553- 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 Langmaid. This week we are back with more brand new research and it's a good one. This is all about how low back pain care has changed and evolved over the last 20 years. So whether you have been in practice more than those 20 years or maybe you're on the newer side of that 20 years, this is gonna be a really cool study to kind of go back and see what's changed, what's evolved, what are some of the pitfalls, We'll break it down, highlight some clinical pearls, and more, all on today's episode. Before we get started, big shout out to two of our partners. If you're looking for a new, uh, flexion distraction table, Leander Tables will give you $750 off their Series 950 using the code EBC2026, or just letting them know you're a listener. Connect on over there. As well as Shockwave Centers of America, $500 off and a free cart. Big savings for being a listener. Please support our partners and sponsors and let them know that you're a listener because it's going to save you big money. But as I talked about at the top, this one is all about low back pain care. What's changed? The title of the study dropped down in the show notes is The Changing Face of Acute Low Back Pain Management by Physiotherapists, Osteopaths and Chiropractors in the UK: A 20-Year Comparison. From 2003 to 2023. So we're basically going to take a 20-year time machine all the way through the management of acute low back pain. And I think this is pretty cool because the researchers asked a pretty simple question: after two decades of clinical guidelines, regulations, continuing education, new research, endless conversations about evidence-based care, are clinicians and providers actually treating low back pain differently? Now, two big carve-outs I wanna give, we might touch on 'em later, but I wanna carve out right at the top before we dive into the results, which is this obviously, as you could tell, did not have medical doctors in there. I think they are the most guideline discordant by and large based upon what we see in the literature. So this is a subset of individuals who are probably pretty, overall pretty guideline concordant to begin with. And we know that just by the fact of many physical therapists and chiropractors are not prescribing opioids and doing pain management for things that need movement-based care. Pretty black and white as far as that's concerned. So we are automatically, I'm gonna say, more guideline concordant because I don't see too many surgeons, pain management doctors, and even too many too many primary care physicians, although we're trying to break through that, and docs are individually using MD Connection through the evidence-based chiropractor, but it's not global, right? These are individual relationships that are based. They're still often providing things, and I'm not talking smack, so to speak. We see this in the literature. They're still prescribing and recommending things way more often than, let's say, a physical therapist or a chiropractor, that are not in line with the guidelines in any way, shape, or form. So this— I'm just bringing this up to say this is, this is a subset of individuals to begin with. So, you know, the question that they asked was, are clinicians treating low back pain differently? And the answer is yes, but probably not in the ways that you'd expect. There are some approaches that have moved closer to some of the recommendations and some moved farther away. Some differences have narrowed and others have remained. So this is evolving, which I think is pretty cool because it showcases to us really what's going on. And quite often the answers to things aren't perfect. They're in constant evolutionary state. And this is one of those things. And perhaps most interesting for us, chiropractors became, I say, less likely to recommend, you know, passive therapies, advanced imaging. And that's interesting, but they also became less likely to select spinal adjustments for a straightforward acute low back pain case. Also very interesting. We're gonna dive into this and much more because this is not just simply a story about healthcare getting quote unquote more evidence-based. This is really how professions evolve. You know, ultimately how clinical identity changes and how guidelines, expectations, risk, education, all of those things, you know, happen and come together in your practice, in the treatment room. So this study was published in 2025, BMC Musculoskeletal Disorders. Again, I'll drop the link down below. And the researchers wanted to, again, understand how the management of acute nonspecific low back pain had changed among these 3 major groups, physiotherapists, physical therapists, osteopaths, and chiropractors. So they compared national survey data collected in 2003 and then again in 2023. And the really valuable feature of this study specifically is that the researchers used the same clinical scenario at both time points. So 20 years later, man, talk about digging back in the data machine and be able to come out with the exact same clinical scenario. Kudos to them. And it really matters because they weren't comparing like one survey in 2003, a totally different survey in 2023. Nope, this was the same case. So the case that they presented, we'll highlight right here. A 28-year-old woman was experiencing her first episode of low back pain after lifting a 10-kilogram box at work 3 weeks earlier. She had not returned to work since the pain began. She was pretty anxious about returning to work, but her work, Managing a hospital cafeteria involved not too many physical demands. She could sit for approximately 10 minutes, walk for approximately 100 meters before stopping because of the pain. She had some morning stiffness lasting around 10 minutes, but she could sleep through the night. The pain was pretty confined to her lower back. There was no radiculopathy, no radiation, no significant trauma, no history of serious illness. Uh, her neurological exams were normal. Uh, SLR, straight leg raise, did not aggravate her symptoms. And the rest of the exam was unremarkable. So this was designed to be a pretty straightforward, uncomplicated case of acute nonspecific low back pain without any outstanding red flags. So the people taking the study, um, and this is just interesting, I guess I'll put it to you right now. Think about that for a moment on yourself because we're going to ask some questions. What would you do? How would you approach this, et cetera? So the individuals that were referenced or questioned were asked what investigations they would order and what interventions they would use during that initial visit. So if you take a moment and think about, well, what, what would you order? And what would you do during that initial visit knowing what you know? And they could select as many or as few options as they felt appropriate. And they, researchers also asked what advice they would give regarding activity, work, and bed rest. So in 2003, you can think about that for a moment, we'll highlight some of the stats around the study. 2003, there's about 1,750 eligible practitioners. And in 2003, about 1,400 practitioners answered. So we're talking about more than 3,100 clinical responses overall. And that's one of the strengths of this study. It was not a survey of like, you know, 7 people at a seminar. It was really a broad snapshot of how 3 different professions reported managing the same exact patient at 2 points separated by 20 years. So The first major finding here was that less routine imaging was really a theme. For this uncomplicated patient, the overwhelming majority of survey— surveyees, is that how you say? Clinicians selected no investigations. So the actual most common answer was not an investigation, it was none. So in 2003, no investigation was selected by 90% of physiotherapists, 82% of osteopaths, and 78% of chiropractors. By 2023, it was 91% of physiotherapists, just up about a percent, 87% osteopaths, up about 5, 6%, and 86% of chiropractors. So that's about an 8% increase. So again, in this case, there was no red flags, no neurological findings, no meaningful trauma, and no other indications that, you know, imaging was immediately necessary. So I always like to give this caveat. There are chiropractic techniques that rely on imaging in order to deliver that technique. And, you know, I'm not here to take a stand pro or against imaging, but I am here to always say, in my opinion, those techniques that rely on imaging should always utilize what they need to be able to deliver the technique in the most effective manner possible for the best results for that patient, as long as the harms are low, of course, right? But overall, it seemed like chiropractors were doing less— I'll call quote-unquote routine imaging. Now, this did not dive in, I don't believe, to the specific techniques and subsets, etc., so it was looking at the profession as a whole. So in 2003, 11.1% of chiropractors said they would order a lumbosacral X-ray. By, uh, 2023, uh, that number had dropped to 4.7%. So it was a reduction by more than half, more than 50%. Osteopaths dropped from 5.4% to 1.3%. Physiotherapists, 3.5% to 2%, although their change was not statistically significant. They don't order a lot of imaging to begin with. So chiropractors remain the group most likely to select a lumbar X-ray, but the proportion was a lot smaller by 2023. So I think, you know, sometimes, you know, the profession can get painted with a pretty broad brush regarding X-ray utilization. But in this case, it showed, hey, 86% of chiropractors, they selected no additional investigation for an uncomplicated case, and fewer than 1 in 20 selected a lumbar X-ray. So that, you know, that's important, I think, just to note. And it's, I've seen in the literature, they kind of push towards not imaging. I like to make the distinction between imaging and advanced imaging. Advanced imaging too early, eh, that's a one-way ticket towards injections to surgery, in my opinion. X-ray, again, technique dependent, suspicion of any fracture, anything like that, I have no issue with it whatsoever. But it shows that everybody's just not getting an X-ray walking through the door. It really is specific to the doctor and the patient, which is really what it should be. Uh, first-line advice was really the next item they dived into, uh, activity, work, and bed rest. So they looked at what they considered first-line recommendations for acute low back pain. Those included, you know, encouraging activity, supporting work participation, avoiding excessive bed rest. And the results were a little more complicated here. Uh, both time points, physiotherapists generally gave the least restrictive recommendations regarding those three things. But, uh, between 2003 and 2023, they actually became more restrictive overall regarding work and bed rest. Chiropractors also became a little more restrictive regarding bed rest specifically in this study, which is interesting. Osteopaths moved the opposite direction. They became less restrictive regarding all three. So statistically speaking, the osteopaths were more than twice as likely in 2023 to provide a less restrictive work recommendation than they had in 2003. For activity recommendations, their odds of providing less restrictive advice increased by approximately 54%, and bed rest recommendations less restrictive increased by almost 60%. Chiropractors, odds of offering less restrictive bed rest recommendation decreased. That does not mean that most chiropractors were recommending prolonged bed rest, but as a group, the recommendations shifted just a little bit. So the takeaway is that patients, you know, should really, you know, try to stay as active as possible, as we know. So keeping moving within their tolerance is really, really the critical component there. And if we dive into how hands-on care changed, this is interesting. So this is, I'm going to say, an area us as chiropractors will immediately focus on— hands-on care. Now, the researchers classified spinal adjustments, mobilization, massage, and acupuncture as second-line or adjunctive interventions. For this acute low back pain case. In 2003, spinal adjustments were selected by about 90% of chiropractors. This is pretty wild. In 2023, it was selected by 75%. So spinal adjustments remain the most popular adjunctive intervention among chiropractors, but the recommendation or use fell by 14%. So that's pretty wild in my opinion. Now I get that there's a variety of things that we can do under our belts. I'm not criticizing the people who responded on this study, but I'm like, man, you got to get in there and check segmental motion. I could— I would be willing to hang my hat that this individual had restricted segmental motion in their lumbar spine based upon the case presentation that I know. So it's really fascinating to me that quite frankly, it's pretty fascinating to me that it's 90% in 2003. I can't believe it's not 99%. And in 2023, being 75% is pretty surprising to me. So It just shows that there is an ebb and flow. There is a shift. It doesn't mean it's always permanent, but clearly I think this shows chiropractors are using more and different things when taking care of routine low back pain. Uh, I'm not commenting on whether that's better or worse, but I am saying that's what this study is highlighting specifically, which I think is pretty, pretty interesting and pretty surprising in terms of my opinion. Uh, acupuncture use, decreased dramatically. So it was pretty— or excuse me, acupuncture use increased dramatically, excuse me, among chiropractors, 5% in 2003 to 20%, osteopaths, 8% to 22%, physiotherapists, 7% to 13%. So in chiropractors, it's a fourfold increase, increase, not decrease, for acupuncture. So That's pretty interesting. Uh, UK guidelines regarding acupuncture have changed over time between these two surveys. So they suspect that that might have been one of the reasons for it. And massage remained popular among chiropractors. Uh, 68% recommended massage in 2003, 69% in 2023. So essentially unchanged as far as the recommendation regarding massage. So, uh, passive modalities kind of fell out of favor. Interferential, almost 10%, uh, back in the day, now 1%. Pretty, that's pretty, pretty sharp decrease. Ultrasound decrease as well. All clinicians, 13% to 4%. Chiropractors were 14% to 3% in ultrasound. So all 3 groups really had moved away from some of the more passive modalities. So I thought this study was super cool because it took place over 20 years, well, 2 separate points over that 20-year period. And it was pretty large, right? Over 3,000 eligible providers participated. In this study. So it was a pretty good, um, analysis of what people were doing then and what people are doing now. Now, the 4 big takeaways ultimately are just the facts. Chiropractors are clearly demonstrating more selective imaging behavior overall, no questions asked. 1, spinal adjustments remain really central and core, but care is becoming a bit more diverse over time, as we saw with some of those statistics. Additionally, activity messaging probably deserves some attention, right? There's a little bit of a shift towards more restrictive bed rest, not prolonged, but it was recommended a little more often than back in the day, which is just an interesting counterpoint. You wouldn't expect that. And ultimately, that passive— the passive component has really dramatically dropped while the educational component has continued to become more and more important, which I think is right in line with what we see. So over the last 20 years, the management of acute low back pain has changed pretty substantially. When you put all those numbers together, you're like, okay, change a little bit here, a little bit there. You put all of it together, there's been a pretty meaningful change across the 3 groups over time. So each and every group and profession had their strengths. Every group and profession had a little bit of a gap, um, and I think that's cool because it showcases to us the evolution that everybody's going through, the changes that are being made on a profession-wide basis, regardless of, regardless of technique or specific location, et cetera. So I think this was an interesting study. My question to you is, how would you have answered those questions? When I gave that case of a younger female that is a little bit scared of moving, hasn't been to work in a little while, no real radiculopathy, no red flags, How would you approach that in your practice? There's not necessarily a right or wrong, it's just an interesting thought exercise to say, hey, am I doing what other people are doing? Am I doing something maybe a little better? Is there something I should be thinking of and adding to my tool belt? I think they're just great ways to consider research like this. Now before we wrap up, big shout out to RehabFix Hybrid Program. If you want to earn more revenue and help more people beyond the four walls of your practice, Grant and his team, there's nobody better out there. RehabFix Hybrid Program, connect with their team. I'll drop that link down in the show notes. In the show notes, as well as the NovoPulse OA Recovery Program. OA, 30 million+ individuals dealing with it, almost zero chiropractors having a program to solve for it. And NovoPulse is a fantastic hardware and software program. Software, I mean, they give you all of the patient attraction tools, et cetera. Hardware, because they have a beautiful device that is patented and FDA listed, super unique, that enables you to take care of people with OA. If you have not left a rating or review for this podcast, I would love it if you would take a moment and do so. Other than that, 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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