399- The Pyschosocial Impact of Chronic 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. This week we are back with more research and another brand new study that is all around the psychosocial impact of chronic low back pain. Great study. A lot of clinical pearls take home messages that you can utilize not only for your knowledge but the communication that you have day in and day out with your patients. We're going to break it down, highlight some of the key findings and more on all on today's episode. Before we get started, I'll say a few words about the smart chiropractor. Send email, generate reactivations. That is what we do at the Smart Chiropractor. So if you would like to have more reactivations coming into your practice and if you have an email list right now in your ehr of past patients that you're not reaching out to, you're missing probably the number one opportunity for growth in your practice right now. We can automate the entire process for you. Schedule a demo atthe smart chiropractor.com Again, that is the smart chiropractor that. But as I said at the top on today's episode, we're talking research. I'm going to link this study down in the show notes so if you want to check it out directly, you can. It is a BMJ open article and it is titled A Qualitative Investigation of the Psychosocial Impact of Chronic Low Back Pain in Ghana. So in a developing country that is where this study was performed. But I think there's a lot of messaging, some that is specific to a developing country, their cultural habits and some that is just part of being human beings. So I love this study because you can look at it through the lens of, well, should I say a few different lenses. All of them are true and all of them give you insight into what are people really dealing with when they're struggling with chronic low back pain. And this comes really impactfully to your communication because the more, as I like to say, that you're proactively answering the questions people have about their health with the content you're putting out, email, social, website, copy, the conversations that you're having in and around town and in your practice, the more aligned those are, the more authority you build and the more that people believe that you're actually the solution because you're sitting, as we say, on the same side of the table as them. So the more that you understand what people are dealing with, the better you can communicate. But you have to have that knowledge. And I think it's always really important to re emphasize this because I know a lot of times we talk about low back pain. I'm going to get into some stats here and it's like eye roll territory for a chiropractor because it's like quote unquote boring. Meaning yeah, we know we do a great job with that. But there's so much more we can do. I agree. There is so much more we can do. Yet there are more than enough people struggling with back pain if only half of the people that in the world right now with back pain, or should I say in your community, let's be really specific when we take the point prevalence of back pain and we break it down. There are thousands of people for every chiropractor, every chiropractor, there are thousands of people just with back pain. So if you are not having a waiting list practice, so to speak, you have a communication challenge. So that is where this knowledge comes into play. And let's talk about that prevalence of back pain because it continues to increase over the last three decades it's increased over 50%. So between 1990 and 2015 over a 54% increase in the prevalence of back pain. So this ain't getting better based upon what people have done in the past, but we can be the future and it's expected to continue to rise, especially in low income and middle income countries. And the point prevalence, annual and lifetime prevalence of back pain in Africa is, is 39%, 57% and 47% respectively. So the point prevalence there, nearly 40% of the population at any given time is struggling with back pain. That is a big deal. Now the risk factors, causes and impact of chronic low back pain spread the gamut, right? We know there are such a variety of things that contribute to it. But if we break it down, there are three primary biological, psychological and social. Those are really the three domains which chronic low back pain thrives or can be eliminated through, so to speak. And we've seen clinical practice guidelines over the past years really suggest the use of a biopsychosocial model for assessment, treatment, management, all of the above of chronic low back pain because it is so multifaceted. And here is the catch. They're going to talk about this in this research paper about Ghana and Africa but quite frankly, I think a lot of this happens in the U.S. canada, Australia, New Zealand, wherever you're tuning in from. This is a worldwide issue that people rely on biomedical and passive strategies way too often. Massage, prolonged pain medication, advanced interventions, and they don't really utilize the biopsychosocial strategies as often. Now, depending upon where you're at in the world, depending upon where you're at literally in the country, if you're listening to this in the United States, there can be fluctuations in terms of how reliant people are on medications versus biopsychosocial strategies, movement based strategies, as I like to say, or whether or not those things have flip flopped. So there are changes, but the bottom line is we look across the globe in biomedical strategies, AKA prolonged medication use is still the number one challenge. It has not been eradicated. It generally, I haven't seen it get that much and it doesn't seem like the medical system really wants to change. The guidelines will continue to pump things out, but in practicality we don't see too many changes, which is why I advocate for getting out there and building referral relationships so much. That's the way to go about it and it's a big opportunity to build and grow your practice. So chronic low back pain, we all know it's a long term and complex condition and it can extend far beyond when things are healed. As a matter of fact, quite often it does. We know how long tissue healing takes and I think towards maybe a month ago, a good friend of mine came and asked me to just kind of have a curbside consult, so to speak, on some MRI images of his friend. And his friend was in a really difficult situation, spiraling with medications, opioids, young guy in his 30s, spiraling with opioids, not sure what to do, not working, really difficult situation. I looked at the imaging, it was about as clean of imaging as I, as I've ever seen in my life. I couldn't barely find it didn't even look like the person had barely reached skeletal maturity. Nevermind, was there no osteophytes, no disc issues, nothing to see whatsoever, which was concurrent with what the MRI report had said. Yet this individual was struggling with. And as I said to my friend, I said, don't take this the wrong way, I believe he does have pain. He does, and that's a very real thing. But that doesn't mean that there's a big disc herniation, that there's stenosis, that there's an abject challenge. And so much of that Showcases that this is psychosocial. There's a lot that goes into that on the psychosocial aspect. And it can extend far beyond tissue healing because you could have totally clean imaging, totally clean, you know, examinations. And people can be in dire pain. And it's real to them. It is absolutely real to them. And the medication does not help. It actually perpetuates that cycle. So this is why reliance on biomedical and passive strategies can be really problematic. And I don't deem movement based care as a passive strategy. They're referring to like e stim and things like that. Getting up, guiding people through motion, delivering chiropractic adjustments, in my opinion is, is not passive. Now the adjustment might be passive for that person, but it comes part and parcel to an array of movement based strategies. And you have to get those joints moving in order to help people get moving. So the role of psychosocial factors on chronic low back pain are really, you can look at them under three domains and that's what they did within this study. They looked at prognostic abilities, treatment effect and treatment mediators. So they're looking at how, how do these domains impact low back pain? And we know that the effects of low back pain can span the gamut. Loss of self, marginalization, shame, guilt, financial difficulties. All of these things have been reported previously and we're gonna see them come up again in this study. And the reason why this study, I think you can split hairs as far as culturally and location wise, but also it's all part of the same THR, so to speak, is that pain is subjective and it could be affected by socio cultural factors, economic factors, structural factors in the society. But there are some things that reign supreme throughout. So this study looked at adults, male and female, above 18 years old, presenting with low back pain that was more than three months. A classic definition of chronic there. And they found patients had pain in this study from one year to 15 years ago. So in that range and all of the participants. So we want to talk about loss of self. Every single participant described some sort of loss resulting from chronic low back pain that could span the gamut. Unpleasant experience of pain, stiffness, altered posture, disruption and movement and sleep. And it resulted in what they defined as the loss of usual physical, physical selves. So this is a big deal. It's clear we see people with this all day, every day. But we shouldn't minimize how impactful this is on people's life because the loss of the usual self results in psychological challenges. And this becomes a focal point for thinking And I've described a friend of mine last year who went through a pretty significant bout of back pain, and it consumed his thing. He's a really smart guy with a really great job, and. And he was consumed by what was going on with his low back, not because there's anything wrong with him, but because that's how impactful it is. And I always think about. I say extremity pain is one thing, but low back pain and spinal issues, they get into your psyche as opposed to just your wrist hurts or your elbow hurts. It's very quick that these things can happen and you start to spiral out of control. So all the participants also expressed how chronic low back pain had caused loss of their livelihoods, either permanently or temporarily, which was stressful, as you can imagine, to everybody in this study. Most of the participants had sadness, frustration, distress. They expressed being tired of it and not being happy, which also is very common. I know we hear that all the time, but it's really important for us as providers to internalize this and really understand it so we can have great communications. In other words, literally saying these things to patients that are coming in. I understand this must be incredibly frustrating. I understand that this must be really consuming a lot of what you're thinking about day in and day out. And you're probably really tired of struggling with this pain. Simple things like that. It might be like, oh, well, that's obvious. It's not unless you say it. And once you begin to speak like that, now these patients, as I said at the top of this episode, now you're sitting on the same side of the table as them, meaning they're sitting there thinking, this doctor knows exactly what I'm going through. And I can guarantee you 99.9% of the providers that they're seeing are not even saying those two simple lines. They're just going through the mechanism, looking down at the chart, prescribing a medication. And maybe they've either seen other chiropractors that haven't communicated in a way that I'm going to say that they deserve, which is really having a clear understanding, getting on the same side of the table. And then we. We move into expressing hope, then we move in to eliminating fear. But you have to be able to break through and help them understand that you understand what they're going through before they're going to pay attention to anything that you have to say. Additionally, participants in this study had a big fear of what the future holds. So some were concerned about deterioration over time. Some were concerned about disability. And this was influenced, as they highlighted in this study, directly by the biomedical model. So as somebody's taking a medication and they're taking higher and higher doses for less and less effect, of course they're concerned about when the, when what's going to happen here. This is not, you know, this strain is off the rails, it's not on the right tracks. And that can be super, super concerning. And especially if you don't know what else to do. And many people out there, again, I think us as chiropractors, we become so blinded to what we know that, that we, it's hard to take a step back. We think everybody must know this about how their body works. They must know this about how to overcome these challenges. And 90% of the population have no idea. That's why it's our job to educate, inspire, engage with these individuals and help them ultimately get back where they want to be. So this study obviously highlighted feelings of loss, loss of identities and a loss of roles. And it all tied into chronic low back pain. And that was the big take home message in this study. A couple other things we'll highlight before we wrap today is bottom line. This study depicted a multidimensional psychosocial level of low back pain that really spanned the gamut. It affected domestic tax, employment obligations, culturally, family wise, emotional consequences, financial consequences, stigmatization, marginalization, all were included in the feedback that was received from these individuals with chronic low back pain. So as they're highlighting here in Ghana, but I'm gonna say beyond, it's time to reconsider the biomedical underpinnings of chronic low back pain. We have to be able to get through because for many people, and we know, also thinking back to previous studies we've highlighted on this podcast, about 30% of people who have low back pain will go on to develop chronic low back pa. And that's especially if they're in a medical course of care. It diminishes greatly if they're going through a chiropractic course of care, a movement based course of care early. But most people still aren't. So many people, 30% plus are going to end up with chronic low back pain. That is why we need to have a firm understanding of how to communicate with these individuals, a firm understanding of what they're dealing with so that when we can absolutely connect with them and ultimately help them take the steps necessary. Because chronic low back pain is not a terminal sentence, it really has in most cases, most of the time, the ability to get better. Now what does that include or what does that need? What does somebody need to get better? They need to understand they can get better, number one. Number two, they need to have the correct action steps to get better. And they need to reduce the fear associated with the movement. Because fear of movement tends to be one of the greatest challenges. And I'm just going to say it straight up, for many people, many times medication just messes the whole thing up. They end up becoming sensitized to the medication. They're in a downward spiral. They don't know where the tunnel will lead to because they're taking more, more and more for less and less response and it takes the onus off of them. Is there this pill that solves the issue when it's really their ability to change and shift their mindset, their ability to get moving in the proper way. I don't mean movement with ramifications of injury, but proper movement, segmental movement, regional movement, whole body movement. The exact things that us as chiropractors can and should be talking about each and every day with all of our patients. That is what these individual needs. All of these people with chronic low back pain need. That is a holistic model in my mind and a psychosocial model, biopsychosocial model that extends to Ghana and beyond. So I hope you had a great time on today's episode. I know I did. I thought the study was really, really great. If you have not left a rating or review for this podcast, I would love it if you would do so. Please scroll on down. Leave how many stars you think we earned. If you leave a sentence or two saying hello to me, that would be awesome as well. It's great to know when people are listening. And before we wrap up, if you are thinking about hiring a new associate, D.C. cA or virtual CA to answer the phones in your practice, head over to Chiro Matchmakers and have a conversation. Chiromatchmakers.com it is impactful to hire right the first time. 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You should love them too and they support this podcast. Pro.powerstep.com sample I'll drop that link down below. Use the code EBC to pick up your free sample pair. Thank you for being a chiropractor. I will talk to you next week. Have an awesome week in practice and I will talk to you soon.

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