumb and dangerous as can be.Ā It was OK to cure smallpox and polio but COVID……nah bruh.
If there were real questions, would basically the entire medical complex be in line taking it? My guess is that they wouldnāt.Ā What if someone can afford to be out of work or out of their office for 2-4-6 weeks and they want to wait to get it? I think itās reasonable if someone wants to wait to see if anyone has adverse effects before they take it. I donāt think thatās unreasonable at all. But I think that itās just delaying the fact that almost everyone is going to do fine with it and most people are going to end up getting it.
They started it in England two weeks ago. Nothing has happened. Because they already did the test trials to make sure nothing would happen. Considering the success of the testing, I think the people not getting it are at far more risk than the people that are getting it. Besides all that, Iām ready to get back in my life. Traveling, doing fun stuff, having a life…..important stuff. Like seeing my mom and step pops and being able to visit my dad in the nursing home for the first time since March.
More power to those that have been doing those things all along but for the above-mentioned reasons, we have not.
So thatās where Iām at. We are all on our own walk and we all need to do what we think is best. Staying healthy, staying open and available, and continuing to provide for my family, my staff, and my patients are what I think is best.Ā So, Iām out front on this. Itāll be good for my patients and family to see a picture of me getting my vaccine on social media. Itāll be good for my patients to see it.
And itāll be good for those in the medical community that is friends with me to see it. Itāll reaffirm that noā¦.Iām not one of THOSE chiropractors.Ā I encourage you to be out front with it if you get one. Be a leader and blaze the trail.Ā And Merry Christmas, Dammit.Ā
Item #1 The first one today is called āImplementation of the Primary Spine Care Model in a Multi-Clinician Primary Care Setting: An Observational Cohort Studyā by Whedon, et. al. (Whedon JM 2020) and published in the Journal of Manipulative and Physiological Therapeutics on September 1, of 2020. And thatās a blistering blast of hotness.Ā If you donāt recognize the Whedon name, he is very prolific in chiropractic research.Ā
Why They Did It
The objective of this investigation was to compare the value of primary spine care with usual care for the management of patients with spine-related disorders within a primary care setting.
How They Did It
- They retrospectively examined existing patient encounter data at 3 primary care sites within a multi-clinic health system
- Designated clinicians serve in the role as primary spinal care as the initial point of contact for spine patients, they coordinated the care, and they followed up for the duration of the episode of care
- A primary spinal care doctor may be a chiropractor, PT, or medical or osteopathic physician trained in primary spinal care for spine-related disorders
- They had sites where the primary spinal care was implemented as well as control sites where they just stuck with the usual care model
- They examined clinical encounters occurring over a 2 year period from February 2016 to March 2018.Ā
What They Found
- Primary spine care was associated with reduced total expenditures compared with usual care for spine-related disorders
- At site one, the average per-patient cost was $162 in a year and $186 in year two.Ā
- That is compared to site II, a control site, where the cost in year one was $332 and $306 in year two. And in site three, also a control site offering only usual care, where the cost in year one was $467 and year two was $323
Wrap It Up
Among patients with SRDs included in this study, implementation of the PSC model within a conventional primary care setting was associated with a trend toward reduced total expenditures for spine care compared with usual primary care. Implementation of PSC may lead to reduced costs and resource utilization but may be no more effective than usual care regarding clinical outcomes.
CHIROUP ADVERTISEMENT
Item #2
Our second item today is called āComparison of Treatments for Frozen Shoulder: A Systematic Review and Meta-analysisā by Challoumas, et. al. (Challoumas D 2020) and published in JAMA Open on December 16, of 2020 and it does not get one degree hotter than that people!
Why They Did It
The authors here wanted to know the answer to the question, āAre any treatment modalities for frozen shoulder associated with better outcomes than other treatments?ā
How They Did It
- It was a meta-analysis of 65 studies with 4097 participants
- They searched Medline, EMBASE, Scopus, and CINHAL in February 2020.
- Studies with a randomized design of any type that compared treatment modalities for frozen shoulder with other modalities, placebo, or no treatment were included.
- Data were independently extracted by 2 individuals
- Pain and function were the primary outcomes, and external rotation range of movement (ER ROM) was the secondary outcome
- Length of follow-up was divided into short-term (ā¤12 weeks), mid-term (>12 weeks to ā¤12 months), and long-term (>12 months) follow-up.
What They Found
- Despite several statistically significant results, only the administration of intra-articular (IA) corticosteroid was associated with statistical and clinical superiority compared with other interventions in the short-term for pain
- Subgroup analyses and the network meta-analysis demonstrated that the addition of a home exercise program with simple exercises and stretches and physiotherapy (electrotherapy and/or mobilizations) to the intra-articular corticosteroid may be associated with added benefits in the mid-term
Wrap It Up
The findings of this study suggest that the early use of intra-articular corticosteroid in patients with frozen shoulder of less than 1-year duration is associated with better outcomes. This treatment should be accompanied by a home exercise program to maximize the chance of recovery.
Item #3
Now, on toĀ Evidence-Based Chiropractic. Our third and final one this week is called āCost comparison of two approaches to chiropractic care for patients with acute and sub-acute low Back pain care episodes: a cohort studyā by Whedon et. al. (Whedon JM 2020) and published in the Chiropractic and Manual Therapies on December 14, 2020. Get your red hots right here, get āem hot right here.Ā I told you Whedon was prolific. Thatās two papers in this one episode that heās the lead author on and I did not do that on purpose. I didnāt realize who the authors of the papers were until I started typing. Heās on his A-game.Ā
Why They Did It
The abstract for our Evidence-Based Chiropractic talk leads off by saying, āLow back pain (LBP) imposes a costly burden upon patients, healthcare insurers, and society overall. Spinal manipulation as practiced by chiropractors has been found to be cost-effective for the treatment of LBP, but there is wide variation among chiropractors in their approach to clinical care, and the most cost-effective approach to chiropractic care is uncertain. To date, little has been published regarding the cost-effectiveness of different approaches to chiropractic care. Thus, the current study presents a cost comparison between chiropractic approaches for patients with acute or subacute care episodes for low back pain.ā How They Did It
- It was a retrospective cohort design to examine the costs of chiropractic care among patients diagnosed with acute or subacute low back pain.
- The study time period ranged between 07/01/2016 and 12/22/2017
- They compared cost outcomes for patients of two cohorts of chiropractors within the health care system: Cohort 1) a general network of providers, and Cohort 2) a network providing conservative evidence-based care for rapid resolution of pain.
- They used generalized linear regression modeling to estimate the comparative influence of demographic and clinical factors on expenditures.
- A total of 25,621 unique patients were included in the analyses
What They Found
- The average cost per patient for Cohort 2 (mean allowed amount $252) was lower compared to Cohort 1 (mean allowed amount $326
- Patient and clinician related factors such as health plan, provider region, and sex also significantly influenced costs.
Wrap It Up In general, providers in Cohort 2 were found to be significantly associated with lower costs for patient care as compared to Cohort 1. Utilization of a clinical model characterized by a patient-centered clinic approach and standardized, best-practice clinical protocols may offer lower cost when compared to non-standardized clinical approaches to chiropractic care.
Soā¦.just who the hell do you all know thatās been preaching this until his face is about to explode? Thatās right, listeners of this podcast. One word, two syllablesā¦..Day-um.Ā Evidence-based and patient-centered care is the future of chiropractic. It is first and foremost, treating our patients with respect and the best care and thatās what they deserve.Ā Secondly, itās speaking the language of the medical community. Which is the language of research. When youāre using their language, youāre starting to communicate more effectively.Ā I think itās time for superhero sound effectsā¦.boom, pow, snap, kawachow!
Alright, thatās it. Yāall 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. Letās get to the message. Same as it is every week.Ā
Store Remember the evidence-informed brochures and posters at chiropracticforward.com.Ā
The Message I want you to know with absolute certainty that when Chiropractic is at its best, you canāt 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. Itās 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 complaintsā¦. Thatās 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.Ā Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on podcast platforms.Ā 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.Ā
Connect We canāt wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward. Website http://www.chiropracticforward.com
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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 Ā
Bibliography
- Challoumas D, B. M., McLean M, (2020). “Comparison Of Treatments For Frozen Shoulder: A Systematic Review and Meta-Analysis.” JAMA Open 3(12): e2029581.
- Whedon JM, B. S., Dennis P, Fischer VA, Russel R, (2020). “Cost comparison of two approaches to chiropractic care for patients with acute and sub-acute low Back pain care episodes: a cohort study.” Chiropr Man Therap 28(68).
- Whedon JM, T. A., Bezdijan S, (2020). “Implementation of the Primary Spine Care Model in a Multi-Clinician Primary Care Setting: An Observational Cohort Study.” J Man Physiol Ther 43(7): P667-674.