033- Chiropractic Care and Spinal Stenosis

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Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. Today we're going to look at an award winning study that features chiropractic care and patients with spinal stenosis. Before we get started, I'll say a few words as I do each and every week about Rock Tape Rock Tape is proud to be a sponsor of the Evidence Based Chiropractor. Rock Tape offers the world's best kinesiology tape, pain relief, topicals, mobility tools and 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. 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 One other bit of housekeeping before we dive into the research this week. If you were online you probably saw that we recently launched Chiro Office coverage and that is chiroofficecoverage. And it is meant to and will be and currently is the premier chiropractic staffing service nationwide serving chiropractors across the United States. So if you are a doc who is looking to provide coverage for offices in your area where you live, or if you happen to be a doc who may need office coverage, I would encourage you to reach out to me. At chiroofficecoverage.com we have simplified and streamlined the process of both providing and getting office coverage. We've made the initial steps absolutely free and we do the legwork to make sure that we match the best docs with the best docs for the best possible outcome. So if you are taking time off, whether it's a half day or a week for vacation, healthcare reasons or personal business and you're not having docs fill in, you are losing significant revenue and your patients are continuing to suffer. Don't let that happen. Visit us@chirooofficecoverage.com It's Chiropractic Office Coverage from the name you know and trust here at the Evidence Chiropractor. So this week, as I said, we are going to dive into an award winning paper that was released in 2015. So this is pretty much hot off the press. It is titled Clinical Outcomes for neurogenic claudication using a multimodal program for lumbar spinal stenosis. A retrospective study. It was released by JMPT in January of 2015 and what they looked at is as we know, effective conservative care of patients with neurogenic claudication is extremely important because of its close association with limited mobility, diminishing independence and ultimately morbidity. Many patients with spinal stenosis experience significant symptomatology with imaging findings that may not support surgical intervention. In this ACCRAC award winning paper, researchers assessed the effectiveness of of a six week boot camp style program and that consisted of education, exercise and manual therapy for patients with spinal stenosis. Manual therapy in this study was defined as soft tissue work in combination with spinal manipulative therapy, high or low velocity. So there was some variation amongst technique. But again when they looked at manual therapy which is an essential part of the exercise, well in conjunction with exercise and education, manual therapy was soft tissue work, not well defined. But it also had of course chiropractic care. The hallmark of chiropractic care I should say spinal manipulative therapy included. Their results indicated a statistically and clinically significant improvement for patients at the conclusion of the program for the patients that went through the boot camp. So this is a very interesting study. I think a lot of us tend to see spinal stenosis every day in our practice and sometimes we may not even assume associate what we are seeing with the patient as a case of spinal stenosis. So when we use the term neurogenic claudication just to clear things up, neurogenic claudication is the symptomatology associated with the pathology of spinal stenosis. Spinal stenosis, narrowing of the central cord. In my practice, in the way I practice with Laser Spine Institute, I probably read somewhere in the vicinity of 400 films per month overread. And when I do that, we look for spinal stenosis on those MRIs and specifically we look at the axial images of the MRIs and we measure the ATP diameter of the canal. A to P diameter of the canal should be 10 millimeters or above and if it is less than 6 then it would be severe spinal stenosis. And it's graded, if you're reading reports, it's graded in terms of no spinal stenosis. There might be abutment or effacement of the central canal, which means there's no touching of the spinal cord or the thecal sac, but perhaps no compression. Then you go into mild, mild, moderate, moderate, moderate, severe and ultimately severe spinal stenosis. So when there's severe compression. Even before there's severe compression, patients often report a very textbook presentation. And what they'll report is a very limited ability to walk or ambulate without having to sit down. And I often say to patients, sort of half jokingly, I bet you were looking for the chair because if you're going to continue to go, you're going to be sitting down one way or the other. And it's better in a chair than on the floor, really. Spinal stenosis is extremely limiting for patients. It hurts typically associated with walking in a flexed position. Forward flexion, specifically the lumbar spine, allows the canal to open up as much as possible. If it's tight to begin with, the patient doesn't want to get anywhere near neutral and forget about extension. They're really going to want to walk in that forward flexed position. And also not an antalgic lean. It's going to be really down the middle as a matter of speaking the other thing, of course, again, they are looking for that chair constantly. There's a limited ability to walk. They rest for two to three minutes and they do the same distance. It's like clockwork. Another component of it, the hallmark, they are looking for the grocery cart. So if they go to the grocery store, they are looking to lean on the grocery cart. It provides a little bit of distraction and it also physically and it also gives them some relief in that flexed forward position. So when you're speaking to patients, if you're thinking nerve compression and you don't really delineate these things down in your practice on a day to day basis, spinal stenosis typically is bilateral in nature. Forward flexed position. Patient loves to have the grocery cart there. And ultimately it's a narrowing of that cord that produces that constellation of symptoms that we would define ultimately as neurogenic claudication. So these patients, from a surgical perspective and the terminal point to things here. From the surgical perspective, I don't think they're very good candidates for medication or injections because it's not doing anything to alter the anatomy at all besides perhaps reduce inflammation. But from a surgical perspective, these patients, primary spinal stenosis, they should be in conservative care for over three months. This is not something that requires one to two visits from a chiropractor or perhaps a visit to a physical therapist and right to surgery to have proper reimbursement. The patient is expected with most insurance plans to go through three months of conservative care. So this is a great opportunity. We highlighted this paper. When did we highlight this paper? This was one of our member briefs in March of 2015. So again we literally had this out hot off the press less than three months to our members to distribute to the docs in their community. You know it's all about relationship building at the evidence based chiropractor. If you are not a member then I don't know what you're doing out there. But I'd recommend visiting theevidencebasedchiropractor.com learn about what we are doing to help chiropractors bridge the gap and build referral relationships. And research like this goes a heck of a long way. So these researchers found. I'm going to go into a few quotes here. They found degenerative lumbar spinal stenosis, which refers to the age related degenerative narrowing of the spinal canal that can often lead to compression and ischemia of the spinal nerves. The clinical syndrome of degenerative lumbar spinal stenosis is known as neurogenic claudication. We basically just reviewed all that together. Next they found the mean age of the patient was 70, 65% were female and the mean duration of symptoms was 11 years for back pain and 8 and a half years for leg symptoms. So this study looked at patients that had long term chronic pain, a decade for axial symptoms and nearing a decade for the radicular symptomatology. They found all outcomes demonstrated both statistical and clinically important improvements at the completion of the program. Now, completion of the program was evaluated six weeks post treatment. So the program went through a six week program and then six weeks after the onset of the program is when they measured things out. And when they looked at the Swiss spinal stenosis score, when they looked at the Swiss spinal stenosis function index, when they looked at the numeric pain score for axial pain and the radicular leg pain all Let me repeat that all outcomes improved in the boot camp of exercise education and manual therapy. If we spend a few minutes talking about what that means, education is informing patients what we do as chiropractors best Inform patients what is going on in their body, inform them as far as what the expectations would normally be and that gives them the education to feel more confident moving around exercise. Active care is an important part of chiropractic. Quite frankly, I don't care whether you do it in your office or not, but making sure that you're giving patients the tools to have some good core stability. If you're doing it in your office, fantastic. But if you're not, make sure you're giving them the tools for an active component to their care. That's an extremely important thing long term and that was included in this study. And of course then we looked at soft tissue work in combination with the spinal manipulative therapy which they deemed both of those combined as manual therapy. Again, things that many of us are already doing in our office. I'm not the biggest soft tissue guy admittedly, but certainly I'm not afraid to get in there when necessary. And with the spinal manipulative therapy core of what we do. And again, when they looked at that it was both high and low velocity so they didn't find any differences between potentially a flexion distraction technique and a gonstead side posture technique. All outcome assessment scores improved regardless of the chiropractic technique. So just a great study to dive into. An absolutely fantastic study for chiropractic and an award winning study that showcases what we do. This gets right to the heart of everything we do at the evidence based chiropractor. If you are looking for a direct link to this study on PubMed, visit our show notes at the evidencebasedchiropractor.com podcast. I recommend you get a copy of this. All docs who were members at the time distributed this. I know it was an absolute hit by what I got, feedback I received back and it created a lot of value for the docs that they gave it to in their community and a lot of discussion which led to referrals. If you're a new member, check it out in the member's vault and don't hesitate to pick it up from the members vault. And if you are not a member again, I encourage you to do so. And one more I'll hit on it one more time before we go. Cairo Office Coverage. Your chiropractic office coverage needs from the evidence based chiropractor. Check it out and I hope you have a great week in practice Doc. I will talk to you soon. We appreciate.