Neck Pain Outcome Measure Associations | Podcast Ep. 346

Foreign hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. This week we are talking research. This is a brand new study that came out in BMC Musculoskeletal Disorders. It is titled association between different Outcome Measures and Prognostic Factors in Patients with Neck Pain. And this was a cohort study and it is a good one. Lots of great take home bits of information that you can apply to clinical practice on today's episode. Before we get started, I wanna say a few words about the Payday Practice. The payday practice is Dr. Jason Deitch and myself. Our new book. It is the number one new release in chiropractic on Amazon. Thank you so much. If you have picked up a copy and if you have not picked up a copy way and we really appreciate everybody that hops over to Amazon and has picked up a copy. We've had sales in uk, us, Brazil, Canada and more. And the book is all about how to generate monthly recurring revenue so that you can decrease your stress, improve the stability of your income and get off that roller coaster. It's happening right now. The Payday Practice is on Amazon. You can check it out there. Thank you so much everybody that's bought a copy and please do so if you have. Not yet, but as I said at the top, we're talking research today. The association between different outcome measures and prognostic factors in patients with neck pain. This is a cohort study and this is a great study because we know chronic pain is the number one reason why people visit chiropractors to begin with. It might come and stay for other reasons, health benefits, performance, et cetera. Chronic pain is one of those things and that breaks up primarily into three categories. Low back, neck, and then you could make a third of headache before you get into extremity. So neck pain is a big deal. We also know that while it is not necessarily a global epidemic such as low back pain is, it still seriously affects globally, hundreds of millions of people in the us, tens of millions of people each and every day. This study was looking at the prognostic factors to identify how can you tell who's gonna do what when they walk into your practice with neck pain. And we know that there's a large variety of individual prognostic factors that have been identified for people to improve. Age, pain intensity, disability, previous history of neck pain, widespread pain expectations. These all have an association with intense pain, intensity disability and global perceived change of outcomes. We've seen that in previous studies and the model basically includes seven predictors and was developed to predict improvement after 12 weeks using a GPE, a global perceived effect. That's kind of the outcome outcome measure. They've identified seven predictors. That's what the previous research has done. Now the aims of this study, specifically there were three of them. One was to examine the association among commonly used outcomes for neck pain, pain intensity, disability, life effect. Two, investigate if the predictive ability of recently developed prognostic model for that GPE of neck pain differs across outcome measures. So does it differ between pain intensity, disability or kind of what I'm calling life effect, which basically is, let me take a look here. Which basically is health related quality of life is what they call it. And the third goal or aim of this study was to explore the predictive strength of the included predictors across the outcome measurements. Now, the study didn't say chiropractic in the title yet the recruitment was by chiropractors, which is why this study is so interesting from a chiropractic perspective. So chiropractors were invited, they invited consecutive patients with neck pain to participate in the study for a little bit over a year from 2015 to 2016. I think this was based primarily in Norway and they got Data for about 1,000 people that responded to 12 weeks of follow up. And that's what constituted the sample size for this. There's a pretty good sized study over a year, really wide in terms of who they were having come in, if you had neck pain and almost 1,000 patients. What they started to discover as they analyzed the data was that there were small to moderate improvements for all outcomes, baseline to 12 weeks. Pretty much what we'd expect. If somebody's getting movement based care in a chiropractic practice, we expect there to be improvement and we've seen that time and time again in the literature, whether it is low back pain, whether it is neck pain or whether it's headaches. We do a fantastic job helping people overcome those challenges. Why? Because of everything that goes in, in my opinion, to being a chiropractor. The hands on care that we provide, the guidance we provide, the inspiration, I'll say it too at times, the hope that we provide our patients. Really the, I guess you'd say the proactive approach to how we talk about health, that's inspiring to people and it's a different thing than they're receiving when they walk into many other practices and that's a real thing and it's an important thing. Now what they found was the pain intensity Overall decreased from 4.7 to 2.7, it's a pretty good clip. The disability decreased from 11.5 to 9.4. Again, nice. And then the EQ5D, let me go back up and make sure I know exactly what that is. The EQ5D was the health related quality of life. So I call that a life effect. But that score increased from 0.85 to 0.88. And the median for the outcome change to all scores was minus two. And that's powerful. So there were great results across all outcome measures. They say small to moderate, it depends upon which one you're looking at. But moderate is a real deal thing. I spoke with surgeons at the multidisciplinary practice used to be at, and if they could clip off like 20% pain, they were really happy. So taking somebody, I'm ballparking the numbers here, but taking somebody from an 8 out of 10 to a 6 out of 10, they were like, that is a win. Taking somebody from a six to a four, that's a win. Taking for somebody from a five to a three out of ten, that is a win. And I think sometimes us as chiropractors, we're almost too hard on ourselves where we're like, wow, if somebody's a 7 out of 10, I want them to get to 0 out of 10. Or if they get to 3 out of 10, I don't know if I did a great job. I think sometimes we need to really take a step back and analyze what's going on now. We can and should be better. So I'm not saying we should shortchange ourselves, but we also need to take pride in the fact that when we're clipping off 20, 30, 40%, that's a, quite often, that's a meaningful, it's a clinically significant difference. For those patients, it is a life improvement. And especially if they're on the higher end of that pain scale, it's a life change for the better. And that's an awesome thing that we provide. And the research like this continues to show across all outcome measures that we, we do a great job. So no real surprises there. So this study found weak to moderate associations between improvements on the scales of pain intensity, disability, and that life effect outcome measurement. Their results showed that with a chosen set of predictors, disability was more accurately predicted than pain intensity. Now this is an interesting one, right? Disability more accurately predicted than pain intensity. This gets back to the age old conversations of chiropractic. I want to touch a little bit more within the study and then I'm going to give a little bit of an aside on why I think this conversation is so important. So in the study, they highlight the fact that musculoskeletal patients emphasize pain as an important goal, and pain is commonly evaluated in clinical practice. Yeah, of course, we're always taking that. Accordingly. Randomized clinical trials use pain intensity as an outcome. And although it seems relevant to assess pain, of course the poor ability to capture improvement may lead to weakness in these trials. So if you're only relying on pain as an outcome measure, you probably are leaving a lot of benefit on the table, is the way I'd say it. And this is a challenge. They say this is a challenge that needs attention and further studies through exploring why changes in pain is difficult to predict and how pain intensity can be used best as an outcome measure. And this is a really important component because a lot of us as chiropractors, we focus on functional ability, yet we're asking and talking about pain a lot with our patients. And I'm not saying that we need to stop talking about pain. It's a real thing, but quite often we trace it back. And this is just the truth of it. Is pain what drives people to your practice 90% of the time? Abjectly. No. The life effect of that pain, what can't they do as a result of that pain drove them into the practice. Where's the proof on that? The proof is that you ask patients how long you've been dealing with this for, and quite often they tell you it's been weeks, months, or years. So they're happy to deal with the pain. It's only when it's gotten to the point that it limits their functional ability. Talking about disability here, right. That limits their functional ability. It becomes a disability in their life that they seek care. And then as chiropractors, we've always, historically, for 125 years or whatever it is, we focused on on the functional ability of the patient. However, often our conversations, our outcome measurements, and how we approach practice heavily emphasizes pain over function. Now, I think that's a balancing act. I like to talk about the spine and the body. Hey, it's a balance between strength and flexibility. Right. When I think about motion, I think about it in three categories. Segmental, regional, whole body motion. And I think pain and function should be thought of in the same way. Doesn't mean never talk about pain, but it means you need to come with the understanding that pain is a very poor predictor. And pain improvement, it's a very Poor predictor. You can't really extrapolate that to other things. Functional ability, they say in the research they use the term disability a lot. They're measuring disability. Has there been an improvement in disability? We saw the stats that there were in this study earlier, but I like to talk about it on more of a positive scale where it's functional ability, as people are more functional with their movement, as they're more functional with their activities of daily living, that's impactful. And the interesting part about this, tying it to this research study, is we see that that is actually more predictive of what's going on with the patient. So don't sleep on functional ability and focus so much on pain. Pain's a real thing. It needs to be addressed in many cases, needs to be charted. However, analyzing functional ability, analyzing biomechanics, analyzing functional movement, I think is a far better and more predictive way to go about your assessment. So the researchers cite here as well. Previously, neck pain history, including previous episodes and duration and future expectations assessed by numeric scales, have been found to be predictors of pain and disability. And their findings support the results of pain history and expectations as consistent prognostic factors. So history of pain does matter. Expectations of improvement, of course, matters, but disability, in my opinion, or functional ability probably reigns supreme. Their conclusions in this study were, quote, the highest correlation between outcome change scores was found between NDI and EQ5D and lower associations with pain. The prognostic model also showed best performance for NDI as an outcome, this disability as an outcome, and the poorest for pain intensity. Previous episodes of pain does matter. If it's happened in the past, it is likely to happen in the future unless the person takes really proactive steps with the care they receive in your practice and their daily habits. But the pain intensity of itself is less relevant. We're talking about EQ5D. That's all about life effect disabilities, all about functional improvement. I view those slightly different ways on the other end of the scale, but both are critically important. So are you talking to your patients about life effect? What couldn't they do that they're getting back to doing? That's an important part of this, and it ties to expectations as well. When you're able to showcase to somebody, here's where you came in and you told me you couldn't do this. You're doing that again. You might not be out of pain, but you're doing those things again and you couldn't do it before. That's meaningful. That also sets the expectation that they're gaining improvement, which only compounds the likelihood that they will continue to improve. So I'm a big fan of this study because it highlights to us the need to discuss functional ability, to discuss life effect and to really understand that pain intensity is a moment in time, historical pain, real thing, need to be aware of it. Have they had pain in the past? Is this episodic or is this something that's been chronic? However, if it's pain intensity alone, that is a not so valuable tool in the assessment and predictor of whether or not they will get out of pain in the future. Just because they have high pain today doesn't mean they're not going to find improvement. And I'm going to go one step farther with that. It's outside of the scope of this paper. I'm going to go outside the scope on this a little bit. People in abject pain very often think they need advanced interventions. So people that have eight out of 10 pain, that's a real thing. And you see somebody in that amount of pain and it's challenging. And many of those people, because of that abject pain, it's difficult to think clearly, number one, honestly. Number two, very often they're looking for advanced intervention quicker. And that is something us as chiropractors need to be very cautious of because number one, the research just doesn't show that that's the case. Just because they have high intensity of pain today doesn't mean they should go through advanced intervention tomorrow. It means you need to really assess what's going on functionally, what's going on with their life effect, what gains can you make and then set the expectations for appropriate improvement. Those are my big take home messages on today's research study. Also, before we wrap up, want to say a few things about power step. Power step Orthotics are what I use. They're what my dad uses. They were developed by a podiatrist over 30 years ago and they are hooking up every single listener to this podcast with a professional free sample Pair Pro powerstep.com sample Pro powerstep.com sample if you use the code EBC evidence based chiropractor EBC, they will hook you up with a free sample pair. Do it. Check it out. Their insoles are awesome. They are a great company and they support me. So I'm going to ask you to support them. 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