Chiropractic Effectiveness – Chiropractic Integration – Chiropractic Future
Today we’re going to talk about what I think is some good news that bodes very well for the chiropractic future, for chiropractic integration, chiropractic effectiveness, and playing well with others. We’ll discuss a paper on non-pharma ways of treating pain and then we’ll discuss an article showing how roadblocks are set up to keep Americans from following those recommendations.
Stick with us as we shake it all out, but first, here’s that bumper music
Welcome to the podcast today, I am still pretty new to the podcast game so, in case you don’t know me just yet,…I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.
You have gallivanted into Episode #46 and we are so glad you did.
DACO Program
Let’s talk a bit about the DACO program, I have gone through 30 hours live and have taken 12 hours online so far. That makes 42 of the 300 but hey, who’s counting right? The last one I took had to do with Cervical pain and neural tension. I’m man enough to admit that, while I have an A in the class, I missed a question on this one and here’s what I’m going to say…..STOP. Stop asking trick questions dammit.
Honestly, you can know the material cold but the way they ask some of the questions, there’s no telling what the hell the answer is. “Which statement makes the most clinical sound?” Fine…no problem. But, as you read through them, there is maybe one answer that is very thorough while the others are not technically incorrect but aren’t quite as comprehensive as the one answer. Then, yes…..the feared…..ALL OF THE ABOVE.
Uh huh….just ask the damn question and be fair about it. That’s all I’m saying. On one hand, one answer is most definitely more clinically sound than the others. On the other hand, all of them have some correct aspects. So, you’re bound to miss some here or there and, with only 5 questions, you miss one, you make an 80. An 80 is hard for me to swallow friends.
So….cut it out, people. Be fair in your questioning. Thank you very much
The material though, my goodness. I can’t even begin to tell you all how wonderful the material is. Of course, I like some of the classes more than others. The one on pain was not necessarily my favorite but I muddled through it and still know a ton more about pain than I did prior to. Pain is a difficult topic but they did an excellent job of lining it out for us.
Every class makes a difference. Without a doubt. Let me know if you need some guidance on getting started on your DACO. Which was the main thing for me….just getting started in the first place. It’s a bit confusing but once you get enrolled and get that first class under your belt, you’re good to go. Just email me at dr.williams@chiropracticforward.com
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Evidently, you and your colleagues are catching onto this here podcast. We appreciate it and we appreciate your continuing sharing it with you people. That’s the only way to grow.
Front Desk Woes
So far, we still have the front desk staff in place. So that’s been amazing to not be obsessing about. It is really hard to find the right person with the right qualities to fill that spot. I’m not spouting fake numbers when I tell you that we see an average of about 60 new patients per month by myself.
No associate. I had a colleague recently tell me they don’t think they could do that by their self. I have to admit, I didn’t realize it was an impressive amount. Lol. I was glad to hear it though. Here’s my deal though, I don’t hold onto them. I see them, get them better, and will have them again in a year or so when they re-injure something.
I have about 40 or so visits booked per day and that’s pretty manageable when you have great staff. I still work from 8-1 on Fridays too. The majority of my time is spent on new patients trying to figure them out. After we have a direction with a patient, however, we have a team of people that really help take the workload off of me other than the actual adjusting.
And, in case anyone is wondering out there, I adjust manually, Diversified with some drops here and there. Very little activator. Some muscle work when appropriate but there’s not a lot of fluff in a visit once we are rocking and rolling with a case.
I tell them that I can really drag this visit out and make it last a lot longer than it takes if they want me to but most are ready to get in and out and back to work. And that works well for us too.
Getting back on track
Anyway, back to the original point: it’s hard to find someone that is not intimidated by the insurance demands, new patients, existing patients, etc…but excited about chiropractic effectiveness….looking them in the eyes all day every day all day.
Plus, a third of the building is massage, day spa services so, the right person is key. They get intimidated and leave. Lol. I suppose it’s a good problem to have. But, so far so good with the new one!
As I’ve said before, I will certainly keep you updated.
We are honored to have you listening. Now, here we go with some vital information that we think can build confidence and improve your practice which will improve your life overall.
Let’s get into the papers
Let’s kick off the discussion today with one from McGregor, et. al. 2014 called “Differentiating intraprofessional attitudes toward paradigms in health care delivery among chiropractic factions: results from a randomly sampled survey.” It was published in BMC Complementary and Alternative Medicine[1].
In the background section of the abstract, the authors’ discuss how healthcare has increased in complexity and there has developed a need for interprofessional collaboration. Amen, brothers and sisters.
It goes on to talk about how different factions within the chiropractic profession are contrary to each other and how one faction holding unorthodox practice beliefs and behaviors may compromise interprofessional relations going forward.
We can have all of the research on our side but when you have one faction of the profession spouting chiropractic effectiveness for everything under the sun, well, the credibility of the profession as a whole really suffers.
The purpose of this paper was, “to quantify the professional stratification among Canadian chiropractic practitioners and evaluate the practice perceptions of those factions.”
How do you go about figuring this stuff out? Luckily, there are far more intelligent people out there in the world. They took a stratified random sample of 740 Canadian chiropractors and surveyed them in an attempt to determine faction membership and how professional stratification could be related to views that could be considered unorthodox to current evidence-based care and guides.
What they found
Out of 740 questionnaires, 503 came back.
Less than 18.8% of the chiropractors were in the faction considered to be unorthodox in the perceptions of the conditions they treat.
They also state that prediction models suggest that unorthodox perceptions of health practice related to treatment choices, x-ray use, and vaccinations were strongly associated with unorthodox group membership.
The conclusions reached here were as quoted, “Chiropractors holding unorthodox views may be identified based on response to specific beliefs that appear to align with unorthodox health practices.”
Despite continued concerns by mainstream medicine, only a minority of the profession has retained a perspective in contrast to current scientific paradigms. Understanding the profession’s factions is important to the anticipation of care delivery when considering interprofessional referral.”
Basically, what they’re saying is that, in Canada at least, there are 20% of you chiropractors walking around saying your nerve doctors, that you fix everything under the sun, and you’re releasing the innate and turning on the power. This isn’t chiropractic effectiveness. This is belief. Not research-based findings.
That 20 % is REALLY putting 80% of us that have busted our butts and learned the latest science and research….you’re putting us at risk of staying right where we’ve always been rather than expanding, integrating, and being the experts in what we do.
We are masters at what we do but there are 20% out there keeping anyone that matters from taking the rest of us seriously. When we are talking about legitimate chiropractic effectiveness, that 20% has taken away our credibility.
Parento’s principle proves to be a real thing once again. 20% of chiropractors do all of the work in discrediting the other 80% of the profession.
Next paper
Let’s go to the next paper before I lose my mind.
This one is called Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care[2]. It was published in June of 2018 in Explore: The Journal of Science and Healing and was written by Heather Tick MD along with a team of other medical doctor/PhDs.
Dr. Tick is a specialist in pain management in Seattle Washington. She even has her own website and blog. All that good stuff. You can check it out at heathertickmd.com if you are so inclined.
A little more about her: She co-founded and directed one of the first inter-disciplinary pain centers in Toronto from 1991 – 2008 and has been involved in research with the University of Waterloo at the Department of Kinesiology, the Canadian Memorial Chiropractic College (CMCC), the University of Washington, and the University of Arizona.
She served as the Director of the Integrative Pain Clinic at the University of Arizona in the Department of Family and Community Medicine until Dec 2011, when the University of Arizona Health Plan recruited her to start the integrative medicine pain clinic for Medicaid patients.
Dr. Tick currently serves at the forefront of research and teaching as a Clinical Associate Professor at the University of Washington in the departments of Family Medicine and Anesthesia & Pain Medicine and is also the first holder of the prestigious Gunn-Locke Endowed Professorship of Integrative Pain Medicine at the University of Washington.
In this paper, Dr. Tick starts by saying “Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths.”
I like that opening quote. I like it a lot, folks. She’s saying that the medical way of managing pain isn’t working and throwing more pills at it is a downward spiral. And I agree as I’m sure you do as well.
She goes on saying, “There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options.
“Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability.”
Conclusion
The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices.
Here’s what I hate to do: I hate quoting an abstract word for word. It’s usually dry and well….boring. But, what she says here is so spot-on, quoting it was the best way to get it across in an equal manner. Meaning that I couldn’t say it better myself. Chiropractic effectiveness is becoming undeniable at this point.
She nails it:
- It’s not working
- We need non-pharma options that are backed by evidence
- There are barriers set up to prevent non-pharma options from being utilized
- There is ignorance in regards to non-pharma options and that needs to be addressed through education
- Continued research is needed
Further down into the paper, the authors mention in one spot that chiropractic care is 60-70% less likely to be reimbursed. Is that accurate? We are typically covered by most insurance plans no?
When they are saying that there are barriers set up to prevent complementary options, this may fit her rhetoric or point but I just haven’t experienced it being that much less likely to have coverage.
They cite a paper by James Whedon, Et. al. where they found, for New Hampshire[3], there was 60%-70% less reimbursement. I wonder if that is consistent throughout the US or if it’s isolated to New Hampshire?
That’s a great question and if one of you out there in podcast listening land knows the answer, please email me at dr.williams@chiropracticforward.com and fill me in. I’m curious and I’m pretty sure the rest of us out there are too.
Under their Evidence-Based Non-pharm Therapies for Acute Pain, they point out that non-pharma therapists have shown effective in acute pain with opioid paring in the hospital setting as a result of their use and the therapies mentioned in the paper are acupuncture, chiropractic, osteopathic manipulative therapy, massage, physical therapy, relaxation, and cognitive behavioral therapy.
The authors also site spinal manipulative therapy as being effective for chronic pain including migraines, cervicogenic headache, neck pain, low back, hip pain, patellofemoral syndrome, and on and on. Of course, we chiropractors know this stuff but it’s great to see it in black and white and as part of a paper written exclusively by MDs and PhDs.
This is a long paper with a lot of excellent information. I highly encourage your checking it out. Just go to our show notes for links and citations.
Wrap it up
A great takeaway from this paper is this quote, “In general, the costs of evidence-based nonpharmacologic options are nominal compared to medical costs of treating chronic pain with risk mitigation and greater potential for engaging patients in ongoing self-care.”
This is exactly why we are discussing chiropractic effectiveness at length these days. It is paramount for the future of our patients as well as for the the chiropractic future for people to get this message.
Last Paper
The last paper I want to talk about is by our very own Dr. Christine Goertz, DC, Ph.D. with Steven George, PT, Ph.D. as her side-kick and is published in JAMA. It’s called “Insurer Coverage of Nonpharmacological Treatments for Low Back Pain—Time for a Change[4]” and published on October 5 of this year so, just this month. Brand new.
Dr. Goertz begins by relating low back pain with the obvious opioid crisis and goes into last year’s recommendation that you’ve heard here a million times.
The recommendations from the American College of Physicians for low back pain which recommended spinal manipulative therapy as a first-line therapy for chronic and acute low back pain.
We will talk about it in upcoming episodes but Dr. Goertz also mentions the new Gallup-Palmer Poll where they found that 78% of US adults prefer to use non-pharma options for back and neck pain.
In the article, she cites a paper by Heyward, et. al[5]. called “Coverage of Nonpharmacologic treatment for low back pain among US public and private insurers” that found coverage of some therapies (like chiropractic) was available in most health plans but that there are significant barriers to patient access identified.
Barriers such as visit limits, prior authorization requirements, and high out-of-pocket expenses. And that payment policies targeted toward coordination of pharmacological and nonpharmacological care were virtually nonexistent.
She says pretty clearly the following: In regards to most health plans surveyed, they did not have policies in place that:
- emphasize the use of nonpharmacological treatments at the forefront of the patient experience
- provide meaningful levels of coverage for care professionals who focus on guideline-adherent nondrug therapies like spinal manipulation, exercise, massage, acupuncture, and cognitive behavioral therapy
- us financial incentives that favor the use of nonpharmacological options over commonly prescribed pharmaceuticals, including opioids
Wrap it up
She also calls out healthcare executives quite effectively I thought by saying, “Relative to stigma, Heyward et al found that health care executives did not believe expanded coverage of nonpharmacological treatments is supported by the existing literature.
As outlined in the ACP guideline referenced earlier, in many cases nonpharmacological treatments offer equal benefit or even improved benefit, with lower risk, than commonly used pharmaceutical options.”
And by suggesting that future coverage policies should be based on unbiased reviews of the evidence appropriately balancing risk with benefit rather than prior dogma or biases.
Lastly, Dr. Goertz discusses cost-effectiveness and the need for future payment policies to decrease patient out-of-pocket expenses to strongly encourage earlier us of evidence-based non-harms options.
The Heyward paper demonstrated how trips to PTs or DCs are usually 6-12 visits with an out-of-pocket of $150-$720 or more. She then showed how Lin et. al. showed the median cost of a 30-day supply of preferred generic opioid by commercial insurers is $10.
How does that add up for the Joe Blow citizen on the street?
It doesn’t.
I love how they sum it up by saying, “Restricting access to opioids without addressing the underlying problem of chronic care management for low back pain is unlikely to positively affect the opioid crisis. Well-conceived guidelines that encourage the use of evidence-based, nonpharmacological treatment options exist and must be enabled by changes in public health policies that better guide care delivery and reimbursement.”
Boom, Snap, kapow, Shazam…
Honestly, where would we be without Dr. Goertz? We’d still be moving the direction we’re moving in because of the opioid issue but she has done some amazing work that is putting us on the fast track where we hope to go rather than on the snail’s pace.
This week, I want you to go forward understanding that It’s happening folks. we are now able to cite papers in JAMA that are pro-chiropractic. Pro-complementary health care. Anti-pharma. This is big stuff. We are in the right place at the right time. And, it was in part, the failure of many in the medical kingdom that put us here.
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 a mechanical pain and responds better to mechanical treatment instead of chemical treatments.
The literature is clear: research and experience show that, in 80%-90% of headaches, neck, and back pain, patients get good to excellent results when compared to usual medical care and it’s safe, less expensive, and decreases chances of surgery and disability.
It’s done conservatively and non-surgically with little time requirement or hassle for the patient. If done preventatively going forward, we can likely keep it that way while raising overall health! At the end of the day, patients have the right to the best treatment that does the least harm and THAT’S Chiropractic, folks.
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.
Being the #1 Chiropractic podcast in the world would be pretty darn cool.
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:
Dr. Jeff Williams – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger
Insurer Coverage of Nonpharmacological Treatments for Low Back Pain—Time for a Change | Complementary and Alternative Medicine | JAMA Network Open | JAMA Network
Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care – Explore: The Journal of Science and Healing
https://www.ncbi.nlm.nih.gov/pubmed/28304182?dopt=Abstract
Differentiating intraprofessional attitudes toward paradigms in health care delivery among chiropractic factions: results from a randomly sampled survey | BMC Complementary and Alternative Medicine | Full Text
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2705853
Bibliography
1. McGregor M, Differentiating intraprofessional attitudes toward paradigms in health care delivery among chiropractic factions: results from a randomly sampled survey. BMC Comp Altern Med, 2014. 14(51).
2. Tick H, Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care. Explore J Science Healing, 2018. 14(3): p. 177-211.
3. Whedon JM, e.a., Insurance Reimbursement for Complementary Healthcare Services. J Altern Complement Med, 2017. 23(4): p. 264-267.
4. C, G., Insurer Coverage of Nonpharmacological Treatments for Low Back Pain—Time for a Chang. JAMA, 2018. 1(6).
5. Heyward J, Coverage of Nonpharmacologic Treatments for Low Back Pain Among US Public and Private Insurers. JAMA, 2018. 1(6).
CF 020: Chiropractic Evolution or Extinction?
CF 027: WANTED – Safe, Nonpharmacological Means Of Treating Spinal Pain
CF 030: Integrating Chiropractors – What’s It Going To Take?
