CF 316: Chronic Pain Central Sensitization & Patient Barriers To Physical Therapy Today we’re going to talk about Chronic Pain Central Sensitization & Patient Barriers To PT and, I would argue….chiropractic care. 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 giving evidence-based chiropractic a little personality and making it profitable. We’re not the stuffy, elitist, pretentious kind of research. We’re research talk over a couple of beers. So grab you a bushel.  I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.  I’m so glad you’re spending your time with us learning together.  Chiropractors – I’m hiring at my personal clinic. I need talent, ambition, smarts, personality, and easy to get along with associates. If this is you and Amarillo, TX is your speed, send me an email at creekstonecare@gmail.com If you haven’t yet I have a few things you should do. 
  • Go to Amazon and check our my book called The Remarkable Truth About Chiropractic: A Unique Journey Into The Research. It’s excellent resource for you and is categorized into sections so the information is easy to find and written in a way that is easy to understand for everyone. It’s on Amazon. That’s the Remarkable Truth About Chiropractic by Jeff Williams. 
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You have found yourself smack dab in the middle of Episode #316 Now if you missed last week’s episode, we talked about The WHO’s Sources For Opinion On Spinal Manipulative Therapy (Part 6).  Make sure you don’t miss that info. Keep up with the class.  On the personal end of things….. Man, we’re going through some stuff at the office recently and it centers around collections. Remember when I said last week that practice is a big long game of whack-a-mole? Well, it’s a fact and what I’m currently dealing with is really a ‘death by a thousand cuts’ type of scenario with one glaringly large issue.  The bright neon sign issue right now is collections. We are billing appropriately but the checks aren’t showing up. We’ve had such a struggle with in-house billing in the past. We lost hundreds of thousands on that years ago so we’ve moved to off-site billers. We are now on our 4th, I believe.  I think we’re in the right spot with this one. However, in the transition, our collections have taken a nose dive and I mean a nose dive. As in, if we billed out $70k+, we had a collections of $28k. Right. Now, carry that out over 3 months with that kind of deficit, your resources that are meant to cover issues start to vanish fairly rapidly.  Remember, I have an overhead of $55k-$60k/month. I remember when I was younger and newer in practice. At the time, my overhead was about $25k. I was talking to an older chiro buddy of mine at a TX Chiro Assoc event and he told me his overhead was $45k/month. And he wasn’t integrated either. It blew me away. I couldn’t imagine having an overhead that high.  And…..well here we are. With 4 full time employees, a full-time NP, an acupuncturist, and 2 massage therapists…..it just sort of happens. All of the medical supplies….holy cow. That’s a pretty penny, folks. Massage supplies, acupuncture needles, 4,000 sq ft. Office, utilities…you get the point. It adds up fast and if you’re not cognizant of what’s up, it’ll get out of hand on you. That’s why I balance my own bank account each month. I know what’s coming in and what’s going out.  It’s why I know that we have a collections issue.  Remember we have death by a thousand cuts, right? Well, other issues of late are that we aren’t performing and charging for codes we could be. We’re letting cold laser patients walk out the door without doing laser. We’re letting exercise patients exit the building without doing their exerrcises. This is happening with patients that are covered under PI or on their insurance plan for rehab.  That’s just a training issue and we’re whacking that mole currently.  Another issue is that we’re still recovering from COVID on some level. In 2019, I had 220 more new patients over the course of that year than I had in 2023. What the hell? So, we’re whacking that mole by ramping up some marketing and website SEO efforts.  I have a call with the collection company today at lunch and I have addressed the other issues. Now, if we can get it happening on the collections, you’ll get to hear happy Jeff in future episodes. Yay!! Why do I share this stuff with you? I like to think this is not just a research article podcast. This is real life. If you know the struggles I’m dealing with and the successes I’m enjoying, you’re either going through the same and can learn, or you WILL be going through the same and can learn from my experiences.  Even when you’re riding the wave of success, things can short circuit and you have to always be paying attention so that you can catch it as quickly as possible so you can avoid disaster. After years of not having to give finances much consideration at all, it’s time to lean on some folks that owe the clinic money, lean on our biller a bit, get ourselves in order, and market.  Easy peasy right? I’ll keep you posted on our progress. Don’t cry for me, Argentina! You’ll be mad at me soon because I’ll be back to seeing 70+ new patients per month. Wait for it. When you’ve got my attention, you’ve got my attention and I have a tendency to really lean in and get focused. That’s where we are right now. While I don’t recommend it, it is a bit exhilerating. I’ll admit.  Item #1 Our first one today is called, “Nociplastic pain and central sensitization in patients with chronic pain conditions: a terminology update for clinicians” by Nijs et. Al. published in Brazillian Journal of Physical Therapy in May of 2023 and that’s hot enough! Remember, the citations can be found at chiropractscforward.com under this episode.  Nijs J, Malfliet A, Nishigami T. Nociplastic pain and central sensitization in patients with chronic pain conditions: a terminology update for clinicians. Braz J Phys Ther. 2023 May-Jun;27(3):100518. doi: 10.1016/j.bjpt.2023.100518. Epub 2023 Jun 14. PMID: 37348359; PMCID: PMC10314229. Why They Did It Acute pain has been tremendously beneficial throughout evolution as it enables us to identify potential harmful stimuli, and as it ensures we protect damaged tissue while it heals.  However, once evolved into a chronic state, its protective role diminishes with a wide range of negative and maladaptive sequelae that massively impact both the individual and society.  Neuroscientific research has significantly advanced our understanding about pain and chronic pain in particular, including the role of central (nervous system) sensitization in the generation and amplification of (persistent) pain experiences. This knowledge innovation created a massive implementation potential but also a challenge for clinicians to remain up-to-date in daily practice.  Particularly the variety of and rapid change in concepts and terminology used can be challenging for clinicians. For these reasons, this second part of the comprehensive pain management editorial series1 provides a terminology update regarding central sensitization and nociplastic pain in a clinically applicable way.  Essentially, central sensitization is the major underlying mechanism of nociplastic pain, which is a pain phenotype. To facilitate the understanding of the concept of central sensitization, it is crucial to understand that central sensitization is a homeostatic mechanism. This implies, similar to inflammation, that central sensitization is adaptive in the short term (e.g., in the days following surgery or following a motor vehicle accident). As such, it avoids further deterioration in acute pain situations.  However, central sensitization becomes maladaptive in the long term, with pain losing its protective value as commonly seen in patients with persistent pain (e.g., months after successful surgery or a motor vehicle accident).  In addition, central sensitization and inflammation – although physiologically very divert mechanisms – share many features, including the notion that multiple biomarkers together rather than a single gold standard are required for assuming its presence, the fact that they are both umbrella terms covering various clinical & biological presentations, that their clinical presentation varies substantially from patient to patient, and that they are both key mechanism in a wide variety of clinical conditions/diseases The presence of clinical features of central sensitization predicts poor treatment outcomes in patients with a variety of chronic pain conditions, at least when the treatment targets local tissues as the presumed source of nociception.  This applies to conservative interventions, but also to surgical interventions. These observations illustrate the need for early recognition of central sensitization in patients with chronic pain, in combination with tailored treatment. Item #2 Our last one today is called, “Patient-related barriers and enablers to the implementation of high-value physiotherapy for chronic pain: a systematic review”’ by Dickson et. Al. and published in Pain Medicine in February 2024 and that one’ll burn your damn eye brows off.  Cameron Dickson, Rutger M J de Zoete, Carolyn Berryman, Philip Weinstein, Kexun Kenneth Chen, Paul Rothmore, Patient-related barriers and enablers to the implementation of high-value physiotherapy for chronic pain: a systematic review, Pain Medicine, Volume 25, Issue 2, February 2024, Pages 104–115, https://doi.org/10.1093/pm/pnad134 Why They Did It To identify and synthesize patient-related barriers to… and enablers of ….the implementation of high-value physiotherapy (HVP) for chronic pain.  Furthermore, to review what patient-related interventions have been used to facilitate the implementation of high-value physiotherapy for chronic pain, as well as their efficacy. How They Did It The authors systematically searched the APA PsycInfo, Embase, CINAHL, Medline, Scopus, and PEDro databases for peer-reviewed studies (published in English) of adults with chronic pain.  They used the Theoretical Domains Framework of behavior change to synthesize identified themes relating to barriers and enablers. Outcomes from studies reporting on interventions were also qualitatively synthesized. What They Found
  • Fourteen studies reported on barriers and enablers, 8 of which related to exercise adherence. 
  • Themes common to barriers and enablers included perceived efficacy of treatment, interrelationship with the physiotherapist, exercise burden, and the patient’s understanding of exercise benefits. 
  • Other barriers included fear of movement, fragmented care, and cost. 
  • Ten studies explored interventions, 9 of which aimed to improve exercise adherence. 
  • Of these, evidence from 4 randomized controlled trials of technology-based interventions demonstrated improved exercise adherence among intervention groups compared with controls.
Wrap It Up
  • Patients with chronic pain experience barriers to high value PT, including their beliefs, the nature of their interaction with their physiotherapist, perceived treatment efficacy, and cost. 
  • Enablers include rapport with their physiotherapist, achievable exercises, and seamless cost-effective care. 
  • Technology-based interventions have demonstrated effectiveness at increasing exercise adherence. 
  • Our findings suggest that interventions seeking to enhance implementation of high value PT, need to consider the multifactorial barriers experienced by patients with chronic pain.
Alright, that’s it. Keep on keepin’ on. Keep changing our profession from your corner of the world. The world needs evidence-based, patient-centered practitioners driving the bus. The profession needs us in the ACA and involved in leadership of state associations. So quit griping about the profession if you’re doing nothing to make it better. Get active, get involved, and make it happen. Let’s get to the message. Same as it is every week.  Store Remember the evidence-informed brochures and posters at chiropracticforward.com.       

Purchase Dr. Williams’s book, a perfect educational tool and chiropractic research reference for the daily practitioner, from the Amazon store TODAY!

Chiropractic evidence-based products

Integrating Chiropractors

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    The Message I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment rather than chemical treatments like pills and shots. When compared to the traditional medical model, research and clinical experience show us patients can get good to excellent results for headaches, neck pain, back pain, and joint pain to name just a few. It’s safe and cost-effective can decrease surgeries & disability and we do it through conservative, non-surgical means with minimal hassle to the patient. And, if the patient treats preventatively after initial recovery, we can usually keep it that way while raising the overall level of health! Key Point: At the end of the day, patients should have the guarantee of having the best treatment that offers the least harm. When it comes to non-complicated musculoskeletal complaints…. That’s Chiropractic! Contact Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show and tell us your suggestions for future episodes.  Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on podcast platforms.  We know how this works by now. If you value something, you have to share it, interact with it, review it, talk about it from time to time, and actively hit a few buttons to support it here and there when asked. It really does make a big difference.  Connect We can’t wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward. Website
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