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CF 043: Stroke Caused By Chiropractor

CF 043: Stroke Caused By Chiropractor

Today we’re going to talk about Stroke caused by chiropractor and we’re to show you once again what a pile of hooey the idea is and we’ll even talk a bit about where it came from.Integrating Chiropractors

Stick with us but first, we’re going wade through this here bumper music. 

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

You have bee-bopped into Episode #43 and we are so glad to have you. I’ve noticed that podcasts are going into Seasons….Shows you how much I pay attention to stuff outside of what I’m doing. I’m ashamed. I should do Seasons. Here’s the deal though. I enjoy it so much. I actually WANT to put one out every week. It’s not work when you’re having fun right?

It can be a little stressful creating content and talking points but hey, we get through it and have a lot of fun in the process. 

Growth

What a great month this has been in regards to listens and downloads. You’ve heard me say it before but it’s fun to watch. Because I’m a numbers nerd and who the heck doesn’t like to see the growth of a brainchild?

Speaking of growth, I’ve started work on something that I hope you’ll love. I’ll hope you’ll think about using for your own offices, and I think may be pretty cool. I’ll fill you in more and more as we go along but just know, I’m working on something and you should get yourself on our email list at www.chiropracticforward.com so I can tell you about it and maybe pass along discounts, stuff like that. Email list. Do it. 

A little personal…

How has your week been? Mine….well….I have to continue the saga of hiring a new front desk person. Hell people. Actual hell. The first one just didn’t show up. The second one we hired lasted three days. Three freaking days, folks. 

But, we think we have a winner in place now. You know I’m going to keep you all updated on this deal. This by itself has been enough for its own reality show. I’ve never seen anything like it. The workforce right now just doesn’t seem to want to work. At least that’s my experience lately. 

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.

Let’s get to the research papers

First thing’s first. I have covered this stroke caused by chiropractor topic in depth. As in….very in-depth. In Episodes 13, 14, and 15. If you do nothing else this week as far as educating yourself, make sure you go listen to those three episodes in stroke caused by chiropractor or read it on our blog at http://www.chiropracticforward.com all of which are linked here in the show notes. 

Podcast Episodes:

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

YouTube Video: https://youtu.be/tRXpG_Ie0Rs

Why go over stroke again?

So, why go over stroke caused by chiropractor again? Well, one reason is that it’s been a while since we touched on the topic. Another being that I heard a prominent speaker just this year talking about chiropractors causing strokes and implying that it happens fairly often. That’s a pro-chiropractic speaker, by the way, acting as if chiropractors are the sole reason for a stroke on a regular basis. 

I don’t think that it is necessarily the way the discussion was meant but it could definitely have been interpreted in that manner if those listening didn’t have the information from our Debunked series. 

The other reason I wanted to cover stroke caused by chiropractor again is that is the main thing in regards to safety that the medical kingdom tries to hold over us. Or that they’ve been told about us. And, instead of doing their work on this, they just believe it. 

New habits take 20 days to cement. We need new habits in the medical realm so I’m doing my part by taking away one of the main things they have against us. One may argue that the philosophy and subluxation model is another thing they hold against us but, all I can do about that is continue to disseminate evidence-based information and keep plugging. We’ll see where that part of it goes in the future. 

Common sense talk

For now, though, it’s about stroke caused by chiropractor this week here on the Chiropractic Forward podcast. Now, let’s compare and contrast shall we?

Did you know that the RAND Institute estimates a chiropractic adjustment is the sole cause of a vertebral artery dissection at the rate of only about 1 in 1 million or more adjustments? And did you know that your chances of winning an Oscar stand at about 1 in 11,500? Your chances of being hit by lightning are 1 in 176,426? 

How about this: NSAIDS like ibuprofen and acetaminophen cause around 16,000 deaths per year and send 100,000 people to the ER in America….EVERY YEAR.

Let’s let all that sink in. I say all of that just to put things into context and to make the point that the medical kingdom needs to quit making such a big damn deal out of trained and licensed chiropractors adjusting necks. 

We’re starting with this paper 2015 by Kosloff and friends titled, “Chiropractic care and the risk of vertebrobasilar stroke: results of a case-control study in U.S. commercial and Medicare Advantage populations[1].” It was published in Chiropractic & Manual Therapies. 

Why They Did It

This is obvious. We’re looking at the real chances of chiropractic adjustments being the culprit for strokes. 

What They Found

There were 1,829 vertebral basilar artery stroke cases

Findings showed no significant association between chiropractic visits and VBA stroke

The Authors’ Conclusion

“We found no significant association between exposure to chiropractic care and the risk of VBA stroke. We conclude that manipulation is an unlikely cause of VBA stroke. The positive association between PCP visits and VBA stroke is most likely due to patient decisions to seek care for the symptoms (headache and neck pain) of arterial dissection. We further conclude that using chiropractic visits as a measure of exposure to manipulation may result in unreliable estimates of the strength of association with the occurrence of VBA stroke.”

Research Paper #2

Just like a rolling stone we are moving on and gathering no grass…..

This next paper is from Church, et. al. and is called, “Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation[2].” It was published in Cureus in February of 2016. 

Just to review the research hierarchy for those unaware, systematic reviews and meta-analysis papers are at the tippy top of the food chain just above randomized controlled trials. It’s like people in the animal kingdom. We’re the top predators ya know. 

Anyway, the point is: this is reliable information folks. 

We already know why they did it so let’s skip to what they concluded. “ There is no convincing evidence to support a causal link between chiropractic manipulation and CAD. Belief in a causal link may have significant negative consequences such as numerous episodes of litigation.”

Uhhuh….numerous episodes of litigation based on belief and NOT based on fact or research. Believing stroke caused by chiropractor is unfortunate.

Now we come to the guy that helped put the matter to rest once and for all. If you are unaware of John David Cassidy, let me introduce you. He is a professor at the University of Toronto Dalla Lana School of Public Health and is a Ph.D.

Research Paper #3

Let’s start with his newer one concerning this topic. It’s called “Risk of Carotid Stroke after Chiropractic Care: A Population-Based Case-Crossover Study[3].” It was published in the Journal of Stroke & Cerebrovascular Diseases in 2017. Newer stuff from JD Cassidy, folks. 

As you’ll see, this paper deals with CAROTID artery and stroke specifically whereas the next and last paper deals with the VERTEBRAL artery and stroke. 

  • The why is obvious once again so, what did they find?
  • They compared 15,523 cases to 62,092 control periods using exposure windows of 1, 3, 7, and 14 days prior to the stroke. 
  • There was no significant difference between chiropractic and PCP risk estimates. 
  • They found no association between chiropractic visits and stroke in those 45 years of age or older. 

The Conclusion

“We found no excess risk of carotid artery stroke after chiropractic care. Associations between chiropractic and PCP visits and stroke were similar and likely due to patients with early dissection-related symptoms seeking care prior to developing their strokes.”

Research Paper #4

You’re about to notice a trend here. Next paper is by Cassidy et. al. as well and is called, “Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-Based Case-Control and Case-Crossover Study[4].” This is the Daddy of papers proving that chiropractic adjustments are not the sole cause of strokes. 

Again, everyone knows why the research was done so let’s get to the meat and taters. 

  • It was done over a nine-year period from April 1993 to March of 2002. 
  • There were 818 vertebrobasilar artery strokes hospitalized in a population of more than 100 million person-years. 
  • There was no increased association between chiropractic visits and VBA stroke in those older than 45 years. 

The Conclusion and nail in the coffin

“VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.”

It’s like the action hero cartoons “Shazam” “Pow” “Bang” “Smack!”

Again, believing stroke caused by chiropractor unfortunate.

Wrap It Up

I’ve said it a thousand times. “If we were wrong, we’d have been wiped out years ago.” Lord knows every force of the medical kingdom focused on our demise for generations and that goes from the national and state associations all the way into the national and state legislatures. 

How do you fight against that amount of money and power and survive if you’re not inherently right in what you’re doing?

We can argue amongst ourselves till the cows come home about how to do our jobs but, in the end, we help our patients, we get them better when nobody else can, and….well…we’re right. 

So, the haters in the medical field can take a long walk off a short pier and stick it in their ears. I’m not always professional and that’s OK. I’ve always felt being strictly professional all of the time is more than just a little bit boring. We need more spice, personality, and a lot more laughter in life don’t we? 

Integrating Chiropractors

Affirmation

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

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

Contact us

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

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

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

Website

http://www.chiropracticforward.com

Social Media Links

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

iTunes

Player FM Link

Stitcher:

TuneIn

About the author:

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

Research Paper Links:

https://www.ncbi.nlm.nih.gov/pubmed/26085925

https://www.ncbi.nlm.nih.gov/m/pubmed/18204390/

https://www.ncbi.nlm.nih.gov/pubmed/27014532

https://www.ncbi.nlm.nih.gov/m/pubmed/27884458/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2271108/

Bibliography

1. Kosloff T, e.a., Chiropractic care and the risk of vertebrobasilar stroke: results of a case–control study in U.S. commercial and Medicare Advantage populations. Chiropractic & Manual Therapies, 2015. 23(19).

2. Church E, e.a., Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus, 2016. 8(2): p. e498.

3. Cassidy, e.a., Risk of Carotid Stroke after Chiropractic Care: A Population-Based Case-Crossover Study. J Stroke Cerebrovasc Dis, 2017. 26(4): p. 842-850.

4. Cassidy, e.a., Risk of Vertebrobasilar Stroke and Chiropractic Car. Spine, 2008. 33(4S): p. S176-S183.

CF 032: How Evidence-Based Chiropractic Can Help Save The Day

CF 029: w/ Dr. Devin Pettiet – Is Chiropractic Integration Healthy For The Profession?

CF 028: Will Chiropractic First Finally Take Its Place?

 

 

CF 041: w/ Dr. William Lawson – Research For Neck Pain

Research for neck pain

Integrating Chiropractors

Today we’re going to talking with Dr. William Lawson from Austin, TX about research for neck pain and what research is available for it. While low back gets all of the attention in the research, neck pain has taken a back seat but not today!

But first, here’s that bumper music

OK, we are back. Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast because I’m the only one that’ll do it.  

Have you taken the time to go to chiropracticforward.com and sign up for our newsletter? It’s important because doing that makes it easier to let you know when the newest episode goes live and we have a ton of ideas around here for the future and we want to be able to let you know about it. An email once per week isn’t going to make you crazy so please go do that so we’re on the same page.  

I also want to let you know about our Facebook page AND our separate Facebook group because they’re important supplements to the podcast. Both are called Chiropractic Forward oddly enough. On the page, we let you all know when a new episode goes live and we share some quotes from the episodes. Through the private Facebook group, we share the papers we went over and lots of time we connect and discuss there so go join up and let’s connect.

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

You have done the mashed potato all James Brown, 60’s style into Episode #41. You know what that means? It means it’s going to be cooler than usual episode. 

Dr. William Lawson, Austin, TX

That’s because, as I mentioned before, we have a guest with us. Dr. William Lawson hails from Austin, TX and has his Diplomate of American Chiropractic Orthopedists designation. Yes, ladies and gentleman, I brought another DACO to you today. Last week, we had Dr. Brandon Steele, also a DACO, so you may be starting to notice a slight trend. We are going to get into the thick of things with research for neck pain.

I met Dr. Lawson through his involvement in the Texas Chiropractic Association. Dr. Lawson is responsible for getting the DACO program to come to Texas and for having the TCA host the program. He’s responsible in a roundabout way for getting me into this whole DACO mess and I thank him for it. 

A little more about Dr. Lawson

  • Prior to attending Parker College of Chiropractic in Dallas, -Texas, I served in the United States Air Force.
  • Graduated from Parker College of Chiropractic 1993.
  • Designated Doctor with Tx Workers Compensation since 1996
  • He has the Diplomate American Academy of Integrative Medicine, college of pain management, 2000.
  • Dr. Lawson acheived Diplomate American Academy of Pain Management 2001.
  • Diplomate American Board of Chiropractic Orthopedists, 2002
  • Certified in acupuncture, 2004
  • Former hospital privileges Vista Hospital Houston and Pecan Valley Surgical Center in San Antonio.
  • Masters degree from UT Pan American in Health Care Administration, 2015
  • Current Chair of State Affairs with TCA
  • Current VP of Texas Council of Chiropractic Orthopedists.

Welcome to the show Dr. Lawson. Since we are friends, formality seems awkward, if you call me Jeff, I’ll call you what? William or Bill? 

Questions for Dr. Lawson

When did you become a DACO and what was the impetus? What started that journey?

What have you noticed about yourself and about your business in regards to pre-DACO and post-DACO?

Let’s get into the research for neck pain. The first thing I want to say here is that we cannot talk about cervical manipulation without addressing the yoke the medical field has tried to lay on us for generations. That is the myth that chiropractors go around causing strokes in everyone all the time. 

I took three episodes of this podcast to address this myth. The series is called “DEBUNKED: The Odd Myth That Chiropractors Cause Strokes” and are specifically episodes #13, #14, and #15. It’s just common sense talk and, if you have any questions in your mind prior to listening to them, they should all be answered by the time you are done. 

I will link them in the show notes as well as the corresponding YouTube Video and the Blog so that you can get the information in your preferred method. 

PODCAST EPISODES:

BLOG:

YOUTUBE:

https://youtu.be/tRXpG_Ie0Rs

Now that we’ve addressed this craziness, we can get on with how well we take care of our neck pain patients. 

Dr. Lawson, I want to hear from you as much as you want to be heard from so, please….if I cover something that you have some extra info on or you just want to add a comment to, please interrupt me and lay it on us!!

We’ll start with the oldest one we have tee-d up here and go to the most recent. 

This first one is from 2001 and is called “A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain[1].” The lead author is G. Bronfort and, if I recall correctly, his full first name is Gert. If you’ve spent any time listening to our podcast, you’ve probably heard his name. He’s fairly prolific with research papers. 

Why They Did It

Their stated goal for this project was to compare the effectiveness of rehab exercises vs. spinal manipulation for chronic neck pain. This one really focuses on research for neck pain.

What They Found

  • Patient satisfaction was higher spinal manipulation + exercise was superior to spinal manipulation alone
  • There was no statistical difference noted between the two groups
  • However, when combined, exercise + manipulation showed greater gains in all measures of strength, endurance, and range of motion. 

Wrap It Up

The authors concluded, “For chronic neck pain, the use of strengthening exercise, whether in combination with spinal manipulation or in the form of a high-technology MedX program, appears to be more beneficial to patients with chronic neck pain than the use of spinal manipulation alone.”

Dr. Lawson, what’s your take on this study? At this point, it’s 17 years old. Is it relevant still and how?

Next paper, this one’s called, “Chronic mechanical neck pain in adults treated by manual therapy: a systematic review of change scores in randomized clinical trials[2].” It is by H. Vernon, et. al. and was published in the Journal of Manipulative Physiological Therapeutics in 2007. 

Why They Did It

This was a systematic analysis of effectiveness in randomized clinical trials of chronic neck pain. The stipulations here are that the neck pain could not be caused by whiplash and could not include a headache or arm pain. Just straight up chronic neck pain. 

What They Found

Out of 1980 papers, they found 16 to accept and include in this project. 

No trials included trigger point therapy or manual traction

Wrap It Up

“There is moderate- to high-quality evidence that subjects with chronic neck pain not due to whiplash and without arm pain and headaches show clinically important improvements from a course of spinal manipulation or mobilization at 6, 12, and up to 104 weeks post-treatment. The current evidence does not support a similar level of benefit from massage.”

Dr. Lawson, on this study, for those that don’t know research hierarchy, a randomized clinical trial is some of the more reliable, solid research for neck pain wouldn’t you agree?

The only thing more impactful in the research world than randomized clinical trials are meta-analyses and systematic reviews. Well, this is a systematic review of 16 randomized clinical trials. 

My point being: this is a reliable systematic review. No doubt about it. This is a great paper, Dr. Lawson and I have no idea how it’s escaped me 11 years into this thing. I have other papers by the same group of authors but somehow missed this research for neck pain?

Would you like to add any comments on this paper?

OK, moving on, this paper is called, “Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial[3].” This one comes to us by G. Bronfort, et. al. as well and was published in the Annals of Internal Medicine in 2012. 

This is not my favorite research for neck pain as we’ll talk about after we go through the conclusion. 

Why They Did It

“To determine the relative efficacy of spinal manipulation therapy (SMT), medication, and home exercise with advice (HEA) for acute and subacute neck pain in both the short and long term.”

How They Did It

  • It was a randomized controlled trial
  • They used 1 university research center and 1 pain management clinic in Minnesota
  • The sample was 272 people from 18-65 years old having nonspecific neck pain from 2-12 weeks
  • The treatment consisted of 12 weeks of spinal manipulative therapy or home exercise advice. 

What They Found

For pain, SMT had a statistically significant advantage over medication after 8, 12, 26, and 52 weeks

Home exercise was superior to medication at 26 weeks

No important differences in pain were found between SMT and HEA at any time point

Wrap It Up

Bronfort concluded, “For participants with acute and subacute neck pain, SMT was more effective than medication in both the short and long term. However, a few instructional sessions of HEA resulted in similar outcomes at most time points.”

As I mentioned, I have covered this research for neck pain before but it’s not my favorite because this is also a paper that I have seen chiropractic detractors use against us. Here’s how: they say that cervical manipulation is extremely risky and, if the outcome of simple exercises at home is just as effective, then what’s the point in cervical manipulation for neck pain?

What would you say in response to this particular argument?

Keepin on keepin on here. This next one is from the Journal of Manipulative Physiological and Therapeutics back in 2014 called “Evidence-based guidelines for the chiropractic treatment of adults with neck pain[4].” This one was done by Bryans, et. al. 

Why They Did It

They wanted to develop evidence-based treatment recommendations for the treatment of nonspecific mechanical neck pain in adults. 

How They Did It

They did a systematic literature search of controlled clinical trials published through December of 2011 and then organized each into strong, moderate, weak, or conflicting)

What They Found

41 randomized controlled trials met the criteria for inclusion. 

Strong recommendations were made for the treatment of chronic neck pain with manipulation, manual therapy, and exercise combined with modalities. 

Strong recommendations were also made for treating chronic neck pain with stretching, strengthening, and endurance exercises alone. 

Moderate recommendations were made for the treatment of acute neck pain with manipulation and mobilization in combination with other modalities. 

Wrap It Up

The authors closed by saying, “Interventions commonly used in chiropractic care improve outcomes for the treatment of acute and chronic neck pain. Increased benefit has been shown in several instances where a multimodal approach to neck pain has been used.”

Do you feel like this is going a little more in our favor than the Bronfort paper but still leaves a little to be desired? For instance, when we look at low back pain papers, it’s clear. Spinal manipulation is as effective or more effective than anything else out there. Even physical therapy or exercise. We’re not getting that satisfaction so far. Am I wrong?

We’re trucking along here. Next paper titled “Mobilization versus manipulations versus sustain apophyseal natural glide techniques and interaction with psychological factors for patients with chronic neck pain: randomized controlled trial[5].” This one was published in European Journal of Physical Rehabilitation Medicine in 2015 and written by A. Lopez-Lopez, et. al. 

Here’s my first question: “Why would you hyphenate the same name?” How can you be Lopez-Lopez and why would you want to say the name twice or make everyone else say the name twice? Isn’t it a bit redundant? Can we just say Lopez and move on?

OK, I get side-tracked sometimes so I have to get myself back on track here and there. Since I’m not familiar with this paper or the authors at all, I want to switch it up a little on this one. 

Dr. Lawson Covers One

I want Dr. Lawson to go over this paper from top to bottom and tell us everything we need to know about this one. I see it’s a randomized controlled trial so it already has my attention. I’m unfamiliar with sustain natural glide (AKA SNAG). Is that term you are familiar with? This research for neck pain is all yours doc. 

Their conclusion was “The results suggest that high velocity/low amplitude and posterior to anterior mobilization groups relieved pain at rest more than SNAG in patients with neck pain.”

Let’s get to our last paper here by Korthalis-de-bos, et. al. It’s called “Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial[6].” It was published in the British Medical Journal back in 2003. 

Why They Did It

The authors wanted to evaluate the cost-effectiveness of physical therapy, manual therapy, and care by a general practitioner for patients with neck pain.

How They Did It

  • The project was an economic evaluation alongside a randomized controlled trial.
  • 42 general practitioners recruited 183 neck pain patients
  • The patients were randomly split for treatment by spinal mobilization, physical therapy, or general practitioner care. 

What They Found

The authors wrapped that research for neck pain up by saying, “Manual therapy which consisted of spinal mobilization, is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner.”

I wanted to wrap up our talk with that research for neck pain because, first of all, it’s from the British Medical Journal so it got some weight. Second it’s alongside randomized controlled trials, and third, it’s one of the main ones that cuts through the noise and says very clearly, “mobilizing the spine is more effective and cost less for neck pain than seeing your primary or a physical therapist.”

Is it just me or is it time to move focus from low back pain and put more effort an attention on how effectively we treat neck pain through research for neck pain?

It just makes complete sense to me. If we are so effective for low back pain in the eyes of researchers, why don’t we have the same pile of research for neck pain? Where is all of the research for neck pain? Both are mechanical in origin. If we can affect low back pain, it makes perfect sense that we can affect neck pain. 

Chiropractors see it every single day. I’m not telling you anything. I just get so frustrated at the lack of focus on neck pain, which is part of the reason we’re doing this podcast today. 

Dr. Lawson, what do you have to add here before we sign off?

I want to thank you for joining us on the Chiropractic Forward Podcast. I hope you’ve enjoyed it as much as I have. 

Maybe we talk some DC PhD’s out there into making neck pain their next project. 

Integrating Chiropractors

 

Going forward

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

Contact Us

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

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

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

Website

http://www.chiropracticforward.com

Social Media Links

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

iTunes

Player FM Link

Stitcher:

TuneIn

About the author:

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

1. Bronfort G, A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain. Spine (Phila Pa 1976), 2001. 26(7): p. 788-97.

2. Vernon H, H.B., Chronic mechanical neck pain in adults treated by manual therapy: a systematic review of change scores in randomized clinical trials. J Manipulative Physiol Ther, 2007. 30(6): p. 473-8.

3. Bronfort G, Spinal Manipulation, Medication, or Home Exercise With Advice for Acute and Subacute Neck Pain: A Randomized Trial. Annals of Internal Medicine 2012. Ann Intern Med, 2012. 156(1): p. 1-10.

4. Bryans R, Evidence-based guidelines for the chiropractic treatment of adults with neck pain. J Manipulative Physiol Ther, 2014. 37(1): p. 42-63.

5. Lopez-Lopez A, Mobilization versus manipulations versus sustain apophyseal natural glide techniques and interaction with psychological factors for patients with chronic neck pain: randomized controlled trial. Eur J Phys Rehabil Med, 2015. 51(2): p. 121-32.

6. Korthals-de Bos IB, Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial. British Medical Journal, 2003. 326(7395): p. 911.

 

CF 013: DEBUNKED: The Odd Myth That Chiropractors Cause Strokes (Part 1 of 3)

CF 030: Integrating Chiropractors – What’s It Going To Take?

CF 020: Chiropractic Evolution or Extinction?

CF 039: Communicating Chiropractic

CF 036: A MishMash Of Research on Chiropractic, On Herniation, Trends, and Ineffectiveness

A MishMash Of Research on Chiropractic, On Herniation, Trends, and Ineffectiveness

Integrating Chiropractors

Today we’re going to talk about research on Chiropractic, research on health trends, and research on disc herniation as a result of a visit to your friendly neighborhood chiropractor. Is that real or is that a bunch of hooey? We’ll talk about it so come along. 

But first, here’s that bumper music

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

Now that I have you here, I want to ask you to go to chiropracticforward.com and sign up for our newsletter. Nope, I don’t have some big prize for you if you sign up. Not big offers. No magical marketing tactics with which to get your email address. Just what we hope is a podcast full of value to you and your business. 

Being on the newsletter list just makes it easier to let you know when the newest episode goes live and, maybe in the future we’ll have some cool stuff to offer those on our email list. Also, when someone new signs up it makes my heart leap and wouldn’t you like to be the one responsible for making someone’s heart leap today? 

Upcoming!

We have a lot of great guests lined up to come on the show! Next week I believe we are going to have Dr. Anthony Palumbo from Staten Island, New York. Dr. Palumbo is very active in the New York State Chiropractic Association and practices in a multidisciplinary practice. We’re going to have a good time picking his brain. 

The week after that, I believe we have Dr. Brandon Steele from ChiroUp and from the DACO program joining us. He’s an excellent resource for what is going on in our profession and where we see things heading in the future for chiropractic. I’m really looking forward to that one. 

We have the green light from Dr. Jerry Kennedy of the Black Sheep DC marketing program to come on the show. We just need to get that date lined up. We have Dr. Tim Bertlesman from the DACO program and also the President of the Illinois Chiropractic Association lined up down the road. 

Good stuff on the way so make sure you’re staying tuned into our little corner here in Podcast land. We’re bringing you the best in research on Chiropractic.

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

You have fainted very dramatically into Episode #36 and we’re so glad you did. 

How’s your week been so far? I shared on the last podcast how we have had a rough 2018 but things have leveled off and we up and running. It feels a little like a sprint these days to tell you the truth. Lol. And thank the good Lord for it. 

Speaking of thanking the Good Lord, my 16-year-old son has been raised in the church. Not every single Sunday. I like to sleep sometimes ya know. But, often enough to say he’s been a church-goer as has my 11-year-old daughter. We’ve not pushed anything on him but he has taken it upon himself to an extent to further the church part of his life. 

He’s gone to a church camp in New Mexico the last two summers and this year he returned ready to get baptized. So he did. Last Sunday he went to church and took a bath and we couldn’t be more proud of that little dude. He’s actually not so little anymore but, we worry about our kids don’t we?

We worry about if we’re raising them right. Am I raising him to be a good man? Am I raising him to work hard and be dependable? Will they be ready for the world? Have I somehow enabled him to be weak? Am I raising him to feel entitled instead of working his butt off for things in his life

I think parents have all of these worries. I might argue that if you’re not asking yourself at least some of these questions, you might give them a deeper look. I’m not a parenting expert. That’s just my opinion. 

Anyway, my point is, we got this aspect of his life right so far. We sure love that kiddo and we love the direction we see him headed. Kids can be a game-changer for sure. From conception throughout their entire lives, they consume our mind space without even realizing it. And that’s OK. We wouldn’t have any other way most to the time. 

With school back in session now, what are some of the ways that you keep your practice from slowing down? Back to school is historically a slow time for us and we’re never quite sure how to keep that from happening. Email me at dr.williams@chiropracticforward.com and tell me how you do it. I’ll be glad to share on next week’s podcast if you don’t mind. 

This week, I just want to throw some seemingly random papers having to do with research on Chiropractic at you and we’ll start with one called “Effectiveness of classic physical therapy proposals for non-specific low back pain: a literature review.” It was written by F Cuenca-Martinez[1], et.al. and published in Physical Therapy  Research in March of 2018. This is a group of physical therapists writing this paper just so you are in the know. 

Why They Did It

The authors were hoping to evaluate the effectiveness of classical physiotherapy in the management of non-specific chronic low back pain. 

How They Did It

  • They did a literature search in English electronic databases from November- December in 2015 for only randomized controlled trials
  • They only accepted the studies addressing chronic non-specific low back pain treated by manual therapy and different types of exercise methods. 

What They Found

Back School exercises and McKenzie’s method were both ineffective

Spinal manipulation proved effective when performed on the lower back and on the thoracic region but only immediately after it was received and not in the medium or in the long term. 

Massage proved effective for short-term relief

Wrap It Up

The authors’ conclusion was “Based on the data obtained, classical physiotherapy proposals show ineffectiveness in the treatment of chronic non-specific low back pain. More multidimensional studies are needed in order to achieve a better treatment of this condition, including the biopsychosocial paradigm.”

What do we get from this? First thought is, the papers they cite are, at this point, old and considering the papers we have been covering, are really pretty irrelevant to an extent. I mean, any good information will always be good information but only until better information becomes available. The most recent paper cited for the spinal manipulation portion of this project is over 5 years old. So….what the hell?

Second….it’s a bit discombobulated when you read through the abstract. I’m either bad at following along (which is highly likely) or it’s just worded so oddly. I dove into the full paper to try to make heads or tails of what they have going on here. It sounds like physical therapists are just trying to be cheeky monkeys and throwing poo at spinal manipulation and we’re not having it. Mostly because they’re wrong and because we are better and more cost-effective at treating low back pain than they are. Period over and out. 

The authors, in regards to spinal manipulation, refer to three studies. One by Oliveira, et. al[2]., one by Bronfort et. al[3]. and one by Senna and Machaly[4]. The Bronfort study was done on 300 patients and they found basically no difference between those that had physical therapy vs. chiropractic vs. home exercises. They all ended up the same. But, they didn’t cite the work we covered previously showing that chiropractic combined with exercise is more effective that physical therapy. 

Or the paper from Episode 26 by Korthals-de Bos[5] that concluded: “Manual therapy (spinal mobilization) is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner.”

There was also no mention of the paper by Blanchette et. al. that we covered in Episode #26 that showed that chiropractic patients experience the shortest duration of compensation, and physical therapists’ patients the longest. Blanchette says in that conclusion, “These differences raise concerns regarding the use of physiotherapists as gatekeepers for the worker’s compensation system.” And all the chiropractors said, “Amen, hallelujah brothers and sisters.”

And the Senna paper they cite actually concluded by saying, “SMT is effective for the treatment of chronic nonspecific LBP. To obtain long-term benefit, this study suggests maintenance SM after the initial intensive manipulative therapy.”

I’m done with that paper. 

Let’s move on from these PTs and their poo-throwing. 

Here’s one more specifically geared toward research on Chiropractic called “Chiropractic care and risk for acute lumbar disc herniation: a population-based self-controlled case series study” by Cesar Hincapie, et. al[6].  

Why They Did It

The objective was to investigate the association between chiropractic care and acute lumbar disc herniation with early surgical intervention and contrast this with the association between primary care physician (PCP) care and acute lumbar disc herniation with early surgery

What They Found

Both chiropractic and primary medical care were associated with an increased risk for acute LDH requiring ED visit and early surgery. Our analysis suggests that patients with prodromal back pain from a developing disc herniation likely seek healthcare from both chiropractors and PCPs before full clinical expression of acute LDH. We found no evidence of excess risk for acute LDH with early surgery associated with chiropractic compared with primary medical care.

This Hincapie fella also had a prior paper published not long ago[7] where he discussed and explored the perception among different medical disciplines and among chiropractors as to whether spinal manipulation causes a lumbar disc herniation. It was an interesting paper. We covered it in episode #27 if you’d like to give it a listen. 

https://www.chiropracticforward.com/cf-027-wanted-safe-nonpharmacological-mean-of-treating-spinal-pain/

Then there’s this research on Chiropractic that came out recently titled “Spine Degenerative Conditions and Their Treatments: National Trends in the United States of America” and published in Global Spine Journal February 2018. It was authored by Buser et. al[8]. 

Why They Did It

The aim of this study was to report the current trends when talking about spine degenerative disorders and their various  treatments.

How They Did It

Patients diagnosed with lumbar or cervical spine conditions within the orthopedic Medicare and Humana databases were included

What They Found

  • Within the Medicare database there were 6 206 578 patients diagnosed with lumbar and 3 156 215 patients diagnosed with cervical degenerative conditions between 2006 and 2012
  • There was an increase of 18.5% in the incidence of fusion among lumbar patients
  • For the Humana data sets there were 1 160 495 patients diagnosed with lumbar and 660 721 patients diagnosed with cervical degenerative disorders from 2008 to 2014
  • There was a 33% (lumbar) and 42% (cervical) increases in the number of diagnosed patients. However, in both lumbar and cervical groups there was a decrease in the number of surgical and nonoperative treatments.

Wrap It Up

The authors wrap it up by saying, “There was an overall increase in both lumbar and cervical conditions, followed by an increase in lumbar fusion procedures within the Medicare database. There is still a burning need to optimize the spine care for the elderly and people in their prime work age to lessen the current national economic burden.”

What do we get from that? I’d say that it’s clear from research on Chiropractic we’ve covered here that neck and back pain is stepping forward for sure. It is being recognized for the problem it really is while treatments available in the medical kingdom continue to show scattered results. Chiropractors are the most uniquely positioned to knock this stuff out of the park. 

Fusion surgeries have gone crazy sky high in the last ten years while the outcomes have remained unchanged. 

Epidural steroid injections have been done at a blistering pace over the last decade with no better outcomes. 

Physical therapists are even starting to question their own effectiveness. Take this article in the journal called Physical Therapy written by Colleen Whiteford et. al[9]. Here is the opening paragraph. Get a load of this:

“We are writing to relay our consternation about the guideline article by Bier et al in the March issue of PTJ. We fully support the increasing emphasis on critical evaluation fo the assessment and intervention models used in physical therapist practice. The long-overdue acknowledgment of research that does not support much of what constitutes the bulk of physical therapist practice is a refreshing and honest introspection that can potentially initiate much-needed change within our profession.”

“Without such change, our profession is destined to continue on our current path of practice that is increasingly shown to be yielding outcomes that are less than desirable. Such exploration inevitably leaves us with gaping holes in practice that can be unsettling. The natural and responsible tendency is to search for alternative measures and interventions to fill this gap.”

I’m going to tell you one of those alternatives they’ll be looking to adopt and are looking to adopt is spinal manipulation. You better listen to me folks. If you’ve listened to our podcast much here then you know they’ve already adopted adjustments and renamed it to translatoric spinal manipulation. 

We can keep monkeying with these chiropractors out on the edge of the ether talking about curing everyone on the planet of everything known to man or we can keep moving in the direction of science and in the direction of evidence. My preference is obvious. 

If you haven’t yet, can you leave us a great review on whatever platform it is that you’re listening to us on? iTunes, Stitcher, or whatever it may be. We sure would appreciate it. 

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. Research on chiropractic shows this clearly.

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. Again, research on chiropractic shows this clearly.

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

Being the #1 Chiropractic podcast in the world would be pretty darn cool. We’ll keep bringing you Research on chiropractic in the hopes of reaching that goal!

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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Bibliography

1. Cuenca-Martínez F, Effectiveness of classic physical therapy proposals for chronic non-specific low back pain: a literature review. Phys Ther Res, 2018. 21(1): p. 16-22.

2. Oliveira RF, Immediate effects of region-specific and non-region-specific spinal manipulative therapy in patients with chronic low back pain: a randomized controlled trial. Phys Ther Res, 2013. 93(6): p. 748-56.

3. Bronfort G, Supervised exercise, spinal manipulation, and home exercise for chronic low back pain: a randomized clinical trial. Spine, 2011. 11(7): p. 585-98.

4. Senna MK, Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome? Spine (Phila Pa 1976), 2011. Aug 15; 36(18): p. 1427-37.

5. Korthals-de Bos IB, Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial. British Medical Journal, 2003. 326(7395): p. 911.

6. Hincapie C, Chiropractic care and risk for acute lumbar disc herniation: a population-based self-controlled case series study. European Spine Journal, 2018. 27(7): p. 1526-1537.

7. Hincapie C, Chiropractic spinal manipulation and the risk for acute lumbar disc herniation: a belief elicitation study. European Spine Journal, 2017.

8. Buser Z, Spine Degenerative Conditions and Their Treatments: National Trends in the United States of America. Global Spine J, 2018. 8(1): p. 57-67.

9. Whiteford C, On “Clinical Practice Guideline for Physical Therapy Assessment and Treatment in Patients With Nonspecific Neck Pain,” Bier JD, Scholten-Peeters WGM, Staal JB, et al. Phys Ther. 2018;98:162–171. Physical Therapy, 2018.

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

WANTED – Safe, Nonpharmacological Means Of Treating Spinal Pain

Today we’re going to talk about treating spinal pain, thoracic manipulation, lumbar manipulation, guidelines from Canada, and perceptions of our profession. Did you know that many people actually think that Chiropractic herniate low back discs all of the time? That’s not our idea of treating spinal pain. That’s for sure!

But first, here’s that bumper music

OK, we are back. Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast and I am honored to have you join me today.  Thank you to those of you that send emails and like and share our content on Facebook and Twitter. You make it fun. If you haven’t already noticed, we have “Tweetable” quotes from our show notes. All you have to do is click the Tweet button and you’re all set. 

Now, here we go with some vital information that we think can build confidence and improve your practice which will improve your life overall. That’s a tall order but that is the goal

You have cavorted your way into Episode #27. Yes, it’s a word. In fact, it’s a synonym of the word dance. Oh how I do love a thesaurus. 

As I’m about to record this episode, it is June 4, 2018 and I am getting ready to head down to the Texas Chiropractic Association’s State Convention. Now, things like that used to make my eyes gloss over but, I wasn’t doing it right or looking at it through the right lens. 

I was a traveling musician for several years and, honestly, chiropractic for me at the time was Plan B while I made a run at music. Well, as usually happens with musicians, it didn’t make me rich. Shock, shock…

During those years, I was a little bit like a guy out on an island all by himself. A lone wolf you might say. I didn’t know anything about research, guidelines, or anything like that. Hell, I was lucky to get to work on time back then. 

Along with being on an island all alone, I thought the idea of being a member of my state association sounded like one to the biggest, best ways to waste my money. Money that I really needed at the time. Well, I was misinformed. Becoming a member of the Texas Chiropractic Association has been one of the best, most rewarding things I have done in my professional life. 

First, I met a ton of people through the TCA. I have a network of colleagues and friends now. If I have a question about ANYTHING, I have an answer! In fact, I was having a hard time with collections for some time and a colleague is the one that came to my rescue. 

Also, the TCA doesn’t just take my money, they take it and use it to help me in my daily life. They have fought some outstanding odds and won several times. They won where, if they had lost, I wouldn’t have the right to diagnose my patients and would be much like a physical therapist depending on referrals from MDs. I’d say that alone is worth my $48 a month wouldn’t you agree?

I went on to serve several years on the Board of Directors for the TCA and am the current chairperson for the Chiropractic Development Initiative fighting to pay for lawsuits, fighting to bolster our profession, and protect it. 

The point here is, I hope you’ll seriously consider joining your state association as well as the American Chiropractic Association. My dues for both combined each month run around $155. It’s just another bill you pay and it goes to securing your job. It’s worth it and I hope you’ll think about doing it. Chiropractic Forward is not just an idea. I walk the walk by being a member and being active. 

Sometimes I end up deviating from research and all that good stuff we do every week but, sometimes, you gotta share what’s on you mind. Thank you for indulging me. 

Let’s get started with the research talk this week with a paper called “Rehabilitative principles in the management of thoracolumbar syndrome: a case report,” by Mathew DiMond who is a DC, DACRB around Bridgeport Connecticut(DiMond M 2017). For those that don’t know what a DACRB is, it stands for Diplomate of the American Chiropractic Rehabilitation Board. To put that into perspective, there are roughly 5,200 chiropractors in Texas and only 5 DACRBs. 

Why They Did It

Dr. DiMond wanted to describe his management of a case where the patient suffered from thoracolumbar syndrome. 

How They Did It

  • The patient was a 33 year old woman. 
  • She had suffered back pain for 3 weeks
  • Nerve tension tests and local tenderness were present
  • Outcome Assessment tools used were the Oswestry Disability Index which was at 62% at baseline, the STarT low back screen tool (6 points total with 2 point subscale), the Numeric Pain Rating Scale (6/10), and the test-retest exercise audits. 
  • 3 treatments rendered to the patient

What They Found

Her scores were substantially improved. Oswestry improved to 8% , STarT (1 point total), Numeric rating scale 1/10.

Wrap It Up

The author concluded by saying, “The patient responded positively to chiropractic care. After a short course of care, the patient reported reduced pain, alleviated symptoms, and improved physical function.” Now that’s treating spinal pain in a nonpharmacological way.

Now onto the next one. We don’t sit still around here. Bam, bam, bam!

This one is titled “Chiropractic spinal manipulation and the risk for acute lumbar disc herniation: a belief elicitation study” by Cesar Hincapie, et. al. and published in the European Spine Journal(Hincapie C 2017). 

Why They Did it

We know low back pain is the number one reason for disability in the world and that chiropractic is moving into the forefront. The author noted that chiropractic has been reported to increase the risk for lumbar disc herniation without any high quality evidence to support the claim. The author wanted to determine the beliefs on this topic going forward.

I have to say all one needs to do is look toward the American College of Physicians new recommendations and The Lancet low back series recommendations for using chiropractic as a first line treatment for low back pain and that should tell you all you need to know on this but, we will go ahead and explore this simply to expand our learning and knowledge. We are the profession best poised for treating spinal pain!

How They Did It

They used a belief elicitation design

They used 47 clinicians made up of 16 chiropractors, 15 family physicians, and 16 spinal surgeons. 

The clinicians estimated how often a chiropractic adjustment could cause a lumbar disc herniation in a hypothetical group of patients with acute low back pain. 

What They Found

  • As one would expect, chiropractors were the most optimistic that the occurrence was rare. In fact chiropractors held the belief that spinal manipulation actually decreases the chance of disc herniation rather than increases it.
  • Family physicians were mostly neutral
  • Spinal surgeons expressed a slightly more pessimistic belief toward the idea

Wrap It Up

The researchers concluded, “Clinicians’ beliefs about the risk for acute LDH associated with chiropractic SMT varied systematically across professions, in spite of a lack of scientific evidence to inform these beliefs.”

My bias is obvious but, the thought of chiropractors going around herniating discs had to have come from someone that either hates chiropractors like the American Medical Association of the 60;s, 70’s, 80’s, and so on…..or it had to come from ignorance. I believe that paper was published just prior to the new updated recommendations putting chiropractic in the driver’s seat for acute and chronic low back pain but geez…. I do get tired of defending the profession. 

Now let’s wrap up the week here with a paper from our chiropractic brethren for the frozen North otherwise known as Canada. The lead author is Dr. Andre Bussieres and the paper is called “Spinal Manipulative Therapy and Other Conservative Treatments for Low Back Pain: A Guideline From the Canadian Chiropractic Guideline Initiative” and was published in the Journal of Manipulative and Physiological Therapeutics in May of 2018(Bussieres A 2018). 

Why They Did It

The objective of this study was to develop a clinical practice guideline on the management and treating spinal pain of acute and chronic low back pain (LBP) in adults. The aim was to develop a guideline to provide best practice recommendations on the initial assessment and monitoring of people with low back pain and address the use of spinal manipulation therapy (SMT) compared with other commonly used conservative treatments.

How They Did It

  • The authors assessed systematic reviews and randomized controlled trials using A Measurement Tool to Assess Systematic Reviews and Cochrane Back Review Group criteria. 
  • Evidence profiles were used to summarize judgements of the evidence quality. 
  • The Evidence to Decision Framework was used to help the panel to determine the certainty of evidence and strength of the recommendations. 
  • Consensus was achieved through the modified Delphi technique
  • This guideline was peer reviewed by an 8-member multidisciplinary external committee. 

What They Found

  • Acute back pain (0-3 months)

Offer advice on posture and staying active, reassure the patients, education and self-management strategies, chiropractic care, usual medical treatment if deemed beneficial, or a combination of chiropractic care and usual medical treatment. These are effective means of treating spinal pain. 

  • Chronic back pain (3 months and beyond)

When treating spinal pain, offer advice and education chiropractic care or chiropractic care in conjunction with exercise, myofascial, or usual medical care. 

  • Chronic back-related leg pain

Offer advice and education with chiropractic care and home exercise such as positioning and stabilization exercises. Treating spinal pain for chronic patients can be challenging for both the patient and the doctor.

Wrap It Up

The authors concluded by saying, “A multimodal approach including SMT, other commonly used active interventions, self-management advice, and exercise is an effective treatment strategy for acute and chronic back pain, with or without leg pain.” Treating spinal pain is just what we do.

Help us spread the news folks. Go out and get on your roof and start yelling it to the masses. Retweet, like and share and all of the stuff you can help with on your end of it. You can find us on Twitter @chiro_forward and on Facebook. We’re there. We’re just waiting on you to join us so go do that right now

I realize this week was a little here and a little there but the point is that no matter what you’ve heard or been told in the past, those days are over. I believe they’re over for good at this point. We are the #1, non-pharma, safe, conservative, non-invasive, research-backed, evidence-backed, treatment for spinal pain, hands down. And that’s a heck of a place to be coming from wouldn’t you agree?

I want you to know with absolute certainty that 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.

When you look at the body of literature, it is clear: research and clinical experience shows that, in about 80%-90% of headaches, neck, and back pain, compared to the traditional medical model, patients get good to excellent results with Chiropractic. It’s safe, more cost-effective, decreases chances of surgery, and reduces chances of becoming disabled. We do this conservatively and non-surgically with minimal time requirements and hassle on the part of the patient. And, if the patient develops a “preventative” mindset going forward, we can likely keep it that way while raising the general, overall level of health! And patients have the right to the best treatment that does the least harm. THAT’S Chiropractic folks.

Please feel free to send us an email at dr dot williams at chiropracticforward.com and let us know what you think or what suggestions you may have for us for future episodes. Feedback and constructive criticism is a blessing and we want to hear from you on a range of topics so bring it on folks!

If you love what you hear, be sure to check out www.chiropracticforward.com. We want to ask you to share us with you network and help us build this podcast into the #1 Chiropractic evidence-based podcast in the world. 

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

CF 011: With Dr. Tyce Hergert: It’s Here. New Guides For Low Back Pain That Medical Doctors Are Ignoring

CF 016: Review of The Lancet Article on Low Back Pain (Pt. 1)

CF 013: DEBUNKED: The Odd Myth That Chiropractors Cause Strokes (Part 1 of 3)

 

Social Media Links

iTunes

Bibliography

Bussieres A, e. a. (2018). “Spinal Manipulative Therapy and Other Conservative Treatments for Low Back Pain: A Guideline From the Canadian Chiropractic Guideline Initiative.” Journal of Manipulative and Physiological Therapeutics 41(4): 265-293.

DiMond M (2017). “Rehabilitative Principles in the Management of Thoracolumbar Syndrome: A Case Report.” Journal of Chiropractic Medicine 16(4): 331-339.

Hincapie C (2017). “Chiropractic spinal manipulation and the risk for acute lumbar disc herniation: a belief elicitation study.” European Spine Journal.

CF 021: Crazy Update On Run-Away Healthcare Spending in America

Crazy Update On Run-Away Healthcare Spending in America

In today’s podcast, we are going to talk about the crazy, run-away healthcare spending in America and we’re going to use an article straight from the leading authority, the Journal of the American Medical Association, to help us out.

Before we get started, I want to share with you how much have enjoyed getting this podcast up and running. I strongly doubt it’s as popular as the other great chiropractic podcasts that have been up and going for a couple of years now. Heck, Chiropractic Forward has just been going since December so, at this point, one would expect for us to still be trying to gain attention and trying to gain some ears. And…..we are. No doubt.

But I can say that is has been pure joy to look up the downloads for each episode and seeing that, no…..its not just me that finds this stuff fascinating. Lol. You guys and gals are starting to listen and starting to pay attention.

We’re still struggling for those like and retweets on Twitter.

That’s the frustrating part if I’m being honest. To KNOW that you have put together an effective article on how chiropractors do not cause strokes and then to have such a hard time getting the word out. It’s frustrating to be sure but it’s also part of building something new and exciting.

So, I will simply continue to remind you that we need your help if we are to make a difference and I will keep reminding you to like our Facebook page, follow us on Twitter, sign up for our weekly reminder newsletter through the form on our homepage, and share us with your network.

We would certainly appreciate that help. Some of you may have actually gotten to see me arguing the stroke issue on our Facebook page. My gosh, some people, you could hit them with a research book full of papers in your favor and some would still argue just to try to prevent being wrong.

Not only do I get to argue about stroke or whatever the topic may be, it always strays into generalized ignorant statements like, “Chiropractic is bunk.”

I can use research to absolutely wipe the floor with people like that. And, the irritating thing is that the people, or trolls spouting off like that are usually computer majors, musicians, or something else completely removed from healthcare.

It is enough to make a man insane if you allow it. So I don’t.

Anyway, check us on Twitter and Facebook. Every now and then, you may find an enthusiastic discussion. lol. To say the least.

Since I haven’t yet, I’ll introduce myself, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast. We are honored to have you listening. Now, here we go with some vital information that we think can build confidence and improve your practice which will improve your life overall. That’s a tall order but that is the goal.

You have shaked, shimmied, and rolled into Episode #21

I’d like to start by saying that it is good to see the medical world beginning to examine itself with a clear lens. We have seen them turn blind eyes to many things we notice and research notices. As we have mentioned, there has been little attention given to the updated recommendations in favor of chiropractic, massage, and acupuncture in February of 2017. It is yet to be known what, or if anything, will change following the series of low back pain papers recently published in The Lancet (March21, 2018).

I have been mentioning how I feel that the opioid crisis has opened many many doors recently in regards to the medical field, clinical pathways, and in they way they are starting to look at the costs. Kudos to those in the medical field for beginning to call out their own protocols and questions them for effectiveness vs. risk. Some procedures may be effective here and there but, in general, if the squeeze is not worth the push, then there is little to zero return on investment and it should be abandoned. Obviously, one’s health is different than a business stat sheet but the metaphor is a valid one I believe.

Obamacare was supposed to heal all of our healthcare woes, right? From what I can tell, all it did was squeeze out the middle class. The folks that make too much to be subsidized but do not make enough to not really care about the new jacked health insurance rates.

For example, the premiums here in Texas have doubled or tripled in many cases while the insurance companies cover less and less. The co-payments have gone from $15-$20 all the way up to $50 and even $100. The deductibles have gone from $250 or $1,000 all the way up to $5000 or $10,000. In addition, the insurance companies are now reimbursing healthcare providers less. in many cases, 3/4 less.

Did you know that here in Texas, where a medical radiologist was once reimbursed up to $28+ or so for reading a neck series, they now get paid in the ballpark of $7 for the same series? I promise the doctors are not living less of a life than they were prior to Obamacare. Not at all. But, what is likely happening unconsciously is they are probably reading more x-rays more quickly to attempt to make up for the reduction in their pay.

Would you agree that this may put patients at more risk? I’m not saying doctors make a conscious decision to put patients at risk but, if a professional in ANY industry has a house in town, a house and boat on the lake, 3 cars, time share on a private plane, and things of that nature, when their income is cut by 3/4 in some cases, they will tend to find ways to make that up in ways that make sense to them. Regardless of profession or industry.

Maybe Obamacare just makes them more efficient rather than raising the patient risk. I do not have the answer on this but I do know that radiologists are responsible for everything on a film and their license is at risk on each and every film. When the government cut their pay that dramatically, the government began putting people at more risk. In my opinion of course.

I am firmly on the side of the medical field on this issue. The same type of thing is currently happening with the chiropractic industry as well. We are being reimbursed at smaller and smaller rates. We are seeing our covered patients being turned into cash patients whether we like it or not. The co-pays and deductibles are so high, the could just as easily be cash patients for our purposes. For this very reason, you are seeing more and more chiropractors in America begin to look at changing over to a cash-based practice model and drop insurance contracts all together.

I’m not certain every bit of this discussion is completely on topic but let me tie it up and bring it home through the use of this research paper. This paper appeared in the Journal of the American Medical Association (JAMA) on March 23, 2018. It was titled “Health Care Spending in the United States and Other High-Income Countries” and was authored by Irene Papanicolas, PhD (Papanicolas I 2018).

Why They Did It
Healthcare spending in America is a long-time hot topic and issue that has never been adequately addressed. Part of the problem is that we Americans spend more than other high-income countries with little information that shows that any efforts to control expenses has done anything to help the problem.

These authors attempted to compare the big ticket items in healthcare in America with the same items in ten other high-income countries in an attempt to learn where improvement might be made here at home.

How They Did It
Information was mostly gained from the Organization for Economic Cooperation and Development (OECD) from 2013-16. The OECD is an international organization comparing underlying differences in structural features, types of health care and social spending, and performance for several high-income countries.

What They Found
In 2016, America spent 17.8% of its gross domestic product on healthcare while the other 10 nations spent from 9.6%-12.4%.
Surprise, surprise….pharmaceutical costs spending per capita in America was $1443 vs. from $466-$939 in the other 10 countries. American doctors and patients love those pills. That is healthcare spending in America at its best.
90% of Americans are insured while 99%-100% were insured in the other 10 countries.
The U.S. has the highest proportion of private insurance when compared to the other 10 countries, which is 55.3%.
When it comes to smoking, Americans actually have the second lowest rate sitting at 11.4%
When we talk about obesity, the US has the highest proportion at 70.1%. Others range from 23.8%-63.4% for comparison purposes.
The US life expectancy was the lowest at 78.8 years.
US infant mortality was the highest rate of the 11 countries.
There was no real difference in the American physician workforce, nurse workforce, etc., when compared to the other 10 countries.
America has comparable numbers of hospital beds
Americans use MRIs and CTs when compared to the other 10 countries.
The US had similar rates of utilization for acute myocardial infarction, pneumonia, chronic obstructive pulmonary disease, hip replacements, knee replacements, and coronary artery bypass graft surgery.
Administrative costs of care in American stood at 8% while the same measure in the other 10 countries ranged from 1%-3%.
Salaries of physicians and nurses were higher in the US; for example, generalist physicians salaries were $218?173 in the US compared with a range of $86?607 to $154?126 in the other countries.

Wrap It Up
The authors of the paper concluded that, “The United States spent approximately twice as much as other high-income countries on medical care, yet utilization rates in the United States were largely similar to those in other nations.

Prices of labor and goods, including pharmaceuticals, and administrative costs appeared to be the major drivers of the difference in overall cost between the United States and other high-income countries”

My own wrap up would be that America spends twice as much money on healthcare while we have the highest rate of obesity, double the amount of pharmaceuticals, lower life expectancy, higher infant mortality, and higher administrative costs when we are compared to 10 other countries of similar income. Healthcare spending in America is out of hand.

That’s not good, folks. Not good at all. When do the pharmaceutical companies stop controlling the medical profession and the medical profession turn it around to control the pharmaceutical companies? When does that happen exactly?

Did you know that, from 1948 until 1996, there was a TV ban on running liquor ads? You may see beer or wine ads but you would never see Jim Beam running a commercial between Alf and Different Strokes. But, how often do we see pharmaceutical ads on TV these days? It’s a shame to be honest. Shouldn’t the doctor be the one that is informed on medications rather than a 320 million people that are almost completely uneducated on pharmaceuticals? Should patients be going into doctors’ offices ready to pressure them into a certain medication because they saw it on TV?

It is absolutely insane and should have been stopped at the first mention of it. To make it fair or legal or whatever may be the case, they state a long laundry list of all of the things that may happen to you if you take it. But, the information is delivered and people are influenced.

If a patient goes in for something like erectile dysfunction, the doctor tells them what they need. They don’t tell the doctor!! Do you see the problem here? If the patient goes in for potential blood clots, the doctor should be telling them they need a certain type of thinner. That is not the patient’s place in any country on the entire planet.

Not only do the pharma companies control patient mentality in this way but they attempt control of the physicians. Pharma reps are skilled at what they do. They are highly trained and very well-paid to effect influence in their market’s physicians. They take them on dinners, bring the office lunches, pay for trips, etc. You can spot them at any doctor’s office you go to. Just look for the well-dressed person in the waiting room with a clip board and a bag of goodies. That’s them!

I had a general practitioner that I had to finally fire. I had been living a bit unhealthy for several months when I went for a yearly checkup. My blood pressure was high. He immediately tried to put me on life-long meds. I was overweight and drank a 12-pack of Bud Light here and there while traveling in a band playing music. You might say that I used to be a little bit ornery. Again, I was admittedly behaving badly. His diagnosis was that I was depressed and needed an anti-depressant. Really?

Instead of trying some behavior modification, according to him, I needed life-long blood pressure meds and life-long antidepressant meds. Where does this mentality come from? What if we treat the CAUSE rather than the SYMPTOM?

First, I lost weight and started to behave. Guess what? My blood pressure returned to normal. As a result of ceasing traveling in a band, I basically quit drinking beer outside of social events. Boom! I was no longer depressed according to his definition.

This may seem like an extreme example to some but, it is my estimation that this sort of “doctoring” and “pill pushing” is far more common than one may even dream.

I am in no way against the medical field or against surgery or against medicine. I am against simple pill fixes. I’m against long-term meds when not needed. There are some conditions like diabetes or genetic high blood pressure that require long-term meds but, in many cases, they should be avoided. I’m against the medical field performing shots and surgeries and using opioids for musculoskeletal pains when the research is clear when it recommends chiropractic, massage, etc.. for those pains.

Basically, the medical field needs to stop thinking the pills are the be all – end all of healthcare and start looking more to the cause rather than just treating the symptoms. The physicians need to take the reins of their profession away from the pharmaceutical companies and wield the power over pharma that they attempt to wield over chiropractic and other alternative means of healthcare.

Enough about them for this episode. I want you to know with absolute certainty that 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.

When you look at the body of literature, it is clear: research and clinical experience shows that, in about 80%-90% of headaches, neck, and back pain, compared to the traditional medical model, patients get good to excellent results with Chiropractic. It’s safe, more cost-effective, decreases chances of surgery, and reduces chances of becoming disabled. We do this conservatively and non-surgically with minimal time requirements and hassle on the part of the patient. And, if the patient develops a “preventative” mindset going forward, we can likely keep it that way while raising the general, overall level of health! And patients have the right to the best treatment that does the least harm. THAT’S Chiropractic folks.

Please feel free to send us an email at dr dot williams at chiropracticforward.com and let us know what you think or what suggestions you may have for us for future episodes. Feedback and constructive criticism is a blessing and we want to hear from you on a range of topics so bring it on folks!

If you love what you hear, be sure to check out www.chiropracticforward.com. We want to ask you to share us with you network and help us build this podcast into the #1 Chiropractic evidence-based podcast in the world.

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

CF 013: DEBUNKED: The Odd Myth That Chiropractors Cause Strokes (Part 1 of 3)

CF 016: Review of The Lancet Article on Low Back Pain (Pt. 1)

Bibliography
Papanicolas I (2018). “Health Care Spending in the United States and Other High-Income Countries.” JAMA 319(10): 1024-1039.

CF 016: Review of The Lancet Article on Low Back Pain (Pt. 1)

Low Back Pain: A Major Global Challenge

On the Chiropractic Forward podcast this week, we are going to do a review of The Lancet article on Low Back Pain. It is a recent paper published in march 2018 that we hope will have a powerful impact in the months and years to follow. 

Before we get started with this review of The Lancet article on Low Back Pain, I want to draw your attention our website at https://www.chiropracticforward.com. Just below the area where you can listen to the latest episode, you’ll see an area where you can sign up for our newsletter. I’d like to encourage you to sign up. It’s just an email about once a week to let you know when the episode is updated and what it’s about. Also, if something brand new pops up, we’ll be able to tell you about it quickly and easily.

Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast where we talk about issues related to health, chiropractic, evidence, chiropractic advocacy, and research. Thank you for taking time out of your day I know your time is valuable and I want to fill it with value so here we go with some vital information that we think can build confidence and improve your practice which will improve your life overall. 

You have illegally u-turned into Episode #16 and criminals are welcome so make yourself at home. Again, we are doing a review of The Lancet article on Low Back Pain.

I’ve been battling a head cold and depending on the day, the head cold is winning. I hope you’ll excuse my graveled voice and my nasal presentation. I’ll do my best on this review of The Lancet article on Low Back Pain. 

Those of us that are hungry for new research and the recommendations that arise from the body of literature being constantly created were excited last week about the release of significant reports coming out in a highly respected research journal called The Lancet. 

Founded in 1823, The Lancet is published weekly is is one of the oldest, most respected, and most well-known medical journals in the world so when it was announced a series of papers were to be published in The Lancet having to do with low back pain, as you may imagine, those of us interested in the research world and musculoskeletal complaints were all ears. 

Not only was the article noteworthy due to its being published in The Lancet, but it was also exciting for those of us in the so-called alternative healthcare world because there were several Doctors of Chiropractic sitting on the steering committee for the series of reports. For some reason, chiropractors are still considered by many to be alternative while this group of papers suggest chiropractic may be a lot more than simply “alternative.”

There are a couple of things in my mind that stand out as reasons for such a series of papers. The first being that low back pain has become a major problem globally and show no sign of stopping the growth of it impact. The second reason would be the ineffectiveness of the treatments commonly used or recommended. This includes surgery, epidural steroid injections, and, the most notable of failed treatments, opioids.

The series of Low Back Pain papers were compiled by a team of leading experts on back pain. The team was made up of an international spectrum  of varied backgrounds. They met for a workshop in Buxton, UK, in June, 2016, to start the journey and the process of setting the outline and some sort of structure for each paper. 

It was quite an undertaking from quite the group of experts. This is not a group of papers to be ignored since these authors and researchers are among the best of the best globally. 

The papers were broken down as follows:

      1. What low back pain is and why we need to pay attention.
      2. Prevention and treatment of low back pain: evidence, challenges, and promising directions. 
      3. Low back pain: a call for action

In this article, I will cover the first of the three papers with plans to highlight the next two papers in the coming weeks so be sure to return for those important discussions. 

How They Did It

For this paper, again titled “What low back pain is and why we need to pay attention,” the researchers identified scientific studies through searches of databases:

  • MEDLINE (PubMed)
  • Scopus. 
  • Google Scholar
  • African Index Medicus Database

In this review of The Lancet article on Low Back Pain I think it’s important to re-iterate the authors assertion that, in order to ensure a high-quality standard, systematic reviews were shown preference for inclusion.

Summary of the introduction of the first paper. 

  • Low back pain is now the leading cause of disability worldwide.
  • Only a small percentage have a well-understood, definite cause for their low back pain. Examples of well-known and udnerstood causes are things like a vertebral fracture, malignancy, or infection.
  • Things that seem to raise the risk of having low back pain complaints would be populations that smoke regulary, people that have physically demanding jobs or routine jobs or jobs that keep them mostly sedentary throughout the day and throughout the work week, people with physical and mental issues that add to a low back complaint or contribute to a low back complaint, and overweight/obese people. These populations are all at risk for developing low back pain.
  • 540 million people were affected at any one time globally.
  • A systematic review (3097 participants) found several MRI findings had a reasonably strong association with low back pain, including Modic type 1 change, disc bulge, disc extrusion, and spondylolysis. To further define Modic 1 changes, in regular vertebral endplate bone, the trabeculae shoud be like a type of scaffolding. Within the trabeculae there is red bone marrow producing blood cells. In a Modic type 1, the trabeculae are fractured intermittently and the patterns are more erratic and the marrow is absent. In the marrow’s place now is serum which is the same substance one can find in a blister. 

Symptoms associated with low back pain

Radicular Pain and Radiculopathy

  • Radiculopathy is usually called sciatica and mostly occurs when there is involvement where the nerve root exits the spine.
  • The authors noted that the term sciatica is used inconsistently by doctors and the public in general and should probably be avoided all together. 
  • The diagnosis of radicular pain relies on clinical findings, such as history of dermatomal leg pain, leg pain that is actually worse than the back pain, aggravation of the symptom when bearing down such as in coughing, sneezing, lying on your back and raising heels off of the table or in going from seated to standing, and straight leg raise test. General rule of thumb for an SLR is that pain in the first 30 degrees of leg elevation hints at a disc origin since that is the movement that first starts to tension the nerve at the root.
  • Patients presenting with low back pain in addition to radicular pain or radiculopathy tend to have worse outcomes than those presenting with low back pain alone.

Lumbar Spinal Stenosis

  • I tell my patients that the simplest way to explain stenosis is to say that a hole that nerves run through has become smaller and, as a result, the nerves sometimes have pressure on them that can cause them to be somewhat dysfunctional. 
  • Lumbar spinal stenosis is clinically characterized by pain or discomfort with walking or standing that radiates into one or both legs and can be eased resting and almost always by lumbar flexion (neurogenic claudication). They call this the shopping cart sign. Meaning, if a person gets relief from leaning on a shopping cart, it sure may be stenosis. If it is aggravated by leaning back or by inducing a “swayback” type of movement, that sure may be stenosis. As a sidenote and from my own studies, if lumbar extension (or swayback) does not hurt, but then rotation in either direction at the endpoint of lumbar extenstion actually does increase the pain, then the patient is likely suffering from a lumbar facet complaint. 
  • Lumbar stenosis is commonly caused by narrowing of the spinal canal or intervertebral foramina as a result of a combination of degeneration such as facet osteoarthritis, ligamentum flavum hypertrophy, and bulging discs. Two or three of these factors can combine to reduce the size and space available for the neural structures to pass through. Obviously that can create issues.
  • Experts tend to agree that the diagnosis of stenosis requires both the presence of the symptoms in addition to imaging findings demonstrating stenosis.

Other causes of Low Back Pain

  • Vertebral fracture, inflammatory disorders, malignancy, infections, intra-abdominal causes.
  • The US guideline for imaging advises deferral of imaging pending a trial of therapy when there are weak risk factors for cancer or axial spondyloarthritis. What does that mean exactly? That means a trial of conservative care. The authors will delve further into this in the second paper from the Lancet series but I will butt my head in here with the opinion of the American College of Physicians. Their updated recommendations from February of 2017 reflect that doctors should be recommending Chiropractic, massage, and/or ice for acute low back pain and should recommend Chirorpactic, acupuncture, and/or exercise/rehab for chronic low back pain. These recommendations are to precede taking even ibuprofen. 

Prevalence

  • Approximately 40% of 9-18-year olds in high-income, medium-income, and low-income countries report having had low back pain.
  • Low back pain prevalence increased 54% since 1990.
  • It is the number one cause of disability globally

Work Disability

Social Identity & Inequality

  • MacNeela and colleagues reviewed 38 separate qualitative studies in high-income countries. They showed found common traits, including: worry and fear about the social consequences of chronic low back pain, hopelessness, family strain, social withdrawal, loss of job and lack of money, disappointment with health-care encounters (in particular with general practitioners), coming to terms with the pain, and learning self-management strategies.
  • Froud and colleagues reviewed 42 qualitative studies from high-income countries, and found that many people living with low back pain struggled to meet their social expectations and obligations and that achieving them might then threaten the credibility of their suffering, with disability claims being endangered. Sometimes we have to almost force low back patients back into the workforce and, did you know that studies show in general that the sooner people are returned to work, the better they tend to recover from the low back pain complaint?
  • Schofield and colleagues found that individuals who exit the workforce early as a result of their low back pain have substantially less wealth by age 65 years, even after adjustment for education. This is just an obvious statement. It makes sense that people that quit working earlier than 65 end up making less money by the time they reach 65. You can also throw the expense of dealing with a back pain complaint in on top of the loss of wages. 
  • Globally, low back pain contributes to inequality. At first, when I read this, it struck me as being silly. Everything’s about inequality these days isn’t it? Certainlly in America it seems. But, this is a little different when you read through the explanation. The authors go on to say that in low-income and middle-income countries, poverty and inequality might increase as participation in work is affected. In addition, regulations on how to properly re-introduce a person into the workforce are absent, and workers are likely to be placed right back into the job they were originally injured without proper re-introduction. The authors felt this might place more strain on family and community livelihoods.

Cost of Low Back Pain

  • Costs associated with low back pain are commonly tallied as direct medical costs, meaning the cost of the doctor’s bill. They are also tallied in terms of indirect costs; meaning the cost of being out of work and the loss of productivity at the work place.
  • Most studies underestimate the total costs of low back pain
  • Although we do not think of low back pain in these terms yet, the truth is that low back pain, in terms of a real problem as far at the cost to treat and the overall indirect costs, are right up there with the biggest issues the global pupulation faces. Issues such as cardiovascular disease, cancer, mental health, and autoimmune diseases. That’s huge. 
  • In the USA, 44% of the population used at least one complementary or alternative health-care therapy in 1997; and the most common reason was low back pain. with 70,000 plus chiropractors in the United States, I can tell you with some confidence the profession most associated with alternative treatment for low back pain or spinal pain of any sort is chiropractic care. 
  • The USA has the highest costs, attributable to a more medically intensive approach as well as higher rates of surgery compared with other high-income countries. We see patients every week that have gone through needless surgeries. Surgeries for which there is plenty of high-level research proving its ineffectiveness yet you see the popularity for these surgeries continuing to rise. 

Natural History

  • A systematic review (33 cohorts; 11?166 participants) provides strong evidence that most episodes of low back pain improve substantially within 6 weeks, and by 12 months average pain levels are low. However, two-thirds of patients still report some pain at 3 months and 12 months
  • The best evidence suggests around 33% of people will have a recurrence within 1 year of recovering from a previous episode.

Risk Factors and Triggers for Low Back Pain Episodes

      • A systematic review (5165 participants) found consistent evidence that people who have had previous episodes of low back pain are at increased risk of a new episode. Likewise, people with other chronic conditions, including asthma, headache, and diabetes, are more likely to report low back pain than people in good health
      • a UK cohort study found psychological distress at age 23 years predicted incident low back pain 10 years later. The Canadian National Population Health Survey with 9909 participants found that pain-free individuals with depression were more likely to develop low back pain within 2 years than were people without depression
      • systematic reviews of cohort studies indicate that lifestyle factors such as smoking, obesity, and low levels of physical activity that relate to poorer general health are also associated with occurrence of low back pain episodes. We know that obesity and lack of exercise has become an American trait that needs to be reversed. 
      • A systematic review found the genetic influence on the liability to develop low back pain ranged from 21% to 67%, with the genetic component being higher for more chronic and disabling low back pain than for inconsequential low back pain.Don’t we all have patients that present to us claimng that their bad back just runs in the family? Mom and Grandma had a bad back so that must be why they have a bad back is the common sentiment. It seems there may be a bit of validity there. 
      • An Australian case-crossover study (999 participants) showed that awkward postures, heavy manual tasks, feeling tired, or being distracted during an activity were all associated with increased risk of a new episode of low back pain. Similarly, work exposures of lifting, bending, awkward postures, and tasks considered physically demanding were also associated with an increased risk of developing low back pain in low-income and middle-income countries

Psychological Factors

For this review of The Lancet article on Low Back Pain, the presence of psychological factors in people who present with low back pain is associated with increased risk of developing disability even though the mechanisms are not fully understood

Social and Societal Factors

      • Cross-sectional data from the USA (National Health Interview Survey 2009–10, 5103 people) found that those with persistent low back pain were more likely to have had less than high-school education and had an annual household income of less than US$20,000. 
      • Suggested mechanisms for the effect of low education on back pain include environmental and lifestyle exposures in lower socioeconomic groups, lower health literacy, and health care not being available or adequately targeted to people with low education.
      • To go along with lower wages, the lower socioeconomic groups are commonly in routine and manual occupations and ahve increased physical workloads is associated with disabling low back pain

Conclusion

In this review of The Lancet article on Low Back Pain, the authors concluded, “Low back pain is now the number one cause of disability globally. The burden from low back pain is increasing, particularly in low-income and middle-income countries, which is straining health-care and social systems that are already overburdened. Low back pain is most prevalent and burdensome in working populations, and in older people low back pain is associated with increased activity limitation. Most cases of low back pain are short-lasting and a specific nociceptive source cannot be identified. Recurrences are, however, common and a few people end up with persistent disabling pain affected by a range of biophysical, psychological, and social factors. Costs associated with health care and work disability attributed to low back pain are enormous but vary substantially between countries, and are related to social norms, health-care approaches, and legislation. Although there are several global initiatives to address the global burden of low back pain as a public health problem, there is a need to identify cost-effective and context-specific strategies for managing low back pain to mitigate the consequences of the current and projected future burden.”

Key Takeaway:

Obviously, if you followed us all the way through on this review of The Lancet article on Low Back Pain, low back pain is an issue that must be addressed in a more effective way globally and irregardless of national ranking in terms of the economy. Just because it’s musculoskeletal doesn’t mean it can be ignored and kicked to the curb while the big stuff like heart disease, diabetes, and cancer are treated. The research for the big stuff is adequately funded but, honestly, in general, most general practitioners don’t have the first clue of what to do for low back pain. I personally suggest they turn to their own American College of Physicians for updated recommendations on chronic and acute low back conditions if I were them. 

Authors

Steering Committee

Rachelle Buchbinder – Australia

Jan Hartvigsen – Denmark

Dan Cherkin – United States

Nadine Foster – UK

Chris Maher – Australia

Martin Underwood – UK

Maruits van Tulder – Netherlands

For this week’s Next Steps in this review of The Lancet article on Low Back Pain, be sure to send us an email at dr.williams@chiropracticforward.com and let us know what you thought or contribute to the show for next week. We love hearing from you all. Also, go and follow Jan Hartvigsen https://twitter.com/JanHartvigsen, and Chris Maher https://twitter.com/CGMMaher on Twitter. 

Next week we will review the second paper of this three paper series. Next week’s paper is called “Prevention and treatment of low back pain: evidence, challenges, and promising directions.” We’ll go through it bit by bit and hit the highlights for those of you that aren’t into reading research papers and things of that sort. Don’t miss it!

If you love what you hear, be sure to check out www.chiropracticforward.com. As this podcast builds, so will the website with more content, products, and chances to learn. This review of The Lancet article on Low Back Pain is just an example of what you can look forward to.

We cannot wait to connect again with you next week for review of The Lancet article on Low Back Pain Part Two. From Creek Stone, my office here in Amarillo, TX, home of the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward. 

Be sure to check out part of our Chiropracrtors Cause Strokes Myth. This is a link to Part Two:

CF 014: DEBUNKED: The Odd Myth That Chiropractors Cause Strokes (Part 2 of 3)

References:

 

CF 013: DEBUNKED: The Odd Myth That Chiropractors Cause Strokes (Part 1 of 3)

This week, we are going to start tackling the chiropractors cause strokes myth that has run rampant for years and I hope to once and for all dispel it. The information could not be clearer on the chiropractors cause strokes myth and we’re gonna to show it to you in a way that you can understand and in a way that allows you to show it to others. I’m done with this myth, folks!

Before we get started, I want to draw your attention to the reviews over at iTunes. If you would be kind enough to leave us a great review we sure would appreciate you! This is a new podcast and we need all the help we can get!

Right now though, it’s time for bumper music!

Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast where we talk about issues related to health, chiropractic, evidence, chiropractic advocacy, and research. Thank you for taking time out of your day I know your time is valuable and I want to fill it with value so here we go.

Unfortunately, you have often read, watched, or heard me complaining about how our profession has been historically attacked by those organizations in charge of the medical profession. I hope those paying attention understand it is not just sour grapes.

It is education.

I continually bring these facts up in my articles, videos, and podcast because many of the things we talk about have their roots in our history, in the attacks our profession has sustained, and in the attacks our profession is currently battling.

From the start, let me state that research simply does NOT support the chiropractors cause strokes myth.

If you have seen the TV series called “Mythbusters,” then you know the smart red-headed guy and the bald bespectacled serious guy both, along with their rascally cohorts, took a common myth and tested its validity.

Some of the myths were outrageous and some seemed like they may actually be plausible. The show, whenever I watched it was highly entertaining and extremely educational. The entertaining part always came toward the end of the show when they would blow something to smithereens. That’s the part where the inner child in me would leap with glee. Internally of course, not externally.

This mythbusting process has already been carried out for the chiropractors cause strokes myth. Several times, in fact. Without the show-ending explosion of course. Although, at the end of this Mythbusting series, I may walk away with a mic drop if you’re all OK with that.

I say mythbusting series because there is SO MUCH information here that I have to split it into 3 different episodes for the chiropractors cause strokes podcast series. I’m pumping my own tires and I am completely full of myself on what I’m about to say here and I’m well-aware of the fact but, from what I have seen out there on the interwebs, I feel like this is, or at least CAN be, the definitive article, the definitive podcast, the definitive gathering of the information for this topic. If that is indeed the lofty goal I’m aiming for, it has to be comprehensive and somewhat exhaustive and I don’t think I can maintain your focus and interest for the entire amount of the information to be compiled into one super long episode. Dispelling the chiropractors cause strokes myth is too important to lose your attention.

I have split it into three episodes that will break up like this

The first episode, the one you’re currently listening to will include some risky odds, some case specific discussion, some signs and symptoms of vertebral artery dissection, and some research dealing with common treatments within the medical profession.

In the second episode coming next Thursday we will discuss research papers demonstrating and validating benefits of having cervical manipulation treatments. Or chiropractic adjustments to the neck. We will talk about the benefits, according to research, for neck pain as well as for headaches. And we’ll also talk a little about where this chiropractors cause strokes myth came from and why it perpetuates to this day.

In the third and final episode we will discuss risky interventions, papers having to do with the risk, or lack thereof, of chiropractic adjustments to the cervical region specifically, and then a wrap up of the information on this chiropractors cause strokes myth.

Stick with us on this.

Now, let’s dive into this first episode of the chiropractors cause stroke series.

Through the RAND institute, it is estimated that a serious, adverse reaction (such as stroke as a result to a chiropractic adjustment alone) happens in approximately 1 out of every 1 million treatments?

Let’s put that finding into perspective by comparing it to some other odds.

  • The odds of being struck and killed by lightning is 1 in 174,426 according to the National Safety Council.
  • The odds of being told to “Come on down,” on The Price Is Right is 1 in 36!
  • The odds of being born with 11 fingers or toes is 1 in 500.
  • The odds of dying from a firearms assault is 1 in 113.
  • How about this one: the odds of winning an Oscars are 1 in 11,500.

I think it’s time to move to LA!

Consider that there are 70,000+ chiropractors in the United States of America. If Doctors of Chiropractic were out in the world causing strokes “all of the time,” it would be apparent, it would be obvious, and our malpractice insurance would reflect the fact that a visit to the chiropractor comes with a considerable amount of risk. To the contrary, we chiropractors have malpractice insurance that costs chiropractors approximately 1/10th of what it costs our medical counterparts. This fact alone should dispel the chiropractors cause strokes myth.

Before we start diving off into the research too deeply, I want to talk about a case that happened within the last couple of years (February 2016) that brought the “Chiropractors Cause Strokes” myth back to the forefront. It had to do with the “Queen of Snapchat” Katie May. Katie died of a stroke at the age of 34 and, by many, it was immediately assumed the stroke was caused by her two visits to a chiropractor to treat her recent onset of neck pain.

I actually wrote about this case shortly after it originally happened. Initial reports stated that she had a horrible fall while on the set of a photoshoot, which resulted in her neck pain. Then, for some reason, this fact seemed to disappear from further reports.

Also, initial reports stated that Katie visited either the ER or a medical professional prior to her visits with a chiropractor. The family later denies this so, admittedly, there is some confusion on the matter. With this information brought back into the reporting, let’s begin breaking it all down.

Katie posted this message to Twitter: “Pinched a nerve in my neck on a photoshoot and got adjusted this morning. It really hurts! Any home remedy suggestions loves? XOXO.”

Keep that in mind as we run through things that can cause a vertebral artery dissection such as Katie May suffered. They are as follows:

  • Physical Trauma (direct blow to the neck, traffic collision, etc.)
  • Strangulation
  • Spontaneous (from underlying connective tissue disorder)

According to one paper by Debette et. al., “Trauma has been reported to have occurred within a month of dissection in 40% with nearly 90% of this time the trauma being minor[1]. “

Vertebral artery dissection (VAD) can be particularly difficult to diagnose without the use of a CT Angiogram. For instance, some common symptoms of VAD are as follows:

  • Pain and/or numbness in the same side of the face.
  • Head pain/Headache that develops gradually and can be dull or throbbing
  • In less than 1/5th of the cases of VAD, people suffer difficulty speaking or swallowing.
  • Possible unsteadiness or lack of coordination
  • Visual abnormalities
  • Hiccups
  • Nausea/Vomiting
  • Hearing loss

When one reads this list, it is easy to diagnose a VAD, right?

It rarely presents with these classic signs.

Is a medical professional or chiropractor going to refer every single one of these patients for a CT Angiogram or an MRI? Not very likely. It is simply not economically feasible to do so and good luck getting insurance companies to cover the costs of the CT Angiograms!

If Katie did indeed visit a medical professional after her fall, they missed it. Unfortunately, it seems obvious that the chiropractor missed it as well. That does not, however, mean the two professionals are inept. As the website for emedicine.com states, “The focal signs may not appear until after a latent period lasting as long as three days, however, and delays of weeks and years also have been reported[2].”

With that being said, I don’t want to be completely biased here. If a healthy person shows up with a headache and neck pain BUT has a history of recent trauma, more exploration is advised, without question. Knowing this, I can relay countless stories of medical doctors having made bad decisions as well. I have heard countless stories throughout my twenty years of practice. Ultimately, we are all human which is why chiropractors and medical doctors both carry malpractice insurance. But, as I mentioned before, chiropractors’ malpractice is approximately 1/10th that of their medical counterparts because, basically, we do not typically cause any harms in our patients.

As we go through more and more papers, it should be clear that Katie likely suffered the VAD as a result of the fall during the photo shoot and the VAD was missed by the medical professionals (if she did indeed go) and then certainly missed by the chiropractor BUT, the chiropractor almost certainly did not CAUSE the VAD. There’s no we he helped it and could have even potentially exacerbated it, but it is highly doubtful and exceedingly rare that he could have been the CAUSE of it.

Some time later, the Los Angeles coroner reported that the chiropractor was responsible for Katie’s death. This finding really opened the door to all of the chiropractic haters to bash away at the profession.

The LA coroner’s office is an appointed position that, in some states, requires little training, to be quite honest. While I am unaware of this particular coroner’s level of training and expertise, this coroner has been under scrutiny for being understaffed and underfunded to mention just a couple of issues. In addition, I would argue that simply because a man or a woman is a county coroner, does not mean they are above being affected by bias or by their profession’s long-held beliefs and teachings. I would say they most certainly are not above influence and, in my opinion, are highly likely to be affected by them. When they are told by their schools, their national and state associations, and their mentors that chiropractors cause strokes, don’t you think they probably believe it?

I would also argue that the coroner likely has little to zero knowledge of the current body of research regarding cervical manipulation and the instance of stroke. How could an educated person aware of the body of literature on the matter decide otherwise?

For years, I have experienced nurses, physician assistants, medical doctors, and others in an online setting claiming that chiropractic adjustments are dangerous and ineffective. A common theme amongst them is, “It happens all of the time.” We see it “all of the time.” Research proves the notion is a lie.

I would like to be less dramatic or inflammatory in my wording but I do not know of another way to describe it.

Let’s assume that this myth has its base rooted in some sort of fact. Let us be clear. It does not. But, for argument sake, let us say that it does. At that point, we would need to assess the benefits of chiropractic treatment vs. the risks of chiropractic treatment.

In Southern terms, “Is the squeeze worth the push?”

Is there a return on the investment?

Again, this is purely for argument sake because the chiropractors cause strokes myth is not real to start with but playing the devil’s advocate can be of use and is almost always entertaining.

Before we step into deeper water with the research papers, let us discuss benefits & effectiveness vs. risk for some common treatments for spinal complaints in the medical world. If the discussion is focused on doing away with cervical adjustments, what then would be the alternatives and how effective are they? Basically, if the medical field is looking in OUR backyard, maybe we should take a peek into theirs as well.

Keep in mind that all of the research we discuss will be cited in the show notes so that those of you that wish can easily research these independently on your own.

  • The opioid crisis cost the US economy $504 billion dollars in 2015 and a total of $221 billion to $431 billion in lost economic output due to there being 33,000 opioid-related deaths in 2015[3].
  • There were 63,600 opioid-related deaths in 2016, which was an increase of 21% from the 2015.[4].
  • Chou R, et. al. – Although the steroid injections for radiculopathy showed some short-term relief in pain and short-term increase in function, the benefits seen in the patients were only small and short-term only. There was no effect long-term and no affect on whether or not the person had surgery eventually. The evidence in this paper suggested there was no effectiveness at all for the treatment of spinal stenosis[5].
  • Epstein N, et. al. – “Although not approved by the Food and Drug Administration (FDA), injections are being performed with an increased frequency (160%), are typically short-acting and ineffectiveover the longer-term, while exposing patients to major risks/complications[6].”
  • Peterson CK, et. al. – “Subacute/chronic patients treated with SMT (spinal manipulative therapy) were significantly more likely to report relevant “improvement” compared with CNRI (CERVICAL NERVE ROOT INJECTION) patients.There was no difference in outcomes when comparing acute patients only[7].”
  • Chou R, et. al. – “Epidural corticosteroid injections for radiculopathy were associated with immediate improvements in pain and might be associated with immediate improvements in function, but benefits were small and not sustained, and there was no effect on long-term risk of surgery. Evidence did not suggest that effectiveness varies based on injection technique, corticosteroid, dose, or comparator. Limited evidence suggested that epidural corticosteroid injections are not effective for spinal stenosis or nonradicular back pain and that facet joint corticosteroid injections are not effective for presumed facet joint pain[5].”
  • Chou R, et. al – “Surgery for radiculopathy with herniated lumbar disc and symptomatic spinal stenosis is associated with short-term benefits compared to nonsurgical therapy, though benefits diminish with long-term follow-up in some trials. For nonradicular back pain with common degenerative changes, fusion is no more effective than intensive rehabilitation, but associated with small to moderate benefits compared to standard nonsurgical therapy[8].”
  • Maghout J, et. al. – “Use of intervertebral fusion devices rose rapidly after their introduction in 1996. This increased use was associated with an increased complication risk without improving disability or reoperation rates[9].”

 

At this point, it is clear the medical field has its own issues to concentrate on and improve upon when it comes to spinal pain and the treatment of it. It is my opinion these facts are but only a few of the concerns in the medical field and, if taken individually, are much more concerning than any one single issue that can be found within the chiropractic profession.

This is where we are going to stop for this first episode of the Chiropractors cause strokes series. Remember, our” chiropractors cause strokes” series is a three part series.

Be sure to tune in next week for the second part of the three part series. Next week, we will be talking about the benefits, according to research, for neck pain as well as for headaches. And we’ll also talk a little about where this myth came from and why it perpetuates to this day.

You may also consider listening to a recent episode in which we covered some great new research on treating neck pain conservatively through chiropractic care. Check it out at https://www.chiropracticforward.com/2018/03/08/proven-means-to-treat-neck-pain/

­­­­­­­­Please feel free to send us an email at dr dot williams at chiropracticforward.com and let us know what you think about the chiropractors cause strokes myth or what suggestions you may have for us for future episodes.

If you love what you hear, be sure to check out www.chiropracticforward.com. As this podcast builds, so will the website with more content, products, and chances to learn.

We cannot wait to connect again with you next week. From Creek Stone, my office here in Amarillo, TX, home of the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.

 

References

  1. Debette S, “Pathophysiology and risk factors of cervical artery dissection: what have we learnt from large hospital-based cohorts?”. . Current Opinion in Neurology, 2014. 27(1): p. 20-8.
  2. Lang E. Vertebral Artery Dissection. Emergency Medicine 2017 January 18]; Available from: https://emedicine.medscape.com/article/761451-overview.
  3. Mutikani L. Opioid crisis cost U.S. economy $504 billion in 2015: White House. 2017; Available from: https://www.reuters.com/article/legal-us-usa-opioids-cost/opioid-crisis-cost-u-s-economy-504-billion-in-2015-white-house-idUSKBN1DL2Q0.
  4. Glenza J. Life expectancy in US down for second year in a row as opioid crisis deepens. 2017 December 21; Available from: https://www.theguardian.com/us-news/2017/dec/21/us-life-expectancy-down-for-second-year-in-a-row-amid-opioid-crisis.
  5. Chou R, Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis. Ann Intern Med, 2015. 163(5): p. 373-81.
  6. Epstein N, The risks of epidural and transforaminal steroid injections in the Spine: Commentary and a comprehensive review of the literature. Surg Neurol Int, 2013. 4(Suppl 2): p. S74-93.
  7. Peterson CK, Symptomatic, Magnetic Resonance Imaging-Confirmed Cervical Disk Herniation Patients: A Comparative-Effectiveness Prospective Observational Study of 2 Age- and Sex-Matched Cohorts Treated With Either Imaging-Guided Indirect Cervical Nerve Root Injections or Spinal Manipulative Therapy. J Manipulative Physiol Ther, 2016. 39(3): p. 210-7.
  8. Chou R, Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine, 2009. 34(10): p. 1094-109.
  9. Maghout J, e.e., Lumbar fusion outcomes in Washington State workers’ compensation. Spine (Phila Pa 1976), 2006. 31(23): p. 2715-23.

CF 011: With Dr. Tyce Hergert: It’s Here. New Guides For Low Back Pain That Medical Doctors Are Ignoring

This week, we are talking about acute and non-acute low back pain. What are current healthcare guidelines? Why does it matter to chiropractic patients and non-chiropractic patients and are those in the medical field getting (and implementing) the information?

I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast where we talk about issues related to health, chiropractic, evidence, and research and how those things all fit into a comprehensive approach for treating different conditions. Thank you for taking time out of your day to give us a listen. I know your time is valuable and I will always try hard to fill our time with valuable content.

We’re going to have more fun this week than stepping on a nail. Which I have done.

Before we dive in, it was so nice we had to do it twice. What am I talking about? I’m talking about bringing on Tyce. Tyce Hergert that is down in Southlake, TX. Owner and operator of Chiropractic Care Center of Southlake as well as Southlake Physical Medicine where he oversees an integrated practice. Dr. Hergert is also the immediate former President of the Texas Chiropractic Association so now he can say what he really thinks. He was the big cheese, the illustrious potentate of chiropractic in Texas.

Although it’s highly unlikely, should you enjoy what Tyce shares with us here today, go and listen to his other guest spot which can be found in Episode #6. You can find episode #6 at the following link:

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

Welcome to the show Tyce. Nice to have you back.

I would say that a chiropractor would be completely oblivious to not understand that Chiropractic is considered to be on the fringe of healthcare by many to most in the medical field. It’s just a fact and chiropractors deal with this daily. We Chiropractors are used to feeling like the black sheep of the healthcare family off in a corner keeping all to ourselves.

In other articles, podcasts, and videos of mine, you’ll notice I have covered the Wilk vs. AMA case. I’ve covered the Doctored film by Jeff Hayes spotlighting mistreatment of chiropractors. I’ve also covered current attacks on Texas Chiropractors by the Texas Medical Association. It is all very well-documented at this point.

Chiropractic is currently undergoing an amazing renaissance. This is due to a couple of key factors. The first being the need to develop non-pharmacological treatment recommendations in the midst of a national opioid addiction crisis. A crisis that has killed thousands and thousands in the last several years. The second reason being the body of high-quality research that is consistently coming to light almost every month showing the effectiveness of Chiropractic and evidence-based chiropractors.

Do you feel this renaissance, Tyce, or is it just me living inside my head?

With all of the new information and new healthcare laws emerging, the questions going forward SHOULD be, “Is the medical field and is the insurance industry listening and implementing?” We shall see. So far, the answer is, “Absolutely not.” In fact, it’s almost defiant.

Is that an accurate statement Tyce? You’re my checks and balance guy on everything.

Let’s begin with the most glaring denial of Federal Law by the insurance companies right now. It has to do with Section 2706 of the Patient Protection and Affordable Care Act. Also commonly known as “Obamacare.” Section 2706 of the PPACA is entitled the nondiscrimination In Health Care section of the Federal Law and is intended to keep insurance companies and health plans from keeping chiropractors and the services they provide out of the system.

It reads as follows, “A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.”

On the American Chiropractic Association’s FAQ site for 2706, they state, “It is important to understand that Section 2706 and its assurance of non-discrimination in terms of participation and coverage requires that doctors of chiropractic not be discriminated against in the provision of any “essential benefit” that is within their scope of practice.”

Here’s the rub on 2706: part of its purpose is to reimburse chiropractors performing the same services under their scope and license at the same level financially as any other profession that provides that service.

For instance, under the PPACA Section 2706 Federal Law, chiropractors are to be paid the exact same for an 99203 exam code as a doctor of medicine or osteopathy is paid.

Would you agree with that assessment Dr. Hergert? Is this your understanding of the law?

Plain and simple. This is not happening. With so many chiropractors now integrating their practices with medical directors, physician assistants, nurse practitioners, and physical therapists like Dr. Hergert has in Southlake, it’s painfully clear that doctors of chiropractic are being discriminated against when it comes to reimbursements for the same codes performed.

In fact, chiropractors are integrating with these other professions just so that they can finally GET the reimbursements that the other practitioners are allowed! It is madness and clearly violates Section 2706 of PPACA.

Dr. Hergert, you are a great resource here since you’re in the middle of the two professions. What is your experience on this?

Tyce: The carriers will come right out and tell you they don’t think they have to play by this rule.

Also, there is violation of the law if an insurer does something such as applying caps on specific services provided by one healthcare provider whereas the cap does not apply to another type of provider. It is my understanding that United Healthcare has moved to a $65 visit cap on chiropractic care here in Texas.

Am I misinformed here Tyce? Does United Healthcare only put caps on Chiropractors or are they capping services with all providers?
Tyce: That gets very frustrating for those patients with a $50-70 copay.

It is the American Chiropractic Association’s opinion that a violation exists if the insurer or plan denies specific forms of care that is otherwise covered if it is a chiropractor providing the service and it is within their scope and licensing. I would suggest that a medical doctor probably gets services such as non-surgical decompression covered under insurance but chiropractors are routinely denied coverage.

Are there any better examples of this disparity, Tyce, since I don’t know any medical doctors that have their patients perform decompression?

There is a possible violation of Federal Law when Chiropractors are denied inclusion into a plan or group purely based on the profession. For example, it is my understanding that FirstCare won’t cover Chiropractic. Is that a violation of 2706?

Is that a violation? I suppose I could offer an opinion if I were a lawyer. I’m not sure why exactly other providers are allowed coverage while chiropractors are left out in the cold. Here is a great example though that I’m aware of here locally. there is a local insurance network that will remained un-named that charges $200 per year for chiropractors to be included for coverage however, medical professionals pay nothing to be included. Could that be a violation of the nondiscrimination law? I would say it smells a little fishy.

In my opinion, Federal Law is being violated all over the place in regards to Section 2706 of PPACA. I’m not sure how it can be perceived any other way.

What can you add here Tyce that I may have left out?
Tyce: What this means for patients is you can’t use that shiny new insurance policy that is costing you more than a $250k house payment would. You have to fork over the more money to pay for your chiropractic care.

Moving on from Section 2706…..I love talking about the New Recommendations For Acute and Chronic Low Back Pain.
It is becoming more and more aggravating that we chiropractors are not seeing a flood of acute and chronic low back pain patients. If you read my articles, watch my videos, or listen to my podcast with any regularity, you have no doubt been informed several times over of these new recommendations which, at this point aren’t that new anymore. They have been around for about a year now.

It is my opinion that no long-held beliefs or protocols will change if new information isn’t continually pounded and yelled about from the top of the roofs with megaphones. In marketing, experts have said that it takes a target 7 times of being exposed to information before it is finally received and, hopefully, acted upon.

I know that the medical field has NOT been exposed to this information at least 7 times because of two factors:
1. I have spoken to several medical practitioners here locally and not a single one of them has heard of or were aware of these new recommendations.
2. I am not seeing an incredible, overwhelming influx of acute and chronic low back pain new patients coming through my doors as a result of medical referrals.

Tyce, are you seeing an incredible influx of new low back patients from the medical field these days?

Is this willful disregard for the changing recommendations and a “clinging on” to old dogmatic beliefs passed down from the AMA years ago? I think some of it most certainly is.

Is it that a few bad seeds in the Chiropractic profession are giving the rest of us a bad image? I would say some of it most certainly is.

What I think it is mostly based on, however, is the fact that medical professionals are busy, they’re stressed, and many times over-worked and they simply don’t always have the time or opportunity to stay completely up on every new recommendation or updated protocol.

What do you think about it, Tyce?
Tyce: “You’re not down with, what you’re not up on.” Most don’t know. They didn’t get this info in school, and the pharma reps aren’t out spreading the good news.

With that being said, let’s be clear; the issues of low back pain, its economic impact, and the national opioid epidemic crisis in America combine to make these new recommendations that much more important.

Let’s start with the American College of Physicians. Remember, the American College of Physicians was proven in the Wilk vs. AMA case to have played a part in collaborating with the AMA in an attempt to rid the Earth of Chiropractic. I think that’s important to note as we go through the information because the ACP is historically known as a detractor or the chiropractic profession to put it mildly.

In response to the opioid epidemic gripping the nation currently, the American College of Physicians developed new recommendations for treating acute and chronic low back pain.

Why They Did It
• The American College of Physicians developed this guideline in order to provide updated recommendations on treatment of low back pain.
• With these recommendations, the ACP hoped to influence clinicians AND patients to make the correct decision for care in acute, subacute, or chronic low back pain conditions.

How They Did It
• They based their recommendations on a systematic review of randomized controlled trials and other systematic reviews.
• The research they reviewed included those papers available through April of 2015.
• The research included only those on noninvasive pharmacologic and nonpharmacologic treatments.

What They Found
• Recommendation #1: patients with subacute or acute low back pain should seek nonpharmacologic treatments such as Chiropractic, Massage, Acupuncture, and superficial heat BEFORE resorting to non-steroidal anti-inflammatories such as Ibuprofen, Tylenol, Aleve, etc… (Graded as a strong recommendation)
• Recommendation #2: patients with chronic low back pain should seek nonpharmacologic treatments such as Chiropractic, Exercise/Rehabilitation, Acupuncture, & Cold Laser Therapy BEFORE resorting to non-steroidal anti-inflammatories such as Ibuprofen, Tylenol, Aleve, etc… (Graded as a strong recommendation)
• Recommendation #3: In patients with chronic low back pain that have had no relief from nonpharmacological means, the first line of treatment would consist of NSAIDs like Aleve, Tylenol, Ibuprofen, etc.. As a second-line treatment, the clinician may consider tramadol or duloxetine. Opioids would be a last option and only if all other treatments have been exhausted and failed and even then with lengthy discussion with the patient in regards to the risks and benefits of using opioids. (Graded as weak recommendation)

Let’s recap: in February of 2017, the American College of Physicians, historically a Chiropractic profession detractor and attacker, now recommends Chiropractic as a first-line treatment for acute and chronic low back pain.

Dr. Hergert, does that make you feel warm and fuzzy inside because it does me?

Next, let us discuss the American Medical Association. If you thought the American College of Physicians was guilty of Chiropractic-hating, the American Medical Association is, or was, “Pablo Escobar” or the “El Chapo” of the attacks on the Chiropractic profession. The “El Jefe” of the Chiropractic haters, and the group that not only sat in the driver’s seat but also OWNED the entire truck of destruction back before Wilk vs. AMA came along. I believe I have been watching too much Netflix.

As a side note, I have realized that I have a wife, a daughter, and an all female staff at my office and…..I’m not the El Chapo or El Jefe of really anything. My son and I just walk around following orders pretty much. Tyce, you’re married with two daughters right?

On April 11, 2017, the Journal of the American Medical Association published a study on their website titled “Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain Systematic Review and Meta-analysis,” authored by Neil Page, MD et. al. In the format of this research paper, they refer to chiropractic treatment as spinal manipulative treatment or SMT. But, because spinal manipulative therapy is what we chiropractors do the most and what we are most identified with, I’m replacing the term “SMT” with “chiropractic adjustment.”

Is that fair, Tyce? I think it’s fair.

Why They Did It
Considering that spinal manipulation, or the chiropractic adjustment, is a treatment option for acute low back pain, and that acute low back pain is one of the most common reasons for visits to the doctor’s office, the authors wanted to systematically review the studies that have been done in the past dealing with the effectiveness as well as the harms of chiropractic adjustments in the treatment of acute low back pain.

How They Did It
• The researchers used searches of MEDLINE, Cochrane Database of Systematic Reviews, EMBASE, and Current Nursing and Allied Health Literature.
• The search spanned 6 years from January 2011 through February 2017 for randomized controlled trials of adults with low back pain comparing spinal manipulative therapy with no treatment or with alternative treatments.
• The accepted papers also had to measure pain or functional outcomes for up to 6 weeks.
• The data extraction was done in duplicate.
• The quality of the study was assessed through use of the Cochrane Back and Neck Risk of Bias tool.
• Finally, the evidence was assessed using the GRADE criteria which stands for Grading of Recommendations Assessment, Development, and Evaluation.
• 26 eligible randomized controlled trials were identified and accepted

What They Found
• 15 of the RCTs, totaling 1699 patients, showed moderate-quality evidence that chiropractic adjustments had a statistically significant association with improvements in PAIN.
• 12 of the RCTs, totaling 1381 patients, showed moderate-quality evidence that chiropractic adjustments have a statistically significant association with improvements in FUNCTION.
• NO RCTs reported any serious harms or adverse event as a result of undergoing chiropractic adjustments.
• There were only minor events reported like some increased pain, muscle stiffness, and headache in roughly 50%-67% of those treated in the large case series. I would be interested to hear more about this statement by the authors. That is not what we commonly see in our practice. Sometimes, if the patient is new and is not accustomed to chiropractic adjustments, they may experience some soreness or stiffness the next day which is to be expected following a change in the body.
• I want to be as thorough as I can here….Tyce, do you see 50%-67% minor harms in your daily practice?

Wrap It Up
In true AMA fashion, instead of just coming out and saying, “Chiropractic adjustments showed moderate quality evidence for effectiveness in pain as well as in function,” the authors instead stated in conclusion, “Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. However, heterogeneity in study results was large.” Heterogeneity is defined as, “The quality or state of being diverse in character or content.” In my opinion, this is to give themselves and “out” by implying there was not enough focus to the RCTs to truly state their findings as fact.

Nonetheless, when the AMA comes even remotely close to endorsing anything having to do with Chiropractic, I’ll take it. And so should those in the medical field that commonly come in contact with those seeking help for their acute and chronic low back pain.

So…….We Should Be All Set For Success Now Right? Maybe they’re about to open up a chiropractic low back pain wing of the hospital, right?

That is what you’ think but there is new information from the White House that this simply is not the case despite the obvious ramifications. You can find the link in the show notes but on page 57 of The President’s Commission On Combating Drug Addiction and The Opioid Crisis report, the authors say, “A key contributor to the opioid epidemic has been the excess prescribing of opioids for common pain complaints and for postsurgical pain. Although in some conditions, behavioral programs, acupuncture, chiropractic, surgery, as well as FDA-approved multimodal pain strategies have been proven to reduce the use of opioids, while providing effective pain management, current CMS reimbursement policies, as well as health insurance providers and other payers, create barriers to the adoption of these strategies.” This is straight from the White House.

At the bottom of page 57, you will also see that it says, “The Commission recommends CMS review and modify rate-setting policies that discourage the use of non-opioid treatments for pain, such as certain bundled payments that make alternative treatment options cost prohibitive for hospitals and doctors, particularly those options for treating immediate post-surgical pain.”

What say you Tyce?
Tyce: You mean like a specialist copay for chiro care and a lower copay for primary care? Or covering surgery 100% and NOT covering non-surgical means.

Essentially, the United States Government is admitting there is professional discrimination at the highest levels…..hello Medicare and Health Insurance plans….I’m talking to you….this discrimination creates barriers to doing the smart thing.

The smart thing is seeing a chiropractor for your back pain. The “Big Guys” (AKA: American College of Physicians and the American Medical Association) recommend it and the government says policies are in place to prevent patients from following those recommendations.

In addition, policies that discriminate against chiropractic or chiropractors run in violation of Section 2706 of PPACA. It comes full circle.
I know you have something good to say here Tyce…

Tyce: The beautiful thing we get to see in our office, since we have both medicine and chiropractic working together, is the end of the story…people getting off the mind altering drugs, healing, and getting their lives back. All we do is follow these simple guidelines.

I have a question to pose to the entire Chiropractic profession: How in the heck do we deal with this?

It has to be through either the legislature at the state and federal levels or it has to be through the legal system. A guarantee I feel comfortable making is that the insurance companies won’t begin enforcing it on their own.

Mobilization and unification of the Chiropractic profession is probably where it starts.

Some steps toward that end include:
• Join or get involved with your state association. They’re the only ones effectively fighting for you and your rights on the state level.
• Join or get involved with your national association. They’re the only ones effectively fighting for you and your rights on the national level.
• If possible, build relationships with your state and national legislators.
• Donate to all of the above in the largest amounts you are comfortable with.
• Tell your friends and your colleagues about what is going on and help them get involved if they’re so inclined.
• Follow the news of your industry closely and stay knowledgeable about your profession. Both the good AND the bad.

Tyce, you have served for years and you’re still serving your profession. What you got on this?
Tyce: “Be part of the solution. You don’t have to dedicate 24/7 to the crusade….but you could do a little more. Right?”

A Chiropractic profession that is unified and playing offense instead of defense is powerful and is one of the worst nightmares of some folks I know out there in the world. Personally, as a side note, I like to see people like that squirm just a little don’t you? It just feels good. Makes what’s left of my hair stand up.

So won’t you consider helping if you haven’t before? If you don’t know where to start, email me at dr.williams@chiropracticforward.com and I will help you get on your way.

Tyce, I want to thank you for taking the time to come on the podcast and share your genius with us. With our history, I’m sure that Chiropractic Forward podcast listeners can count on your being a guest many many times. And, the next time will be the third time and I can say something like, “It was so nice, we had to do it thrice, with Tyce….or something stupid but entertaining like that.” Thanks for joining us today.

When Chiropractic is at its best, you cannot beat the risk vs reward ratio.

Did you know that 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!

Please feel free to send us an email at dr dot williams at chiropracticforward.com and let us know what you think or what suggestions you may have for us for future episodes. If you love what you hear, be sure to check out www.chiropracticforward.com. As this podcast builds, so will the website as we add more content, educational products, and a little further down the road, webinars, seminars, and speaking dates as they get added.

 

In the meantime, here are some of our recent podcasts that may be of interest:

CF 012: Proven Means To Treat Neck Pain

CF 008: With Dr. Craig Benton – Brand New Information Based on Results Chiropractic Proven Effective For Low Back Pain

CF 010: Surprise Unique Information Shows Chiropractic May Work On The Brain Too

 

 

 

 

We cannot wait to connect again with you next week. From Creek Stone here in Amarillo, TX, home of the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.

References and Source Material
1. https://www.amarillochiropractor.com/startling-medical-professional-attacks-chiropractic/
2. https://www.amarillochiropractor.com/healthcare-in-texas-the-battle-against-a-monopoly-a-true-story-about-david-goliath-3/
3. https://www.whitehouse.gov/sites/whitehouse.gov/files/images/The%20Underestimated%20Cost%20of%20the%20Opioid%20Crisis.pdf
4. https://www.acatoday.org/Portals/60/Docs/Advocacy%20and%20Reimbursement/2706/2706-FAQs.pdf?ver=2015-12-23-125425-503
5. https://annals.org/aim/fullarticle/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice
6. https://jamanetwork.com/journals/jama/article-abstract/2616395?widget=personalizedcontent&previousarticle=2616379
7. https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Final_Report_Draft_11-3-2017.pdf

 

CF 010: Surprise Unique Information Shows Chiropractic May Work On The Brain Too

Surprise Unique Information Shows Chiropractic May Work On The Brain Too

Welcome to the Chiropractic Forward podcast. I am your host Dr. Jeff Williams and we’re exctied to have you along for the ride. In today’s show, we’re going to talk about how chiropractic may work in the brain itself rather than how it affects just the musculoskeletal system.  We include some intriguing stuff from New Zealand that will make you think, hmmmm, that’s interesting, and we’ll have a little fun along the way

Bring on the bumper music

Again, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast This is where we talk about issues related to health, chiropractic, evidence, and research and how those things all fit into a comprehensive approach for treating different conditions. Thank you for taking time out of your day to give us a listen. I know your time is valuable and I will always try hard to fill our time with valuable content.

You have bobbed and weaved your way into episode #9 of the Chiropractic Forward podcast.

Before we get started, I want to draw your attention to the reviews over at iTunes. If you would be kind enough to leave us a great review, that tells iTunes that people are finding value in what we are sharing and it will help us grow this podcast. We sure would appreciate you!

For anyone that has paid any amount of attention to chiropractic, it’s clear that chiropractic treats muscles, bones, and the biomechanics overall. But what some people don’t commonly consider is the fact that chiropractic is effective when treating the nerves that make it all work together.

For instance, what do you think about when you think of chiropractic? More than likely, you think about back pain, neck pain, athletes, and headaches and migraines. It is unlikely that phrases like “cortical drive” or “movement related cortical potential” comes to mind.

According to the author of the paper we’re going to be talking about today, “Scientists use to believe spinal manipulation was a biomechanical treatment option for spinal pain conditions. However, the growing basic science evidence suggests there may be more of a neurophysiological effect following spinal manipulation than previously realized.”

When we begin to talk about the brain, physiology, neurology, and neurological processes, you can get into some highly complicated terms and ideas. I’m going to do everything I can to put it into terms that anyone and everyone can easily process without having a year of neurology classes.

And let’s be crystal clear, I’m not a neurologist or a chiropractic neurology diplomate either with tons of extra education on the brain and nervous system specifically. Many of these terms go above MOST of our heads and MOST of the heads in the medical field as well. That is just a matter of fact. But that doesn’t mean we can’t read, comprehend, and relay the overall pertinent information, which is what we are doing here.

Basically, “What’s the big idea?” That’s what I’m trying to bring to you here without making your eyes glaze over and making you fall into a deep state of hibernation.

Now, with all of that being said, there is some potentially fascinating research coming out of New Zealand we’re going to be talking about here having to do with the dact that chiropractic may work on the brain itself. We are going to talk about two papers that have been done by roughly the same group at the Centre for Chiropractic Research at the New Zealand College of Chiropractic in Auckland New Zealand. Just the name “Auckland” makes me want to go visit. I hear New Zealand is fantastic and the Lord Of The Rings was filmed there so you know it’s stunning. If an epic is filmed in your country, then you know it must be truly epic.

Here is a bit of a disclaimer to start off with. I have seen some dispute from other evidence-based chiropractors online of a different study from Dr. Haavick so I want you to understand that this sort of research cannot be accepted as the gospel. Not just yet anyway. I’d say it’s promising to an extent but there needs to be A LOT more exploration here before we hold it up as the gospel truth. Today’s podcast is more of a, “Hey, look what they’re studying, look what their findings are, and look what the potential for this sort of study could be.” rather than drawing any firm conclusions at this time.

The first study is titled, “Impact of Spinal Manipulation on Cortical Drive to Upper and lower Limb Muscles,” and was published in the journal ‘Brain Sciences’ in December of 2016(1).

Why They Did It

The researcher wanted to find out whether chiropractic care changes motor control. Motor control is basically the messages your brain sends your body in order make it move. Bending your arm, writing on a piece of paper, kicking your leg, or walking are examples of motor control. They assessed whether chiropractic care affected motor control for the arms as well as the legs and tried to find out if the changes may partly happen in the cortical part of the brain, which   is the part that issues motor commands. Although the researchers couldn’t completely rule out the idea that chiropractic adjustments can help motor function at the actual spinal level manipulated, the theory was that some of the changes must happen in the brain itself.  Basically, do chiropractors change how the brain controls muscles(2)? 

How They Did It

  • They conducted two experiments to test their theory. One for the arm and one for the leg.
  • In the first, transcranial magnetic stimulation input-output curves for an upper limb muscle known as the abductor pollicis brevis were recorded.
  • They also recorded F-waves before and after spinal manipulation or the control intervention for the control group on the same subjects on two different days.
  • The researchers did the same in a separate experiment for the lower limb using the tibialis anterior muscle.

What They Found

Before getting into what they found, let’s define the term motor evoked potential.”  According to Medscape, the definition is, “Single- or repetitive-pulse stimulation of the brain causes the spinal cord and peripheral muscles to produce neuroelectrical signals known as motor evoked potentia ls. Clinical uses of motor evoked potential include as a tool for the diagnosis and evaluation of multiple sclerosis and as a prognostic indicator for stroke motor recovery(3).”

With that knowledge the following was noted:

  • Spinal manipulation caused an increase in maximum motor evoked potential in both muscles tested.

Wrap It Up

In a quote from the research abstract, the authors conclude, “Spinal manipulation may therefore be indicated for the patients who have lost tonus of their muscle and or are recovering from muscle degrading dysfunctions such as stroke or orthopaedic operations. These results may also be of interest to sports performers. We suggest these findings should be followed up in the relevant populations.”

In another quote from the lead author, she said, “This research has big implications,says an enthusiastic Heidi Haavik. “It is possible that patients who have lost muscle tonus and/or are recovering from muscle degrading dysfunctions such as stroke or orthopaedic operations could also benefit from chiropractic care. These findings are also very relevant to sports performers (although this too must also be followed up with more research), because it indicates that chiropractic care may help their brains to more efficiently produce greater outputs. So all in all a very exciting study!”

Guess what? They took their own advice in their conclusion and followed up this paper with another similar paper focused more specifically on athletic performance. Here’s the last paper we will discuss called, “The Effects of a Single Session of Spinal Manipulation on Strength and Cortical Drive in Athletes” published in the European Journal of Applied Physiology in January of 2018. Brand new information(5).

Why The Did It

Of course, they did it because they suggested the need for the paper in the conclusion of the previous study but more specifically, they did it because they wanted to test if a single chiropractic adjustment could change things in the muscles of the lower leg for an elite Taekwondo athlete.

How They Did It

  • The muscle measured was the soleus muscle, which lies just under what is commonly known as the calf muscle or the gastrocnemius.
  • Soleus evoked V-waves, H-reflex and maximum voluntary contraction of the plantar flexors were recorded from 11 elite Taekwondo athletes
  • A randomized controlled crossover design was utilized.
  • Treatments used consisted of either spinal manipulation in the treatment group or passive movement control in the control group.
  • Outcome measurements were noted prior to treatment, immediately after treatment, 30 minutes after treatment, and an hour after treatment.

What They Found

  • Spinal manipulation was responsible for increasing each factor measured when compared to the control group.
  • The differences were considered significant through each time interval.

Wrap It Up

The authors are quoted in the conclusion of the paper as saying, “A single session of spinal manipulation increased muscle strength and corticospinal excitability to ankle plantar flexor muscles in elite Taekwondo athletes. The increased maximum voluntary contraction force lasted for 30 minutes and the corticospinal excitability increase persisted for at least 60 minutes.“

As I said in the beginning, I feel that this sort of research is really just beginning and consider it in its infancy but I also think that the results are enough to demand more exploration into this area of how chiropractic can affect neurology.

There is actually a court case in Texas this very minute. The appeals argument starts on February 28th down in Austin. The Texas Medical Association is attacking Texas Chiropractors’ rights to treat the “neuromusculoskeletal” system. They argue that chiropractors do not (and cannot) treat anything further than the “musculoskeletal”system. Certainly, NOT the “neuromusculoskeletal” system.

Regardless of the opinions held by those in the leadership of the Texas Medical Association and their legal team, both of these papers (and many other by the way), in my opinion, render their arguments ignorant, nit-picky, archaic, and obsolete. It’s not a question of what research is out there. It’s a question of if they can understand it or will let their pride go. My guess is, “No.” They have to prevent Chiropractic from moving into their territory at any and all costs. It is NOT about patient safety. It never has been and it never will be. It’s purely based on power and the threat of losing it.

What’s your opinion. We would love to hear it.

Research and clinical experience shows that, in about 80%-90% of headaches, neck, and back pain, compared to the traditional medical model, patients get good or excellent results with Chiropractic. It’s safe, more cost-effective, decreases chances of surgery, and reduces chances of becoming disabled. We do this conservatively and non-surgically and do it with minimal time requirements and hassle on the part of the patient. And, if the patient develops a “preventative” mindset going forward, we can likely keep it that way while raising the general, overall level of health! And, of course now, we see that chiropractic may work on the brain too!

Please feel free to send us an email at dr dot williams at chiropracticforward.com and let us know what you think or what suggestions you may have for us for future episodes. If you love what you hear, be sure to check out www.chiropracticforward.com. As this podcast builds, so will the website as we add more content, educational products, and a little further down the road, webinars, seminars, and speaking dates as they get added.

We cannot wait to connect again with you next week. From Creek Stone here in Amarillo, TX, home of the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.

Sources:

  1. Haavik H, Niazi IK, Jochumsen M, Sherwin D, Flavel S, Türker KS. Impact of Spinal Manipulation on Cortical Drive to Upper and Lower Limb Muscles. Brain Sci. 2016 Dec 23;7(1).https://chiropracticscience.com/increase-cortical-drive-following-spinal-manipulation/

2) https://spinalresearch.com.au/new-study-reveals-impact-spinal-manipulation-cortical-drive-limb-muscles/

3) https://emedicine.medscape.com/article/1139085-overview

4) https://www.researchgate.net/publication/322199907_The_Effects_of_a_Single_Session_of_Spinal_Manipulation_on_Strength_and_Cortical_Drive_in_Athletes

5) Christiansen L, et. al. (2018). The Effects of a Single Session of Spinal Manipulation on Strength and Cortical Drive in Athletes. European Journal of Applied Physiology. . 10.1007/s00421-018-3799-x/fulltext.html.

CF 009: With Dr. Tom Hollingsworth: The Case Against Chiropractic In Texas

We’ll be talking about any and every past attack on chiropractic in Texas and on our profession by the medical field heavyweights…..what’s at risk and why. In addition, we’ll be sharing some personal opinions, some facts, some research….and we’ll be discussing what you all can do to help if you are an active person that wants to pitch in.

Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast where we talk about issues related to health, chiropractic, evidence, and research and how those things all fit into a comprehensive approach for treating different conditions. Thank you for taking time out of your day to give us a listen. I know your time is valuable and I will always try hard to fill our time with valuable content.

Right off the top today, I want to welcome a good friend and colleague of mine, Dr. Tom Hollingsworth originally from Brady, TX and now living in Corpus Christi, TX. Dr. Hollingsworth is a master of linguistics and he’s a master of the material when it comes to what we’ve been through and what we are going through currently. In fact, Tom has helped prepare the court drafts so he has intimate knowledge and it’s a special treat to have Dr. Hollingsworth here to walk us through it all.

Welcome to the Chiropractic Forward podcast Dr. Hollingsworth. We’re so glad to have you with us today…

Have you ever heard the song “Corpus Christi Bay” by Robert Earl Keen and is it indeed hard to stay sober on the Corpus Christi Bay?

Tell me a little about your background and your family.

We have both been highly active in the Texas Chiropractic Association over the years. Everyone fits a certain function for sure. What have been your functions in the past on the Statewide level?

With this being an evidence-based podcast, can you offer some thoughts on whether or not there is room in an evidence-based model for chiropractic philosophy to maintain any sort of footprint in it?

There is so much material here, I want you to know that you have free-reign to interrupt, stop me, correct me, and keep me on track here. I encourage any and all participation from you on this.

When Chiropractors start talking about the attack on chiropractic in texas and other attacks we’ve endured and are enduring, we can go on for hours. We are going to try to convey a very serious and meaningful message about it all right here today but without getting into a three hour conversation.

I can only hope that all chiropractors in practice are well-aware of the trials and tribulations this amazing professions have, not only been through, but overcome and grew as a result. It is profound.

The unfortunate reality is that most do not know and, if they do, they normally lack any important details to truly place their knowledge in the correct context.

I believe that Dr. Hollingsworth will agree with me that, in our experience, lots of folks don’t know what’s going on with their profession….is that correct sir?

As a former board member of the Texas Chiropractic Association myself and a current member of the leadership statewide, we are intimately aware of many of the issues, both current and historically.

And I think, from the top here, it’s important to say that, even though Dr. Hollingsworth and myself are TCA members and leaders, our opinions may or may not represent the opinions of the TCA but we are NOT representing the TCA as we go through this podcast and in this capacity.

Anything you’d like to add to that disclaimer Dr. Hollingsworth?

We have all heard the stories of chiropractors being jailed for practicing. I remember a story from a documentary by Jeff Hayes called Doctored where a chiropractor is recalling how his father, who was also a chiropractor was in a bowling league. There was a medical doctor on the other team that refused to bowl against his father’s team simply because the team had a chiropractor on it.

Now, let’s run through the BIG ATTACK first. Folks, if you don’t know about Wilk vs. AMA, please do yourself, and all other chiropractors, a big favor and go check it out. To put it into a very brief blurb, basically, after 11 years of court proceedings, Dr. Chester Wilk and four other chiropractors, led by attorney George McAndrews, ultimately prevailed in proving the American Medical Association guilty of violating the Sherman anti-trust act. Meaning the AMA and several other medical institutions like the American Hospital Association, the American College of Surgeons, the American College of Physicians, and the Joint Commission on Accreditation of Hospitals were found guilty of conspiring to eliminate chiropractic from the Earth. According to Chiro.org….”the suit claimed that the defendants had participated for years in an illegal conspiracy to destroy chiropractic. On August 24, 1987, after endless wrangling in the courts, U.S. District Court judge Susan Getzendanner ruled that the AMA and its officials were guilty, as charged, of attempting to eliminate the chiropractic profession. “

Does that about sum it up, Dr. Hollingsworth, and would you like to add to any of that?

Basically the AMA and others were proven guilty of the following acts against Chiropractic:

  • Encourage ethical complaints against doctors of chiropractic
  • Oppose chiropractic inroads into workmen’s comp
  • Oppose chiropractic inroads into health insurance and make it difficult for patients to get covered for chiropractic care
  • Oppose inroads into hospitals
  • Contain or eliminate Chiropractic schools
  • They conducted nationwide conferences on Chiropractic
  • Distributed anti-Chiropractic publications and propaganda
  • Helped other organizations prepare anti-chiropractic literature
  • Deemed it unethical for medical doctors to refer to, or accept referrals from, chiropractors.
  • And, they discouraged colleges, universities, and faculty from cooperating with chiropractic schools.

Can you believe that things have progressed to the point now that two of those organizations came out last year in support of Chiropractic for the treatment of acute and chronic and low back pain?

In referencing a blog of mine from November 11th, 2015 called Healthcare in Texas: The Battle Against a Monopoly. A True Story About David & Goliath,” I reminded myself of some more recent minor attacks. I’ll put the link in the show notes.

  • The Texas Medical Association attempted to remove Doctors of Chiropractic from the high school concussion oversight teams. They wanted to allow simple high school trainers but not chiropractors.
  • The same year, the TMA attempted to remove Chiropractors’ ability to perform physical exams on school bus drivers.
  • Same year, they tried to introduce legislation to remove our ability to perform high school exams on athletes. A function chiropractors have been performing for generations.

Now Dr. Hollingsworth, you’d think this would have put the battle to rest right? Can you go ahead and run through TMA #1 one for us please? The when, why, and what happened…

Before we get any further, how about we define Chiropractic. At least as far as the State of Texas is concerned, Tom.

I’d like to take just a second to direct everyone to an excellent video on YouTube that the Texas Chiropractic Association published about a year and a half ago concerning a lot of this. The link will be in the show notes but you can also find it by going to YouTube and searching the term “The Texas Chiropractic Defense From The Texas Medical Association A Timeline.” This ten minute video sums up what kind of constant attacks our profession is still enduring today.

So, we have Wilk vs. AMA that Chiropractic ultimately won, and we prevailed in the TMA #1 diagnosis case for the diagnosis issue…….now, surely, when the TBCE and the TCA triumphed in that one, that had to have killed any further attacks from the TMA right, Dr. Hollingsworth?

(Discuss VONT, Diagnosis #2, Sublux, and Neuro)

Tom, what is the current status on this case? It’s about to be go time right?

What kind of research is the TCA and TBCE team looking at using to bolster the case and why are we using these particular papers?

1.   MSK includes “associated” nerves

a. Concerning balance is Ex Parte Halsted

b. Careful to avoid claims toward entirety of nervous system (Hogs get slaughtered.)

2.   TMA depended greatly on UT Med School’s Leonard Cleary, PhD.’s deposition

a. Understandably supported TMA position MSK is not neuro

b. Heavily focused on structure considerations only in isolation from function

c. Ivory Tower challenged

i. by TBCE presenting Grays, and

ii. TCA presenting simpler TEA authors defining elements of muscle.

d. PRE-TRIAL appeal allowed for exam outside of MSK if it will lead to opinion of bio-mechanical condition of MSK.  So…

i. Neurotrophic effects on muscle

ii. Neurotrophic effects on bone  (Deposition Ex. 10)

3. Subluxation Complex

a. TBCE presented definitions of WHO, Dorland’s and compared them to TBCE’s. Can you expound on the different definitions for us please?

b. TCA presented Texts by Strang, Leach, King & Janig , and

i. AMA’s CPT definitions, 

ii. Bakris/Dickholtz NUCCA BP study

Now This is a paper we covered in podcast episode #7 but we also cited a couple others by AP Wong and by Yates, et. al. There’s no doubt we’re on solid ground here. 

c. TMA offered no witness qualified to opine on subluxation complex

i. However, a letter from them to TBCE when adding “subluxation” stated they preferred TBCE choosing the WHO definition (that includes “nerve”).

4. Vestibular-Ocular-Nystagmus Testing (VONT)

a. TMA offered a NeurOtologist (ENT subspecialty) and a PT

i. Argued training length (residency, etc.)

ii. Mostly Fair witness

iii. One key was distinguishing Vestib Apparatus from Vestib System

1. Had to get out of ear into processing centers

2. (Vestib Nuc and V-spinal tracts)

3. Attempt to utilize MD cultural authority on basic fact

4. Build on basic facts later.

iv. After hours of testimony from TMA’s vestibular experts, trial judge asked: “When are we going to hear about VONT?” 

Well, I suppose all we can do at this point is to continue to raise money from chiropractors that want to pitch in. We know that an appeals process is expensive. We also know that what happens in a state with over 5,000 chiropractors in it, usually tends to happen in other states down the line so it’s likely in every American chiropractor’s interest to get on board with this issue and contribute to its success.

If you would like to donate to this victory, I would direct you to the TCA since they are leading the way on this. Go to www.chirotexas.org/cdi

Please feel free to send us an email at dr dot williams at chiropracticforward.com and let us know what you think or what suggestions you may have for us for future episodes. If you love what you hear, be sure to check out www.chiropracticforward.com. As this podcast builds, so will the website as we add more content, educational products, and a little further down the road, webinars, seminars, and speaking dates as they get added. Also, find our Facebook page where we’ll be sharing all kinds of good stuff from the shows and from our guests.

Reviews….folks, we need reviews over at the iTunes Chiropractic Forward page. That’s what tells iTunes that people are finding value in what we’re doing. We sure would appreciate it.

We cannot wait to connect again with you next week. From Creek Stone here in Amarillo, TX, home of the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.

Show Note resources

  1. Bakris G. (2007). “Special chiropractic adjustment lowers blood pressure among hypertensive patients with misaligned C-1 vertebra.”   Retrieved February 7, 2018, from http://www.uchospitals.edu/news/2007/20070314-atlas.html.
  2. Wong AP (2018). “Review: Beyond conventional therapies: Complementary and alternative medicine in the management of hypertension: An evidence-based review.” Pak J Pharm Sci 31(1): 237-244.
  3. Yates RG (1988). “Effects of chiropractic treatment on blood pressure and anxiety: a randomized, controlled trial.” Manip Physical Ther 11(6): 484-488.
  4. https://www.chiro.org/Wilk/
  5. https://jamanetwork.com/journals/jama/article-abstract/2616395
  6. https://www.amarillochiropractor.com/healthcare-in-texas-the-battle-against-a-monopoly-a-true-story-about-david-goliath-3/
  7. The Texas Chiropractic Defense From The Texas Medical Association A Timeline.
  8. https://youtu.be/XHGfAQwIqNo

 

Bibliography

Bakris G. (2007). “Special chiropractic adjustment lowers blood pressure among hypertensive patients with misaligned C-1 vertebra.”   Retrieved February 7, 2018, from http://www.uchospitals.edu/news/2007/20070314-atlas.html.

Wong AP (2018). “Review: Beyond conventional therapies: Complementary and alternative medicine in the management of hypertension: An evidence-based review.” Pak J Pharm Sci 31(1): 237-244.

Yates RG (1988). “Effects of chiropractic treatment on blood pressure and anxiety: a randomized, controlled trial.” Manip Physical Ther 11(6): 484-488.