The Exercise Research Crisis: How to Prescribe with Precision in 2026 | #522

Hello and welcome to the Evidence Based Chiropractor. I'm your host, Dr. Jeff Langmaid. On today's episode, we are talking research. This one is all about exercise for musculoskeletal pain. If you are a rehab based doc or if you just prescribe exercise in your practice or recommend exercise, this is an episode for you. This is gonna be all around prescribing exercise with precision for chronic musculoskeletal pain. How this plays out, what we can learn from the research and how to ensure that our patients get the best results possible. Now, before I get started, a few shout outs to some of our fantastic sponsors. BlueHonest Lasers. We'll hook you up with $2,500 off their full spectrum Pro VX laser. This thing is awesome. I'm gonna drop a link down in the show notes for you to check it out. Connect with their team and it is a perfect, perfect modality to your practice coming into next year. And if you're looking to step up those adjustments, leander tables save $1,000 off their series 950 using the code EBC2025. You can visit their page that I will link down in the show notes. Connect with our team, have a conversation. Our fantastic sponsors help bring the show to you each and every week and they offer you awesome discounts. So be sure to connect with them and get everything you need to make sure you are doing everything you can so your patients get the best results possible. That is what it is all about. And that ties in directly with today's episode. We're gonna highlight a study titled Precision Exercise Prescriptions for MSK Pain why the Future is About to Change. That is a pretty good title there. And we're gonna talk about why. So this deals with something that we talk about every single day in practice, which is exercise for neuromusculoskeletal pain. But here's the twist. Today we're not gonna talk about why exercise is good. We're gonna talk about why the way exercise is studied and reported has some broken components to it and that we still don't really know the optimal exercise prescription for chronic musculoskeletal pain, even after decades worth of research. So this is a new 2025 editorial in BMJ Open Sport and Exercise Medicine. And it says flat out, it is time to prescribe exercise with precision. But we can't do that until the research stops hiding the details. This is about strengthening our base of knowledge. It's about strengthening our clinical recommendations and also just really refining what we tell our patients each and every day. So this study is not a traditional experiment or clinical trial. It's actually an editorial written by a panel of international experts, including chiropractors. And they're summarizing the state of exercise research for chronic musculoskeletal pain. And the big message was, let's get this right out of the way. We know exercise works. There are small to moderate improvements across back pain, neck pain, osteoarthritis, all confirmed across multiple systematic reviews. And in many cases, exercise performs as well or better than many other conservative treatment options. But the research they highlight, they say it's pretty poorly reported. We still don't really know the optimal dose, the right frequency, the right intensity, intensity, the ideal progression, or the best way to tailor the exercise recommendations to specific musculoskeletal conditions. Now, I'm gonna stop right there for a moment. There are plenty of fantastic protocols, softwares, techniques out there that provide recommendations. I'm not taking, and I don't, I'm not speaking for the researchers here, but I'll say from my point of view, this isn't taking anything away from what's out there. This is just looking at the literature, not necessarily the application of this through every single modality. And hey, as they said at the top, exercise works. There's no question. It's just that some of the specificity around that could probably use a critical eye. Now, the reason that this probably is surprising is actually simple, is that most trials that they looked at did not report what they actually did. So it's like reading a nutritional study that says the participants ate food. You know, that's not, that's not very helpful. So this editorial breaks down what's wrong, what needs to change so that chiropractors and other clinicians can actually deliver exercise with precision. And I'll kind of correlate this, maybe unfairly, but I'll correlate this. Often we see, well, patient received manual therapy. Well, that can mean a lot of things. The question, like what, when, where, how all of those things really matter. The same holds true for exercise. When there's an quote, air quotes, exercise group. That can mean a lot of different things. And I think that's really what this study is getting towards, is that the specificity under these big buckets can make a massive difference in the outcomes associated with those interventions. So let's hit some of the big numbers because I think they're pretty shocking. Over 94% of exercise related systematic reviews were rated low or Critically low for quality. That's pretty much all of them, in less than 7% of systematic reviews evaluated adverse events. So, you know, imagine trying to, you know, prescribe a medication when almost nobody reports side effects. It's just. It's not good. Right? We want to have complete data sets. Now, only one third of the trials adequately reported their exercise intervention details, meaning things like dose, frequency, progression, intensity, adherence, supervision. All of that was often missing. And there was a high risk of bias for inflated effect sizes, meaning some exercise studies looked better than they actually were because the outcome assessments weren't blinded. And that creates a massive amount of publication bias over time as well. So studies with null results were rarely published. And that's kind of like that file draw drawer effect. Excuse me, I was just. File that one away for later. Right. So all of this really limits our ability to gain the information necessary out of the research that's been published. And that's really meaningful when we're trying to create guidelines and specifics around things.

So this episode of the podcast is brought to you by Patient Pilot, your most valuable asset, your patient list. Patient Pilot turns it into action automatically. Send weekly personalized emails to reactivate patients who already know, like, and trust you. When they click to schedule, ask a question, or refer a friend, you're instantly notified, making follow ups easy. Patient Pilot helps you help more people and grow your practice schedule. Your demo today@thesmartchiropractor.com to see the difference. Now back to the episode.

The authors in this study, they described two major barriers that were blocking progress. Barrier number one was that the primary studies were poorly reported, so the researchers often failed to include what exercises were performed, how often, how much, how the program progressed, whether the patients were supervised, what quote, unquote, usual care actually means. Again, you've probably heard like usual care a million times, probably on this podcast many, many times. But it's like, what does that even mean? Because that can mean a ton of different things to a ton of different people. Usual care, I'm gonna assume, to a chiropractor is gonna mean something dramatically different than a medical doctor. And there's a million shades of gray in between those things. So without these specific details, clinicians can't really replicate the protocol. We, you and I, we can't replicate the protocol very effectively. And the reviewers, they can't really compare the interventions with good meta analysis. The second barrier that they highlighted were the systematic reviews were pretty low quality. So most failed at really having transparent methods assessing risk of bias, evaluating adverse events as we talked about. So there's bad reporting, kind of feeding into low quality reviews, feeding into poor clinical guidance, and this creates that compounding problem, or what they referred to as a double barrier. So the solution is really just to strengthen both of those things, right. So that the primary studies in the systematic reviews start using established tools like the consensus on exercise reporting template or similar registries. Systematic reviews should use things like Prospero or osf, and the journal should require compliance. So the bottom line was, if we want precise exercise prescriptions, I like the word recommendations better, but they'll use prescriptions. If we want precise exercise recommendations, we need precise research reporting. And that goes from the ground up. So for you and I, exercise is probably a core component of what you do, of what we do when we take care of people with musculoskeletal issues. But the research foundation is kind of wobbly, so we use exercise every day. I'm sure you do for mobility work, for spinal stabilization, for hip and shoulder rehab, nerve gliding, postural intervent, all of those things. But without having that solid evidence of dose response, we're kind of flying on our clinical experience and not abject precision. And hey, clinical experience can go a long way. But it's nice when the research supports who we are and what we do and we're able to become even more specific. Now, of course, I am not a one size fits all kind of guy. So ultimately, your clinical experience, patient presentation, clinical preference, patient preference, those are all gonna play a role. But man, the research has been a little vague for a pretty significant amount of time. And when patients are asking questions like, how many times a week should I do this, how long until it helps, should I push through the pain? What intensity is ideal? The research doesn't give us great answers. Now, again, you're probably answering that with a pretty good amount of specificity based upon what you know and what you've seen. But the research could use a little help to catch up to where we're at in terms of our clinical knowledge. So you and I, we're uniquely positioned to lead here. And that's because we already blend things like manual therapy, spinal adjustments, education, exercise, and behavior change into who we are and what we do. And I'm going to say this editorial actually reinforces the chiropractic model, highlighting non pharmacologic ways that active care is important. Progressive loading is important, Personalized movement strategies are important. So as this research continues to evolve, the exciting thing is not that it needs to be improved. The exciting thing is that we're gonna be amongst the first to benefit as it continues to do so. And to me, that's really the big take home message from this research. So I think some thought processes behind this are just, you know, taking a look now is probably a great time of year to take a look at your structured exercise programs. You know, are they embedded in all of your care plans? How are they embedded? What are your recommendations, you know, what are your, you know, doses, so to speak, your progressions, your frequency, your functional goals? Really just taking a look at that and taking stock, this is the perfect time of year to do that. And I'm going to say, you know, on the vein of exercise and rehab based care, you know, if that's a part of your practice, are you talking about it right? Have you produced any blog content, video content, social media, any patient facing material that highlights who you are and what you do in that realm? Because many patients may be totally, many people in your community may be totally unaware. So as you look at your recommendations and plans related to exercise, great opportunity to highlight exactly what those are out in your community. And that can go across all patient education channels. Again, short videos, blog posts, newsletters. And you can highlight how exercise can help chronic pain, why how much you do or don't do matters, right? Why supervision can improve outcomes, which variables make the biggest difference. You can get super, super creative with that and I think that should be really, really exciting. So the big takeaway from this study is that exercise works. We know that, but the research behind exercise tends to be missing some of the details that we need to prescribe it with total precision. So the research crew, they can do their thing. Let them do their thing. We'll keep an eye out for it on this podcast and highlight new studies as they come to fruition. But from a clinical and practical sense, you should know it's a good thing to continue doing exercise in your practice. You are right where the research says in terms of how you approach neuromusculoskeletal care. And I'm just gonna encourage you, refine, take a look at your care plans, make sure that they are dialed into exactly what you're looking for as we head into next year. And, and also make sure that you're highlighting the details of that literally just about every single thing you do in your practice. You can turn that into a blog, a social post, a video and highlight that, showing people that haven't been in your practice, exposing, you know, within those four walls, people have no clue what you do. So highlighting who you are what you do, how you think about things and how you take care of people is a really, really fantastic way when you do that consistently and at scale and to build and grow a practice. Now before we wrap up, a few words about Shockwave centers of America. $500 off and a free cart. If you're looking to get involved in Shockwave, they have fantastically affordable devices that help get you going that produce fantastic clinical results. Shockwave Centers of America as well as neck care, objective assessments and cervical spine. My favorite hardware software combo for reliable assessments of proprioception, range of motion, sensory motor integration, and neuromuscular control. They'll hook you up with 10%. Thank you so much for tuning into this podcast. Whether it is your first episode or whether you have been listening for a long time, I deeply appreciate it. I hope you have a fantastic holiday. We're not missing a beat. We'll be back next Monday with a brand new episode and if you have not left a rating or review I would love it. You could give me a early holiday gift here and leave a rating or review for this podcast that helps more and more people find out about it and I hope you 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.