375- The Importance of Understanding Multimorbidity and Low Back Pain

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 Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langme. Today we are back with more research. A brand new study that came out just this year in chiropractic and manual therapies. It's titled Multimorbidity in Patients with Low Back Pain in Danish Chiropractic Practice. A cohort study. And in my opinion this study has a lot of take home messages that we as chiropractors need to be aware of as we're seeing people with low back pain in our practices. The statistical likelihood of other challenges that they're dealing with super important to know because it helps us manage the patient in a better fashion, set expectations more clearly and that ultimately yields better clinical results. Now before we get started, I want to say a few words about Patient Pilot by the smart chiropractor. Patient Pilot is live. It's rocking. Currently we are seeing an average member of patient pilot generate 26 reactivations each and every month. So if you are listening to this and a chiropractor and if you have a list, an email list of more than 300 that would be past patients, any leads from ads, that kind of thing. If your email list is more than 300, we will guarantee a 3x return on investment. Come on, hop on a demo. Thesmartchiropractor.com, hop on a demo, ask any questions that you want. 3x ROI guarantee we drop. Our goal is to be the technology that drives more people back into chiropractic practices than any other. And I think we are already maybe that technology. But to do that at the highest level possible, we need chiropractors that want to reach out to their community through automated email campaigns. Check it all out, schedule a demo. Thesmartchiropractor.com but as I said at the top, we're talking research. I'm going to drop a link to this research down in the show. Notes. I'll repeat the title one more time. Multimorbidity in Patients with Low Back Pain in Danish Chiropractic Practice. A cohort study. So let's start out by defining what multimorbidity means and it is the coexistence of two or more chronic conditions. Now here is something that I found unbelievably surprising was people Presenting in primary care, age 18 and older, multimorbidity is around 13% on average. That makes sense. Now let's go to age 65 and older. 95% of people presenting in primary care have multimorbidity. 95% of people 65 years and older. So that's pretty much everybody that you're seeing that's 65 and older. Now, what are some of these conditions could be chronic musculoskeletal disorders, including degenerative conditions, osteoarthritis, inflammatory rheumatic diseases, rheumatoid arthritis, fragility conditions, osteoporosis, regional pain syndromes, low back pain, neck pain, fibromyalgia, all are included there. And a substantial portion of people with musculoskeletal disorders do have multimorbidity. So people with multimorbidity often then have pain and functional limitations caused by the aforementioned musculoskeletal disorder. So this is sort of one of those cyclical things where if somebody's presenting with back pain and they're more than 65 years old, I mean, it is a pretty strong likelihood that they have other things going on. It was super important from a clinical management perspective. We'll dive into the specifics as we unpack it on this episode. So why is this a big deal? Well, musculoskeletal issues, you know, affect quality of life, right? Lower quality of life, decreased ability to work. And these are big deals. We always say. I always say, and it's just the truth, people don't come to you for relief of pain. They will live for days, weeks, months, and years with pain. It's when they can't do something they want to do. Think about yourself. I think I'll speak for myself. I kind of do the same thing. So, you know, I might have a little issue now and then, but it's only when it impacts my quality of life or ability to do something that then I'm like, okay, now I gotta take this seriously. And human beings are all the same. So it's important to consider that, and in my opinion, for two reasons. One is emphasizing the quality of life benefits and understanding the functional limitations is super important for setting expectations during your report of findings, during your exam and on your visit. The secondary component of that is this popularity. I'm gonna say bone to pick right now. The popularity with sort of getting people out of pain and out of my practice as quickly as possible. And I have a PVA of 1.6. I'll just say in My opinion, that is not patient centric care. People. Pain is the last thing to come and the first thing to go. Have you changed any habit at that point? Have you really spent enough time with that individual? Have you? If you're prescribing at home exercise or doing in clinic rehab in two or three visits, do you really think they know what they're doing and have been guided appropriately? And guess what, they're going back to the same thing that brought them in 99% of the time, the same habits, the same challenges. So I say that to really emphasize the point of understanding pain is a symptom, it's not the challenge. The challenge is the diagnosis, but it also is intimately intertwined with what are their functional limitations. So in chiropractic practice, about 2/3 of patients are treated for low back pain. So it's a majority of what we deal with. Not every chiropractor has a practice like that, but most do. And a majority have low back pain. So in this study they asked a few questions, this was a questionnaire, they asked a couple different questions. And multimorbidity was defined as the presence or two or more, excuse me, of these chronic conditions. There are 15 listed. I'm going to go through them all. Some of these are going to sound very familiar to probably what your patients are dealing with. They included diabetes, osteoporosis, a thrombus, hypertension, psoriasis, rheumatoid arthritis, osteoarthritis, fibromyalgia, metabolic diseases, asthma, migraines, chronic inflammatory bowel disease, cancer, chronic obstructive pulmonary disease or bronchitis, and neurological diseases. So they analyzed pain levels, but mostly they were looking for those comorbidities. They also asked people to self rate their health using a one to five scale from excellent to poor. Monitored a couple other things, but those were really the big ideas in this study. And how big was this study? Well over 2,800 patients consented. Over 2,000 completed the analysis and guess what? About 50% of participants reported to have at least one chronic condition and 20% had two or more chronic conditions. So those are important things to keep in mind. And again, this was 18 and older. But these numbers escalate rapidly as people get older. So they found 20% of patients had multimorbidity, which was associated. And this is important because it's not just that they have it going on, it's what's the effect of that. And the effect of that was poorer self rated health, worse physical fitness, decreased muscular strength, Decreased endurance, decreased balance at baseline. So these are all things that are really important for you and I to, to be aware of if you're going through active care in your practice, understanding that if they have more than one condition, or excuse me, in this case multimorbidity, more than two conditions going on, their starting point is by definition going to be lower. So expectations need to be managed in that case. I find that there are too many times. Here's the reason why I'm harping on this. Too many times patients come in to a chiropractic practice and, and they either feel better quickly, AKA after an adjustment or two, many people feel better and then they're like, peace, I'm out. Well, have they really at that point improve their fitness, improve their muscular strength and endurance? Have they improved their balance? Hard for me to believe that that would be true. The other side of that equation takes longer than that for it to happen. The other side of that equation is maybe they're not hitting their goals and maybe like, I don't know, the pain's knock. I've been in here six visits now and I don't feel 100% better. Well, cool your jets. You know, you have poor physical fitness, poor self rated health, you have, you know, crappy endurance, not very good muscular, muscular strength, you have poor balance. These things take time. So setting expectations is the name of the game and to me is the one of the most important components of why this study is so valuable. The additional component here is patients with multimorbidity and high low back pain intensity had poorer recovery, recovery in terms of disability, improving everyday activities and the continued need for pain medication. So this ties into the medication aspect as well. Make sure you're asking your patients these questions or have them on your intake form so you really have a clear understanding of what's going on. Now in Australia, there was a study done a few years ago and it studied the profile of patients seeking care from chiropractors and found that 24% reported circulatory issues, 24% also had endocrine and metabolic issues and 12% had respiratory comorbidities. Now they kind of touch on the fact that the 20% highlighted as multimorbidity in this study was lower than maybe you'd expect. And this is generally due, as they say, to the good health of people who visit chiropractic practices compared to those who don't. Now again, I use the term good. I'm gonna throw air quotes on here because that's still a High percentage of people that have multimorbitities and significant challenges. And clearly not everybody that walks through your front doors in your chiropractic practice is a bastion of wonderful health. But that is even more important to understand. Imagine the people who aren't walking through your door, who aren't, you know, taking a chiropractic, who aren't taking an active route in their health. You can go walk around any store or mall and generally visualize what's going on with the health of many people, or any other healthcare provider's office for that matter, and see what's walking in. And gosh, there are just so many health challenges now. The beauty of that is what we do as chiropractors with movement based healthcare is a foundational aspect of pretty much all health in my opinion. So that should give us power, oomph, desire, you know, motivation to get out there and tell the story. And, and I'll kind of tie this to both patient pilot and evidence based chiropractor really quickly because telling the story is critical. There are more than enough people. I was talking with a doc yesterday about this and I'm like, we do so much more than low back pain, but just with low back pain alone, everybody has low back pain. 90% of people. How is every, there's only 50,000 practicing chiropractors, maybe 60,000 really practicing day in and day out. How is every practice not full? That is a communication. If your practice is not full, it's a marketing and communication issue. It's not that you're lacking techniques, it's not that you're lacking the knowledge. It's not any of those things. It is a marketing and a communication issue. And marketing is so much more than paid advertising marketing. To me, I love relationship building marketing, relational marketing tactics like getting out there and building relationships with other healthcare providers, adding, I mean Maybe it's not 200 new patients a month, but adding 2, 4, 6, 10. We work with some docs in the evidence based chiropractor that have added that do have 30 patients coming in or more each month from other healthcare providers. But if it was just five, not only is that beneficial for your business, but you've changed people's lives like they're getting bad care, often in a musculoskeletal realm, other places, specifically in the medical realm. We know their guideline discordant. We know that there's over medicine, pharmaceutical use. We know that there's advanced imaging too early which leads to advanced interventions. Why not get out there for the benefit of your community and your business. Secondary component Tying back to where we started this episode when I was kind of shouting out Patient pilot is automated email campaigns. Staying top of mind. Converting more of your website traffic by having a new patient pop up. That's just a good idea. What's the easy alternative not to do it? Having a world class onboarding campaign through email. Yeah, text is great for transactions but it's not good for relationship building. There's not enough characters there in a to be able to really tell a story. And that's where email comes in. So critically important. And again, what's the alternative? Not to do it. And then the third part. Weekly email newsletters, reaching out, weekly teaching and inviting so that you have a consistent flow of reactivations. People are going back to the habits. These people that know like and trust you, that have been in the past could be hundreds of people. The most valuable asset in your practice are you staying top of mind with them? Are you staying in their life? Are you continually adding to them? Not with discounts and specials, but with actual teach and invite information that helps them live a better life positions you as the great chiropractor you are and helps you build flow of reactivations day in and day out. To me it's our responsibility. When I look at it, I say there's 60,000 practicing chiropractors. Let's say many are not at capacity yet. There's people going for elective surgeries, drugs, medication, injections all day, every day. It's time for us to step up our marketing in a meaningful way. And that's not just running paid TikTok ads to get people in. It's about communicating with the audience that we're building so that you can build and grow your practice over time. So I'll get off that soapbox and get back to the study. But it ties into people are struggling out there and they need us. But we have to be able to accurately tell that story for them to understand why they should choose you, why they should choose a chiropractor as somebody that can help them because far too many are not as is very clear about what we see in the data. So the other thing with this is it's well known people with back pain and musculoskeletal conditions respond less well to drugs. They respond less well to non pharmacological treatment, they respond less well to surgical intervention. So helping people overcome as carburetors we might not be able to overcome. Help them overcome every piece of multimorbidity that they're struggling with. Some of this might be beyond the scope of what we do, but I'd still say the foundational aspect is when people are moving, exercising, eating right and have a positive mindset, you're going to wipe away a lot of this and probably wipe away a majority in my opinion. So, you know, the challenge for chiropractors and all healthcare professionals is not to view low back pain as this super isolated thing, but more so as it impacts the overall health of the individual in so many different ways. So as you're doing your evaluations, don't be so myopic, just to that area. Ask questions, probe about what's going on, set great expectations. That is what is absolutely key. Additionally, patients with multimorbidity had a continued use of pain medications for low back pain as compared to those without chronic disease. So this leads into that cascade that we want to help people avoid, which is chronic medication use. I'll just say it as is causes more problems than it takes care of. Specifically related to neuromusculoskeletal issues 99% of the time, meaning you need more. Your body becomes sensitized. By definition, you're using the medication a chronic. When you're using it chronically, you're using it to live, not for an acute issue. Therefore you're probably not moving very well. You have a false sense of body position. And this is just a challenge that far too many people, tens of millions of people. No matter if you're in a small town, hundreds of people within a 10 mile radius of you are probably dealing with. If you're in a large city, tens of thousands of people within a, within your circle of practice are dealing with getting back to that marketing and communications issue, getting out there and telling the story. So I loved the study. I think it's a really, really good look into what's really going on with people that present to our offices and practices with low back pain. And it's also good information for us to again be able to set great expectations so that patients can get the best care possible so they can get the most relief possible and, and that they can do it in the most natural way possible. So that is tidying up this episode. But before we wrap up, I want to say a few things about Zing it. 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