CF 302: Spinal Manipulative Therapy And Benzodiazepines & Yanking Someone’s Head Off Today we’re going to talk about Spinal Manipulative Therapy And Benzodiazepines & Yanking Someone’s Head Off
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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, look down your nose at people 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. 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, drive, smart, and easy to get along with associates. If this is you and Amarillo, TX is your speed, send me an email at firstname.lastname@example.org 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 educational resource for you AND your patients. It saves you time putting talks together or just staying current on research. It’s 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 #302 Now if you missed last week’s episode , we talked about Excessive Generalization Of Fear Avoidance. Make sure you don’t miss that info. Keep up with the class.
On the personal end of things….. The difference between an evidence based, patient centered practice and a vitalistic, philosophy-driven practice. In my view. The vitalists believe that a patients or as they call them, a practice member…..should be seen in the clinic A LOT. Like some feel 1x/week or 1x every 2 weeks.
Even if nothing hurts. No pain. That’s just to stay healthy and all that stuff. So, their PVA is off the charts. Some are at 80 and above. Even if no randomized controlled trials, the ACA, or any other respected guides back that up. Then, there’s the evidence-based, patient-centered model.
We depend on new patients. And a lot of them. I have to see a lot of new patients to keep the machine turning. And when I’m out for any length of time, the ripples are felt for a while. So, I was out sick for a couple of days two weeks ago. Then, the very next week, I went to Chicago and was out for 2.5 days. So, guess what that did to my practice? Yep, you guessed it. Slower than COVID. Everything for me is now compared to COVID numbers, by the way.
Anyway, it took me a week to start turning this Titanic back around and moving the other way but it’s turning. I’m back up to 44 today, which is a Monday. We’ll see how the rest of the week unfolds but it’s looking pretty good right now. I would assume a vitalist that gets sick and has to miss is still loaded up when they return because these people have been led to believe that they have to make their appointments or their lack of neck curvature will cause degeneration or their immune system will quit working or something of that nature. More power to them. It’s a good business model if all you care about is money but that’s just not a model I was ever on board with.
So, yes, it took me a week or so but we are plugged in and back on track and kicking some derierre.
Our first one this week is called, “Association between chiropractic spinal manipulative therapy and benzodiazepine prescription in patients with radicular low back pain: a retrospective cohort study using real-world data from the USA” by Trager et. Al. and published in BMJ Open on June 12, 2022…..and it’s only lukewarm… Trager RJ, Cupler ZA, DeLano KJ, Perez JA, Dusek JA. Association between chiropractic spinal manipulative therapy and benzodiazepine prescription in patients with radicular low back pain: a retrospective cohort study using real-world data from the USA. BMJ Open. 2022 Jun 13;12(6):e058769. doi: 10.1136/bmjopen-2021-058769. PMID: 35697464; PMCID: PMC9196200.
Why They Did It Although chiropractic spinal manipulative therapy (CSMT) and prescription benzodiazepines are common treatments for radicular low back pain (rLBP), no research has examined the relationship between these interventions. We hypothesise that utilisation of manipulation for newly diagnosed radicular low back pain is associated with reduced odds of benzodiazepine prescription through 12 months’ follow-up.
How They Did It
- Retrospective cohort study.
- National, multicentre 73-million-patient electronic health records-based network (TriNetX) in the USA, queried on 30 July 2021, yielding data from 2003 to the date of query.
- Adults aged 18–49 with an index diagnosis of rLBP were included.
- Serious etiologies of low back pain, structural deformities, alternative neurological lesions and absolute benzodiazepine contraindications were excluded.
- Patients were assigned to cohorts according to CSMT receipt or absence.
- Propensity score matching was used to control for covariates that could influence the likelihood of benzodiazepine utilisation.
- The number, percentage and OR of patients receiving a benzodiazepine prescription over 3, 6 and 12 months’ follow-up prematching and postmatching.
- 9206 patients age, 37.6 years, 54% male per cohort.
What They Found
- Odds of receiving a benzodiazepine prescription were significantly lower in the spinal manipulation cohort over all follow-up windows prematching and postmatching.
- After matching, benzodiazepine prescription at 3 months was 0.56, at 6 months 0.61 and 12 months 0.67.
- Sensitivity analysis suggested a patient preference to avoid prescription medications did not explain the study findings.
Wrap It Up
These findings suggest that receiving CSMT for newly diagnosed rLBP is associated with reduced odds of receiving a benzodiazepine prescription during follow-up. These results provide real-world evidence of practice guideline-concordance among patients entering this care pathway. Benzodiazepine prescription for rLBP should be further examined in a randomised trial including patients receiving chiropractic or usual medical care, to reduce residual confounding. Before getting to the next one, Next thing, go to https://www.tecnobody.com/en/products
That’s Tecnobody as in T-E-C-nobody. They literally have the most impressive clinical equipment I’ve ever seen. I own the ISO Free and am looking to add more to my office this year or next. The equipment you’re going to find over there can be marketed in your community like crazy because you’ll be the only one with something that damn cool in your office. When you decide you can’t live without those products, send me an email and I’ll give you the hookup. They will 100% differentiate your clinic from your competitors. I have to tell you, Dr. Chris Howson, the inventor of the Drop Release tool re-activated the code! Use the code HOTSTUFF upon purchase at droprelease.com & get $50 off your purchase. Would you like to spend 5-10 minutes doing pin and stretch and all of that? Or would you rather use a drop release to get the same or similar results in just a handful of seconds. I love it, my patients love it, and I know yours will too. droprelease.com and the discount code is HOTSTUFF. Go do it.
For our last one, we have “Spinal Cord Injury, Vertebral Artery Dissection, and Cerebellar Strokes After Chiropractic Manipulation” by Ramos etl al. and published in American Academy of Neurology in November of 2022 and I’m using my soundclip anyway because this is a hot topic!
Why They Did It Let’s just say it appears this provider stops at nothing. This injury to this woman happened after a visit with a chiropractor where she had cervical manipulative therapy. That’s putting it simply but it is both mine and Dr. Brown’s opinion that this was likely an axial traction move that gets all of the views on YouTube or a Y-strap type of adjustment that caused this issue. We have no way of knowing that nor are we stating that as a fact in any way.
We are simply surmising this because a simple diversified cervical break type of adjustment, to my knowledge, would be difficult to duplicate results like this. Seriously, if you saw the pictures on this, you’d know what I’m saying and would be nodding in agreement.
This isn’t fun stuff to think about or talk about but I think it’s important. It came to me through Dr. Steven Brown out in Gilbert, AZ, one of my new connections and friends through the Forensics conference I attended in Chicago a couple of weeks ago. This is from Brazil and they’re just not good at putting this sort of thing together so there’s really only a paragraph or so that I’ll just go ahead and quote here. “A 48-year-old woman with chronic neck pain presented with a history of sudden neck pain and generalized weakness during a chiropraxis session. Neurological examination showed tetraplegia with C5 sensory level. Cervical spine CT revealed a fracture affecting C5 and C6 vertebra. Cervical spine MRI confirmed spinal cord injury. Also, bilateral vertebral artery occlusion and acute cerebellar infarction were found. Bony ankylosis was found in cervical CT spine suggesting undiagnosed ankylosing spondylitis was a risk factor for spine fracture.
Other neurological lesions related to chiropraxis include vertebral artery dissection, epidural hematoma and acute disk hernition. “ Y’all the pictuures on this patient’s imaging is just awful. I’ll try to include it in the show notes if the software allows an old man to figure it out. When Dr. Brown sent over the information, he sent me his impression and review of the information as well and I’ll just share that with you now. The greatest weakness of this report is the lack of details about the CSM procedure. It is difficult to see how a properly performed CSM could cause such catastrophic injuries.
This report is brief, lacking in detail about the CSM procedure, and has only two references. Another weakness of this report was that the actual time lapse from CSM to the onset of ischemic stroke symptoms was poorly documented. The term “during” needs to be clarified in terms of seconds or minutes. The symptoms that prompted the patient to seek CSM are unknown. The catastrophic nature of the injures makes it appear the bilateral VAD was a direct result of an improperly performed CSM. However, a weakness of this report was the failure to consider that the practitioner may have failed to diagnose and refer a pre-existing cervical artery dissection. The report does not review the patient’s past medical history of risk factors for dissection or stroke. The patient’s BMI (body mass index) was not recorded.
A low BMI is a risk factor for dissection, a high BMI is a risk factor for ischemic stroke. The report does state that “bony ankylosis” was found on cervical spine CT examination, suggesting undiagnosed ankylosing spondylitis, which was a risk factor for spine fracture. However, Ramos did not verify if the patient had AS or not. A weakness of this report was the failure to verify the type of practitioner that performed the CSM.
The report states “chiropractic”, but no effort was made to verify that the practitioner was an actual Doctor of Chiropractic. Numerous cases reports have attributed CSM to a DC when another type of practitioner performed the procedure. A further weakness of this report was a failure to review the records from the practitioner performing the CSM. It is unknown if Informed Consent to the risk of stroke from CSM was obtained. The history and examination done by the practitioner of CSM are unknown. It was unknown if any neck injury occurred prior to CSM.
Ramos concluded that CSM caused the cervical artery dissection was “related to” CSM. Studies showing no evidence of a causal relationship between CSM and dissection were not referenced. However, these studies assume the CSM was properly performed. In this case, the CSM was likely not properly performed if it caused such catastrophic injuries.
So, I agree with everything Dr. Brown has to say here and will add that bias against chiros is present here. However, if this is a chiropractor that nearly yanked this woman’s head from her torso, I would be biased against he or she as well. Even as a chiropractor myself. Just because something gets a ton of views on social media or YouTube does not mean it’s amazing and without risk. You’re all smart enough to know that you see the wins on videos. You don’t see the fails. I’ve seen a YouTube chiro almost yank a 70+-year-old tiny woman off of the table.
She had to lay there and recover for a good 3-5 mintues. Is that really what we enjoy or want to be known for? Of course it isn’t. I want to be known for the woman that came to see me with lumbar radciulopathy that was developing mild foot drop and we were able to get her by. And fully recovered.
Or the veteran that couldn’t sleep or function and who’s neck made all kinds of crunchy sounds and since seeing me, it no longer makes noise and he’s feeling much better. Or the patients that was 35 and came in on a walker. He’d been to the ER twice before with bowel and bladder symptoms consistent with cauda equina but they never even did an MRI on him. I had a talk with him, told him exactly what he need to go to the ER and tell them and the next thing you know, he went through emergency surgery and now he’s back to leading a full and functional life.
It’s not just me. You men and women have those stories too if you’ve been in practice long enough. These things don’t get views on YouTube and these patients aren’t typically dressed in yoga pants. You know what I’m saying here. But, they are the patients that we need to be known for.
Keep plugging away. It’s a hell of a lot better time to be a chiropractor in 2023 than it was in 2000. I can guarantee it. Cooperation between evidence-based chiropractors and medical professionals is at an all time high and I only see it getting better from here.
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.
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Purchase Dr. Williams’s book, a perfect educational tool and chiropractic research reference for the daily practitioner, from the Amazon store TODAY!
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!
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About the Author & Host
Dr. Jeff Williams – Fellow of the International Academy of Neuromusculoskeletal Medicine (FIANM) and Board Certified Diplomate of the American Board of Forensic Professionals (DABFP) – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger