CF 222: Forward Head Posture And Spinal Manipuative Therapy Effectiveness Today we’re going to talk about spinal manipulative therapy and forward head posture. But first, here’s that sweet sweet bumper music
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You have found yourself smack dab in the middle of Episode #222
Now if you missed last week’s episode , we talked about The Importance of Movement & Steps. Make sure you don’t miss that info. Keep up with the class.On the personal end of things….. Business is back. Time is getting more limited. Especially for someone like me that tends to bite off as much as I can possibly chew. It’s a bad habit of mine but I always seem to be in hyperdrive. I get everytihng done and I have to say a whole bunch of ‘no’s’ in order to get it all done…..but I do indeed typically get most of it done. It would not be possible without a To Do list. I keep it open in a document on my computer. It’s a life saver. The problem right now is that I have abotu 15-20 items on it that need to be done. So how do you address that? Prioritize them. Put them in order from most important to least. I also list them keeping in mind the time and energy each will take to complete. Not to mention the fact that I do what I can to identify which can be delegated and how they’ll be delegated. Meaning, my office manager is typically overwhelmed. I want to limit what gets delegated to her and try to utilize the other 4 girls that work for us on our chiropractic and medical side of the office. So, which tasks are the most important or the most time sensitive. Then, which tasks can be easy and fast ‘wins’ so I can pop them out and knock them off with ease. Like an important phone call or email I’m supposed to send. Then delegate what can be delegated to the people most capable. Up to and including virtual assisstants. I have a VA in South Africa, one in Nigeria, and one in India. Those are for the chiro side of things. I also have one for voice over marketing and he’s in Pakistan. When you’re busy busy, a VA can be the difference in being heavily buried vs. being slightly buried. So, when you have an integrated office like I do, a voice over side gig that is demanding more and more time, and real estate investments…..VAs are lifesavers. If you are interested in exploring the world of VAs, look into upwork.com, fiverr.com is an excellent site as well. There are virtual networks here in America as well. There is one that I’ve heard great things about based in the Phillipines called virtualstaff.ph. Alright, just a tip from your ol’ Uncle Jeffro. Now, let’s get to the research, shall we? Item #1 This one is called “Clinical Effectiveness and Efficacy of Chiropractic Spinal Manipulation for Spine Pain” by Gevers-Montoro, et. al. (Gevers-Montoro C 2021) and published in Frontiers In Pain on October 25 of 2021. Aye chi wa wa… Why They Did It For the vast majority of patients with back and neck pain, a specific pathology cannot be identified as the cause for their pain, which is then labeled as non-specific. In a growing proportion of these cases, pain persists beyond 3 months and is referred to as chronic primary back or neck pain. To decrease the global burden of spine pain, current data suggest that a conservative approach may be preferable. One of the conservative management options available is spinal manipulative therapy (SMT), the main intervention used by chiropractors and other manual therapists. The aim of this narrative review is to highlight the most relevant and up-to-date evidence on the effectiveness and efficacy of SMT for the management of neck pain and low back pain.Wrap It Up SMT may be as effective as other recommended therapies for the management of non-specific and chronic primary spine pain, including standard medical care or physical therapy. Currently, SMT is recommended in combination with exercise for neck pain as part of a multimodal approach. It may also be recommended as a frontline intervention for low back pain. Despite some remaining discrepancies, current clinical practice guidelines almost universally recommend the use of SMT for spine pain. Due to the low quality of evidence, the efficacy of SMT compared with a placebo or no treatment remains uncertain. Therefore, future research is needed to clarify the specific effects of SMT to further validate this intervention. In addition, factors that predict these effects remain to be determined to target patients who are more likely to obtain positive outcomes from SMT.
They say that the main gap identified in clinical research on SMT for spine pain lies in the low quantity and quality of studies addressing its efficacy against inactive controls. Hence, the effects of SMT against placebo or sham SM remain uncertain. This parallels the state of research on most interventions for spine pain, as no treatment has been demonstrated to be superior to any other or to placebo Item #2 Our last one this week is called “The association between forward head posture and non-specific neck pain: A cross-sectional study” by Bahat et. al. (Sarig Bahat H 2022) and published in Physiotherapy Theory & Practice. And this one should get the CBP people riled up. Mostly because it’s more and more apparent that you don’t need to charge your patients $5,000 for 80 visits this year to correct a curve issue or forward head posture that honestly likely doesn’t cause much of an issue long term.Why They Did It Poor posture is traditionally associated with various musculoskeletal disorders. Consequently, educators in the musculoskeletal field have been teaching postural observation as part of the physical assessment. Forward head posture (FHP) is hypothesized to be associated with neck pain; however, evidence in this topic remains inconclusive.
To investigate the association between FHP and neck pain intensity, disability, and cervical kinematics in individuals with neck pain compared to asymptomatic individuals. A secondary aim of this study was to explore the possible effect of a head-mounted display (HMD) used in a virtual reality (VR) assessment on FHP. How They Did It
The study was conducted with 43 volunteers
20 asymptomatic individuals, 23 individuals with neck pain
Aged 19 to 62.
FHP was assessed by measuring craniovertebral angle on profile photographs.
Secondary outcome measures included pain intensity, the neck disability index (NDI) questionnaire, and neck kinematics using specialized virtual reality software.
What They Found
There were no significant differences between individuals with neck pain and asymptomatic individuals in FHP
The neck pain group demonstrated a restricted range of motion and slower neck movements (p < .05).
We found no significant correlation between FHP and visual analog scale, NDI, and most neck kinematic measures.
Wrap It Up Our findings cannot support a clinically applicable association between FHP and neck pain. I know there is research to the contrary but those projects are typically low quality and performed by one of the biggest stakeholders who owns a company that promotes treating patients based on forward head posture and decreased cervical curvature. So that stakeholder has a specific and direct bias. The research likely reflects that.At the end of the day, my recommendation is to not treat patients like a sales target. They don’t usually need $5,000 of treatment over 80 visits in a year to fix a lack of curve that longitudinal research suggests is of little to no consequence.Treat them like you’d treat your mom or your child. Period. 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 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!
The Message I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment rather than chemical treatments like pills and shots.
When compared to the traditional medical model, research and clinical experience show us patients can get good to excellent results for headaches, neck pain, back pain, and joint pain to name just a few.
It’s safe and cost-effective can decrease surgeries & disability and we do it through conservative, non-surgical means with minimal hassle to the patient.
And, if the patient treats preventatively after initial recovery, we can usually keep it that way while raising the overall level of health! Key Point: At the end of the day, patients should have the guarantee of having the best treatment that offers the least harm. When it comes to non-complicated musculoskeletal complaints….
That’s Chiropractic! Contact Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show and tell us your suggestions for future episodes. Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on podcast platforms. We know how this works by now. If you value something, you have to share it, interact with it, review it, talk about it from time to time, and actively hit a few buttons to support it here and there when asked. It really does make a big difference.Connect We can’t wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward. Website
Social Media Links https://www.facebook.com/chiropracticforward/ Chiropractic Forward Podcast Facebook GROUP https://www.facebook.com/groups/1938461399501889/ TwitterTweets by Chiro_ForwardYouTube https://www.youtube.com/channel/UCtc-IrhlK19hWlhaOGld76Q iTunes https://itunes.apple.com/us/podcast/chiropractic-forward-podcast-chiropractors-practicing/id1331554445?mt=2 Player FM Link https://player.fm/series/2291021 Stitcher: https://www.stitcher.com/podcast/the-chiropractic-forward-podcast-chiropractors-practicing-through TuneIn https://tunein.com/podcasts/Health–Wellness-Podcasts/The-Chiropractic-Forward-Podcast-Chiropractors-Pr-p1089415/ About the Author & Host Dr. Jeff Williams – Fellow of the International Academy of Neuromusculoskeletal Medicine (FIANM) and Board Certified Diplomate of the American Board of Forensic Professionals (DABFP) – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger Bibliography Gevers-Montoro C, P. B., Descarreaux M, (2021). “Clinical Effectiveness and Efficacy of Chiropractic Spinal Manipulation for Spine Pain.” Front Pain Res.
Sarig Bahat H, L. A., Yona T, (2022). “The association between forward head posture and non-specific neck pain: A cross-sectional study.” Physiother Theory Pract: 1-10.
Today, we have one of the giants of chiropractic research as our guest. I will go further into her background in a moment but we have Dr. Christine Goertz joining us today and, if you do not know who she is, it is time to listen up. Don’t you go anywhere because this is going to be an excellent episode full of great information.
But first, here’s that “oh how sweet it is” bumper music
OK, we are back. Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.
You have bounced your way into Episode #68 and we are so glad you did.
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Part of that is having the right patient education tools in your office. Tools that educate based on solid, researched information. We offer you that. It’s done for you. We are taking pre-orders right now for our brand new, evidence-based office brochures available at chiropracticforward.com. Just click the STORE link at the top right of the home page and you’ll be off and running. Just shoot me an email at [email protected] if something is out of sorts or isn’t working correctly.
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Christine Goertz, D.C., Ph.D., is the Chief Operating Officer of the Spine Institute for Quality. She is also an Adjunct Associate at the Department of Orthopaedic Surgery, Duke University Medical Center and Adjunct Professor in the Department of Epidemiology, College of Public Health at the University of Iowa. Prior to joining Spine IQ, she was Vice Chancellor of Research and Health Policy at Palmer College of Chiropractic for eleven years.
Dr. Goertz received her Doctor of Chiropractic (D.C.) degree from Northwestern Health Sciences University in 1991 and her Ph.D. in Health Services Research, Policy and Administration from the School of Public Health at the University of Minnesota in 1999. Her 25-year research career has focused on working with multi-disciplinary teams to design and implement clinical and health services research studies designed to increase knowledge regarding the effectiveness and cost of complementary and integrative healthcare delivery.
She has extensive experience in the administration of Federal grants, both as a PI and as a program official at the National Institutes of Health (NIH). Dr. Goertz has received nearly $32M in federal funding as either principal investigator or co-principal investigator, primarily from NIH and the Department of Defense, and has authored or co-authored more than 100 peer-reviewed papers. Her primary area of focus is the investigation of patient-centered, non-pharmacological treatments for spine-related disorders. Dr. Goertz is a former member of the NIH/NCCIH National Advisory Council and currently serves on the Board of Governors for the Patient Centered Outcomes Research Institute (PCORI), where she has assumed numerous leadership roles. In September 2018 Dr. Goertz was appointed to a 3-year term as Vice Chair of the PCORI Board by the Comptroller General of the United States.
Welcome to the show Dr. Goertz. I can’t tell you how excited I am to have on our podcast.
Can I first ask you what was the impetus for your wanting to get into the research end of the profession? How do you come to the decision to dive into research full-time vs. treating patients day-to-day like so many of us do?
I noticed on your CV that you are currently an adjunct professor with the Department of Orthopaedic Surgery at Duke University Medical Center in Durham, North Carolina and also an Adjunct Professor in the Department of Epidemiology, College of Public Health, University of Iowa. All the while, you are working with The Pine Institue for Quality (AKA Spine IQ). Can you tell us what a regular day looks like for you?
Whether you know it or not, you have been a game-changer for this profession. You have, likely unknowingly, played a big part in some of our podcast episodes. I want to start with a paper we covered. I called it The Veterans Paper and it was HUGE. Though I call it the Veterans Paper, you say it was done as part of the Department of Defense. I wonder….did you notice anything BIG after it was published in JAMA? Was it, in your opinion, any more impactful than your other papers?
Here’s what happened as soon as that paper came out from my perspective; almost immediately, we began getting interest from our local VA and, once we completed credentialing, we started seeing referrals. Before that paper…..nothing. No interest. I don’t know if you’re ready to take all of the credit for that but I’m going to give it to your regardless. On behalf of the entire evidence-informed chiropractic profession, thank you for that.
In emails we have exchanged leading up to our time together today, you mentioned you have a large pragmatic trial funded by the NIH in the VA. Can you tell us anything about that?
In your work called “Insurer Coverage of Nonpharmacological Treatments for Low Back Pain – Time for a Change” published in JAMA October 2015, you say there are no policies emphasizing nonpharma treatment at the forefront of the patient experience, no meaningful levels of coverage for care professionals focussing on nonpharma therapy, and no policies providing financial incentives in favor of nonpharma. I have seen your work make huge differences but have to admit, I’m still seeing reimbursements for chiropractors being a challenge. We have folks out here struggling in practice in spite of everything in our favor. Have you experienced any changes after this came out in JAMA? Can we expect these sentiments you describe to gather steam in the next year or so?
In another piece of yours called “What does research reveal about chiropractic costs?” you say something I want to commend you on. You say, “without a doubt, the most common issues raised by those outside the profession relate to the quality and consistency of chiropractic care delivery.” I think we can all agree that standardization is likely the biggest hurdle our profession faces in regard to integration. Do you believe chiropractic residency training would better prepare chiropractic providers to offer high quality care within medical facilities?
I’m currently over 2/3 of the way through the Diplomate for the Academy of Chiropractic Orthopedists. I see the value every day but, in your opinion, should Board Certification become the norm for chiropractic providers rather than the exception?
In that same paper, when talking about costs for chiropractic care you point out that we are likely equal or less in cost. You say, “In particular, it appears that patients who visit a chiropractor are less likely to undergo hospitalization, resulting in lower global healthcare costs than those who receive medical care only.” Do you feel that the medical field is coming to the point they are seeing our potential in improvement as well as our cost-effectiveness on more of a widespread scale or are there just little pockets here and there? Is the medical field starting to catch on but the insurance companies are still not allowing the change? What are you seeing on your end of things?
You recently were part of a paper that was published just this year, 2019, called, “Effect of chiropractic manipulative therapy on reaction time in special operations forces military personnel: a randomized controlled trial.” I really have to talk to you researchers about trying to shorten the names of these papers.
Anyway, you all concluded on that one that one session of chiropractic manipulative therapy had immediate effect of reducing the time required for asymptomatic special operations forces to complete a complex whole-body motor response task. Tell me….what are we looking at here? Where is this line of research leading future research?
I personally love it and think it has extremely high value so when I ask you this question, please don’t take it as a negative. Are you responsible for instigating the Palmer-Gallup Poll? What were the main goals for starting it and has it lived up to the original thought process behind its beginning?
I thought this was an interesting question. A listener and member of our private group on Facebook, Dr. Trent Peng, suggested I ask you which chiropractic adjustment techniques are sufficiently evidence-based in the scientific literature?
In an article by Lisa Rappaport, called “Adding chiropractic to back pain care may reduce disability,” she interviewed you for the article. She had a quote in the article from you that said, “Spinal manipulation (often referred to as chiropractic adjustment) may help heal tissues in your body that form as a result of injury, decreasing pain and improving your body’s ability to move correctly.”
The other was, “It is also possible that manipulation impacts the way that your body perceives pain through either the brain or the spinal cord and/or decreases pain from muscle strain, inflammation and/or spasm in the muscles next to your spine.”
The first comment I have on this is that I love the second quote because there is more and more information coming out about what part the central nervous system plays in regard to pain. Pain sensitization, movement dysfunction, joint proprioception and thing of that nature. I thought that quote brought some of that into consideration without getting too complicated for a normal reader. So, kudos on that!
I remember thinking to myself that there are a lot of “may help” and “it is possible” kind of language. I understand that researchers shouldn’t formulate opinions or conclusions in definite terms or absolutes and I completely understand that, but my question to this point is do you ever see a time that all chiropractors can say with a high degree of confidence exactly what happens and exactly why it helps people heal or feel better?
I was sent a paper I believe you have in progress called “Assessment of chiropractic care on strength, balance, and endurance in active-duty US military personnel with low back pain: a protocol for a randomized controlled trial. In the Background section, you all say, Chiropractic care may facilitate the strengthening of trunk muscles, the alteration of sensory and motor signaling, and a reduction in pain sensitivity, which may contribute to improving strength, balance, and endurance for individuals with low back pain.”
As you probably know, here in Texas, we are in a perpetual battle against the Texas Medical Association. Recently, they won a decision that was upheld on appeal to remove the ‘neuro’ snippet from our scope description of treatment the neuromusculoskeletal system. Essentially, they say we only treat the musculoskeletal system. With the research you have done and are currently involved in, what do you say to this?
What has been your favorite project or finding you have been a part of so far?
What has been your favorite paper, project, or finding that a colleague has written but you were not a part of?
What conclusion have you had to draw at the end of a paper that surprised you the most?
How do you see quality research translating into a greater level of inter-professional collaboration and how do you see the future of chiropractic unfolding in terms of integration into the healthcare system?
A tie-in question here, where do you see the profession in 10 years?
I know that low back is one of the biggest reasons for disability worldwide, if not the biggest. It deserves the attention it has received. We have research on low back pain now to the point that even traditional chiropractic detractors can’t really argue all that much with us on low back pain. But we still have a fight on our hands when it comes to cervical manipulation. My question is why do you think we don’t see more research for cervical manipulation and do you see the spotlight ever changing and the research beginning to focus on cervical manipulation and the benefits for neck pain and headache/migraine?
In the private Chiropractic Forward Facebook Group, we are curious….what are you up to right now? What are you working on?
Apart from what you are working on right now, what are your goals in regard to research in the next 10 years?
Thank you so much for taking time out of your day to join us. I hope our listeners got as much use out of our talk as I did. I truly believe that our profession is where it is and going the direction it’s going in large part because of you an d your efforts.
And I thank you so much.
I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment instead of chemical treatments like pills and shots.
When compared to the traditional medical model, research and clinical experience show that many patients get good or excellent results through chiropractic for headaches, neck pain, back pain, joint pain, to name just a few.
Chiropractic care is safe and cost-effective. It can decrease instances of surgery & disability. Chiropractors normally do this through conservative, non-surgical means with minimal time requirements or hassle to the patient.
And, if the patient develops a “preventative” mindset going forward from initial recovery, chiropractors can likely keep it that way while raising the general, overall level of health of the patient!
Patients should have the guarantee of having the best treatment offering the least harm.
Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show or tell us your suggestions for future episodes. Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on iTunes and other podcast services. Y’all know how this works by now so help if you don’t mind taking a few seconds to do so.
Help us get to the top of podcasts in our industry. That’s how we get the message out.
We can’t wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.
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About the Author & Host
Dr. Jeff Williams – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger
3501 SW 45th St., Ste. T, Amarillo, Texas, United States