565- Chiropractic Dominates in VA Integrative Care for Chronic 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 research all about the integrative treatment options for chronic low back pain. This one ties directly into the chiropractic, what's going on in the VA, and I think a lot of it can be applied to you in your practice, in your town with other docs. And the question is, are you getting referrals? If you're getting 0, 1 referral a month and you're not doing anything to actually get those referrals, You're missing a massive opportunity and you're just not taking care of as many people as you can. And if you think people should be in your practice and you're not reaching out to other healthcare providers systematically, you know, that's just gonna be a difficult proposition, spending more on paid ads for less year after year. Referral relationships are a great piece to add into your practice. We're gonna talk about all that and more on today's episode. Big shout out to a few of our partners before we get started. Shockwave Centers of America. As a listener, you get $500 off one of their units and a free cart, as well as Leander Tables, $750 off their Series 950 using the code EBC2026. Connect with their team and have that conversation. Additionally, Care Plan Pro, the best way to sell care plans, memberships, and concierge-level care. And I view a care plan as more than one visit at a time. Doesn't mean a year. So if you're a doc who'd like to help more people and make more money, with systems and automation, Care Plan Pro with Patient Pilot built in is a fantastic way to do it. I'll drop that link down below as well. But today's episode, we're going to start with a question. If you walked into a VA hospital and asked a group of veterans with chronic back pain, hey, which of these non-drug treatments have you actually used? Which one do you think comes out on top? Could it be acupuncture, maybe massage, cognitive behavioral therapy, yoga? The answer is no. It is what we do. It's chiropractic, and in the VA system, it's not even close. This is a study published earlier this year where 71% of veterans with chronic low back pain said they'd used chiropractic care. 71%! That was the single most used integrative option in the entire survey. And the part that I love is that the medical doctors In that same system, we're right there with them. 3 of 4 primary care providers said they recommend chiropractic for chronic back pain. That is not the way it is outside the VA. So think about that for a second. These aren't chiropractors surveying other chiropractors. This is the VA. There are MDs, DOs, PAs, mid-level providers, you know, ARNPs, nurse practitioners, all of those, and their patients are voting with their feet, right? Like, where are they actually going? Yeah. And this study also uncovered some interesting gaps. So gaps between what doctors recommend and what patients actually get, we're gonna talk about that. Gaps in what patients even know what is available to them, big problem. And those gaps are really the opportunity I'm gonna say for you and your practice. So this study was published in the Federal Practitioner. It's a journal for clinicians working within federal health systems like the VA. The research team was out of the VA in Ann Arbor, Michigan. And the big question that they wanted to ask and answer in this study was what do primary care doctors and patients actually know about integrative therapies for chronic low back pain? Are they interested? Are they using them? And what's getting in the way? And if we zoom out for a minute, there are more than 50 million American adults, 50 million. There's no shortage of opportunity in your town. 50 million American adults live with chronic pain. About 7% have what's called high-impact chronic pain. And that's the kind that really limits your life, your work, your ability to show up. That, that is like the you're not doing much but living with the pain kind of story. Veterans have it even worse. Estimates from 2021 put chronic pain among veterans at over 30%, with over 11% dealing with high-impact pain. So who's on the front lines handling all of it? Same as in your town, primary care. And for a long time, the go-to tool, so to speak, in primary care was of course the prescription pad. We all know how that story played out. Opioid epidemic, drug interactions, side effects. In my opinion, it's a complete mess with neuromusculoskeletal care in the primary care profession. But authors point out that the opioid crisis plus a shift towards what's called the biopsychosocial model, as you're probably aware, has placed a huge emphasis positively on non-pharm, non-drug treatments. Uh, and that's where the integrative care comes in. Uh, and that's where we come in. So the VA has actually leaned into this in a big way, what they're calling the Whole Health System of Care. And the idea is to empower the veterans themselves to take charge of their own health and wellbeing so that they can live life to the fullest. And part of Whole Health is using evidence-based complementary and integrative options like a multimodal approach, like us. So researchers said, okay, the VA wants more of this, but to expand it, we need to understand where the doctors and patients are at right now. So they ran 2 separate but similar surveys. Survey 1 went to the actual primary care providers. In the summer of 2023, they emailed a little bit under 100 PCPs, and those were mostly DOs and MDs, median age 48, practicing for about 20 years. So pretty experienced clinicians. Survey 2 went to patients. They pulled a random sample of 200 veterans who they knew had been diagnosed with low back pain on at least 2 visits over the previous 18-month window. They mailed them a survey, a little gift card, and basically they got some answers. Patients in that cohort had a median age of 66. 71% of them had dealt with back pain for more than 5 years. 81% had flare-ups at least once a week over the previous year. So these are very similar to people who walk into your practice. I've tried everything. You know, they're trying to take care of the issue. They just haven't found success yet. So the surveys asked a whole menu of therapies grouped into basically 5 buckets: manual therapies, where chiropractic lives along with massage and osteopathic manipulation, plus energy and biofield therapies like acupuncture, mental health therapies, Like cognitive behavioral mindfulness, nutritional counseling, movement therapies. And if we start to dive into the stats, it's where things get good. So stat number 1, 71% of veterans, as we highlighted at the top, with chronic low back pain had used chiropractic care. That was the highest of any integrative therapy in the survey. The only other therapy used by at least half the patients was acupuncture at right there at 51%, massage 46%, cognitive behavioral So chiropractic just wasn't number 1. It really lapped the field and cognitive behavioral almost 3 to 1. Stat number 2, and we have a bunch of stats we're gonna hit here. 75% of VA primary care providers said they recommend chiropractic for chronic pain. So that puts chiropractic right up there with acupuncture recommended almost 80% of the time, cognitive behavioral 82%. Probably already start to see some of the disconnect on these numbers. Uh-huh. 68% of primary care providers said chiropractic was one of the therapies they'd most like to have available for their patients. Probably surprised to hear that. And they could only pick a few. So this wasn't like, well, you just pick everything you can ever think of. So they placed it up there. So 2 out of 3 doctors, you know, are telling the surveyors, saying, I want to be able to offer chiropractic. Very powerful. Probably a little different than the primary cares in your community, but that's the opportunity that you have. Yeah. is that opportunity for education and referrals. Stat number 4, chiropractic, acupuncture, and massage were the big 3. So these were the therapies both doctors and patients most wanted available. And that lines up with normal national data. So no big surprises there. Stat number 5, 72% of patients said they were somewhat or very interested in integrative therapies for their back pain. But here's a big one. Yeah. 48%, almost half, said nobody had ever given them any information about those therapies. So let that sink in. Almost half, 3 out of 4 want it, and almost half have never been told about it. We'll come back around to that in a moment. Stat number 6 were some of the barriers on the doctor's side. 93% said access to services was a barrier. You know, that's like a hard stop territory. Like if 9 out of 10 doctors are like, Access is a barrier. And like, I'm surprised so many, so many patients had seen a chiropractor. Quite frankly, many are probably seeing them out of the VA. If 9 out of 10 of the docs are like, yeah, we'd love to do this, but I don't know how. That, man, talk about opportunity as being just massive. And on the patient side, 40% didn't know what the services were even available at their facility, almost 40%. So like, you know, nearly half of people like, I don't even know what's offered here. Yeah. That's wild to me. People show up to work every single day. They think they're doing a good job. They will retire maybe with benefits, pensions, and all sorts of accolades, and the patient experience is not good. That's, you know, again, I look— I'm a hardliner on this. I look at that almost as gross negligence. Like, if 40% of patients being surveyed that have neuromusculoskeletal issues and specifically chronic low back pain, which we know can cause so many catastrophic downstream events, 40% of people are like, yeah, I don't even know what's available at the facility because nobody's told me. That's derelict and things need to change. But the good news is that a lot of the doctors would like to know more about it, which I think is massive. And if we go one layer deeper there, one of the big takeaways is chiropractic has the tightest match between recommended and utilized. So there were bigger gaps elsewhere. Cognitive behavioral, 80% plus recommending, 25% of patients using it. So just massive drop. For chiropractic, it was 75% primary care recommend it, 71% of patients used it. Now, again, there's still a knowledge gap clearly in terms of the doctor saying, I don't have access to it, or I don't know how to do it, but I'm recommending it. There's some conflicting stories going on here in my mind in this study. Yeah. But I think that's the way it is in real life often. There's just a lot of stuff going on. So just because somebody responds to a survey one way doesn't mean that that's the way it's happening in actual practice. A big takeaway number 2 in this study was patients who'd used chiropractic want it to stay available. So when they asked what therapies people would most like to have available, patients picked massage at 51%. Well, feels good. I don't blame them there. Chiropractic, 41%. Acupuncture at 33%. So to me, that's powerful. 4 out of 10 patients, and probably growing. This is not longitudinal, but 4 out of 10 in this study, I would be interested to know if that's grown over time. I suspect it was. And the takeaway number 3 is sort of what we circled around here, which is the real barrier is not skepticism, it's access and awareness. When you look at the barriers primary care doctors reported, the top 2 weren't about whether integrative care works. Like, that ship, anybody who's still like, well, chiropractic's placebo, I don't know if it works, They don't know what they're talking about and they are completely disconnected. And I probably wouldn't trust them on pretty much anything else they're saying, because if they're that disconnected from what's going on in the literature, in the guidelines, with what we do as chiropractic, I can assure that they have those massive gaps of knowledge in other places as well. And I like my doctors to actually be up to date with what's going on, which is why I appreciate you listening to this podcast, because we try to keep you as up to date as possible so that you can make the best decisions possible for your patients and not phone it in. Like too many doctors are. And yes, I'm looking at the MDs and DOs. So however, they were practical when we say integrative care works. 93% said access to services was an issue. And in their words, here's a quote, I'd send more patients, but it's hard to get them in, and I only have so many minutes in the visit. So there's like literally every piece of the, every one of the 3 pieces of the sentence, I think deserve just a little bit of highlighting. I would send more patients. That's awesome. That means they are not questioning whether it works. They want to. Awesome. 2 thumbs up. Awesome for the VA. Still a lot of work to do in private practice, I think. Next part of that sentence. But it's hard to get them in. In the VA, I think that's really just due to the fact that there's a limited number of chiropractors. There's not infinite chiropractors. There's a limited number of chiropractors. It's a whole procurement process and requisition process to get the chiropractors hired. I can understand that gap, and that's something I think is important to highlight as well. I hope that the VA clinicians of DC, MD, and DO are making that well known so that more chiropractors can be hired. In the third part, and I only have so many minutes in the visit. Hey. This is where like RVUs come into a thing, you know, production, etc. I hate to hear that because it should be about doing what's best for the patient, Not, well, I would do better, but I only had so many visits. I only had so many minutes, so I couldn't talk about it. That does not make me feel good about the quality of care. I'm not expecting people to take forever, but I am expecting somebody to be able to spend literally 20 to 30 seconds explaining something simply. Here's what chiropractic is, here's why I recommend it, and here's your next steps. That's not that hard. But in this case, it seems as though it is for many doctors. Now, on the patient side, only 17% said cost was a barrier. Only 17% said services weren't available, but 40% weren't— were unknowing of what was available, right? So there's like this weird disconnect where it's like, it seems like people want it. Those that go after it are aware of it. But if not, there's just this cloud, this haze. Well, I don't know what's available. My doc didn't really tell me. Well, I didn't know really what the next step was. So that— the good news there is I feel like the evidence gap is actually a communication gap. Right. 64% of PCPs said lack of evidence was a barrier to recommending care. 61% said lack of familiarity, and 46% had no formal training. So that's really the evidence right there. I mean, if 2017 was when the American College of Physicians came out with their clinical practice guidelines recommending spinal manipulation, chiropractic, non-drug treatments as a first line, so this stuff's been out like a decade, Decade at this point. So, and the weird part, the interesting part is the same doctors who said they're not really familiar with the evidence are still recommending chiropractic 3/4 of the time, at least according to the survey. So, you know, imagine what happens when they start seeing this evidence consistently. To me, that's the big opportunity for us is really to take the knowledge that we have here and let's make it easy for that primary care doctor down the street from you. Yeah. You know, have that referral sheet ready. Be reaching out, use the MD Connection. It's the best program by far. I can clearly say that. So if you have not checked out MD Connection by the Evidence-Based Chiropractor and you want more referrals, it's the way to do it because it makes it easy for you to communicate with the other doctors without feeling cheesy and it's just an easy, simple process to follow. Leading with the evidence is a really important component when you're speaking to medical doctors. It's not overwhelming them with everything they never wanted to know about chiropractic, But it's drip, drip, drip knowledge, asking the right questions, and positioning, not pitching, positioning yourself. And if you live near a VA, pay attention. There's a lot of veterans out there with chronic pain. They're already utilizing chiropractic care. Make yourself available. Just because they have VA benefits doesn't mean that they won't come in and see you. Maybe they have Medicare, maybe they have third-party service, maybe they're happy to pay cash. But there is opportunity just funneling, you know, falling out the bottom of the VA With individuals that have neuromuscular issues, individuals that have chronic low back pain that aren't— that would like to have chiropractic care that aren't able to get it either due to time, access, or availability at their location. So all of those things I think are really good things for you and I to be able to lean into locally and say, wow, great study, continues on our knowledge and makes it really actionable for us as well. Now, before I wrap up today's episode, big shout out to the NovoPulse and their OA Recovery Program. Awesome. Hardware and software, no capital expense, no big expense, tens of thousands of dollars to bring the hardware and software into your practice. Osteoarthritis is booming, and if you don't have a clear solution, people don't know how to pick you. Inovopulse makes it easy. I'll drop that link down below, as well as Dr. Grant Elliott, Rehab Fix Hybrid Program, expanding your impact and revenue beyond the 4 walls of your practice. Fantastic program. Grant's done it himself. He has coached more doctors probably than anybody I know for sure. Uh, on being able to not necessarily get rid of their brick and mortar. He can help you if you want to go online only, but he's really built this program for the practicing doctor who says, I love my brick and mortar, I want to keep it, but man, I'd love to take care of more people beyond my town. I'd love to create more revenue, and I would love to have an online component. He does a great job with it. So if you've 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, I hope you have a fantastic week in practice. And I will talk to you soon.

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