migraines

CF 159: Set Yourself Apart In Your Chiropractic Care For Migraines

CF 159: Set Yourself Apart In Your Chiropractic Care For Migraines Today we’re going to talk about chiropractic care for migraines. What does new research tell us.  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, 
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You have found yourself smack dab in the middle of Episode #159 Now if you missed last week’s episode , we talked about chiropractors within a primary spine care model, we talked about frozen shoulder treatments, and we talked about how evidence-based care is more cost-effective. Make sure you don’t miss that info. Keep up with the class. 

On the personal end of things…..

Alright alright alright. Christmas is over and as of the typing of this episode we are staring down New Year’s. No big deal for me. I’m not going anywhere so there’s nothing to get too excited or worked up about.  I guess the biggest news for me is that my wife and I got vaccinated last week. We got the Moderna version of the vaccine. Didn’t hurt a bit. I was one of the fortunate ones. I had absolutely zero reaction. No sore arm, no fever, no aches…..nothing. I guess if you poked on my arm fairly hard it would have been a bit sore but really, nothing at all.  If I had been in the research trial, I would think I got the placebo. That’s how uneventful it was for me.

My wife though, she felt a little crummy. No fever but maybe a little bit of overall achey-ness. Sore arm for a few days. But that’s about it. Nothing severe at all and she recovered quickly.  I’ve had several ask me online how we got ours so quickly. The first thing I’d say is that I have a network of providers here locally that I refer to, they refer to me, and on some level, we are friends. They know how closely we work with our patients. They don’t want us getting it and they don’t want us giving it to others.  So, when the vaccine came to town, they called and told us to come down and get ours. So we did. Here’s the cool part; they told me to reach out to fellow chiropractors and tell them to come to get vaccinated if they want one.

I thought to myself, “Can you imagine if this pandemic were just 10 years ago? Would the medical community have extended that offer to chiropractors then?” My guess is probably not.  Here’s the not-so-cool part. I reached out to about 40 in the area and only ONE of them accepted the offer. So, we gots some work to do in making chiropractors more evidence-science-based. Though I do want to be fair. I don’t think it’s unreasonable at all to wait 4-6 weeks just to make sure everyone does OK with this thing. even though the proper trials were done….it’s not unreasonable.  It’s just delaying the fact that people are going to do fine and everyone will end up getting it anyway but whatever. 

What I do think is unreasonable is continuing to refuse it beyond the 4-6 week mark. This thing is far beyond the flu both in transmissibility and in the risks of death and or disability. Sometimes that disability is short-term and sometimes it’s long-term. Don’t think of this as a death vs. living thing. Long-haulers is a real thing.  We don’t need to be out of work that long. We don’t need to have to figure out how to keep our employees paid while we are out sick for 2-4-6 weeks or however long we have to be out.  We don’t need to think we just have a sniffle or allergies and then spread this to our elderly or immunocompromised patients.  Being out of work for far too long or passing this onto risky patients….when all we had to do was just get the damn shot.

So….I got the damn shot and so far, so good. 

In other news, I have formed a collection of all of my research blogs from 2007 onward. I’ve organized them into categories so they can be easily found so now I have a book. I’m in the process of getting the book cover made. This dude is about 220 pages or so. It could be much longer but I’m trying to make it skinnier on purpose.  It is called “The Remarkable Truth About Chiropractic: A Unique Journey Into The Research”. We still have a lot of steps and hoops to jump through to get to the finished product but we are well on our way. Of course I’ll keep you updated on the progress.  Happy New Year folks. Let’s get on with the research today. 

Item #1

This one is called “Association of drinking water and migraine headache severity” by Khorsha, et. al. (Khorsha F 2020) and was published in the Journal of Clinical Neuroscience in July of 2020 and that’s still a steaming pile of sizzle! Before we get into chiropractic care for migraines, let’s cover a little headache primer here for you. First thing, the history of the headache is key. In general, a headache is considered dangerous if there is any recent change in a headache’s character. Some have a long history with headaches but if that history changes, further exploration is needed. Recent onset of less than 6 months is more worrisome. Focal neurological signs. And lastly, cognitive changes. Changes in behavior for example. 

Getting back to headache types, 38% of headaches seen in a clinical setting are tension-type headaches right off the bat. Only about 10% are actual migraines. Only 4% of headaches are actually classified as true cervicogenic headaches. Then cluster headaches, and on and on….those are very rare. Here’s the fine print though. Tension-type and migraine headaches exist on the same continuum. Meaning, they share characteristics. I suppose you could even say that tension-type is a very very mild form of migraine while migraine is a very very extreme tension-type.

That may be overstating it a bit but there is a relationship between the two and they can share characteristics with each other.  According to Dr. Anthony Nicholson and Dr. Matthew Long with the CDI learning from the Diplomate in Neuromusculoskeletal Medicine, “It is a pervasive neurological condition with genetic underpinnings. Indeed, when you look more closely you will soon realize that migraineurs do not function normally in between headache episodes either (the interictal period). In other words, the headache symptoms are simply a feature of what might be described as a chronic neurological ‘disorder’ or ‘illness’. As we shall explore in this Drill, migraine is the manifestation of an abnormally excitable brain that is capable of over-activating the trigeminal system in genetically susceptible individuals.

The result is not only nasty headaches but also a host of other autonomic, cognitive, emotional and musculoskeletal disturbances. Furthermore, these can occur both during the headache or outside of the acute pain episode. It is therefore important that we immediately recognize a patient as a migraineur because it should influence the way we interpret their entire case. Not only that, but we certainly need to approach a migraine sufferer a little differently when it comes to dispensing manual treatment. “

If you think that makes a ton of sense, Dr. Anthony Nicholson just signed on to be a presenter for the Texas Chiropractic Association’s Winter Conference, which will be online for ALL OF YOU to enjoy. It’ll be march 5-6 and will also include myself, Annie O’Connor, Jay Greenstein, Brandon Steele, and Carlo Ammendolia as presenters. Don’t miss it folks! That’s huge. So, getting back to Dr. Nicholson’s description, we wouldn’t describe a tension-type headaches that way, would we? As you have probably experienced or at least guessed, migraines are much more difficult to address or treat than are the other types of headaches. 

I don’t have the time or space to go into the full treatment of migraines here but I do want to highlight some studies that we might leverage to our advantage and we can go that extra mile to help our patients with the issues of headaches and migraines.  Many times, they’re at the bottom of their rope when we get them. If we succeed where everyone else failed, well then, don’t we always enjoy being that practitioner? Hell yeah, we do.  Just remember 3 important questions:

  • Do you have recurrent headaches that interfere with work, family, or social functions?
  • Do your headaches last at least 4 hours?
  • Have you had a new or different headache in the last 6 months?

These should give you some guidance considering migraines typically last 4-72 hours and interfere with work, family, and social functions. Patients cannot simply muscle through migraines. It’s a nope. 

Why They Did It

“Based on evidence dehydration is closely related to promoting migraine headache frequency and severity. The Water intake is the best intervention to reduce or prevent headache pain. water intake in migraine patients has rarely been studied. the present study aimed to evaluate the relation between water intake and headache properties in migraine.”

How They Did It

  • It was a cross-sectional design with 256 women
  • They were aged 18–45 years old
  • They had all been referred to neurology clinics for the first time
  • The diagnosis of migraine by a neurologist according to ICHD3 criteria
  • To assess migraine severity the Migraine disability assessment questionnaire (MIDAS), visual analog scale (VAS), and a 30-day headache diary were used.
  • Pearson correlation analysis was used to evaluate the relationship between the number of days and duration of headache with daily water intake.

What They Found

The results showed that the severity of migraine disability, pain severity, headaches frequency, and duration of headaches were significantly lower in those who consumed more water or total water. Wrap It Up “The present study found a significant negative correlation between daily water intake and migraine headache characteristics but further clinical trials are needed to interpret the causal relationship.”

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Item #2 This second one is called “Endogenous Melatonin Levels and Therapeutic Use of Exogenous Melatonin in Migraine: Systematic Review and Meta‐Analysis” by Liampas L, et. al. (Liampas L 2020) and published in the Journal of Head and Face Pain on April 30 2020 schizza it’s hot.  Why They Did It The aim of this study was to review the existing evidence for the deployment of melatonin in migraine prophylaxis.  How They Did It

  • MEDLINE EMBASE, CENTRAL, PsycINFO, trial registries, Google Scholar, and OpenGrey were comprehensively searched
  • The quality of studies was assessed according to the Newcastle‐Ottawa Scale (case‐control studies) and the Risk‐of‐Bias Cochrane tool (RCTs)
  • Random‐effects (RE) or fixed‐effects (FE) model was used based on heterogeneity among studies 
  • Publication bias was assessed by funnel plots.
  • Literature search provided 11 case‐control studies
  • Regarding the treatment‐prevention of migraine, 7 RCTs and 9 non‐randomized studies were retrieved
  • Overall, melatonin was more efficacious and equally safe with placebo in the prevention of migraine in adults (3 of 4 RCTs provided superior efficacy results for melatonin

Wrap It Up

“Melatonin may be of potential benefit in the treatment‐prevention of migraine in adults, but complementary evidence from high‐quality RCTs is required.”

Item #3

Next up is “Integrating Chiropractic Care Into the Treatment of Migraine Headaches in a Tertiary Care Hospital: A Case Series” by Bernstein et. al. (Bernstein C 2019) and published in Global Advances in Health And Medicine” in 2019. Not hot but definitely not cold. 

Why They Did It

They ran a case series to illustrate an integrated model of care for migraine that combines standard neurological care with chiropractic treatment.

How They Did It

  • For each patient, we describe the rationale for referral, diagnosis by both the neurologist and chiropractor, the coordinated care plan, communication between the neurologist and chiropractor based on direct face-to-face “hallway” interaction, medical notes, team meetings, and clinical outcomes.
  • Findings are evaluated within the broader context of the multicause nature of migraine and the impact of integrative chiropractic. 

They highlighted 3 cases that we’ll touch on briefly.  Case 1

  • She was 40 when she first went to the neurologist for daily migraines. 
  • She started integrative care at 42 years old. 
  • She had had migraines since she was 29 years old. 
  • After seeing the neuro, the frequency went down to 3-4 times per week
  • She also had some TMJ issues and neck pain and stiffness. with some radicular symptoms that were only a few months in duration
  • Upon going to the chiro, they found trigger points that would stimulate the headache on compression, abnormal tracking of the TMJ, and tenderness over the right C2/3 facet joint. 
  • After spinal manipulative therapy, the patient experienced almost immediate reduction in headache and neck pain and a reduced headache frequency of 1 per month. 

Shazam! Pop! Smack. KaPow! Case 2

  • She was 31 at the start, 34 when integrating treatment. 
  • She had been having them since 12 years old that she managed with Excedrin for years. But they got more out of hand after her 2 pregnancies
  • 2 of the headaches even sent her to the ER
  • Associated symptoms included unilateral neck pain, nausea, and vomiting
  • She tried multiple trials of different medications with limited relief
  • Once making her way to the chiropractor, they found trigger points in the suboccipitals, temporalis, and masseters. Weakness in the deep neck flexor muscles, and substantial postural faults, forward head carriage, and rounded shoulders. 
  • Where her headaches had been rated from 7-8, after 9 months of treatment with admittedly poor adherence to the at-home exercises, she rated them at a 3 out of 10 and after 10 months experienced her first headache-free month. 

Pow! Zap! Slap! Case 3

  • 27 years old when first going to the neuro and 29 when she made it to the chiro
  • Migraines started when she was 13
  • Pounding and throbbing with aura. The whole nine yards. 
  • Migraines were nearly daily, disabling and interfering with life to the point she could only take 1-2 college classes each semester. 
  • Multiple medication trials
  • She underwent botox treatments that helped her have as many as 8 pain free days in a month. Which means she still had about 22 days of headaches in a month. How miserable. 
  • Fortunately the botox helped the severity dampen by about 50% but she still complained of the disabling neck pain. 
  • The chiropractor found trigger points in the sub occipital area and the traps and could reproduce the pain on compression. The chiro also noted substantial segmental mobility restriction in the upper cervical spine. 
  • After seeing the chiropractor, there was a nearly immediate positive response to initial care in headache and neck pain intensity and frequency. with a reported 50% reduction in the intensity. The average headache dropped to 3.5 out of 10. 

Zowey, Kapowey, Thunk! 

Wrap It Up

“Our case series highlights the promise of and the need to further evaluate integrated models of chiropractic and neurologic care. Although we observed improvement in patient outcomes in this small case series, rigorously designed studies with adequate control groups are needed to determine the efficacy and safety of chiropractic care for migraine patients.”

Item #4

Yep, it’s a longer podcast today but I can’t leave you without doing this paper real quick! It’s called “The Impact of Spinal Manipulation on Migraine Pain and Disability: A Systematic Review and Meta‐Analysis” by Rist et. al. and published in the Journal of Head and Face Pain on March 14, of 2019. Again, not hot but damn sure not cold.  Why They Did It They wanted to perform a systematic review and meta‐analysis of published randomized clinical trials (RCTs) to evaluate the evidence regarding spinal manipulation as an alternative or integrative therapy in reducing migraine pain and disability.

How They Did It

  • PubMed and the Cochrane Library databases were searched for clinical trials that evaluated spinal manipulation and migraine‐related outcomes through April 2017
  • The methodological quality of retrieved studies was examined following the Cochrane Risk of Bias Tool.

What They Found

  • The search identified 6 randomized controlled trials eligible for meta‐analysis.
  • Intervention duration ranged from 2 to 6 months
  • Outcomes included measures of migraine days (primary outcome), migraine pain/intensity, and migraine disability
  • They observed that spinal manipulation reduced migraine days with an overall small effect size as well as migraine pain/intensity.

Wrap It Up

The authors concluded, “Spinal manipulation may be an effective therapeutic technique to reduce migraine days and pain/intensity. However, given the limitations to studies included in this meta‐analysis, we consider these results to be preliminary. Methodologically rigorous, large‐scale RCTs are warranted to better inform the evidence base for spinal manipulation as a treatment for migraine.” It’s like a computer. It only spits out information that is based on the information that was put into it. Same with a meta-analysis. If the studies going into it are few, your output won’t be too robust.

Of course, we know that the effect we have on migraines is much more than small. In the 3rd study we covered today, do you think any of those 3 case study patients thought that the relief they got from the chiropractor was small? Nope, they thought the results were worthy of superhero sound effects. At least if they had a brain like mine that’s what they’d think.  So, for our research community, there are your marching orders. We have research on the low back in spades. Let’s prove neck pain and headache/migraine now please? I’ve been asking for 3 years now. Please?

Besides the claims of the vitalists in our profession, those are the things that keep us from really stepping up. Lack of proof for neck pain effectiveness, headache/migraine effectiveness, and the lack of risk for spinal manipulation in the cervical region.  I feel the stroke risk has been debunked and handled. Now if we can get the other two firmly under our belts, we’ll be good to go.  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.   

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

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

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

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

Website http://www.chiropracticforward.com

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

Bibliography

  • Bernstein C, W. P., Rist P, Osypiuk K, Hernandez A, Kowalski M, (2019). “Integrating Chiropractic Care Into the Treatment of Migraine Headaches in a Tertiary Care Hospital: A Case Series.” Glob Adv Health Med 8.
  • Khorsha F, M. A., Togha M, Mirzaei K, (2020). “Association of drinking water and migraine headache severity.” J Clin Neuroscience 77: 81-84.
  • Liampas L, S. V., Brotis A, Vikelis M, Dardiotis E, (2020). “Endogenous Melatonin Levels and Therapeutic Use of Exogenous Melatonin in Migraine: Systematic Review and Meta‐Analysis.” J Head Face Pain 60(7): 1273-1299.

 

CF 033: Did You Need Proof That Chiropractors Help Headaches?

Did You Need Proof That Chiropractors Help HeadachesIntegrating Chiropractors

Today we’re going to talk about how chiropractors help headaches, we’ll discuss a couple of pretty cool papers that came out fairly recently, one of them only a couple of weeks ago from this recording, that had to do with spinal manipulation and the effectiveness in treating headaches and migraines. Psssst…..here’s a hint…..it’s good for chiropractors. Except for the very ending.

 

But first, here’s that bumper music

 

OK, we are back. You have shimmied into Episode #33. Chiropractors help headaches is basically our topic.

 

Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.  I have to say that in the last month specifically, this podcast really started to take off in terms of downloads and listens.

 

You know, when you first start something, there’s an excellent chance that nobody really gives a hoot. Lol. Isn’t that always the fear when starting something new? Does anyone care? Am I going to be able to offer any value? I have diagnosed myself with an anxiety issue. I over think and over think things. In the end, it’s simply because, no matter what it is I’m doing, I just want to do a good job.

 

I tell my son that, even if I don’t necessarily like somebody on a personal level if they are a hard worker, I will respect them. Everyone can respect a hard worker. Well, that’s what I try to be. I try to work hard and I try to bring things of value to me to you through writings, videos, social media, and podcast.

 

I’ll be honest with you. I have zero clues where all of this will eventually lead me. Lol. No clue at all. There’s no grand plan behind it.

 

All I know is I see it’s value and more and more of you are finding it’s value every week and it’s exciting. Maybe I’ll eventually put a course together for marketing your practice from an evidence-based perspective. Maybe I’ll have in-office patient education products. I’d love to be a speaker and travel the world bringing this information to evidence-hungry crowds. I have no idea where it can go but for now: I’m having fun.

 

Maybe it’s the old traveling musician in me. Maybe I just have to have people tuned in or I’m just lost. Lol. I have no idea but I know it’s fun and I’m glad you’ve come along with us so far. I’ll keep working hard if you’ll keep listening and we’ll just see where things go down the road together. I’m always keeping my eyes out for colleagues that see what I see. If that’s you, send me and email and let’s connect. Also, we’d like to ask you to join not only our Chiropractic Forward Facebook page but we also have a Chiropractic Forward Facebook GROUP where we have started sharing the papers we use, accepting comments, and will probably be including some of them in future episodes. We want our podcast to be a group effort if you’d like to participate. Come join us. The link is in the show notes.

 

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

 

On a completely different note, I had mentioned back in mid-June or so that I was at the ChiroTexpo event in Dallas that was put on by the Texas Chiropractic Association and I met Dr. Tim Bertelsman down there. He was there for two reasons. One reason was as a vendor for his and Dr. Brandon Steele’s ChiroUp product and the other reason was to teach the Low Back portion of the Diplomate of American Chiropractic Orthopedists (DACO) program put on through the University of Bridgeport.

 

As this episode is recorded, I am about a week and a half from going through my second ten-hour course. This one will be taught by Dr. Brandon Steele down in Dallas again and I’m looking forward to it.

 

This is a really valuable program these guys are teaching and I encourage you all to check it out but, what I really wanted to tell you about is this ChiroUp thing they have going on. It’s crazy. Crazy in a good way.

 

I saw in one of the private groups on Facebook where a poster was asking for some good pointers on a report of findings.

 

Immediately, about 7 of the 10 posts had to do with recommending ChiroUp and, one of those posts was mine. I said it’s a game changer because, well….it is. I started using it about a month ago and it has literally changed the game for my busy office without adding a lot of demand to my staff. We’re talking patient education, activities of daily living, patient follow up, patient exercise-rehab recommendations, and even expediting online reviews. I have tried several products and services during my 20 years and most of them are just hype and take your money.

 

In my experience, so far….ChiroUp has been beyond what I expected. I’m jaded as hell. But, when Dr. Bertelsman started showing it to me, my jaw dropped a bit. I think I started slobbering. I’m not sure. Anyway, he showed it to me for about a minute and a half and that was it. Shut up and just take my money.

 

I want you to know, I don’t have any “deal” set up with those guys. Not yet anyways!! Lol. If it’s up to me I will because they’re amazing but, as of now, they don’t sponsor this show, no affiliate marketing deal….nothing like that. I’m just like your buddy down the road telling you hey man, I’m doing this thing and it’s been pretty freaking great. You should look at it. That’s all.

 

If you want to look into ChiroUp, go to www.chiroup.com and give it a look-see. And, if you like what you see and join up, you may mention our podcast and me, Dr. Jeff Williams. It never hurts for people to know who was out there pumping their tires, ya know. Sometimes what goes around comes around and I believe in always trying to project the good mojo.

 

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

 

It’s all about headaches from this point forward today. I want to first direct you to a podcast we did that cited a bunch of headache papers that I hope you’ll go and listen to right after you listen to this one. It was Episode #14 but 14 is right smack dab in the middle of a series of podcasts I did on Debunking the myth that Chiropractors cause strokes. Specifically, the series starts on episode #13, #14 is the one with the headache research, and #15 is the conclusion of the stroke series we did. I CANNOT stress enough how valuable I feel those three episodes are.

 

We will have them linked in the show notes.

 

https://www.chiropracticforward.com/debunked-the-odd-myth-that-chiropractors-cause-strokes/

 

https://www.chiropracticforward.com/cf-episode-14-debunked-the-odd-myth-that-chiropractors-cause-strokes-part-2-of-3/

 

https://www.chiropracticforward.com/cf-015-debunked-the-odd-myth-that-chiropractors-cause-strokes-part-3-of-3/

 

We will get going with this paper from February of 2018 called, “Dose-response and efficacy of spinal manipulation for the care of cervicogenic headache: a dual-center randomized controlled trial.” It was done by Haas et. al[1]. and was published in the prestigious Spine Journal on February 23, 2018. Here’s how chiropractors help headaches.

 

Why They Did It

Although the researchers know that spinal manipulation chiropractors help headaches (which is nice to see) there has been little information on the dosage of spinal manipulation for them. They wanted to evaluate the efficacy of chiropractic by comparing it to a light massage control group.

How They Did It

  • This is a two-site, open-label randomized controlled trial.
  • Participants were 256 adults with chronic cervicogenic headache.
  • The primary outcome was the number of days with cervicogenic headache in the previous 4 weeks evaluated at the 12- and 24-week primary endpoints
  • Secondary outcomes included cervicogenic headache days at remaining endpoints, pain intensity, disability, perceived improvement, medication use, and patient satisfaction.
  • Participants were randomized to four dose levels of chiropractic SMT: 0, 6, 12, or 18 sessions
  • They were treated three times per week for 6 weeks and received a focused light-massage control at sessions when SMT was not assigned
  • Linear dose effects and comparisons with the no-manipulation control group were evaluated at 6, 12, 24, 39, and 52 weeks.

 

Wrap It Up

In the authors’ conclusions, they say, “There was a linear dose-response relationship between spinal manipulative therapy visits and days with cervicogenic headache. For the highest and most effective dose of 18 spinal manipulative therapy visits, cervicogenic headache days were reduced by half and about 3 more days per month than for the light-massage control.”

Here’s one I thought was pretty darn cool when we talk about how chiropractors help headaches and it’s buried all the way down in the middle of a website for the Wiley Online Library. This site has all of the research covered at the 60 thAnnual Scientific Meeting American Headache Society June 28-July 1, 2018 at the San Francisco Marriott Marquis in San Francisco, CA.

This particular paper covered was by C. Bernstein and called “Rationale and Design of a Randomized Controlled Trial of Chiropractic Therapy for Migraine Pain Alleviation[2]”

Why They Did It

While medications are often the first?line treatment for a migraine, many migraineurs do not experience clinically meaningful responses to preventive drug treatments or discontinue medication use due to side effects. Chiropractic care is a non?pharmacologic intervention commonly used for the treatment of pain conditions, including a migraine. You got that right!

 

They go on to say, “Observational studies and small trials have shown that spinal manipulation may be an effective therapeutic technique to reduce migraine pain and disability. We present results of a meta?analysis of spinal manipulation on migraine pain and disability and describe the design of a randomized controlled trial (RCT) evaluating comprehensive chiropractic care for the treatment and prevention of migraines.”

 

Oh yeah!! Sounding good. It appears that indeed, chiropractors help headaches. This talk appears to be on a new study they will be going through based on some preliminary work here.

 

How They Did It

  • They searched PubMed and Cochrane Library databases for clinical trials that evaluated spinal manipulation and migraine-related outcomes published through April 2017
  • The effect sizes and heterogeneity for pain and disability were estimated using meta?analytic methods.
  • The Cochrane Risk of Bias Tool was used to evaluate the methodological quality of retrieved studies
  • The results of this meta?analysis informed the design of a randomized controlled trial evaluating the addition of chiropractic care to usual medical care for women diagnosed with low-frequency episodic migraine.

 

What They Found

  • On the basis of 6 identified RCTs, random effects models indicated that spinal manipulation significantly reduced pain with an overall moderate effect size
  • Spinal manipulation also significantly decreased disability with an overall moderate effect size
  • However, the existing studies focused primarily on isolated spinal manipulation and not on comprehensive chiropractic care. To address this gap in the literature, our RCT will assess the safety, feasibility, and effectiveness of multi?modal chiropractic care for women aged 20?55 who experience 4?10 migraines per month and are not using preventive medications
  • Our modular chiropractic care approach may include, as needed, posture correction/spinal stabilization exercises, soft?tissue relaxation techniques, spinal manipulation/mobilization, breathing and relaxation techniques, stretches, self?care, ergonomic advice, and/or bracing and supports

 

Conclusion

The authors said the following, “Our meta?analysis indicated that spinal manipulation shows promise as a therapeutic technique to reduce migraine pain and disability, yet highlighted the need for rigorous studies evaluating the full scope of chiropractic care for migraineurs. The results of our meta?analysis provide the rationale for the design of our RCT.”

I can’t wait to see the result of the RCT. Wanna know why? Because I already know the results. At this point, it’s anecdotal but the results will show that chiropractors help headaches and migraines. I’m looking forward to hearing all about it.

 

If I don’t find it first, I know my colleague, Dr. Craig Benton down in Lampasas, TX. He’ll probably find it before me though. Lol. He’s on it every single day. I get a lot of information from a lot of different places but that guy just gets it first.

 

Lastly, I want to direct you to Episode #6 of our podcast. This one was with Dr. Tyce Hergert down in Southlake, TX called “Astounding Expert Information On Immediate Headache Relief. “

 

https://www.chiropracticforward.com/dr-tyce-hergert-astounding-expert-information-immediate-headache-relief/

 

We covered a paper. A paper that I thought had an outstanding quote in the conclusion.

 

The quote from the authors themselves reads as follows, “Upper cervical translatoric spinal mobilization intervention increased upper, and exhibited a tendency to improve general, cervical range of motion and induce immediate headache relief in subjects with cervicogenic headache[3].”

 

Now, in that episode, we explain that it was authored by Physical Therapists and that they have come up with their own term for a chiropractic adjustment and their term is “translatoric spinal mobilization.”

 

The point being that chiropractic adjustments can provide immediate relief for cervicogenic headaches. That’s sexy folks. Straight up awesome. Chiropractors help headaches.

 

The sub-points or something extra I’d like you to notice is the fact that physical therapists are moving in, adopting our ONE THING. So much so that they have taken it upon themselves to re-name our ONE THING for their own use.

 

This goes back to what we covered in episodes 28, 29, and 30….. We must integrate into the medical field and quit being out on the fringe. Otherwise, those that are already in the medical realm (physical therapists) will simply take our ONE THING, steal it, and we will still be sitting out there in the rain knocking on the window and watching them all eating steaks inside the private club. Lol.

 

That’s a little dramatic. There are those in our field that want to stay separate and distinct and I understand that. I understand your stance and your viewpoint. I just don’t agree with it. That’s all.

 

For me, integration into the medical realm ensures our profession’s survival and the health or our ONE THING. We make sure it sticks around. I’m afraid that if we stay out on the fringe, we LOSE our ONE THING to other professions, our reimbursements continue to fall, our income falls year after year because they getting “translatoric spinal manipulation” rather than chiropractic adjustments, and eventually, we cease to exist.

 

Just some random thoughts but, I truly think it’s time. Move toward the middle or suffer the consequences. I honestly see very few other options.

 

The research proves time and time again that we can EASILY move toward the middle. It’s coming out every week. More and more validation.

 

But, then there’s this. The ACA sent out an email recently discussing the fact that, in a continuing effort to be the absolute worst health insurance company in the world, United Healthcare is now discontinuing any coverage of chiropractic for the treatment of headaches[4]. What? What in the hell? Wait, let’s go through the website for UHC real quick so we know exactly what’s going on here. Got your gripey pants on? You’re going to need them. Chiropractors help headaches but UHC hasn’t received the message apparently.

 

On their website we’re linking here in the show notes:

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/manipulative-therapy.pdf

 

UHC says the following:

Manipulative therapy is unproven and/or not medically necessary for treating: ·Non-musculoskeletal disorders, including but not limited to:

o Lungs (e.g., asthma)
o Internal organs (e.g., intestinal)
o Neurological (e.g., headaches)
o Ear, nose, and throat (e.g., otitis media)

  • Temporomandibular joint (TMJ) disorder
  • Scoliosis

Manipulative therapy is unproven and/or not medically necessary for preventive or maintenance care. The role of manipulative therapy in preventive or maintenance care has not been established in scientific literature. A beneficial impact on health outcomes has not been established.

They go on to say Craniosacral therapy (cranial manipulation/Upledger technique) or manipulative services that utilize nonstandard techniques including but not limited to applied kinesiology, National Upper Cervical Chiropractic Association (NUCCA), and neural organizational technique are unproven and/or not medically necessary for any indication.

Manipulative therapy is unproven and/or not medically necessary when ANY of the following apply:

  • The member’s condition has returned to the pre-symptom state.
  • Little or no improvement is demonstrated within 30 days of the initial visit despite modification of the treatment plan.
  • Concurrent manipulative therapy, for the same or similar condition, provided by another health professional whether or not the healthcare professional is in the same professional discipline.

I went that far into the paper just for the “huh, really?” effect but the main point here is, how can they say that spinal manipulation/mobilization is not clinically proven for headaches? In addition to the papers I pointed to here in this podcast, there are more in the links and episodes I provided. As in around 10 or so others showing and proving effectiveness. Just in episode 14 alone.

 

What exactly do they need and why the change?

 

Is this part of the Texas Medical Association’s attack on Texas Chiropractors where they are attempting to remove the neuro- from the neuromusculoskeletal treatment scope from chiropractors? It sounds like it to me when you look at it. I get the internal organs part. I get the asthma part. I do NOT understand how they classify headaches as strictly neuro in nature and have made a line where they do not cover any neuro treatment for chiropractors.

 

It’s unreal. It really is. Here on this site, they cite Chaibi et. al. (2017) and Seffinger and Tang (2017). In these papers they site, both conclude that spinal manipulation was effective. The second paper showed spinal mobilization to be more effective than physical therapy but….guess what. They need more studies. Probably studies like I’ve been telling you all about for 7 months now.

 

This kind of stuff makes me want to punch myself in the nose and go home and kid my daughter’s cat. Straight up punt that sucker. That’s nothing new though but seriously. To borrow a phrase from one of my very favorite football coaches, “This kind of garbage just makes my pee hot.” It really does folks.

 

Chiropractors help headaches. Every day all day and the research sure as hell shows it too.

 

Just keep on keepin on and stay strong, ladies and gents. What other option do you have without going back to school? It’s still the best time to be a chiropractor. It’s still the time in which there is more opportunity than ever before. This stupid insurance company cites only two papers and both of them showed effectiveness for headaches. It’s only a matter of time before all of the idiots start to catch up with the research and with what chiropractors have known for generations.

 

This week, I want you to go forward speaking with confidence and knowing that you are effective for headaches and migraines. You can change people’s lives. If you are not being effective for your patients’ headaches, seek some advice from a mentor. Sometimes it’s just a little tweak here and there and you’ll be on the road to being your patients’ hero. When done well, research backs us on this all over the place. For more proof, go check out show notes on Episode #14 or our Stroke blog at https://www.chiropracticforward.com/blog-post/debunked-the-odd-myth-that-chiropractors-cause-strokes-revisited/

Integrating Chiropractors

 

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

 

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

 

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

 

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

 

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

 

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About Dr. Jeff

 

 

  1. Haas M, Dose-response and efficacy of spinal manipulation for care of cervicogenic headache: a dual-center randomized controlled trial.Spine, 2018: p. S1529-9430.
  2. Bernstein C. Rationale and Design of a Randomized Controlled Trial of Chiropractic Therapy for Migraine Pain Alleviation. in 60th Annual Scientific Meeting American Headache Society. 2018. San Francisco Marriott Marquis San Francisco, CA.
  3. Malo-Urries M, Immediate Effects of Upper Cervical Translatoric Mobilization on Cervical Mobility and Pressure Pain Threshold in Patients With Cervicogenic Headache: A Randomized Controlled Trial.J Manipulative Physiol Ther, 2017. 40(9): p. 649-658.
  4. Policy, U.H.C.M. Manipulative Therapy. 2018 1 June 2018]; Available from: https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/manipulative-therapy.pdf.

 

CF 006: With Dr. Tyce Hergert: Astounding Expert Information On Immediate Headache Relief

This episode is all about headaches, it highlights one service dressed up and parading around as another sort of like it’s Halloween or something, and we’ll tell some personal stories about what we have seen in practice during our years of service to our patients. It should be a good one.

We are excited to welcome Dr. Tyce Hergert to the Chiropractic Forward podcast. Dr. Hergert has the distinct privilege of being the very first guest that we’ve ever had. Dr. Hergert was the Texas Chiropractic Association President, the head honcho, for 2016/2017 and, under his leadership the TCA was able to get 5 Chiropractic friendly bills through the legislation whereas we had failed to get even one through in all the years prior to that as far back as I had paid any attention so that was quite a feat.

Dr. Hergert is the owner/operator of Chiropractic Care Center of Southlake as well as the owner/operator of Southlake Physical Medicine in Southlake, TX

In addition, Dr. Hergert and myself both grew up in Perryton, TX. He was a couple of years younger than myself but we grew up on the same neighborhood, went to chiropractic school at the same time roughly, and have both served in the Texas Chiropractic Association at the same time. You could say that we know each other.

Welcome to the Chiropractic Forward Podcast Dr. Hergert. How do you feel about being the very first guest that we have ever had?

In this episode, I promise that we’re going to have more fun than being on the receiving end of a purple nurple.

This week, I want to discuss headaches and conservative, alternative headache treatment. It’s common for people to look at chiropractors as “spine people” and “back doctors”.

Is that your experience as well, Dr. Hergert?

What people don’t commonly know is that chiropractors can knock it straight out of the park when it comes to treating headaches. Yes, I said, “Knock it out of the park.” That’s an old metaphor comparing baseball players hitting home runs and I’m telling you, chiropractors mostly hit home runs on headache cases.

I have to admit that I was a terrible baseball player. I played college football and I’m Texan born and raised where football is King so I should probably put it in football terms.  In football terms, you might say that we chiropractors have a record of 80-yd touchdown passes when it comes to headaches. We return headache punts for a score almost every time. We pick-six those suckers. That’s probably enough to drive the point home.

Not every single headache of course. I’ve met my match several times over my 20 years in practice. But I don’t think it’s too bold to say that about 80%-90% of headache patients just improve. And not just improve, but DRAMATICALLY improve.

Before we get into the research, let me take a minute to give you just a couple of personal experiences in treating headache patients in my practice here in Amarillo.

Case #1: We will call this patient Andy McFuddlesticks just because I’m feeling a little goofy today. That sounds a little like a Harry Potter character, doesn’t it?

Andy had experienced migraines his whole life and was around 40 years old at the time we crossed paths. He had been to all of the medical doctors. He had endured injections if his suboccipital region. I don’t recall what the injection was exactly because this was about 18 years ago. I don’t believe they did botox for migraines at that point in time. He had gone through nuclear bones scans as well. Andy McFuddlesticks had been through it you might say.

He came to see me only a few times. It was frustrating that he didn’t finish his treatment plan but the reason he didn’t finish is satisfying. Andy only came a handful of times because the headaches were gone. After all of the years and procedures, just a few visits to a very new and green chiropractor made them vanish. How do I know? Well, I was in a civic organization with his brother who confirmed months later that his brother was doing great and had not had a headaches since seeing me. How is Andy 18 years later? I have no idea. I switched towns but I know he did great for a long time and we are putting that one in the “win” column.

Dr. Hergert, would you like to share one of your more memorable headache case stories with us?

Case #2: Sally McGullicutty I believe was her name. Red hair. Irish. Anyway, Sally had migraines for years. I actually knew Sally personally and had been friends for some time. Evidently I was not skilled at getting my message out on how successfully we can deal with headaches because it took Sally way longer than it should have taken her to make an appointment with us.

Sally shared with me that she had migraines, on average, several times a week and once or twice every month would find herself in a dark bathroom floor sitting my the toilet throwing up. How awful of an existence is that? I cannot even imagine being forced to live that way. I say it often but it bears repeating, “Pain can absolutely change a person.” Not only the person but it can change everyone around the person that is consistently in and out of contact with them.

After approximately 2-4 weeks of working with Sally, she just started to not have the migraines anymore! I would say she “magically” recovered but chiropractors know this isn’t accurate. We got the right joints moving, we got the right muscles to relax, and we got out of the way and let the body do the rest. There’s no magic in that. It’s just common sense to chiropractors.

Fast forward a few years and Sally is still a patient and Sally comes here for other reasons and conditions from time to time but she doesn’t visit because of migraines anymore. She just doesn’t have them.

How about one more story Dr. Hergert?

I’m pretty sure we could both absolutely go on and on with examples from personal experience in practice. I have 20 years of dealing with headaches and I can tell you, Chiropractors are modern day headache whisperers.

Let’s dive into a little research just to show you what I’m talking about. There are more we will go over in the future episodes but I want to touch on two this week. One new study and one older.

The first one is the more recent research paper and comes to us from a group in Spain. The lead author was Miguel Malo-Urries, PT, PhD with the University of Zaragoza Aragon Spain and it was published in Journal of Manipulative and Physiological Therapeutics in the November-December 2017 issue, Volume 40, Issue 9, Pages 649-658. The study was titled “Immediate Effects of Upper Cervical Translatoric Mobilization on Cervical Mobility and Pressure Pain Threshold in Patients With Cervicogenic Headache: A Randomized Controlled Trial.” What a name.

Did you catch that word, “Translatoric?” Dr. Hergert, have you run across this term prior to this interview?

I’m going to define that word for everyone. Translatoric is not commonly in the Chiropractic verbiage or vernacular. At least I don’t recall it from my education at Parker University in Dallas but that was eons ago. I have gray sideburns now. It has been a while. The authors of the paper all have PT behind their names so we have physical therapists setting the terms for the research project. Understanding this, then the use of translatoric makes more sense.

I found a site that gives a pretty good definition of Translatoric Spinal Manipulation. The term Translatoric Spinal Manipulation or TSM “consists of a series of high and low-velocity manipulative spinal techniques, which emphasize the use of small amplitude, straight-line (or translatoric) traction and gliding impulses delivered parallel or perpendicular to an individual vertebral joint or movement segment. Furthermore, TSM emphasizes the use of either direct manual stabilization or the use of spinal pre-positioning to restrict the amount of motion occurring at adjacent spinal segments during the translatoric impulse.” The website goes on to say, “Delivering translatoric impulses (in the form of disc traction, disc glides, facet traction and facet gliding) to an individual joint or spinal motion segment while using stabilization provides the manual therapist with a manipulative tool that has a predictable effect in terms of pain reduction and motion restoration with minimal potential risk of patient injury.”

Do you know what that sounds like to me? Dr. Hergert, what does it sound like it’s describing to you?

It sounds like a “Chiropractic Adjustment.” Another term it sounds like is “Spinal Manipulative Treatment/Therapy.” Something we chiropractors have been doing for over 100 years and have been called crazies and quacks for doing. It sounds like the exact thing that the medical world has touted as being responsible for strokes for years and years. Of course, research proves that they don’t have a clue what they’re talking about on the storke issue but translatoric spinal manipulation is nothing more than a Chiropractic Adjustment.

Now that that is clear, let’s get back into the research.

Why They Did It

The good folks in Spain performing Translatoric Spinal Manipulation rather than Chiropractic Adjustments wished to assess the response in terms of range of motion and pain in patients suffering cervicogenic headaches.

How They Did It

  • It was a randomized controlled trial
  • The paper included 82 patients.
  • The patients ranged in age from about 25-55 or so.
  • All patients suffered from cervicogenic headaches.
  • The patients were randomly split up into two groups. One was a control group and one was a treatment group.
  • The treatment group received Chiropractic Adjustments…..I’m sorry…Translatoric Spinal Manipulation.
  • The control group received no treatment or sham treatment.
  • The researchers tested Cervical range of motion, they tested the pressure pain thresholds over the upper trapezius muscles, the C2-3 zygapophyseal joints and sub occipital muscles were tested, and the current headache intensity were all measured on the Visual Analog Scale prior to the Chiropractic adjustment and right after.
  • The testing was done by two blinded investigators

What They Found

  • Afterward, the Chiropractic Adjustment group had significantly increased range of motion in the neck region overall as well as in the flexion-rotation test.
  • And, while there was no changes in the pain thresholds, patients reported significantly lower intensity in their headaches!

Wrap It Up

The quote from the authors themselves reads as follows, “Upper cervical translatoric spinal mobilization intervention increased upper, and exhibited a tendency to improve general, cervical range of motion and induce immediate headache relief in subjects with cervicogenic headache.”

Dr. Hergert….do the findings in the study surprise you at all?

What are your initial impressions of the study?

I’d say that, if you have issues with chiropractors, now you can just take it straight from physical therapists with PhD’s that are performing chiropractic adjustments but calling it something else.

I want to be honest here: the frustrating part of this for me isn’t necessarily the fact that PTs are doing cervical chiropractic adjustments. Heck, chiropractors have been doing PT for years but the physical therapists claim ownership of the term so the chiropractic industry just call it exercise rehab.

Although, their doing adjustments may be irritating on some level, the most irritating thing is that a certain aspect of the physical therapy community and a larger aspect of the medical community have spent years ridiculing, mocking, and belittling generations of chiropractors. And now, doctors of osteopathy and physical therapists are trying to do the exact same thing without going through any chiropractic training. You would think they would at least release a statement saying, “You know, we have thrown rocks at chiropractors for years but it turns out they were right all along so, since we can’t beat them, we’re going to just join them.”

Wouldn’t that be refreshing?

Can I get an amen on that Dr. Hergert? Do you have any other thoughts on that?

I’m geting all bothered over here so let’s go over the older study before I start getting too ugly about the whole deal.

This one is by GV Espi-Lopez et. al. and is called, “Do manual therapy techniques have a positive effect on quality of life in people with tension-type headache? A randomized controlled trial.” It was published in the European Journal of Physical and Rehabilitation Medicine  on February 29th of 2016.

Why They Did It

Although there have been lots of studies that prove the impact of manual therapy and spinal mobilization for frequency and intensity of pain suffered from tension type headaches, there have been no studies in regards to the effectiveness of the same therapies for the quality of life for the people suffering from them.

The authors of this paper wished to focus on patient quality of life.

How They Did It

•The study was again, a randomized, single blinded, controlled clinical trial.

•Comprised of 62 women and 14 men.

•Aged between 65 years old all the way down to 18 years old.

•All subjects suffered from chronic tension type headaches or episodic tension type headaches.

•The subjects were categorized into four separate groups: suboccipital inhibitory pressure, suboccipital spinal manipulation, a combination of the two together, and then a control group.

•An SF–12 questionnaire was used to help assess the subjects’ quality of life at both the beginning of treatment, the ending of the treatment, as well as at the one month follow-up.

What They Found

•The suboccipital inhibition group improved significantly in their quality of life at the one month mark as well as improvements in moderate physical activities.

•Not the control group, but all other treatment groups had an improvement in physical activities, pain, and social functioning at the one month mark.

•After treatment, as well as that the one month mark, the combined treatment category had improved vitality.

•Following treatment and at the one-month mark, both groups that had manipulation to the sub occipital region also showed improved mental health.

Wrap It Up
All three therapy approaches showed significant effectiveness toward improving the quality of life, however the combined treatment therapy had the most dramatic change for the good.
In short, manual therapy techniques and manipulation applied to the sub occipital region for four weeks or more showed great improvement and in effectiveness for several aspects that measure the quality of life of a patient having suffered from tension type headaches.

Dr. Hergert…you like apples? Lol Do these findings reflect what you have seen over the years there in Southlake, TX?

These are just a couple of studies to get us started off on the right foot for headache discussions on the Chiropractic Forward Podcast. There are several more I will be sharing in the future so stay tuned.

When Chiropractic is at its best, you cannot beat the risk vs reward ratio. Plain and simple. Spinal pain is a mechanical pain and responds better to mechanical treatment rather than chemical treatment such as pain killers, muscle relaxants, and anti-inflammatories.

I mentioned this in episode #1 but Dr. Hergert and myself spend some time trying to generate a concise, responsible statement regarding chiropractic care in general. A statement that could easily be shared. An elevator speech for the profession if you will. You will find it at the end of every blog, every video, and every chiropractic forward podcast. It is as follows:
Research and clinical experience shows that, in about 80%-90% of headaches, neck, and back pain, in comparison to the traditional medical model, patients get good or excellent results with Chiropractic. Chiropractic care is safe, more cost-effective, it decreases your chances of having surgery, and it reduces your chances of becoming disabled. We do this conservatively and non-surgically. In addition, we can do it with minimal time requirements and minimal hassle on the part of the patient. And, if the patient develops a “preventative” mindset going forward from initial recovery, we can likely keep it that way while raising the general, overall level of health!

Thank you to Dr. Hergert for spending his valuable time with us today. We look forward to many more guest appearances.

Please feel free to send us an email at dr dot williams at chiropracticforward.com and let us know what you think or if you have any suggestions for future episodes.

From Creek Stone in Amarillo, TX and the flight deck of the Chiropractic Forward podcast, this is Dr. Jeff Williams saying upward, onward, & forward.

https://www.jmptonline.org/article/S0161-4754(16)30281-0/fulltext?elsca1=etoc&elsca2=email&elsca3=0161-4754_201711_40_9_&elsca4=Physical%20Medicine%20and%20Rehabilitation%7CHealth%20Professions

https://www.optp.com/Translatoric-Spinal-Manipulation-for-Physical-Therapists-Book-and-DVD

https://www.amarillochiropractor.com/get-rid-of-migraines-and-headaches-once-and-for-all/