564- Transforming Back Pain Pathways: Chiropractor-Led Triage in Neurosurgery Referrals

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're talking research, and this is about a chiropractor in a spine triage seat. What happens when chiropractors screened neurosurgical referrals? Uh, this one hits close to home because this is basically a job that I had for a number of years at a few different orthopedic groups. We're gonna dive into this brand new study and what they found. When they researched it. Now before we get started, big shout out to a few of our partners. Leander Tables, you can save $750 off their Series 950 clicking the link down below. Shockwave Centers of America, $500 off and a free cart by clicking down below. And CarePlan Pro, Patient Pilot is now built directly into CarePlan Pro, and we have literally built— I released it yesterday— one-click patient reactivation campaigns. It is awesome.

Awesome.

I am more proud of this software than anything that we have ever produced, and there are really good reasons why. It is helping nearly 500 doctors already reach out to more people, help more people, make more money. Care plans, memberships, follow-up, all built into a single system. But as I said at the top, today we are talking research, um, and this one is titled Effects of Musculoskeletal Expert Input On low back pain outcomes, a randomized controlled trial. We're going to kick this off with a number, 80%. And here's what that number means. Researchers in Quebec looked back at low back pain referrals sent to a neurosurgical department, and roughly 80% of those referrals were— drumroll— inappropriate. 8 out of 10. These are people sent to a spine surgeon who did not need a spine surgeon. And almost 90% of those inappropriate referrals Came from general practitioners, MDs, PCPs. This is so in line with what I saw day in and day out when I worked at some outpatient surgery companies. People come in, and I mean, this sounds totally insane, but I'd see people literally weekly. Great to meet you. Well, tell me what's going on. Oh, my back started hurting last week. Well, have you done anything yet? No. You're here for a surgical consult? Yes. You know, and then on the other, I mean, just really wild stuff. And this study speaks into that. Now, picture what this does to sort of a waiting list. At the same hospital network, more than 2,500 people were waiting to see a neurosurgeon, some of them for over a year.

Wow.

Sitting at home in pain, afraid to move, not doing anything because they were quote unquote waiting to see the specialist. This is, you know, in my opinion, this goes straight to negligence. That's a whole nother story. But you already know who should be seeing a lot of these people. Somebody who lives and breathes neuromuscular care, somebody that can tell the difference between nonspecific back pain and a true surgical problem, somebody exactly like you. So here's the question this team asked. Well, what happens if you put chiropractors right in the middle of that pathway? Let a chiropractor do a triage exam before the surgeon sees the patient. Does it help? Does it hurt? Does it not change anything? And they ran an RCT, a randomized controlled trial, to find out. So you've heard me talk about the 2018 Lancet low back pain series a bunch of times on this show.

Yeah.

One of the big calls to action in that series was simple. It's time to redesign the care pathway, get people to the right provider at the right time, and keep them away from the low-value stuff. Routine MRIs, opioids, injections, surgery when it's not needed. And all around the world, health systems have started, started, that's 2018 to 2026 right now, health systems have started building those models. Basically a middle step between primary care and the surgeon. They're not doing it for better results quite often. They're doing it for, you know, it always comes down to the same thing, and that's revenue into the system. And they realize that jamming the surgeons and mid-levels up often does not yield the best results. The surgeon is making the most money in surgery, and the mid-level's really facilitating that surgical intervention. So they started, many systems have started to kind of screen these patients. And Canada has a few of these already. There's one in Ontario where chiropractors and physios are part of the team. a few others as well. And there's some early data, you know, better referral appropriateness, less unnecessary advanced imaging, shorter wait times. One of them had 70% of referred patients go on to surgery, which actually tells you that screening was sending the right people forward, not the wrong people. But there is a catch. Most of that evidence has been observational, not randomized trials. And because of that, the models have not been widely adopted. Decision makers want more proof. So Quebec is a physician-led system with very little integration of musculoskeletal experts, and this same research group had already published something really important for us. In a previous study, they looked at chiropractors and neurosurgeons independently and assessed, basically having them assess the same low back pain patients, and they found substantial agreement between the two on diagnosis and management. Chiropractors and neurosurgeons looking at the same patient, mostly landing in the same place.

Yeah.

That's cool. So the next logical step was, okay, if chiropractors can triage accurately, does plugging them into a pathway actually change patient outcomes or care trajectories? So here's how this worked in plain English. It was a single-center randomized controlled trial at a neurosurgery outpatient clinic in Quebec. That region serves over half a million people, and the department had 3 neurosurgeons, 3 for that entire population. So they enrolled adults referred to neurosurgery for low back pain between like mid-2021 and the end of 2023.

Wow.

People in litigation, work comp, those individuals were excluded, different motives, different kind of care pathway there. So here's the clever part. Every single participant got the chiropractic triage. So all of them. The randomization only decided one thing, whether the neurosurgeon got to see the chiropractor's report. So the triage was done by 3 chiropractors who are all full-time professors and lecturers at a university with somewhere between like 4 and 20 years of clinical experience. They did a standardized history and exam. They sorted each patient into a diagnostic bucket, nonspecific low back pain, radicular symptomatology, specific spinal pathology, or something outside the lumbar spine. They then stratified these individuals according to risk, low, medium, high risk, and then they made a management call: conservative care, more testing, neurosurgery referral, emergency, or a different specialist. In the intervention group, the neurosurgeon got the clinical note, With all of that before seeing the patient. In the control group, the note stayed in the drawer and all— and the neurosurgeon just kind of did their usual thing. The patients and the chiropractors did not know which group everyone was in. And then they followed everybody for a year, you know, 1 week, 3 months, 6 months, 12 months. And they measured a few different things. They met primary outcome, back pain intensity at 3 months on the 0 to 10 scale. They also tracked—

Yeah.

Leg pain, disability with ostomy, quality of life, how people felt they changed, and what healthcare they used. Did they use imaging, lab tests, prescriptions, medications, GP visits, and/or private pay care? So if we dive into the numbers, we'll hit it right at the top. They contacted 150 eligible patients, about 120 agreed to participate, so almost 80%. Patients were mostly in their late 50s and early 60s. About half and half, men and women. Around a third were rated high risk, and they came in hurting with 5 out of 10 average back pain, Oswestry Disability Scores around 40. So meaningful disability, meaningful functional disability. So here are some of the standouts. Zero adverse events, no adverse events, no unintended effects during the chiropractic triage, and none reported a week after. Sky-high patient satisfaction, satisfaction with the chiropractic triage, Average like 97 out of 100 in one group and 99 out of 100 in another. So it's like, you never see numbers like that. Often these triages are done, I can speak because of my experience, extremely quickly, and they basically are used as a portal for surgery. In this case, it was clearly being done as an actual triage to assess what's going on. And guess what? People were really happy with that. 'Cause quite often, I used to hear this all the time, patients come in and they're like, I've never had anybody actually do a physical exam. I mean, these are patients that are medicalized quite often, right? They went to their MD for back pain. They know nothing about their body. They're scared of movement. They don't know movement is what heals things. So they are immediately trying to jump to, can I fix the problem? I use big air quotes there because they're thinking surgery fixes the problem. Wrong answer in most cases, most of the time, definitively wrong answer if you're not even a surgical candidate. So, Often they're just kind of pushed through a system very quickly. So when somebody takes the time to actually triage, explain things, do a movement assessment, understand what's going on, it's a total game changer for these patients. And the sooner we can do that, the better. These individuals also had fewer general provider GP visits, PCP visits at 6 months. In the group where the neurosurgeon saw the chiropractor's report, 49% had gone back to a general practitioner 3 to 6 months. In the non-chiropractor report, it was almost 70%. So it was almost a 20-point gap between those 2. I think a lot of that's gonna come down to education during that process. Both groups did improve. Outcomes wasn't really the big deal here. And the neurosurgeons recommended conservative care for about half of their patients. And from this team's related work, the chiropractors and neurosurgeons agreed substantially on who those patients were. There's one more stat I wanna point out. Among the patients the neurosurgeons said should get conservative care, nearly 70% Had waited more than 6 months just to get that appointment. Over a quarter had waited a year. A year. So to be told, you should try conservative care, and they've been sitting around for a year, they are so far into chronic pain, they're so far into, literally, their brain has adapted to it, their function has adapted to it, their neurology has adapted to it, the pain. That is going to put them in a—

Pain.

Unbelievably compromised position in terms of trying to get really good results with any sort of expeditious flow, 'cause they've been waiting on a shelf for 6 months or a year, not knowing what to do, thinking they might need surgery of all things, and then be told, hey, you should go see a PT or chiro. Absolutely, completely unacceptable in my mind, but not the primary point of this study. So if we go one layer deeper, We'll talk about really what they saw in terms of how to approach this information. This was designed as an equivalence trial. That's a little different from what we usually see. So they weren't trying to prove the chiropractic report made people better. They were trying to show that it gave the same results as usual care within a certain margin, 1.2 points. So they picked that margin to be pretty strict. So that's important to keep in mind because this wasn't about necessarily pain-based outcome. It was really about decision-making. So, you know, that decision-making ultimately is what things come down, is really where this is most relevant, I'll say, for us. The researchers tracked what kind of care people used after that neurosurgery visit. Imaging, lab tests, prescriptions, again, publicly funded care, private care, GP visits. And for most of those, the groups looked pretty familiar. But at 6 months, there was a big gap in GP visits. That was that 50 to 70% Differential. So why does that matter? If we think back to that original problem, 90% of people were getting inappropriate surgical referrals from their GPs. So when people kept cycling back to the GP, that's how they ended up in this referral loop. And I think the offers— the authors, excuse me, offered a nice explanation. You know, most people with a new episode of back pain improve in the first 6 to 12 weeks. After that, if symptoms hang around, people tend to go looking for more medical visits. Around 6 months, the usual care group may have been doing exactly that. Meanwhile, the chiropractor's recommendations may have nudged that intervention group towards more evidence-based conservative care. So I think this was a really great study because it really points out the importance, I'm gonna say, aside from gross negligence in many of these providers, the GPs making the referrals far too early, doing far more diagnostics than necessary, Not doing a physical exam. I'll get off the soapbox. The positive aspects are, you know, your own triage skills. So this study is another piece of evidence that shows a well-trained chiropractor using history, exam, risk stratification makes the same kind of calls that an experienced neurosurgeon would make. And that's the, that's the backbone of this conversation. So that's really great. You can be the front door, not the back door. And that's the biggest lesson here is about timing. The chiropractors Got the patient after months of waiting. The real opportunity is far earlier. When a patient walks in and says, my doctor referred me to a surgeon and I'm on the waiting list, you know, if anybody ever says that, that's your moment to lean in, to step in. You can screen them, rule out flags, and hopefully get to these individuals far before that by building bridges with local MDs. This is what we do with MD Connection. It's what we've done longer and better than anybody else in chiropractic through The Evidence-Based Chiropractor, our MD Connection referral program. is the best in the business, bar none. I can say that super confidently, that building relationships, MDs, DOs, midwives, doulas, PAs, nurse practitioners, you name it, it's about all healthcare. We say MD referrals because it's good for Google search, to be honest with you. However, it is good for all types of providers. Building referral relationships with other providers ultimately makes your practice stronger. It's the cheapest patient acquisition you're ever going to get, and it also allows— there's this momentum there. It's like a snowball effect. It is not easy to get that first referral or 2, but once you do, you start to see scale happen. 2 becomes 4, 4 becomes 8, 8 becomes 8 per my life, 8 all time to 8 per year to 8 per 6 months to 8 per month to some, and some doctors we work with, 8 per week. So ultimately, building those referral relationships, I cannot recommend enough. I will drop a link down to this study in the show notes. We'll probably highlight it through MD Connection as time goes on into 2027 as well. Before we wrap up, big shout out to NovoPulse and their OA Recovery Program. You can bring an OA Recovery Program hardware and software into your practice for no capital expense. I know there are docs out there spending tens of thousands of dollars on lasers, 6 figures on spinal decompression. You can bring an OA Recovery Program with fantastic hardware and software in at no capital expense. I'm an advisor to NovoPulse. I stand behind the tech. It is patented. I'm gonna drop that link down below. Just have a conversation. As well as the RehabFix Hybrid Program, expanding not only your revenue opportunity, but the people you can help beyond the 4 walls of your practice. Grant has done this probably better than anybody out there, and he's a trusted partner. So if you want to, again, expand the reach, bring an online component while not abandoning your in-practice, in-office brick and mortar, Grant's the guy to do so. The RehabFix Hybrid Program, connect with him and his team. 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. You can scroll on down on your phone if you're listening to this on Apple Podcasts, tap how many stars, leave a line or two of feedback, deeply, deeply appreciated. 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.

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. Visit thechiropractor.com and join our MD Marketing membership today.

The Chiropractor.