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The Evidence For Some Surgeries, Searching for How We Help, and Opioid vs. Non-Opioid

CF 078: The Evidence For Low Back Surgery, Searching for How We Help, and Opioid vs. Non-Opioid

Today we’re going to talk about evidence for low back surgery, we’ll talk about if spinal manipulative therapy is partyly in the brain, opioid information for back, hip, or knee osteoarthritis….what does the research say?

But first, cool like a velvet Elvis, here’s that bumper music

Chiropractic evidence-based products

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

You have flip flopped into Episode #78


We’re here to advocate for chiropractic while we also make your life easier using research and some good solid common sense and smart talk. 


I should have in my first order of the decompression brochures in in just a few days. These dudes are going to look great. I’ll put some pics in the show notes and in the email we send out once a week to our email list. 

If you’re like me, you get tired of answering the same old questions. Well, these brochures make great ways of educating while saving yourself time and breath. They’re also great for putting in take-home folders. 

Go check them out at chiropracticforward.com under the store link. While you’re there, sign up for the newsletter won’t you? We won’t spam you. Just one email per week to remind you when the new episode comes out. That’s it. 

Personal Happenings

I’ve been asked to emcee the Texas Chiropractic Association’s President’s Gala which will be during the ChiroTexpo event in Dallas, TX on June 8th. 

I’m trying to figure out if I need to be making fun of everyone I introduce or not. Maybe I should trip them? You know we chiropractors….some of us can’t take a joke right? We’ll see how it goes. Most of the guys and gals in the TCA are pretty good with having fun. 

I always heard that people don’t join state associations because they think they’re made up of a bunch of old white dudes sitting around bitching. 

Well, not at the TCA, people. We have young people and certainly not all white. That doesn’t happen in Texas these days. We are a pretty mixed state in regard to ethnicity. We are also mixed in respect to gender. Several smart and highly capable women are either on the board or in a position of influence. Heck, we have a female going through the executive chairs starting in June. I’m excited to hear her ideas and see where we go under her direction. This girl is making it happen. She has young ones too. Nothing slows her down it seems. 

Let’s get to the topics today. 

Item #1

The first item we’re talking about is called “Randomised trial support for orthopaedic surgical procedures” authored by Hyeung Lim, Sam Adie, Justine Naylor, and Ian Harris(Lim HC 2014) and published in Plos One in June 13, 2014. 

This is an interesting one because we think that the surgical procedures we undergo have been fully validated. Fully vetted. Hell, you wouldn’t lay someone open unless it’s been researched and proven beyond a doubt to fix the issue would you? One would think so…..but…..let’s dive in a bit. 

Why They Did It

The authors wanted to investigate the proportion of orthopedic procedures supported by evidence from randomized controlled trials. Trials that compared surgical procedures to non-surgical alternatives. 

How They Did It

  • Orthopedic procedures conducted in 2009, 2010 and 2011 across three metropolitan teaching hospitals were identified, grouped and ranked
  • Searches of the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Systematic Reviews (CDSR) and the Database of Abstracts of Reviews of Effects (DARE) were performed to identify RCTs evaluating the most commonly performed orthopaedic procedures
  • A risk of bias analysis was conducted for included studies using the Cochrane Collaboration’s Risk of Bias tool
  • 9,392 orthopedic procedures were performed across the index period

What They Found

Of the 83 RCTs, 23% were classified as supportive of operative intervention.23%. Twenty three percent were supportive of operative intervention. 

Only 37% of the total volume of procedures were supported by at least one RCT showing surgery to be superior to a non-operative alternative. ONLY 37% y’all. 

19.6% of the total volume of procedures were supported by at least one low risk of bias RCT showing surgery to be superior to a non-operative alternative.

Sounds crazy right? 

Of the most common orthopedic surgical interventions….the most common…..of those surgeries, less than 20% of them had a low risk of bias randomized controlled trial backing them up. 

I have some problems with cussing in my personal life but I’m determined to keep this show mostly PG-13 but man. 

That’s just shocking. Cutting people open with no better evidence than that. 

One word – two syllables. Day-um. 

The Conclusion was “The level of RCT support for common orthopaedic procedures compares unfavourably with other fields of medicine.” 

Good Lord I hope the other areas of medicince have more scientific support. 

What procedures are we talking about? Let’s be fair, we’re mostly spine people and the majority of the procedures their taling about here have nothing to do with the back. They’re talking about things like:

  • Knees
  • Hips
  • Intrnal fixation of proximal or shaft fracture of the femur
  • Ankle fracture fixation
  • Shoulder arthroscopy
  • Arthroscopy of the ankle…….no studies at all. Lol

It’s just crazy to think about. If we’re talking about evidence-based practice, is this it? 20% of our profession is about half crazy I think. Well, that’s about the same number of procedures they do that only have one RCT with low bias risk. 

Is it evidence-informed? I don’t know. That still sound awfully low to even consider it evidence-informed. 

I don’t know all of the answers and I don’t pretend to. Do what you do, but…..why they hell do they question spinal manipulation and say we have weak evidence to perform it? What? Stupid. 

Makes me want to cuss in Spanish.

Item #2

This one is just building on what we understand about what a manipulation does. It doesn’t answer any questions definitively but it does lay more groundwork for the future. 

It’s called “Spinal manipulation therapy: is it all about the brain? A current reveiew of the nurophysiological effects of manipulation.” It is authored by Gile Gyer, Jimmy Michael (never trust a guy with two first names. Especially if he’s left handed), Jame INklebarger, and Jaya Tedla. Published in the Journal of Integrative Medicine in May of 2019(Gyer G 2019). 

Hot stuff coming up

Why They Did It

While spinal manipulation has become more and more accepted after being more and more validated by research, the fact remains that we still don’t know exactly HOW it works and according to my interview with Dr. Christine Goertz in Episode 67, we are far away from having that satisfaction. The authors say there are certainly biomechanical and neurophysiological reasons for it’s effectiveness, 

The paper says, “Although both biomechanical and neurophysiological phenomena have been thought to play a role in the observed clinical effects of spinal manipulation, a growing number of recent studies have indicated peripheral, spinal and supraspinal mechanisms of manipulation and suggested that the improved clinical outcomes are largely of neurophysiological origin.”

“The body of literature reviewed herein suggested some clear neurophysiological changes following spinal manipulation, which include neural plastic changes, alteration in motor neuron excitability, increase in cortical drive and many more.” The nerual plastic changes part of that is really fascinating. It was once thought that the brain is the brain and we just start chipping away at brain cells as we age and go stupid stuff. Lol. 

They’re finding out that the brain changes. It can be trained. It can be built sort of like a muscle but in a neural sense. It’s fascinating. But that’s a different episode all together. 

I don’t have access to this full paper but, the point is, they’re trying to find out HOW we are effective through spinal manipulation and they recommend we plan for long-term follow up studies to help us determine the clinical significance of the neural responses that happen from spinal manipulation. 

Pretty interesting stuff there. 

Item #3

Last one for this week. It’s called “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.” It was authored by Dr. Erin Krebs, MD et. al(Krebs E 2018). and published in JAMA on March 6 of 2018 so a little over a year ago. 

The question to answer here was, “For patients with moderate to severe chronic back pain or hip or knee osteoarthritis pain despite analgesic use, does opioid medication compared with nonopioid medication result in better pain-related function?”

How They Did It

They had 240 patients and found that the use of opioid vs. nonopioid medication did not result in significantly better pain-related function over 12 months. But they may have gotten some folks addicted in on the way to the conclusion. Lol. 

Basically, this study says stay away from opioids for moderate to severe chronic back pain or hip and knee osteoarthritis. the official conclusions was, “Treatment with opioids was not superior to treatment with nonopioid medications for improving pain-related function over 12 months. Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain.”

Boom. Pop. Pow.

I feel like I’m preaching to the choir here but you never know who listens. 

Speaking of that, Dr. David Graber shared with me that after his episodes with us, he got an email all the way from Switzerland from a chiropractor that was pretty jazzed by his comments and thoughts and Dr. Graber wanted me to know that we are indeed reaching folks and influencing on some level. 

I can’t tell you how incredibly satisfying that is. Every now and then, I get a little bit of encouraging feedback but honestly, not enough. You never know what the reach is. Are you enjoying the show? Are you listening regularly? Send me an email at dr.williams@chiropracticforward.com and let me know. I love to hear from you guys. I really do. 

Not only is it inspirational like filling up your gas tank…..but feedback can help me direct the show in a direction that I know you guys are interested in or focused on. Feed back only helps me learn more and get better so send me an email won’t you?

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 instead of chemical treatments like pills and shots.

When compared to the traditional medical model, research and clinical experience show that many patients get good or excellent results through chiropractic for headaches, neck pain, back pain, joint pain, to name just a few.

Chiropractic care is safe and cost-effective. It can decrease instances of surgery & disability. Chiropractors normally do this through conservative, non-surgical means with minimal time requirements or hassle to the patient. 

And, if the patient develops a “preventative” mindset going forward from initial recovery, chiropractors can likely keep it that way while raising the general, overall level of health of the patient!

Key Point:

Patients should have the guarantee of having the best treatment offering the least harm.

That’s Chiropractic!


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

Help us get to the top of podcasts in our industry. That’s how we get the message out. 


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


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About the Author & Host

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


  • Gyer G, M. J., Indlebarger J, Tedla JS, (2019). “Spinal manipulation therapy: Is it all about the brain? A current review of the neurophysiological effects of manipulation.” J Integrative Med.
  • Krebs E (2018). “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 319(9): 872-882.
  • Lim HC, A. S., Naylor JM, Harris IA (2014). “Randomised Trial Support for Orthopaedic Surgical Procedures.” PLoS One 9(6).

CF 056: What Does A Spinal Manipulation Do In Medical Terms & What I Despise About My Profession

Today we’re going to talk about what a chiropractic spinal manipulation is, we’ll talk about what it does and what happens there. We’re also going to talk about what I sincerely despise about our great profession. Depending on how fired up I get here, this one should be a good episode.