forward chiropractic

Extruded Discs – Surgery or No Surgery?

CF 197: Extruded Discs – Surgery or No Surgery? Today we’re going to talk about extruded discs – surgery or no surgery? This one may surprise some of you.  But first, here’s that sweet sweet bumper music

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

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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. 

  • Go to Amazon and check our my book called The Remarkable Truth About Chiropractic: A Unique Journey Into The Research. It’s an invaluable resource for your patient education and for you. It can save you time in putting talks together or just staying current on research. It’s categorized into sections so that the information is easy to find and it’s written in a way that is easy to understand for practitioner as well as patient. You have to check it out. 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 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 #197 Now if you missed last week’s episode , we talked about How Car Wrecks Contribute To Future Neck and Back Pain. Make sure you don’t miss that info. Keep up with the class. 

On the personal end of things…..

Alright, I’m feeling pretty good today. Last week was the very first time since February of 2020 that we hit the average weekly visit number that we were doing. I don’t know if that came out right. Before Rona, we were averaging 185 visits per week in 2019.  Rona came along and the best we’ve been able to eke out was about 160. Maybe 165. With the rollercoaster ups and downs of the Rona outbreaks, that number has been down but since February of 2020, it’s never been any higher than that.  Until last week. Last week, by myself, I hit 187. 23 of them were new patients. When you are evidence-based and patient-centered, you don’t hold on to patient unnecessarily for extended visits and treatment schedules so, unfortunately, you live and die by your new patient count. 

Fortunately for me, I’m to a point that new patients aren’t a huge concern. I always have my eye on the count, but it doesn’t give me anxiety these days. We are pretty established here in my community and it tends to mostly take care of itself. Thank my good Lord.  I don’t know if you’ve listened this long but back in February of 2020, the 14th to be exact, my wife and I took a trip to Key Largo. It was amazing.

I left a bustling, busy as hell practice to go on vacation. There was some concern about this COVID stuff but nothing crazy.  In fact, I remember asking my wife on the way to Florida if we should take a mask just in case they told us we needed one. She told me if I brought a mask, that she’d punch me in the nose. Lol. Yes, I have that kind of a wifey. She’s a feisty Texas woman, ya know.  After a week in The Keys, I came back to a ghost town. And then it got worse. I swore I’d never go on vacation again if it was going to tank my practice like that. Well, obviously, it was COVID. And it’s taken a year and a half to start to reclaim our lost business.

But, at 45 patients today as I type this and 5 of them being new patients, this week is looking good too.  Here’s the best news about it all; this is in the midst of a BIG resurgence of COVID here in Amarillo locally. They are adding numbers at the rate they were adding them back in the worst of times. But people are done with it. They just are.  I was one of the first group of providers to be vaccinated here locally. My friends and connections in the medical world here called me when it first came available. They recognized that we work in very close proximity with patients and reached out. Most of my staff and I accepted. I’ve been vaccinated since January 2021. 

I just got the booster on August 26th. It’s a personal thing for each of us but, when you have had a hit on your business like I have, and you’ve had all of the ups and downs, and you’re just now getting back to where you left off after basically losing a year and a half…….well, I’m not about to take a chance on getting sick and being out for 2-4 weeks and watching my business go to crap again.  Including me, I have 12 employees.

That includes 4 CA’s, 3 LMT’s, an NP, an acupuncturist, an esthetician, a billing pro, and I have an intern from Parker College here. These people have families, mortgages, bills, car payments, and gambling debts just to name a few things.  The point is, when you’re the main provider and breadwinner, for me, it’s up to us to be as responsible as we can to make sure we are able to do our jobs.  For example,  here in Amarillo, TX, we are fairly close to the Colorado and New Mexico mountains. About 3 and a half hours to NM and about 5 or so to Colorado. Pretty close. We grew up going skiing in the mountains.

But it dawned on my during my last trip a few years ago; they call them accidents for a reason.  If I fall and break a wrist or twist a knee up, I could be out of a job for up to 6 weeks or more. Well hell, in most cases, that’s more time out than COVID would take you out. I’m the major provider at this time for this clinic. I can’t allow that. So, I gave up snow skiing. It’s not worth it to me.  Why should the pandemic be looked at any differently? For me, it shouldn’t be.  Anyway, I got a little sidetracked there.

Things are going well. I’m hoping business is back to normal and stays normal. For me and for you. We have all fought hard and deserve it.  Now, let’s get some folks to feeling better shall we? Let’s hop into research having to do with large extruded discs.  Once upon a time, I would send them straight to a Neurosurgeon. Not so quickly these days. Knowledge and clinical experience tell me to think twice. Especially in the absence of progressive neurological deficits. 

Item #1

Item one is called “Spontaneous Regression of a Large Lumbar Disc Extrusion” by Ryu et. Al (Ryu Sung-Joo 2010) and published in the Journal of Korean Neurosurgical Society back in 2010. It’s got a little dust on it but not a ton.  

Why They Did It

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

How They Did It

  • It’s a case report so it’s not incredibly impactful but still helpful for something like this. You can see it on one MRI and then 6 months later, it’s gone. 2+2=4 so I’m OK with a case report on something like this here. 
  • A 53-year-old woman was referred to our clinic with a 6-month history of low-back and left lateral leg pain with numbness. Six months earlier, her symptoms had developed suddenly as severe left lateral leg pain. 
  • A neurological examination showed no neurological deficits. The straight leg raise test was negative bilaterally. The lumbar spine MRI performed 6 months earlier revealed a left posterolateral herniated nucleus pulposus which was migrated caudally and compressed the left L5 root
  • She received conservative treatment including pain-relieving medication, physical therapy and spinal anesthetic block therapy due to her poor medical conditions

What They Found

  • After conservative treatment, her clinical symptoms subsided gradually but the numbness of her left lateral leg still remained. A second MRI study performed approximately 6 months after the prior examination reveal almost complete disappearance of the extruded fragment that had been located posterolateral to the L5 vertebral body, and no evidence of compression or displacement of the dural sac or nerve root
  • The height of the L4/5 disc space remained decreased compared to the other levels and was unchanged from the previous MRI examination.

Wrap It Up

  • The precise mechanisms of disc regression are unclear. Three hypotheses have been proposed to explain the process of disc regression. 
  •  
  • The first hypothesis, “retraction of a herniated disc”, proposes that the herniated disc retracts back into the intervertebral space17). Theoretically, this can occur if there is a disc bulge or if the disc material protrudes through the anulus fibrosus but is not separated from it6). However, it would be unlikely in cases of completely extruded or migrated fragments. 
  •  
  • The second explanation, “dehydration of herniated disc”, states that the herniated fragment would disappear due to gradual dehydration and shrinkage16). 
  •  
  • The third hypothesis, “inflammatory reaction and neovascularization”, which is the most compelling and studied hypothesis, states that extruded disc material into the epidural vascular space of spine is recognized as a “foreign body” and induces an inflammatory reaction by the autoimmune system. This would cause neovascularization of the cartilaginous tissue along with infiltration by inflammatory cells, such as macrophages, granulocytes, and lymphocytes7,8,10,11,15). Several histopathology studies from surgical specimens and experimental animal research support this theory
  • Nevertheless, it is possible that all 3 mechanisms play a role in the regression and disappearance of herniated disc tissue.
  • Motor and sensory deficits are present in 50-90% of patients with a herniated lumbar disc18). Surgery can be carried out as an emergency when bladder symptoms or progressive motor weakness are present. In the absence of these symptoms, 75-90% of patients with acute sciatica due to a protruded lumbar disc experience a resolution of symptoms without surgery 
  • Conservative treatment should be considered when cauda equina syndrome or progressive motor weakness are absent in the acute stage of the lumbar herniated disc. Surgical intervention should be considered in cases with neurological deficits or intractable low back and leg pain despite the initial conservative treatment

CHIROUP ADVERTISEMENT

Item #2

Our last one is called “Spontaneously disappearing large herniated lumbar disc fragment”’ by Reddy et. al. (Reddy UV 2014) and published in the Journal of Orthopaedics and Allied Sciences in 2014. As impactful as this information is, why do you think there aren’t more studies on it that are recent? Could it because it suggests they shouldn’t be doing surgery on these large extruded discs?

Why They Did It There are reports of spontaneous regression of large extruded disc; however, the exact underlying mechanism and management of such cases remains controversial. We report a 40-year-old female who opted for conservative management for a large extruded lumbar disc. Follow-up magnetic resonance imaging (MRI) showed complete disappearance of the disc fragment; however, there were degenerative changes in the upper and lower adjacent margins of the vertebral body.  Herniated lumbar disc is one of the common causes of low back pain and smaller disc herniations tend to regress over a period of time; and thus, the pain is known to improve with conservative management. 

How They Did It

A 40-year-old female presented with low back pain of 2 year duration. The pain was radiating to lower limbs more to the left side. There was no history of motor or sensory deficits. There was no history of bowel or bladder dysfunction. She was investigated for the similar problem with an MRI 6 months back and it showed a large disc protrusion [Figure 1]. However, she opted for conservative management. On examination, there were no focal motor or sensory deficits. Deep tendon reflexes were normal except bilateral sluggish ankle jerks. Planters were flexor. As the patient was complaining in the severity of the pain with numbness and a repeat magnetic resonance imaging (MRI) was performed. Follow-up MRI showed complete disappearance of the disc fragment;

What They Found

The exact timing for spontaneous regression of the protruded disc material is not known; however, it ranges from few weeks to months. The fastest regression of the fragmented disc material was reported in 2 months.

Wrap It Up

Present case illustrates that a conservative approach can be adopted for a large extruded lumbar disc as it can resolve in a selective group of patients. [24],[38],[39] Spine surgeons should be aware of spontaneous regression of the disc phenomenon as a patient with a large extruded disc who opted for the conservative management initially can have persistence pain, but there may not be an underlying protruded disc. It is important to perform a repeat imaging of the spine to assess the degree and severity of the disc protrusion before making a plan for surgery or any further conservative management.

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 so 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 https://www.chiropracticforward.com

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

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

Twitter https://twitter.com/Chiro_Forward

YouTube https://www.youtube.com/channel/UCtc-IrhlK19hWlhaOGld76Q

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

Player FM Link https://player.fm/series/2291021

Stitcher: https://www.stitcher.com/podcast/the-chiropractic-forward-podcast-chiropractors-practicing-through

TuneIn https://tunein.com/podcasts/Health–Wellness-Podcasts/The-Chiropractic-Forward-Podcast-Chiropractors-Pr-p1089415/

About the Author & Host Dr. Jeff Williams – Fellow of the International Academy of Neuromusculoskeletal Medicine – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger

Bibliography

  • Reddy UV, A. A., Hegde KV, Suneetha P, Rao MG, (2014). “Spontaneously disappearing large herniated lumbar disc fragment.” J Orthop Allied Sci 2: 26-28.  
  • Ryu Sung-Joo (2010). “Spontaneous Regression of a Large Lumbar Disc Extrusion.” J Korean Neurosurg Soc. 48(3): 285-287.    

How Car Wrecks Contribute To Future Neck and Back Pain

CF 196: How Car Wrecks Contribute To Future Neck and Back Pain

Today we’re going to talk about How Car Wrecks Contribute To Future Neck and Back Pain. I have two different papers with what I thought were surprising conclusions in one way or another. Not only did I find themm a bit surprising but I don’t think the defense attorneys in PI cases will like either paper much. Just an assumption on my part. All of that coming up in this episode. But first, here’s that sweet sweet bumper music      

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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        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 an invaluable resource for your patient education and for you. It can save you time in putting talks together or just staying current on research. It’s categorized into sections so that the information is easy to find and it’s written in a way that is easy to understand for practitioner as well as patient. You have to check it out. 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 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 #196 Now if you missed last week’s episode , we talked about Spinal Manipulative Therapy vs. Opioids and Young Elite Pitchers, Hips, and Elbow Pain. Make sure you don’t miss that info. Keep up with the class. 

 

On the personal end of things…..

We just ended our fourth week as an integrated practice and starting our fifth. It’s a struggle. I’m not going to lie. You see the money going out but you don’t see it coming in. That’s why, to pull this off, you need to be a busy Chiro and you need to have reserves in place.

Otherwise, it could be doomed. Unless you’re a hype machine. A marketing mastermind that fills the schedule before the integration even takes place. Let’s be honest, most of us just aren’t. I know the value of marketing. I know how to market on a fundamental level. But it’s hard. It’s hard to get your message out there and it’s hard to break through.

So, week one, maybe 4-5 appointments. Week two, maybe 18 appointments. Week 2 was about the same. Then last week was maybe only 8-9. So it’s up and down. We aren’t covering the salary but, we have reserves set back AND I’m fortunate enough to be busy.  The trick is just getting the message out and I feel like we’re doing that both externally as well as internally.

We have in-office brochures, flyers, and posters. Email marketing, social media, and all that good hoopla. It’s happening. We’re making it happen. 

In other news, I recovered from my five days in Washington DC. Geez. What a go-cation. It’s not the cost of taking a trip. It’s the cost of being gone. How much money you lose by not being in the office. That’s the real number and it just kills me!! So, I don’t think about it because I truly believe we need to be taking a trip once per quarter. You have to so you don’t lose your damn mind. It’s just a must.

Speaking of, I have a trip in just about three weeks to Chicago for business to finish off my Fellowship in Forensics. I’m looking forward to that and to networking with everyone involved with that whole side of the profession. Multiple streams of income folks. I do it inside the office as well as outside. Speaking, mentoring, authoring, medico-legal, Ortho fellowship, personal injury, family, triwest, acupuncture, massage, laser, esthetician, Texas Chiropractic Association, Texas Council of Chiropractic Orthopedists, Nurse Prac, and everything that falls under that.

That’s inside.

Outside is music, voice-over, art, real estate investing, and all kinds of other things I’m looking at.  What would it be like to just do a couple Of things?  Who knows? That’s just not me.  I make myself crazy but I honestly don’t know any other way. 

If you were thinking you could get into business for yourself and sit on the computer half the day fiddle assing on the computer, I got news. Your competition is out there getting Diplomates, certifications, and expertise to run circles around you.

Get busy.

Or wonder where all of those new patients are going since they don’t seem to be coming to see you.

Item #1

Alright, let’s hop in with our first one today called “Exposure to a Motor Vehicle Collision and the Risk of Future Neck Pain: A Systematic Review and Meta-Analysis” by Nolet et. al. (Nolet PS 2019) and published in PM&R in November of 2019. In case you didn’t know, PM&R stands for physical medicine and rehabilitation. 

Why They Did It

They say in the abstract that neck injury resulting from a crash is associated with a high rate of chronicity. Prognosis studies indicate 50% of injured people continue to experience NP a year after the collision. This is difficult to interpret due to the high prevalence of NP in the general population. In other words, those that have not been in a car wreck still have neck pain, right? The stated goal of the authors here was to summarize the literature that has examined the association between a motor vehicle collision (MVC) related neck injury and future neck pain (NP) when compared to the population that has not been exposed to neck injury from a crash.

How They Did It

  • They performed a systematic review of the literature using five electronic databases, searching for risk studies on exposure to a car crash and future neck pain published from 1998 to 2018. 
  • The outcome of interest was future neck pain. 
  • Eligible risk studies were critically appraised using the modified Quality in Prognosis Studies (QUIPS) instrument. 
  • Eight articles were identified of which seven were of lower risk of bias. Six studies reported a positive association between a neck injury in an MVC and future NP compared to those without a neck injury in an MVC

What They Found

  • Pooled analysis of the six studies indicated an unadjusted relative risk of future neck pain in the car crash-exposed population with neck injury of 2.3, which equates to a 57% attributable risk to those having been in a car wreck. 
  • In two studies where exposed participants were either not injured or injury status was unknown, there was no increased risk of future neck pain

Wrap It Up

They wrap it up by saying, “There was a consistent positive association among studies that have examined the association between MVC-related neck injury and future neck pain. These findings are of potential interest to clinicians, insurers, patients, governmental agencies, and the courts.” I see personal injury patients. This is good info for their reports, their file, and their attorneys if they’re represented. 

 

Item #2 This one is called, “Exposure to a motor vehicle collision and the risk of future back pain: A systematic review and meta-analysis” by Nolet, et. al.  (Paul S. Nolet 2020)and this one was published in Accident Analysis and Prevention in 2020.  It’s not that hot but I’m using it anyway just because I like it and cuz I say so….

Why They Did It The purpose of this study is to summarize the evidence for the association between exposure to a motor vehicle collision (MVC) and future low back pain (LBP).

How They Did It

  • A systematic search of five electronic databases from 1998 to 2019 was performed. 
  • Eligible studies describing exposure to a MVC and risk of future non-specific LBP were critically appraised using the Quality in Prognosis Studies (QUIPS) instrument. 
  • The search strategy yielded 1136 articles, three of which were found to be at low to medium risk of bias after critical appraisal. 

What They Found

  • All three studies reported a positive association between an acute injury in a MVC and future LBP. 
  • Pooled analysis of the results resulted in an unadjusted relative risk of future LBP in the MVC-exposed and injured population versus the non-exposed population of 2.7, which equates to a 63 % attributable risk under the exposed.

Wrap It Up

There was a consistent positive association in the critically reviewed literature that investigated the risk of future LBP following an acute MVC-related injury. For the patient with chronic low back pain who was initially injured in a MVC, more often than not (63 % of the time) the condition was caused by the MVC.  Thats a lot right, folks? Look, it’s obvious to say an injury was caused by a car wreck. It’s common as a chiropractor to hear patients tell you that their neck pain started with a car wreck they had 20 years before. We hear it all of the time.  But for reals, 57% for the neck and 63% of the back?

That’s solid and flies directly in the face of the other side of the courtroom when they try to tell jurors that the forces experienced in a low-speed impact are about the same as stepping off of a curb on the street. This is, by the way, one of the most ridiculous things I’ve ever heard in my entire life but an argument that they most certainly use periodically.  Fools!!!! The fools we must suffer in life!! I’m sure plenty of folks refer to me in the same manner. It is what it is. Let’s all just try to be the least of the fools…., if that makes any sense at all. 

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 so 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

Home

Social Media Links

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TuneIn https://tunein.com/podcasts/Health–Wellness-Podcasts/The-Chiropractic-Forward-Podcast-Chiropractors-Pr-p1089415/

About the Author & Host Dr. Jeff Williams – Fellow of the International Academy of Neuromusculoskeletal Medicine – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger

Bibliography

Nolet PS, E. P., Kristman VL, Murnaghan K, Zeegers MP, Freeman MD (2019). “Exposure to a Motor Vehicle Collision and the Risk of Future Neck Pain: A Systematic Review and Meta-Analysis.” PM R. 11(11): 1228-1239.  

Paul S. Nolet, P. C. E., Vicki L. Kristman, Kent Murnaghan, Maurice P. Zeegers, Michael D. Freeman (2020). “Exposure to a motor vehicle collision and the risk of future back pain: A systematic review and meta-analysis.” Accid Anal and Prev 142.          

Chiropractic Prevents Opioids & Chiropractic Adverse Events

CF 191: Chiropractic Prevents Opioids & Chiropractic Adverse Events Today we’re going to talk about chiropractic care preventing opioids and chiropractic adverse events.  But first, here’s that sweet sweet bumper music

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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  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 an invaluable resource for your patient education and for you. It can save you time in putting talks together or just staying current on research. It’s categorized into sections so that the information is easy to find and it’s written in a way that is easy to understand for practitioner as well as patient. You have to check it out. 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 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 #191 Now if you missed last week’s episode , we talked about Obesity In Youths With Chronic Pain, The Healing Journey of Pain, and Fibromyalgia Treatment. Make sure you don’t miss that info. Keep up with the class. 

On the personal end of things…..

So, if you’re a regular listener, then you know that I’ve been slowly going through the Forensics Diplomate program. The initial 40 hours through ChiroCredit were not my favorites. Learning about court cases, procedures, and all that stuff…..let’s just say it’s not my skill set.  But, I did it. I sat through it all. Now I’m on to the course for impairment ratings through the AMA. It’s speaking my language a little more. OK….a lot more. It’s still very technical and all that good stuff but it makes a little more sense. However, it is written by medical doctors for medical doctors so there is a section that got me a bit hot. Did you know in the 6th edition of the Guides to Impairment, it says that chiropractors should stick with only assessing impairment of the spine….because….you know……we didn’t spend two full semesters dissecting an entire body or anything like that. Right?

The presenter said he realizes that statement may bring about some discussion but the evaluator must have knowledge, skills, and ability in that organ system or in that region to assess impairment. Otherwise, the impairment rating is likely to be faulty. So…..I guess chiropractors somehow have the inability to learn, know, or understand a shoulder, hip, ankle, etc? Let’s be fair, I get it if they think a chiropractor shouldn’t really be assessing impairment of the liver or GI system.

That’s not within our wheelhouse. But muscles, bones, ligaments, tendons, and joints of all sorts are damn well within our wheelhouse and it’s just dumb to act like a regular impairment doc doing impairment ratings are any more intimately familiar with them than we are.  That’s some elitist BS right there. And it stinks and smells like old outdated dogma. But let’s also be fair to them. Even though they’ve rarely given us the same respect in return. This was reprinted in 2009. I’m not sure when the original printing was. I’m sure the course I’m watching was done around the same time as well.  Think about it; how many changes have you seen in the MD/DC relationship arena in just the last 10 years alone? I’ve seen a lot.

Especially since the American College of Physicians came out in 2016 recommending spinal manipulative therapy for acute and chronic low back pain. On the heels of that The Lancet report on low back pain echoed the recommendation. Then Dr. Goertz’s paper was in JAMA showing how well veterans did when spinal manipulative therapy was added into the treatment protocol.  Plus, I see more and more chiropractors moving in the right direction. The direction of evidence-based, patient-centered care. Where decades ago, an MD wouldn’t bowl against a team that had a chiropractor on it and they wouldn’t even accept referrals from us, to now.

Now, I have a nurse practitioner working hand and hand with me every day. Some of the people I count as buddies are a vascular surgeon, and ER doc, and a neurosurgeon.  So….maybe the course just needs an update. Who knows? But it pissed me off a little and I paid $487 to get pissed off. Lol. This too shall pass. In fact, it may already have passed.  Alright, NP medical integration week #2. It’s getting there. Our NP did hormone pellet procedure last week. That whole process is pretty cool. Patients have to do the lab work first to make sure it’s necessary. But if it is, it can make a big difference for folks. We doing PRP shots, trigger point shots, B12 shots….it’s all pretty darn interesting and it’s multimodal. Which is evidence-based and, as always, I balance it in a patient-centered way. 

So, now in my office, we have me, exercise/rehab, medical services, acupuncture, 3 massage therapists, and all of the other stuff you’d expect in therapies. It’s grown into quite a deal.  I had a patient ask me the other day if I was a franchise. I asked why they’d think that? They just said that we offer so many things that he figured it was a franchise. I said no, we’re not. But I likened it to my step-dad’s shop. He’s got every tool, cord, clamp, and gadget you’d ever want in a shop. But when you ask him how he got it all, he’ll tell you that he got it one at a time. Kind of like Clint Eastwood in El Torino.  You just gather and grow as you need. As the risk makes sense. There was a time when getting a $13,000 decompression table was a big damn deal and came with a lot of financial risks. 

Now, understandably, the risk is different. To expand and grow, it costs more. You have to stick your neck out a little further and hope it doesn’t get chopped off.  There are sinkers and swimmers in this world. I like to think I’m a swimmer. It’s OK to venture out a little further each time you stretch. As long as you know how to swim. And I have the doggy paddle down, folks. Just keep swimming just keep swimming.  Alright, let’s dive into the research. 

Item #1

This one’s called “Impact of Chiropractic Care on Use of Prescription Opioids in Patients with Spinal Pain” by Whedon et. Al. (James M Whedon 2020) and published in Pain Medicine in December of 2020 and that’s just hot enough. 

Why They Did It They say “Utilization of nonpharmacological pain management may prevent unnecessary use of opioids. Our objective was to evaluate the impact of chiropractic utilization upon use of prescription opioids among patients with spinal pain.”

How They Did It

  • We employed a retrospective cohort design for analysis of health claims data from three contiguous states for the years 2012–2017.
  • They included adults aged 18–84 years enrolled in a health plan and with office visits to a primary care physician or chiropractor for spinal pain
  • They identified two cohorts of subjects: Recipients received both primary care and chiropractic care, and nonrecipients received primary care but not chiropractic care.
  • The total number of subjects was 101,221

What They Found

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

Wrap It Up

Patients with spinal pain who saw a chiropractor had HALF the risk of filling an opioid prescription.   

CHIROUP ADVERTISEMENT

Item #2 Number two today is called “Safety of spinal manipulation in the treatment of lumbar disk herniations: a systematic review and risk assessment” by Drew Oliphant (Oliphant D) and published in the Journal of Manipulative Physiological Therapeutics in 2004. Definitely not hot. 

Why They Did It The authors wanted to provide a qualitative systematic review of the risk of spinal manipulation in the treatment of lumbar disk herniations (LDH) and to estimate the risk of spinal manipulation causing a severe adverse reaction in a patient presenting with LDH.

How They Did It

  • They considered relevant case reports, review articles, surveys, and investigations regarding treatment of lumbar disk herniations with spinal manipulation and adverse effects and associated risks
  • Prospective/retrospective studies and review papers were graded according to quality, and results and conclusions were tabulated. 
  • From the data published, an estimate of the risk of spinal manipulation causing a clinically worsened disk herniation or cauda equina syndrome (CES) in patients presenting with LDH was calculated. 
  • This was compared with estimates of the safety of nonsteroidal anti-inflammatory drugs (NSAIDs) and surgery in the treatment of LDH.

What They Found An estimate of the risk of spinal manipulation causing a clinically worsened disk herniation or CES in a patient presenting with LDH is calculated from published data to be less than 1 in 3.7 million.

Wrap It Up The apparent safety of spinal manipulation, especially when compared with other “medically accepted” treatments for LDH, should stimulate its use in the conservative treatment plan of LDH.

Item #3 The last one is called “Serious Adverse Events and Spinal Manipulative Therapy of the Low Back Region: A Systematic Review of Cases” by Herbert et. al.  and published in the Journal of Manipulative Physiological Therapeutics in 2015. Again….not hot but that’s OK. It’s a Systematic Review. 

Why They Did It The purpose of this study was to systematically search the literature for studies reporting serious adverse events following lumbopelvic spinal manipulative therapy (SMT) and to describe the case details.

How They Did It

  • A systematic search was conducted in PubMed including MEDLINE, EMBASE, CINAHL, and The Cochrane Library up to January 12, 2012, by an experienced reference librarian. 
  • Study selection was performed by 2 independent reviewers using predefined criteria. 
  • We included cases involving individuals 18 years or older who experienced a serious adverse event following SMT applied to the lumbar spine or pelvis by any type of provider (eg, chiropractic, medical, physical therapy, osteopathic, layperson). 
  • A serious adverse event was defined as an occurrence that results in death or is life threatening, requires hospital admission, or results in significant or permanent disability. 
  • A total of 2046 studies were screened, and 41 studies reporting on 77 cases were included.

What They Found

  • Important case details were frequently unreported, such as descriptions of SMT technique, the pre-SMT presentation of the patient, the specific details of the adverse event, time from SMT to the adverse event, factors contributing to the adverse event, and clinical outcome. 
  • Adverse events consisted of cauda equina syndrome (29 cases, 38% of total); lumbar disk herniation (23 cases, 30%); fracture (7 cases, 9%); hematoma or hemorrhagic cyst (6 cases, 8%); or other serious adverse events (12 cases, 16%) such as neurologic or vascular compromise, soft tissue trauma, muscle abscess formation, disrupted fracture healing, and esophageal rupture.

Wrap It Up

The anecdotal nature of these cases does not allow for causal inferences between SMT and the events identified in this review.  When chiropractic is done responsibly and appropriately, it’s safer than almost any medical intervention. It just is. Now, when you have people damn near yanking people’s heads off of their bodies, aggressively adjusting patients on YouTube that have had a significant history of stroke, and adjusting 80 year old women with the same gusto you’d use with a 25 year old male…..well….those folks are just asking for it.  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 so 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 https://www.chiropracticforward.com

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

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

Twitter https://twitter.com/Chiro_Forward

YouTube https://www.youtube.com/channel/UCtc-IrhlK19hWlhaOGld76Q

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

Player FM Link https://player.fm/series/2291021

Stitcher: https://www.stitcher.com/podcast/the-chiropractic-forward-podcast-chiropractors-practicing-through

TuneIn https://tunein.com/podcasts/Health–Wellness-Podcasts/The-Chiropractic-Forward-Podcast-Chiropractors-Pr-p1089415/

About the Author & Host Dr. Jeff Williams – Fellow of the International Academy of Neuromusculoskeletal Medicine – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger  

Bibliography

  • James M Whedon, D., MS, Andrew W J Toler, MS, Louis A Kazal, MD, Serena Bezdjian, PhD, Justin M Goehl, DC, MS, Jay Greenstein, DC (2020). “Impact of Chiropractic Care on Use of Prescription Opioids in Patients with Spinal Pain.” Pain Med 21(12): 3567-3573.  
  • Oliphant D “Safety of spinal manipulation in the treatment of lumbar disk herniations: a systematic review and risk assessment.” J Man Physiol Ther 27(3): 197-210.  

Obesity In Youths With Chronic Pain, The Healing Journey of Pain, and Fibromyalgia Treatment

CF 190: Obesity In Youths With Chronic Pain, The Healing Journey of Pain, and Fibromyalgia Treatment

Today we’re going to talk about obesity in youth and chronic pain, we’ll talk about fibromyalgia and hyperbaric oxygen chambers, and we’ll talk about chronic pain and the healing journey.  But first, here’s that sweet sweet bumper music

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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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 an invaluable resource for your patient education and for you. It can save you time in putting talks together or just staying current on research. It’s categorized into sections so that the information is easy to find and it’s written in a way that is easy to understand for practitioner as well as patient. You have to check it out. 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 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 #190 Now if you missed last week’s episode , we were joined by the amazing Dr. Brett Winchester from the St. Louis area. This doctor is just phenomenal in everything he does and says and we are all fortunate to have him in this profession. Make sure you don’t miss that info. Keep up with the class.  On the personal end of things….. Day 1 of our nurse practitioner starting is today. This morning has, of course, had its hiccups. We have the EHR where we have him set up but he has to have his own login and password and all that good stuff so that’s been one challenge so far.  Just getting oriented with where all of the stuff is, lidocaine, lab tubes, swabs, blah blah blah. Still waiting on the autoclave and still getting the malpractice policy in place this morning. What a process that’s been.  But we knew there’d be hiccups, and we’re getting them addressed. Then I have my regular life to contend with. I have patients to treat and a podcast to write so here we go. Short and sweet on this one because my cup is running over this morning.  Item #1 Our first item today is called “Obesity in Youth with Chronic Pain: Giving It the Seriousness It Deserves” by Hainsworth et. al. (Keri R Hainsworth 2021) and published in Pain Medicine in June of 2021 and day-um…..that’s hot! Why They Did It The aim of this commentary is to review the current science on co-occurring chronic pain and obesity in children and adolescents. In so doing, we also highlight some of the current gaps in knowledge. It is our hope that this commentary will draw attention to an overlooked area of research and clinical endeavors within the field of pediatric pain. The authors note that it is becoming increasingly clear that we should be familiar with this research. Both chronic pain and obesity have been rising in children for some time and studies are showing that obesity exacerbates the negative outcomes associated with chronic pain.  In addition, accumulating research exists on all facets of the co-occurrence of chronic pain and obesity in adults. Given all this, the paucity of research in this area of pediatric chronic pain and obesity is at a minimum, disheartening, and at a maximum, unconscionable. Ooooweee! That’s like putting a white glove on and smacking some clown around the room a little bit, isn’t it? I like it. It give me a little tickle.  Here are their main points:
  • On average, it can take 2 years longer for youth with obesity to be referred to a pediatric pain clinic than it does for youth with a normal weight
  • Pediatric patients with CPO have health-related quality of life that is more impaired in every domain than patients with chronic pain and a healthy body mass index percentile
  • Although systemic inflammation is commonly elevated in youth with obesity, patients with CPO have significantly higher levels of systemic inflammation than those with chronic pain alone or obesity alone 
  • Children with CPO are at increased risk of being treated as though they bear more responsibility for their health (and by extension, their pain) than youth without obesity and are at increased risk of pain dismissal and biased medical care
  • CPO in children and adolescents is associated with more impaired physical functioning and lower levels of physical activity than youth with chronic pain alone or obesity alone Further, parents report that their children with CPO (particularly girls) have greater functional disability (one of the most important outcomes in our field) than parents of youth with chronic pain and a normal body mass index
  • While multidisciplinary pain management programs work well for patients with a healthy weight, this is not true for those with comorbid obesity. Patients with a healthy weight improve in functional disability within 3 months of intake, whereas patients with CPO stagnate
First, even though we as clinicians and researchers need to address obesity in the context of chronic pain, we must be extremely thoughtful about how we move forward. Weight is a very sensitive subject, therefore, the call for more research in this area must strongly consider the need for sensitivity. CPO is the co-occurrence of a typically “invisible,” debilitating condition coupled with a condition so visible that it is sadly associated with victimization from important people in the child’s life, including peers, parents, and teachers Second, we would do well to closely follow the admonitions and advice of our colleagues whose primary clinical and research focus is on obesity and stigma. Suggestions from these experts include first recognizing that weight bias exists even among pediatric health care providers [20]. Additionally, language must be very carefully considered. Puhl et al. [20] offer the practical and sensitive suggestion to ask the patient and family about preferred words or terms in discussions about weight-related health Third, like other health care professionals, we would benefit from a greater understanding of the complexity of obesity and the “potential benefits and disadvantages of introducing weight-management discussions with patients” [14](p865). Certainly, there will be times when weight-related discussions would be contraindicated by the patient’s and/or family’s psychological or emotional state. However, when weight needs to be raised in relation to a child’s chronic pain, it may be best received in the context of health implications. Obesity is a multifactorial disease with strong genetic contributions. It is also associated with systemic inflammation, metabolic syndrome, and increased risk for diabetes and cardiovascular disease, as well as chronic pain. In fact, most are unaware that obesity is a risk factor for migraines in pediatric populations. That said, weight-related health or weight-related pain discussions cannot focus entirely on losing weight. For many, it is a struggle to change their weight status, and even if it is possible, this process takes time. We must not ignore managing pain while we wait for possible weight reduction. CHIROUP ADVERTISEMENT Item #2 Our second one today is called “Evaluation of a Hyperbaric Oxygen Therapy Intervention in Individuals with Fibromyalgia” by Curtis et. al.(K Curtis 2021)  and published in Pain Medicine in June of 2021…….pork chops and apple sauce.  Why They Did It To evaluate the feasibility and safety of hyperbaric oxygen therapy (HBOT) in patients with fibromyalgia (FM). How They Did It
  • A total of 17 patients completed the study
  • A cohort study with a delayed treatment arm used as a comparator.
  • Hyperbaric Medicine Unit, Toronto General Hospital, Ontario, Canada.
  • Eighteen patients diagnosed with FM according to the American College of Rheumatology and a score ≥60 on the Revised Fibromyalgia Impact Questionnaire.
  • Participants were randomized to receive immediate HBOT intervention (n = 9) or HBOT after a 12-week waiting period
  • HBOT was delivered at 100% oxygen at 2.0 atmospheres per session, 5 days per week, for 8 weeks
  • Both groups were assessed at baseline, after HBOT intervention, and at 3 months’ follow-up.
What They Found
  • HBOT-related adverse events included mild middle-ear barotrauma in three patients and new-onset myopia in four patients
  • The efficacy of HBOT was evident in most of the outcomes in both groups
  • This improvement was sustained at 3-month follow-up assessment.
Wrap It Up HBOT appears to be feasible and safe for individuals with FM. It is also associated with improved global functioning, reduced symptoms of anxiety and depression, and improved quality of sleep that was sustained at 3-month follow-up assessment. I don’ tank about you but I’m not going to go out and buy an oxygen chamber this afternoon but, it’s interesting and I’ve always heard positive things about them so this one peaked my interest a bit. I figured it would with you as well.  Item #3 The last one is called “A Healing Journey with Chronic Pain: A Meta-Ethnography Synthesizing 195 Qualitative Studies” by Toye et. al. and also published in Pain Medicine in June of 2021….Smoke show!! You know, it’s almost like I got an email from Pain Medicine last week highlighting some of their newest research in their June edition. Weird how all of these articles were all in the same month and in the same episode here. Right? Why They Did It There is a large body of research exploring what it means for a person to live with chronic pain. However, existing research does not help us understand what it means to recover. We aimed to identify qualitative research that explored the experience of living with chronic pain published since 2012 and to understand the process of recovery. How They Did It
  • A synthesis of qualitative research using meta-ethnography.
  • We used the seven stages of meta-ethnography. 
  • We systematically searched for qualitative research, published since 2012, that explored adults’ experiences of living with, and being treated for, chronic pain. 
  • We used constant comparison to distill the essence of ideas into themes and developed a conceptual model.
  • We screened 1,328 titles and included 195 studies.
Wrap It Up The innovation of our study is to conceptualize healing as an ongoing and iterating journey rather than a destination. Health interventions for chronic pain would usefully focus on validating pain through meaningful and acceptable explanations; validating patients by listening to and valuing their stories; encouraging patients to connect with a meaningful sense of self, to be kind to themselves, and to explore new possibilities for the future; and facilitating safe reconnection with the social world. This could make a real difference to people living with chronic pain who are on their own healing journeys. 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 so 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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This image has an empty alt attribute; its file name is Screen-Shot-2018-07-12-at-10.23.09-AM-150x55.jpg
The Message I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment rather than chemical treatments like pills and shots. When compared to the traditional medical model, research and clinical experience show us patients can get good to excellent results for headaches, neck pain, back pain, and joint pain to name just a few. It’s safe and cost-effective can decrease surgeries & disability and we do it through conservative, non-surgical means with minimal hassle to the patient. And, if the patient treats preventatively after initial recovery, we can usually keep it that way while raising the overall level of health! Key Point: At the end of the day, patients should have the guarantee of having the best treatment that offers the least harm. When it comes to non-complicated musculoskeletal complaints…. That’s Chiropractic! Contact Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show and tell us your suggestions for future episodes.  Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on podcast platforms.  We know how this works by now. If you value something, you have to share it, interact with it, review it, talk about it from time to time, and actively hit a few buttons to support it here and there when asked. It really does make a big difference.  Connect We can’t wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward. Website
Home
Social Media Links https://www.facebook.com/chiropracticforward/ Chiropractic Forward Podcast Facebook GROUP https://www.facebook.com/groups/1938461399501889/ Twitter YouTube https://www.youtube.com/channel/UCtc-IrhlK19hWlhaOGld76Q iTunes https://itunes.apple.com/us/podcast/chiropractic-forward-podcast-chiropractors-practicing/id1331554445?mt=2 Player FM Link https://player.fm/series/2291021 Stitcher: https://www.stitcher.com/podcast/the-chiropractic-forward-podcast-chiropractors-practicing-through TuneIn https://tunein.com/podcasts/Health–Wellness-Podcasts/The-Chiropractic-Forward-Podcast-Chiropractors-Pr-p1089415/ About the Author & Host Dr. Jeff Williams – Fellow of the International Academy of Neuromusculoskeletal Medicine – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger Bibliography
  • K Curtis, P., J Katz, PhD, C Djaiani, BSc, G O’Leary, MD, FRCPC, J Uehling, MS, CCRP, J Carroll, BHA, D Santa Mina, PhD, H Clarke, MD, PhD, FRCPC, M Gofeld, MD, PhD, FRCPC, R Katznelson, MD, FRCPC, (2021). “Evaluation of a Hyperbaric Oxygen Therapy Intervention in Individuals with Fibromyalgia.” Pain Med 22(6): 1324-1332.
  • Keri R Hainsworth, P., Monica L Gremillion, PhD, W Hobart Davies, PhD, Stacy C Stolzman, PT, MPT, PhD, Steven J Weisman, MD, (2021). “Obesity in Youth with Chronic Pain: Giving It the Seriousness It Deserves.” Pain Med 22(6): 1243-1245.
       

w/ Dr. Rob Pape – Quadrant Analysis & Practice Mechanics

CF 188: w/ Dr. Rob Pape – Quadrant Analysis & Practice Mechanics Today we’re going to be joined by Dr. Rob Pape.

I’ll get into his bio a bit deeper in the interview and introduction but Dr. Pape is the creator of Quadrant Analysis improving patient assessment by breaking down the evaluation process. He is also a co-creator of Practice Mechanics. Along with one of our previous podcast guests, Dr. Michael Massey, they have created Practice Mechanics to help their doctors hit that next level. We’ll get into it here shortly.  But first, here’s that sweet sweet bumper music    

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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  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 an invaluable resource for your patient education and for you. It can save you time in putting talks together or just staying current on research. It’s categorized into sections so that the information is easy to find and it’s written in a way that is easy to understand for practitioner as well as patient. You have to check it out. 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 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 #188 Now if you missed last week’s episode, we talked about hypermobile patients, sports-related concussions, and obesity’s pain connection. Make sure you don’t miss that info. Keep up with the class. 

On the personal end of things…..

Still in the middle of medical integration. Our nurse practitioner starts on August 2nd so, we’re pretty close at this point. I just ordered the centrifuge for the PRP therapy. I have heard of PRP for a little while now but mostly for hair loss. I have a close family member that has a little hair loss going on so he and his mother were asking me about PRP for hair loss.  I didn’t know much about it. In case you aren’t familiar, PRP stands for plasma-rich platelets. They draw your blood, spin it down in the centrifuge, extract the platelets, and then inject it into the problem.  I literally spent 2 hours this weekend going through research on PRP therapy.

I filtered PubMed to only show me randomized controlled trials. I don’t need a lot of BS. Let’s just go further up the research pyramid for the good stuff, right? So what I found was actually surprising as hell. While I could find 2, 3, maybe 4 papers tops that showed equal effectiveness to cortisone or something like that…..the large majority of the papers were clear that PRP is showing impressive effectiveness for just about damn near anything they try it on including ACL surgery recovery, hair loss, plantar fasciitis, general osteoarthritis, shoulders, knees, hips, ankles, carpal tunnel, and the list goes on.  I have me a big ol’ file on my computer full of them all now. I can really get behind things like this that I can find a ton of positive research on. Just like everything else in my practice.

If I can find support in the literature, I have no problem encouraging it. Notice I didn’t say, “Sell it.” I’m a healthcare provider. Not a salesman. We should always be honest and tell our patients about the cool research behind something you think will truly help them but then we should shut up and be there for them however they want to use us. Plain and simple.  So, again, I have no problem encouraging and educating on something that has shown such effectiveness. It’s pretty amazing actually so I’ll keep you updated on that. If you’re integrating or considering doing it, it’ll come in handy for you. If you’re not, it might give you some direction on what to do with those patients that have some stubborn conditions. More to come on that.  OK, let’s get to today’s guest so we don’t go too long here. I want him to have plenty of time.  Before we do that though, let’s hear a word from our sponsors, shall we?

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Dr. Rob Pape is our guest today. He is a long-time innovator in clinical evaluation and treatment instruction. He created Quadrant Analysis, which combines a sub-classification system with practical biomechanics. Quadrant Analysis improves and simplifies patient assessment, breaking the body down into traceable patterns which chiropractors can utilize to get better and faster patient results. 

The Practice Mechanics resources include detailed information about Quadrant Analysis and specific techniques so you can help your patients get the results you want for them. Rob graduated from Life Chiropractic College West in 1996 and has been in successful practice ever since. His clinical approach is full body and generally combines joint and soft tissue work with movement therapy.

Welcome welcome Rob. Tell me where you are living these days, tell me about your family, and how long you’ve been in the trenches. What’s your story? Why are you a chiropractor today? What does your regular workday look like these days? You went to Life, a school that is notorious for being very philosophy-heavy, shall we say? With that as your initial base of knowledge and influence, what pointed you down the evidence-based/evidence-informed path? What’s your take on the profession today? What are we getting better at? Where are we losing ground? Where can we improve? If you could wave a wand and change one thing about the profession forever, what would you change? What would other chiropractors say is your best attribute? And what would the ones that know you really well say is your worst? What is the goal for Practice Mechanics? Outside of the obvious, which is building business, what do you hope to achieve by growing it?

How can doctors that are interested get in contact with you for more information? 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 so 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

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

Western Diet Hurts and Acupuncture

 CF 186: Western Diet Hurts and Acupuncture Today we’re going to talk about new research based on chronic pain and our regular Western diet. Then we discuss  But first, here’s that sweet sweet bumper music

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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  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 #186 Now if you missed last week’s episode , we talked about high impact chronic pain and we talked about newer research on the use of cannabinoids in adolescence. Make sure you don’t miss that info. Keep up with the class. 

On the personal end of things…..

I’m feeling pretty good today, folks. I’m feeling pretty optimistic. If I had known what a process building a medical clinic truly is, I may have thought it through just a little bit more than I did. There really is a solid reason more chiropractors don’t take the steps to do it. And that’s because it isn’t easy.  Attorneys, medical directors, hiring the nurse pracs, setting up training, getting the malpractice in place, getting the DEA number of the medical director to have your address on it so your NP can order the things they need, getting your NP credentialed, getting the entities created correctly by the CPAs……it’s a process for damn sure. 

I remember when I started this path, my good buddy and consultant on it, Dr. Tyce Hergert in Southlake, TX, he told me get your seatbelt on because the majority of the work is in the first 90 days. I feel like it’s starting to loosen up a bit and the clouds are clearing on this integration deal. Which is exciting. Because then you can go from wading through the paperwork and minutiae and start focusing on their training and growing the word of mouth and actually start working on the business. That’s where my skill level lies.  I’m not 100% out of the initial struggle to get it set up and off the ground but I’m getting toward the rear end of it and that’s encouraging. For instance, my morning this morning was setting up an account with a medical supplies company and getting started with my first order of IV equipment, cotton swabs, medipore tape, and things of that nature.  Right…..I know…..ugh.

But it’ll be worth it eventually. At least it damn sure better be! Beyond that, last week was better as far as clinic numbers. Moving in the right direction. I believe as a solo practitioner I had about 167. Still not pre-COVID numbers but not awful. I can deal with stuff mentally when I know it’s moving the right direction. It’s when it’s staying slim and there’s no longer rhyme or reason for it that makes me lose my mind. 

So, the mind is intact today and I’m looking forward. Onward and upward today.  Still no emails from any of you on what you’ve done to help the rest of you get your patients back. So, any help and advice from the think tank here would be good for the rest of the crew. Share. Give. It’ good for you. 

Item #1

This first one his an article that appeared in the Seattle Times called “Study finds correlation between high-fat Western diet and pain” by Theresa Braine of the New York Daily News (Braine 2021). It was published on June 24, 2021 and it’s hotter than hot stuff! And on a side note, You’d be in a hell of an awkward position if you last name was Braine but you were an idiot wouldn’t you? Think about that a minute. Your name is brain but you’re basically walking around bumping into walls…..people snickering behind your back…..Brain….right, right.  Anyway, that’s a little peak into my brain for you.

Anyway…since it’s an article, as always I just basically summarize and hit the high spots. 

  • They say the Western diet is associate with many ills and now chronic pain might be added to the list. 
  • A new study looks at the potential for omega-6 fats’ influence on neuropathic pain in people with diabetes and other conditions.
  • Researchers at the University of Texas Health Science Center at San Antonio studied the effects of omega-6 fatty acids themselves by measuring the role of these dietary lipids in pain conditions and found that the substances themselves seem to cause pain and inflammation.
  • Diabetes, autoimmune disorders and cardiovascular diseases are known to be affected by nutritional choices, the researchers said. But excessive consumption of omega-6 fats, which are found largely in commonly consumed processed foods, had not been studied in terms of the acids themselves and their role specifically in pain.
  • They studied polyunsaturated fatty acids in both mice and humans.
  • The five-year study was published in the June edition of the journal Nature Metabolism.
  • Omega-6 fats mainly occur in foods with vegetable oils
  • “But Western diets associated with obesity are characterized by much-higher levels of those acids in foods from corn chips to onion rings, than healthy omega-3 fats, which are found in fish and sources like flaxseed and walnuts,” the researchers’ statement said. “Generally, unhealthy foods high in omega-6 fats include processed snacks, fast foods, cakes, and fatty and cured meats, among others.”
  • Reversing those dietary habits and increasing omega-3 fats “greatly reduced these pain conditions,” the researchers found. “Also, the authors demonstrated that skin levels of omega-6 lipids in patients with Type 2 diabetic neuropathic pain were strongly associated with reported pain levels and the need for taking analgesic drugs.”

So, we’re seeing more and more studies like this talking about inflammatory diets, high-fat, and things of that nature. All being related to increased levels of pain. This is something chiropractors can get behind. I can be very honest when I say that the main gap missing in my clinic is weight loss. Diet and nutrition. Things of that nature. As a result, I’m having our nurse practitioner trained in medical weight loss so we can fill that gap and be well-rounded. 

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Item #2

Next up, I’ve been asked to put together a talk based on evidence-based, patient-centered practice and what makes it the future of our profession. The special request was to end the talk with some research-based around acupuncture research. Texas chiropractors continue to go through battles and one of them is against the acupuncturists in the state.  So, with that, I’m going to offer up a couple of papers. I’ve got a bunch of good ones but thought I’d just cover a couple here. The first one is called “Clinical Evidence for Association of Acupuncture and Acupressure With Improved Cancer Pain A Systematic Review and Meta-Analysis” by He et. al. (He Y 2019) and published in JAMA Oncology on December 19, 2019 and it goes a little sumpin’ like this. 

The first thing that jumps out here, especially for those somewhat new to reading through research, is that this is a systematic review and meta-analysis. That is at the top of the research pyramid. For example simple little case studies and animal studies, pilot studies….things of that nature….they live at the bottom, less meaningful or less impactful part of the pyramid. As you climb the pyramid to the more important stuff, you’ll see cohort studies and randomized controlled trials. Then, at the very top, the most meaningful studies are the systematic reviews topped off by the meta-analysis.  What I’m saying is that this paper is good stuff. It’s good information. And it appears in a very respected journal. The Journal of the American Medical Association’s Oncology branch. It’s high level from several aspects.  

Why They Did It

The authors wanted to answer the question, “Is the use of acupuncture and acupressure associated with improved cancer pain management compared with sham intervention and/or analgesic therapy alone?

How They Did It

  • It was a systematic review of 17 randomized clinical trials and meta-analysis of 14 trials in the current English-language and Chinese-language literature
  • Three English-language databases and 4 Chinese-language biomedical databases were searched for RCTs published from database inception through March 31, 2019.
  • Randomized clinical trials that compared acupuncture and acupressure with a sham control, analgesic therapy, or usual care for managing cancer pain were included.
  • The quality of RCTs was appraised with the Cochrane Collaboration risk of bias tool
  • The primary outcome was pain intensity measured by the Brief Pain Inventory, Numerical Rating Scale, Visual Analog Scale, or Verbal Rating Scale.

What They Found

A significant association was found between real (compared with sham) acupuncture and reduced pain, and acupuncture combined with analgesic therapy was associated with decreased analgesic use. However, heterogeneity lowered the level of certainty of the evidence.

Wrap It Up

This study found a moderate level of evidence that acupuncture and/or acupressure was significantly associated with lower pain intensity in patients with cancer compared with a sham control, which suggests a potential for a combination of acupuncture and acupressure to help reduce opioid doses in patients with cancer.

Item #3

This last one is called “Acupuncture for neck disorders (Review for The Cochrane Collaboration)” by Trinh et. al. (Trinh K 2016) and it can be found in the Cochrane Library published in May of 2016 so it’s about 5 years old at this point. 

Why They Did It

  • Acupuncture has been used as an alternative to more conventional treatment for musculoskeletal pain. This review summarises the most current scientific evidence on the effectiveness of acupuncture for acute, subacute and chronic neck pain.
  • To determine the effects of acupuncture for adults with neck pain, with focus on pain relief, disability or functional measures, patient satisfaction and global perceived effect.

How They Did It

  • They searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Manual, Alternative and Natural Therapy Index System (MANTIS), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Index to Chiropractic Literature (ICL) from their beginning to August 2015
  • They searched reference lists, two trial registers and the acupuncture database Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS) in China to 2005.
  • We included published trials that used random assignment to intervention groups, in full text or abstract form. We excluded quasi-randomized controlled trials 
  • Of the 27 included studies, three represented individuals with whiplash‐associated disorders (WADs) ranging from acute to chronic (205 participants), five explored chronic myofascial neck pain (186 participants), five chronic pain due to arthritic changes (542 participants), six chronic non‐specific neck pain (4011 participants), two neck pain with radicular signs (43 participants) and six subacute or chronic mechanical neck pain (5111 participants). So there was a big mix of conditions represented with a solid sample size when you add them all up. 

What They Found

  • For mechanical neck pain, we found that acupuncture is beneficial at immediate‐term follow‐up compared with sham acupuncture for pain intensity; at short‐term follow‐up compared with sham or inactive treatment for pain intensity; at short‐term follow‐up compared with sham treatment for disability; and at short‐term follow‐up compared with wait‐list control for pain intensity and neck disability improvement.
  • This effect does not seem sustainable over the long term. Whether subsequent repeated sessions would be successful was not examined by investigators in our primary studies.

Wrap It Up

Moderate‐quality evidence suggests that acupuncture relieves pain better than sham acupuncture, as measured at completion of treatment and at short‐term follow‐up, and that those who received acupuncture report less pain and disability at short‐term follow‐up than those on a wait‐list. Moderate‐quality evidence also indicates that acupuncture is more effective than inactive treatment for relieving pain at short‐term follow‐up. Alright, for those not yet on the acupuncture train, take another look.

The VA here locally are sending veterans to us right now for our acupuncturist to work with them and these old grizzly vets absolutely love it. Yep, that’s anecdotal as hell but I’m telling you, there’s something to it and research seems to be catching up to it.  Patients ask me how it works and I have to be honest……I’m not sure. I have some guesses but it’s a lot like a damn TV. I can’t tell you the exact way a program’s signal gets to my house and shows up when I turn the damn TV on. But I know how to enjoy the results.  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.   

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

https://www.amazon.com/dp/B096RST3WW

 

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 & disabilities and we do it through conservative, non-surgical means with minimal hassle to the patient. And, if the patient treats preventatively after initial recovery, we can usually keep it that way while raising the overall level of health!

Key Point:

At the end of the day, patients should have the guarantee of having the best treatment that offers the least harm. When it comes to non-complicated musculoskeletal complaints…. That’s Chiropractic!

Contact

Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show and tell us your suggestions for future episodes.  Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on podcast platforms.  We know how this works by now. If you value something, you have to share it, interact with it, review it, talk about it from time to time, and actively hit a few buttons to support it here and there when asked. It really does make a big difference. 

Connect

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

Website

Home

Social Media Links

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

Chiropractic Forward Podcast Facebook GROUP

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

Twitter

YouTube

https://www.youtube.com/channel/UCtc-IrhlK19hWlhaOGld76Q

iTunes

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

Player FM Link

https://player.fm/series/2291021

Stitcher:

https://www.stitcher.com/podcast/the-chiropractic-forward-podcast-chiropractors-practicing-through

TuneIn

https://tunein.com/podcasts/Health–Wellness-Podcasts/The-Chiropractic-Forward-Podcast-Chiropractors-Pr-p1089415/

About the Author & Host

Dr. Jeff Williams – Fellow of the International Academy of Neuromusculoskeletal Medicine – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger

Bibliography

  • Braine, T. (2021). Study finds correlation between high-fat Western diet and pain. Seattle Times.
  • He Y, G. X., May BH, (2019). “Clinical Evidence for Association of Acupuncture and Acupressure With Improved Cancer Pain: A Systematic Review and Meta-Analysis.” JAMA Oncol 6(2): 271-278.
  • Trinh K, G. N., Irnich D, Cameron ID, Forget M (2016). “Acupuncture for neck disorders. Cochrane Database of Systematic Reviews 2016,.” Cochrane Database of Systematic Reviews 5.

 

What Sitting On Your Butt Will Get You & Catastrophizing An MRI Result

CF 180: What Sitting On Your Butt Will Get You & Catastrophizing An MRI Result Today we’re going to talk about sitting on your butt and we’ll talk about catastrophizing from an image.  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 #180 Now if you missed last week’s episode, we talked about the alarming rising death rate among the working-age population and we discussed the role nutrition can play in chronic pain. Make sure you don’t miss that info. Keep up with the class. 

On the personal end of things…..

It’s going to be a short one this week. I have to fit a full week if work responsibilities into three days because I’m taking off Thursday through Tuesday. My wife and kids and I are heading out to New Orleans to get fat and drink funny drinks.  I love Louisiana. I was in the football team at West Texas State for one semester before transferring to Northwestern Louisiana in Natchitoches. Same town Steel Magnolias was filmed in. Absolutely gorgeous. Going from the Texas Panhandle to Louisiana was a culture shock y’all. Whole different wonderful world. I tell people that you simply cannot spend any amount of real-time in Louisiana without absolutely falling in love with the people, the music, the culture, the food…..the VIBE. It’s special. We like to travel. I’ve told you here several times that you need a trip at least once per quarter. Something to look forward to. Something to work toward.  Once we see a place, it’s time to move on and see something else. There are too many places to see in the world to be going back to the same ol’ places all of the time.

Except for New Orleans. We go back just as often as we get the opportunity to.

It’s somewhat close and we love it So, we’re going this week. And I have to keep it short. The medical integration is going slowly. Business is steady but not Pre- Covid numbers. I’m frustrated with that if Imm. Ring honest and I’m always honest with you all. It’s really kind of pissing me off. But I’m a Christian. It’s not always in my hands. Good luck looks a whole lot like hard hard work. So do what’s right. Treat people right. Love folks. It’ll work out. Just be prepared and try to be a learn it all instead of a know it all. Here we go. But first, let’s hear from our amazing, practice-changing sponsors!

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Item #1

The first item up is called “The Association Between Leisure-time Physical Activity, Sedentary Behavior, and Low Back Pain: A Cross-sectional Analysis in Primary Care Settings” by Lemes, et. al. [1] and published in Spine Journal on May 1, 2021 Hot tamale, hot tamale….get ‘em while they’re good ’n’ hot!

Why They Did It To investigate the association between leisure-time physical activity (LTPA) and low back pain (LBP) in adults from primary care settings, and to explore how sedentary behavior influences this association.

How They Did It

  • Cross-sectional analysis of an ongoing longitudinal study with adults from Bauru, Brazil – that was 557 individuals.
  • Data on physical activity, sitting time, LBP, BMI, and chronic diseases were assessed by face-to-face interviews, physical evaluation, and medical records. 
  • Sociodemographic, behavioral, and health variables were used as covariables in the multivariable models.

What They Found

  • The fully adjusted model showed that active participants were 33% less likely to have LBP when compared with those insufficiently active
  • A significant association was found for active participants who spent less than 3 h/day sitting but not for those who spent 3 h/day or more in sedentary activities
  • An inverse association of LTPA with LBP was observed in obese participants, but not in those with normal BMI and overweight.

Wrap It Up

Leisure-time physical activity was inversely associated with the prevalence of LBP in adults from primary care. This association was influenced by sedentary behavior and BMI.

Item #2

Our last one this week is called, “The catastrophization effects of an MRI report on the patient and surgeon and the benefits of ‘clinical reporting’: results from an RCT and blinded trials” by Rajasekaran, et. al. [2] and published in European Spine Journal in March of 2021.  Pork chops and hot sauce. 

Why They Did It Inappropriate use of MRI leads to increasing interventions and surgeries for low back pain (LBP). We probed the potential effects of a routine MRI report on the patient’s perception of his spine and functional outcome of treatment. An alternate ‘clinical reporting’ was developed and tested for benefits on LBP perception.

How They Did It In Phase-I, 44 LBP patients were randomized to Group A who had a factual explanation of their MRI report or Group B, who were reassured that the MRI findings showed normal changes. The outcome was compared at 6 weeks by VAS, PSEQ-2, and SF-12. In Phase-II, clinical reporting was developed, avoiding potential catastrophizing terminologies. In Phase-III, 20 MRIs were reported by both routine and clinical methods. The effects of the two methods were tested on four categories of health care professionals (HCP) who read them blinded on their assessment of the severity of disease, possible treatment required, and the probability of surgery.

What They Found

  • Both groups were comparable initial by demographics and pain. 
  • After 6 weeks of treatment, Group A had a more negative perception of their spinal condition, increased catastrophization, decreased pain improvement, and poorer functional status(p = significant for all). 
  • The alternate method of clinical reporting had significant benefits in the assessment of lesser severity of the disease, shift to lesser severity of intervention and surgery in three groups of HCPs.

Wrap It Up

Routine MRI reports produce a negative perception and poor functional outcomes in LBP. Focused clinical reporting had significant benefits, which calls for the need for ‘clinical reporting’ rather than ‘Image reporting’. Words matter, folks. Words matter. If you’re telling people that they have abnormal degeneration or an abnormally straightened cervical spine and telling them how concerned you are for their future if they don’t spend 70 visits and $5,000 this year to fix it……blah blah blah.  If you’re doing this, you either don’t understand stuff and you need to do a lot more sciencing……or…..or you’re predatory, unethical, and a sorry human being that needs to reconsider how you treat your fellow humans. 

Sorry, I realize that’s harsh. But it’s the truth. If you are taking images and using them to scare people into treatment to build your clinic and your numbers, you are in the wrong business. Go sell cars. This is healthcare and people’s very lives and the quality of their lives are involved.  Learn to communicate in a positive, optimistic manner. Learn to get people moving and functioning.

Learn to address the biopsychosocial aspect of pain. Learn to use it in the patient’s favor, not in your favor. Just learn if you don’t know these things. Raise the game. If you have the chance, and you do, why not just be a big deal then? Let’s all be big deal by being learn it alls. Being ethical, moral, honest, and loving. Oh, and by acting responsibly based on the model of evidence-based, patient-centered care.  We have companies out there teaching chiropractors how to ‘close’ patients. What clowns. That’s clown stuff folks. Don’t do it. Raise the game.  Way too many shenanigans have been going on in this profession for way too long.  Alright, that’s it. Y’all be safe. Keep changing our profession from your little corner of the world. Keep taking care of yourselves and everyone around you. Tough times are upon us but, the sun will shine again. Trust it, believe it, count on it. Let’s get to the message. Same as it is every week. 

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

Chiropractic evidence-based products

Integrating Chiropractors

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The Message

I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment rather than chemical treatments like pills and shots. When compared to the traditional medical model, research and clinical experience show us patients can get good to excellent results for headaches, neck pain, back pain, and joint pain to name just a few. It’s safe and cost-effective can decrease surgeries & disability and we do it through conservative, non-surgical means with minimal hassle to the patient. And, if the patient treats preventatively after initial recovery, we can usually keep it that way while raising the overall level of health!

Key Point: At the end of the day, patients should have the guarantee of having the best treatment that offers the least harm. When it comes to non-complicated musculoskeletal complaints…. That’s Chiropractic!

Contact Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show and tell us your suggestions for future episodes.  Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on podcast platforms.  We know how this works by now. If you value something, you have to share it, interact with it, review it, talk about it from time to time, and actively hit a few buttons to support it here and there when asked. It really does make a big difference. 

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

Website https://www.chiropracticforward.com

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

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

Twitter https://twitter.com/Chiro_Forward YouTube https://www.youtube.com/channel/UCtc-IrhlK19hWlhaOGld76Q

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

Player FM Link https://player.fm/series/2291021

Stitcher: https://www.stitcher.com/podcast/the-chiropractic-forward-podcast-chiropractors-practicing-through

TuneIn https://tunein.com/podcasts/Health–Wellness-Podcasts/The-Chiropractic-Forward-Podcast-Chiropractors-Pr-p1089415/

About the Author & Host Dr. Jeff Williams – Fellow of the International Academy of Neuromusculoskeletal Medicine – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger  

Bibliography

1. Lemes ÍR, P.R., Turi Lynch BC, Codogno JS, Oliveira CB, Ross LM, Araújo Fernandes R, Monteiro HL,, The Association Between Leisure-time Physical Activity, Sedentary Behavior, and Low Back Pain: A Cross-sectional Analysis in Primary Care Settings. Spine (Phila Pa 1976), 2021. 46(9): p. 596-602. 2.

2. Rajasekaran S, D.C.R.S., Pushpa BT, Ananda KB, Ajoy Prasad S, Rishi MK,, The catastrophization effects of an MRI report on the patient and surgeon and the benefits of ‘clinical reporting’: results from an RCT and blinded trials. Eur Spine J, 2021.

Useless Research & Insulin or Inflammation

CF 172: Useless Research & Insulin or Inflammation Today we’re going to talk about how I treat my staff, we’ll talk about insulin vs. inflammation, and we’ll talk about some trash research that came out in JAMA recently that you may wind up being confronted with at some point so listen up.  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 #172 Now if you missed last week’s episode , we talked about going the way of the non-pharma world. If we could just get the the medical world to take a look at it. We also talked about insurance coverage trends and how they’re not very favorable to chiropractors. As you probably already feel. Make sure you don’t miss that info. Keep up with the class. 

On the personal end of things…..

On the personal end of things, we’re still interviewing nurse practitioners and still getting our ducks in a row. We have the attorney that is setting up the medical entity meeting with our CPAs out in St. Louis to make sure it is set up in the most tax-advantageous as well as the most ideal legal way.  Any time you have your CPA and your attorney working together, you’re probably in a good place me thinks. I have a meeting with the medical director this week to go over what services he’s going to be OK with us offering. When appropriate, we’ll be looking at things like intra-joint injections, trigger point injections, low-level scripts but no narcotics.  Basically, anything we offer here will be very low risk. Not only because it inherently lowers our risk to adverse events, which makes me sleep better every night, but it also helps to keep a happy medical director. If it all works right, this is almost mailbox money for the medical director while providing an awesome gig for a nurse practitioner that is at least halfway motivated to build their practice. 

Think about it, nurses and nurse pracs are used to 12-hour shifts. They’ve missed important holidays and important events in their personal life due to having to work. Here, there are no weekends, there are not holidays spent working, vacation time, it’s all good in the hood at my place. Plus, they get to learn as much about orthopedics as they want to learn and a whole bunch they maybe don’t want to learn but is required to learn in order to work here.  That’s the deal though right?

Gotta pick the right NP because it all hinges on that one decision. Pick the wrong one and you’re out of business until you can get another hired. Doesn’t sound like a big deal until you factor in the 3 months it takes to get a new one credentialed. Speaking of, I have to get re-credentialed under the new medical entity. That’s because of Stark and anti-kickback laws.  This isn’t something to go into lightly. It’s like I said last week or two weeks ago here on the podcast, the wheels on this thing turn slowly and I’m OK with that. That way I don’t get out over my skis and lose control.  So, that’s where we’re at on that. 

Currently, I’m taking the opportunity to type this out on a Sunday afternoon. We are up at the office throwing a staff member her baby shower. No, I’m not a baby shower kind of dude as you may have guessed. I’m a Bud Light and guitars kind of guy. But, my wife decided we’re throwing our staff member a baby shower so here I am at the office recording this while the chicks and the hens are out there clucking and cackling. And I don’t mean that in a misogynist way. I mean it in a funny, playful kind of way so take it that way. 

It brought up a thought; do you treat your staff members like workers? Or do you treat them more like family? Right or wrong, as a result of my nature and my heart, we treat ours like family when appropriate. I’ve had staff ask me advice on deep dark stuff they were struggling with. I’ve had staff whose family was going to prison, the whole town knew, they were ashamed, and they just need some love, a little extra consideration, and a few big hugs. That one still gets me a little emotional when I think about it.  I’m going to give you a few more examples here but before I do, I don’t want you to misunderstand anything here. I’ve learned over the years that you cannot buy loyalty from your staff. They’re either with you every step of the way, or they are not. And that’s OK. Everyone is coming from different places, experiences, and motivations. Not a thing wrong with that.  But don’t do things for the wrong reasons. Don’t think you’re going to do a bunch of things for staff thinking it’ll ensure they stay with you forever. That’s just not reality and it’s a good way to allow yourself to get hurt on some level.  If you’re going to treat staff like family, you do it for all of the right reasons. Love, appreciation for them and their character, admiration for a job well done, team building, and things like that.  Getting back to it, I’ve sold a car to a staffer that was coming out of a bad relationship and had no transportation. I sold it to them for about $4,000 less than I could have gotten for it and let them pay it out $50 a paycheck and zero interest.  I’ve created a new, extra job for a staffer that was about to lose their house. It cost me an extra $1500/month for the following 2-3 years but that’s the way I am. 

I’ve sponsored kids sports for staffers more times than I can even start to recall.  In the end, money will come and go. It can be lost and it can be made. But it’s the relationships that stay with us.

Were we put on the planet just to make money and take care of our families? 

Or were we put on this planet to make ALL of our immediate relationships prosper and make the world, or at least our part of it, a better place?  You probably know where I come down on all that. It may sound a little hippy-dippy there, which I’m not at all, but I do see it that way. Money is nice and I see it as a challenge. A challenge to make it and see how much I can make ethically and morally. It’s fun to make money! But money really isn’t my main motivation any more.

I’m a huge stats person and track stuff like crazy. I balance my own bank statement every month. But I don’t count pennies anymore. I just don’t. I’m more into people, smiles, and all the good feels. Making people’s lives better when possible.  Alright, enough mushy stuff. 

Item #1 This first one today is called “Temporal Associations Among Body Mass Index, Fasting Insulin, and Systemic Inflammation: A Systematic Review and Meta-analysis” by Wiebe et. al. [1] and was published in JAMA on March 12, 2021 and that so hot it’s got my glasses all steamy. I can’t see a thing. 

Why They Did It The authors wanted to answer the question of “What are the temporal associations among higher body mass index (BMI) and chronic inflammation and/or hyperinsulinemia?” They say that Obesity is associated with a number of noncommunicable chronic diseases and is supposedly a cause of premature death. They wanted to summarize evidence on the temporality of the association between higher body mass index (BMI) and chronic inflammation and hyperinsulinemia.

How They Did It

  • MEDLINE (1946 to August 20, 2019) and Embase (from 1974 to August 19, 2019) were searched
  • The data analysis was conducted between January 2020 and October 2020.
  • Longitudinal studies and randomized clinical trials that measured fasting insulin level and/or an inflammation marker and BMI with at least 3 commensurate time points were selected.
  • Of 1865 records, 60 eligible studies with 112 cohorts of 5603 participants were identified

Wrap It Up

The finding of temporal sequencing (in which changes in fasting insulin level precede changes in weight) is not consistent with the assertion that obesity causes non-communicable chronic diseases and premature death by increasing levels of fasting insulin. Meaning that that adverse consequences currently attributed to obesity could be attributed to hyperinsulinemia (or another proximate factor). Which is interesting in my book. I thought you all might like it. 

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Item #2 And our last item today is called “Effect of Osteopathic Manipulative Treatment vs Sham Treatment on Activity Limitations in Patients With Nonspecific Subacute and Chronic Low Back Pain: A Randomized Clinical Trial” by Nguyen et. al.  [2] and published in JAMA Internal Medicine on March 15, 2021 which is indeed too hot to manipulate by one’s hand. 

Why They Did It They say that Osteopathic manipulative treatment (OMT) is frequently offered to people with nonspecific low back pain (LBP) but never compared with sham OMT for reducing LBP-specific activity limitations. Knowing this, they wanted to compare the efficacy of standard OMT vs sham OMT for reducing LBP-specific activity limitations at 3 months in persons with nonspecific subacute or chronic LBP.

How They Did It

  • This prospective, parallel-group, single-blind, single-center, sham-controlled randomized clinical trial recruited participants with nonspecific subacute or chronic LBP in France starting February 17, 2014, with follow-up completed on October 23, 2017. 
  • Participants were randomly allocated to interventions
  • Six sessions (1 every 2 weeks) of standard OMT or sham OMT delivered by nonphysician, nonphysiotherapist osteopathic practitioners.
  • The primary end point was reduction in LBP-specific activity limitations at 3 months as measured by the self-administered Quebec Back Pain Disability Index. 
  • Secondary outcomes were mean reduction in LBP-specific activity limitations; mean changes in pain and health-related quality of life; number and duration of sick leaves, as well as number of LBP episodes at 12 months; 
  • and consumption of analgesics and nonsteroidal anti-inflammatory drugs at 3 and 12 months. 
  • Adverse events were self-reported at 3, 6, and 12 months.

What They Found

Overall, 200 participants were randomly allocated to standard OMT and 200 to sham OMT, with 197 analyzed in each group

Wrap It Up In this randomized clinical trial of patients with nonspecific subacute or chronic LBP, standard OMT had a small effect on LBP-specific activity limitations vs sham OMT. However, the clinical relevance of this effect is questionable. So, look…..this paper and these researches absolutely wasted time, effort, and money in an attempt to make spinal manipulative therapy look bad. Who in the h e double hockey sticks sees new patients once every 2 weeks for only 6 visits?? Especially in a chronic pain sufferer. Trash, garbage.

Or since it was in France…..garbage.  It’s dumb, useless, and meaningless and I’m almost offended that this is even a paper. I’m starting ANY brand new case with 3 per week for a week or two minimum. Minimum. Combined with other appropriate ancillaries including exercise, soft tissue stuff, maybe acupuncture, maybe laser, maybe a referral to cognitive-behavioral therapist, maybe biomechanics coaching, and on and on and on. 

Papers like this and authors like this should give it up and get out of the game if they’re not going to be able to throw something together that’s better than this heap of trash.  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 preventativly after initial recovery, we can usually keep it that way while raising the overall level of health!

Key Point:

At the end of the day, patients should have the guarantee of having the best treatment that offers the least harm. When it comes to non-complicated musculoskeletal complaints….

That’s Chiropractic!

Contact

Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show and tell us your suggestions for future episodes. 

Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on podcast platforms. 

We know how this works by now. If you value something, you have to share it, interact with it, review it, talk about it from time to time, and actively hit a few buttons to support it here and there when asked. It really does make a big difference. 

Connect

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

Website

Home

Social Media Links

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Chiropractic Forward Podcast Facebook GROUP

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

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https://player.fm/series/2291021

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https://www.stitcher.com/podcast/the-chiropractic-forward-podcast-chiropractors-practicing-through

TuneIn

https://tunein.com/podcasts/Health–Wellness-Podcasts/The-Chiropractic-Forward-Podcast-Chiropractors-Pr-p1089415/

About the Author & Host

Dr. Jeff Williams – Fellow of the International Academy of Neuromusculoskeletal Medicine – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger

Bibliography

1. Wiebe N, Y.F., Crumley ET, Bello A, Stenvinkel P, Tonelli M,, Temporal Associations Among Body Mass Index, Fasting Insulin, and Systemic Inflammation: A Systematic Review and Meta-analysis. JAMA Netw Open, 2021. 4.

2. Nguyen C, B.I., Zegarra-Parodi R,, Effect of Osteopathic Manipulative Treatment vs Sham Treatment on Activity Limitations in Patients With Nonspecific Subacute and Chronic Low Back Pain: A Randomized Clinical Trial. JAMA Intern Med, 2021.

Texas Chiropractors Beat TMA & Smack Goliath In The Nose – w/ Dr. Tyce Hergert & Dr. Tom Hollingsworth

CF 168: Texas Chiropractors Beat TMA & Smack Goliath In The Nose

Today we’re going to talk about the state of the chiropractic profession in Texas and we’ll do a walkthrough of the case and court battle the Texas chiropractors just won. We’re going to be joined by two chiropractors with intimate knowledge and front row seats to the show through the years. 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. 

  • 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 #168 Now if you missed last week’s episode , we talked about overcoming challenges. We talked about hip and knee osteoarthritis, and we talked about the risks for pain going from acute to chronic. Make sure you don’t miss that info. Keep up with the class. 

On the personal end of things…..

We talked about the challenges of my life last week. Well, then my pickup died on top of all of the rest of the list I laid out for you last week. So…..that’s fun.  Rolling with the punches. That’s what I’m doing here. Rolling with the punches. We have times in our lives when more is going on than really should be going on. Best we can do is just hold on tight, take the ride, and enjoy it when it all settles down a bit.  And it will most certainly settle down a little bit. For most people, life isn’t something we can just settle in the back row and watch from afar without involvement or participation. Which means, when your must partake, you will have times that are more hectic than others. This is that time. I don’t need a car payment right now with all of the other things I have going on.

But you know what; I’m not broke, business is coming back, and it’s all going to take care of itself. I just have to hold on and ride that ride. Maybe even try to smile here and there and find something to enjoy out of it. Who knows? But I’m damn sure on a ride currently. Better believe it. Speaking of a ride; my wife and I took a quick weekend out to Tampa Bay and Clearwater Florida last weekend. Nice trip. It wasn’t Key Largo which is where we went a year ago, just before the pandemic. But it was pretty. We stumbled right into Spring Break without knowing it so it was a bit too busy and tourist-y for our liking but it was gorgeous nonetheless.  So far, the retirement plan is taking us to Key Largo one of these days. On the flight back, they routed our plane through Las Vegas.

If you don’t know American geography, that is 4 time zones toward the west just to go back 2 time zoned back to the east just to get home. It was stupid. Well over 6 hours of flying on a trip that should have been around 3 hours of flying. Dumb.  Alright, let’s get on with it this week shall we?

First I need to recognize one of the best sponsors a podcast could ever have. 

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OK, before we bring our guests on, I want to introduce them to you. They have both been my close friends for years now. First I need to say that there are literally about 20 people that could or should be joining us on this podcast today. But then it would get disorganized and it would be a mess. I felt it was easier to keep it streamlined and simple so we could have a good, focused conversation. 

I’ll first tell you about Dr. Tom Hollingsworth.

Tom is the longest serving Board member for the Texas Chiropractic Association. Dr. Hollingsworth’s fingerprints are on all parts of what makes the TCA the TCA in 2021 not to mention, as you’ll hear momentarily, all over the defense the TCA helped the TBCE put up against the Texas Medical Association.

Dr. Hollingsworth practices in Corpus Christi, TX down on the Texas Gulf Coast at Beacon Chiropractic. Also, Tom was one of my first guests back when I first started this podcast over three years ago and I’m so happy to have him joining us again. http://www.beaconclinics.net

My second guest is Dr. Tyce Hergert. Tyce has been a guest two or three times on this podcast but it’s been a while. Dr. Hergert has been involved in the TCA for a lifetime it seems and it instrumental in getting yours truly active in the TCA as well. Tyce has served in lots of different capacities in the TCA culminating with his post as President where he was instrumental in guiding the TCA to 4 or 5 legislative wins during his term as well as steering the defense of this assault from the TMA. Tyce is the owner of Southlake Physical Medicine in Southlake, TX. http://southlakephysmed.com

Just to give you a brief history of my involvement, I was on the Board of Directors for the TCA when the case prior to this one was concluded. Which was about the time this latest assault was started. So, I was there for its beginnings. I was on the Board for about 4 or 5 years before moving through the ranks as the Chiropractic Development Initiative Chairman, the Pubic Relations Chairman, and now the Scientific Affairs Department Coordinator. So, while not knee deep in the trenches at all times, I’ve been there helping make promotional material, get the word out, and sweating and worrying with everyone else that really knew what was going on.  If you really knew what was going on, you would have been sweating as well. 

There are few folks on this planet that can speak on this case any better than our two guests today so let’s dive in shall we? Welcome, welcome, welcome, friends and colleagues…

First of all, how did everyone do with the Texas deep freeze that made the news world wide just a week or so ago?

Since our time is limited, let’s go ahead and jump right into the meat and taters here. I think we should start with the case we beat the TMA on just prior to this latest one. Who wants to describe that whole debacle?

Now, about the time that case wrapped up was about the time I very first heard the term VONT. I have to admit, I thought that was such a random little piddly thing that I did not give it much thought at all. I thought it would be a simple little whatever and would have little to zero impact on regular practicing chiropractors. What were your first thoughts on the VONT case in the very beginnings of it all?

A case that started with VONT had a way of morphing and transforming into all kinds of attacks, didn’t it? Tell us how that happened and what it meant?

Besides fighting the court case, what did chiropractors at the TCA do to fight this thing outside of the courtroom? Talk a little about the fundraising we all did. 

Can we stop just a second and let’s recognize some of the key players here from the TCA and the TBCE that really made the difference for Texas Chiropractors?

Talk about how the TCA was fighting this case in the Texas legislature. 

Now, we lost this case twice, right? Why do you think the two lower courts got it wrong? We know that it sure feels like Hurley just doesn’t like chiropractors. She’s been overruled on our cases at least twice that I know of. 

What could a loss have meant to not only Texas Chiropractors but also to chiropractors around the nation? Maybe globally?

Along with the crushing defeat the TMA suffered here, they had to pay all court costs and legal fees. Do we have a number on that yet? 

Tell me what you think this loss means to the TMA? Any idea of where their next attack might be?

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 preventativly after initial recovery, we can usually keep it that way while raising the overall level of health!

Key Point: At the end of the day, patients should have the guarantee of having the best treatment that offers the least harm. When it comes to non-complicated musculoskeletal complaints…. That’s Chiropractic!

Contact Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show and tell us your suggestions for future episodes.  Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on podcast platforms.  We know how this works by now. If you value something, you have to share it, interact with it, review it, talk about it from time to time, and actively hit a few buttons to support it here and there when asked. It really does make a big difference. 

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

Website https://www.chiropracticforward.com

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

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

Twitter https://twitter.com/Chiro_Forward

YouTube https://www.youtube.com/channel/UCtc-IrhlK19hWlhaOGld76Q

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TuneIn https://tunein.com/podcasts/Health–Wellness-Podcasts/The-Chiropractic-Forward-Podcast-Chiropractors-Pr-p1089415/

About the Author & Host Dr. Jeff Williams – Fellow of the International Academy of Neuromusculoskeletal Medicine – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger

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

CF 167: My Insane Life, Hip & Knee Osteoarthritis, Risks For Acute to Chronic Pain Today we’re going to talk about hip and knee osteoarthritis and we’ll talk about the risks for back pain going from acute to chronic pain. Interesting couple of papers. Plus all my current ongoings.  But first, here’s that sweet sweet bumper music

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. The Bon Jovi and Def Leppard kind of research.  Not the stuffy, high-brow, high and mighty, better than you kind of research.  We’re research talk over a couple of beers.

I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.   If you haven’t yet I have a few things you should do. 

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

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

On the personal end of things…..

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What a wonderful life.

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

OK, let’s get to the papers.

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

CHIROUP 

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

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

Conclusions and Relevance  

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

Item #2

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

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

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

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

What They Found

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

Wrap It Up

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

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

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

Chiropractic evidence-based products

Integrating Chiropractors

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The Message 

I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment rather than chemical treatments like pills and shots. When compared to the traditional medical model, research and clinical experience show us patients can get good to excellent results for headaches, neck pain, back pain, and joint pain to name just a few. It’s safe and cost-effective can decrease surgeries & disability and we do it through conservative, non-surgical means with minimal hassle to the patient. And, if the patient treats preventatively after initial recovery, we can usually keep it that way while raising the overall level of health!

Key Point:  At the end of the day, patients should have the guarantee of having the best treatment that offers the least harm. When it comes to non-complicated musculoskeletal complaints…. That’s Chiropractic!

Contact  Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show and tell us your suggestions for future episodes.  Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on podcast platforms.  We know how this works by now. If you value something, you have to share it, interact with it, review it, talk about it from time to time, and actively hit a few buttons to support it here and there when asked. It really does make a big difference. 

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

Website  https://www.chiropracticforward.com

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

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

Twitter  https://twitter.com/Chiro_Forward

YouTube  https://www.youtube.com/channel/UCtc-IrhlK19hWlhaOGld76Q

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

Player FM Link  https://player.fm/series/2291021

Stitcher:  https://www.stitcher.com/podcast/the-chiropractic-forward-podcast-chiropractors-practicing-through

TuneIn  https://tunein.com/podcasts/Health–Wellness-Podcasts/The-Chiropractic-Forward-Podcast-Chiropractors-Pr-p1089415/

About the Author & Host  Dr. Jeff Williams – Fellow of the International Academy of Neuromusculoskeletal Medicine – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger    

Bibliography

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