Low Back Pain Guidelines Don’t Change MD Behavior (27 RCTs Explain Why) | #527

Hello and welcome to the Evidence Based Chiropractor. I am your host, Dr. Jeff Lengmaid. On today's episode, we are talking about a topic near and dear to my heart, and that is the effectiveness of strategies for implementing guideline concordant care with low back pain. It's a really fancy way of basically saying, how do you take the research and put it into action so that the guidelines are actually followed? Now, as a listener this podcast, I know you're probably doing that, but there are many other MDs, DOs, ARNPs, PAs in your community who are absolutely not doing that. And this ties into the core and heart of what we do at the Evidence Based Chiropractor. With our MD Connection Program, understanding and influencing the referral habits of other healthcare providers in your community. We're gonna dive into a research study that answers a lot of questions, stimulates a few new questions, and really sets the stage for the importance of having a system when we go out and build referral relationships. Now, before I get started, few quick shout outs, one to leander tables. You can save $1,000 off their Series 950 table. It is awesome. Use the code EBC2025 or visit the down in the show notes to learn more and connect with their team. Additionally, a supporter of the show Shockwave Centers of America is going to hook you up just by being a listener. How awesome is that? $500 off and a free cart. So if you're looking to add Shockwave in in an affordable and effective manner, Shockwave Centers of America is a great way to do it. Now, as I said at the top, today's episode is all about the guidelines. And I'm going to say, really, if I just say it bluntly, what, why the guidelines themselves don't change behavior and what actually can. So you've probably had the thought in your mind in the past saying, well, I know what the guidelines say, but the real world doesn't always cooperate with that. Maybe you've had a patient that's pushed hard for advanced imaging really early. Maybe you've had somebody who's kind of dead set on medications being the answer to their challenges. Or maybe you've had even referral partners. Or I won't even say referral partners, say other doctors in your community who have practiced the care of low back pain. I'll be ginger and say creatively, AKA not at all what they should be doing. And this is probably something that you see all day, every day in and around your community and with your patients. And we live In a pretty weird space right now where the science is really clear on low back pain education matters. Unnecessary advanced imaging does not help. Over reliance on medication creates more problems than it solves. Yet pretty much the medical system keeps drifting back to their old habits. So today we're going to dig in to a massive new paper and study came out in 2025 that asked a very simple but very powerful question. Do implementation strategies actually change provider behavior when it comes to low back pain guidelines? This is not opinions or antidotes, it's actual randomized control trials. And the results are pretty fascinating. They can be a little bit humbling, but they are super useful for how we communicate with our patients and with other providers. So this study was a systematic review and meta analysis published late 2025 and it looked at 27 randomized control trials. It involved just about 7,800 health care professionals, nearly 34,000 patients with low back pain across 10 countries. And the goal was to evaluate whether different strategies actually increased guideline concordant care for low back pain or the opposite. And specifically, they focused on three core guideline behaviors. One, providing patient education and advice seems pretty simple. Two, discouraging routine advanced imaging when not clinically necessary, and three, reducing unnecessary analgesic and medication use, including opioids. So these are consistent with global guidelines. Who in the US and Europe and Australia, pretty much every single organization agrees on these fundamentals. But I can tell you, almost no organization is actually holding their members accountable to them. So knowing something and doing something in practice, very, very different. So the researchers looked at different implementation strategies used to change provider behavior, including educational materials, meetings, audits and feedback, reminders, tailored interventions and multi component programs. And most studies did not just use one tactic. 24 out of 27 used multifaceted approaches. Then they measured what happened over time, especially kind of what they termed a medium term, three to six months after. So important to note the interventions and strategies, implementation strategies, as they will say in the study that they used, are not what we do with the MD connection. So you'll see this as we go through it and it's why with MD connection we take a multi pronged approach. Build your target list and then the three pillars of relationship building, case notes, research and meetings, all do different things and all can influence behavior over time. Absolutely no questions asked. Because we see docs in our program, 30 plus referrals per month on the high mark. And then we see our many of our members, they average, whatever it might be, 4, 5, 6, 7, 8 more referrals from other healthcare providers per month that can ebb and flow a little bit. But man, that is nice when you start to get that engine going. And as I let everybody know that is a part of MD connection, I'll let you know right now. It is. Unless you're in a town of one, it's impossible that there's not three, four, five other healthcare providers in your community that would be great referral partners for you. Whether they're an md, A, do, a midwife, a doula, A and arnp. I don't care about their designation. There are other healthcare providers that would be great referral sources for you in your community. The hard part is finding out who they are and you have to kiss some frogs to find the prints. You got to meet some other providers that you can't believe even are in business as a provider. That's okay. It's not. I mean it's not okay. But from a relationship still building standpoint, not everybody's going to be a great partner. So that's why you work a target list. You meet some people you know you don't want to work with, which is actually really good for you to be able to guide and direct your patients away from their practice. And also in that process, guess what? You're going to find other healthcare providers that you do want to work with. And the beauty of it, As I always say, while ads that get shut down turn off that day, relationships last forever.

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It blows my mind the amount of chiropractors not getting using any time, effort, energy or resources to building referral relationships. When it's one of the best, it's the best. Let me be very clear. It's the best long term strategy to build stability within a practice, yet it is overlooked by 99% of the profession. Anyhow, I'll get off my soapbox and get back to this study and let's dive into a high level summary and implementation strategies did reduce analgesic use, so there is moderate evidence suggesting that and when clinics actively implemented guideline strategies, providers were meaningfully more likely to reduce unnecessary medication use. We've seen this. I'll kind of extrapolate this a little bit. We see this when people come in to see chiropractors, right? Pretty much every single study ever has shown when somebody has early and, or at any time, but early, specifically exposure to chiropractic, the likelihood of them filling a medication from the low stuff all the way up to opioids gets slashed dramatically. So if for no other reason than just the health of your community reaching out to other health care providers, it's a really, really good idea and it's a massive win. Now, let's talk about the reduction in advanced imaging. Implementation strategies in this study did not reliably reduce unnecessary advanced imaging. So some individual studies did show improvement, but when they were pooled together, the overall effect wasn't strong enough to say that it truly changed behavior consistently. And this doesn't surprise me because if somebody goes in to see a, for example, if you're going to, if you're going to have surgery done, you are going to have imaging done, right? Many times, if you're going to a pain management doctor, you are going to have imaging done. And quite often the primary care doctors are ordering imaging prior to that referral because that's just how it works in that system. So it's not surprising to me that even though there's education that, hey, advanced imaging might not be the right idea, that when a primary care doctor is making a referral to a pain management doctor, it's kind of part of the package they're sending. And if that's their habit, I don't see that changing. Because what's gonna happen that they would in theory refer to a pain management doctor. A pain management doctor's gonna call them immediately if there's no imaging and say, what are you doing? So this is where the guidelines and practice really, I'm gonna say, need to come together more because old habits die hard. Now, if we talk about patient education and advice, it's another surprising one. Implementation strategies in this study did not really significantly improve how often providers deliver education and advice. So some programs actually worked really, really well and others didn't. So the data wasn't really stable enough to draw any strong conclusions. And there's one more really important finding. There was not enough evidence to show that one implementation strategy was clearly better than another. Now what does that mean? It means that a multi pronged approach is going to be best and it doesn't have to be overly convoluted, overly taxing. We're talking case notes, research and meetings. Just getting out there to those people. Case notes to show you, co manage, show you exist. So show the results you get. I think of them like business to business. Google reviews research to fill in the gaps between the case notes and continue to drip your name. Staying top of mind. Breaking through obscurity is the hardest thing. So that allows you to stay top of mind. And then of course, meetings accelerate that progress. So if we unpack some of what the researchers found in this study, we can see that reducing meds obviously is something that providers can control directly. They can control what they prescribe, what they don't prescribe, and that gives them the opportunity to change that habit. As we saw imaging on the other hand, specifically advanced imaging, it's pretty emotionally loaded. Like you got patients demanding clarity, there's fear that drives that behavior. Defensive medicine, quite frankly plays a role. I don't want to miss anything. And time pressure makes it easier to order a scan, quite frankly, than many of these doctors having a 10 minute conversation. So the paper even notes that patient demand is actually one of the biggest barriers to reducing advanced imaging. So even when there are providers that intellectually agree with the guidelines, the system itself can actually push them back towards imaging. So let's talk about education as well. Many providers already believe that they educate patients. Well, by definition that's not true. If you look at a bell shaped curve, half the people have to be on one side, half the people have to be on the other side. So when you implement another educational initiative, it may not move the needle. Not much, not because the education didn't matter, but because the baseline is already perceived at high. And this is education to the patient from the provider. So the challenge is really time, it's workflow, it's repetition, and that's really hard to standardize in a practice. So education is, when you're looking at 60 and 90 second visits in a traditional medical, healthcare, medical space, how are you possibly going to educate somebody and take them from the knowledge level that they're at, which for many people is extremely low. Let's say one more time, the general healthcare knowledge level of the public is extremely low. And then you start to get into what I'll call specialized things like the spine and you know, what's a vertebra, what's a disc, what's a nerve? Where does it even sit here? What does it mean that there's pressure and compression? This starts to become, we live in this world day in and day out, so sometimes we get blinded to the fact of, well, everybody else knows this. Many people have a extremely low knowledge level of their body. So if they're sitting in with a medical doctor for 60 seconds, how you can't even start the conversation in that amount of time, obviously. So never mind, get through. And this is what ultimately result in a massive amount of confusion and a massive amount of problems. So here's where it gets fun for us. As chiropractors, we're uniquely positioned and that's the really great news in all this. We already spend time educating our patients, we already emphasize conservative care, we already avoid advanced imaging when we don't need it, and we already inherently reduce reliance on medications. So your opportunity in your community is to position yourself and as the guideline aligned solution. And when the system struggles, the medical system struggles to implement best practices that creates market differentiation for you and that is massive. This research supports the ideas that reducing medication reliance is achievable, that patient education needs consistency in systems, and that reducing advanced intervention requires better patient communication. So this aligns perfectly with what high performing chiropractic practices already do day in and day out. And it reinforces the value, as we've discussed, of structured patient education, not random conversations, but repeatable systems. So I loved this study because to me it just reinforces so much of what we know. That communicating with your patients at the time of ordering imaging during your report of findings, and really applying the framework of what I'll call function over fear, movement over advanced imaging, education over dependency. This really, I'm gonna say this enforces and reinforces the philosophical tenets that I think you and I take into practice each and every day. And this is fantastic information for again, your blog posts, email, social posts, and clearly as you're getting out there, this paper builds and gives you authority when discussing best practices with primary cares, ortho groups, PTs, pain clinics. You're not sharing opinion, you're actually sharing the. And that is massive. So the big takeaway is that even when the science is really clear, changing behavior is hard. In this research shows that number one, we can reduce medication reliance utilizing the right strategies. To me, we don't even need to go farther than that. That should practice. It won't be a hard stop, but it should be a hard stop. How do you not get out there and reach out to other healthcare providers, if for nothing else, that you'd reduce the reliance on medication in your community. But beyond that, that when you do get out there, you can see referrals come back in and that makes a meaningful business benefit for you beyond the care of your community. Chiropractic is perfectly positioned to lead in this space. You already do each and every day what the guidelines recommend. So now is really just the opportunity to communicate it better, to systematize it better, and to leverage that information more strategically. So I'm going to drop a link to MD connection with the Emerson Chiropractor down below if you want to check that out. We just made it really easy. We give you the system and process to implement to get out there and build referral relationships. But as you can see clearly, this study and the topic is something I am super passionate about. If you are as well, I'd welcome you to connect with us at and with the MD Connection. If you are a first time listener or a longtime listener of this podcast, thank you so much for tuning in. If you'd left, leave a rating or review, that would be awesome. And before we wrap up, big shout out to Novopulse in their OA recovery program. I'm gonna drop a link down below. If you're looking to take care of more people with osteoarthritis through a specific program, it's pretty awesome. Check it out. Novopulse. I'll drop that link down below. As well as the Diabetes Reversal Group, if you're looking to take care of more people and help people reverse diabetes in your community, they have a fantastic program as well. Thank you so much for tuning in. Thank you for being a chiropractor. Have a fantastic week in practice and and I will talk to you soon.

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