Breaking the Myths: Manual Therapy vs. Epidural Steroids | Podcast Ep. 321

Foreign hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. On today's episode, we're back at the research. We're talking about a brand new study. I'm talking 2022, hot off the presses. It is all around non operative treatment for lumbar spinal stenosis. This is an update of a systematic review that took place quite a few years ago and and it is loaded with clinical pearls, tips and information that you can and should know to help your patients every step of the way. Before we get started, I wanna say a few words about the smart chiropractor. The smart chiropractor is here to power your patient's journey and to provide you with more qualified leads, more new patients, better patient retention and consistent reactivations. Drumroll. Without spending any money on advertising that that is what we do at the smart Chiropractor. If that sounds of interest to you this year, and I hope it does, you should head over to thesmartchiropractor.com we're helping hundreds of docs reach tens of millions of people. Last year alone we helped generate tens of thousands of patient reactivations, thousands of new patients into our docs offices. And we would love to have that conversation with you. Thesmartchiropractor.com but as I said at the top, today we're talking research on this podcast. And this is a new study by bmj. It is titled non operative treatment for Lumbar Spinal Stenosis with Neurogenic Claudication an updated systematic review. And this came out in 2022. So lumbar stenosis, we're probably all super familiar with this at this point in time. It is the number one reason why us adults have spine surgery and the neurogenic claudication component characterized by bilateral or unilateral pain in the butt and lower extremity discomfort, pain, weakness and challenges with walking. The number one question I'd always ask my patients is are you always looking for, if you go to the grocery store, are you leaning on that shopping cart or looking for a seat? And that seems to be a very practical question where if they answer yes, chances are they, especially if they're older, chances are they're struggling with some, some form of lumbar stenosis. So how does this happen? Well, mostly age related changes, osteoarthritic changes to the lumbar spine, the facets can become hypertrophic, ligaments become hypertrophic and it narrows down that central or lateral spinal canal and it causes compression of the spinal cord and the spinal nerves. That's really the gist of it. So limited walking ability due to stenosis is associated with a significant decline in functional status, quality of life and independence in people struggling with it. And this is really the challenge. Once you stop walking and you're starting to really slow down and become less mobile, quality of life goes down, functional ability goes down, and other stuff creeps in. I almost think of it like a hip surgery which are done day in and day out. But if you don't get up and walking, all of a sudden, other things start to take hold and creep in. And lumbar stenosis is kind of like that. If you start slowing down, not walking as much, not moving, all of a sudden, chances are, and you just see it too often, that other health issues creep in and it becomes a slippery slope down towards, in some cases, mortality. So it's very, very important to help people that have lumbar stenosis stay as mobile as possible, stay as functional as possible. And this study does a great job breaking down some of that research. So they screened over 15,000 titles and abstracts and checked out one. It basically ended up with a little bit under 3,800 participants, male and female, were split just about equally and a couple hundred that were non disclosed. As far as gender goes, the mean age of participants was 63 years old. Again, normally you see stenosis in an older population, specifically lumbar stenosis and neurogenic claudication. And the duration of the symptoms varied with a mean ranging from 12 weeks to 15 years. So generally speaking, an older population, symptomatology, pretty wide range. But a lot of people deal with this for a long period of time. I mean, even 12 weeks to 15 years, that's a huge, you know, gulf between them. But 12 weeks is chronic. I mean, you're starting to get into that chronic. This is a chronic issue for millions and millions of people. So they looked at studies in oral medication. Pre gabalin, basically, they found does not improve pain, distance, walked function, or global health status compared with placebo. And additionally, adverse events were reported in 64% of the Pregabalin group. So if you hear people taking that, they might want to ask their doctor if that's the best medication for them. And they found another study where oral corticoids did not improve the outcomes in the short term compared to placebo. And, and there's just very low quality evidence that gabapentin can improve distance walking or pain compared to placebo. Medication just is Not a very good treatment strategy if we just get down to it. Now, does this happen millions of times per day? Yep. Are there millions of individuals whose first line treatment by their primary care doctor and in some cases, you know, head and hands, their orthopedic doctor who, who should know better for sure is prescribing these medications? Yep. And they're generally speaking no better than placebo. Limited quality evidence with high risks compared to not doing anything. If it's not even better than placebo, a 64% risk of adverse events, that's to me unconscionable. Yet it happens each and every day. Important for us to know. So what they did find was vitamin B12 plus conservative treatment improves walking distance in the intermediate and long term compared with conservative treatment alone. So if you look at oral medication, I use medication loosely when we talk about B vitamins. But they found B vitamins can be helpful in addition to conservative treatment alone. So a little clinical pearl there to keep in mind. I think a lot of people, B vitamins can be helpful in a lot of different cases and with neurogenic claudication. Interesting to know that it can potentially help there. So they also found there's moderate quality evidence from a trial that manual therapy and exercise provides superior and clinically important short term improvements in symptoms and function compared with medical care. So that's a good one, right? Moderate quality evidence, I like that. Manual therapy and exercise, I like that. Superior and clinically important improvements. I like that. And it's compared with medical care. So that's a great one to know. Another great one to know is moderate quality evidence that comprehensive care, manual therapy, education, exercise, cognitive behavioral approach demonstrate superior and clinically important improvements in walking distance in the intermediate short and long term. So that's another great one to keep in mind. And there was a small trial with low quality evidence that pre surgical exercise improves post surgical outcome. So, you know, is prehab a wise idea? I think so, yes. This is an idea, I think that's been bounced around for decades, prehabilitation before surgical intervention. And I just have never seen it executed at any sort of real level, at a high level, in any sort of large scale system that really leads to beneficial results. And I just think there's a lot of meat on that bone for all of us to be able to dive into. And here's the good news. From a business point of view, that means there's no question you should be taking care of people with lumbar spinal stenosis as a primary point of contact. As Long as they don't have red flags. To me that's unequivocal as far as what we're seeing in the research. So second part about it is if they fail, you should still go through a pre habilitation program to prepare them for the surgery. You don't just give up, let them decondition, go to surgery and hope for the best. This really is a continuity of care and it's an opportunity to help people across their entire continuum of care, which I think is really, really important. So there was a meta analysis that included a couple trials that showed laminectomy improves outcomes only at the two year follow up compared with conservative care. One of these studies showed there was no difference in outcomes after eight. I think we've referenced that on this podcast in the past. Wild to think, but let me repeat that one more time. Surgical intervention, they did a laminectomy, they took the roof off, they did an incision, the patient's under anesthesia, the whole kitten caboodle. They probably billed out about $80,000 for the procedure, for probably a procedure that would take 30 minutes. And there is no difference in outcomes after two years. And one of them showed no difference after eight years. So these are really big deals. And again people, people in your community, most people believe that surgery is a fix. And I can tell you, working in multi surgery groups with very, very well esteemed surgeons, it's not. In cases of red flags, it is important and it can be life saving. However, it is not a fix for a lot of these chronic conditions as people believe them to be. And in some cases, some surgeons in the medical community also lead the patient to believe. Not everybody, but it's so important to be able to tell our story in a way that patients understand, in a way that makes sense, so that they can compare apples to apples. And to me that's one of the most important things we can do as chiropractors. So among patients with degenerative spondylolisthesis, we one study showed no difference in outcome with laminectomy compared with conservative care, including that eight year follow up as well. So spinal manipulation specifically there was only one study, it was really limited in terms of evidence. So they basically said let's hold the phone on spinal manipulation as far as this research study was concerned. And this meta analysis basically due to a lack of great information. So they've really focused conservative care on the exercise component and the movement component. So two trials demonstrated that translaminar or caudal steroid injections were no better than placebo. Nothing like getting shot up with injections. No better than placebo while deteriorating the joint at the same time. So injections are a common thing. Again, I don't mean to be negative on this. I think there's actually a lot of positive to be taken from this, but that's a big deal. No better than placebo for those injections. And there's moderate evidence that a multimodal six week program consisting of manual therapy, exercise intensive is an effective approach. Epidural steroid injections do not provide clinically important improvements in the short term or the long term compared with the lidocaine injection. So the bottom line is this. There's been recent guidelines that have come out for lumbar stenosis, you know, that really recommend, based on moderate quality evidence, multimodal care consisting of education, exercise, manual therapy. That's us. And these guidelines recommend against the use of epidural steroid injections. Epidural steroid injections are one of the most common things that are before they're done millions of times per year for this and they're billed out hundreds if not thousands of dollars. It doesn't mean they always get that those are the billed charges and there's no evidence to support it. So stand firm in your conviction as a chiropractor, in your understanding of the literature and research that we're here to help in that movement based care is where it's at. Movement based care is probably as close to a fix as you're going to get without a red flag. And loading up on steroids is gonna. Quite frankly, this study doesn't say this, but we know this. It deteriorates cartilage, it promotes degenerative changes of a joint. In a pinch they can help. Don't get me wrong, however, an overwhelming majority of the time your three shots a year for life, as many people go through trying to, quote, unquote, avoid surgery, by getting three injections a year, they're actually pushing themselves towards surgery. I don't think that's a coincidence, but I'll leave that for another day. So a recent clinical update published in the British Medical Journal recommended supervised exercise and manual therapy as a first line treatment and recommended again against the use of steroids. So these researchers are saying, hey, a multimodal approach would appear to be the rational approach given the complexity of the symptoms. And a lot of these factors, there's physical factors, functional factors, psychosocial factors that impact recovery. And for all of those reasons, a multimodal approach makes a lot of sense. One more thing on those epidural steroid injections, 25% of all injections are performed for lumbar spinal stenosis. Yet the researchers say, yet the evidence from our current review and those of others do not support their use. So 25% of all epidural steroid injections spinal are for lumbar spinal stenosis. And essentially there is absolutely no benefit more than placebo. There's no support for their use. And quite frankly, we get back to the same story. Placebo, there's about a zero risk tolerance. Epidural steroid injections, there's a kitchen sink. Now, thankfully, a lot of people don't suffer severe and catastrophic side effects. However, there's a real thing that there are side effects and there are real risks and those need to be kept in mind. So bottom line, to empower you as a doc, as a chiropractor, listening to this, stand firm in your convictions. Take some of the clinical pearls here. If somebody's leaning towards thinking that a steroid shot is a good idea and they're not in an acute exacerbation, have an open conversation with them. If they think that surgery is a long term fix because they're not getting as well as they'd like to in your practice, have a real conversation with them, get heart to heart, Help them understand that movement based conservative care is where it's at. This is what's clinically recommended. It's where they're going to get the most improvement. It's what has the least burden of risk. And all of those things have to be kept in mind. They have to be kept in mind throughout this entire process. So hopefully this has been a great podcast for you. I loved this study. This was a great one in my mind. If you have feedback on it, hit me up. Jeff the evidence basedchiropractor.com and before we close, if you are building and growing your team in 2022, hit us up at ChiroMatchmakers. If you're looking to add an associate doctor, if you're looking to add a chiropractic assistant, you want to do it the right way. Adding the right person to your team can be a seven figure benefit. Adding the wrong person to your team can be a six figure mistake. We've all seen it time and time again. So if you're looking to add to your team, we have a proven process that that really goes through behavioral assessments, cultural assessments, in a team of 15 recruiters working full time that is far more and far more specialized than any chiropractic office and practice can do on their own. So if you want to hire right the first time, head over to ChiroMatchmakers.com and if you are on the other side of that coin, you're looking for your next career opportunity. We have over 100 open positions right now. You can check it all out@chiromatchmakers.com I hope you have a fantastic week in practice Doc and I will talk to you soon.

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