032- Chiropractic Adjustments after Steroid Injections

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Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. Today we are going to dive again back into the research with a study from JMPT that was released in September 2004. The title is Spinal Manipulation Post Epidural Steroid Injection for Lumbar and Cervical Radiculopathy A Retrospective Case Series. This is a very unique piece of research and and we're going to dive into a lot of different aspects of it, so stay tuned. But before we get started, I'll say a few words about Rocktape. Rocktape is proud to be a sponsor of the Evidence Based Chiropractor. Rocktape offers the world's best kinesiology tape, pain relief, topicals, mobility tools and functional fitness accessories. New from Rock Tape is Rocksauce Chill, a powerfully cool pain relief topical in a convenient roll on with 6% menthol. It's stronger than the freeze competition. The they are more than a tape company, they are a movement company. Learn more and get access to your medical discount by visiting rocktape.com also I know we have a lot of chiropractors in California listening each and every week to the Evidence Based Chiropractor podcast. I will be out in California next month in August speaking at the California Chiropractic Association Sports Symposium. And that's the third week in August and I believe I'm speaking on Friday, August 19th. I'm really looking forward to it. And if you happen to be in California, please check out the California Chiropractic association sports symposium. Dr. Paris and Kim put on an absolutely fantastic program. I am honored to be a part of it again this year. I spoke at that last year. So please shoot me an email. Jeffevidence Based Chiropractor if you're going to go, I'd love to meet up and chat, but I will be there the third week in August. So without further ado, let's dive into this week's research again. It is a piece from JMPT from September 2004 and it's titled Spinal Manipulation Post Epidural Injection for Lumbar and Cervical Radiculopathy A Retrospective Case Series as we know and see every day in practice, cervical and lumbar radiculopathy is often multifactoral in Nature. When I speak to patients, I point to three items. One, it can be injury, of course, micro trauma, big trauma, some sort of injury. Number two, these symptoms can be brought on by age. Walking upright under gravity does a number on our body. And certainly the third component is genetics. Build. What do the angles look like? Were they predisposed to injury or degenerative changes earlier on in life? Or were they built with wide canals with good disc spaces and they maintained longer? So I think those are always three big pieces to look at when patients ask, why is this occurring with me? And when framed appropriately, I think they typically have a great understanding. The bottom line is mechanically, compressive forces commonly lead to an inflammatory response and eventual nervous system sensitization. So when there's a mechanical compression, whether by a disc, ligament or bone, causing radiculopathy, typically disc, ligament and bone are of course, are compressive tissues if it's in a foraminal canal or if it's in the central canal. We're talking about either nerve root compression, foraminal stenosis or central stenosis. Typically, your foraminal stenosis is going to provide the radiculopathy as seen in this study. And a combination of conservative care options may be the best solution for patients who are unresponsive to single treatment protocols. And a multimodal approach can address the full spectrum of pain mechanisms. Inflammatory, mechanical, et cetera. Research has shown that spinal manipulation, of course, is safe and effective for patients with radicular pain. Nervous tissue stimulation, facet, joint gapping, decreased intradiscalcal pressure can all occur during a spinal manipulation and provide really a foundational basis for the mechanism of action. And if you've been listening each and every week, that should sound very familiar because that's exactly the type of research that we have dove into every week here on the Evidence based Chiropractor podcast. Clinically, it's important to consider that patients suffering from radicular pain may benefit from a common combination of manipulation post injection. So this study I think really hones in on a few different aspects here. Number one is, as you can imagine, I'm not the biggest proponent of injections, specifically epidural steroid injections. The efficacy is EH at best. And with 9 million given per year, 25,000 a day, I don't think there's anything to say that at this point that they're not already overblown. They're already being performed too often in coordination with their effectiveness. The effectiveness does not substantiate the amount of injections that are being given so the other aspect of that is typically when a patient is sent for an injection, it's kind of a terminal point before surgery. So this is where I feel like the study has significant value, is showcasing that even when a patient gets an injection, so the primary care physician may send that patient for an injection. They can also concurrently, and the research substantiates that they should send that patient for chiropractic care for manipulation or adjustment along with the injection. And this gets to the heart of things. Injections are typically interventions that patients don't like. The effects are not great if they are, they last a very short time. And of course, as we know, when you perform the injection, there's steroid, the feel good medicine. Of course, there's anti inflammatory nature of that as well. But by itself, good luck. It's very unlikely to help a patient get where they want to be without some sort of ancillary, active or passive component. And this study really heavily supports chiropractic care, spinal adjustments, spinal manipulation, as the brother or sister to the injection when prescribed. So let's take a look at a few quotes that the researchers found regarding these findings. The clinical rationale for the use of spinal manipulation is to increase the range of motion of the functional spinal unit and also to modulate sensory input to the central nervous system. Great quote. Because it touches on what we do as chiropractors, which is impact the central nervous system by addressing functional spinal units. They also found the majority of patients showed a positive response with only one treatment. 76% of patients who received chiropractic adjustment or manipulation post injection had a positive response with just a single treatment that is exceptionally powerful. Three they found theoretically, epidural injections are proposed to address the inflammatory and central components of spinal pain, whereas spinal manipulation is proposed to address the mechanical and neural aspects of the pain syndrome. So this touches on the multifactoral aspect of pain. Sometimes there can be a compressive force and an inflammatory response, muscle spasm with that. We see patients like that every day. And in some cases, perhaps injections may be able to help get those patients over the hump. Absolutely. Never as a first choice. But you and I both know with the numbers that we touched on earlier of 9 million per year, 25,000 perhaps per day, that primary care physicians are sending for injections daily. So while we might not stop the tide of that tomorrow, it's important to showcase what we can do at least concurrently, if not in place of that. And with this, they are touching on the fact that the epidural steroid injection with the inflammatory and central components is only addressing half of the equation, so the other half is left untouched unless there's ancillary care and in this case spinal adjustments. Finally, they found the data suggest that spinal manipulation post epidural injection is a safe non surgical procedure to use in the treatment of the patient with radiculopathy of spinal origin. So that's quite clear as far as that goes. Really, this study frames the treatment plan or plan of care that patients should already be going through, but are not, which gets to really the middle or the heart of why we as chiropractors those of you listening to the podcast right now, and certainly all the members of the Evidence based chiropractor, we've actually featured this as a research brief in June of 2015. But members of the evidence based chiropractor have been promoting this research now for months or years in some cases. But if you haven't, you have to reach out with research such as this. I'd welcome you to be a member of the Evidence Based Chiropractor. Of course, you can check that out@the evidencebasedchiropractor.com but in the bare minimum, you should be aware of this research and be letting your patients know. Because you and I both know you'll probably have a patient this week that'll come in and say, well, I'm going to discontinue care because now I've been recommended get to get the injection as if that's a stop point for chiropractic and a start point for pain management. And the research concurrently and conclusively shows that chiropractic care should be done in coordination with injections. And this again is cervical and lumbar radiculopathy. So it encompasses both aspects. Now, when they looked at the distribution of clinical outcomes of no improvement, temporary improvement or significant improvement, I think the biggest thing with that is that the patients that had chiropractic care had significant improvement substantially more than those who did not. So using these two modalities in concert, of course we'd like to keep patients from having to get the injection in the first place. But this study touches on those patients that are already going to have injections. And we both know again there'll be plenty of patients coming into your office that are going to have an injection. So to be able to showcase to them and perhaps first, if not secondary showcase to their care providers, the pain management docs, the internal medicine docs, the primary care physicians, the physiatrist, all of those physicians that while that patient may be getting that injection, it's going to be a good idea for them to seek chiropractic care to address the other half. So the medicine, the epidural injection can take care of some aspect of the pain, but the active component or passive, depending upon which way you want to phrase it in a chiropractic office is really going to help them get where they want to go. So I'll have this linked the paper linked in the show notes. Again, this is Spinal Manipulation Post Epidural Injection for Lumbar and Cervical Radiculopathy A retrospective case series jmpt September 2004. You should definitely get familiar with this research if you have not if you have any questions on it. As always, feel free to shoot me an email email@jeffevidencebasedchiropractor.com One more item that I'll touch on before we go today. You may have saw we recently launched Chiro Office Coverage. It is an elegant, reliable solution for your office coverage needs. If you are a provider looking to provide coverage, or if you're a clinic director chiropractor who may need to take a vacation and is looking for coverage, go to chirofficecoverage.com I believe next week's podcast we will focus a little bit more on Cairo Office coverage, but please check that out and I hope you have a great week in practice Doc. I will talk to you soon.

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