395- Australia's New Clinical Care Standard for 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 Langmaid. We are back with more research this week, another brand new publication that's all around Australia's clinical care standard for low back pain. We're going to talk about what a clinical care standard is, how it applies maybe to your practice and what they found, what are they putting out there, because that is important for all of us to be aware of because when countries take action action, eventually that trickles down to patient action. It also could influence insurer behaviors, a variety of different things that we'll get into and more on today's episode. I will also drop a link down in the show notes if you want to check it out yourself because it is hot off the press. Before we get started, say a few words about the smart chiropractor. If you would like to have the number one reactivation system in chiropractic working for you, schedule a demo@thesmartchiropractor.com for every 100 people on your email list. We can drive one over two, click to call and click to schedule actions each month. That's our average. We do that for over 300 practices. We send about a million 75 emails per month. So we have really good data, I like to say predictive analytics to know exactly what you can expect based upon your list size. If you'd like to talk with our team, learn more, see how we can do it for you so you can experience the results of having more reactivations and less dependency on needing more new patients each and every month, come visit us thesmartchiropractor.com, schedule a demo. Again, that is the smart chiropractor.com but as I said at the top, we're talking research. I'll drop a link down in the show notes. The official title is introducing Australia's Clinical Care Standard for Low Back Pain and this just came out now. In September of 2022, the Australian Commission on Safety and Quality in Healthcare released its low back pain clinical care standard. Now you might say, well, what is a clinical care standard and what's the difference between that and a guideline? That's a great question. Care standards differ from clinical practice guidelines as they focus on key areas of care where the need for quality improvement is greatest. Rather than providing this like all encompassing coverage of all aspects of management. So one, clinical guidelines are way longer because they encompass everything under the sun relative to that condition or relative to that guideline. Where a standard is really saying, where are the biggest areas of opportunity? What are the areas of deficiency that can and should be improved upon? So in some ways I'm going to say standards get really interesting because they're shortened to the point they help us understand where are the greatest areas of opportunity. And as a practicing chiropractor, you that gives you empowerment to know, well, whether it's conversationally, whether it's clinically, where can I lean in? Where are things going in the future? And is Wayne Gretzky, how can I be ahead of the puck? Right? I want to be where the puck is going to be passed in. Looking at a care standard identifies, hey, here's where we see challenges. That means money, time, effort is going to be going into those in the future. So once you know that, you can take action, which is a great, great way to, to be. So a clinical care standard comprises a small number of quality statements rather than describing all of the care options patients should be offered by clinicians and health services. So again, it's sort of pared down and it's looking at it from the perspective of how do we make things better, not what's out there and what's better and worse, but what's not going so well that we can make better. So in Australia, just like pretty much everywhere on planet Earth, low back pain is the leading cause of, of disability. I know I say that all the time and I know I say this next line all the time as well, but I want to, I want to say it one more time, which is that can be like same Z sometimes I think we're like, yeah, no kidding. Low back pain, big issue. Like, let me be super clear. If all you did was accurately take care of low back pain and communicate that message appropriately, you have an infinitely sustainable business that you could never open up enough locations. Why? Because it's literally the number one leading cause of disability. This is not a niche topic, right? So there is so much opportunity there because we know that almost everybody's gonna deal with low back pain. And about 30% of any given population is dealing with low back pain at any given moment in time. And it costs money. That's where the pain comes in. Not the physical pain, but the psychological pain. The Australian health System spends like 5 billion. That's in Australia, relatively small country from a population perspective. $5 billion on low back pain each and every year. And it's the most, here's the most impactful aspect. It's the most common health reason. Forcing middle aged Australians to retire early, that's a big issue. I won't get into, you know, financial advice on this podcast, but many people out there can't really afford to retire early. And if you have low back pain, which has a psychologically devastating component and a depressive component to begin with, that's forcing you into an early retirement. And, and you're not saved well enough to be riding out into the sunset living your best life or say you even had the money and now you can't do the things you've been waiting to do your whole life. That's a real issue. This is what I call turning over the stone. When you're speaking with a patient with low back pain understanding, as my friend Dr. Steven Fransen would say, what's the life effect? What is this person really dealing with as a result? Yeah, they have pain right now, but how is that impacting their life? Is it forcing them to miss days from work? Are they concerned about potentially being let go? Are they considering, in this case, early retirement even because they're unable to perform their job duties? These are really, really important things to understand because it helps you communicate in a more direct and accurate level with your patients. Now, people retiring early, you know, how big of an impact is that? Really big. That just, that, just that facet. Low back pain, forcing early retirement cost, the Australia's cost, Australia's gross domestic product, about $11 billion each year. This is, you want to talk about high stakes in getting people's attention and it can cause long term financial hardship, of course, for those individuals. So when you think about this from the standpoint of, I'm going to say leveling up from, from your practice and trying to acquire a patient via an advertisement or something to that effect. If you decide to have discussions with employers, if you decide to have discussions with your town, your city representatives, understanding data like that is really impactful because when you look at a business and a business, believe me, a business that has 100, 250, 500, 1,000, 10,000 employees, they know they feel the pain and not literally the business feels the psychological pain because they deal with decreased production, they deal with people out of work, and they deal with truly lowered productivity and profits as a direct result of low back pain. And those are the things I can tell you that are going to get business owners attention more so than many other things. It is literally a pain point. So in this study they highlight the landmark previous study, the Lancet series that came out in 2018. Can't believe those 20. 2018 feels like just yesterday. Lancet presented the case that the burden of low back pain was amplified by an epidemic of poor care, which I could not agree with more. And it argued that while we now have good understanding of how low back pain should be managed, should be managed, no doubt about it, many people with low back pain continue to receive just bad healthcare recommendations. And it's crazy. And it's still happening. I commented on Facebook post because there was some somebody saying, oh well, opioids, you know, the doctors aren't really doing that anymore. I'm like, are you crazy? There was over 100,000 deaths last year and a majority of those stemmed initially from a prescription medication. Relative to neuromusculoskeletal care, it is just as bad, if not worse, than it's ever been before. Make no mistake about it, patients are still walking in. Not everywhere, every time. But clearly if you're listening to this podcast and you do not have a line out the door, you're trying to open five more locations. Today, 99% of people with low back pain, probably, probably at least 90, should be exploring chiropractic care. Why? Because we're movement based. Why? Because they probably don't have red flags, which is great. And we are what is recommended across multiple guidelines. So if you're not getting an avalanche of referrals coming in from other healthcare providers, I can genuinely say they're getting bad advice. And that's not a total hit on these other healthcare providers. They kind of highlight here. Why is this the case? And I agree with this, for many professions, low back pain is only briefly covered in their training. And even when it's not briefly covered, what they were previously taught is totally out of date. We see this improving with many of the younger docs coming out, specifically primary care GPs, family docs that are now more in tune with movement based care. Most of them, most likely because many of them are fit themselves. So they might have suffered an injury, went to a chiropractor, seen a great result, but it's still a really, really big bias that goes on. And it's a knowledge bias when I say that. Sometimes there can be a personality or profession bias, but often it's a knowledge bias. I always say nobody becomes a family care doctor because they don't like people. I say that jokingly. They love people. You have to think about it, think about how little they understand. If what they do is prescribe a medication and go to advanced interventions, that's literally a representation of how little they know that they're not referring. So are, you know, this ties into evidence based chiropractor, of course, and MD referrals. You know, are you getting out there and building those relationships, bridging that gap? Because it's probably not gonna happen on its own. You have to take action to get the result. We say results follow actions. What are the actions that you're taking today to get the result you want tomorrow? And part of that is building relationships. In my opinion, it's the best thing you can do in your community. So they also highlight the fact that the general medical understanding of how to manage low back pain has fundamentally shifted. So now things like adrenaline, addressing psychological barriers to recovery, providing education and advice, promoting self management and movement are now a core aspect where things of yesteryear, imaging, pain medications, bed rest, surgery now play, as they say, limited role. Now unfortunately my gripe is that those things are still utilized at such a ridiculously high level compared to where it should be. Is it better a little bit overall than before? Probably, but it's still so disproportionately, proportionately used all of those things, advanced imaging, super early on, when I say that, I mean mri, ct, pain medication, bed rest, surgery, all of these things. And you've probably heard me talk about this before, I have a very, very close friend, smart, educated guy who's worked on Wall street in Manhattan. He suffered, really active, really fit, suffered a low back injury and he was petrified to move to Bend. Ridiculously petrified. And quite frankly, many of the medical providers he went to didn't exactly inspire him to move. So when I was speaking with him, which I tried to stay on the sidelines as much as possible, unless he was asking me questions, but it was really difficult to overcome what he had heard so aggressively. And yes, he got prescribed medication immediately. Yes, he had multiple times where imaging was taken. That is still going on. He was told to rest. He only thing he didn't have of that was surgery. And that was because he started really taking seriously yoga and movement based therapies that helped get him well, which is the key component here. So let's put that aside, let's dive into some of these quality statements as they, as they say, which really are this low back standard. So there's a handful of them. I think the easiest way to do this is I'm just going to read them because it helps give you the complete picture and of course you can download this study as one as well with the link down below. So Quality statement number one Initial clinical assessment. The assessment of a patient with a new presentation of low back pain symptoms with or without leg pain or other neurological symptoms should focus on screening for specific or serious pathology and consideration of psychosocial factors. It also should include a targeted history and physical examination with focused neurological exam when appropriate. Arrangements should be made for follow up based upon evidence based low back pain care pathways. Makes a lot of sense to me. A couple key components there are being mindful of psychosocial factors and being targeted in your assessment and I think we do that as chiropractors naturally, but many other healthcare providers are not particularly doing a great job. Quality statement number two Psychosocial assessment. Early in each new presentation a patient with low back pain, with or without leg pain or other neurological symptoms should be screened and assessed for psychosocial factors that may affect their recovery. This includes understanding understanding concerns about the diagnosis and pain and the impact on their quality of life. This assessment is repeated at subsequent visits to measure progress. Again, understanding life effect literally the number two thing here and we do a good job of this as chiropractors, but I'm going to say all of us can always do better understanding what mental limitations they might have to recovery, which is potentially one of, if not the most important thing you can help understand. Reinforcing that confidence, helping people understand they are built to move and giving them a really clean and easy to understand picture of what's to come, even if that involves some setbacks. Quality statement number three Reserve imaging for suspected serious pathology. Expectations of imaging and its limited role in diagnosing back pain are discussed early. Inappropriate referral for imaging occurs when there are signs and symptoms of specific or serious pathology. The likelihood of incidental findings are reported and discussed with the patient. They don't highlight in this, if I'm not mistaken. Whether I believe when they're referring to imaging they're meaning MRI or CT scan, but I don't know with 100% certainty. Clearly there are chiropractic techniques that rely upon imaging to understand the appropriate care plan and I have no issue with that whatsoever. Quality statement number four Patient education and advice Provide your patients with information about their condition and receive targeted advice to increase their understanding and address their concerns and expectations. I'll say that one more time. Address their concerns and expectations. The best you do that, the better the patient outcome will be. I can assure you that. Quality statement number five I'LL hop through these last few pretty quickly. Encourage self management and physical activity. Always a good idea to do that. Maximize function, limit the impact to pain and highlight how they can get better with self management. Really important. Quality statement number six. Physical and or psychological interventions. If somebody has persistent low back pain, it's not a bad idea at times, when appropriate to offer physical or psychological interventions based upon the psychosocial social assessments that you found earlier. And if somebody's just having a hard time overcoming things because of things like depression, because of other things, being able to make the appropriate referral is really, really important. Now that can be nuanced, it can be delicate. I appreciate that with that conversation, but if you're not going to do it, who is? That's really, really important. Quality statement number seven. Judicious use of pain medications. Pain medications is. The goal is to enable physical activity, not to eliminate pain. Let me say it one more time. The goal is to enable physical activ not to eliminate pain. If a medication is prescribed, it should be in accordance with the guidelines in an ongoing review of the benefits. And benzos should never be done. Antidepressants, the risks outweigh the potential benefits. And consider opioids only in carefully selected patients. I find it hard to understand when the appropriate time for that is. I'm going to say never in my book because there always are alternatives. But that's for the doctors that can prescribe it to decide themselves. Quality statement number eight Review and referral. So when there are worsening signs, symptoms diminishing function, being able to understand when to review and refer. Critically important. So those were the quality statement assessments. Now again those statements come about because these are areas that could use improvement in Australia. So clinical assessments, the initial assessment, they're highlighting that because clearly it's not as good as it could or should be. 2 Psychosocial assessment. Understanding that reserving imaging, understanding patient education and advice, encouraging self management, you know, looking at psychological interventions when necessary and limiting the use of pain medications. All super, super important. All things. While they might not apply to all of us as chiropractors and while quite frankly we do a pretty good job with most of these, most of the time important to keep in mind. And when we see things laid out as a care standard, it's nice to know where things are going in the future. So as we talked about earlier, you can be where the puck already is, you can be there already and take proactive steps with your communication in your practice. So I love this study. It's a great one you could check it out yourself as well. And before we wrap up, I'll say a few words about powerstep Orthotics. They support this podcast. You should support them and for that they'll hook you up with a free sample pair. 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Otherwise, thank you for being a chiropractor. Have an awesome week in practice and I will talk to you soon.

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