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Chiropractic: Evolution Or Extinction?

04/20/2018

chiropractic and low back pain treatments amarillo tx

This week, I want to continue with discussions on low back pain (LBP) because that is the topic that is on fire at the moment. The momentum low back pain has picked up recently is a once in a lifetime rebooting of an entire thought process, of long-held clinical pathways, and of stubborn practitioner mentality and dogmatic beliefs.

I blame the national emergency we know as the “Opioid Crisis” for starting a more focused attack on low back pain. The statistics on low back pain are some incredible numbers. It’s the number one reason for disability in the world. That is truly impressive. However, low back pain as a global issue did not crop up in only the last several years. Granted, due to an older, aging population, it has increased, but low back pain has been a serious concern for many years at this point.

Yet, there were no global papers on low back pain. There were no articles in the journals for the American Medical Association and for the American College of Physicians recommending spinal manipulation (chiropractic adjustments) as an effective, first-line treatment for low back pain. We have simply never seen the attention based on the research that we have seen since the onset of the opioid crisis.

One must give kudos to the medical field in the sense that they recognize they have been partly the cause of the opioid crisis and, in turn, are taking steps to address the problem through new thinking and alternative means. Even if that means going against old dogmatic beliefs and against the common grain. I applaud the new directions. Although, there is still a very clear gap that will take time to fill in regards to what the practitioner is doing and what they SHOULD be doing.

We recently discussed a series of papers in The Lancet from March 21, 2018 that dealt with low back pain. The Lancet is one of the oldest and most respected medical journals in the world dating back to 1823 and the series of papers was compiled by an international, interdisciplinary group of experts. It is considered the best current information we have dealing with low back pain, it’s prevention, and going forward. I highly encourage you to read through the papers.

Since it would get a little boring going over the same three papers over and over, I am going to move along with other research and other information concerning low back pain.

I want to start with a paper that echoes the sentiments of The Lancet series in regards to the gap in what the evidence suggests and in what is actually happening in the real world. In all actuality, from here forward, I believe most of what we discuss on the topic of low back pain will somewhat echo the sentiments found in the recent Lancet papers.

Moving on, the papers we will discuss are arranged strategically and tell a story if you follow along.

To start, here is a paper from 2010 titled “Managing low back pain in the primary care setting: the know-do gap.” It was published in Pain Research & Management and authored by NA Scott, et. al. with the Institute of Health Economics in Edmonton, Alberta, Canada.

Why They Did It

The goal for these authors was to identify gaps in knowledge in regards to diagnosis of acute and chronic low back pain in a primary care clinical setting for primary practitioners in Alberta, Canada in order to further determine what barriers lie in the way of the primary practitioners adopting a multidisciplinary approach in the treatment process.

How They Did It

  • The authors accepted papers from 1996-2008.
  • The papers compared clinical pathway patterns found in the primary practices and in the guides and recommendations found through searching literature databases, websites of various health technology assessment agencies, and libraries.
  • The data was organized qualitatively.

What They Found

The search for quality papers yielded 14 that were considered relevant. Knowledge gaps were identified in the primary practices for red flags, imaging use, advice for bed rest and sick leave for low back pain, medications, and recommendations of alternative treatment means such as chiropractic, acupuncture, physiotherapy, etc.

Wrap It Up

The authors stated that a “know-do” gap certainly exists. Meaning, there is a difference in what the research is telling primary practices to do for low back pain and in what they are actually doing in the real world. The authors plan to use this information to develop a plan to implement more multidisciplinary protocols for low back pain by educating the primary practitioners on the guides and recommendations[1].

If we are to talk about the “Know-do” gap, what is a common result of there being a gap in knowledge of diagnosis and treatment when compared to actual researched guides?

To help shed some light on this, let us look at a paper from March of 2018 by Richard Deyo, et. al. at the Department of Family Medicine at Oregon Health Science University in Portland, Oregon. This paper is titled “Use of prescription opioids before and after an operation for chronic pain (lumbar fusion surgery)”

Why They Did It

Considering low back fusion surgery is typically performed to treat chronic low back pain, and considering that patients have the expectation of no longer needing opioids after a surgery, the authors were looking to discover three things:

  • What amount of patients having long-term preoperative opioid use discontinued or reduced dosage after surgery?
  • What amount of patients having had a smaller amount of preoperative opioid use initiated long-term use?
  • What predicts whether a patient goes on to use opioids in the long-term after surgery?

How They Did It

  • This was a retrospective cohort study
  • There were 2,491 participants that had undergone lumbar fusion surgery to treat degenerative conditions.
  • The researchers used Oregon’s prescription drug monitoring program to determine pre-op and post-op use of opioids by the test subjects.
  • Long-term use was defined as more than 4 prescription refills 7 months after hospitalization, with at least 3 occurring more than 30 days after hospitalization.

What They Found

  • 1,045 patients were identified as having long-term opioid use PRE-operatively.
  • 1,094 were determined to have had long-term opioid us POST-operatively.
  • From the long-term PRE-op patients, 71% continued long-term in POST-op use and 13.8% experienced episodic opioid use.
  • A mere 9.1% of the long-term PRE-op patients had short-term use POST-op.
  • In the group of patients that received no pre-operative opioids, 12.8% went on to use opioids long-term.

Wrap It Up

This paper suggests that the strongest predictor of whether a patient would use opioids long-term was the cumulative effect of PRE-op opioid doses. The paper also suggests that lumbar fusion surgery commonly had no effect on eliminating long-term opioid use, so patients that are unaware of the risks of opioid use run a risk of long-term use[2].

While I’m no orthopedic surgeon, I would ask, “Why are they doing lumbar fusions on stable segments in the first place considering the research showing that it should be a treatment of last resort?”

It should come after spinal manipulation, acupuncture, massage, exercise rehab, physiotherapy, cognitive behavior therapy, yoga, etc….. That is A LOT any sort of surgery should typically follow so why? Of course, I’m not making the money those folks make so, that may be the decision maker for some of them at least.

Moving from things going wrong to ways they can go right, there is this paper from the journal Pain from March 27, 2018 titled, “Spinal Manipulation and Exercise for Low Back Pain in Adolescents: A Randomized Trial by R. Evans, et. al. with the University of Minnesota’s Integrative Health and Wellbeing Research Program.” As a side note, Gert Bronfort was also listed as an author in this paper. If you are unfamiliar with Bronfort, he has authored several key papers previously.

Why They Did It<

The authors state that there is a “paucity” in high quality research on the matter of exercise vs. spinal manipulative therapy in the treatment of low back pain.

How They Did It

  • The research was a multicenter, randomized trial
  • 185 adolescents were included
  • The participants ranged in age from 12-18 years old
  • All had chronic low back pain
  • Outcome assessments were measured at 12 weeks, 26 weeks, and at 52 weeks

What They Found

  • The inclusion of spinal manipulative therapy (chiropractic adjustments) to exercise therapy had a greater effect on the reduction of low back pain severity over the course of a year.
  • At the 26-week mark, the spinal manipulative therapy with exercise group had better effectiveness for disability and improvement over the exercise alone group.

Wrap It Up

The spinal manipulative therapy with exercise group had a significantly greater satisfaction with care at all time points. “There were no serious treatment-related adverse events. For adolescents with chronic LBP, spinal manipulation combined with exercise was more effective than exercise alone over a one-year period, with the largest differences occurring at six months. These findings warrant replication and evaluation of cost-effectiveness[3].”

We chiropractors have to love that paper now, don’t we?

Next, let’s look at a different level of recovery that deals with the way patients think as much as the treatment they undergo. Here is an article that appeared in HealthDay called “Overcoming Fear of Back Pain May Spur Recovery” by Steven Reinberg. The article was based on a recent paper that appeared in JAMA Neurology in April 16, 2018 published by lead researcher Anneleen Malfliet. It is usually wise to at least listen up when it’s in journals such as The Lancet or in the Journal of American Medical Association.

The research paper being cited once again echoes much of the sentiment laid forth in The Lancet low back series. Basically, their recommendations were as follows:

  • We need to help patients think differently about their pain.
  • We need to encourage patients to move in ways they had been afraid of.
  • We need to teach patients with neck and back pain to remain active and/or increase their activity level gradually.
  • We should avoid the use of scary or un-reassuring labels or diagnoses.
  • We should not use pain levels as a reliable symptom or guideline to limit activity.

In short, research proved that patients following these guidelines showed less disability, a reduced fear of moving, and improvement in mental and physical outlook.

“Pain neuroscience education aims to change patients’ beliefs about pain, to increase their knowledge of pain and to decrease its threat,” Malfliet said[4].

Be sure to read the full article at:
https://consumer.healthday.com/bone-and-joint-information-4/backache-news-53/overcoming-fear-of-back-pain-may-spur-recovery-732970.html

Now that we chiropractors are taking the step more and more into the spotlight as the experts in the treatment of biomechanical issues, what can we do on our end to ensure our colleagues can confidently refer to us and see us as peers for these issues?

I can tell you that, being in the ER one night as a result of a viral infection, not only was the virus running crazy through me but my neck was killing me as well. I thought I would ask the ER doc if he had any orthopedic exams up his sleeve that could determine what on Earth was hurting me so bad. Between you, me, and the light post, I already had a good idea but was curious as to what he knew and I thought it may be something that both of us could learn from.

It was. He did a Spurling’s move and that was about it before he gave up and said, “Honestly man, you probably know what’s going on better than I do.” And he was right. I did. But, it showed me that he was honest and that he saw me as an expert in my field and I appreciated it. Of course, he’s more of an expert in his field which is why I was there in the first place. We all have our part to play in the treatment of patients. Don’t we?

Back to my original point: how do we increase our profile as spinal, biomechanical experts. How do we increase interdisciplinary, interprofessional trust in who we are and what we can do for our patients?

I can tell you what NOT to do if that helps anything. I do not see any use for chiropractic terminology that our colleagues do not understand. I personally do not use the term subluxation. In the dictionary, it is described as a partial dislocation. What does that mean in the medical mentality? It means a shoulder that was almost dislocated but reduced naturally. It means something along those lines. It does not mean a slight misalignment of a vertebra that causes cancer or whatever other conditions some describe.

I understand chiropractors wanting to stay separate and distinct. I get it. But, there is a difference between being separate and distinct and putting yourself in a category nobody understands, that everyone thinks is out on the fringe, and that nobody knows exactly how to utilize.

If our profession is not careful, it will separate itself into oblivion now that physical therapist, physiotherapists, and the medical world in general have discovered something we have known all along. That is that spinal manipulation and mobilization is one of the best and most effective means of treating neck and back pain.

What has kept us safe from them taking our business all of these years is that they all thought we were crazy! For some, they were right, but the basic principle our profession is based on was one that evidence eventually backed up and proved. Now we are in danger of losing it if we do not learn that separate and distinct may not be the most effective means of conducting our business.

The last paper I want to discuss is one called “How frequent are non-evidence-based health care beliefs in chiropractic students and do they vary across the pre-professional educational years” by Stanley Innes, et. al. It was published in Chiropractic & Manual Therapies in March 15, 2018.

Why They Did It

The authors wanted to determine what proportion of chiropractic students in Australia hold non-evidence-based beliefs from the start and what their beliefs are in the treatment of non-musculoskeletal health condition. In addition, the authors wanted to determine if the beliefs changed any over the course of their education.

How They Did It

  • The study was performed in 2016.
  • The information was taken from two chiropractic schools in Australia.
  • The students answered a questionnaire with the following questions:
    1. How often would they give advice on five common health conditions in their future practices?
    2. What was their opinion about if chiropractic spinal adjustments could prevent or help seven health-related conditions?
  • There were 444 responses to the questionnaire.

What They Found

  • Students were highly likely to offer advice on non-musculoskeletal health conditions.
  • The chances of a student doing so rose to the highest level in the last year of their education.
  • High numbers of students held non-evidence-based ideas of the capabilities of chiropractic spinal adjustments in beginning which then tended to decrease in proportion until the last year. In the last year, the pattern reversed.

Wrap It Up

The authors were quoted as saying, “New strategies are required for chiropractic educators if they are to produce graduates who understand and deliver evidence-based health care and able to be part of the mainstream health care system[5].”

I want you to know that I am a chiropractic advocate. I want chiropractors to practice how they wish. I want the minimal practices to be comfortable and be as stripped down and as effective as they can be. I want the interdisciplinary doctors to do everything they can do to get people well and make a difference in lives. But I want them to do things in a way that is backed by science, that brings us to the center of healthcare rather than the fringes, I want us using terminology and ideas that garner confidence and respect rather than ridicule and scorn, and I want us all to thrive and prosper while we grow our incredible profession.

There will always be an internal feud amongst chiropractors. Likely, some of my close colleagues whom I respect immensely will take offense to what I am saying and to them, I can only say, “I’m sorry, but it’s the way I feel about it and it’s the way I see it.” Thank God we are all different. The same would be boring.

A colleague of mine told me he feels that philosophy and science can live hand in hand. I want to believe that too. I hope it is true. But, what I do know for a fact is that if we do not take this once-in-a-lifetime opportunity that opioids and low back pain has presented us, and move toward better integrating ourselves with the medical profession, I fully believe we will have our techniques and treatment stolen from us and we will cease to exist in our current form.

One constant you can always count on in life is change. I hope the inner-professional feuding does not keep change from happening quickly and in the right direction.

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 leave a comment and tell me your thoughts. I’d love to hear what you think. And….SHARE, SHARE, SHARE!! We cannot make a difference without your help.

Till next time……
The Amarillo Chiropractor Blog is written by Dr. Jeff Williams.
Amarillo TX Amarillo Pain & Accident Chiropractic Clinic provides customized chiropractic care to the Amarillo TX, Canyon TX, Pampa TX, Happy TX, White Deer TX, Dumas TX, Groom TX, Conway TX, Panhandle TX, Claude TX, Clarendon TX, Borger TX, Tulia, TX, Hereford TX, Fritch TX, Bushland TX, and Vega TX communities.

Visit our main website at www.amarillochiropractor.com for customized Chiropractic in Amarillo TX. Choose several options to schedule your appointment: call (806) 355-3000 or click the button below for our contact info.

by Jeff S. Williams, D.C.
Chiropractors in Amarillo
Spinal Decompression Amarillo
Creek Stone Integrated Care
http://www.amarillochiropractor.com
http://www.creekstonecare.com

References

  1. Scott NA, Managing low back pain in the primary care setting: the know-do gap. Pain Res Manag, 2010. 15(6): p. 392-400.
  2. Deyo R, Use of prescription opioids before and after an operation for chronic pain (lumbar fusion surgery). Pain, 2018.
  3. Evans R, Spinal Manipulation and Exercise for Low Back Pain in Adolescents: A Randomized Trial. Pain, 2018.
  4. Malfliet A, Effect of Pain Neuroscience Education Combined With Cognition-Targeted Motor Control Training on Chronic Spinal Pain
    A Randomized Clinical Trial. JAMA Neurology, 2018.
  5. Innes S, How frequent are non-evidence-based health care beliefs in chiropractic students and do they vary across the pre-professional educational years. Chiropr Man Therap, 2018. 26(8).



Review of The Lancet Article: Low Back Pain: A Call To Action (Part Three)

04/12/2018

expert chiropractic in amarillo texas

This week, we’re going to review the last of the three papers from a recent series published in The Lancet on March 21, 2018. If you don’t know the impact or why this series is so important, please review the last two episodes of the Chiropractic Forward Podcast at www.chiropracticforward.com or the last two articles of my blog over at amarillochiropractor.com/blog. That will get you up to speed. In short, the series on low back pain was compiled and authored by an international panel of experts on the matter. Essentially, the best of the best. This series is as up to date, as current, and as reliable as can be had at this point in our understanding of low back pain, so it is worth your time and attention.

This last of the three papers is titled “Low Back Pain: A Call To Action.”

Summary

We have already covered several times that low back pain is now the leading cause of disability globally and is only growing in significance because the global population is living longer. The issue may be more profound in low to middle-income countries. In addition, most low back pain doesn’t even appear to be directly related to any specific trigger or origin. Some of the key areas for improvement for the treatment of low back pain are in health & workplace policies as well as disability benefits and payments. They claim they are wasteful and can certainly stand a re-boot. In many cases, patients are being restricted from attempting resolution of the back pain via conservative approaches such as self-management support, specialized interventions like spinal manipulations (I added that part) and multidisciplinary rehab.

The panel suggests the following:

  1. Address the political aspect. They recommend calling on the World Health Organization to make low back pain one of its priorities by putting it on the target list in an effort to increase attention and decrease treatment that is not recommended initially. They recommend calling on political, medical, and social leaders to make sure public health initiatives are properly funded and geared toward the prevention of low back pain and treatment.
  2. Public health challenge.
    • Change priorities – Make low back pain a priority. Create and implement ways to prevent it and combine these strategies with other strategies that are chronic and somewhat related. Strategies such as weighing the right amount, being active physically, and maintaining good mental health as well. These tactics treat more than simply low back pain. The panel also recommends strategies that can modify the factors putting the population at risk of developing low back pain.
    • Change systems and change practice – Provide early recommendations for maintaining workload as much as possible and/or return to work as quickly as possible. Attempt to ensure early ID of people that are at risk of developing long-term, chronic disability as a result of low back pain. Address co-morbidities raising a person’s risk of developing low back pain and promote a healthier lifestyle in addition to altering disability benefits and get people back to work as soon as possible. And lastly, address low back pain through multidisciplinary rehabilitation in an effort to return the patient to work quickly.
  3. Healthcare challenge –
    • Change culture – The panel appears to me to be promoting the use of a Public Relations campaign to focus and promote living well with low back pain, self-management, staying healthy, and to change the public perception of low back pain.
    • Change clinician behavior – The recommendation is to place effort and finances into finding out the best way to change the way clinicians recommend care for low back pain and to fill the evidence/real world gap. After developing the best evidence-based systems, there will be a need to get everyone on the same team in regards to the way clinicians refer and treat, the patients, as well as the professional journals.
    • Change systems – There is a need to develop and implement systems allowing a patient to receive the right care at the right time. Clinical pathways will need a reboot and will need to become consistent across interdisciplinary lines and differing clinical settings.
    • Tackle Vested Interests – The panel discusses the fact that governments and insurance companies need to regulate in a manner consistent with evidence-based treatment for low back pain and eliminate conflicts of interest. Regulation through contracts, and payment schedules for treatments with little to no evidence for effectiveness.

The idea that a healthy weight and regular physical activity will help reduce low back pain must enter the global subconscious through public programs, especially in low to middle-income countries.

An assertion I fully agree with the authors on is that, thus far, healthcare dollars have been wasted on treatments that are ineffective and, many times, downright dangerous. The risk vs. reward ration just doesn’t make sense more times than not currently. Not to mention the issue of opioid addiction, which we all should know the stats on by now.

Boiling it down, the panel aims to get rid of practices that harm and create waste while, at the same time, opening the door to effective and affordable means of treating low back pain to patients in need. The authors are quoted here as saying,”Protection of the public from unproven or harmful approaches to managing low back pain requires that governments and health-care leaders tackle entrenched and counterproductive reimbursement strategies, vested interests, and financial and professional incentives that maintain the status quo.”

The authors promote the idea of implementing a positive health concept as the umbrella idea aiming for prevention of long-term disability. This includes alternatives to treatments and cures and promoting more meaningful lives.

Another great quote from this third paper is as follows, “Improved training and support of primary care doctors and other professionals engaged in activity and lifestyle facilitation, such as physiotherapists, chiropractors, nurses, and community workers, could minimize the use of unnecessary medical care.”

The panel also calls for an active monitoring system in order to assess and keep an eye on the recommendations and implementation as well as the outcomes of the changes.

To read more for yourself, follow this link to the third paper:
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30488-4/fulltext

If access is unavailable, just simply register at The Lancet. It is completely free of charge.

References:

Paper 1 – “What low back pain is and why we need to pay attention: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30480-X/fulltext
Paper 2 “Prevention and treatment of low back pain: evidence, challenges, and promising directions.”: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30489-6/fulltext
Paper 3 – “Low back pain: a call for action”: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30488-4/fulltext

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 leave a comment and tell me your thoughts. I’d love to hear what you think. And….SHARE, SHARE, SHARE!! We cannot make a difference without your help.

Till next time……
The Amarillo Chiropractor Blog is written by Dr. Jeff Williams.
Amarillo TX Amarillo Pain & Accident Chiropractic Clinic provides customized chiropractic care to the Amarillo TX, Canyon TX, Pampa TX, Happy TX, White Deer TX, Dumas TX, Groom TX, Conway TX, Panhandle TX, Claude TX, Clarendon TX, Borger TX, Tulia, TX, Hereford TX, Fritch TX, Bushland TX, and Vega TX communities.

Visit our main website at www.amarillochiropractor.com for customized Chiropractic in Amarillo TX. Choose several options to schedule your appointment: call (806) 355-3000 or click the button below for our contact info.

by Jeff S. Williams, D.C.
Chiropractors in Amarillo
Spinal Decompression Amarillo
Creek Stone Integrated Care
http://www.amarillochiropractor.com
http://www.creekstonecare.com




Review of The Lancet Article: Prevention and treatment of low back pain: evidence, challenges, and promising directions (Part Two)

04/06/2018

chiropractic in Amarillo, Texas

This week, I want to continue with the series published in The Lancet on March 21, 2018. For a quick re-cap, this series: The Lancet is one of the oldest and most respected medical journals in the world. It has been around since 1823. In addition to the credibility of the journal, this series of papers dealing with Low Back Pain was compiled and authored by the leading experts on the matter globally. On top of that, the experts were a group of interdisciplinary practitioners which meant they ranged from medical doctors and PhD’s, to physical therapists and chiropractors.

Essentially, EVERYONE had a seat at the table, so it is the general consensus at this point that this series of papers is as current, as credible, and as accurate as can be had at this point in time with our understanding of Low Back Pain.

The three papers were broken down as follows:

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

Last week, we reviewed the first of the three papers which was titled, “What low back pain is and why we need to pay attention.” We went through it note by note and section by section trying to strip away the embellishments to simply boil it down to a leisure read and, hopefully, an enjoyable learning process.

We will do the same this week with the second paper of the series titled, “Prevention and treatment of low back pain: evidence, challenges, and promising directions.”

I want to start this week in the same way we started last week: by discussing how the papers were accomplished.

How They Did It

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

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

In order to ensure a high-quality standard, systematic reviews were shown preference for inclusion.

Paper 2 Summary:

Recommendations commonly offered for those with low back pain include:

  • Pharmacologic implementation is not typically a first line choice
  • Education supporting self-management
  • Resumption of regular daily activities
  • Resumption of exercise
  • Psychological programs for those with low back pain that tends to linger
  • Limited or non-use of medication
  • Limited or non-use of imaging
  • Limited or non-use of surgery

The authors state that these recommendations are derived from high-income countries and that they are concentrated on treatment rather than preventative recommendations.

The authors state there is an inappropriate high usage of the following treatments for low back pain:

  • Spinal injections
  • Imaging
  • Opioids
  • Surgery
  • Rest

The authors also say that doing a lot of the same will get us the same results so, in going further, the treatments should be more in line with what evidence suggests is effective. Things like exercise and getting back to work as soon as possible. Makes sense to us!

In the rest of the paper, the authors identify some promising directions and solutions for low back pain including the redesign of clinical pathways, an integrated health partnership, and occupational interventions to get workers back when possible.

Prevention

  • A 2016 systematic review with 30,850 adults showed that there was moderate quality evidence that exercise alone, or in combination with education, is effective for prevention of low back pain.
  • However, the review was mainly for secondary prevention and the exercise program required an intense schedule of twenty 1-hour supervised sessions.
  • A 2014 systematic review with 2,700 children that found moderate quality evidence that education is not effective. They also found that ergonomic furniture was likely no more help in preventing low back pain than regular furniture.
  • Some key messages for Prevention were to use self-management, physical and psychological regimens, and some forms of complementary medicine. In regards to Treatment, there should be less emphasis on pharmacologic protocols and less instances of surgical intervention. Also, the authors write that, although their popularity in healthcare has been steadily on the rise, there should be less utilization of imaging, opioids, and spinal injections.

Treatment

  • The authors cite three studies. The studies come from Denmark, the UK, and the USA.
  • All three of the studies (Danish, UK and USA) recommend spinal manipulation as an effective regimen for low back pain. The UK study specifically recommends spinal manipulation in conjunction with an exercise protocol.
  • As my own side note, in America, chiropractors perform 90% of all spinal manipulations. When we are discussing spinal manipulation and its role in treating low back pain, it is important to keep in mind which profession is the one being recommended. Although the authors do not come out and recommend chiropractic specifically, when spinal manipulations are recommended, it is a well-known fact that chiropractors are the doctors that are best-equipped to perform the treatment.
  • Also in the US guidelines, there is a recommendation for the marked reduction of pharmacologic care.
  • Some key advice coming from these updated recommendations (besides the use of spinal manipulation) is to assure patients they are not suffering from serious disease, that they will indeed improve in time, that they should continue as much movement and exercise as can be tolerated, they should avoid bed rest, and they should get back to work as soon as possible.
  • The authors recommend physical treatments. Certainly for chronic low back pain, which refers to pain lasting longer than 12 weeks. Physical treatments included exercise programs targeting the patient’s’ abilities, preferences, etc.
  • The authors stated that passive therapies such as electric stim, interferential, traction, diathermy, and back supports seem to be ineffective. As a side note, it’s strictly anecdotal, but this panel of experts are going to have a hard time convincing me traction, when done correctly, is not effective. I’ve seen patients avoid surgery from traction therapy alone.
  • They say new recommendations encourage doctors to consider psychological therapies such as cognitive behavior therapies, progressive relaxation therapy, and mindfulness-based stress reduction alone or in combination with other physical and psychological treatment for chronic low back pain with or without radiculopathy having not responded to other treatments.
  • If the condition persists and the patient is functionally disabled, the authors then recommend multidisciplinary rehab with supervised exercise, cognitive behavior, and medication.
  • Of course, routine use of opioids is not advised.
  • Recommend no spinal epidural injections or facet joint injections for low back pain.
  • Do recommend epidural injections of local anesthetic & steroid for radicular pain, however, as we have discussed before, epidural steroid injections show short-term effectiveness only if they are effective at all and have no influence at all on long-term disability or future need for surgery. In my own research, epidural steroid injections have shown to increase risk of spinal fracture up to 21% after each subsequent injection.
  • Surgery – the benefits for spinal fusion when the back pain was thought to be due to degenerated discs were about equal to the results gained with intensive multidisciplinary rehab and only a modest improvement over non-surgical treatment. In addition, surgery has obvious downsides like expense, recovery, medication, and the risk of adverse events. However, surgery may be indicated when the patient is suffering severe or progressive neurological symptoms and surgery may be indicated when patients suffer radicular pain, have failed first line treatment, and the symptoms can be traced via imaging to a disc or stenosis origin.
  • Ultimately, the authors say low back pain patients have a tendency to resolve without surgical intervention, so waiting and trying to avoid surgery is certainly appropriate.
  • Research dealing with low back pain in children or in low and middle income countries is limited, so a lot is unknown for those categories. However, the two studies that actually have been done in low and middle income countries (Brazil and Philippines) have similar results as those in high income countries.

The global gap between evidence and practice

This section masterfully demonstrates the difference between evidence-based medicine and what is really happening in the real world. When it comes to low back pain, the medical field is not adhering to research globally as they “overuse low-value care and underuse high-value care.”

  • They start by stating that low back pain should be managed by primary care practitioners and then go on to list studies showing how it is being managed, in many cases, by emergency rooms, hospitals, and surgeons.
  • Their next directive is to provide low back pain patients with education and advice on self management and then show how, in the real world, roughly only 20%-23% of practitioners seem to actually do so.
  • The next directive is for low back pain patients to stay active and get to work or stay at work if possible. They go on to cite research showing how, in the real world, medical professionals are recommending rest and time off work. In India, for example, 46% of physiotherapists recommended rest to low back pain patients and in Brazil, rheumatologists recommended rest.
  • The next comparison was for the guideline that imaging should only be ordered if the practitioner suspects a specific cause that would guide treatment and case management differently from normal care recommendations. In the USA, for example, from 2010-2013, the rate of imaging the low back with no red flags stayed consistent at 53.7%. If we thought that was excessive, the authors go on to cite information from India showing 100% of chronic low back pain patients in an orthopedic clinic underwent imaging for non-specific low back pain. Similar results were found through the other studies cited for low and middle income countries.
  • The next comparison was for the guideline that the first line treatments should be non-pharmacologic. They found that this guideline is not commonly followed, citing research for high income countries demonstrating that 64.5% of low back pain patients in Australia from 2000-2010 were prescribed meds on the first visit. On a personal note, I had a patient here in the USA just this morning with acute low back pain that was prescribed pain meds on the first day. To be fair, his pain is severe but, they are not following guidelines and the meds have had no impact on his level of pain; still, he continues to take them as ordered. Medication for no effect essentially. In the lower and middle-income countries, the authors cite research showing that in South Africa, 90% of the low back pain patients going to a primary care physician received medication.
  • The next guideline was that many times, there was advice to avoid electrical physical modalities such as diathermy, etc. In the high-income setting, Swedish physiotherapists recommend transcutaneous stim for low back pain to the tune of 38%. 75% of American PTs use lumbar traction, and a Spanish National Health Service study suggested 38.6% of physical therapy costs were for treatments known to have no effectiveness.
  • The next guide comparison was that the use of opioids is discouraged. The authors go on to cite prescription rates from 2004-2009 and, to be honest, I think the opioid epidemic has likely caused the numbers cited to actually drop. Although opioid addiction is on the rise, it’s my opinion that it is now at the forefront of the national story. With the sort of attention it has demanded, I cannot imagine the numbers staying the same. That is my opinion, of course.
  • Next guide was that surgery and interventional treatment should be very limited or possibly eliminated for low back pain. In the real world, this is not occurring. In the USA in 2011, spinal fusion was the reason for the most costs of any surgical procedure in the nation. US Medicare covered 2,023,481 epidural injections (a substantial increase from 2000-2011), 990,449 lumbar or sacral facet injections as well as 406,378 lumbar or sacral facet neurotomy treatments. Medicare also funded 252,654 sacroiliac joint injections. Two-thirds of Dutch spinal surgeons perform spinal fusion surgeries.
  • The next guide comparison was that exercise is now recommended for the treatment of chronic low back pain. A 2009 paper the authors cited showed that 54% of Americans with chronic low back pain were not prescribed any exercise as treatment.
  • The final guide comparison was done for the recommendation that a biopsychosocial framework guide the management for low back pain patients. In the USA, only 12% of chronic low back pain patients had been treated for their diagnosed depression in the year prior and only 8.4% were recommended cognitive behavioral treatment.

Promising Directions

Implementation of the best available evidence

The authors state here that some of the biggest issues toward implementation of new low back guidelines may be short consultation times, the practitioners having a decreased amount of knowledge on the guides, fear of being sued if missing serious pathology, and an effort to appease patients’ desires and, in my opinion, be the “good guy” in the patient’s’ eyes. However, the authors explain that there are some examples of successful implementation and that widespread use may be achieved through dispelling existing established practice patterns, repetition of the guides, and finding out what are the most effective and cost-effective treatments.

The authors suggest integrated education of health-care professionals surmising that such a thing could not only educate & innovate but also break through professional barriers that exist. Professional barriers such as exist between many in the medical field and the chiropractic field.

Clinical systems and pathways

The authors say that one solution could be a radical departure from current procedure and move toward a stratified primary care model known as STarT Back. This model is a two-part model with the first part consisting of a questionnaire to help the practitioner identify the patient’s risk of persistent disabling pain. The second part consists of treatments tailored to the patients level of risk according to the first part of the questionnaire.

Another option along these lines would be to redesign the entire case management paths from first contact all the way through to the specialized care practitioner. They argue that a current barrier to doing this is the fact that healthcare reimbursements are currently geared toward quantity rather than quality. Two programs the authors cited for examples of promising pathways are Canada’s Saskatchewan Spine Pathway as well as NHS England’s program.

Integrate health and occupational interventions

The authors argue in this section that healthcare and occupational health interventions need to be considered simultaneously when it comes to patients with low back pain and work disability issues. Return to work commonly happens before the absence of pain. Even hurting, people can still return to work. The authors tend to have a very strong recommendation on never leaving work or returning as quickly as possible.

Due to very specific examples, I have admittedly glossed over this section to avoid inaccuracies and unintended generalizations. I highly encourage your reading the paper on your own time for accuracy.

Public health interventions

In this section, the authors are discussing public relations: how to get the word out. How to change public perception of back pain. They cite a successful campaign in Australia that used television ads with prominent public figures serving as the spokespeople. They felt it was well-funded and was successful in part due to the proper messaging but also due to laws and public policies that supported the campaign.

Conclusions

There is a large gap between what evidence suggests and what practitioners are actually doing in their day-to-day practice and in the recommendations they commonly make. The authors admit that even the solutions put forth in this paper are based on relatively limited evidence. The following are quotes from the conclusion:

  • “Focusing on key principles, such as the need to reduce unnecessary health care for low back pain, support people to be active and stay at work, and reform unhelpful patient clinical pathways and reimbursement models, could guide next steps.”
  • “No single solution will be effective, and a collective, global effort will take time, determination, and organization. Without the collaborative efforts of people with low back pain, policy makers, clinicians, and researchers necessary to develop and implement effective solutions, disability rates, and expenditure for low back pain will continue to rise.”

A paper of this size and of this magnitude, and with the level of education of contributors honestly cannot be done complete justice by a review such as this. I admittedly hit the high spots. I am more focused in some areas than in others. More specific for some topics and more general in others. That is the nature of a summarization and I hope I am allowed that latitude.

If you are research minded, if you are a low back pain patient, or if you are a practitioner regularly coming in contact with low back pain patients, it is my opinion that taking the time to read these three papers yourself is of utmost importance.

Please find the links to the papers in the “References” section and get it done. Together, we can make a big, big difference in the lives of our low back pain patients. Without a doubt.

References:

Paper 1 – “What low back pain is and why we need to pay attention: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30480-X/fulltext

Paper 2 “Prevention and treatment of low back pain: evidence, challenges, and promising directions.”: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30489-6/fulltext

Paper 3 – “Low back pain: a call for action”: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30488-4/fulltext

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 leave a comment and tell me your thoughts. I’d love to hear what you think. And….SHARE, SHARE, SHARE!! We cannot make a difference without your help.
Till next time……

The Amarillo Chiropractor Blog is written by Dr. Jeff Williams.
Amarillo TX Amarillo Pain & Accident Chiropractic Clinic provides customized chiropractic care to the Amarillo TX, Canyon TX, Pampa TX, Happy TX, White Deer TX, Dumas TX, Groom TX, Conway TX, Panhandle TX, Claude TX, Clarendon TX, Borger TX, Tulia, TX, Hereford TX, Fritch TX, Bushland TX, and Vega TX communities.

Visit our main website at www.amarillochiropractor.com for customized Chiropractic in Amarillo TX. Choose several options to schedule your appointment: call (806) 355-3000 or click the button below for our contact info.

by Jeff S. Williams, D.C.

Chiropractors in Amarillo
Spinal Decompression Amarillo
Creek Stone Integrated Care
http://www.amarillochiropractor.com
http://www.creekstonecare.com




Review of The Lancet Article: Low Back Pain: A Major Global Challenge (Part One)

04/02/2018

chiropractor in amarillo tx

This week, we are going do a review of a recent paper published on low back pain that we hope will have a powerful impact in the months and years to follow.

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

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

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

We chiropractors are typically not sitting at the table when the bigger discussions or decisions are made so, thanks to research that has been done prior to this, we are in the thick of it now it seems. And that is exciting to say the least.

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

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

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

The papers were broken down as follows:

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

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

How They Did It

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

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

In order to ensure a high-quality standard, systematic reviews were shown preference for inclusion.

Summary of the introduction of the first paper.

  • Low back pain is now the leading cause of disability worldwide.
  • Only a small percentage have a well-understood, definite cause for their low back pain. Examples of well-known and understood causes are things like a vertebral fracture, malignancy, or infection.
  • Things that seem to raise the risk of having low back pain complaints would be populations that smoke regularly, people that have physically demanding jobs or routine jobs or jobs that keep them mostly sedentary throughout the day and throughout the work week, people with physical and mental issues that add to a low back complaint or contribute to a low back complaint, and overweight/obese people. These populations are all at risk for developing low back pain.
  • 540 million people were affected at any one time globally.
  • A systematic review (3,097 participants) found several MRI findings had a reasonably strong association with low back pain, including Modic type 1 change, disc bulge, disc extrusion, and spondylolysis. To further define Modic 1 changes, in regular vertebral endplate bone, the trabeculae should be like a type of scaffolding. Within the trabeculae there is red bone marrow producing blood cells. In a Modic type 1, the trabeculae are fractured intermittently and the patterns are more erratic and the marrow is absent. In the marrow’s place now is serum which is the same substance one can find in a blister.

Symptoms Associated With Low Back Pain

Radicular Pain and Radiculopathy

  • Radiculopathy is usually called sciatica and mostly occurs when there is involvement where the nerve root exits the spine.
  • The authors noted that the term sciatica is used inconsistently by doctors and the public in general and should probably be avoided all together.
  • The diagnosis of radicular pain relies on clinical findings, such as history of dermatomal leg pain, leg pain that is actually worse than the back pain, aggravation of the symptom when bearing down such as in coughing, sneezing, lying on your back and raising heels off of the table or in going from seated to standing, and straight leg raise test. The general rule of thumb for an SLR is that pain in the first 30 degrees of leg elevation hints at a disc origin, since that is the movement that first starts to tension the nerve at the root.
  • Radiculopathy is not just the feeling of pain. Radiculopathy can also be weakness, decreased sensation, decreased reflexes, or all of those combined. In addition they can be identified with, or without, the presence of pain.
  • Patients presenting with low back pain in addition to radicular pain or radiculopathy tend to have worse outcomes than those presenting with low back pain alone.

Lumbar Spinal Stenosis

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

Other Causes of Low Back Pain

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

Prevalence

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

Work Disability

  • Jobs are less-regulated in lower and middle income countries. Many times, employers and companies are unwilling to modify the job duties or the workload. As a result, having low back pain can be particularly concerning or difficult for an employee in these circumstances.
  • To go along with jobs that are poorly regulated, heavy manual labor has no regulation or proper safety instruction adding to low back pain injury instances.
  • In Europe, low back pain is the most common cause of medically certified sick leave and early retirement.
  • In the USA, low back pain accounts for more lost workdays than any other occupational musculoskeletal condition.

Social Identity & Inequality

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

Cost of Low Back Pain

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

Natural History

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

Risk Factors and Triggers for Low Back Pain Episodes

  • A systematic review (5,165 participants) found consistent evidence that people who have had previous episodes of low back pain are at increased risk of a new episode. Likewise, people with other chronic conditions, including asthma, headache, and diabetes, are more likely to report low back pain than people in good health.
  • A UK cohort study found psychological distress at age 23 years predicted incident low back pain 10 years later. The Canadian National Population Health Survey with 9,909 participants found that pain-free individuals with depression were more likely to develop low back pain within 2 years than were people without depression systematic reviews of cohort studies indicate that lifestyle factors such as smoking, obesity, and low levels of physical activity that relate to poorer general health are also associated with occurrence of low back pain episodes. We know that obesity and lack of exercise has become an American trait that needs to be reversed.
  • A systematic review found the genetic influence on the liability to develop low back pain ranged from 21% to 67%, with the genetic component being higher for more chronic and disabling low back pain than for inconsequential low back pain. Don’t we all have patients that present to us claiming that their bad back just runs in the family? Mom and Grandma had a bad back so that must be why they have a bad back is the common sentiment. It seems there may be a bit of validity there.
  • An Australian case-crossover study (999 participants) showed that awkward postures, heavy manual tasks, feeling tired, or being distracted during an activity were all associated with increased risk of a new episode of low back pain. Similarly, work exposures of lifting, bending, awkward postures, and tasks considered physically demanding were also associated with an increased risk of developing low back pain in low-income and middle-income countries.

Psychological Factors

The presence of psychological factors in people who present with low back pain is associated with increased risk of developing disability even though the mechanisms are not fully understood.

Social and Societal Factors

  • Cross-sectional data from the USA (National Health Interview Survey 2009–10, 5,103 people) found that those with persistent low back pain were more likely to have had less than high-school education and had an annual household income of less than US$20,000.
  • Suggested mechanisms for the effect of low education on back pain include environmental and lifestyle exposures in lower socioeconomic groups, lower health literacy, and health care not being available or adequately targeted to people with low education.
  • To go along with lower wages, the lower socioeconomic groups are commonly in routine and manual occupations and have increased physical workloads associated with disabling low back pain.

Conclusion

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

Source Material

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30480-X/fulltext

Authors

Steering Committee
Rachelle Buchbinder – Australia
Jan Hartvigsen – Denmark
Dan Cherkin – United States
Nadine Foster – UK
Chris Maher – Australia
Martin Underwood – UK
Maruits van Tulder – Netherlands

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 leave a comment and tell me your thoughts. I’d love to hear what you think. And….SHARE, SHARE, SHARE!! We cannot make a difference without your help.

Till next time……
The Amarillo Chiropractor Blog is written by Dr. Jeff Williams.
Amarillo TX Amarillo Pain & Accident Chiropractic Clinic provides customized chiropractic care to the Amarillo TX, Canyon TX, Pampa TX, Happy TX, White Deer TX, Dumas TX, Groom TX, Conway TX, Panhandle TX, Claude TX, Clarendon TX, Borger TX, Tulia, TX, Hereford TX, Fritch TX, Bushland TX, and Vega TX communities.

Visit our main website at www.amarillochiropractor.com for customized Chiropractic in Amarillo TX. Choose several options to schedule your appointment: call (806) 355-3000 or click the button below for our contact info.

by Jeff S. Williams, D.C.
Chiropractors in Amarillo
Spinal Decompression Amarillo
Creek Stone Integrated Care
http://www.amarillochiropractor.com
http://www.creekstonecare.com

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30480-X/fulltext




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

03/21/2018

chiropractic is more effective for back pain treatment than opioids

This week will be a bit of a mishmash of a couple studies but they will ultimately intertwine into a valid discussion. The papers we will go over cover Chiropractic preventative care ideas and research, and opioid vs. non-opioid research out of Minnesota and I’m going to issue a warning and maybe even a challenge.

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’ titled “The Underestimated Cost of the Opioid Crisis” put forth by the Council of Economic Advisers in November of 2017[1].

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

The authors of this paper wanted to test opioids vs. nonopioids over a time span of twelve months for function, pain intensity, and adverse effects.

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 NONaopioid group.
  • Adverse harms (bad side-effects) were significantly greater in the opioid group.

Wrap It Up

The authors’ conclusion 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.”

Again, I don’t wish to belabor the points 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 Physicians updated 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 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.

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.

Treatment recommendations aren’t always dependent on the date of injury. 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 http://www.chiropracticforward.com. The guides can be found in Episode #5 which can be found at this link: http://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 wellness care? The point being made is that there are a lot of different chiropractors. There are 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.

Then consider that there is a common chiropractic misconception by potential patients out there in the world that, if you go to a chiropractor, you will always have to go. For the rest of your life!

Of course, this is not true but, don’t chiropractors commonly recommend preventive or wellness 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 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 “preventative wellness” care in some sort of ongoing fashion.

There is research for preventative/wellness care. Take a paper from 2011 for example. It is by MK Senna, 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 maintenance chiropractic 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:
    1. 12 treatments of fake treatment for one month
    2. 12 treatments of chiropractic adjustments for a month only
    3. 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 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.”

Considering this research, it appears plausible, if not obvious, that chiropractic care in a long-term maintenance use, is indeed effective in treating patients with chronic low back pain.

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, 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 “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 leave a comment and tell me your thoughts. I’d love to hear what you think. And….SHARE, SHARE, SHARE!! We cannot make a difference without your help.

Till next time……

The Amarillo Chiropractor Blog is written by Dr. Jeff Williams.

Amarillo TX Amarillo Pain & Accident Chiropractic Clinic provides customized chiropractic care to the Amarillo TX, Canyon TX, Pampa TX, Happy TX, White Deer TX, Dumas TX, Groom TX, Conway TX, Panhandle TX, Claude TX, Clarendon TX, Borger TX, Tulia, TX, Hereford TX, Fritch TX, Bushland TX, and Vega TX communities.

Visit our main website at www.amarillochiropractor.com for customized Chiropractic in Amarillo TX. Choose several options to schedule your appointment: call (806) 355-3000 or click the button below for our contact info.

by Jeff S. Williams, D.C.
Chiropractors in Amarillo
Spinal Decompression Amarillo
Creek Stone Integrated Care
http://www.amarillochiropractor.com
http://www.creekstonecare.com

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.
  3. 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.
  4. 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.
  5. Baker G, Algorithms for the Chiropractic Management of Acute and Chronic Spine-Related Pain. Topics in Integrative Health Care, 2012. 3(4).
  6. 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.
  7. 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).
  8. The President’s Commission on Combating Drug Addiction and The Opioid Crisis. 2017.



Proven Means To Treat Neck Pain

02/28/2018

chiropractic for neck pain in amarillo texas

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 for neck pain when compared to low back pain.

This does not mean there isn’t great research in our favor. 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 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 on 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 measures 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, 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 leave a comment and tell me your thoughts. I’d love to hear what you think.And….SHARE, SHARE, SHARE!! We cannot make a difference without your help.

Till next time……
The Amarillo Chiropractor Blog is written by Dr. Jeff Williams.
Amarillo TX Amarillo Pain & Accident Chiropractic Clinic provides customized chiropractic care to the Amarillo TX, Canyon TX, Pampa TX, Happy TX, White Deer TX, Dumas TX, Groom TX, Conway TX, Panhandle TX, Claude TX, Clarendon TX, Borger TX, Tulia, TX, Hereford TX, Fritch TX, Bushland TX, and Vega TX communities.

Visit our main website at www.amarillochiropractor.com for customized Chiropractic in Amarillo TX. Choose several options to schedule your appointment: call (806) 355-3000 or click the button below for our contact info.

by Jeff S. Williams, D.C.
Chiropractors in Amarillo
Spinal Decompression Amarillo
Creek Stone Integrated Care
http://www.amarillochiropractor.com
http://www.creekstonecare.com

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/




It’s Here: New Guides For Chiropractic That Doctors Are Ignoring

02/23/2018

In this article, 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?

To start off the discussion, I would say that one 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.

In other articles, I have covered the Wilk vs. AMA case1,2. I’ve covered the Doctored film by Jeff Hayes that spotlights some of the mistreatment of chiropractors. I have 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 crisis3. One 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.

With all of the new information and new healthcare laws emerging, the questions going forward will 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.

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.” 4

On the American Chiropractic Association’s FAQ site for 27064, 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 the same as any other professional that provides that service. For instance, under the PPACA Section 2706 Federal Law, chiropractors are to be paid the exact same for a 99203 exam code as a doctor of medicine or osteopathy is paid. 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, it is 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.

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.

It is the American Chiropractic Association’s opinion that a violation exists if the insurer or plan denies specific forms of care that are 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 likely gets services such as non-surgical decompression covered under insurance, but chiropractors are routinely denied coverage.

There is also a possible violation when doctors of Chiropractic 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. There is a local insurance network that charges $200 per year for chiropractors to be included for coverage, but medical professionals pay nothing to be included. Could that be a violation of the nondiscrimination law?

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.

New Recommendations For Acute and Chronic Low Back Pain

Now, I would like to move on to the medical field’s updated recommendations I mentioned at the first of this article. 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. It is my opinion that no long-held beliefs or protocols will change if new information is not continually pounded and yelled about from the top of the roofs. In marketing, experts have said that it takes a target 7 times of being exposed to information before it is 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 had heard 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.

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 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.

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 information5. 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.

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.

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. al6. 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.”

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 1,699 patients, showed moderate-quality evidence that chiropractic adjustments had a statistically significant association with improvements in PAIN.
  • 12 of the RCTs, totaling 1,381 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 events 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.

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, where the AMA is 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.

We Should Be All Set For Success Now, Right?

That is what you would think but there is new information from the White House that this simply is not the case despite the obvious ramifications. On page 57 of The President’s Commission On Combating Drug Addiction and The Opioid Crisis7 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.”

Essentially, the United States Government is admitting there is professional discrimination at the highest levels (Medicare and health insurance plans) that 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.

How 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 will not begin enforcing it on their own. Mobilization and unification of the Chiropractic profession is likely the first step.

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.

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

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 leave a comment and tell me your thoughts. I’d love to hear what you think.And….SHARE, SHARE, SHARE!! We cannot make a difference without your help.

Till next time……

The Amarillo Chiropractor Blog is written by Dr. Jeff Williams.
Amarillo TX Amarillo Pain & Accident Chiropractic Clinic provides customized chiropractic care to the Amarillo TX, Canyon TX, Pampa TX, Happy TX, White Deer TX, Dumas TX, Groom TX, Conway TX, Panhandle TX, Claude TX, Clarendon TX, Borger TX, Tulia, TX, Hereford TX, Fritch TX, Bushland TX, and Vega TX communities.
Visit our main website at www.amarillochiropractor.com for customized Chiropractic in Amarillo TX. Choose several options to schedule your appointment: call (806) 355-3000 or click the button below for our contact info.

by Jeff S. Williams, D.C.

Chiropractors in Amarillo
Spinal Decompression Amarillo
Creek Stone Integrated Care
http://www.amarillochiropractor.com
http://www.creekstonecare.com

References and Source Material

    https://www.amarillochiropractor.com/startling-medical-professional-attacks-chiropractic/

    https://www.amarillochiropractor.com/healthcare-in-texas-the-battle-against-a-monopoly-a-true-story-about-david-goliath-3/

    https://www.whitehouse.gov/sites/whitehouse.gov/files/images/The%20Underestimated%20Cost%20of%20the%20Opioid%20Crisis.pdf

    https://www.acatoday.org/Portals/60/Docs/Advocacy%20and%20Reimbursement/2706/2706-FAQs.pdf?ver=2015-12-23-125425-503

    http://annals.org/aim/fullarticle/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice

    https://jamanetwork.com/journals/jama/article-abstract/2616395?widget=personalizedcontent&previousarticle=2616379

    https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Final_Report_Draft_11-3-2017.pdf




Surprise Unique Information Shows Chiropractic Works On The Brain Too

02/13/2018

In today’s article, we’re going to talk about how chiropractic affects the brain itself rather than how it affects just the musculoskeletal system.

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

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

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

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

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

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

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

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

Why They Did It

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

How They Did It

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

What They Found

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

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

Wrap It Up

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

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

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

Why The Did It

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

How They Did It

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

What They Found

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

Wrap It Up

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

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

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

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

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

Just another reason to call a chiropractor TODAY!

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 leave a comment and tell me your thoughts. I’d love to hear what you think.And….SHARE, SHARE, SHARE!! We cannot make a difference without your help.

Till next time……

The Amarillo Chiropractor Blog is written by Dr. Jeff Williams.
Amarillo TX Amarillo Pain & Accident Chiropractic Clinic provides customized chiropractic care to the Amarillo TX, Canyon TX, Pampa TX, Happy TX, White Deer TX, Dumas TX, Groom TX, Conway TX, Panhandle TX, Claude TX, Clarendon TX, Borger TX, Tulia, TX, Hereford TX, Fritch TX, Bushland TX, and Vega TX communities.

Visit our main website at www.amarillochiropractor.com for customized Chiropractic in Amarillo TX. Choose several options to schedule your appointment: call (806) 355-3000 or click the button below for our contact info.

by Jeff S. Williams, D.C.
Chiropractors in Amarillo
Spinal Decompression Amarillo
Creek Stone Integrated Care
http://www.amarillochiropractor.com
http://www.creekstonecare.com

Sources:

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

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

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

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

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




Startling Medical Professional Attacks On Chiropractic

02/09/2018

In today’s edition, we’ll be talking all about current and past attacks on our profession by the medical field heavy weights…..what’s at risk and why. In addition, we’ll be sharing some personal opinions, some facts, and some research.

If you’ve seen our videos before, then you know this is where we talk about issues related to health, chiropractic, evidence, and research and how those things all fit into a comprehensive approach for treating different conditions. Thank you for taking time out of your day to give us a read. I know your time is valuable and I will always try hard to fill our time with valuable content.

Right off the top today, I want to say that Dr. Tom Hollingsworth from Corpus Christi, TX was instrumental in helping with this edition and he is our guest on the Chiropractic Forward podcast Episode #9, where we spend about an hour discussing all of this. So, go listen to Episode #9 at www.chiropracticforward.com or on iTunes for the words straight from Dr. Hollingsworth’s mouth.

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

I can only hope that all chiropractors in practice are well-aware of the trials and tribulations this amazing profession has not only been through, but overcome and grown from as a result. It is profound. The unfortunate reality is that most do not know and, if they do, they normally lack any important details to truly place their knowledge in the correct context.

As a former board member of the Texas Chiropractic Association myself and a current member of the leadership statewide, I am intimately aware of many of the issues, both current and historical.

And I think, from the top here, it’s important to say that, even though I am a TCA member and leader, my opinions may or may not represent the opinions of the TCA, but I am NOT representing the TCA in this capacity.

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

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

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

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

It’s funny to me that things have progressed to the point now that two of those organizations came out last year in support of Chiropractic for the treatment of acute and chronic and low back pain – the American Medical Association and the American College of Physicians.

You’d think winning the Wilk vs. AMA case would have put the battle to rest right? Well it didn’t. The Texas Medical Association has been historically more aggressive in their continuing battle to rid the world of the scourge of chiropractic. The TMA’s political arm has attacked chiropractors running for office as quacks and as being no different than Dr. Pepper or Dr. Jekyll. The TMA sent out direct mail to the voting districts with that message. Just a couple of years ago people! It’s real, it’s hate, and it’s NOW!

The worst part is that the TMA….or Evil Empire…Originator of the Opioids…..they raised over $400,000 in one dinner just a year or so ago. And they know that the Texas Chiropractic Association cannot raise that sort of money so, because they can, the attacks keep coming and the rights keep getting chipped away at while we play defense rather than offense. Wouldn’t it be nice if we could just co-exist some day? If research and evidence mattered, we could, but that would mean releasing some control on their Monopoly and the TMA is there to protect their members. That’s it. They don’t exist to protect the patient. That’s the Texas Medical Board’s job. The TMA is there to keep ANY other health profession from expanding their scope into their territory. In fact, if they can just get rid of the professions they cannot control….that’s the BIG IDEA there, folks, and you need to understand it, receive it. Feel it.

The TMA sued Texas Chiropractors challenging their right to diagnose a patient. Can you imagine? The nerve of these people. Down in Austin, Judge Rhonda Hurley ruled against chiropractors, agreeing that we cannot diagnose, but more on her later. Texas Chiropractors appealed and won the appeal. The TMA appealed that and the Supreme Court of Texas finally ruled in favor of the Texas Chiropractors after 7 years of a legal battle. You’d think that would put things to a rest right? Nope. Not with the TMA.

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

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

That stuff isn’t enough, though. The TMA decided they don’t want Texas Chiropractors doing VONT testing. VONT stands for vestibular ocular nystagmus testing and neuro diplomates, only after significant extra training, are allowed to perform VONT. Not good enough for TMA since it’s messing with their territory. Since the TMA is only interested in total destruction, they saw a chance to amend the original suit and now, the suit threatens not only VONT, but also the subluxation complex, the term “Neuro” as it fits in neuromusculoskeletal, and….yes….somehow they have found a way to include our right to diagnose again. Even though we already won that case. You cannot make this stuff up folks. Chiropractors treat nerves, muscles, and bone but they don’t want “neuro” in the description. That’s really what part of the suit is. They just want chiropractors treating the musculoskeletal system. That’s it. I think the winner here is the TMA’s attorney honestly because this stuff is absolutely absurd. Or so one would think. That same Judge, Rhonda Hurley down in Austin got hold of this second case and guess what….she ruled against Texas Chiropractors once again. I think she’s either a Chiropractic hater, or she’s in the TMA’s pocket somehow, or she has a family member that is a medical doctor, or she just doesn’t understand the material very clearly. Who knows the reason?

Regardless, Texas Chiropractors get to appeal this case. Aren’t we lucky? Hopefully, the appeals court is as reasonable as the last appeals court we had to go through. But, for now, we are most definitely in jeopardy.

I’d like to take just a second to direct everyone to an excellent video on YouTube that the Texas Chiropractic Association published about a year and a half ago concerning a lot of this. The link will be in the description below, but you can also find it by going to YouTube search and entering the term “The Texas Chiropractic Defense From The Texas Medical Association A Timeline.” This ten minute video sums up what kind of constant attacks our profession is STILL enduring today. If you think you’re just showing up for work and humming along, and everything is rosy and there’s a rainbow above your office, you’re mistaken. Danger lurks at all points and even if we chiropractors in Texas win, they’ll keep coming back for more. Vigilance, being knowledgeable, and being active are the keys to continuing to enjoy your professional privileges.

The best thing we can do at this point is to stress to you all the need for you to understand the gravity of the situation here in Texas for the Chiropractic profession. Everyone knows that what happens in Texas with over 5,000 chiropractors in it will happen elsewhere. In fact, the TMA’s attorney, Mr. Bad Bragg, has previously stated that if they can get the domino to fall in Texas, he has 7 or so other states ready to follow suit, and then on and on. So, if you think this doesn’t affect you, you are incorrect. Dead wrong. Wake up. It’s bigger and badder than you.

We also know that an appeals process is expensive and it takes everyone, all chiropractors, to fight the powers we are up against.

If you would like to donate and be a part of this victory, I would direct you to the TCA, since they are leading the way on this. You can also go to www.chirotexas.org/cdi, which is a fund that pays for the appeals process, so you’ll know it’s going to the right place to help the most.

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 leave us a comment 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 some of my other blogs and videos, check out my podcast called Chiropractic Forward which you can find at www.chiropracticforward.com. As the 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. And….SHARE, SHARE, SHARE!! We cannot make a difference without your help.

Till next time……

The Amarillo Chiropractor Blog is written by Dr. Jeff Williams.
Amarillo TX Amarillo Pain & Accident Chiropractic Clinic provides customized chiropractic care to the Amarillo TX, Canyon TX, Pampa TX, Happy TX, White Deer TX, Dumas TX, Groom TX, Conway TX, Panhandle TX, Claude TX, Clarendon TX, Borger TX, Tulia TX, Hereford TX, Fritch TX, Bushland TX, and Vega TX communities.

Visit our main website at www.amarillochiropractor.com for customized Chiropractic in Amarillo TX. Choose several options to schedule your appointment: call (806) 355-3000 or click the button below for our contact info.

by Jeff S. Williams, D.C.
Chiropractors in Amarillo
Spinal Decompression Amarillo
Creek Stone Integrated Care
http://www.amarillochiropractor.com
http://www.creekstonecare.com
http://www.chiropracticforward.com

Show Note resources

  1. http://www.chiro.org/Wilk/
  2. https://jamanetwork.com/journals/jama/article-abstract/2616395
  3. https://www.amarillochiropractor.com/healthcare-in-texas-the-battle-against-a-monopoly-a-true-story-about-david-goliath-3/
  4. The Texas Chiropractic Defense From The Texas Medical Association A Timeline.
    https://youtu.be/XHGfAQwIqNo



Brand New Information Based on Results Chiropractic Proven Effective For Low Back Pain

01/31/2018

chiropractic care helps with low back pain

This entry is all about chronic low back pain. By now, as I’ve said in the past, even traditional Chiropractor-hating, quasi-scholastic detractors are admitting that, yes, Chiropractic is indeed helpful for low back pain.

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, and mobilization are so incredibly effective above and beyond anything else for this sort of issue, including medication.

I have overheard medical doctors (more than once) talking about having back pain and just injecting themselves with something to try to get over it. I would argue that they are simply covering an underlying trigger or cause and ignoring it is to their detriment. It’s my opinion that medication for neuromusculoskeletal complaints is akin to 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.

Here are some low back pain statistics:

  • 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.

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:

  • 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.
  • 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 waist level.

What does the research say?

The research says a lot, to be honest. In fact, there is more research for the effectiveness of manipulation/mobilization in low back pain than for any other conditions chiropractors commonly treat. The research shows Chiropractic beating general practitioners in effectiveness as well as cost. The research also shows Chiropractic beating common medications prescribed for low back pain. It shows Chiropractic beating physical therapy alone. and Chiropractic beating epidural spinal injections for low back pain. 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.” Spine Journal sounds a little bit like it may be a Chiropractic publication, but it is not. Spine Journal is one of the most highly respected research journals available and is widely read by orthopedic surgeons, neurologists, and just about any other practitioner interested in the spine. This project was funded by the National Center for Complementary and Integrative Health.

Why They Did It

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 but it seems that these authors did.

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 trials of manipulation 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 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.

Just another reason to call a chiropractor TODAY!

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 leave a comment and tell me your thoughts. I’d love to hear what you think.And….SHARE, SHARE, SHARE!! We cannot make a difference without your help.

Till next time……

The Amarillo Chiropractor Blog is written by Dr. Jeff Williams.
Amarillo TX Amarillo Pain & Accident Chiropractic Clinic provides customized chiropractic care to the Amarillo TX, Canyon TX, Pampa TX, Happy TX, White Deer TX, Dumas TX, Groom TX, Conway TX, Panhandle TX, Claude TX, Clarendon TX, Borger TX, Tulia TX, Hereford TX, Fritch TX, Bushland TX, and Vega TX communities.

Visit our main website at www.amarillochiropractor.com for customized Chiropractic in Amarillo TX. Choose several options to schedule your appointment: call (806) 355-3000 or click the button below for our contact info.

by Jeff S. Williams, D.C.

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




Jeff Williams, DC


Serving the Panhandle for 15 years, and spending several of those years as an Amarillo chiropractor, Dr. Williams has seen it all with conditions ranging from various car wreck or auto injury to whiplash, scoliosis, herniated discs, sciatica, neck “cricks” and pinched nerves, neck pain, back pain, and low back pain, to migraines and sports injuries. I have a dream job in a dream practice where we get to help people on a daily basis. We have been very fortunate and truly blessed.


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