Back Clinic Integrative medicine Team. It is the practice of medicine that focuses on the whole person and utilizes all appropriate therapeutic approaches, healthcare practitioners, and disciplines to achieve optimal healing and health. It combines state-of-the-art and conventional medical treatments and other carefully selected therapies because they are effective and safe.
The goal is to unite the best of conventional medicine and other healing systems/therapies brought from cultures and ideas. This type of medicine is based on a model of health and wellness compared to a disease model. Integrative medicine is geared to the use of low-tech, low-cost interventions.
This model recognizes the critical role of how the practitioner-patient relationship plays in a patient’s healthcare experience. Its purpose is to care for the whole person by considering all of the interrelated physical and nonphysical factors that affect health, wellness, and disease. These include psychosocial and spiritual factors in people’s lives.
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.
Hippocrates, the father of modern medicine, stated all healing starts in the gut. And researchers carry on to prove him accurate as they unravel how a healthier gut microbiome plays a function in fat decline, disease prevention, and much additional. As we know, diet plays a very important function in keeping a healthier gut setting and dysbiosis, or a gut-flora imbalance, ramps up inflammation, and triggers lots of diseases like inflammatory bowel disease.
As a health practitioner of chiropractic, gut health gives insight into why my clients (in particular overweight or overweight clients) establish osteoarthritis in non-fat-bearing joints like the wrist, by pointing to a difficulty with systemic inflammation. And when my clients have an understanding of how an out-of-whack gut impacts digestion, they do not generally make the link concerning gut health and joint agony or other issues like head aches, mood swings, eczema, fat acquire, or tiredness that frequently accompany agony.
Gut issues can trigger agony.
How does this perform? To start with, consider that truth that your gut maintains a reliable barrier concerning your digestive tract and your inside setting, enabling important vitamins to go by when preserving out anything else. Retaining the integrity of the gut is a a person-cell-thick barrier that varieties a limited junction, which keeps out foreign invaders like bacteria, poisons, and big undigested foods particles. When these limited junctions crack down, that barrier will become infected and porous bacteria, poisons, and undigested foods particles start off slipping by. We connect with these foreign invaders antigens, or foreign substances that trigger an immune response. A double whammy ensues: You are not finding optimal vitamins when foreign invaders barge by, a problem termed intestinal permeability or leaky gut.
This link has anything to do with inflammation.
Your immune program responds with antibodies, which assault and ruin these antigens. When an antibody binds with an antigen, an immune advanced happens. Persistent leaky gut ramps up these immune complexes they flow into all-around your entire body and deposit into several tissues and organs including�you guessed it�skeletal muscle tissues and joints, creating additional inflammation. Leaky gut also contributes to autoimmune conditions, or immune responses towards unique tissues that develop destruction and decline of functionality. When that takes place in your joints, inflammation makes agony, inflammation, and stiffness. When multifactorial, researchers link leaky gut with rheumatoid arthritis as bacterial merchandise slip by your gut lining and deposit in your joints, creating an immune reaction.
You can lessen agony by healing the gut.
When my clients recover their leaky gut, they lastly set out the fireplace that feeds inflammation. That healing calms their immune program, reverses autoimmune conditions like rheumatoid arthritis, and decreases agony. And you can do this in a natural way without the need of medicine or surgical treatment. Further than concentrating on a entire-food items diet that gets rid of foods intolerances, I�ve located these 7 tactics to improve gut health to reverse agony:
1. Stage up your fiber.
Studies display that enough dietary fiber could possibly be your greatest technique to keep a healthier microbiome. Amid its benefits, fiber aids pull poisons from your gut for elimination.
2. Take in additional anti-inflammatory food items.
Omega-three fatty acids have anti-inflammatory qualities and aid alleviate agony. If wild-caught fish isn�t aspect of your diet, just take a large-high quality fish oil nutritional supplement with about three,000 milligrams of EPA and DHA.
three. Repopulate smartly.
Probiotics aid re-set up a balanced gut microbiome. Fermented food items like coconut yogurt, kefir, and sauerkraut are great sources of probiotics, but if you do not on a regular basis consume them, appear for a professional multistrain probiotic nutritional supplement with billions of microorganisms.
4. Get enough vitamin D.
Scientists link vitamin D deficiencies with several issues like inflammation, leaky gut, and autoimmune conditions like rheumatoid arthritis and chronic agony. Request your health practitioner for a twenty five-hydroxy vitamin D take a look at and perform with him or her to attain and keep optimal ranges.
5. Ditch the gluten.
If you have joint agony or other sorts of agony, gluten�s gotta go. Gliadin is the protein located in wheat, rye, and barley lots of men and women are delicate to or that leads to an outright autoimmune reaction. Your immune program sees gluten as the enemy and will unleash weapons to assault it, triggering inflammation in your gut, joints, and other regions of the entire body.
6. Avoid GMOs.
Eradicating genetically modified food items (GMOs) will become very important for healing your leaky gut considering the fact that GMOs destruction your digestive tract and may possibly be a person of the leads to of your leaky gut in the initial place.
7. Nix nightshades.
Colourful bell peppers, tomatoes, potatoes, and eggplants supply vitamins and phytonutrients, but they can be a difficulty for clients with leaky gut, autoimmune disease, or osteoarthritis. Nightshades incorporate glycoalkyloids, which can develop gut issues.
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.
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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.
Chiropractic in the United States: Training, Practice, and Research�; accessed January 17, 2017.
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.
45 Spinal Manipulation for Low-Back Pain. (2016, April 20). Retrieved January 17, 2017, from nccih.nih.gov/health/pain/spinemanipulation.htm.
46 Wong, J., C�t�, P., Sutton, D., Randhawa, K., Yu, H., Varatharajan, S., . . . Taylor-Vaisey, A. (2016). Clinical practice guidelines for
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
47 Doctor, Jason, October 4, 2016.
48 Goodrich, Kate, MD; Agrawal, Shantanu, MD; The CMS Blog; Addressing the Opioid Epidemic: Keeping Medicare and Medicaid
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
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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.
54 Blanchette, MA., Rivard, M., Dionne, C.E. et al. J Occup Rehabil (2016). doi:10.1007/s10926-016-9667-9; link.springer.com/article/10.1007/s10926-016-9667-9.
55 Keeney BJ, et al. Early predictors of lumbar spine surgery after occupational back injury: results from a prospective study
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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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61 U.S. National Institutes of Health
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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
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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
Conventional knowledge wants us to believe that athletes must eat a high carb diet in order to function at optimum levels. While many people believe this, nothing could be further from the truth. Ben Greenfield conducted extensive tests on himself to prove that it is possible to be a fat burning athlete, and that being a high carb athlete should be a thing of the past.
Ben�s analysis was very detailed and impressive: he had blood work, biopsies, urine and stool samples taken before the study began. He then walked on the treadmill for three hours and retook the blood work, biopsies the urine, and the stool samples, then analyzed the data. The study was called The Faster Study, and the data is available via PDF for those interested in looking at his findings and Ben�s write-up on the experience can be found here.
The Faster Study
When I asked Ben why he did the study, he said it was for his own selfish reasons. He said he was training for an Ironman triathlon at the time and wanted to go faster or at least maintain his speed for longer periods without experiencing the deleterious effects that chronically elevated blood sugar�can cause. He also wanted to avoid the potentially unsettling effects that carbohydrates fermenting in your gut can cause.
Ben also had another incentive: he was diagnosed as having a 17% higher than normal risk for Type 2 diabetes. As a result, he needed to figure out a way to complete an Ironman triathlon without going the traditional route of fueling with gels, bars, and energy drinks.
I can attest that his theory works because I tried it myself: while on an 18 hour intermittent fast, I went on a 3 hour bike ride. By the time I got home, it was 22 or 23 hours before I�d eaten one bite of food, and to everyone�s surprise, I didn�t bonk. Everyone on the ride that day was a seasoned athlete and eating constantly. I was the only one not eating, yet had plenty of energy, even after 20 hours without food. Ben proved that in a laboratory and I successfully tested his hypothesis in a real life situation.
The Faster Diet
In preparation for his experiment, Ben followed a diet of 80 to 90% fat and 5 to 10% carbohydrates. His protein intake would vary depending on the day�s activities. For example, protein intake would be approximately 20% on days he�d run or do weight training. On average, the majority of his diet was fat based. He jokingly said he was banned from Italian restaurants during this time.
While on his high fat/low carb diet, Ben did two ironman triathlons that year (Ironman Canada and Ironman Hawaii.) He stresses that that a low carbohydrate diet does not mean a zero carbohydrate diet. Using Ironman triathlon as an example, participants may be out competing for ten or more hours. When passing someone the on the bike, a person may go from their normal race pace of 250 watts up to 400 watts for a few moments. This surge of energy being exerted can cause a pretty significant glycolytic shift, resulting in the body needing to burn through a high amount of carbohydrates.
Ben took in about a quarter of the amount of carbohydrates that he�d normally consume during the actual event, along with ample amounts of easy to digest proteins, amino acids, easy to digest fats, and medium chain triglycerides. After his triathlon season was completed, Ben added exogenous ketones�to his diet in powder form to increase ketone levels. Ben admitted that he finds the ketones extremely beneficial and says he wish he�d known about them while training for previous triathlons. Personally, I have experimented with exogenous ketones in my own fat burning regime, after learning more about how they work during my interview with Dominic D�Agostino (watch the interview here.)
Study Findings
During that triathlon season, Ben conducted quite a few studies, with a few standing out in particular. In this test, a microbiome analysis was conducted to see how the gut differs between someone who follows a high-carbohydrate diet and someone who follows a high-fat diet.
Fat biopsies were taken both before and after exercise to see to see if his actual fat tissue make-up was any different. Tests were also conducted to see if there was any difference in the ability of his muscles to store carbohydrate and how quickly the muscle would burn through carbohydrates. A resting metabolic test was conducted, which is an analysis of how much fat and carbohydrate is burned at rest. And another measurement was taken to determine how many carbohydrates, fats, and calories are burned during exercise.
What makes these tests interesting is even though most physiology textbooks claim that the average person will burn about 1.0 grams of fat per minute during exercise, the athletes who followed a ketogenic or low-carbohydrate diet for close to 12 month were experiencing fat oxidation values of closer to 1.5 to 1.8 grams of fat per minute. This is significantly higher than what experts expected.
Initially, there was some confusion pertaining to this study because it was called � The Faster Study.� Critics would say Ben wasn�t going any faster on the high fat/low carb diet than those on the high carb diet. What they neglected to understand was the purpose of the study wasn�t to go faster than those on high carb diets. Instead, the goal was to maintain similar speeds while limiting (and possibly eliminating) the chronic fluctuations and elevations of blood sugar.
Ben�s thought process behind the study was simple: If he could go just as fast by eliminating sugars, why not do it? If he slowed down or felt his energy levels being depleted, he�d be forced to ask himself the following questions as an endurance athlete:
What kind of balance did he want between health and performance?
How many years of his life was he willing to sacrifice in exchange for going just a little bit faster?
How much pressure was he willing to put on his joints?
As it turns out, Ben could go just as fast on a carbohydrate-limited diet.
Go Just as Fast, Live Longer
While people are focused on getting faster, the ultimate goal should be to go just as fast and live longer doing it. Unfortunately, many high-carb athletes have a wide assortment of health problems, which can range from joint problems to life threatening emergencies such as heart attacks. Many of them are dying prematurely and don�t realize a contributing factor to their ailments is the high carb diet they had been following for years. Ironically, many athletes are thin but show evidence of degenerative disease indicating years of inflammation and oxidative stress�caused by repeated glucose and insulin spikes. We know this damage is oxidative, is harmful to the cells, and causes premature aging.
There are many studies with research illustrating how endurance sports increase oxidation and aging, but I believe as more research is done this belief will change. Studies by Ben and others show that a fat-adapted endurance athlete does not have the same levels of oxidative stress as high carb endurance athletes. At age 50, I have 8% body fat and can exercise for hours without ingesting carbohydrates because, like Ben, I�m very efficient at fat burning.
I firmly believe Ben�s study proves that people who are efficient at fat burning can burn well over one gram of fat per minute of exercise, whereas before it was believed one gram (or less) was a more realistic number. It should be noted that in order to burn that much fat, a person has to be fat adapted. It�s impossible to accomplish this level of fat burning on a high-carbohydrate diet (read more on how to get fat-adapted here: Part 1 and Part 2.)
Fat Adaption: A trick to Accelerate the Process
Becoming an efficient fat burner takes time. Many of the athletes that Ben coaches have been on a high fat diet for twelve months or more. While the greatest benefits aren�t felt for several months, a person can experience lower blood sugar levels and less oxidation within a few short weeks of starting a high fat diet. However, in order to achieve the mitochondrial density necessary for producing a lot of ATP on a high-fat diet while exercising, a person will need to follow a high-fat diet for at least a year.
It can take anywhere from 6 months to 2 years for a person to become fully efficient at burning fat. While some may balk at how long it can take, it�s not long when compared to the time it may take to become proficient in a sport, learning to play a musical instrument, or getting a college degree.
Adjusting to a high fat diet takes time and patience. To accelerate the process, one can choose to eat within a compressed time window, a strategy known as intermittent fasting. Intermittent fasts can range from 14-24 hours with just liquids being consumed. Intermittent fasting can be a challenge for beginners as the body begins to adapt, but becomes easier with each subsequent fast. I intermittent fast daily and must say it�s been the great contributor to my overall cellular health.
Some side effects beginners may experience while intermittent fasting the first few times may include the following
Fatigue
Nausea
Vomiting
Diarrhea
Headaches
Lack of focus
Bad breath
Lethargy
Joint pain
Minor depression
These side effects are normal as the body eliminates various toxins. Drinking pure water�helps to alleviate some side effects and quickly remove them from the body via urination. Staying focused on the long term is key when embarking on these changes.
Occasionally, I will receive emails from my clients or the doctors of my clients, telling me they are keto-adapted, but they�re not burning fat, they don�t notice any significant changes in their bodies, and they haven�t lost any weight. I explain how this is normal, and the body has to adjust. It takes time for the body to realize it is not starving and that it can begin to burn its own fat for energy. Using my wife as an example, it was almost a year before she was able to use her fat storage for energy. Now, she�s an efficient fat burner and finds it much easier to stay lean.
Not All Fat is the Same
An important aspect of being efficient at fat burning is the type of high fat diet you follow. A plant-rich, ketogenic diet not only limits oxidation and free radical production, but it also causes an increase in stable energy sources due to high fiber content. Having high levels of plant-based chlorophylls in the bloodstream also has the potential to increase ATP production beyond what we fully understand in nutrition science.
Ben encounters many people who follow the Bulletproof Coffee type of approach:
Three cups of coffee with grass-fed butter and MCT oil during the day
Coconut milk with some coconut flakes and some chocolate stevia
Fatty grass-fed steak for dinner
Macadamia nuts for a snack
The problem with this type of diet is there�s very little plant matter eaten, and plants are an integral part of a healthy high fat diet.
Ben Greenfield�s Diet
Ben eats an astonishing 20 to 25 servings of plants per day. He has an enormous backyard garden and eats kale, butter lettuce, bok choy, mustard greens, cilantro, parsley, and tomatoes daily. He says these foods do not count towards his total daily carbohydrate intake, and that eating a high-fat diet does not mean that you�re not eating plants. It�s the opposite. �I eat a lot of plants, a lot of fiber, and it makes a night-and-day difference.�
In order to get 20-25 servings Ben eats huge salads and drinks nutrient dense smoothies. He�ll drink one or two large smoothies a day, using a powerful blender that blends everything from the pit of an avocado to an entire bunch of kale. A sample smoothie includes the following ingredients:
Six to eight different plants (both wild plants and herbs)
Lunch. Lunch is a salad in an enormous bowl filled exclusively with vegetables. Ben will spend 30 to 60 minutes chewing each bite 20 to 25 times and �eating lunch like a cow while I go through emails and things like that during lunch.�
Dinner. Another big salad.
Snack. Snacks are normally smaller versions of the smoothie�he had for breakfast.
He stresses that his salads are extremely large and he prefers thicker smoothies: �If you were to see the size of my salads and the size of my smoothies, you would be shocked. You�d think I would be morbidly obese, but if you dig in and you look at it, it�s really just mostly plant volume. That�s generally what I do, salads and smoothies. I make them so thick I need to eat them with a spoon because I really like to chew my food. Yeah, I�m a smoothie and a salad guy.�
He goes on to say �When I look over the blood and bile markers of people following a high-fat diet, a lot of times I see really high triglycerides and really low HDL, which is often what you�ll see in someone who is eating a ton of animal fats without many plants or without much fiber. I�ll see a lot of CO2 and really low chloride levels, an indicator of a net acidic state, and a lot of biomarkers that aren�t necessarily favorable and that can be a result of a high-fat diet done improperly. I think that�s one important thing to bear in mind, too, is that you don�t want to necessarily eschew plant intake and vegetable intake; you just want to ensure that those are accompanied primarily by healthy fats and oils rather than accompanied by high amounts of protein and starches.�
When it comes to good fats, Ben prefers the following:
Animal fats are eaten sparingly. He�ll eat a grass-fed steak and wild fish a couple of times a week. He also likes pemmican, which comes in a tube that he can snack on while flying or if he needs a quick snack on the go.
When Ben was a bodybuilder, he would aim for 200 grams of protein per day but now only consumes between 100 to 120 grams. Currently, he weighs about 180 pounds and consumes between 0.5 and .8 grams of protein per pound of body weight. He feels this is the amount is sufficient to avoid any loss of muscle.
Ben says he has excellent colonic health. Since he started the high fat diet four years ago, he doesn�t have the fermentation, gas, bloating, or constant gas that many endurance athletes have. He also believes the high fat diet offers a lower risk for things like small intestine bacterial overgrowth (SIBO) and fermentation in the gut.
Diet Variation
In addition to eating a variety of plant based foods, an important eating concept that I have written about is something I like to call �diet variation,� which is basically emulating what our ancestors have done: They were forced into different diet variations seasonally, and in some instances, weekly.
When we look at the Hunza people as an example, they were relying mostly on plant food in the summers to survive. During the cold winter months, vegetables and fruits were scarce or nonexistent, and as a result, they were forced to eat higher-fat foods (meats and animal fats). Over time we can see a pattern: there would be long stretches where their diet consisted mostly of vegetables (summer,) then extended periods of time where their diet was mainly meat products (winter.) This type of seasonal eating created a variation in their diet they had little control over. Today, we have the ability to vary our diet at all times, which can work for us and against us.
I go into ketosis every summer and eat more good fats and protein than I do in the winter, when I eat more healthy carbs. Like Ben, I�m very fat adapted, yet still able to stay in ketosis while eating a lot of plants in my diet. I intermittent fast in the morning and by the afternoon I�m burning high ketones.
One of the popular diet trends these days is the Paleo Diet, where a person is instructed to eat large amounts of protein. Quite frankly, I am not a fan of this diet. I have read many studies on high-protein diets and feel they are not healthy. Eating too much protein can cause weight gain, extra body fat, increased stress on the kidneys, dehydration and other health issues.
If you include the dangers of eating grain fed beef instead of the healthier grass fed beef, we can clearly see how the Paleo Diet could be a recipe for disaster. I tell people as a general rule, eating protein that is equivalent to half your body weight (considering that you�re not morbidly obese) is usually safe and practical. Athletes like Ben (and those who do a lot of strenuous physical exercise) can consume more protein than the average person and utilize it safely. These individuals may require 0.7 to 0.8 grams of protein per day, while the average person only needs .55 grams per day.
Fasting
Ben goes on a 24 hour fast once a month, just to �clean things out a little bit.� He will start the fast Saturday at lunchtime end it at lunchtime on Sunday. Or, he�ll skip dinner on Saturday night and won�t eat again until dinner on Sunday. He�ll drink water, coffee�and tea primarily during the fast, and kombucha on occasion. He also goes on a 12-16-hour intermittent fast daily. The majority of the fast is overnight where he�ll finish dinner around 7:00 or 8:00 p.m. and eat breakfast sometime 9 and 10:30 a.m. During the daily fast, Ben will perform a few low-level exercises in the morning: yoga, foam rolling, or mobility work are exercises of choice.
In addition to daily intermittent fasting, Ben believes a likely factor that helps him to stay lean and maintain a low body fat percentage is taking cold showers. He likes to do one of the following daily:
Fast, perform a low intensity exercises then take cold shower or�
Fast, sit in a sauna for a few minutes, followed immediately with a cold shower.
Ben�s Exercise Regimen
Ben is active all day, but in an unconventional way:
�I generally am active all day long. Today, while I�m writing, doing consults, and reading emails, I�ll walk somewhere in the range of three to five miles at a low intensity like I am right now. When I get up in the morning, I�ll generally spend 20 to 30 minutes doing some deep-tissue work and some mobility work, some foam roller, and some band work for traction on my joints. By the time I get to the end of the day, I�ve been mildly physically active for six to eight hours at just very low-level intensity.
�At the end of the day, I�ll throw in 30 to 60 minutes of a hard workout. That might be a tennis match. It might be kickboxing or jujitsu. It might be some kind of an obstacle course workout with sandbags, and kettlebells, and things like that. It might be a swim. It varies quite a bit, but generally it�s 30 to 60 minutes of something hard in the afternoon to the early evening, then up until that point, low-level physical activity all day long. It�s just tough to quantify because I�m always moving. As far as a formal workout, it comes out to about 30 to 60 minutes a day. We�re talking about a workout where the average heart rate is very close to maximum heart rate, so like a puke-fest style workout. That�s pretty draining from an energy standpoint. Generally, for me to do daily�exceeding 16-hour fasts daily�that gets tough.�
What�s Next For Ben?
Ben is an outdoorsman and wants to experiment with living on the land:
�I�d like to look into more of an ancestral application, a more practical application. I would like to look a little bit more into persistence hunting, something closer to where I live where I�d be going after elk or moose or something like that, preferably in the snow where tracking is a little bit easier, but seeing if it�s doable.
�A five to eight day hunt is realistically what you�re looking at with a bow, or with a spear, or with a close-range weapon, and seeing if it�s possible to actually go and get your own food in the absence of food, just to begin to get people thinking about the state that we live in, the culture that we live in where food is just constantly readily available. What would happen if we didn�t have food but we had to figure out a way to feed ourselves?�
Ben also shares the outdoor life with his children: One day week in the summers, they can only eat the plants they find outside in the garden until dinner. As part of their childhood, he wants them to learn how to take care of themselves. They can use the stove and the blender, stuff like that, but they can�t use ingredients from the pantry, or from the refrigerator. It�s all based on plants.
While many people may think this way of thinking and living is extreme, Ben believes more people can benefit from it if they stay open minded and give it a try:
�I would like to get people more aware of that type of practice because it really goes quite handily with the things that we�ve talked about�fasting and ketosis, and denial of modern food sources and starches and instead just learning how to take care of yourself. I think that there�s a lot of lessons to be had from a health and survival standpoint, and so plant foraging, spreading our message, as well as the potential of seeing the persistence hunting in the absence of any significant sources of calories, to be able to take what allows one to, say, do an Ironman Triathlon with very little calorie intake and then turn that into a more practical level like going out and getting your own meat and stuff. Again, without carrying a bunch of power-bars out with you, I think that�d be a cool little adventure to embark upon.�
A Life of Fitness
Ben believes fitness is a lifestyle, and everyone can incorporate fitness into their daily activities:
If you work in a traditional office setting, put a kettlebell underneath your desk.
Get one of these stools that you lean back on rather than sitting down.
Every time that you go to the bathroom have a rule that you�ve got to do 50 air squats.
�Start to work in those little things throughout the day. You�d be surprise at how fit you can stay and how prepared you can be for a big event without necessarily neglecting your family, your friends, hobbies, or work.�
Ben Greenfield is an inspiration. His research on high fat diets is sure to revolutionize the way athletes view diet and endurance exercise as a whole.
Proponents of mindfulness-based stress reduction claim it can improve relationships, mental health, weight and more. But, one complaint it’s unlikely to fix is lower back pain, researchers now say.
Lower back pain doesn’t respond to the programs, which embrace meditation, heightened self-awareness and exercise, according to a review.
Although short-term improvements were reported, “no clinical significance” was found in terms of overall pain or disability when mindfulness was compared to standard treatment, said study lead author Dennis Anheyer. Anheyer is a psychology research fellow in the faculty of medicine at the University of Duisburg-Essen in Germany.
About eight out of 10 American adults will experience lower back pain at some point in their lives, according to the U.S. National Institute of Neurological Disorders and Stroke. Roughly one in five of them will struggle with chronic lower back pain, lasting three months or more, which is a major cause of job-related disability.
Because no sure-fire treatment of back pain exists, many patients try complementary therapies such as mindfulness.
Mindfulness and Stress Reduction for Back Pain
Mindfulness programs, which are growing in popularity in the West, derive from the Buddhist spiritual tradition and are used to treat pain. They include sitting meditation; walking meditation; hatha yoga and body scan along with focusing attention sequentially on different parts of the body.
The seven studies that were reviewed involved close to 900 patients who had lower back pain for at least three months. Six of the studies were conducted in the United States; the seventh in Iran.
Some patients were offered standard back pain treatment, such as physical therapy and exercise routines that aim to strengthen the back and abdominal muscles; prescription and over-the-counter pain medications; ice packs and heat packs; and spinal manipulation and/or massage (chiropractic care). In some cases, surgery is recommended for chronic back pain.
Other patients engaged in mindfulness programs aimed at stress relief. Six of the programs were variations on an eight-week program developed at the University of Massachusetts. Most had a weekly 2.5 hour group session; one also had a day-long silent retreat.
Practitioners were also encouraged to engage in 30 to 45 minutes of meditation at home, six days a week. “We found that mindfulness-based stress reduction could decrease pain intensity at short-term, but not at long-term,” said Anheyer. Despite the negative findings, Michigan orthopedist Dr. Rachel Rohde isn’t ready to rule out mindfulness as a back-pain treatment.
The size of the research review was relatively small, said Rohde, an associate professor of orthopedic surgery at the Oakland University William Beaumont School of Medicine.
Also, “pain” is perceived differently by everyone, she said. In the case of chronic pain, people tend to try everything they can to feel better, making it difficult to figure out exactly what works and what doesn’t, she added.
The idea that changing the way you think can change the way you feel — the premise of cognitive behavior therapy — is used as a treatment for chronic pain, Rohde continued. “I think that mindfulness-based stress reduction is somewhat of an extension of this and probably would work very well for some and perhaps not so well for others,” she added.
The researchers behind the new review suggested that future studies look at specific components of mindfulness programs, such as yoga and mindful meditation. Yoga, they said, has been shown to increase function and decrease disability in patients with low back pain.
SOURCES: Dennis Anheyer, M.A., B.Sc., psychology research fellow, faculty of medicine, University of Duisburg-Essen, department of internal and integrative medicine, Kliniken Essen-Mitte, Essen, Germany; Rachel S. Rohde, M.D., associate professor of orthopedic surgery, Oakland University William Beaumont School of Medicine, Michigan Orthopaedic Institute, P.C., Royal Oak, Michigan; April 24, 2017, Annals of Internal Medicine
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 .
Additional Topics: Whole Body Wellness
Maintaining overall health and wellness through a balanced nutrition, regular physical activity and proper sleep is essential for your whole body�s well-being. While these are some of the most important contributing factors for staying healthy, seeking care and preventing injuries or the development of conditions through natural alternatives can also guarantee overall health and wellness. Chiropractic care is a safe and effective treatment option utilized by many individuals to ensure whole body wellness.
Doctor of Chiropractic, Dr. Alexander Jimenez examines people that see�a chiropractor and their reduced�usage of opioids and other types of drugs.
The draft Guidance for Prescribing Opioids for Chronic Pain, issued in December 2015 by the U.S. Centers for Disease Control and Prevention, included �many complementary and alternative therapies (e.g., manipulation, massage, and acupuncture)� among its recommended non-pharmacologic approaches. However, when the final Guidance was released three months later, manipulative therapy and its 75,000 licensed chiropractic practitioners was not directly referenced. A recent study from James �Jim� Whedon, DC, MS, pictured, suggests that the CDC harmed its mission with its excision of explicit reference to manipulation. Patients using chiropractors were less likely to use prescription opioids.
Whedon is currently a researcher at the Southern California University of Health Sciences, and is co-chair of the Research Working Group of the Academic Collaborative for Integrative Health. He is a relatively rare resource in the integrative health community, as a specialist in diving into huge data sets of insurers and seeking to extract useful information. Whedon is a veteran of arguably the most important research center in this type of work, The Dartmouth Institute at the Geisel Medical School at Dartmouth College.
Whedon�s research began with awareness that �little is known about the comparative effectiveness of non-pharmacological care for low back pain as a strategy for reducing the use of opioid analgesics.� What is well known, as Whedon shared in his poster and presentation at the 2016 conference of the Academy of Integrative Health and Medicine, is that patients with such pain are swimming in opioid prescriptions. Whedon�s presentation included a Baskin-Robbins-like list of 39 opioid varieties. He postulated that opioid use would be less likely among those receiving chiropractic care.
Association Between Utilization Of Chiropractic For Back Pain & Use Of Prescription Opioids
Preliminary results of a health claims study,� Whedon reports what he found through examining the New Hampshire All Payer Claims Database.� Of roughly 33,000 adults registered as having low back pain, slightly over a third saw a chiropractor. Of these, 38 percent had at least one opioid prescription. Of those who did not see a chiropractor, 61 percent had at least one opioid prescription.
The core question that interested Whedon was how many prescription fills the two sets of insured patients received. Those whose opioid prescription was integrated with chiropractic care had an average of 3.9 fills. Those who did not receive chiropractic manipulative therapy averaged 8.3 fills per patient. He estimated that the average per person opioid charges were $88 for those using chiropractors. The figure was $140, or 60 percent higher for those not using chiropractic care.
Whedon�s conclusions were, first, that the likelihood of filling a prescription for a high-risk drug of any type was 27 percent lower. Secondly, the likelihood of filling a prescription for an opioid analgesic was 57 percent lower in the chiropractic-using population.
�These are preliminary results,� Whedon cautioned. �We intend to analyze the data further, applying robust methods to reduce the risk of bias that can result from other differences between people who use chiropractic care and those who do not.�
Comment: While Whedon takes care to note that �no causal inferences can be made,� the associations should be of real interest to the CDC and other policy makers. A follow-up study might attempt to compare the whole costs of the chiropractic-using population and those who didn�t.� These costs could include, on the one hand, the cost of chiropractic treatment, and on the other, the costs of other medications or treatment that may be prescribed for those on longer-term opioid treatment who may end up cycling into the addiction.
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