research

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

CF 144: Common Surgeries Aren’t Well-Researched & Chiropractic Wins Again Today we’re going to talk about how some of the most common musculoskeletal surgeries aren’t very well-researched and we’ll talk about how chiropractic performs when lined up with multidisciplinary treatment.  But first, here’s that sweet sweet bumper music  
Chiropractic evidence-based products

Integrating Chiropractors

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  OK, we are back and you have found the Chiropractic Forward Podcast where we are making evidence-based chiropractic fun, profitable, and accessible while we make you and your patients better all the way around.  We’re the fun kind of research. Not the stuffy, high-brow kind of research. We’re research talk over a couple of beers. I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.   If you haven’t yet I have a few things you should do. 
  • Like our Facebook page, 
  • Join our private Facebook group and interact, and then 
  • go review our podcast on iTunes and other podcast platforms. 
  • We also have an evidence-based brochure and poster store at chiropracticforward.com
  • While you’re there, join our weekly email newsletter. No spam, just a reminder when the newest episodes go live. Nothing special so don’t worry about signing up. Just one a week friends. Check your JUNK folder!!
Do it do it do it.  You have found yourself smack dab in the middle of Episode #144 Now if you missed last week’s episode, we talked about a new paper that came out in JAMA that said spinal manipulative therapy doesn’t work and what our research experts have to say about that and what my big mouth has to say about it. Make sure you don’t miss that info. Keep up with the class. There may come a time you need to take a stance on that.  While we’re on the topic of being smart, did you know that you can use our website as a resource? Quick and easy, you can go to chiropracticforward.com, click on Episodes, and use the search function to find whatever you want quickly and easily. With over 100 episodes in the tank and an average of 2-3 papers covered per episode, we have somewhere between 250 and 300 papers that can be quickly referenced along with their talking points.  Just so you know, all of the research we talk about in each episode is cited in the show notes for each episode if you’re looking to dive in a little deeper.  On the personal end of things….. I’m trudging through the designated doctor program here in Texas to assess the extent of the injury, return to work, and all of that fun fun stuff. I’m not even sure why I’m doing it. Just to have back up plans. I like multiple streams and I like options. If I get as busy as I was in 2019, I’ll never have the need for it. If it stays where I’m at – 75% of where I was, well it may be something I entertain.  Either way, will it make me a better doctor for personal injuries, work comp, and all patients in general? Hell yeah, it will. Even if I never use it for a DD exam, I’ll be a better doc after going through it. Guaranteed. Even if I don’t pass the damn test!! Which I hear is stupid and has nothing to do with the curriculum. Even if I fail the test, I’ll be better.  It is slowly cooling off here in the Texas Panhandle. While I realize we just went through the longest Spring and Summer known to mankind, I’m going to miss it. Despite all that went into making it the longest Spring and SUmmer ever….I’m going to miss the aspect of time slowing down, sitting on the back patio with my wife, dinner outside in the outdoor kitchen, swimming in the pool, and just being warm in general.  Oh, how I despise the cold weather. Lol. Here’s where you Northerners call me a pansy but….it’s like needles when the cold wind blows. I grew up a couple of hours north of where I live now and there was a difference in weather. At times, it would get bone-chilling cold growing up. I would take a shower in the morning before school, drive there and park, and walk into the school. My wet hair from showering would freeze before I got into the building. Now that’s cold, folks.  I grew up with that, yes, even in Texas. My hometown is called Perryton, TX and it’s only 7 miles from the tiny little strip of Oklahoma and it’s about 45 miles from Kansas. So, it’s not deep in the heart of Texas. It’s way up North.  My point is, I went to school down in Natchitoches, Louisiana, and then lived in Dallas for about 6 years before relocating back to the Texas Panhandle and Amarillo, TX.  Having not been in the cold cold for 8-10 years got me spoiled to the point that I can’t even tolerate cold weather anymore. At all. For any reason. It borderline pisses me off.  Everything dies, it’s cold, it’s windy, people are all yay about pumpkin spice crap, my bones ache a bit, and I’m bitchy 2/3 of the time.  I’m just warning you all, this is what you get to look forward to dealing with for the next 3-4 months. My whiny butt being all cold-weather fussy. But here’s the saving grace and the best thing since sliced bread; the remote start vehicle.  Yes, as any good Texan, I have a pickup and that dude has remote start with defrost and heated seats. You damn right. This is the ONE thing that has made Winter somewhat tolerable for me and, being a good Christian, I thank God and the car companies on the frigid mornings for blessing us all with such wonderous inventions like the remote start.  Now, I don’t want you North Dakota or Canadian friends of mine rolling your eyes too hard at me here. I’m sure you’d melt down here in TX in the Summers so…..we agree to play to our strengths and roll on down the road. Trust me, go through two-a-days in college in Louisiana and tell me how tough you are. Lol. Something you don’t see on TV when you watch football is the humidity. It’s REAL.  I went from three-a-days at one college playing football here in the Texas Panhandle to two-a-days in Louisiana. Not a problem by anyone in the Panhandle but in Lousiana, it looked like a battlefield with players dropping left and right with cramps and having to get IVs there on the practice field….it was insane. So, I’m cold intolerant but I can handle the other end of it. Don’t be too hard on me. Lol.  What does all of this have to do with chiropractic and research? Not a damn thing. Just a little bit of fun rambling and brain dump.  Let’s get on with the real reason we’re here. Item #1 This first one came to me from Dr. Craig Benton, one of my buddies, down in Lampasas, TX where it’s always a bit balmy almost year-round. It’s called “Integrating a multidisciplinary pain team and chiropractic care in a community health center: an observational study of managing chronic spinal pain” by Prater et. al(Prater C 2020). and published in Journal of Primary Care & Community Health on September 10th of 2020. Holy smokin scorchin’ blaze of newness! Look, y’all should know how I feel about chronic pain by now. This is right down my alley. Not a dark alley. No, one that’s lit up like an airport runway. Bright alley.  Why They Did It They say that chronic pain is one of the most common diseases in the US with the underserved population being most affected for obvious reasons. They say the underserved are at more risk of opioid misuse or overuse since they lack therapeutic access otherwise. For this reason, they are looking for other avenues to provide treatment to chronic pain sufferers.  How They Did It
  • This was a prospective observational pilot study
  • Held at a community health center
  • Measured the effectiveness of two interventions among the underserved population
  • The two interventions were 
  • Multidisciplinary team
  • Chiropractic care
  • The outcomes measured were pain and functional disability measured via the Pain Disability Questionnaire and reduction of opioid dosage at 6 and 12 months. 
  • 35 folks complete baseline and follow-up outcome measures from August 2018 to May 2020
Wrap It Up A key finding was quote, “Participants in the chiropractic team and those completing the study before COVID-19 were found to have significantly greater improvement at follow-up.” Well isn’t that sexy? Indeed.  “This observational study within a community health center resulted in improvement in spinal pain and disability with chiropractic care versus a multidisciplinary pain team. Offering similar services in primary care may help to address pain and disability, and hopefully limit external referrals, advanced imaging, and opioid prescriptions.” This was a pilot study with small sample size. Nothing to do backflips about but it’s a start down this path or thinking and learning so hopefully, we’ll see some very cool and very positive things for the chiropractic profession down the line if papers like this continue to come out. Before we get to the next paper, I want to tell you a little about this new tool on the market called Drop Release. I love new toys! If you’re into soft tissue work, then it’s your new best friend. Heck if you’re just into getting more range of motion in your patients, then it’s your new best friend. Drop Release uses fast stretch to stimulate the Golgi Tendon Organ reflex.  Which causes instant and dramatic muscle relaxation and can restore full ROM to restricted joints like shoulders and hips in seconds.   Picture a T bar with a built-in drop piece.  This greatly reduces the time needed for soft tissue treatment, leaving more time for other treatments per visit, or more patients per day.  Drop Release is like nothing else out there, and you almost gotta see it to understand, so check out the videos on the website. It’s inventor, Dr. Chris Howson, from the great state of North Dakota, is a listener and friend. He offered our listeners a great discount on his product. When you order, if you put in the code ‘HOTSTUFF’ all one word….as in hot stuff….coming up!! If you enter HOTSTUFF in the coupon code area, Dr. Howson will give you $50 off of your purchase. Go check Drop Release at droprelease.com and tell Dr. Howson I sent you. Item #2 I think I got this one from Dr. Craig Benton as well. Dr. Benton is a former guest of this podcast. Sounds like we need to have him back on. He’s my Allstar this week. Thank you, Dr. Benton. For keeping me in business and helping me keep everyone, including myself, educated.  This one is called, “Surgery for chronic musculoskeletal pain: the question of evidence” authored by Harris et. al(Harris IA 2020). and published in Pain Journal in September of 2020. Blisters!!! I got blisters on my fingers!!! You Beatles fans…..you’ll get it.  Why They Did It They say that globally, the most common reasons surgery is performed relate to the musculoskeletal system, and outside of injury, the most common reasons pertain to arthritis and back or neck pain. AKA – chronic pain. Yes, I love me some chronic pain people! Not suffering from it. Learning about it and treating it.  They say, “Although the surgical treatment of chronic pain generally relies on attributing pain to objective, often visible changes on imaging studies, the causes of chronic pain are more complex and are strongly influenced by psychosocial factors.” Things like Yellow Flags. Go look up yellow flags and Annie O’Connor’s book called World Of Pain please and thank you.  They say that surgeries like debridement of degenerative joints and things of that nature ignore the complexity of chronic pain. They look at surgery as purely mechanistic in nature with little to no involvement otherwise and the procedures often rely on observational evidence only, rather than rigorous, comparative trials.  In addition, they say that when the trials have actually been performed for these surgeries have been mostly subjective and measurements are usually not blinded to reduce the bias of the outcomes.  Do you want yourself or loved ones cut into when the procedure has not been thoroughly investigated, researched, and tested? Uh hell no. No thank you.  This paper was written to demonstrate that observational evidence is not adequate when you consider the costs and risks of surgical intervention. They advocate surgical procedures that should undergo randomized controlled trials with blinding and showing statistical and clinically important symptomatic improvement when compared to no surgery at all.  Wouldn’t you expect that they already do this???? Evidently not. At all, really.  Ultimately in this paper the goal here was to quantify what kind of support exists in the literature for some common procedures.  How They Did It
  • The first thing to do was identify the common procedures performed for chronic pain
  • Secondly, they had to identify the number of published RCTs comparing each procedure to a control group treated without that procedure
  • They did a search of the Cochrane Central Register of Controlled Trials
  • Each paper was reviewed by two independent authors
pastedGraphic.png What They Found
  • A very low proportion of the RCTs on the selected procedures compared the procedure to not performing the procedure. 64 from the more than 6,735 studies. Less than 1% if you’re keeping track. Is that not stunning? And infuriating?
  • Of those 64, only 9 were favorable to surgery. 
  • When considering individual surgical procedures, the majority of comparative trials did not favor surgery 
  • None of the studies using patient blinding for any procedure found it to be significantly better than not having the surgery at all. 
Wrap It Up We conclude that many common surgical procedures performed for musculoskeletal conditions causing chronic pain have not been subjected to randomized trials comparing them to not performing the procedure. Based on the observation that when such studies have been performed, only 14% (on average) showed a statistically significant and clinically important benefit to surgery; there is a need to produce such high-quality evidence to determine the effectiveness of many common surgical procedures.  Furthermore, the production of high-quality evidence should be a requirement before widespread implementation, funding or professional acceptance of such procedures, rather than the current practice of either performing trials after procedures have become commonplace, or not performing comparative trials at all.” Wouldn’t you like it in the year 2020, when we hear bragging about the amazing advances of medical wonders and technology, and sometimes rightfully so…..would you like it if these things that should go unsaid are actually done? Wouldn’t you like to know that your mom’s spinal surgery procedure was fully vetted? It was researched against not doing it at all? They haven’t done that? Seriously? Look, ever heard of phantom limb pain? Just in case, it’s where a limb is amputated. Cut off completely. Yet, it still hurts. Why the hell does something that is gone and no longer exists still hurt? It’s because chronic pain lives as much or more in the brain as it lives in a peripheral source.  So, if you go in and do surgery on arthritis for a chronic pain sufferer, what are the real chances that you got rid of that pain? How many people have arthritis that commonly doesn’t bother them much at all beyond the first 15 or so minutes after they wake up? The answer isn’t precise but it’s probably a hell of a lot if I’m placing bets.  Did you know that if a person has surgery and they’re in chronic pain syndrome that even if the surgery goes perfectly, they will still have a 60% chance of developing pain at the new site of surgery? That’s what happens when you have a sensitized or upregulated central nervous system. It’s on high alert and using pain to make your future decisions and to protect you. You have to turn the volume down on the central nervous system if you’re ever going to control the pain in the brain. It’s actually the MOST IMPORTANT aspect of treating chronic pain.  How many people get surgery when they don’t need it because the arthritis isn’t really the issue. When the issue actually lies withing the limbic system in the brain? To be fair, how many people get adjusted by the chiropractor a million times because they’re trying to pop out the pain? Hell, doing that a million times only deepens the issue.  Don’t get me wrong, there’s SMT benefit in regard to proprioceptive input, sensorimotor function, movement dysfunction, blood flow, and pain modulation but…..beyond a certain point, it will create instability and that will deepen the issue.  I tell new chronic patients that we treat this issue through a combined approach. They must be approaching the issue from a cognitive aspect simultaneously with my physical treatment as well as the exercise/rehab. If we have that comprehensive, three-pronged approach to their condition, we are going to stand a much better chance at getting this sucker under control.  If you’re adjusting and sending them out the door, that’s low-level and borderline ineffective at best. At the worst, with too many appointments, you compound the issue by adding spinal instability to the mix. Too many chiropractors and subluxation slayers just do not understand this concept. They think they’re being specific. The research is pretty clear. You’re adjusting segments at a time. Not one. You’re not that good.  Alright, that’s it. Y’all be safe. Keep changing the world and our profession from your little corner of the world. Continue taking care of yourselves and taking care of your neighbors. Tough times are upon us but, the sun will shine again. Trust it, believe it, count on it. Let’s get to the message. Same as it is every week.  Store Remember the evidence-informed brochures and posters at chiropracticforward.com.   
Chiropractic evidence-based products

Integrating Chiropractors

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The Message I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment rather than chemical treatments like pills and shots. When compared to the traditional medical model, research and clinical experience show us patients can get good to excellent results for headaches, neck pain, back pain, and joint pain to name just a few. It’s safe and cost-effective can decrease surgeries & disability and we do it through conservative, non-surgical means with minimal hassle to the patient. And, if the patient treats preventatively after initial recovery, we can usually keep it that way while raising the overall level of health! Key Point: At the end of the day, patients should have the guarantee of having the best treatment that offers the least harm. When it comes to non-complicated musculoskeletal complaints…. That’s Chiropractic! Contact Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show and tell us your suggestions for future episodes.  Feedback and constructive criticism is a blessing and so subscribe and excellent reviews on podcast platforms.  We know how this works by now. If you value something, you have to share it, interact with it, review it, talk about it from time to time, and actively hit a few buttons to support it here and there when asked. It really does make a big difference.  Connect We can’t wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward. Website
Home
Social Media Links https://www.facebook.com/chiropracticforward/ Chiropractic Forward Podcast Facebook GROUP https://www.facebook.com/groups/1938461399501889/ Twitter YouTube https://www.youtube.com/channel/UCtc-IrhlK19hWlhaOGld76Q iTunes https://itunes.apple.com/us/podcast/chiropractic-forward-podcast-chiropractors-practicing/id1331554445?mt=2 Player FM Link https://player.fm/series/2291021 Stitcher: https://www.stitcher.com/podcast/the-chiropractic-forward-podcast-chiropractors-practicing-through TuneIn https://tunein.com/podcasts/Health–Wellness-Podcasts/The-Chiropractic-Forward-Podcast-Chiropractors-Pr-p1089415/ About the Author & Host Dr. Jeff Williams – Fellow of the International Academy of Neuromusculoskeletal Medicine – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger   Bibliography
  • Harris IA, S. V., Mittal R, Adie S, (2020). “Surgery for chronic musculoskeletal pain: the questions of evidence.” Pain 161(9): S95-S103.
  • Prater C, T. M., Battaglia P, (2020). “Integrating a Multidisciplinary Pain Team and Chiropractic Care in a Community Health Center: An Observational Study of Managing Chronic Spinal Pain.” Journal of Primary Care & Community Health.

w/ Dr. Aric Frisina-Deyo – Chiropractors In An FQHC Setting & Setting The Bar High Early On

CF 137: w/ Dr. Aric Frisina-Deyo – Chiropractors In An FQHC Setting & Setting The Bar High Early On

 Today we’re going to be joined by Aric Frisina-Deyo. We’re going to discuss the ins and outs of working in an FQHC. You’ve heard us talk about it before with Dr. James Lehman. How do you do it, what can you expect out of it, and what does it look like? But first, here’s that sweet sweet bumper music

Chiropractic evidence-based products

Integrating Chiropractors

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OK, we are back and you have found the Chiropractic Forward Podcast where we are making evidence-based chiropractic fun, profitable, and accessible while we make you and your patients better all the way around.  We’re the fun kind of research. Not the stuffy, high-brow kind of research. We’re research talk over a couple of beers. I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.   If you haven’t yet I have a few things you should do. 

  • Like our Facebook page, 
  • Join our private Facebook group and interact, and then 
  • go review our podcast on iTunes and other podcast platforms. 
  • We also have an evidence-based brochure and poster store at chiropracticforward.com
  • While you’re there, join our weekly email newsletter. No spam, just a reminder when the newest episodes go live. Nothing special so don’t worry about signing up. Just one a week friends. Check your JUNK folder!!

Do it do it do it. 

You have found yourself smack dab in the middle of Episode #137

Now if you missed last week’s episode, we talked about adjustments making a person stronger, providing more endurance, and providing improved balance. We talked about new evidence on muscle relaxers, and we talked about the best recovery posture after some intense training. Find out if it’s better to recover having your hands on your knees or standing up with your hands behind your head like we’ve been taught over the years. Make sure you don’t miss that info. Keep up with the class. 

While we’re on the topic of being smart, did you know that you can use our website as a resource? Quick and easy, you can go to chiropracticforward.com, click on Episodes, and use the search function to find whatever you want quickly and easily. With over 100 episodes in the tank and an average of 2-3 papers covered per episode, we have somewhere between 250 and 300 papers that can be quickly referenced along with their talking points.  Just so you know, all of the research we talk about in each episode is cited in the show notes for each episode if you’re looking to dive in a little deeper. 

On the personal end of things….. So far, so good. Staying steady, healthy, and strong. No big drop-offs in business but no big growth beyond our 80% mark either. Like I said last week, 80% is my new normal for now and, if that’s my new cap, then it’s time to simply start comparing my weekly numbers to the 80% mark and just continue growing and comparing to that.  Basically, my 80% is what I’m now accepting as my new 100% if that makes sense. That’s my roof or my ceiling. I have stopped comparing my numbers currently to the numbers of last year or the numbers of pre-COVID.

It’s not fair to me or my employees. Like it or hate it, there is a new normal for now and for the foreseeable future and I’m living and operating in that world for now.  That just makes more sense to me. Otherwise, I’m trying to reach a bar that is very difficult to reach and I think I’ll be perpetually frustrated and nobody’s got time for that.

So, I’m comparing my numbers to last week’s numbers and last month’s numbers. It just makes more sense.  I have a new assistant taking care of the Chiropractic Forward website. You’ll have to go check it out here and there. She’s in the process of updating the Store link where we have evidence-based patient education brochures and brand new posters for your offices.  Just go to chiropracticforward.com and click on the Store link while you’re there. Maybe sign up for our weekly email newsletter while you’re at it. No spam, just a weekly reminder on Thursdays when the new episodes go live. That’s it. 

Introduction Alright, let’s get on with the show and introduce our guest today. Today we’re joined by Dr. Aric Frisina-Deyo. Being in only his second year of practice, Aric was wondering why I’d be interested in his story. Well, it’s simple, he is integrated into and working for an FQHC. Meaning, he’s already functioning at the top of the game and I want to know about it. 

I’m guessing if I want to know about it, many of you would like to know about it.  First, you may think your area doesn’t have an FQHC and for the most part, you’re probably wrong. Just pull out your Google machine and type in ‘FQHC and the area you live in’. See what it pulls up. Dr. James Lehman pulled that one on me when I told him I didn’t think my area had any.

Well, turns out we had two of them and I had no idea. One more in the win column for Dr. Lehman.  What is an FQHC, you might ask? It stands for Federally Qualified Health Center. If you have listened to either of the episodes we have had with Dr. James Lehman from the Neuromusculoskeletal Medicine Diplomate of the University of Bridgeport.    to start the second year of the three year Neuromusculoskeletal Medicine Residency through the University of Bridgeport. Very active while a student holding numerous positions in clubs and student government, Aric was able to take MDT and MPI which, along with this schooling, has helped to shape his practice style.

He is currently providing care to underserved populations in New Britain, Danbury and Clinton, CT in Federally Qualified Health Centers in a multidisciplinary setting alongside MDs, DOs, APRNs, PAs, Podiatrists, Dentists, Dieticians, other Allied Health Professionals. Aric is also working toward his diplomate in Neuromusculoskeletal Medicine and has had the privilege to assist in instruction for the orthopedic and neurological examination labs at UBSC. When not treating patients, studying or moderating FTCA, Aric can be found spending time with his wife and two children. He has already co-authored 6 research publications. 

So let’s welcome Aric to the show thank you for joining us today. 

Tell us where you are located and a little about the area if you don’t mind. 

Before we get to the FQHC’s, tell me a bit about your journey to becoming a chiropractor. I always say that it’s not the first thing that comes to mind when most kids are deciding what they want to be when they grow up. 

Tell me about where you attended college and your unique experience there that has led to your position and the current practice environment.   

Is there an advantage to being a resident in an FQHC? Explain the pros and cons of your experience. 

Do you evaluate or see many chronic pain patients?

Do your patients tend to present with many co-morbidities or are they usually just spinal pain.

If so, how do you manage the co-morbidities?

Do you care for many high-impact chronic patients with disabilities? And…..for our audience, can you explain the difference between high-impact chronic pain and run-of-the-mill chronic pain?

Tell us about your experience working with and interacting with your medical field counterparts there at the FQHC. 

Do you see the FQHC being your preferred practice setting going forward or is a private practice in your future?

Before we wrap up here, I met you through Dr. Kris Anderson up in North Dakota. He’s been a previous guest on our podcast. He has suggested you have something working with dry needling research. Can you share some of that information with us?

Alright, that’s it. Y’all be safe. Keep changing the world and our profession from your little corner of the world. Continue taking care of yourselves and taking care of your neighbors. Tough times are upon us but, the sun will shine again. Trust it, believe it, count on it. Let’s get to the message. Same as it is every week.  Store Remember the evidence-informed brochures and posters at chiropracticforward.com.   

Chiropractic evidence-based products

Integrating Chiropractors

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

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

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

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

Website http://www.chiropracticforward.com

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

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

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

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

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 025: Vets With Low Back Pain. Usual Care + Chiropractic vs. Usual Care Alone

Vets With Low Back Pain: Usual Care + Chiropractic vs. Usual Care Alone

Today we’re going to talk about our vets with low back pain. We have already shown how chiropractic is backed completely by research for low back pain. For us, that’s not even in question. But, this week, there’s brand new research out in JAMA, yes, THAT JAMA, talking about vets with low back pain and chiropractic.

But first, make way for 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.  

I want to  humbly, with my hat in my hand and puppy dog eyes ask you to go to chiropracticforward.com and sign up for our newsletter. Make it easy on us to update you when a new episode come out. It’s just the nice thing to do folks. 

On another note, do you need an hour or two for your Continuing Education seminar on low back pain guidelines or on Debunking the myth that chiropractors cause strokes? Do you need a guest for YOUR podcast?

Look no further, you have found your man. Just send me an email at dr.williams@chiropracticforward.com and we will get it done. Heck, we’re trying to get the word out about what we’re doing here don’t ya know?

We are honored to have you listening today. 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 grooved nice and easy……. 70’s style right into Episode #25

As you may have heard me say several times before, I’m in practice. Day to day, week to week, month to month. In fact, I’ve been in active daily practice for over 20 years. I’ve answered the phones, booked the appointments, been an associate that basically answered to a receptionist. I’ve also been a busy chiropractor having a hard time keeping up with my own head. 

I tell you this because I think it’s important to know that the information you get from me is not only from research journals but is also from daily experience. Twenty years of it at this point! 

When we start discussing active military and veterans, if you’ve been in practice very long at all, you know these men and women are hurting and, many times, are not getting the help they desperately need. I see them every week. I’m actually in the process of signing up for the Choice Program as we speak so I can see more and more of them. Vets with low back painare a priority.

As a side note, you’d think that veterans are among the most honorable of all American citizens wouldn’t you? And wouldn’t you expect that the most honorable of all Americans would be worthy of healthcare that adequately addresses their needs based on current research and knowledge? 

One would think but, as we see over and over, that just isn’t the case, unfortunately. 

Here’s one example, a friend of mine….her father is in the VA hospital right now with several issues. She went to visit and was looking for his room. When she asked a staffer for directions, they directed her through this plywood board attached to a door that kind of opened up all together and allowed passage into the hallway that led to his room. Can you imagine our veterans being in a place that has plywood boarded up on the doors? One door…..any damn door?

Another would be the father of a friend of mine. He died waiting on a referral to a pulmonologist through the Choice Program. He couldn’t just go and make his own appointment. Not if he wanted it covered anyway. The VA system failed this decorated Vietnam Vet whereas medical professionals made it clear to him that his pulmonary hypertension could be treated after seeing a specialist to determine his specific level of PH. Well, the referral didn’t come and time ran out. Doesn’t seem right does it?

Let’s get to the musculoskeletal part of things. Military services leads to a high rate of chronic pain. That is just the facts. Knowing this fact, it is not surprising that veterans succumb to opioid overdose at twice the rate of the general population. That is just astonishing. It’s understandable but astonishing just the same. Not only were they twice as likely to succumb to opioid overdose, but they were twice as likely to be prescribed opioids in the first place!

One would think with the new recommendations from international low back experts published in The Lancet, new recommendations from the American College of Physicians, and the mountains of randomized controlled trials showing the efficacy of Chiropractic Care of low back pain, you’d expect to have an automatic referral from the VA primary care physicians. But, again, common sense doesn’t alway seem to reign in the medical kingdom. Money, politics, group-think, and false dogmatic believes of yesteryear tend to control the thought process. In my opinion, of course. 

If you are unaware of the body of research, I’m sure this just sounds like belly-aching. I’m telling you as straightforward and as honestly as I can, chiropractic’s effectiveness has been proven through research so many times I can’t begin to count. We have been shown to be as effective or more effect than medication including NSAIDS. On top of that, we recently talked about research showing opioids having less effectiveness than NSAIDS. Veterans need a source of treatment for their musculoskeletal pain that is non-pharmacological, cost-effective, and has a high degree of overall effectiveness. 

Everything and everyone already mentioned in this podcast (The Lancet, ACP, etc…) agrees one of those options is Chiropractic specifically. Especially when it comes to vets with low back pain.

With all of that in mind, let’s get into the paper that recently came out in the Journal of the American Medical Association (JAMA). It’s titled “Effect of Usual Medical Care Plus Chiropractic Care vs. Usual Medical Care Alone on Pain and Disability Among US Service Members With Low Back Pain,” and authored by Dr. Christine Goetz, DC, PhD. 

It was published in May of 2018(Goertz C 2018). 

Why They Did It

The authors recognized the need for non-pharmacological low back pain treatments and hoped to determine if chiropractic care being added to traditional medical care resulted in a better outcome than if the chiropractic care was left out completely for vets with low back pain. 

How They Did It

  • For you research nerds, the paper was a 3-site pragmatic comparative effectiveness clinical trial using adaptive allocation
  • It was conducted from September 28, 2012 to February 13, 2016
  • The sites studied included 2 large military medical centers and 1 smaller hospital at a military training site. 
  • Active duty aged 18-50 with low back pain originating in the musculoskeletal system were accepted for the study
  • Outcomes used were low back pain intensity measured through the Numerical Rating Scale (NRS) and disability using the Roland Morris Disability Questionnaire. 
  • Secondary outcomes measured were perceived improvement, satisfaction, and medication use. 

What They Found

  • 250 patients at each site were accepted. 
  • 750 total
  • The mean participant age was 30.9
  • 23% were female
  • 32.4% were non-white
  • Adjusted mean differences in scores at the 6-week mark were statistically significant favoring usual medical care PLUS Chiropractic Care. 
  • There were no serious related adverse effects. 

Wrap It Up

The authors concluded, “Chiropractic care, when added to usual medical care, resulted in moderate short-term improvements in low back pain intensity and disability in active-duty military personnel. This trial provides additional support for the inclusion of chiropractic care as a component of multidisciplinary health care for low back pain, as currently recommended in existing guidelines. However, study limitations illustrate that further research is needed to understand longer-term outcomes as well as how patient heterogeneity and intervention variations affect patient responses to chiropractic care.”

I realize this is a brand new paper. I also realize that Dr. Goertz is among the leaders of the body of research when it comes to chiropractic. This is exactly why I question the need for further research to understand longer-term outcomes. We have had longer-term outcomes research. Plenty of them as a matter of fact. 

If you go to this paper’s website and click on the link you’ll find in the show notes, ( https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2680417 ) you’ll notice that you can click on a “Comments” icon just under the “Download PDF” icon. 

If you navigate to that Comment section and click on it, you’ll notice the following quote from May 21, 2018 from Dr. Frederick Rivara, MD, MPH at the University of Washington in Seattle, “As a sufferer myself of chronic low back pain, I was very interested to see the results of this comparative effectiveness trial. To me, it points out the importance of integrated care for the treatment of chronic conditions. What are the likely barriers to implementing this in medical practices in general? Do we really need more research on the right treatments for low back pain?” Here is Dr. Rivara’s stated conflict of interest at the end of the quote: he’s the Editor in Chief of JAMA Network Open. The Editor in Chief made that statement folks. He gets it. Now it’s time for the rest of the medical kingdom to get it.

Key Takeaways

  1. We don’t need any more research into whether low back pain is effectively treated with chiropractic care. It’s been done a hundred times over. What we need is acceptance and a shift in the groupthink of the medical field. When it comes to treating vets with low back pain, there is no better starting point than chiropractic care. 
  2. We also need to chiropractors to step up and take the golden scepter the medical field had dangled out there. It’s ours for the taking. 
  3. We also need more research into the effectiveness of chiropractic care for headaches and neck pain. The research is there supporting our effectiveness. No doubt about it. But, it needs to be there by the hundreds just like you see in low back pain. There needs to be so much of it that the deniers start to look like flat-Earthers in the healthcare world. 

This week, I want you to go forward with doing some of your own research on vets and opioids, on Chiropractic and low back pain, and on the Choice Program through the VA. We can help our active military and our vets. We can help them better than anyone else for their low back pain and that includes physical therapists. There is research showing that exercise/rehab + chiropractic is more effective than exercise/rehab alone(Korthals-de Bos IB 2003, Coulter I 2018). 

Either way you boil it down, we win. We can help these people so help me figure out how we get that message out there and how we’re supposed to reach out and grab it for our profession. 

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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. 

Social Media Links

iTunes

Bibliography

Coulter I (2018). “Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis.” Spine 0(0).

Goertz C (2018). “Effect of Usual Medical Care Plus Chiropractic Care vs Usual Medical Care Alone on Pain and Disability Among US Service Members With Low Back Pain A Comparative Effectiveness Clinical Trial.” JAMA 1(1): E180105.

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

CF 019: Non-Opioid More Effective While Chiropractic Maintenance May Be The Most Effective

Non-Opioid More Effective While Chiropractic Maintenance May Be The Most Effective

This Chiropractic Forward podcast this week is a bit of a mishmash of a couple studies that will ultimately intertwine into a valid discussion including chiropractic maintenance and a discussion about non-opioid vs. opioids.

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.

Before we get started, I want to draw your attention our website at 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.

You have moonwalked into episode #19. I hope you have enjoyed the previous episodes. Particularly the last six which were a part of a series all debunking the “Chiropractors Cause Strokes” myth and then another series of podcasts reviewing the lancet articles on low back pain. The Chiropractic profession NEEDS you to share those 6 episodes in particular

Now, since we have covered the impact of the opioid crisis exhaustively, I will cover it only briefly for reference purposes.

  • Low back pain is the single leading cause of disability worldwide.
  • 8 out of every ten people will experience back pain. I will admit that I have never met anyone in 45 years of life on this Earth that fits into the 20% that apparently never suffers from any low back pain.
  • Back pain is the second most common reason for visits to the doctor’s office right behind upper-respiratory infections.
  • With such gains and leaps in the medical industry as far as treatment goes, low back pain is stubbornly on the rise.
  • More than half of Americans who experience low back pain spend the majority of the work day sitting. 54% to be exact. Did you know that an equal number of patients first seek help with a chiropractor as seek help with a medical practitioner for back pain?
  • Back pain in general costs $100 billion dollars every year when you factor in lost wages and productivity, as well as legal and insurance overheads.

Should there be any doubting the necessity of non-pharmacologic treatments for low back pain at this point, then a person is simply beyond help. We can only refer you to a report from the Executive Office of the President of the United States’ report titled “The Underestimated Cost of the Opioid Crisis” put forth by the Council of Economic Advisers in November of 2017[1].

That reminds me, that paper citation as well as any others we talk about here will be in the show notes so always check out www.chiropracticforward.comfor those show notes.

The report paints a fairly complete picture of this national crisis. The medical field helped create the national crisis. Now, will they help put the fire out? It seems the answer to that question is, “Yes!”

Now that the nation and the medical field understand the danger of opioids, we are certainly starting to see an increase in research having to do with opioids. A brand new paper of particular note was published March 6, 2018 in JAMA, performed by Dr. Erin Krebs, MD, et. al. and is titled “Effect of Opioid vs. Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain. The SPACE Randomized Clinical Trial [2].”

Why They Did It

How They Did It

  • 240 subjects
  • 12-month trial
  • Randomized with masked outcome assessments
  • Test subjects experienced moderate to severe chronic back, hip, or knee osteoarthritis pain despite analgesic use.
  • Interventions tested were opioids and nonopioids
  • The first step of the opioid group included immediate-release morphine, oxycodone, or hydrocodone/acetaminophen
  • The nonopioid group’s first step was acetaminophen or a nonsteroidal anti-inflammatory drug.
  • Medication was changed and/or adjusted within each group according to patient response.
  • The main outcome assessment used was Brief Pain Inventory (BPI) scale.

What They Found

  • 240 subjects completed the trial
  • There was little difference between the two groups in terms of function over the course of the 12 months of testing.
  • Pain intensity was actually much more improved (statistically significant) in the NONopioid group.
  • Adverse harms (bad side-effects) were significantly greater in the opioid group.

Wrap It Up

Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain.”

Again, I don’t wish to belabor a point we have covered several times but, for the purpose of this discussion, we must mention them. The medical field is stepping up to the challenge slowly but, I would argue significantly. The American College of Physiciansupdated their treatment recommendations for chronic and acute low back pain just last year. In the report[3]they recommended spinal manipulation prior to taking ibuprofen or other over-the-counter NSAIDs for low back pain. One month later, in JAMA (the journal for the American Medical Association) there was a paper demonstrating the effectiveness of spinal manipulative therapy[4]. IN JAMA!! The significance of this cannot be overstated.

Next, let us talk a little bit about chiropractic treatment for low back pain, what it looks like, and whether chiropractic maintenance care really makes any sense. that recommend preventative (AKA Wellness Care) to their patient bases.

Let me start by stating my opinion and the opinion of most evidence-based chiropractors I would assume: active, complaint-focused treatment should have a start and it should have an end. Plain and simple, cut and dry. How does chiropractic maintenance fit in there?

If a patient is coming in for a complaint such as neck pain, the practitioner should decide whether the pain is acute, subacute, or chronic and, based on history and exam findings, be able to give some good, responsible recommendations for the treatment of the complaint. Typically, the acute schedule will be shorter in terms of treatments and time vs. a chronic condition. A chronic condition is more difficult to treat and one would reasonably expect the schedule for a chronic condition to be longer and more intense. The CCGPP guides[5]can be useful for this sort of decision-making.

For example, Medicare has broken down how they value diagnosis codes into groups A-D. In their system, the secondary diagnosis codes can be the difference between seeing a patient only 12 times or as much as 30 visits for a specific complaint. A simple low back pain diagnosis or muscle spasm diagnosis garners 12 visits from Medicare while degeneration of lumbar intervertebral disk or lumbar spinal stenosis will indicate up to 30 visits for treatment.

In the personal injury world, according to the Quebec Taskforce on Whiplash Associated Disorders, if a patient is assessed with a Grade III whiplash, assuming complications, they can be treated up to 76 visits over 56 weeks. That’s a lot of treatment but the length of treatment reflects the severity of injury as a Grade III whiplash is associated with ligament tearing and/or neurological findings.

For more information on general guides for practice protocol, please reference a previous blog of ours on the topic at https://www.amarillochiropractor.com/valuable-reliable-expert-advice-clinical-guides-practice/or listen to our podcast at https://www.chiropracticforward.com. The guides can be found in Episode #5 which can be found at this link: https://www.chiropracticforward.com/2018/01/18/cf-episode-5-valuable-reliable-expert-advice-on-clinical-guides-for-your-practice/

What does all of that have to do with chiropractic maintenance care? The point being made is that there are a lot of different chiropractors. Seventy thousand plus in America alone and, although there are guidelines out there, chiropractors do not typically seem to have a general overall desire to implement them. One chiropractor may tell you that they will need to see a chronic neck pain patient 50 visits a year to clear it up while another may see the same condition for 18-20 visits. This is not only frustrating for chiropractors, it’s highly frustrating for patients as well.

Of course, this is not true but, don’t chiropractors commonly recommend preventative or chiropractic maintenance care that may resemble “rest of your life” care? It’s my opinion that once a complaint resolves, patients should see their chiropractor once a month. Minimally, they should be seen once every two months. That is chiropractic maintenance and that is my opinion. I will find more than a handful of chiropractors that will disagree with me on both ends of the spectrum but the key to the idea is “chiropractic maintenance” care in some sort of ongoing fashion.

There is research for chiropractic maintenance care. Take this paper from 2011 for example. It is by MK Senna, it’s titled “Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome?” and was published in the prestigious Spine journal[6]. For the purpose of this study, keep in mind that SMT stands for spinal manipulation therapy. Also of special note is that chiropractors perform over 90% of SMTs in America so I commonly interchange SMT or spinal manipulation therapy with the term “Chiropractic Adjustment.”

Why They Did It

The authors of this paper wanted to check how effective spinal manipulation, also known as chiropractic adjustments, would be for chronic nonspecific low back pain and if chiropractic maintenance adjustments were effective over the long-term in regards to pain levels and disability levels after the initial phase of treatment ended.

How They Did It

  • 60 patients having chronic low back pain of at least six months duration
  • Randomized into three different groups:
  • 12 treatments of fake treatment for one month
  • 12 treatments of chiropractic adjustments for a month only
  • 12 treatments for a month with maintenance adjustments added every 2 weeks for the following 9 months.
  • Outcome assessments measured for pain and disability, generic health status, and back-specific patient satisfaction at the beginning of treatment,

What They Found

  • Patients in groups 2 and 3 had significant reduction in pain and disability scores.
  • ONLY group 3, the group that had chiropractic maintenance adjustments added, had more reduction in pain and disability scores at the ten-month time interval.
  • The groups not having maintenance adjustments, pain and disability scores returned close to the levels experienced prior to treatment.

Wrap It Up

The authors conclusion is quoted as 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.”

For my own wrap up this week I would say simply this:

  • Low back pain is a significant issue for Americans
  • It is one of the biggest reasons people get hooked on opioids
  • As shown above, opioids are no more effective than non-opioids so why would anyone use them?
  • Chiropractic has been shown superior to nonopioids (specifically Diclofenac[7])
  • The big boys of the medical field (ACP and AMA) and the White House itself are recommending chiropractic for the treatment of low back pain before using even NSAIDs

So, why is this even in the discussion phase rather than the implementation phase? Why are we not inundated with low back pain patients at this very minute?

We have to go back to a different White House report that came out recently discussing the fact on page 57 of the report that although chiropractic has been proven effective, barriers to chiropractic treatment have been put in place by CMS and health insurance providers[8].

The specific wording is as follows: “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.” “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.”

It’s all there. It’s simple. All we can do is continue to tell everyone and beg for your help in telling everyone as well.

It is up to us to spread the good news and all it takes is hitting the Share button on social media. Retweet, help get the word out.

I challenge you to tell your people. It’s so easy but it takes a little initiative on your part. You actually have to do something now. Your profession is poised on the edge of stepping into a role it is uniquely able to fulfill and excel in but NOT unless we reach out and take that role and hold onto it.

Our effectiveness is proven. It’s time. Help us help you. I’m not asking for donations. I don’t want your money. I want your influence. So do us a favor if you will and share this information and, if it didn’t get the response you hoped for, share it again. Print out the parts of this article you find particularly effective and send it to medical practices in your area.

Make a difference.

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 “chiropractic maintenance” mindset going forward from initial recovery, 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.

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.

Source Material

  1. The Council of Economic Advisers, The Underestimated Cost of the Opioid Crisis. 2017: The Executive Office of the President of the United States of America.
  2. Krebs E, Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain – The SPACE Randomized Clinical Trial.JAMA, 2018. 319(9): p. 872-882.
  1. Qaseem A, Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians.Ann Intern Med, 2017. 4(166): p. 514-530.
  2. Page N, Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain.Journal of American Medical Association (JAMA), 2107. 317(14): p. 1451-1460.
  3. Baker G, Algorithms for the Chiropractic Management of Acute and Chronic Spine-Related Pain.Topics in Integrative Health Care, 2012. 3(4).
  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. Wolfgang J, e.a., Spinal HVLA-Manipulation in Acute Nonspecific LBP: A Double Blinded Randomized Controlled Trial in Comparison With Diclofenac and Placebo.Spine, 2012. 38(7).
  6. The President’s Commission on Combating Drug Addiction and The Opioid Crisis. 2017.

 

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 012: Proven Means To Treat Neck Pain

Proven Means To Treat Neck Pain

In today’s podcast, we are going to talk about research on how to treat neck pain but hopefully in a fun way. We like to have fun on the Chiropractic Forward podcast. Let’s face it, research can be a bit boring so why not try to have some fun with it?

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!

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.

In the words of Chris Berman, you have back back back backed into Episode #12 and this week we’re going to have more fun than having your teenage son spank you in video games that you’ve always beat him at. Yes, this recently happened to yours truly. Not only that but he did it with a pistol and I’m asham   ed. Call of Duty was my safe space y’all…..

So, I’ll just bury myself into my work, stuff it deep down inside to explode at a later date.

Now, If you have spent any significant amount of time with our videos, podcasts, or blogs, you are probably aware that there is an excess of research regarding chiropractic’s effectiveness in patients suffering from low back pain.

Although there are some excellent research papers having to do with chiropractic and neck pain, I would argue that it demands more attention. Without question. The first reason being that neck pain is as important or more so than low back pain. In the paper we will be discussing this week, they cite research suggesting that neck pain is responsible for up to 25% of the patients seen in outpatient orthopedic practices and 50% of the general population will have neck pain at some point in their lives.

The second reason I believe neck pain demands more attention from our industry is that we have been unfairly labeled as the profession out there in the world causing strokes every day. There needs to be a clear, factual representation of the risk vs. reward ratio and, if there is a small body of evidence, our case doesn’t stand up quite as strongly.

To be more clear, there is an abundance of evidence that Chiropractic is not linked to strokes any more than going to the primary practitioner. However, there is scant evidence of Chiropractic’s effectiveness to treat neck pain WHEM COMPRAED to the research available to treat low back pain.

This does not mean there isn’t great research in our favor on hwo to treat neck pain. That is not what I’m saying at all. It just means we have not documented it through research in the amounts that we have for the low back pain and I would like to see more. If I were a researcher myself, it is the condition I would be targeting without question.

Now, with that being said, this week’s paper is titled “The Immediate Effects of Upper Thoracic Translatoric Spinal Manipulation on Cervical Pain and Range of Motion: A Randomized Clinical Trial” published in the Journal of Manual Manipulative Therapeutics in 2008 that shows the effectiveness of spinal manipulative therapy. Here’s the catch, it was performed by physical therapists, not chiropractors. It was done by John Krauss, PT, PhD, OCS, FAAOMPT, et. al. Look at all of those letters.

At this point, I would like to diverge from the original path for a few moments. If chiropractors are unaware, along with research validating the chiropractic adjustment to treat neck pain, low back pain, and other maladies comes more competition for the service.

Physical therapists were restricted to muscles and exercise essentially. Now, they are adjusting. This is going to become a turf war between chiropractors doing what we have always done and physical therapists adopting our treatments as their own.

Of course, physical therapists can’t call what they do “chiropractic adjustments” so they have changed the term to “translatoric spinal manipulation.”

It’s irritating to the chiropractic profession but it is a fact the profession will be facing more and more in the years to come so be prepared for it.

It is particularly irritating when you consider that physical therapists have been part of the medical machine that have torn down the chiropractic profession for generations prior to adopting its techniques as their own.

Now, back to the research paper.

Why They Did It

The authors of the paper wanted to determine the effectiveness of thoracic (upper back) adjustments to treat neck pain and neck range of motion.

How They Did It

  • The active range of motion of the neck in each subject was measured before and after the manipulation. The term “active range of motion” means the patient turned their neck as far as possible in rotation both ways without the assistance of the researcher.
  • The range of motion was measured with a cervical inclinometer.
  • The patient’s neck pain was measured prior to and after treatment with the Faces Pain Scale. A quick trip to Wikipedia tells us that the Wong-Baker Faces Pain Rating Scale is a pain scale that was developed by Donna Wong and Connie Baker. The scale shows a series of faces ranging from a happy face at 0 which represents “no hurt” to a crying face at 10 which represents “hurts worst.”
  • The study included 32 patients having pain in the cervical region and limited range of motion.
  • 22 of these were randomly split into an experimental group while the other ten were randomly placed into a control group.
  • The evaluator measuring the pre- and post-manipulation outcomes was a blinded evaluator to reduce risk of bias.
  • The experimental (treatment) group received the manipulation treatment to the areas of the upper back region that had been determined to be hypomobile. In simpler terms, they delivered the adjustment to the areas of the upper back that were stiff or not moving like they should.
  • The control group had no treatment.
  • Paired t-tests were used to determine the changes within the group for cervical rotation and pain. A paired t-test is used to compare two population means where you have two samples in which observations in one sample can be paired with observations in the other sample.
  • A 2-way repeated-measure ANOVA was used to analyze between-group differences in cervical rotation and pain. A two-way repeated measures ANOVA is often used in studies where you have measured a dependent variable over two or more time points, or when subjects have undergone two or more conditions. The primary purpose of a two-way repeated measures ANOVA is to understand if there is an interaction between these two factors on the dependent variable.

What They Found

  • Significant changes were found for neck rotation within the group as well as between the groups.
  • The translatoric spinal manipulative group showed more range of motion in right rotation as well as in left rotation.
  • The levels of pain the subjects experienced after the manipulation were significantly reduced.

Wrap It Up

The authors of the paper concluded by saying, “This study supports the hypothesis that spinal manipulation applied to the upper thoracic spine (T1-T4 motion segments) significantly increases cervical rotation ROM and may reduce cervical pain at end range rotation for patients experiencing pain during bilateral cervical rotation.”

Did you know that 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! What better way 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 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.

Source Material

Krauss J, et. al., “The Immediate Effects of Upper Thoracic Translatoric Spinal Manipulation on Cervical Pain and Range of Motion: A Randomized Clinical Trial.” J Man Manip Ther. 2008; 16(2): 93–99.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2565124/

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

Today’s episode is all about chronic low back pain and some great, brand new research. By now, as I’ve said in the past, even traditional Chiropractor-hating, torch-wielding, quasi-scholastic chiropractic detractors are admitting that, yes, Chiropractic is indeed helpful for low back pain.

If you love what you hear, be sure to check out www.chiropracticforward.com. As the podcast builds, so too will the website content, educational products, webinars, seminars, and speaking dates as they get added.

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

We will dive into the research in a few minutes but first, I have to introduce my guest this week. His name is Dr. Craig Benton. Dr. Benton is the owner/operator of Benton Chiropractic down in Lampassas, Texas but that’s not where the intro stops. Dr. Benton is the chair of Scientific Affairs for the Texas Chiropractic Association. He is where I have found a healthy percentage of the material that I have covered over the years for my blog, my YouTube videos, and now for the Chiropractic Forward podcast. Dr. Benton has been unknowingly instrumental in keeping me in business and making my life easier.

Welcome to the show Dr. Benton, how is life in Lampassas this week? My first question today is, have you been playing any guitar lately?

Dr. Benton and I are both in active practice. In fact, there’s a chance we may both have a patient show up at any time. That’s how actively we are practicing. I think that’s incredibly important to note because, so many times, you hear podcasts and attend seminars where the guys and gals speaking don’t really know a thing about actively practicing for 20 plus years. I’ve always felt that experience matters. Even when I was young and green. I was well-aware that I didn’t know it all and I’m even more aware of that today than ever.

So Dr. Benton, I’m looking forward to hearing your opinions and insight today.

Since the podcast today is about chronic pain, I think we should begin with a definition of what Chronic really is. When we define “chronic” in the context of neuromusculoskeletal complaints, we define it as being a complaint that is greater than 12 weeks in duration. Right at 3 months. Some patients will come into the office having had a condition for 15-20 years. I tell them that they are more than a little stubborn to have put up with something for so long.

It is common sense that a condition that is chronic will be more difficult to treat. Also, most chronic conditions can be traced back to a biomechanical, neuromusculoskeletal origin. One of my favorite quotes is from Dr. Lee Green, Professor of Family Medicine at the University of Michigan. He said, “Neck pain is a mechanical problem, and it makes sense that mechanical treatment works better than a chemical one.” Although Dr. Green is referring to neck pain in this instance, “low back pain” can easily be substituted. What he says could not make more sense. It’s an easy and very concise way to understand why Chiropractic, manipulation, mobilization is so incredibly effective above and beyond anything else for this sort or issue, including medication.

Do you have a quote or quotes that you love sharing that make sense to you and that help you boil down what it is we chiropractors are doing to help our patients?

I have overhead medical doctors (more than once) talking about having back pain and just injecting themselves with something to try to get over it. If they asked me, I’d tell them that they’re just covering up an underlying trigger or cause and ignoring it is to their detriment.

A good metaphor I came across for using medication for neuromusculoskeletal complaints is that it’s like unplugging a smoke alarm because you don’t like the noise. But, the fire is still slowly growing. What have they done to treat anything in a responsible and effective way? Nothing at all. We tend to live in a society that wants a pill for this and a potion for that so they can get over it and get on with life. But it doesn’t work that way.

Dr. Benton, has this been your experience as well?

Dr. Benton, don’t you treat soldiers through the VA program? Can you tell us all a little bit about that?

Let’s go over some low back pain statistics just we can try to stress the importance of what we’re talking about here. Dr. Benton, please feel free to jump in with anything you’d like to add:

  • Low back pain is the single leading cause of disability worldwide.
  • 8 out of every ten people will experience back pain. I will admit that I have never met anyone in 45 years of life on this Earth that fit’s into the 20% that apparently never suffers from any low back pain. Dr. Benton….have you ever met anyone that has never had back pain? Is it just me?
  • Back pain is the second most common reason for visits to the doctor’s office right behind upper-respiratory infections.
  • With such gains and leaps in the medical industry as far as treatment goes, low back pain is stubbornly on the rise.
  • More than half of Americans who experience low back pain spend the majority of the work day sitting. 54% to be exact. It’s good to be a chiropractor I guess. Our patients keep us up and moving most of the day.
  • Dr. Benton, did you know that….now…an equal number of patients seek help with a chiropractor first as seek help with a medical practitioner first for back pain? That’s new information to me that I found interesting.
  • Back pain in general costs $100 billion dollars every year when you factor in lost wages, productivity as well as legal and insurance overheads.

Now that we all know more about low back pain, let’s go through some things that may put you at greater risk of suffering from the condition. Dr. Benton, with your experience on the research, stop me if you have anything to add to any of these:

  • Age: as the spine and supporting structures begin to age and decline, the rate of low back pain will understandably increase.
  • Fitness Level: physically active people do not suffer low back pain to at the rate inactive people suffer. A healthy exercise and core building protocol can help reduce symptoms or instances of low back pain.
  • Weight Gain: Being overweight or obese and gaining weight quickly places increased strain on the low back.
  • Pregnancy: This one goes without saying. Pelvic changes and weight gain both contribute.
  • Genetics: Some forms of arthritis or other systemic conditions are genetic in nature
  • Work: Jobs that include heavy labor and or twisting or expose people to vibration consistently can be problematic. Jobs that require long periods of sitting in a chair can be equally problematic.
  • Mental health factors: Many people are able to deal with chronic pain but anxiety and depression are conditions that can cause a person to focus on the pain which tends to raise the perceived severity and significance for the person suffering from the condition. Dr. Benton, have you come across any patients that fit this description in your practice?
  • Improper backpack use: Kids suffer back pain needlessly since they are not traditionally in an age range we would consider to be a risk factor. However, backpacks used improperly are a common culprit. A backpack should never be more than 15%-20% of a child’s weight and should be carried on both shoulders with the bottom being at or about waste level.

What does the research say?

As I’m sure Dr. Benton will agree…..the research says a lot, to be honest. In fact, I’d say that there’s more research for the effectiveness of manipulation/mobilization in low back pain than for any other conditions chiropractors commonly treat. Am I out of bounds here Dr. Benton?

The research shows Chiropractic beating general practitioners in effectiveness as well as cost. The research shows Chiropractic beating common medications prescribed for low back pain. The research shows Chiropractic beating physical therapy and exercise alone. The research shows Chiropractic beating epidural spinal injections for low back pain. And the two of us can point you to randomized controlled trials proving it. Basically, the research is clear.

In January of 2018, a brand new research paper dealing with manipulation and mobilization was published in Spine Journal by Ian Coulter, PhD et. al. titled “Manipulation and mobilization for treating chronic low back pain: a systematic review” and funded by the National Center for Complementary and Integrative Health.

Now, to be clear, Spine Journal sounds a little bit like it may be a Chiropractic publication for those of you that don’t commonly read research abstracts…… but it is not.

Dr. Benton, can you describe Spine Journal for us?

Here’s why the authors took this project on.

The authors of the paper stated that there remained questions about manipulation and mobilization efficacy, the proper dosing of the techniques, how safe they are, as well as how they compare to other treatment protocols commonly used for chronic low back pain.

I have to say that I had no remaining questions regarding really ANY of those topics but it seems that these authors did.

Dr. Benton, again, please feel free to jump in anywhere you’d like as we go through the hows, why’s and the what’s here.

Here’s How They Did It

  • This paper was a systematic review and meta-analysis.
  • They searched databases for relevant studies from January 2000-March 2017
  • They chose randomized controlled trials that compared manipulation or mobilization to sham treatment, no treatment, other therapies, and multimodal therapeutic approaches.
  • They assessed the risk of bias using the Scottish Intercollegiate Guidelines Network.
  • Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was applied to determine the confidence in effect estimates.
  • 51 trials were included

What They Found

  • Within 7 of those trials on manipulation and/or mobilization there was reduction of disability when compared to other forms of therapy.
  • Further analyses showed that manipulation specifically was responsible for significant reduction in pain and disability when put up against therapies such as exercise and physical therapy.
  • Mobilization was also was significantly more effective when compared to exercise regimens for pain reduction but not for disability.

Wrap It Up

In the conclusion of the paper abstract, the authors say, “There is moderate-quality evidence that manipulation and mobilization are likely to reduce pain and improve function for patients with chronic low back pain; manipulation appears to produce a larger effect than mobilization. Both therapies appear safe.”

As I’ve said many times, “a lot of research in your favor becomes fact.” Chiropractic has A LOT of research in its favor.

Dr. Benton, would you like to add any final thoughts?

I’d like to thank Dr. Benton for taking the time to be with us today. He really is one of the guys out here in the real world trying his best to help change things for Chiropractors in Texas and in the world.

I want to finish off by saying that when Chiropractic is at its best, you cannot beat the risk vs reward ratio. Plain and simple.

Just another reason to call a chiropractor TODAY!

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!

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. Please remember, we need your help to spread the word and grow this podcast. If you would help us out by sharing our podcast information, our website, and social media entities, we would greatly appreciate your help.

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.

Research Citation:

Coulter I, et. al. “Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis” The Spine Journal, Volume 0 , Issue 0 ,

https://www.thespinejournalonline.com/article/S1529-9430(18)30016-0/fulltext