New Guidelines for Chronic Musculoskeletal Pain Care | Podcast Ep. 245

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid and on today's episode we are going to break down a brand new clinical practice guideline. This one is all about the chiropractic management of patients with chronic musculoskeletal pain. There's no question this is something that you can utilize and can impact your practice. Literally. Starting today, we're gonna break down what the researchers found, how you can apply it to the care that you provide and also how you can utilize this to stimulate relationships with other healthcare providers in your community. All that and more on today's episode. Before we get started, I will ask you if you have not left us a review or a rating on itunes, please do so. It helps more and more people find out about this podcast. So if you're listening on your iPhone you can scroll down and do it directly from the app. I'll also just thank you for tuning in and listening. We are coming up on 250 episodes, which is really wild. I had no particular goal in mind when I got started in terms of number of episodes, but with 250 I think we'll do something special. We'll do some giveaways, some shout outs and have some fun with that. So stay tuned over the next couple of weeks as we hit 250. But today we're talking research and we are talking about an article that is epublished already and coming out soon in the Journal of Alternative and Complementary Medicine. This is from 2020, so it is brand new and it is titled Best Practices for Chiropractic Management of Patients with Chronic Musculoskeletal Pain. A clinical practice guideline and it is a good one. I'm going to list a link to this on PubMed in the show notes, so if you want to check it out directly, you can do so. There's. But the bottom line is we all know the management of chronic pain conditions has undergone a dramatic shift over the past five to 10 years. Really nearly every single major healthcare organization is now supporting non pharmacological approaches due to the absolute craziness and pandemonium of the opioid epidemic. Also say one thing about that as we dive into these guidelines. If you did not see this, all of the progress that had been made kind of the last couple years on the opioid epidemic, that last year was the most deaths ever. So you know this is a real thing. It has not gone away. All of the attention and all of these guidelines are very, very Important towards moving people towards a non pharmacological approach. And it's really, really important. So keep your eye on that. You know, it has definitely not gone away. More deaths last year due to opioids than ever before. This is a real thing. And a lot of these patients start out with prescribed medication from their doctor for chronic pain. And a lot of it is musculoskeletal. So we can make a huge impact here. But we have to get out there in order to see these patients because if they ever make it into your practice, it's all for naught. So this new clinical practice guideline emphasizes a biopsychosocial approach to care. Includes both physically active, they'll kind of call exercise, and physically passive intervention such as chiropractic adjustment or manipulation, as well as a strong emphasis on the psychosocial factors associated with chronic pain. So approaching treatment from really a management perspective instead of a curative model, really they're saying leads to improved outcomes and a more appropriate management of expectations. So, and this is a big deal, and this is an important distinction here when we talk about management model versus curative model. You know, the goal of medications, quote, unquote, historically in chronic pain has been really just to manage pain. You go in and get your injections three times a year. You go, you go and get your prescription filled. You take one every day, you know, and that's been the reality of that. Now the bizarro world aspect of this is that people have come into chiropractic practices and you know, they're doing well, but not 100% quite quote, unquote cured, and they move on to that sort of model with medications. Right. So my point of that is that it's not a failure if somebody's not quote unquote cured due to the care that you give. A management approach is much more important when we talk about chronic pain because there'll be episodic fluctuations of pain and dysfunction. It's the management of those episodes and the time between the episodes that matters. And most importantly, the that you're doing it in a non pharmacological way. So those are really the key aspects of this. It's really a shift in thinking from curative to management with what we do, even though it's always been management on the other side. A lot of that needs to come over to what we do within active care, chiropractic. So there's hundreds of millions of people around the world struggling with chronic pain. We all know that. And the evidence is clear at this point that non pharmacological approaches could provide patients with an effective balance of efficacy and safety. Right. That's really what it is. It's a balance. We are highly, highly effective, but we're also safe. You're not giving up efficacy for safety, you're not giving up safety for efficacy. We really have both when we talk about active care, exercise, spinal manipulation, these sort of things are the hallmarks and tenants of what we do as chiropractors. And they've been shown time and time again to be the best modes of care for patients. So I'm sure that your practice is dedicated to providing these sort of evidence based strategies and helping your patients become active as soon as possible. The most important thing again is to be able to see the patients. Just because you do it is one thing, but getting patients to come in, building relationships that help patients understand who you are and what you do, a whole nother side of the equation. So let's dive into a few important quotes from the research directly, then we can break down some of what they found. So the researchers found, quote, pain prevalence has increased among United states adults by 25% from 1998 to 2014, according to a 2019 report. With 41% of people reporting pain in the period of 2013 to 2014 and at least 70 million US adults having chronic pain. 70 million out of 330 million people. 330 million people, that's not even, you know, we take the adolescents out. There's. There's maybe 150, 200 million adults and 70 million of them have chronic pain. If you don't think there's opportunity here, I don't know where there is opportunity. There's a lot of people out there struggling, suffering. There's no question the events of the last five to six months Covid people sleeping in weird positions, working from home, kids at home, stress out the wazoo, gyms are closed. That number has probably dramatically increased. So there's a lot of opportunity here. The researchers also found the Agency for Healthcare Research and Quality and the American College of Physicians have recommended that chronic back pain and other chronic musculoskeletal pain be treated initially through non pharmacological approaches. This is an important quote here. It's not only that it's the Agency for Healthcare Research and Quality, it's not only that, it's the American College of Physicians recommending, but it's initially, this is not something that should be attempted, quote unquote, after a medication has failed. What you and I do as chiropractors each and every day. This should be, and this is from the American College of Physicians, not from me saying it. For back pain and other chronic musculoskeletal pain, initial care should go through non pharmacological approaches. It's a very important distinction because if people can avoid, and we've seen this in other studies, people can avoid getting on the medication early as they can receive gains in your practice, whether it's 100% relief, whether it's 80% relief, sometimes even if it's 30% relief, it takes the pain down enough, it gives them enough functionality that they don't end up on the slippery slope of medications that lead to opioids. This is really, really critical that they're talking about initial care. And finally, the researchers found, quote, this guideline is meant to emphasize the use of evidence based approaches to chronic musculoskeletal pain management that help patients become active as soon as possible and empower themselves to manage their pain successfully. It also aims to encourage DCs to work collaboratively with other providers to provide patients with optimal resources for successfully managing their chronic pain. That sounds familiar. I think that's a, that's a really good way of saying what I've been trying to say for over a decade, which is working together with other healthcare providers, nursing not only can help build and grow your practice, not only stabilizes your revenue, not only decreases your advertising costs, but it's what's best for the patient. It is easy to say, doesn't mean it's simple to implement, but you gotta have a strategy to get there. But let's break down some of the research, some of directly what they found in this paper and really how it can impact your practice. So a couple things, they highlighted a few specific conditions. Chronic low back pain, chronic tension headaches, chronic chronic neck pain were a couple of the things. They also highlighted OA and fibromyalgia. But with those big items, right, we're talking headaches, we're talking neck pain, we're talking low back pain. These are making up tens and tens of millions of people, probably over 100 million people worldwide, no question about it. And basically what they're emphasizing throughout for all three of those conditions, I guess you could say is working through spinal manipulation, making sure people are active. You'll have active interventions. So active interventions could be exercise, could be self care at home. Right. They're actively doing things, encouraging. That is very, very important because it also builds confidence with movement, which is critically important. The other component that they're emphasizing are passive interventions. So passive interventions would be the act of an adjustment as defined in this study. And manipulation has been shown throughout their research. They were basically reviewing hundreds of papers. Manipulation, spinal manipulation, chiropractic adjustments are very effective and should be included. It's not just exercise, it's exercise. And getting the segmental biomechanics back. On top of that, they really emphasize a mind body approach. So whether that is something like a cognitive behavioral therapy, you know, things like that, you know, being able to get out there and address the underlying psychological challenges that people in chronic pain deal with is also incredibly important. This is why it's called the biopsychosocial model. Because all of these things are, you know, weaved together in the tapestry of chronic pain. So if somebody is afraid, you know, they have an injury, they're afraid to move. Now they start to have fear of movement. On top of that, there starts to become depression. And. And of course, as we know from a physiological perspective, joints that aren't moving, then they're. Then they're regionally not moving right. Then I don't wanna move my neck. Right. They had an initial injury in one spot, now they don't wanna move their neck at all. This creates a cascade of events and sensitization that results in chronic pain. In movement, exercise, I always say segmental, regional, whole body movement. Right. Segmental movement adjustments, regional movement exercise and adjustments, whole body movement, exercise. Critically important to helping people overcome the fear of movement in a controlled way, which plays into the psychological aspect. So don't, I'd say, as a chiropractor, be cognizant of the true impact you can make with these patients and for these patients, because it's there, it's real, and it is impactful. So they also break out some contraindications, which I think are always good to just do a quick review of. They sort of break out the contraindications in terms of musculoskeletal, inflammatory, neurologic, hematologic or clinician attributes. So from a musculoskeletal perspective, obviously tumors, severe osteoporosis, structural instability, surgical instability, Very, very important to rule people out with that inflammatory osteomyelitis. Ra, you know, things you want to keep a very close eye on, obviously progressive, sudden neurological deficits. You want to look at that. Spinal tumors and unstable aortic aneurysms. Very, very important things, I think, for all patients, we want to keep an eye on, but specifically for chronic pain as well. So let's break down sort of an algorithm for patient care quickly, as we come to a close, help you kind of frame this. They're recommending patients that present with chronic pain, which is pain over three months, musculoskeletal in nature. Sort of evaluate them, right? If they have red flags, refer for the appropriate management. They don't have red flags. Begin physical and mind body approaches to care, manipulation, soft tissue work, exercise and cognitive behavioral. So that's, I mean it's right there, it's directly right there. At that point, you know, if they are hitting their goals, then continue in a management instead of a curative fashion. And being upfront with your patients about that's explicitly important. However, if you don't seem to get any benefit, if you're not seeming to hit any markers at all, then certainly be on the lookout for who you can refer to. Because with chronic pain people have to be able to see improvement. So this is about improving and then managing, not necessarily just managing. So there's a fine line there. Those are all of what you need to dive into with patient goals. What are you finding, you know, during your examination? Understanding where those things come together so you can create the proper care and treatment plan. Additionally, we're going to focus and feature the this piece of research for our evidence based chiropractor members to get out in their community network with other healthcare providers. And this is just one of those papers that I know can make an impact in your practice. Evidence based chiropractor members get research each and every single month as well as our entire system and process for building referral relationships. It's how I built and grow my practice. It's how I ended up working at a couple different orthopedic groups in a surgery center. Ultimately, by bridging the gap and building relationships, you don't have to want to do that in order to have a successful practice. So building referral relationships help again, get more people into your front door, helps rectify and stabilize the income that you have coming in and ultimately, number one, helps people get the relief they need without the drugs, without the surgery, without the risks associated from it. It's what's clinically appropriate, it's what's recommended in the clinical guidelines. Now we need to get out there, have those conversations to ensure it happens in our community. So. So if you have any questions, hit me up. Jeffevinousbasedchiropractor.com Otherwise, have a fantastic week in practice and I will talk to you soon.

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