494- Prognostic Factors in Nonspecific 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. This week we are back with more brand new research and it is a great one. It's all about prognostic factors associated with improvements for patients that have nonspecific low back pain. What can you count on? What should you do? What should you avoid? We're gonna get into that and much more on today's episode. Before we get started, I wanna say a few words about my brand new partnership with Leander Tables. Yes, you heard that right. Yes. You can save $1,000 on their Series 950 by using the code EBC 2025. You can click down in the show notes, connect with their team, have a conversation, let them know you are a listener of this podcast in my ecosystem and you can save a thousand bucks. Leander Tables are one of the best and oldest names in the business. They're tables that I, I've utilized myself personally and I cannot encourage you enough. If you are in the market for a table, the reflection distraction with elevation is, is awesome. You can check out that link down in the show notes. But as I said at the top on today's episode, we're talking research. This study just came out in 2025. Again, I'll drop a link to this down below as well. The title is Prognostic factors associated with improvement in patients with an episode of non specific low back pain without radiculopathy. That is the title of the study. It tracked patients over four weeks time to see what actually predicts improvement. Not based upon guesses or previous research, but based upon the data. They looked at 11 chiropractic practices across a multi year period and this is what they refer to as a prospective observational study. There was just shy of 250 patients enrolled and again, they all had nonspecific low back pain. No, none of them had sciatica radiculopathy. Just kind of that classic mechanical low back pain. So this is highly what I'll call pragmatic, meaning it's probably what you see every single day in practice. Are these patients so understanding what I'll call the levers you can pull to help improve the outcomes that they're receiving is a really good idea. And also to understand, hey, what are maybe some talk tracks? I Should update, adjust, no pun intended, or avoid altogether so that I'm inspiring my patients each and every step of the way so that they can get the best results possible. So every one of these patients did receive care from a chiropractor and they received a variety of different things. They could have received spinal adjustments, mobilization, soft tissue work, and they were tracking improvement across a couple different domains. One of them, pain intensity, pretty standard there, Pain unpleasantness, the ODI scale, disability indexes, of course, and patient reported global change. So they considered patients to be quote, unquote improved if they hit at least three of these criteria. So it's a pretty high bar to reach to really meet and exceed that threshold. I think us as clinicians in a practical, clinical sense would say, hey, we're, if we're firing on one of those, in other words, we're decreasing pain or we're decreasing disability or they have a global change self reported that's improving. Any one of those would be awesome. So I just want to stress the fact this with what I'm about to say on the research. This was like a super high bar for what they set things at. So they found about 25% of the patients that met those strict improvement criteria at seven days. Now don't let me lose you right now and say, oh well, that's not very good. There's a lot more to come and a lot more context here that really, really matters. Now that number also, it's in, here's where we already start to get into it. That number increased to nearly 40% at four weeks. So what does that mean? This shows that real change, measurable change, does take time even with the best care. So setting your patient expectations accordingly is absolutely critical. Most patients, most of your patients won't hit all of those benchmarks I just mentioned in a week. And that doesn't mean they're not getting better. It doesn't mean they need to be referred out. It doesn't mean that you've reached maximum medical improvement. Get out of here. I find I've said this before, I'll say it again. I find there are way too many chiropractors, especially young chiropractors, in some cases, some of the sports minded chiropractors, or certainly many chiropractors that classify themselves as evidence based chiropractors that release patients from care far too early. So this is another study kind of piling on that saying, give things time, pain is the last thing to come and the first thing to go. If you actually care about functional improvement measure Functional improvement. And you probably, if you are, you know, the fact that functional improvement doesn't change, and I'm going to say habitual functional improvement. What do I mean by that? The habits that drive functional ability, they don't change in three visits. They don't change in four visits. It probably takes a month or more for anything to really change. Now, you can get out of pain in a visit or two. But meaningful, demonstrative functional change does take time. And not just to hit it one time and say, okay, we're done, but ultimately to understand the lifestyle, the habits, and to ensure that not only are they better, but are they staying better. Are you doing enough visits where somebody should plateau in my mind, in your practice, why? Because now you're checking. You're checking and balancing. You're ensuring that they've met that threshold and have stayed there. And that's really important to not slide back into the reason why they came into your practice. Because if they slide back because you discontinue care too early for most people, most of the time they deem it that your care didn't work. It's ironic, it's twisted, it's all of those things, but it's happening each and every day unless you're really methodical in how you're going about your care. So let's move on to pain and disability reduction. At baseline, the average pain intensity was about 5 out of 10. The disability score, 11 out of 50. By week four, they dropped to less than 2 out of 10 and disability dropped to 4.5 out of 50. So. So that's more than a 50% drop in pain and nearly a 60% drop or reduction in disability in just four weeks. You probably see this all the time in your practice, but now it's really nice to see, and I hope that this is what you're getting out of listening, is that this is backed up by the data. So that's something you can lean into. Again, we'll talk about this as we continue on this podcast. But. But these are all talking points for you. These are all opportunities for blog posts, social media content, things for your website. Obviously, you want to stay compliant in terms of whatever your state, regional or national laws are regarding what you can say and what you can't say. But say everything you can. It's really important. Far too few people come in to see you in your community right now. I can guarantee that chiropractic utilization, about 15%, way too low that that means most people don't know that you should be the first choice and quite often are the best option to help them overcome the challenges that they have. So let's talk about what was sort of deployed, so to speak, with these patients. So within the realm of manual therapy, what happened? Well, 86% of the patients in this study received spinal adjustments, 87%. Interesting. 1% more received soft tissue therapy, 74% got advice. I don't know how that's so low. I would think 100% of patients would get some form of advice, and 33% received proper, quote, unquote, therapeutic education. So this wasn't just about, excuse me, this wasn't only about delivering adjustment. This was about a blend of things, of hands on care, of patient education, about a multimodal approach. And important to consider. Multimodal does not mean things outside your four walls. Multi, multimodal care can mean are you deploying all of the things you have available and everybody listening probably has a slightly different tool set. That's awesome. That's great. So are you utilizing it? Are you ensuring that the patient gets everything that they need? So now let's dive into some of these clinical prognosis and predictors. And this is powerful. When the chiropractor, the chiropractor believed the patient had a good prognosis, the patient was nearly four times more likely to improve at four weeks. That's wild to me. I mean, we all know if the patient feels good. But when the provider actually believed the patient had a good prognosis, then the patient was nearly four times more likely to improve at four weeks. So this is important to never underestimate the power of your beliefs in your patient's recovery and process and journey to better health. This is not just a mindset showing up, it's actually predictive. Now, how does that work? I have no idea. But what I can say, there's a, like, I have a bunch of, I have a bunch of ideas, but I don't have a definitive. Some of the ideas that I have regarding this are somebody, you're more engaged. Many of these providers might have been more engaged with those patients. They might have done just that little bit extra. They, they might have helped that patient with again, additional education, additional exercises because they're like, oh, I see the road here. So it's important for all of us to see that path for as many patients as we can, because it's clear it literally will impact your results. Now, negative expectations, negative treatment expectations reduce the odds of improvement by more than 50%. If your patient walks in thinking that it won't work, meaning your care, there's a pretty darn good chance that it won't. So your first job is very likely to be shifting or at least taking stock of your patient's mindset when they come into your practice. Yes, we've all had that. Patients that we've had that say, yeah, this isn't gonna work, and then they're happy and they refer everybody. But the bottom line is we don't know what we. We know those because those cases came back and referred everybody. And we're like, wow, I can't believe it. You know, John was one of the toughest nuts I've ever had. And once he opened up, once he started to see what was going on, he's now one of my best referring people. For every John that's like that, there are a lot of people that aren't getting as good of a result and probably, quite frankly, are dropping off care. So understanding your patient's mindset from the moment they come in, absolutely critical. Why? Because then you can tailor your talk track to what is going to be most impactful for them. And that is one of the most powerful things you can do. 50% reduction, doesn't matter. Good clinician, bad clinician, you're the best chiropractor, you're not. You're in middle or road chiropractor, whatever it might be, you're reducing the odds of improvement in your patients by 50% or should say they're reducing the odds of the great care you deliver by 50% if they're not on board. So get them on board. Additionally, more people, more providers, worse results. For every additional provider that a patient saw for their back pain, their chance of improvement decreased. So why? Well, probably because of confusion, mixed messages, you know, catastrophizing, a lot of different things there. And this is tough for us as chiropractors because there's a lot of patients we see that have seen a lot of other doctors even more. So gets back to our last item, which was shifting mindset. But the bottom line is when patients have bounced from provider to provider, they're gonna be more complex, they're gonna have less confidence. So that means that's like a big cue to you to double down on clarity and confidence with yourself and with your patients. In terms of adverse events, zero reported adverse events. You know, chiropractic care is safe. This study tracked it, and the serious adverse events were completely non existent, which is always nice to see. So this study also talked about perceived stiffness as a predictor. It went into a little bit of again the number of prior providers consulted, more equals worst outcomes. And also patient status. New versus returning. Returning patients, you know, had a better four week outcome. Why? Because they know like and trust you. They have that relationship built in which ties directly in to the mindset. So how can you apply this types of information in this research in your practice? Couple different things. One, you can set expectations with your patients early. Your belief in your patient's recovery isn't just like motivational rah rah, it's actually predictive. So taking that really seriously and really taking stock of how you're communicating, your literal posture, how you are communicating non verbally and of course how you're communicating verbally, educating about timelines, this is really, really important. Helping patients understand that just because they're out of pain, it doesn't mean that everything's back to normal. Also on the other side of the coin, helping them understand that early interventions are better and it leaves them more options where if they wait for things to get worse, there's a risk that they reduce the number of options, they elongate the time to get well and it's going to just cost them more time and money. And I just don't think we set those stages appropriately often enough not to ignore stiffness. How a patient feels is really important. That subjective component, I know we love objective things as providers, but. But understanding the subjective components are the most important thing for the patient. Objective measures, they don't care about. Can I do what I wanna do? Am I feeling the way I wanna feel? So balancing your objective and subjective measures and tracking and optimizing those pain scores and disability scores, they're not just outcomes, they're actually indicators of the path that the patient is on. So this research continues to add to the body of knowledge showcasing what you do works. It's not just anecdotal, it's data backed and patient centered care that' you deliver, it's what we deliver. And it also should act as a reminder that you're not just out there treating pain, you're restoring function, you're restoring confidence. You're changing the mindset of people to be more proactive in a reactive medical world. So keep doing that work that matters. And you know, thank you so much for listening to this podcast. Whether it's your first episode, whether it's your 493rd or whatever it is episode, thanks so much for tuning in. If you would leave us a rating or review, that would be awesome. We're gonna be pulling out all the stops doing something big at Episod 500 coming up soon and also want to say a few more words about a couple partners before we wrap Turncloud Minimalist Design without being sparse, turncloud is stripped away everything that's not essential. It's a really, really sweet ehr. If you are looking to make everyday functions simpler and you are somebody who doesn't want a user manual. If that's the case, head over to turncloud.com, do a demo, take a few minutes of your time and see what's out there. That's just being a good business person. If you choose to move forward with them, tell them that the Evidence Based Chiropractor sent you over and they will hook you up. Other than that, I want to say thank you so much for tuning in. Thank you for being a chiropractor. Have a fantastic week in practice and I will talk to you soon.

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Sam.