chronic pain

Adjustments As Immune Boosters & Pain – Mind or Matter?

CF 182: Adjustments As Immune Boosters & Pain – Mind or Matter? Today we’re going to talk about adjustments being immune boosters and then we talk about osteoarthritis and if pain is mind or matter.  But first, here’s that sweet sweet bumper music
Chiropractic evidence-based products

Integrating Chiropractors

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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. 
  • Like our Facebook page, 
  • Join our private Facebook group and interact, and then 
  • go review our podcast on iTunes and other podcast platforms. 
  • We also have an evidence-based brochure and poster store at chiropracticforward.com
  • While you’re there, join our weekly email newsletter. 
You have found yourself smack dab in the middle of Episode #182 Now if you missed last week’s episode , we talked about NSAIDS causing GI events and we talked about chronic pain and how it’s being handle within the VA system. Make sure you don’t miss that info. Keep up with the class.  On the personal end of things….. As seems to be the common thread lately, time is short this week. I am preparing for the book launch tomorrow. Now I’m recording this on Monday, June 7. And the lunch is Tuesday, June 8 so when you get this when you hear this, it’s already up and live. I would love for you to go and purchase yourself a copy of my new book. It is called the remarkable truth about chiropractic: a unique journey into the research. It has been a long time coming and it is finally finished. For those of you that reached out enjoying the lunch team, thank you so much. I have some special people in my life and I am grateful for each of them. So, about the time I am recovering from the New Orleans trip, it’s time to take two days off this week to go to the state chiropractic convention which is called Cairo Texaco.  Of course, we missed the chiropractic conference last year because nobody could be in the same room with each other for fear of dying a slow and painful death. But this year is different. We are looking forward to seeing each other again and shaking hands and hugs and conquering the chiropractic world yet again.  Going to your state conference and being involved in your state association is one of the most important and impactful things you can do for yourself, your business, and your profession. If we are to ever get the message of evidence-based, patient-centered practice to be big business and the way things are done, it Hass to be done through leadership, activity, and guidance on our part. And that starts not only locally, but also on the state level.  So I implore you to get active in your state association. Get to know the players. And once they get to know you and respect you, and you can start to steer the ship a bit. It takes all of us. Including vitalists by the way, because some evidence chiropractors have taken it so far that they don’t even use spinal manipulative therapy. Do you have to have a vitalist to offset that?  But, the point is to get active and if you don’t recall part of the podcast from last week, I don’t wanna hear that crap about not having time. Nobody has time. But if not us, then who?  Make it a priority and just get involved. Dive in. Raise your hand. Volunteer. It’s that simple Seriously, nobody has time. It’s like voting. If you don’t vote, don’t bitch. If you don’t get active in your state association and maybe eventually your national association, don’t bitch. Sit down and let the A Team handle it.  Sorry for the harsh tone there but after being so active for so long and watching the benchwarmers gripe about everything all the time no matter what…..well…..I’m over it.  Here we go.  Item #1 Let’s step into it here, shall we. It’s called “The Potential Mechanisms of High-Velocity, Low-Amplitude, Controlled Vertebral Thrusts on Neuroimmune Function: A Narrative Review” by Heidi Haavik, [1] the vitalist’s brand new hero, and it was published in Medicina on May 25, of 2021.  Servin’ it up fresh!  Why They Did It Heidi says, “The current COVID-19 pandemic has necessitated the need to find healthcare solutions that boost or support immunity. There is some evidence that high-velocity, low-amplitude (HVLA) controlled vertebral thrusts have the potential to modulate immune mediators. However, the mechanisms of the link between HVLA controlled vertebral thrusts and neuroimmune function and the associated potential clinical implications are less clear. This review aims to elucidate the underlying mechanisms that can explain the HVLA controlled vertebral thrust–neuroimmune link and discuss what this link implies for clinical practice and future research needs.” How They Did It
  • A search for relevant articles published up until April 2021 was undertaken. 
  • Twenty-three published papers were found that explored the impact of HVLA controlled vertebral thrusts on neuroimmune markers, of which eighteen found a significant effect. 
  • These basic science studies show that HVLA controlled vertebral thrust influence the levels of immune mediators in the body, including neuropeptides, inflammatory markers, and endocrine markers. 
  • This narrative review discusses the most likely mechanisms for how HVLA controlled vertebral thrusts could impact these immune markers. 
What They Found
  • The mechanisms are most likely due to the known changes in proprioceptive processing that occur within the central nervous system (CNS), in particular within the prefrontal cortex, following HVLA spinal thrusts. 
  • The prefrontal cortex is involved in the regulation of the autonomic nervous system, the hypothalamic–pituitary–adrenal axis and the immune system. 
  • Bi-directional neuro-immune interactions are affected by emotional or pain-related stress. Stress-induced sympathetic nervous system activity also alters vertebral motor control.
Wrap It Up She says, “There are biologically plausible direct and indirect mechanisms that link HVLA controlled vertebral thrusts to the immune system, suggesting HVLA controlled vertebral thrusts have the potential to modulate immune function. However, it is not yet known whether HVLA controlled vertebral thrusts have a clinically relevant impact on immunity. Further research is needed to explore the clinical impact of HVLA controlled vertebral thrusts on immune function” OK, Heidi is way more intelligent than I am so I’m not debating or arguing with her. I would just say that is getting hit in the butt with a board influential on the immune system as well? How about exercise? Having sex? What about getting slapped in the face?  Then I would wonder how long-lasting any effect on the immune system is, is any effect a strong enough effect on the immune system to actually be able to fight of viruses, and…..if its that effect needed 3 x per week? Once per week? Would trying to maintain this immune boost lifetime lead to worse things like spinal instability? I have my doubts on this line of research but will definitely be watching. Wouldn’t it be great if she can prove it 100%? I doubt that’s going to happen so don’t hold your breath, please.  CHIROUP ADVERTISEMENT Item #2 Our last one today is called “Factors associated with pain intensity and magnitude of limitations among people with hip and knee arthritis” by Kopp et. al. [2] and published in the Journal of Orthopaedics in the May-June 2021 issue and you can’t get any steamier than that my friends.  Why They Did It The pain and limitations associated with osteoarthritis of the hip and knee have a notable variation that does not correspond directly with pathophysiology. The purpose of this study is to assess the influence of location of the arthritis on pain intensity and magnitude of limitations accounting for personal and psychological factors. How They Did It
  • 154 patients with osteoarthritis of the hip or the knee were enrolled in this prospective cross-sectional cohort study. 
  • Patients answered questionnaires which included demographics, site of arthritis, laterality, pain intensity,(PROMIS PF CAT), and psychologic questionnaires 
What They Found
  • Magnitude of limitations was independently associated with years of education, work status, time spent exercising, catastrophic thinking (PCS-4), and symptoms of depression.
  • They accounted for 50% of variability in physical function, with the major contributor being catastrophic thinking. The model for pain intensity included time spent exercising and fear of painful movement (TSK-4). Anatomic site and radiographic severity of arthritis were not associated with either physical function or pain in our patient sample.
Wrap It Up This study confirms that limitations and pain from osteoarthritis of the hip and knee are more closely related to personal and psychological factors, less effective cognitive coping strategies such as catastrophic thinking and kinesiophobia in particular, than to pathological and anatomical factors such as location and severity of arthritis.  Care that incorporates incremental correction of common misconceptions that accompany the nociception from osteoarthritis have the potential to improve function and comfort in people with osteoarthritis. The power of the mind folks. Use it to your advantage. Remember, words matter. Be optimistic, relay confidence and be supportive. Never be pessimistic or communicate in a catastrophic way. Ever.  See what happens.  Alright, that’s it. Y’all be safe. Keep changing our profession from your little corner of the world. Keep taking care of yourselves and everyone around you. Tough times are upon us but, the sun will shine again. Trust it, believe it, count on it. Let’s get to the message. Same as it is every week.  Store Remember the evidence-informed brochures and posters at chiropracticforward.com.   
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 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
Home
Social Media Links https://www.facebook.com/chiropracticforward/ Chiropractic Forward Podcast Facebook GROUP https://www.facebook.com/groups/1938461399501889/ Twitter YouTube 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 & VloggerBibliography 1. Haavik, H.N., I.K.; Kumari, N.; Amjad, I.; Duehr, J.; Holt, K, The Potential Mechanisms of High-Velocity, Low-Amplitude, Controlled Vertebral Thrusts on Neuroimmune Function: A Narrative Review. Medicina, 2021. 57(6): p. 536. 2. Kopp B, F.K., Goldberg T, Ring D, Koenig K,, Factors associated with pain intensity and magnitude of limitations among people with hip and knee arthritis. J Orthopaedics, 2021: p. 295-300.  

NSAIDS And GI Events & Chronic Pain In The VA System

CF 181: NSAIDS And GI Events & Chronic Pain In The VA System

Today we’re going to talk about NSAIDS and their relation to GI events and then we’ll talk about how primaries are handling things within the VA system for their chronic pain veterans here in the US.  But first, here’s that sweet sweet bumper music    
Chiropractic evidence-based products

Integrating Chiropractors

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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. 
  • Like our Facebook page, 
  • Join our private Facebook group and interact, and then 
  • go review our podcast on iTunes and other podcast platforms. 
  • We also have an evidence-based brochure and poster store at chiropracticforward.com
  • While you’re there, join our weekly email newsletter. 
You have found yourself smack dab in the middle of Episode #181 Now if you missed last week’s episode, we talked about Sitting on your butt and what that’ll get you and we talked about catastrophizing MRI results. Both for the practitioner as well as the patient. Make sure you don’t miss that info. Keep up with the class.  On the personal end of things….. New Orleans was great. We stayed a little longer than we normally do but it was good. They acted like it’s been a bit of a ghost town down there since COVID came along. Restaurants were still closed and some of the ones open were understaffed. The door guy at our hotel was trying to hire our Uber driver today on the way to the airport. Life is getting there but it is most definitely not back to normal and business as usual just yet. We’ll get there though.  Priorities. Let’s talk briefly about if. Here’s some honest talk about what ‘I didn’t have the time” really truly means. This is actually a blog I just wrote for my personal website but it’ll work for you as a chiropractor and business owner as well.  We all seem to be short on time, don’t we? Emails, notifications, pings, bells, chimes, and phone calls just to name a few. It seems that we are always on call and expected to respond.  That goes for our actual jobs but it goes for our personal lives too. Social media alerts alone are enough to make a person lose it.  So when someone says, “You know, I just didn’t have the time,” you want to believe them. Because it makes sense. Life has just gotten very busy and more complicated than it has ever been before. Weren’t computers and technology supposed to make our lives easier? But then you remember that people still make time to go to the movies. They make time to go out to eat. They make time go to the park with their kid. At least they should be! When it comes to observing my own kids, they make time for friends, sitting around on their phones, or lounging and watching TV. Time is available. It may be in short supply for some of us, but it is most definitely available. I heard a saying once that went like this, “Saying that you didn’t have time to do something is just a less abrasive way of saying that it wasn’t a priority.” That hit me between the eyes.  Because it’s so very true. I’ve seen this in my kids’ and acquaintances’ actions and I’ve seen it in my own actions. When I’m interested in something and when I really want it, I can typically make it happen. Because it’s a priority. It’s a focus and our focus goes where energy flows. Or something like that I’m sure came from Tony Robbins. When I want to get better at one of my hobbies, I obsess a little about it and I make the time for it. The point is, when it’s important, we make it a priority and we make the time. We get it done. Stop using a lack of time as an excuse to not get the things done you know need to be done. Maybe it’s marketing. Maybe it’s calling that one attorney you need to speak with but don’t really really want to speak with. Maybe it’s going to a Chamber of Commerce event. Maybe it’s writing that blog or starting that podcast you’ve wanted to start for a while.  Make it a priority. Make the time. Item #1 This first one is called “A Retrospective Database Study of Gastrointestinal Events and Medical Costs Associated with Nonsteroidal Anti-Inflammatory Drugs in Japanese Patients of Working Age with Osteoarthritis and Chronic Low Back Pain” by Kikuchi et. al. [1] and published in Pain Medicine in May of 2021.  Hot stuff, coming up.  Why They Did It The authors say the reason for the paper is that the real-world burden of gastrointestinal (GI) events associated with the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in Japanese patients with osteoarthritis (OA) and/or chronic low back pain (CLBP) remains unreported. How They Did It
  • Used the Japanese Medical Data Center database to retrospectively evaluate anonymized claims data of medical insurance beneficiaries employed by middle- to large-size Japanese companies who were prescribed NSAIDs for OA and/or CLBP between 2009 and 2018.
  • 180,371 patients were included in the analysis
  • 32.9% had OA
  • 53.8% had CLBP
  • 13.4% had both OA and CLBP
  • NSAIDs were administered as first-line analgesics to 161,152 (89.3%) of the patients in the sample
What They Found
  • The incidence of GI events was 9.97 per 10,000 person-years
  • The risk of developing GI events was high in elderly patients and patients with comorbidities and remained similar for patients receiving oral vs. topical NSAIDs
  • Longer treatment duration and consistent NSAID use increased the risk of GI events
Wrap It Up NSAID-associated GI toxicity imposes a significant health and economic burden on patients with OA and/or CLBP, irrespective of whether oral or topical NSAIDs are used. Well, that’s what it’s about isn’t it? It’s about getting people well without the use of drugs or surgery if possible. I’m not advocating never using medicine. Medicine is vital to our health and our lives but let’s don’t pretend they don’t have consequences. They do. Even the mild ones.  CHIROUP ADVERTISEMENT Item #2 Our last item today is called “Barriers to and Facilitators of Multimodal Chronic Pain Care for Veterans: A National Qualitative Study” by Leonard et. al. [2] and published in Pain Med on September 24, 2020 and that’s just hot enough! Why They Did It Chronic pain is more common among veterans than among the general population. Expert guidelines recommend multimodal chronic pain care. However, there is substantial variation in the availability and utilization of treatment modalities in the Veterans Health Administration. We explored health care providers’ and administrators’ perspectives on the barriers to and facilitators of multimodal chronic pain care in the Veterans Health Administration to understand variation in the use of multimodal pain treatment modalities. How They Did It
  • They conducted semi-structured qualitative interviews with health care providers and administrators at a national sample of Veterans Health Administration facilities that were classified as either early or late adopters of multimodal chronic pain care according to their utilization of nine pain-related treatments.
  • Interviews were conducted by telephone, recorded, and transcribed verbatim. Transcripts were coded and analyzed through the use of team-based inductive and deductive content analysis.
  • They interviewed 49 participants from 25 facilities from April through September of 2017
What They Found
  • They identified three themes
  • First, the Veterans Health Administration’s integrated health care system is both an asset and a challenge for multimodal chronic pain care
  • Second, participants discussed a temporal shift from managing chronic pain with opioids to multimodal treatment.
  • Third, primary care teams face competing pressures from expert guidelines, facility leadership, and patients.
Wrap It Up Health care providers often perceive inadequate support and resources to provide multimodal chronic pain management. Efforts to improve chronic pain management should address both organizational and patient-level challenges, including primary care provider panel sizes, accessibility of training for primary care teams, leadership support for multimodal pain care, and availability of multidisciplinary pain management resources. I know where we fit in. IF they’re using an evidence based, patient-centered chiropractor in the mix, their patients are getting off of the pharmaceuticals, they’re sleeping better, they’re not thinking of suicide as much, and they’re beginning to become a part of their lives again.  I see it all of the time because we see veterans straight from the VA. You’re getting it from he horse’s mouth. We make such a difference in these people’s lives. But we still battle that BS all of the time don’t we? No matter how good you try to be, you still have that jackass primary somewhere inside the system spoiling the water. Locker room poison. Just bashing chiropractors when they don’t have any experience themselves regarding the things they’re saying.  Keep trudging though. If we were wrong, we’d have been eliminated generations ago.  Alright, that’s it. Y’all be safe. Keep changing our profession from your little corner of the world. Keep taking care of yourselves and everyone around you. Tough times are upon us but, the sun will shine again. Trust it, believe it, count on it. Let’s get to the message. Same as it is every week.  Store Remember the evidence-informed brochures and posters at chiropracticforward.com.     
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 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
Home
Social Media Links https://www.facebook.com/chiropracticforward/ Chiropractic Forward Podcast Facebook GROUP https://www.facebook.com/groups/1938461399501889/ Twitter YouTube 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 1. Shogo Kikuchi, M., PhD, Kanae Togo, PhD, Nozomi Ebata, Koichi Fujii, MD, PhD, MBA, Naohiro Yonemoto, PhD, Lucy Abraham, MSc, CPsychol, Takayuki Katsuno, MD, PhD,, A Retrospective Database Study of Gastrointestinal Events and Medical Costs Associated with Nonsteroidal Anti-Inflammatory Drugs in Japanese Patients of Working Age with Osteoarthritis and Chronic Low Back Pain. Pain Med. 22(5): p. 1029-1038. 2. Chelsea Leonard, P., Roman Ayele, PhD, MPH, Amy Ladebue, BA, Marina McCreight, MPH, Charlotte Nolan, MPA, Friedhelm Sandbrink, MD, Joseph W Frank, MD, MPH,, Barriers to and Facilitators of Multimodal Chronic Pain Care for Veterans: A National Qualitative Study. Pain Med, 2020. 22(5): p. 1167-1173.  

Working Class Rising Death Rates & Nutrition Affects Chronic Pain

CF 179: Working Class Rising Death Rates & Nutrition Affects Chronic Pain Today we’re going to talk about the fact that there are rising death rates among folks that are of working-class age. Not just the elderly. Why is that happening? Then we’ll talk about diet and chronic pain.  But first, here’s that sweet sweet bumper music
Chiropractic evidence-based products

Integrating Chiropractors

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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. 
  • Like our Facebook page, 
  • Join our private Facebook group and interact, and then 
  • go review our podcast on iTunes and other podcast platforms. 
  • We also have an evidence-based brochure and poster store at chiropracticforward.com
  • While you’re there, join our weekly email newsletter. 
You have found yourself smack dab in the middle of Episode #179 Now if you missed last week’s episode , we talked about  whether chiropractors cause disc herniations or not and we talked about how family doctors still aren’t getting the message. Make sure you don’t miss that info. Keep up with the class.  On the personal end of things….. This medical integration thing is about to take off. Wee ahve the contracts all drawn up, questions answered, and ready to get them all signed.  New EIN, new credentialing for me and the NP, and full steam ahead. Did you know that I have to re-credential under the new entity as well? What a pain in the backside, right? Hell yeah it is. I’m OK referring patients back and forth within the same group. You start to run into risk of getting in trouble with the Stark, anti-kickback laws when you are referring patients back and forth across different entities.  So, yeah….there’s that. I won’t bore you with the particulars but it’s definitely a ride we’re on and it’s go time.  Everything I’ve seen and experienced thus far tells me that we’re in a good spot and things are proceeding fairly smoothly. Slowly but smoothly. Next will be credentialing and that will slow everything down for a couple of months but that’s probably a good thing I’m guessing.  I’m fortunate to have a genius for a wife that understands a lot of the legal end of things that I’m just not talented at. Plus we have an attorney in Austin that literally wrote the integration law that has set it all up for us. And we have Dr. Tyce Hergert with Southlake Physical Medicine consulting us so we have a talented and very smart team.  Surrounding yourself with good people is the first step to success. We can’t be expected to be the smartest expert on everything that we encounter in our personal or professional lives. We need good people in our lives and our network. Good and talented people who have the right kind of heart for our style.  That’s exactly what I have right now so I’m very confident going forward. I don’t take big risks. I take measured, smart risks. That’s exactly where I’m at.  Alright, busy busy this week so let’s get scooting with this episode.  Item #1 This one called “High and Rising Working-Age Mortality in the US. A Report From the National Academy of Sciences, Engineering, and Medicine” by Mullan Harris, et. al. [1] published in JAMA on May 10, 2021. Servin em up steamy and saucy.  Why They Did It They say, “Life expectancy has increased in the US and in the world for the past century. In 2010, life expectancy plateaued in the US while continuing to increase in other high-income nations. In the US, life expectancy declined for 3 consecutive years (2015-2017) due primarily to an increase in mortality among working-age adults (those aged 25-64 years).1 Although the increase in mortality was first described among White middle-aged adults, mortality is now increasing among young and middle-aged adults and in all racial groups. This increase in premature death, claiming lives during the prime working ages, has important implications for individuals, families, communities, employers, and the nation.” They found that average working-age mortality rates decreased after 2010 in 16 high-income countries but increased in the US. Three causes of death were identified as chiefly responsible: (1) drug poisoning and alcohol-induced causes, (2) suicide, and (3) cardiometabolic diseases. The first category includes mortality from mental and behavioral disorders, which often involve drugs or alcohol. Cardiometabolic diseases include endocrine, nutritional, and metabolic diseases (eg, diabetes, obesity); hypertensive heart disease; and ischemic heart disease and other diseases of the circulatory system (eg, arrhythmia, cardiomyopathy, heart failure). Drug and alcohol use were the largest contributors to increasing mortality among working-age adults, accounting for 8% (an estimated 1.3 million) of deaths in this population between 1990 and 2017 (an average of 44 869 per year). The increase was largest among White male adults and older Black male adults. They go on. They say, “The drug crisis was the product of 2 influences: an increase in access to legal and illegal drugs and the vulnerability of certain populations. The licensing of OxyContin in 1996, subsequent flooding of the market with prescribed opioids, and waves of highly potent heroin and fentanyl that coincided with growing demand for these substances have been described as a perfect storm.3 The drug supply expanded with limited government oversight, substantial marketing by the pharmaceutical industry, and overprescribing by physicians.” With regards to Suicide, they say, “Suicide, which accounted for 569 099 deaths among working-age adults during 1990-2017 (an average of 20 325 per year), increased primarily among White adults, especially White men, and in less populated, rural areas. Few studies have established a cause for this trend. Economic stresses are a possibility; suicide is associated with economic downturns, wage stagnation, weak health care safety nets, and foreclosures.4 Another potential contributing factor is declining social support from churches, civic organizations, and families. Such social supports, which protect against self-harm, have declined in recent decades, especially among lower-educated White adults. Easier access to firearms is associated with increased suicide rates; however, the greater increase in nonfirearm suicides during this period suggests other causes. Other risk factors for suicide include mental illness, comorbid conditions, disability, and substance use.” With regard to cardiometabolic disease they say, “Cardiometabolic diseases caused more than an estimated 4.8 million deaths among working-age adults during 1990-2017 (an average of 173 062 per year). The largest relative increases in cardiometabolic mortality occurred among younger adults (aged 24-44 years) in all racial/ethnic groups, White men and women, Black men (in recent decades), and those living in rural areas. Cardiometabolic mortality rates increased after 2010 for 2 reasons: (1) mortality from endocrine, nutritional, and metabolic diseases and hypertensive heart disease generally increased during 1990-2017 and (2) after a period of substantial reductions in mortality from ischemic heart disease and other circulatory diseases from the 1970s onward, progress stalled after 2010.” “The report discusses 3 explanations for this trend. First, the most important was the increased prevalence of obesity and its cardiometabolic consequences. Obesity rates increased in the early 1980s as a period-based phenomenon that affected the entire population, but the related cardiometabolic consequences occurred in a cohort fashion; younger cohorts born in the 1970s-1990s experienced obesogenic environments their entire lives, whereas exposure in older cohorts was limited to older ages.5 As a result, many young adults are entering their work lives with a high prevalence of chronic diseases associated with obesity. “ “The recent increase in mortality among working-age adults shows no signs of receding. Obesity rates are unrelenting, drug- and alcohol-related deaths and suicide rates, already high among working-age adults, increased during the COVID-19 pandemic” So what does all of that mean? Well, it means we are providers and we need to know this stuff and be aware of it. We need to be able to refer to specialists when we see the signs of drug or alcohol abuse, suicidal tendencies, or nutritional concerns.  It’s not just a, “‘hey he should get his crap together while he still can.” It’s a little more immediate than that I think .  CHIROUP ADVERTISEMENT Item #2 Item 2 today is called “Dietary Interventions Are Beneficial for Patients with Chronic Pain: A Systematic Review with Meta-Analysis”” by Field et. al. [2] published in Pain Medicine on November 17, 2020 and that’s a bit roasty.  Why They Did It The standard Western diet is high in processed hyperpalatable foods that displace nutrient-dense whole foods, leading to inflammation and oxidative stress. There is limited research on how these adverse metabolic drivers may be associated with maladaptive neuroplasticity seen in chronic pain and whether this could be attenuated by a targeted nutritional approach. The aim of this study was to review the evidence for whole-food dietary interventions in chronic pain management. How They Did It
  • A structured search of eight databases was performed up to December 2019.
  • A meta-analysis was performed in Review Manager.
  • Forty-three studies reporting on 48 chronic pain groups receiving a whole-food dietary intervention were identified
What They Found
  • A visual analog scale was the most commonly reported pain outcome measure, with 17 groups reporting a clinically objective improvement
  • Twenty-seven studies reported significant improvement on secondary metabolic measures.
  • Twenty-five groups were included in a meta-analysis that showed a significant finding for the effect of diet on pain reduction when grouped by diet type or chronic pain type.
Wrap It Up There is an overall positive effect of whole-food diets on pain, with no single diet standing out in effectiveness. This suggests that commonalities among approaches (e.g., diet quality, nutrient density, weight loss) may all be involved in modulating pain physiology   Alright, that’s it. Y’all be safe. Keep changing our profession from your little corner of the world. Keep taking care of yourselves and everyone around you. Tough times are upon us but, the sun will shine again. Trust it, believe it, count on it. Let’s get to the message. Same as it is every week.  Store Remember the evidence-informed brochures and posters at chiropracticforward.com. 
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 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
Home
Social Media Links https://www.facebook.com/chiropracticforward/ Chiropractic Forward Podcast Facebook GROUP https://www.facebook.com/groups/1938461399501889/ Twitter YouTube 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 1. Harris KM, W.S., Gaskin DJ,, High and Rising Working-Age Mortality in the US: A Report From the National Academy of Sciences, Engineering, and Medicine. JAMA, 2021. 2. Rowena Field, M.P., Fereshteh Pourkazemi, PhD, Jessica Turton, Kieron Rooney PhD,, Dietary Interventions Are Beneficial for Patients with Chronic Pain: A Systematic Review with Meta-Analysis. Pain Med, 2020. 22(3): p. 694-714.

They Still Have Low Back Pain Management WRONG

CF 170: They Still Have Low Back Pain Management WRONG Today we’re going to talk about some personal observations from two different patients I saw today and we’ll cover a new article on what should be done with low back pain patients. Hint, many are still getting it wrong over there in the medical profession.  But first, here’s that sweet sweet bumper music

Chiropractic evidence-based products

Integrating Chiropractors

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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. 

  • Like our Facebook page, 
  • Join our private Facebook group and interact, and then 
  • go review our podcast on iTunes and other podcast platforms. 
  • We also have an evidence-based brochure and poster store at chiropracticforward.com
  • While you’re there, join our weekly email newsletter. 

You have found yourself smack dab in the middle of Episode #170 Now if you missed last week’s episode , we talked about living with chronic pain, screen time for the kiddos, and low back pain delivery. Make sure you don’t miss that info. Keep up with the class. 

On the personal end of things…..

The wheels turn slow on the medical integration front. Which is probably a good thing honestly. You don’t want to get out over your skis too far now, do you?? It’s like wading into the water a little at a time so you can get used to it. Some people just jump right out into the middle of it all. I’m a gradual guy. I like to slowly get in and get the lay of the land. That’s kind of how this integration is proceeding right now.  We have the medical director.

He’s been a long time friend of mine and was actually a chiropractor back before he went to medical school. He’s an excellent human being and should be a great fit with me and my way of approaching healthcare.  I got to see a veteran today as a new patient. This is a guy that has had chronic pain that has suffered for years. He just got out of the Army in 2019. He’s been in it for 25 years so you can imagine.  He gets cortisone shots 3-4 times per year. He’s never been told about yellow flags. Warned against allowing doctors to treat from an MRI. He’s only been given shots and turned loose every time he has a flare-up.

He has slipped into fear avoidance.  Now, I had the opportunity to teach him about fear avoidance, about CNS upregulation, about how over 60% of asymptomatic in his age group have disc-related findings on their MRI that means nothing, I got to teach him about stabilizing his low back instead of always popping hit on his own for through a chiropractor. I got to teach him about the difference between hurt and harm. I got to give him a recommendation for Back In Control by Dr. David Hanscum. I got to teach him McGill’s Big 3. I got to teach him how the medical doctors are still turning the treatment tree upside down when they do shots and medication first instead of movement, exercise, manipulation, massage, and all of that good stuff. I think…..I THINK….I got to help give him a roadmap to change his life today.  For an appointment that could have taken 30 minutes, I probably spent well over an hour with him.

First, because he was a really pleasant dude and I instantly liked him on a personal level.

Secondly, he’s a vet and that’s just amazing. But beyond that, I knew it would take some time to change his life. After all….that’s what we’re here for, right? Some time ago, I did an episode of the podcast that had to do with a vitalist nut job from Oklahoma City that posted on social media that he had treated 99 patients and 9 new patient exams within 3 hours. One table, one doctor, blah blah vitalist BS blah blah. Then telling others he could teach them how to do the same if they pay him as a consultant/mentor/guru.  I broke down the time constraints in that episode but I believe it boiled down to about 10 minutes per new patient.

For a vitalist that believes the source of all of the Earth’s imperfections boils down to a subluxation, I suppose you could bounce around down the spine and find 6 sore spots, hammer ‘em back down and go on about the day. I suppose a new patient could take even less than 10 minutes if done that way, quite honestly.  But, in my opinion, and compared to evidence-based docs in the profession, you’d be a piss poor doctor.

One I wouldn’t want anything to do with. One I’m embarrassed is in my profession. 

You have to take the time it takes to fully evaluate someone orthopedically, neurologically, and cognitively. There is no way around it if you’re going to be a next-level practitioner. It’s not optional. Ever. And 10 minutes won’t get it. It just won’t.

I had to adjust a couple of patients that showed up and then return to the vet to keep talking and teaching but we got it done. He’s my new project. It was cool to see him nodding his head and understanding what I was telling him.  I think I saw the light bulb come on. And that’s just pretty damn cool. I’m a little jazzed. A little energized that I think I can take this lifelong veteran and lifelong pain sufferer and turn his situation into a positive one.  We shall see but it should be a lot of fun if my plan comes together. I guess the point is; be a doctor. Be their advocate. Take the time that it takes. Their lives depend on us to function on a higher level than just pounding down the sore spots. 

On a separate note, I had a young girl come in for a consult. I’ve known her and her family for several years. She had a car wreck 9 months ago and fractured L1. You could see where the posterior/superior corner of the vertebra was broken off and the spinous process was broken off completely.  No paralysis, no dysfunction neurologically.  A neurosurgeon fused her spine. Not just 2 segments. Or 3 segments. He fused 5 segments. He told them it was because it was the T/L junction and fusing that many would give it more stability.

Now….who am I to argue about that?? I’m not a surgeon. But it seems drastic. Once that is stabilized and healed, can they go and remove some of the fused areas? I have no idea. But damn. 5 vertebrae when only one was fractured? Beyond that, he told her no twisting. Her understanding was forever. He has her in a back brace with no recommendations on when to quit wearing the back brace. He has the crap scared out of her as far as moving and having any activity really. It’s been popping down low lately and that kind of hurts.

He told her to go on 6 weeks of bed rest.  I think I’m dealing with incompetence here. That’s what I’m building up to. 6 weeks of bed rest for and 18-year-old girl that is functional. Bracing with no end in sight. Scaring her out of even twisting. She was afraid to do nerve flossing for her leg and low back. Fusing 5 segments instead of 2 or 3.  So, I’ll never pretend to be the smartest dude on the planet but can I really know more than a freaking neurosurgeon? Certainly not about surgery specifically. But the follow-up, the rehab, and the future…..yeah, I think we can actually know quite a bit more than they do.  And now here we have another patient from today that we are charged with changing their lives. I’m all about spinal manipulative therapy but this one will be through exercise, movement, biomechanics, cognitive work, confidence building, support, and most importantly, through finding an orthopedic expert for the second set of eyes and another set of recommendations. Except I’m going to be the one picking this one out. We have to save these people.

Don’t get me wrong. The medical complex saves lives every day all day. Thank God for them. But we can save their lives too. When they hurt too bad to go shopping or play a part in their own lives, that’s no life at all is it? When we turn that around, on some level, we absolutely save their lives. We keep them from slipping into depression, pills, chronic pain, fear avoidance, inactivity, and everything that goes along with all of it.  We save lives too and every chiropractor knows exactly what I’m talking about.  Let’s get on with it, shall we?

CHIROUP ADVERTISEMENT

Item #1 This first one is called “Pathways for managing low back pain. The collaborative effort of four PM PIs Yield a Paper and a call to action.” (1) and published in Pain in December of 2020. Hotter than Hell.  First, Dr. Christine Goertz was cited at the end for further reading. Because she’s amazing and awesome and a chiropractic treasure if you ask me. if you don’t know of and absolutely adore Dr. Christine Goertz, then you are insane or don’t value chiropractic research. 

Second, this is an article so we’ll do what we do and hit the high spots.  They start by saying that many of the best practice guides for low back pain involve evidence-based therapy that is not typically integrated into a single clinical setting.  They bring up the examples of physical therapy and chiropractic and mention how they are typically delivered outside of the majority of first-line access points in the US.  They say this leads patients to fall through the gaps. Which is understandable.

We, chiropractors, see this all of the time. Every week. Think about it, they mention here how PCPs will order tests and imaging but the pain is complex and harder to coordinate the diagnosis and effective treatment and care management outside of an integrated setting.  Now, pay attention to the last line in this quote from the paper, “All of the Pain Management Collaboratory trials are focused on delivering non-drug options to effectively ease the experience of pain in Veterans and Active service members. No matter the type of patient, or where the patient enters the system for their pain, treatment options need to be organized and delivered in such a way that it is easy for patients to receive and comply with treatments, and for providers to follow up.  Hastings, a clinician with a focus on geriatric care as well as a researcher, poses the question, “Is it really realistic for every individual primary care provider to be the expert on how to access all of these different types of therapies, you know, in his or her community?”

They go on to say, “This is where the authors propose a health navigator—a local resource expert who is trained in how to factor in an individual’s previous experiences and preferences when making recommendations—for developing a pain pathway for the individual.  A pain care navigator could be a chiropractor, a nurse, a physical therapist or other health care provider that one might see as the first step in seeking help for their pain. “We are really testing this idea of individualization so that we ensure optimal adoption of therapies for pain,” says Dr. Hastings.  Developing an effective treatment model for pain that takes into account patient preferences, lifestyle, and current needs and is more than just a “cookbook kind of an approach.” This approach acknowledges that patients enter the healthcare system from many different starting points, and so there is a need to train providers from a number of different disciplines to organize, plan, and deliver individualized care options.”

Does that sound anything like the Primary Spine Practitioner program? Yes, it does. It also sounds like the paper we covered some time back where they did a study in a Stanford area ER where the DCs directed the musculoskeletal pain ER patients. They had so much success that they expanded the program.  This really is, in my opinion, the way to do this, y’all. This is the way to effectively treat pain. 

Then our very own Dr. Goertz comes down with the People’s Elbow when she says, “In addition to navigating through different treatment modules, other barriers to effectively managing a pain treatment plan include cost, the need for more providers, and appropriate delivery of treatments.  “One of the biggest barriers right now has to do with payers who are willing to pay high dollars for spine surgeries or injections but are less willing to cover guideline-concordant treatments such as spinal manipulation, acupuncture, cognitive behavioral therapy, and yoga,”  “I think until we are better at embracing payment models that put an emphasis on conservative care and reward all of those involved, we’re going to continue to struggle. Fortunately, I see some signs that our healthcare system is changing in this direction.”

Dr. Goertz addresses the biopsychosocial aspect a bit when she says, ““It’s really important to have the patient involved in the process [of developing a pain management plan],” “When it comes to low back pain, we know that people who are more frightened by their pain can have worse outcomes. Anything that can help patients better understand their pain can paradoxically lead to less pain in the future, which is why patient education is really important.”  Additionally, healthcare providers need to be well-versed in effective communications techniques to ensure that patients understand, feel supported, and are involved in the decision-making process.  Conversations should focus on lessening the experience of pain and increasing understanding, as opposed to exacerbating fear.  “This is important with healthcare delivery in general, but especially important with people who have low back pain,” Goertz says. “

There’s really going to be no reason for y’all to read this yourself because I’m basically going line for line but every line is solid and true so they kind of leave me no choice.  The article continues, “Dr. Goertz also pointed to a Gallup study that asked individuals which types of providers they thought were the safest and most effective for managing back and neck pain.  Participants indicated that physical therapists and chiropractors were the safest and most effective; however, when asked which provider they would see for pain management, more than half said that they’d prefer to see a medical doctor first. “It is crucial that clinicians are aware of coordinated care guidelines for back and neck pain and are able to facilitate access to that care for their patients,” Goertz asserts. “For instance, the American College of Physicians recommends that patients and their clinicians consider nonpharmacological treatments including acupuncture, massage, yoga, Tai Chi and spinal manipulation before prescription medication for low back pain.” 

Historically, these treatments have had less emphasis during clinical training for many health care providers, and facilitating access and coordinating the follow-up can be challenging.  Additionally, a patient’s insurance may not cover all the recommended considerations.” Here’s the last paragraph and pay attention again to the very last line, “At the center of evaluating pathways for pain management is a call to action to put more thought and organization into what happens to patients when they first seek care for pain and the long term consequences of the patient’s earliest experiences with the health care system.  “It takes a really intentional effort to say, ‘What are the first set of decisions that need to be made? And then what are the next decisions that need to be made?’” observes Dr. Fritz. 

To avoid the early intensification of pain care, which results in greater expense and invasiveness escalating rapidly, we need to ensure that the evidence-based guidelines are getting put into practice, and patients understand that managing pain isn’t a linear process where a person goes in to see a provider, gets a diagnosis, gets a treatment, and the pain goes away.

Communication among patient and providers is essential to get on the right pathway for pain management. “If we can be more aligned in our messaging around back pain in the community—before individuals become patients, where they may not yet be experiencing back pain, or before it affects their ability to function—it can help set expectations and set up the conversation with care providers when they do come in,” says Dr. Hastings.  “The first thing we ought to be reaching for are these non-drug therapies, and reserving imaging for specific cases since it’s not going to change what we do in the majority of cases.”” Amen. Researchers and authors, please for the love of everything, keep writing these papers.

Over and over again until it finally starts filtering down to the doctor in the field. The PCP, the VA doc that used to just give pills and shots, the surgeon that is still telling an 18-year-old girl to go on 6 weeks of bed rest and wear a brace while never twisting. Forever.  This garbage has to stop, y’all. There’s little wonder why low back pain is still #1 in the world for global disability. It’s because the primary stakeholders and medical industry can’t get their crap together. Or, worst-case scenario, don’t want to get their crap together due to financial considerations. Why get your crap together if it means you do fewer surgeries and make less money through the year? There’s no financial incentive to do the right thing. 

I got it….Pay them MORE for the NECESSARY surgeries to offset the loss of income when they quit performing the UNNECESSARY surgeries.  There you go. I just fixed the world.

Bam, snap, thwack, kow-a-pow! Alright, that’s it.

 

Y’all be safe. Keep changing our profession from your little corner of the world. Keep taking care of yourselves and everyone around you. Tough times are upon us but, the sun will shine again. Trust it, believe it, count on it. Let’s get to the message. Same as it is every week. 

Store Remember the evidence-informed brochures and posters at chiropracticforward.com.     

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 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 https://www.chiropracticforward.com

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iTunes https://itunes.apple.com/us/podcast/chiropractic-forward-podcast-chiropractors-practicing/id1331554445?mt=2

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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

  1. Pathways For Managing Low Back Pain. Pain. December 2020. https://painmanagementcollaboratory.org/pathways-for-managing-low-back-pain/?fbclid=IwAR1r5H4ZRvQr4Gw9wmIGYbJGSMr9e9aaPybvLujtdjEoE06Q6ppehNEGol8

 

Living With Chronic Pain, Screen Time, & Low Back Pain Delivery

CF 169: Living With Chronic Pain, Screen Time, & Low Back Pain Delivery

Today we’re going to talk about living well with chronic pain, screen time, and changing the delivery of low back pain care.

But first, here’s that sweet sweet bumper music

 

Chiropractic evidence-based products

Integrating Chiropractors

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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. 

  • Like our Facebook page, 
  • Join our private Facebook group and interact, and then 
  • go review our podcast on iTunes and other podcast platforms. 
  • We also have an evidence-based brochure and poster store at chiropracticforward.com
  • While you’re there, join our weekly email newsletter. 

You have found yourself smack dab in the middle of Episode #169

Now if you missed last week’s episode, we were joined by a couple of key players in the Texas Chiropractors’ fight against the Texas Medical Association for the right to diagnose patients, treat the Neuromusculoskeletal system rather than just the musculoskeletal system, and the right to perform VONT testing. All in one court attack. And we won after losing twice. It’s crazy. Make sure you don’t miss that info. Keep up with the class. 

On the personal end of things…..

I’ve talked in the last 3-4 weeks how my life has become complicated and how I’m working through it slowly. This week feels like it’s leveling out a little. I hate to say that and jinx it but I’m a glass is a half full type of dude. 

Let’s start with a new one though that’s stressing me out a little and may pertain to some of you as well. I’ve started getting some trickles of complaints here and there on one of my staff members. A key staff member. Now, what do you do when that happens? First, it probably depends on the complaints, wouldn’t you agree?

If they’re egregious, well then they gotta go. These aren’t. These are more personality conflicts and they’re from females. I’ve never had a male complain about her. So, what’s going on there?

Second, if they’re not necessarily fire-able offenses, what do we do to correct them? Are they just strictly personality-driven and there’s nothing we can do to change the inherent behavior of a person? Or….can she be trained to suppress a certain aspect of her nature? If it’s built into her nature that is.

I buy into staff. I care about staff. On this, I’m in no hurry to get rid of an employee. Not at all. Mostly because she’s really good at a lot of key aspects of her job. Like….REALLY good. I’m rooting for her. I want her to succeed. 

For that reason, I have found some training for her to do. I want her to have every tool at her disposal that I can provide to give her the chance to succeed and do well. Not everyone is a natural. Sometimes we need training. Sometimes people don’t even realize certain aspects of their personality are off-putting to others. 

I’m sure I have certain off-putting parts of my personality. Just nobody ever tells me about it. Either because I’m the doctor in the office, or I’m the boss in the office, or because I’m 6’4” and big as hell. 

Anyway, we are getting her some training, supporting her, and keeping our fingers crossed because she’s a hard worker, she’s smart, and I think she can be a valuable part of our team.

Now, for the good stuff…..Last week I mentioned my pickup dying. 

Always get a second opinion on your vehicle when they tell you that you need a new engine for $6500 because I remembered a good friend of mine is a mechanic. We took it to him and it turns out it just need an oil pump and parts and labor ran us about $800. No sweat. I’m back up and running. 

The computer that contained my entire life was able to be backed up just before its demise so the new one is getting up and running. My old programs are getting up and running. And my life is returning to some sense of normal as more and more of the computer and the software starts to behave the way it is supposed to behave. 

So, yes, we have valleys and peaks but hold on and try to enjoy the ride. We are going through the medical integration slowly but surely. We have found our medical director. He’s been one of my long-time friends and actually used to be a chiropractor so it’s perfect. He knows me well, knows how I treat patients, and knows how I approach healthcare. I think it’s an amazing fit. 

Now, we are searching for a nurse practitioner to help us make it all happen. Here’s the key on that though, it has to be someone that fits my personality and my approach. It has to be an NP that doesn’t mind learning from a damn chiropractor if you know what I mean. If it’s someone that sees chiropractors as lowly servants, well that won’t work out at all now, will it? I’d rather lose $20,000 than put up with something like that. 

But if it’s someone that is open and eager to learn about the biopsychosocial aspect of pain, communicating correctly with patients, and things of that nature, then we probably have a fit. For example, some NPs can be told that the Canadian Medical Association Journal published a systematic review where 13 of 14 papers showed no effect for using gabapentin in radiculopathy. They can get that info and ignore it. That’s not the NP for me. 

On the other hand, they can see the paper and say to themselves, “Maybe we don’t want to prescribe anti-convulsants for radicular pain after all.” THAT’S my kind of NP.  That’s who I’m looking for. As always, I’ll let you know how it goes. 

But, the long and short of it is, we’re getting past the loss of the office manager, all of the big oopsies are starting to get sorted out, we have big stuff still on the worry plate but life is starting to retreat from the danger zone. The crisis zone if you will. It’s still on high alert but the alarm bells are going silent again. Thank God. 

CHIROUP ADVERTISEMENT

Item #1

Our first one today is called ““Living Well with Chronic Pain”: Integrative Pain Management via Shared Medical Appointments” by Znidarsic et. Al. (1) and published in Pain Medicine in January of 2021….dammit, it’s hot. 

I want to point out that the first three listed authors on this paper were a DO and two PhDs and out of 18 authors, there was only one DC on the list. In addition, several of the authors were MDs. Three of them to be exact. 

Why They Did It

To evaluate the effectiveness of a multidisciplinary, nonpharmacological, integrative approach that uses shared medical appointments to improve health-related quality of life and reduce opioid medication use in patients with chronic pain.

How They Did It

  • Retrospective, pre-post review of “Living Well with Chronic Pain” shared medical appointments (August 2016 through May 2018)
  • The appointments included eight 3-hour-long visits held once per week at an outpatient wellness facility.
  • It included patients with chronic, non–cancer-related pain.
  • Patients received evaluation and evidence-based therapies from a team of integrative and lifestyle medicine professionals, as well as education about nonpharmacological therapeutic approaches, the etiology of pain, and the relationship of pain to lifestyle factors
  • Experiential elements focused on the relaxation techniques of meditation, yoga, breathing, and hypnotherapy, while patients also received acupuncture, acupressure, massage, cognitive behavioral therapy, and chiropractic education
  • Patients self-reported data via the Patient-Reported Outcomes Measurement Information System (PROMIS-57) standardized questionnaire.
  • 178 participants completed the PROMIS-57 questionnaire at the first and the last visits

What They Found

  • Statistically significant improvements in all domains were observed between the pre-intervention and post-intervention scores
  • Average opioid use decreased nonsignificantly over the 8-week intervention, but the lower rate of opioid use was not sustained at 6 and 12 months follow-up.

Wrap It Up

Patients suffering from chronic pain who participated in a multidisciplinary, nonpharmacological treatment approach delivered via shared medical appointments experienced reduced pain and improved measures of physical, mental, and social health without increased use of opioid pain medications.

Item #2

This one is called “Association Between Screen Time and Children’s Performance on a Developmental Screening Test” by Madigan et. al. (2) and published in JAMA Pediatrics on January 28, 2019. Not all that hot. Little steamy but not enough for my favorite soundbite. Unfortunately. 

I’ve highlighted some of these screen time posts before because they just make me crazy and I have to say, I’m guilty of having my kid on electronics years ago. And I’ve spent the last 15 or so years trying to keep them off of the electronics. We all make mistakes and turning our kids over to electronics is one of the biggest I think.

Why They Did It

The authors wanted to answer the question, “Is increased screen time associated with poor performance on children’s developmental screening tests?”

How They Did It

  • This was a longitudinal cohort study using a 3-wave, cross-lagged panel model in 2441 mothers and children in Calgary, Alberta, Canada, drawn from the All Our Families study.
  • Data were available when children were aged 24, 36, and 60 months.
  • Data were collected between October 20, 2011, and October 6, 2016. So…5 years.
  • At age 24, 36, and 60 months, children’s screen-time behavior (total hours per week) and developmental outcomes (Ages and Stages Questionnaire, Third Edition) were assessed via maternal report.

What They Found

A random-intercepts, cross-lagged panel model revealed that higher levels of screen time at 24 and 36 months were significantly associated with poorer performance on developmental screening tests at 36 months and 60 months.

Wrap It Up

The results of this study support the directional association between screen time and child development. Excessive screen time can impinge on children’s ability to develop optimally; it is recommended that pediatricians and health care practitioners guide parents on appropriate amounts of screen exposure and discuss potential consequences of excessive screen use.

Item #3

This last one is called “Transforming low back pain care delivery in the United States” by George et. al. (3) and published in Pain in December of 2020 and that’s a stout stack of steam stuff right there. This paper has our friend and previous guest, Dr. Christine Goertz, on it. She is amazing so I can only assume the rest of these authors are as well.

They say, “Low back pain (LBP) continues to be a challenging condition to manage effectively. Recent guideline recommendations stress providing non-pharmacological care early, limiting diagnostic testing, and reducing exposure to opioid pain medications. However, there has been little uptake of these guideline recommendations by providers, patients or health systems, resulting in care that is neither effective nor safe. This paper describes the framework for an evidence-based pathway that would transform service delivery for LBP in the United States by creating changes that facilitate the delivery of guideline adherent care.”

They’re saying that the guidelines and the recommendations are there but people aren’t listening. On both sides in my estimation. You have MDs going straight to shots and surgery and even the ones that are open to referral are just going straight to the PT. If the PT fails, then it’s shots and surgery rather than spinal manipulative therapy, or laser, or yoga, or maybe the PT wasn’t good at diagnosing the issue and providing targeted exercise. 

On the other hand, we have chiropractors moving bones when they should be stabilized. Or ordering x-rays over and over and over. Or treating 100 times for a curve problem that probably isn’t that big of a problem. 

They go on to say, “An evidence-informed clinical service pathway would be intentionally structured to include; a) direct linkages to community and population-based resources that facilitate self-management, b) foundational LBP care that is appropriate for all seeking care, c) individualized LBP care for those who have persistent symptoms, and d) specialized LBP care for instances when advanced diagnostics and intensive treatments are indicated.”

“There is an urgent need to transform LBP care by optimizing clinical care pathways focused on multiple opportunities for non-pharmacological treatments, carefully considering the escalation of care, and facilitating self-management.” 

We have chiropractors telling people to come to see them weekly to ward off disease, build the immune system, and things of that nature. That’s creating dependency on the clinic and it is not supported by any research. Certainly not in the context that so many vitalist chiropractors yell out and are so obnoxious about. Patients need to be taught at-home self-management techniques to deal with their pain. The rest is unnecessary noise. 

They close with this, “Such approaches have the potential to increase patient access to guideline adherent LBP care as an alternative to opioids, unwarranted diagnostic tests, and unnecessary surgery.”

Alright, that’s it. Y’all be safe. Keep changing our profession from your little corner of the world. Keep taking care of yourselves and everyone around you. Tough times are upon us but, the sun will shine again. Trust it, believe it, count on it.

Let’s get to the message. Same as it is every week. 

Store

Remember the evidence-informed brochures and posters at chiropracticforward.com. 

 

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 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. 

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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

 

Bibliography

  1. Josie Znidarsic, DO, Kellie N Kirksey, PhD, Stephen M Dombrowski, PhD, Anne Tang, MS, Rocio Lopez, MS, Heather Blonsky, MAS, Irina Todorov, MD, Dana Schneeberger, PhD, Jonathan Doyle, MCS, Linda Libertini, Starkey Jamie, LAC, Tracy Segall, LMT, Andrew Bang, DC, Kathy Barringer, LISW, Bar Judi, CYTERYT 500, Jane Pernotto Ehrman, MEd, RCHES, Michael F Roizen, MD, Mladen Golubić, MD, PhD, “Living Well with Chronic Pain”: Integrative Pain Management via Shared Medical Appointments, Pain Medicine, Volume 22, Issue 1, January 2021, Pages 181–190, https://doi.org/10.1093/pm/pnaa418
  2. Madigan S, Browne D, Racine N, Mori C, Tough S. Association Between Screen Time and Children’s Performance on a Developmental Screening Test. JAMA Pediatr. 2019;173(3):244–250. doi:10.1001/jamapediatrics.2018.5056
  3. George SZ, Goertz C, Hastings SN, Fritz JM. Transforming low back pain care delivery in the United States. Pain. 2020 Dec;161(12):2667-2673. doi: 10.1097/j.pain.0000000000001989. PMID: 32694378; PMCID: PMC7669560.

My Insane Life, Hip & Knee Osteoarthritis, Risks For Acute to Chronic Pain

CF 167: My Insane Life, Hip & Knee Osteoarthritis, Risks For Acute to Chronic Pain Today we’re going to talk about hip and knee osteoarthritis and we’ll talk about the risks for back pain going from acute to chronic pain. Interesting couple of papers. Plus all my current ongoings.  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. The Bon Jovi and Def Leppard kind of research.  Not the stuffy, high-brow, high and mighty, better than you 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. 

  • Like our Facebook page, 
  • Join our private Facebook group and interact, and then 
  • go review our podcast on iTunes and other podcast platforms. 
  • We also have an evidence-based brochure and poster store at chiropracticforward.com
  • While you’re there, join our weekly email newsletter. 

You have found yourself smack dab in the middle of Episode #167  Now if you missed last week’s episode, we talked about dry needling, types of exercises that count, motor skills for chronic low back, and the relationship between high blood pressure and dementia. Keeping you folks smart! Check it out.  Keep up with the class.  

On the personal end of things…..

Alright, you wanna talk about juggling a bunch of balls in the air, I’m here to tell you about having balls in the air. Let’s go through it a bit, shall we? Then you can find yourself and your situation and maybe my path helps you on yours. 

    • I lost my office manager of over 11 years – here’s what I’m doing about that. 
    • Setting up a medical entity – what’s that about?
    • Looking at RHC’s – explanation to follow
    • I have finished my book – The Remarkable Truth About Chiropractic: A Unique Journey Into The Research.  – What’s that process like so far?
    • I have a virtual Assistant helping me build a website to help you all succeed – what’s the timeline? 
    • I started my second Fellowship/Diplomate program last week. Maybe I’ve lost my mind
    • Here in Texas, we went through SNOWVID 19
    • We are switching CPAs. Maybe this group gets it right. 
    • The Voice Over career has started going a little crazy here lately – I’ll explain
    • I’m about to head to Florida because…..well….because my life.
    • My main computer that holds my life has been dead for two weeks now. 

Hell yeah, folks. Lol. It’s a wonderful life, right? Let’s start at the top. As I’ve mentioned a time or two, my main employee, my OG staffer, over 11 years, and basically almost family member actually quit me and went to work elsewhere making a little more money with the change of making even a bit more next year. 

So, my main right-hand wo-man is adios but Jiminy crickets people….do you have a clue how much money I’m saving on this? She got raises every year for 11 years in her normal capacity and we created an extra marketing position for her as well at a considerable amount monthly as well.  Now, that means I’m out a marketing position but it also means I can take that money and try some different marketing for a while. Because, if I’m being honest, I’m not sure how much what we were doing was actually helping.  Plus, with the money I’m saving here, I can transition.

With the closing of doors, we usually get to experience the opening of other doors. And that’s what we’re doing. As mentioned, we are using some of the funds we are now saving to move our practice into a medical entity, hire a nurse practitioner, and move toward being finally truly integrated.  This has been a goal for years but I’ve just never pulled the trigger. Now, with PPP in place to help us pay for our payroll, it makes sense to use our existing resources, in addition to what we are now saving, to go ahead and get it done.  I’ll update you on the process as I make my way.

So far, we’ve signed paperwork with the attorneys to create the entity, we have our attorney in communication with our new CPA, which I’ll talk about later, and I’ve started reaching out. I’ve also signed up with a consulting firm on it to try to make sure I have a head start and I’m not trying to re-invent the damn wheel. I don’t like making costly mistakes. My wife and I call them ‘dummy taxes.’

If you’ve been a regular listener here, you know I’ve paid some MONSTROUS, CATACLYSMIC dummy taxes.  First, I have some fairly close relationships in the medical community. So, not only to put them all on notice of what we have planned but also to test the waters of who may be interested in being a part of it….I started reaching out. Here’s how: Hey Friend! I’m in the process of transitioning to a medical entity and hiring a nurse practitioner eventually. I’ll need to have a medical director (MD/DO) to serve in that capacity.

As I go through the process of finding one, would you be willing or able to serve as a potential character witness on my behalf if the MD or DO wants to talk to people in healthcare that know me, have experience with me and my clinic, and can speak to how I approach healthcare? I just want to be sure and ask first before I get too much further into the process. Hope you’re doing well and having a good Monday. Now, my MD/DO friends may just step up and say, “Hey I’ll be your medical director!” They may not. We’ll see. I have one in mind but it’s always good to have more than one or two options, me thinks. Also, when I reach out to my NP friends, one may raise their hands to sign up. Either way, I’m being polite, I’m putting all my friends and network on notice of intentions, and who knows, maybe it serves as some sort of guerrilla marketing. I don’t see a downside.  So, that’s the process there so far.

We almost looked at a Rural Healthcare Clinic before we decided on going the NP route. And we may still eventually. We had a call with a consulting and management firm for the RHCs and it was alright but it was also clear that the ROI wasn’t where we had heard it was and it was clear that it’s quite an endeavor and even more regulated than the medical entity endeavor would be.  It made sense to go with what my colleagues and network is the most familiar with and potentially stray off into the RHC thing if the interest is still kicking around our brains in a couple of years. 

Next on my list, the book. Being an author has always been a big goal of mine.

I love books, I love reading, and I love the idea of facilitating learning. It’s a natural progression for me. As mentioned, it’s called ‘The Remarkable Truth About Chiropractic: A Unique Journey Through The Research’. It’s essentially all of these papers I go through every week organized into their relevant categories so that they’re all in one resource and are easy to find for quick reference. Some just have the Why They Did It, How They Did It, What They Found, and The Wrap It Up sections for each paper. Some topics go further into discussion and talking points.  I believe the way to do it these days is to self-publish. I’m still figuring it out right now while it is off being edited. You wanna know who’s editing it? It’s my good friend, literary scholar, and inventor of the Drop Release tool, and hospitalist chiropractor extraordinaire from the frozen tundra of North Dakota, Dr. Chris Howson! Thank you sir. This will give you all something to look forward to in the near future. I hope you’ll all need your very own copy! So…..that’s exciting. 

On top of that, I’ve had a virtual Assistant helping me build something I think some of you will be interested in. I don’t want to give to say too much until it’s built. First, I don’t want anyone beating me to the idea, and second, I don’t want to move in that direction and then figure out I can’t make it work and then it was for nothing. Nobody wants their failure in the shop’s front window….right there on Main Street! Lol. So I’ll just say that it is something that if you need it and haven’t used it before, will 100% help you be more successful and more cognizant of what’s going on with your business from day to day. So….that’s exciting as well. 

I started my second Fellowship/Diplomate program last week. Maybe I’ve lost my mind. I probably have. Or….I’m secretly a genius. Here’s what I’ve always said; I may get beat. I may not be the best ever. And that’s OK. But I can damn sure guarantee you that it will not be due to a lack of effort. It most certainly won’t be because someone else out-worked me. Maybe they were unethical. Maybe they were lucky. Maybe they inherited something I did not. But it won’t be because I got outworked or because I didn’t try hard enough. Maybe that’s just me. Maybe it’s totally Gen-X. I don’t know. But that’s the way it is in my life. 

Here in Texas, we went through SNOWVID 21. First, you have to know that my area of Texas is very used to snow and ice and blizzards and all of that good stuff. I grew up in it. What South Texas is not used to is the ice and blizzards and snow. That was rough on them but the real kicker was losing power for not only hours but for days. Losing electricity led to losing water. Then water pipes busting and homes and offices ruined. It’s a mess. Chiropractors and Texans, in general, are trying to recover but it wasn’t any little thing. It was the worst Winter Weather event since 1890 or something like that. People can figure out -30 degree wind chill. What they can’t figure out is no power, no water, and no food. It was that real for some folks. 

We are still going through the intro phases of the Wealthability program with the Tom Wheelright group, new CPAs, the whole thing. Part of that was figuring out that our previous CPAs have been wrong and we have to figure out how to get right and part of that answer is money so…..fun fun fun.

What a wonderful life.

I’ve been without my main computer for about two weeks due to Snowvid but it’s getting up and running today which means my life is going to be up and running just a bit smoother within a day or two. Yay!! The voice-over side gig is going a little crazy at the moment. I’ve found a way to get another full-time job I think. I’ll keep you updated as that goes along but, in short, I signed with a talent agency called Heyman Talent in Cincinnati Ohio and they cover Ohio, Indiana, and Kentucky. I signed with Crown North out of San Francisco some time back as well so it’s an interesting adventure. I’m 48 years old and signing with talent agents. What the hell is that about exactly? Who knows but I’m a do-er. Let’s see what happens. 

OK, let’s get to the papers.

Only two this week because the personal side of things took a little longer than usual. Before we get to the papers though, let’s recognize my friends and this show’s amazing sponsors. 

CHIROUP 

Item #1 This first one is called “Diagnosis and Treatment of Hip and Knee Osteoarthritis – A Review” by Katz et. al. (1) and published in JAMA on February 9 of 2021, Hot off the press, smokin’ stack of steam.  What we have here on our hands…..on our meaty little mitts….is a good ol fashioned learnin’ sesh on Osteoarthritis. This is truly some good stuff, folks. Where in here can you find an opportunity to help patients and, in turn, make a living and be the expert in your community?

  • Osteoarthritis (OA) is the most common joint disease, affecting an estimated more than 240 million people worldwide, including an estimated more than 32 million in the US. Osteoarthritis is the most frequent reason for activity limitation in adults. This Review focuses on hip and knee OA.
  • Patients with OA typically present with pain and stiffness in the affected joint(s). Stiffness is worse in the morning or on arising after prolonged sitting and improves within 30 minutes. Pain is use related early in the course but can become less predictable over time. Although OA is sometimes viewed as a disease of inexorable worsening, natural history studies show that most patients report little change in symptoms over 6 years of observation.
  • Nearly 30% of individuals older than 45 years have radiographic evidence of knee OA, about half of whom have knee symptoms.
  • Osteoarthritis leads to substantial cost and mortality. Forty-three percent of the 54 million individuals in the US living with arthritis (most of whom have OA) experience arthritis-related limitations in daily activities
  • Persons with knee OA spend an average of about $15 000 (discounted) over their lifetimes on the direct medical costs of OA.
  • Osteoarthritis can involve almost any joint but typically affects the hands, knees, hips, and feet. It is characterized by pathologic changes in cartilage, bone, synovium, ligament, muscle, and periarticular fat, leading to joint dysfunction, pain, stiffness, functional limitation, and loss of valued activities, such as walking for exercise and dancing
  • Risk factors include age (33% of individuals older than 75 years have symptomatic and radiographic knee OA), female sex, obesity, genetics, and major joint injury.
  • Persons with OA have more comorbidities and are more sedentary than those without OA. It has been estimated that 31% of persons with OA have at least 5 comorbid conditions.2 Persons with hip and knee OA have approximately 20% excess mortality compared with age-matched controls, in part because of lower levels of physical activity. They become sedentary
  • The reduced physical activity leads to a 20% higher age-adjusted mortality. 
  • Several physical examination findings are useful diagnostically, including bony enlargement in knee OA and pain elicited with internal hip rotation in hip OA. 
  • Radiographic indicators include marginal osteophytes and joint space narrowing. 
  • The cornerstones of OA management include exercises, weight loss if appropriate, and education—complemented by topical or oral nonsteroidal anti-inflammatory drugs (NSAIDs) in those without contraindications. 
  • Intra-articular steroid injections provide short-term pain relief and duloxetine has demonstrated efficacy. 
  • Opiates should be avoided. 
  • Clinical trials have shown promising results for compounds that arrest structural progression (eg, cathepsin K inhibitors, anabolic growth factors) or reduce OA pain (eg, nerve growth factor inhibitors). 
  • Persons with advanced symptoms and structural damage are candidates for total joint replacement. 

Conclusions and Relevance  

  • Education, exercise and weight loss are cornerstones of management, complemented by NSAIDs for the right patients, corticosteroid injections, and several adjunctive medications. 
  • For persons with advanced symptoms and structural damage, total joint replacement effectively relieves pain.

Item #2

Our second and last one today is called “Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care” by Stevans et. al. (2) and published in JAMA Network Open on February 16, 2021. Pop goes the weasel it’s fresh outta the oven!

Why They Did It To figure out the transition from acute to chronic low back pain using a tool to assess and predict the transition; demographic, clinical, and practice characteristics; and whether treatments that did not fit within common guidelines were partly to blame. 

They termed these treatments as nonconcordant. Treatments like opioids. Additionally, prescriptions that included benzodiazepines and/or systemic corticosteroids alone without the presence of nonsteroidal anti-inflammatory drugs or short-term skeletal muscle relaxants were considered nonconcordant. Nonconcordant diagnostic imaging consisted of an order for lumbar radiograph or computed tomography/magnetic resonance imaging (CT/MRI) scan. Nonconcordant medical subspecialty referral included referrals to nonsurgical or surgical specialties (eg, PTs, orthopedists, neurologists, neurosurgeons, or pain specialists). That was all considered nonconcordant care

How They Did It It was a cohort study with 5233 patients having acute low back pain Nearly half of the patients were exposed to at least one treatment recommendation that was not actually recommended within the first 21 days after the first visit   

What They Found

  • Patients were significantly more likely to transition to chronic low back pain as their risk on the prognostic tool increased and as they were exposed to more bad recommendations
  • Overall transition rate to chronic LBP at six months was 32%
  • Patient and clinical characteristics associated with the transition to chronic LBP included obesity, smoking, severe baseline disability, and depression/anxiety.
  • Patients exposed to 1, 2, or 3, bad recommendations in the first 21 days of pain were about 2 times more likely to develop chronic low back pain

Wrap It Up

This large inception cohort study found that the transition from acute to chronic LBP was substantial and the SBT was a robust prognostic tool. Early exposure to guideline nonconcordant care was significantly and independently associated with the transition to chronic LBP after accounting for patient demographic and clinical characteristics, such as obesity, smoking, baseline disability, and psychological comorbidities.

Boom. Instantly you’re smarter.  Alright, that’s it. Y’all be safe. Keep changing our profession from your little corner of the world. Keep taking care of yourselves and everyone around you. Tough times are upon us but, the sun will shine again. Trust it, believe it, count on it. Let’s get to the message. Same as it is every week. 

Store  Remember the evidence-informed brochures and posters at chiropracticforward.com.     

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 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  https://www.chiropracticforward.com

Social Media Links  https://www.facebook.com/chiropracticforward/

Chiropractic Forward Podcast Facebook GROUP  https://www.facebook.com/groups/1938461399501889/

Twitter  https://twitter.com/Chiro_Forward

YouTube  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

  1. Katz JN, Arant KR, Loeser RF. Diagnosis and Treatment of Hip and Knee Osteoarthritis: A Review. JAMA. 2021;325(6):568–578. doi:10.1001/jama.2020.22171
  2. Stevans JM, Delitto A, Khoja SS, et al. Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care. JAMA Netw Open. 2021;4(2):e2037371. doi:10.1001/jamanetworkopen.2020.37371

 

Impact Of Chiropractic Care on Opioid Use & Garbage Marketing In The Chiropractic Profession

CF 163: Impact Of Chiropractic Care on Opioid Use & Garbage Marketing In The Chiropractic Profession

Today we’re going to talk about the impact of chiropractic care on opioid use and then we’ll talk about garbage marketing in the chiropractic profession. I go off a bit. I can’t help it. They make me nuts.  But first, here’s that sweet sweet bumper music

Chiropractic evidence-based products

Integrating Chiropractors

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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. 

  • Like our Facebook page, 
  • Join our private Facebook group and interact, and then 
  • go review our podcast on iTunes and other podcast platforms. 
  • We also have an evidence-based brochure and poster store at chiropracticforward.com
  • While you’re there, join our weekly email newsletter. 

You have found yourself smack dab in the middle of Episode #163 Now if you missed last week’s episode , we had Dr. Bobby Maybee of the Forward Thinking Chiropractic Alliance and the Chiropractic Success Academy. It was Part Two of a two-part interview that I think you’ll all get plenty of excellent insight and inspiration from. Make sure you don’t miss that info. Keep up with the class. 

On the personal end of things…..

I had the second Moderna vaccine shot on January 20th and all’s well. My experience is that, if you remember, I had zero symptoms with the first shot. Not even a sore arm. Nothing at all.  With this second one, I had a pretty sore arm. It felt like when I got the flu shot. Just a sore arm. It was red for a couple of days too. It was honestly about two days and that was it. I may have been hyperfocused on whether I was having symptoms or not but was maybe a touch tired that day.

I got the shot at 2:30 in the afternoon and then went back to work until 6pm so….I may have been a touch draggy but like I said, that could have just been me being hyperfocused. It wasn’t anything very noticeable.  My wife felt a little crummy for one day. Then she was back at it.  Overall, not a bad deal. They say the full protection is approximately 2 weeks after shot #2 so we’re looking pretty good and, outside of the first two weeks we took off in late March of 2020, I haven’t had to take any days off due to illness and if it all works out, I won’t have to in the future. As a result of COVID anyway.  As I’ve said here, I don’t think it’s unreasonable at all to wait to get yours until you’ve seen how everyone else reacts to it.

I really don’t. I’m not a ‘get your shot instantly’ type of guy. Especially if you have associates that will pick up your slack should you get COVID and be out sick. But when you’re a solo doc like me, the business depends on your presence. I can’t get sick and be out for 2-4 weeks. Some folks are out much longer than that. For me, there’s nothing that makes more sense than getting the vaccine as quickly as possible.  In addition, I have a wife that is 100% over this mess and is ready to go traveling. So, happy wife – happy life in full effect.  Also, I have a local surgeon running advertisements all over TV and it makes me want to punt baby bunnies into the stratosphere.  He says in thw commercial that we all deserve to live without pain and then he goes into his campaign in support of back and neck surgery. Who am I to try to keep someone from marketing their business?

But day-um. One word, two syllables. Day-um. 

Years ago it was illegal to run an ad for hard liquor. You don’t see any cigarette commercials do you?  Now, I’m not saying surgery is equal to cigarette smoking and hard liquor but I know several that have done worse through one surgery they they would ever do from a life of smoking and drinking.  I see that commercial come on TV and I start talking to the TV. I have a strongly worded conversation with the TV every time. It’s because I know that there’s little to no support for spinal surgeries in the research and there’s not better outcomes from them either. The problem is that the common, every day patient does not know that. 

They see the damn white coat and lose their damn minds and just say, “OK.” A pharma commercial could say that you butt could fall out of you walking across a room if you take this medicine and people would still line up for it.  You tell them we’re going to get you moving and exercise and they think you’re dangerous or crazy. It’s a conundrum.  Alright, let’s get to the good stuff shall we?

Item #1

This first item is called “Impact of Chiropractic Care on Use of Prescription Opioids in Patients with Spinal Pain” by Whedon et. al(Whedon JM 2020)….there’s that Whedon name again. It was published in Pain Medicine in December of 2020 and that a lot hot

Why They Did It

Utilization of nonpharmacological pain management may prevent unnecessary use of opioids. Our objective was to evaluate the impact of chiropractic utilization upon use of prescription opioids among patients with spinal pain.

How They Did It

  • The total number of subjects was 101,221.
  • It was a retrospective cohort design for analysis of health claims data from three contiguous states for the years 2012–2017.
  • included adults aged 18–84 years enrolled in a health plan and with office visits to a primary care physician or chiropractor for spinal pain.
  • We identified two cohorts of subjects: Recipients received both primary care and chiropractic care, and nonrecipients received primary care but not chiropractic care.
  • We performed adjusted time-to-event analyses to compare recipients and nonrecipients with regard to the risk of filling an opioid prescription. We stratified the recipient populations as: acute (first chiropractic encounter within 30 days of diagnosis) and nonacute (all other patients).

What They Found

Overall, between 1.55 and 2.03 times more non-recipients filled an opioid prescription, as compared with recipients.  Similar differences were observed for the acute groups.

Wrap It Up

Patients with spinal pain who saw a chiropractor had half the risk of filling an opioid prescription. Among those who saw a chiropractor within 30 days of diagnosis, the reduction in risk was greater as compared with those with their first visit after the acute phase. CHIROUP ADVERTISEMENT

Item #2

Alright, I’m going after vitalists a bit here today in item #1. I came across a script and I just can’t ignore this stuff anymore. If we’re not willing to call it out, then we are complicit. And I refuse to be that. In fact, if you have any of these scripts you’ve been given from vitalist gurus, please email them to me at [email protected] I would love to read them on future podcasts and discuss my disdain for the tom foolery within. 

This script is to be used when a patient hasn’t been in for a while. It’s basically used to scare the holy hell out them and force them back to your office because…..you know…..they depend on you to keep them healthy and there are no other means of keeping one healthy outside of the removal of the magical subluxation.  So, here is the script: Dear Patient I have been thinking about you! (with an exclamation mark because, you know….bilking and scaring people is super exciting and all). I realized I have not seen you in a while.

So, I reviewed your file and looked at your last x-ray.  I am concerned that based on your past history, you might be suffering the effects of spinal degeneration without being aware of it. The first effect of spinal degeneration is that the nerve that supplies the area stops performing its normal function.  This means that your nerve is unable to alert you to a problem that is potentially developing…. That’s not emotionally manipulative at all now, is it? It would be like cutting the wire to your fire alarm when your house is on fire!!! OMG!! Cutting….it sounds so awful!! 

The alarm can’t warn you of the fire in time to get out of the house, Holy s-word!!! That must mean I’m going to burn the hell up then. I better call this knucklehead’s office and be seen before I look like a crispy curly fry!! Gimme a damn break. I can’t believe professionals are sending out garbage like this.  It continues; Another sign of spinal degeneration is the loss of flexibility. You lose files without being aware of it. You begin to turn with your shoulders instead of using your neck.

You lift with your back instead of bending your knees. You should have enough flex to enjoy your life. This means you should be able to get out of bed in the morning without feeling stiff or sore. It means you can do the things you enjoy in life. You should be flexible enough to exercise and enjoy your hobbies and leisure time including sitting down to watch your favorite TV programs without being stiff when you get back up. 

The most serious effect of spinal degeneration is loss of vitality. Oh that sounds horrible. Not vitality!!  You should feel healthy!! Yes, you should but you can do that by making yourself move and exercise and eat better while getting a good amount of sleep. You don’t need a chiropractor to feel healthy.   You should have a sense of wellness and energy. You should be able to get out of bed ready to go. You don’t feel this way when your systems do not function properly. You feel that something is just not right but you can’t quite put your finger on it.

You feel stressed and tense. Yeah….like 100% of every other American on this planet.  Last paragraph of the garbage. 

I have set aside the next month for you as “Welcome back to Chiropractic month.” Damn, that’s so nice. They set aside a whole month for me. Sweet bastards. 

Do yourself a favor and call our office to schedule a visit. I will perform a ‘back to chiropractic adjustment and exam including x-rays if needed at no cost.’ Way to value you treatment, doc!! This visit has a normal valued of up to $175 and is yours absolutely FREE during the next month. It’s my way of encouraging you to get back on track and avoid the consequences of spinal degeneration. Please bring the enclosed ‘back to chiropractic’ coupon with you when you come to the office. I look forward to seeing you again soon! Now, if you can read through that without throwing up, congratulations. You have a stomach of iron.

Secondly, if you ever hear a vitalist claim they do not use scare tactics to take advantage of their patients, they’re simply not being honest. In essence, that’s exactly what the subluxation theory is in the first place. IT’s a scare tactic. The silent killer, right? You’ll get sick, you’ll be unhealthy. You’ll develop degeneration. Not because of the consequences of normal freaking aging but because you had all those subluxations all up in ya. 

Talking about the person and using the word ‘you’ is a sales tactic. They use the word ‘you’ or its variants 39 times in that mess of a sales letter.  Can I say that I’m not sure I’ve gotten a birthday card from my family MD much less a scare tactic-laden sales letter.  We can do better than this folks.

Crap like this make us all look like fools. Not to mention what it makes the ones sending their crap out look like. They look like bozo the clown in full makeup, y’all.  “I am concerned that based on your past history, you might be suffering the effects of spinal degeneration without being aware of it. The first effect of spinal degeneration is that the nerve that supplies the area stops performing its normal function.”

Come on man. Spinal degeneration is a normal part of aging. You quit building bone and then you start to regress over the years. This is natural. Stop making patients believe they have to depend on you. It’s not right and if the state boards have any teeth on this kind of garbage, they should start using it. That’s if chiropractic is ever going to step its game up.  We are better than this. When you and your heart and your business are built on things like, honestly, ethics, character, education, and love……you could never in your life send out something like that.  When you are built on selfishness, low-character, deceitfulness, and an anything to get ahead, then you’re more than happy to send it out and you won’t think twice when they come in because you scared them and then you scare them into treating every other week for the next year with upfront payment, blah blah blah. How do these types of practitioners live with themselves?  The absolute worst are the ones that claim it’s a God thing.

If they don’t come in and get their regular adjustment, they can’t allow God to express his true power in their body’s? Oh….is that right? The dude we Christians claim created the world and man in his own image……the dude controlling everything on Earth and beyond…..that dude needs a chiropractor to adjust their patients all of the time because he didn’t make quite perfect enough. The hell you say.

Remember, I’m a Christian. I can make fun. The hypocrisy in this type of practitioner is about as low as it gets for me.  All of these practitioners have big houses. No doubt. But at what cost personally and to our profession?  We’re better than that. Stop it dammit. Stop it now

Alright, that’s it. Y’all be safe. Keep changing our profession from your little corner of the world. Keep taking care of yourselves and everyone around you. Tough times are upon us but, the sun will shine again. Trust it, believe it, count on it. Let’s get to the message. Same as it is every week. 

Store Remember the evidence-informed brochures and posters at chiropracticforward.com. 

Chiropractic evidence-based products

Integrating Chiropractors

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This image has an empty alt attribute; its file name is Screen-Shot-2018-07-12-at-10.23.09-AM-150x55.jpg

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 preventativly 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 https://www.chiropracticforward.com

Social Media Links https://www.facebook.com/chiropracticforward/

Chiropractic Forward Podcast Facebook GROUP https://www.facebook.com/groups/1938461399501889/

Twitter https://twitter.com/Chiro_Forward

YouTube 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 Whedon JM, T. A., Kazal L, Bezdijian S, (2020). “Impact of Chiropractic Care on Use of Prescription Opioids in Patients with Spinal Pain.” Pain Med 21(12): 3567-3573.  

New Paper: Spinal Manipulation Has No Effect On Chronic Pain – Our Experts Rebuttal

CF 143: New Paper: Spinal Manipulation Has No Effect On Chronic Pain – Our Experts Rebuttal  

Today we’re going to talk about a new paper in JAMA saying that spinal manipulative therapy has not effect. Yeah…..BIG topic today so keep your seat, buckle up, I got some stuff to say. 

But first, here’s that sweet sweet bumper music

Subscribe button

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. 

  • Like our Facebook page, 
  • Join our private Facebook group and interact, and then 
  • go review our podcast on iTunes and other podcast platforms. 
  • We also have an evidence-based brochure and poster store at chiropracticforward.com
  • While you’re there, join our weekly email newsletter. No spam, just a reminder when the newest episodes go live. Nothing special so don’t worry about signing up. Just one a week friends. Check your JUNK folder!!

Do it do it do it. 

You have found yourself smack dab in the middle of Episode #143

Now if you missed last week’s episode , we talked about nonoperative disc treatment, Vitamin D3 for depression, and the biopsychosocial part of chronic pain. I used big words on this one folks. 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…..

First thing is, my website is jacking up in the last few weeks and it’s about to make me lose every marble I ever had in my noggin. So if you prefer reading the transcript on the website or listening via the website, I apologize if you’ve had issues doing so lately. Trust me, I am working diligently with people that know how to do this stuff to get it lined out and working properly and dependably

Next, my kid is coming home for the weekend from college. Pretty excited to see the knucklehead. 

My practice was busier this week. Not necessarily in the total numbers of visits. We ended up somewhere back around 140 last week. Which was about where we started when we came back from COVID full time. 

We were at about 140-145 or so per week and then fell off to about 125. That was mad Jeff time. Pouty Jeff time there. But, it was also back to school time and that’s traditionally the slower part of the year for me. 

Last week, we ended up with about 22 new patients in one week. Hell yeah I’ll take it. Bet you’re sweet bippy….pass me some more of that deep dish of deliciousness. 

That 22 should boost next week’s totals and that makes for content Jeff. Not happy…..no….I’m still down from Pre-Rona and still don’t have an associate so….not happy Jeff but definitely more content Jeff. Not only did I have the 22 new patients but a heaping spoonful of re-exams on patients that haven’t been in since the Rona began ruining crap. 

So, all in all, we’re moving the right direction. 

I was listening to an episode of mine from a couple of weeks ago. Kind of like game tape. Like the coaches go back and watch the game tape so they can learn about what they want and don’t want. My wife just says I like to hear myself talk and to her I say….you are fake news. 

But anyway, I predicted that by now, more schools would be closing down. At the moment, I stand corrected. More schools have not yet shut down. I also said that I hope I am wrong. And I’m saying right now that I’m glad I was wrong. I’m a big enough man to say it out loud and proclaim mine own idiocy!! 

Or am I an idiot. Today, which is 9/4, happy birthday to my wife Meg BTW, today I took note that Lubbock has reported 849 new cases in the last 3 days. Three days, y’all. 

They’re averaging 283 new cases every single day. And it’s because of that college. A little birdy in the Texas Tech healthcare system told me they got an internal email saying basically that things are getting out of control on the campus already because people living off-campus are being dumb and spreading it on campus. They say it’s expected to get a lot worse after this weekend. 

So, maybe I’m not an idiot after all. We know the incubation on this thing is about 2 weeks and they went to school right at 2 weeks ago. And now here we are. 

I do still believe it’s only a matter of time but for now, I was sort of wrong and I’m sort of OK with it. 

Let’s get on with it shall we?

Before we get to the next paper, I want to tell you a little about this new tool on the market called Drop Release. I love new toys! If you’re into soft tissue work, then it’s your new best friend. Heck if you’re just into getting more range of motion in your patients, then it’s your new best friend.

Drop Release uses fast stretch to stimulate the Golgi Tendon Organ reflex.  Which causes instant and dramatic muscle relaxation and can restore full ROM to restricted joints like shoulders and hips in seconds.  

Picture a T bar with a built-in drop piece.  This greatly reduces the time needed for soft tissue treatment, leaving more time for other treatments per visit, or more patients per day.  Drop Release is like nothing else out there, and you almost gotta see it to understand, so check out the videos on the website.

It’s inventor, Dr. Chris Howson, from the great state of North Dakota, is a listener and friend. He offered our listeners a great discount on his product. When you order, if you put in the code ‘HOTSTUFF’ all one word….as in hot stuff….coming up!! If you enter HOTSTUFF in the coupon code area, Dr. Howson will give you $50 off of your purchase.

Go check Drop Release at droprelease.com and tell Dr. Howson I sent you.

Item #1

Alright, let’s get to this POS paper. I say that because it doesn’t confirm my bias. Lol. It’s called “Effect of Spinal Manipulative and Mobilization Therapies in Young Adults With Mild to Moderate Chronic Low Back Pain: A Randomized Clinical Trial” by Thomas et. al(Thomas J 2020). published in JAMA on August 5, 2020. Hot steamy pile of dog crap here…big plate of shooey. 

Why They Did It

To evaluate the comparative effectiveness of spinal manipulation and spinal mobilization at reducing pain and disability compared with a placebo control group (sham cold laser) in a cohort of young adults with chronic LBP. As if this question has not already been answered a million jillion times. 

How They Did It

  • The study was single-blinded
  • placebo-controlled randomized clinical trial
  • 3 treatment groups
  • Conducted at the Ohio Musculoskeletal and Neurological Institute at Ohio University from June 2013 to August 2017
  • 4903 subjects eligible
  • 4741 did not meet inclusion criteria
  • 162 patients with Chronic Low Back Pain qualified for randomization 
  • Participants received 6 treatment sessions of 
  • spinal manipulation
  • spinal mobilization
  • sham cold laser therapy – placebo – during a 3-week period. 
  • Outcome measures were the change from baseline in Numerical Pain Rating Scale (NPRS) score over the last 7 days and the change in disability assessed with the Roland-Morris Disability Questionnaire 48 to 72 hours after completion of the 6 treatments.

What They Found

  • There were no significant group differences for sex, age, body mass index, duration of LBP symptoms, depression, fear-avoidance, current pain, average pain over the last 7 days, and self-reported disability.
  • At the primary endpoint, there was no significant difference in change in pain scores between spinal manipulation and spinal mobilization, spinal manipulation, and placebo, or spinal mobilization and placebo
  • There was no significant difference in change in self-reported disability scores between spinal manipulation and spinal mobilization, spinal manipulation, and placebo, or spinal mobilization and placebo

So it appears from this paper that spinal manipulation and spinal mobilization has absolutely NO utility NO use and makes NO sense for anything. Basically. This….when so many other papers have shown incredible utility, incredible effectiveness, and incredible cost-effectiveness. It makes very little to zero sense at all. 

Wrap It Up

Their conclusions was as follows, “In this randomized clinical trial, neither spinal manipulation nor spinal mobilization appeared to be effective treatments for mild to moderate chronic LBP.”

OK, I had to consult with those much smarter than I to really get a full picture of what’s going on here. Because I feel like someone’s picking on us a little here. You cannot have so many papers supporting spinal manipulative therapy and then this say there’s no use whatsoever. You simply can’t. Something smells awry in the land of Denmark, up in here, up in here. 

I’ll start with Dr. James Lehman. Dr. Lehman is an Associate Professor of Clinical Sciences at the University of Bridgeport/College of Chiropractic and Director of Health Sciences Postgraduate Education. Dr. James Lehman is a board-certified, chiropractic orthopedist. He teaches orthopedic and neurological examination and differential diagnosis of neuromusculoskeletal conditions. In addition, he provides clinical rotations for fourth-year chiropractic students and chiropractic residents in the community health center and a sports medicine rotation in the training facility of the local professional baseball team. He’s the driving force behind the Diplomate program for Neuromusculoskeletal Medicine. 

As Director, Dr. James Lehman developed the three-year, full-time resident training program in chiropractic orthopedics and neuromusculoskeletal medicine. The program offers training within primary care facilities of a Federally Qualified Health Center and Patient-Centered Medical Home. While practicing in New Mexico, he mentored fourth-year, UNM medical students. He has been generous with advice and mentorship for yours truly as well. We could go on and on. 

I sent this paper to Dr. Lehman and asked for his opinion on it. 

Dr. Lehman said, “I am not favorably impressed with the study for several reasons. It is my opinion that this study was simplistic and non-specific. When studies base the effort on determining the outcomes of a specific modality without a specific diagnosis, I question the outcomes.

 

As a chiropractic specialist, I use the definition promulgated by the National Pain Strategy. Chronic pain occurs more than 50% of the days for six months or longer. This study mentioned that pain occurred only greater than 3 months with no mention of the number of days that pain was experienced. In addition, this study used only mild and moderate chronic pain. It is my opinion that these patients may be experiencing mild symptoms for several reasons that are not relieved by manual medicine interventions. For example, poor posture and distress with resultant myofascial pain without joint dysfunction. Another example would be a patient with a true chronic pain condition that has centralized in the CNS.  These patients normally experience only a reduction in pain for a short period of time.

 

This study offers a simplistic diagnosis and not one that indicates the need for manual medicine interventions.

 

I always question studies that base the need of spinal manipulation on the finding of reduced joint motion. Although chiropractic programs teach motion palpation, the evidence demonstrates the examination procedure to be less than dependable.

 

“Regardless of the degree of standardization, interrater reliability of motion palpation of the thoracic spine for identifying pain and motion restriction performed by experienced examiners was poor and often not better than chance. These findings question the continued use of motion palpation as part of the clinical assessment as an isolated tool to detect loss of intersegmental joint play.” Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4480941/

 

As we know, patients that present for chiropractic care for chronic low back pain demonstrate pain scale findings higher than 2/10 but more likely 5-10/10. Less than 5/10 indicates that the pain does not interfere with the patient’s activities of daily living. Hence, I believe the study was poorly designed. Why study the effectiveness of a manual medicine for an insignificant condition?

Thank you Dr. Lehman for such a thorough response and for laying out his thoughts so effectively on this. He really is a gem of this profession. 

I exchanged emails with Dr. Christine Goertz. Her resume is again, so long and impressive that we can’t do it right here but, in short, she is the Chief Operating Officer of the Spine Institute for Quality. She is also an Adjunct Associate at the Department of Orthopaedic Surgery, Duke University Medical Center, and Adjunct Professor in the Department of Epidemiology, College of Public Health at the University of Iowa. She has received nearly $32M in federal funding as either principal investigator or co-principal investigator, primarily from NIH and the Department of Defense, and has authored or co-authored more than 100 peer-reviewed papers. 

I almost hated to ask Dr. Goertz because I know how busy she is, but honestly, who better to ask, right? And, at the end of the day, I followed an old saying I’ve kept in mind my whole life. And that saying is, “No asky, no getty”

And, as expected, she did not have the chance to dive into it headfirst but did offer this, “Although I can’t comment on the details of the methods Without a deeper dive, one thing that strikes me is the decreased utility of studying spinal manipulation in isolation, as it is generally delivered in the larger context of chiropractic care.”

Which alludes to something I’ve said on this podcast so many times. Chiropractic according to every chiropractor outside of strictly subluxation slayers, is not a modality. It is a profession with A LOT of tools under its umbrella. Still, there’s something smelly about a paper claiming absolutely zero effectiveness of SMT. Really? None?

I emailed one of the smartest dynamic duos I have ever experienced in my entire chiropractic career, Dr. Anthony Nicholson and Dr. Matthew Long. They’re like the batman and robin of chiropractic geniuses. Honestly, good luck finding more intelligent and more thoughtful chiropractors anywhere. They are the creators of all online education curriculum through the CDI courses which are what is used by the Diplomate of Neuromusculoskeletal Medicine. Dr. Nicholson is a Diplomate of Orthopedics as well as a Diplomate in Neurology. 

Dr. Nicholson shared this with me. He said, “In relation to the article, firstly, I’d say that I don’t have researcher-level credentials in critiquing study design, validity, statistical methods etc.

I do obviously read a fair bit of research and integrate that with teaching and clinical experience.

This study seems pretty light to me in several respects and I’m not surprised by the conclusions.  The number of participants was pretty low (162), which lowers the power of the study to draw accurate conclusions.  Overwhelmingly though, here is the dilemma: there is obviously a strong desire to test certain clinical interventions and compare them.  

This means reducing the number of variables and attempting to isolate the specific effect of each intervention to the greatest degree possible.  The problem is that these interventions aren’t meant to be delivered in such a sterile way.  This omits the extremely important context effect and ritualistic aspect of a clinical encounter.  It doesn’t take into account the words, concepts, explanations, and empathy of the doctor that creates a certain context in which the specific intervention is delivered.  The same goes for any intervention, be it drugs or surgery.  Pain is all about meaning.  We are priming a patient’s brain to receive a certain sensory input in terms of what that means.  

The bottom line is that a clinical interaction is so much more than the sum of its parts, and each individual part is very tricky (I won’t say impossible, but you could say it’s pretty close) to evaluate in isolation.  Where does that leave us?  I don’t know!

But, what I do know (like all clinicians I suspect) is that I see meaningful changes to people’s lives every day with these interventions when they’re wrapped in the right clinical context (a successful therapeutic alliance with the patient that is built upon trust and rapport).  It’s difficult to study that!”

I don’t know how one could say it any better than Dr. Nicholson. He has such a way with words, I swear. Are all Australians as eloquent? I’m not sure. I’m a Texan, I’m pretty gruff and rough around the edges I’m afraid. I don’t speak his language but luckily I understand it. Lol. 

His partner in CDI and in fighting chiro crime….remember the batman and robin reference….anyway, Dr. Matthew Long wrote an outstanding article on this type of study that I’ll link in the show notes. Please go check it out. 

He says, “For many chiropractors the realities of clinical practice and the supposed truths of scientific research often seem irreconcilable. This is particularly apparent when reviewing research that investigates the effects of spinal manipulation upon a specific condition. 

Adjusting Disc Herniations and Bulges

 

Often there is little, if any, the difference in outcome between the placebo (sham) intervention and the ‘real’ procedure. In both cases, the patient is seen to improve, often quite substantially. However, the study is unable to show conclusively that active treatment is better than the sham. This phenomenon is especially prevalent when the intervention is being tested for its capacity to reduce pain, which carries a large emotional connotation into the experimental setting. We can see this in a recent migraine study by Chaibi and colleagues (1), who concluded that the significant beneficial effect obtained by sufferers was “probably a placebo response”.

To most clinicians this is deeply unsatisfying. While it is true that the science of placebo has undergone a reappraisal and a softening of opinion in recent years, the average hard working chiropractor probably feels that there is more to their daily practice than simply putting on a good show. 

While many experiments are based upon our ability to modulate pain, others seek to determine how manipulation might influence the biomechanics of a patient’s spine. After all, the dominant model by which spinal manipulation has been justified for over 100 years is largely mechanical in nature (whilst acknowledging the desire to reduce some sort of neural distress that resulted). 

Unfortunately, these biomechanical experiments are sometimes even less impressive in their outcomes, and there is little difference between the active treatment and the control. However, before we become too jaded I think that we should pause for a moment and ask ourselves two important questions:

  1. Are we posing research questions based upon a legacy model of spinal manipulation?
  2. Can the design of these studies preclude us from finding any meaningful answers?

It is my contention that the science of neuromusculoskeletal health has evolved considerably, and yet we are perhaps still looking at the world through an outdated lens.

This dynamic duo is the future of this profession. I’m including the link to the article in the show notes at this point in the show so go there to episode 143, scroll down and click on it. Stop arguing like a damn teenager and just do it or you go to bed with no supper. Don’t you roll your eyes at me, Give me your phone, you’re grounded.”

Another very relevant though from Dr. Long in the article is this:

“Some of the things we know about spinal manipulation include:

1. It is not a mechanical realignment.

2. It does not help relieve pain by increasing range of motion.

3. It can produce changes in smoothness and quality of movement, which are critical for stability and control.

4. It influences the brain’s perception of the spine, and how it can (and should) move.”

It goes on and, as with anything from Dr. Nicholson and Dr. Long, it is eloquent, easy to understand, and basically amazing. This is why you always hear the Neuromusculoskeletal Medicine Diplomates talk about the outstanding education you get in the program. It’s largely due to these two amazing doctors and educators. 

Go read the rest of that article, please.  

https://cdi.edu.au/clarity/its_the_whole_package.php

Now, last but absolutely not least is one of my new favorite research superstars in our profession. We are going to have her on a future episode so keep watching for that. Dr. Katie Pohlman from Parker University was kind enough to send me her thoughts on the paper. 

Dr. Pohlman is Director of Research at Parker University and an inaugural fellow of the Chiropractic Academy of Research and Leadership (CARL) program. She received Researcher of the Year in 2020 from the American Chiropractic Association (ACA), is the current Vice President of the ACA’s Council on Women’s Health, and has served as Vice President of the ACA’s Council on Chiropractic Pediatrics. Dr. Pohlman received her Doctor of Chiropractic (D.C.) degree and M.S. in Clinical Research from Palmer College of Chiropractic and her Ph.D. in Pediatrics from the University of Alberta. We could keep going but I think you get the point. 

She’s one of the most impressive ‘newer’ researchers in our profession. I say newer in quotes because I only found out about Dr. Pohlman in the last few years. But trust me here, you’re going to be hearing and seeing A LOT more out of her in the future. 

Dr. Pohlman said this, “This was a well-designed study of manipulation and mobilization with a strong placebo arm. The population was young, non-obese individuals with chronic back pain. 

As stated in the discussion, the sample population baseline pain level on a 0-11 scale was ~4.3, which I feel left little room the clinical meaningful 2 points decrease. The study also used characteristics from a clinical prediction rule for the inclusion of patients. 

That Episode Where Vitalists Tune Out & NSAIDS vs. Cognitive Behavioral Therapy

The characteristic list that they use included patients having pain for less than 16 days. Since this study was looking at chronic pain this characteristic was not included. 

I support the idea of pre-identifying responders versus non-responders; however, the characteristics used in this study may not have been most useful for chronic pain patients. 

A more useful model at this time is the Andres Eklund ‘s psychological subgroups (which also have not be validated… watch for more studies in the near future). 

(NOTE: this study was published after the start of the RCT being discussed.) 

Another consideration for this study was the 3 weeks of care and the manipulation/mobilization techniques that were used. I will leave these concerns for clinicians to discuss.”

Katie is wonderful for taking time out of her day to offer us some insight on this. 

Now, I want to address the F4CP. The Foundation For Chiropractic Progress. They came out shortly after this paper with a press release in support of this paper. Saying it’s correct, they support it, and it is further proof that a D.O. or any other practitioner outside of a Doctor of Chiropractic is clearly ineffective. 

The insinuation is that no other practitioner can deliver an adjustment as well and as effectively as a chiropractor and that had the study included spinal manipulative therapy delivered by chiropractors, it would have shown clear effectiveness. 

Because you know….chiropractors are evidently the ONLY practitioners that can adjust I guess. 

Let me get this straight upfront; I love the F4CP. I support them. I love what they’ve done for our profession and are doing for our profession. I would say that I believe there are some TICs and some TORs in there and that’s not necessarily helpful for the evidence-based side of the profession but overall, it’s a great group and does a good job of being well-rounded and representing the profession as a whole.

With that being said, in this paper, I think the F4CP is just wrong to support the paper like this. For me, it’s lazy and almost comes off like the way a politician would slide around something. You know what I mean? Avoid the elephant in the room and say, “See there, had they used chiropractors, it’d been a different dealio all together because we’re the superstars’ nobody else can be. I don’t know…..I guess if the other spinal manipulative therapy people would maybe….I don’t ….try not to suck so much….that’d be great and all”

It’s BS and I don’t like their handling of it. I like their handling of just about everything else but whoever pulled the trigger on this, I just can’t agree with. There are holes to be poked in it. There are too many papers showing the effectiveness to sit around and let 3 PhDs set the tone for spinal manipulative therapy going forward. 

You think insurance companies, chiro haters, and trolls aren’t going to grab this and run like they stole something with this thing? Of course, they will. And are. Hell, I’ve seen where chiropractors themselves are now saying the manipulation isn’t all that effective. Chiropractors y’all. Then you have the Airrosti folks who don’t adjust. We all have to do what we do and what we feel but come on man. I always say chiropractic isn’t an adjustment, it’s a profession. But let’s have some real talk here. The adjustment is still damn well the cornerstone of the profession. Don’t any of you kid yourselves on this? It is and it is for a reason. 

So for me, on this deal, the F4CP is wrong. Sorry to any of you that may be in the F4CP. I’m aware you didn’t ask my opinion first but I’m giving it second. Lol. 

I do support you overall. Just not here. 

The study isn’t an indictment of chiropractic in general but I’d say that this paper doesn’t take any of the other things a chiropractor does into account at all. When the pain is centralized and the CNS is upregulated, simple manipulation is a start but is only a tiny piece of the puzzle. 

Alright, that’s it. Y’all be safe. Keep changing the world and our profession from your little corner of the world. Continue taking care of yourselves and taking care of your neighbors. Tough times are upon us but, the sun will shine again. Trust it, believe it, count on it.

Let’s get to the message. Same as it is every week. 

Key Takeaways

Store

Remember the evidence-informed brochures and posters at chiropracticforward.com. 

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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!

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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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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

Bibliography

  • Thomas J, C. B., Russ D, (2020). “Effect of Spinal Manipulative and Mobilization Therapies in Young Adults With Mild to Moderate Chronic Low Back Pain
  • A Randomized Clinical Trial.” JAMA Open 3(8).

 

Nonoperative Disc Treatment, D3 for Depression, & The Biopsychosocial Part Of Chronic Pain

CF 142: Nonoperative Disc Treatment, D3 for Depression, & The Biopsychosocial Part Of Chronic Pain

Today we’re going to talk about Nonoperative Disc Treatment, D3 for Depression, & The Biopsychosocial Part Of Chronic 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 aro

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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.  

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Do it do it do it. 

You have found yourself smack dab in the middle of Episode #142

Now if you missed last week’s episode , we talked about the update from the authors on The Lancet low back series and we talked about movement disorders and whether or not they translate into 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…..

Kids still in school. I called it early. I’m giving most of the schools about 4-6 weeks before they decide the numbers are too high. I do not want to be a pessimist. I just don’t see how they’ll keep it under control. I drove by my daughter’s junior high at lunch and they had 100-200 kids out on the playground playing basketball. Right up on each other. Lol. 

I know they’re outside. I know. We’ll see. I know the University of Alabama just reported 1200 positives at the campus. Notre Dame, University of North Carolina. I just see it as a start. 

My son told me a kid in his math class turned up positive so that got him all up in a wrinkle. I told him he’s got a better chance of getting it riding in a car with someone to eat or gathering up in dorm rooms than getting it in a big huge classroom. It’ll hold 300 kids but there’s around 50 or 60 in there all wearing masks and distanced. Minimal risk. 

Then I had a patient in here just last week, I treated her on a Tuesday. No temp, no symptoms at all….she goes home. The next day she feels a little funky. Her husband had the Rona a couple of weeks ago if I remember right. Anyway, she’s on high alert because of her husband so she goes and gets tested and she’s positive. The day after we had her in the clinic. 

Now, she was masked the whole time and my time with her was less than 3-5 minutes, she had no symptoms at the time so the risk, to my knowledge, while certainly not ideal, in the long run is probably minimal. 

Had that happened 3-4 weeks ago, I’d probably have been down at the place getting the tests and all that good stuff. Had Jake had a positive kid in his big ol math class a month ago, they’d probably be doing something more than just saying, hey this happened. Y’all wear a mask. 

Things ahve changed slightly in the past month I believe. I think more and more, we’re seeing we can live with this and it’s not the end of the world like some thought it’d be back in March and April. We still see cases going down but they’re still higher than they were in the first wave. Yet deaths aren’t. They’ve leveled and dropped as well. Which is all great news. 

I’m a nerd so I watch interviews with experts on vaccines and epidemilology and all that stuff done through the Journal of the American Medical Association. One of the experts said that’s it’s just not in the virus’s best interest to kill us off. It’s in its best interest to become more transmissible but less deadly so it can spread easier but not kill us…..so it can survive. Basically. 

That’s an interesting way to look at it. Then, yesterday, the CDC comes out and says that only 6% of deaths are due strictly to COVID. Well now hell. Doesn’t that give fuel to the fire for the science hating conspiracy nut cases? More ammo to confuse other dummies into their way of thinking but the truth is, it changed nothing. It just meant that 94% of COVID deaths have an average of 2.6 co-morbidities. 

Well, no durr Sherlock. That’s one of the few things we’ve all actually known this whole time. The CDC just was finally able to quantify it. That’s all. I’m still overweight. I’m still more at risk than John Workout over there drinking his fruit smoothie after his 6 mile run. No change whatsoever but day-um if the nut cases didn’t jump all over that one. 

Watching science haters just explode and reveal themselves on Facebook over the last 6 months has been such a disappointment. Especially the ones that you respected as doctorate level caregivers. 

Now look, I’ll admit something, in the very beginning, when nobody knew what the hell, how many would die and this and that, I got caught up in some of it. A whole bunch of us did. As more information comes to light, as we learn more about it, as we experience life with it, the danger is still there but, education has lessened any fear that might have been there in the beginning. 

Now, it’s just life and we have to keep living. We have to try to send kids to school. Let’s see what happens. We have to go to work. I’ve been working full time for basically 6 months following guidelines and so far so good. Can you imagine what business would look like if I just took off for months? Nope. Can’t do it. 

And isn’t there something to be said about government over reach on some of this stuff? How can they shut down bars yet allow people to gather up in a church? How can some bars stay open with music and bands but they’re able to stay open because you can buy a hamburger. Yet other bars are closed because they don’t sell a hamburger? How does any of it make sense? It’s a stack of hooey balls. 

I’m a Christian, I want people to want to go to church. So don’t get the wrong idea there. It’s a valid comparison. You can group up in church but not in a bar. It’s silly. 

We’ll know more about the back to school thing in jsut a few weeks. 

Alright, I’m rambling, let’s get to it. 

Item #1

The first article here is called “Effect of Long-term Vitamin D3 Supplementation vs Placebo on Risk of Depression or Clinically Relevant Depressive Symptoms and on Change in Mood Scores. A Randomized Clinical Trial” by Okereke et. al(Okereke O 2020). and published in JAMA on August 4, 2020. Hot tamale, hot tamale….

Why They Did It

The authors wanted to know if long-term supplementation with vitamin D3 prevent depression in the general adult population? What’s your guess? D3 is a bit of a wonder kid, right?

How They Did It

  • 18353 men and women aged 50 years or older 
  • Randomized clinical trial 
  • Randomized testing happened from November 2011 through March 2014
  • Randomized treatment ended on December 31, 2017
  • Randomization was D3 or placebo

Wrap It Up

“Among adults aged 50 years or older without clinically relevant depressive symptoms at baseline, treatment with vitamin D3 compared with placebo did not result in a statistically significant difference in the incidence and recurrence of depression or clinically relevant depressive symptoms or for change in mood scores over a median follow-up of 5.3 years. These findings do not support the use of vitamin D3 in adults to prevent depression.”

Before we get to the next paper, I want to tell you a little about this new tool on the market called Drop Release. I love new toys! If you’re into soft tissue work, then it’s your new best friend. Heck if you’re just into getting more range of motion in your patients, then it’s your new best friend.

Drop Release uses fast stretch to stimulate the Golgi Tendon Organ reflex.  Which causes instant and dramatic muscle relaxation and can restore full ROM to restricted joints like shoulders and hips in seconds.  

Picture a T bar with a built-in drop piece.  This greatly reduces time needed for soft tissue treatment, leaving more time for other treatments per visit, or more patients per day.  Drop Release is like nothing else out there, and you almost gotta see it to understand, so check out the videos on the website.

It’s inventor, Dr. Chris Howson, from the great state of North Dakota, is a listener and friend. He offered our listeners a great discount on his product. When you order, if you put in the code ‘HOTSTUFF’ all one word….as in hot stuff….coming up!! If you enter HOTSTUFF in the coupon code area, Dr. Howson will give you $50 off of your purchase.

Go check Drop Release at droprelease.com and tell Dr. Howson I sent you.

Item #2

This second one here is called “An Assessment of Nonoperative Management Strategies in a Herniated Lumbar Disc Population: Successes Versus Failures” by Lilly et. al(Lilly D 2020). published in Global Spine Journal in July of 2020. Is it hot in here? I need some air!

Why They Did It

To compare the utilization of conservative treatments in patients with lumbar intervertebral disc herniations who were successfully managed nonoperatively versus patients who failed conservative therapies and elected to undergo surgery (microdiscectomy).

How They Did It

  • Clinical records from adult patients with an initial herniated lumbar disc between 2007 and 2017 were selected from a large insurance database.
  • Patients were divided into 2 cohorts: patients treated successfully with nonoperative therapies and patients that failed conservative management and opted for microdiscectomy surgery.
  • Nonoperative treatments utilized by the 2 groups were collected over a 2-year surveillance window.
  • “Utilization” was defined by cost billed to patients, prescriptions written, and number of units disbursed.

What They Found

  • 277 941 patients with lumbar intervertebral disc herniations were included.
  • Of these, 269 713 (97.0%) were successfully managed with nonoperative treatments,
  • 8228 (3.0%) failed maximal nonoperative therapy (MNT) and underwent a lumbar microdiscectomy.
  • failures occurred more frequently in males (3.7%), and patients with a history of lumbar epidural steroid injections (4.5%) or preoperative opioid use (3.6%).
  • A cost analysis indicated that patients who failed nonoperative treatments billed for nearly double ($1718/patient) compared to patients who were successfully treated ($906/patient).

Wrap It Up

“Our results suggest that the majority of patients are successfully managed nonoperatively. However, in the subset of patients that fail conservative management, male sex and prior opioid use appear to be independent predictors of treatment failure.”

Item #3

The last one is called “Biopsychosocial baseline values of 15 000 patients suffering from chronic pain: Dutch DataPain study” by Brouwer et. al (Brouwer B 2020) . and published in Regional Anesthesia and Pain Medicine in August of 2020….only the freshest for you fresh people. 

Why They Did It

They did this one in an effort to understand multidisciplinary approaches to solving chronic pain. 

How They Did It

  • 11,214 patients suffering from chronic pain
  • The pain was analyzed using relevant Initiative on Methods, Measurement, and Pain assessment in Clinical Trials Instruments. 
  • Most patients were female

What They Found

  • The mean age was 55.6 years old
  • Severe pain was reported by 71.9%
  • Psychological and quality of life values deteriorated when pain severity increased
  • About 36% of them showed severe signs of depression or anxiety
  • 39% had high pain catastrophizing
  • Of all patients, 17.8% reported high values for pain severity, catastrophizing and anxiety or depression 

Wrap It Up

“Based on baseline biopsychosocial values, this study shows the complexity of patients referred to pain centers. Pain management with a biopsychosocial approach in an integrated multidisciplinary setting is indispensable. Above all, adjusted education on chronic pain and attention to its biopsychosocial aspects are deemed necessary.”

It becomes more and more clear that if all you’re doing is adjusting and sending them on their way, you’re wrong. 

If you’re adjusting and doing some exericises and sending chronic pain on its way, you’re partly wrong. 

If you’re adjusting when appropriate, if you’re prescribing patients exercises and teaching them how to self manage at home, addressing yellow flags and building confidence while you encourage addressing the cognitive aspect of chronic pain…..well….now you’re starting to get it. You’re becoming someone that can make a realy difference in your patients’ lives. 

Alright, that’s it. Y’all be safe. Keep changing the world and our profession from your little corner of the world. Continue taking care of yourselves and taking care of your neighbors. Tough times are upon us but, the sun will shine again. Trust it, believe it, count on it.

Let’s get to the message. Same as it is every week. 

Key Takeaways

Store

Remember the evidence-informed brochures and posters at chiropracticforward.com. 

Subscribe Button

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 preventativly 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

Home

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https://www.facebook.com/chiropracticforward/

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https://www.facebook.com/groups/1938461399501889/

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https://itunes.apple.com/us/podcast/chiropractic-forward-podcast-chiropractors-practicing/id1331554445?mt=2

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https://player.fm/series/2291021

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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 & VloggerBibliography

Brouwer B, W. S., Jacobs C, Overdijk M, (2020). “Biopsychosocial baseline values of 15 000 patients suffering from chronic pain: Dutch DataPain study.” Reg Anesth Pain Med.

Lilly D, D. M., Eldridge C, (2020). “An Assessment of Nonoperative Management Strategies in a Herniated Lumbar Disc Population: Successes Versus Failures.” Global Spine J.

Okereke O, R. C., Mschoulon D, (2020). “Effect of Long-term Vitamin D3 Supplementation vs Placebo on Risk of Depression or Clinically Relevant Depressive Symptoms and on Change in Mood Scores A Randomized Clinical Trial.” JAMA 324(5): 471-480.

Updated Thinking On Chronic Pain and Exercise

CF 129: Updated Thinking On Chronic Pain and Exercise Today we’re going to talk about chronic pain and exercise.  But first, here’s that sweet sweet bumper music
Chiropractic evidence-based products

Integrating Chiropractors

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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. 
  • Like our Facebook page, 
  • Join our private Facebook group and interact, and then 
  • go review our podcast on iTunes and other podcast platforms. 
  • We also have an evidence-based brochure and poster store at chiropracticforward.com
  • While you’re there, join our weekly email newsletter. No spam, just a reminder when the newest episodes go live. Nothing special so don’t worry about signing up. Just one a week friends. Check your JUNK folder!!
Do it do it do it.  You have found yourself smack dab in the middle of Episode #129 Now if you missed last week’s episode, we talked about Tylenol failures, cervical disc research, and we talked about complementary and alternative treatment for headaches and migraines. What’s the current research and thinking? 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, so far, no blowback from my rant on last week’s podcast so sometimes no news is good news. You either all agree with me or you’re not listening.  Rocking and rolling here at work, last week was finally the busiest I have been since late January or early February. It was quite a blessing. I have to admit, I’m not used to working that damned hard anymore but it’s OK. I just need to get back into fighting shape so I can see them all.  Last week we saw about 135 patients. Pre-COVID numbers were anywhere from 185-225 so I’m still significantly down but it’s trending upwards and it’s looking good right now. I cannot and will not fuss about it. Especially when I read that several are just now going back to work and have been closed completely this entire time. We’ve been fully, completely open for more than a month now. It’s hard to imagine being closed down any longer than we were honest. I don’t know how companies survive.  I see reports that the virus may have mutated to a lesser severity. Not only are some doctors claiming that people are getting less severe when they do get sick, but they are not getting sick as easily. That’s some exciting news if it is indeed a fact. Time will tell.  I don’t want to hear anything about ‘new normals’. Once this dude settles down, life will be normal. Not a new normal. It’ll be back to the way it was. I’m guessing August but who knows? It could be in the Fall. Maybe even the Spring. But it will be the old normal. You can count on that.  I hope your businesses are picking back up as well. I hope you’re seeing those old familiar happy faces coming back into the office to greet you. I hope you’re back on track to showing the world how effective and amazing chiropractic can be when practiced by an evidence-based, patient-centered professional. That’s you. That’s who listens to this show and I’m proud of you all. You make this profession better every day and I thank you.  I just hope you get something good from me every week. If you do, I won’t be shy about asking you to share this podcast with your colleagues. We are growing all of the time but it’s never quite fast enough to feel like I’m on a roll. So, with your help in sharing and talking about us, I think we can truly make a big difference and take this thing of ours to another level.  Item #1 This first one this week is called “Exercise Induced Hypoalgesia Is Impaired in Chronic Whiplash Associated Disorders (WAD) With Both Aerobic and Isometric Exercise” by Smith et. al(Smith A 2020). and published in Clinical Journal of Pain in May of 2020. Oy…..that’s smokin’ hot! Why They Did It First, let’s define Exercise Induced Hypolagesia. It is a generalized reduction in pain and pain sensitivity that occurs during exercise and for some time afterward. So, for normal, asymptomatic people, when they exercise, there’s less pain and they feel better and that lasts for a while when they finish exercising.  Exercise induced hypoalgesia can be impaired in patients with chronic pain and may be dependent on exercise type. Factors predictive of Exercise induced hypoalgesia are not known. This study aimed to: 
  1. compare Exercise induced hypoalgesia in participants with chronic whiplash associated disorders to asymptomatic controls, 
  2. determine if exercise induced hypoalgesia differs between aerobic and isometric exercise, 
  3. determine predictors of Exercise induced hypoalgesia.
How They Did It
  • A pre-post study investigated the effect of single sessions of submaximal aerobic treadmill walking and isometric knee extension on exercise induced hypoalgesia in 40 participants with chronic whiplash associated disorders and 30 controls
  • Pressure pain thresholds were measured at the hand, cervical spine and tibialis anterior
  • Appropriate baseline measurements were performed
What They Found Participants with whiplash-associated disorders demonstrated impaired exercise-induced hypoalgesia There was no difference in exercise-induced hypoalgesia between exercise types Wrap It Up “Individuals with chronic whiplash-associated disorders have impaired exercise-induced hypoalgesia with both aerobic and isometric exercise. Higher levels of physical activity and less efficient conditioned pain modulation may be associated with impaired exercise-induced hypoalgesia.” Item #2 This last one is by the great Dr. Craig Liebenson and is called “Pain with Exercise: Is it acceptable & if so how much & for how long?” and was published in First Principles Of Movement on May 20, 2020(Liebenson C 2020). Pow! Hot like a firecracker folks. https://firstprinciplesofmovement.com/pain-with-exercise-is-it-acceptable-if-so-how-much-for-how-long/ For articles, we dispense with our normal outline and we hit the high spots and interesting points.  Craig starts by quoting a paper by Smith, Littlewood where they say “Protocols using painful exercises offer a small but significant benefit over pain-free exercises in the short term, with moderate quality of evidence……Pain during therapeutic exercise for chronic musculoskeletal pain need not be a barrier to successful outcomes.” He also quotes Annie O’Conner’s, author of World of Hurt, where she says we must violate the patient’s expectation that hurt equals harm. Especially with light pain.  Craig also refers to a photograph from Silbernagel’s paper demonstrating a Pain-Monitoring Model where the safe zone on the VAS was 0-2, the Yellow or acceptable zone was 3-5 on the VAS, and the red high-risk zone was 6-10.  Silbernagel says, “Biological plausibility/explanation and reasoning ranks high and then you can individualize. Meaning waiting for the pain to subside does not work because you get weaker and the tissue decreases its tolerance to load. So loading with pain is beneficial to get the structures to improve. However, if it is a fracture it might be very different so know the injury and tissue.” I like this quote of Craig’s from the article: “Many people believe the medical adage – “if it hurts don’t do it”. We know that for some this promotes illness behavior by giving the idea that the body is fragile. Ben Smith & Chris Littlewood’s shoulder paper, Annie O’Conner’s WOH book, some of K Thorberg’s groin work, & you’re tendonopathy paper all show yellow pain is acceptable.  He says the idea of, if it hurts, don’t do it brings about clear yellow flags. Yellow flags such as
  • Hurt = harm
  • activity is harmful
  • if an activity hurts it should be stopped
On the topic of osteoarthritis, he says 
  • The patient decides what’s tolerable, 
  • Above 5 is the red area
  • If pain increases with exercise, that’s OK as long as by the next day it has calmed. 
He goes on to cite a new paper in JAMA by Ben Cormack asking about pain tolerance vs. using the traditional Numeric Rating Scale. They’re suggesting asking if the pain is tolerable is a better way to deal with it.  Cormack says:
  • “The exclusive focus of the numeric rating scale (NRS) on pain intensity reduces the experience of chronic pain to a single dimension.”
  • “This drawback minimizes the complex effects of chronic pain on patients’ lives and the trade-offs that are often involved in analgesic decision-making.”
  • “Furthermore, continually asking patients to rate their pain on a scale that is anchored by a pain-free state (ie, 0) implies that being pain-free is a readily attainable treatment goal, which may contribute to unrealistic expectations for complete relief.”
The modern approach to managing disabling musculoskeletal pain is to shift the focus from chasing symptomatic relief to addressing activity intolerances related to symptoms.
  • “ The overarching goal of chronic pain treatment is to make the pain tolerable for the patient rather than to attain a targeted numeric rating.”
  • “Our findings confirmed the intuitive assumption that most patients with low pain intensity (ie, NRS score, 1-3) find their pain tolerable.”
  • “In contrast, the tolerability of pain rated between 4 and 6 varies substantially among patients.
  • “In this middle range, if a patient describes the pain as tolerable, this might decrease the clinician’s inclination to initiate higher-risk treatments.”
  • “A substantial subgroup of patients with severe pain reported their symptoms as tolerable.”
Dr. Liebenson wraps up the article by saying, “This discussion highlights that hurt does not necessarily equal harm. Nearly all musculoskeletal pain guidelines over the last 30 years have emphasized that pain does not equal tissue damage or impending injury. This study goes a long way to show us better ways to educate people in reassuring ways that will get them back to activity and thus build a mindset that can make them feel less fragile.” Chronic pain is interesting stuff and is a HUGE market where there are lots of opportunities for educated, smart chiropractors to stick their flag in the dirt and stake a claim.  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, believe it, count on it. Let’s get to the message. Same as it is every week.  Key Takeaways Store Remember the evidence-informed brochures and posters at chiropracticforward.com.   
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 preventativly 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
Home
Social Media Links https://www.facebook.com/chiropracticforward/ Chiropractic Forward Podcast Facebook GROUP https://www.facebook.com/groups/1938461399501889/ Twitter YouTube 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 – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger   Bibliography
  • Liebenson C (2020). “Pain with Exercise: Is it acceptable & if so how much & for how long?” First Principles Of Movement.
  • Smith A, R. C., Warren J, Sterling M, (2020). “Exercise Induced Hypoalgesia Is Impaired in Chronic Whiplash Associated Disorders (WAD) With Both Aerobic and Isometric Exercise.” Clin J Pain.