18 Factors That Predict Instant Relief from Low Back Pain | Podcast Ep. 275

Hello and welcome to the Evidence Based Chiropractor. I am your host, Dr. Jeff Langmaid. And on this week's episode, we have an incredible piece of research that was just released in 2020, and it is titled Predictors of Instantaneous Relief from Spinal Manipulation for Non Specific Low Back Pain. And this is a Delphi study. So this is a really, really cool paper. It's interesting, Interesting. It stimulates a lot of questions and there's probably gonna be a couple things in here that might surprise you as well. And this was a study again, released in chiropractic and manual therapies just last year in 2020. And it's all about predicting instantaneous relief from spinal manipulation in non specific low back pain. So we know the current literature and evidence in clinical practice suggest that that spinal manipulation is utilized to really do a couple things right. Improve joint ranges of motion, release muscular tension in order to improve joint function, and decrease or relieve musculoskeletal pain at a base level. That's what the researchers say. I could not agree more. So we also look back and every week we touch on literature on this podcast about how does an adjustment work, how does spinal manipulation work? And there's a number of theories. They're all still based on, being worked on, being proven. Some are more likely, some are less likely. But I think that you can break these down in a couple different categories. Neurophysiological and biomechanical effects. So there's no question there is a neurological effect. As far as what goes on. We generate and stimulate and influence the peripheral and central nervous systems. And also there's biomechanics. Right. When we see that there's, you know, for instance, facet joint adhesions and intra articular and myofascial adhesions, and those are either, quote, unquote, broken up, or bottom line is there's an increased range of motion, there's biomechanical effects, and that's a big deal. We also know that in the facet joints there can be entrapment. So it's not only adhesions, but there can be sort of entrapment of those folds. And when you gap that quickly with a high velocity, low amplitude adjustment, there seems to be benefit. People are moving better, the joint functions better, and ultimately higher quality of life and getting back to doing the things that they love to do. And that's what we've seen time and time again. But what we see, the questions is there's really been a big push and call to action over the Last few years for the care and treatment of low back pain. The days of take some medications and bed rest, surgery or injections are your only option, thankfully are long gone in the research now. We still see time and time again doctors, you know the guideline discordance, as they say, right? What the literature shows and what the guidelines say and what many healthcare providers are recommending and doing, there still is a divide there. As a chiropractor, that divide, in my opinion, is your opportunity, but it doesn't make life easy. It means that you need to get out there, start conversations with other healthcare providers. If you're looking for referrals coming in. It also means that if you're looking just to build your practice direct to consumer, so to speak, you need to get out there across your social media channels, tell your story of health, highlight some of these studies in a accurate, but also in a consumer friendly way. And that's what's gonna help build and grow your practice. Because what's being recommended in literature is not always what's being implemented by doctors around the world. So, so with that, we've seen low back pain expense dramatically has risen over the last 25, 20 years. We've seen the rates of disability due to back pain. It's now the number one cause of disability worldwide. And we've seen a lot of efforts now saying, hold the phone, it's time for a better way, it's time for a new way. And the literature has supported that. So studies like this, that showcase, hey, who's gonna get the best results the quickest from chiropractic care, again, this is therapeutic specifically, right? Not necessarily proactive care, but therapeutically, that's an important thing. And the aim of this study was to seek a consensus among a whole bunch of experts and try to identify what are those clinical predictors that could help us outline and identify patients who are most likely to receive instantaneous relief if they have nonspecific low back pain with an adjustment. So this, this list started, Experts had basically 54, 55 items that they were able to throughout a series of three rounds. Sort of, you know, group, I guess you could say, in terms of, hey, out of these 55, how would you rank them? And they started to narrow and whittle things down. So the 55, there's a lot, right? 55, but things like, you know, stiffness in the morning of less or great, you know, less than or greater than 30 minutes, age ranges, you know, sex, BMI, pain present at all times, duration of symptoms, fear, avoidance, beliefs Questionnaire scales. The first episode of pain, pain associated with, and then you name almost any motion, right flexion, extension. All of these things were part of that initial list of 55 to try to determine, okay, where we take, we grab some experts, we try to narrow these down, what happens and what are the results. And what they were able to do throughout a series of three rounds is identify eight items in five separate domains that are the most validated, so to speak. So the five domains and predictors were patient factors, domain number one, practitioner factors, domain number two, signs and symptoms of the low back pain presentation. That's domain number three. Domain number four was an instrument of measurement. In this case it was the fear avoidance beliefs questionnaire. Mouthful there. And domain number five was the presence of cavitation following an adjustment. Sounds pretty self explanatory. But if we break down these 18, we'll kind of go through them here. And I'll also of course link this paper in the show notes. But if we look at the patient factors, so these are predictors of instantaneous relief. These were the factors. In the patient factor domain category we have patient history of a good response from previous manipulation. Patient has a high trust and confidence in the practitioner. Patient, patient is quote, unquote susceptible to placebo effect. And patient has a comprehensive understanding of their condition. So those are the five, excuse me, the four patient factors in that domain. And that makes sense, right? In the business world we say who's the person who's most likely to buy something from you in the future? It's somebody who's bought something from you in the past. And the same holds true in care. If somebody's had a good response to spinal manipulation in the past, hey, that's a good predictor. They're gonna have a good response in the future. Now if we look at the second domain, which were practitioner factors, we have four items there as well. Good patient, practitioner relationship. Ding, ding ding, Important, right? Relationships, not transactions. And tying back into, in the patient domain, a comprehensive understanding of the condition. So these things tie together. Number two in the practitioner factors was professional opinion of health status, excellent or very good. Number three was practitioner understanding of patient expectations and goals. Very important there, right? Identifying through your opp qrst and what's somebody coming in for? What are the life effects of what's going on? What are they unable to do? Is this merely a pain? Is this a functional? What's driven them? What do they want to do? What are their goals and expectations? So critical. And in this case it showcases that. And number Four is professional opinion of health status good? So overall health status was good. So that's the second domain. There's a laundry list under the signs and symptoms and I'll just kind of hit them sequentially here. I think they're all very important. Important again, these are predictors that somebody's gonna have instantaneous relief. Duration of symptoms of less than 16 days. Pain improves with exercise but not rest. No symptoms in the lower extremities. Patient has an acute condition, less than 14 days, no symptoms distal to the knee. Decreased active range of motion, decreased passive range of motion and close reproduction of symptoms on spinal springing or end range loading. So those are all signs and symptoms during their present that are going to lead you to be saying, gosh, the more of those that they have, as you kind of go through things, the more likely it is that you're going to do an adjustment. They're going to say, man, I feel 100% better. Instantaneous relief in the final two domains just had one piece underneath each of them. So an instrument of measurement, which was that Fear Avoidance Beliefs Questionnaire scale score less than 19 out of a high of 42. So if they were less than a 19 of 42, if you're using that scale in your practice. And finally, the presence of cavitation following an adjustment, the production of a clicking sound, cavitation at the moment of thrust has an impact in the opportunity for somebody to have instantaneous relief. Now, some of that this paper breaks down very interestingly is really about expectations and the thought of potential placebo because we know an adjustment or a manipulation, just because there's a sound, it doesn't mean that you didn't get get what you wanted. If there is not a sound, right? The sound is loosely correlative but not causative to whether the joint was manipulated in a way that is what you'll want. So important to keep that in mind. So they presented all these items to 17 experts. They were reduced down to those 18 and they were able to allocate these into five clinically relevant domains. So these researchers found the 18 factors identified in this study can theoretically be used to create an instrument of measurement that may be used clinically to predict those with non specific low back pain patients who will receive instantaneous relief post spinal manipulative therapy. Future research on these factors and their reliability and validity is recommended. So again, this paper, as with many papers, it's the start of a conversation, it's not the end of the conversation, but it's a heck of a Start really being able to narrow in and focus in on, okay, what are the things that. In these five different domains, clinically relevant domains, mind you. Again, they were patient factors, practitioner factors, signs and symptoms of low back pain, instrument of measurement, and the presence of cavitation. In those five things, there's 18 items. Now, they don't really quantify how many, how little. But the bottom line is the more of those you stack up as you start to understand who this patient is, what they're going through, and what their goals and expectations are, and understand also about you. Are you good? Are you establishing a great relationship? Would you say this person is relatively healthy? Do you have a great understanding of their expectations or goals? There are some things here that are very, very controllable. You might not be able to control the duration of their symptoms. Right. They're gonna come in when they come in. But things that you can control 100% are, does that patient have trust and high confidence in you? Have you built a great relationship? Do you have a great understanding of their expectations and goals? Does the patient have a comprehensive understanding of their condition? There's many of these factors here that you have direct control of as a healthcare provider. And that's super, super powerful. When you can literally, by how you communicate and how you go through your patient intake, so to speak, really directly impact their outcomes of the care they're gonna receive in your practice, that's exceptionally powerful. One thing I'll say on that, as we kind of tidy up this episode, is that most docs I speak to, incidentally, when I ask chiropractors, hey, like, what's. How many patients, what percent of patients leave your practice, you know, feeling great about their care and having a positive result? It's very routine that Most chiropractors answer. 80 to 90% of my patients. That's powerful. When we look at some of these studies regarding surgery, regarding injections, regarding medications, and there's barely better than 50. 50. They're kind of barely. Some of these interventions barely beat placebo. And we are in. Now, it's subjective when I'm asking to doc this, obviously, but 80 to 90%, I think that's relatively accurate. I think a lot of people that go in, that's why people who do see chiropractors have an unbelievably high satisfaction rate with their care. The challenge is we're kind of stuck at this, like, 12% utilization rate. So, you know, people aren't utilizing chiropractic to the degree that they should. And once. But. But Once they get in, they're exceptionally happy. So my point of that is understanding these factors that you can control that help patients get even better results. Man, that is only going to help you and your practice continue to grow through referrals, through word of mouth and through ultimately just helping people get what they're after, communicating that at a higher level and using the latest research as we cited here today, to help you facilitate those conversations. So I'm gonna drop the link to the paper down in the show notes, so if you wanna check it out, reference it, you can go ahead and do that. Also, I am teetering right at 200 reviews of this podcast actually on Apple and itunes. So if you have not left a rating or review, I would greatly appreciate it. I'd love to crush and get over that 200 review marker. Thank you so much for tuning in week in and week out. If you have any topics you'd love to see addressed, hit me up. Jeff the Evanistbacechiropractor.com Also, if you are looking to automate your social media, your email and your video streaming, check out the Smart Chiropractor. We recently launched a blog that's got a whole bunch of clinical stuff, whole bunch of marketing stuff. You will find something to help you and your practice there. And we recently launched a store which enables you to a la carte item. So if you just want email marketing, we now offer that. If you only want the social posting, we now offer that. If you only want the video streaming, which by the way is awesome. All done automated via an Amazon firestick. Do it one time and it gets automatically updated each month. You can grab those things a la carte right now at the store@thesmartchiropractor.com and finally, if you are looking, looking for coverage in your practice, if you are out with an injury right now, if you are taking a weekend for vacation or continuing education, there's no reason to shut down your practice. You can head over to chirofficecoverage.com and we can help you out. Chiroffice Coverage last year. It's a company I founded years ago. We've helped docs all throughout the United States. If you are talent, if you're a doc out there listening and saying, man, I would love to provide coverage in a practice, hit us up. We're always looking for great docs throughout the United States. Or if you are looking to take a step out of practice, don't shut your doors, stay profitable, keep things moving, keep your patients under that care by utilizing us chirofficecoverage.com so check that out. Have a fantastic week in practice and I will talk to you soon.

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