How Many Adjustments Are Too Many? Lumbar SMT & Spine Care Explored | Podcast Ep. 435

Foreign hello and welcome to the Evidence Based Chiropractor. I am your host Dr. Jeff Langme. This week we are back with more brand new research all about lumbar adjustments and the association between how many adjustments somebody gets and escalated spine care. This is a great study. Again, tons of clinical pearls, tons of take home messages. We'll get into this and much more on today. Before we kick things off, I want to say a few words about patient pilot by the smart chiropractor and I'm going to keep this real short. If you have inactive patient list patients you've seen that not actively coming in of more than 500, we want to talk with you. Why? Because we believe you have an opportunity to generate patient reactivations consistently utilizing our automations that create patient recall lists, help people schedule it automatically and more. You can head over to the smartchiropractor.com schedule a demo with our team. Again that is thesmartchiropractor.com, schedule a demo with our team and we would love to help you help more people in your community this year, next year, the following year. But it all starts by taking action today. But as I said at the top on today's episode, we're talking research, brand new study. I'll drop a link of course down in the show notes and the title is Dosing of Lumbar Spinal Manipulative Therapy and its association with Escalated Spine Care. A Cohort Study of insurance claims. So big study, lot of information and some really good information in terms of understanding the state of what's going on with current spine care. Maybe even analyzing and saying hey, how do I fit into that in terms of my typical recommendations and the implications for that that at least they found in this study. So there's not a wrong or a right. This is just highlighting what they've seen in the insurance claims. And again, this is insurance claims. So that is a subset of the population that it might be different than cash paying patients. Right. So low back pain. Why is this a big deal? Well, same big deal we've been highlighting for many many years. It is the leading cause of global disability for more than 20 years at this point with a one year prevalence of near 40%. That means about 40% of the population will have back pain over the course of any given year. Now here's what's real interesting. There is data suggesting that this prevalence has more than doubled over the past 20 years. That is a telling statistic. That means that what has been done over the last 20 years is not exactly working very well when we see that it has doubled over the last two decades. People should be getting healthier as time goes on, as they understand more about their bodies. And theoretically, if all of these advanced interventions were doing what they should be doing, we should see that dropping, not increasing. But that's obviously not the case. So approximately 70%, almost 70% of U.S. citizens with low back pain will utilize healthcare services for the management. So that's an interesting study statistic as well. 7 out of 10 people that have back pain will try something. And the cost of that, the amount of money put in, just a cool $87 billion per year. So that tells you all you need to know because it showcases this is a big deal with a high impact on quality of life, high direct and indirect cost. And for all of this, this was shocking to me. Low back pain ranks in the quote unquote, very critical category along with coronary artery disease and diabetes. When prioritizing research funding support that is how big of a deal this is. Now, what we know, and we've highlighted many times on this podcast, is here's the good news. Treatment guidelines for initial management of low back pain have supported, advocated and recommended non pharmacological care, including self management, exercise and literally of the three things, spinal manipulation. So they're highlighting the keystone and cornerstone of what we do as education. Self management, exercise, spinal manipulation, three of those four outside of self management directly tie to the core tenets of who we are as movement based healthcare professionals. I mean, can you serve it up on a silver platter any better? Now, that's the good news. Here's the bad news. Contrary to those guidelines, many patients are given low value, non guideline based care that cost a heck of a lot more money. And this escalation of low back pain interventions is usually found with early use of CT and mri, opioid medications, injections and surgery, which have dramatically increased over the past two decades. And I want to be clear because sometimes I've kind of rallied against those items. You know, having worked in orthopedic groups and multidisciplinary practices, I've always said I kind of know how it goes from the inside as a practicing doc in those groups and then on the leadership and executive teams as well. And I feel like there might be this almost approach in some cases some of the time where chiropractors out there are like, oh, it's getting better. No, it's not. You know, they're making more, more, more, more, more, more, more money every single year. With more elective surgeries, more medications. We know that all of the work on the opioid crisis was completely wiped out during the pandemic and people are worse off more. It's just, it's insanity and there's absolutely no accountability for this whatsoever. That's a conversation for a different day. But for you and I, we just need to be aware of it. Doesn't mean we need to be mad or angry. Maybe we should be. But you can be. But at the bare minimum, you need to be aware of what's going on. Because as you get out there, whether you're building relationships using MD connection with the evidence based chiropractor, whether you're getting out there reactivating patients with patient pilot by the smart car, whatever you're doing, people have decisions to make, right? And if they have low back pain, of which many of the patients in your practice do or will this year, they're going to be making decisions. Where am I going to go? What am I going to do? And really all of it boils down to are you making the choice easy for them and are you staying top of mind? If you're not staying top of mind super consistently, that's where the email marketing comes in with patient pilot or you're not making the choice super clear and linear. Obviously, if you have referral relationships and they're going elsewhere and being told to come back to your practice, that's like the ultimate win, right? Hopefully they never even get to that point. But talk about the ultimate goalie for your practice is if you have other referring providers in your community reinforcing it. So my point of saying this is it's really, really important to understand that that's really what it boils down to. And if you're struggling, you're unable to get over the hump, you have retention issues. It really boils down to those two things. Do people know how to say yes in your practice? And do you have the system set up to stay top of mind as consistently as possible? Really, really important. So spinal adjustments or SMT spinal manipulation therapy is the most common treatment offered of course by us as chiropractors and recommended for both the really important. Recommended for both acute and chronic low back pain. Short term relief with adjustments is similar to NSAIDs. So we compete head to head with medications in terms of results, if not better, with none of those side effects. So 92% of patients, also really interesting, 92% of patients who chose chiropractic for initial episode of low back pain will choose chiropractic again versus 49% for primary care. So if somebody goes in, let me say this clearly, somebody goes into a primary care for low back pain, literally less than half of them will go back for a subsequent episode. Why? Because the care is horrible. 99% of the time, 92% of people, 9 out of 10 people will go back and see their chiropractor. Why? Because it showcases there's a high degree of effectiveness and patient satisfaction. That's the good news challenge is we gotta open up the floodgates at the top so more people get in. Because once they come in, the they will typically come back. Which is great because movement based healthcare, assessing what's going on and not spending one minute and writing a script for a NSAID or an opioid or an injection is the better way to take care of things, to really do movement assessments and understand what's going on. So this study sought to fill the gap between understanding what's the relationship between, as they say, adjustment dose, how many, quote unquote, and exposure to escalated spine care. So that's what they were taking a look at. And let's dive into some of it. Their hypothesis was that the more adjustments somebody were given would be a significant predictor of escalated spine care. And what they found was that was true to a certain degree. People who had a low or a moderate dose were associated with a significant decrease. So this was kind of bifurcated in binary here. Now let me be clear. This does not mean more adjustments was not necessary. This does not mean more adjustments is not right. This does not mean more adjustments is wrong by any stretch. Because guess what, Many people who are receiving more care probably have more significant issues, so they were escalated to more significant care. However, on the flip side, low and moderate dose, those individuals saw a significant decrease, which is great because it wasn't linear. It wasn't like, oh, the more care you receive, the more escalated your spine care becomes. It was like if you're in the low and moderate dose, this actually pulls the other direction. But if you're receiving a lot of spinal manipulation, spinal manipulative care, that was a indicator that there might be some more advanced interventions in your future. But let's be clear, the associations in the high dose group, they were mixed. There was an increased risk of imaging, advanced imaging, there was actually a decreased risk of injection in emergency room department visits and there was no significant association with surgery opioids as well. So it really was more of an advanced imaging. Why is that the case? I am postulating here. But chances are I'm gonna assume that some people who received more care probably had more radiculopathy, more sciatica, more nerve root compression type issues. And if it was taking longer and they were struggling to get over the hump, that's where an MRI would typically come into play, as we well know. So kind of making an assumption there, but that makes sense to me as I read it. So the group including chiropractic benefits, looking again at previously performed services on insurance claims had statistically significant decrease in utilization of surgery, 32% less chance of surgery, 23% less chance of advanced imaging and an 8% less chance of plain film radiography. So interesting, there's in a study evaluating nearly 15,000 episodes low back pain. So big, big study. Individuals accessing chiropractic were significantly less likely to record guideline incongruent use of imaging, medications and surgery. What do you know? When people received the right care, they tended to continue to receive the right care instead of things that were non congruent with the guidelines. They also highlight a systematic review and meta analysis found that spinal pain patients had a 64% reduction in in the odds of receiving an opioid medication when accessing chiropractic versus other types of care. You want to cut the opioid crisis in half, get people where they actually should be, which is chiropractic practices 9 out of 10 times when they're having musculoskeletal issues. So their hypothesis that escalated spine care would vary depending upon spinal manipulation dose was confirmed, but it was mixed, low dose, moderate dose and they had a high dose. I believe it was 13 plus visits for that single bout. Low and mid were obviously basically, let's just call it 12 and under roughly. And that doesn't mean all time, that doesn't mean over the course of a lifetime, but that specific bout. So low and moderate dose SMT were consistently associated with lower risk of escalated spine care, while high dose had mixed associations because of that advanced imaging component. But the bottom line is across the board we saw reduced medication use, reduced opioids, reduced injections, reduced surgical interventions. That is powerful stuff. Now I also want to be super clear. If you are somebody who makes your living based upon injections and surgery, this is not exactly enticing to you to send everybody to a chiropractor knowing that 90% of people will come back and most people will not need your services in the end. That's a real challenge. And human beings are human beings. We've all taken, including all doctors, DOs, MDs, DCs, the Hippocratic Oath. But there's also just pragmatism involved in healthcare and it's just the way it is. I don't like it, but we need to be aware of that because I have seen it again in multiple orthopedic groups and multidisciplinary practices. They are businesses and they are typically run, even if they're shareholder physicians, they are run by very astute CFOs with deep experience. They have deep pockets, they, they have great structural CEOs, COOs, CFOs, and they are there to create revenue for their shareholders, whether they're public company, private company especially. I'm gonna say if they're a private company, they want to keep that revenue train flowing. So does a study like this from a medical perspective, healthcare perspective, hat only make a lot of sense that everybody should be referred to us minus red flags? Absolutely. Does it probably make a few people apprehensive about referring to us? Absolutely. That's where everything circles back to the onus being on you and I to get out there, tell our story, build those relationships and find our dance partners. If somebody is going to be, let's say, more business minded than healthcare minded for the people that they're taking care of, they might not be a good partner for you, but I can guarantee you for my doom and gloom earlier, there are people in your community that take the Hippocratic Oath seriously, that do want to do no harm, that want to do what's best, and that are happy to refer appropriately. So if you don't have a good referral channel, I'm talking 5, 10, 15 referrals coming in from other healthcare providers per month. Consistently head over to the MD connection at the evidencebasedchiropractor.com, we'll get you hooked up. We've worked with over a thousand docs around the world. The process works 100% of the time when implemented. Why? Because there's no magic. It's about building case notes, research and meetings. We guide the entire process, walk you through it, even have an implementation call. So if you're interested in that, you can head on over and check it out. Otherwise, I really appreciate it. Appreciate you listening into this podcast. Also. Neckcare.com Objective, reliable assessments for proprioception, range of motion, sensory motor integration, my preferred technology. If you are using goniometers or eyeballing it, those days are over. Neckcare.com, connect with their team, have a conversation. Also drop that link down in the Show Notes and Stop Pain Clinical. They support this podcast. Love it. If you support them, I'll drop a link that has a sample pack for them available and and this sample pack you can pick up for less than a hundred bucks. It can get you profitable. It looks awesome. It's great. Topical analgesics are something that all of us have in our practice. Why not use one of the best companies that supports who you are and what you do? Stop pain clinical stoppa.inebc hard to say that. I'll drop the link down in the Show Notes. Have a fantastic week in practice and I will talk to you soon.

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