173- The Biochemistry of Low Back Pain

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Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. This week we are diving back into the science. We are looking at a article that was published in 2018 in the Clinical Journal of Pain and this is about the biochemistry that occurs in pain, specifically low back acute versus chronic and also how spinal manipulation can play a role in altering that. So the paper was titled Elevated production of nociceptive Chemotherapy, Chemokines and selectin in patients with low back Pain and the effects of spinal manipulation. A non randomized clinical trial. So this is a great one. When people ask questions about, you know, really, why does my back hurt? You might not want to go into the biochemistry of it, but this gives you certainly a foundation and a better understanding. At least it did for me. That's what I hope to give to you this week. Also, adjust your marketing 2019. The tickets still are on sale. It is early bird time. 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Literally it's about working together, it's about getting stuff done. So join me for adjust your marketing. You can check out all the information and pick up your ticket right now at again, that's@the evidencebasedchiropractor.com events. But for this week's episode of the podcast, as I hit on on the top we are talking about really what I'm gonna call the biochemistry of low back pain and how spinal manipulation or an adjustment, plays a role in that. So I'll repeat the title of this one more time and also you can find the paper linked in the show notes, as always, elevated production of nociceptive chemokines and selectin in patients with low back in the effects of spinal manipulation. A non randomized clinical trial. So where do we begin with this? That is a good question. I'm gonna cite a few things by the researchers straight from the paper to get kickstarted. Then we'll dive into the action steps and how we can make it real for you and your practice. So the researchers start out by saying, quote, while correcting segmental restrictions and biomechanical aberrations may provide a feasible justification for the efficacy of spinal manipulation, biological mechanisms associated with this form of therapy remain unclear. Recent investigations suggest that manipulative therapy may exert anti inflammatory effects and thereby impact the integrated network of inflammatory and immunoregulatory mediators inherent in spinal pain. So we're talking right there, we're breaking it down, right? We're looking at, hey, how does an adjustment work? Well, we're still learning, but certainly there's a biomechanical component. But it looks as though there might be an anti inflammatory effect. So that starts to get interesting. Researchers go on to say tissue injury associated inflammatory responses are accompanied by increased neuronal excitability and migration of leukocytes to the affected area. This process is mediated by a gradient of subfamily of chemotactic cytokines. They're calling these CCL2, CCL3 and CCL4 and they're generated by the endothelial cells. So, okay, now we're starting to get somewhere, right? So we know now levels of CCl2 and CCl3 production have been shown to be significantly increased alongside with inflammatory cytokines in patients with chronic and recurrent neck pain. Okay, so we know historically they've looked at this with neck pain. This paper is gonna look at it in terms of the low back. But by and large what they're saying right there is when there is a tissue injury, right, when something's going on, we see elevated levels of CCl2 and CCl3 and CCl4. So that's what we know to be the case already. So that's what they're gonna look at with this paper and say, okay, we're, well, what's going on with acute and chronic low back pain Regarding that. And then Secondarily, or perhaps in our case, most importantly, how does spinal manipulation, how does an adjustment change that? What they started to find was as follows. They found the baseline production of CCl4 is significantly higher in the acute compared with the chronic pain group. In contrast, systemic release of selectin, significantly elevated in patients with chronic low back pain, only trends higher in acute in the acute pain group. So we know CCL4 significantly higher in the acute compared to the chronic. So what does that mean? Well, it means probably that whether you want to define it as a mediator or whether you want to define it as the thing itself. Ultimately, in an acute injury, CCL4 spikes, and then it goes down a little bit as time goes on. And when we look at selectin, we found that it was significantly elevated in chronic low back pain, but with acute. Wow. Through the roof. So let's take a closer look. The researchers go on to say the underlying physiological mechanisms of the aforementioned variability in chemokine production via chronic low back pain are complex and cannot be completely encapsulated within the scope of this study. It is known that a production of chemokines is differentially regulated by pro inflammatory and immunoregulatory cytokines. And inflammatory profiles may differ in patients with acute and chronic low back pain, a possibility that is currently under study in our laboratory. Such differences may at least partially contribute to divergence in chemokine production observed between the groups presenting with acute and chronic low back pain. So let's break that down a little bit. Basically, what they're saying is when we look at chemokine production, acute and chronic, there are gonna be different chemokines that pop up or become. The production of them becomes much heavier in acute cases, and other chemokines that we're going to see stay strong in chronic cases. Now, that's interesting because that shows that our body's immunoregulatory response or our inflammatory response changes as our pain goes from acute to chronic. Our body deals with it differently, and different inflammatory mediators are produced at different levels based upon the timing or cadence of the pain. So that gets pretty interesting because as we start to look at this, we say, okay, so that means people coming into our practice, literally their biology, their biochemistry is different, whether or not they just had the injury or whether the injury is downstream. Now, again, these are interesting things to take a look at. Now let's start to go one step farther and say, well, how does that play a role in potentially what we're doing? And the researchers found While significantly relevant differences in the production of both CCL3 and CCL4 were found for the acute patients, SMT exerted a statistically significant effect only with respect to CCl3 production in patients with chronic low back pain. This is, that's interesting, right? When we see a manipulation changes the biochemistry or changes the release of a mediator, but it's not wholehearted, it's not across the board. So that means some input is telling our central nervous system, some input is telling a response mechanism to do something specific with that input with the manipulation. In this case, that gets interesting to me. As suggested by Balaski et al, the molecular mechanisms implicated in pain perception may have been altered by neurophysiological responses triggered within the peripheral and central nervous system by a force applied through spinal manipulation. Such responses might include modification of sensitivity or expression of nociceptive receptors within the affected spinal tissues or throughout the central nervous system at the level of the cord. Wow, there's a lot to break into there. But ultimately they're referencing another study and they're talking about the molecular mechanisms of pain perception and how a spinal manipulation can change that based upon the fact of the force being input at a certain level. That starts to get really intriguing as far as where the research can go. And finally, the researchers found changes in pain perception related to the placebo effect have been reported. It is possible, however, that the reduction in pain and disability in SMT treated patients may be related to the chemokine controlled shift in the migration of leukocytes releasing pain inhibiting rather than pain inducing mediators. Selectins and chemotactic cytokines mediate migration of leukocytes producing both hyperalgesic and pro algesic mediators not only in circulation, but also in the site of inflammation. Gosh, this stuff is really technical. But when I look at that and what do I take from it? I take from it the fact that it seems as though the emerging research is starting to showcase the possibility that with an adjustment, with a force put into the spine, there is a chemo kind shift. The mediators, the production of certain mediators shifts. Some of those mediators are causing, let's say, the perception of pain or enhancing the perception of pain. Some of them are inflammatory by nature, in which you can impact that and shift that. Whether it's down regulating the heightened perception of pain or whether it is down regulating the inflammatory response. That starts to become, as you can probably put together at this point, a very intriguing possibility of where we can go and what we can do with Chiropractic. So that's why this paper, to me it's 2018. This paper just came out. It was in the Clinical Journal of Pain. Yes, it's a little bit geeky in terms of the biochemistry. I read quite a bit there because I didn't want to misrepresent the facts and I certainly want to make sure I'm giving some of this gets really, really specific in terms of what's going on. But my big take on this is between acute and chronic low back pain patients, there is no question that their biochemistry is different. Their pain perception is in the in the mediators enhancing that pain perception change throughout time. Secondary component of that is the emerging component of. Let's take a look and see where the research can push us in terms of when you put a force in, when you make an adjustment, when you provide a spinal manipulation, how is shifting or changing the release of those mediators? That starts to get really, really interesting when we talk about how a chiropractic adjustment can affect the nervous system, how it affects perception of pain, how it can affect acute versus chronic pain. A paper like this is the first step towards that. It's a brand new paper. It's awesome. I'd recommend checking it out if you want to do a deeper dive into it. And that's really the take home message for this week. One last ask. If you have not rated or left a review for this podcast on itunes, I would greatly, greatly appreciate it. You can do it right within your app. If you are using an iPhone and leave rating or review. That's what helps more and more docs. Be able to see, learn and listen to the podcast, which is awesome and I would appreciate it. I definitely appreciate you taking the time to listen in each Monday morning. Get your research, get your marketing and get your week set up right. If we can do that, then that is a huge win for this podcast. I appreciate all the positive feedback I've received. We're gonna keep trucking with it. Any research you'd love to have me touch on, hit me up jeff the evidencebasedchiropractor.com and don't forget to pick up your ticket to adjust your marketing@the evidencebasedchiropractor.com events. I hope you have a great week in practice and I will talk to you soon.

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