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Chiropractic Care

MRI for Back Pain: Which Back Pain Doctor Uses the Evidence?

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Everyone wants an MRI for back pain. Society teaches us that more information is better, but which type of back pain doctor actually uses MRIs most effectively?

In interests of full disclosure…I’m a chiropractor. But, in my defense, what I’m about to say is not hearsay. The evidence of chiropractic care’s effectiveness and “correctness” continues to mount. Although at times we seem to remain at the bottom of the insurance company totem pole, I do believe that the future remains very bright for those of us that can survive the current storm of shrinking reimbursements despite high value care.

The term “high value care” is probably the best description of what we have to offer. Orthopedics is the highest cost driver for almost every insurance company. Within this, non-surgical spinal care is the biggest chunk. Costs in this category include providers (chiropractors, primary care, internists, physical therapists, neurosurgeons, orthopedic surgeons and a few others), medications, injection-type therapies (think epidurals) and imaging.

Ah yes. Imaging. MRIs. CT scans. X-rays.

Evidence be damned–we still hand out prescriptions for these like candy on Halloween.

Strong evidence links CT scans with thousands of cancer cases from radiation and yet their use in the emergency room setting has not changed.

Despite evidence against their use, 20% of primary care doctors hand out opioids for uncomplicated low back pain.

The standard recommendation for a course of 3 epidurals is not backed by evidence (but costs thousands of dollars for the series). Worse, evidence suggests it may cause more harm than saline injections.

Even early use of pain medication or anti-inflammatories can create a chronic problem out of an acute one.

Back to the imaging topic.

Ever since medicine has relied more and more on advanced imaging like CTs and MRIs, our physical exam and history taking has been getting worse and worse. In all honesty, in many cases, the evidence of involvement of a disc bulge or spinal stenosis can be determined without imaging. I know that in our office we are very conservative with ordering additional imaging.

However, patients seem to want the results from an MRI for whatever reason. Maybe it’s because they think that an MRI will give a definitive answer to what is wrong with them. (Not true–the only thing that will give an absolute answer to what is going on with your back is an autopsy, something we try to leave as the last resort)

After all, an MRI is harmless, right?

Very, very wrong.

The evidence that MRIs can create harm when ordered inappropriately is plentiful:

Clearly an MRI needs to be ordered only when appropriate. The alternative is not only a waste of money and time, but come with an increased risk of something being done that doesn’t need to be done.

This particular study looks at what happens with MRI ordering within the context of a workplace injury. Researchers looked at what factors increased the risk of an injured patient getting an MRI within the first 6 weeks (termed an early MRI). The results are pretty much exactly what I would expect:

  • 20% of the injured patients received an early MRI
  • Initial visit type with a surgeon was associated with 78% greater likelihood of an early MRI than that with a primary care physician
  • Having a chiropractor as the initial provider saw a 47% lower chance of an early MRI compared to a primary care physician

I DID clearly state in the beginning that I had a bias towards the chiropractic treatment of the injured worker, but it’s hard not to see my side of the story. Overall, getting an early MRI in the absence of certain red flags increases the risk of procedures like epidurals and surgery that may not be needed.

The bottom line is, according to this study, sending an injured worker to the chiropractor first, before a PCP or surgeon, results in a much lower rate of an inappropriate MRI being ordered which may lead to undesirable and unnecessary invasive procedures.

If you have been injured at work in the past, what type of provider did you see initially and how did that overall experience go?

CASE SERIES OF ROLLER COASTER INJURIES – (12-12-05)

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Significant Spinal Injury Resulting From Low-Level Accelerations: A Case Series of Roller Coaster Injuries

Obviously, being a chiropractor, this article hits home with me. We hear it over and over again, that patients that were in minor accidents couldn’t have been injured. This just isn’t true and the insurance companies know it because THEY are the ones that ran the studies to show injuries do occur at low speeds!! How’s that for hypocritical? The thing to look at is not only the acceleration/deceleration, but how fast that occurs. Sitting down into a chair may involve to same deceleration, but it occurs over a much longer period of time than a motor vehicle accident or a roller coaster.

Read entire article here

Chiropractic And Wellness Center for Frozen Shoulder Symptoms

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Shoulder pain sucks. Work, sports and even sleeping are affected. But is visiting a chiropractic and wellness center for frozen shoulder symptoms a good idea?

Before we answer that question, we need a little overview.

The human shoulder is capable of a wide degree of movement. Unfortunately, this comes with a price– the shoulder is very prone to injury. Couple this with poor posture, prolonged periods of time sitting in front of a computer and sedentary lifestyles and you begin to understand why shoulder problems are so common.

At the far end of the spectrum of shoulder problems is a condition referred to as frozen shoulder, aka adhesive capsulitis.  Frozen shoulder occurs from avoiding motion in a painful shoulder.  Shoulders love to move.  Less moving = less movement.  Ultimately, you realize that you’ve lost a large chunk of the movement your shoulder used to be able to perform.

At this point, procedures such as manipulation under anesthesia may be a good option.

Before patients develop frozen shoulder, they are often given a diagnosis of tendonitis and / or bursitis.  The “itis” component means that inflammation is present and creating the pain.  But, when looked at under a microscope, inflammation is not often present.

So what gives?

“Tendonosis” is the description that more likely fits your shoulder condition.  This is NOT an inflammatory condition, and so anti-inflammatories and most prescriptions will have little effect.  As a matter of fact, using anti-inflammatories at this point may very likely make things worse.

The “osis” in tendonosis is a Latin word for pathology (in other words, something is just not normal).  So, tendosis refers to the presence of scar tissue within the tendons of the shoulder.

When we suffer any type of injury, there is inflammation created.  This can occur easily:

  • As a result of a sports injury
  • An injury that occurs every so often from home improvement projects
  • As a repetitive stress that occurs on a daily basis such as computer work.

What about other things that you do on a daily basis that you may not factor in to your shoulder problem?  Like sleep..

This particular study looked at sleeping side of people who had one sided shoulder pain.  Researchers found that the side that was bothering the patient was more likely to be the affected side.  Leads to a potentially very simple therapy–switch sides of the bed…

So what happens after this injury?

  • As the body heals from an injury, it will not heal at 100%
  • Scar tissue forms
  • Scar tissue is more prone to re-injury, recycling the process and depositing more and more scar tissue as time goes on
  • Given enough time, tearing of weakened scar tissue portion of the rotator cuff tendons becomes much more likely, and even quite common.

As a matter of fact, a large percentage of women over 50 have rotator cuff tears that they aren’t even aware of (meaning they are pain-free rotator cuff tears).

For this reason, just because an MRI shows a tear does not mean that it wasn’t already present before you painted that ceiling last weekend.  That means that it is likely that a rotator cuff tear may have been present even before an injury, and that an injury just worsened what had been present for a long time.

If tendonosis with scar tissue is present, no amount of rehab stretching and strengthening, ultrasound, massage or interferential will change that.  Unless the scar tissue is addressed the shoulder isn’t really fixed. Tendonosis requires a different soft tissue approach.

So what can be done?  Luckily, there are many things that can be done to help with your shoulder pain.

  1. Studies have should that chiropractic manipulation can speed along recovery.
  2. Advanced soft tissue techniques like Graston technique can help address the scar tissue.
  3. Facial Manipulation
  4. Prolotherapy
  5. And, as mentioned early, try switching the side of the bed you sleep on to reduce chronic stress on the affected shoulder.

So what did you do that helped your shoulder pain the most?

ROLE OF LIGAMENTS AND TENDONS IN OSTEOARTHRITIS – (12-27-06)

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Combined high-resolution magnetic resonance imaging and histological examination to explore the role of ligaments and tendons in the phenotypic expression of early hand osteoarthritis

As a chiropractor that has a strong focus on the soft tissue component of musculoskeletal health, I found this article rather intriguing.  Basically, whenever they looked at arthritis in the small joints of the hand, those areas that had ligaments with pathological changes (basically scar tissue and thickening) had more arthritis.  While no one study confirms anything, this articles does lend support to those physicians focusing much more strongly on how much the soft tissues contribute to long term joint health.

Read entire article here

Insurance Premiums Go Up? Blame Your Chiropractor

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This blog is designed to educate us on improving our health and avoiding the pitfalls of modern medicine. This past week I flew over the edge about something else.

I received an explanation of benefits (EOB) from one of the largest insurance companies (who shall remain nameless) this week.  An EOB goes over what our office had billed for services, how much the insurance companies allows, how much they paid and how much the patient owes us.

Now, receiving an EOB is nothing new.  Our office gets them all the time.  But last year things changed drastically.

Before I describe the changes, you need a little more info as way of background.

I sit on a provider advisory panel for another very large insurance company.  They have very clear data that, if a chiropractor is the first person seen for any type of musculoskeletal complaint, we save around 30% (don’t quote me on the 30%–but I’m in the ballpark..).  That could potentially mean billions of dollars in savings to this insurance company annually if everyone saw a chiropractor first.

There are now multiple studies that confirm these findings: chiropractic care is safe, saves money and patients are very happy with their care in our offices.  But, much like every other profession, we have those in our ranks that have some integrity issues.  Here in AZ, much of this centered around billing issues, and, from the information I had been able to gather, it was about 5% of chiropractors that were billing way out of line with their peers.

Billing for massage inappropriately was a biggie.  I mean seriously–who would NOT overuse massage therapy if your insurance was paying for it???  But insurance will only pay for massage under some very detailed scenarios, and this is not what was being billed out.

In a perfect world, we would’ve round up a modern day posse and drilled these 5% on their billing behaviors.  Maybe they really did have a unique practice that meant they were billing out of line with the other 95% and their treatment notes would’ve held up to scrutiny.  Most likely not, though…

Certainly, these outliers were costing this particular insurance company more money.  But in the scheme of things, chiropractic reimbursement is a drop in the bucket.  As an example of waste billed in other professions:

  1. More complex spinal surgeries billed to Medicare for $50K more than simple surgeries went up 1500% in 5 years with worse outcomes
  2. Half of the $50,ooo procedures for putting a stent in the heart (in a non-emergency situation) were unecessary
  3. Statins like Lipitor and Crestor are just short of worthless, and yet cost society tens of billions per year

Either one of these alone exceeds the entire amount reimbursed to the chiropractic profession annually.  In other words, we are such a drop in the bucket cost wise that just the cost of any number of these abuse situations in other aspects of medicine would pay for every chiropractic claim in a year.

Despite this drop in the bucket, we add tremendous value to the system far out of proportion to our direct costs.  Our office alone is frequently instrumental in getting patients to change unhealthy habits that will save tens of thousands of dollars for that patient alone.

So back to the story..

Instead of the posse, two of the biggest insurance companies decided to hire a middleman company to manage their chiropractic claims beginning in 2011.  Additional paperwork and massive blunders by the middleman company aside, the bottom line is that the contract with this middleman company paid chiropractors in Arizona, on average, 50% less.

Much like every other chiropractic office in Arizona last year, our office took a massive hit.  Also, like every other chiropractic office in Arizona, we absorbed almost every dime of this loss so that patients wouldn’t be provided with less care or worse outcomes even if we were no longer getting paid for it (a perfect example–orthotics for the shoes to help people with foot, ankle, knee or low back pain are reimbursed at LESS than the actual cost of the orthotics!!  This means that it costs our office money to provide this needed device to patients).

So how does this relate to my recent EOB that I received?

You see, this is clearly discriminatory towards chiropractic care for some strange reason.  We are the only provider group that has to use a middleman to manage our claims and take a huge chunk of our money.

Ironically, in AZ this is actually against statute (Unfair Claims Practice Act, ARS 20-461), but the Director of the Dept of Ins wasn’t really interested in getting the problem fixed when asked under oath in court.

Worse, the allowed amount that this particular insurance company now pays dropped massively only for those codes typically billed for by a chiropractor.  Evaluation and management codes (referred to as E/M codes–they are the codes that are attached to the initial exam of a new patient or an existing patient that comes in with a new problem) which are billed by all groups of physicians (not just chiropractors) were NOT TOUCHED.

So when I saw this EOB and saw the E/M code reimbursed at it’s normal level, but the other codes that our office typically bill were hacked to pieces, the discrimination was smacking me upside the head more so than at any point in the past.

Where do you come in?  Remember that I said that the EOB also describes how much YOU owe?  Since your insurance company (if you are insured with one of these two that moved to using a middleman in 2011) now pays less, YOU OWE MORE.

Let me put this in clearer language.  Nothing changed.  You still get the same great service you always have gotten.  But now, the insurance company is saving mass amounts of money on chiropractic services by hiring a middleman, AND you have to pay more!!

I think one of the reasons why this EOB hit me so hard now (rather than over the past 1.5 years) is that I also happen to be insured by this particular insurance company.  I have never filed a claim.  Never missed a payment.

I just got notice that my premium is jumping 13%.

It must be because of all those damn chiropractors getting paid 50% less…

So, now that you know that insurance companies are slasihing costs everwhere, have you noticed your premiums and out of pocket costs going down?

Healing Yoga is Bad for Chiropractors

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Most patients are in my office because they’re locked up. Muscles, ligaments, tendons and joints just aren’t moving. Anything that stimulates movement is good.

This is why exercise and chiropractic can be so powerful for so many.  Because we take areas on a patient in pain and help them move better.  It really can be put into that simple of terms.  This is why yoga is so dangerous for a chiropractic practice.  Of course, our office still recommends yoga heavily.  After all, our main goal is to destroy our practice by having patients do everything they need to do outside of the office so that they no longer need us.  Unfortunately not likely to happen, it still remains a primary goal for every patient that enters the office.

As I mentioned, so many patients are experiencing pain because they just don’t move.  We live in a sedentary society both at work and at home.  If we exercise, many opt for a linear aerobic exercise like the elliptical, treadmill or stair-climber.  These lock us into a specific movement and really don’t fully allow our bodies to move.  Weight training is not too much different.  We isolate a muscle and work out that muscle to make it grow bigger.  Again–this does not take our bodies through full ranges of motion.

Activities like the martial arts (my personal choice), hiking (second choice), tennis and racquetball require your body to move in unrestricted patterns.  THIS is what we need to stay healthy and pain free.  So where does yoga fit in?

Perfectly.

This particular study demonstrates just how effective yoga can be at controlling pain.  Here are the details:

  1.  Researchers looked at 6 studies
  2. These included back pain, rheumatoid arthritis, headache/migraine were the most common
  3. All studies reported positive effects in favor of the yoga interventions
  4. With respect to pain, the overall improvement was 26%
  5. For pain-related disability, overall improvement was 21%

Not too shabby overall considering the safety of yoga.  In addition, none of these address the potential stress reduction that can occur with yoga as well, which would have benefits far beyond pain and disability.

So, if you are dealing with chronic pain issues, make sure you combine your visits to your chiropractor with regular yoga sessions to get the best benefits.

What type of yoga do you find the best for your body and mind?

HOW DO YOU MANAGE ACUTE LOW BACK PAIN? – (02-13-06)

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Physicians’ Initial Management of Acute Low Back Pain Versus Evidence-Based Guidelines

This is one of those articles that, as a chiropractor, really gets to me. We are frequently called quacks and non-evidence based. Unfortunately, it appears that no one has the ability to throw any stones.

However, given that many studies have now shown that chiropractic care is a more cost effective approach, we can begin to see why. I know I have patients come into my office with a simple case of LBP that’s pretty clear cut, and yet they have X-rays and MRI in tow when they come in. Talk about expensive care!!!

Read entire article here

Warning–That Episode of Low Back Pain Will Likely Be Back

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As a chiropractor, this issues hits near and dear to my heart.  When someone develops an episode of low back pain for the first time in their lives, one of three things happens.  The patient ignores it hoping it will go away.  Or, they see a non-chiropractor (PCP, ortho, PT, massage therapist, etc..) for that episode.  Or, they choose to see a chiropractor.
Which one you choose may well determine what happens for the rest of your life.

The prevailing wisdom states that most cases of acute low back pain will resolve spontaneously within 4-6 weeks.  And that’s it.  No more worries.

However, what do many people do in this situation?  The typical response may include rest, maybe some ice and some type of over the counter analgesic.  If it’s not better in a few days or weeks, a trip to urgent care, the ER or the primary care physician may result with a high likelihood of these getting a morphine derivative prescription inappropriately (such as Percocet, hydocodone or Vicodin).

Let me relay a personal experience that happened recently.  My 10 year old pug got pushed down an entire flight of stairs by my 55 pound muscled pit bull mix.  I watched in horror as he literally rolled end over end and crashed on the landed.  He could barely move.  I immediately picked him up and settled him down, but he was having much difficulty with walking on both back legs and his right front leg.  Not good.  Xrays were imminent if this did not resolve quickly.

No ice.  No OTC pain meds.  I did adjust him that night.  He also refused to sit still and continued to follow me through the house as he normally did.

Within 3 days you’d have no idea anything had happened to him.

How would most of us have handled a tumble down a full flight of stairs?  Quite differently, I’m sure.  But how much of our “typical” behaviors following an episode of low back pain actually promote chonicity?  This particular study sheds some light on how untrue our assumptions about what happens to those who suffer their first episode of low back pain are.

In this study of 605 patients who sought care for an episode of acute low back pain:

  1. 8% declared sick leave
  2. 13% experienced chronic pain at 6 months
  3. 19% experienced chronic pain at 2 years
  4. At 6 months, 54% had experienced at least 1 LBP recurrence
  5. Another 47% had experienced at least one flare up in the next 18 months

These are not good numbers.  This is my personal opinion based on my own experience, but I feel that these numbers are so high because there was no actual treatment designed to address the problem.  Anti-inflammatories do not address the problem (after all–did you have inflammation and THEN an injury?) and are very, very likely to make it worse because they interfere with the normal healing process.

Rest is extremely bad for acute episodes because it allows any injury to the fascia to thicken and perpetuate the dysfunction.  Although the pain goes away, the changes to the fascia are sitting there, just waiting for the next “wrong” movement.

The answer?  Get into your chiropractor ASAP.  This is not my opinion as the evidence suggests that this produces better outcomes.  Get treatment that includes soft tissue methods combined with adjusting to address all aspects of your condition and get back to activity as quickly as possible.  Make sure you’re in the OTHER 50%…