441- Clinical Practice Guidelines for Low Back Pain Management

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. This week we are back with more brand new research. I'll drop a link down below. It's titled Recent Clinical Practice Guidelines for the Management of Low Back Pain. A Global Comparison. Fantastic study that takes a look at all of these clinical practice guidelines that we discussed quite frankly week in and week out on this podcast and puts it together and says hey, what's going on out there? What are the lessons we can learn as clinicians and and how can we implement this in our practice and where are there discrepancies? And that's a really interesting point. So we're going to break this down on today's episode. Again I'll drop a link down in the show notes. Before we get started, I'll say a few words about patient pilot by the smart chiropractor. We have made massive upgrades to patient pilot and they keep coming. Bottom line is this. If you have more than 500 inactive patients, people you've seen in your EHR that aren't actively coming into your practice, meaning they have not been in in the last 30 days or or they don't have a future appointment scheduled, head over and schedule a demo@the smartchiropractor.com Chances are we can help you communicate with your people more consistently and make it super easy for them to schedule and give you and your team hot lists of individuals who are engaging with your practice so that if you choose to make patient recalls are gonna be super successful. If you have online scheduling, this is a total no brainer the smart chiropractor.com but as I said at the top, today's episode we're talking research again title Recent Clinical Practice Guidelines for the Management of Low Back Pain. A global Comparison. And this starts with a story old as time on this podcast which is low back pain is a big deal. It continues to be the leading cause of years lived with disability and this has been on the increase. So between 1990 and 2017 we, we jumped actually from 42 and a half million years as if that's really comprehensible to 64.9 million years lived with disability. So things are getting worse, not better. That means these guidelines need to be put into place, hopefully quite frankly by probably many of the Healthcare providers that aren't listening to this podcast that are guideline discordant. But there is a lot of suffering going on related to low back pain. The point prevalence of low back pain is about 18% at its height, resulting in increased activity, limitation and absenteeism from work, which affects global production and all of those things when we start talking about numbers that are this big. So yes, does it. And this is a multifactorial, should I say type impact, meaning it impacts the person. If you have a low back pain and you're unable to go to work, you're unable to do the things you love, it has a high life effect that affects you big time. It also affects one step beyond that, your family, because they have to deal with those issues. It then affects your community if you're unable to be productive, if you're unable to do the things you'd love to do, and we're talking about a thick percentage of people that impacts a community, then we talk and we look regionally and globally. And you can literally trace it up to that when we look at these years lived with disability. And it is a big deal. And I always like to say, because it's the truth, is it kind of boring for us as chiropractors? Probably it's more exciting to take care of sports cases, performance, you know, challenges and performance benefits. But the bottom line is there's nobody better on planet Earth that takes care of low back pain than us. And the fact that we're still hovering at, you know, 15%, very, very being very nice saying 15% of of the population uses a chiropractor, yet a ridiculously high percentage will have low back pain at some point in time. And 18% literally have back pain at any given time. That delta hurts. I view our penetration probably closer to 10%. And if 18% is the point prevalence, nearly one out of two people is not choosing to see a chiropractor. Why, that's a communication issue, of course. So listen, let's keep trucking on this data though. So there have been, here's the good news. There's been a lot of growth in clinical practice guidelines since the first ones were published in 1987. So the first clinical practice guideline was by the Quebec task force in 1987. And we've seen since then a plethora of these clinical practice guidelines come out. And they've evolved over time as well, which is actually really good. They've shifted from being basically expert opinion, quote unquote in the past to, to more evidence Based and using really sophisticated methodologies, using implementation strategies, recommending these types of things, which are really really important because a guideline is for nothing if it's not utilized. So the shift from being just some guy's opinion or gal an expert opinion to being more methodical in terms of the data collection and in terms of the empirical evidence is a really, really great step in the right direction. So it's important because guidelines that are incorrectly written lead to ineffective interventions, inefficient use of resources and even potential patient harm. And we can look outside the low back pain space to see this. There have been plenty of things that have been doctor recommended throughout the years. Whether it was smoking way back in the day or whether it was some medications that were prevented prescribed in the 70s and 80s and you pulled off the market, never to be seen again. And quite frankly, in my opinion, many more that are on the market right now that will be pulled off and never seen again that are recommended. So the recommendations, just because there's a guideline that doesn't mean that work is done. One, the guideline needs to be written in a proper effective fashion, two, it needs to be implemented appropriately and three, it the guidelines should guide that process in terms of what do we know and how can we implement this in our practices. So they took a look at 22 different clinical practice guidelines from 15 different countries specifically related to low back pain and what's recommended, what's not recommended, Is there evidence, sufficient evidence, insufficient evidence? They basically narrowed it down to 22 guidelines written by 15 different countries. Nine of the guidelines, so 41% targeted, after they did a little bit of sorting, targeted recommendations regarding acute, subacute and chronic low back pain. So those were predominantly what a lot of these guidelines were looking at. And that's important because we know that the model or ideas around acute progression to subacute to chronic really matters. And those individuals that move on to chronic pain because they didn't have the right interventions at acute or subacute, they tend to take up a majority of the resources. They also tend to have much higher intervention rates than those who addressed it early on. And there are some findings that I think are really important for all of us to know which are recommendations from these guidelines addressed most of the non pharmacological and pharmacological treatments used in the management of acute, subacute and chronic low back pain. And key recommendations were placed on active treatment, including things like education, exercise, staying active, avoiding bed rest and self management. These guidelines also recommended pretty highly targeting psychosocial factors, which is consistent with the Lancet back pain series. We reviewed that on this podcast. Incredible series of papers that came out a few years ago now that I highly recommend. Why? Because they advocated really to avoid pharmacological approaches whenever possible, which is really, really, really important because that has been the predominant way people have taken care of back pain for decades. So the Lancet series put a stake in the ground and said non pharmacological approaches, physical approaches, movement based approaches are what's absolutely important. And when we look at things like education, who can educate better on low back pain, movement and neuromusculoskeletal care than a chiropractor, I'd be hard pressed to find somebody exercise. Of course, physical therapists could dive into the exercise world as well, but we're experts there. Staying active, self explanatory, avoiding bed rest. Of course, movement based care is the heart of what we do and self management, which I think many chiropractors do a really good job of. We need to communicate at a clearer and higher level. But in conception and concept, we do a great job with all of these things. So that shows to me that we're perfectly suited to be recommended in these guidelines. Now, the guidelines design is not to recommend professions specifically, it's to recommend modalities and approaches. But when the modalities and approaches completely are in line with what we do each and every day, that's a really, really good thing. Now, current clinical practice guidelines do place an emphasis on self management advice, education, as well as, again, less of an emphasis on those pharmacological and surgical options. About time. Now, chronic low back pain, let's set a few definitions. Chronic low back pain, generally accepted in most of the guidelines to be lasting more than 12 weeks. But acute and subacute, there was some variability, some definitions, less than four weeks to less than 12 weeks. So acute and subacute can become a little difficult to parse out in terms of some of these practice guidelines. But chronic, pretty stagnant in terms of above 12 weeks. So some studies also did show that pain does typically improve within four to six weeks of an initial acute episode. But there is a clear demarcation between acute and subacute phases, which is lacking. In other words, when does that shift take place from acute to subacute? Hmm, that's up for discussion. But pain does typically improve within four to six weeks. This is also why, and I wanna highlight that especially for the docs out there, I know there's a couple listening that really take pride in getting people out of your office as quickly as possible. I'm not saying you go to the other. These are two ends of the spectrum. Just because I'm saying that doesn't mean it means infinite care three times a week, forever, or else bad things are gonna happen to you. The pendulum doesn't have to swing from one side to the other. We all know pain is the last thing to come and the first thing to go. So if you are releasing your patients based upon pain and pain alone and not functional ability, and I'm going to say even beyond that, in my opinion, the most important thing. Have their habits changed. It doesn't happen in two to three visits. It's literally impossible. And we know here pain typically improves within four to six weeks. You have to give the body time to heal, and you have to give that person time to understand what's going on. Do not make the mistake that just because somebody sat with you for 30 minutes between their examination and their second and third visit, then all of a sudden they have the same knowledge base that you have. It's not true at all. And that difference between the knowledge that you have, the knowledge that they have, and the fact that they're coming out of pain, they have motivating factors is really, really important to understand. And it's also important to give people time to. To digest what's going on. Physical therapy has no problem working in cycles of four to six weeks. And U.S. as chiropractors, we shouldn't be afraid of that. There are times when less care might make sense. There are also plenty of times where more care makes sense. But understanding that processes take time, habits take time to change, and pain is the first thing to go. Continue to do your assessments. Are they making actual material gains and changes outside of I feel better today. Really, really important. So historically, guidelines had recommended NSAIDs, but we've seen a shift towards more therapeutic exercise. Spinal manipulation, they pointed out directly in this study, and staying active. And there are numerous examples where recommendations have diverged on acupuncture, electrotherapy, heat and cold, and medication. So pretty conflicted as far as that goes. But it's really consistent in terms of recommending spinal manipulation, therapeutic exercise, and staying active. So it is all there in black and white for us and for people, but that the word needs to get out. So drugs like opioids, muscle reluctance, antidepressants vary considerably. I'm gonna say I'd be interested to know who's paying for those studies depending upon what the result is, because it's super Clear in my mind that's not the way to go about things. Yes, in less than in a fractional percentage of acute cases it makes sense to get over the hump and then to get off of them as quickly as possible. We're talking about fractional percentages here. And part of the variation recommendations might reflect different medical practices across the country, which is very bizarre to hear because the guidelines should be the guidelines regardless of the practice approach. And guess what the practice approach is generally driven by if it's a large enough practice. Dollars and cents of course. So really important to keep all of those things in mind. So there's insufficient evidence to identify that there's one medication that has a net benefit because there's a lot of trade offs in terms of benefits and harms. Biopsychosocial model we've discussed pretty substantially and that is strongly recommended for low back pain self management focusing on of course physical, psychological, educational and work related components and spinal manipulation. The only challenge in their studies regarding spinal manipulation is that they do use spinal manipulation and spinal mobilization interchangeably. Of course we know manipulation to be high velocity techniques, very specific, enhancing joint mobility and mostly associated with chiropractic and osteopathy. Spinal mobilization is slow, slow velocity, low velocity techniques with smooth repeated motions, more for flexibility and that takes place more in a phys physical therapy or physiotherapy practice. They're used interchangeably a lot within the research. That's something that needs to be parsed out over time because there is an important distinction between a high velocity adjustment and in a low velocity move, so to speak. So the fact that they can be used interchangeably in my mind highlights the fact of how important movement is overall. However, the approaches are dramatically different in terms of the mechanisms of action, which is why they should be sorted out. So this review identified 22 clinical practice guidelines produced between and these guidelines were just between 22. Just between 2017 and 2022. So that's really, really important. Clinical practice guidelines had some variation but most recommended against passive bed rest, against medication and for active therapies. So a review of the guide, the guidelines are kind of a review and these are a review of the reviews highlight the fact of how important the model that you are going to do as you drive to practice today with your patients, with your community and why it is so critically important that you have these conversations out on your social channels through your email patient pilot plug to other healthcare providers in your community if you want more referrals. Plug for evidence based chiropractor These marketing tools that I put together over my career are not based upon what I think is just a good idea. It's based upon what's needed to get you from where you're at today to where you want to be tomorrow. And that is consistent communication with your existing pace building of patients so that people know to say yes again on their terms, of course, by you staying present, how is that not possibly a good idea? And on evidence based chiropractor land, getting out to other healthcare providers. We call it MD marketing, but I don't care if it's md, do midwife, doula. Who are the other healthcare providers? Concierge, medicine, you name the credential, it doesn't matter to me. The bottom line is you have a ton of people in your community seeing individuals with low back pain. The only question is, are they referring to you or not? And if they're not, then I'm gonna recommend you change that. And how do you change that? By having systems, processes and tools that enable you to get results. So thank you so much for being a chiropractor. Thank you for getting out there. Couple other things I wanna highlight before we wrap up today. If you are a doc who really is into objective assessments, you probably are. If you listen to this podcast, check out neckcare.com reliable assessment tools and exercises for neuromusculoskeletal control, proprioception, range of motion, sensory motor integration. Some of the coolest tech that I have seen regarding objective assessments of the cervical spine a long time. You can also check out my YouTube channel, bunch of videos on it. You can see me actually doing the examination and you can see my results actually. So you can head over to neckcare.com to check out their cervical assessment tool. And if you are looking for extra help in your practice, you don't necessarily have to hire somebody in house. You can hire a virtual chiropractic assistant. That's not AI. This is a college educated human being that can get stuff done. Head over to ChiroMatchmakers.com, schedule a call if that's interesting to you. Otherwise, if you have not left a rating review for this podcast, I would love it if you would take a moment and do so. It helps more and more people find out about this podcast. So that'd be awesome. Thank you for being a chiropractor. Have a fantastic week in practice and I will talk to you soon.

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