Chiropractic vs. Nerve Injections for Cervical Radiculopathy | Podcast Ep. 208

Hello and welcome to the Evidence Based Chiropractor. I am your host, Dr. Jeff Langmaid. We are through Thanksgiving and firmly into the holiday season. I hope your December has been awesome so far. On today's episode we're going to break down a super cool paper. It was put out by JMPT just a year or two ago and it examined chiropractic cares spinal manipulative therapy directly against nerve root injections for cervical disc herniations that are MRI confirmed. The results of this study are going to be what you want to talk about in your community with your patients and with the other healthcare providers in your community for sure. So I think you'll be really excited at the results. We'll break it down in just a moment as well. Also, if you have not had the opportunity to check it out, I put up in full interview that I had with Shantae Cofield, also known as the Movement Maestro. It was shot on location at Rock Stock just a month or two ago where she breaks down how she has used her Instagram profile channel platform to literally change her life, engaging with people far beyond the scope of the four walls of her house and practice and how ultimately she's taken that channel and grown it to 50,000 plus followers. It's practical, it's patient centered, it's super cool. You definitely want to check that out. You can see see it@YouTube.com the evidence based chiropractor or you can check it out on the Evidence Based Chiropractor Facebook page. I highly recommend taking a peek if you have an Instagram page if you want to grow your brand and your audience. She's doing it the right way. So check out that interview with the Movement Maestro Shantae Cofield and one other bit of housekeeping before we dive into the research. I just got back from Hustlecon out in San Francisco. Super exciting. It was a tech entrepreneurial conference where there were the founders of companies like Threadup, Madison Reed, Calm Native deodorant, you name it. There was a ton of highly influential founders there basically breaking down their business, so learned a ton. A lot of what I learned I'm going to be putting into and instituting within the Evidence Based Chiropractor. If you're looking to build referral relationships and more specifically on the technology side into the smart chiropractor which is our social media email patient engagement tool service system that really nothing competes with on the market as we sit here today. But man, I am super pumped at our product map for 2020 seeing what these other, the technology that a lot of these other founders are utilized in figuring out how I can bring it into the chiropractic space gets me super pumped. It's what I love to work on and it is going to line up to equal some super exciting stuff coming down the the pipe in 2020. So with all that out of the way, let's dive into the research. So the title of the article today is Symptomatic MRI confirmed cervical disc herniation patients. A comparative effectiveness prospective observational study of two age and sex match cohorts treated with either image guided indirect cervical nerve root injections or spinal manipulation. Man, that is a mouthful. It was published by JMPT in 2016 and basically what that title means is they had people who had cervical radiculopathy, pain shooting down the arm, they took MRIs of those individuals and said, yup, there is a huge disc pressing on the nerve. MRI confirmed disc herniation. Then they took those individuals and they said, alright, let's match these cohorts by age and sex. So they're sort of uniform throughout. And send some to get indirect cervical nerve root injections and send some to get spinal manipulation and let's see what happens. Now we know age or injury related compression and inflammation of a cervical nerve root can be difficult to treat, especially when we look at our colleagues, so to speak, in the primary care world. They struggle with this. When there's a disc pressing on a nerve, an NSAID typically doesn't cut it right. And age is going to decrease disc height, traditionally not every case. And also age is gonna create decreased space in that neuroforamine as osteophytes form, as ligaments become hypertrophic, et cetera, et cetera. And again, what we've seen, medications are largely ineffective. Compounding that challenge is that imaging findings can often be misleading. We talk about that all the time, right? Just because there's something out of picture or an MRI doesn't mean it is specifically what's going on with that individual. Now in the case of this study, this was matched. So yes, it was brought down to say, okay, it's this disc pressing on this nerve. So this study evaluated the improvement of patients either receiving spinal manipulation by a chiropractor, super important or nerve root injections. Now the results, they are exciting. They show that spinal manipulation dramatically outperformed cervical maneuver injections in providing improvement at three months. And of particular interest to me was the subset of patients with subacute and chronic pain, subacute and chronic pain, typically super Hard to treat. A medication almost never works in that case had substantial benefits from chiropractic care. So super exciting stuff. The acute patients did great with chiropractic too, or spinal manipulation, adjusting, however you want to define that specifically for you and your practice. The gist of it is, hey, there was a big disc pressing on a nerve. There was a lumbar study that was similar to this done a few years back as well. But this is the cervical version. And we see regardless of whether it's in the lumbar spine or whether it's in the cervical spine, if there is a disc pressing on a nerve, we know the medications typically don't work that great. So even if that's stepped up to an injection, you're dumping steroid right on that area, which would seem to provide some relief. And it does provide some relief. What we can do as chiropractors can outperform that and has outperformed that time and time again in the research, which is awesome. So let's take a look at a few quotes from this paper. They found, quote, the research evidence for spinal manipulation as a treatment for patients with symptomatic cervical disc herniations is sparse but slowly increasing with a recent cohort outcome study showing that more than 3/4 of patients with subacute and chronic symptoms reported clinically relevant improvement at three months after the start of treatment. So they're saying, and we've talked about this before, right? 20, 30 years ago, our last generation of chiropractors did not have the fortune of standing on all of the research supporting what we do that we can today. But that doesn't mean we should be lazy. That means we need to take this research and promote it to the people in our community. If you want help with that, visit the smart chiropractor or definitely to the other healthcare providers in your community, which is what we do with the membership at the evidence based chiropractor. These researchers also found, quote, 86% of the spinal manipulation patients reported clinically relevant improvement at three months, compared to 49% of the nerve root injection patients. So less than half of the patients who received nerve root injections had clinically relevant improvement. Nearly 90% of the chiropractic patients had clinically relevant improvement. If that's not staggering to you, then I don't know what is. That is a stark difference. It is meaningful. That is a huge gap when we're talking 86% with spinal manipulation with chiropractic with improvement at three months to only 49% of nerve root injections. Finally, the researchers found, quote, subacute chronic patients treated with SMT were significantly more likely to report relevant improvement compared to the nerve root injection patients as we had previously discussed. So this is super, super important stuff to keep in mind. Now you might be saying to yourself, how do you define improvement? Well, how they define improvement was this. They utilized the patient's global impression of Change PGIC scale and it was overall improvement in terms of disability, function and well being. So it's a great tool. And the PGIC is a seven item scale. It includes responses such as much better, better, slightly better, unchanged, slightly worse, worse and much worse. Only the responses much better and better were considered clinically relevant improvement, which is consistent with what's been accomplished in a lot of other studies as well. So it's a seven item scale and only two of those items, the top tier, are considered clinically relevant. And, and this is where what we do with an adjustment far, far, far outperforms what was able to be accomplished with the nerve root injection. Now additionally on top of that, this is where I think things also get really interesting is now you start to say to yourself, okay, cool, that is great in terms of improvement, but anybody get worse? What happened with anybody getting worse? And what we see is this is that there is 0000 of the patients who were assigned to the spinal group that were worse at three months. There was 6% of the nerve root injection patients who were worse at three months. So not only did spinal manipulation, chiropractic care and adjustments dramatically outperform nerve root injections, but those patients who deteriorated were non existent in the chiropractic group and made up nearly 6% of the total volume associated with the nerve root injections. So this is the type of stuff, I say it time and time again on this podcast because it's so, so important. This is the type of stuff people in your community and the physicians in your community need to know about. I guarantee you if you poll, you could probably poll your current patients and ask them, hey, an injection versus an adjustment, what do you think performs better? I have a feeling that a lot of them, while they trust you and they love you and they love the care, probably believe you dump steroid on it, it's gonna feel better than getting an adjustment. A steroid injection is, you know, more interventional. Well, they're right about that. It certainly has way more risks. It is way more interventional. However, the results just quite frankly don't stack up. And I always look at this from the perspective of we've seen it and talked about it again time and time again. Individuals who have cervical radiculopathy. The average age of a patient in this study was 44 years old. These are people that can respond unbelievably and did unbelievably well to what we do as Chiropractors. But 44 year old has some numbness, tingling, maybe pain down the arm. They go in to see their primary care physician. Primary care physician prescribes an nsaid. Two weeks later, nothing's changed, duh. Then the patient gets an mri. The doctor says, oh my gosh, you have a disc pressing on the nerve, you gotta go see and get an injection and you might even need surgery. We've seen it. The research shows that is not the way a care algorithm should be executed on in the absence of red flags. Yet it is happening each and every day in your community. I will guarantee it. How do you change that? You change it by getting out there and proactively having these conversations. You change it by letting the people in your community know who you are, what you do and the research behind it. And you change it ultimately by bridging the gap and building relationships so patients don't have to undergo these high risk, dangerous type interventions, but they can actually get the proven, effective, conservative care that they need. If you want to step up your game with that, I'd invite you to become a member at the Evidence Based Chiropractor. If you want to just take everything here in this podcast and do it yourself, that is awesome. That is the number one goal. But if you want to make it clean, easy, have the proven system to do so, check out the evidencebasedchiropractor.com I hope you have a great week in practice and I will talk to you soon.

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