CF 317: The WHO’s Sources For Opinion On Spinal Manipulative Therapy (Part 7) Today we’re going to talk about The WHO’s Sources For Opinion On Spinal Manipulative Therapy (Part 7) But first, here’s that sweet sweet bumper music

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OK, we are back and you have found the Chiropractic Forward Podcast where we are giving evidence-based chiropractic a little personality and making it profitable. We’re not the stuffy, elitist, pretentious kind of research. We’re research talk over a couple of beers. So grab you a bushel.  I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.  I’m so glad you’re spending your time with us learning together.  Chiropractors – I’m hiring at my personal clinic. I need talent, ambition, smarts, personality, and easy to get along with associates. If this is you and Amarillo, TX is your speed, send me an email at creekstonecare@gmail.com If you haven’t yet I have a few things you should do. 
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You have found yourself smack dab in the middle of Episode #317 Now if you missed last week’s episode, we talked about Chronic Pain Central Sensitization & Patient Barriers To Physical Therapy.  Make sure you don’t miss that info. Keep up with the class.  On the personal end of things….. Alright, we’re keeping it a little short this week because I’m going to the Bahamas Thursday through Monday. Now, if you’re a regular listener, you’re probably like…..last week you were talking about having a collections issue and stressing and now you’re going on a trip out of town. That seems like poor money management Ol’ Uncle Jeffro.  And that’s when I would say, you’re right. Lol. I’d say it’s nunya damn business but then I’d say…..yeah. I’m with you on that. I don’t really want to go because, for the first time in a month or so, it looks like my numbers are returning to where I want them and I’m building some steam so taking Thursday, Friday, and Monday off is tough. But…..a wise mentor once told me, you have to get out and go on a non-work-related vacation once per quarter or you’ll never survive.  Heres the deal, back in December, before the collections issue was realized, I told my wife, Hey honbun, you hate any jewelry I buy you, you won’t allow me to get you any clothes, you won’t allow me to get anything for the house because you didn’t get it and match your style, blah blah blah.  So, instead of more useless crap…..instead of buying things, we’re going to start buying experiences. Instead of gifts to each other, we bought a Valentine’s trip to The Bahamas. So it’s non-refundable and basically already paid for anyway so what do you do? You go to the damn Bahamas and try to get some rest.  2023 and the beginning of 2024 have literally been the hardest, most challenging times of my 26 year career in chiropractic. Personally and professionally. But mostly professionally. It’s been a grind, it’s been tough, and I wouldn’t recommend a year like we had on anyone.  We are currently hiring our 4th front desk girl and our third CA position has seen 4 or 5 turnovers in the last year. A couple of those kind of hurt personally, if I’m being honest. They were people I cared about.  Now that seems to reflect poorly on me but if we’re being honest here, I’ve never had an issuue with keepign folks for 3 years or so minimum. I had a manager for 11 years that still comes back to visit. I had another that was here 6 years or so.  The point being, I’m as fun and relaxes in real life as I hope I am here on theh podcast. We laugh and have fun and I don’t believed I’ve ever raised my voice to a staff member in 26 years. No matter how mad I get. Sometimes, we just have a run of bad luck. I’ve gone from about 65-70 new patients per month down to about 45-55. Not a huge hit for a month but carry that out over a year and……one word two-syllables…..Day-um.  Then throw in the fact that we’re on our 4th billing/collecting group in the last 5-6 years. That’s been a nightmare and cost me crazy money. Now we’re in a battle with a PI attorney in Houston that wormed his way into the Texas Chiropractic Association and, despite having signe Assignment Of Benefits and Letter of Protection on 7 different patients, is refusing to pay us around $27,000.  It’s a journey folks and 2023 was a bumpy road on that journey. Lots of potholes but I’m ever the optimist and, with our latest biller/collector, I think we’re in a good spot. Hopefully clinic numbers begin responding.  We’ve taken the necessary steps to remedy what’s been going on here. For those reasons, we are goign to the damn Bahamas and we are goign to eat, drink, and be merry and save it for when we get back. Trust me, the stress will still be here so we might as well just leave it here at the office when we leave.  So let’s continue our hunt for the reason behind the WHO recommending SMT but at ‘very low confidence’, which is at the same level as ultrasound. Not to diminish the effects of ultrasound but seriously, I’ve never seen ultrashound deliver the immediate results that spinal manipulative therapy can deliver.  We’ve learned so far that the WHO is using some garbage research to base this recommendation on. Old, out-dated studies, small sample sizes, and studies that just literally make no sense at all for the most part. Let’s see what Part 7 reveals.  Item #1 The first one today is called, “Osteopathic manipulative treatment for chronic low back pain: a randomized controlled trial” by Licciardone et. Al. and published in Spine in July of 2003. Which is 21 years old at this point. OK….duly noted…..so cold that it’s frozen solid….got it… Remember, the citations can be found at chiropractscforward.com under this episode.  Licciardone JC, Stoll ST, Fulda KG, Russo DP, Siu J, Winn W, Swift J Jr. Osteopathic manipulative treatment for chronic low back pain: a randomized controlled trial. Spine (Phila Pa 1976). 2003 Jul 1;28(13):1355-62. doi: 10.1097/01.BRS.0000067110.61471.7D. PMID: 12838090. Why They Did It The authors wanted to determine the efficacy of osteopathic manipulative treatment as a complementary treatment for chronic nonspecific low back pain. They say, “Osteopathic manipulative treatment may be useful for acute or subacute low back pain. However, its role in chronic low back pain is unclear.” How They Did It This trial was conducted in a university-based clinic from 2000 through 2001.  91 met the eligibility criteria.  They were randomized, with 82 patients completing the 1-month follow-up evaluation, 71 completing the 3-month evaluation, and 66 completing the 6-month evaluation.  The subjects were randomized to osteopathic manipulative treatment, sham manipulation, or a no-intervention control group, and they were allowed to continue their usual care for low back pain.  The main outcomes included the SF-36 Health Survey, a 10-cm visual analog scale for overall back pain, the Roland-Morris Disability Questionnaire, lost work or school days because of back pain, and satisfaction with back care. What They Found As compared with the no-intervention control subjects, the patients who received osteopathic manipulative treatment reported greater improvements in back pain, greater satisfaction with back care throughout the trial, better physical functioning and mental health at 1 month, and fewer cotreatments at 6 months.  The subjects who received sham manipulation also reported greater improvements in back pain and physical functioning and greater satisfaction than the no-intervention control subjects.  There were no significant benefits with osteopathic manipulative treatment, as compared with sham manipulation. Wrap It Up Osteopathic manipulative treatment and sham manipulation both appear to provide some benefits when used in addition to usual care for the treatment of chronic nonspecific low back pain. It remains unclear whether the benefits of osteopathic manipulative treatment can be attributed to the manipulative techniques themselves or whether they are related to other aspects of osteopathic manipulative treatment, such as range of motion activities or time spent interacting with patients, which may represent placebo effects. Alright John C Licciardone, DO, MS, MBA, FACPM. ….Go to his experts website and find the following.  https://experts.unthsc.edu/en/persons/john-licciardone Dr. Licciardone’s research focuses on prevention and treatment of chronic pain. He holds the Richards-Cohen Distinguished Chair in Clinical Research and directs the Osteopathic Research Center, including its PRECISION Pain Research Registry. The latter studies precision medicine and biopsychosocial approaches to pain management, including use of pharmacogenetics to optimize opioid prescribing and avoid unintended consequences of their use. He received a Midcareer Investigator Award from the National Institutes of Health (NIH) and served as an expert panelist for NIH in the area of chronic pain. He recently served on the Work Group that developed NIH’s Federal Pain Research Strategy. Dr. Licciardone is recognized by Expertscape as the leading international expert in osteopathic manipulation, and has served as a consultant to the World Health Organization on regulatory and safety issues relating to osteopathy in Europe and other nations. He directed the OSTEOPATHIC Trial, a five-year study funded by NIH that demonstrated substantial improvements and recovery from chronic low back pain with osteopathic manipulation. He is presently a Co-Investigator in the $14 million Prevention of Acute to Chronic Back Pain Trial (PACBAC Trial), a national study to assess the efficacy of patient self-management and spinal manipulation in preventing chronic low back pain. Item #2 Our second one today is by the same author and is called, “Osteopathic manual treatment and ultrasound therapy for chronic low back pain: a randomized controlled trial” by Liccardone et al published in Annals Of Family Medicine in March of 2013 so…..it’s only 11 years old then.  Licciardone JC, Minotti DE, Gatchel RJ, Kearns CM, Singh KP. Osteopathic manual treatment and ultrasound therapy for chronic low back pain: a randomized controlled trial. Ann Fam Med. 2013 Mar-Apr;11(2):122-9. doi: 10.1370/afm.1468. PMID: 23508598; PMCID: PMC3601389. Why They Did It We studied the efficacy of osteopathic manual treatment (OMT) and ultrasound therapy (UST) for chronic low back pain. How They Did It A randomized, double-blind, sham-controlled, 2 × 2 factorial design was used to study OMT and UST for short-term relief of nonspecific chronic low back pain.  The 455 patients were randomized to OMT or sham OMT, and to UST or sham UST main effects groups.  Six treatment sessions were provided over 8 weeks.  Intention-to-treat analysis was performed to measure moderate and substantial improvements in low back pain at week 12.  Five secondary outcomes, safety, and treatment adherence were also assessed. What They Found There was no statistical interaction between OMT and UST.  Patients receiving OMT were more likely than patients receiving sham OMT to achieve moderate  and substantial improvements in low back pain at week 12.  These improvements met the Cochrane Back Review Group criterion for a medium effect size.  Back-specific functioning, general health, work disability specific to low back pain, safety outcomes, and treatment adherence did not differ between patients receiving OMT and sham OMT.  Nevertheless, patients in the OMT group were more likely to be very satisfied with their back care throughout the study.  Patients receiving OMT used prescription drugs for low back pain less frequently during the 12 weeks than did patients in the sham OMT group Ultrasound therapy was not efficacious. Wrap It Up The OMT regimen met or exceeded the Cochrane Back Review Group criterion for a medium effect size in relieving chronic low back pain.  It was safe, parsimonious, and well accepted by patients. Item #3 As a quick bonus, I was looking the dude up and found this paper: It’s called, “Osteopathic Medical Care With and Without Osteopathic Manipulative Treatment in Patients With Chronic Low Back Pain: A Pain Registry–Based Study” by….again…..Licciardone et al and pulished in Journal of Osteopathic Medicine in February of 2020 but they WHO didn’t use this one for whatever reason…..let’s see what it says.  Licciardone, John C. and Gatchel, Robert J.. “Osteopathic Medical Care With and Without Osteopathic Manipulative Treatment in Patients With Chronic Low Back Pain: A Pain Registry–Based Study” Journal of Osteopathic Medicine, vol. 120, no. 2, 2020, pp. 64-73. https://doi.org/10.7556/jaoa.2020.016   Why They Did It To assess osteopathic medical care and the effectiveness of OMT for chronic low back pain in a real-world setting without the constraints of a rigid research protocol.   How They Did It An observational study of 445 adults with chronic low back pain who had an established osteopathic physician (ie, DO) or allopathic physician (ie, MD)  It was conducted within the PRECISION Pain Research Registry from April 2016 through February 2019.  Primary outcome measures included a numerical rating scale for low back pain intensity, the Roland-Morris Disability Questionnaire for back-related functioning, and use of nonsteroidal anti-inflammatory drugs or opioids for low back pain.   What They Found A total of 79, 48, and 318 patients, respectively, were treated by DOs who used OMT, DOs who did not use OMT, or MDs.  Patients treated by DOs who used OMT reported significantly lesser low back pain intensity and back-related disability than patients treated by MDs.  Patients treated by DOs who used OMT also reported less frequent use of nonsteroidal anti-inflammatory drugs or opioids   There were no significant differences in primary outcomes between DOs who did not use OMT and MDs   Wrap It Up This study of community-based patients in a pain research registry supports the effectiveness of OMT as an integral component of osteopathic medical care for chronic low back pain.  Patients treated by DOs who did not use OMT did not experience better results than patients treated by MDs in any primary outcome measure.  But…..the WHO didn’t include this. Maybe because it was an observational study rather than an RCT. Who knows? But this says SMT is an integral component of back pain whereas the others are less flattering.  It just feels dirty, WHO….it feels dirty! Don’t let those damn chiropractors get a head of steam or we’ll ALL be out of a job!! Alright, that’s it. Keep on keepin’ on. Keep changing our profession from your corner of the world. The world needs evidence-based, patient-centered practitioners driving the bus. The profession needs us in the ACA and involved in leadership of state associations. So quit griping about the profession if you’re doing nothing to make it better. Get active, get involved, and make it happen. Let’s get to the message. Same as it is every week.    Store Remember the evidence-informed brochures and posters at chiropracticforward.com.   

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The Message I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment rather than chemical treatments like pills and shots. When compared to the traditional medical model, research and clinical experience show us patients can get good to excellent results for headaches, neck pain, back pain, and joint pain to name just a few. It’s safe and cost-effective can decrease surgeries & disability and we do it through conservative, non-surgical means with minimal hassle to the patient. And, if the patient treats preventatively after initial recovery, we can usually keep it that way while raising the overall level of health! Key Point: At the end of the day, patients should have the guarantee of having the best treatment that offers the least harm. When it comes to non-complicated musculoskeletal complaints…. That’s Chiropractic! Contact Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show and tell us your suggestions for future episodes.  Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on podcast platforms.  We know how this works by now. If you value something, you have to share it, interact with it, review it, talk about it from time to time, and actively hit a few buttons to support it here and there when asked. It really does make a big difference.  Connect We can’t wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward. Website
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2 comments on The WHO’s Sources For Opinion On Spinal Manipulative Therapy (Part 7)

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