Podcast episode (recorded Nov 18, 2019) in which Dr. Jeff Langmaid reviews a randomized trial titled "Spinal Manipulation and Exercise for Low Back Pain in Adolescents." The host summarizes that adding spinal manipulation to exercise was more effective than exercise alone over one year, with the largest differences at six months. Key sample features: majority had chronic pain (>1 year), mean pain ~5.3/10, ~11% had radicular symptoms, and >50% had prior treatment. Main effects: adjusted mean pain reduction advantage for manipulation+exercise vs exercise alone of ~0.5 points at 12 weeks, >1 point at 26 weeks, and ~1 point at 52 weeks; difference-in-proportions favored manipulation+exercise by ~7% (12w), 17% (26w), and 10% (52w). Both groups reported ~80% reduction in medication use sustained through follow-up. The episode also situates the trial in the broader opioid/pain-management crisis (noting estimates that chronic pain affects >1/3 of the population and that 20–40% of adolescents with spine pain receive opioids) and offers clinical/marketing suggestions for chiropractors to translate research into referrals.
Questions this episode answers
November 18, 2019
5.3 out of 10
Over 70%
11%
More than 50%
Welcome to the Evidence Based Chiropractor where each week we deliver the latest chiropractic research and marketing strategies all in the time it takes to get to your office. Now here's your host, Dr. Jeff Langman.
Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. This week we have an awesome study, brand new, published by the International association for the Study of Pain and it looks at spinal manipulation and exercise for low back pain in adolescence. A randomized trial. The results of this paper are awesome. There are some key takeaway messages and I'm pumped to break it down. But before we get started, let me say a few words about Rock tape real quick. Rock Tape has revolutionized the soft tissue world again with new rock blades Mohawk. Featuring three tools in one, a surgical stainless steel hand polished tool, two attachments silicon sleeve and an ABS comb. Mohawk unlock never before seen treatment protocols. You can pick it up right now for 175 bucks and see all of the educational courses@rocktape.com Mohawk so be sure to check that out. Additionally, huge shout out to everybody who came out for our MD DC mixer events in Southern California last week. It was awesome. Hung out in Beverly Hills in Marina Del Rey one night, drove on down to kind of Oceanside, San Diego area on the second night. Had a ton of fun. I think it was a great experience. I plan on doing much more of these in the future, so keep your ears and eyes peeled. In 2020, I want to deliver as much value as possible. I think one of the, one of the things that I'm able to do is sort of generate those referral relationships. Obviously that's the heart of what we do within the evidence based chiropractor from a membership standpoint. But when I can get docs, MD, DOs, DCs in a room together and prime the pump, I think there is huge, huge value there. So if you're listening and you would like one of these in your area or your neck of the woods, shoot me an email. Jeff the evidencebasedchiropractor.com Let me know that you have an appetite for it in your area and I will do my best to schedule and make it happen as we roll into 2020. So big shout out to everybody that came down, a couple podcast listeners, which is always really nice to hear. So thanks for tuning in, thank you for coming out. And I want those relationships to be beneficial and ultimately be great referral relationships for you to have good access to high quality docs and also to be Able to get more new patients into your practice once more MDs and DOs know who you are and what you do. I think the best way to do that is in person. So keep your eyes and ears peeled for that. But, but on today's episode, as I said at the top, we are breaking down a paper that is super cool. It's new and it is titled Spinal Manipulation and Exercise for Low Back Pain in Adolescents. And it is a randomized trial. So it is a nice top tier of research. And basically what they looked at, primary outcome is they looked at what is low back pain look like at 12, 26 and 52 weeks after either getting exercise or, or exercise and adjustments, manipulation. Secondary outcomes they looked at were disability, quality of life, medication use and improvement and satisfaction. So what did they find? That's what we are going to talk about today. So one of the things that they talked about was for adolescents with chronic low back pain, ultimately what they found was spinal manipulation combined with exercise was more effective than exercise alone over a one year period for with the largest differences occurring at six months. So let's take one step. Let's kind of break down what's going on in this space with adolescents and low back pain. Is it a big deal or is it not? And where did this research fit in? So the authors of the study point out United States specifically is in the midst of a massive and unprecedented pain management crisis and chronic pain is affecting over a third of the population. Think about that. Over a third of the population of this country is in chronic pain. I would say in most countries that probably holds true. And chronic pain affects more people. Think about shocking. The stat is chronic pain affects more people than heart disease, diabetes and cancer combined. Think about that. Chronic pain more than heart disease, diabetes and cancer combined. So we are undoubtedly in a pain management crisis. Now what they also found was that there is a significant portion of adolescents that deal with low back pain. And if you have low back pain, chronic low back pain as an adolescent, it's a high likelihood or correlative to you experiencing low back pain when you get older. So then we say to ourselves, okay, well those, those kids, quote unquote, are probably receiving conservative care. Well, you might want to think again. The researchers found 20 to 40% of adolescents receive opioid medications for their spine pain. This is despite the fact of all of the guidelines we've seen come out, all of the emphasis we've seen on conservative care, all of the emphasis we've seen on things such as chiropractic care before even starting NSAIDs, we still see 20 to 40% of adolescents with chronic low back pain or back pain in general, receiving opioids. So again, this goes hand in hand with the fact that recent guidelines for low back pain in adults so strongly recommend manipulation as well as exercise prior to initiating any pharmacological treatment. So there is a divide here. That divide, in my opinion, is the opportunity for you to reach out, for you to have these conversations, for you to understand exactly this type of research so you could get it out to the people in your community. It is unbelievably important and it can undoubtedly save lives. So when they looked at who enrolled in this study, well, for many of the people, the duration of back pain was more than one year in over 70% of the participants. So think about that. You know, people, you know, adolescents 12 to 18 years old, almost three quarters of these kids had back pain that was more than one year. So easily meeting the chronic threshold, let's say of three months and with a mean severity of 5.3 out of a 0 to 10 VAS scale. So they're rating it over a 5 out of 10 in over a year in duration. 11% of the individuals in the study had radiating pain to the leg and more than half reported having treatment for back pain in the past. So these were people in chronic. Let me break that down. Majority of people chronic pain over one year. At least 5 out of 10 on the pain spectrum, 11% had radicular components to their pain and over half had already experienced some treatment in the past. So by all accords, this would be considered a pretty tough group to get good results with. Right. Chronic pain had treatment in the past, some ridiculous symptomatology, 5 out of 10. So it's not that, you know, 9 out of 10 that you can chop down to a 5 and somebody's, that's life changing to somebody. And it's not a one or two out of ten where it just comes and goes. It's that consistent constant 5 out of 10 pain for over a year. That's typically very, very difficult to treat. Which also re emphasizes how great the results of this study were. So I wanna break down a couple of the stats. This gets a little bit heady, but I think it's important to really understand, based on the adjusted means for reduction in pain severity on a 0 to 10 scale, there is an advantage of half a point for spinal manipulation plus exercise over exercise alone at the end of 12 weeks, by over a point at 26 weeks, and by just about a point at 52 weeks. So when I say a point, if we're using a zero to ten scale, right, that would mean a point is about a 10% reduction. So I'll say that one more time based upon that. On a 0 to 10 scale, at 12 weeks, spinal manipulation plus exercise was a half a point better than exercise alone. It was over a point better at six months or 26 weeks. And it was just about a point better at 52 weeks. So important there, secondary portion, we'll break it down a little bit of a different way. On average, the difference in proportions for reduction of low back pain severity across all possible thresholds for improvement favored manipulation plus exercise by approximately 7% at 12 weeks, 17% at 26 weeks and 10% at 52 weeks. So just saying the same thing a different way. But the bottom line is we can see right there, 7%, 10%, 17%. 1. When chiropractic care, when spinal manipulation was added above and beyond exercise alone, that's a significant, that's an average of over a 10% improvement or reduction. So that is a very, very big deal in my opinion. Now furthermore, there was some more exciting things coming up here. They found that in the spinal manipulation and exercise group experienced significantly greater satisfaction alone than exercise only. So let me say that one more time. Spinal manipulation plus exercise experienced significantly greater satisfaction than exercise alone at all timeframes at 12, 26 and 52 weeks. And most important, both groups reported approximately 80% reduction in medication use at the end of treatment, which was sustained during the entire follow up period. An 80% reduction in medication use. As we talked about earlier, third of people walking around have chronic pain, 20 to 40% of adolescents are being prescribed opioids, which is unbelievable and should not be happening. And this study not only showed that exercise people can find improvement with exercise, these adolescents for low back pain, but when chiropractic and spinal manipulation is added on top of that or in conjunction with it, the results are far better to the tune of being statistically and clinically significant. And there's an 80% reduction in medication use not only during the treatment, but throughout the entire follow up period. That is unbelievably game changing and cannot be overstated in terms of its importance. Finally, the researchers found, quote, the parent rated improvement favored the manipulation plus exercise group and was statistically significant at week 52. Patient rated satisfaction with treatment showed a statistically significant advantage for spinal manipulation pulse exercise group at all time points. So re emphasizing what we've seen time and time again, when Somebody goes in for chiropractic care, the patient satisfaction is unbelievably high. This is why I emphasize why it is so crucially important for you to send case notes for you to show the social proof that you're co managing with these other physicians in your community and that you're getting these fantastic results. Because that is so, so key. If we look at the overall picture here, we know that chiropractic utilization, I say it time and time again, hovers between 10 to 15%, which is woefully pathetic, with over 90% of people experiencing a spine and musculoskeletal complaint and 99% of people wanting better functional performance out of their life. Right. So we see that chiropractic is a great fit for that. But translating that into new patients into your practice for many docs tends to be the challenge. So we just came out of a big open enrollment with the smart chiropractor. So if you're looking for the tools and resources to get out to your community, social posts, video scripts, videos done for you, automated emails, the whole kitten caboodle, check out thesmartchiropractor.com however, if you're looking to bridge the gap with other healthcare providers, I'd encourage you to check out the evidence based chiropractor. But both serve different needs and different purposes. But both are so, so important. When again, I'll say it one more time. We look at the millions, tens of millions of individuals dealing with chronic pain. More than heart disease, cancer, all of these diseases we hear about all the time, disease processes, chronic pain accounts for more people suffering than those combined. And we see this pain management epidemic, we see even in adolescents as they broke down, 20 to 40% receiving opioid medications. That's inexcusable. But the bright side of that story is we're able to as chiropractors, you listening right now? You're able to make a huge dent in that 80% reduction in medication use, the ability to provide statistically and clinically significant benefit over exercise, that is so, so important. That is ultimately what can save the lives of people in your community and save a lot of heartache along the way as well. So important to keep in mind. The challenge is always translating this into a way that gets that patient in your front door. That's why I'd emphasize take this podcast, take the understanding, shoot your own short video utilizing the information you pick up on this podcast. Get out there, have conversations with other healthcare providers in your community. If you want some guidance and some direction. Become a member of the Evidence Based Chiropractor. If you're looking to get out there on social media, through email, within office patient handouts, et cetera, that's where the Smart Chiropractor fits in. All of these services are meant and designed to use the research that we talk about week in and week out on this podcast and put it into a way that you can utilize, as we say, with the Smart Chiropractor to turn research into referrals. Because you have the skills, the tools and you're a member of the profession that can make a huge change. We just need to keep our foot on the gas, keep, keep pushing, keep making sure that other individuals in our community understand the value of who we are and what we do. Hopefully this podcast can play a small role in that for you and your practice. And if there's any way I can help you whatsoever, never hesitate to reach out. Jeffevidencebasedchirofractor.com I hope you have a great week in practice and I will talk to you soon.
Thank you for joining us on this episode of the Evidence Based Chiropractor. If you want to grow your practice, come back for next week's episode. If you want to grow faster, visit the evidencebasedchiropractor.com and join our MD Marketing membership today.
