452- How Radiographs Predict Persistence of Back Pain in Older Adults

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 Lengmaid. On this week's episode we're talking research. This one is all around radiographs and whether or not there is a prognostic or predictive factor of long term back pain in older adults. It's a good one. Lots of clinical pearls, some take home messages and of course we'll talk about how and why this this information can be communicated to your patients. But before we get started, I want to say a few words about Jane app. Today's episode is sponsored by Jane, My favorite emr. The Jane team knows that when you finish your day spending time caring for your patients, it can feel like there aren't enough hours for admin tasks. That's why I use Jane in my personal practice. Cannot recommend it enough. And as a listener to this podcast, they're going to hook you up with a one month grace period using the code EBC1MO. I'll drop a link down below if you are on the fence, maybe not so happy with your current ehr. Talk with the team at Jane Support is awesome. Again, I'll drop a link down below and they will hook you up with a month grace period to get started. But as I said at the top, it is all about research on today's episode and the title of the study we're gonna highlight is Clinical and Radiographic features of Spinal Osteoarthritis Prediction, long term persistence and severity of back pain in older adults as you've come to expect. I'll drop a link down to this in the show notes so you can access where the paper is at. And why is this a big deal? Well, there's a couple different reasons. Number one is low back pain is the number one reason why people initially visit a chiropractor. It is the number one reason people associate care with a chiropractor. And we also know that up to or over 80% of adults will experience back pain in their life. So just about everybody's gonna deal with it. We see 80 to 90% the typical statistics on how many people will deal with a bout of back pain and we also know about 30% of people. That's kind of the prevalence factors. About 30% of people are dealing with back pain at any given time. So you walk into, wherever you walk into a PTA meeting, you walk into a school, you walk into a business, you, you see 10 people, random people, about three of them statistically are dealing with back pain right then. And about 8 or 9 out of 10 will deal with it at some point in their life. And that is one of the reasons why, it's the number one reason why people initially visit a chiropractor. So understanding factors that might be able to be predictive factors of long term persistence and severity, super important for a variety of different reasons. One, the first thing that comes to mind for me is communication, understanding how to set the right expectations for your patients. And this is something that I'm continuing to dig deep into week after week on this podcast because it's so important. The patients that just stop coming, I think we're all maybe, I don't think we take an accurate view, let's put it that way, of just how many people come in to see you and then just kind of stop coming in over time? You, you didn't discharge them, they're not released from care. As a matter of fact, you might believe that they need more care, that they might have a reduction in pain, but they're still looking towards and experiencing functional improvement and they just kinda go off into the ether. That's why over 90% of patients in chiropractic practices are inactive by and large. And with that, a lot of that stems, I can tell you, from the other side, working in a few orthopedic groups, that the number of people that came in happy with their chiropractic care, yet coming in for a potential surgical consult because the pain came back, that is 100% expectation management and helping people be able to understand what is this gonna look like, not predicting to a T or guaranteeing anything in the future? None of us can do that. But what we can do is understand what's likely to happen, prepare people for that. And that's expectation setting 101. And we can and should be better about that with our communication because it's going to lead one, to better patient outcomes. Two, it's going to lead to less people getting advanced interventions, injections, surgery, getting on the medication train. And three, it is going to lead to happier patients as they really understand the process of what's going on just a little bit better, not through the complexity of medical language, but through what I'm going to call clear communication, direct plain English communication, which is often, I think, lost. And even those of us who believe we are really Great. Communicators can always take a moment to audit how we are communicating. And I can guarantee you there'll be some things where you're like, oof. That's an area of improvement for me, which is great. Keep on improving. Keep on building clarity. Because we know confusion kills conversion, as we say in the marketing world. And clarity converts. And when I say conversion, I don't mean selling somebody into a care plan in this instance. I mean helping them understand what's actually going on and make better decisions for their future. So we know there's a couple things that are important to codify as we get into the study. One is that we know that back pain can be influenced by a variety of prognostic factors, one of them clearly being age. There are others that have been brought up in previous studies, such as poor recovery duration of the back pain, poor general health, increased psychological or psychosocial stress. All of these have been brought up as potentially prognostic factors in the past. We also know that lumbar disc degeneration, or they're calling LDD in this study, is defined pretty clearly. And that's the presence of osteophytes, bone spurs, and or disc space narrowing on lumbar radiographs. And this has been studied super extensively and is considered a FE of spinal osteoarthritis. So you can think of spinal osteoarthritis, it's kind of the bigger bucket. It encapsulates a variety of different things. One of those things is lumbar disc degeneration, of which the hallmarks are disc osteophyte complex. So certainly osteophytes have grown. And again, that doesn't happen in a day. Right. When we see an osteophyte, that tells us that that area has been dysfunctional for a pretty significant amount of time. Chances are years. And then we see disc space narrowing again. Disc space narrowing can happen acutely with a traumatic injury and a blowout of a disc, so to speak, whether it's an extrusion or a herniation or whatever that might be. However, an overwhelming majority of the time, that took a long time to happen. And these two items happen together. So there is an association between lumbar disc degeneration at baseline and back pain after 22 months. And there also has been reported that disc degeneration seen on MRI can, can be indicated as a prognostic factor for the recurrence of back pain in the future. So we're starting to put some things together here. This study really had a clear focus and that was to investigate the prognostic role of osteoarthritis related features for long term back pain in older adults. And key to keep in mind here, these older adults were actually presenting to a primary care practice, not a chiropractic practice. And this study, again with abject specificity, was looking at factors such as spinal morning stiffness, range of motion, radiographic features of lumbar disc degeneration, and persistent back pain and severity at one year post follow up. So that's really what they were taking a look at. Now couple prognostic factors from baseline that they analyzed and there's kind of a slew of them here, but a lot of these, we'll go through them quickly, they'll stimulate thoughts for you, which is, are your patient, are you hearing this as you go through your opp, qrsd, as you're going through your examination and evaluation and history with the patient? Are you asking these questions and, or are patients reporting this frequently? Because some of these prognostic factors, as we're about to learn, might indicate a higher propensity for them to be dealing with pain down the road. So what are these factors? Presence of morning stiffness, specifically spinal morning stiffness, defined as a greater than 2 out of 5 on an NRS scale, Duration of that stiffness, so is it lasting greater or less than 30 minutes? Do they have restriction in lateral flexion, lateral bend, and do they have restriction in rotation? Do they have restriction in true flexion? All important, do they have pain during lateral bend? Do they have pain during rotation? Do they have pain during straight up flexion? And then we get into some of these others which are, do they have osteophytes? Right. And are those defined as a greater than or equal to 2, or are they at two or more levels between L1 and S1? And then finally, do they have multilevel disk space narrowing equal to or greater than a grade one at two or more levels between L1 and S1? So those were some of the key factors that they were looking at on the front end at baseline and at one year follow up they were also measuring, at that point they're saying, hey, was there persistent back pain, you know, defined as a score greater than or equal to one on an NRS scale? And what was the severity assessed on an NRS scale of 0 to 10? So what was the persistence and what was the severity? Did it come back? Have you been dealing with it and how bad has it been? They looked at over 500 individuals and of the included people, 63% had back pain and 30, 37% had no back pain at all. One year follow up. So we can take the good and the bad from that. Good is that one year post we saw nearly 40% of the individuals had no back pain one year later. That's good. The other side of that coin was about 60%, over 60% did have back pain. One year follow up. Now, again, keep in mind, these individuals did not necessarily receive chiropractic care before, during or at any point in that one year. So this is not indicative of the care they received. This is more indicative of the natural course of what they were dealing with and relating that again to some of those prognostic factors. So for persistent back pain and back pain that had some level of severity after one year, they found really strong associations between the morning stiffness duration, pain during rotation and multilevel osteophyte. So out of all those factors we just discussed, a couple really popped out as being strongly associated with having pain a year later. Again, those three things were the duration of the morning stiffness, was it greater than 30 minutes? The pain during rotation specifically, and multi level, not single multilevel osteophytes. Really, really important. So the duration of spinal morning stiffness greater than 30 minutes was a prognostic factor for back pain. One year follow up. The prevalence of at least grade one osteophytes were actually similar to other studies as they highlighted. And there was an association ultimately between lumbar disc degeneration and back pain after one year. Their conclusion in this study was, quote, we found an association between three clinical and radiographic features of spinal OA and back pain after one year in older adults presenting with back pain in primary care. Thus, identifying patients with spinal OA may help predict long term back pain. That is their finding. So what's the clinical pearls here? What's the take home messages? Couple different things. One, are you asking the right questions up front? I'm not saying you have to go through every one of those prognostic factors, but are you gathering enough information up front to be able to understand the likely course of the future? The best, as my friend Dr. Steven Francis says, the best predictor of tomorrow's weather is today's weather. Right. So what's going on today? What have they done in the past? How is that impact? You know, have they had this before? Right. Obviously part of the natural history, part of asking that history. Two, how long they been dealing with this now? What's the pain level and then understanding if you have this isn't a, you know, necessarily a commercial to shoot x rays on every single person. That's not what this study's about. But if there are images, whether you are taking those images, nothing wrong with it. If you are taking those images or if they have previous images, do they have multi level osteophytes? Are you asking questions about pain with rotation? These are probably important questions to be asking to be able to highlight the long term benefit of your care, I'm going to say, and expectation management of what that might look like. Now again, this study is kind of all things considered equal, meaning they did not receive chiropractic and hey, chiropractic care probably dramatically alters the course of back pain. I believe that absolutely to be true. This study was not looking at that. This was just saying, hey, if these people live on under time and gravity, as I like to say, are undefeated, what's the most likely thing to happen? Most likely thing to happen is continued pain. If those three items are found or discovered at baseline. So again, really great information I believe for us to know as providers, to accurately set expectations with our patients, to accurately communicate as well. If somebody has a setback during the care that they're receiving in your practice, helping them understand that this is not like for most people most of the time, this isn't one or two adjustments and you're good for the rest of your life. Time, gravity, undefeated, previous injuries, what are they doing all day, every day, between stress, between movement or lack thereof, exercise, weight, all of these things really play a role in understanding how to best communicate. And most importantly, I'm gonna say above all of that, when a patient comes in, what is their goals? When somebody says that they're looking for pain relief, it is typically because they're looking for the life impact to change. Here's what I mean by that. We all know most patients come in and it's like, how long you been dealing with this? 1 year, 5 years, 25 years? They've been dealing with a lot of these things. Yes, there are the acute cases, but in most of the cases, most of the time people have been dealing with pain forever. People will put up with pain like crazy, but what happens is eventually they can't play with their grandchild, eventually they can't go play in that adult softball league, whatever. They can't get to the gym. And that's their goal. That's what actually drove them to your practice. Not the pain, they've been dealing with that forever, but the pain got bad enough that it impacted their life and understanding that is absolutely critical to having productive conversations with your patients, setting the right expectations and ultimately providing the best care possible. So great message I think from this study to be able to extrapolate and to understand setting those expectations in your practice. As we wrap up, let's talk Cervical Spine Are you into objective assessments of the cervical spine? I am and the best tool out there is neckcare, bar none. Reliable assessments and exercises for neuromuscular musculoskeletal control, proprioception, range of motion and sensory motor integration. I'll drop the link down below. Net Care supports this podcast. Support them this tech is awesome. You probably have seen me speaking with Orey, their CEO and highlighting the device. If you haven't, head over to the YouTube channel, you can see me highlight it there. And additionally, if you are looking to build and grow your team, Chiral Matchmakers can help. Whether you're looking for a virtual Chiropractic assistant, that's not AI, that's a college trained CA trained. A college educated CA trained individual to do things in your practice. Social media management, maybe insurance verification, making sure your phones are answered. These are really important things and ChiroMatchmakers can help with that through the virtual Chiropractic Assistant program. Additionally, in a fraction of the cost of an in office CA or if you're looking to hire a new in office CA or a new associate DC in your practice, head over to ChiroMatchmakers.com and as we are getting down to the middle and end of August, we have a screaming deal going on with Patient Pilot. If you are not doing anything with your current inactive patient list, you're just missing out. And quite frankly, we're doctors, we're teachers, we're educators. That can't happen. It's time to step up to the plate. It's time to consistently communicate with your inactive patients for their benefit. And guess what? Many will reactivate and that's what Patient Pilot Assist piloting patients back into your practice. If you have a few hundred patients or a few thousand patients, I know some of you listening of inactive people that are inactive in your EHR that you are not consistently communicating with. Come on, head over to smartchiropractor.com we are offering 50% off the first month of patient pilot and then 25% off every additional month. We'll hook you up with smart patient recall lists, personalized emails that go out, patient reactivation emails. Everything your team needs to make patient reactivations faster, easier and better than ever before. Patient Navigator is brand new. It's awesome. Get in there, take advantage of the discount, use it and watch your patient reactivations grow the smartchirobacter.com I hope you have a fantastic week in practice. Thank you so much for listening into this podcast and I will talk to you soon.

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Sam.