CF 170: They Still Have Low Back Pain Management WRONG Today we’re going to talk about some personal observations from two different patients I saw today and we’ll cover a new article on what should be done with low back pain patients. Hint, many are still getting it wrong over there in the medical profession. But first, here’s that sweet sweet bumper music
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You have found yourself smack dab in the middle of Episode #170 Now if you missed last week’s episode , we talked about living with chronic pain, screen time for the kiddos, and low back pain delivery. Make sure you don’t miss that info. Keep up with the class.
On the personal end of things…..
The wheels turn slow on the medical integration front. Which is probably a good thing honestly. You don’t want to get out over your skis too far now, do you?? It’s like wading into the water a little at a time so you can get used to it. Some people just jump right out into the middle of it all. I’m a gradual guy. I like to slowly get in and get the lay of the land. That’s kind of how this integration is proceeding right now. We have the medical director.
He’s been a long time friend of mine and was actually a chiropractor back before he went to medical school. He’s an excellent human being and should be a great fit with me and my way of approaching healthcare. I got to see a veteran today as a new patient. This is a guy that has had chronic pain that has suffered for years. He just got out of the Army in 2019. He’s been in it for 25 years so you can imagine. He gets cortisone shots 3-4 times per year. He’s never been told about yellow flags. Warned against allowing doctors to treat from an MRI. He’s only been given shots and turned loose every time he has a flare-up.
He has slipped into fear avoidance. Now, I had the opportunity to teach him about fear avoidance, about CNS upregulation, about how over 60% of asymptomatic in his age group have disc-related findings on their MRI that means nothing, I got to teach him about stabilizing his low back instead of always popping hit on his own for through a chiropractor. I got to teach him about the difference between hurt and harm. I got to give him a recommendation for Back In Control by Dr. David Hanscum. I got to teach him McGill’s Big 3. I got to teach him how the medical doctors are still turning the treatment tree upside down when they do shots and medication first instead of movement, exercise, manipulation, massage, and all of that good stuff. I think…..I THINK….I got to help give him a roadmap to change his life today. For an appointment that could have taken 30 minutes, I probably spent well over an hour with him.
First, because he was a really pleasant dude and I instantly liked him on a personal level.
Secondly, he’s a vet and that’s just amazing. But beyond that, I knew it would take some time to change his life. After all….that’s what we’re here for, right? Some time ago, I did an episode of the podcast that had to do with a vitalist nut job from Oklahoma City that posted on social media that he had treated 99 patients and 9 new patient exams within 3 hours. One table, one doctor, blah blah vitalist BS blah blah. Then telling others he could teach them how to do the same if they pay him as a consultant/mentor/guru. I broke down the time constraints in that episode but I believe it boiled down to about 10 minutes per new patient.
For a vitalist that believes the source of all of the Earth’s imperfections boils down to a subluxation, I suppose you could bounce around down the spine and find 6 sore spots, hammer ‘em back down and go on about the day. I suppose a new patient could take even less than 10 minutes if done that way, quite honestly. But, in my opinion, and compared to evidence-based docs in the profession, you’d be a piss poor doctor.
One I wouldn’t want anything to do with. One I’m embarrassed is in my profession.
You have to take the time it takes to fully evaluate someone orthopedically, neurologically, and cognitively. There is no way around it if you’re going to be a next-level practitioner. It’s not optional. Ever. And 10 minutes won’t get it. It just won’t.
I had to adjust a couple of patients that showed up and then return to the vet to keep talking and teaching but we got it done. He’s my new project. It was cool to see him nodding his head and understanding what I was telling him. I think I saw the light bulb come on. And that’s just pretty damn cool. I’m a little jazzed. A little energized that I think I can take this lifelong veteran and lifelong pain sufferer and turn his situation into a positive one. We shall see but it should be a lot of fun if my plan comes together. I guess the point is; be a doctor. Be their advocate. Take the time that it takes. Their lives depend on us to function on a higher level than just pounding down the sore spots.
On a separate note, I had a young girl come in for a consult. I’ve known her and her family for several years. She had a car wreck 9 months ago and fractured L1. You could see where the posterior/superior corner of the vertebra was broken off and the spinous process was broken off completely. No paralysis, no dysfunction neurologically. A neurosurgeon fused her spine. Not just 2 segments. Or 3 segments. He fused 5 segments. He told them it was because it was the T/L junction and fusing that many would give it more stability.
Now….who am I to argue about that?? I’m not a surgeon. But it seems drastic. Once that is stabilized and healed, can they go and remove some of the fused areas? I have no idea. But damn. 5 vertebrae when only one was fractured? Beyond that, he told her no twisting. Her understanding was forever. He has her in a back brace with no recommendations on when to quit wearing the back brace. He has the crap scared out of her as far as moving and having any activity really. It’s been popping down low lately and that kind of hurts.
He told her to go on 6 weeks of bed rest. I think I’m dealing with incompetence here. That’s what I’m building up to. 6 weeks of bed rest for and 18-year-old girl that is functional. Bracing with no end in sight. Scaring her out of even twisting. She was afraid to do nerve flossing for her leg and low back. Fusing 5 segments instead of 2 or 3. So, I’ll never pretend to be the smartest dude on the planet but can I really know more than a freaking neurosurgeon? Certainly not about surgery specifically. But the follow-up, the rehab, and the future…..yeah, I think we can actually know quite a bit more than they do. And now here we have another patient from today that we are charged with changing their lives. I’m all about spinal manipulative therapy but this one will be through exercise, movement, biomechanics, cognitive work, confidence building, support, and most importantly, through finding an orthopedic expert for the second set of eyes and another set of recommendations. Except I’m going to be the one picking this one out. We have to save these people.
Don’t get me wrong. The medical complex saves lives every day all day. Thank God for them. But we can save their lives too. When they hurt too bad to go shopping or play a part in their own lives, that’s no life at all is it? When we turn that around, on some level, we absolutely save their lives. We keep them from slipping into depression, pills, chronic pain, fear avoidance, inactivity, and everything that goes along with all of it. We save lives too and every chiropractor knows exactly what I’m talking about. Let’s get on with it, shall we?
Item #1 This first one is called “Pathways for managing low back pain. The collaborative effort of four PM PIs Yield a Paper and a call to action.” (1) and published in Pain in December of 2020. Hotter than Hell. First, Dr. Christine Goertz was cited at the end for further reading. Because she’s amazing and awesome and a chiropractic treasure if you ask me. if you don’t know of and absolutely adore Dr. Christine Goertz, then you are insane or don’t value chiropractic research.
Second, this is an article so we’ll do what we do and hit the high spots. They start by saying that many of the best practice guides for low back pain involve evidence-based therapy that is not typically integrated into a single clinical setting. They bring up the examples of physical therapy and chiropractic and mention how they are typically delivered outside of the majority of first-line access points in the US. They say this leads patients to fall through the gaps. Which is understandable.
We, chiropractors, see this all of the time. Every week. Think about it, they mention here how PCPs will order tests and imaging but the pain is complex and harder to coordinate the diagnosis and effective treatment and care management outside of an integrated setting. Now, pay attention to the last line in this quote from the paper, “All of the Pain Management Collaboratory trials are focused on delivering non-drug options to effectively ease the experience of pain in Veterans and Active service members. No matter the type of patient, or where the patient enters the system for their pain, treatment options need to be organized and delivered in such a way that it is easy for patients to receive and comply with treatments, and for providers to follow up. Hastings, a clinician with a focus on geriatric care as well as a researcher, poses the question, “Is it really realistic for every individual primary care provider to be the expert on how to access all of these different types of therapies, you know, in his or her community?”
They go on to say, “This is where the authors propose a health navigator—a local resource expert who is trained in how to factor in an individual’s previous experiences and preferences when making recommendations—for developing a pain pathway for the individual. A pain care navigator could be a chiropractor, a nurse, a physical therapist or other health care provider that one might see as the first step in seeking help for their pain. “We are really testing this idea of individualization so that we ensure optimal adoption of therapies for pain,” says Dr. Hastings. Developing an effective treatment model for pain that takes into account patient preferences, lifestyle, and current needs and is more than just a “cookbook kind of an approach.” This approach acknowledges that patients enter the healthcare system from many different starting points, and so there is a need to train providers from a number of different disciplines to organize, plan, and deliver individualized care options.”
Does that sound anything like the Primary Spine Practitioner program? Yes, it does. It also sounds like the paper we covered some time back where they did a study in a Stanford area ER where the DCs directed the musculoskeletal pain ER patients. They had so much success that they expanded the program. This really is, in my opinion, the way to do this, y’all. This is the way to effectively treat pain.
Then our very own Dr. Goertz comes down with the People’s Elbow when she says, “In addition to navigating through different treatment modules, other barriers to effectively managing a pain treatment plan include cost, the need for more providers, and appropriate delivery of treatments. “One of the biggest barriers right now has to do with payers who are willing to pay high dollars for spine surgeries or injections but are less willing to cover guideline-concordant treatments such as spinal manipulation, acupuncture, cognitive behavioral therapy, and yoga,” “I think until we are better at embracing payment models that put an emphasis on conservative care and reward all of those involved, we’re going to continue to struggle. Fortunately, I see some signs that our healthcare system is changing in this direction.”
Dr. Goertz addresses the biopsychosocial aspect a bit when she says, ““It’s really important to have the patient involved in the process [of developing a pain management plan],” “When it comes to low back pain, we know that people who are more frightened by their pain can have worse outcomes. Anything that can help patients better understand their pain can paradoxically lead to less pain in the future, which is why patient education is really important.” Additionally, healthcare providers need to be well-versed in effective communications techniques to ensure that patients understand, feel supported, and are involved in the decision-making process. Conversations should focus on lessening the experience of pain and increasing understanding, as opposed to exacerbating fear. “This is important with healthcare delivery in general, but especially important with people who have low back pain,” Goertz says. “
There’s really going to be no reason for y’all to read this yourself because I’m basically going line for line but every line is solid and true so they kind of leave me no choice. The article continues, “Dr. Goertz also pointed to a Gallup study that asked individuals which types of providers they thought were the safest and most effective for managing back and neck pain. Participants indicated that physical therapists and chiropractors were the safest and most effective; however, when asked which provider they would see for pain management, more than half said that they’d prefer to see a medical doctor first. “It is crucial that clinicians are aware of coordinated care guidelines for back and neck pain and are able to facilitate access to that care for their patients,” Goertz asserts. “For instance, the American College of Physicians recommends that patients and their clinicians consider nonpharmacological treatments including acupuncture, massage, yoga, Tai Chi and spinal manipulation before prescription medication for low back pain.”
Historically, these treatments have had less emphasis during clinical training for many health care providers, and facilitating access and coordinating the follow-up can be challenging. Additionally, a patient’s insurance may not cover all the recommended considerations.” Here’s the last paragraph and pay attention again to the very last line, “At the center of evaluating pathways for pain management is a call to action to put more thought and organization into what happens to patients when they first seek care for pain and the long term consequences of the patient’s earliest experiences with the health care system. “It takes a really intentional effort to say, ‘What are the first set of decisions that need to be made? And then what are the next decisions that need to be made?’” observes Dr. Fritz.
To avoid the early intensification of pain care, which results in greater expense and invasiveness escalating rapidly, we need to ensure that the evidence-based guidelines are getting put into practice, and patients understand that managing pain isn’t a linear process where a person goes in to see a provider, gets a diagnosis, gets a treatment, and the pain goes away.
Communication among patient and providers is essential to get on the right pathway for pain management. “If we can be more aligned in our messaging around back pain in the community—before individuals become patients, where they may not yet be experiencing back pain, or before it affects their ability to function—it can help set expectations and set up the conversation with care providers when they do come in,” says Dr. Hastings. “The first thing we ought to be reaching for are these non-drug therapies, and reserving imaging for specific cases since it’s not going to change what we do in the majority of cases.”” Amen. Researchers and authors, please for the love of everything, keep writing these papers.
Over and over again until it finally starts filtering down to the doctor in the field. The PCP, the VA doc that used to just give pills and shots, the surgeon that is still telling an 18-year-old girl to go on 6 weeks of bed rest and wear a brace while never twisting. Forever. This garbage has to stop, y’all. There’s little wonder why low back pain is still #1 in the world for global disability. It’s because the primary stakeholders and medical industry can’t get their crap together. Or, worst-case scenario, don’t want to get their crap together due to financial considerations. Why get your crap together if it means you do fewer surgeries and make less money through the year? There’s no financial incentive to do the right thing.
I got it….Pay them MORE for the NECESSARY surgeries to offset the loss of income when they quit performing the UNNECESSARY surgeries. There you go. I just fixed the world.
Bam, snap, thwack, kow-a-pow! Alright, that’s it.
Y’all be safe. Keep changing our profession from your little corner of the world. Keep taking care of yourselves and everyone around you. Tough times are upon us but, the sun will shine again. Trust it, believe it, count on it. Let’s get to the message. Same as it is every week.
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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!
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About the Author & Host
Dr. Jeff Williams – Fellow of the International Academy of Neuromusculoskeletal Medicine – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger
- Pathways For Managing Low Back Pain. Pain. December 2020. https://painmanagementcollaboratory.org/pathways-for-managing-low-back-pain/?fbclid=IwAR1r5H4ZRvQr4Gw9wmIGYbJGSMr9e9aaPybvLujtdjEoE06Q6ppehNEGol8