244- The Best Care for Chronic Neck Pain

Welcome to the Evidence Based Chiropractor where each week we deliver the latest chiropractic research and marketing strategies all in the time it takes to get to your office. Now here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. In today's episode we are looking at a really interesting study and it pitted mobilization against manipulation against natural glide and tried to break down which increases range of motion the most, which decreases pain the most. And it starts to tease into why that may be so impactful, clinically important study that we're going to review here on today's episode. Before we get started, I will ask if you have not left us ratings or review on itunes, please do so. It's how more and more docs find out about this podcast. If you're listening on your iPhone, you can just scroll on down and do it directly from there. Again, if you have not left us a rating or review on itunes for this podcast, please do so. It helps more and more docs find out about it. And on today's episode, as I said, we are breaking down a really interesting and important study. So this came out in April 2015 and in the European Journal of Physical and Rehabilitative Medicine. The title of the study is Mobilization versus Manipulation versus Sustained Apophyseal Natural Glide Techniques and Interaction with Psychological Factors for Patients with Chronic Neck Pain. And this is a randomized controlled trial. So let's take it from the top. We understand that chronic neck pain is a hazard. It relates to decreased quality of life, it relates to increased disability. And what I've seen is anywhere from 10 to 30% of individuals who have neck pain will go on to have chronic neck pain. Additionally, we know that many individuals in a state of chronic pain end up by the nature of how the system is built, many end up going towards long term medication use or and again, we've seen this time and time again in clinical practice, right? Somebody comes in, they've had chronic pain, they've gone through, through taking medications. Medications don't work because of course they have some form of a structural issue probably combined with other things. And then they go to get injections, they get their three injections per year. And not only does that have the opportunity, it doesn't happen every time, but the opportunity to further degrade the joint, which is a self fulfilling prophecy for more pain. But again, a lot of temporary pain relief without taking care of the inherent biomechanical challenge or in some cases Psychological challenge as well. So this is a really important aspect of things when we're looking at it from a conservative care perspective and saying, okay, there's mobilization, there's manipulation, there's natural glide. How do these things play out clinically and which might have the best efficacy? Really important because it can help drive our clinical decision making. Now, we might do as chiropractors, we might do a little bit of all of it with the patients that come into our practice. But it's important to understand the underlying mechanisms of this as best as we can and also to be able to share this information not only with patients in our community, but, but other physicians. Basically what the evidence based chiropractor was built upon, building referral relationships with other healthcare providers. So again, we know many individuals suffering from chronic neck pain experience a significant reduction in quality of life. It is a pain in the neck, literally and figuratively, and the resulting disability can affect both the professional and personal lives of these patients. Right. Many people will live in pain for years and years and years. But it's when they are unable to do something they'd like to do, what we call the life effect. That's what drives them to call the doc. That's what drives them to come into your practice, which it's really important to understand and ask those questions upfront, right during your intake, during your case history, hey, I understand you've been living in pain. What has this prevented you from doing that you'd love to do? The answers may surprise you and they really tell the motivating factor for why the patient is seeking relief. So don't forget to ask those questions up front because they're really, really important. So for many healthcare providers, the decision on the appropriate treatment modality can be difficult. Now for us, it's probably not as difficult, but when we think about a primary care doctor, you know, again, we look at what are their, what is in their tool belt? Well, basically three things. They see a patient come in with some sort of musculoskeletal complaint, chronic neck pain being one of those. And it's medications, it's referral to physical therapy or it's referral to a specialist. That specialist, typically being an orthopedic doc or a neurologist, you know, physical therapy, probably the best option of those three. But we also know the limitations that active care can have in strictly physical therapy if you're not doing some of these adjacent modalities. So that's where we see, roughly, I'm gonna say that 25% failure rate with physical therapy is ultimately, it's not able to address all of the things right. When you get sent to an outpatient rehab facility, outpatient orthopedic care facility. A lot of those therapists are great, but they're seeing like everything they're seeing post surgical rehab on knees. Then they have somebody with a neck. They do a lot of heat, a lot of ice, a lot of stim. But there is something to be said, and I think this study starts to show it. There's really something to be said about an adjustment or a manipulation. And things happen with that that don't happen with other modalities. And for many patients, those things can be very, very beneficial. So this study evaluated the efficacy of mobilization, spinal manipulation and natural glide for patients with chronic neck pain. They found that spinal manipulation provided the greatest breadth and depth of improvement. Now, manipulation was able to increase the overall cervical range of motion while also providing the greatest reduction in pain intensity. So these are really, really important things. I'll break down a few numbers, then we'll dive into some important quotes from this study. So when we look at cervical range of motion, we know, you know, having a full range of motion is really imperative to establishing proper biomechanics to. I think there's some correlation, you know, don't quote me on this, but I think there's some correlation between having a good range of motion and really having a decreased likelihood for pain. Right. Our bodies are designed to move. Restrictions that limit that motion can create compensations and altered biomechanics that over time can create challenges to the joints and ultimately pain. Right. So range of motion is generally a good thing. Now, what they found is pre intervention, the cervical range of motion for, for the people who underwent pre interventions, they had not had it yet was for the manipulation group around 50 degrees, mobilization group around 59 degrees, and the glide group around 55 degrees. Now, post intervention manipulation group shot up to about 62, mobilization shot up to 64, and the apopsile glide shot up to about 60. So what were the differences there? Pretty astounding. When we look at the manipulation group, the difference between pre and post was over 11, it was almost 12 degrees. Whereas the mobilization and the snag group or the apopceal glide group was just about five. So it was almost double. The mean difference in range of motion was had with manipulation. That makes a lot of sense, right? When you're manipulating a joint, you're getting into the paraphysiological space, specifically in the cervical, cervical spine. Get in that paraphysiological space. You break up any adhesions in the facet joints. You facilitate better motion. You get that spindle and that Golgi tendon reflex based upon the joint itself in getting into that paraphysiological space and what do you end up with? A heck of a lot greater of a range of motion. So that's one thing. The other thing I will talk about in a moment is the reduction in pain. And that's really where we see the impact in I'm going to call immediate quality of life with the patient. Right. I feel better decreased pain, but the range of motion. I'm going to go under the thought process that if you can increase the range of motion especially that significantly, you might have the potential now this paper doesn't go there, so this is theoretical, but you might have the potential to ward off future episodes or take the time between the yo yo effect pain coming and going and extend that out. Because the biomechanics have been improved, the compensations might be a little bit less. Very, very important stuff. So let's take a look at a couple quotes from this study. Break it down in a clinical aspect. Researchers found, quote, all the manual therapy techniques study produced a decrease in pain during active movement and an increase of cervical range of motion and local hypoalgesic effects. But only the manipulation and mobilization groups experienced pain relief at rest. Pain relief at rest is important, right? If you're sitting there at rest and you're still in pain, that's not ideal. They also found quote, under low anxiety levels a better prognosis is expected after manipulation and snag technique intervention. So remember the title of this had the psychological factors as well. Which is important, right? To talk about this in the biopsychosocial model. But there is a psychological component here in understanding if somebody has high anxiety, they're super anxious and nervous about what's going on or about the they could be anxious and nervous about being in pain or about trying to get treatment to get out of pain. That can limit the effectiveness. Right. There's just a lot to be said as far as the state of mind of the individual going into the care. So they found probably no surprise there, lower anxiety levels, better prognosis. So you know, talking with the patient, understanding, reinforcing resilience, super, super important. I think things that we do really, really well overall as chiropractors. This showcases keep on doing it. Very, very important. And finally, the researchers found high velocity low amplitude manipulation group showed more reduction of pain intensity and rest and more increase of cervical range of motion than the others. So that's really putting a bow on everything. The adjustment group had a greater decrease in pain intensity, so it was a better outcome in terms of pain relief. And also again, we looked at about more than double. As a matter of fact, we over double the mean difference in cervical range of motion pre to post intervention. So very, very important clinically from a variety of standpoints. Number one is this was looking. It's a randomized controlled trial as well, which is the highest aspect of research, except for maybe a double blind randomized controlled trial. However, we look at chronic neck pain. Chronic neck pain has to start somewhere. It always starts in acute neck pain, right? So keeping in mind as patients come in, what's their anxiety level, how are they feeling, how are they feeling about the pain and how are they feeling about the potential to find relief? These factors can be really, really important in that patient's ability to find long lasting relief. The other components of that is understanding if they have apprehension, what are the best ways, best tools, best techniques that you can choose as their clinician to help not only reduce that anxiety around the care, but also to improve the results. So a lot to be said about decreasing the anxiety. Now when we take that one step farther, as I touched on a few minutes ago, when we see pain, maybe 30%, 10% to 30% of individuals with acute pain go on to chronic pain, understanding that you can not only head that off before it gets into chronic pain territory, very, very important. However, there's a second component here that is also clinically relevant and that's understanding that even in individuals who are already in chronic pain, as this study showcased, there can be significant benefits through what you do as a chiropractor. Whether that's in manipulation, whether that's mobilization or whether even that's the glide techniques and displaying that, educating other healthcare providers and the public, the people in your community about that is critical. And here is why is there's many individuals, and I saw this time and time again working at the surgical, orthopedic, surgical group and the orthopedic group that I practiced with for years, where patients would come in and based upon the fact that they have been in pain a while, they're like, I'm past the point where a chiropractor can help me, which is completely foolish as we know, but that's a very common belief that chiropractic is, let's say, the bottom of the pyramid. And if you've already failed medications or injections, well, there's no way a chiropractor could help me because I've already gone beyond that. And the research shows us time and time again that that's just not true. But perception's reality and you have to get out there and tell that story time and time again so that you can make that change in your community. I'm gonna go also and say for many providers, the same thing holds true. If you go into primary care provider, you go to see a neurologist, they see a disc bulge on a film and they're like, oh boy, here we go. It is time to head into injection territory because, whew, there is this big time structural issue and it's just not the case. This is where it gets back to understanding man. Knowing how to let the neuroradiologist do their job, but knowing how to read and understand the sagittal and the axial im. If somebody's already had an MRI and being able to explain it to a patient, live with them in a way that makes sense and is congruent and it's obviously medically true is so important because you start to build trust with that patient, they start to understand that you know what you're talking about and that the recommendations aren't just based off of, hey, I have a hammer, everything looks like a nail. But it's based off of the fact that you understand what's going on. You know, the biomechanics and you know, the fact that the body is so dynamic and that quite often in the absence of red flags, that patient has a very good likelihood of getting a fantastic result in your practice. So I'm putting together a lot of different things there, but all things to think about clinically. I'm just reinforcing to you the importance of not only understanding the research that we dive into week after week on this podcast, but the really, the central aspect of it is also translating that knowledge. It's fantastic for you to know, but it starts to make an impact on your practice when the people and providers in your community know. So if you want help with that, head over to the Evidence Based Chiropractor. We do that all day, every day. If you want help being able to read MRIs better, we have a course on that. But bottom line is, take what you learn each and every week on this episode on these episodes of the Evidence Based Chiropractor. Utilize it to bridge the gap, build relationships, and ultimately help more people in your community. If you have any questions, hit me up Jeff at the Evidence Based Chiropractor. Thank you. I hope you have a fantastic week in practice and I'll talk to you soon.

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