Podcast episode by Dr. Jeff Langmaid reviewing a 2019 randomized clinical trial published in JAMA Open Network titled "Comparative Clinical Effectiveness of Non Surgical Treatment Methods in Patients with Lumbar Spinal Stenosis." The host summarizes that manual therapy (chiropractic/mobilization plus exercise) produced better short-term outcomes on the Swiss Spinal Stenosis Questionnaire and the self-paced walking test versus medical care (medications/injections) and non-specific group exercise, and discusses implications for reducing unnecessary spine surgery. The episode also includes promotional segments for RockTape products and a June 7–9 live intensive event in Tampa.
Questions this episode answers
"Comparative Clinical Effectiveness of Non Surgical Treatment Methods in Patients with Lumbar Spinal Stenosis."
JAMA Open Network (Journal of the American Medical Association Open Network).
2019.
A 30% improvement threshold was used to indicate clinically significant change.
137% increase in complex fusion procedures between 1998 and 2008.
Welcome to the Evidence Based Chiropractor providing you with elegant and efficient research based content to help your practice prosper and succeed. Now get ready for a variety of dynamic communication tools designed for immediate growth courtesy of your host, Dr. Jeff Langmaid.
Hello and welcome to the Evidence Based Chiropractor. I am your host Dr. Jeff Langmaid. This week we are talking about Spinal Stenosis and probably in a way that you have not heard before. There was a brand new paper that came out from the JAMA Open Network Journal of American Medical association and it looked at chiropractors doing adjustments and the results are what you are going to want to stick around for for sure. But before we get started I'll say a few words about Rock Tape Rock Tape has revolution the soft tissue world again with new Rock blades Mohawk featuring three tools in one surgical stainless steel hand polished tool and two attachments silicon sleeve and an ABS comb. Mohawk are pretty much awesome so they're 175 bucks. You can get them@rocktape.com Mohawk and see all of the educational courses which are going on in perpetuity throughout the world. So be sure to check out what they have going on@rocktape.com Mohawk Additionally, we have a few super early bird tickets left for the first evidence based chiropractor live intensive weekend. It's happening June 7th through 9th. Short story on It I have taken everything that I have learned. Marketing as a sole proprietor, as an associate, as a clinic director in a group that spent 5 million-plus per month on advertising and all of the seminars that I've went to. I've distilled it down to practical information that you can utilize to grow your business. We are going to shoot video together, we are going to write emails together. You are going to have the staff stuff you need to get out there in your community and to market your practice. All with an evidence based, evidence informed idea and concept behind it. So if that is interesting to you, if you have liked what has been going on with me at the Evidence Based Chiropractor, I'd invite you to pick up a super Early Bird ticket. There are just a couple left. June 7th through 9th here in Tampa. The evidencebasedchiropractor.com events. Again that is the evidencebasedchiropractor.com/events. But today it is all about spinal stenosis. We are taking a look at an article that came out in 2019. This is brand new. It is called Comparative Clinical Effectiveness of Non Surgical Treatment Methods in Patients with Lumbar Spinal Stenosis, physical medicine and rehabilitation, that is part of the JAMA open network. And this just came out. So we know lumbar spinal stenosis, whether it's central canal or lateral resource, for that matter, it's the number one reason, reason that adults have spine surgery. And while the research supporting this aggressive treatment, quite frankly, is not very strong, in the absence of red flags, there really hasn't been great evidence. There's been a big evidence gap in our understanding of non surgical options, in my opinion, until now. So this is a randomized clinical trial that evaluated hundreds of patients dealing with lumbar stenosis. And like we see in practice, they were dealing with pain, right? They were dealing with the inability to walk any substantial distances. And they have significant decreases and quality of life, which ultimately is what drive people to search for answers and search for treatment. So this research paper found improvement in both the Swiss Spinal Stenosis Questionnaire and the self paced walking test for patients who experience manual therapy as part of their treatment program and that include mobilization adjustments by chiropractors. And similar to the researchers, I know, all of us, probably you listening, you know, have found mobilization, stretching, spinal stabilization exercises, very, very effective, even though you probably aren't receiving the overwhelming amount referrals you should based upon the efficacy of what you do. So let's take a look at a couple quotes from this paper, then we'll dive into some concepts regarding it. So the researchers found, quote, lumbar spinal stenosis accounts for the fastest growth in lumbar surgery in older adults in the United States. The rate of complex fusion procedures for this condition has increased by 137% between 1998 and 2008. Let me just repeat that one more time. The rate of complex fusion procedures for this condition has increased by over 137% in a 10 year span that ended not too long ago. Is that because there was overwhelming amount of research showing that that was the best thing to do? Absolutely not. But it has occurred anyway. They also found mounting concern about the rising rates of spine surgery and opioid use in older adults makes a compelling case for the dissemination of new evidence about safe and effective non surgical, non opioid pharmacological treatment options for lumbar stenosis. They're saying, hey, this might not be the right thing and now is the time to start looking for what can we do that's non surgical, what can we do? Conservative, what can we do that doesn't rely on opioids? And timing's right. They also found, quote, it Appears that the chiropractic physical therapy intervention had better short term outcomes at two months. So what did they find? Well, when we break things down, they were looking for a 30% improvement. Greater than 30% improvement is really where they kind of said, hey, that's clinically significant, significant, that's gonna impact somebody's life. And what they found was, quite frankly, manual therapy, which is the chirophoretic group, outperformed the rest. So when they looked at that Swiss spinal stenosis questionnaire, roughly 30% of the individuals reported being 30% better if they received manual therapy, where it was only maybe 8% reported 30% improvement or more if they were under what we'll call the medical care group. Additionally, that self paced walking test, this is probably one of really the pragmatic items here. It's literally how far are you walking? Right? That's the quality of life. I mean, that's really the lack of being able to ambulate is what drive people to surgery. So I can't overstate how important the self paced walking test is. And what they found was nearly 70% of the individuals who received the conservative care, manual therapy, chiropractic, mobilization, nearly 70% of those individuals had a 30% or greater improvement. Whereas just a little bit over half of that, maybe 35 to 40% had received 30% improvement if they were in the medical care group. There are a lot of percentages there. But the bottom line was manual therapy, mobilization, stretching, exercise outperformed the medical care group and the group exercise group as well. Group exercise was just, hey, you know, go and work out with a non specific trainer, let's say for an hour, a couple times a week. So that was the third group there. There was a medical care group which was basically medication and or injections. There was a group that was group exercise, which is what I'll call non professional or non healthcare professional. And then there manual therapy, which was mobilization, kind of the chiropractic, physical therapy, mobilization, exercise, spinal strengthening, et cetera. So clearly what the researchers found is probably what we would expect. But many people don't know, hey, the most benefit. The percentage of individuals who had the most benefit resided in the manual therapy group. Now one interesting thing that they brought up in this paper was that when they looked at about six months down the road, everybody had some improvement, but it was not really, it didn't lean heavily one way or the other. Now that gets to be really interesting because when we start to look and say, okay, well six months down the road everybody had some improvement. Okay, so that's really interesting. Every group, right, Each individual might have had some ebb and flow, but the groups universally did a little bit better as time went on. So that means as they point out in this study, that with spinal stenosis there can be an ebb and flow of the symptomatology. It's not always linearly downhill. So to me that means in the absence of red flags, no individual should be jumping into a surgical solution because we find pretty much no matter what they do, they're going to see some improvement. Now they can push that pace of improvement or that degree of improvement up. In my opinion, that could be with mobilization, flexion, distraction technique, exercise, all of those wonderful things, or they could slow that process down by probably not doing anything. So there are different things that each individual within the group, different choices they can make regarding their care, treatment and daily activities that can either push the accelerator or push the brake of their progression of their disease. But what that means in totality again is when there is an ebb and flow with the symptoms, that unless there are red flags, there is really no need to jump into a surgical solution. And we've seen that tickled what I'll say in some other papers before where surgical intervention and non surgical intervention kind of were equitable at a certain point down the road. In other words, the individual at surgery didn't do crazy better than the individuals who didn't have surgery for this. And that's a really important thing. I don't know, I've looked at some other stats where we're well above a half a million fusions being performed in the U.S. each and every year. Half a million fusions being performed, it's probably tracking towards 3/4 of a million now. And in this study they cite that 137% increase in a 10 year period in complex fusion and spinal stenosis is the number one reason why people are having those surgeries. This is a very, very important thing to keep in mind as you bridge the gap and reach out with other healthcare professionals in New York community. Now, quite frankly, I believe that surgeons are out there doing the best job they can. But it's probably not going to be a surgeon who all of a sudden starts ref out every single patient and essentially stops doing surgery except for red flags. That's just not gonna be realistic. But when we look farther upstream towards our pain management doctors, our interventional spinal physicians, and absolutely the primary care physicians, these are exactly the items, the topics that you need to bring up to those other healthcare providers in your community. So as you can imagine, we're featuring this research update this research brief for all members of the Evidence Based Chiropractor because of how powerful it is. This is exactly the type conversation that you want to have with the other healthcare providers in your community. You need to do it consistently once a month. You need to get out there and reach out. You need to be educational, entertaining, informative. Doesn't necessarily mean you need to be unbelievably charismatic, but you need to have a system and process in place that enables you to achieve the results you desire. And if that's something you're interested in, of course I'd always recommend check out our membership@the evidencebasedchiropractor.com no one has done a better job for as long as you building relationships with other healthcare providers in your community. We have guided hundreds of chiropractors towards that process and helped you get the result you desire. More influence, ultimately more referrals into your practice and a better healthier community. People that are making better choices and informed of better choices by their healthcare providers. So that is on today's episode. It was all spinal stenosis. You have any questions regarding that paper, shoot me a email. Jeff the evidencebasedchiropractor.com I will also put a link in the show notes so you can check out the paper itself. And if you want to step up your marketing, I want to help you. So check out adjust your marketing. It is happening June 7th through 9th here in Tampa, Florida at the evidencebasedchiropractor.com events. I hope you have a great week in practice and I will talk to you soon.
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