456- Understanding Systematic Reviews on 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. On today's episode, we are talking all about systematic reviews regarding low back pain with and without radiculopathy. Some of what the World Health Organization's recommendations are. We'll get to that in just one moment. But before we get started, today's episode is sponsored by Jane, my favorite emr. Jane has designed a user friendly online booking system so your patients have the freedom to book their appointments at their convenience, even if it's after hours or on the weekends. Patients can manage their appointments, fill out intake forms and enable reminders, which saves you a ton of time. And they're willing to give you a one month grace period by using the code EBC1MO. Click the link down in the show notes, connect with their team and see if Jane can help run your practice in a more efficient manner. But as I said at the top, we're talking research today. The title is a long one. I'm going to drop it, of course down in the show notes, but the title is A Systematic Review of Clinical Practice Guidelines for Persons with Nonspecific Low Back Pain with and Without Radiculopathy. Identification of Best Evidence for Rehabilitation. To develop the WHO's package for interventions for Rehabilitation. Very long title. We will drop it in the show notes. Great study. Highlighting a lot of, I think reinforced knowledge that we've talked about on this podcast many times, but hopefully it inspires you a little bit and gets you to take action on this information, which is the most important thing. Knowing it's out there is one thing. Helping other people know that this is out there is a whole different thing. And that is really where the benefit comes into play because we know as if you tune in frequently. We talk about research pretty much every single week. And I can guarantee you all, almost nobody in your community has any idea that this research is being published in any meaningful way and at any scale of the volume that's actually happening. Why? Well, quite frankly, because research is really hard to read and it doesn't provide often simple answers. It actually creates more questions. So our job, you, me, hopefully my job is from the very top to be able to start to put this into terms that we can all understand and, and make it a little bit actionable. And your Job is to do exactly the same in your community, which is take the knowledge that you know and make sure people understand that. Because I can tell you with neuromusculoskeletal care, there are a ton of people in your town today, literally right now, as you're listening to this, making suboptimal, and I'm gonna put that very lightly, bad decisions about their healthcare, because they don't know any different. And the first. First step is knowledge. Second step is putting it into action. So let's get into this study. Study's all about low back pain. We know it is the greatest cause of disability worldwide. The global prevalence, over half a billion people, 568 million people. I don't know how you come up with that specific stat, but over half a billion people at any given time are dealing with low back pain. So this is a big issue. Yeah. Is it a big market? Just about the biggest. And radiculopathy, as it ties into that, we all know it refers to the inflammation could be compression of the nerve roots. And what can that cause? Pain, weakness, numbness. And that can travel, it can stay more local. A lot of that is, it depends. And it can be caused by things like spinal stenosis, narrowing of the spinal cord, and canal lumbar disc herniations, which is when the disc, of course, pushes beyond the natural margin, which gets into foraminal stenosis or lateral recess stenosis, of course, meaning narrowing. And the first word there, spinal lateral recess or foraminal. Just telling you where it's happening in that segment. So what else do we know? Well, we know that the point prevalence of low back pain around the world is about 7.5%. So it's actually, I think, a lot higher in the United States from a prevalence perspective. Excuse me. Than when we look at things worldwide. So it's more prevalent in the United States than it is across other countries. And interestingly, I did not know this one. The prevalence globally is actually higher in women than men. And when we talk about radiculopathy, prevalence there is about 2.2%. And we know radiculopathy has a lot to do with age. It's super rare to see it below 20 years old, except when there's like a total acute injury, it naturally, due to degenerative changes, disc changes, as I like to say, the instantaneous axis of rotation migrating posteriorly low in those facet joints, causing all of those challenges as gravity and time become undefeated. This peaks in the fifth decade of life and then declines thereafter. And risk factors for Radiculopathy, they're pretty wide. I think they're still being debated, but we know some general buckets, and that is acute injury. Heavy lifting, twisting, bending, smoking, pregnancy, actually, because of the laxity, diabetes, body mass index being too high, hypertension and family history. All these things, amongst a few others, can play a role in the likelihood that somebody is going to experience radiculopathy. So what can we take away from that? Well, knowing it is one thing. The other is putting that into action. Well, if we know that those items increase likelihood, those are great conversations to have. One, to set the stage, another, but two, to be able to say, well, how do we decrease the likelihood? Well, not getting an acute injury is one way. Right. Nobody wants to do that. But that ties in to topics that you can talk about, like ergonomics. And when we talk about heavy lifting, twisting, bending, driving, smoking, these are all, I'm gonna say, lifestyle factors to a certain degree that not everybody who bends, lifts and twists ends up with radiculopathy and a disc herniation. Why? Well, there's a variety of factors there, but conditioning, ergonomics, flexibility, the balance of strength and flexibility, as I always like to think about it, these are really, really meaningful things that can go into rabbit holes, kind of. But you can keep at a high level and have a really productive conversation with your patients so that they understand these are all risk factors. And to minimize your risk, here's some of the things that you can do. And. And again, I always think about this when it ties into what I'll call like, retention of a patient. But I don't mean, like, keeping them hostage in your practice. I mean setting the right expectations. Meaning somebody that's like, smokes, drives super far to work, is completely out of shape, bends, lifts and twists, and had previous disc injuries. And they continue to do that all day, every day. And they're like, in their 50s. They're pretty likely that this is going to happen again. They got a lot of risk factors. So if they come in one time, you take care of them setting the stage. Because what absolutely crushes me on the inside is the amount of patients I've seen in multidisciplinary practices that are coming in after seeing a chiropractor successfully. And then, quote, unquote, it came back, so now I'm here to have surgery. Well, did chiropractic work the first time? Oh, it worked great, but then I stopped going, and then this came back. So now I want surgery. It's like, that's crazy. And that is happening today in your town unequivocally. And that comes down to one thing and one thing only, and that's education. And that is hopefully what I'm inspiring you to do a little bit more of today. So in the past three decades, we have seen fortunately a shift, and that's from interventions around low back pain, going from treating the pain to, to really emphasizing the role of rehab in targeting function. And we saw pain as a vital sign. Go off the rails with the opioid epidemic. Won't get into that too deep today. But the bottom line is this is about function and it's about helping reclaim their people, reclaim their quality of life. As we know, people will live with pain forever. It's when it impacts their life in a way that matters to them, that then they make a decision to go in to see you or somebody else. So with this study, they were looking at an array of different studies. They included pharmacological and non pharmacological interventions, amongst other things. And they defined rehabilitation according to the World Health Organization definition, which is, quote, a set of interventions that assist individuals who experience or are likely to experience disability to achieve and maintain optimal functioning when interacting with their environment. And they took a look at a variety of different clinical practice guidelines published in a variety of different languages basically from 2009 to 2019. There were a ton of them and they whittled them down pretty aggressively so that there was only, I think maybe about a dozen that were ultimately included. And I think there were thousands that were initially found over 3,000. And they really whittled that down with some pretty strict guidelines to try to really determine what are some of the best interventions here or what should we be looking at in terms of moving forward. Now, there's a couple interesting aspects of how they lay out their findings here. One is that in what I'll call the chart section of this, they reference spinal manipulative therapy as well as manual therapy a ton. Yet in the discussion they hardly touch on it. Why? I don't know. They don't reference that at all. It's quite odd to me that you would see spinal manipulation and manual therapy, crazy high levels of interest and reference throughout the charts and graphs and then hardly referenced at all in the discussion of the paper. And it, it's odd to me. I don't, I don't really know why. But what I can discuss is what they have put in here in terms of education modalities and some of that discussion, incidentally, spinal manipulation and, and manual therapy seemed to, in My eyes perform very well in terms of what they highlight in the charts. It's mentioned often. It's in a variety of systematic reviews. They highlight in the chart section why? For patients with chronic pain, manual therapy, spinal manipulation specifically is actually recommended to decrease pain and increase ability levels. And they also mention how considering manual therapy including spinal manipulation for managing low back pain with and without sciatica is an essential part of a treatment package including exercise with and without psychological therapy. And that spinal manipulation should be considered in early intervention for acute and subacute low back pain. So we hit acute, subacute and chronic. I don't see too much else in these charts that really references across the board like that. But again it's not particularly referenced in the discussion section which I find to be quite odd. They do reference however education and the importance of education. I think this is a great thing that ties in with what we do each and every day in our practices. So patients should receive advice and information tailored for their needs and abilities to help them self manage their low back pain throughout the care. Couldn't agree more. Modalities, mixed bag there several recommendations did not support some of the modalities including TENS and interferential. Ultrasound and interferential they say were not effective. Conflicting evidence on TENS for pain. So make a little bit of a mixed bag there. In terms of NSAIDs really not recommended in terms of being used alone for low back pain. Duh. Opioids should not be used routinely but could be recommended for short treatment of acute low back pain. That's what they're saying here. I could not disagree more. I find it pretty offensive that at this point there would be a paper coming out saying well they shouldn't be used all the time. But still leaving wiggle room I feel like is just really counterproductive. And they say antidepressant should not be recommended for the treatment of low back pain. Again, I'll give it a big duck as far as that one's concerned. Yet this is still happening and there's yet to be any reproach for the physicians doing that, which I think is a big problem ultimately in terms of interdisciplinary rehab, complex cases with persistent pain. They do recommend an interdisciplinary approach regarding having rehab including exercise, cognitive behavioral to reduce the fear of movement, fear, avoidance behaviors. Couldn't agree more. Spinal injections only recommended for tort term benefits in patients with low back pain, but the side effects must be discussed. Again. I'll kind of take a little bit of exception with that. You're putting here that they could be recommended Short term. Yet the side effect, the Hippocratic oath do no harm if the side effects outweigh the potential benefit. I don't really see why that's happening yet. It's still happening all the time. So they highlight that clinical practice guidelines were consistent with recommendations against the use of ultrasound tens and interferential. Overall, they found quality evidence for pharmacological therapies is poor. Well said. Clinical guidelines suggest that these pharmacologic therapies have a very limited role and should only be used when necessary and with other modalities. And they say there is recommendations for multimodal approaches that combine things like exercise manipulation and education and cognitive behavioral approaches for chronic low back pain patients. So overall a really interesting study. I like the fact that they continue to highlight medications and treating the pain is just not the way to go about it. I think we're a few decades on from that really being a hot take. However, it's still being done, which is absolutely not. So papers like this I think continue to put pressure on those individuals that are doing that because the body of evidence continues to grow, which is great. I find it a little bit odd in terms of how much they emphasize throughout the charts and the results of their research the benefits of spinal manipulation, yet they don't really mention it in the discussion at all. Again, not sure why regarding that, but it's a good step in the right direction to highlight really rehab as opposed to pain to showcase exercise education and multimodal care as really being great ways to help people find relief long term without the use of drugs and surgery. That's my big takeaway from this study. I like that takeaway and it agrees with a lot of what we see in the research. So hopefully you're able to take a few clinical pearls there, put it into action in your practice and if you are taking care of a lot of people with spine issues and specifically cervical spine issues, check out the objective assessment tools from neckcare neckcare.com, drop a link down below. Reliable assessments and exercises for neuromuscular control, proprioception, range of motion and sensory motor integration. Their tools are awesome. Super apple like they're just designed really well. No cords, no wires, it's wireless, it's elegant. The software looks great. Check it out neckcare.com let them know that they have in a space chiropractor sent you over if you have a conversation with the their team. And finally, if you're looking to generate more patient reactivations, head over to the smartchiropractor.com schedule a demo we have the best and most comprehensive patient reactivation suite of software tools available on the market. That's a complicated way of saying head over if you're interested in more patient reactivations and have a conversation with our team. Let's see if we can help. It's super affordable. Your patient list is the most valuable asset that you have and chances are you are not maximizing the value out of it in any meaningful way, which means you're not helping as many people as you could. So we'd love to help you with that. Thesmartchiropractor.com Schedule a demo Other than that, I hope you have a fantastic week in practice and I will talk to you soon.

Thank you for joining us on this episode of the Evidence Based Chiropractor. If you want to grow your practice, come back for next week's episode. If you want to grow faster, visit theevidencebasedchiropractor.com and join our MD Marketing membership today.

Sam.