disc herniation

Kids Still Hurt, Manipulation For Lumbar Radiculopathy, & Lack Of Attention On The Boards For Biopsychosocial Matters

CF 145: Kids Still Hurt, Manipulation For Lumbar Radiculopathy, & Lack Of Attention On The Boards For Biopsychosocial Matters Today we’re going to talk about how kids can hurt, SMT for chronic lumbar radiculopathy, lack of testing on biopsychosocial matters.  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, 
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  • 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.    https://www.chiropracticforward.com/chiropractors-affected-by-covid-2019-opioid-overdoses-insurance-compensation-for-chiropractic/   You have found yourself smack dab in the middle of Episode #145 Now if you missed last week’s episode , we talked about some of the most common musculoskeletal surgeries and the incredible lack of research backing them up. We also talked about how chiropractic performs when lined up against multidisciplinary treatment. Check it out after this one. 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….. I think I’m getting busier. Feels like it anyway. 143 last week and the new patients are staying steady. Which is a good thing. I have the kind of practice that depends on new patients. When you’re evidence-based and you don’t make a ton of long-term recommendations…..you don’t make patients think they need to depend on you every week for the rest of their lives….well then, you have a constant turnover of patients.  My longest recommendation is for about a 3 month plan. Honestly, most people are feeling so good that they don’t wrap up a 3 month plan. Some of you agree with that and some of you will say I should be holding them to the program but, research is clear on this.  We should be teaching patients to self-manage at home. Not depending on us. And that’s part of it. Once they start self-managing and they’re feeling great, where’s the motivation to pay someone to mostly do what they’re doing at home already? I get it. And I don’t fuss with patients over their schedules when they’re doing amazing in the first damn place. There’s a point where that type of fussing and borderline bullying starts to look like greed. And I’m sure none of us want to look greedy. At least I don’t.  That’s the epitome of being patient-centered, right? But the point is, patient-centered, evidence-based chiropractors need a steady stream of new patients.  Now don’t get me wrong; I have wellness patients. They just aren’t the bulk of my practice. If I just depended on wellness/maintenance patients, we’d be in a world of hurt up in here, up in here.  Not long ago, evidence-based chiros threw monkey poo at maintenance. Then Andres Eklund came around and cleaned up the monkey mess. Then a systematic review recently came out saying maintenance care can now be considered evidence-based. It felt like slipping into a warm coat in the winter, ya know. Lol.  Now, that doesn’t mean once a week for life like the subluxation slayers lay on people. For the right population, once every month or two….or maybe every three months….that does indeed make difference and make some sense. If you’re unfamiliar with Andres Eklund, just go to our episodes link at chiropracticforward.com and use the search function there to search for maintenance care or Nordic papers and dive in. It’s wonderful stuff.  I love it when the hard work has already been done by people smarter than me. It’s good stuff.  Outside of all that boring stuff, still just trying to stay strong and healthy. I’m exercising much more regularly and really watching what I’m eating. It’s paying off too. I lost 7 pounds last week. Yeah, I know what you’re thinking…..how could Jeff get any sexier than he already is but I’m just going to say, hold my beer and watch. My michelob ultra beer that is…..because, you know….I’m on a diet and all. Lol.  I have one kid at Texas Tech where COVID is spreading like a bad STD and then I have another in person in junior high. So far in the first 5 weeks they’ve had 2 teachers and 2 kids out with the Rona. That may sound like a lot but, honestly, this junior high has about 1400 kids so……that’s not much.  The kid at Tech thinks he wants to come home every 2 weeks for the weekend. I love seeing the little knucklehead but another part of me is like…..you stay over there on that side of the house…..I’ll be on this side. He’s a big hugger. I’m normally good for a hug and all but…..Rona has me trying to stay healthy. You can’t turn down a hug from your kiddo though. Still……it’s a bit nerve wracking.  I tell people and you may have heard me say it but, most folks do fine if they get COVID and I expect I’ll do fine as well. Other than being out of shape and overweight, I’m not particularly unhealthy. Most folks, if they get it, they just stay home in bed, fluids, all that rigamarole but no big deal really.  Me….and most of you….we have to close down out businesses essentially. I have 14 employees, y’all. They have families. We bill out anywhere from $20k-$25k per week typically. At minimum, I’m probably out for 2 weeks. That means missing out on up to $50k in billing.  One word, two syllables….Day-um….Hell no. I’ll just do everything I can to stay healthy in the first place. Even if some knuckleheads don’t understand or get it.  Speaking of…..These anti-maskers….good Lord. I don’t know how they are where you live but here in Texas, did you know all kinds of degrees have morphed into now allowing the owner of the degree to now be an expert on epidemiology? Very powerful degrees. I’ve never heard of a degree that morphs into epidemiological expertise but evidently, it’s a fact these days.  I saw a great quote from a fellow chiro that went something like this, “I guess I just don’t understand the argument anti-maskers make in general. Regardless of anything, for me, as a healthcare professional, I need to be flexible and consider being wrong as part of my logic. Simply put, maybe masks work, maybe they don’t but it really doesn’t matter what you believe. The question sreally is, if you’re wrong can you live with the consequences? I wear a mask because I believe it reduces the risk of exposure for me and to those around me, but more importantly, if I’m wrong I won’t hurt anybody at all. Including myself. If you don’t wear a mask and you’re wrong, then the effects can be devastating during a really off day when things go they way they’re not supposed to go.  Or, how about the sneeze test? Have someone sneeze on you with a mask on and then have them sneeze on you without a mask on.  Which do you prefer? End of story.  Let’s get on with it. We have some pretty cool stuff to breeze through today.  Item #1 Let’s start with this one called “Musculoskeletal pain distribution in 1,000 Danish schoolchildren aged 8–16 years” by Fuglkjaer et. al. it also has Jan Hartivigsen on it as well. It was published in Chiropractic and Manual Therapies in August of 2020(Fuglkjaer S 2020).  Hot tamale, hot tamale, that tamale….it’s hot… Why They Did It The objectives were to group children aged 8 to 16 according to their distribution of pain in the spine, lower- and upper extremity, determine the proportion of children in each subgroup, and describe these in relation to sex, age, number- and length of episodes with pain. How They Did It Data on musculoskeletal pain from about 1,000 Danish schoolchildren was collected over 3 school years (2011 to 2014) using weekly mobile phone text message responses from parents, indicating whether their child had pain in the spine, lower extremity and/or upper extremity. Result are presented for each school year individually. What They Found

  • Around 30% reporting no pain, around 40% reporting pain in one region, and around 30% reporting pain in two or three regions.
  • Most commonly children experienced pain from the lower extremities at about 60%, the the spine at about 30%, and then upper extremities at about 23%. 
  • Twice as many girls reported pain in all three sites

Wrap It Up Danish schoolchildren often experienced pain at more than one pain site during a schoolyear, and a significantly larger proportion of girls than boys reported pain in all three regions. This could indicate that, at least in some instances, the musculoskeletal system should be regarded as one entity, both for clinical and research purposes. Item #2 This one is excellent. It’s called “Spinal manipulation for subacute and chronic lumbar radiculopathy: a randomized controlled trial” by Ghasabmahaleh, et. al. and published in The American Journal of Medicine on September of 2020(Ghasabmahaleh S 2020).  Sizzlin, smokin’. some stout stuff, y’all.  Why They Did It The authors wanted to evaluate the efficacy of spinal manipulation for the management of non-acute lumbar radiculopathy. How They Did It

  • It was performed in a university hospital
  • It was a randomized controlled trial with two parallel arms. 
  • 44 patients with unilateral radicular low back pain lasting more than 4 weeks were randomly allocated to manipulation and control groups.
  • The primary outcome was intensity of the low back pain on the VAS scale
  • Secondary outcome was the Oswestry Disability Questionnaire score
  • In addition they measure spinal ranges of motion. 
  • All patients had physiotherapy
  • The manipulation group got three sessions of manipulation therapy, one week apart. 
  • For manipulation, they used Robert Maigne’s technique. 

What They Found

  • Both groups experienced a significant decrease in back and leg pain
  • However, only the manipulation group showed significantly favorable results in the Oswestry scores, and the straight leg raise test. 
  • All ranges of motion increased significantly with manipulation but the control group showed favorable results only in right and left rotations and in extension
  • Between-group analyses showed significantly better outcomes for manipulation in all measurements with large effect sizes

Wrap It Up They wrap it up by saying, “Spinal manipulation improves the results of physiotherapy over a period of three months for patients with subacute or chronic lumbar radiculopathy.” I say hell with that conclusion. Lol. I say that PT ADDS TO spinal manipulation. I’ve told my patients for years now that there is great research for spinal manipulation and there is great research for exercise. It’s not about one or the other. They’re not mutually exclusive. The research is best for combining the two.  If you go to a PT and just get exercise, that’s not the full meal deal. You’re a taco or two short of a combo meal there.  If you go to a chiropractor and only get adjustments, yes, there should be some relief but, again, you a taco short. You could be better.  You don’t want evidence-based chiros out there in the world wishing you didn’t suck so much. Get on the exercise rehab. Learn. I didn’t used to know much about it. Hell, if I’m being honest, there’s A LOT more I still need to learn but I’m a hell of a lot better than I once was.  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 #3 Last one today is called “The prevalence of psychosocial related terminology in chiropractic program courses, chiropractic accreditation standards, and chiropractic examining board testing content in the United States” by Gliedt et. al. published in Chiropractic and Manual Therapies on 21st of August 2020(Gliedt J 2020).  On the hottest, freshest frijoles for the Forward fans.  Why They Did It Chiropractors treat spine complaints and therefore should be trained in the full spectrum of the biopsychosocial model. This study examines the use of psychosocial related terminology in United States doctor of chiropractic program (DCP) curricula, the Council on Chiropractic Education (CCE) standards, and the National Board of Chiropractic Examiners (NBCE) test plans. How They Did It Nineteen academic course catalogs, CCE curricular standards and meta-competencies, and NBCE test plans were studied Wrap It Up Despite evidence suggesting the influential role of psychosocial factors in determinants of health and healthcare delivery, these factors are poorly reflected in United States DCP curricula. This underappreciation is further evidenced by the lack of representation of psychosocial terminology in NBCE parts III and IV test plans. The reasons for this are theoretical; lack of clarity or enforcement of CCE meta-competencies may contribute. So when you hear people ask what we can do to make this profession better, stronger, and more respected…..this is just one more thing that can be done.  Our institutions can recognize the biopsychosocial aspect of chronic pain, they can teach it, they can teach yellow flags, and then they can test it.  Then we can look at making entrance into the schools a little more stringent and we can look at taking the subluxation slayers and spine whisperer courses out of our colleges. If someone wants to learn how to be doctor-centered and use x-rays to manipulate patients out of thousands of dollars a year, they need to be learning that garbage outside of an accredited chiropractic college. It has no place in our institutes beyond some historical perspective.  Over and out. Mic drop, bam, shazam, ala cazam.  https://www.chiropracticforward.com/common-surgeries-arent-well-researched-chiropractic-wins-again/   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.   

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 http://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

  • Fuglkjaer S, V. W., Hartvigsen J, Dissing KB, Junge T, Hestbaek L, (2020). “Musculoskeletal pain distribution in 1,000 Danish schoolchildren aged 8–16 years.” Chiropr Man Therap 28(45).
  • Ghasabmahaleh S, R. Z., Dadarkhah A, Hamidipanah S, Mofrad R, Najafi S, (2020). “Spinal manipulation for subacute and chronic lumbar radiculopathy: a randomized controlled trial.” The American Journal Of Medicine.
  • Gliedt J, B. P., Holmes B, (2020). “The prevalence of psychosocial related terminology in chiropractic program courses, chiropractic accreditation standards, and chiropractic examining board testing content in the United States.” Chiropr Man Therap 28(43).

CF 048: Do Disc Herniations On An MRI Worsen When Sitting Or Standing (PART TWO)?

CF 048: Do Disc Herniations On An MRI Worsen When Sitting Or Standing (Part TWO)?

Today we’re going to continue our talk from last week on whether or not a disc herniations change as you sit up, stand up, or move around. We went over some pretty good research last week. This week, it’s time for the cherry on the top. 

But first, here’s that bumper music

Integrating Chiropractors

 

OK, we are back. Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.  

You have scampered into Episode #48. I use scamper this week because, as my son was playing with his aunt and uncle’s dog named Rowdy down in Dallas last weekend, that was the way he described when the dog would take off after the tennis ball every time. Scamper. Great word that I plan on using more from here on out where appropriate. 

Diplomate of Chiropractic Orthopedists

The DACO this weekend down in Dallas. The class was with James Lehman. Dr. Lehman, in case you do not know, is with the University of Bridgeport Connecticut. His official title from their website is Associate Professor of Clinical Sciences, Health Sciences, College of Chiropractic. 

Dr. Lehman is also one of the main drivers of this DACO program. Through Univ. of Bridgeport Connecticut, he has teamed up with CDI out of Australia and their courses in neuromusculoskeletal online education. It is VERY well done. Very professional and very worthwhile. You can find that at https://cdi.edu.au

We talked a lot about some stuff that I want you to hear straight from him so we’ll do an interview with him very soon but the gist of it all is this: get certified in something other than simply having your doctor of chiropractic degree. 

FQHC

I’ve heard a couple of opinions. I’ve heard the Diplomate programs are worthless now and that people are moving away from them. But, I think that’s coming from people that don’t want to take the time or put in the effort. The real story is most likely that our system, for good or bad, is moving away from private practice and TOWARD integrating through the group offices and through the Federally Qualified Health Centers. 

There are chiropractors being reimbursed in the system up to $300 for a Medicaid visit and around $150 on the lower end. 

I have to thank Dr. Craig Benton once again for bringing this to my attention. Did you guys know that, given the right positioning, you could make that much per appointment from freaking Medicaid?

Here’s the deal though: you have to be a specialist. A Diplomate. So, is it really useless? I say it most certainly is not. 

Whiplash Section

Now the course, the course this weekend was on whiplash. I’ve been through Art Croft’s 4 part Advanced Certification on Whiplash Biomechanics and Traumatology so I can say with a lot of honesty that a good portion of the course was a refresher for me. 

But, I absolutely learned a solid amount of new stuff as well. Such as Axillary compression. Axillary compression was not a condition of the shoulder that was on my radar screen prior to this course. 

That is one simple little example but there was a gob of nuggets for the nugget pouch and as always, I really walked away feeling that I will be better at my job on Monday. But it’s always that way. Even after just a 2-hour online course. It’s phenomenal.

Personal

Continuing the ongoing saga of hiring a front desk staff member in the year 2018. Here’s what all I’m going to say about it. Looks like my wife has found a new full-time job. Lol. Get the picture?

It looks like I may have a cool speaking gig coming up in February. Nothing solid but, if I were to come to your state convention or to some sort of event you are at, what topic along the vein of Chiropractic Forward’s typical content would you like to learn more about? 

If you are a regular listener and familiar with what we have been doing here this last year, I’d really appreciate it if you would take just a minute and email me at dr.williams@chiropracticforward.com and give me a little guidance. What topics would you want to see in a presentation?

I’m glad you’re here and hopefully, I didn’t ramble too much before getting to the meat and taters. Here we go with some vital information that we think can build confidence and improve your practice which will improve your life overall.

On To The Research

Picking up from last week, we want to start in on the changes disc herniations undergo when axial pressure is placed on them. In other words, what happens to disc herniations from the time the MRI is taken laying down to the point where the person sits up. 

I have to preface it all by saying go listen to last week’s episode which is #47, please. It tells you how it is very common in the medical field amongst even radiologists to assume or guess that there is no change in the disc or in the herniation when axial pressure is applied. Research tells us differently. 

This week we want to start with a paper called “Evaluation of intervertebral disc herniation and hypermobile intersegmental instability in symptomatic adult patients undergoing recumbent and upright MRI of the cervical or lumbosacral spines.” It was done by Ferreiro Perez, et. al[1]. and published in the European Journal of Radiology

How they did it

  • 89 Patients studied
  • 45 of them had their low back imaged
  • 44 patients had their necks imaged
  • The images were done in both the lying down position as well as the sitting.

What They Found

  • The overall combined recumbent (lying down) miss rate in cases of pathology was 15%
  • Overall combined recumbent underestimation rate in cases of pathology was 62%
  • Overall combined upright-seated underestimation in cases of pathology was 16%.

Wrap It Up

Upright-seated MRIs were seen to be superior to recumbent MRIs in 52 of the patients studied for conditions of posterior disc herniations and spondylolisthesis. Recumbent MRIs were only superior in 12% of the patients.

Next, this one is titled, “Effect of intervertebral disk degeneration on spinal stenosis during magnetic resonance imaging with axial loading” by Ahn et al[2].

Why They Did It

The authors in this paper were wanting to determine if disc degeneration will increase the severity of spinal stenosis when the spine is loaded with axial pressure. 

How They Did It

They had 51 patients with symptoms of neurogenic intermittent claudication and/or sciatica that had their MRIs loaded as well as non-loaded. 

The foramen involved were all measured for changes in sizes.

Wrap It Up

Here’s what they found, “More accurate diagnosis of stenosis can be achieved using MR imaging with axial loading, especially if grade 2-4 disc degeneration is present.”

AKA:” Seated or loaded MRIs are superior for assessing lumbar stenosis. 

Next, this one is by Willen[3] and it’s called “Dynamic effects on the lumbar spinal canal: axially loaded CT-myelography and MRI in patients with sciatica and/or neurogenic claudication.” It appeared in Spine Journal in 1997. 

They had 50 people with CTs, 34 were imaged with MRI, the imaging was performed laying down as well as axially loaded. 

They closed it up by saying, “Axial loading of the lumbar spine in computed tomographic scanning and magnetic resonance imaging is recommended in patients with sciatica or neurogenic claudication when the dural sac cross-sectional area at any disc location is below 130 mm2 in conventional psoas-relaxed position and when there is a suspected narrowing of the dural sac or the nerve roots, especially in the ventrolateral part of the spinal canal in psoas-relaxed position”

Next Paper

This one is by Kanno, et. al[4]. called “Axial loading during magnetic resonance imaging in patients with lumbar spinal canal stenosis: does it reproduce the positional change of the dural sac detected by upright myelography?” It appeared in Spine Journal in 2012. 

44 patients, with imaging in the supine position and then with axial load added. The dural sack was measured 

“The size of the sack was significantly reduced in the axially loaded imaging and the axial loaded MRI detected severe constriction with a higher sensitivity (96.4%) and specificity (98%) than the conventional MRI.”

Next paper

This one is by Danielson et. al. from 2001 called, “Axially loaded magnetic resonance image of the lumbar spine in asymptomatic individuals.” This paper appeared in Spine Journal in 2001 as well. 

MRIs were performed lying down as well as with axial load on the participants. The axial loading was performed lying down, face up with a compression device built for this study specifically. The diameter of the dural sack was measured to check for the differences. 

The authors said, “A significant decrease in dural cross-sectional area from psoas-relaxed position to axial compression in extension was found in 24 individuals (56%), most frequently at L4-L5, and increasingly with age.”

Pretty cool stuff right there people. 

I want you to go forward this week knowing what you get from listening to this podcast every week. You get things you can absolutely use and implement immediately. Some of you may gain confidence now that you know some research that you maybe didn’t know previously. Some of you may now be able to tell a patient that has a 5mm central posterior herniation that 5mm isn’t telling us the whole story. 

It’s telling us part of the puzzle but that discs respond to positioning and various stresses we put on the discs through our activities. 

Use it or lose it

This can give you some extra guidance in your recommendations when you consider disc herniations change and get worse, stenosis gets worse when the patient sits up or bends forward. 

If you aren’t up on directional preference exercises, McKenzie, and CRISP protocols, it’s time to get there folks. It’s time to get there. The anatomy absolutely responds to movement and positioning. 

Integrating Chiropractors

I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is a mechanical pain and responds better to mechanical treatment instead of chemical treatments.

The literature is clear: research and experience show that, in 80%-90% of headaches, neck, and back pain, patients get good to excellent results when compared to usual medical care and it’s safe, less expensive, and decreases chances of surgery and disability.

It’s done conservatively and non-surgically with little time requirement or hassle for the patient. If done preventatively going forward, we can likely keep it that way while raising overall health! At the end of the day, patients have the right to the best treatment that does the least harm and THAT’S Chiropractic, folks.

Contact Us!

I want to ask you to go to chiropracticforward.com and sign up for our newsletter. We love to stay in touch and want to offer you discount specials when we get our educational products up and rolling. 

Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show or tell us your suggestions for future episodes. Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on iTunes and other podcast services.

Y’all know how this works by now so help if you don’t mind taking a few seconds to do so.

Being the #1 Chiropractic podcast in the world would be pretty darn cool. 

We can’t wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward. 

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About the author:

Dr. Jeff Williams – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger

CF 047: Do Disc Herniations On An MRI Worsen When Sitting Or Standing (PART ONE)?

CF 035: Chiropractic & Disc Herniations

Bibliography

1. Ferreiro P, e.a., Evaluation of intervertebral disc herniation and hypermobile intersegmental instability in symptomatic adult patients undergoing recumbent and upright MRI of the cervical or lumbosacral spines. Eur J Radiol, 2007. 62(3): p. 444-8.

2. Ahn TJ, e.a., Effect of intervertebral disk degeneration on spinal stenosis during magnetic resonance imaging with axial loading. Neurol Med Chir (Tokyo), 2009. 49(6): p. 242-7.

3. Willen J, e.a., Dynamic effects on the lumbar spinal canal: axially loaded CT-myelography and MRI in patients with sciatica and/or neurogenic claudication. Spine (Phila Pa 1976), 1997. 22(24): p. 2968-76.

4. Kanno H, e.a., Axial loading during magnetic resonance imaging in patients with lumbar spinal canal stenosis: does it reproduce the positional change of the dural sac detected by upright myelography? Spine (Phila Pa 1976), 2012. 37(16): p. E985-92.

CF 035: Chiropractic & Disc Herniations

Chiropractic and Disc HerniationsIntegrating Chiropractors

Today we’re going to kick around information on disc herniations, disc bulging, and radiculopathy as a result. Is there anything we can do about it? Well, I’m a chiropractic advocate and research backs us on it so I’ll say, “Hell yes.” Come along with us, won’t you?

 

First, I feel some sweet sweet bumper music moving in….

 

OK, we are back. Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.

 

Now that I have you here, I want to ask you to go to chiropracticforward.comand sign up for our newsletter. It makes it easier to let you know when the newest episode goes live and it makes me feel good. Don’t you like to make people feel good? Of course, you do so….do it do it.

 

Also, our group on Facebook. It’s called the Chiropractic Forward Group and I think that’s as appropriate of a name as I could come up with. Lol. Just in case you didn’t know, there’s the page on Facebook. That’s for getting the word out and telling people about the podcast. Then there’s the private group. That’s for interacting with each other, learning from each other, posting new papers when they come out, and maybe organizing into a powerful group someday, somewhere down the line. That sort of deal must grow organically. It can’t be forced so we won’t try to do that.

 

We’ll just let you all know about its existence and hope to start seeing you over there. Let’s start a conversation outside of the podcast!

 

We are honored to have you listening. Now, here we go with some vital information that we think can build confidence and improve your practice which will improve your life overall.

 

You have back-flipped head-on into Episode #35

 

Before we talk about all of the disc herniations stuff, I want to tell you all about my weekend. I spent Saturday and part of Sunday morning with my butt firmly planted in a chair in a hotel conference room listening to Dr. Brandon Steele talk about shoulder issues. He was the teacher as his company ChiroUp was a sponsor of the event but he was there teaching as part of the DACO program which is run by the University of Bridgeport.

 

What the heck is DACO right? Well, what used to be called DABCO is now called a DACO which stands for Diplomate of American Chiropractic Orthopedists. I have mentioned before where I sat through the first 10 DACO hours back in June. That was over the low back. These ten were over the shoulder. Topics covered included Scapular Dyskinesis. I knew nothing of this mess and, I already identified and started working with one of these patients the day after I got home. We also covered shoulder impingement, rotator cuff issues, thoracic outlet syndrome, and adhesive capsulitis to name a few.

 

Good stuff all around and, even if I don’t go all the way through the DACO program, I get better and better every time I take a class. And not just better. I get exponentially better.

 

In talking with Dr. Steele this weekend, he agreed to come on to the podcast as a guest. We’ll get that all lined up. I have a ton of questions for him. Some questions about the DACO program, some about ChiroUp (it’s really a game-changer and you better use my name if you sign on!!!), and I want to ask him about practice standardization and some things along those lines. It should be a fun conversation so make sure you keep your eyes out for it in the near future.

 

I encourage you…..a lot of what we talk about here is integrating with the medical community and really stepping up. Part of that is taking the steps to get educated at higher and higher levels. The DACO is in line with that. I have zero association with the people running it other than the fact that I love the product they have created and use it regularly. There is nothing in it as far as reimbursement goes. I just believe in what they’re doing. I encourage you all to look into this DACO program. If you don’t know where to start, just email me at dr.williams@chiropracticforward.com and I’ll get you pointed in the right direction.

 

Now, on to disc herniations

 

Have you ever been told we can’t do anything for discs? Have you been told to not adjust if they have a low back disc issue? Do you know how to recognize a disc issue? What’s the best way to treat it? So many questions!!

Here’s the deal for me today. I’m no guru. I’m going to throw research on you but in the end, a lot of it is just experience. So, don’t take my word as the gold standard. I didn’t expect you to anyway but, I wanted to be sure. Lol.

 

Let’s look first at recognizing disc herniations. There are some simple questions that can get you moving in the right direction on this:

  • Do you have static position irritation meaning, do you have to move around in your chair often to get comfortable?
  • Do you have pain going from seated to standing?
  • Is there a positive Milgram’s
  • How about a positive Modified Slump test?
  • Valsalva’s is part of that but some do it separately.
  • Same with SLR. I was taught that pain on SLR in the first 30 degrees, when the nerve is first tensioned, was indicative of a disc issue but the DACO folks say it’s between 30 and 70 degrees.
  • Worst position is seated
  • Best is lying down
  • Deep buttock pain
  • Pain in the first 1/3 of trunk flexion or trunk extension that cannot be alleviated by bracing or tightening a belt around the waist.
  • Radiating pain into the leg
  • As a general rule of thumb, the further pain radiates beyond the knee, the more likely it is caused by a disc.
  • Sometime you’ll encounter diminished reflexes or differences in sensory or motor information from side to side.

 

When should we get an MRI for disc herniations and other issues? Red flags like the history of cancer, fever, chills, recent unexplained weight loss, immunosuppression, and corticosteroid use give you a reason. Symptoms lasting longer than 6 weeks or symptoms showing progressive neurological deficit also give you a reason to get that MRI.

 

What can we do about it?

Again, that’s going to depend on who you ask. Are we going by The Lancet? Why not go by some chiropractic gurus? We can go by the medical fields recommendation or by physical therapists techniques? I say yes, yes, and yes.

 

I had a neurosurgeon buddy of mine tell me, whatever the hell works without doing surgery…..do that. I agree. That’s why we are friends coincidentally.

 

So, knowing all of that, I’m going to tell you what has been effective for me in my practice. The first thing is something that the insurance companies call experimental and investigational. I think they’re full of it. They don’t seem to be in any hurry to pick up new services to have to pay for, do they? But you know what? I’d rather them NOT cover it so we can actually get paid what it is worth.

 

What I’m talking about here is decompression for disc herniations. This was a game-changer for me in my practice. I have three short stories for you here. They all have to do with guys I tried to send to the surgeon. I’m not going into why we ordered the MRIs or the exam findings. It would take too long for this format so we’re going to jump to the chase in each of their cases.

 

  1. The first is a dude was in town visiting for work and was only going to be here for a few months before returning home. The MRI showed us that his disc herniations was 14 mm caudal migration. I sent him straight to the surgeon. The surgeon set him up for surgery in 6 weeks. The guy was on board with having surgery but couldn’t wait 6 weeks for some kind of relief. Any kind of relief. He begged me to do decompression. I figured that we could go light. In the end, it’s traction and he had no contraindications to decompression so we did it. This guy was back to working and dancing around in the office in about a week and a half y’all. If you want to say it’s placebo, that’s OK, we’re just going to disagree. If you want to say people just like to be touched and I could have pulled on his big toe and it may have had the same effect, I’m going to tell you to jump in a lake.
  2. The second was a guy that was a truck driver. He was in his 70’s and had had heart surgeries and was on blood thinners. He was a physical wreck honestly. When he came in, he was in a wheelchair and unable to work or function. I got an MRI and his herniation was posterior with 18 mm of caudal migration. That used to be a ticket to the surgeon so off he went. Well, his cardiologist would not take him off of the blood thinners so surgery was out of the question. He came back to me just like the other case we discussed. He had no other options and would I please do decompression on him to try to get him some relief. It had been going for quite some time. OK, sure. I’m a nice guy but I told him, I doubt it’s going to help something like you have going on. Yeah, yeah, yeah, hook me up, please. So we did. Guess what? He came in just a time or two later on a walker instead of a wheelchair. Then, a week or so later, he came in without a walker. Then a month or two down the road, he got a new job and was out there telling everyone that would listen about what we were able to do for him. You can take a long walk off a short pier if you’re going to suggest that was anything other than significant effects due to direct intervention.
  3. Last and worst of all disc herniations I’ve ever seen. He is actually a good friend of mine. He came in with numbness and weakness all the way into his foot. Limping, the whole deal. He worked in a warehouse and would have to be forklifted to the second floor where his office is because he couldn’t get there any other way. He thinks it was due to a motorcycle wreck several years ago. Whatever the cause, it was pretty crazy. His MRI showed disc herniations of 23mm of caudal migration. Almost all the way down to the next disc below. I had never seen that before and haven’t seen it since. I, of course, told him he needed to go to the surgeon muy pronto. He agreed but his wife, bless her heart, did not. And thank goodness. She was adamant about him not going to the surgeon. She strongly urged him to not go until he at least gave decompression a try. I told him about the first two cases we just talked about but that he was really in a different ballpark than those guys and I really didn’t know how I could help at all. They understood but decided to give it a go anyway. And thank God they did. Sometimes our patients teach us instead of us teaching them, don’t they? It took a couple of months but he started to turn around and never had that surgery. I just checked with him the other day, 2 years later, and he’s doing great. He said he has a little numbness in the outside of his foot but nothing bad and nothing he can’t handle. All’s well and guess who the hero is? Well….his wife. She’s the hero. Lol. I’m still the buddy and buddies can’t be heroes.

 

These are the worst of the worst disc herniations but what about all of the others that were more minor disc herniations? Think of all of the successes we have had with disc herniations over the years. When I say it’s a game-changer, I damn well mean it and, once again, I care not what insurance companies have to say about it.

 

Let’s look at some papers on it.

 

This one is called “Simple pelvic traction gives inconsistent relief to herniated lumbar disc sufferers” by Edward Eyerman, MD. It was published in the Journal of Neuroimaging in June of 1998[1].

 

Why They Did It

The aim was to do before and after MRIs to correlate improvement in the clinic with MRI evidence in terms of disc herniations repair in the annulus, nucleus, facet joint, or in the foramen as a result of decompression treatment.

 

Eyerman was testing the effectiveness of decompression in a sample of 12 men and 8 women aged 26-74. No, not a big sample.

His MRI finding was as follows:

Disc Herniations: 10 of 14 improved significantly, some globally, some at least locally at the site of the nerve root compression.

Measured improvement in local or general disc herniation size varied in the range of 0% in 2 patients, 20% in 4 patients, 30% to 50% in 4 patients and a remarkable 90 % in 2 patients that did all 40 sessions.

As far as clinical outcomes of the subjects go, he noted that all but 3 patients had very significant pain relief, complete relief of weakness when present, and of immobility and of all numbness except for in 1 patient with herniation and 2 with foraminal stenosis without herniation.

Summed up, he said “Serial MRI imaging of 20 patients treated with the decompression table shows in our study up to 90% reduction of subligamentous nucleus herniation in 10 of 14. Some rehydration occurs detected by T2 and proton density signal increase. Torn annulus repair is seen in all. Transligamentous ruptures show lesser repair. Facet arthrosis can be shown to improve chiefly by pain relief.

Then we have this one by Thomas Gionis, MD published in the Orthopedic Technology Review in December of 2003[2].

They concluded, “Results showed that 86% of the 219 patients who completed the therapy reported immediate resolution of symptoms, while 84% remained pain-free 90 days post-treatment. Physical examination findings showed improvement in 92% of the 219 patients, and remained intact in 89% of these patients 90 days after treatment.”

When is surgery necessary? Well, that’s going to depend on who you ask but a good general rule I follow is that cauda equina syndrome is a quick trip to a surgeon. I personally don’t like foot drop and am likely to send to a surgical consult. I think any progressive worsening of neuro symptoms is cause to pause and reconsider whatever you’re doing. If what you’re doing ain’t fixing it, change directions.

 

But there is this paper I found interesting. It’s from 2010 and called “Spontaneous Regression for a Large Lumbar Disc Extrusion[3]” by Ryu Sung-Joo, MD and was published online for the Journal of Korean Neurosurgical Society. I have no idea what the quality of this journal is or what the impact is but it’s interesting and I’ve seen studies before about spontaneous resolution of disc herniations.

 

The authors say, “Although the spontaneous disappearance or decrease in the size of a herniated disc is well known, that of a large extruded disc has rarely been reported. This paper reports a case of a spontaneous regression of a large lumbar disc extrusion. The disc regressed spontaneously with clinical improvement and was documented on a follow-up MRI study 6 months later.”

 

The case report was on a 53-year-old female after 6 months of low back pain and left lateral leg pain with numbness. Y’all go to the show notes and get the reference to this paper. The MRI images are great.

 

They mention, “After conservative treatment, her clinical symptoms subsided gradually but the numbness of her left lateral leg still remained. A second MRI study performed approximately 6 months after the prior examination reveals almost complete disappearance of the extruded fragment that had been located posterolateral to the L5 vertebral body and no evidence of compression or displacement of the dural sac or nerve root.” Wowza.

 

They go on to explain, “Our patient is an example of the resolution of a large protruded disc without surgery. This phenomenon may be due in part to the fact that larger fragments have a higher water content8) and may regress through dehydration/shrinkage, retraction, and inflammation-mediated resorption.” Meaning….her body ate it and it went bye bye.

 

They finished up the paper by saying, “Even in patients with large lumbar disc extrusion, non-surgical conservative care can be considered as an option for the treatment when radiculopathy is acceptable and neurological deficit is absent.“

That’s pretty cool. I don’t think surgeons are going to want to hear it but it’s cool. If all they can do is surgery on cauda equina or foot drop, they’re going to have a hard time financially.

 

Alright, moving beyond decompression or spontaneous resorption, what else can we do?

 

Here’s one I got from Dr. Tim Bertlesman. It was authored by G McMorland and called “Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study[4].” This one was published in the Journal of Manipulative Physiology and Therapeutics in 2010 and goes like this. The authors concluded, “Sixty percent of patients with sciatica who had failed other medical management benefited from spinal manipulation to the same degree as if they underwent surgical intervention. Of the 40% left unsatisfied, subsequent surgical intervention confers excellent outcome. Patients with symptomatic LDH failing medical management should consider spinal manipulation followed by surgery if warranted.“

 

Go check it out in the show notes if you want the nuts and bolts and bells and whistles, please.

 

Then there are your directional preferences exercises. If you have not familiarized yourself with directional preferences, please do so yesterday. They are based upon the idea of centralization and peripheralization. McKenzie’s program uses it, the CRISP protocol uses it, Kennedy’s decompression system uses it, and the DACO program teaches it. Do you see a pattern of some sort emerging here?

 

Other things that are helpful are exercise recommendations like McKenzie or Williams exercises depending on the directional preference, core building.

 

These patients also need strong at-home suggestions like:

  • Get an inversion table for the house.
  • Get back to work as soon as possible
  • Don’t lay up in bed hoping it goes away
  • Sleep correctly
  • Work advice like get up and walk every 45 minutes or so
  • Don’t use catastrophic language and make sure they know it’s not a disease and most disc cases resolve

 

I don’t have all of the answers but, I’m guessing none of you do either. In the end, it’s experience, isn’t it? For example, without experience, I wouldn’t have known that it COULD be possible to help three guys with caudal migration of a disc from 14mm all the way up to 23mm. Nothing but experience can show someone that.

 

While we don’t know it all, we DO find means that are effective and help us get the job done and make a difference in our patients’ lives. That’s for sure.

This week, I want you to go forward with the knowledge that, in case you didn’t already know it, you’re powerful. You can take disc herniations that used to be sent straight to surgery and you can treat that complaint with safe, conservative, non-invasive, and non-pharmacologic means. That’s a hell of a deal right there, folks.

 

We’re not done talking about disc herniations, decompression, and all of that fun stuff. There’s too much left in the tank to be done but, in the interest of time, we’ll get to it on another episode.

 

Integrating Chiropractors

 

I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is a mechanical pain and responds better to mechanical treatment instead of chemical treatments.

 

The literature is clear: research and experience show that, in 80%-90% of headaches, neck, and back pain, patients get good to excellent results when compared to usual medical care and it’s safe, less expensive, and decreases chances of surgery and disability. It’s done conservatively and non-surgically with little time requirement or hassle for the patient. If done preventatively going forward, we can likely keep it that way while raising overall health! At the end of the day, patients have the right to the best treatment that does the least harm and THAT’S Chiropractic, folks.

 

Send us an email at dr dot williams at chiropracticforward.comand let us know what you think of our show or tell us your suggestions for future episodes. Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on iTunes and other podcast services. Y’all know how this works by now so help if you don’t mind taking a few seconds to do so.

 

Being the #1 Chiropractic podcast in the world would be pretty darn cool.

 

We can’t wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.

 

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  1. Eyerman E, e.a., MRI Evidence of Nonsurgical, Mechanical Reduction, Rehydration and Repair of the herniated Lumbar Disc.J Neuro Imaging, 1998. 8(2).
  2. Gionis T, Surgical Alternatives: Spinal Decompression.Orthopedic Technology Review, 2003. 6(5).
  3. Ryu Sung-Joo, Spontaneous Regression of a Large Lumbar Disc Extrusion.J Korean Neurosurg Soc., 2010. 48(3): p. 285-287.
  4. McMorland G, Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study. J Manipulative Physiol Ther, 2010. 33(8): p. 576-584.

 

CF 027: WANTED – Safe, Nonpharmacological Means Of Treating Spinal Pain

CF 025: Vets With Low Back Pain. Usual Care + Chiropractic vs. Usual Care Alone

CF 026: Chiropractic Better Than Physical Therapy and Usual Medical Care For Musculoskeletal Issues

https://www.chiropracticforward.com/cf-019-non-opioid-more-effective-while-chiropractic-maintenance-may-be-the-most-effective/ Adolphus Washington Womens Jersey