evidence based chiropractor

The Case Of The Disappearing Disc & Vitamin D And Back Pain

CF 204: The Case Of The Disappearing Disc & Vitamin D And Back Pain Today we’re going to talk about The Case Of The Disappearing Disc & Vitamin D And Back Pain. But first, here’s that sweet sweet bumper music  

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  OK, we are back and you have found the Chiropractic Forward Podcast where we are making evidence-based chiropractic fun, profitable, and accessible while we make you and your patients better all the way around.  We’re the fun kind of research. Not the stuffy, high-brow kind of research. We’re research talk over a couple of beers. I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.   If you haven’t yet I have a few things you should do. 
  • Go to Amazon and check our my book called The Remarkable Truth About Chiropractic: A Unique Journey Into The Research. It’s a great resource for patient education and for YOU. It saves you time in putting talks together or just staying current on research. It’s categorized into sections and written in a way that is easy to understand for you and patients. Just search for it on Amazon. That’s the Remarkable Truth About Chiropractic by Jeff Williams. 
  • Then go Like our Facebook page, 
  • Join our private Facebook group, and then 
  • Review our podcast on whatever platform you’re listening to 
  • We also have an evidence-based brochure and poster store at chiropracticforward.com
You have found yourself smack dab in the middle of Episode #204 Now if you missed last week’s episode, we talked about Reduced Access To Chiropractic & The Ideal Diet. Make sure you don’t miss that info. Keep up with the class.  On the personal end of things….. The clinic numbers have cooled a bit. Still busy but more manageable. Since things have cooled a bit on that end of things, let’s switch focus to side gigs. I see questions about side gigs periodically in the forward-thinking chiropractic alliance group.  We chiros are doing all kinds of different things from being real estate agents and hunting guides to selling stuff on eBay and Etsy.  Here’s some of what I do and why. First, I’m very happy with my income from chiropractic but, as with anything, I don’t like my eggs being in one basket, and let’s face it, we’re in a business where if something were to happen to us, it’s game over. If we are not at work and able to perform, then we can kiss all of those years of hard work goodbye.  In our profession, we are literally on a knife’s edge and it could go good or bad in a heartbeat. Literally.  So, I like other options. Do you know what else I like? Success, freedom, achievement, and wealth. All of that gives you a better chance at happiness. People say you can’t buy happiness. Well, that’s what people with no money tell themselves so they feel better. It’s like someone saying it’s not all about looks. Well….that’s true but looks sure as hell to help land a suitable partner. Wouldn’t you agree? In the say way, wealth helps you have more security and security helps you have a better chance at happiness.  So, for all of those reasons, I do a lot of stuff. I’m an artist as many of you might know. I just finished up a series of several Charlie Chaplin watercolor paintings and a sculpture of a horse and jockey in the middle of a race. They’re flying down the track!  You can see all that stuff on Facebook at Jeff Williams Art.  I have a band and have been a traveling musician in my past. It seems like another life at this point. You can check that out on Facebook at Flying Elbows Perspective. Can you imagine another band would have the band name Flying Elbows? Well they do. It’s a fiddle band from Massachusetts. That’s not us. We’re the ones from Amarillo, TX I created evidence-based posters and brochures for you guys over at chiropracticforward.com Then I create live edge furniture. But I like to be honest, nobody has ever bought any of the pieces but that’s not because they’re not good. It’s because they’re expensive! You can see that on Facebook at Amarillo Furniture – Live Edge and Customs. It’s fun. My office and home are full of these original pieces.  The idea is to be able to retire and still be comfortable. Still have income in retirement. How are you going to accomplish that and what is your exit number? What do you have to have at the end that allows y But here’s where things have freaking gone nuts. It’s in the land of voice-over. Holy cow, y’all. Now, my results are not normal as I’m coming to find out. But, just in the last 10 months, I’ve made about $50,000 I never planned on having in my life. I’ve done over 400 commercials in the last 10 months in about 22% of the countries throughout the world and landed talent agencies that represent California, Texas, Indiana, Ohio, Kentucky, and New Jersey/New York.  How at the age of 49 this voice over thing has just come into my life is a twisted tale but briefly, the drummer for my very first band way back in college in Natchitoches, LA became a Lieutenant Colonel in the Army and we stayed in touch. Well, he became the voice of Hand Unit in the video game called Five Nights At Freddie’s. He got to do a bunch of other really cool stuff too but when the pandemic came along, it got me thinking that I need to have options.  That’s when I hit him up about voice over. A year and a half later, here we are it’s crazy.  Now, what do we do with the extra money? Well, we put it to work. That’s what we do. I’ve also spent the last 6-12 months educating myself on real estate investing. Long-term rentals, multi-plexes, short-term rentals, vacation rentals, flipping, wholesaling, and things like that. So, you may have guessed it, voice over will be funding down payments on investment properties.  What a deal. Right?!? The problem in this market if finding a good deal but we’re on some good ones and are hoping to land them in the next week or two.  Here is a little real estate tip for you. Two tips actually. First, money has always been in real estate and it always will be. Through ups and downs, the money is still there. Secondly, losses in your real estate business can offset gains in your chiropractic business come tax time. That’s if you can qualify as a real estate expert. Well…..they made it really hard to qualify so basically, if you have a job like we all have, you can’t. Your loophole, however, is this; short-term rentals don’t count.  Short-term rentals can offset tax gains without you having to qualify as a real estate expert. So, if you’re a chiropractor, short-term rentals probably make a lot of sense so that real estate losses and depreciation can offset the money you make in your chiropractic business so that you can reduce or eliminate taxes.  As a disclaimer, I am not a lawyer nor a CPA so make sure you run that by them.  OK, just some tips from you Ol’ Uncle Jeffro.  Now to the good stuff.  Item #1 This first one is called “Relationship between Vitamin D and Nonspecific Low Back Pain May Be Mediated by Inflammatory Markers”’ by Xu et al   (Xu HW 2021) and published in Pain Physician in November of 2021 and that’s a steamy as a sizzling sirloin.  I believe I got this one from my esteemed colleague, Dr. David Graber who always always posts great research findings. He’s a fountain of knowledge nuggets so go search him up on Facebook and follow his page. One of the smartest guys you’ll find out there.  Why They Did It To explore the mediating effects of inflammatory markers on the relationship between vitamin D levels and pain outcomes. How They Did It
  • This study was done at the Department of Spinal Surgery of a hospital affiliated to a medical university.
  • It was a cross-sectional study
  • They selected patients with non-specific acute low back pain and non-specific chronic low back pain, 
  • The study included 60 people without Ns-LBP as controls, 
  • The study was done from January 2018 to January 2019. 
  • Serum 25(OH)D and inflammatory marker levels were examined.
  • Regression and causal mediation analysis were used to evaluate the mediating effects of inflammatory markers on the association between vitamin D and pain.
What They Found
  • After adjustment for clinical factors, vitamin D deficiency was associated with Ns-LBP
  • however, when the interleukin 6 (IL-6) level was added to the multivariable models, the association was no longer significant in Ns-CLBP patients
Wrap It Up Patients with Ns-LBP had lower vitamin D and higher inflammatory marker levels. This association between hypovitaminosis D and Ns-CLBP may be mediated by IL-6.  Very interesting findings. They do say there are some limitations to the study. They say a retrospective study may include inevitable bias. More sensitive biomarkers were not investigated in this study. Pain intensity evaluation using the visual analog scale is inevitably subjective. Item #2 Alright, item 2 is called “Clinical and Radiological Follow-Up Results of Patients with Sequestered Lumbar Disc Herniation: A Prospective Cohort Study” by Sucuoglu et. al. (Sucuoğlu H 2021) and published in Medical Principles and Practice in February of 2021 and that’s got my glasses fogged up! Why They Did It The authors wanted to assess radiological changes and clinical outcomes of patients with sequestered lumbar disc herniation (LDH) and evaluate the relationship between them. How They Did It
  • Patients diagnosed with sequestered LDH were followed up in 2 groups: operated (within the 1st month after diagnosis) and nonoperated. 
  • Visual analog scale (VAS) and Oswestry Disability Index (ODI) scores at baseline and 1st , 3rd, and 6th-month visits were used. 
  • Radiological evaluation was performed by measuring the sequestered herniation level and herniation volume using 2 MRIs spaced out between 1st and 4th months
  • After the second MRI, patients in the nonoperated group were divided into 3 groups: non-regression, partial regression, and complete resolution
What They Found
  • Signifi
  • cant improvements were observed in VAS and Oswestry scores at month 2 and month 3 in all groups and at month 4 in partial regression and complete resolution groups. 
  • VAS and Oswestry score improvements at months 2 and 3 were significantly higher in the operated group than in other groups. 
  • At month 4, there were no significant differences in VAS and ODI scores between the operated group and partial regression and complete resolution groups.
Wrap It Up
  • Spontaneous regression was observed in the 6th month post-MRI in most of the nonoperated sequestered herniation patients with conservative treatment.
  • Improvements in pain and disability scores were higher among the operated patients at the early stage, whereas they were not significantly different compared to patients with spontaneous regression at the 6th month.
If you remember, I did a whole episode on disappearing discs. Here’s the deal. You have to know this. The more a disc herniates, protrudes, or extrudes into the spinal canal and migrates either cephalad or caudal, the more likely the body is to recognize it as foreign and gobble it up like the cookie monster.  What I thought was instant surgery several years ago, I now know may be a waiting game that ends up being non-surgical.  Here’s the thing that episode taught me though; the disc material can be dissolved but the symptoms remain. At least for a while while the nerve tissue in the region undergoes the healing process.  Alright, that’s it. Keep on keepin’ on. Keep changing our profession from your corner of the world. The world needs evidence-based, patient-centered practitioners driving the bus. The profession needs us in the ACA and involved in the leadership of state associations. So quit griping about the profession if you’re doing nothing to make it better. Get active, get involved, and make it happen. Let’s get to the message. Same as it is every week.  Store Remember the evidence-informed brochures and posters at chiropracticforward.com.   

Purchase Dr. Williams’s book, a perfect educational tool and chiropractic research reference for the daily practitioner, from the Amazon store TODAY!

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
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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 Sucuoğlu H, B. A. (2021). “Clinical and Radiological Follow-Up Results of Patients with Sequestered Lumbar Disc Herniation: A Prospective Cohort Study.” Med Princ Pract 30(3): 244-252.   Xu HW, Z. S., Yi YY, Chen H, Hu T, Wang SJ, Wu DS, (2021). “Relationship between Vitamin D and Nonspecific Low Back Pain May Be Mediated by Inflammatory Markers.” Pain Physician 24(7): E1015-E1023.      

Car Crashes and Research To Go Along With It (Part Two)

CF 176: Car Crashes and Research To Go Along With It (Part Two) Today we’re going to continue to talk about car wreck research. It’s good stuff and useful for all clinics and docs that deal with personal injury patients.  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 #176 Now if you missed last week’s episode, we talked about Car crashes and awesome research around that topic. Part one I guess. Today’s episode is pretty much part two. So, make sure you don’t miss that info. Keep up with the class.  On the personal end of things….. On the personal side of things, we are still going down the path towards having the medical entity completed. I made a hire that I feel confident in. The nurse practitioner was referred to me by another nurse practitioner here in town who was his preceptor or teacher for his clinical hours when he was going through school. She told me that he is super smart, excellent with patients, eager to learn, and his wife is an amazing cook. So I was sold. And just taking the time to get to know him, I’m even more confident that I have made a good decision going forward. The majority of the work on this is going to be in the first 3 to 6 months I think. We have to get systems in place, I have to teach the nurse practitioner the exam I do. How do you teach somebody how to do the exam that an ortho fellowship practitioner does? Well, we shall find out.  I’ve already loaned him one of my dr. Stuart McGill books to get started on. I’ve been sharing with him a lot of the information that I learned in the Neuromusculoskeletal program, I’ve talked to him about McKenzie protocols and migrating the disc, and started him on the path of different ways to think of chronic pain. Including the up-regulated and sensitized central nervous system as well as the biopsychosocial aspect of chronic pain. Yellow flags, words matter, limiting MRIs, and all of the associated Tom Foolery.   He was unfamiliar with quite a bit of what I have been teaching him and showing him. But very receptive and very interested in learning about that side of pain and newer ways of thinking about it and approaching it. I think we’re going to be a great team.  Outside of that part of my life, I’ve started with the book launch. Not really the launch itself as much as getting the book ready for launch and putting together a launch team. What does a launch tram do exactly? Well, let me tell you. Basically, I’m going to be uploading it to Amazon once it’s formatted for it and everything is in place. Then, it’ll be free for the first 3 days. That’s when everyone on my launch team will go download it. Then, leave a review for it…..because my launch team is cool and they know that’s part of the launch process.  The free downloads and the Amazon book reviews give the book a little Amazon juice which will propel it up the charts a bit. That way, when the initial 3 days are over, and I can start charging money for it, the Amazon Juice has it set up for success and sales.  So, that’s the plan and guess what?? I’d love it if you regular listeners would like to be on my launch team. If so, just send me an email to [email protected] and make sure you tell me you’re on the launch team. It’s that easy. Or, send me a message through our Facebook group or the Facebook page or through smoke signal.  Whatever means you can get me a message that you want to help us, that’ll work for me.  It would be rude of me to not thank a couple of folks. I need to thank Dr. Chris Howson and Dr. Steven Roffers for helping me with the editing process. Dr. Howson is the inventor of the Drop Release tool, he’s smarter than hell, and he’s a good person on top of all of that. Go check out the Drop Release tool and show Dr. Howson some love won’t you? Dr. Roffers is the group admin of the Facebook group called Chiropractic Research Alliance with over 8,000 members, he’s a certified medical editor and serves on the editorial boards of 14 journals. Dr. Roffers offered to help me edit the draft as well.  So, these two pros need to be thanked and properly recognized for their efforts and their generosity. I appreciate you two and just appreciate you.  I honestly thought I’d ask for launch team members and there’d be crickets. In the first post I made on my Facebook properties, I’ve now got about 25 super awesome people that want to help support and promote the project. And in the process, they’re supporting and promoting evidence-based, patient-centered healthcare.  It’s a win-win and I thank you all. More to come as I get further down the road.  Now, on with the research.  CHIROUP ADVERTISEMENT As I mentioned last week, this podcast episode was inspired by a recent episode of the Chiropractic Science podcast hosted by Dean Smith. It was episode number 55.  His guest was Dr. Michael Freeman who I talked about in last week’s episode. These papers are papers they talked about on that episode so, if you want it from the horse’s mouth, go over to Chiropractic Science and find the recent episode with Dr. Michael Freeman and hit play. Then come back here and get my take on it.  Now let me pause just a second and say that if you haven’t jumped into personal injury, don’t. Unless you plan on getting the education it takes to do a good job. Take courses. Make yourself the expert. Know your worth. It pays well but the stakes are high for your patients. You have to deal with attorneys. You might have to testify under oath in court. Do you REALLY want to do that if you’re education and experience are not up to snuff? When I jumped in back in 2007, I had a basic Chiro education but I was not specialized in car wrecks or whiplash. I could have been better. So I made myself better. I recognized my shortfalls and I filled the gaps. I got the Advanced Certification in whiplash biomechanics and Traumatology through the SPINE Institute out in San Diego, CA. I got the certification from the Personal Injury Institute through Matthew DeGaetano who was also a Croft Commando.  I have attended CE hours on PI specifically. I ended up compiling all of the experience and education into a macro for ChiroTouch. If you want to check that out, go to personalinjurymacro.com but you’re not going to want to buy it unless you’re using ChiroTouch. It’s like gold though if you have ChiroTouch.  It’s got all of the Croft stuff in there, the research citations, crash descriptions, risk assessments, the whole thing. Plus all of my customization after I went through the Fellowship for the Neuromusculoskeletal program. IT’s gold, folks.  Anyway, my point was that you do your reputation and you do your patients a disservice if you are in the PI arena but you don’t know what the hell you’re doing. Plain and simple. It’s lucrative but dammit, get educated or get out. And understand that you’re not going to get 100% on every case.  To demonstrate my point, as I said, I’m a specialist now with the Fellowship, I have the cert in whiplash biomechanics and Traumatology, and I’ve been recognized as an expert in whiplash at the District Court level. Because of my macros I created, I can make narrative reports that nobody I’ve met can beat.  And YET…..I still don’t get 100% of my bills. Don’t think you’re going to get 100% either.  Because that’s the way PI works. Not all cases are created equally. Some fall apart completely. Some attorneys are truly awful people so stay on your toes. Some are amazing people and those are the ones you want to work with. Sometimes, the patient disappears. Sometimes they get in trouble and go to jail. Sometimes the insurance company just won’t budge and the attorney doesn’t feel there’s a strong enough case to go to court on.  At those times, you better be willing to wheel and deal. Otherwise, you might get that one bill paid but that attorney won’t be sending you any more clients and guess what? Attorneys talk to each all of the time. They’re mostly all good friends.  Some of my best friends professionally are attorneys. Some of my biggest enemies professionally through the years have been attorneys. One still owes me $42,000 and I don’t expect I’ll ever get it out of him because he’s a worthless, useless, terrible human being. But, it’s part of the dangers of swimming in this particular lake. Some of the fish have no souls.  But again, some are amazing people that I have forged solid friendships with.  I went off the rails a bit there but the point again is this; either get educated and do it at a high level or leave it to others that did actually put the work in to get the extra education. Plain and simple.  Item #1 Our first paper is called, “A systematic approach to clinical determinations of causation in symptomatic spinal disk injury following motor vehicle crash trauma”’ by Dr. Michael Freeman, et. al. (Freeman MD 2009)  and published in Physical Medicine and Rehabilitation back in 2008.  Why They Did It This is a really long description of the objective here so follow along and we’ll discuss, “Clinical determinations of causation in cases of intervertebral disk (IVD) injury after a motor vehicle crash (MVC) are often disputed in court settings.  No published systematic guidelines exist for making such determinations. This has resulted in nonclinical people determine injury causation and performing the evaluations. This is traditionally a clinical activity.  The result is causal determinations that are potentially disconnected from clinical observations of injury. Meaning, when non-clinical people are doing the evaluation, they get it wrong a lot.  The purpose of this review was to evaluate the current literature on causation, causal determinations after trauma and intervertebral disk injury after a motor vehicle crash, and to develop a practicable, logical, and literature-based approach to causation determinations of symptomatic intervertebral disk injury after a motor vehicle crash. That was almost all quoted from the paper’s abstract but I tried to make it even more basic and less confusing.  What They Found
  • The results of the review indicate IVD injury can result from any MVC regardless of magnitude, thus meeting the first criteria of causation, biologic plausibility.
  • Individual determinations of causation depend entirely on the temporal association between the collision and the symptom onset (the second criterion) and a lack of a more probable explanation for the symptoms (the third).
  • When these causal elements are met, clinicians can assert causation on a “more probable than not” or “reasonable probability” basis.
  • You may have heard me mention I’m currently undergoing the Forensics Diplomate program right now. That is legal speak there. Probably meaning ‘greater than a 50% chance.”
Wrap It Up For the conclusion, they say, “Because of a lack of an established or reliable relationship between collision force and the probability of IVD injury the investigation of collision parameters is not a useful adjunct to causal determinations.” Item #2 Our last one today is called “Diagnostic Accuracy of Videofluoroscopy for Symptomatic Cervical Spine Injury Following Whiplash Trauma” by Freeman et. al. (Freeman MD 2020) and published in the International Journal Of Environmental Research and Public Health in 2020 and that’s still got some smoke! Now….if you don’t know, what is Videofluoroscopic examination? It’s basically x-rays (and video) that are dynamic. X-rays that are moving. So you can see the patient go into cervical flexion. It’s cool as hell. But you can accurately see when there is ligament injury or ligament laxity as well because in real time, you can observe the one vertebra slide forward on the one under. It’s crazy and a bit spooky.  When you see one vertebra slip forward on the one underneath as the patient goes into cervical flexion, it’ll make you anxious in your belly. It might make you pee a little. Anyway, look it up. See if you can find some videos through your Google machine.  Why They Did It Intervertebral instability is a relatively common finding among patients with chronic neck pain after whiplash trauma. Videofluoroscopy (VF) of the cervical spine is a potentially sensitive diagnostic tool for evaluating instability, as it offers the ability to examine relative intervertebral movement over time, and across the entire continuum of voluntary movement of the patient. At the present time, there are no studies of the diagnostic accuracy of Videofluoroscopy for discriminating between injured and uninjured populations. How They Did It
  • Symptomatic (injured) study subjects were recruited from consecutive patients with chronic (>6 weeks) post-whiplash pain presenting to medical and chiropractic offices equipped with Videofluoroscopy facilities.
  • Asymptomatic (uninjured) volunteers were recruited from family and friends of patients. 
  • Three statistical models were utilized to assess the sensitivity, specificity, positive and negative predictive values (PPV and NPV) of positive Videofluoroscopy findings to correctly discriminate between injured and uninjured subjects.
What They Found
  • A total of 196 subjects (119 injured, 77 uninjured) were included in the study.
  • Videofluoroscopic examination of the cervical spine provides a high degree of diagnostic accuracy for the identification of vertebral instability in patients with chronic pain stemming from whiplash trauma.
Wrap It Up “Videofluoroscopic examination of the cervical spine provides a high degree of diagnostic accuracy for the identification of vertebral instability in patients with chronic pain stemming from whiplash trauma.”     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
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  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 Freeman MD, C. C., Kohles S, (2009). “A systematic approach to clinical determinations of causation in symptomatic spinal disk injury following motor vehicle crash trauma.” PM R. 1(10): 951-956.   Freeman MD, K. E., Rosa S, Gatterman B, Strommer E, Leith W, (2020). “Diagnostic Accuracy of Videofluoroscopy for Symptomatic Cervical Spine Injury Following Whiplash Trauma.” Int J Environ Res Public Health 17(5): 1693.  

The Failure Of Lumbar Fusion Surgery

CF 160: The Failure Of Lumbar Fusion Surgery

Today we’re going to be talking all about lumbar fusion surgery and my growing disdain for the procedure. 

But first, here’s that sweet sweet bumper music

 

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 #160

Now if you missed last week’s episode, we talked about setting yourself apart in the way you treat migraines. This was an excellent episode that has no choice but to make you better. Make sure you don’t miss that info. Keep up with the class. 

On the personal end of things…..

I watched an ESPN 30 For 30 the other night. It was on Jim Valvano and his North Carolina State Wolfpack that won the national championship in basketball in 1983 I believe. It was such an unlikely story and some of his techniques were a bit wonky. 

For example, he used to make the team practice cutting down the nets from the goals after winning the championship. Far before it was ever even in the realm of possibility. The players said that was more than a little weird at first but that they came to enjoy it and it was just a part of goal-setting and visualizing. 

Visualization is such a big part of a mental process we can, and should, partake in. I myself forget to think to do it. Even though I know how impactful visualization can be. 

I can give you a personal example where visualization came in handy for me. I was a mediocre discus and shot put thrower in high school. OK, probably above average to be honest but I don’t want to pump my own tires too much. 

I ended up my junior year at 150’. That throw might win district but won’t do a lot for a guy at a regional meet. 

When my senior year came around, in the early Spring, I began getting recruited by a lot of colleges. Mostly DII colleges. One of the coaches recruiting me knew about my discus and shot put throwing. He recommended a book. It was called Peak Performance: Mental Training Techniques Of The world’s Greatest Athletes by Charles A. Garfield. 

This book was about relaxation and visualization techniques of the top athletes in the world. It was like nothing I’d ever read. Now, this was back in 1990. They may have improved visualization and relaxation techniques since then but I’m telling you, this book punted me into a different stratosphere on this stuff. I’ll put a link to it on biblio.com in the show notes for this episode. Go check it out. 

https://www.biblio.com/book/peak-performance-mental-training-techniques-worlds/d/1362768092?aid=frg&currency_id=1&gclid=Cj0KCQiAlsv_BRDtARIsAHMGVSZ40_eKAIMbAHTRPRIUrdGXJN5c6n4SG74XgCEYiPpihaJGbuny2QgaAmgHEALw_wcB

Anyway, while I was throwing in the low 160s in the discus and low 50-foot range in the shot put, when I got this book it was toward the middle of the season so it was a bit rushed. But I dove in immediately. 

Within two weeks I was at 168’ and then at the end of the season, I won state in Texas (not an easy feat with a state of 25 million people)  with a personal meet best of 176’ 4 1/2 inches. I beat my best throw of my junior year by 26’. Not only that but I went to state in the shot put. Most definitely my weak event and threw my personal best there. It was my best throw by about a foot which is a huge jump in that event ending up at 55’. Just a couple of inches from our school record. Not an accomplishment that would have ever happened without this book. 

i apologize. I went out on a tangent a bit there but I’m talking about this book and this visualization topic because it’s real and I know it can make a difference in your life and your practice. 

Listeners of this podcast know I’m not a hippy-dippy kind of dude. This isn’t a hippy-dippy thing. It’s real and I’ve experienced it. This book is meant for business as well. I encourage you to check it out yourself. 

That 30 For 30 is my favorite. It’s very inspiring and he has some great quotes in the show. You can Google his quotes as well to save some time. But, in one part, he was quoting Ralph Waldo Emerson and the quote was, “Nothing great was ever achieved without enthusiasm.”

For many of us, 2020 and COVID stole our enthusiasm. If you take Emerson at his word here, then that would mean that 2020 and COVID also stole our greatness. 

I want to encourage the listeners of the Chiropractic Forward Podcast to get your enthusiasm back. Get your greatness back. Do it right now. Make it a priority. Make it a foundation of your practice this month and let’s see what happens. 

Pass it down to your staff. Keep them pumped up. Even when or if numbers are down. My numbers are down. I’ve made no secret about that. But around here, we’re going to make enthusiasm a key ingredient of our values. Along with honesty, integrity, ethics, love, fun, and being evidence-based and patient-centered. When we add enthusiasm into that mix, I think we have a winning concoction. 

This discussion portion was meant to only deal with enthusiasm but I got to talking about Jimmy V and his visualization efforts and like an ADD guy, I saw a squirrel and just went that direction. Thank you for indulging me. I hope you found something helpful in it all. 

 em today. I first want to say that I am not against surgery for the right person and the right issue. If it’s needed and the last resort, well why the hell not? But a stat I came across a year or so ago said that out of the 56 million back pain sufferers in our country, only about 5% of them actually, truly, clinically need surgery. 

Then, as you’ll see, when you have something as invasive and impactful on life as lumbar fusion being performed so often with no improved overall outcomes on the back end of it all….well, don’t you have to be responsible and step back and take another look at that and ask yourself, what are we as surgeons doing this for, and should we continue?

Item #1

This first one today is called “Is Lumbar Fusion Necessary for Chronic Low Back Pain Associated with Degenerative Disk Disease? A Meta-Analysis” by Xu et. al. (Xu W 2020) and published in World Neurosurgery on November 27, 2020. 

Hot potato, hot potato, get ‘em while they’re good and hot!

Why They Did It

The authors wanted to evaluate the efficacy and safety of lumbar fusion versus nonoperative care for the treatment of chronic low back pain associated with degenerative disk disease.

Remember this is a meta-analysis. It’s right up there at the top of the research pyramid with systematic reviews. Meaning….it’s good stuff.

How They Did It

  • They did a comprehensive duplicate electronic database search that included PubMed, Embase, Cochrane Library, and China National Knowledge Infrastructure. 
  • They took studies published up to June 30, 2020
  • The main outcomes including clinical results, complications, and all-cause additional surgeries were presented in the form of short and long-term follow-up results. 
  • Six prospective studies involving 159 patients for short-term follow-up and 675 for long-term follow-up were included.

What They Found

  • The 2 interventions exhibited little difference in regard to short- and long-term Oswestry Disability Index and visual analog scale scores for back and leg pain, 
  • Lumbar fusion might bring about lower additional surgery rate 
  • Lumbar fusion might bring about a higher complication rate in the long term.

Wrap It Up

“The present meta-analysis determined that fusion surgery was no better than nonoperative treatment in terms of the pain and disability outcomes at either short- or long-term follow-up. It is necessary for clinicians to weigh the risk of complications associated with fusion surgery against additional surgeries after nonoperative treatment. Considering lax patient inclusion criteria in the existing randomized clinical trials, the result needs to be further confirmed by high-quality research with stricter selection criteria in the future.”

So, since we know systematic reviews and meta-analyses are like computers, then we know that they are only as good as the data you put into it. What you put into it determines what you get out of it. If they haven’t done a lot of quality research on low back fusions, well then they won’t have a lot of good quality information to assemble a meta-analysis. Right? 

When we look at 6 studies with 159 patients for the short-term part and we have 675 patients for the long-term…..I’m not a researcher but, to me, that sure doesn’t seem like a huge sample size. Certainly not when you consider the number of lumbar fusions happening around the world every single day. For such an expensive and invasive surgery, you’d sure think there’d be more to go on out there for a project like this. Is it just me?

CHIROUP ADVERTISEMENT

Item #1 was a new paper. Now I want to re-visit a couple of papers we have covered on the podcast before. One in episode 144 and one all the way back in Episode 54. 

Item #2

Item #2 is titled “Lumbar Spine Fusion: What Is The Evidence?” by Harris et. al(Harris I 2018). and published in the Journal of Internal Medicine in 2018. 

Basically, in this paper, they say that lumbar spinal fusion is common and associated with the high cost and a risk of serious adverse events. They state that they aim to summarize systematic reviews on the effectiveness of lumbar spine fusion for most diagnoses. 

Of important note is where they say that they found NO high-quality systematic reviews and the risk of bias of the randomized controlled trials they found was generally high. For something as serious as lumbar fusion surgery. Where they cut into the body, take two vertebrae that usually aren’t unstable on each other, and then drive screws into them and affix hardware to fuse them together forever and ever amen. 

No high-quality systematic reviews for lumbar fusion surgery and the RCTs out there generally carry a high risk of bias. 

Doesn’t that just give you a warm fuzzy feeling inside when a surgery like lumbar fusion doesn’t have a lot backing it?

They go on to say that the available evidence doesn’t support a clinical benefit from lumbar fusion surgery compared to non-operative treatment or stabilization without fusion for thoracolumbar burst fractures. 

They say that surgical intervention for metastatic carcinoma of the spine associated with spinal cord compromise improves mobility and neurological outcome. That was based on a single trial. 

Item #3

This one we covered in episode 144 is called, “Surgery for chronic musculoskeletal pain: the question of evidence” authored by Harris et. al(Harris IA 2020). and published in Pain Journal in September of 2020.

Why They Did It 

They say that globally, the most common reasons surgery is performed relate to the musculoskeletal system, and outside of injury, the most common reasons pertain to arthritis and back or neck pain. AKA – chronic pain. Chronic pain has become a special interest of mine after going through the orthopedic diplomat last year. It’s fascinating. 

They say, “Although the surgical treatment of chronic pain generally relies on attributing pain to objective, often visible changes on imaging studies, the causes of chronic pain are more complex and are strongly influenced by psychosocial factors.” 

Things like Yellow Flags. Go look up yellow flags and Annie O’Connor’s book called World Of Pain please and thank you.  Annie will be speaking at the Texas Chiropractic Association’s Winter Conference on March 5-6. I encourage you to be watching out on www.chirotexas.org for more info because you’ll be able to take this seminar from anywhere in the world. And I recommend you do because my hero, Dr. Anthony Nicholson from Australia will be one of the presenters. Dr. Carlo Amendolia, I will be a speaker at this thing, Dr. Brandon Steele, and Dr. Jay Greenstein as well. This is quite the conference getting put together, folks. So make your plans. 

They say that surgeries like debridement of degenerative joints and things of that nature ignore the complexity of chronic pain. They look at surgery as purely mechanistic in nature with little to no involvement otherwise and the procedures often rely on observational evidence only, rather than rigorous, comparative trials.  

In addition, they say that when the trials have actually been performed for these surgeries have been mostly subjective and measurements are usually not blinded to reduce the bias of the outcomes.  

Who really wants to go under the knife for anything other than having a mole cut off when the procedures have not been thoroughly investigated, researched, and tested? 

Uh hell no. No thank you. 

This paper was written to demonstrate that observational evidence is not adequate when you consider the costs and risks of surgical intervention. They advocate that surgical procedures should undergo randomized controlled trials with blinding and showing statistical and clinically important symptomatic improvement when compared to no surgery at all.  

Well no duh. Who on Earth would put something into widespread use….surgically that is…..without doing their due diligence through research? Well…..evidently everyone in the medical profession from this.  

Ultimately in this paper, the goal here was to quantify what kind of support exists in the literature for some common procedures.  

How They Did It

  • The first thing to do was to identify the common procedures performed for chronic pain
  • Secondly, they had to identify the number of published RCTs comparing each procedure to a control group treated without that procedure
  • They did a search of the Cochrane Central Register of Controlled Trials
  • Each paper was reviewed by two independent authors

What They Found

  • A very low proportion of the RCTs on the selected procedures compared the procedure to not performing the procedure. 64 from the more than 6,735 studies. Less than 1% if you’re keeping track. Is that not stunning? And infuriating?
  • Of those 64, only 9 were favorable to surgery. 
  • When considering individual surgical procedures, the majority of comparative trials did not favor surgery 
  • None of the studies using patient blinding for any procedure found it to be significantly better than not having the surgery at all. 

Wrap It Up We conclude that many common surgical procedures performed for musculoskeletal conditions causing chronic pain have not been subjected to randomized trials comparing them to not performing the procedure. 

Based on the observation that when such studies have been performed, only 14% (on average) showed a statistically significant and clinically important benefit to surgery; there is a need to produce such high-quality evidence to determine the effectiveness of many common surgical procedures.  

Furthermore, the production of high-quality evidence should be a requirement before widespread implementation, funding or professional acceptance of such procedures, rather than the current practice of either performing trials after procedures have become commonplace, or not performing comparative trials at all.” 

Wouldn’t you like to know that your mom’s spinal surgery procedure was fully vetted? It was researched against not doing it at all? They haven’t done that? 

Make memes and/or infographics from the sound bites I’ve given you here. You can use all of this stuff if you have a little imagination. 

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. 

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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

  • Harris I, T. A., Stanford R, (2018). “Lumbar spine fusion: what is the evidence?” Internal Med J.
  • Harris IA, S. V., Mittal R, Adie S, (2020). “Surgery for chronic musculoskeletal pain: the questions of evidence.” Pain 161(9): S95-S103.
  • Xu W, R. B., Luo W, Li Z, Gu R, (2020). “Is Lumbar Fusion Necessary for Chronic Low Back Pain Associated with Degenerative Disk Disease? A Meta-Analysis.” World Neurosurg 146: 298-306.

Common Surgeries Aren’t Well-Researched & Chiropractic Wins Again

CF 144: Common Surgeries Aren’t Well-Researched & Chiropractic Wins Again Today we’re going to talk about how some of the most common musculoskeletal surgeries aren’t very well-researched and we’ll talk about how chiropractic performs when lined up with multidisciplinary treatment.  But first, here’s that sweet sweet bumper music  
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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 #144 Now if you missed last week’s episode, we talked about a new paper that came out in JAMA that said spinal manipulative therapy doesn’t work and what our research experts have to say about that and what my big mouth has to say about it. Make sure you don’t miss that info. Keep up with the class. There may come a time you need to take a stance on that.  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’m trudging through the designated doctor program here in Texas to assess the extent of the injury, return to work, and all of that fun fun stuff. I’m not even sure why I’m doing it. Just to have back up plans. I like multiple streams and I like options. If I get as busy as I was in 2019, I’ll never have the need for it. If it stays where I’m at – 75% of where I was, well it may be something I entertain.  Either way, will it make me a better doctor for personal injuries, work comp, and all patients in general? Hell yeah, it will. Even if I never use it for a DD exam, I’ll be a better doc after going through it. Guaranteed. Even if I don’t pass the damn test!! Which I hear is stupid and has nothing to do with the curriculum. Even if I fail the test, I’ll be better.  It is slowly cooling off here in the Texas Panhandle. While I realize we just went through the longest Spring and Summer known to mankind, I’m going to miss it. Despite all that went into making it the longest Spring and SUmmer ever….I’m going to miss the aspect of time slowing down, sitting on the back patio with my wife, dinner outside in the outdoor kitchen, swimming in the pool, and just being warm in general.  Oh, how I despise the cold weather. Lol. Here’s where you Northerners call me a pansy but….it’s like needles when the cold wind blows. I grew up a couple of hours north of where I live now and there was a difference in weather. At times, it would get bone-chilling cold growing up. I would take a shower in the morning before school, drive there and park, and walk into the school. My wet hair from showering would freeze before I got into the building. Now that’s cold, folks.  I grew up with that, yes, even in Texas. My hometown is called Perryton, TX and it’s only 7 miles from the tiny little strip of Oklahoma and it’s about 45 miles from Kansas. So, it’s not deep in the heart of Texas. It’s way up North.  My point is, I went to school down in Natchitoches, Louisiana, and then lived in Dallas for about 6 years before relocating back to the Texas Panhandle and Amarillo, TX.  Having not been in the cold cold for 8-10 years got me spoiled to the point that I can’t even tolerate cold weather anymore. At all. For any reason. It borderline pisses me off.  Everything dies, it’s cold, it’s windy, people are all yay about pumpkin spice crap, my bones ache a bit, and I’m bitchy 2/3 of the time.  I’m just warning you all, this is what you get to look forward to dealing with for the next 3-4 months. My whiny butt being all cold-weather fussy. But here’s the saving grace and the best thing since sliced bread; the remote start vehicle.  Yes, as any good Texan, I have a pickup and that dude has remote start with defrost and heated seats. You damn right. This is the ONE thing that has made Winter somewhat tolerable for me and, being a good Christian, I thank God and the car companies on the frigid mornings for blessing us all with such wonderous inventions like the remote start.  Now, I don’t want you North Dakota or Canadian friends of mine rolling your eyes too hard at me here. I’m sure you’d melt down here in TX in the Summers so…..we agree to play to our strengths and roll on down the road. Trust me, go through two-a-days in college in Louisiana and tell me how tough you are. Lol. Something you don’t see on TV when you watch football is the humidity. It’s REAL.  I went from three-a-days at one college playing football here in the Texas Panhandle to two-a-days in Louisiana. Not a problem by anyone in the Panhandle but in Lousiana, it looked like a battlefield with players dropping left and right with cramps and having to get IVs there on the practice field….it was insane. So, I’m cold intolerant but I can handle the other end of it. Don’t be too hard on me. Lol.  What does all of this have to do with chiropractic and research? Not a damn thing. Just a little bit of fun rambling and brain dump.  Let’s get on with the real reason we’re here. Item #1 This first one came to me from Dr. Craig Benton, one of my buddies, down in Lampasas, TX where it’s always a bit balmy almost year-round. It’s called “Integrating a multidisciplinary pain team and chiropractic care in a community health center: an observational study of managing chronic spinal pain” by Prater et. al(Prater C 2020). and published in Journal of Primary Care & Community Health on September 10th of 2020. Holy smokin scorchin’ blaze of newness! Look, y’all should know how I feel about chronic pain by now. This is right down my alley. Not a dark alley. No, one that’s lit up like an airport runway. Bright alley.  Why They Did It They say that chronic pain is one of the most common diseases in the US with the underserved population being most affected for obvious reasons. They say the underserved are at more risk of opioid misuse or overuse since they lack therapeutic access otherwise. For this reason, they are looking for other avenues to provide treatment to chronic pain sufferers.  How They Did It
  • This was a prospective observational pilot study
  • Held at a community health center
  • Measured the effectiveness of two interventions among the underserved population
  • The two interventions were 
  • Multidisciplinary team
  • Chiropractic care
  • The outcomes measured were pain and functional disability measured via the Pain Disability Questionnaire and reduction of opioid dosage at 6 and 12 months. 
  • 35 folks complete baseline and follow-up outcome measures from August 2018 to May 2020
Wrap It Up A key finding was quote, “Participants in the chiropractic team and those completing the study before COVID-19 were found to have significantly greater improvement at follow-up.” Well isn’t that sexy? Indeed.  “This observational study within a community health center resulted in improvement in spinal pain and disability with chiropractic care versus a multidisciplinary pain team. Offering similar services in primary care may help to address pain and disability, and hopefully limit external referrals, advanced imaging, and opioid prescriptions.” This was a pilot study with small sample size. Nothing to do backflips about but it’s a start down this path or thinking and learning so hopefully, we’ll see some very cool and very positive things for the chiropractic profession down the line if papers like this continue to come out. 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 #2 I think I got this one from Dr. Craig Benton as well. Dr. Benton is a former guest of this podcast. Sounds like we need to have him back on. He’s my Allstar this week. Thank you, Dr. Benton. For keeping me in business and helping me keep everyone, including myself, educated.  This one is called, “Surgery for chronic musculoskeletal pain: the question of evidence” authored by Harris et. al(Harris IA 2020). and published in Pain Journal in September of 2020. Blisters!!! I got blisters on my fingers!!! You Beatles fans…..you’ll get it.  Why They Did It They say that globally, the most common reasons surgery is performed relate to the musculoskeletal system, and outside of injury, the most common reasons pertain to arthritis and back or neck pain. AKA – chronic pain. Yes, I love me some chronic pain people! Not suffering from it. Learning about it and treating it.  They say, “Although the surgical treatment of chronic pain generally relies on attributing pain to objective, often visible changes on imaging studies, the causes of chronic pain are more complex and are strongly influenced by psychosocial factors.” Things like Yellow Flags. Go look up yellow flags and Annie O’Connor’s book called World Of Pain please and thank you.  They say that surgeries like debridement of degenerative joints and things of that nature ignore the complexity of chronic pain. They look at surgery as purely mechanistic in nature with little to no involvement otherwise and the procedures often rely on observational evidence only, rather than rigorous, comparative trials.  In addition, they say that when the trials have actually been performed for these surgeries have been mostly subjective and measurements are usually not blinded to reduce the bias of the outcomes.  Do you want yourself or loved ones cut into when the procedure has not been thoroughly investigated, researched, and tested? Uh hell no. No thank you.  This paper was written to demonstrate that observational evidence is not adequate when you consider the costs and risks of surgical intervention. They advocate surgical procedures that should undergo randomized controlled trials with blinding and showing statistical and clinically important symptomatic improvement when compared to no surgery at all.  Wouldn’t you expect that they already do this???? Evidently not. At all, really.  Ultimately in this paper the goal here was to quantify what kind of support exists in the literature for some common procedures.  How They Did It
  • The first thing to do was identify the common procedures performed for chronic pain
  • Secondly, they had to identify the number of published RCTs comparing each procedure to a control group treated without that procedure
  • They did a search of the Cochrane Central Register of Controlled Trials
  • Each paper was reviewed by two independent authors
pastedGraphic.png What They Found
  • A very low proportion of the RCTs on the selected procedures compared the procedure to not performing the procedure. 64 from the more than 6,735 studies. Less than 1% if you’re keeping track. Is that not stunning? And infuriating?
  • Of those 64, only 9 were favorable to surgery. 
  • When considering individual surgical procedures, the majority of comparative trials did not favor surgery 
  • None of the studies using patient blinding for any procedure found it to be significantly better than not having the surgery at all. 
Wrap It Up We conclude that many common surgical procedures performed for musculoskeletal conditions causing chronic pain have not been subjected to randomized trials comparing them to not performing the procedure. Based on the observation that when such studies have been performed, only 14% (on average) showed a statistically significant and clinically important benefit to surgery; there is a need to produce such high-quality evidence to determine the effectiveness of many common surgical procedures.  Furthermore, the production of high-quality evidence should be a requirement before widespread implementation, funding or professional acceptance of such procedures, rather than the current practice of either performing trials after procedures have become commonplace, or not performing comparative trials at all.” Wouldn’t you like it in the year 2020, when we hear bragging about the amazing advances of medical wonders and technology, and sometimes rightfully so…..would you like it if these things that should go unsaid are actually done? Wouldn’t you like to know that your mom’s spinal surgery procedure was fully vetted? It was researched against not doing it at all? They haven’t done that? Seriously? Look, ever heard of phantom limb pain? Just in case, it’s where a limb is amputated. Cut off completely. Yet, it still hurts. Why the hell does something that is gone and no longer exists still hurt? It’s because chronic pain lives as much or more in the brain as it lives in a peripheral source.  So, if you go in and do surgery on arthritis for a chronic pain sufferer, what are the real chances that you got rid of that pain? How many people have arthritis that commonly doesn’t bother them much at all beyond the first 15 or so minutes after they wake up? The answer isn’t precise but it’s probably a hell of a lot if I’m placing bets.  Did you know that if a person has surgery and they’re in chronic pain syndrome that even if the surgery goes perfectly, they will still have a 60% chance of developing pain at the new site of surgery? That’s what happens when you have a sensitized or upregulated central nervous system. It’s on high alert and using pain to make your future decisions and to protect you. You have to turn the volume down on the central nervous system if you’re ever going to control the pain in the brain. It’s actually the MOST IMPORTANT aspect of treating chronic pain.  How many people get surgery when they don’t need it because the arthritis isn’t really the issue. When the issue actually lies withing the limbic system in the brain? To be fair, how many people get adjusted by the chiropractor a million times because they’re trying to pop out the pain? Hell, doing that a million times only deepens the issue.  Don’t get me wrong, there’s SMT benefit in regard to proprioceptive input, sensorimotor function, movement dysfunction, blood flow, and pain modulation but…..beyond a certain point, it will create instability and that will deepen the issue.  I tell new chronic patients that we treat this issue through a combined approach. They must be approaching the issue from a cognitive aspect simultaneously with my physical treatment as well as the exercise/rehab. If we have that comprehensive, three-pronged approach to their condition, we are going to stand a much better chance at getting this sucker under control.  If you’re adjusting and sending them out the door, that’s low-level and borderline ineffective at best. At the worst, with too many appointments, you compound the issue by adding spinal instability to the mix. Too many chiropractors and subluxation slayers just do not understand this concept. They think they’re being specific. The research is pretty clear. You’re adjusting segments at a time. Not one. You’re not that good.  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.  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 subscribe 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
  • Harris IA, S. V., Mittal R, Adie S, (2020). “Surgery for chronic musculoskeletal pain: the questions of evidence.” Pain 161(9): S95-S103.
  • Prater C, T. M., Battaglia P, (2020). “Integrating a Multidisciplinary Pain Team and Chiropractic Care in a Community Health Center: An Observational Study of Managing Chronic Spinal Pain.” Journal of Primary Care & Community Health.

Chiropractic’s Effect On Strength and More, Status of Muscle Relaxers, And The Best Recovery Posture

CF 136 Chiropractic’s Effect On Strength and More, Status of Muscle Relaxers, And The Best Recovery Posture

Today we’re going to talk about Chiropractic’s Effect On Strength and More, Status of Muscle Relaxers, And The Best Recovery Posture 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 #135 Now if you missed last week’s episode, we talked about adjusting in the areas of known disc complications, bulges, herniations..things of that sort. 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….. Nothing new to report really. We aren’t growing in our visit count week to week but, at the same time, we aren’t shrinking either. We’re holding steady at about 80% of where we were before the COVID train wreck and here’s what I’ve sort of decided. I’m just going to be OK with 80%.

Like I said last week, while we’re billing out less and collecting less, we’re also spending less both in the practice as well as in my personal life. Some of you aren’t. Some of you think it’s a hoax and all that stuff. You’re going out and traveling and vacationing and all that jazz. We aren’t. We are not afraid but we also do want to be smart and be diligent. I’ve come to the mindset that if I wind up getting it, I’ll probably do just fine with some time but regardless of how severe or mild symptoms are, I’ll STILL have to shut my office down.

Now, how many of us can afford to just shut the doors for 2-4 weeks without any issues? Honestly, I’m a saver so I could actually do it and survive but I damn sure don’t want to. I have other plans for that money don’t you know. It wasn’t saved so that I could cover my practice financially if I get sick for a month. Hell no. It was saved to invest. So, we are being smart, we are wearing our masks and no….I don’t give one damn what anyone thinks about masks. Honestly. This has been the most disappointing aspect of human observation in recent memory.

The mask debate or debacle. Absolutely a waste of time and energy talking or listening to people on that deal. Anyway, we are wearing our masks. Our patients are wearing their masks. We are still cleaning and having our lobby closed. We are still not allowing visitors in with our patients. We are still using our UV air scrubbers in each room. We are still doing it to keep my most fragile patients safe and confident in us as a clinic, we doing it all to protect the staff, and we’re doing it to protect me as much as possible so we don’t all have to shut down for a month.

Makes perfect sense to me.

We know some things that increase your chances of having a hard time with COVID. Or at least there is some research to back up that low vitamin D puts you at risk. Obesity, underlying conditions like diabetes, low testosterone, smoking, and being of the blood type A. These are just a few things I recall off the top of my head. My question to you is, “What factors under your control are you bolstering or addressing?” I am overweight. I’m naturally a big guy but I’ve gotten a little lazy in the last 5 years. OK…..A LOT lazy.

I started the Couch to 5K program a few weeks ago and am slowly trudging through that. My knees are super pissed at me about it but I’m still doing it. I have addressed any hormone issues I needed to look at. I have gotten on a Vitamin D replacement regimen. I am trying to get more sleep more consistently. I don’t smoke.

Of course, there’s nothing you can do about what type of blood you are but….my point is, what steps are you taking to lower your risk of complications should you wind up with it? I’d love to hear if you’ve changed anything at all or if you’re just like the Russian boxer Drago in Rocky 4…..If he dies, he dies.

Item #1 Let’s get to it. This first one is not sexy. I’m saving the better ones for here in just a minute. Let’s start off nice and simple here with one called “Effects of Two Different Recovery Postures during High-Intensity Interval Training” by Michaelson, et. al(Michaelson J 2019). and published in Translational Journal of the ACSM in February of 2019. Hmmmmmm…..yep… Hot enough. Out of the way.

Why They Did It The purpose of this study was to examine the effects of two different recovery postures, hands on head (HH) and hands on knees (HK), as a form of immediate recovery from high-intensity interval training (HIIT).

How They Did It Twenty female Division II varsity soccer players completed two experimental trials in a randomized, counterbalanced order. Each trial consisted of four intervals on a motorized treadmill consisting of 4 min of running at 90%–95% max heart rate with 3 minutes of passive recovery between each interval. Heart rate recovery was collected during the first 60 seconds of each recovery, where the volume of carbon dioxide and tidal volume were recorded each minute during the 3-min recovery period.

What They Found Results showed an improved heart rate recovery, greater tidal volume, and increased volume of carbon dioxide, with hands on the knees when compared with hands on the head.

Wrap It Up “These data indicate that HK posture may be more beneficial than the advocated HH posture as a form of immediate recovery from high-intensity interval training.”

Before we get to the next paper, I want to tell you a little about this new tool on the market called Drop Release. If you’re into IASTM also known as instrument-assisted soft tissue manipulation, 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 is a revolutionary tool that harnesses the body’s built-in protective systems to make muscles relax quickly and effectively.  This greatly reduces time needed for soft tissue treatment, leaving more time for other treatments per visit, or more patients per day. Its inventor, Dr. Chris Howson, from the great state of North Dakota has 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 Item 2 is called “Assessment of Physician Prescribing of Muscle Relaxants in the United States, 2005-2016” by Soprano et. al(Soprano S 2020). and published in JAMA Open on June 24, 2020 and that’s damn sure a steaming heaping helping right there.

Why They Did It They wanted to measure national trends in muscle relaxant prescribing over a 12-year period. 2005-2016

How They Did It It was a cross-sectional study It used data from the National Ambulatory Medical Care Survey The study included those with ambulatory care visits with non-federally funded, office-based physicians in the US Included almost 315,000,000 office visits.

What They Found Get this y’all – During the study period, office visits with a prescribed muscle relaxer nearly doubled from 15.5 million in 2005 to 30.7 million in 2016 Although visits for new muscle relaxer prescriptions remained stable, office visits with continued muscle relaxer drug therapy tripled from 8.5 million visits in 2005 to 24.7 million visits in 2016 Older adults accounted for 22.2% of visits with a muscle relaxer prescription. Concomitant use of an opioid was recorded in 67.2% of all visits with a continuing muscle relaxer prescription.

Wrap It Up “This study found that SMR use increased rapidly between 2005 and 2016, which is a concern given the prominent adverse effects and limited long-term efficacy data associated with their use. These findings suggest that approaches are needed to limit the long-term use of SMRs, especially in older adults, similar to approaches to limit the long-term use of opioids and benzodiazepines.” And we wonder how we ended up with an opioid and pill problem. Cheese ’n’ rice people. Godzilla it’s just clear as day but nobody’s listening. Are you inundated with referrals from physicians in 2020? Some of you are. Most of you, the large very vast majority of you are not at all and it’s a shame because we can prevent so much of this garbage.

Item #3 Alright, the last item and my favorite one this week. It’s called “Effects of Chiropractic Care on Strength, Balance, and Endurance in Active-Duty U.S. Military Personnel with Low Back Pain: A Randomized Controlled Trial” by Vining et. al(Vining R 2020). published in the Journal of Alternative and Complementary Medicine in July of 2020. Another helping of boiling thought nuggets for you to feast upon.

Why They Did It They wanted to investigate whether chiropractic care influences strength, balance, and/or endurance in the active-duty United States military personnel with low back pain

How They Did It It was a prospective randomized controlled trial using a pragmatic treatment approach Participants were randomly allocated to 4 weeks of chiropractic care or to a wait-list control Chiropractic care consisted of spinal manipulation, education, advice, and reassurance Naval Air Technical Training Center branch clinic at the Naval Hospital Pensacola Florida One hundred ten active-duty military personnel 18-40 years of age with self-reported LBP Outcome measurements included Isometric pulling strength from a semi-squat position was the primary outcome. Secondary outcomes were single-leg balance with eyes open and eyes closed, and trunk muscle endurance using the Biering-Sorensen test. Patient-reported outcomes such as pain severity and disability were also measured. Outcomes were measured at baseline and 4 weeks. Linear mixed-effects regression models over baseline and 4 weeks were used for analysis.

What They Found Participants had a mean age of 30 years, 17% were female, 33% were non-white, and 86% reported chronic LBP. Mean maximum pulling strength in the chiropractic group increased by 5.08 kgs and decreased by 7.43 kgs in the wait-list group, with a statistically significant difference in mean change between groups Statistically significant differences in mean change between groups were also observed in trunk muscle endurance and balance with eyes closed, but not in balance with eyes open Differences in mean change between groups were statistically significant in favor of chiropractic for LBP-related disability, pain intensity and interference, and fear-avoidance behavior.

Wrap It Up “Active-duty military personnel receiving chiropractic care exhibited improved strength and endurance, as well as reduced LBP intensity and disability, compared with a wait-list control.”

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

Bibliography

Michaelson J, B. L., Suprak D, McLaughlin W, Dahlquist D, (2019). “Effects of Two Different Recovery Postures during High-Intensity Interval Training.” Translational J ACSM 4(4): 23-27.

Soprano S, H. S., Bilker W, (2020). “Assessment of Physician Prescribing of Muscle Relaxants in the United States, 2005-2016.” JAMA Open 3(6).

Vining R, L. C., Minkalis A, Gudavalli MR, Xia T, Walter J, Coulter I, Goertz C, (2020). “Effects of Chiropractic Care on Strength, Balance, and Endurance in Active-Duty U.S. Military Personnel with Low Back Pain: A Randomized Controlled Trial.” J Altern Complement Med 26(7): 592-601.

New Information On 5 Actions To Change Clinical Practice

CF 131: New Information On 5 Actions To Change Clinical Practice Today we’re going to talk about moving toward being patient-centered. There are 5 actions recommended. What does it even mean? I might just ruffle some feathers here but a damn I do not giveth. 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 #131 Now if you missed last week’s episode , we were joined by Dr. Kevin Christie with The Modern Chiropractic Marketing podcast and author of a new book that’s coming out on chiropractic marketing. Kevin is a rising star in chiropractic and is a must-not-miss. 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….. Still climbing in the patient numbers. Where I’m located here in Amarillo, TX, there is a population of approximately 280,000 people. Last week, on Thursday and Friday we added 3 total cases of COVID on Thursday and only 2 cases on Friday. Then the following Monday, we added 11.  So, as you can see, the numbers here are no longer high. People are sort of ‘over it’ and you can see that and hear it when you talk to the patients. Hell, I’m sort of over it but still being smart. I’m having friends to the house again but we stay outside by the pool and have a couple of adult beverages.  I have a friend that is a musician. Last weekend, he played a rodeo on Woodward, OK. He said there were probably 1,000+ people at the event and it was indoors. So, in Woodward, OK at least, they are REALLY over it. No way in hell I’m grouping up with that many people indoor or outdoor right now. It just doesn’t make sense to me for now.  I guess if I were 28 and at the top of my game physically it wouldn’t make any difference to me either. But going to an event where people are yelling and cheering right behind, beside, and in front of me….big nopers right now. Ain’t happnin’ I noticed that while cases seem to be leveling off across America, they’re not increasing or decreasing as much as you’d like but, what I noticed is that the deaths are going down. Fairly signficantly. So wouldn’t that fit with the news that started coming out a couple weaks ago about the virus losing some potency?  People are still getting it but not as many dying from it. Another explanation could be that we’ve gotten better at treating it. Either way, that’s not my lane so I’m not going to act like the expert. I’ll just say hell yay-us and keep the good news coming so we can all get back to life as it was meant to be lived.  I hope you’re all well and staying healthy. As always, if you care about the kind of information I share every week and you listen consistently, I’m proud of you. I think you care about the right stuff and even though I don’t know you all, I consider you my friend.  Item #1 Let’s kick this week’s research reviews off with this one called ‘It is time to move beyond body region silos to manage musculoskeletal pain; five actinos to change clinical practice’ by Caneiro et. al(Caneiro JP 2020). published in British Journal of Sports Medicine in 2020. We got a hot one over here!! This paper actually has a lot of big names in the industry like Caneiro, O’Sullivan, O’Sullivan and Jan Hartvigsen. If you don’t know Jan’s name, you just haven’t been a regular listener.  Why They Did It They say that current clinical research, education, and practice approaches musculoskeletal pain and conditions in silos. Basically it’s a focus on body regions like the knee, hip, neck, shoulder, etc.  But current thinking actually shows that the pain disorders are frequently comorbid and share common biopsychosocial risk profiles for pain and disability.  They say that a shift to focusing on the person is what is needed and that this would encourage the doctors to:
  1. focus on the patients’ context and modifiable biopsychosocial factors that influence their pain and disability
  2. Use education to facilitate active management approaches (targeted exercise therapy, physical activity, and healthy lifestyle habits) thus reducing reliance on passive interventions
  3. Consider evidence-based surgical procedures only for those with a clear indication and where guideline-based non-surgical approaches have been rigorously adhered to. 
Well who the hell can’t get behind all of that? Honestly, it’s odd when you think about it that in the year 2020, we’re still saying that surgery should be evidence-based and follow certain guides and that conservative treatment should be first basically. How’s that not just common sense and common procedure in 2020? We’re supposed to have freaking flying cars by now but the medical field doesn’t have this stuff down they way they should just yet?  It’s money. I know. I understand it. But it’s frustrating as hell all the same.  In this paper, the authors say to be truly patient-centered, they have five actions they recommend for managing a person with musculoskeletal pain, irrespective of body region. 
  1. Screen for biopsychosocial factors and health comorbidities. Notice this is #1 on their recommendations. If you’re just getting them in a pop a crack a lack and sending them on without this step, your results are going to be less than you or the patient desires. They say we need to communicate clearly with the patient to identify potential biopsychosocial drivers of the pain and then provide the therapy to fill that gap. These things include pain beliefs, emotional and coping responses to pain, social contest, physical and lifestyle factors and the presence of comorbidities. They recommend using the Orebro Musculoskeletal Pain Questionnaire. 
  2. Embrace patient-centered communication. This one is huge and this is one of the key things we learned in the Fellowship training for the neuromusculoskeletal medicine program. Clinicians should use open and reflective questioning to elicit the patient’s understanding of factors, which include the pain experience (tell me your story), causation beliefs (what do they think is the cause of the pain?), coping (what do you do when the pain increases?), impact (Tell me how your symptoms affect your ability to move and function), concerns (do your symptoms worry you?), beliefs (why do you think you shouldn’t bend/lift, or run?), social factors (tell me about your home life or work life), goals (what are you rgoals?), and expectations. Yes, to an extent, updated research and thinking has us behaving a bit like a psychologist I think. It’s not my favorite stuff. But, when you learn and consider how much pain is held in the brain due to these yellow flag indicators, then you start to realize that pain, certainly chronic pain, cannot just be treated at a peripheral source. You have to address the pain from a central sensitization perspective at least equally or you risk never being able to help these patients. 
  3. Educate beyond words using active learning approaches. doctors have to embrace education as a central part of patient care if we are going to change behavior. We have to dispel myths about pain, imaging findings, and activity engagement (for example, hurt does not equal harm). They say that behavioral learning like exercise therapy can be used to bust myths that are unhelpful. Myths and beliefs that lead to things like fear avoidance. 
  4. Coach towards self-management. A large portion of the chiropractic profession wants and desires patients to depend on them week after week, month after month and that’s just not real world stuff. And it’s not helpful for the patient’s recovery either. We should be empowering patients to engage in exercise, valued activities and a healthy lifestyle with confidence. Can you feel the difference here? “Mary, I know you’re only 35 but you already have some degenerative discs in your neck and I’m so concerned about it. This should be considered urgent and I’m going to need to see you 5 million times for the rest of your life.” Is that helpful or is this helpful? “Mary, I know you read on your rad report here that there is a finding of a degenerative disc in your neck but the truth is, that’s very common and not something you should be concerned with. Certainly not over-concerned with. I actually prefer the word ‘deconditioned’ over ‘degenerative.’ A good percentage of 30-40 year old patients have some mildly deconditioned discs but these rarely ever cause any issues. You’re young, you’re strong, and you’re healthy. We’re going to get everything moving correctly and then I’m going to give you some excellent exercises to really focus on the region and build plenty of support. You’re going to do great.” When you stack those two next to each other, it’s easy to see how harmful one is as opposed to the other more positive, more hopeful one. I got a little side tracked there, the point is, help them take control and self manage. Active amnagement relieves pain and improves function across pain conditions and health comorbidities. 
  5. Address comorbid health factors. They say clinicians should refer for co-care in teh presence of comorbid mental and physical health complaints like high levels of emotional distress, eating disorders, and type 2 diabetes. The authors say they contend that multidisciplinary care needs to be integrated, with consistent messages across the team to prevent care fragmentation and patient distress. 
Wrapping up the paper, the authors say Patient-centered care will optimize the value of healthcare provided. Shifting funding to support high-value evidence-based care options and educating society will be critical to enable this transition and will likely be cost-effective. Integrated cross-discipline clinical networds are required for effective co-care. We believe clinicians are ready to change, but they require the support of health systems and payers.  One word….two syllables. Day-um. You day-um right. But, health systems and payers are stuck on the part of our profession that doesn’t care about movement, function, yellow flags, exercise, or proper patient-centered practice. They’re stuck on the portion of our profession that is TIC or TOR or principled or whatever the hell useless drivel they’re using this week.  The hardcore, philosophy, doctor-centered, faith-based rather than evidence-based group of chiropractors are smaller but they’re so much louder. And dangerous. They’re flat-earthers. They’re the reason the evidence-based group will never reach any kind of cultural authority.  You can have a GROUP of guys and girls go through years of continuing education and maybe get a couple of diplomats in neuro or orthopedics or rehab….wahtever….and they can be the smartest chiropractor on the planet and almost 100% of their patients get well.  And then you have just ONE lowsy-ass guy or girl go and bait and switch just ONE patient into 80 visits in a year with a contract and all of the bells and stupid whistles of a doctor-centered practice, and that group that worked so so hard loses every ounce of legitimacy. Because of ONE jackhole that refuses to understand or read research or refuses to sacrifice some money in the interest of their patients well-being.  It’s gross. It’s awful. But it’s chiropractic. We are already looked at with a side-glance untrusting gaze. So any deviance of behavior that would be widely considered normal is magnified. Just one ruins the batch for all of us.  I remember a preacher once saying that you gain trust in drops but you lose it in buckets. The reality in chiropractic is that just one faith-based, doctor-centered jackhole loses trust in ALL chiropractors in buckets. For ALL of us.  My plea is to start sharing this podcast with your subluxation friends. Especially the young students that haven’t yet decided to be ‘principled.’ Maybe we can help lead them down the right path from the very start. The more people are exposed to the research and to the idea of being patient-centered, the more they’ll latch onto it. They have to. One is borderline evil, and the other is not. It’s backed by science. One destroys reputations for the sake of the dollar. One builds reputations and respect. One is built on ideas and theories over a century old that cannot or have not been proven while the other is backed by science and progress. How is it even a damn choice to begin with? We’re either a healthcare profession. Or we are a faith. True healthcare professions do research and then they do more and they change according to what works well and they drop the stuff that doesn’t, and on and on to the point of really being on the cutting edge of the science and on the health of our patients.  I’ll never understand how such a percentage of our profession can’t get on board with that. Whatever the answer to that question might be, it’s that answer that keeps us at the bottom of the cultural authority ladder.  Unfortunately, I don’t see if changing any time soon. Not until the governing boards decided it’s time to change once and for all.   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.   
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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
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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 Caneiro JP, R. E., Baron CJ, et. al., (2020). “It is time to move beyond ‘body region silos’ to manage musculoskeletal pain: five actions to change clinical practice.” Br J Sports Med 54: 435-443.