130- Clinical Predictors of Low Back Pain

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Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmead. This week we are looking at a great piece of research which took a look at predictive elements of low back pain. So a few things that I know all of us look for in daily practice, questions that we ask, findings that we see and how that plays into the development of low back pain. So it's a great, great episode, a great piece of research that we're going to review today. Before we get started I will say a few words about Rock Tape. Rocktape is revolutionizing the soft tissue world again with new Rock Blades Mohawk. Featuring three tools in one, a surgical stainless steel hand polished tool and two attachments silicon sleeve and an ABS comb. Rockblades Mohawk unlock never before seen treatment protocols to reduce pain, improve mobility and address issues like nerve glide and neuropathy. 175 bucks and you can check out the educational courses@rocktape.com Mohawk so as I said at the top we are going to talk about a paper which showcased the predictive capacity of low back pain. This was released just last year 2017 by BioMed Central and it is titled Restriction and Lateral Bending Range of Motion, Lumbar Lordosis and Hamstring Flexibility Predicts the Development of Low Back pain. A Systematic Review of Prospective Cohort Stage Studies. I have this linked in the show notes so you can check it out on PubMed or on BMC and I'll repeat that title one more time. Restriction in Lateral Bending Range of Motion, Lumbar Lordosis and Hamstring Flexibility Predicts the Development of Low Back Pain. A Systematic review of Prospective Cohort Studies. So this is a nice one because it looks at all of those elements, we're gonna go deeper on each one, but it looks at a variety of factors that in my mind are applicable to what we see and do every day in practice and, and how those contribute to back pain and how they contribute to the prediction of that pain. So it's a great paper, it's very pragmatic and basically what the researchers did is they scoured the PubMed article, they scoured everything online, they came up with 12 research papers that ultimately formed the basis for their findings. And we know that with a lifetime prevalence of low back pain, you know it can be 80 plus percent, almost 90%. Now, the interesting part about that 23% of people develop chronic back pain. So this is really the implications of research that showcase predictive mechanisms is it's about not only the intervention, right? There is no question that the literature supports what we do, the efficacy of chiropractic care, chiropractic adjustment, spinal manipulation. But when there are predictive assets or predictive type of findings, that's also important because if you can start to develop some patterns and see some patterns early on, predicting things early gives at least some opportunity down the road to start talking about prevention. And to me, that is really where the rubber meets the road and the exciting part of where the literature like this can move forward. So as we go through, I'm gonna read a couple quotes from this paper to kind of set the stage and get you caught up with what their thoughts were. So they found, quote, based on the results of our meta analyses, restrictions in lateral flexion range of motion, hamstring flexibility and lumbar lordosis were found to increase the risk of participants developing low back pain. So just a take on the title, and if we break that down, let's look at it one more time. Their predictors of back pain that they found across the literature was restriction and lateral flexion range of motion. That's an important one, right? That's part of our examination process. And restricted joints, restricted lateral bend is something that can be addressed and with chiropractic care, hamstring flexibility, soft tissue work, right? Tight hamstrings that lower cross syndrome and lumbar, lower doses. For many docs out there that are shooting X rays and looking at the radiography, you're taking a look at George's line, you're looking at that curve. And when there is a inadequate lumbar lordosis, when there is less than the ideal curve, it does become a predictor for low back pain. So let's take a look at a couple other quotes as well to set the stage. Quote, Lateral flexion, in addition to sagittal plane motion, facilitates the spine to absorb force and is perhaps due to this restriction in motion and therefore stiffness in the lower back that participants developed low back pain. We found a reduction in lateral flexion range of motion to be prospectively associated with the development of lbp, which concurs with the results previously reported in a systematic review. So again, lateral flexion, it's what many of us are doing, probably on a visit by visit basis. Of course, it's on your examination, part of your examination. But Visit, Visit by visit. Excuse me, Visit by visit. Looking at how somebody is moving segmentally, right? Whether it's with palpation, whether it's with a visual look at it. You know, identifying these restrictions is very, very, very important because ultimately that restriction and lateral bend is a predictor of low back pain. So important to keep an eye on that. So they also found, quote, our findings are contrary to this and suggest that a reduced lumbar lordosis is an important musc risk factor for the development of low back pain. So previous research was a little bit divided on whether a hypo or hyperlordosis of the lumbar spine contributed to or could be a predictor for low back pain. These researchers are saying reduced lumbar lordosis, a hypolordotic lumbar spine, in their opinion, is definitively a predictor for low back pain. So again, if you are checking out imaging, sometimes patients come in, they have previous imaging. You can, of course, take a quick peek. If they have a previous mri, perhaps you're shooting pictures in your office as well. These are all opportunities to take a look at the lumbar spine. Now, you know, visually, you know, if you don't have the radiography, visually is a little bit tougher. There's a lot of variability with that. But quite frequently you can also get a decent initial idea just by your visual analysis during examination. And finally, the research has also found, quote, restricted hamstring range of motion has been linked to reduced lumbar lordosis. And it is perhaps through this mechanism and subsequent stiffness in the lower back that a significant association is demonstrated. So again, that hamstring tightness, right, Hamstring tightness can wreak havoc with the pelvis, with the hips, and ultimately, the compensatory nature, you know, compensatory happens in the lower, lower lumbar spine. So when we look at how the hamstrings in the lower extremities, that closed kinetic chain, as we're kind of walking around and doing a lot of activities throughout the day, how that impacts the lower lumbar spine is very, very important. And when you have tight hamstrings, when you have a decreased lumbar curve, when you have a decrease in the ability to laterally flex, these are all important factors that are predictors of low back pain. Now, consequently, let's flip that and say if you can address some of these items, then you are doing some very big, you know, benefits. You're providing some significantly nice benefits for individuals to perhaps not have back pain in the future. Again, getting towards that prevention model. These researchers are not necessarily saying that and the literature out there is evolving, but I just want to throw it out there as a point that if you can conversely improve the hamstring, you know, decrease the tightness in those hamstrings, for lack of a better way to put it, if you can improve that lateral bend, that lateral flexion in the lumbar spine, and if you can get back to a normal lordosis instead of a hypolaridosis, then you've done a couple different things. You've taken a few predictors of back pain off of the table. So you're setting people up for success. So identifying some of these things with your current patients is very, very important because as you address different components of this, you're able to take different factors which could predict a future episode of low back pain potentially off the table. So that is the very nice thing and the powerful aspect of this pat paper, in my opinion. And in conclusion, the researchers. I'll read one more quote and it kind of rounds up what we've spoken of all episode, but they found in summary, we found that a restriction in lateral flexion and hamstring range of motion, as well as reduced lumbar lordosis were associated with an increased risk of developing low back pain over a 12 month period. So again, just putting context around that, we're looking at that lateral bend, we're looking at that lumbar curve, and we're certainly checking out those hamstrings. These are great items to look for with your current or new patients and start addressing and see how your clinical outcomes change. I estimate that if you are able to really do some good work on those items, those predictors that I think there's a potential that you could see a reduction in future episodes or potentially even a prevention of future episodes. But that is the exciting place where the literature is going. This was from BioMed Central in 2017, a great paper, clinically relevant. I linked it down in the show notes. If you have any comments about this paper, fire them over to me. Jeffeedencebasedchiropractor.com and as we come to the conclusion of this episode and I wanted to give a special shout out to everyone that I met at Forward kc, which was an event I attended this past weekend, Forward Thinking Chiropractic alliance put on an event. Well over 300 docs were in attendance and a ton of people were coming up saying that they listened to the podcast and appreciate what I did. If you are somebody who listens. I appreciate you. So each and every week I try to deliver the best content I can, but it would just be an exercise in futility if nobody listened. So I truly appreciate everyone who came up, gave kind words, talked about the podcast that gives me a ton of inspiration and a ton of motivation to do the best job that I can continuing week after week. If you have anything that you'd like to hear about as a topic, shoot me an email. Jeff the evidencebasedchiropractor.com and as always, one thing I would ask you if you have not left a rating, feedback or review on itunes for this podcast, please do so. You can do it right from the app on most iPhones at this point in time and that helps more and more chiropractors hear the podcast, get the information that can help them be more successful in practice. That is the goal. To get all this wonderful research, this wonderful literature that's out there out to as many docs as possible. Take what you will with it, take pieces of it, utilize it in practice, hone those clinical skills, get better at marketing and make a bigger impact in your community. So I hope you have a great week in practice and I will talk to you soon.

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Sam.