How Often Should You Visit a Chiropractor? | Podcast Ep. 277

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. This week we're talking research, we're talking chronic pain and visit frequency to a chiropractor. This is a new study that came out in 2020 and they're analyzing predictors of visit frequency for patients using ongoing chiropractic care for chronic low back and chronic neck pain. And this is analysis of observational data. This came out in BMC in 2020. I'll drop that link down below. There's a lot of clinical application to this study and as always, it leaves a few good questions to be answered in follow up studies as we continue to learn more about how people with chronic pain get engage with chiropractic services, how we can be of value and ultimately how we can help people live more productive lives with higher quality of life without having to resort to drugs, medications and or surgical intervention. So this is a big deal. Chronic low back pain and chronic neck pain are some of the most common types of chronic pain. Probably no surprise there. And it's estimated that there's a 10 to 20% prevalence in adults in. That's pretty startling when you think about the prevalence, which means out of any group of people you grab any group of adults that 10 to 20% of them have chronic pain. That's substantial. We think about hundreds of millions of adults in the United States, billions of adults worldwide. Chronic pain is a big deal and chronic low back pain and chronic neck pain are at the top of the list. So if you're listening to this as a chiropractor and I said, hey, do you think you do a good job taking care of and helping people that have chronic neck pain and low back pain? I imagine your answer would be absolutely yes. So the real statement is you have a ton of opportunity out there because there's a lot of people dealing with pain and many people that have chronic neck pain or chronic low back pain use medications including opioids. And this is just a reality of what's gone on because of the standard of care in medicine and the fact that the guidelines have changed. However, practice and habits by and large are very, very slowly coming along. So guidelines now recommend a number of non pharmacological therapies, as we know and we've talked about, for chronic low back pain and neck pain, such as conservative movement based options like chiropractic adjustments. And this is a really, really big deal. I know we've talked about it on this podcast and we'll continue to talk about it, but because it's such a big deal, guidelines 10 or 20 years ago just weren't that way. If I think back to when my great grandfather practiced in the 1920s, I mean, forget about it, chiropractors were literally at that point still being jailed for practicing chiropractic. So the fact that now major healthcare organizations and guidelines recommend exactly what we do is important. And the fact that there's a lot of people struggling, this isn't something where we're recommended for this super niche item that applies to less than 5,000 people in the whole United States. And it's like, gosh, that's a small segment of the population. There are tens of millions, if not hundreds of millions of people that need our care and services. The guidelines recommend it still need to get out there and tell our story and make sure people understand what the truth is and how to take action with it. Because habits are so hard to change. So bottom line is, as time has gone on, we've seen the question then becomes, well, how come so many people aren't utilizing chiropractic for chronic pain? And a lot of this comes down to policy. So documentation continued clinical meaningful improvement and the implication that treatment should end when a patient's symptoms plateau at some sort of maximum therapeutic benefit has really hindered because in many cases, again, treating chronic pain quite often is not curative. It is management. And our insurance guidelines specifically, I'm going to say in the United States, but I think this takes place elsewhere as well. Guidelines are like, well, plateauing is not a good thing. Well, plateauing could be a very good thing if you've received benefit and you maintain that benefit. I'd argue that's a fantastic thing that you don't always have to have continued improvement. I think we've all seen and had patients come into our practice, you know, 7, 8 out of 10 pain daily, that we get down to 2 or 3 out of 10 pain daily. That's life changing, by the way, for that individual. And they stick around at 2 out of 3, 2 or 3 out of 10. And when they go X amount of days, weeks without having our care, they shoot right back up to an 8. And many insurance companies are built where you almost have to play the game of the patients either coming out of pocket, which is okay, or that, you know, they have to have a crash quote unquote and an acute exacerbation to kind of be able to come in and get the care that they need. And that yo yo effect isn't good for anybody. And it certainly is not patient centric. But insurance companies have built it that that's often the way it is because we are crisis care based from an insurance policy perspective. We're not management based. Now it's estimated that 30. Here's the good news. It's estimated that 30% of patients with spinal pain have vaginalized visited a chiropractor. So again, these numbers vary so heavily depending upon what research study you look at. I don't believe that really the usage and utilization of chiropractic is over 10 to 12%. But if we look at people that specifically have had spinal pain and ask them if they've ever visited a chiropractor even one time in their life, I could see 30%. But I don't think that that's not utilization. I guess that's more about who has potentially seen a chiropractor. Splitting hairs there. So how did this study look at things? Well, they looked at visit frequency and they based it off patient self reported use over the past two weeks, gathered every two weeks for three months. And they viewed visit frequency and basically defined it as the average number of chiropractic visits per 30 day period or each month. So that's how they looked at it and analyzed it. Now here's what they found. They found that the average visit frequency per month was 2.3 visits for both conditions, meaning neck pain and low back pain, chronic, which is a bit more often than every other week. Now here's something interesting. Almost half of the patients in this study, which was I think well over 1500 people, pretty sizable study, well over half of them had patients for 10 or more years. These are people that are living in chronic pain. We're not talking chronic pain. It's the 91st day and the incident happened 91. These are individuals have been dealing with this at 10 years, thousands upon thousands of days. A decade of a life is a long period of time. And again, the average frequency that somebody saw a chiropractor in both the groups combined was basically every other week. It's not a ton, right? These aren't like these people aren't in care three times a week and it's been 27 years later every other week for chronic pain, especially depending upon what the individual does for work, as we'll talk about in a moment, I don't think is extreme in any situation. So they also looked at, well, does insurance play a role? And they found that having some insurance coverage does increase visit frequency by about 0.44 visits per month. For patients with chronic low back pain, but really had no effect if there was insurance coverage or not on frequency for patients with chronic natural neck pain. They also found that visit frequency was significantly higher for patients of chiropractors who saw more patients per day. So that's interesting. And it was significantly lower for patients of chiropractors who had been in practice for 20 to 30 years. So newer providers tended to see patients a little bit more often than veteran providers. And the more visits that somebody saw per day, if you saw over 50 visits per day, the frequency was generally higher than if you saw less than 25 visits per day. It's just interesting antidote. So patients with chronic low back pain and some insurance coverages for chiropractic had an average of less than 1, 1/2 of a visit more per month than those without coverage. As we just talked about, however, having insurance coverage had little to no effect on visit frequency for patients with neck pain. Why was the difference? I have no idea. But the bottom line is insurance coverage didn't make a huge difference. So some people might, oh well, insurance coverage. If they have insurance, they're going to come so often if a patient doesn't have insurance, we can't get them in here. This data that might be, that's a communication issue probably in your practice more than it is the truth. Because when we look at data at scale, we see that whether somebody has insurance coverage or not, in neck pain, it didn't matter at all. And then in low back pain, it was literally less than 1/2 of a visit per month. So less than 6 visit difference per year in those with insurance coverage and those without. So not really a big deal. Patients with chronic low back pain that had, you know, heavy labor, right. That increased their frequency by less than a half a visit per month. And incidentally, female patients had lower visit frequency by about a third of a visit per month. So all of this is sort of incremental is what I'm getting at. In none of these classifications did they have heavy labor for activities. Were they male or female? Did they have insurance coverage? Were they seeing a new provider or a veteran provider? None of this really. How many patients per day did these providers see? None of this really swung things dramatically. Now, if you're looking at big data and you're an insurance company, half a visit per month extrapolated over 50,000 chiropractors. That's what makes insurance companies apprehensive and scared because they're just looking at the bottom line and they're profit producing companies. But we look at it in terms of individual clinical practice, it's not much of a difference, like less than half a visit. Almost all these factors were less than half of a visit per month difference. So every other week, every other week was about the average. Now one thing I thought this study brought up, that was very, it's just a bizarre statement in my opinion, but they had, they quote, there has been concern amongst payers and providers that patients use of ongoing care was not based on medical necessity or need, but on clinician dependence or coercion, including through lowered patient self efficacy or heightened patient fear. Now that statement, I take exception to it. I think it's pretty outrageous to be honest with you, especially when we look at what's going on in the medical realm. If we want to talk about dependence and we talk about getting three cortisone injections per year, that destroys the joints, if we want to talk about dependence, AKA medication, I mean there is addiction levels that are outrageous. You want to talk about dependence, that's where you need to look. Now this study also found basically that there is no proof of any of this. So why you would put that in this study, even having that statement is beyond me. But hey, I thought it was worth bringing up on this podcast just so you know exactly what's going on. And the final piece of the puzzle, or second to last piece of the puzzle I guess I should say, is that they did compare primary care visits to chiropractic visits and they found that the average number of chiropractic visits per year for somebody with chronic neck or back pain was 6.7. And they found that the same numbers for medical were around two visits per year. Now this is an apples to oranges comparison of course, because chiropractic care is in general hands on care that's delivered to manage and medical care is scripting, that is referral. And so there's a big difference here. I think it's important to note. Yeah, people saw chiropractors more, no kidding, just as they would see physical therapists more than they would see a surgeon. So I don't think there's a take home message but just something to keep aware of. Now the conclusions I think with this study were nih, Medline, plus a publication of the National Institutes of Health has said, quote, chronic pain usually cannot be cured but it can be managed. And that's so, so true. So several, we've seen several non pharmacological therapies being recommended for chronic spinal pain and these therapies as this study proves, can be used on a long term basis by patients for pain management. And I think that's the most important point here, is for patients that have struggled in and or are suffering with chronic pain, if you get in there and have just realistic conversations with them about these are items that will be managed, probably not cured. And that's the same in many instances, whether they're thinking about having injections, taking medications or having surgical intervention. Quite often this is about management, not cure. And the bottom line is when you look at that, you say, okay, well what's going to get me the best? If I look at the cost benefit analysis or if I look at the risk reward analysis, what's going to get me the best opportunity to get the best results with the least amount of downside? Chiropractic care comes out head and shoulders above everything else, in my opinion. So get out there and have those conversations with your patients, set those expectations, let them know that, hey, I might be seeing you every other week for a while, you have a heavy labor job, you've been in chronic pain for five to 10 years and then base your recommendations on their goals and your findings. That's really the crux of what we're talking about here and I think that's the take home message for you as a chiropractor. And bottom line is we can take care of and help a lot of people with chronic pain, but we need to be better at our communication, we need to be more accurate with our storytelling and we need to let people know agreements and expectations, let them know what is going to happen, how you can help them and what you're looking for in terms of success. The more that you more clearly clear you are with that, the better off your practice will be, the more referrals you'll get in and the more patients you'll be able to help, which is what it's all about. So thanks for tuning in to this episode. Thank you for putting me over 200, which is incredible, over 200 reviews for this podcast on itunes. So if you haven't left a review, it's never too late. You can scroll on down, give us some feedback, let us know what you think about the podcast. Thank you for tuning in. I think we have somewhere over 12,000 docs listening to this each and every week. So thank you again. Thank you so much for tuning in. And I'll wrap it up by letting you know if you are looking for office coverage or you're looking to provide coverage, please let us know@chiroffice coverage.com that is our locum services. It is coverage services. So whether you're going to be out on continuing education, whether you have an unexpected injury, whether you're looking to take a vacation, bottom line is you do not need to close down your practice, break up your patient's care and lose revenue. You we make things super easy. Chirofficecoverage. Com we do all the heavy lifting for you. And also if you are looking to increase leads in your practice, if you are looking to automate your marketing and you think content is better than discounts, then head over to the smartchiropractor.com and see what we have going on. Also, we've put up a ton of new blog posts at the Smart Chiropractor, clinically related blogs, marketing blogs, and head over check it out@the smartchiropractor.com if you have any feedback on this podcast. As always, you can hit me up. Jeff the evidencebasedchiropractor.com I hope you have a fantastic week in practice and I will talk to you soon.

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