CF 202: Pain And Clumsiness & Treatment Escalation Today we’re going to talk about pain that causes clumsiness and we’ll talk about treatment escalation.  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.   If you haven’t yet I have a few things you should do. 

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You have found yourself smack dab in the middle of Episode #202 Now if you missed last week’s episode , we talked about breast plan illness and treating chronic pain centrally. Make sure you don’t miss that info. Keep up with the class. 

On the personal end of things…..

Things may have leveled out last week. We shall see. Still busy as can be but instead of 215 in a week, I believe last week was more around 185. This is exactly what we averaged weekly before COVID so I can live with that. I didn’t feel 100% overwhelmed. Tired, yeah. But not overwhelmed.  Let’s talk about the staff.  Have you ever hired a staff member that started out as a kid and just blossomed into something pretty darn special? Wouldn’t it be nice if we could predict these things? Unfortunately, hiring can be a bit of a crapshoot. The ones that look the best turn into clowns. Then you have the ones that are meh and stay meh. Then you have the ones you kind of aren’t sure about and they either sink or swim.  I found a swimmer.

I hired the daughter of one of my long-time friends. I didn’t want to hire her because I didn’t want to treat her differently because of my friendship with her mother and I also didn’t want to risk losing a friend because a problem popped up and I had to fire her daughter. Or something of that nature. You never know what’s going to happen but that was my thought process.  Anyway, she was the best applicant so I hired her. I had an office manager that had been there for roughly 11 years. She trained her up well. Her only job had been with Kohl’s so she’d been in retail and was only about 19 I think. Maybe 20. She was a kid. It took her a bit to settle in I think but once she did, she blossomed.  Fast forward a year or two and my long-time office manager got an offer for more money and she took it. This could have been catastrophic. But then this girl the had started as a kid stepped up and said, “I got it.” 

And no kidding…..she had it. She started marketing. She started setting up meetings with the staff where the weekly meetings and training had kind of fallen off. She started going to networking events. Now, a year after taking over as office manager, she’s the ‘go to’ for the entire office, she’s worked every position including billing and the front desk, and at 23 years old, I have every bit of confidence in that girl.  I told that story for no real reason but to just say ‘isn’t it a bit hinky?’ Wouldn’t it be nice to be able to bottle that up and figure out how to tell who’s going to crash and who’s going to soar? I know everyone has a different opinion on relationships in the office but my opinion, and my personality, is for my staff to be funny, professional, a little bit ornery, and a bit like family.

I care about my staff.  I root for them and they root for me. We tease each other non-stop but we are a family. I spend more time with those girls than I spend with my own family. That’s a big deal. Why would I want a boss-employee relationship with people I basically spend my entire life with? I’d rather them be bought in. Be like family. And when they’re no longer on my team, they’re still on the team to an extent because they became part of the family.  I could be wrong but of all of the people that have worked for me over the years, I can only think of maybe 3 that left on bad terms. Out of maybe 30 or more people.

That sounds like a high turnover rate but honestly, I’ve been in the job for 24 years almost and right now alone I have 13 employees. So, there have been plenty come and go over the years for different reasons. Going back to school, leaving to have babies, moving out of town. It is what it is. 

Most just don’t leave on bad terms and that’s the way I’d like to keep it. I hear horror stories about other chiropractors throwing fits, kicking furniture, yelling down at their staff, and basically acting like children in a grown-up’s body. That’s embarrassing for them.  Leaders come in all shapes and sizes but for me, funny, professional, friendly, respectful, and family sum it up. And love. I love most of the staff that has worked for me. Yes, I paid them.

But they also dedicated themselves to my clinic. That means something and I value it.  Alright, let’s hop in

Item 1

This one is called “Does my neck make me clumsy? A systematic review of clinical and neurophysiological studies in humans” by Harman et. al. (Harman S 2021) and published in Frontiers in Pain Research on October 11, 2021 and that’s spectacularly steamy. 


Why They Did It

Clumsiness has been described as a symptom associated with neck pain and injury. However, the actuality of this symptom in clinical practice is unclear. The aim of this investigation was to collect definitions and frequency of reports of clumsiness in clinical studies of neck pain/injury, identify objective measures of clumsiness and investigate the association between the neck and objective measures of clumsiness.

How They Did It

Six electronic databases were systematically searched,  records identified and assessed including a risk of bias.  Heterogeneity in designs of studies prevented pooling of data, so qualitative analysis was undertaken. Eighteen studies were retrieved and assessed;  the overall quality of evidence was moderate to high.  Eight were prospective cross-sectional studies comparing upper limb sensorimotor task performance and ten were case series involving a healthy cohort only. 

What They Found

Clumsiness was defined as a deficit in coordination or impairment of upper limb kinesthesia.  All but one of 18 studies found a deterioration in performing upper limb kinesthetic tasks including a healthy cohort where participants were exposed to a natural neck intervention that required the neck to function toward extreme limits.

Wrap It Up

Alterations in neck sensory input occurring as a result of requiring the neck to operate near the end of its functional range in healthy people and in patients with neck pain/injury are associated with reductions in acuity of upper limb kinesthetic sense and deterioration in sensorimotor performance. Understanding the association between the neck and decreased accuracy of upper limb kinesthetic tasks provide pathways for treatment and rehabilitation strategies in managing clumsiness. In the Fellowship program for Neuromusculoskeletal Medicine, we actually learned a great deal about this.

Which is why I’ve included it this week. We know that when sensory information comes in if there is an alteration in the signal or in it’s processing, there will be alterations in the motor portion of the sensorimotor capability leading to aberrant movements and motion.  What if incidental pops and clicks were due to faulty sensorimotor and aberrant movement? It can be due to instability, sure. But it can also be to a smudged brain map. We know that when patients have chronic low back pain, the brain map can be smudged. Our brains have a map of our bodies.

Every joint, its capabilities, and it’s limitations. Chronic pain smudges that map. We also know that a large portion of our proprioception and sensory information also comes from our deep upper cervical muscles. In combination with the inner ear and eyes.  It doesn’t take a stretch of imagination to see chronic pain, either in low back or neck, or neck dysfunction being the source of issues for balance, proprioception, and accurate motor function.  It’s all fascinating, folks! Good stuff. 

Item #2

This one is called “Risk of treatment escalation in recipients vs. non recipients of spinal manipulation for musculoskeletal cervical spine disorders; an analysis of insurance claims.” by Anderson et. al (anderson BR 2021) and published in June of 2021 so hot! 

Why They Did It

The purpose of this study was to evaluate the relationship between treatment escalation and spinal manipulation in a retrospective cohort of people diagnosed with musculoskeletal disorders of the cervical spine.

How They Did It

  • They used retrospective analysis of insurance claims from 2012-2018 from a single Fortune 500 company.
  • They categorized 58,147 claims into 7,951 unique patient episodes.
  • Treatment escalation included claims where imaging, injection, emergency room, or surgery was present.

What They Found

  • Treatment escalation was present in 42% of episodes overall: 2,448 (46%) associated with other care and 876 (26%) associated with spinal manipulation. 
  • The estimated risk of any treatment escalation was 2.38 times higher in those who received other care than in those who received spinal manipulation

Wrap It Up

Among episodes of care associated with neck pain diagnoses, those associated with other care had twice the risk of any treatment escalation compared with those associated with spinal manipulation.  In the United States, over 90% of spinal manipulation is provided by doctors of chiropractic; therefore, these findings are relevant and should be considered in addressing solutions for neck pain. Additional research investigating the factors influencing treatment escalation is necessary to moderate the use of high-cost and guideline-incongruent procedures in people with neck pain. So, how many times have you seen patients that had fusions that they should have never had?

Many or most times based on MRI images from MRI’s they probably should have never had. Conservative care first, folks.  Failure to respond to conservative care. Conservative care being spinal manipulative therapy, exercise, laser, massage, acupuncture, yoga, tai chi, cognitive behavioral therapy, and I will add one from the anecdotal observation that is backed by non enough research….and that’s spinal decompression. I’ve never seen anything like it for discs and radiculopathy. Plain and simple.  Once those have been tried and failed, then you look at meds. Then you look at injections. Then you look at surgery. 

Understanding that cauda equina and progressive neurological deficits are really the main reasons for surgery. Pain, by the way, is not a reason for surgery.  No cauda equina? No altered sensory, motor, or reflexes? No surgery. 

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 the 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       

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 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.


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


Anderson BR, M. W., Long CR, (2021). “Risk of Treatment Escalation in Recipients vs Nonrecipients of Spinal Manipulation for Musculoskeletal Cervical Spine Disorders: An Analysis of Insurance Claims.” J Manipulative Physiol Ther 44(5): 372-377.

Harman S, Z. Z., Kendall J, Vindigni D, Polus B, (2021). “Does My Neck Make Me Clumsy? A Systematic Review of Clinical and Neurophysiological Studies in Humans.” Front Pain Res 2: 756771.      

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