#20 - GameChangers: Practical Research for Improving Clinical Outcomes, Part 1

FAKTR, spelled F-A-K-T-R, stands for Functional and Kinetic Treatment with Rehabilitation. Over the past decade, this unique approach to treating pain and dysfunction has been utilized by healthcare providers on 6 continents. Serving as a framework that guides clinical decision-making in patient visits around the globe on a daily basis. With this podcast, our goal is simple: to bring the best and brightest in clinical education to the forefront and empower practitioners with cutting-edge, evidence-based content that improves patient outcomes and inspires healthcare providers to continually evolve their approach to treatment. In each episode, we will feature a training or interview with some of the top minds in healthcare in a short format that is easy to digest with actionable information that you can implement into practice right away. Let's get started. Hi guys, welcome to a new episode of the Factor Podcast. I'm your host, Jessica Riddle. If this is your first time tuning in, welcome and thanks for listening. Today we kick off a new training for the new year titled Game Changers: Practical Research to Improve Patient Outcomes. Now, as a healthcare practitioner, you probably understand that it's important to be up to speed on what the research says regarding common conditions that you see in practice, or even treatments that you tend to utilize with your patients. But let's be honest here, most research articles aren't the easiest to read, and sometimes you may pore through dozens of papers before you find one that is relevant to your practice. Our friends at ChiroUp.com are trying to change that. In fact, they've created an entire platform to assist practitioners. Now, amongst other things, ChiroUp.com provides relevant research for hundreds of conditions, all at the click of a button for you as a practitioner to utilize to help guide your patient care. Now, in this 2-part training, they talk through the highlights of some of the most impactful research papers published, and then bring it back around to how this research should affect how you approach treatments for these conditions. Now, by they, I mean the co-founders of ChiroUp.com, Drs. Brandon Steele and Tim Bertelsmann. Now, ChiroUp.com is a company whose mission is to help evidence-based chiropractors produce exceptional patient outcomes, then market their brand of excellence to the people who matter— their patients, other physicians, and healthcare decision makers. They do this through empowering docs with automated tools for clinical and business success. If you haven't heard these guys speak or present before, you're in for a real treat. They really do a great job of taking the research, making it clinically relevant, and adding a little bit of humor in as well. So without further ado, let's cue the intro music and get started with today's episode.

Thank you. We actually started working together about 10 years ago and with Chiro about 7, and that is actually the first time that anyone's mentioned my name first and then your name. So that was kind of a—

Everybody's entitled to an error here and there. So one error that we'll try not to make is you joining the presentation today. We're going to do our very best over the next hour to provide you with skills that you can use in your office come this afternoon or tomorrow. The first thing that we'll talk about is the future of healthcare, that healthcare is changing markedly, that it used to be pretty simple, that we sent a bill to a payer and they sent the bill, sent the check back. But now that's different, that accountable care organizations and all sorts of managed processes have added a layer to that. And those accountable care organizations have 3 goals. Number one, to have higher levels of patient satisfaction. Number 2, to have better outcomes. And number 3, to do that at a lower cost. Those first 2 sound really good, but the last one, not so exciting. So our focus today is going to be what did the research tell us over the past couple of years as to how we can get better outcomes and better patient satisfaction? We have a score, it's called the V score, our value. And our value score is the results that we can achieve divided by the price of a visit and the number of times that we need to see that patient. Anything that increases the numerator makes us more valuable and anything that increases the denominator makes us less valuable. So in the future of healthcare, we're looking for value and the good news is As manual therapy providers, we deliver value that we know that there's plenty of research that's come out over lower back pain, over cervical spine pain, and the types of things that we can have, the effects that we can have on patients.

And we're going to talk about a lot of different things, including the clinical effectiveness of what we do as manual therapists, but we often have to take a step back and not focus directly on the technique, directly on the specific spinal manipulation, myofascial release, Or instrument-related treatments that we can provide and really focus on what does the research offer us on everything that we can give to a patient, whether it is a treatment in office or maybe it's patient education or maybe it's just advice. So we're gonna go through really in the last 2 years how this has changed and how this impacts your practice and my practice. And we'll have a little bit of Q&A between us and then also hopefully answer some questions on what we do, why we do it, and how we can get better results than any other profession when we do it well. A lot of us focus on the manual aspect and the mechanical things that we do is, in today's world, has never been more valuable. Not using medication, not using invasive therapies, and really focusing on spinal manipulation is a safe way for mechanical treatment. However, we also do more. We also do things chemically. Now, with spinal manipulation as a mechanical therapy, we can also impact systemic problems or systemic issues. Meaning just with spinal manipulation in this study, we can see here is we're decreasing pro-inflammatory cytokines. So it's not often we think about the mechanical things we do as having a chemical result. Another neat thing is that we think of spinal manipulation as a localized treatment, and that's just not the case either. That when we can do spinal manipulation of the thoracic spine, we can have a dramatic impact on things up the chain. In this case, cervical radiculopathy, article in Sports Physical Therapy. And we also can think about the aftereffects of spinal manipulation. It's not just manipulation. It's that now with thoracic spine extension, can we now get our patient into doing the right set of exercises or the better posture when they're our work. So the things that we can do over and above the specific aspect or action of spinal manipulation can have dramatic effects in the long term.

And the use of all manual therapy has increased— physical therapy, athletic trainers, and chiropractic inclusive— that we had, would often suffer from a lower utilization. And that's increased. And fortunately, I think that's going to keep increasing in the years that follow. Dr. Steele talked about moving up chain. The first treatment that we're going to talk about is migraine headaches. So there's a lot of data on migraine headaches. Some of that data tells us things that we can do a little bit better.

So migraines are tough. And the reason migraines are so difficult is because we just don't have a specific etiology. So when we have an arm squeeze test, we're looking for cervical radiculopathy. We have a C-sign test looking for hip pathology. We have the uppercut test for biceps lesions. Migraines, there's not that specific etiology that can be related to that one problem. So that's why we see it happen so often. We see migraines as a syndrome. And when we have syndromes, that just means it's a collection of symptoms. And we often have multiple etiologies and what we call, in migraines, triggers. And these triggers can be any number of things and can often be different per patient. So it's very difficult to say, I can treat migraines, because really what we're doing is we're treating the person. One thing that I would encourage everybody to do is to not look at just the diagnosis they're presenting with. In fact, 50% of people with migraines also have vertigo. So don't forget to go above and beyond that specific diagnosis of neck pain-related TMJ or vertigo related to migraines. Often, we have to look at what's been lurking in the shadows and is now presenting as a migraine.

One of the things that we had learned in recent years is that migraines only happen to brains that are predisposed to migraines, much like epileptic seizures only happen to brains that are predisposed. And all of those contributors from the last slide drip into the glass. So the patient says, what brought on this headache? Well, it wasn't any one thing generally. It was a combination of the weather and stress and insomnia, and all of those things put together have set that patient over the edge. And when they go over the edge, there's a little bit of a variable presentation that about 60% of patients are going to go through a prodrome, and then another chunk of them are going to have an aura. And the aura is sometimes a little bit scary that we see an aura that might have some sensory symptoms, some motor symptoms, things that aren't just headache-related. We see lightheadedness or dizziness or even numbness and tingling that radiates into the arm or even the face. And so one of our challenges is differentiating what's a threatening cause of that headache and that cluster of symptoms versus something that's a little bit more benign in that process. And a couple of the things that we can take confidence in is, number one, if this is the first time, we probably have to work it up as threatening. It's always better to start with the worst possibility and work toward a better one than have a discussion about how you started with a better one and it turned out to be something much worse. So we want to say, number one, if it's the first occurrence, we're going to work that up a little bit more thoroughly. But once that patient has met the criteria where they've had the same constellation type of symptoms over the same period of time, then we can be a little bit more certain that this is probably more migraine-related than stroke-related. We need to rule out stroke in that process. So that's number one. And number two is that rarely do those migraine-type symptoms expand beyond one or two things, whereas stroke-type symptoms are more like a constellation, that there's multiple things happening on. They have numbness and tingling. They have weakness in their face. They have some memory issues. And all those things put together give us a much stronger hint that this is something more threatening. The other thing clinically that gives me a stronger hint is how quickly did the symptoms come on? Whereas a prodrome and an aura typically come on slowly and go away slowly over a course of 5 to 20 minutes, they're going to come on and then go away in the same type fashion, where strokes-type symptoms typically come on pretty abruptly. As soon as that vessel is no longer carrying fluid to the computer, there's a problem that happens a lot more quickly. So the rate at which they happen, And how many of them are there give us a little bit of a clue as to what's going on. So once that migraine has happened, what are we going to do? Well, we're going to look at the triggers. What are the things that could have set that off, and what are the things that we can change about the patient's life? And so now we'll dive into some of the research that is game-changing.

And the research is vast. In fact, when we did our literature review on migraines, there's a lot of different insertion points for therapy. When you look at a migraine, since you have multiple etiologies, you're also going to have multiple treatments. However, there are some things that we can do on a systemic fashion, like supplements. And I'm not someone who prescribes supplements in my office, and that's okay. That just means it's not what I'm great at. In fact, I'd rather change—

What are you great at?

Good point. I'd rather change your religion than change what you eat. It's just, it's a tough field. However, it's valuable. So we don't do that in our practice, but we refer out to another chiropractor down the street who does functional medicine that can impact that part of our patient's life. And one of the things that she does, and she does very well, Is supplementation, and along with lifestyle advice. But vitamin D is showing— a lot of research is showing how powerful it is. And we look at it as just a vitamin, but its impact on anti-inflammation is big. And what we know about that is that if we can suppress that nitric oxide and suppress that vasodilation, we can really have an impact on blood flow issues. So vitamin D is one of those things that she'll prescribe frequently. And I'm always stuck with that thing. Well, how much do you give? How much do you measure? I'm a data kind of guy. Well, there is some pretty good research on that saying that between 1,000 and 4,000 IUs. But when you really want to look at the specific amounts of where to start someone, Zing had a great paper that came out in Clinical Neuropharmacology that said about 2,000. And that just came out, what, last year?

Last month.

Last month that came out that if you just take 2,000 IUs, you can really have a dramatic impact on the frequency and severity of migraines. And that's the systemic level. What else can we do at a local level?

Yeah, mechanically, we know that anytime there's joint restriction in the area that combines with muscle tightness, both of which are triggers for migraines. So while our spinal manipulation may not be a great abortive tool for a migraine, and there aren't a lot of nonmedical abortive tools, there are a lot of great conservative tools that we can all use, and spinal manipulation is one of those. This study by Rist that came out of Harvard said that spinal manipulation decreases the intensity and the frequency of migraine attacks. In fact, Rist had a follow-up study in October of 2020 that said it decreases— spinal manipulation decreases migraine attacks by 1.9 days on average.

Wow.

And although that doesn't seem like a whole lot, if you consider a patient might have 4 migraines a month and you cut it in half, that's a big quality of life. And for the value that we're trying to achieve, that's significant, that a couple of spinal manipulations can produce results like that. That's going to be a happy patient. One of the things that's even simpler than spinal manipulation that we can use is prescribing water, that so many of our patients walk around chronically dehydrated. And whether this be a myofascial pain syndrome or fibromyalgia, tendinopathy, All of these things that are fluid-dependent, migraines is one of those that needs a good hydrated body. And so we can just— we see a correlation. This study told us that increasing the patient's fluid to the optimal level is enough to back down their migraines.

I did a survey of the parents in my neighborhood, and they had a very different result from my research, and that is that there is a significant positive correlation between the year 2020, kids staying home all day, Migraine headaches and beer consumption. I'll let you figure out the correlation there. But let's go back into the evidence-based stuff. TMD, and this is something that really built my practice, and it really has nothing to do with any special skills or techniques or evaluation that I provided in my practice, and it had everything to do with patient education and linking that multimodal approach to care. And it's no longer focusing on just the jaw pain or the discomfort or the clicking or the popping. And it's really focusing on what's really wrong with this patient. Fortunately, as musculoskeletal care providers, we know that there is a neurologic and neurophysiologic connection there right at the trigeminocervical nucleus. We see the muscles of mastication and we see the suboccipital muscles converge in the spinal cord at the exact same spot. And this is good for us to recognize that because a lot of times when you see neck pain and you see that forward head posture, And you see that restriction in motion, we have to stop just focusing on the jaw and really go after the root cause. There was a great study last year about hypolordosis of the cervical spine and TMJ, just showing or highlighting the interconnection there.

And again, spinal manipulation, one of those tools that can definitely make a difference in patients with TMD. Such an intimate relationship. We see a number of studies that have told us that spinal manipulation is beneficial.

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Here's one. This one, Reynolds study, said that spinal manipulation over a 4-week— 4 visits over a 4-week period produced significant improvements not only in pain but also in function. So these are happy patients that are glad that they found an alternative to the other things that we can add in their life. So moving on to the elbow, this is one that we're going to see a whole lot of as opposed to a small segment of the population that's predisposed to migraines. We see a whole big chunk of the population that's predisposed to tendinopathies. And our thought process on tendinopathies has changed a lot the past couple of years. Certainly, the elbow is one of those that's one of the most common that we see, probably second most common after the rotator cuff. One of the most typical sites of an elbow tendinopathy is on the lateral epicondyle affecting that extensor carpi radialis brevis tendon about 1 or 2 centimeters just after its insertion on the lateral epicondyle. And so that's an area of relative hypovascularity in general. That's where things are just not flowing quite as well. And what we're going to see and what you know is, as evidenced based practitioners is that vascularity is so connected to tendinopathies and neuropathies that really anytime that there's a decrease in blood flow, we're going to have an increase in tendinopathies and neuropathies. And the elbow is definitely one of those sites that makes that very apparent in our daily practice. This is something that affects a ton of people, 1 to 3% of the population every year, usually somebody who's middle-aged. Again, because that's when we're starting to see hypovascularity, that there's a lot of blood flow. As a young person, And there's also a lot of activity and just getting their heart pumping helps. That's why exercise helps almost everything. There's not a tendinopathy or neuropathy or really a condition that exercise is not beneficial for. And this is oftentimes a dominant type side problem. Like so many of our tendinopathies are dominant-sided problems, not all, but many. And it's because we're contracting that muscle so much. Interestingly, even though we call it tennis elbow, only about 5% of the people who suffer from tennis elbow have ever played tennis. So it's something that may be inaptly named, but gripping a racket is one of those things that is not handy, not helpful.

And that's, that's the fun part about what we do is really not necessarily treating patients, but really understanding who to treat and how to treat them. And if we took every single person with lateral elbow pain and we said, you have tennis elbow or lateral epicondylitis, chances are we'd get a lot of those people out of pain. But the vast majority of us would just get them out of pain. And as soon as they return to that activity, it's going to come back because that tissue is no longer in -itis. Chances are if they've had it for a couple of weeks to months and sometimes, of course, years. That's degenerated tissue that's not coming back. That tissue capacity to do work has diminished. And unfortunately, we have to now work around it and build up the tissue around it. So really differentiating which one of these patients have tendinosis versus tendonitis becomes the aspect of care. And what is susceptible or what makes those patients susceptible is the ability to heal. It's not necessarily the activity like Dr. Bertelsmann said. It's not that all these people were avid tennis players. It's that they've done something. Their wife went to IKEA and bought cabinets and now they're taking their screwdriver constantly screwing all these cabinets together. They did some damage. And damage is okay. We all do that. Unfortunately, some people can't heal from that damage. They can't get the proper nutrition or waste out of the area. And now that damage turns into tissue degeneration. We see with cholesterol levels and lateral condylopathy, you shouldn't see that correlation. What's the number one risk factor for rotator cuff syndrome? It's not overhead activities. It's the ability to heal from any kind of a trauma. Speaking of complications, one of those things we have to kind of We're going to pare down our variables and we're going to call it obesity. But obesity is a sign of being sedentary, a sign of unhealthy life, a sign of poor blood flow. And what we see their risk factors for are not heart disease. While that is one of the major conditions, as a musculoskeletal provider, this is a huge risk factor for the things that we treat and needs to be addressed with these patients because unfortunately their decisions are impacting my clinical results, which can have a dramatic impact on my practice reputation in my community.

Yeah, twice as likely to have a rotator cuff problem if, if you have obesity. So, these are patients who just have a lack of blood flow, and it kind of falls into that same model that our treatment has really changed pretty markedly in recent years, in the past decade or so. Some really smart people like Tom Hyde figured this out a while back, that this is a lack of blood flow. So, we have to do things to create a controlled inflammatory reaction. And that's where a lot of our treatments go. Now, the one passive treatment that may be of benefit is a counterforce brace. There's a number of studies, even recent studies, that show that putting a counterforce brace on this patient can help with that discomfort.

And I would say that absolutely because it does change the orientation of how that tendon attaches to the bone. But think about it. If we're trying to create a pro-inflammatory reaction to bring blood flow to the area, what's the last thing that I want to do? I want to create an ischemic response around that. So these things work wonderful and I'm not taking anything away from these braces. However, use them when you absolutely have to and don't use them all the time. In fact, a lot of patients try to sleep with them on and they wear them 24 hours a day and create other kinds of issues.

And some patients who have lateral epicondylopathy don't, they have radial tunnel syndrome. So radial tunnel syndrome is going to present in a really similar fashion except maybe we might see a little bit more distal radiation of some numbness or tingling. And these patients have a neuropathy, that's some compression of the nerve through the radial tunnel, and the last thing that a neuropathy wants is additional compression. So if we do put a tennis elbow brace on our patient and they say, I feel a whole lot worse from that, we need to take a closer look and say, are you one of the 10% who has radial tunnel syndrome? So instead of having tenderness 1 to 2 centimeters distal to the lateral epicondyle, it'd be more like 3 or 4 finger breadths. And if we poke on that spot and bang, there's symptoms or any radiation of discomfort, that's a different diagnosis that definitely doesn't need an elbow brace. Now, they might appreciate a wrist brace. In fact, there's some data that says that our lateral epicondylopathy patients improve when we put a brace on their wrist. Again, Keeping that patient out of a state that they have prolonged stretch of that muscle, that anything that's ischemic does not like to be stretched. The blood flow is going to go away and the symptoms are going to stay.

And keeping their wrists in constant extension with even just typing can cause constant postural stress in those wrist extensors. Just another thing to think about. One thing that I was very opposed to when I first started practice was to be— and I'm still opposed to that— was to be protocol-driven. And now what I find after 10 years in practice or 50 years in practice is that I really automate 99% of the things that I do. So I can really focus on that 1%, the 1% of what that patient is telling me or presenting with that I can make a deep impact on. And in this kind of case, the way they're responding to your treatment may be just as valuable or more valuable than your initial evaluation. So don't be afraid to peel back an onion and say, hey, my diagnosis is right, but now maybe something that I'm doing might be aggravating their symptoms. Speaking of that, with any kind of a tendinosis, this for lateral epicondylopathy. However, eccentric loading is a progressive loading program. There's really no research that says progressively loading somebody is bad. The question is, how fast do you load them? And that's sometimes difficult. A patient comes into your practice and they have pain. The one thing they want in life is to get rid of pain. So when you say, great, Sally, here's what we're going to do, and we're going to induce more pain, that's sometimes a difficult conversation to have with somebody when they thought they were coming in for a different reason. But we know the clinical effectiveness of progressive loading is going to help them in the long run. How do you have that conversation with someone?

Yeah, setting expectations to let them know that we expect that you're going to have some discomfort with eccentric loading. And really, with tendinopathy treatment in general, there's going to be some discomfort, and it's okay for that patient to have a 3 or a 4 on the VAS while they're doing exercises that are eccentrically loading it. One of the things that we want to do is to make sure they understand that that could cause a little discomfort, and then when it does cause discomfort, It's met a positive expectation as opposed to causing a question of, have I picked the right practitioner? Now, one of the clues, one of the questions that we definitely want to answer is, did we do too much? That is progressive muscular loading for tendinopathies. And sometimes if we do too much, that patient will have nighttime pain. So I use nighttime pain as a gauge of, did I ramp that up too quickly? If they have some discomfort when you're doing the exercise, tough. If you have some discomfort that wakes you up at night again, because tendinopathies and neuropathies tend to wake people up, so do scary things, but the tendinopathies wake people up. And so if If I've gotten you back up at nighttime, now that's an issue. So I need to back that down a step and I use that as a gauge. Did I do too much?

That patient education is critical because if they walk out of your office and the next day they're in more pain, guess what they're going to get? They're going to get something that makes them feel better. And the simple fact is, if you inject someone with a steroid, it will decrease pain, it will decrease inflammation. But what we know from these kind of diagnoses, in this case lateral condylitis, is that it makes people worse in the long run. It stops or suppresses that inflammatory reaction, that blood flow process that really is going to make the patient better in the long run.

So all the things that we used to do for this, to tendinopathies or tendonitis, when you think back 10 or 15 years, is we would suppress the inflammation. We'd put ice on it. We'd use ultrasound. If we really didn't like them, we'd put them in a splint. And none of those things worked. What worked was when we started creating controlled inflammatory reactions. And now we do dry needling and cold laser and do transverse friction massage. We do our FACTOR technique. We do eccentric loading. All of those things have made such an impact on outcomes because we've recognized we went in the right direction. So we don't want to go backwards and put a cortisone injection into that patient's elbow unless that's an acute inflammation that we truly want to suppress the inflammation. The other thing that might not work is cutting it open. That, yes, that's going to create a controlled inflammatory reaction, but there are probably better ways to do that in the hands of manual therapists like you and I.

And it's the same thing that you talked about. Like, I doubt you can remember 20 years ago. However, it's not just stopping the activity. It's controlling the amount of rest and letting somebody heal. The same case for a 12-year-old who's throwing a curveball. It's not the curveball. It's not the working on assembly line. It's not the digging. It's that you can't do those things every single day, all day, and not give your body time to rest. Because when that happens, you're going to end up with a disc lesion if you're shoveling, with Little League elbow if you're throwing curveballs all day long. So you really have to find a way to insert yourself into your patient's life. Sometimes it's through what you can do in your practice.

Other times it's infographics and ways you can educate sometimes the patient, sometimes the patient's parents on what's going on and what we can do to improve One of the things that we put together here to kind of tag team off that last slide saying that it's not really the curveball, it's just the quantity of pitches, not the type of pitch, is this healthy throwing infographic. We've got a couple of dozen infographics and we'll share this with you as well as the other couple dozen infographics if you stick around till the end of the presentation. We'll give you the link that you can download any of those as well as a few other things that you can use that hopefully help boost your outcomes.

That's it for today's episode. Be sure to tune in for episode 21, where we continue discussing this game-changing research and its clinical relevance. We will talk more about the importance of tracking patient outcomes, carpal tunnel syndrome, and wrap up with a lively Q&A segment where the topics discussed truly cover a broad range of conditions and best practices.

Thanks, Jessica.

You won't want to miss it. Episode 21 drops in 2 weeks, or 1 week for our Patreon subscribers. You can subscribe to The Factor Podcast on Apple, Spotify, iHeartRadio, or the podcast app that works best for you. Give us a 5-star rating and help us grow the show. Every little bit helps. And last but certainly not least, please be sure to visit the show notes for a link to download the PDF and any of the resources that were featured in today's episode. You'll also be able to see more information about any special offers that were featured on our commercials in today's episode as well. We'll see you next time. Hey guys, if you like what you heard today, I encourage you to visit our website at factor-store.com. That's spelled F-A-K-T-R-store.com to find out more information about all that we have to offer. We have a variety of online offerings as well as our hands-on FACTOR Rehab System course scheduled in cities around the globe. Be sure to also check out our event calendar and bookmark any of these upcoming live webinar dates coming up in the near future so you can join us live. And of course, the biggest compliment we can receive is for you to help us spread the word to your friends, colleagues, and classmates. You'll find all the important links as well as info about our sponsors in the show notes, so be sure to check those out.