What Changes First? Chiropractic Care for Active-Duty Military Low Back Pain | #543

Hello and welcome to The Evidence-Based Chiropractor. I am your host, Dr. Jeff Langmaid. On today's episode, we are back with more brand new research all about the effects of chiropractic care at 12 weeks and 52 weeks for active military personnel with low back pain. This is secondary analysis of a clinical trial It's a good one. Lots of clinical pearls, take-home messages, and much more that we will dive into all on today's episode. But before we get started, few big shoutouts to some of our partners. Number 1, Leander Tables. You can still save $1,000 off their Series 950 using the code EBC2026 or visiting their website. Additionally, $500 off a shockwave unit with Shockwave Centers of America and a free cart. $1,500 in savings. Just for being a listener. And thank you so much for tuning in. But as I said at the top, on today's episode, all about the research. And we're gonna talk about something that you probably see in your practice every single day, and that's patients coming in with low back pain, uh, and they want the pain to be decreased. And you probably know that there's a bigger story going on than that. We call this the life impact or life effect. People who are coming into your practice for pain They're not coming in for pain. They're coming in because the pain eventually stopped them from doing something that they love. Many people, if you ask them, how long you been in pain? They will say 2 weeks, 2 months, 2 years, 20 years. So it is very clear that pain was not the motivator. It was when the pain hit a point where they were unable to do something they love to do, they made the decision to come into your practice. That could be highly varied, that life impact for everybody that comes in. They might not be sleeping well, they might be tired, they might not be working out like they used to. Maybe they're avoiding certain activities or they're just cranky. They have chronic pain. Maybe they're not playing with their kids, enjoying their hobbies, et cetera. And that is where this week's research gets interesting, cuz the study wasn't just asking, does chiropractic care help people with low back pain? It's been studied in this population a lot. He was asking a deeper question and a more nuanced question, and that was when people improve with chiropractic care, what changes first? What seems to drive longer-term improvements? That's what we're going to dive into. And I apologize if I stop a few times on today's episode and take a drink of water. My throat is not 100%, but I'm going to give 100% on this. But if you hear me stop for a moment, I'm taking a swig of water, stay lubricated over here. So When a patient's pain and disability improve during a course of care in your practice, you know, does that improvement ripple out to other parts of their life? Does it affect sleep, fatigue? Does it affect their ability to participate socially and in functions of their daily activities of daily living ultimately? And on the flip side, do those improvements drive better long-term patient outcomes?? Because that's really the kind of question that matters in practice. People don't just want like a lower pain score. They want their life back. They wanna be able to move better, sleep better, work better, feel better, and really trust their body each and every day again. And this study gave us a great opportunity to talk about those things and to talk about chiropractic through that bigger, I'm gonna say more human lens. So again, this paper was a secondary analysis. I'll drop a link down below. Of a pragmatic clinical trial looking at chiropractic care for active duty US military personnel with low back pain. And secondary analysis is important. It means the researchers were using data from a previously completed clinical trial and asking new questions from that dataset. The original trial compared two groups. One group received usual medical care alone, the other group usual medical care plus chiropractic. And again, they were all active military with musculoskeletal low back pain, of course. And the population matters because those individuals are not sedentary individuals with low physical demands. These are active duty service members. They have physically demanding jobs. Their bodies are, are literally part of their ability in many cases to work, to serve, to deploy, to train, and to function each and every day. And you're probably keen, you know, keenly aware that low back pain is one of the leading causes of disability globally. It impacts things like work satisfaction and life, daily activities, quality of life. And in military populations, musculoskeletal pain and injuries are really, really important because they can affect readiness, deployment status, and performance. And this paper points out that early treatment with non-pharmacologic approaches have been associated with a lower likelihood of military duty limitation. That's a massive deal because it frames chiropractic not just as pain relief alone, but really as part of a broader strategy for function, for readiness, and ultimately for life participation. So the clinical trial showed that adding chiropractic care to usual medical care produced better outcomes at 12 weeks for pain-related disability and pain intensity. This paper goes one step farther and they're saying what factors might be mediating those results. What improvements during chiropractic care, during the course of care, may help explain better outcomes later on? So they looked at a variety of things: pain-related disability, pain intensity, fatigue, sleep disturbance, and social role participation. And the big idea here is that health is connected, right? Our bodies are dynamic. Pain can affect sleep, sleep can affect energy, energy can affect activity, activity then affects mood, confidence, social participation, function, and much more. So In real practice, in real life, these things don't live in separate boxes. They all interact. That's why this paper was cool, because it moves us beyond that narrow pain-only conversation and towards a more complete conversation of how chiropractic can influence somebody's overall health. So they had 144 active duty military personnel, low back pain again, provided outcome data at 12 weeks or later, and they were assigned to one of two groups: that usual medical care group and of course that medical care plus chiro group. And the chiropractic group could receive up to 12 visits over 6 weeks with a chiropractor at a military facility. And importantly, this was like pragmatic trial. That means the care was delivered in like real world. So it wasn't like artificially lab-based protocols. It was just how a chiropractor would actually take care of somebody. So the chiropractors were not forced into a single treatment option. The care reflected what really happens in actual clinical practice. So there were like active and passive interventions, spinal adjustments, exercise, heat, cold. It wasn't just singularly the adjustment. It was really the totality of what you'd expect going in to see a chiropractor. And the researchers looked at outcomes at 12 and 52 weeks. So it wasn't just right after— there's a lot of papers we see that are like right after the adjustment, and that's cool, and that, that information is really valuable. But what's even more interesting is 12 and 52 weeks. Why is that interesting? We're in chronic territory, right? So the measurements that they were doing— pain-related disability, pain intensity, fatigue, sleep disturbance, um, social or participation— and all of these were kind of mediators. And a mediator is basically like, through what pathway? That was the variable. So did Chiropractic Care improve sleep, for example, because it first improved disability? Or did it improve social participation because pain intensity dropped? Those were really what they were looking for. So the average age of the person in this study, 33 years old, just about, you know, 70-some-odd percent male, 60-some-odd percent white, and the participants had a baseline average low back pain intensity of about 4.3 out of 10. The duration was pretty evenly split between acute and chronic going into the trial, and 53% had acute low back pain and 47% chronic in the chiropractic care plus medical care group. So it wasn't just a chronic pain study or just an acute pain study, it really included both. So at 12 weeks, the total effect favored the chiropractic group for both disability and pain intensity reduction, which is really cool. At 52 weeks, the total effect still favored the chiropractic group for pain-related disability, but the difference in pain intensity became pretty negligible.

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So pain intensity improved at 50— at 12 weeks, excuse me, but by 52 weeks the intensity difference was pretty small. But the disability outcomes, really important because that's like how you live your life, uh, still favored chiropractic at 52 weeks. Um, so while pain and disability are related, they're not The same thing, obviously. A patient can still have some pain, but might be functioning a lot better. And in most cases, most of the time, that's a massive win. Like, that's what everybody's looking for. So the researchers found that improvements in pain intensity and pain-related disability during the first 6 weeks appeared to help drive better long-term outcomes in sleep disturbance and social role participation. Probably no surprise there. At 52 weeks, Improvement in pain-related disability, uh, mediated 44% of the effect on fatigue, 17% of the effect on sleep disturbance, and 33% of the effect on social role outcomes. So really, really important, uh, you know, when people improved in pain-related disability and pain intensity with chiropractic care, that improvement seemed to help explain some of the later improvements in sleep and social function. And the strongest total effect at 52 weeks was among the non-pain outcomes, and that was for sleep disturbance. The total effect difference for sleep disturbance at 52 weeks was almost 5 points favoring the chiropractic group. Social role favored chiropractic, decreased from 12— though it decreased, excuse me, from 12 weeks to 52 weeks. So another important finding quickly: fatigue, sleep disturbance, and social role did not appear to drive longer-term pain outcomes. So the pathway seemed to be stronger in one direction, which was improving pain and disability during care helped drive those outcomes in sleep and life participation later on. It's a really practical insight because it suggests helping patients reduce pain-related disability early can have ripple effects into other areas of their life, which is really awesome because the effect of what you do in your practice each and every day today is going to outlast the time spent in your practice. Now, that doesn't mean you try to get people out as quick as you can. You want to make sure you're changing habits, you're changing fear avoidance behavior, you're reducing pain, you're of course improving functional ability. But even after care concludes or they move into a maintenance wellness type situation, they're still going to be getting additional ramifications, additional benefits, especially if you've made some really good inroads in terms of reducing pain early on. So this paper looked at two broad directions of the mediation. First, it was like, do changes in fatigue disturbance, sleep disturbance, and social role during chiropractic mediate longer-term outcomes? And the second question was, do changes in pain intensity and disability during chiropractic mediate longer outcomes in fatigue? So it's like, you know, the second pathway I think is the more interesting one, but they were analyzing it both directions. And what they found was when patients improved in pain and disability during the initial care, some of the longer to— longer-term improvements in sleep and uh, social participation appeared to follow after that. So when a patient, you know, think about a patient with low back pain, for example, they, they can't bend very well, they can't sleep normally, they can't sit through dinner, and they're avoiding activities. If that patient improves their functional ability early, their world really starts to open back up. They might move more, they sleep a little better, they're more confident, they're getting back to those tasks. And that is a really, really powerful aspect of who we are and what we do. And this again was a pragmatic clinical trial, so it wasn't theoretical. And the population is also really meaningful because we're looking at individuals who are really physically active, who have an occupation that is really demanding, and functional ability is absolutely critical. So I really liked this study because it highlighted, I think, what we all know and see, but in a very black and white— literally, it's a, it's a paper of black and white fashion showcasing The earlier the benefit in your practice, the more that benefit can extend out over time. And secondarily, increases in functional ability and decreases in pain early can really manifest in other additional benefits as time goes on, because quite often it's the stress associated with the disability and the pain that's preventing people from doing a lot of what they like to do. So it makes total sense to think, well, if I can reduce that, we're going to see some additional benefits. So Letting people know early on in care, we're gonna focus very early on these first few weeks of the practice. We're gonna be improving your mobility and reducing pain as much as we can, cuz that's gonna help you build confidence in your back again. It's gonna, and you're in, as those things improve, many people that come in here also notice that they sleep better and get back to more normal activity. So again, I just said a couple weeks. I didn't say, well, tomorrow you're gonna feel better and everything's fine. You're setting the stage appropriately for the patient based upon your findings and their health goals. But ultimately, in most cases, most of the time, it's going to take a little time. Uh, so letting people know the next few weeks we're focused on pain reduction and improving mobility, that's to build up your confidence. And also, you should notice in many cases that you're going to start sleeping better and feeling better when you're out and about. Simple. Again, simple, powerful language, but it helps frame what you're doing, why you're doing it, and what a patient can expect moving forward. So I really like this study. I'm gonna drop a link to it down in the show notes. And before we wrap up, few extra shoutouts. One, NovoPulse's OA Recovery Program. Osteoarthritis, you're seeing it every day. If you don't have a program, many people adding programs in for things like, you know, shockwave for joint issues, inflammatory issues, spinal decompression for obviously spinal disc issues, but you're probably missing out on osteoarthritis, which is the most common thing that walks through your front door. NovoPulse's OA recovery program is fantastic. Also, type 2 diabetes— Diabetes Reversal Group, awesome plug-and-play program. You don't need to bring anything into your practice with Diabetes Reversal Group. They actually take the referral, and it's a win-win-win. A win for the patient, a win for your practice, and of course, a nice win for Diabetes Reversal Group as they continue to help thousands and thousands of people reverse type 2 diabetes. And if you are looking to build additional revenue in your practice, I cannot recommend Grant Elliott's program Rehab Fix, the hybrid program that enables you to utilize online opportunities while retaining your brick-and-mortar practice. Absolute awesome program. Check it out. I'm gonna drop links to all of them down in the show notes below. I hope you have a fantastic week in practice, and I will talk to you soon.

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