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Chiropractic Forward Podcast - Jeff Williams, DC

Headaches and the Neck, Absolute Contraindications, More Maintenance Care

December 12, 2019 chiropracticforward 11 Comments

CF 102: Headaches and the Neck, Absolute Contraindications, More Maintenance Care

Today we’re going to talk about new information on how working on the neck could help headaches of all kinds. Who woulda thunk it? We’ll talk about absolute contraindications to spinal manipulative therapy. Do you remember them all? I’ll give you a refresher to be sure. We’ll wrap up the episode with another paper on maintenance care. Is it evidence-based?

But first, here’s that sweet sweet bumper music

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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

Do it do it do it.

You have sauntered into Episode #102

Now if you missed last week’s episode, it was episode #101 and it covered 9 characteristics that make up a good chiropractor, make sure you don’t miss that info. Put that one on your listen-to list muy pronto, mi amigo.

On the personal end of things that whole DACO thing you’ve heard me talk about since June of 2018…..well, I got word last week that I passed the part II exam. That also happens to be the FINAL exam I’ll have you know which means……yes, it means I’m now officially a Diplomate or Fellow of the International Academy of Neuromusculoskeletal Medicine.

It turns out that we can choose whether to go by Diplomate or Fellow and I choose Fellow. So, when it comes to adding alphabet soup to the end of my signature, I now get to add FIANM(us).

Besides graduating with a doctorate, this is the biggest thing I’ve done and I can’t really express how excited I am to join the amazing group of doctors in this specialization.

Did you know that only 2% of chiropractors go on to specialize? We really really need to change that. I want to be honest here: the hours were absolutely, 100%, without a single doubt one of the most enjoyable and most rewarding things I’ve done. WAaaaaayyyy better than chiropractic school.

The course was current with research. It was smart. It was professionally done. It was just amazing.

The testing process……welll…..that was a different story for me. I felt that the material in Part I was just irrelevant to the course. In fact, had little to nothing to do with what we learned. BUT – the good news is that they’ve created a new test now and it should be more relevant.

Part II was amazing, imaginative, and well-put together and conducted. But, I believe there were doctors making the questions that had never undergone the current course load so, once again, there were questions that were a bit random and just seemed out of place to a person that had all of those hours.

Again, the good news is that they are consistently adding updated questions and I have no doubt they will get more and more focused in regard to what was actually covered in the course.

So, I in short, doctors should undertake this Diplomate. The hours are so rewarding. You literally cover a topic in the course and then it shows up in your clinic. It’s scary as hell how that works.

The testing part is cumbersome and clunky but they’re working on lining it out. Even if that part didn’t get any smoother or any better, it is still 100% absolutely worth every dime spent and every hour spent achieving the goal.

Trust me, I’d tell you straight up if it weren’t. If you have the money, do it. Don’t give me that excuse about time. I didn’t have time either. I just made time. I did it while I watched football. I did it with coffee on Saturday and Sunday mornings. I took off early on Tuesdays just to study. It can be done and YOU can do it.

Send me an email at dr.williams@chiropracticforward.com if I can help point you in the right direction and get you started. I’d be happy to help you.

More chiropractors need to specialize. Just think about it.

My Dad…..well….If you listened to previous episodes, you know he had a stroke a couple of weeks ago. I can’t tell you how emotionally challenging this has been. To work and still get out there to spend time every day…..it’s a process and it’s a commitment.

But that’s it. He’s my Dad and I’m committed to being there to help and do whatever I can to help him get restored to whatever level we can get.

We are both guitar players so I brought my guitar up to the rehab facility last night and played for him for a while. We are both sculptors. We make bronzes. Check riverhorseart.com and we have a Facebook page as well.

So, I bought him some new sculpting tools and some clay and took them up to him today at lunch. He can only use is dominant hand, his right hand, but he was pretty excited. He started sculpting before I even left.

Fingers crossed that we see some improvement in a hurry. Thank you to each of you that sent me emails and messages through Facebook offering prayers and good wishes. I value each of them as much as I value you. Thank you.

Before we dive into the reason we’re here, it’s good to support the people that support you don’t you think? Well, ChiroUp certainly supports evidence-based practices.

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

Let’s start with absolute contraindications shall we? This comes from the WHO Guidelines(Sweaney J 2004). That’s right the World Health Organization. The actual name of the document is WHO guidelines on basic training and safety in chiropractic.

I literally never knew this existed until I saw it in a Facebook group last week. Some kind hearted individual shared it. I can’t recall whether it was the Forward Thinking Chiropractic Alliance group or if it was the Evidence Based Chiropractic group. Either way, I found it interesting and here we are.

I’m going to leave a link to the document at this point in the show notes so just go to chiropracticforward.com and episode 102. You’ll find it and you’ll be happy.

https://www.who.int/medicines/areas/traditional/Chiro-Guidelines.pdf

If we go down to page 21, we find a list of Absolute contraindications to spinal manipulative therapy. Many of them, you already know but let’s just stroll through them for a refresher just in case.

1. anomalies such as dens hypoplasia, unstable os odontoideum, etc.

2. acute fracture

3. spinal cord tumor

4. acute infection such as osteomyelitis, septic discitis, and tuberculosis of the spine

5. meningeal tumor

6. hematomas

7. malignancy of the spine

8. frank disc herniation with accompanying signs of progressive

neurological deficit

9. basilar invagination of the upper cervical spine

10. Arnold‐Chiari malformation of the upper cervical spine

11. dislocation of a vertebra

12. aggressive types of benign tumors, such as an aneurysmal bone cyst, giant cell tumor, osteoblastoma, or osteoid osteoma

13. internal fixation/stabilization devices – metal hardware such as after a surgical fusion

14. neoplastic disease of muscle or other soft tissue

15. positive Kernig’s or Lhermitte’s signs – these are orthopedic meningitis signs. Go look up Kernig’s and Lhermitte’s if you don’t know them please.

16. congenital, generalized hypermobility – Are you using the Beighton Scale for hyper mobility? Are you adjusting chronic pain, hyper mobile people? Sometimes, even if they like the popping sounds, that’s not best. Sometimes, strengthening and support exercises are better than mobilizing joints that are already too mobile.

17. signs or patterns of instability

18. syringomyelia

19. hydrocephalus of unknown etiology

20. diastematomyelia – a congenital disorder in which a part of the spinal cord is split, usually at the level of the upper lumbar vertebra. Fortunately, we almost never see this.

21. cauda equina syndrome – I caught one not long ago in my office. A new patient who had been to the ER 3 times already and they never even took the time to do any imaging. A young guy in his 30’s on a walker, difficulty controlling bowel and bladder function, saddle anesthesia. I told him to go directly back to the ER and tell them you are concerned you are suffering from cauda equina and tell them you have saddle anesthesia.

As soon as he did that, boom, imaging, and emergency surgery. He says I saved his life. While that’s not true specifically, it sure as hell feels good to hear.

Alright. I hope you enjoyed that brief refresher and it gave you a little food for thought. You can go to the show notes and get the document or just go to get the list if you like.

Item #2

This one is pretty cool. It’s called “A neuroscience perspective of physical treatment of headache and neck pain,” by Rene Castien and Willem De Hertogh and published in Front Neurology in March of 2019(Castien R 2019).

This one is probably going to tell you what you instinctively already knew but it’s going to lay some scienc-ing in on the top there for you.

Just like a warm blanket, a layer of scienc-ing is all warm and fuzzy and makes you feel good. Can’t get enough of scienc-ing can we?

OK, we know that the most prevalent headache is tension type headache. In fact, about 40% of those presenting in your clinic are TTH. Not migraine, not cervicogenic…..TTH. In fact, only about 10% of the headaches that present to your office are actually migraines. That’s not very many is it?

Which is a good thing because migraine is more of an issue in the brainstem – in the descending pain inhibitory complex. In the words of Dr. Anthony Nicholson and Dr. Matthew Long from the CDI coursework – The experience of head pain requires activation of the trigeminal nucleus. After all, this is where the neurons that sense the head and neck are located.

Adjustments don’t always knock out a migraine issue right? It’s wired into the brain. However, adjustments tend to show more success when we’re dealing with a TTH.

Now, the TTH is also an issue with impaired inhibition. It’s on the same spectrum….the same continuum as is migraine. Migraine way off to the right and TTH way off to the left. But there’s a lot of middle ground in there where their symptoms can overlap into each other a bit.

But, in general, we are able to be more effective with TTH than we are with migraine.

They mention in this paper that physical treatment is a frequently applied treatment for headaches. They say that although physical treatment is often applied to the neck, the neurophysiological background…..how it works or helps…..is unclear.

So, the authors had the goal of taking more recent knowledge from neuroscience and enhancing clinical reasoning in using physical treatment for headaches and to understand why it’s so common for headaches and neck pain to exist together so oftenly.

Some of the highlight quotes from this article are as follows:

“Headache (migraine, tension-type headache, cervicogenic headache), neck pain, and cervical musculoskeletal dysfunctions seem to be related in case-control studies, although the strength, significance and explanation of this relation varies per type of headache.”

“It is a great challenge for clinicians and researchers to develop effective treatment strategies for headache targeted on modulation of cervical afferent input in order to decrease the excitability of first- to second order neurons at the level of the TCC. Experimental studies of the neurophysiological effect of physical treatment and randomized clinical trial on this topic are scarce and urgently warranted. Meanwhile, there is no standard recipe for physical treatment on the neck for different types of headache. But clinicians may be encouraged by recent evidence and new insights on headache and neck pain and may use this knowledge in clinical reasoning to provide a tailored and evidence based neuro-physiological approach for patients with headache and neck pain.”

“The relation between brainstem nuclei and the (upper) neck and trigeminal nerve has to be incorporated in development of physical treatment for headache targeted at the cervical spine, especially the upper cervical region.

According to the ‘gate-control’ hypothesis, the relative high amount of proprioceptive muscular input from the upper cervical segments particularly C1-3….. to the central nervous system may alter nociceptive input.

Stimulation of proprioceptive input by active exercises for neck muscles may decrease the excitability of second order neurons at the trigemino-cervical complex and activation of the supraspinal diffuse noxious inhibitory control system by stimulation of myofascial fibers through manual pressure techniques at the upper cervical spine can be of added value.”

Pretty cool stuff. Physical treatment is effective for different kinds of headache through the trigemino-cervical complex via proprioceptive stimulation of the upper cervical region.

You’re welcome. This is something covered extensively in the coursework we did for our Neuromusculoskeletal Fellowship/Diplomate.

Like I said, it’s absolutely worth going through the course.

Item #3

Our last paper here is paper #3 in the last year on Chiropractic Maintenance. It’s called, “Chiropractic maintenance care – what’s new? A systematic review of the literature”. It was published in Chiropractic and Manual Therapies and authored by Iben Axen, Lise Hestbaek, and Charlotte Leboeuf-Yde in November 2019(Axen I 2019) – Hot steamin’ greasy plate of enchiladas here.

If you notice the name Iben Axen, then you will remember he is the one that authored the paper on how a patient’s improvement in the first visit or two can really help you know how they will do through the course of the treatment. He’s pretty active in research and we appreciate him here at the Chiropractic Forward Podcast.

Why They Did It

Here’s why they did this one: knowing that maintenance care is an age old tradition with chiropractors, and knowing that systematic reviews in ’96 and in /08 both found evidence lacking for maintenance care, and then considering Andreas Eklund’s Nordic papers on maintenance care recently (we’ve covered them both here), these authors decided it was time to review the newest evidence on the matter.

How They Did It

Knowledge of chiropractic Maintenance Care has advanced. There is reasonable consensus among chiropractors on what Maintenance Care is, how it should be used, and its indications. Presently, Maintenance Care can be considered an evidence-based method to perform secondary or tertiary prevention in patients with previous episodes of low back pain, who report a good outcome from the initial treatments. However, these results should not be interpreted as an indication for Maintenance Care on all patients, who receive chiropractic treatment.

You know it feels good when a paper can conclusively say ‘presently, maintenance care can be considered an evidence-based method.” It reminds me of Jim Carrey in the Ace Ventura movies saying, “Can you feel that? Huh?” Lol.

Good stuff there. I love slapping people with research. It’s a warm feeling going down kind of like Bailey’s and coffee. You know what I’m saying.

Key Takeaways

Be smart and know your absolute contraindications
Treating the neck for headaches is evidence-based
Chiropractic maintenance is evidence-based

Speaking of evidence-based, make sure you go to chiropracticforward.com and go to the store link to check out our evidence-based brochures and posters. You’ll like them.

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

Axen I, H. L., Leboeuf-Yde C, (2019). “Chiropractic maintenance care – what’s new? A systematic review of the literature.” Chiropr Man Therap 27(63).
Castien R, D. H. W. (2019). “A Neuroscience Perspective of Physical Treatment of Headache and Neck Pain.” Front Neurol 10: 276.
Sweaney J (2004). WHO guidlines on basic training and safety in chiropractic. WHO: 44.

An Inverse Relationship With Chiropractic & Opioids, Anti-Inflammatory Diets, & Screen Time Might Make Dummies

October 10, 2019 chiropracticforward 00:25:37 0 Comments

CF 095: An Inverse Relationship With Chiropractic & Opioids, Anti-Inflammatory Diets, & Screen Time Might Make Dummies

Today we’re going to talk about the relationship between chiropractic and opioids, we’ll talk about anti-inflammatory diet ideas, and a little ditty about screen time and dumb butts.

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 and accessible while we make you and your patients better all the way around. Welcome, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.

You have slinkied into Episode #95

Now i you missed last week’s episode on my trip to St. Louis for the Forward ’19 seminar, decompression research, and young baseball pitchers, make sure you don’t miss that info. I’d like to think that all of our episodes are such that you walk away better than before you hit the play button. That’s my goal anyway.

I usually am not at a lack of words when it comes to the personal side of what’s been going on lately. I have to say though, not much is going on around the office these days. It’s slower this week but not much slower. I’m just trying to get everything done.

For a chiropractor, what exactly does that mean? Well, I’ve created two or three new graphics for social media posts and loaded them into the hopper for realease later this week.

I proofread two blog articles my writer sent to me for two websites. I’ve gotten those posted after making corrections.

I’ll be proofreading and scheduling my patient weekly email as soon as my staff member finishes it.

I met with our marketing staff member to go over what marketing we are doing and want to do before she headed out onto the town this morning.

It’s 1 pm and I’ve already seen two new patients and my fair share of established patients.

I’ve dealt with a roof leak, a staff member that ended up with a migraine that required us to take her to be treated. Taht’sAn Inverse Relationship With Chiropractic & Opioids, Anti-Inflammatory Diets, & Screen Time Might Make Dummies a whole different crazy story.

CF 062: Chiropractic Prevalence, JAMA’s Awful Info on Opioids, & New Info on Screen Time

I get off early on Tuesdays to go home and study for the DACO part II test so I’ve got that going for me today.

So…..my point is, even when we are a bit slower, we don’t slow down. Hell, that’s when we are actually able to ramp it up.

If you are not doing external AND internal marketing consistently, you are behind your colleagues. Wake up. Dan Kennedy has a saying I follow. It’s YCDBSOYA. That stands for you can’t do business sitting on your ass.

I hate a liar but I love a hustler. I mean that in the ethical manner. Not hustling someone as in lying and cheating for financial gain. I mean hustling as in constantly busy getting the word out about how amazing your office is. The more you hustle in that manner, the more business you see. It’s magical like that.

You want a slow practice, sit on your butt in your office playing games on the computer. That’s exactly how you can accomplish that.

You would have a hard time coming up with any form of marketing that I either have not tried or am not currently doing. I’m probably doing some marketing you’ve never even thought of.

So, here’s your pro tip. When things get a little slower in the fall when the kids get back to school, that’s when you have the time it takes to really market effectively. So do it.

I may end up doing a marketing epsiode. I should totally do that. If I forget in the next several weeks, y’all send me an email or two and I’ll do it.

w/ Dr. Anthony Nicholson – (Part One) Decoding Chronic Pain

The first paper we’ll breeze across is a brand new one about the association between chiropractic use and opioid use.

First, It’s good to support the people that support you don’t you think? Well, ChiroUp certainly supports evidence-based practices.

If you’re a regular listener of our podcast, you know I used it since about June of 2018. Let me tell you about it.

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.

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

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

Item #1

OK, back to the research. As I mentioned, this first paper is called “Association Between Chiropractic Use and Opioid Receipt Among Patients with Spinal Pain: A Systematic Review and Meta-analysis” Now remember, systematic reviews and meta-analyses are at the top of the research pyramid. It was authored by Corcoran, et. al(K 2019). and published in Pain Medicine on September 27, 2019…whoa….that’s like last week. Scorching hot off the presses, watch out, don’t burn your finger prints off….

Why They Did It

They wanted to investigate the current evidence to determine if there is an association between chiropractic use and opioid receipt.

How They Did It

The study was as systematic review and meta-analysis
The databases mined for information were Medline, pubmed, embase, amed, cinahl, and web of science.
The search was through April 18 of 2018
They identified 874 articels
Those were whittled down to 6 articles
5 studies focused on back pain while one focused on neck pain

What They Found

In a random-effects analysis, chiropractic users had a 64% lower odds of receiving an opioid prescription than nonusers.

Bam pop snap!

Come on MDs, DOs, and all of your flock. It’s time to start turning the back and neck pain folks over to the profession that continually proves, through research I might add, that we can get them better safely, effectively, non-invasively, non-pharmaceutically, with better outcomes assessments, and better patient satisfaction than any other healthcare practitioner in the world.

If it’s really all about the patient, and you all REALLY mean that, then start referring these patients to evidence-informed chiropractors. Like yesterday.

If you want to try PT first, OK. Do that. Then, when PT isn’t as effective as the patient was hoping it to be, send them to an evidence-informed chiropractor.

That’s if it really is all about the patient.

Item #2

Item 2 is from Harvard Health Publishing from Harvard Medical School and is called “Foods that fight inflammation.” (2014)They published it in June of 2014. It’s an older study. Old Man River, that old man river….

They start by asking what does an anti-inflammatory diet do? Your body creates inflammation in response to anything it recognizes as foreign. Things like microbes, plant pollens, and chemicals. That’s great obviously but sometimes inflammation persists right? The article goes on to state that many major diseases like cancer, heart disease, diabetes, arthritis, depression, and even Alzheimer’s have been linked to long-standing, chronic inflammation.

Dr. Frank Hu, professor of nutrition and epidemiology in the Dept. of Nutrition at Harvard School of Public Health says, “Many experiemental studies have shown that components of foods or beverages may have anti-inflammatory effects.”

Wouldn’t it be nice if we can reduce our risk of these deadly serious diseases just by eating more of the right stuff?

First they list foods they have identified as CAUSING inflammation so that you can stay away from them. Take a deep breath, this is going to hurt a little bit. OK, it’s going to hurt a lot.

Refined carbohydrates – yes, white breads, pastries, noodles, yep I know
French Fries – no real loss there.
Soda and other sugar-sweetened drinks. Honestly, if you’re still drinking soda as an adult, you’re behind the curve.
Red Meat – like burgers, steaks, and processed meat like hot dogs and sausage. Although I saw a report this morning that red meat isn’t as bad as they thought.
Margarine – shortening, and lard

The anti-inflammatory foods they highlight are:

Tomatoes
Olive oil
Green leafy vegetables – spinach, kale, and collards
Nuts – almonds and walnuts
Fatty Fish – like salmon, mackerel, tune, and sardines
Fruits – strawberries, blueberries, cherries, and oranges.

That would be a brief overview of the article but I’d encourage you all to go read the whole thing. Very interesting stuff. I just wanted to give you the short version of it.

Store

Part of making your life easier is having the right patient education tools in your office. Tools that educate based on solid, researched information. We offer you that. It’s done for you. We are taking pre-orders right now for our brand new, evidence-based office brochures available at chiropracticforward.com. Just click the STORE link at the top right of the home page and you’ll be off and running. Just shoot me an email at dr.williams@chiropracticforward.com if something is out of sorts or isn’t working correctly.

If you’re like me, you get tired of answering the same old questions. Well, these brochures make great ways of educating while saving yourself time and breath. They’re also great for putting in take-home folders.

Go check them out at chiropracticforward.com under the store link. While you’re there, sign up for the newsletter won’t you? We won’t spam you. Just one email per week to remind you when the new episode comes out. That’s it.

Item #3

On to our last item here. It doesn’t have anything to do with musculoskeletal issues but might be a little something you could print up and put in your lobby for your patients to look over and think – Dayum.

It’s called “Association Between Screen Media Use and Academic Performance Among Children and Adolescents A Systematic Review and Meta-analysis” by Adelantado-Renau, et al and published in JAMA Pediatrics on September 23, 2019(Adelantado-Renau M 2019).

Why They Did It

They were trying to find out if there was any association between screen-based activites and academic performance areas among children and adolescents.

How They did It

They took 58 cross-sectional studies, television viewing and video game playing were inversely associated with academic performance.
In addition, it was more profound in adolescents than it was for the smaller children.

Wrap It Up

Television and video games were the worst of the screen time culprits.
This study suggests that education and public health professionals should consider screen media use supervision and reduction as strategies to improve the academic success of children and adolescents.

The Message

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

Chiropractic care is safe and cost-effective. It can decrease instances of surgery & disability. Chiropractors normally do this through conservative, non-surgical means with minimal time requirements or hassle to the patient.

And, if the patient develops a “preventative” mindset going forward from initial recovery, chiropractors 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.

That’s Chiropractic!

Contact

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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TuneIn

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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

(2014). “Foods that fight inflammation.” Harvard Health Publishing https://www.health.harvard.edu/staying-healthy/foods-that-fight-inflammation.
Adelantado-Renau M, M.-U. D., Cavero-Redondo, (2019). “Association Between Screen Media Use and Academic Performance Among Children and Adolescents A Systematic Review and Meta-analysis.” JAMA Pediatr.
K, C. (2019). “Association Between Chiropractic Use and Opioid Receipt Among Patients with Spinal Pain: A Systematic Review and Meta-analysis.” Pain Med.

Chiropractic Wins Again, Push Ups Say A Lot, Low Iron & The Disc

March 7, 2019 chiropracticforward 00:25:59 0 Comments

CF 064: Chiropractic Wins Again, Push Ups Say A Lot, Low Iron & The Disc

Today we’re going to talk about how chiropractic and spinal manipulative therapy win again, we’ll talk about how push ups may tell us more than what you see on the surface, we’ll discuss some new information on low back discs and how they’re affected by low iron, and then we’ll gloss over a paper on physical therapy to toss you some thought nuggets.

But first, jsut for my friend and collegue, Dr. Michael Henry down in Austin, here’s that ‘you know you love it’ bumper music. He’s a big fan.

OK, we are back. Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.

You have shimmied all 60’s like into Episode #64

Introduction

We’re here to advocate for chiropractic and to give you some awesome information to make your life easier from day-to-day. We’re going to keep you from wasting time in your week and give you confidence in your recommendations and treatments. And I feel confident in guaranteeing that to you if you listen and stick to it here at the Chiropractic Forward Podcast.

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Just click the STORE link at the top right of the home page and you’ll be off and running. Just shoot me an email at dr.williams@chiropracticforward.com if somehting is out of sorts or isn’t working correctly.

DACO

Let’s talk a bit about the Diplomate of the Academy of Chiropractic Orthopedists probgram also known as the DACO. I finished up all 50 of the required live hours this weekend down in Austin, TX during the Texas Chiropractic Association’s legislative seminar.

Not only did I get all of the hours wrapped up but I also got to see a lot of colleagues I have been doing battle along side with for the last 8 years or so. You may or may not know that the Texas Medical Association is particularly aggressive and attacks at will for anything and everything. Which means we have to constantly raise funds to defend the attacks.

It’s this cute thing we do with each other from year to year. It’s really a special relationship chiropractors have with the TMA. I keep thinking one day they’ll start listening to their own profession and leave us the hell alone but nope. Not so far. Not until they have full and complete control of chiropractic care in Texas. Which is not going to happen. Just so you know..

They sued us because 2 docs in texas who were Neuro Diplomates were doing VONT testing. I’d never even heard of VONT until this last time we got sued by TMA. IF you can give me a good reason why a neuro diplomate cannot do VONT testing, I’ll send you a candy bar or some chicklets or something like that.

It’s enough to make a guy crazy. I got to meet a lot of bright new people ready to help the TCA fight and overcome. Andrea Ohmann recently moved to Texas from Minnesota. She is in a hospital setting if I understood correctly. She’s a bright star to keep an eye on. I also need to thank Dr. Jamie Marshall for listening to us down in Conroe, TX. I really appreciate it!

I got to see Staff Sergeant Shilo Harris speak. I mentioned him a couple of episodes ago but I have to tell you, this man is a hell of a speaker and he’s in our corner specifically. He gives chiropractic care all of the credit for helping him get through all of his injuries and surgeries. He was blown up by an IED in Iraq and has been through absolute hell to get to where he is now and chiropractic was key to getting him there.

Very emotional and very impactful. I can’t imagine a legislator being confronted by him and his story and not being forced to see it our way. It’s powerful. Thanks to Shilo for eveything he’s doing for this profession. I hope you’ll go to http://shiloharris.com and see what he’s about.

Beyond that our DACO hours were taught by Jeffrey Miller who is a chiropractor on staff at the University of Missouri medical school. He’s not as sharp as a tack. He’s actually sharper than a tack and told me he’d love to join us on the podcast so I’m going to do us all a favor and get that set up. We also have Dr. Christine Goertz’s episode coming up quickly so keep your eyes peeled for that one too.

This get on with this deal here.

Item #1

Our first item here is called “Manipulative Therapies: What Works” and is authored by Dr. Michael Smith, an MD, and his herd of collegues. It was published in American Family Physician on Febraury 15, 2019(Smith M 2019). I got this one from Dr. William Lawson in Austin, TX who is a DABCO and a swell dude on top of that.

In case you missed it, this herd of authors are medical doctors. They start by saying that manipulative therapies include things like osteopathic manipulative treatment which is the same as chiropractic manipulative treatment.

They say that, when you compare manipulative therapy to oral analgesics, cervcial manipulation and/or mobilization appears to provide better short-term pain relief and improved funciton in patietns with neck pain.

They go on to say that manipulative therapy may be as effective as amitriptyline for treating migraine headaches and can reduce the frequency and intesity of pain.

While there is some evidence showing that manipulative therapy can reduce length of hospital stays for preterm infants, there is ZERO research for some of the other reasons we see chiropractors treating infants. Things like otitis media, colic, allergies, and respiratory conditions.

That was all in the abstract. That’s the medical world starting to take note. Can you hear it? When do the insurance companies start to take note as well?

THAT’S REALLY when our lives start changing. Oh happy day….I have a dream. A dream where we are no longer pursecuted for being right all the damn time. A dream that chiropractors don’t go around saying crazy crap and making the rest of us look bad. I have a dream people. I’m not going to pretend to be as good of an orator as Martin Luther King Jr. but you get the point.

You know that the more of these articles that come out, the more they have to start gathering steam. Turn on a light bulb at night in South Texas and see what happens. The bugs start swarming. Turn on this kind of light and you’ll see these articles begin catching more and more attention until we finally have a consensus in the medical field. A consensus that says, “Hell, looks like they’ve been onto something this whole time. We better take another look at it.”

This is an excellent paper. And we need to keep seeing this more and more. Even if they’re talking specifically about osteopathic manipulative therapy, we know that chiropractors do it too and, in fact, chiropractors do almost all of it these days. DO’s have moved almost completely to medicine. We are the ones moving joints. Make no mistake about it.

Item #2

Pushups…what can they tell us? Well, it appears they can tell us quite a lot from an article in StudyFinds called “Men Who Can Do More Than 40 Push-ups Far Less Likely To Develop Heart Disease.(Finds 2019)”

This article covers a new study that showed that men posessing the ability to perform 40 push-ups in one attempt are much less likely to suffer from heart disease wihtin the next 10 years.

They showed where middle-aged men who can put in more than 40 in a single try have a 96% less chance of having heart disease when compared to those who could complete no more than 10 push-ups.

So, it appears, to me…..that it’s time to start doing some push-ups muy pronto.

Item #3

This one comes to us from the American Journal of Translational Research and is called “Iron defficiency accelerates intervertebral disc degeneration through affectring the stability of DNA polymerase epsilon complex(Zhang C 2015).”

It was published in November of 2015 and appears to be mostly Chinese researchers. Could be Japanese, Korean, or Vietnamese but the name of the lead author is Chungiang Zhang and whole host of names that appear to be just as difficult to pronounce.

We will not get deep into the details here because I’m not too proud to admit that the information here goes far above my head in many ways. I’ve said it before, I’m no guru. I’m like Alex Trebec on Jeopardy. He delivers the info but I promise he’s no expert on every question coming across his lips. Lol.

But, when we stick with the basics, we see that iron serves as an important cofactor of iron-containging proteins that play critical roles in the maintenance of DNA stability and cell cycle progression. They say that disturbed iron homeostasis gives rise to things like cancer and anemia.

In addition, they say that they found clear correlation between iron deficiency and intervertebral disc degeneration.

They wrapped up their paper by saying, “In summary, our study suggests that iron deficiency is an important factor in the aggravation of IDD. Proper iron supplementation may be an effective strategy to alleviate the symptoms of patients with intervertebral disc degeneration.”

Item #4

Our last on the list, it has to do with PTs and is called “Minimal physical therapy utilization compared with higher physical therapy utilization for patients with low back pain: a systematic review,” authored by Heidi Ojha and a gaggle of others and published in Physiotherapy Theory and Practice in February 2019(Ojha H 2019).

This was a systematic review to compare the effects of minimal physical therapy utilization (two visits or less) vs. typical physical therapy utilization consisting of 3 or more visits on patient-important outcomes for patients with low back pain.

They say this research is needed because there is such variation in physical therapy use for those with low back pain.

Interestingly, they found that, when compared with minimal utilization, higher utilization demonstrated no significant differences on pain, disability, or quality of life at the 1-year follow-up.

Even more interesting was that the conclusion of the paper said the following, “While higher utilization may not result in significant improvements in patient-important outcomes, it may be more cost-effective for patients with chronic or complex LBP conditions when compared to minimal utilization.”

So, what the hell is that? It’s not going to make you any difference to see us a lot but the price point is agreeable so, by all means, we’d like to see you a crap load. Which isn’t as much as a crap ton. By the way. But I think you see what I mean.

I have noticed so many papers that basically cast a lot of doubt on PT in general while all we seem to find in regards to manipulative therapy are positive reaffirmation of the chiropractic profession.

It just makes me wonder where the tipping point is to be honest. When does the medical industry start to look at chiropractic as being more effective for these conditions that PT and making those referrals accordingly? I had some insight on a PT private group on Facebook a couple of weeks ago.

The PTs were piling on a chiropractor’s advertisement techniques. Let’s be fair, the DC was a knucklehead and wasn’t being honest and identifying himself as a chiropractor in his marketing but, for discussion purposes here, that’s beside the point.

They were bashing not only on that chiropractor but our profession as a whole. I bash on aspects of my profession as well but, where the rubber hits the road, we average better patient outcomes, we are safe, we are effective, and we average higher patient satisfaction. Even if some in our profession would win a county craziness competition.

Don’t believe me? Go listen to Episode #49 of this podcast where we go over the Parker-Gallup poll. Very interesting episode and there are some valuable marketing nuggets in that one for you as well. Definitely worth the listen.

Also Episode #26 talks about PTs and DCs. The age old grudge match. Go check them out and see what you think.

Some in our profession are simply imbeciles. That sounds harsh but for a time after graduating, I held no interest in furthering my education. I wanted to coast. I’d done the hard work, right? I was so smart already after all those years of college. Well, you don’t know what you don’t know. And, I can admit that for a few years there, I was an imbecile.

They learned enough to pass but that doesn’t make them smart or ethical and that’s sad. But again, when said and done, our profession consistently proves itself and is proven by insurance companies, governments, polls, surveys, and universities.

From what I’ve seen recently, I can’t say the same for them and I just can’t see where they feel they have some moral high ground or platform to stand on and spout a bunch of denigrating thoughts at us.

I thought it’d be a good idea once to refer to a PT. I had a car wreck patient and thought they could use PT and at that time, I wasn’t equipped to do much rehab. So onto the PT they went. In two damn weeks, the PT ran up a bill that would have literally taken me 4 months to run up. I was astounded. And, in that two week period, there was little to no improvement for the patient.

On a separate occasion, I had a disc patient finally settled down and doing great. She was very active and very much into working out. I had her disc settled down to a point that she thought she’d go get PT on top of what I was doing. She did not talk to me about it. She just did it. Her thought process was that it would just be that much better to combine the two. Chiropractic and PT. Honestly, that’s not bad thinking in theory.

She came back after one visit almost unable to walk or function. We tried and tried to get it to settle back down but she ended up taking herself to a surgeon to get our of pain. Sorry PTs. Quit talking smack and work with us instead of against us.

Ideally, PTs and chiropractors work hand in hand and complement each other. Many offices can and should operate in this manner. In reality though, I see PTs as great for post-operative rehab and rehab after certain types of injury. When it comes to joints and spines in general though, they can’t touch us. They talk bad about us, they steal services from us, they think they have the moral ground on us, but they can’t touch us.

Those of us practicing in an evidence-informed manner anyway. Those not practicing evidence-informed actually continue to provide them with whatever moral ground they believe they have.

I for one would like to move on from the beginnings and progress our profession much like the MDs have done over the last 150 years. They went from blood-letting, leeches, and labotomies to what they can do now. Yet, there’s still a part of our profession wanting to hold on dearly to our originations of 100+ years ago.

Chiropractors, let go. Progress. Practice current, in the current day and age. Practice evidence-informed. It’ll help you and it’ll help the profession in general.

That’s my opinion anyway. Take it or leave it.

This week, I want you to go forward with

Chiropractic wins and wins and wins again. We made the right decision. We just need to only use our powers for the good.
Push-ups….let’s get to doing them!
Iron deficiency for disc degeneration is something worth looking at.
When we are practicing evidence-informed chiropractic care, PTs only wish they could get the results we can get.

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The Message

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Patients should have the guarantee of having the best treatment offering the least harm.

That’s Chiropractic!

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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

Finds, S. (2019) “Men Who Can Do More Than 40 Push-Ups Far Less Likely To Develop Heart Disease.” StudyFinds.

Ojha H, M. M., Johnston M, (2019). “Minimal physical therapy utilization compared with higher physical therapy utilization for patients with low back pain: a systematic review.” Physio Theory Practice.

Smith M (2019). “Manipulative Therapies: What Works.” AMerican Family Physician 99(4): 248-252.

Zhang C (2015). “Iron deficiency accelerates intervertebral disc degeneration through affecting the stability of DNA polymerase epsilon complex.” Am J Transl Res 10(11): 3430-3442.

CF 041: w/ Dr. William Lawson – Research For Neck Pain

September 27, 2018 chiropracticforward 00:38:01 1,125 Comments

Research for neck pain

Today we’re going to talking with Dr. William Lawson from Austin, TX about research for neck pain and what research is available for it. While low back gets all of the attention in the research, neck pain has taken a back seat but not today!

But first, here’s that bumper music

OK, we are back. Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast because I’m the only one that’ll do it.

Have you taken the time to go to chiropracticforward.com and sign up for our newsletter? It’s important because doing that makes it easier to let you know when the newest episode goes live and we have a ton of ideas around here for the future and we want to be able to let you know about it. An email once per week isn’t going to make you crazy so please go do that so we’re on the same page.

I also want to let you know about our Facebook page AND our separate Facebook group because they’re important supplements to the podcast. Both are called Chiropractic Forward oddly enough. On the page, we let you all know when a new episode goes live and we share some quotes from the episodes. Through the private Facebook group, we share the papers we went over and lots of time we connect and discuss there so go join up and let’s connect.

We are honored to have you listening. Now, here we go with some vital information that we think can build confidence and improve your practice which will improve your life overall.

You have done the mashed potato all James Brown, 60’s style into Episode #41. You know what that means? It means it’s going to be cooler than usual episode.

Dr. William Lawson, Austin, TX

That’s because, as I mentioned before, we have a guest with us. Dr. William Lawson hails from Austin, TX and has his Diplomate of American Chiropractic Orthopedists designation. Yes, ladies and gentleman, I brought another DACO to you today. Last week, we had Dr. Brandon Steele, also a DACO, so you may be starting to notice a slight trend. We are going to get into the thick of things with research for neck pain.

I met Dr. Lawson through his involvement in the Texas Chiropractic Association. Dr. Lawson is responsible for getting the DACO program to come to Texas and for having the TCA host the program. He’s responsible in a roundabout way for getting me into this whole DACO mess and I thank him for it.

A little more about Dr. Lawson

Prior to attending Parker College of Chiropractic in Dallas, -Texas, I served in the United States Air Force.
Graduated from Parker College of Chiropractic 1993.
Designated Doctor with Tx Workers Compensation since 1996
He has the Diplomate American Academy of Integrative Medicine, college of pain management, 2000.
Dr. Lawson acheived Diplomate American Academy of Pain Management 2001.
Diplomate American Board of Chiropractic Orthopedists, 2002
Certified in acupuncture, 2004
Former hospital privileges Vista Hospital Houston and Pecan Valley Surgical Center in San Antonio.
Masters degree from UT Pan American in Health Care Administration, 2015
Current Chair of State Affairs with TCA
Current VP of Texas Council of Chiropractic Orthopedists.

Welcome to the show Dr. Lawson. Since we are friends, formality seems awkward, if you call me Jeff, I’ll call you what? William or Bill?

Questions for Dr. Lawson

When did you become a DACO and what was the impetus? What started that journey?

What have you noticed about yourself and about your business in regards to pre-DACO and post-DACO?

Let’s get into the research for neck pain. The first thing I want to say here is that we cannot talk about cervical manipulation without addressing the yoke the medical field has tried to lay on us for generations. That is the myth that chiropractors go around causing strokes in everyone all the time.

I took three episodes of this podcast to address this myth. The series is called “DEBUNKED: The Odd Myth That Chiropractors Cause Strokes” and are specifically episodes #13, #14, and #15. It’s just common sense talk and, if you have any questions in your mind prior to listening to them, they should all be answered by the time you are done.

I will link them in the show notes as well as the corresponding YouTube Video and the Blog so that you can get the information in your preferred method.

PODCAST EPISODES:

BLOG:

https://www.chiropracticforward.com/blog-post/debunked-the-odd-myth-that-chiropractors-cause-strokes-revisited/

YOUTUBE:

https://youtu.be/tRXpG_Ie0Rs

Now that we’ve addressed this craziness, we can get on with how well we take care of our neck pain patients.

Dr. Lawson, I want to hear from you as much as you want to be heard from so, please….if I cover something that you have some extra info on or you just want to add a comment to, please interrupt me and lay it on us!!

We’ll start with the oldest one we have tee-d up here and go to the most recent.

This first one is from 2001 and is called “A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain[1].” The lead author is G. Bronfort and, if I recall correctly, his full first name is Gert. If you’ve spent any time listening to our podcast, you’ve probably heard his name. He’s fairly prolific with research papers.

Why They Did It

Their stated goal for this project was to compare the effectiveness of rehab exercises vs. spinal manipulation for chronic neck pain. This one really focuses on research for neck pain.

What They Found

Patient satisfaction was higher spinal manipulation + exercise was superior to spinal manipulation alone
There was no statistical difference noted between the two groups
However, when combined, exercise + manipulation showed greater gains in all measures of strength, endurance, and range of motion.

Wrap It Up

The authors concluded, “For chronic neck pain, the use of strengthening exercise, whether in combination with spinal manipulation or in the form of a high-technology MedX program, appears to be more beneficial to patients with chronic neck pain than the use of spinal manipulation alone.”

Dr. Lawson, what’s your take on this study? At this point, it’s 17 years old. Is it relevant still and how?

Next paper, this one’s called, “Chronic mechanical neck pain in adults treated by manual therapy: a systematic review of change scores in randomized clinical trials[2].” It is by H. Vernon, et. al. and was published in the Journal of Manipulative Physiological Therapeutics in 2007.

Why They Did It

This was a systematic analysis of effectiveness in randomized clinical trials of chronic neck pain. The stipulations here are that the neck pain could not be caused by whiplash and could not include a headache or arm pain. Just straight up chronic neck pain.

What They Found

Out of 1980 papers, they found 16 to accept and include in this project.

No trials included trigger point therapy or manual traction

Wrap It Up

“There is moderate- to high-quality evidence that subjects with chronic neck pain not due to whiplash and without arm pain and headaches show clinically important improvements from a course of spinal manipulation or mobilization at 6, 12, and up to 104 weeks post-treatment. The current evidence does not support a similar level of benefit from massage.”

Dr. Lawson, on this study, for those that don’t know research hierarchy, a randomized clinical trial is some of the more reliable, solid research for neck pain wouldn’t you agree?

The only thing more impactful in the research world than randomized clinical trials are meta-analyses and systematic reviews. Well, this is a systematic review of 16 randomized clinical trials.

My point being: this is a reliable systematic review. No doubt about it. This is a great paper, Dr. Lawson and I have no idea how it’s escaped me 11 years into this thing. I have other papers by the same group of authors but somehow missed this research for neck pain?

Would you like to add any comments on this paper?

OK, moving on, this paper is called, “Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial[3].” This one comes to us by G. Bronfort, et. al. as well and was published in the Annals of Internal Medicine in 2012.

This is not my favorite research for neck pain as we’ll talk about after we go through the conclusion.

Why They Did It

“To determine the relative efficacy of spinal manipulation therapy (SMT), medication, and home exercise with advice (HEA) for acute and subacute neck pain in both the short and long term.”

How They Did It

It was a randomized controlled trial
They used 1 university research center and 1 pain management clinic in Minnesota
The sample was 272 people from 18-65 years old having nonspecific neck pain from 2-12 weeks
The treatment consisted of 12 weeks of spinal manipulative therapy or home exercise advice.

What They Found

For pain, SMT had a statistically significant advantage over medication after 8, 12, 26, and 52 weeks

Home exercise was superior to medication at 26 weeks

No important differences in pain were found between SMT and HEA at any time point

Wrap It Up

Bronfort concluded, “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.”

As I mentioned, I have covered this research for neck pain before but it’s not my favorite because this is also a paper that I have seen chiropractic detractors use against us. Here’s how: they say that cervical manipulation is extremely risky and, if the outcome of simple exercises at home is just as effective, then what’s the point in cervical manipulation for neck pain?

What would you say in response to this particular argument?

Keepin on keepin on here. This next one is from the Journal of Manipulative Physiological and Therapeutics back in 2014 called “Evidence-based guidelines for the chiropractic treatment of adults with neck pain[4].” This one was done by Bryans, et. al.

Why They Did It

They wanted to develop evidence-based treatment recommendations for the treatment of nonspecific mechanical neck pain in adults.

How They Did It

They did a systematic literature search of controlled clinical trials published through December of 2011 and then organized each into strong, moderate, weak, or conflicting)

What They Found

41 randomized controlled trials met the criteria for inclusion.

Strong recommendations were made for the treatment of chronic neck pain with manipulation, manual therapy, and exercise combined with modalities.

Strong recommendations were also made for treating chronic neck pain with stretching, strengthening, and endurance exercises alone.

Moderate recommendations were made for the treatment of acute neck pain with manipulation and mobilization in combination with other modalities.

Wrap It Up

The authors closed by saying, “Interventions commonly used in chiropractic care improve outcomes for the treatment of acute and chronic neck pain. Increased benefit has been shown in several instances where a multimodal approach to neck pain has been used.”

Do you feel like this is going a little more in our favor than the Bronfort paper but still leaves a little to be desired? For instance, when we look at low back pain papers, it’s clear. Spinal manipulation is as effective or more effective than anything else out there. Even physical therapy or exercise. We’re not getting that satisfaction so far. Am I wrong?

We’re trucking along here. Next paper titled “Mobilization versus manipulations versus sustain apophyseal natural glide techniques and interaction with psychological factors for patients with chronic neck pain: randomized controlled trial[5].” This one was published in European Journal of Physical Rehabilitation Medicine in 2015 and written by A. Lopez-Lopez, et. al.

Here’s my first question: “Why would you hyphenate the same name?” How can you be Lopez-Lopez and why would you want to say the name twice or make everyone else say the name twice? Isn’t it a bit redundant? Can we just say Lopez and move on?

OK, I get side-tracked sometimes so I have to get myself back on track here and there. Since I’m not familiar with this paper or the authors at all, I want to switch it up a little on this one.

Dr. Lawson Covers One

I want Dr. Lawson to go over this paper from top to bottom and tell us everything we need to know about this one. I see it’s a randomized controlled trial so it already has my attention. I’m unfamiliar with sustain natural glide (AKA SNAG). Is that term you are familiar with? This research for neck pain is all yours doc.

Their conclusion was “The results suggest that high velocity/low amplitude and posterior to anterior mobilization groups relieved pain at rest more than SNAG in patients with neck pain.”

Let’s get to our last paper here by Korthalis-de-bos, et. al. It’s called “Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial[6].” It was published in the British Medical Journal back in 2003.

Why They Did It

The authors wanted to evaluate the cost-effectiveness of physical therapy, manual therapy, and care by a general practitioner for patients with neck pain.

How They Did It

The project was an economic evaluation alongside a randomized controlled trial.
42 general practitioners recruited 183 neck pain patients
The patients were randomly split for treatment by spinal mobilization, physical therapy, or general practitioner care.

What They Found

The authors wrapped that research for neck pain up by saying, “Manual therapy which consisted of spinal mobilization, is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner.”

I wanted to wrap up our talk with that research for neck pain because, first of all, it’s from the British Medical Journal so it got some weight. Second it’s alongside randomized controlled trials, and third, it’s one of the main ones that cuts through the noise and says very clearly, “mobilizing the spine is more effective and cost less for neck pain than seeing your primary or a physical therapist.”

Mobilizing the spine is more effective and cost less for neck pain than seeing your primary or a physical therapist.

Click To Tweet

Is it just me or is it time to move focus from low back pain and put more effort an attention on how effectively we treat neck pain through research for neck pain?

It just makes complete sense to me. If we are so effective for low back pain in the eyes of researchers, why don’t we have the same pile of research for neck pain? Where is all of the research for neck pain? Both are mechanical in origin. If we can affect low back pain, it makes perfect sense that we can affect neck pain.

Chiropractors see it every single day. I’m not telling you anything. I just get so frustrated at the lack of focus on neck pain, which is part of the reason we’re doing this podcast today.

Dr. Lawson, what do you have to add here before we sign off?

I want to thank you for joining us on the Chiropractic Forward Podcast. I hope you’ve enjoyed it as much as I have.

Maybe we talk some DC PhD’s out there into making neck pain their next project.

Going forward

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 a mechanical pain and responds better to mechanical treatment instead of chemical treatments.

The literature is clear: research on neck pain and experience show that, in 80%-90% of headaches, neck, and back pain, patients get good to excellent results when compared to usual medical care and it’s safe, less expensive, and decreases chances of surgery and disability. It’s done conservatively and non-surgically with little time requirement or hassle for the patient. If done preventatively going forward, we can likely keep it that way while raising overall health! At the end of the day, patients have the right to the best treatment that does the least harm and THAT’S Chiropractic, folks.

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Being the #1 Chiropractic podcast in the world would be pretty darn cool.

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:

Dr. Jeff Williams – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & VloggerBibliography

1. Bronfort G, A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain. Spine (Phila Pa 1976), 2001. 26(7): p. 788-97.

2. Vernon H, H.B., Chronic mechanical neck pain in adults treated by manual therapy: a systematic review of change scores in randomized clinical trials. J Manipulative Physiol Ther, 2007. 30(6): p. 473-8.

3. 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.

4. Bryans R, Evidence-based guidelines for the chiropractic treatment of adults with neck pain. J Manipulative Physiol Ther, 2014. 37(1): p. 42-63.

5. Lopez-Lopez A, Mobilization versus manipulations versus sustain apophyseal natural glide techniques and interaction with psychological factors for patients with chronic neck pain: randomized controlled trial. Eur J Phys Rehabil Med, 2015. 51(2): p. 121-32.

6. 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.

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

CF 030: Integrating Chiropractors – What’s It Going To Take?

CF 020: Chiropractic Evolution or Extinction?

CF 039: Communicating Chiropractic

CF 031: No More High Risk & Useless Drugs From Here On – Getting Off Opioids

July 19, 2018 chiropracticforward 00:28:50 0 Comments

No More High Risk & Useless Drugs From Here On – Getting Off Opioids

Today we’re going to talk about getting off opioids. Even with the opioid crisis going crazy in our country, every single week, I have patients come in and they’ve been prescribed opioids as knee-jerk reactions right off the bat. We know that ain’t right! It’s time to start getting off opioids.

But first, here’s that bumper music

OK, we are back. Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.

Before we get started, I want to ask you to go to chiropracticforward.com and sign up for our newsletter. It makes it easier to let you know when the newest episode goes live and it’s just nice of you.

We are honored to have you listening. Now, here we go with some vital information that we think can build confidence and improve your practice which will improve your life overall. Big goals. It’s a thing, folks… shoot big, and even if you fail, you’re still getting somewhere you weren’t going previously. It’s a win-win.

You have sashayed all fancy like into Episode #31

I spent the weekend last week in Longview, TX. Folks, I swear if you just looked out to check the weather, your face would fry right up like a pork rind. And pork rinds are gross so, if you’re down South, keep your face in the house. The sun is downright dumb right now, at this point in time. Certainly in the South.

Now, let’s turn our attention to drugs. Or getting patients off of them. Getting off opioids. This brings to mind an uncle of mine. He’s having some chronic pain. Granted, he’s very elderly but, he’s always been a healthy guy. Always. No seriously bad habits. Nothing like that.

The doctor said he was going to try taking him off of some of his 16 medications to see if that helped. Lol. Ya think so doc? Holy smokes and save the gravy. Sixteen medications. Imagine the obstacle courses of side effects with every single one of the sixteen medications he was taking? It boggles the mind. Hell yes, he’s sick. When does this mentality change?

We hope with podcasts like this, like evidence-based chiropractic groups on social media. There are people out there like us screaming and hollering to make it happen.

I had a young lady in my office just two weeks ago. Probably about 24 or 25 years old. She had fairly acute low back pain and had gone to the Urgent Care for it the day before. Guess what they did? Gabapentin was their first-line choice. First line.

No sir, no ma’am. That is NOT in keeping with every known current recommendation from the medical field. Here it is lined out for you.

Chiropractic, exercise/rehab, heat, and massage, maybe acupuncture if it’s a chronic issue. Throw in cognitive behavioral therapy and some other therapies I’m not all that familiar with to round it out. Some guides will say aspirin, ibuprofen, etc..

Second line would mostly be the anti-inflammatories like ibuprofen and aspirin. We covered a study some time back on the blog where ibuprofen was shown more effective than Tylenol but, other than that, do as you will.

Last line would be injections, more serious medications, and very last would be surgery. This is all about getting off of opioids.

That’s the order. You don’t skip everything and go right to Gabapentin. Not anymore anyway. The word isn’t percolating through the ether right now and getting to the physicians seeing this stuff on the front line. It’s all about getting off opioids, folks.

Here’s why. Let’s start with this one called “Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis” by Oliver Enke, et. al. and published in CMAJ(Enke O 2018). CMAJ stands for the Canadian Medical Association Journal so, it’s basically JAMA for Canadians. By making this clear to the listeners here, you know this isn’t chiropractors picking apart medical doctors and medicine. This comes from the authorities in the medical field.

Why They Did It

There’s scant evidence that an anti-convulsant like gabapentin is effective for low back pain yet the incidence of its use has gained significantly recently. The authors here wanted to find out if there was actually any effectiveness for the medication for low back pain.

How They Did It

5 databases were used to search for prior info and research on the matter.
The outcomes were self-reported pain, disability, and adverse events
Risk of bias was assessed and taken into account
Quality of the info was assessed as well
The info was gathered and numbers put on the information to make it make sense.
9 trials compared Topiramate, Gabapentin, or Pregabalin to placebo
There were 859 participants

What They Found

14 out of 15 so…..93.3%….found anti-convulsants were not effective to reduce pain or disability in low back pain or lumbar radicular pain
There was HIGH-QUALITY evidence of no effect vs. placebo for chronic low back pain in the short term.
There was HIGH-QUALITY evidence of no effect for lumbar radicular pain in the immediate term
The lack of effectiveness also comes with HIGH-QUALITY evidence of an increased risk of bad side effects.

Wrap It Up

The authors wrapped it up by saying, “There is moderate- to high-quality evidence that anticonvulsants are ineffective for treatment of low back pain or lumbar radicular pain. There is high-quality evidence that gabapentinoids have a higher risk for adverse events.”

So, we can close the door on gabapentinoids right? Time shall tell. How are we going to do our part to get the word to the right folks on this? Shoot me your suggestions. Count me in.

OK, we know now that gabapentinoids are foolish to prescribe for low back pain. What about opioids? If you’ve been listening very long to the Chiropractic Forward Podcast, then you likely already know the answer. But I like to add to the pile so here we do with a new one called “Changes in pain intensity following discontinuation of long-term opioid therapy for chronic non-cancer pain” by McPerson, et. al. and published in the Journal of the International Association for the Study of Pain. This paper was published on June 13 of 2018. (McPherson S 2018)

Why They Did It

The objective of this study was to characterize pain intensity following opioid discontinuation over 12 months.

How They Did it

The paper was a retrospective VA administrative data study
551 patients were identified and included.
They took data over a 24 month time period which included 12 months before discontinuation and 12 months after discontinuation.
The Numeric Rating Scale for pain was used as an outcome assessment

Wrap It Up

“Pain intensity following discontinuation of LTOT does not, on average, worsen for patients and may slightly improve, particularly for patients with mild-to-moderate pain at the time of discontinuation. Clinicians should consider these findings when discussing risks of opioid therapy and potential benefits of opioid taper with patients.”

Well then, getting off of opioids should be easy. All of the info tells they do no good anyways right?

I had a new patient come in today. She’s 23. Last year, she had discectomies at three different levels. Can you imagine? Now, to be fair to the surgeon, she tried two months of physical therapy and was still unable to work or function in her daily life. She would intermittently go numb from the waist down. That’s big stuff but, should she have had surgery that quickly?

Does that mean she had cauda equina syndrome? Well….maybe. Numb from the waist down sort of sounds like it but did that include loss of bowel or bladder control? I’m not sure yet. I’m going to find out more about it as we treat. The surgeon may have been correct if it was indeed cauda equina and I’m not one to second-guess the guy right now going off of what I know right now.

The main point here is that she said she was on all kinds of meds the whole time and afterward and is still on gabapentin and trying to wean herself off of it. I went over the Canadian Medical Journal article we just went over at the start of this podcast and showed her how it’s doing nothing for her. She said she knows that. It doesn’t help her one bit but she has withdrawal issues if she takes less than a certain amount per day. These folks need our help and I hope I’m able to do my part for her.

We can avoid this stuff. I hate that I’m getting to her afterward though. I have to tell you. What if, on top of physical therapy (which I don’t see doing a ton of good for discs in my experience), what if on top of PT she would have been told to do massage, spinal manipulation, and I would argue spinal decompression and cold laser as well? Did she try an inversion table at all? What about Tai Chi, yoga, cognitive behavior therapy?

What I’m saying here is that PT is just part of the cocktail. The power is when PT is mixed with the rest. We are getting off opioids, folks.

I have shown you all paper after paper showing evidence-based proof of the effectiveness of chiropractic care but how about some cultural proof? Let’s do it!

What name is more respected by consumers in American than Consumer Reports? Honestly, I remember the name from when I was a kid. Consumer Reports is ingrained in the membrane, isn’t it? I say that it is so it must be so.

Here is an article from Consumer Reports from May 4, 2017(Carr T 2017). Just over a year ago.

The article talks about Thomas Sells, a veteran receiving alternative therapies through the VA. Along with chiropractic care, the article mentions alternatives for low back pain treatment like tai chi, yoga, massage, and physical therapy.

The article says, “Growing research shows that a combination of hands-on therapies and other nondrug measures can be just as effective as more traditional forms of back care, including drugs and surgery. And they’re much safer.”

That feels pretty nice, doesn’t it? Just a little “Awwww yeah…..”

They refer to the updated recommendations from the American College of Physicians that we have mentioned a million times here on the Chiropractic Forward Podcast. Even with only having had 31 episodes, we’ve probably mentioned it that many times.

They also mention a prior Consumer Report survey of 3,562 back pain sufferers where over 80% of them had tried yoga, tai chi, massage, or chiropractic and said it helped.

A big kudos to Consumer Report for also saying this, “But here’s the problem: People also told us that their insurers were far more likely to cover visits to doctors than those for non-drug treatments—and that they would have gone for more of that kind of treatment if it had been covered by their health insurance.”

Remember in the previous episodes where we have talked about the White House report that said clearly that CMS and health insurance policies in general “create barriers” to a patient seeking out effective, but an alternative, means of treatment? The link is in the show notes for your perusal.(2017)

https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Final_Report_Draft_11-3-2017.pdf

Well, there you have it. Right there in Consumer Reports.

They also include a great quote from a woman in St. Charles, Illinois, “Spinal manipulation did me a world of good. My chiropractor had me do a lot of exercises on my own, which I continue to do. I’m so happy to get my active life back.”

We, chiropractors, see and hear this stuff all of the time but, the average Joe reading Consumer Reports or some other popular publication doesn’t usually.

This week, I want you to go forward with the knowledge that this profession is moving ahead. Not at a snail’s pace either. It’s moving fast right now. Paper after paper is coming out and 99% are in our favor.

Not only are we moving ahead, we’re moving ahead with help. Help from the big boys. Help from the White House to a certain extent, help from Congress to a certain extent (VA Bills), help from the medical profession to a certain extent, and help from your evidence-based colleagues like this podcast, the Forward Thinking Chiropractor podcast, the Evidence-based chiropractors facebook group, and other groups similar to them.

This stuff is happening. You can hold onto your ideas whatever they may be but I’m telling you, the door is cracked open and, if we are to bust that sucker down and shatter it into splinters, we will only do it through research and through an integration or merging of our profession with the thoughts and actions of other professions.

Key Takeaways

We can get these folks off useless and harmful drugs and we can help keep more from becoming addicted. The process of getting off opioids has begun.
You are educated at a level that you should never be intimidated or nervous to tell a GP that gabapentin is no longer a first-line treatment. Do it for yourself, do it for your patients, and do it for future patients. If not you, then who?

When you look at the body of literature, it is clear: research and clinical experience show that, in about 80%-90% of headaches, neck, and back pain, patients get good to excellent results with Chiropractic when compared to usual medical care. It’s safe, less expensive, decreases chances of surgery and disability. Chiropractors do it conservatively and non-surgically with little time requirement or hassle for the patient. And, if the patient has a “preventative” mindset going forward, chiropractors can likely keep it that way while raising the general, overall level of health! At the end of the day, patients have the right to the best treatment that does the least harm and THAT’S Chiropractic, folks.

Please feel free to send us an email at dr dot williams at chiropracticforward.com and let us know what you think or what suggestions you may have for us for future episodes. Feedback and constructive criticism is a blessing and we want to hear from you on a range of topics so bring it on folks!

If you love what you hear, be sure to check out www.chiropracticforward.com. We want to ask you to share us with your network and help us build this podcast into the #1 Chiropractic podcast in the world.

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

https://www.chiropracticforward.com

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CF 019: Non-Opioid More Effective While Chiropractic Maintenance May Be The Most Effective

CF 026: Chiropractic Better Than Physical Therapy and Usual Medical Care For Musculoskeletal Issues

Bibliography

(2017). The President’s Commission on Combating Drug Addiction and The Opioid Crisis.

Carr T. (2017). “The Better Way to Get Back Pain Relief: Growing research suggests that drugs and surgery may not be the answer for your bad back.” Consumer Report Retrieved May 4, 2017, from https://www.consumerreports.org/back-pain/the-better-way-to-get-back-pain-relief/.

Enke O (2018). “Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis.” CMAJ(190): E786-793.

McPherson S (2018). “Changes in Pain Intensity Following Discontinuation of Long-Term Opioid Therapy for Chronic Non-Cancer Pain.” PAIN.

Getting off opioids

CF 025: Vets With Low Back Pain. Usual Care + Chiropractic vs. Usual Care Alone

June 7, 2018 chiropracticforward 00:21:29 0 Comments

Vets With Low Back Pain: Usual Care + Chiropractic vs. Usual Care Alone

Today we’re going to talk about our vets with low back pain. We have already shown how chiropractic is backed completely by research for low back pain. For us, that’s not even in question. But, this week, there’s brand new research out in JAMA, yes, THAT JAMA, talking about vets with low back pain and chiropractic.

But first, make way for that bumper music

OK, we are back. Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.

I want to humbly, with my hat in my hand and puppy dog eyes ask you to go to chiropracticforward.com and sign up for our newsletter. Make it easy on us to update you when a new episode come out. It’s just the nice thing to do folks.

On another note, do you need an hour or two for your Continuing Education seminar on low back pain guidelines or on Debunking the myth that chiropractors cause strokes? Do you need a guest for YOUR podcast?

Look no further, you have found your man. Just send me an email at dr.williams@chiropracticforward.com and we will get it done. Heck, we’re trying to get the word out about what we’re doing here don’t ya know?

We are honored to have you listening today. Here we go with some vital information that we think can build confidence and improve your practice which will improve your life overall. That’s a tall order but that is the goal

You have grooved nice and easy……. 70’s style right into Episode #25

As you may have heard me say several times before, I’m in practice. Day to day, week to week, month to month. In fact, I’ve been in active daily practice for over 20 years. I’ve answered the phones, booked the appointments, been an associate that basically answered to a receptionist. I’ve also been a busy chiropractor having a hard time keeping up with my own head.

I tell you this because I think it’s important to know that the information you get from me is not only from research journals but is also from daily experience. Twenty years of it at this point!

When we start discussing active military and veterans, if you’ve been in practice very long at all, you know these men and women are hurting and, many times, are not getting the help they desperately need. I see them every week. I’m actually in the process of signing up for the Choice Program as we speak so I can see more and more of them. Vets with low back painare a priority.

As a side note, you’d think that veterans are among the most honorable of all American citizens wouldn’t you? And wouldn’t you expect that the most honorable of all Americans would be worthy of healthcare that adequately addresses their needs based on current research and knowledge?

you’d think that veterans are among the most honorable of all American citizens wouldn’t you? And wouldn’t you expect that the most honorable of all Americans would be worthy of healthcare that adequately addresses their needs based on current research and knowledge?

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One would think but, as we see over and over, that just isn’t the case, unfortunately.

Here’s one example, a friend of mine….her father is in the VA hospital right now with several issues. She went to visit and was looking for his room. When she asked a staffer for directions, they directed her through this plywood board attached to a door that kind of opened up all together and allowed passage into the hallway that led to his room. Can you imagine our veterans being in a place that has plywood boarded up on the doors? One door…..any damn door?

Another would be the father of a friend of mine. He died waiting on a referral to a pulmonologist through the Choice Program. He couldn’t just go and make his own appointment. Not if he wanted it covered anyway. The VA system failed this decorated Vietnam Vet whereas medical professionals made it clear to him that his pulmonary hypertension could be treated after seeing a specialist to determine his specific level of PH. Well, the referral didn’t come and time ran out. Doesn’t seem right does it?

Let’s get to the musculoskeletal part of things. Military services leads to a high rate of chronic pain. That is just the facts. Knowing this fact, it is not surprising that veterans succumb to opioid overdose at twice the rate of the general population. That is just astonishing. It’s understandable but astonishing just the same. Not only were they twice as likely to succumb to opioid overdose, but they were twice as likely to be prescribed opioids in the first place!

One would think with the new recommendations from international low back experts published in The Lancet, new recommendations from the American College of Physicians, and the mountains of randomized controlled trials showing the efficacy of Chiropractic Care of low back pain, you’d expect to have an automatic referral from the VA primary care physicians. But, again, common sense doesn’t alway seem to reign in the medical kingdom. Money, politics, group-think, and false dogmatic believes of yesteryear tend to control the thought process. In my opinion, of course.

If you are unaware of the body of research, I’m sure this just sounds like belly-aching. I’m telling you as straightforward and as honestly as I can, chiropractic’s effectiveness has been proven through research so many times I can’t begin to count. We have been shown to be as effective or more effect than medication including NSAIDS. On top of that, we recently talked about research showing opioids having less effectiveness than NSAIDS. Veterans need a source of treatment for their musculoskeletal pain that is non-pharmacological, cost-effective, and has a high degree of overall effectiveness.

Everything and everyone already mentioned in this podcast (The Lancet, ACP, etc…) agrees one of those options is Chiropractic specifically. Especially when it comes to vets with low back pain.

With all of that in mind, let’s get into the paper that recently came out in the Journal of the American Medical Association (JAMA). It’s titled “Effect of Usual Medical Care Plus Chiropractic Care vs. Usual Medical Care Alone on Pain and Disability Among US Service Members With Low Back Pain,” and authored by Dr. Christine Goetz, DC, PhD.

It was published in May of 2018(Goertz C 2018).

Why They Did It

The authors recognized the need for non-pharmacological low back pain treatments and hoped to determine if chiropractic care being added to traditional medical care resulted in a better outcome than if the chiropractic care was left out completely for vets with low back pain.

How They Did It

For you research nerds, the paper was a 3-site pragmatic comparative effectiveness clinical trial using adaptive allocation
It was conducted from September 28, 2012 to February 13, 2016
The sites studied included 2 large military medical centers and 1 smaller hospital at a military training site.
Active duty aged 18-50 with low back pain originating in the musculoskeletal system were accepted for the study
Outcomes used were low back pain intensity measured through the Numerical Rating Scale (NRS) and disability using the Roland Morris Disability Questionnaire.
Secondary outcomes measured were perceived improvement, satisfaction, and medication use.

What They Found

250 patients at each site were accepted.
750 total
The mean participant age was 30.9
23% were female
32.4% were non-white
Adjusted mean differences in scores at the 6-week mark were statistically significant favoring usual medical care PLUS Chiropractic Care.
There were no serious related adverse effects.

Wrap It Up

The authors concluded, “Chiropractic care, when added to usual medical care, resulted in moderate short-term improvements in low back pain intensity and disability in active-duty military personnel. This trial provides additional support for the inclusion of chiropractic care as a component of multidisciplinary health care for low back pain, as currently recommended in existing guidelines. However, study limitations illustrate that further research is needed to understand longer-term outcomes as well as how patient heterogeneity and intervention variations affect patient responses to chiropractic care.”

I realize this is a brand new paper. I also realize that Dr. Goertz is among the leaders of the body of research when it comes to chiropractic. This is exactly why I question the need for further research to understand longer-term outcomes. We have had longer-term outcomes research. Plenty of them as a matter of fact.

If you go to this paper’s website and click on the link you’ll find in the show notes, ( https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2680417 ) you’ll notice that you can click on a “Comments” icon just under the “Download PDF” icon.

If you navigate to that Comment section and click on it, you’ll notice the following quote from May 21, 2018 from Dr. Frederick Rivara, MD, MPH at the University of Washington in Seattle, “As a sufferer myself of chronic low back pain, I was very interested to see the results of this comparative effectiveness trial. To me, it points out the importance of integrated care for the treatment of chronic conditions. What are the likely barriers to implementing this in medical practices in general? Do we really need more research on the right treatments for low back pain?” Here is Dr. Rivara’s stated conflict of interest at the end of the quote: he’s the Editor in Chief of JAMA Network Open. The Editor in Chief made that statement folks. He gets it. Now it’s time for the rest of the medical kingdom to get it.

Key Takeaways

We don’t need any more research into whether low back pain is effectively treated with chiropractic care. It’s been done a hundred times over. What we need is acceptance and a shift in the groupthink of the medical field. When it comes to treating vets with low back pain, there is no better starting point than chiropractic care.
We also need to chiropractors to step up and take the golden scepter the medical field had dangled out there. It’s ours for the taking.
We also need more research into the effectiveness of chiropractic care for headaches and neck pain. The research is there supporting our effectiveness. No doubt about it. But, it needs to be there by the hundreds just like you see in low back pain. There needs to be so much of it that the deniers start to look like flat-Earthers in the healthcare world.

We don’t need any more research into whether low back pain is effectively treated with chiropractic care. It’s been done a hundred times over. What we need is acceptance and a shift in the groupthink of the medical field.

Click To Tweet

This week, I want you to go forward with doing some of your own research on vets and opioids, on Chiropractic and low back pain, and on the Choice Program through the VA. We can help our active military and our vets. We can help them better than anyone else for their low back pain and that includes physical therapists. There is research showing that exercise/rehab + chiropractic is more effective than exercise/rehab alone(Korthals-de Bos IB 2003, Coulter I 2018).

Either way you boil it down, we win. We can help these people so help me figure out how we get that message out there and how we’re supposed to reach out and grab it for our profession.

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I want you to know with absolute certainty that When Chiropractic is at its best, you cannot beat the risk vs reward ratio. Plain and simple. Spinal pain is a mechanical pain and responds better to mechanical treatment rather than chemical treatment such as pain killers, muscle relaxants, and anti-inflammatories.

When you look at the body of literature, it is clear: research and clinical experience shows that, in about 80%-90% of headaches, neck, and back pain, compared to the traditional medical model, patients get good to excellent results with Chiropractic. It’s safe, more cost-effective, decreases chances of surgery, and reduces chances of becoming disabled. We do this conservatively and non-surgically with minimal time requirements and hassle on the part of the patient. And, if the patient develops a “preventative” mindset going forward, we can likely keep it that way while raising the general, overall level of health! And patients have the right to the best treatment that does the least harm. THAT’S Chiropractic folks.

If you love what you hear, be sure to check out www.chiropracticforward.com. We want to ask you to share us with you network and help us build this podcast into the #1 Chiropractic evidence-based podcast in the world.

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

Social Media Links

iTunes

https://itunes.apple.com/us/podcast/chiropractic-forward-podcast-chiropractors-practicing/id1331554445?mt=2

Bibliography

Coulter I (2018). “Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis.” Spine 0(0).

Goertz C (2018). “Effect of Usual Medical Care Plus Chiropractic Care vs Usual Medical Care Alone on Pain and Disability Among US Service Members With Low Back Pain A Comparative Effectiveness Clinical Trial.” JAMA 1(1): E180105.

Korthals-de Bos IB (2003). “Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial.” British Medical Journal 326(7395): 911.

CF 024: They Laughed When I Said I Could Still Help After Back Surgery

May 31, 2018 chiropracticforward 00:19:49 0 Comments

They Laughed When I Said I Could Still Help After Back Surgery

Today, we’re going to talk about people coming into our office after having had back surgery wanting us to perform miracles. Well, why didn’t they come to us BEFORE the surgery would be my big question. We’ll toss all that stuff around today on the Chiropractic Forward Podcast.

But first, here’s that bumper music!

OK, we are back. Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.

Before we get started, I want to ask you to go to chiropracticforward.com and sign up for our newsletter. On another note, do you need an hour or two for your Continuing Education seminar on low back pain guidelines or on Debunking the myth that chiropractors cause strokes?

Go no further, you have found your man. Just send me an email at dr.williams@chiropracticforward.com and we will get it done.

You have done the electric slide right into Episode #24 and that’s exciting

Now, as I mentioned previously, how many times do chiropractors have new patients come through the doors but they’ve already had back surgery? They’ve had back surgery they hoped would be a quick fix usually. But it wasn’t.

Now, they’re sitting in your office, looking at you with a very scared and concerned face, and it’s up to you to lead the way and, hopefully, be able to provide them some sort of relief with your magical abilities.

I can tell you from 20 plus years of experience that it happens all of the time. At least a time or two per month for a busy practice. That’s what I would guess.

The truth is, sometimes we can help these back surgery people and sometimes we just can’t. I tell patients that surgery, many times, is permanent and anything we do toward trying to get some relief can be a little bit like pushing a wheelbarrow uphill. Depending on the weight in the wheelbarrow, we may get it to the top and we may not get it to the top but we’re sure as hell going to try while making sure we keep them safe from further damage.

At first glance, when you’re looking at an x-ray of a post-surgical patient, many times I find myself thinking, “What in the heck can I possibly do with this trainwreck.” I’m sure I’m not the only one to ever feel like that. It’s a little bit of a helpless feeling sometimes. Especially when you see parts missing like you’ll see in a laminectomy. Or when you see parts added like boney fusions or fusions with hardware. I get a sinking feeling in my stomach for patients like that. Back surgery is no joke.

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Especially when we know for a researched-fact that these patients most likely did not have to endure those procedures. For any reason. If you aren’t sure about that statement, please review our podcast episodes we did no The Lancet low back series. Episodes #16, #17, and #18 dealt with this very issue.

Back surgery is gaining in popularity while the outcomes show no change. They are no longer recommending surgery for acute or chronic low back pain. Period. Sure, cauda equina syndrome, foot drop, and severe symptoms like that may indicate surgical intervention but, otherwise, they say no shots, no surgery, no bed rest, and no medications.

Surgeries are gaining in popularity while the outcomes show no change. They are no longer recommending surgery for acute or chronic low back pain. Period.

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We will be hammering these things consistently until we start seeing some change. I can guarantee it.

OK, but…..what if nobody listened to the experts and they just did the surgery with no relief? Can we do anything about it?

Let’s look at a couple of possiblities:

The spine was fused years ago and now, due to the immobilization and increased workload on the segments above and below, the segments above and/or below begin to show signs of wear and tear.
The spine was not fused but the complaint never improved. This may be the case in people that have the microdiscectomies or epidural spinal injections.

Of course there are a lot of different, very specific outcomes that don’t fit in those two categories but I’d say these are the ones I commonly see.

Let’s take the first one: a fusion that caused issues above and below the fused segment. If you go through nonsurgical spinal decompression certification through the Kennedy Decompression Technique, you’ll be taught that a fusion with hardware is a hard contraindication. At least it was 6 years ago.

Assuming these people develop disc issues above or below the fusion, that would mean you can’t do any decompression on the site. An orthopedic surgeon that is familiar with non-surgical decompression however, may tell you that the segment is more solid after the fusion than it ever was before and decompression won’t cause any issues with the fusion itself.

OK, so, we’re stuck between two worlds on that and, honestly, if you’re an expert on this and you’re listening, email me at dr.williams@chiropracticforward.com and tell me your experience and understanding.

After bouncing the problem off of several highly trusted colleagues, I think a light pull on decompression is tolerated just fine and does in fact provide relief to fusion patients. No, you cannot pull them at 1/3 or 1/2 of their body weight. We’re talking a LIGHT pull. This combined with gentle McKenzie and Core exercises as well as self-management recommendations at home will go toward getting them back on their feet and getting back after it.

If any of you disagree, I’d love to talk about it. My first question would be, “What would the alternative be?”

I am by no means the final and ultimate opinion on this. We have to depend on trusted advice and clinical experience, don’t we? That’s just what I do and what I’ve found is that about 80% of patients just get better. There’s about 10% that gets better but not quite what we hoped for. Then there’s that 10% that …”Hey, we tried and it looks like I’m not your homey on this deal.”

Now, what about the second option? Let’s say that they had a discetomy back surgery but it was a failure (surprise surprise) and now it’s up to us to help the patient and attempt to keep them from enduring any more back surgery or shots. What do you do? Maybe I should say, “What do WE do?”

I say adjust them!! After a certain healing time has passed, of course.

I say we do all the other stuff I mentioned previously for them as well. We may do decmopression. We may do laser. We certainly do McKenzies, Core Building, McGill’s Big Three, no bed rest, and home self-management.

If you have paid much attention to our previous episodes then you know the American College of Physicians and the global panel of experts on low back pain that published the low back pain papers in The Lancet back in March of 2018 say that spinal mobilization is a researched and recommended first-line therapy for acute and chronic low back pain.

In my opinion, a discetomy doesn’t change these recommendations much. Sometimes, cases are so specific, that they just don’t get researched in depth for that certain instance.

However, I CAN offer a case study if you’re willing to listen.

It was titled, “Chiropractic/Rehabilitative Management of Post-Surgical Disc Herniation: A Retrospective Case Report” and was published in the Journal of Chiropractic Medicine in the Summer edition of 2004(Estadt G 2004).

Why They Did It

To explore management of lumbar disc herniation following sugery using a regimen of chiropractic manipulation and exercise/rehab.

How They Did It

The patient was a 54 yr old male
The patient had a history of acute low back pain with left sciatic pain down the left posterior thigh and lateral calf as well as numbness inthe bottom of the left foot.
The patient previously had steroid anti-inflammatory drugs and lumbar microdiscectomy surgery.
The patient did not recover completely.
The patient couldn’t walk without hurting and was unable to return to activities of daily living.
He was antalgic in flexion.
His lumbar range of motion was restricted in flexion as well as in extension.
He had a positive SLR as well as foot drop on the left.
Intervention consisted of patient education on posture, bending, and lifting.
Exercise/Rehab was started in-office progressing to at-home based exercise/rehab.
Active rehab was continued after early improvement (7 visits) in order to return lumbar spinal extensor strength.
The patient was ultimately released to home therapy and supportive chiropractic care and continued to show improvement.

Wrap It Up

The author concluded, “Management of postsurgical lumbar disc herniation with chiropractic and active rehabilitation is discussed. Spinal deconditioning and weakness of the lumbar spinal extensor muscles appeared to be related to the patient’s symptoms. Patient education on proper posture, proper lifting techniques, core stabilization exercises, active strengthening exercise and chiropractic manipulation appeared effective in this case.”

OK, a case study with one subject. What does that tell us as far as research goes? Very little. What is the impact of the Journal of Chiropractic Medicine? It’s peer-reviewed and it has an impact factor of 0.74 and has climbed significantly since 0.36 in 2011.

Although this case study is only one patient’s experience, from my own anecdotal evidence, I would come very close to guaranteeing you and betting the farm that these post back surgery results can be repeated time and time again.

Although this case study is only one patient’s experience, from my own anecdotal evidence, I would come very close to guaranteeing you and betting the farm that these results can be repeated time and time again.

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I’ve seen it time and time again. My experience tells me we can help these people. YOU can help these people. Back surgery doesn’t always mean we are helpless to pull out the power of chiropractic.

I want you to know with absolute certainty that when Chiropractic is at its best, you cannot beat the risk vs reward ratio. Plain and simple. Spinal pain is a mechanical pain and responds better to mechanical treatment rather than chemical treatment such as pain killers, muscle relaxants, and anti-inflammatories.

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

Social Media Links

iTunes

https://itunes.apple.com/us/podcast/chiropractic-forward-podcast-chiropractors-practicing/id1331554445?mt=2

Bibliography

Estadt G (2004). “Chiropractic/Rehabilitative Management of Post-Surgical Disc Herniation: A Retrospective Case Report.” Journal of Chiropractic Medicine 3(3): 108-115.

CF 020: Chiropractic Evolution or Extinction?

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

CF 021: Crazy Update On Run-Away Healthcare Spending in America

May 10, 2018 chiropracticforward 00:33:31 0 Comments

Crazy Update On Run-Away Healthcare Spending in America

In today’s podcast, we are going to talk about the crazy, run-away healthcare spending in America and we’re going to use an article straight from the leading authority, the Journal of the American Medical Association, to help us out.

Before we get started, I want to share with you how much have enjoyed getting this podcast up and running. I strongly doubt it’s as popular as the other great chiropractic podcasts that have been up and going for a couple of years now. Heck, Chiropractic Forward has just been going since December so, at this point, one would expect for us to still be trying to gain attention and trying to gain some ears. And…..we are. No doubt.

But I can say that is has been pure joy to look up the downloads for each episode and seeing that, no…..its not just me that finds this stuff fascinating. Lol. You guys and gals are starting to listen and starting to pay attention.

We’re still struggling for those like and retweets on Twitter.

That’s the frustrating part if I’m being honest. To KNOW that you have put together an effective article on how chiropractors do not cause strokes and then to have such a hard time getting the word out. It’s frustrating to be sure but it’s also part of building something new and exciting.

So, I will simply continue to remind you that we need your help if we are to make a difference and I will keep reminding you to like our Facebook page, follow us on Twitter, sign up for our weekly reminder newsletter through the form on our homepage, and share us with your network.

We would certainly appreciate that help. Some of you may have actually gotten to see me arguing the stroke issue on our Facebook page. My gosh, some people, you could hit them with a research book full of papers in your favor and some would still argue just to try to prevent being wrong.

Not only do I get to argue about stroke or whatever the topic may be, it always strays into generalized ignorant statements like, “Chiropractic is bunk.”

I can use research to absolutely wipe the floor with people like that. And, the irritating thing is that the people, or trolls spouting off like that are usually computer majors, musicians, or something else completely removed from healthcare.

It is enough to make a man insane if you allow it. So I don’t.

Anyway, check us on Twitter and Facebook. Every now and then, you may find an enthusiastic discussion. lol. To say the least.

Since I haven’t yet, I’ll introduce myself, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast. We are honored to have you listening. Now, here we go with some vital information that we think can build confidence and improve your practice which will improve your life overall. That’s a tall order but that is the goal.

You have shaked, shimmied, and rolled into Episode #21

I’d like to start by saying that it is good to see the medical world beginning to examine itself with a clear lens. We have seen them turn blind eyes to many things we notice and research notices. As we have mentioned, there has been little attention given to the updated recommendations in favor of chiropractic, massage, and acupuncture in February of 2017. It is yet to be known what, or if anything, will change following the series of low back pain papers recently published in The Lancet (March21, 2018).

As we have mentioned, there has been little attention given to the updated recommendations in favor of chiropractic, massage, and acupuncture in February of 2017. It is yet to be known what, or if anything, will change following the series of low back pain papers recently published in The Lancet (March21, 2018).

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I have been mentioning how I feel that the opioid crisis has opened many many doors recently in regards to the medical field, clinical pathways, and in they way they are starting to look at the costs. Kudos to those in the medical field for beginning to call out their own protocols and questions them for effectiveness vs. risk. Some procedures may be effective here and there but, in general, if the squeeze is not worth the push, then there is little to zero return on investment and it should be abandoned. Obviously, one’s health is different than a business stat sheet but the metaphor is a valid one I believe.

Obamacare was supposed to heal all of our healthcare woes, right? From what I can tell, all it did was squeeze out the middle class. The folks that make too much to be subsidized but do not make enough to not really care about the new jacked health insurance rates.

For example, the premiums here in Texas have doubled or tripled in many cases while the insurance companies cover less and less. The co-payments have gone from $15-$20 all the way up to $50 and even $100. The deductibles have gone from $250 or $1,000 all the way up to $5000 or $10,000. In addition, the insurance companies are now reimbursing healthcare providers less. in many cases, 3/4 less.

Did you know that here in Texas, where a medical radiologist was once reimbursed up to $28+ or so for reading a neck series, they now get paid in the ballpark of $7 for the same series? I promise the doctors are not living less of a life than they were prior to Obamacare. Not at all. But, what is likely happening unconsciously is they are probably reading more x-rays more quickly to attempt to make up for the reduction in their pay.

Would you agree that this may put patients at more risk? I’m not saying doctors make a conscious decision to put patients at risk but, if a professional in ANY industry has a house in town, a house and boat on the lake, 3 cars, time share on a private plane, and things of that nature, when their income is cut by 3/4 in some cases, they will tend to find ways to make that up in ways that make sense to them. Regardless of profession or industry.

Maybe Obamacare just makes them more efficient rather than raising the patient risk. I do not have the answer on this but I do know that radiologists are responsible for everything on a film and their license is at risk on each and every film. When the government cut their pay that dramatically, the government began putting people at more risk. In my opinion of course.

I am firmly on the side of the medical field on this issue. The same type of thing is currently happening with the chiropractic industry as well. We are being reimbursed at smaller and smaller rates. We are seeing our covered patients being turned into cash patients whether we like it or not. The co-pays and deductibles are so high, the could just as easily be cash patients for our purposes. For this very reason, you are seeing more and more chiropractors in America begin to look at changing over to a cash-based practice model and drop insurance contracts all together.

I’m not certain every bit of this discussion is completely on topic but let me tie it up and bring it home through the use of this research paper. This paper appeared in the Journal of the American Medical Association (JAMA) on March 23, 2018. It was titled “Health Care Spending in the United States and Other High-Income Countries” and was authored by Irene Papanicolas, PhD (Papanicolas I 2018).

Why They Did It
Healthcare spending in America is a long-time hot topic and issue that has never been adequately addressed. Part of the problem is that we Americans spend more than other high-income countries with little information that shows that any efforts to control expenses has done anything to help the problem.

These authors attempted to compare the big ticket items in healthcare in America with the same items in ten other high-income countries in an attempt to learn where improvement might be made here at home.

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How They Did It
Information was mostly gained from the Organization for Economic Cooperation and Development (OECD) from 2013-16. The OECD is an international organization comparing underlying differences in structural features, types of health care and social spending, and performance for several high-income countries.

What They Found
In 2016, America spent 17.8% of its gross domestic product on healthcare while the other 10 nations spent from 9.6%-12.4%.
Surprise, surprise….pharmaceutical costs spending per capita in America was $1443 vs. from $466-$939 in the other 10 countries. American doctors and patients love those pills. That is healthcare spending in America at its best.
90% of Americans are insured while 99%-100% were insured in the other 10 countries.
The U.S. has the highest proportion of private insurance when compared to the other 10 countries, which is 55.3%.
When it comes to smoking, Americans actually have the second lowest rate sitting at 11.4%
When we talk about obesity, the US has the highest proportion at 70.1%. Others range from 23.8%-63.4% for comparison purposes.
The US life expectancy was the lowest at 78.8 years.
US infant mortality was the highest rate of the 11 countries.
There was no real difference in the American physician workforce, nurse workforce, etc., when compared to the other 10 countries.
America has comparable numbers of hospital beds
Americans use MRIs and CTs when compared to the other 10 countries.
The US had similar rates of utilization for acute myocardial infarction, pneumonia, chronic obstructive pulmonary disease, hip replacements, knee replacements, and coronary artery bypass graft surgery.
Administrative costs of care in American stood at 8% while the same measure in the other 10 countries ranged from 1%-3%.
Salaries of physicians and nurses were higher in the US; for example, generalist physicians salaries were $218?173 in the US compared with a range of $86?607 to $154?126 in the other countries.

Wrap It Up
The authors of the paper concluded that, “The United States spent approximately twice as much as other high-income countries on medical care, yet utilization rates in the United States were largely similar to those in other nations.

The authors of the paper concluded that, “The United States spent approximately twice as much as other high-income countries on medical care, yet utilization rates in the United States were largely similar to those in other nations.

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Prices of labor and goods, including pharmaceuticals, and administrative costs appeared to be the major drivers of the difference in overall cost between the United States and other high-income countries”

My own wrap up would be that America spends twice as much money on healthcare while we have the highest rate of obesity, double the amount of pharmaceuticals, lower life expectancy, higher infant mortality, and higher administrative costs when we are compared to 10 other countries of similar income. Healthcare spending in America is out of hand.

That’s not good, folks. Not good at all. When do the pharmaceutical companies stop controlling the medical profession and the medical profession turn it around to control the pharmaceutical companies? When does that happen exactly?

Did you know that, from 1948 until 1996, there was a TV ban on running liquor ads? You may see beer or wine ads but you would never see Jim Beam running a commercial between Alf and Different Strokes. But, how often do we see pharmaceutical ads on TV these days? It’s a shame to be honest. Shouldn’t the doctor be the one that is informed on medications rather than a 320 million people that are almost completely uneducated on pharmaceuticals? Should patients be going into doctors’ offices ready to pressure them into a certain medication because they saw it on TV?

Should patients be going into doctors’ offices ready to pressure them into a certain medication because they saw it on TV?

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It is absolutely insane and should have been stopped at the first mention of it. To make it fair or legal or whatever may be the case, they state a long laundry list of all of the things that may happen to you if you take it. But, the information is delivered and people are influenced.

If a patient goes in for something like erectile dysfunction, the doctor tells them what they need. They don’t tell the doctor!! Do you see the problem here? If the patient goes in for potential blood clots, the doctor should be telling them they need a certain type of thinner. That is not the patient’s place in any country on the entire planet.

Not only do the pharma companies control patient mentality in this way but they attempt control of the physicians. Pharma reps are skilled at what they do. They are highly trained and very well-paid to effect influence in their market’s physicians. They take them on dinners, bring the office lunches, pay for trips, etc. You can spot them at any doctor’s office you go to. Just look for the well-dressed person in the waiting room with a clip board and a bag of goodies. That’s them!

I had a general practitioner that I had to finally fire. I had been living a bit unhealthy for several months when I went for a yearly checkup. My blood pressure was high. He immediately tried to put me on life-long meds. I was overweight and drank a 12-pack of Bud Light here and there while traveling in a band playing music. You might say that I used to be a little bit ornery. Again, I was admittedly behaving badly. His diagnosis was that I was depressed and needed an anti-depressant. Really?

Instead of trying some behavior modification, according to him, I needed life-long blood pressure meds and life-long antidepressant meds. Where does this mentality come from? What if we treat the CAUSE rather than the SYMPTOM?

First, I lost weight and started to behave. Guess what? My blood pressure returned to normal. As a result of ceasing traveling in a band, I basically quit drinking beer outside of social events. Boom! I was no longer depressed according to his definition.

This may seem like an extreme example to some but, it is my estimation that this sort of “doctoring” and “pill pushing” is far more common than one may even dream.

I am in no way against the medical field or against surgery or against medicine. I am against simple pill fixes. I’m against long-term meds when not needed. There are some conditions like diabetes or genetic high blood pressure that require long-term meds but, in many cases, they should be avoided. I’m against the medical field performing shots and surgeries and using opioids for musculoskeletal pains when the research is clear when it recommends chiropractic, massage, etc.. for those pains.

Basically, the medical field needs to stop thinking the pills are the be all – end all of healthcare and start looking more to the cause rather than just treating the symptoms. The physicians need to take the reins of their profession away from the pharmaceutical companies and wield the power over pharma that they attempt to wield over chiropractic and other alternative means of healthcare.

Enough about them for this episode. I want you to know with absolute certainty that When Chiropractic is at its best, you cannot beat the risk vs reward ratio. Plain and simple. Spinal pain is a mechanical pain and responds better to mechanical treatment rather than chemical treatment such as pain killers, muscle relaxants, and anti-inflammatories.

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

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

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

Bibliography
Papanicolas I (2018). “Health Care Spending in the United States and Other High-Income Countries.” JAMA 319(10): 1024-1039.

CF 019: Non-Opioid More Effective While Chiropractic Maintenance May Be The Most Effective

April 26, 2018 chiropracticforward 0:23:32 0 Comments

Non-Opioid More Effective While Chiropractic Maintenance May Be The Most Effective

This Chiropractic Forward podcast this week is a bit of a mishmash of a couple studies that will ultimately intertwine into a valid discussion including chiropractic maintenance and a discussion about non-opioid vs. opioids.

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.

Before we get started, I want to draw your attention our website at chiropracticforward.com. Just below the area where you can listen to the latest episode, you’ll see an area where you can sign up for our newsletter. I’d like to encourage you to sign up. It’s just an email about once a week to let you know when the episode is updated and what it’s about. Also, if something brand new pops up, we’ll be able to tell you about it quickly and easily.

You have moonwalked into episode #19. I hope you have enjoyed the previous episodes. Particularly the last six which were a part of a series all debunking the “Chiropractors Cause Strokes” myth and then another series of podcasts reviewing the lancet articles on low back pain. The Chiropractic profession NEEDS you to share those 6 episodes in particular

Now, since we have covered the impact of the opioid crisis exhaustively, I will cover it only briefly for reference purposes.

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 fits into the 20% that apparently never suffers from any low back pain.
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. Did you know that an equal number of patients first seek help with a chiropractor as seek help with a medical practitioner for back pain?
Back pain in general costs $100 billion dollars every year when you factor in lost wages and productivity, as well as legal and insurance overheads.

Should there be any doubting the necessity of non-pharmacologic treatments for low back pain at this point, then a person is simply beyond help. We can only refer you to a report from the Executive Office of the President of the United States’ report titled “The Underestimated Cost of the Opioid Crisis” put forth by the Council of Economic Advisers in November of 2017[1].

That reminds me, that paper citation as well as any others we talk about here will be in the show notes so always check out www.chiropracticforward.comfor those show notes.

The report paints a fairly complete picture of this national crisis. The medical field helped create the national crisis. Now, will they help put the fire out? It seems the answer to that question is, “Yes!”

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Now that the nation and the medical field understand the danger of opioids, we are certainly starting to see an increase in research having to do with opioids. A brand new paper of particular note was published March 6, 2018 in JAMA, performed by Dr. Erin Krebs, MD, et. al. and is titled “Effect of Opioid vs. Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain. The SPACE Randomized Clinical Trial [2].”

Why They Did It

The authors of this paper wanted to test opioids vs. nonopioids over a time span of twelve months for function, pain intensity, and adverse effects.

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How They Did It

240 subjects
12-month trial
Randomized with masked outcome assessments
Test subjects experienced moderate to severe chronic back, hip, or knee osteoarthritis pain despite analgesic use.
Interventions tested were opioids and nonopioids
The first step of the opioid group included immediate-release morphine, oxycodone, or hydrocodone/acetaminophen
The nonopioid group’s first step was acetaminophen or a nonsteroidal anti-inflammatory drug.
Medication was changed and/or adjusted within each group according to patient response.
The main outcome assessment used was Brief Pain Inventory (BPI) scale.

What They Found

240 subjects completed the trial
There was little difference between the two groups in terms of function over the course of the 12 months of testing.
Pain intensity was actually much more improved (statistically significant) in the NONopioid group.
Adverse harms (bad side-effects) were significantly greater in the opioid group.

Wrap It Up

The authors’ conclusion was, “Treatment with opioids was not superior to treatment with nonopioid medications for improving pain-related function over 12 months.

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Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain.”

Again, I don’t wish to belabor a point we have covered several times but, for the purpose of this discussion, we must mention them. The medical field is stepping up to the challenge slowly but, I would argue significantly. The American College of Physiciansupdated their treatment recommendations for chronic and acute low back pain just last year. In the report[3]they recommended spinal manipulation prior to taking ibuprofen or other over-the-counter NSAIDs for low back pain. One month later, in JAMA (the journal for the American Medical Association) there was a paper demonstrating the effectiveness of spinal manipulative therapy[4]. IN JAMA!! The significance of this cannot be overstated.

Next, let us talk a little bit about chiropractic treatment for low back pain, what it looks like, and whether chiropractic maintenance care really makes any sense. that recommend preventative (AKA Wellness Care) to their patient bases.

Let me start by stating my opinion and the opinion of most evidence-based chiropractors I would assume: active, complaint-focused treatment should have a start and it should have an end. Plain and simple, cut and dry. How does chiropractic maintenance fit in there?

If a patient is coming in for a complaint such as neck pain, the practitioner should decide whether the pain is acute, subacute, or chronic and, based on history and exam findings, be able to give some good, responsible recommendations for the treatment of the complaint. Typically, the acute schedule will be shorter in terms of treatments and time vs. a chronic condition. A chronic condition is more difficult to treat and one would reasonably expect the schedule for a chronic condition to be longer and more intense. The CCGPP guides[5]can be useful for this sort of decision-making.

Treatment recommendations aren’t always dependent on the date of injury.

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For example, Medicare has broken down how they value diagnosis codes into groups A-D. In their system, the secondary diagnosis codes can be the difference between seeing a patient only 12 times or as much as 30 visits for a specific complaint. A simple low back pain diagnosis or muscle spasm diagnosis garners 12 visits from Medicare while degeneration of lumbar intervertebral disk or lumbar spinal stenosis will indicate up to 30 visits for treatment.

In the personal injury world, according to the Quebec Taskforce on Whiplash Associated Disorders, if a patient is assessed with a Grade III whiplash, assuming complications, they can be treated up to 76 visits over 56 weeks. That’s a lot of treatment but the length of treatment reflects the severity of injury as a Grade III whiplash is associated with ligament tearing and/or neurological findings.

For more information on general guides for practice protocol, please reference a previous blog of ours on the topic at https://www.amarillochiropractor.com/valuable-reliable-expert-advice-clinical-guides-practice/or listen to our podcast at https://www.chiropracticforward.com. The guides can be found in Episode #5 which can be found at this link: https://www.chiropracticforward.com/2018/01/18/cf-episode-5-valuable-reliable-expert-advice-on-clinical-guides-for-your-practice/

What does all of that have to do with chiropractic maintenance care? The point being made is that there are a lot of different chiropractors. Seventy thousand plus in America alone and, although there are guidelines out there, chiropractors do not typically seem to have a general overall desire to implement them. One chiropractor may tell you that they will need to see a chronic neck pain patient 50 visits a year to clear it up while another may see the same condition for 18-20 visits. This is not only frustrating for chiropractors, it’s highly frustrating for patients as well.

Also consider that there is a common chiropractic perception by potential patients out there in the world that, if you go to a chiropractor, you will always have to go. For the rest of your life!

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Of course, this is not true but, don’t chiropractors commonly recommend preventative or chiropractic maintenance care that may resemble “rest of your life” care? It’s my opinion that once a complaint resolves, patients should see their chiropractor once a month. Minimally, they should be seen once every two months. That is chiropractic maintenance and that is my opinion. I will find more than a handful of chiropractors that will disagree with me on both ends of the spectrum but the key to the idea is “chiropractic maintenance” care in some sort of ongoing fashion.

There is research for chiropractic maintenance care. Take this paper from 2011 for example. It is by MK Senna, it’s titled “Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome?” and was published in the prestigious Spine journal[6]. For the purpose of this study, keep in mind that SMT stands for spinal manipulation therapy. Also of special note is that chiropractors perform over 90% of SMTs in America so I commonly interchange SMT or spinal manipulation therapy with the term “Chiropractic Adjustment.”

Why They Did It

The authors of this paper wanted to check how effective spinal manipulation, also known as chiropractic adjustments, would be for chronic nonspecific low back pain and if chiropractic maintenance adjustments were effective over the long-term in regards to pain levels and disability levels after the initial phase of treatment ended.

How They Did It

60 patients having chronic low back pain of at least six months duration
Randomized into three different groups:
12 treatments of fake treatment for one month
12 treatments of chiropractic adjustments for a month only
12 treatments for a month with maintenance adjustments added every 2 weeks for the following 9 months.
Outcome assessments measured for pain and disability, generic health status, and back-specific patient satisfaction at the beginning of treatment,

What They Found

Patients in groups 2 and 3 had significant reduction in pain and disability scores.
ONLY group 3, the group that had chiropractic maintenance adjustments added, had more reduction in pain and disability scores at the ten-month time interval.
The groups not having maintenance adjustments, pain and disability scores returned close to the levels experienced prior to treatment.

Wrap It Up

The authors conclusion is quoted as saying, “SMT is effective for the treatment of chronic nonspecific LBP. To obtain long-term benefit, this study suggests maintenance SM after the initial intensive manipulative therapy.”

Considering this research, it appears plausible, if not obvious, that chiropractic care in a long-term chiropractic maintenance use, is indeed effective in treating patients with chronic low back pain.

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For my own wrap up this week I would say simply this:

Low back pain is a significant issue for Americans
It is one of the biggest reasons people get hooked on opioids
As shown above, opioids are no more effective than non-opioids so why would anyone use them?
Chiropractic has been shown superior to nonopioids (specifically Diclofenac[7])
The big boys of the medical field (ACP and AMA) and the White House itself are recommending chiropractic for the treatment of low back pain before using even NSAIDs

So, why is this even in the discussion phase rather than the implementation phase? Why are we not inundated with low back pain patients at this very minute?

We have to go back to a different White House report that came out recently discussing the fact on page 57 of the report that although chiropractic has been proven effective, barriers to chiropractic treatment have been put in place by CMS and health insurance providers[8].

The specific wording is as follows: “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.” “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.”

It’s all there. It’s simple. All we can do is continue to tell everyone and beg for your help in telling everyone as well.

It is up to us to spread the good news and all it takes is hitting the Share button on social media. Retweet, help get the word out.

I challenge you to tell your people. It’s so easy but it takes a little initiative on your part. You actually have to do something now. Your profession is poised on the edge of stepping into a role it is uniquely able to fulfill and excel in but NOT unless we reach out and take that role and hold onto it.

Our effectiveness is proven. It’s time. Help us help you. I’m not asking for donations. I don’t want your money. I want your influence. So do us a favor if you will and share this information and, if it didn’t get the response you hoped for, share it again. Print out the parts of this article you find particularly effective and send it to medical practices in your area.

Make a difference.

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 “chiropractic maintenance” mindset going forward from initial recovery, we can likely keep it that way while raising the general, overall level of health! And patients have the right to the best treatment that does the least harm. THAT’S Chiropractic folks.

Please feel free to send us an email at dr dot williams at chiropracticforward.com and let us know what you think or what suggestions you may have for us for future episodes.

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.

Source Material

The Council of Economic Advisers, The Underestimated Cost of the Opioid Crisis. 2017: The Executive Office of the President of the United States of America.
Krebs E, Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain – The SPACE Randomized Clinical Trial.JAMA, 2018. 319(9): p. 872-882.

Qaseem A, Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians.Ann Intern Med, 2017. 4(166): p. 514-530.
Page N, Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain.Journal of American Medical Association (JAMA), 2107. 317(14): p. 1451-1460.
Baker G, Algorithms for the Chiropractic Management of Acute and Chronic Spine-Related Pain.Topics in Integrative Health Care, 2012. 3(4).
Senna MK, Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome?Spine (Phila Pa 1976), 2011. Aug 15; 36(18): p. 1427-37.
Wolfgang J, e.a., Spinal HVLA-Manipulation in Acute Nonspecific LBP: A Double Blinded Randomized Controlled Trial in Comparison With Diclofenac and Placebo.Spine, 2012. 38(7).
The President’s Commission on Combating Drug Addiction and The Opioid Crisis. 2017.

Wellness

Dr. William Lawson, Austin, TX

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We’re still struggling for those like and retweets on Twitter.

You have shaked, shimmied, and rolled into Episode #21

Non-Opioid More Effective While Chiropractic Maintenance May Be The Most Effective

So, why is this even in the discussion phase rather than the implementation phase? Why are we not inundated with low back pain patients at this very minute?

Make a difference.

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