CF 141: Lancet Low Back Update & Movement Disorders Mean Pain

Today we’re going to talk about The Lancet Low Back Series Update and Movement Dysfunction and Pain

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.

I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.  

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Do it do it do it. 

You have found yourself smack dab in the middle of Episode #141

Now if you missed last week’s episode , we were joined by Dr. Chris Howson to talk about his job working in a hospital out-patient setting. Not an FQHC but the actual hospital. Pretty cool stuff. Make sure you don’t miss that info. Keep up with the class. 

While we’re on the topic of being smart, did you know that you can use our website as a resource? Quick and easy, you can go to chiropracticforward.com, click on Episodes, and use the search function to find whatever you want quickly and easily. With over 100 episodes in the tank and an average of 2-3 papers covered per episode, we have somewhere between 250 and 300 papers that can be quickly referenced along with their talking points. 

Just so you know, all of the research we talk about in each episode is cited in the show notes for each episode if you’re looking to dive in a little deeper. 

On the personal end of things…..

The kids are back in school. I know some parts of the country are still doing video, off-site learning but here in Texas they’re back at it on-site, in-person and I’m concerned about it. How could you not be. Unless you’re one of the conspiracy, it’s the same as the flu, science-haters of course. Sorry, my eyes just rolled out of my head. Let me pick those up real quick and pop them back in. 

Alright….so, my son is at Texas Tech in Lubbock living in the dorm with a room mate and riding the elevators with groups of kids and hanging out in dorm rooms and all that college stuff. I’m telling you all that I support the idea of trying to get back to normal but this is a recipe for disaster and it’s only a matter of time. 

It’s like having some dead, dry brush sitting there on the ground and tossing a match on it. All schools, if I’m guessing are on borrowed time because the same thing that happened in North Carolina and Notre Dame and however many are added to the list by the time this airs…..that’s going to happen across the country and this second wave the CDC thinks we’re getting control of is about to get out of control again. 

Then we’ll close down the in-person classes again and we’ll all have to sit at home and idle again for another 2 months before it calms down again. I truly feel this is going to happen for grades k through college. How can it not?

I know I know….we need to get back to normal, kids need to socialize with peers, some kids are in awful situations, some kids don’t eat if they’re not in school, I get it. 

But at the same time, it’s a real danger. It won’t be gone after the election in November. You guys that think that are going to be so sad. I know you won’t admit you’re wrong but that’s OK. Science-y people have seen your social media posts and know who you are and we’ll pray for some peace of mind for you. 

Time will tell if I’m right. I don’t want to be right. But I don’t see how it can go any other way. 

As far as business, same same same. Hell, if anything, like I said last week, it’s gotten even slower for us. With back to school being our slowest time of the year traditionally, it makes sense that it’s gotten slower. But I damn sure don’t like it. In fact, it makes me hyper as hell. 

This in spite of advertising like crazy and creating an online presence that is twice of what it was before the Rona came and destroyed an amazing practice. 

But, that’s OK. We were never promised a life with no bumps in the road. A worry-free life. Yeah, that’s not real life. We take challenges and obstacles and we adapt and overcome. And that’s where we’re at. Adapting and overcoming. 

Item #1

Here’s a new one that is actually an update to a key paper a couple of years ago. It’s by Buchbinder et. al. and called, “The Lancet Series call to action to reduce low value care for low back pain: an update” published in Pain in September of 2020(Buchbinder R 2020). Well hell, lookie here. It’s only September 3 and here we are, smoking, sizzlin’ and steaming hot. 

This is a bit long but it’s important. While Jan Hartvigsen, a chiropractor, is in this group of authors, the rest are not and, I’d argue, bent a bit toward the medical field and PT. They’ll claim they’re not profession specific but it just seems a little more bent to PT. However, the information is still very relevant to chiropractors and, relevant to the medical field and insurance industry. Unfortunately, none of those seem to be paying any attention. 

Now, this is not necessarily a research paper but more of a commentary so let’s dive in with a good solid summary of the contents here. Pay attention. I promise you’ll learn some factoids to put into your social media posts. 

  • The 2018 Lancet Low Back Pain Series, comprising 3 papers written by 31 authors from disparate disciplines and 12 different countries, raised unprecedented awareness of the rising global burden of low back pain partly attributable to poor quality health care.
  • The series described current guideline recommended care of low back pain, and new strategies that show promise, but require further testing, to reduce low value care.
  • Low back pain is still the number one cause of disability in the world
  • In 2015, low back pain was responsible for 60·1 million disability-adjusted life-years; a 54% increase since 1990
  • A recent study estimated that US$134.5 billion was spent on health care for low back and neck pain in 2016 in the United States, the most out of 154 conditions studied, and this had increased by 6.7% annually between 1996 and 2016
  • For the vast majority of people with low back pain, it is currently not possible to accurately identify specific causes or nociceptive sources. Risk factors and triggers for episodes of nonspecific low back pain include previous episodes of back pain, the presence of other chronic conditions such as asthma, headache, and diabetes, poor mental health (including psychological distress and depression), genetic influences, as well as awkward postures, lifting, bending and heavy manual tasks, and being tired or being distracted during an activity.44 Smoking, obesity, and low levels of physical activity, all related to poorer general health, are also associated with occurrence of low back pain episodes.
  • Many patietns with low back pain are still receiving the wrong care. Even 2 years after the series came out. 
  • A 2018 systematic review that included 14 studies mostly from the United States (6 studies), United Kingdom (3 studies), and other high-income countries found that overall more than 50% of people with low back pain seek care annually and 30% have sought care within the past month.
  • A 2012 study in a US Veterans Affairs Health Care facility found that 59% of outpatient lumbar spine scans were inappropriate.3 This suggests that unnecessary lumbar spine magnetic resonance imaging scans for people not suspected of having a serious condition cost $US300 million per year in the United States. 
  • This is supported by a 2019 systematic review (14 studies) which found evidence that imaging is associated with higher medical costs, increased health care utilization and more work absence compared with nonimaged groups. Despite little evidence to support its use for most back conditions,43 and a 20% failure rate, another US study estimated that $US12.8billion was spent on spinal fusion surgery in 2011, the highest aggregate hospital costs of any surgical procedure.
  • Major international clinical guidelines have moved away from medicalized management of low back pain and prioritized nonpharmacological approaches as first line care.
  • A Los Angeles Times investigation has revealed that aggressive marketing appears to be leading to new epidemics of opioid prescribing in low-income and middle-income countries.
  • Although the high rates of opioid prescribing are now beginning to fall in some high-income countries such as the United States74 and the United Kingdom,22 worryingly, opioid medication is being substituted for or used with gabapentinoids.
  • In England, the number of prescriptions for gabapentin and pregabalin were 30% and 56% more, respectively, in the 12 months to December 2019 than the 12 months to December 2015.73 In one study of 251 patients referred to a pain service in the Northeast of England, 82.5% were taking an opioid, over half of whom (56.2%) were also on gabapentinoids, while 16% of those on dual therapy were on high doses of both drugs.
  • Not only does the evidence not support use of gabapentinoids for nonspecific low back pain (or sciatica),27 studies in both Canada and Australia have reported an increased number of overdose deaths associated with dual opioid and gab apentinoid use.
  • UK National Institute for Health and Social Care Excellence did not find any randomised controlled trials of cannabinoids to treat low back pain and advised against their use for chronic pain in adults.
  • A four-year prospective observational study found cannabis users had greater pain and lower self-efficacy in managing pain, and there was no evidence it reduced pain severity or interference or exerted an opioid-sparing effect.
  • There is therefore an urgent need to address politician and public misconceptions about cannabinoids and preventive action to limit the same aggressive marketing approaches for medicinal cannabinoids that enabled the opioid epidemic; a new prescribing epidemic may be imminent.
  • Regenerative medicines such as autologous platelet-rich plasma or stem cell injections into degenerated lumbar discs or facet joints aims to help discs and/or joints regenerate. However, there is only a weak relationship between radiological change and the presence/absence of low back pain (eg, disc degeneration is present in 54% of those symptomatic with low back pain and 34% of those who are symptom free11), which means that even if these products successfully produce regeneration they are unlikely to affect low back pain for most people.
  • Much of the money spent on low back pain is wasted and better solutions are needed.
  • The Lancet Series identified promising solutions that included focused implementation of best practice, the redesign of clinical pathways, integrated health and occupational care, changes to payment systems and legislation, and public health and prevention strategies.30 Yet, we also indicated that most were not yet ready for widespread implementation as the evidence underpinning them was inadequate.
  • Targeted efforts to reduce overuse of imaging for low back pain, a major source of healthcare waste and even iatrogenesis, have not met with much success
  • Global initiatives to decrease health care waste and iatrogenesis such as Choosing Wisely are therefore specifically targeting imaging for low back pain8; however, large-scale impact of these initiatives have not yet been well documented.
  • A controlled before-after study of a spine care pathway that incorporated conservative spine care recommendations introduced in one primary care practice (with 11 primary care physicians) but not another (with 74 primary care physicians) reported a reduction in health care expenditure, mostly attributable to reduced spine surgery costs.90 Opioid utilization was also reduced while manual care costs were increased.

In summary:

The Lancet Low Back Pain Series outlined a way forward to address the increasing and costly effects of disabling low back pain. As a starting point, it garnered enormous media attention and continues to do so, but attention should now be directed towards engaging with consumers and patients, policy makers, clinicians, and researchers to identify and implement effective solutions. While effecting solutions will take time, measuring and benchmarking our progress in different countries will be crucial to these efforts.

Before we get to the next paper, I want to tell you a little about this new tool on the market called Drop Release. I love new toys! If you’re into soft tissue work, then it’s your new best friend. Heck if you’re just into getting more range of motion in your patients, then it’s your new best friend.

Drop Release uses fast stretch to stimulate the Golgi Tendon Organ reflex.  Which causes instant and dramatic muscle relaxation and can restore full ROM to restricted joints like shoulders and hips in seconds.  

Picture a T bar with a built-in drop piece.  This greatly reduces time needed for soft tissue treatment, leaving more time for other treatments per visit, or more patients per day.  Drop Release is like nothing else out there, and you almost gotta see it to understand, so check out the videos on the website.

It’s inventor, Dr. Chris Howson, from the great state of North Dakota, is a listener and friend. He offered our listeners a great discount on his product. When you order, if you put in the code ‘HOTSTUFF’ all one word….as in hot stuff….coming up!! If you enter HOTSTUFF in the coupon code area, Dr. Howson will give you $50 off of your purchase.

Go check Drop Release at droprelease.com and tell Dr. Howson I sent you.

Item #2

The last one we’re going to cover this week is called “Passive intervertebral motion characteristics in chronic mid to low back pain: a multivariate analysis” by Brownhill et. al(Brownhill K 2020). published in Medical Engineering and Physics on 18th of August in 2020. Boiling and smoking and simmerin’!

Why They Did It

Studies comparing back pain patients and controls on how the vertebrae interact with each other and if dysfunction causes pain…..those studies have shown differences. A multivariate re-analysis was carried out to estimate main modes of variation, and explore group differences.

How They Did It

40 participants w/ mechanical back pain and 40 matched controls underwent passive recumbent quantiative videofluoroscopy

Intervertebral angles of L2/3 to L4/5 were obtained for right and left side-bending, extension, and flexion

What They Found

There were three main modes of variation and all of them were related to range of motion and its distribution between joints. 

Significant differences were found for coronal plane motions only

Wrap It Up

“The results confirm altered motion sharing between intervertebral joints in back pain, and provides more details about this. Further work is required to establish how these findings lead to pain, and so strengthen the theoretical basis for treatment and management of this condition.”

Alright, that’s it. Y’all be safe. Keep changing the world and our profession from your little corner of the world. Continue taking care of yourselves and taking care of your neighbors. Tough times are upon us but, the sun will shine again. Trust it, believe it, count on it.

Let’s get to the message. Same as it is every week. 

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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 preventativly 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!

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

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About the Author & Host

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

Brownhill K, M. F., Breen A, Breen A, (2020). “Passive Intervertebral Motion Characteristics in Chronic Mid to Low Back Pain: a Multivariate Analysis.” Medical Engineering & Physics.

Buchbinder R, U. M., Harvigsen J, Maher C, (2020). “The Lancet Series call to action to reduce low value care for low back pain: an update.” Pain 161: p 557-564.

 

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