514- How Low Back Pain Care Has Changed Over 20 Years

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 today's episode, we are back with more research. Another fantastic study, brand new, it's all about the changing face of low back pain care. This is looking at 20 years of how physical therapists, osteopaths and chiropractors take care of people with back pain, how they refer and how they think about the care that they deliver. Fantastic study, retrospective, multi decade. I love it. We're gonna dive into it and much more, highlighting what the research says, how this can be applied in your practice, and some key takeaways in the conversations that you have with your patients each and every day. Now, before I get started, I wanna say a few words about Neck Care, my favorite cervical assessment tool on the market, the best hardware and software package. And as a listener to this podcast, they're gonna hook you up with technologies 10% off. You can check it out@neckcare.com or click the link down in the show notes. But as I said at the top, today we are all about research. And if I had a question for you, I'd lead with this. If I asked you how much the average chiropractor's approach to low back pain has changed over the last 20 years, what would you say? Do you think it's a lot? Do you think it's a little? Do you think that it's not at all? Well, this research study gave us an answer and some of it might surprise you. Again, the researchers looked at how chiropractors, osteopaths and physical therapists specifically in the UK have managed acute low back pain. So keywords there, this was in the UK and it's acute, low back pain, not chronic, over the last two decades, the same survey, 20 years apart. And what they found, well, it tells us a really pretty fascinating story about how our professions have evolved, where there's some work to do and maybe some gaps as well. And the more that you understand this, I'm going to say the more that you can understand how to position yourself in your community, whether that's building referral relationships with MD connection by the evidence based chiropractor, which maybe it's getting out there with patient pilot messaging to reactivate your patients. Maybe it's social media content using avatar DC Digital clone producing hundreds of videos, getting out there without having to shoot all of those videos. By using AI, however, you're gonna apply it. Understanding the referral habits and the sentiment of how have things changed? How are other healthcare providers, including ourselves, at least those that took part in the study, thinking about acute low back pain? So this study surveyed over 1700 clinicians back in 2003 and another 1300 in 2023. Again across chiropractic, physiotherapy and osteopathy. Everybody was given the same case, which was a 28 year old woman with acute low back pain after lifting a box at work three weeks ago. No red flags, no sciatica, no radiculopathy and no abject trauma. So every clinician, I love the simplicity in this. Every clinician was asked to two primary questions. One, what they say investigations, quote unquote, would you order on her first visit. And then number two, what interventions would you apply or use? And because they use These identical surveys 20 years apart, they can actually directly compare how clinical behavior has shifted or changed over time and additionally how different professions line up or not with with the guidelines. So some of the headline stats and numbers were that no investigations was the most common response then and now. In 2003, 85% of the surveyed clinicians said they would not order any imaging or tests. By 2023, that number rose to nearly 90%. So less clinicians over the last 20 years were were apt to order any sort of investigations. When they say investigations, they mean diagnostics, X ray, MRI, CT and speaking of that, we can dive into X rays. Specifically the use of lumbar X rays dropped really sharply, especially for chiropractors, which I'll come back to in a moment. Only about 5% of the chiropractors in 2023 said that they'd take an X ray. And this was down from nearly 11% 20 years earlier. So the amount of chiropractors that would shoot an X ray so dropped by nearly half. There was a lot to unpack there. One is the questions which some of those questions are, are people utilizing techniques as often today as back in the day that have X ray as a foundational component? I don't know the answer to it, but that would be a reason if X ray based modalities are not as common. Well, there's probably going to be fewer X rays shot. Clearly some of the guidelines have tightened up, so to speak, the use of X rays. But I'm still a big fan of giving the latitude to the Docs who utilize X ray in their technique to be able to take those X rays and be able to implement their technique. So clearly there's been a shift, whether that's in education, the educational school, you know, schools out there, either I'm gonna say diminishing the use of X ray or, or a combination, again, with technique utilization. There's a variety of different potential reasons. This study does not get into that. But I think it's just fascinating to see that far less X rays are shot. I'm not for or against that. I think it really depends. And again, I am a big fan of allowing those techniques that utilize X ray to continue to shoot X ray. However, it's just a fascinating thing when we see less X rays being shot by a significant margin. Now, on the other side of this coin, this is wild to me. MRI use ticked up slightly across all groups. So again, this is a single case. 28 year old, no radiculopathy, lifting a box from roughly 1% of people saying they would order an X ray to nearly 3%. So still pretty low overall, 3%. But it's pretty wild to me that X ray use would be cut in half. Yet MRI use would be roughly 3%. So it's tripled in usage, so to speak, while X rays have halved in usage over 20 years. And again, especially, you have to keep in mind this is not a general, how do you take care of people? This is specifically related to the case in this study. Another very, very interesting component is adjustments decreased with chiropractors. So it dropped from almost 90% of chiropractors saying that they would adjust the patient 75%. Now, clearly there's been a massive amount of shift, I'll say, in the chiropractic profession in terms of, you know, utilizing things like high modalities. Right. We look at shockwave, we can look at things like spinal decompression, we look at laser, we look at the, the really the, the great advances that have been made in exercise science. So I'm not particularly surprised that we see a decrease in 90% of chiropractors adjusting to 75%. But that's still 15% or whatever it might be in that case, 15%, that's a pretty good shift down. So to me, I can look at that and understand why because of the additional modalities. Now, they don't get into the second questions, which are, well, what else would you do? But we can highlight some of the other things that they specifically responded to. Massage and acupuncture. Radio rose sharply, massage jumped from 53% 20 years ago to 67% and acupuncture from 7 to 20%. So nearly doubling. Specific exercise prescription declined. That makes no sense to me, but 54%, excuse me, to 43% and advice to stay active and avoid bed rest remained about the norm. So there was lots of movement in the details of how people were responding. Even if I'm going to say the big picture hasn't changed dramatically. So this study found that there was a clear shift away from routine X rays and tests. Now this is what the guidelines have pushed for over time, only using imaging when red flags are present. And chiropractors again in particular, cut their X ray use by nearly half. So there's a lot, again a lot of different factors that could go into that. But I'm shocked to see that X ray use declined by 50% while MRI use increased by 300% or three times. Now, the physical therapists were the most consistent at recommending patients stay active and getting back to work as soon as possible. Probably no surprise there, but they became a little bit more conservative now over that 20 year period. Now osteopaths on the other hand, became significantly less restrictive, a sign that their approach has started to advance to the actual evidence. Over time and across all professions, spinal adjustments decreased slightly. Mobilization was mixed, it was up for chiropractors, down for physios and massage and acupuncture rose. So there's a variety of different facts. What I'd love to see is a follow up study that's, well, why answering the question, well, why did these changes take place? And a follow up survey to these clinicians would be super impactful to understand the motivations behind the decision making, not just the answers themselves. So specific exercise prescription declined, which is kind of interesting. Ultrasound interferential almost disappeared from about 10% to under 2%. So the overall trend is kind of a convergence. It's not perfect, but we are more aligned now between all three professions than we were in the past when we look specifically at these statistics. So why does this matter for your practice? I think it shows that care across our profession and others continues to evolve, but it's not uniform. So imaging has reduced, but spinal manipulation remains a very strong component of who we are and what we do. As I always say, it's, it's the hallmark of who we are and what we do, but there seems to be a little bit of an offset and it's not utilized, you know, 90% of the time, which is nearly every single time down to 75%. And my, my gut tells me that that's an evolution of what I'll call sports chiropractic. As anybody who knows me personally knows, I always say, you know, pretty much every single chiropractor. Most chiropractors below 35 years old say they're a sports chiropractor, even if they're really not a sports chiropractor. So, but there's been a popularity within chiropractic associated with sports chiropractic that's had a trickle down effect and I think a lot of that's positive. Utilizing exercise, utilizing additional modalities, and still retaining the core essence of what we do by delivering adjustments and helping people live their best lives, not only to get out of pain, but to ultimately improve quality of life and performance. So in this study, again, there was a rise in massage and acupuncture and that probably reflects patient demand because it feels pretty good and it's perceived as safe. So there's a lesson there for all of us in terms of understanding that patients value their experience as much as they value their outcomes and the future success of our profession. Your practice depends on balancing those two things, delivering fantastic results while also giving patients a really positive hands on experience. So helping people understand the old adage that movement is medicine, helping them understand fear, avoidance behavior is real and spinal pain has psychological ties like nothing else to depression, et cetera. So really encouraging people to stay as active as possible and helping them understand that even gentle motion helps their body heal faster. This isn't about avoiding motion and it's about leaning into it safely. It's also about helping people understand that they are literally built to recover. A vast majority, an overwhelming majority of acute low back pain cases improve without drugs or surgery. And that your job, literally you, is to guide that natural healing process. So reinforcing these concepts and ideas during your report of findings by letting people know. Research continues to show that people who stay active and start care early get better, better, faster. This reinforces the care plan recommendations that you're making, helps people understand the why behind it, and also influences them to do the right thing. Utilizing information like we highlighted today in your marketing and patient education, helping people understand, you know, why you may not need an X ray for back pain, why you may need an X ray for back pain, why you may not need an MRI for back pain, why you may and or may not, both of these are different content pieces for imaging. It's a great way for you to be able to highlight who you are personally and your personal thoughts on it and connect with those people in your community that have the same thought process as you. Those are going to be your ideal patients. Of course. Team training Highlighting this type of research to your team and staff to help them understand how can they continue to reinforce the messaging that you're delivering. I think this is often overlooked. Our team members are taking care of Many of our team members are spending more time with patients than we are. Whether they're at the front desk and check in and check out, answering the phones, they are spending time with your patients. So there's a real question here on if they are reinforcing the messaging that you want your patients to hear or do they not have enough education and information to be able to do so? You should be lockstep with your team in terms of the messaging that's going out and additionally using this for your clinic, your own clinical decision making, understanding the preferences of other professions and where can you step in with your unique selling proposition to highlight who you are and what you do? So I thought this was a fascinating study. It's the start of what I'm gonna say is a much longer story. There's a lot more questions than answers, but this gives a really cool snapshot of the last 20 years and how professions have changed. Now, before we wrap up today, if you're looking to step up your clinical game and you're looking for a new table, Leander Tables As a listener to this podcast, they're going to hook you up with $1,000 off their series 9 50. I'll drop that link down below. You can connect with their team, ask them questions, let them know you're a listener to this podcast and they're going to hook you up with $1,000 off their series 950 table, which is awesome. Whether this is your first episode listening to this podcast or whether you've been along for 500 plus episodes, thank you so much for taking time out of your day to do so. New episodes are released every Single Monday at 6am and if you would take a moment, scroll down, tap how many stars you think this podcast should have and if you leave a line of text, some feedback, that is awesome. It goes such a long way to helping this reach more people. So please take a moment and do that. Thank you so much for being a chiropractor. Have a fantastic week in practice and I will talk to you soon.

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