CF 115: Why Steer Your Patients Clear Of Epidural Steroid Injections
Today we’re going to talk about more recent findings on epidural steroid injections and what this new information tells us in regard to how we should be directing recommendations for our patients.
But first, here’s that sweet sweet bumper music
OK, we are back and you have found the Chiropractic Forward Podcast where we are making evidence-based chiropractic fun, profitable, and accessible while we make you and your patients better all the way around. r
We’re the fun kind of research. Not the stuffy, high-brow kind of research. We’re research talk over a couple of beers.
I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.
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Do it do it do it.
You have found yourself smack dab in the middle of Episode #115
Now if you missed last week’s episode, we talked about TEN Keys To practice success. If you listen to just one episode this year, this is the one. Nobody wants to push their brew too much because then you look narcissistic but…I really think many of you can benefit from 22 years of my mistakes. Lol. That’s not egotistical. That’s just the damn truth. So go listen to that episode as soon as you’re done with this one. Keep up with the class.
While we’re on the topic of being smart, did you know that you can use our website as a resource? Quick and easy, you can go to chiropracticforward.com, click on Episodes, and use the search function to find whatever you want quickly and easily. With over 100 episodes in the tank and an average of 2-3 papers covered per episode, we have somewhere between 250 and 300 papers that can be quickly referenced along with their talking points.
On the personal end of things…..
I just returned from Key Largo, Fl so I’m behind this week. I was gone Monday and Tuesday this week so I’m doing everything I can to get all of my stuff done this week. Including this podcast. I usually start writing a podcast on Monday morning and here I am on Thursday morning getting finally started.
So, it’ll probably be a little shorter than the others
If you’ve not been to the Florida Keys go ahead and pull out your bucket list and get that sucker added asap. It was amazing. I’m usually chomping at the bit to get back to work but not this time.
I won’t take long here but we flew into Key West and drove 2 hours up the keys along the overseas highway to Key Largo. Key West is a little more raucous which will fit some well but Key Largo is a little more laid back and that’s what we wanted.
The first thought is that driving that overseas highway is a trip. I’m not talking physically. It’s a trip mentally. In some spots, it’s you, the highway, and the ocean. That’s literally it. It’s insane. We flew in and started driving. The sun went down and at one point, the sky became the exact same color as the ocean. It was some outer space experience man. I don’t know….it was crazy for this flatlander from the Texas Panhandle. Definitely a cool thing to see and do.
Beyond that, we stayed at the Playa Largo Resort and Spa and I cannot recommend it enough. My wife and I actually had a three-day spa package so two massages and a facial. I’m just going to drop two syllables / one word……Day-um.
It was awesome, their restaurants on the resort were excellent, the fires at night, the sunsets, 80 degrees every day, laying on the beach all damn day and being served funny drinks….I was not ready to come home.
But I did. And here I am in 28-degree weather with snow flurries. Whatever the hell ever. I’m trying to finagle a way to get a vacation property down there. That’s how much we loved it. It’s like an exotic island destination but everyone speaks English and looks and sounds just like you. And all the laws are the same. It’s still America.
Anyway, just go. Just make it happen.
Dino Pappas said “I think the biggest things for me were: 1). Don’t forget about yourself — We give and give and give to other people, our community, and our patients. We often don’t take care of our ourselves and our identity becomes providing for others. Don’t forget about what brings you joy. You can’t fully help others unless you take care of yourself. 2). Clinical Skills Do Not Equal Business Success…I worked hard to build my skill set, but patients don’t necessarily care about that. They care about their results, their outcome and the presentation of the business via business systems. If there’s drama in anything else (front office staff not cordial or prompt, insurance not verified, patient phone calls not made or returned) that impacts the patient’s happiness and ultimately can impact their outcome. We are all running a patient care business, not a practice and there’s a difference. 3). Begin With The End In Mind & Reverse Engineer From There: Sit down before you go into practice and create your vision board, your goals and identify what your exit will be. Engineer your life, your practice and your systems around those long term goals. Think and operate strategically, not tactically.” I agree with every word. Dino is right here in Texas and is a smart smart doctor. If you’re near him, give him a call and connect. I promise, buy him some breakfast and you’ll walk away a smarter person.
Dr. Bill Lawson who was just on our podcast a couple of weeks ago says, “I would say treat every patient as if they are your family. It is from them where you build your practice. Don’t be afraid to look outside the box. There are so many ways to create little streams of income. Say no to the scams! There are a lot of them out there. Read the Parker Principals. There’s something in that wisdom. Keep learning! Get a specialty diplomate. At the end of the day, it’s not how much money you made, it’s how much you got to keep! Low overhead equals low stress.”
For me personally, I tell patients, when I’m having a difficult time deciding what to do with them, that I just ask myself, “If this were my daughter or son sitting in front of me, what would I tell them to do?” When I approach patients in that manner, I will ALWAYS make the right decision.
Another former and future podcast guest, Dr. David Graber up in New Jersey said, “Get help but only from doctors who are where you want to be. Someone might be a great clinician and a great person, but can’t make a living in practice, don’t go to them for practice advice. Think long-term – reputation, respect, a clean conscience, profit, stress, etc. Meet people, meet people meet people. People who feel ripped-off don’t stay, return, or refer – treat people fairly. Get at least 600-1200 patients as a base that uses your services on a regular or irregular basis. Develop competency in the 3M’s of practice: marketing, management, money. Learn how to run your business or have someone else do it for you (usually your spouse or parent who has an interest beyond $). You will never arrive, especially in 2020- practices are recreated regularly. The relationships and interaction with patients are the best thing about practice, nurture & enjoy it, and never forget that or take it for granted.”
Dr. Jerry Kennedy of RocketChiro says, “1.) Get help. You aren’t ready to be successful. Trying to do everything yourself is foolish. 2.) Networking is more important than you think. The more business owners and professionals in your community who know you, like you, and trust you…the easier your practice growth will be. 3.) Calm down. Success is a process. Processes take time. You’re going to be fine. 4.) Enjoy the journey. You’re going to get older faster than you think.”
One of our former podcast guest stars and the chiropractor of the Florida State Seminoles, Dr. John Van Tassel had this to say, “Dino is absolutely right. Project where you want to be at the end then set a plan for that. Don’t acquire skills and say “Let’s see where this takes me. Be kind. Be kind to people by creating an atmosphere, an organization where you can serve them. Being kind doesn’t just mean be polite. Speak their language. Meet them where they are. Find the dysfunction and teach them the importance of correcting that, rather than just turning off the pain alarm. But there is more: As I taught a staff member recently, triple booking me because 3 different patients insisted they HAD to be seen at 8 is not being kind, not being polite, it is letting the patients run the asylum. Not one of those three received patient satisfaction that day. That’s not being kind. That’s being a doormat. You MUST stand up on your hind legs and be IN CHARGE in order to be kind and give patients what they need. You must set policies that allow you to serve patients, and do not waver from those policies. What rings to me is “real kindness gives others a feeling of hope” So it is being kind to others that you take a break to refresh yourself. It is kindness to others that you build your skillset and knowledge base. It is the drive to serve through kindness that moves you to plan who you are going to be, then execute the plan. It is with kindness that we build ourselves into a gift worth giving through service. It is through kindness that we protect ourselves in all relationships. Protect the gift.
Wow – right? I haven’t thought of kindness in that way before. What outstanding words.
Before we dive into the reason we’re here, it’s good to support the people that support evidence-informed practitioners. Well, ChiroUp certainly does just that.
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This save you so much time – no more explaining & re-explaining your patient’s care, because they have access to it right there at their fingertips.
You can be confident that your patients are getting the best possible care, because the reports and exercises are populated based on what the literature recommends and isn’t that re-assuring? All of that work has been done FOR you by people that are deep into the research.
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The first item is called “Comparing the short-term cost-effectiveness of epidural steroid injections and medical management alone for discogenic lumbar radiculopathy” by Pennington et. al. published in Clinical Neurology and Neurosurgery in get this the date on it is actually April of 2020(Pennington Z 2020). That’s as smoking hot as it gets. Stand back it’s steamy…
Why They Did It
Epidural steroid injections (ESIs) are a commonly used treatment strategy for low back pain and lumbar radiculopathy. However, their cost-effectiveness and ability to mediate long-term quality of life (QOL) improvements is debated. We sought to analyze the cost-effectiveness of lumbar epidural steroid injections (ESIs) compared to medical management alone for patients with lumbar radiculopathy and low back pain.
How They Did It
- QOL outcomes were prospectively collected at 3- and 6-months following initial consultation
- Metrics included the EuroQol-5 Dimensions (EQ-5D) questionnaire, the Pain Disability Questionnaire (PDQ), the Patient Health Questionnaire (PHQ-9) and the Visual Analogue Scale (VAS)
- Cost estimations were based on Medicare national payment amounts, median income, and missed workdays
- One hundred forty-one patients met our inclusion/exclusion criteria
- 89 received ESI and 52 were treated with medical management alone.
What They Found
- Both groups showed improved scores at 3 months but were similar to one another
- No significant difference was seen between groups for total costs or cost-utility ratios
- Medical management alone was more cost-effective at both points owing to lower expenditures, however, these differences were not significant.
Wrap It Up
The authors concluded by saying, “Epidural steroid injections were not cost-effective at either the 3-month or 6-month follow-up period. At 3 months, epidural steroid injections provide similar improvements in quality of life outcomes relative to medical management and at similar costs. At 6 months, neither epidural steroid injections nor conservative management provides significant improvements in quality of life outcomes.”
My first thought is well….No soft serve, Sherlock!!
Then, my next thought is that we’ve covered research showing only limited effectiveness in the short-term and absolutely zero effectiveness in the long-term and no difference in whether a patient ends up having surgery.
Then we covered research demonstrating how steroid shots put the bones of certain individuals at a disadvantage down the road.
We have also covered research showing how chiropractic beats them at a lower cost, non-invasively, more effectively, and non-pharmacologically.
No brainer here folks. Just always default to the recommendations from the American College of Physicians recommending spinal manipulation, acupuncture, and massage as first-line therapies for acute and chronic low back pain and steroid injections as a last-line option right above surgery. After every other option has failed. I’ve cited that paper in the show notes for episode 115 at chiropracticforward.com It was authored by Qaseem, et. al. Go get it. (Qaseem A 2017)
Since I’m short on time this week, that’s all we’re covering for this episode but it’s new, it’s fresh, and it’s HIGHLY relevant.
Recommend to your patients that they do NOT get these epidural steroid injections. Epidural steroid injections have side effects. Epidural steroid injections have consequences. Epidural steroid injections don’t typically work and if they do, it’s strictly short-term relief with absolutely zero long-term benefits. If you’re an evidence-informed doctor, you are the one that should be fixing them. Nobody else.
Remember the evidence-informed brochures and posters at chiropracticforward.com.
I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment rather than chemical treatments like pills and shots.
When compared to the traditional medical model, research and clinical experience show us patients can get good to excellent results for headaches, neck pain, back pain, and joint pain to name just a few.
It’s safe and cost-effective can decrease surgeries & disability and we do it through conservative, non-surgical means with minimal hassle to the patient.
And, if the patient treats preventativly after initial recovery, we can usually keep it that way while raising the overall level of health!
At the end of the day, patients should have the guarantee of having the best treatment that offers the least harm. When it comes to non-complicated musculoskeletal complaints….
Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show and tell us your suggestions for future episodes.
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We can’t wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.
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About the Author & Host
Dr. Jeff Williams – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & VloggerBibliography
Pennington Z, S. M., Lubelski D, Mehta V, (2020). “Comparing the short-term cost-effectiveness of epidural steroid injections and medical management alone for discogenic lumbar radiculopathy.” Clinical Neurology and Neurosurgery 191.
Qaseem A (2017). “Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians.” Ann Intern Med 4(166): 514-530.