CF 198: MRI’s and Clinic Presentation & Surgery vs. Conservative Care For Discs Today we’re going to talk about surgery vs. conservative treatment for discs and we’ll talk about MRI findings and clinical 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. 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 #198 Now if you missed last week’s episode , we talked about Extruded Discs – Surgery or No Surgery? Make sure you don’t miss that info. Keep up with the class.On the personal end of things….. Well, we went with ReviewWave and I have to say it’s overall been a very positive experience. Except for this one thing. Today, we showed up for work and we have it set to where new patients can pick their schedule and make the appointment themselves. Within certain parameters, of course. Well. Something’s wonky because we showed up at work and, instead of the 6 or 7 new patients we expected today, we now have 10 new patients and 4 re-exams on top of our regular load of established patients. As you can imagine, this presents a certain set of difficulties. Especially when my exam takes 20 minutes minimum and more typically takes about 30-40 minutes per new patients. So, we’re forced to step on the gas a touch. We’ll get through it and we’ll do a good job but, being too busy is as bad as not being busy enough in some ways. Patients like to know they’re going to a provider that a lot of other folks go to and find value in. But, when it looks like you’re running them through like cattle and your one on one time is 30-45 seconds rather than a couple of minutes or more….they notice it and I don’t care what the vitalistic philosophy wonk gurus in the profession try to convince you, patients don’t like that. They feel it and sense it and they don’t like it. I don’t like it. I don’t like people waiting on me. I don’t like making a bad first impression. I don’t like to be rushed any more than I normally am. More than anything, I don’t want to fall into quantity over quality. I always want quality here. And never forsake it in the search for quantity. That’ll get us nowhere that we want to go. So, this part of the show will be short, we will survive and do a good job regardless of time constraints, and we have a call scheduled with ReviewWave to remedy the issue. When you get too busy to fit them in, create a waiting list, hire help, or raise your pricing to thin the herd. Just a little tip from your Ol’ Uncle Jeffro. Let’s dive in Item #1 The first one is called “Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study” by Gugliotta et. al.(Gugliotta M 2016)and published in BMJ Open, that is the British Medical Journal for the peasants in the crowd. It’s a joke! Anyway, it was published in December of 2016 and it goes a lil sumpin like dis…. Why They Did It We sought to compare short-term and long-term effectiveness of surgical and conservative treatment in sciatica symptom severity and quality of life in patients with lumbar disc herniation in a routine clinical setting. How They Did It
It was a prospective cohort study of a routine clinical practice registry consisting of 370 patients.
Outcome measures were the North American Spine Society questionnaire and the 36-Item Short-Form Health Survey to assess patient-reported back pain, physical function, neurogenic symptoms and quality of life.
Primary outcomes were back pain at 6 and 12 weeks.
Standard open discectomy was assessed versus conservative interventions at 6, 12, 52 and 104 weeks.
What They Found
Surgical treatment patients reported less back pain at 6 weeks than those receiving conservative therapy, were more likely to report ≥50% decrease in back pain symptoms from baseline to 6 weeks and reported less physical function disability at 52 weeks.
The other assessments showed minimal between-group differences with CIs, including the null effect.
Wrap It Up Compared with conservative therapy, surgical treatment provided faster relief from back pain symptoms in patients with lumbar disc herniation, but did not show a benefit over conservative treatment in midterm and long-term follow-up. So, bad for conservative interventions in the short term. Good in the long term. When they spread it out and look long term, there’s minimal difference. So, why risk it in the first place. The rate that low back surgeries must be re-done is too high to risk it. They estimate that around 40% of back surgeries fail. Yeah, I’m good as long as I don’t have cauda equine or progressive neurological deficits. You keep your full dose of surgery. I’ll have none on this day! So, long-term, minimal difference,…..well then we’re going with no surgery any time it’s appropriate and makes sense. CHIROUP ADVERTISEMENT Item #2 Alright, the last paper we have today is called, “Association of Lumbar MRI Findings with Current and Future Back Pain in a Population-Based Cohort Study” by Kasch et. al. (Kasch R 2021) and published in Spine Journal.Why They Did It The authors wanted to examine associations between common lumbar degenerative changes observed on MRI and present or future low back pain.How They Did It
Participants from a population-based cohort study were imaged at study entry,
LBP status measured at baseline and 6-year follow-up.
MRI scans were reported for the presence of a range of MRI findings.
LBP status was measured on a 0-10 scale.
What They Found
MRI findings were present in persons with and without back pain at baseline.
Higher proportions were found in older age groups.
76.4% of participants had a least one MRI finding and 8.3% had 5 or more different MRI findings.
Most MRI findings were slightly more common in those with LBP and pain severity was slightly higher in those with MRI findings
In the longitudinal analyses we found most MRI findings were not associated with future LBP-severity regardless of the presence or absence of baseline pain.
Compared to zero MRI findings, having multiple MRI findings (≥5) was associated with mildly greater pain-severity at baseline and greater increase in pain-severity over 6 years in those pain free at baseline, but not in those with baseline pain
Wrap It Up Our study shows that the MRI degenerative findings we examined, individually or in combination, do not have clinically important associations with LBP, with almost all effects less than one unit on a 0-10 pain scale Meaning, quit catastrophizing MRI findings. Quit telling 40 year olds they have the backs of 85 year olds. Quit pushing them into the chronic pain pit because you don’t know schiza from shinola and you’re too damn lazy to take the time and energy to get some smarts beyond what you learned in chiropractic college. Slap pow pop kazow!! 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 so 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!
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
Social Media Links https://www.facebook.com/chiropracticforward/ Chiropractic Forward Podcast Facebook GROUP https://www.facebook.com/groups/1938461399501889/ TwitterTweets by Chiro_ForwardYouTube https://www.youtube.com/channel/UCtc-IrhlK19hWlhaOGld76Q iTunes https://itunes.apple.com/us/podcast/chiropractic-forward-podcast-chiropractors-practicing/id1331554445?mt=2 Player FM Link https://player.fm/series/2291021 Stitcher: https://www.stitcher.com/podcast/the-chiropractic-forward-podcast-chiropractors-practicing-through TuneIn https://tunein.com/podcasts/Health–Wellness-Podcasts/The-Chiropractic-Forward-Podcast-Chiropractors-Pr-p1089415/ 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 Bibliography Gugliotta M, d. C. B., Dabis E, Theiler R, Jüni P, Reichenbach S, Landolt H, Hasler P. (2016). “Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study.” BMJ Open 6(12). Kasch R, T. J., Hancock MJ, Maher CG, Otto M, Nell C, Reichwein N, Bülow R, Chenot JF, Hofer A, Wassilew G, Schmidt CO (2021). “Association of Lumbar MRI Findings with Current and Future Back Pain in a Population-Based Cohort Study.” Spine (Phila Pa 1976).
CF 068: British Medical Journal Research, Surgeons Against Back Surgery, and Pediatric Chiropractic Under Attack
Today we’re going to talk about a BIG new study helping us out in the British Medical Journal, we’ll talk about spinal surgeons against back surgery, and we’ll talk about pediatric chiropractic under attack. That’s a big topic right now. Especially down in Australia.
But first, get ready to shake your tail feathers……here’s that bumper music
OK, we are back. Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.
You have done the mashed potato right into Episode #68. Just like we were back in the 50’s. Sometimes I wonder if I was born in the wrong generation. Seriously. Speaking of, if you’d like to hear what we listen to in my office all day every day, go to Spotify and get my Old, New, Memphis & Motown Too. My profile is amarillopacc. That’s the amarillo platypus, absinthe, crustacean, crap ton.
You’re welcome…. I’m here all week. Tip your waitresses.
Now, we’re here to advocate for chiropractic while we also make your life easier.
Part of that is having the right patient education tools in your office. Tools that educate based on solid, researched information. We offer you that. It’s done for you. We are taking pre-orders right now for our brand new, evidence-based office brochures available at chiropracticforward.com. Just click the STORE link at the top right of the home page and you’ll be off and running. Just shoot me an email at [email protected] if something is out of sorts or isn’t working correctly.
If you’re like me, you get tired of answering the same old questions. Well, these brochures make great ways of educating while saving yourself time and breath. They’re also great for putting in take-home folders.
Go check them out at chiropracticforward.com under the store link. While you’re there, sign up for the newsletter won’t you? We won’t spam you. Just one email per week to remind you when the new episode comes out. That’s it.
Let’s talk a bit about the DACO program. I went on a short little spring break vacay last week so didn’t get many hours in. I got three hours I believe. The class I took was Class 3 of the Pain In The Frame series. It was over chronic shoulder pain. I have to tell you that the neurology is not something that comes naturally to me but, in the same breath, I want you to know that it is presented in a way that is finally understandable. Even by me and when it comes to hardcore neuro topics, that’s saying a lot, folks. Seriously.
And the concept is repeated repeatedly. That sounds redundant but I know you’re pickin up what I’m throwin down here.
Dr. Anthony Nicholson who is part of the team that has set up the educational program, and who will also be a guest in the very near future here with us on the podcast, he was a neuro diplomate before getting his DACO so there is plenty of neuro but don’t let that scare you. Had I known that going in, it probably would have scared me a touch but, it’s no biggie. It’s explained very well and though I didn’t completely grasp it the first time or two it was run by me, I got by the 10th time for sure. Lol.
I’m a slow learner. Lol. I beat myself up. I’m almost done with the whole thing and I have a 95 in the class. Trust me, I’m not a neuro guy. I hate hardcore neuro but it’s excellent stuff that you need to know and if I can do it, I promise you can too.
Be looking for that interview with Dr. Nicholson all the way from Australia in just a couple of weeks or so. Maybe sooner. He’s fascinating.
If you hear something here that you really like and would like it in written form rather than spoken, just hop onto chiropracticforward.com, find the episode, and just scroll down to copy and paste it. If you’re using it for content or on your website for some reason, just be cool and give us some credit please. I’d sure appreciate it and I’m sure the researchers we discuss would too.
Onward we march to the first item here. It’s a biggie and it’s brand new. It’s called “Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials” and authored by Sidney Rubinstein, Annemarie de Zoete, Marienke van Middelkoop, and a herd of others. It was published in the British Medical Journal on March 13th of 2019.
Hot stuff coming through
The first thing I’ll say here is that there is a pyramid of research hierarchy out there. I’ll post it in the show notes at www.chiropracticforward.com episode #68 so go check it out.
If you look at it, you’ll see that randomized controlled trials and systematic review/meta-analysis studies are at the very top of the hierarchy.
Well, this paper, for example, as the title says, is a systematic review and meta-analysis of randomized controlled trials. See what I’m saying here? That’s why it’s a biggie.
Why They Did It
They wanted to assess the benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain. Ah….low back gets all the attention. Still waiting to see them get those cervical pain studies rolling. Anywhoo…..
They did a systematic review on 47 randomized controlled trials including 9,211 participants that all examined the effect of spinal manipulation or mobilization in adults over 18 years old with chronic low back pain with or without referred pain. They did not accept the studies that looked at sciatica exclusively.
What They Found
Moderate quality evidence suggests that spinal manipulative therapy has similar effects to other recommended therapies for short term pain relief.
The same quality evidence suggests a small, clinically better improvement in function.
High quality evidence suggested that , compared with non-recommended therapies, SMT results in small, not clinically better effects for short term pain relief and small to moderate clinically better improvement in function.
They say about half of the studies examined adverse and serious adverse events. They say most of the observed adverse events were musculoskeletal related, transient in nature, and of mile to moderate severity.
They concluded, “SMT produces similar effects to recommended therapies for chronic low back pain, whereas SMT seems to be better than non-recommended interventions for improvement in function in the short term. Clinicians should inform their patients of the potential risks of adverse events associated with SMT.”
I have to say, when we dive a bit deeper in, while the study shines brightly on spinal manipulative therapy and its practitioners, we as chiropractors can’t lean on this thing completely for the good OR the bad. That’s because, of the 47 randomized controlled trials accepted, chiropractors were the practitioners delivering the manipulative therapy in only 16 of them. Fourteen were delivered by a PT, 6 by a medical manipulator (whatever the hell that is), 5 by a DO, 2 by a bonesetter…(that’s a real thing?) and on and on.
So, keep that in mind. This isn’t fully representative of what chiropractors do and how effective we can be.
Also, the techniques used in the 47 studies ranged from high velocity, low amplitude like a Diversified adjustment, to low velocity, low amplitude passive movement techniques or a combination of both of those.
Again, not entirely representative of what we chiropractors that move the bones do. In my opinion.
What they say down deep in the paper that, considering recent systematic reviews and information showing that SMT and massage should be considered cost-effective options for low back pain and then this study showing the effectiveness…..basically….what are we waiting for to get this rocking and rolling. OK, not their words exactly but….yeah, I said that but I said it based on their research speak.
I am including an infographic the authors generated on this that cuts to the chase and may be something you can use for your waiting room. Go check it out.
Great paper, very impactful, and it supersedes the recommendations that you heard us talking about from The Lancet Medical Journal back in episodes #16, 17, and 18 of this podcast.
I’ve said it so many times and it remains a true, considering the forces and powers that have been against us for generations, if we were inherently wrong in what we do, we would have been wiped off the face of the Earth years and years ago. Yet we persist. It is my opinion that we do not persist because of creative sales, influential legislation, and millions and billions in lobbying efforts. It’s because we are right in what we do on the most basic levels.
Our second item this week is an interesting article I came across from painchats.com called “This Spine Surgeon says Avoid Spinal Surgery for Low Back Pain: Stop and Think Carefully about Back Surgery.” the article is written by David Hanscom, MD and linked in our show notes for episode 68 at chiropracticforward.com.
The article starts off with this, “If you’re considering having spinal surgery as the final fix for your back pain, I’d like to help you to think again about your options.
I’m a spinal surgeon and I want you to know that surgery is not your best option for recovery from low back pain.
Surgery for relieving back pain has never been shown to be effective in a stringent research study. The most careful research paper published in 2006 demonstrated that only 22% of patients were satisfied with the outcomes two years later. Essentially, all research shows consistently poor outcomes for fusion surgery performed for back pain.”
Well….all I have to say is….HALLELUJAH!!!
We are going to look back at x-rays of fusions in 10-15 years and wonder what in the hell the surgeons were thinking. Mark my words people.
He breaks it down into reasons. I will shorten the article but please, go read the whole thing. It’s really good and makes so much sense.
Reason #1: Fusion back surgery doesn’t help pain. I love everything about this section but in particular this quote, “We also know that disc degeneration, ruptured discs, bulging discs, arthritis, and narrowed discs have been clearly shown to NOT be the source of chronic back pain.” Thank you for some common sense, man!
Reason #2: Increased risk of more pain after back surgery. Obviously, people having spinal back surgery want less pain so you can easily see the issue here. He says if you’re already having chronic pain elsewhere, totally unrelated to the surgical issue, you are going to develop chronic pain at the new surgical site up to 60% of the time.
Day-um… But that ties in so nicely with the neurology I’ve learned in the DACO program. When your CNS is already hyper sensitized or up-regulated, it makes sense that new insult is going to behave this way. He also says that re-operation rates within the first year are as high as 20%. Aren’t you just ecstatic that we don’t have to deal with patients that have had failed spinal surgery from day to day in our offices? Good Lord, the surgeons can have it. I don’t want it.
Reason #3: Other treatment options are more effective. Praise the Lord and Hallelujah once again. He ties in the new finding in neurology for chronic pain. The stuff I’ve been talking about in the DACO program. He says, “Your brain memorizes pain just like an athlete, artist, or musician learns his or her skill.”
The best example is that of phantom limb pain. There is no limb, yet, the pain persists, right? I’m hoping that in your mind you just agreed with me and said, “Right,” to yourself.
He says that once a patient understands the neurological nature of chronic pain, it becomes solvable and the key is to shift off the painful and unpleasant circuits onto functional and enjoyable ones or create detours around them. Basically re-wiring the brain to an extent.
I can’t encourage you all enough to go read this article. Again, I’ve linked it in the show notes so go check it.
Item #3: Chiropractic used for in infants and pediatrics has become quite the hot topic recently. Especially with the government in Australia looking at restricting any chiropractic treatment to the point where it may not be able to be utilized in patients under the age of 12 years old if I remember correctly.
In addition, this is expected to be spreading. If my information is correct, it’s already looking to head that way in British Columbia as well as Ontario. So, it’s worth paying attention to.
My first advice would be this: If you want to film your adjustments and put them on the interwebs, then go for it but, when it comes to hanging newborns upside down and performing manipulations on them that make them cry out and things of that nature…..I would encourage you to do your fellow pediatric chiropractors a favor and NOT put those videos on the internet.
Not because I think you’re wrong. I don’t mess with babies myself but that’s because I’m not trained in it and am honestly uncomfortable with it. But that doesn’t mean I think it’s wrong either. Regardless, it’s not about right or wrong as much as it is perception. Particularly the perception by people that don’t know anything about or don’t understand chiropractic at all. Especially those ignorant but then also in a seat of power and influence.
Just don’t freaking do it, OK? That’s what I’m saying.
With all that in mind let’s get going with this one called “Manual therapy for the pediatric population: a systematic review” authored by Carol Prevost, Brian Gleberzon, Beth Carleo, and others. It was published in BMC Complementary and Alternative Medicine on 24 of July 2018. Remember the research hierarchy pyramid and remember that this is a systematic review of 50 studies.
What They Found
Moderate-positive overall assessment was found for 3 conditions: low back pain, pulled elbow, and premature infants. Inconclusive unfavorable outcomes were found for 2 conditions: scoliosis (OMT) and torticollis (MT). All other condition’s overall assessments were either inconclusive favorable or unclear. Adverse events were uncommonly reported. More robust clinical trials in this area of healthcare are needed.
This one is called “Utilization of Chiropractic Care in US Children and Adolescents: A Cross-Sectional Study of the 2012 National Health Interview Survey” authored by Dr. Trent Peng, et. al. Dr. Peng is also a member of our Chiropractic Forward private group on Facebook. Congratulations Dr. Peng!
Why They Did It
The purpose of this study was to describe the prevalence of chiropractic utilization and examine sociodemographic characteristics associated with utilization in a representative sample of US children and adolescents aged 4 to 17 years.
How They Did It
They analyzed data from 9,734 respondents to the 2012 National Health Interview Survey and chiropractic utilization in the past 12 months was the targeted outcome.
What they found
They found that
The 12-month prevalence of chiropractic utilization in US children was 3.0%
The adjusted odds (95% confidence interval) of chiropractic utilization were higher among 11- to 17-year-olds
That’s just to give you an idea of how underserved the younger population is
Last thing, it’s titled, “Change in young people’s spine pain following chiropractic care at a publicly funded healthcare facility in Canada” authored by Christian Manansala, Steven Passmore, Katie Pohlman, and others and published in Complementary Therapies in Clinical Practice online on March 16, 2019.
Hot stuff, coming up.
That’s five articles this week. We are getting some serious schooling here right? The reason for this one was knowing that spinal pain in young people has been established as a risk factor for pain later in life, and considering the fact that recent guidelines recommend spinal manipulation and other modalities for back pain, the authors wanted to begin exploring the response to chiropractic treatment in young people with spinal pain.
We already know it helps all of us old people but what about the kids?
The study utilized a retrospective analysis of prospectively collected quality assurance data attained from the Mount Carmel Clinic chiropractic program database.
What they found
Young people 10-24 years old showed statistically and clinically significant improvement on the numeric scale in all four spinal regions following chiropractic management.
The official conclusions reads as follows, “The findings of the present study provide evidence that a pragmatic course of chiropractic care, including SM, mobilization, soft tissue therapy, acupuncture, and other modalities within the chiropractic scope of practice are a viable conservative pain management treatment option for young people.”
Of course. For us that’s a duh sort of thing but, until it is written in research, you can’t treat it as a duh thing. While we think it’s an obvious conclusion, it’s not so obvious to others so thanks to these fine folks for doing the hard work and allowing all of us to stand on the shoulders of your efforts.
This week, I want you to go forward with:
Big time research in medical journals keep proving you made the right decision to be a chiropractor. I know you didn’t need that validation personally but professionally, it’s a hell of a nice thing to have in our back pockets.
Chronic back pain will never be cured by a surgery-first mentality and we knew that. But, our central nervous system plays as much a part in the resolution of pain as any mechanical factor plays a part in it.
Pediatrics is under attack. Stop filming what you do. You’re not wrong but perception plays as much a part in the problems pediatric chiropractors are having as does any thing else. We get results in kids too but, if you don’t watch it, it’ll get taken away. Be smart.
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 instead of chemical treatments like pills and shots.
When compared to the traditional medical model, research and clinical experience show that many patients get good or excellent results through chiropractic for headaches, neck pain, back pain, joint pain, to name just a few.
Chiropractic care is safe and cost-effective. It can decrease instances of surgery & disability. Chiropractors normally do this through conservative, non-surgical means with minimal time requirements or hassle to the patient.
And, if the patient develops a “preventative” mindset going forward from initial recovery, chiropractors can likely keep it that way while raising the general, overall level of health of the patient!
Patients should have the guarantee of having the best treatment offering the least harm.
Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show or tell us your suggestions for future episodes. Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on iTunes and other podcast services. Y’all know how this works by now so help if you don’t mind taking a few seconds to do so.
Help us get to the top of podcasts in our industry. That’s how we get the message out.
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
1. Rubinstein S, d.Z.A., van Middlekoop M,, Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials. BMJ, 2019. 364(1689).
2. Hanscom D “This Spine Surgeon says Avoid Spinal Surgery for Low Back Pain: Stop and Think Carefully about Back Surgery.”. Pain Chats, 2019.
3. Prevost C, G.B., Carleo B,, Manual therapy for the pediatric population: a systematic review. BMC Comp Altern Med, 2019. 19(60).
4. Peng T, C.B., Gabriel K,, Utilization of Chiropractic Care in US Children and Adolescents: A Cross-Sectional Study of the 2012 National Health Interview Survey. J Manipulative Physiol Ther, 2018. 41(9): p. 725-733.
5. Manansala C, P.S., Pohlman K,, Change in young people’s spine pain following chiropractic care at a publicly funded healthcare facility in Canada. Complementary Therapies in Clinical Practice, 2019.
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