090- Shot or Not? The Truth About Injections

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Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. This week we are back with more hard hitting research. Last week was a banger of an episode with my guest Noah Kagan, the 30th employee at Facebook, fourth at Mint, all talking about chiropractic marketing. If you did not check that one out, make sure you do. So I've gotten a ton of great feedback from docs just loving the content. But this this week we are back with more research and it is all about injections. This is one you do not want to miss. Before we get started, I'll say a few words as I do each and every week about Rock tape rock stock 2017 is coming up in September. I just got the email from the team at Rock Tape with the final schedule for Rock Stock. Wow. It is impressive. Check it out. Rocktape.comrockstock Pick up your tickets before it is too late. It is one of the top events. Beautiful Huntington Beach, California in September. It is coming up fast. So this week, as I teased at the top, it is all about injections. And really this is about the story of your patients and it's potentially the story of family members too. People you know, they may or may not have gotten chiropractic care and they're recommended for an injection. And for us as chiropractors, it's very important that we understand the science and the literature behind what is going on with nerve root injections or epidural steroid injections and how our care plays a role and how we can best inform and educate our patients regarding those interventions. So that is really the key in what we're going to talk about this week on the podcast. Also, it is what we are going to touch on this upcoming month, or should I say next month with the smart chiropractor. The smart chiropractor. You guys know the evidence based chiropractor is all about those referrals with other healthcare providers in your community. Nobody does it better. Nobody's done it longer than us at the Evidence Based Chiropractor. But last year I got an itch on my side and it was saying to myself, this information is so great for other healthcare providers, but why don't we frame it in a way that works for patients and make it social media focused with videos, with graphics, with handouts that are weekly for your practice. And that was the impetus for the Smart Chiropractor. You can check it out. Thesmartchiropractor.com this is a little bit of a teaser almost to where we are going next month with the Smart Chiropractor. It's all about injections. But really on the podcast I wanna focus on the science of it. And the key of today is concurrent care. So one thing that I often see, and you might have seen this yourself, it's that somebody goes or they're recommended to get an injection and all of a sudden they feel like they should stop coming into your practice as a result of that. And interestingly, the literature shows the exact opposite. So how many times have you had a patient come into your practice, they receive some care, they might not be getting ex where they want to be and they go to their PCP or somebody else, an MRI is ordered, they see a disc herniation, the patient goes to get an injection. You don't hear from them for who knows how long. It happens to all of us. But the truth is the literature shows that should not be the case. There was actually a paper from JMPT in 2004 that's titled Spinal manipulation post Epidural injection for Lumbar and Cervical radiculopathy. And what they found, what the researchers found was, I'll give you two big quotes here. Theoretically, epidural injections are proposed to address the inflammatory and central components of spinal pain, whereas spinal manipulation is proposed to address the mechanical and neural aspects of the pain syndrome. End quote. So that's why these things work together in one fashion. They work on different things, so there could be overlap between those. But if a patient's having radiculopathy, pain traveling down that arm or leg, they may, I'm going out on a limb, they may want to address both components of that pain syndrome. The researchers also found in the same study. Quote, this data suggests that spinal manipulation post epidural injection is a safe non surgical procedure to use in the treatment of a patient with radiculopathy of spinal origin. So that's very interesting, but let's get down to those outcomes. Outcomes rule all. And what they found is on the outcomes, when patients had significant improvement, it was when they had both treatments. So basically, let me break that down a little more simple. Every patient in this study got an injection. Now let me be clear. Not every patient in your practice needs an injection. But for this study, they took Patients who had received injections and then half of those patients received chiropractic care, spinal manipulation afterward, and half didn't. And unequivocally, the patients that had the additional component of chiropractic care after that injection did better than those who did not. And that is an important distinction made in that paper. Now let's peel that story back even a little bit farther. Did those patients need the injections to begin with? Well, we can't really do happenstance not knowing the individual charts, but we can look at some literature and another paper from JMPT in 2013. This is a long title, but give me some leeway through this. Symptomatic MRI confirmed lumbar disc herniation patients, a comparative effectiveness prospective observational study of two matched cohorts with either spinal manipulation or image guided nerve root injections. So I'm gonna break that down and cut it down a little bit. Basically, people had an MRI with a big disc herniation causing pain. Some of them received an injection, some of them received chiropractic care or what happened. Let's take a look at a few of the quotes from these researchers that really tell the story. So quote, both of the treatment groups had significant decreases in their NRS scores at one month with a 60% reduction for spinal manipulation and a 53% reduction for nerve root injection group. So head to head chiropractic spinal manipulation outperformed the nerve root injection group. Let's look at another quote. Lumbar NRIS nerve root injections are a commonly used and accepted treatment option for these patients, whereas lumbar spinal manipulation as a treatment for disc herniation remains controversial among some emphasis some healthcare professionals. We know that some of these docs are recommending up to 9 million ESIs are given per year, 25,000 a day. And many are not referring to chiropractic care before. And also, as we just learned, they definitely should be referring afterward even if they're utilizing those injections. The research has also found, quote, the fact that 53% of the chronic patients in the manipulation cohort reported improvement is important to note because these patient symptoms have exceeded the timeframe for improvement due to natural history. So this is something, you might have caught my video, that talking, you know, speaking to Joe Rogan. And if you don't want to look at nasty, nasty comments, don't go on YouTube and find it unless you're really looking to sort through some riff raft there. But the bottom line is a lot of people were saying, and I think it's you know, when somebody posts something on YouTube like that, there's some nastiness. But the bottom line is just as with anything, there's probably more than one person thinking that. And there were a couple people that said, hey, chiropractic care, it's not better than doing nothing at all. Well, this paper shows otherwise. They put chiropractic head to head with nerve root injections and they're showing and saying, the researchers that hey, chiropractic care resolved the symptoms in these patients with chronic complaints that were not resolving on their own. There is no natural history there. That is intervention based outcome. That is the beauty of chiropractic care. So I wanted to frame a little bit of this. Because epidural steroid injections for pain in the spine is truly used off label by FDA standards doesn't mean it's a bad decision. But it's something that a lot of people don't know. They're so commonly prescribed at the medical direct or medical doctor excuse me's discretion that it's something that's overlooked, that truly the medication has never, it's basically used off label for all of those injections, which amount to 9 million per year. And my point today is not to kind of pile on injections as a bad treatment option for patients with drastically acute pain. And there's varying situations where they might be completely appropriate and the best thing to do. But my point is, is that we as chiropractors need to understand the story of this and where we play a role. And number one, even if that patient has had an MRI that has a disc herniation that's pressing on the nerve, which is usually when the PCPs are referring for the injection, chiropractic care, spinal manipulation outperformed those injections head to head. That's a very important piece of research and literature that you need to be able to know and understand. The second component of that with the injections is that the injections, when performed, the patients that then received chiropractic care after their injection did significantly better than those who didn't. So even in the event that the patient has to go or they decide to go or they're, you know, kind of, they make their best decision to go get that injection, that shouldn't be the end of the story at your office. That needs to be the point where they definitely make that appointment to come back if they want to get the best result from the injection. So those are really the take home messages that I've wanted to kind of Talk about today. I know a lot of us, we really focus on that, you know, the kind of that in person conversation. And that's what you listen to. The evidence based chiropractor that comes out every Monday morning at 6am for hopefully is some tips and some tricks and some information to get through your week. But I want to make sure that you also don't neglect that messaging online. So reinforcing your messaging offline and online is very, very important. One of the best ways to do that, of course, as you probably know, is with being able to hand out updated research briefs to your patients and then being able to follow that up with great, beautiful modern informational graphics online. I know I talked to patients, I had a doc just probably I talked to patients, I had to talk to docs. And just last week I had a doc reach out to me that really started utilizing both the online marketing components and the offline. So he was able to post social media graphics and he was able to give some of this information to his patients in practice. And he noticed that his referrals started driving through the roof as patients were better able to understand what was going on. And it takes multiple touch points for people to retain information. So that's really where kind of getting back to it, where he was saying, hey, I am so happy that the smart chiropractor exists because it's given me the ability to reinforce my message, my science based message supporting chiropractic both online and offline. And you guys give me all the done for you tools to do so. And it's really made a huge difference in my practice as far as patient retention goes, as far as patient compliance goes, and as far as practice confidence goes. So that's something that really sticks out to me. If you don't have a great system to do that again, I'd really emphasize check out what we're doing@the smartchiropractor.com it's taking the research and putting it in. I know some docs out there, they might not be interested in building that bridge with other healthcare providers in their community. That's the evidence based chiropractor. But every doc out there I know wants to make sure that they're communicating with their patients and their prospects at the highest level possible. And that is exactly what the smart chiropractor is all about. So check it out. Thesmartchiropractor.com it just might be what you need to build and grow your practice to the next level. But I hope you have a fantastic week in Practice Doc and I will talk to you soon.

We appreciate you joining us for this episode of the Evidence Based Chiropractor. Learn more tips for explosive practice development@the evidencebasedchiropractor.com you can also join the Premier MD monthly membership, enabling you to use what you just heard to maximize results in your office. We look forward to providing you with more dynamic communication tools for immediate growth right here on the Evidence Based Chiropractor.