Spinal Manipulative Therapy for Older Adults with Chronic Low Back Pain | Podcast Ep. 357

Foreign welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. This week we are back with the research. We are taking a look at a study that came out earlier this year. It is a good one, came out in European Spine Journal and it is titled Spinal Manipulative Therapy in Older Adults with Chronic Low Back Pain in Individual Participant Data Meta Analysis. Lot to take in right there but there is a lot of really interesting clinical pearls, good takeaways and confidence builders. Ultimately in this study we're going to break it down on today's episode. Before we get started, I want to say a few words about the smart chiropractor. The smart chiropractor powers your patient journey to provide you with more qualified leads, more new patients, better retention and more consistent reactivations without spending any money on advertising. How do we do that? We do that by guiding the patient journey and really utilizing a sophisticated system of email marketing that's automated for you, that generates results. If you want to check that out, you can head over to thesmartchiropractor.com again, that is the smartchiropractor.com but as I said at the top today we are talking research study that came out in May of 2022, earlier this year in the European Spine Journal. And again it is titled I'll drop the link down in the show notes or episode notes. It should go over to pubmed if you want to check it. Spinal Manipulative Therapy in Older Adults with Chronic Low Back Pain and Individual Participant Data Meta Analysis. So what were they taking a look at? They were taking a look at pain and functional status examined at 4 weeks, 13 weeks, 26 weeks and 52 weeks. And I love that longitudinal perspective because it gives us a great idea of what happens down the road. And that's really important because as we've talked about on previous episodes, this transition or potential transition from acute to chronic pain is a really big deal. That is something we want to avoid at all costs on a physiological level, on a psychological level, on an interventional level. It's a big deal to thwart things at acute before they become chronic. Nobody better than us to do that. I think the research shows that pretty clearly that's a big deal. There's a secondary component to this as well and it's what I call the roller coaster. A lot of times I talk about the rollercoaster in terms of marketing. You do things and when you don't need patients, you have patience, all this kind of stuff. But patient flow. But there's also a roller coaster in your patient's mind. And what I mean by that is related to their symptoms. And this happens. This sounds crazy and I realize it, but it actually happens day in and day out. Patient comes into your practice, they get great results with it. Let's say they have low back pain, for instance, with this study. They have great results with your care. You take care of them X amount of visits, they're feeling good, they then drop out of care of your practice. They've either completed active care and you didn't offer maintenance or wellness care, which I think is a bad idea, or they've just fallen out of care as time went on cause they were feeling better. Well, I can tell you often if they've had what's the best predictor of tomorrow's weather is today's weather. If they had an issue before and they go back to the same lifestyle as they had, that brought on the issue before they. The issue is very likely to come back in the future when that issue comes back. And I say this as somebody who practiced within orthopedic groups. I would then see these patients come in, they would sit down with me in an ortho group and say, wow, you know, what have you done? What are you struggling with? I have low back pain. What have you done for in the past? Well, I went to a chiropractor when I had this go on about a year ago or two years ago. And the chiropractor took great care of me and I felt better once I got out, no question. But it came back and I sit there, you know, sitting there like, what are you doing in an orthopedic? You got great results at the chiropractor a year ago. And in their mind it was that it quote unquote didn't work because it didn't keep them pain free for life. This is the healthcare level of knowledge that many people have now. How do you get around that? How do you take care of that in a really proactive way? One by having really great conversations with your patients so that they understand this is likely to come back if you keep doing the same things that brought you here in the first place. So that is why we recommend X, Y and Z or why we would like you to do X, Y and Z. We want to minimize that. If you don't do these things, it is higher likelihood that this issue could pop up in the future. So don't be surprised and don't think you need advanced intervention just because something comes back as a Matter of fact, if you find relief or you are finding relief in our practice, it's a great indicator that if and when this comes back, you'll find relief again. Little tip there in terms of patient communication, because many of the patients that you don't ever see again, I hate to break it to you, it's not that they lived and went off happily into the sunset, it's that something came back and they went somewhere else. That's just the harsh reality. But we can prevent a lot of that by having great communication. This ultimate tie in right here. But that's also why the smart chiropractor is so great. Staying top of mind, consistently communicating with your patients keeps you in their ecosystem, keeps them in your ecosystem, they're more likely to come back to you instead of just letting them go off forever. Weekly email newsletters, monthly campaigns, going out, critically important to retention and reactivation in an ethical way. 99% of chiropractors don't do anything about this whatsoever. If you want to be different, it'd be better. I'd recommend checking out the smart chiropractor. But in this study specifically they looked at 10 previous studies which included 780 some odd people, of which 261 of them very specific, there were between 65 and 91 years of age. And basically what they found, we're gonna break it down, but they said there's moderate quality evidence that spinal manipulative therapy, that's always really hard to say, results in similar outcomes at four weeks to kind of standard medical care or the other stuff that's recommended. Break that down. But let's pause on it and keep trucking through some of the data here. So we know low back pain is a big deal. Every time I say this I kind of say the same thing, which is it sounds like old hat, like, yeah, we've heard this a million times, but you need to hear it again because this is a really big deal. It's the leading cause of disability and the number one cause of lower quality of life in older adults. It's one of the top three reasons, top three reasons why older adults visit a general practitioner, a medical doctor, gp, internal medicine, primary care doctor. It's one of the top three reasons. This is where we talk about evidence based chiropractor on the referral side, 30%. Typically there's sway here, but 30% of the daily volume in a primary care internal medicine GP practice is related to neuromusculoskeletal care. It's insane. Number one, that can be disheartening when you're like, gosh, how come I'm not getting a gazillion referrals? Because there's a gazillion people in your community visiting GPS right now. 30%. You look at how many primary care doctors are in your town, it could be dozens. If you're in a city, it could be hundreds. And literally 30% of their daily volume is neuromusculoskeletal care. And only a fraction of those people have red flags. So an overwhelming majority are applicable to be referred into your practice if you bridge the gap and build the relationship, which is why it's so important. But studies have demonstrated that low back pain in older adults often lasts longer than three months and, and is usually undertreated or mismanaged. Now that's an interesting fact right there. So older adults tend to have chronic pain. It's longer than three months, they tend to have chronic pain. So that's a big deal. Now, there's a couple things with that. One, important to get, be able to take care of them earlier on. So it doesn't get there. Very, very important. The second component is those with chronic pain. You're dealing with a host of other issues. Fear, avoidance behavior, catastrophizing. When you're older, you've been dealing with pain, there's sensitization, there's a lot that goes on right there that when they walk in your practice, you're gonna have to overcome. And also I think this is where it ties in. I'm sort of putting my own spin on this. But when it talks about being under, treated or mismanaged, undertreated is a big deal. You know, somebody that has very poor habits, they've been dealing with pain forever. We all know two to four adjustments, visits to the practice, most people are gonna feel a bit better. But pain is literally the last thing to come and the first thing to go. And helping people understand that this is about functional ability. So whether you're using DNS, sfma, motion palpation, a combination of all these, like, take a look and analyze what's going on functionally with the people in your practice, because it's gonna really be able to inform how you can best take advantage, take, take care of them in a really, really meaningful way, as opposed to feeling like somebody's taking advantage of a patient because they're treating them longer than necessary. Number one, as a chiropractor, we are just about the safest thing out there. Number two, movement based care is what people should be doing. Number three, the confidence instilled in people, even if they're not adjusted, the lifestyle benefits that we can provide. This notion of over treating, if you're saying somebody should come in for X amount of visits, yes. Do many people need 36 visits in 27 days? Probably not, thankfully. But you know, nitpicking on, you know, whether it's 6 visits, 12 visits, 18 visits, 24 visits is insanity to me. When we look at the lifestyle and conditions that people are walking around with that are mostly lifestyle induced, that we can assist with, help with Coachon and have movement based biomechanical challenges underpinning many of them. This is a really big deal and I think we need to take a look inward and really say, who's the best people to take care of this? It's us. How do we go about that? By literally telling the truth. These are processes and the process to get well. While pain might go quickly, the process to get well is going to take a little bit longer. There's nothing wrong with that. As a instructor of mine, many people know him from the nutrition world. Dr. David Seaman used to say at Palmer College of Chiropractic, Florida, many years ago he would say getting a crunch every now and again is not a bad idea. And I could not agree with that anymore. That's maybe a crude and funny way to say it, but it underpins a philosophy that I have. Getting adjusted every once in a while is a really good idea. We all have lifestyle deficiencies, we all have movement deficiencies, and chiropractors are great people to take care of that. So older adults also tend to have more than one illness and the odds of having low back pain are actually higher in adults with multiple comorbidities. So probably no surprise there. But also important to keep in mind. You see people walking around with all of these health challenges. Chances are they have back pain and that back pain could be limiting them from the movement they need to be getting and doing each day to get well from some other things as well. If they're unable to exercise now, they're gaining weight now they may be depressed now, their blood pressure's going crazy, now they're eating more and certainly their cardiovascular health goes down. So it's important to treat, to find treatment options which are safe and effective. No question about that. So finding options should be a priority. And many systematic reviews and meta analysis have taken a look at how does smt, how does spinal manipulation work? And their results suggest that it is an effective intervention for both the reduction in pain and the improvement in function. And that's a big deal. So with this study, occlusion criteria were patients with low back pain, with or without leg pain, more than 12 weeks duration. And they found 10 RCTs, randomized control trials, nine compared SMT to exercise therapy and one took a look at SMT compared to standard medical care and drumroll, please. What they found was pain and function improved by the end of treatment. And this improvement was sustained up to 12 months after randomization for all groups. So can we help? Absolutely. And the interesting thing about that is when they say it was sustained up to 12 months in many of these studies, the patients actually weren't treated for that entire time. So the, I don't know what you'd really call it, the dose effect response maybe is what I'll say. You take care of somebody now, there's actually some lasting benefits there. Now I want to say that's also not a, I want to say escape to get out of actually monitoring what's going on with the patient long term, but it's beneficial because it's not just they get an adjustment. By the time they walk out the front door, they're back to where they. Back to where they started. Now when they start care, they might report that, of course, because they haven't had any changes really occur yet. If they're like, gosh, like between my last visit and this visit, it kind of came back, that's normal. But once they are feeling good, that feeling good should sustain for quite a while. So the mean difference for SMT compared to recommended interventions was negative 2.56 on a 10 point scale. That's a big deal. 25% differential is incredibly awesome. Also, after one month, these effects appear similar over the subsequent 12 months. So what's the predictor of tomorrow's weather, today's weather? If after one month they're doing well, that's a really good indication that 12 months from now they're going to be in the same spot, which is great. So that gives you a month to get to. I mean if we had, if you think about man, if money, insurance, if, you know, communication, if everything were no, no issue whatsoever. Imagine if you had a month to work with every patient that worked, walked in your front door, man, the changes you could make would be absolutely crazy. And the lifestyle benefits they'd continue to have from there I think would be really, really impactful. So the bottom line is they say there's moderate quality evidence that SMT has similar benefits than recommended interventions at all points for functional status. Now the part that they don't talk about here, which I think is one of the most important points of this, are that there's so few harms. And this is a really important point. Now, when you're putting it against exercise, the harms are probably similar, super, super low. But when you're putting it medication, injections, NSAIDs, obviously surgical intervention, the harms from what we do are so low, the benefits are so great and there is nothing like getting in there. Exercise is great. I think of it as whole body, I think of it as regional. And yes, when you're going through yoga, when you're going through exercise, sometimes you can have release of a joint, but there is really nothing aside from getting in there and putting your hands on somebody, for lack of a better way to say it, and getting in and helping. Segmental motion, then an adjustment, then a manipulation. And segmental motion is the foundation of regional motion and the foundation of whole body motion. If you have poor segmental motion, if you have joints that are all locked up, your regional motion is not going to be optimal and a whole cascade goes down from there. So the findings in this study, they say have important implications. The recent Lancet series suggests that SMT should be considered a second treatment option following the more commonly recommended treatments. Or our results suggest that SMT produced similar effects to other recommended interventions and probably should be on par at the top right there. So great study, lot of take home messages, a lot of asides in this episode as I kind of went through and gave some of my communication tips and strategies as well as just encouraging you to think about things a little wider, think about things a little deeper, think about really how you can guide your patient's health over the course of their lifetime. They might not come into your practice every week for a lifetime by any stretch of the imagination, but, but they certainly can be involved in the ecosystem of your practice, which will pay dividends in their health. Where else are they going to get the information that you can provide? Probably not too many places. So don't shortchange them, don't shortchange your practice. Get out there. Ensure people understand what's going on with their health, ensure that you are communicating consistently and you and they are going to be better for it for sure. So as we wrap up today, I want to say a few words about power step orthotics. If you have ever checked out orthotics, if you've never checked out orthotics, now's the time to do so. Powerstep. They support me. I want you to support them. I'm just gonna make an ask right there. They'll hook you up with a free sample. Head over to pro.powerstep.com samplepro.powerstep.com sample use the code EBC evidence based typewriter EBC. 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We'll keep our eye out for you. So have a fantastic week in practice and I will talk to you soon. Thank you for joining us on this episode of the Evidence Based Chiropractor. If you want to grow your practice, come back for next week's episode. If you want to grow faster, visit the evidencebasedchiropractor.com and join our MD Marketing membership today.