CF 123: Primary Spinal Practitioner, Gabapentin, Cervical Curvature
Today we’re going to talk about the primary spinal practitioner program, research on gabapentin and its use in low back pain and radiculopathy, and we’ll talk about cervical curvature…what’s the research?
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, 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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Do it do it do it.
You have found yourself smack dab in the middle of Episode #123
Now if you missed last week’s episode , we talked about chiropractic primary prevention research, we talked about TENS use for migraines in the ER, and we talked about research for acupuncture with chronic pain. 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…..
Well another pandemic week in the books. I’m recording this on April the 29th, 2020 and it’s quite a mess still. We have states that are still climbing in cases dramatically but still opening up businesses.
I’ve been telling people that I’m in the middle on this deal. We have to get out. We can’t stay in our cocoons and watch our businesses die. I was that way for a bit honestly. But we just can’t do that. At the same time, it’s not time to open wide and let ‘er rip either. We have to have a measured opening keeping a watch on the cases.
The great news emerging is the number of asymptomatics they are identifying. It really does all come down to testing. You don’t know what you’re dealing with if you can’t tell who the heck has it. Wouldn’t it be amazing if we are blessed enough to be one of those asymptomatics that simply have no symptoms and no idea we even had the damn thing?
The problem is that at least for now, we have to go about as if we are asymptomatic carriers basically. The last thing I’d ever want is to unknowingly give it to my 74-year-old mother or my 80-year-old stepdad. That’s not my idea of being a good person at all. Lol.
I also have a dad in a nursing home and that’s been tough for sure. I know they do what they can to entertain them but they’re basically forced to keep all of the residents separated in case the bug is lurking about. So, they end up in their rooms most if not all of the day I think.
We haven’t been allowed in to see him since middle March or so. Which is frustrating. He had a stroke so he’s not always all there and can be a bit confused about why people aren’t visiting. Getting him on the phone has been a challenge as well but we’re making due.
It’s a tough time for everyone right now. But I’m a glass half-full guy. This too shall pass. We’re going to be OK. People are going to eventually get out and about. People are going to eventually start re-engaging in the economy. Until then, financial institutes and the government will continue to make accommodations for business owners.
Keep the faith brothers and sisters. The general curve in our country right now is downward. I believe there’s light at the tunnel. Just stay smart and stay safe until we reach that light.
Before we get started, I did a thing
I’ve always wanted to help others with their message and how they’re getting it out there. Keeping that in mind, during this lull in business due to the pandemic, I decided to try something different and invest my time instead of waste it. I’ve certainly had the time to invest as have most of us.
I did two episodes on marketing an evidence-based practice a few months ago and both of those episodes are among our most listened to, most popular episodes so I know there is value there and I know there’s an interest in the topic.
Over the years, if I wanted to learn more about excel, I’d take a course over at udemy.com. If I wanted to learn more about marketing, udemy proved to be a valuable resource. If you’re not familiar with sites like Udemy or Teachable, you should go check it out.
I haven’t really looked into what other chiropractors are using it for but I thought, if I wanted to offer a course, Udemy would be a good place to start. While I’m still building the course and adding content every week, it’s live and ready to go for those interested. If it’s not, it will be live in only a day or two.
If you’re interested, I created, basically, my playbook for marketing and my thoughts on each topic or technique. I also have created downloads, checklists, and examples to show what my stuff looks like.
Just go to udemy.com and do a search on Marketing An Evidence Based Chiropractic Practice and check it out. See what you think. It’s my first online course to create so any feedback is appreciated. Over time, I’ll be updating the content and adding graphics, and things like that as I finish the initial bulk of the work and am able to revisit and re-work parts that could use it. Plus, I plan on responding to feedback and make any needed changes from there as well.
This one is not a research paper as much as it is an article. It is from way back in 2011 but is as relevant or more relevant than it’s ever been today. This one is called, “The establishment of a primary spine care practitioner and its benefits to health care reform in the United States” by Donald Murphy et al(Murphy D 2011) and published in Chiropractic and Manual Therapies journal. I have the citation in the show notes if you’d like to look deeper at this
Why They Did It
They highlight the issue with spine-related treatments, the costs, the lack of any real effectiveness to justify the rising costs and make the argument that a key answer to theses issues includes having a group of practitioners trained to function as primary care practitioners for the spine.
Let’s hit some of the highlights here:
- Spine-related disorders (SRDs) are among the most common, costly and disabling problems in Western society. For the purpose of this commentary, we define SRDs as the group of conditions that include back pain, neck pain, many types of headache, radiculopathy, and other symptoms directly related to the spine. Virtually 100% of the population is affected by this group of disorders at some time in life.
- A variety of physicians and other providers have traditionally been involved with the diagnosis and treatment of these patients. This includes primary care physicians, chiropractic physicians, orthopedic surgeons, neurosurgeons, physiatrists, osteopathic physicians, physical therapists, psychologists, massage therapists, kinesiologists, naprapaths and acupuncturists. This has resulted in what has been termed the “supermarket approach” to the management of SRDs . That is, the SRD patient is faced with an environment in which there is a large number of practitioners, each offering a solution to SRDs, with the patient left to sort out which of these disparate approaches is best for his or her particular problem. Oftentimes this determination is based more on salesmanship and marketing than on science, clinical benefit and cost-effectiveness. Lawd don’t we know some surgeons and some chiropractors that are salesmen? And scare care tacticians?
- Treatment for SRDs has become increasingly specialist-focused, imaging-oriented, invasive and expensive.
- One approach to health care reform would designate primary care physicians (PCPs) or groups of PCPs as “patient homes”, responsible for the comprehensive care and management of a designated patient population under a risk-sharing agreement
- In their book Redefining Health Care , Porter and Teisberg state that for health care reform to be successful, it must incentivize competition based on value, i.e., outcome per dollar spent. To maximize value in health care, they recommend physicians and other health care providers organize themselves around conditions in which they have maximal expertise and experience (chronic kidney disease, diabetes, SRDs) rather than around medical specialties (orthopedics, internal medicine, neurology, etc.) and compete on the level of providing the best health outcomes for these conditions at the best possible cost (i.e., providing value). Ohhhh, that sounds fun because the Palmer/Gallup surveys show chiropractors get patients better for less money and patients are happier with chiropractors than PTs and GPs. I think the good chiropractors would fair particularly well in this scenario.
- We think that the health care system needs an appropriately trained and skilled clinician who can fill the role of a primary care provider for the diagnosis and non-surgical management of SRDs; a “primary care physician for the spine”.
- The primary spine care practitioner will require a particular skill set that includes the ability to apply evidence-based procedures, appropriately educate and motivate patients and effectively prevent and manage disability related to SRDs. The benefits in terms of improved outcomes of care for SRDs, improved patient satisfaction, and reduced costs (i.e., the value of care for SRDs) would be well worth the effort of grooming practitioners toward filling this role.
Dr. Murphy and his crew have established the Primary Spine Practitioner Certification Program through the University of Pittsburgh. I’ve provided their link in the show notes. If I were 10 years younger, I’d probably do it now that I’ve completed the Ortho Diplomate.
On to item #2 called “Anticonvulsants in the Treatment of Low Back Pain and Lumbar Radicular Pain: A Systematic Review and Meta-Analysis” by Enke et. al.(Enke O 2018) published in the Canadian Medical Association Journal in July 2018.
Why They Did It
The use of anticonvulsants (e.g., gabapentin, pregabalin) to treat low back pain has increased substantially in recent years despite limited supporting evidence. We aimed to determine the efficacy and tolerability of anticonvulsants in the treatment of low back pain and lumbar radicular pain compared with placebo.
How They Did It
- A search was conducted in 5 databases for studies comparing an anticonvulsant to placebo in patients with nonspecific low back pain, sciatica or neurogenic claudication of any duration.
- The outcomes were self-reported pain, disability and adverse events.
- Risk of bias was assessed using the Physiotherapy Evidence Database (PEDro) scale
- Quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE)
- Nine trials compared topiramate, gabapentin or pregabalin to placebo in 859 unique participants.
What They Found
- Fourteen of 15 comparisons found anticonvulsants were not effective to reduce pain or disability in low back pain or lumbar radicular pain;
- For example, there was high-quality evidence of no effect of gabapentinoids versus placebo on chronic low back pain in the short term or for lumbar radicular pain in the immediate term
- The lack of efficacy is accompanied by increased risk of adverse events from use of gabapentinoids, for which the level of evidence is high.
Wrap It Up
“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.”
Our last one is called “Cervical lordosis in asymptomatic individuals: a meta-analysis” by Guo et. al(Guo G 2018). and published in the Journal of Orthopedic Surgery and Research in 2018.
Why They Did It
Cervical lordosis has important clinical and surgical implications. Cervical spine curvature is reported with considerable variability in individual studies. The aim of this study was to examine the existence and extent of cervical lordosis in asymptomatic individuals and to evaluate its relationship with age and gender.
How They Did It
- A comprehensive literature search was conducted in several electronic databases
- Random effects meta-analyses were performed to estimate the proportion of asymptomatic individuals with lordosis and the effect size of cervical lordotic curvature in these individuals which followed metaregression analysis to examine the factors affecting cervical lordosis
- Data from 21 studies were used in the study.
- 15,364 asymptomatic individuals, age 42.30 years
What They Found
- 64% individuals possessed lordotic curvature
- Degree of lordotic curvature differed by method of measurement
- Lordotic curvature was not significantly different between symptomatic and asymptomatic individuals but was significantly higher in males in comparison with females
- Age was not significantly associated with lordotic cervical curvature
Wrap It Up
Majority of the asymptomatic individuals possesses lordotic cervical curvature which is higher in males than in females but have no relationship with age or symptoms.
There are a lot more papers out there on cervical curves and the meaning and impact of hypolordosis. Here’s the deal, I’m standing strong that hypolordosis is minimally impactful and is not anywhere near important enough to to sell $6,000, 70 visit annual plans to correct it.
It’s just not. And I don’t care what the owner of a curvature correction system says about it or what biased BS research they try their best to pump out there. It’s Just NOT.
It’s a hell of a marketing scare tactic and it’ll put money in your pockets but it won’t give you respect and it might even keep you up at night if you allow your conscience to have a seat at the table.
Alright, that’s it. Y’all be safe. Continue taking care of yourselves and taking care of your neighbors. Tough times are upon us but, the sun will shine again. Trust it, belive it, count on it.
Let’s get to the message. Same as it is every week.
Remember the evidence-informed brochures and posters at chiropracticforward.com.
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!
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….
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.
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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.
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
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.
Guo G, L. J., Diao Q, (2018). “Cervical lordosis in asymptomatic individuals: a meta-analysis.” J Orthop Surg Res 13(147).
Murphy D, J. B., Paskowski I, Perle S, Schneider M, (2011). “The establishment of a primary spine care practitioner and its benefits to health care reform in the United States.” Chiropr Man Therap 17.