El Paso Back Clinic & Integrative Functional Wellness Team.
Chiropractic Doctors provide preventative care to help establish healthy habits in patients at all stages of their lives. For example, posture analysis can help identify posture habits that can greatly impact overall health, including energy levels, breathing, stress, and sleep. Chiropractic medicine is a form of integrative medicine that focuses on natural, non-invasive, evidence-informed practices of disease prevention and health promotion.
Through a broad scope of assessment and treatment modalities such as manipulation, functional medicine, physical rehabilitation therapy, targeted nutritional and botanical care, acupuncture, and diet/lifestyle management, chiropractic medicine can effectively treat a wide range of conditions and improve overall health. Functional Nutrition focuses on optimizing cellular and metabolic function for optimal health. Functional Medicine Practitioners specialize in helping uncover the root causes for imbalances that may be contributing to past, current, and even future conditions.
The information herein is not intended to replace a one-on-one relationship with a qualified healthcare professional or licensed physician and is not medical advice. We encourage you to make your own health care decisions based on your research and partnership with a qualified health care professional.
Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. In addition, we provide and present clinical collaboration with specialists from a wide array of disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure.
We use functional health & wellness protocols to treat and support care for the injuries or disorders of the musculoskeletal system. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and support, directly or indirectly, our clinical scope of practice.*
Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. In addition, we provide copies of supporting research studies available to regulatory boards and the public upon request.
We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900.
Functional Medicine Doctor Explains Women’s Hormones
We discussed the basics for men�s hormones. Now let�s discuss the basics for women�s hormones. Unfortunately, the effects of our diet and our environment become more obvious in the anatomy and biochemistry of women. These may frequently manifest as hormone imbalances and they can greatly affect their quality of life. Mood disorders have become an epidemic.
By way of instance, depression affects 20 percent of women, about twice as much in women than in men. And premenstrual syndrome, or PMS, affects between 60 and 75 percent of women in the United States. Infertility is also an epidemic which affects more than one in seven couples and it is generally managed by reproductive endocrinologists through invasive procedures, hormone treatments, and in vitro fertilization, or IVF, often without even evaluating what is the cause of the reproductive health issues. I�ve helped many women improve their hormone imbalances through the basic principles of functional medicine.
Now, these are only several of the reasons why we need to determine the source of hormonal imbalances in women. And I believe this knowledge can help women find the answers they need to improve their overall health and wellness. Most importantly, you need to learn to listen to what your body is telling you. After all, the human body is one of the best doctors.
Taking Control of Women’s Hormones
Women�s hormones are much more complex than men�s hormones because they�re constantly changing based on their cycle as well as on their stage of life. If you�re experiencing mood swings, irregular cycles, menstrual pain, heavy bleeding, infertility, weight gain, and brain fog, functional medicine can help improve your symptoms by balancing your hormones.
So, let�s discuss the differences between pre-menopausal women and post-menopausal women. Pre-menopausal women should experience regular cycles every 28 days that last two or three days without a lot of pain, not too heavy bleeding, and no PMS. However, most women don�t experience regular cycles. A proper nutrition consisting of low sugar and starch, high fat, and more fiber can help correct abnormal cycles. A plant-rich diet can also help improve abnormal cycles. Caffeine and alcohol consumption can even cause hormone imbalances in women. Proper nutrition, including taking supplements like magnesium, B vitamins and fish oil, exercise, sleep, and stress management can help regulate your hormones. This is generally enough to help most women.
A doctor or functional medicine practitioner can also help balance your hormones. Because women�s hormones fluctuate throughout their cycle, progesterone and estrogen levels may be different for each woman. Also, depending on the hormonal health issues, patients may need to run their hormone lab panel tests on either day three or day 21 of their cycle for best results.
Furthermore, we will also need to evaluate your ratio of hormones, like that of estrogen to progesterone, because these can be the cause of numerous symptoms for many women. Estrogen dominance is one of the most common problems associated with a woman�s hormone ratio. Progesterone levels in women should be at their highest during the last half of their cycle. The hormone ratio between progesterone and estrogen should be 10 to one. However, if the human body is not producing the required amounts of progesterone, symptoms of estrogen dominance may begin to manifest, regardless if the human body�s estrogen levels themselves are low. Symptoms of estrogen dominance can include: anxiety, heavy bleeding, PMS, breast tenderness, shorter cycles or spotting between cycles, infertility, fluid retention, weight gain, and sleeping problems.
FSH is produced by the brain to help the follicles and the ovaries prepare to release an egg. LH is another hormone produced by the brain which triggers the release of an egg into the uterus so that conception can occur. LH also helps produce progesterone during the second half of your cycle, which may be another reason why many women have low progesterone levels.
These hormones are fundamental to look at if you�re trying to have a baby. The elevated hormone ratio between LH and FSH can demonstrate the presence of a common health issue known as PCOS or polycystic ovarian syndrome. PCOS is actually not an ovarian health issue. As a matter of fact, it�s a common problem associated with a poor diet and insulin resistance. An increased consumption of sugar and starch can cause irregular cycles, heavy bleeding, acne, hair loss, and infertility.
As for post-menopausal women, hormone blood panel tests are just as important and we generally don�t need to worry about having to evaluate them on a specific day of the month. Also, when we test a woman who�s in their perimenopause, their hormones may be tremendously unstable. Therefore, it�s ultimately essential to diagnose a woman�s symptoms to help treat the source of the health issue.
We previously discussed the importance of testosterone in men. However, testosterone is also important in women. Many women visit numerous doctors after experiencing low energy levels as well as a decreased sex drive. Most doctors will associate these symptoms with aging or they may even tell them it�s all in their head and simply prescribe them some Prozac. But if we were to run a blood panel test on them, their testosterone levels would often come back undetectable. It�s no wonder why women don�t feel like themselves after they�ve lost their libido and their vitality.
Total testosterone levels in women should be between 60 and 80 while free testosterone levels should be over 0.5. Testosterone is fundamental towards maintaining lean muscle mass and optimizing energy. Testosterone is also important for clear brain function.
Now women, if you have low testosterone levels, this may be causing you to experience a reduced sex drive or it may even be making you feel fatigue. However, this isn�t always the cause of these symptoms. That�s why it�s so essential for women to test their sex hormone levels. Testosterone is what is known as an androgen, or a male hormone, but it�s also found in women. Other androgens that help contribute to male characteristics include androstenedione, dihydrotestosterone, or DHT, and DHEA. In polycystic ovarian syndrome, or PCOS, women will commonly develop elevated levels of any of these hormones. Women who consume a lot of sugar and starch may also develop acne, hair loss or they may even grow facial hair. All of these are symptoms of too much testosterone in women.
PCOS affects approximately 8 to 12 percent of women. As previously mentioned, this health issue is a metabolic problem caused by poor nutrition which ultimately affects the human body�s insulin levels. It can also affect other hormones, such as the androgens we previously discussed. When women develop insulin resistance, the production of male sex hormones can increase. Other tests are important when PCOS is caused by FSH and LH hormones.
FSH generally triggers ovulation. However, if a woman�s FSH is too low due to PCOS, ovulation, and therefore, conception can�t occur. This is why women with PCOS are also commonly diagnosed with infertility. And the key is in a woman�s LH to FSH ratio. Increased levels of LH can stimulate androgens, such as testosterone, and decreased levels of FSH can stimulate the follicles and estrogen. Furthermore, facial hair or thinning of the head hair, irregular menstrual cycles, heavy bleeding, and weight gain in women can be symptoms of PCOS. Although PCOS is believed to be a health issue which exclusively affects overweight women, we�re starting to see an increase of women with healthy weights develop PCOS.
Because functional medicine focuses on finding the source of the health issue, if we see cysts on your ovaries or if any other lab tests indicate the presence of PCOS, we won�t simply stop there. And most often, we just have to look back at the patient�s diet. The high consumption of sugar and starch causes a tremendous metabolic disturbance which can cause a variety of other health issues. We will discuss these various metabolic conditions in another article.
Hormones are fundamental to women’s health. Female sex hormones, including estrogen and progesterone, influence a woman’s mood, menstruation, pregnancy, menopause, and more. A variety of other hormones can also affect other aspects of a woman’s health. One of the most common health issues associated with hormonal imbalances in women is known as polycystic ovarian syndrome or PCOS. Women can be tremendously affected by hormone fluctuations. It’s essential for women to seek help from a doctor to find out if their symptoms are caused by hormone imbalances. Functional medicine can also help regulate hormones. Dr. Alex Jimenez D.C., C.C.S.T. Insight
Understanding Women’s Hormones
We measure hormonal imbalances through simple blood tests and we can also measure hormones through urine tests. Tests known as the �DUTCH� and the �Essential Estrogens� are provided by Genova to determine hormone metabolites. These can also determine the downstream breakdown products of hormones in order to help demonstrate what�s happening with your hormone metabolism.
Now, let me explain what are some of the most important things doctors or functional medicine practitioners look at when ordering a DUTCH test or an Essential Estrogens test. Hormone metabolism tests demonstrate your absolute hormone levels as well as which types of metabolites are being triggered. And this is what we utilize to look at your estrogen levels, androgen levels, and progesterone levels, as well as your cortisol levels, which we will discuss later. These are essential metabolites that can be found through our saliva, blood, and urine. We even look at all the different varieties of estrogens which get broken down by the liver.
So, it�s fundamental that we look carefully at our hormone levels. Testing for hormonal imbalances in both men and women can tell us a lot about what�s causing our symptoms as well as what we can do to treat them. We can recommend a series of lifestyle modifications, including guidance and advice in nutrition and exercise. At least that�s what a good functional medicine doctor would do.
The scope of our information is limited to chiropractic and spinal health issues as well as functional medicine topics and discussions. To further discuss the subject matter, please feel free to ask Dr. Alex Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topic Discussion:�Acute Back Pain
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief. �
XYMOGEN�s Exclusive Professional Formulas are available through select licensed health care professionals. The internet sale and discounting of XYMOGEN formulas are strictly prohibited.
Proudly,�Dr. Alexander Jimenez makes XYMOGEN formulas available only to patients under our care.
Please call our office in order for us to assign a doctor consultation for immediate access.
If you are a patient of Injury Medical & Chiropractic�Clinic, you may inquire about XYMOGEN by calling 915-850-0900.
For your convenience and review of the XYMOGEN products please review the following link.*XYMOGEN-Catalog-Download
* All the above XYMOGEN policies remain strictly in force.
Functional Medicine Doctor Explains Men’s Hormones
Hello there, it�s Dr. Alex Jimenez again and welcome to part four of �Taking Control of your Healthcare�. Today, we�re going to discuss hormones. Hormones regulate most of the human body�s systems as they are recognized as the messenger molecules of the endocrine system. Hormone imbalances can cause subtle changes, however, their effects can tremendously impact an individual�s overall health and wellness. And what�s worse, most healthcare professionals don�t treat hormonal imbalances unless they�ve already been considered extreme.
The sex hormones, the thyroid hormones, and the adrenal hormones are the most important hormones we have to keep in balance. There�s a variety of other hormones, of course, but health issues associated with those are often more rare. Many doctors generally won�t test a person for hormone imbalances unless they�ve been trying to conceive a baby or they have sexual dysfunction or any other health issue of this type. And frequently, many doctors miss other problems by performing a screening test rather than a complete test.
What are Hormones?
Hormones are essential towards mental health, gut health, and reproductive health. In functional medicine, we even believe that hormones are vital towards maintaining a healthy immune system. Even if you�re not trying to conceive a baby or if you don�t have sexual dysfunction, it�s important for both men and women to known what their hormone levels look like.
Now, let�s discuss hormonal imbalances in sex hormones. First of all, How does a hormone imbalance manifest itself? Do you experience mood swings and fluctuations in your energy levels? Or if you�re a female, do you experience symptoms of PMS? Or perhaps you need coffee to wake up in the morning and wine to sleep at night? Has your sex drive, or libido, decreased? Do you have brain fog? Or is it difficult for you to focus on tasks?
If you�ve experienced any of these symptoms, you might have a hormonal imbalance in your sex hormones. Hormones are small molecules in charge of transmitting signals from one body system to another. But, if these molecules aren�t functioning accordingly, our energy levels and our mood can be tremendously affected. If you feel that something is off within your own body, talk to your doctor and seek proper testing. Don�t simply guess.
Let�s begin by discussing how you test your hormones. In functional medicine, we can test through saliva, blood, urine, and even stool. But, which is best for testing hormones? The truth is, knowing how and when to test your hormones is important because testing can depend on the marker that you want to look at. By way of instance, blood testing is one of the best and most affordable if you�re simply looking for a preliminary screening. A functional medicine doctor can also determine when a urine test will be more helpful than a blood test or a saliva test.
Taking Control of Men’s Hormones
So, now that you know how to test your hormones, we�ll discuss the different health issues caused by hormonal imbalances in the sex hormones of both men and women. First, let�s talk about men. As for the women, this is still an essential topic for you to learn about because the men in your lives are much less likely to schedule a doctor�s appointment for themselves.
Approximately 39 percent of men over the age of 45 have low levels of testosterone, or what�s known as low T. Elevated insulin levels associated with diabetes and obesity can lower your testosterone levels, which in turn, can increase estrogen levels. When testosterone goes down, your sex drive, or libido, and other functions can be tremendously affected. Excess consumption of sugar and starch can have different impacts for both men and women. Additionally, the utilization of certain drugs and/or medications, lack of exercise and physical activity, as well as inflammation, can also contribute to lower testosterone levels. While the majority of doctors won�t test testosterone levels in a man unless they have sexual dysfunction, I always want to make sure to test the sex hormones if a man has belly fat.
I would also like to discuss the serious side effects of a drug/medication which is commonly prescribed for sexual dysfunction. Statins can help lower cholesterol, however, did you know that your testosterone is made from cholesterol? That�s right. And when you start taking a drug/medication which was designed to decrease your cholesterol, you may also potentially be decreasing your sex hormones. It�s well-known that statins can decrease testosterone, leading to sexual dysfunction and even sometimes causing men to grow breasts, a condition known as gynecomastia. Side effects like these occur when we don�t treat the source of a health issue.
What you eat, including mainly sugar and starch, can be associated with your low testosterone levels and your abnormal cholesterol levels. Treatments like these where you take a drug for one thing but then end up taking another medication for the side effects of the fist medicine is unfortunately something that happens a lot in the medical field, and it can be a real nightmare.
Male testosterone levels are decreasing so much with each generation that normal reference ranges for testosterone levels in males are changing. But, that�s not something we want to happen. We don�t want these abnormal changes to become normal. Therefore, shouldn�t we be trying to find out why the overall health and wellness of our population is decreasing at such an alarming rate rather than lowering our normal standards of well-being?
Before we do that, however, we first have to understand why this problem is happening. From our increased exposure to toxins and our elevated levels of stress to our higher consumption of processed foods, these are only several of the more obvious reasons why our hormones are being affected.
In conventional medicine, the reference ranges for testosterone are between 264 and 916.
When you think about it, however, this is a tremendous range. Does a man with a testosterone level of 265 have the same sexual function as a man with a testosterone level of 916? Most definitely not. Yet these two people are classified under the same category. And with that in mind, what are the optimal reference ranges for testosterone? Men under the age of 30 should have a testosterone level of over 700, and men over the age of 30 should have a testosterone level of at least 500.
Evaluating men�s total testosterone levels is essential but we also need to evaluate their active hormone levels, or their free testosterone levels. Testosterone is carried around on what is known as a sex hormone binding globulin, which then releases it as the human body needs it. This carrier protein is found in the blood and when there�s too much of it, it becomes difficult for the human body to release testosterone when it�s needed.
In men, free testosterone levels should be of at least 10 but, they should optimally be closer to 15 or 20. Additionally, your doctor should check the sex hormone binding globulin or SHBG. As we discussed before, this carrier protein for testosterone and other hormones, can decrease your free testosterone levels. If you don�t check your SHBG, your total testosterone levels might be normal but your free testosterone levels might be too low.
By way of instance, SHBG is similar to a bus filled with many workers. In this case, the workers are testosterone. When we have too many buses, the majority of the workers will stay on the bus while only a few will be out doing their job. A man can have a total testosterone level of 700, however, if they have a free testosterone level of only 5, they�re bound to still feel like they have a total testosterone level of 300.
In summary, we want to make sure that our total testosterone level is over 500 or better, over 600 and we also want to make sure that our free testosterone level is between 15 and 20.
Another hormone you might want to make sure you get tested for is known as dehydroepiandrosterone, or DHEA. DHEA is a precursor hormone for testosterone. It�s also an adrenal hormone, however, we will discuss this later in another article. If an individual�s DHEA is too low, it can indicate that the adrenal glands, which are in charge of the human body�s stress response, may not be functioning appropriately. DHEA levels should be between two to 400.
DHEA, or dehydroepiandrosterone, can be supplemented directly. Many doctors and functional medicine practitioners may also implement stress-relieving methods and techniques into your life, such as mindfulness meditation and yoga, to treat the source of the health issue. Herbal supplements can also help regulate DHEA as well as testosterone levels.
Now, we will discuss a fundamental hormone that is generally only considered to be important in female health, however, this hormone also plays an essential role in men; estrogen. Estrogen helps maintain a healthy sex function as it promotes your libido. It is also protective for the brain. In men�s health, estrogen is often demonized because it can cause health issues like breast development if estrogen levels are too high in men. But, normal estrogen levels are fundamental towards maintaining hormone balance as well as mental health.
Estrogen can increase in men with diabetes and obesity. Elevated insulin exchanges more testosterone into estrogen which may cause additional symptoms like fatigue. This can also create more problems alongside sexual dysfunction, including hair loss. So, if you have less than optimal testosterone levels, you should seek help from a doctor or functional medicine practitioner to find out why. And looking at your estrogen levels is a great place to start.
There are two types of estrogen tests which can help demonstrate your estradiol and estrone levels. These are important markers to look at because one can be elevated while the other can be in the normal range. The brain is the other place you can look at to determine your estrogen levels. Your brain produces hormones which can stimulate sex hormones, such as the follicle stimulating hormone, or FSH, and the luteinizing hormone, or LH, which helps produce testosterone and sperm within the testicles. If your LH is low, then your low testosterone levels may be caused by a brain health issue. However, it�s much more likely that sugar and starch consumption may be causing hormonal imbalances in your sex hormones.
Approximately 70 percent of the testosterone deficiencies in the United States are associated with insulin resistance due to diabetes and obesity. So, if your diet is filled with sugar and starch or if you have belly fat, you may already have decreased testosterone levels.
Hormones are secreted directly into the blood stream in order to control a variety of bodily functions. These can affect growth and development, mood, sexual function, reproduction, and metabolism. As a fundamental part of the endocrine system, hormone imbalances can have a tremendous effect on our overall health and wellness. Men’s hormones, by way of instance, can significantly impact a man’s quality of life. Research studies have demonstrated that decreased testosterone in men can cause a variety of health issues. Evaluating sex hormones in both men and women is essential towards overall health and wellness. Dr. Alex Jimenez D.C., C.C.S.T. Insight
Understanding Men’s Hormones
While we keep discussing the importance of lab tests, we also need to keep asking ourselves why these health issues are happening in the first place. The answers trace back to the basics of health and wellness. What are you eating? Do you participate in exercise or physical activities? Do you sleep properly? Do you have stress? What are your nutrient levels? Of course, several of these answers require more evaluations. That�s why I highly recommend you find a functional medicine doctor who can help get you on the right path towards optimal health and wellness. Most of the time, basic lifestyle modifications including diet, exercise, stress management, sleep and supplements can help. Other times you may need hormone replacement therapy.
The scope of our information is limited to chiropractic and spinal health issues as well as functional medicine topics and discussions. To further discuss the subject matter, please feel free to ask Dr. Alex Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topic Discussion:�Acute Back Pain
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
XYMOGEN�s Exclusive Professional Formulas are available through select licensed health care professionals. The internet sale and discounting of XYMOGEN formulas are strictly prohibited.
Proudly,�Dr. Alexander Jimenez makes XYMOGEN formulas available only to patients under our care.
Please call our office in order for us to assign a doctor consultation for immediate access.
If you are a patient of Injury Medical & Chiropractic�Clinic, you may inquire about XYMOGEN by calling 915-850-0900.
For your convenience and review of the XYMOGEN products please review the following link.*XYMOGEN-Catalog-Download
* All the above XYMOGEN policies remain strictly in force.
Holistic: Migraine headaches are typically debilitating, and require a comprehensive approach for successful treatment. It is helpful to consider migraine headache as a symptom of an underlying imbalance, rather than simply a diagnosis. A holistic approach is a satisfying way to think about and treat migraine headache. Physicians trained in this approach will consider a broad array of features that may contribute to the experience of migraine headache, including disturbances within the following key areas:
Nutrition
Digestion
Detoxification
Energy production
Endocrine function
Immune system function/inflammation
Structural function
Mind-body health
Migraine headache is an excellent example of biologic uniqueness; the underlying factors participating in each individual�s outcome may differ quite a bit from person to person. The journey of identifying and addressing these factors often results in an impressive improvement in frequency and intensity of the expression of migraine. Committed individuals will find the added benefit of better general health along the way.
Nutritional Considerations: Holisitic
Food Allergy/Intolerance
Numerous well-designed studies have demonstrated that detection and removal of foods not tolerated will greatly reduce or eliminate migraine manifestations. True allergy may not be associated with migraine in most individuals, but food intolerance is more common. Migraine frequency and intensity have been demonstrated to respond well to elimination diets, in which commonly offending foods are removed for several weeks. Elimination diets are easy to perform (although they do require a high degree of commitment and education), and can help in identifying foods that are mismatched to an individual. The majority of patients who undergo an elimination diet learn that their diets were contributing to chronic symptoms, and they typically feel much better during the elimination phase. Common foods that act as migraine triggers include: chocolate, cow�s milk, wheat/gluten grains, eggs, nuts, and corn. In children specifically, common migraine triggers include cheese, chocolate, citrus fruits, hot dogs, monosodium glutamate, aspartame, fatty foods, ice cream, caffeine withdrawal, and alcoholic drinks, especially red wine and beer.
There are several methods which may be used to detect food allergies. Laboratory testing can be convenient, but is not always a reliable means of detecting food intolerance. (See Summary of Recommendations for information on how to implement the elimination diet).
Foods such as chocolate, cheese, beer, and red wine are believed to cause migraine through the effect of �vasoactive amines� such as tyramine and beta-phenylethylamine. These foods also contain histamine. Individuals who are sensitive to dietary histamine seem to have lower levels of diamine oxidase, the vitamin B6-dependent enzyme that metabolizes histamine in the small bowel. The use of vitamin B6 improves histamine tolerance in some individuals, presumably by enhancing the activity of this enzyme.
Other diet-related triggers associated with migraine headache include: glucose/insulin imbalances, excessive salt intake, and lactose intolerance. Aspartame, commonly used as a sweetener, may also trigger migraines. Each of these factors may be readily avoided by adopting more conscious eating habits, and by carefully reading labels.
Magnesium
An estimated 75% of people consuming the standard American diet (SAD) are not getting adequate magnesium, and it is felt to represent one of the most common micronutrient deficiencies, manifested by a diverse range of problems. Though many elements can contribute to magnesium depletion, stress is among them, and both acute and chronic stress are associated with increased episodes of migraine. Daily doses of magnesium should be first line considerations for migraine sufferers (caution if kidney function is impaired), and intravenous magnesium can be very helpful in an emergency room setting, but probably only works to terminate an acute migraine if the individual is truly magnesium deficient.
Essential Fatty Acids
It is important to remember that the brain is largely composed of fat. Although essential fatty acids have not received much research attention relative to migraine, there may be a significant role of fatty acids and their metabolites in the pathogenesis of migraine headache. Two small placebo-controlled studies demonstrated that omega-3 fatty acids significantly outperformed placebo in reducing headache frequency and intensity. High quality fish oil should always be used. A good frame of reference is that each capsule should contain at least 300 mg of EPA and 200 mg of DHA. A reasonable starting dose would be two to four capsules twice daily with meals.
Digestive Function: Holistic
Holistic practitioners are generally sensitive to the centrality of the gastrointestinal tract in producing overall health. Though we utilize a reductionistic approach to understanding human anatomy and physiology, we might consider that no system functions as an independent entity (GI, endocrine, cardiovascular, immune, etc.), and that a complex symphony of interrelated functions cuts across organ systems. For example, much of the immune system is found in the Peyer�s patches of the GI tract; in this light, we can see how food, chemicals, and unhealthy microbes might produce immune system activation from gastrointestinal exposure. We also recognize the importance of a balanced ecosystem of intestinal microbes; intestinal dysbiosis, or disordering of the gastrointestinal ecology, may readily produce symptoms, both within and distant from the GI tract. Some colonic bacteria act upon dietary tyrosine to produce tyramine, a recognized migraine trigger for some individuals. H. pylori infection is a probable independent environmental risk factor for migraine without aura, especially in patients not genetically or�hormonally susceptible. A high percentage of migraine patients experienced relief from migraines when H. Pylori infection was eradicated.
Detoxification: Holistic
Patients with migraine headache sometimes report that strong chemical odors such as tobacco smoke, gasoline, and perfumes may act as triggers. It is not uncommon for migraineurs to report that they are triggered by walking down the laundry soap aisle in the grocery store. Support for phase 1 and especially phase 2 detoxification may be beneficial for these individuals, as toxic overload or impaired enzymes of detoxification could theoretically be a significant mediator of headaches. Susceptibility to toxicity may be potentiated by a combination of excessive toxic exposures, genetic polymorphisms leading to inadequate detoxification enzyme production, or depletion of nutrient cofactors that drive phase two detoxification conjugation reactions Support for detoxification function is particularly important in modern life, given our exposure to unprecedented high levels of toxic chemicals. Some nutrients that supply support for detoxification function include: n-acetyl cysteine (NAC), alpha lipoic acid, silymarin (milk thistle), and many others.
Energy Production: Holistic
Riboflavin (Vitamin B2)
Energy production within the parts of the cell called mitochondria can be impaired in some migraine sufferers. Riboflavin is a key nutrient that is involved in energy production at this level. Riboflavin at 400 mg/day is an excellent therapeutic choice for migraine headache because it is well tolerated, inexpensive, and provides a protective effect from oxidative toxicity. Its use in children has been investigated, leading to similar conclusions,suggesting that, for pediatric and adolescent migraine prophylaxis, 200 mg per day was an adequate dose, but four months were necessary for optimal results.
Coenzyme Q10
CoenzymeQ10 (CoQ10) is also a critical component of energy function, and is an important antioxidant. Evidence supports the administration of CoQ10 in reducing the frequency of migraines by 61%. After three months of receiving 150 mg of CoQ10 at breakfast, the average number of headache days decreased from seven to three per month. Another study, using 100 mg of water soluble CoQ10 3x/day, revealed similar results. CoQ10 deficiency appears to be common in the pediatric and adolescent population, and can be an important therapeutic consideration in these age groups. Like riboflavin, CoQ10 is well tolerated (though expensive), with little risk of toxicity. It must be used with extreme caution in patients who also take warfarin, as CoQ10 may counteract the anticoagulation effects of warfarin. It is also noteworthy that many medications can interfere with CoQ10 activity, including statins, beta-blockers, and certain antidepressants and antipsychotics.
Endocrine (Hormone) Function
Female Hormones
It does not appear coincidental that migraine onset correlates with the onset of menstruation and that episodes are linked to menstruation in roughly 60% of female migraineurs. Although there is no universal agreement over the precise relationship between female hormones and migraine headache, it is apparent that the simultaneous fall of estrogen and progesterone levels before the period correlates with menstrual migraine. Estrogen gel used on the skin can reduce headaches when used premenstrually. Some researchers have found that continuous use of estrogen may be necessary to control menstrual migraines, which tend to be more severe, frequent, longer lasting, and debilitating than general migraines. Although published studies are lacking, many practitioners have used transdermal or other bioidentical forms of progesterone premenstrually with success. Of course, the risks of using hormones must be weighed against the benefits. Interestingly, administration of magnesium (360 mg/day) during second half of the menstrual cycle in 20 women with menstrually related migraines resulted in a significant decrease of headache days.
Melatonin
Melatonin, the next downstream metabolite of serotonin, is important in the pathogenesis of migraines. Decreased levels of plasma and urinary melatonin have been observed in migraine patients, and melatonin deficiency appears to increase risk for migraine. Melatonin has been used with some success, presumably via a restorative effect on circadian rhythms. A small study in children demonstrated significant improvement in their migraine or tension headache frequency with a 3 mg nightly dose of melatonin Melatonin appears to modulate inflammation, oxidation, and neurovascular regulation in the brain, and in one study, a dose of 3 mg/day was shown to be effective in reducing migraine headache frequency by at least 50% in 25 of 32 individuals. Ironically, some patients anecdotally report an increase of headaches (generally not migraine) when administered melatonin. The brains of migraineurs do not seem adaptable to extremes; a regular schedule of sleep and meals and avoidance of excessive stimulation are advisable to reduce excessive neural activation.
Immune Function/Inflammation: Holistic
Medications that produce an anti-inflammatory effect, such as aspirin and nonsteroidal agents, frequently produce an improvement in migraine symptoms during an acute attack. The herbs described below also play a role in reducing inflammation. Inflammation and oxidative stress can be identified in many conditions and disease states. It is important to acknowledge that the standard �modern� lifestyle is pro-inflammatory; our bodies are constantly reacting to one trigger after another (foods mismatched to our physiology, toxic burden, emotional stressors, excessive light and other stimulation) that activate our inflammatory cytokines (messengers of alarm). Providing broad-based support through lifestyle change and targeted nutrients may improve outcomes substantially, and this may be achieved foundationally by simplifying our�ingestions/exposures and supporting metabolic terrain. Herbal therapies are included in this section because of their relevant effects upon inflammation.
Feverfew (Tanacetum parthenium)
The precise mechanism of action of feverfew as a migraine preventive is unknown Though at least three studies found no benefit with feverfew, several controlled studies have revealed favorable results in improving headache frequency, severity, and vomiting when feverfew was compared to placebo. There are several caveats that should accompany the use of this herb:
Because of its anti-platelet effects, feverfew must be used with caution in patients on blood thinning products; avoid in patients on warfarin/Coumadin.
Feverfew does not have a role in managing acute migraine headache.
When withdrawing feverfew, do so with a slow taper, since rebound headache may occur.
Feverfew is not known to be safe during pregnancy and lactation.
Proceed with caution if an individual has an allergy to other members of the Asteraceae family (yarrow, chamomile, ragweed).
Most commonly reported adverse effects are oral ulceration (particularly for those chewing the leaves raw), and GI symptoms, reversible with discontinuation.
Feverfew is otherwise well tolerated. The typical dosage range is 25-100 mg 2x/day of encapsulated dried leaves with meals.
Butterbur (Petasites hybridus)
Butterbur is another effective herbal therapy for migraine headache. Butterbur is well tolerated, with no known interactions. Some individuals have reported diarrhea when using butterbur. In one study, its efficacy was demonstrated in children and adolescents between the ages of 6 and 17 years. Its safety is unknown during pregnancy and lactation. The plant�s pyrrolizidine alkaloids can toxic to the liver and carcinogenic, so only extracts that have specifically removed these compounds should be utilized. Many of the studies on Butterbur utilized the product Petadolex� because it is a standardized extract that has removed these alkaloids of concern. The usual dosage is 50 mg, standardized to 7.5 mg petasin and isopetasin, 2-3x/day with meals (although recent studies show that higher doses appear to be more effective1,2 ). Interestingly, butterbur�s diverse qualities make it useful for other conditions, including seasonal allergic rhinitis, and possibly painful menstrual cramps.
Ginger (Zingiber officinalis)
Ginger root is a commonly used botanical, known to suppress inflammation and platelet aggregation. Little clinical investigation has been performed relative to ginger use in migraine headache, but anecdotal reports and speculation based on its known properties make it a safe and appealing choice for migraine treatment. Some practitioners advise patients with acute migraine to sip a cup of warm ginger tea. Though evidence for this practice is lacking, it is a low-risk, pleasant, and relaxing intervention, and ginger is known to have anti-nausea effects. The most anti-inflammatory support is found in fresh preparations of ginger and in the oil.
Structural Considerations: Holistic
Practitioners of manual medicine seem to achieve success in reducing headache through various techniques such as spinal manipulation, massage, myofascial release, and craniosacral therapy Manual medicine practitioners frequently identify loss of mobility in the cervical and thoracic spine in migraineurs. While many forms of physical medicine seem helpful in shortening the duration and intensity of an episode of migraine, literature support is sparse with regard to manipulation as a modality to prevent recurrent migraine episodes. However, a randomized controlled trial of chiropractic spinal manipulation performed in 2000 revealed a significant improvement in migraine frequency, duration, disability, and medication use in 83 treatment group participants. Tension headache may also respond favorably to these techniques because of the structural component involved in muscular tension. The incidence of migraine in patients with TMJ dysfunction is similar to that in the general population, whereas the incidence of tension headache in patients with TMJ dysfunction is much higher than in the general population. Craniosacral therapy is a very gentle manipulative technique that may also be safely attempted with migraine.
Mind-Body Health: Holistic
There are few things more insulting than to be told by a medical professional to �Just reduce your stress.� Though the total load of stress experienced by an individual can be reduced through paring down unnecessary obligations, many everyday life stressors are unavoidable and cannot be simply eradicated. Thus, the answer to reducing stress for unavoidable contributors lies in two important areas: enhancing physical and mental resilience to stress, and modifying the emotional response to stress.
A multitude of programs to reduce the impact of stress on our physical and emotional well-being are rapidly becoming mainstream. For example, mindfulness meditation programs by Jon KabatZinn, PhD and many others are being offered to communities by hospitals around the country. This technique is simple to perform and has demonstrated positive outcomes in heart disease, chronic pain, psoriasis, hypertension, anxiety, and headaches. Breathwork and guided imagery techniques are likewise effective in producing a relaxation response and helping patients to feel more empowered about their health.
Biofeedback and relaxation training have been used with mixed success for migraine headache. Thermal biofeedback uses the temperature of the hands to help the individual learn that inducing the relaxation response will raise hand temperature and facilitate other positive physiologic changes in the body. Learning how to take more active control over the body may reduce headache frequency and severity. The effectiveness of biofeedback and relaxation training in reducing the frequency and severity of migraine headaches has been the subject of dozens of clinical studies, revealing that these techniques can be as effective as medication for headache prevention, without the adverse effects. Other relevant modalities to consider in this light include cognitive behavioral therapy, neurolinguistic programming, hypnosis, transcutaneous electrical nerve stimulation, and laser therapy.
Exercise should not be overlooked as a modality helpful in migraine headache. Thirty-six patients with migraine who exercised 3x/week for 30 minutes over six weeks experienced significant improvement in headache outcomes. Pre-exercise beta-endorphin levels in these individuals were inversely proportional to the degree of improvement in their post-exercise headache parameters. All patients should understand the critical importance of exercise on general health.
Acupuncture: Holistic
A discussion about a holistic integrative approach to migraine headache would be incomplete without acupuncture, which is an effective treatment modality for acute and recurrent migraine. A qualified/licensed practitioner of Traditional Chinese Medicine or a physician trained in medical acupuncture should be consulted.
Holistic: Summary Of Recommendations
Since initiators of migraine headache may be cumulative, identify and avoid them when possible. Consider the basic areas of dysfunction bulleted on the first page of this syllabus.
The incidence of food intolerance is high in patients with migraine headache; consider a comprehensive elimination diet for four to six weeks, during which time the following foods are eliminated: dairy products, gluten-containing grains, eggs, peanuts, coffee/black tea, soft drinks, alcohol, chocolate, corn, soy, citrus fruits, shellfish, and all processed foods. Careful reintroduction of one food at a time, no more often than every 48 hours, may help identify a food culprit. Meticulous recording of foods reintroduced is necessary. Most patients feel improved vitality during the elimination phase. Foods that clearly produce migraine (or other) symptoms should be avoided or used on a rotation schedule of not more than once every four days. If multiple foods introduced back into the diet seem to produce migraine headache, consider the possibility of altered intestinal permeability (leaky gut syndrome).
Consider the following supplements (Consult a qualified practitioner for advice):
Magnesium glycinate: 200-800 mg/day in divided doses (decrease to tolerance if diarrhea occurs)
Vitamin B6 (pyridoxine): 50-75 mg/day, balanced with B complex o 5-HTP: 100-300 mg 2x/day, with or without food, if clinically appropriate
Vitamin B2 (riboflavin): 400 mg/day, balanced with B complex
Coenzyme Q10: 150 mg/day
Consider hormonal therapies
Trial of melatonin: 0.3-3 mg at bedtime
Trial of progesterone or estradiol, carefully individualized, under medical supervision.
Botanical medicines
Feverfew: 25-100 mg 2x/day with meals
Butterbur: 50 mg 2-3x/day with meals
Ginger root
Fresh ginger, approximately 10 gm/day (6 mm slice)
Dried ginger, 500 mg 4x/day
Extract standardized to contain 20% gingerol and shogaol; 100-200 mg 3x/day for prevention, and 200 mg every 2 hours (up to 6 x/day) for acute migraine
Manual medicine may be helpful for some individuals.
Acupuncture
Mind-body support
Thermal biofeedback
Read The Relaxation Response by Herbert Benson, MD
Mindfulness meditation programs
Centering prayer
Breathwork
Guided imagery
Yoga, tai chi, qi gong, etc.
Many other modalities to consider!
Conclusion: Holistic Medicine
Patients will often request a more natural and self directed approach to health care. The recommendations above are typically very safe to implement, and are often welcomed by migraine sufferers. A practitioner with an integrative holistic focus will investigate an extensive array of predisposing factors to determine the underlying features most likely involved in a given individual�s condition. In this way, we treat the individual, rather than his or her diagnosis, and we will generate a favorable impact upon his/her overall health in the process.
Chiropractic Care & Headaches
�American Board of Integrative Holistic Medicine. All rights reserved.
Is coconut oil a metabolism-boosting superfood or an artery-clogging threat to heart health?
That question has fueled a raging debate for many years, and it was reignited in mid-June when the American Heart Association (AHA) issued an advisory reiterating its longstanding recommendation to avoid saturated fats. Attention quickly focused on coconut oil, which has become trendy in natural health circles despite its high saturated fat content.
Proponents of coconut oil say its medium-chain triglycerides are quickly burned for energy, increasing metabolism. Coconut oil fats are also said to be good for the brain, which is made mostly of fat, and help regulate blood sugar and, ironically, cholesterol levels.
But the AHA advisory contends that all saturated fats raise risk of cardiovascular disease.
“Taking into consideration the totality of the scientific evidence…we conclude strongly that lowering intake of saturated fat and replacing it with unsaturated fats, especially polyunsaturated fats, will lower the incidence of cardiovascular disease,” states the advisory.
The AHA researchers specifically advise against using coconut oil, which they note is 82 percent saturated fat and raises “bad” LDL cholesterol levels, “a cause of atherosclerosis.”
But many other scientific reviews in recent years — including one meta-analysis encompassing nearly 350,000 people followed for as long as 23 years — found no link between saturated fat and heart disease.
“Those reviews were much more limited because they didn’t take into consideration what the substitution [for saturated fats in the diet] was,” explains Dr. Alice Lichtenstein, co-author of the AHA advisory. “The better reviews that looked at replacing saturated fat with either carbohydrates or mono- or polyunsaturated fats, show clear differences.”
Many natural health practitioners take exception to the AHA conclusions, including integrative cardiologist Dr. Jack Wolfson. He contends that AHA researchers cherry-picked data from decades-old studies, and that branding all LDL as harmful is outdated science.
“Total LDL numbers are a very poor prognosticator of heart disease,” says Wolfson, a doctor of osteopathy and board-certified cardiologist based in Phoenix, Ariz. “What’s more relevant is LDL particle size and numbers. Small, dense particles are bad for the heart, but studies show that large fluffy particles, like those promoted by coconut oil, cause no harm.”
But Lichtenstein, director of the Cardiovascular Nutrition Laboratory at Tuft University’s Human Nutrition Center on Aging, dismisses the LDL particle size factor, saying, “There’s much more written on the Internet about that than data to support it.”
Wolfson further questions AHA recommendations to use “highly processed” vegetable oils, saying their omega-6 fatty acids can contribute to systematic inflammation. In an AHA newsletter, the advisory’s lead author, Dr. Frank Sacks, suggests that people forsake butter and coconut oil for cooking and use canola, corn, soybean, and extra virgin olive oil instead.
“There’s nothing wrong with deep frying as long as you deep fry in a nice unsaturated vegetable oil,” Sacks adds.
That suggestion may send shudders through natural health practitioners, who widely contend that vegetable oils break down into harmful compounds under high heat.
“Coconut oil has a high smoke point, which makes it more stable for cooking,” explains Wolfson. “Unsaturated vegetable oils oxidize through the cooking process and cause oxidative stress and inflammation in the body.”
Lichtenstein once again cites a lack of data on the adverse effect of cooking with vegetable oils, telling Newsmax Health, “It’s not a concern.”
Wolfson also points out that the evolving science of heart disease seems to be shifting away from cholesterol and more toward inflammation as the primary cause.
“The risk of a cardiovascular event – heart attack, stroke and dying — is much higher when you have inflammation,” says Wolfson, author of “The Paleo Cardiologist: The Natural Way to Heart Health” and advocate of eating diets similar to our caveman ancestors.
“Coconut oil doesn’t cause inflammation. Sugar, artificial ingredients, pesticide residue in food…these are the types of things that cause inflammation.”
He emphasizes that it’s important to eat healthy saturated fats that are organic and, if animal-based, come from grass-fed pasture-grazers. Wolfson adds that he has history on his side in the debate over whether they are healthy or harmful.
“Our ancestors ate saturated fats for millions of years,” he tells Newsmax Health. “Why would evolution make it plug up our pipes and kill us? People in the South Pacific have diets that are more than 50 percent coconut-based, and they have virtually no heart disease. If we were all on a deserted island eating coconuts, fish and vegetables, and getting plenty of sunshine and sleep, heart disease would be a non-issue.”
Eating fish at least twice a week may significantly reduce the pain and swelling associated with rheumatoid arthritis, a new study says.
Prior studies have shown a beneficial effect of fish oil supplements on rheumatoid arthritis symptoms, but less is known about the value of eating fish containing omega-3, the researchers said.
“We wanted to investigate whether eating fish as a whole food would have a similar kind of effect as the omega 3 fatty acid supplements,” said the study author, Dr. Sara Tedeschi, an associate physician of rheumatology, immunology and allergy at Brigham and Women’s Hospital in Boston.
Generally, the amount of omega 3 fatty acids in fish is lower than the doses that were given in the trials, she said.
Even so, as the 176 study participants increased the amount of fish they ate weekly, their disease activity score lowered, the observational study found.
In rheumatoid arthritis, the body’s immune system mistakenly attacks the joints, creating swelling and pain. It can also affect body systems, such as the cardiovascular or respiratory systems. The Arthritis Foundation estimates that about 1.5 million people in the United States have the disease, women far more often than men.
The new study, which was heavily female, draws attention to the link between diet and arthritic disease, a New York City specialist said.
“While this is not something that is new, per se, and it was a small trial, it does raise an interesting concept of what you eat is as important as the medications you take,” said Dr. Houman Danesh.
“A patient’s diet is something that should be addressed before medication is given,” added Danesh, director of integrative pain management at Mount Sinai Hospital.
When his patients with rheumatoid arthritis ask about diet, he said he often suggests they eat more fish for a few months to see if it will help.
“I encourage them to try it and decide for themselves,” he said, explaining that study results so far have been mixed.
In this case, the majority of study participants were taking medication to reduce inflammation, improve symptoms and prevent long-term joint damage.
Participants were enrolled in a study investigating risk factors for heart disease in rheumatoid arthritis patients. The researchers conducted a secondary study from that data, analyzing results of a food frequency questionnaire that assessed patients’ diet over the past year.
Consumption of fish was counted if it was cooked — broiled, steamed, or baked — or raw, including sashimi and sushi. Fried fish, shellfish and fish in mixed dishes, such as stir-fries, were not included.
Frequency of consumption was categorized as: never or less than once a month; once a month to less than once a week; once a week; and two or more times a week.
Almost 20 percent of participants ate fish less than once a month or never, while close to 18 percent consumed fish more than twice a week.
The most frequent fish eaters reported less pain and swelling compared to those who ate fish less than once a month, the study found.
Researchers can’t prove that the fish was responsible for the improvements. And they theorized that those who regularly consumed fish could have a healthier lifestyle overall, contributing to their lower disease activity score.
While they were unable to get specific data on information such as patients’ exercise, its benefits are proven, Tedeschi said.
She acknowledged that fish tends to be an expensive food to purchase. For those unable to afford fish several times a week, Danesh cited other options.
“In general, patients should eat whole, unprocessed foods,” he said. “If you can’t for whatever reason, an omega 3 pill is a second option.”
Because the study was not randomized, researchers were unable to make definite conclusions, but they were pleased with what they learned.
One finding that impressed Tedeschi “was that the absolute difference in the disease activity scores between the group that ate fish the most frequently and least frequently was the same percentage as what has been observed in trials of methotrexate, which is the standard of care medication for rheumatoid arthritis,” she said.
The findings were reported June 21 in Arthritis Care & Research.
Abstract objective: �To examine the diagnosis and care of a patient suffering from chronic low back pain with associated right leg pain and numbness. ���Diagnostic studies include standing plain film radiographs, lumbar MRI without contrast, chiropractic analysis, range of motion, orthopedic and neurological examination. ���Treatments include both manual and instrument assisted chiropractic adjustments, ice, heat, cold laser, Pettibon wobble chair and repetitive neck traction exercises and non-surgical spinal decompression. ��The patient’s� outcome was very good with significant reduction in pain frequency, pain intensity and abatement of numbness in foot.
Introduction: �A 58 year old, 6�0�, 270 pound male was seen for a chief complaint of lower back pain with radiation into the right leg with right foot numbness. �The pain had started 9 months prior with an insidious onset. ��The patient had first injured his back in high school lifting weights with several episodes of pain over the ensuing years. ��The patient had been treating with Advil and had tried physical therapy, acupuncture, chiropractic and ice with no relief of pain and numbness. ��Walking and standing tend to worsen the problem and lying down did provide some relief. ���A number of activities of daily living were affected at a severe level including standing, walking, bending over, climbing stairs, looking over shoulder, caring for family, grocery shopping, household chores, lifting objects staying asleep and exercising. ��The patient remarked that he �Feels like 100 years old.� �Social history includes three to four beers per week, three diet cokes per day.
The patient�s health history included high blood pressure, several significant shoulder injuries, knee injuries, apnea, hearing loss, weight gain, anxiety and low libido. ���Family history includes Alzheimer�s disease, heart disease, colon cancer and obesity.
Clinical Findings
Posture analysis revealed a high left shoulder and hip with 2 inches of anterior head projection. Bilateral weight scales revealed a +24 pound differential on the left. ��Weight bearing dysfunction and imbalance suggest that neurological compromise, ligamentous instability and or spinal distortion may be present. �Range of motion in the lumbar spine revealed a 10 degree decrease in both flexion and extension. There was a 5 degree decrease in both right and left lateral bending with sharp pain with right lateral bending.
Cervical range of motion revealed a 30 degree decrease in extension, a 42 and 40 degree decrease in right and left rotation respectively and a 25 degree decrease in both right and left lateral flexion. ��Stability analysis to assess and identify the presence of dynamic instability of the cervical and lumbar spine showed positive in the cervical and lumbar spine and negative for sacroiliac dysfunction. ��Palpatory findings include spinal restrictions at occiput, C5, T5, T10, L4,5 and the sacrum. ��Muscle palpation findings include +2 spasm in the psoas, traps, and all gluteus muscles.
Cervical radiographs reveal significant degenerative changes throughout the cervical spine. This represents phase II of spinal degeneration according the Kirkaldy-Wills degeneration classification. ���Cervical curve is 8 degrees which represents an 83% loss from normal. ��Flexion and extension stress x-rays reveal decreased flexion at occiput through C4 and decreased extension at C2, C4-C7.
Lumbar radiographs reveal significant degenerative changes throughout representing phase II of spinal degeneration according to the Kirkaldy-Willis spinal degeneration classification. ���There is a 9 degree lumbar lordosis which represents a 74% loss from normal. ��There is a 2 mm short right leg and a grade II spondylolisthesis at the L5-S1 level.
Lumbar MRI without contrast was ordered immediately with a 4 mm slice thickness and 1 mm gap in between slices on a Hitachi Oasis 1.2 Telsa machine for optimal visualization of pathology due to the clinical presentation of right L5 nerve root compression.
Lumbar MRI Imaging Results
Significant degenerative changes throughout the lumbar spine including multi-level degenerative disc changes at all levels.
Transverse Annular Fissures at L1-2 (17.3 mm), L2-3 (29.5 mm), L4-5 (14.3 mm) and L5-S1 (30.8 mm) and broad based disc bulging at all levels except L5-S1. ���The fissures at L2-3 and L5-S1 both have radial components extends through to the vertebral endplate.
Facet osteoarthritic changes and facet effusions at all levels.
Grade II spondylitic spondylolisthesis is confirmed at L5-S1 with severe narrowing of the right neural foramen compressing the right exiting L5 nerve root.
Degenerative retrolisthesis at L1-2.
Modic Type II changes at L2 inferior endplate, L3 superior endplate, L4 inferior endplate and L5 inferior endplate.2
There is a 18.9 mm wide Schmorl�s node at the superior endplate of L3.
There is a 5.7 mm wide focal protrusion type disc herniation at L4-5 which impinges on the thecal sac.
T2 sagittal Lumbar Spine MRI:� Note the Modic Type II changes and the L2-3 Schmorls node.
T1 Sagittal Annular fissures at multiple levels and spondylolisthesis at L5S1
T2 Axial L4-5:� Focal Disc Protrusion Type Herniation
Definition �Bulging Disc: A disc in which the contour of the outer annulus extends, or appears to extend, in the horizontal (axial) plane beyond the edges of the disc space, over greater than 50% (180 degrees) of the circumference of the disc and usually less than 3mm beyond the edges of the vertebral body apophyses.3
Definition: Herniation is defined as a localized or focal displacement of disc material beyond the limits of the intervertebral disc space.3
Protrusion Type Herniation: is present if the greatest distance between the edges of the disc material presenting outside the disc space is less than the distance between the edges of the base of that disc material extending outside the disc space.3
Definition: Extrusion Type Herniation: �is present when, in at least one plane, any one distance between the edges of the disc material beyond the disc space is greater than the distance between the edges of the base of the disc material beyond the disc space or when no continuity exists between the disc material beyond the disc space and that within the disc space. 3
Definition: �Annular Fissures: �separations between the annular fibers of separations of the annual fibers from their attachments to the vertebral bone. 4
Definition � Radiculopathy: Sometimes referred to as a pinched nerve, it refers to compression of the nerve root – the part of a nerve between vertebrae. This compression causes pain to be perceived in areas to which the nerve leads.
The patient underwent multimodal treatment regime consisting of 4 months of active chiropractic adjustments, non-surgical spinal decompression with pretreatment spinal warm-up exercises on the Pettibon wobble chair and neck traction and heat. Post spinal decompression with ice and cold laser. ��The patient reported long periods of symptom free activities of daily living with occasional short flare-ups of pain. ��Exacerbations are usually of short duration and much lower frequency. �The only activity of daily living noted as affected severely at the end of care is exercising.
Post care lumbar radiographs revealed a 26 degree lumbar curve a 15 degree (38%) increase
Post care cervical x-rays revealed a 10 mm decrease in anterior head projection and a 2 degree improvement in the cervical lordosis.
Range of Motion
pre
post
increase
Lumbar
flexion
60
60
0
extension
40
40
0
r. lateral flexion
20
25
5
l. lateral flexion
20
25
5
cervical
pre
Post
increase
flexion
50
50
0
extension
30
40
10
r. lateral flexion
20
35
15
l. lateral flexion
20
20
0
r. rotation
38
70
42
l. rotation
40
80
40
Discussion of Results
It is appropriate to immediately order MRI imaging with radicular pain and numbness. ��Previous health providers who did not order advanced imaging with these long term radicular symptoms are at risk of missing important clinical findings that could adversely affect the patient�s health. ��The increasing managed care induced trend to forego taking plain film radiographs is also a risk factor for patients with these problems.
This case is a typical presentation of long standing spinal injuries that over many years have gone through periods of high and low symptoms but continue to get worse functionally and eventually result in a breakdown of spinal tissues leading to neurological compromise and injury.
Chiropractic treatment resulted in a very favorable outcome aided by an accurate diagnosis. �This is also the case where the different treatment modalities all contributed to the success of the protocol. ��The different modalities all focus on different areas of pathology contributing to the patients� disabled condition.
Modality
Therapeutic Goals
Chiropractic adjustment
Manual and instrument assisted forces introduced to the osseous structures that focuses on improving motor segment mobility
Cold laser
Increases speed of tissue repair and decreases inflammation.4
Pettibon
wobble chair
Loading and unloading cycles applied to injured soft tissues and
Pettibon
neck traction
speeds up & improves remodeling of injured tissue as well as rehydrates dehydrated vertebral discs.5
Non-surgical
spinal decompression
Computer assisted, slow and controlled stretching of spine, creating vacuum effect on spinal disc, bringing it back into its proper place in the spine.6,7
Ice
Decrease inflammation through vasoconstriction
Heat
Warm up tissues for mechanical therapy through increasing blood flow.
Posture Correction Hat
Weighted hat that activates righting reflex resetting head posture.8
A major factor in the success of the care plan in this case was an integrative approach to the spine. �John Bland, M.D. in the text Disorders of the Cervical Spine writes
�We tend to divide the examination of the spine into regions: cervical, thoracic and the lumbar spine clinical studies.� This is a mistake.� The three units are closely interrelated structurally and functionally- a whole person with a whole spine.� The cervical spine may be symptomatic because of a thoracic or lumbar spine abnormality, and vice versa!� Sometimes treating a lumbar spine will relieve a cervical spine syndrome, or proper management of cervical spine will relieve low backache.�9
When addressing the spine as an integrative system, and not regionally it has a very strong benefit to the total care results. ��The focus on the restoration of the cervical spine function as well as lumbar spine function is a hallmark of a holistic spine approach that has been a tradition in the chiropractic profession.
The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .�
References:
Kirkaldy-Willis, W.H, Wedge JH, Young-Hing K.J.R. Pathology and pathogenesis of lumbar spondylosis and stenosis. �Spine 1978; 3: 319-328
David F. Fardon, MD, Alan L. Williams, MD, Edward J. Dohring, MD. Lumbar disc nomenclature: version 2.0 Recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology. The Spine Journal 14 (2014) 2525�2545
Shealy CM, Decompression, Reduction and Stabilization of the Lumbar Spine: A cost effective treatment for lumbosacral pain.�� Pain management 1955, pg 263-265
Shealy, CM, New Concepts of Back Pain Management, Decompression, Reduction and Stabilization.�� Pain Management, a Practical guide for Clinicians.� Boca Raton, St. Lucie Press: 1993 pg 239-251
Bland, John MD, Disorders of the Cervical Spine WB Saunders Company, 1987 pg 84
Additional Topics: Preventing Spinal Degeneration
Spinal degeneration can occur naturally over time as a result of age and the constant wear-and-tear of the vertebrae and other complex structures of the spine, generally developing in people over the ages of 40. On occasion, spinal degeneration can also occur due to spinal damage or injury, which may result in further complications if left untreated. Chiropractic care can help strengthen the structures of the spine, helping to prevent spinal degeneration.
The sheer magnitude of America�s prescription opioid abuse epidemic has evoked visceral responses and calls-to-action from public and private sectors. As longtime advocates of drug-free management of acute, subacute and chronic back, neck and neuro-musculoskeletal pain, the chiropractic profession is aligned with these important initiatives and committed to actively participate in solving the prescription opioid addiction crisis.As professionals dedicated to health and well-being, Doctors of Chiropractic (DCs) are educated, trained and positioned�to deliver non-pharmacologic pain management and play a leading role in �America�s Opioid Exit Strategy.�
Data released by the Centers for Disease Control and Prevention (CDC) revealed that opioid deaths continued to surge in 2015, surpassing 30,000 for the first time in recent history. CDC Director Tom Frieden said,�The epidemic of deaths involving opioids continues to worsen. Prescription opioid misuse and use of heroin and illicitly manufactured fentanyl are intertwined and deeply troubling problems.�1
The human toll of prescription opioid use, abuse, dependence, overdose and poisoning have rightfully become a national public health concern. Along with the tragic loss of life, it is also creating a monumental burden on our health and related health care costs:
Health care costs for opioid abusers are eight times higher than for nonabusers.2
A new retrospective cohort study shows a 72 percent increase in hospitalizations related to opioid abuse/dependence from 2002 to 2012. Not surprisingly, inpatient charges more than quadrupled over that time. Previous estimates of the annual excess costs of opioid abuse
to payers range from approximately $10,000 to $20,000 per patient, imposing a substantial economic burden on payers.3
A recent government study puts the economic burden to the U.S. economy at $78.5 billion annually. For this study, CDC researchers analyzed the financial impact to include direct health care costs, lost productivity and costs to the criminal justice system.4
AMERICA�S COMMITMENT TO PRESCRIPTION OPIOID ABUSE: A PAINFUL REALITY CHECK
As a non-pharmacologic approach to effectively address acute, subacute and chronic non- cancer pain, integrative care management answers the needs of individuals nationwide.
With patient access to opioids becoming more restricted through more responsible clinician prescribing and government-mandated reduced production of opioids — and as those who are addicted become empowered to reduce their utilization — people experiencing pain face new, daunting challenges:
Without the use of drugs, how will they cope with pain?
How can they get referrals and access to drug-free care that will be effective for acute, subacute and chronic pain?
How can they ensure that their health care plans and insurance will cover the cost of non- pharmacologic care?
While the chiropractic profession lauds many of the noteworthy announcements and strides to overcome opioid addiction, these recommendations fall short in providing meaningful answers and solutions for those who are suffering from pain.
It is encouraging to see the July 22, 2016 enactment of the Comprehensive Addiction and Recovery Act (P.L. 114-198), the first major federal addiction legislation in 40 years, and the most comprehensive effort undertaken to address the opioid epidemic. It encompasses
all six pillars necessary for such a coordinated response � prevention, treatment, recovery, law enforcement, criminal justice reform and overdose reversal.5 The recent passage of the 21st Century Cures Act included $1 billion for states to use to fight opioid abuse.6 Unfortunately, this legislation has drawn critics who say it is simply a huge de-regulatory giveaway to the pharmaceutical and medical device industry.7
Closer examination of these legislative initiatives points to the absence of programs that address non-pharmacologic options for those fighting drug addiction, notably chiropractic care. When paired with the U.S. Surgeon General�s declaration of war on addiction,8 the government�s designation of �Prescription Opioid and Heroin Epidemic Awareness Week,� 9 and the commitment from 40 prescriber groups to ensure that 540,000 health care providers would complete training on appropriate opioid prescribing within two years,10 these �solutions� appear woefully inadequate to address the challenges of those who need effective, drug- free pain management.
This follow-up discussion to �Chiropractic: A Safer Strategy than Opioids� (June 2016), examines the positive steps as well as the shortcomings of initiatives undertaken from July 2016 – March 2017 to address the opioid crisis. It also assesses the current landscape of opportunities to offer patients, doctors and payers meaningful programs to effectively address acute, subacute and chronic neck, low back and neuro-musculoskeletal pain without the use of painkillers.
The chiropractic profession contends this should be a top priority, and it appears that a growing number of stakeholders are in agreement. In fact, the world�s second-largest pharmaceutical company has agreed to disclose in its marketing material that opioid painkillers might carry a serious risk of addiction, and promised not to promote prescription opioids for unapproved uses, such as long-term back pain.11
Based upon the evidence articulated in this document, it becomes clear that chiropractic care is a key component of �America�s Opioid Exit Strategy� on several levels:
�Perform first-line assessment and care for neck, back and neuro-musculoskeletal pain to avoid opiate prescribing from the first onset of pain.
�Provide care throughout treatment to mitigate the introduction of drugs.
�Offer an effective approach to acute, subacute and chronic pain management that helps addicts achieve a wellness focused, pain-free lifestyle as they reduce their utilization of opioids.
It�s also a compelling opportunity for our health system, commercial and government payers, employers — and most importantly patients — to resolve the issues surrounding pain at lower costs, with improved outcomes and without drugs or surgery.
Further complicating the situation: escalating prices of the opioid OD drug naloxone may threaten efforts to reduce opioid-related deaths across America, warn teams at
Yale University and the Mayo Clinic.13
Naloxone is a drug given to people who overdose on prescription opioids and heroin. If administered in time, it can reverse the toxic and potentially deadly effects of �opioid intoxication.�
The research team called attention to skyrocketing prices for the lifesaving antidote, noting:
Hospira (a Pfizer Inc. company) charges $142 for a 10-pack of naloxone — up 129 percent since 2012.
Amphastar�s 1 milligram version of naloxone is used off-label as a nasal spray. It�s priced around $40 — a 95 percent increase since September 2014.
Newer,easier-to-use formulations are even more expensive — a two-dose package of Evzio (naloxone) costs $4,500, an increase of more than 500 percent over two years.�The challenge is as the
price goes up for naloxone, it becomes less accessible for patients,� said Ravi Gupta, the study�s lead author.
Government & Regulators Restrict Access To Opioids
In the wake of this firestorm surrounding opioid abuse, and following the dissemination of prescribing guidelines introduced by the CDC, it becomes evident that certain market forces are influencing the battle against opioid addiction and the availability of drugs.
Among the most egregious stakeholders are those in the pharmaceutical sector.There are numerous instances which document their role attempting to thwart many legislative initiatives throughout the country to combat drug abuse.They impose exorbitant costs for life-saving antidotes, and aggressively develop and market the use of more drugs to fight opioid-induced side effects such as constipation. It becomes apparent that many of their answers to opioid addiction are simply more pills.14
The opioid market is worth nearly $10 billion in annual sales, and has expanded to include an unlimited universe of medications aimed at treating secondary effects rather than controlling pain.15 Given the financial incentives to produce, sell and distribute drugs, it�s no wonder that pharmaceutical companies (pharmcos) have a material interest in promoting drug utilization.
This set of behaviors has drawn extensive criticism.
�The root cause of our opiate epidemic has been the over-prescribing of prescription pain medications. Physicians get little to no training related to addiction in general, but particularly around opiate prescriptions. Over the past year, however, you hear more and more physicians admitting �we are part of the problem and can be part of the solution�.�16
—- Michael Botticelli, former White House drug policy director, commonly called the nation�s drug czar.
While physicians have been responding to calls for more responsible prescribing, the drug industry has historically been accused of providing physicians with misleading information regarding the addictive qualities of certain drugs.Appropriate education of prescribers is a key component of necessary change.
For example, when semisynthetic opioids like oxycodone and hydrocodone � found in Percocet and Vicodin respectively � were first approved in the mid�20th century, they were recommended only for managing pain during terminal illnesses such as cancer, or for acute short-term pain, like recovery from surgery, to ensure patients wouldn�t get addicted. But in the 1990s, doctors came under increasing pressure to use opioids to treat the millions of Americans suffering from chronic non-malignant conditions, like back pain and osteoarthritis.
A physician pain specialist helped lead the campaign, claiming prescription opioids were a �gift from nature,� with assurances to his fellow doctors � based on a 1986 study of only 38 patients � that fewer than one percent of long-term users became addicted.17
Today, drug makers may be getting their �wings clipped� with the introduction of new government directives slashing production of popular prescription painkillers. In 2016, the U.S. Drug Enforcement Administration (DEA) finalized a previous order on 2017 production quotas for a variety of Schedule I and II drugs, including addictive narcotics like oxycodone, hydromorphone, codeine and fentanyl. The agency has the authority to set limits on manufacturing under the Controlled Substances Act. The DEA said it is reducing �the amount of almost every Schedule II opiate and opioid medication� by at least 25 percent.18 Some, like hydrocodone, commonly known by brand names like Vicodin or Lortab, will be cut by one-third.
Despite these setbacks, the drug industry continues to launch strong initiatives that fight state- mandated opioid limits. Amid the crisis and regardless of the pressures urging a shift away from opioid use, the makers of prescription painkillers recently adopted a 50-state strategy that includes hundreds of lobbyists and millions in campaign contributions to help kill or weaken measures aimed at stemming the tide of prescription opioids.19
While the drug makers vow they�re combating the addiction problem,The Associated Press
and the Center for Public Integrity found that these manufacturers often employ a statehouse playbook of delay and defend tactics.This includes funding advocacy groups that use the veneer of independence to fight limits on the drugs, such as OxyContin, Vicodin and Fentanyl, a potent, synthetic opioid pain medication with a rapid onset and short duration of action that is estimated to be between 50 and 100 times as potent as morphine.20
In its national update released Dec. 16, 2016 in the Morbidity and Mortality Weekly Report, the CDC reported that more than 300,000 Americans have lost their lives to an opioid overdose since 2000.
As enforcement restricts the availability of prescription opioids, people addicted
to painkillers — such as oxycodone (OxyContin) and morphine — have increasingly turned to — street drugs like heroin.21
These independent sources also found that the drug makers and allied advocacy groups employed an annual average of 1,350 lobbyists in legislative hubs from 2006 through 2015, when opioids� addictive nature came under increasing scrutiny.
�The opioid lobby has been doing everything it can to preserve the status quo of aggressive prescribing.They are reaping enormous profits from aggressive prescribing.�22
Andrew Kolodny, MD, founder, Physicians for Responsible Opioid Prescribing
Undaunted by these interferences, and buoyed by a thirst for profits, pharmcos are now fueling other creative solutions to drive even greater revenues from the sale and distribution of drugs.
It now appears that pharmcos are directing their activities toward medicines known as abuse-deterrent formulations: opioids with physical and/or chemical barriers have built-in properties that make the pills difficult to crush,chew or dissolve.This aims to deter abuse through intranasal and intravenous routes of administration.These drugs ultimately are more lucrative, since they�re protected by patent and do not yet have generic competitors.They cost insurers more than generic opioids without the tamper-resistant technology.23
Skeptics warn that they carry the same risks of addiction as other opioid versions, and the U.S. FDA noted that they don�t prevent the most common form of abuse � swallowing pills whole.
�This is a way that the pharmaceutical industry can evade responsibility, get new patents and continue to pump pills into the system,� said Dr. Anna Lembke, Chief of Addiction Medicine at the Stanford University School of Medicine.24
Drug makers have discovered yet another way to profit from addicts taking high doses of prescription opioid painkillers � the new billion-dollar drug to treat opioid-induced constipation (OIC) rather than controlling pain.
Studies show that constipation afflicts 40-90 percent of opioid patients.Traditionally,doctors advised people to cut down the dosage of their pain meds, take them less often or try non-drug interventions. By promoting OIC as a condition in need of more targeted treatment, the drug industry is creating incentives to maintain painkillers at full strength and add another pill instead.25
Collectively, the subsets of new pharmaceutical submarkets to treat opioid addiction, overdoses, and side effects such as OIC are estimated to be worth at least $1 billion a year in sales.These economics, some experts say, work against efforts to end the epidemic.26
While there is continued pressure to limit the number and scope of opiates for patients, new government statistics reveal that drug overdose deaths continue to surge in the United States, now exceeding the number of deaths caused by motor vehicle accidents.27 Although it is reported that the number of opioid prescriptions has fallen across the U.S. over the past three years, with intermittent data on this decline in states such as West Virginia and Ohio, they still kill more Americans each year than any other drug.
Just over 33,000 (63 percent) of the more than 52,000 fatalities reported in 2015 are linked to the illicit use of prescription painkillers.28 States including Massachusetts, and most recently Virginia, have declared public health emergencies as the number of deaths has escalated.29
Regardless of whether these issues are viewed from the perspective of patients, clinician prescribers, or government regulators, the status quo is clearly not acceptable.
Responsible Prescribing
�My new patient didn�t mention his back pain until the very end of the visit.As he was rising to leave, he asked casually if I could refill his Percocet. I told him I am not a pain or a back specialist and that I generally prescribe muscle relaxants or anti-inflammatory medications for back pain � not opioids, which are addictive and do not really treat the underlying problem.
The patient persisted. He said his prior internist always prescribed it, and the medication also helped his mood. He promised he had its use under control and did not feel he needed to take more and more to achieve the same effect.
I didn�t relent. I offered to refer him to a back specialist instead. It was an uncomfortable end to an otherwise positive visit.
Unfortunately, we doctors are enablers.Too many of us fill those prescriptions for chronic pain. And when we don�t, too many of our patients leave us for other doctors who will. Or worse, they turn to buying heroin on the street.�30
Marc Siegel, MD, FOX NEWS
Clinical prescribers of pain medications are beginning to recognize their responsibilities for increased prescribing vigilance, and are expected to become important advocates for drug-free pain care. More than half of doctors across America are curtailing opioid prescriptions, and nearly 1 in 10 have stopped prescribing the drugs, according to a new nationwide online survey. More than one-third of the respondents said the reduction in prescribing has hurt patients with chronic pain.
The survey, conducted for The Boston Globe by the SERMO physicians social network, offers fresh evidence of the changes in prescribing practices in response to the opioid crisis that has killed thousands in New England and elsewhere around the country.The deaths awakened fears of addiction and accidental overdose, and led to state and federal regulations aimed at reining in excessive prescribing.
Doctors face myriad pressures as they struggle to treat addiction and chronic pain, two complex conditions in which most physicians receive little training.Those responding to the survey gave two main reasons for cutting back: the risks and hassles involved in prescribing opioids, and a better understanding of the drugs� hazards.31
In Wisconsin, the Medical Society says the state�s effort to fight the opioid epidemic is showing results.A new report found about eight million fewer opioids were dispensed between July and September 2016 compared to the same time during the previous year.The Medical Society says it�s doing more to help physicians monitor patients� use of opioids by supporting the release of an enhanced prescription drug monitoring program � or PDMP. Starting in April 2017, doctors will have to access the program while pharmacists will only have 24 hours to enter information instead of seven days.This gives doctors an update in case patients are going from doctor to doctor for more prescriptions.32
Prescription drug monitoring programs (PDMPs), launched in 2013, are state-run electronic databases used to track the prescribing and dispensing of controlled prescription drugs to patients.They are designed to monitor this information for suspected abuse or diversion (i.e., channeling drugs into illegal use), and can give a prescriber or pharmacist critical information regarding a patient�s controlled substance prescription history.This information can help prescribers and pharmacists identify patients at high-risk who would benefit from early interventions.
PDMPs continue to be among the most promising state-level interventions to improve opioid prescribing, inform clinical practice and protect patients at risk.33
Hospital Admissions Due To Heroin, Painkillers Rose 64% 2005-2014
Researchers found misuse of prescription painkillers and street opioids climbed nationwide, related hospital stays jumped from 137 per 100,000 people to 225 per 100,000 in that decade.
States where overdoses required at least 70 percent more hospital beds between 2009 and 2014 were North Carolina, Oregon, South Dakota and Washington.
In 2014, the District of Columbia, Maryland, Massachusetts, New York, Rhode Island and West Virginia each reported rates above 300 per 100,000 people — far above the national average.34
Health Plans Report Limited Prescribing Is Paying Off
According to IMS Health, a global health information and technology firm, the rate of opioid prescribing in the U.S. has dropped since its peak in 2012.The drop is the first that has been reported since the early 1990s, when OxyContin first hit the market and pain became �the fifth vital sign� doctors were encouraged to more aggressively treat.35
However, continued pressure on physician prescribing patterns and opportunities for therapies other than opioids may be paying off. Prescriptions for powerful painkillers dropped significantly among patients covered by Massachusetts� largest insurer after measures were introduced to reduce opioid use.36 The Blue Cross Blue Shield of Massachusetts program serves as an example of a private health insurer collaborating on a public health goal.
In 2012, the insurer � the state�s largest, with 2.8 million members � instituted a program intended to induce doctors and patients to weigh the risks of opioids and consider alternatives.As part of that initiative, first-time opioid prescriptions are limited to 15 days, with a refill allowed for 15 more days. Blue Cross must approve in advance any prescription for longer than a month or for any long-acting opioid such as OxyContin. Pharmacy mail orders for opioids are prohibited.
Doctors and others who prescribe must assess the patient�s risk of abusing drugs and develop a treatment plan that considers options other than opioids. And patients with chronic pain are referred to case managers who advise on therapies other than opioids.
By the end of 2015, the average monthly prescribing rate for opioids decreased almost 15 percent, from 34 per 1,000 members to 29. About 21 million fewer opioid doses were dispensed during the three years covered in the study.37
In another example, Highmark (Pennsylvania) shared data in December 2016 showing that the number of prescriptions for opioids it reimbursed in each of the past three months was lower than in any of the prior nine months. One leading health plan in the state reported that 16 percent of its insured population received at least one opioid prescription in 2016, down from 20 percent in 2015.38 UPMC Health Plan indicated it is using �an algorithm to identify patients who may be at risk for opioid addiction,� and training doctors to use other pain management tools.
Mounting Evidence & Support For Non-Pharmacologic Care For Acute, Subacute & Chronic Back, Neck & Neuro-Musculoskeletal Pain
The earlier sections of this white paper have focused on the continuing and growing problem of opioid use, abuse and addiction. It is essential that this information is understood and appreciated as it clearly calls for a wholesale change in the approach American health care providers and patients bring to the care and management of pain.
No matter what is done to address the use, abuse and addiction associated with opioids it is a fact of life that opioid containing products will continue to be required by individuals suffering severe, intractable and unrelenting pain.This issue is not about the cessation of all opioid use, rather it is about not turning to opioids before they are required, and not until all less onerous approaches to pain management have been exhausted.
We began this discussion with three questions in mind:
�Without the use of drugs, how will they cope with pain?
How can they get referrals and access to drug-free care that will be effective for both acute, subacute and chronic pain?
�How can they ensure that their health care plans and insurance will cover the cost of non- pharmacologic care?
According to new guidelines developed by the American College of Physicians,39 conservative non-drug treatments should be favored over drugs for most back pain. The guidelines are an update that include a review of more than 150 recent studies and conclude that,�For acute and subacute pain, the guidelines recommend non-drug therapies first, such as applying heat, massage, acupuncture, or spinal manipulation, which is often done by a chiropractor.�
The Wall Street Journal
As we have previously noted the CDC, FDA and IOM have all called for the early use of non- pharmacologic approaches to pain and pain management. Unfortunately, beyond asserting the need to move in this direction, little, if any, guidance has been offered to providers, patients and payors on how to accomplish this important transition.
It is a fact that a chasm exists between the worlds of pharmacologic based management of pain, and the non-pharmacologic based management of pain. Medical physicians are not going to suddenly attain knowledge and understanding of practices, procedures and management options that they have never been trained in or exposed to. Similarly, the non-pharmacologic providers addressing pain management do not encounter or understand the barriers that prevent prescribers from directing patients toward non-pharma approaches.These two spheres of healthcare are distinct and separate, and demonstrate little, if any, knowledge about the other.
The first step is to provide resources to prescribers that will detail the indications, effectiveness, efficiency and safety of non-pharmacologic approaches. In particular, the chiropractic profession, through its 70,000 practitioners in the United States, represents a significant and proven non- pharmacologic approach for reducing the need for opioids, opioid-related products and non- opioid pain medications.
Chiropractic, like other complementary health care approaches, suffers from a lack of awareness about its high level of education, credentialing and regulation. In addition, a substantial awareness gap exists among frontline providers in terms of referring patients to chiropractors as part of patient care.
The chiropractic profession and the health care consumer are equally supported by a robust oversight infrastructure.This infrastructure ranges from institutional and programmatic accreditation of chiropractic education by agencies recognized by the U.S. Department of Education to standardize national credentialing examinations and licensure by state agencies and ongoing professional development as a requirement for continued practice in many states.
Typically, after earning a Bachelor of Science, chiropractors follow a four-year curriculum to earn a Doctor of Chiropractic (DC) as a prerequisite to earning the right to independent practice. Chiropractic, medical, osteopathic, dental, optometric and naturopathic education share a similar foundation in the basic sciences, followed by discipline-specific content that focuses on the unique contribution of each provider type. For example, a medical student pursues the study of pharmacology and surgery, while a chiropractic student studies the intricacies of manual approaches to health care and the acquisition of the skills needed to perform spinal adjusting or manipulation.
Chiropractors also pursue specialization in specific areas, such as radiology, through structured residency programs, similar to other disciplines. DCs also pursue focus areas related to various methods of spinal adjusting and related patient management.
For over a century, DCs have studied the relationship between structure, primarily the spine, and function, primarily of the nervous system, and how this interrelationship impacts health and well- being. Due to this emphasis on the spine, chiropractors have become associated with spinal and skeletal pain syndromes, and bring their non-surgical, non-drug rationale to the management of these problems.
DCs are the quintessential example of non-pharmacologic providers of health care with particular expertise in neuro-musculoskeletal conditions.
A Look At The Evidence
While the United States is attempting to deal with its opioid epidemic, our nation is making only limited headway in providing non-pharmacologic approaches to patients with pain.
Over 100 million Americans suffer with chronic pain,40 and an estimated 75 to 85 percent of all Americans will experience some form of back pain during their lifetime. However, 50 percent of
all patients who suffer from an episode of low back pain will have a recurrent episode within one year.41 Surgery has a very limited role in the management of spinal pain, and is only considered appropriate in a handful of cases per hundred patients. Likewise, opioids have very limited utility in the spinal pain environment with the recommended use of these drugs being limited to three days.
Of special relevance, this data relates to the most commonly-reported pain conditions:42
When asked about four common types of pain, respondents of a National Institute of Health Statistics survey indicated that low back pain was the most common (27 percent), followed by severe headache or migraine pain (15 percent), neck pain (15 percent) and facial ache or pain (4 percent).
Back pain is the leading cause of disability in Americans under 45 years old. More than 26 million Americans between the ages of 20-64 experience frequent back pain.
Adults with low back pain are often in worse physical and mental health than people who do not have low back pain: 28 percent of adults with low back pain report limited activity due to a chronic condition, as compared to 10 percent of adults who do not have low back pain. Also, adults reporting low back pain were three times as likely to be in fair or poor health and more than four times as likely to experience serious psychological distress as people without low back pain.
Results of a 2010 study indicate that DCs provide approximately 94 percent of the manipulation services performed in the U.S.,43 with a number of published studies documenting manipulation, along with other drug-free interventions, as effective for the management of neck44 and back pain.45 Most high-quality guidelines target the noninvasive management of nonspecific low back pain and recommend education, staying active/exercising, manual therapy, and paracetamol or NSAIDs as first-line treatments.46
Action Needed
Care pathways and clinical guidelines need to be modified to bring greater attention to the use of non-pharmacologic approaches to pain management. Primary medical care providers must be encouraged to make recommendations or referrals to drug-free resources and appropriate providers, such as DCs, rather than turning to the prescription pad when managing patients who have pain, particularly those with spinal pain. Patients should be educated about non- pharmacologic options for dealing with pain first and foremost, and the dangers of opioids.
For these good intentions to be effective, drug-free pathways will need to be funded by payers in the private sector and government. Government leadership and policy support for introducing innovative reimbursement initiatives by the CMS is a critical step toward allowing health providers to acquire familiarity with non-pharmaceutical approaches.These could frame and stimulate use of evidence-based care options and promote referrals, access to care and reimbursement. By re- engineering these approaches to care to fit the current health care landscape, rather than simply reacting to the opioid crisis by de-emphasizing pain treatment, CMS can better serve patients.
One example: CMS should consider a chronic pain shared-savings program targeting accountable care organizations (ACOs), where success is tied explicitly to patient functional outcomes. Benchmarking against ACO performance measures to determine if care results in savings or losses would allow these organizations to work towards meeting or exceeding quality performance standards � leading to receiving a portion of the savings generated. By incorporating incentives, this type of model would be consistent for more effective integrative intervention for pain.47
Fortunately, progressive thinking is gaining traction in this area. In a January 5, 2017 posting on the CMS Blog, authors wrote that the CMS is focusing on significant programs, including increased use of evidence-based practices for acute and chronic pain management.
�We are working with Medicare and Medicaid beneficiaries, their families and caregivers, health care providers, health insurance plans and states to improve how opioids are prescribed by providers and used by beneficiaries, how opioid use disorder is identified and managed, and how alternative approaches to pain management can be promoted.�48
While we applaud CMS, we feel it is important to point out that this approach begins with a focus on how opioids are prescribed.The focus needs to shift to early applications of non-pharmacologic approaches first and not as a follow-on after the drug path has been established.
Documented Results & Cost Savings
WORKPLACE INJURIES
Back pain is the most common occupational injury in the United States and Canada,49 and represents the most common non-fatal occupational injury, according to the U.S. Bureau of Labor Statistics. Musculoskeletal disorders (MSDs), such as sprains or strains resulting from overexertion in lifting, accounted for 31 percent (356,910 cases) of the total cases for all workers.50
Most recently, Maine Department of Labor data showed injuries to a person�s lumbar region represented 14.3 percent of all injuries reported in 2014, up from 10.7 percent just five years earlier.51 Health care employees have among the highest rates of musculoskeletal injuries for workers, second only to those working in the transportation and warehousing sectors.52
Opiates are not a safe alternative especially when operating heavy machinery, transportation or caring for patients because side effects can alter performance and have tragic outcomes.
Take for example, a 56-year-old nurse at the Maine Medical Center in Portland. She relies on a comprehensive strategy to address her chronic back pain, which originates from having to wear heavy lead aprons when giving radiation treatments, and moving patients and equipment. Her regimen, which includes regularly seeing a chiropractor, exercises, stretches and building up her core muscles, has helped her to control her pain.53
In terms of the value of a �gatekeeper� health care provider for insured workers like this nurse, a study published in Journal of Occupation Rehabilitation (September 17, 2016) cites this factor as
a significant predictor of the duration of the first episode of a worker�s compensation claim. They analyzed a cohort of 5,511 workers, comparing the duration of financial compensation and the occurrence of a second episode of compensation for back pain among patients seen by three types of first health care providers: physicians, chiropractors and physical therapists in the context of workers� compensation.54
When compared with medical doctors, chiropractors were associated with shorter duration of compensation and physical therapists (PT) with longer ones.There was also greater likelihood that PT patients were more likely to seek additional types of care that incurred longer compensation duration.
Additionally, earlier research confirms that on a case adjusted basis 42.7 percent of workers who initially visited a surgeon underwent surgery compared with only 1.5 percent of those who first consulted a chiropractor.55
Medicaid
The National Academy for State Health Policy (NASHP), an independent academy of state health policymakers dedicated to helping states achieve excellence in health policy and practice, recently studied chronic pain management therapies in Medicaid, including policy considerations for non-pharmacological alternatives to opioids. A non-profit and non-partisan organization, NASHP provides a forum for constructive work across branches and agencies of state government on critical health issues.56
SURVEY RESULTS:
�Has your Medicaid agency implemented specific policies or programs to encourage or require alternative pain management strategies in lieu of opioids for acute or chronic non-cancer pain?�
A September 2016 NASHP report states that although most Medicaid agencies cover services that can be used as alternatives to opioids for pain management, significantly fewer states have policies or procedures in place to encourage their use.
Between March and June 2016, NASHP conducted a survey of all 51 Medicaid agencies to determine the extent to which states have implemented specific programs or policies to encourage or require non-opioid therapies for acute or chronic non-cancer pain.They contacted each Medicaid director via email and, in cases of non-response, followed up with Medicaid medical directors. Ultimately, they received responses from 41 states and the District of Columbia.
Because reimbursement is a key incentive to access alternative care, they also note the most recent results of Medicaid agency reimbursement data from The Henry J. Kaiser Family Foundation (KFF):57
Among the key findings, researchers found most Medicaid agencies cover services that can be used to treat pain in lieu of opioids, but less than half have taken steps to specifically encourage or require their use. Non-pharmacological therapies commonly used to address pain include physical therapy, cognitive behavioral therapy, and exercise, as well as other services, commonly known as Complementary and Alternative Medicine (CAM), including chiropractic manipulation, acupuncture and massage.
They point out that while the current literature on non-pharmacological alternatives is mixed, there is a growing body of evidence to support the use of alternative services to treat chronic pain. For example, a systematic review suggests lower costs for patients experiencing spine pain who received chiropractic care.58
This finding is substantiated in Rhode Island, where the state�s Section 1115 Demonstration authorizes certain individuals enrolled in Medicaid managed care delivery systems to receive CAM services for chronic pain.59 Rhode Island Medicaid has implemented this benefit through its Communities of Care program, a state initiative designed to reduce unnecessary emergency room utilization. Medicaid managed care enrollees with four or more emergency room visits within a 12-month period are eligible to receive acupuncture, chiropractic or massage therapy services.
The state�s two managed care plans, Neighborhood Health Plan of Rhode Island (NHPRI) and United HealthCare of New England, were responsible for developing participation criteria for their enrollees. For example, NPRHI published clinical practice guidelines for its Ease the Pain program, which specified when CAM services referrals were appropriate. Under NHPRI�s guidelines, qualifying individuals diagnosed with back pain, neck pain, and fibromyalgia can be referred for chiropractic services, acupuncture and massage.
Substantiating the results for CAM, Advanced Medicine Integration Group, L.P. in Rhode Island contracted with the two health plans to identify and manage their Medicaid eligible members suffering from chronic pain through its Integrated Chronic Pain Program (ICPP).The target Medicaid population for this program was the Community of Care (CoC) segment — high utilizers of ER visits and opioids/pharmaceuticals.
The objectives of the ICPP are to reduce pain levels (and opioid use), improve function and overall health outcomes, reduce emergency room costs and, through a holistic approach and behavioral change models, educate members in self-care and accountability.
The design of the program for this patient population features holistic nurse case management with directed use of patient education, community services and CAM modalities, including chiropractic care, acupuncture and massage.
Individuals with chronic pain conditions were identified using proprietary predictive modeling algorithms applied to paid claims data to determine opportunities for reducing chronic pain-related utilization and costs.
Results for enrolled CoC Medicaid members with chronic pain conditions document:
�Reduced per member per year (PMPY) total average medical costs by 27 percent
�Decreased the average number of ER visits by 61 percent
Lowered the number of average total prescriptions by 63 percent
�Reduced the average number of opioid scripts by 86 percent
These reductions exceeded by two to three times those reported for a non-enrolled control group of conventionally managed CoC chronic pain patients. Every $1 spent on CAM services and program fees resulted in $2.41 of medical expense savings.
Military
At the time of publication, a study entitled: Assessment of Chiropractic Treatment for Low Back Pain and Smoking Cessation in Military Active Duty Personnel, has completed its clinical trial activities and is currently in the analysis phase. Funded by a four-year grant from the Department of Defense, it is the largest multi-site clinical trial on chiropractic to date, with a total sample size of 750 active- duty military personnel.60
The purpose of this study is to evaluate the effectiveness of chiropractic manipulative therapy for pain management and improved function in active duty service members with low back pain that do not require surgery.The study also measures the impact of a tobacco cessation program delivered to participants allocated to the chiropractic arm.
Low back pain (LBP) is the most common cause of disability worldwide, but it is even more prevalent in active duty military personnel. More than 50 percent of all diagnoses resulting in disability discharges from the military across all branches are due to musculoskeletal conditions. LBP has been characterized as �The Silent Military Threat� because of its negative impact on mission readiness and the degree to which it compromises a fit fighting force. For these reasons, military personnel with LBP need a practical and effective treatment that relieves their pain and allows them to return to duty quickly. It must preserve function and military readiness, address the underlying causes of the episode and protect against re-injury.
This multisite Phase II Clinical Comparative Effectiveness Trial is designed to rigorously compare the outcomes of chiropractic manipulative therapy (CMT) and conventional medical care (CMC) to CMC alone. Chiropractic treatment will include CMT plus ancillary physiotherapeutic interventions. CMC will be delivered following current standards of medical practice at each site. At each of the four participating sites, active military personnel, ages 18 to 50, who present with acute, sub-acute or chronic LBP that does not require surgery will be randomized to one of the two treatment groups.
Outcome measures include the Numerical Rating Scale for pain, the Roland-Morris Low Back Pain and Disability questionnaire, the Back Pain Functional Scale for assessing function, and the Global Improvement questionnaire for patient perception regarding improvement in function. Patient Expectation and Patient Satisfaction questionnaires will be used to examine volunteer expectations toward care and perceptions of that care. Pharmaceutical use and duty status data will also be collected.The Patient Reported Outcomes Measurement Information System (PROMIS-29) will be utilized to compare the general health component and quality of life of the sample at baseline.
Also, because DCs are well positioned to provide information to support tobacco cessation, this clinical trial includes a nested study designed to measure the impact of a tobacco cessation program delivered by a DC.The results will provide critical information regarding the health and mission-support benefits of chiropractic health care delivery for active duty service members in the military.61
This current research was preceded by a pilot study on LBP, conducted at an Army Medical Center in El Paso,Texas, with 91 active-duty military personnel between the ages of 18 and
35.62 Results reported in the journal SPINE showed that 73 percent of those who received standard medical care and chiropractic care rated their improvement as pain �completely gone,��much better� or �moderately better.� In comparison, 17 percent of participants who received only standard medical care rated their improvement this way.These results, as well as other measures of pain and function between the two groups, are considered both clinically and statistically significant.
Recommendations & Next Steps
The opioid crisis has provided a wake-up call for regulators, policy experts, clinicians and payers nationwide. As the support for complementary health techniques builds, interdisciplinary and integrative approaches to chronic pain management are considered best practices.
While the Centers for Disease Control and Prevention�s Guideline validates the need for a shift away from the utilization of opioid prescription painkillers as a frontline treatment option for pain relief, the mention of chiropractic care as a safe, effective and drug-free alternative is omitted.
Instead, CDC recommendations encourage utilization of physical therapy, exercise and over- the-counter (OTC) pain medications prior to prescription opioids for chronic pain.63
�Though the guidelines are voluntary, they could be widely adopted by hospitals, insurers and state and federal health systems.�
CBS News64
The CDC rarely advises physicians on how to prescribe medication — which further adds to the significance of their pronouncements. Many payers and state legislators have already added these findings to their coverage on the use of opioids.
With the likelihood of major players in the industry adopting the well-respected guidelines, it is critical that chiropractic care receives the consideration it deserves.
Chiropractic care has earned a leading role as a pain relief option and is regarded as an important element of the nation�s Opioid Exit Strategy: a drug-free, non-invasive and cost-effective alternative for acute or chronic neck, back and musculoskeletal pain management.
For individuals who may be suddenly �cut-off� from painkillers, chiropractic offers a solution. But access to care will depend upon several important factors:
�Pharmaceutical Industry �Re-engineering�: A change toward responsible marketing and physician education.
�Physician Referrals to Ensure Access to Chiropractic Care: Physician prescribing of chiropractic care rather than opioids.
�Benefit Coverage and Reimbursement for Chiropractic Care: Government and commercial payers as well as plan sponsors have a responsibility to offer patients the option of chiropractic care � and reimburse DCs as participating providers.
�Access to Chiropractic Care for Active Military and Veteran Populations: Chiropractic care should be expanded in the Department of Defense and veterans� health care systems.
As a nation, we have all come to recognize that pain is a complex, multifaceted condition that impacts millions of Americans, their families and caregivers. Unfortunately, the lessons learned about long-term opioid therapy for non-cancer pain have been deadly and heartbreaking.We now understand that there is little to no evidence to support their effectiveness for ongoing chronic pain management.
It is now incumbent upon all stakeholders to increasingly explore the appropriateness, efficacy and cost-effectiveness of alternative pain management therapies and embrace these solutions as a realistic opportunity for America�s Opioid Exit Strategy.
accessed December 8, 2016.
15 Cha, Ariana Eunjung, 2016.
16 Shedrrofsky, Karma, 2016.
17 America�s Painkiller Epidemic, Explained; The Week, February 13, 2016; theweek.com/articles/605224/americas-painkiller-epidemic-explained
18 Wing, Nick; DEA Is Cutting Production Of Prescription Opioids By 25 Percent In 2017; Huffington Post, October 5, 2016; www.huffingtonpost.com/entry/dea-cutting-prescription-opioids_us_57f50078e4b03254526297bd
19 Mulvihill, Geoff, Whyte, Liz Essley, Wieder, Ben; Politics of pain: Drugmakers fought state opioid limits amid crisis; The Center
for Public Inegrity, December 15, 2016. www.publicintegrity.org/2016/09/18/20200/politics-pain-drugmakersfought-state-opioid-limits-amid-crisis;
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ADJUVANT TO BUPIVACAINE, Journal of Evolution of Medical and Dental Sciences; jemds.com/latest-articles.php?at_id=7552; accessed December 31, 2016.
21 CDC: 10 Most Dangerous Drugs Linked to Overdose Deaths, Health Day, December 22, 2016. www.empr.com/
news/cdc-10-most-dangerous-drugs-linked-to-overdose-deaths/article/580540/; accessed January 1, 2017.
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25 Cha, Ariana Eunjung, 2016.
26 Cha, Ariana Eunjung, 2016.
�2017 Foundation for Chiropractic Progress PAGE 27
27 Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS). 2014
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28 Thompson, Dennis; Drug Overdose Deaths Climb Dramatically in U.S.; HealthDay News, December 20, 2016; consumer.healthday.com/bone-and-joint-information-4/opioids-990/drug-overdose-deaths-climb-dramatically-inu-s-717988.html;
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30 Siegel, Marc, MD; We doctors are enablers: A physician�s take on the opioid epidemic; FOXNews, December 21, 2016; www.foxnews.com/opinion/2016/12/21/doctors-are-enablers-physicians-take-on-opioid-epidemic.html;
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31 Freyer, Felice J.; Doctors are cutting opioids, even if it harms patients; Boston Globe, January 3, 2017; www.bostonglobe.com/metro/2017/01/02/doctors-curtail-opioids-but-many-see-harm-pain-patients/z4Ci68TePafcD9AcORs04J/story.html.
32 Blair, Nolan; Doctors prescribing less opioids; ABC WBAY.com, November 2, 2016. wbay.com/2016/11/02/report-finds-decrease-in-opioid-prescriptions/
33 Centers for Disease Control; www.cdc.gov/drugoverdose/pdmp/; accessed January 5, 2017.
34 Lord, Rich; Attention to opioids may be curbing doctors prescriptions; Pittsburgh Post-Gazette, December 26, 2016; http://
www.post-gazette.com/news/overdosed/2016/12/26/Attention-to-opioids-may-be-curbing-doctors-prescriptions/stories/201612260013
35 Nuzum, Lydia; Opioid prescriptions in US, WV down for first time in two decades; The Charleston Gazette-Mail, June 6, 2016. www.wvha.org/Media/NewsScan/2016/June/6-6-16-Opioid-prescriptions-in-US,-WV-down-for-fir.aspx
36 Freyer, Felice J.; Opioid prescriptions drop among patients covered by state�s biggest insurer; Boston Globe, October 20,
2016; www.bostonglobe.com/metro/2016/10/20/opioid-prescriptions-drop-significantly-among-patients-covered-state-biggest-insurer/06jIYorfogaG2o8Wrhr8ZN/story.html
37 Freyer, Felice J., 2016.
38 U.S. Agency for Healthcare Research and Quality, Opioid Overdoses Burden U.S. Hospitals: Report, HealthDay News, December
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39 Reddy, S. (2017, February 13). No Drugs for Back Pain, New Guidelines Say. Retrieved from www.wsj.com/articles/no-drugs-for-back-pain-new-guidelines-say-1487024168
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America, A Blueprint for Transforming Prevention, Care, Education and Research. The National Academies Press, 2011. books.nap.edu/openbook.php?record_id=13172&page=1.
41 American Association of Neurological Surgeons; Low Back Pain, May 2016. www.aans.org/Patientpercent20Information/Conditionspercent20andpercent20Treatments/Lowpercent20Backpercent20Pain.aspx
42 American Academy of Pain Medicine; Facts and Figures About Pain; www.painmed.org/PatientCenter/Facts_on_Pain.aspx#refer; accessed January 7, 2017.
43 Daniel C. Cherkin, Robert D. Mootz; Chiropractic in the United States: Training, Practice, and Research, 2010.
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44 Wong, J. J., Shearer, H. M., Mior, S., Jacobs, C., C�t�, P., Randhawa, K., . . . Taylor-Vaisey, A. (2016). Are manual therapies, passive
physical modalities, or acupuncture effective for the management of patients with whiplash-associated disorders or
neck pain and associated disorders? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated
Disorders by the OPTIMa collaboration. The Spine Journal, 16(12), 1598-1630. doi:10.1016/j.spinee.2015.08.024.
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the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management
(OPTIMa) Collaboration. European Journal of Pain, 21(2), 201-216. doi:10.1002/ejp.931
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Beneficiaries Healthy, January 5, 2017; blog.cms.gov/2017/01/05/addressing-the-opioid-epidemic/
49 Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine.
2006;31(23):2724�7. doi:10.1097/01.brs.0000244618.06877.cd
PAGE 28 �2017 Foundation for Chiropractic Progress
CHIROPRACTIC � A KEY TO AMERICA’S OPIOID EXIT STRATEGY
50 Bureau of Labor Statistics; Nonfatal Occupational Injuries and Illnesses Requiring Days Away From Work, 2015,
November 10, 2016; www.bls.gov/news.release/osh2.nr0.htm; accessed January 8, 2017.
51 Lawlor, Joe; Back injuries most common type of injuries for workers; Portland Press Herald, October 16, 2016; www.
pressherald.com/2016/10/16/back-injuries-most-common-type-of-injuries-for-workers/; accessed 1.8.2017.
52 Lawlor, Joe; 2016.
53 Lawlor, Joe; 2016.
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of workers in Washington State. Spine 2013 May 15;38(11):953-64.
6 Dorr, Hannah and Townley, Charles; Chronic Pain Management Therapies in Medicaid: Policy Considerations for Non-Pharmacological
Alternatives to Opioids; National Academy for State Health Policy, September 2, 2016; nashp.org/chronic-pain-management-therapies-medicaid-policy-considerations-non-pharmacological-alternatives-opioids/
57 It is important to note that the KFF data tracks which states allow direct reimbursement to the specific provider type (e.g.,
directly reimbursing a physical therapist for physical therapy services); states that do not directly reimburse these providers
may actually cover the service if billed by another provider (e.g., an institutional setting). For more information, please
see the notes in the following references.
Kaiser Family Foundation. �Medicaid Benefits: Physical Therapy Services.� Retrieved August 24, 2016. kff.org/medicaid/state-indicator/physical-therapy-services/
Kaiser Family Foundation. �Medicaid Benefits: Psychologist Services.� Retrieved August 24, 2016. kff.org/medicaid/state-indicator/psychologist-services/
Kaiser Family Foundation. �Medicaid Benefits: Occupational Therapy Services.� Retrieved August 24, 2016.http://
kff.org/medicaid/state-indicator/occupational-therapy-services/
Kaiser Family Foundation. �Medicaid Benefits: Chiropractor Services.� Retrieved August 24, 2016. kff.org/medicaid/state-indicator/chiropractor-services/
58 Dagenais, S., Brady, O., Haldeman, S., & Manga, P. 2015, October 19. A systematic review comparing the costs of
chiropractic care to other interventions for spine pain in the United States. Retrieved February 08, 2017, from www.ncbi.nlm.nih.gov/pmc/articles/PMC4615617/
59 Neighborhood Health Plan of Rhode Island Clinical Practice Guideline, Complementary and Alternative Medicine (CAM).
December 18, 2014.
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Active Duty Personnel; clinicaltrials.gov/ct2/show/NCT01692275; accessed January 8, 2017.
61 U.S. National Institutes of Health
62 Goertz, Christine M. DC, PhD, et. al; Adding Chiropractic Manipulative Therapy to Standard Medical Care for Patients With
Acute Low Back Pain: Results of a Pragmatic Randomized Comparative Effectiveness Study; SPINE, Volume 38, Issue 8,
April 15, 2013; journals.lww.com/spinejournal/Abstract/2013/04150/Adding_Chiropractic_Manipulative_Therapy_to.2.aspx
63 Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain � United States, 2016. MMWR
Recomm Rep 2016;65(No. RR-1):1�49. DOI: dx.doi.org/10.15585/mmwr.rr6501e1.
64 CBS News/AP. (2016, March 15). CDC guidelines aim to reduce epidemic of opioid painkiller abuse. Retrieved January 15,
2017, from www.cbsnews.com/news/opioid-painkiller-guidelines/.
Foundation For Chiropractic Progress�
BOARD OF DIRECTORS
Kent S. Greenawalt, CEO, Foot Levelers; Chairman of the Board of Directors, F4CP
Mickey G. Burt, DC, Executive Director of Alumni and Development, Palmer College of Chiropractic Gerard W. Clum, DC, Director, The Octagon, Life University
Kristine L. Dowell, Executive Director, Michigan Association of Chiropractors
Joe Doyle, Publisher, Chiropractic Economics
Charles C. Dubois, President/CEO, Standard Process, Inc.
J. Michael Flynn, DC
R. A. Foxworth, DC, FICC, MCS-P, President, ChiroHealthUSA
Arlan W. Fuhr, Chairman/Founder, Activator Methods International Ltd.
Greg Harris, Vice President for University Advancement, Life University
Kray Kibler, CEO, ScripHessco
Thomas M. Klapp, DC, COCSA Representative
Carol Ann Malizia, DC, CAM Integrative Consulting
Fabrizio Mancini, DC, President Emeritus, Parker University
Brian McAulay, DC, PhD
William Meeker, DC, MPH, President, Palmer College of Chiropractic � San Jose Campus
Robert Moberg, CEO, Chirotouch
Donald M. Petersen, Jr., Publisher, MPA Media
Mark Sanna, DC, FICC, ACRB, Level II, President, Breakthrough Coaching
Paul Timko, Vice President/General Manager of U.S. Clinical Business, Performance Health
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