73% Of Pain Research Ignores This One Thing | #558

Hello and welcome to The Evidence-Based Chiropractor. I'm your host, Dr. Jeff Langmaid. On today's episode, we are tackling a research topic, which is all about, are we researching the right things in back and neck pain? Scoping review, it's going to set the stage for future research, kind of inform where things are going and ask some tough questions along the way. I think it's a fantastic study. Before we get started, big shout out to a few of our supporters. CarePlan Pro, care plans made easy. If you'd like to sell more care plans, membership concierge without feeling like a salesperson, you gotta check out careplanpro.ai. I'll drop a link down below as well as Leander Tables, $750 off their Series 950 using the code EBC2026 or reaching out and connecting with their team directly. I'll drop a link down below for them as well. But as I said at the top, today's episode, all about the research, and it's a research study about research. So the title is Global Research Priorities for Back Pain, Neck Pain, and Osteoarthritis, and this is a scoping review. And the question sounds pretty simple, but there's a lot of depth to it. So it's really, when it comes to back pain and neck pain, are we actually researching the things that matter most? So there can be a lot of different opinions on this. This is not a chiropractic-centric study, so you might have some bones to pick with that in terms of what's really being done. But this is looking at the totality of research, and as you know, there is no shortage of research. Every single month there are new papers on exercise, imaging, biomechanics, pain mechanisms, manual therapy, injection, surgery, medications, diagnostic testing. We cover a lot of that. Well, maybe not a lot of it. We cover at least one every single week on this podcast, but there's a lot. And there's back and neck pain. They continue to sit at the top of the list when we talk about disability around the world. So it's really that we, maybe we don't need more research. Maybe we need to ask the question, are we pointing enough of that research in the right direction? And that's what this study— was about, they zoomed way out and they looked at the research community itself and said, what have researchers, clinicians, patients, policymakers, all of the above, what have they said should be the priorities for future research in neck pain, back pain, and osteoarthritis? And then they asked a bigger question. Do these priorities actually match what we need if we want to reduce the global burden of musculoskeletal conditions? And the answer is not entirely. And there's one number that jumps off the page, just, It's outrageous. 73% of the identified research priorities were focused on clinical and basic science. That means diagnosis, treatments, mechanisms, biomarkers, and interventions. That's important stuff. But only a small percentage was focused on public health, population health, access to care, and really the systems that are required to get the care to millions of people around the world. And as chiropractors, I think we need to remember Chiropractic is not a licensed profession in every country. There's great institutions, I think World Federation of Chiropractic being one of them, amongst others, that are doing really hard work making sure that there's access. But realistically, there's like 100,000 licensed chiropractors, like 50,000 really practicing, 75,000 tops. And we look at other industries, MDs, DOs, physical therapists, they eclipse us by orders of magnitude.

Yeah.

Orders of magnitude. So, you know, there is way more places in the world where there is zero access to chiropractic care than where there is access to chiropractic care, which might seem wild because you might be saying, man, there's like 30 chiropractors in my town. It's hard to compete. But when you look at the global aspects of things, it's wild. I mean, there, you know, hardly anybody is actually getting chiropractic care when we look at the billions upon billions of people that are spread throughout the world. So that distinction is really the heart of today's episode, because it's not just an academic discussion. It has a lot to do with musculoskeletal healthcare, where it's headed, where our profession fits in, and where the next generation of research might lead things beyond that. So as you're very well aware, musculoskeletal conditions, massive global health issue, back pain, neck pain, osteoarthritis, some of those most common musculoskeletal conditions around the world. create tremendous levels of pain, disability, and healthcare utilization. Brought to you by CarePlan Pro. Build care plans in seconds, present them with confidence, and grow your recurring revenue through memberships and concierge. See how at careplanpro.ai. So the authors point out that the burden of these conditions continues to rise, which means that the research community needs to think strategically about what are the questions that need to be asked, what needs to be answered, because often, When we look at policy, it's where's the research? And research is, while research attempts to be objective, what gets published is very subjective. What gets noticed is very subjective. And what people want to raise on a pedestal or put in the gutter often can be subjective as well. Now, there clearly are things that are not valid and valid, et cetera, but there's a lot more subjectivity to this than many people would want to believe from the outside looking in. And it's important because research resources are not unlimited. There's only so many dollars in institutions and investigators and clinical trials that can really do this work. So the process of saying what should be answered first is really what they call research priority setting. And over the years, there have been different groups that have created formal lists. And some of the priorities were developed mostly by researchers, some by clinicians, some by patients, and they vary all over the place. So the researchers behind this new study wanted to basically pull them together and say, where has the research community been putting its attention? And the primary goal was to identify and to synthesize published research priorities for back pain, neck pain, osteoarthritis. So the secondary goal was to compare those priorities with the broader categories laid out in, maybe not a study, but a document called the Global Strategy to Improve Musculoskeletal Health. So that's really, really important. It touches on things like public health research, Population health, health policy, clinical, health economics, and that's the framework that they used, and it highlights something that we can often forget, which is improving healthcare requires a lot more than knowing whether a treatment works. You can have a really great intervention, but if nobody has access to it, if it's not integrated in a healthcare system, if there's no reimbursement, if the patients don't actually do anything about it, and the public doesn't understand what it is, Then the— this might sound a lot like chiropractic, then a good treatment doesn't necessarily translate to better population health. And I'll be blunt, when we look at the incidence of global burden due to neck pain, back pain, just the basics, continues to rise, well, if there were enough chiropractors doing enough great work with enough implementation, even with all of the things that I'm not a big fan of, elective surgeries, injections, et cetera, even in spite of that, that that's going to continue, it's not going to go to zero. Then we would be making a dent and things would be moving to less disability, not more. Now, more disability is partially because there's more people, but we're just, we're not making as much of a big impact as we can or as we should be, in my opinion. Now, we're doing a lot of great work and there's a lot of people. I'm not taking anything away from the chiropractors out there working hard every day to ensure that there is access. But what I am saying is we are still a grain of sand on the beach of healthcare. So it's really hard to create a mountain when you're a grain of sand. A grain of sand on a beach. So there is some work to do, and research ties into that. So this is a scoping review. So they evaluated Medline, a variety of different databases, and they found 18 studies that they looked at. 6 were related to neck pain or back pain, 12 related to osteoarthritis. And those studies had multiple priority lists.

Wow.

And 8 priority sets for back pain and neck pain, 15 priority sets for osteoarthritis, 23 research priority sets overall. Those 23 sets had 361 unique research priorities, and that translated basically to 155 priorities related to neck and back pain, 206 to osteoarthritis. So that's a pretty good size. And the number one finding was that we're heavily focused on clinical research. That was the dominant category by a mile. So, 73% of all research, clinical or basic science, so it's nearly 3 out of 4, and for neck and back pain, it was 61% of that, osteoarthritis, 82%. So I am not saying that clinical research is not needed. I think it is really, nor are the authors, but we need to understand pain mechanisms, diagnostics, et cetera, but when we look at health policy and systems, 14%, health economics, less than 5%, public health, 4%, Epidemiology, just under 2%. So we have conditions affecting enormous populations, billions of people, that tie directly to disability, lost productivity, spending, and quality of life, and yet less than 5% of research studies were actually focused on health economics. Less than 5% were focused on health policy. Less than 2% on population health and epidemiology. So the authors point out that when you combine all of those together, it made up like 11%. So it's a pretty dramatic imbalance.

Yeah.

And from a chiropractic perspective, I think this is one of the most important points because there's a huge opportunity for us as chiropractors over the next decade to live in those underdeveloped categories. Not simply does a spinal adjustment help with low back pain? We have decades of research showcasing that, but bigger questions. How do you build conservative musculoskeletal care into health systems at scale? Who should patients see first? Chiropractors most often. What happens when access to conservative care improves? Does early nonsurgical care downstream improve or decrease utilization? Can better musculoskeletal care reduce imaging, medication, surgery? How about digital health? There's a lot of questions that can be dove into there. And there's another key finding, and that is nearly 70% of the research priority sets included patients in the priority setting process. So for a long time, research questions were largely academic. Researchers decided what researchers thought was interesting, right? But what matters scientifically is not always identical to what matters with the person that has the problem. So I thought that was a really interesting component. And policymakers, the big third one was policymakers are barely involved. So only 17% of research priority sets included policymakers. And for the neck and back pain priority sets, none, zero.

So—

That's just a massive, massive opportunity. If the people involved in deciding where money goes aren't involved in the research in any capacity whatsoever, they're probably not going to have a lot of interest in that. So that means there's a lot of other people involved. Hey, other people can be great as well, but policymakers very likely should be brought into some of this. And I'm not saying everything needs to flip. What I am saying is— more of a balance might improve our ability to influence policymakers by having them more involved, showcase the benefits of what we do at an economic and implementative level that allows people to say, hey, that is something we need to bring in here. And I think that's a really, really great thing. A 4th finding, research priorities mostly coming from the wealthier countries. No surprise there. Most of the wealthier countries, Europe, North America, Australia, they drive the research because they have the funds that enable that research to be driven. But On the counterpoint to that, you miss out on the flip side, which is for the underserved populations and maybe the countries and populations that are not as wealthy. What's going on there? You know, what do they have access to? What don't they have access to? Now, clearly we can do, you know, ChatGPT and searches on Google, but I'm talking at a research-based level. A 5th finding, we generate priorities. As you can see, a lot of priorities. but we rarely generate an implementation plan. So that's massive. None of the 8 priority sets of neck and back pain had an implementation plan or evaluation timeline. So they're like, this research is great, what happens next? Crickets. That's bad, right? So there's a huge difference between publishing evidence, of which you know, and I'm a big fan of, we have decades of supporting who we are and what we do in changing healthcare, which has been— Monolithically slow, barely perceptible. So evidence does not automatically become practice. A guideline can sit for 10 years. A great paper can get thousands of citations, and absolutely nothing happens. Implementation is at the behest of the individual industries, categories, and providers, whether they choose to read it, and whether they choose to implement it. Of course, they can be influenced by the organizations that they belong to. But I thought that these findings were just really, really fascinating, because this isn't a paper that changes your adjusting technique. It's not a treatment protocol. But what it does is it starts to showcase to, I think, to me anyway, where the opportunities lie. And to me, that should be the most exciting fact of this. You've heard me probably say this before. It's like, if everybody in your town already saw a chiropractor, you either have to be cheaper or way better to get their attention. So the double-edged sword is a fractional percentage of people in your community see a chiropractor. That's the bad part. But the good part is, man, talk about opportunity. There's just unlimited opportunity for you to be able to increase new patients, talk with other providers, get referrals coming in. All of those things are the good news. The bad news is, hey, we're not at that threshold and tipping point. Okay, but that's opportunity for you and I today. It's not things we need to wait for. You can start driving these conversations forward, start to be able to contribute, start to be able to understand where you can spend time, money, and, you know, time, energy, resources, whatever it might be, to continue to drive more opportunities, not only for yourself but for other chiropractors as well. And I really like that component of this study. So I'll drop a link down below if you want to check it out. Also, big shout out to Shockwave Centers of America— $500 off and a free cart by being a listener. Big savings by being a listener here. Uh, NovoPulse OA Recovery Program available if you want to Really have an OA recovery program, osteoarthritis, in your community. Gives you all the hardware, software, no capital expense upfront for a limited time. We'll drop that link down below, as well as Dr. Grant Elliott with the RehabFix Hybrid Program. If you'd like to help more people beyond the 4 walls of your practice, drive more revenue, and ultimately have what I consider to be a more stable, durable practice, Grant and RehabFix is a fantastic program to be able to implement. He's done it himself. He knows it inside out, and he can help you. If you're interested in that, Click on down below, connect with Grant 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. 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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