268- Manual Therapy of the Thoracic Spine for 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. And on today's episode we are talking about a very pragmatic piece of research. This one is all around neck pain and how manual therapy, care and treatment to the thoracic spine may be able to impact the results that you get with challenges in the cervical spine. It's a new study, it's impactful, it's powerful and it is clinically relevant and there are some data, definite clinical pearls that you're going to take from it. We're going to break that down on today's episode. Before we get started, I want to say a few words about Jane. What's in a name? You ask? Everything. Meet Jane, the only name you'll need to remember in the EHR world. Jane is HIPAA compliant online platform. Clinical management capabilities are going strong with Jane. They have online booking, charting, scheduling, telehealth, invoicing all in one easy to use system. Things like narrative, smart options and dictation make it very, very very easy to get things done in practice. You can learn more and watch a demo by heading to Jane App Cairo. Again that is Jane App Cairo and if you would like a 30 day grace period as you get started, use the code evidence based2021 if you'd like a 30 day grace period when you get started evidence based2021 I see threads all the time in groups all over Facebook about EHRs challenges people are having with some of the biggest big names out there. Check out Jane Jane app Cairo and use that code EVIDENCEBASE2021 to get a one month grace period. But as I said at the top today we are focusing this episode all around a new study that came out just last year in 2020, March of 2020 to be exact. And it is titled Effectiveness of Manual Therapy to the Cervical Spine with and Without Manual Therapy to the Thoracic Spine in the Management of Nonspecific Neck pain. And this is a randomized controlled trial. Those RCTs are always what we like to see. There's some of that top tier of research and literature. So the goal of this study was to compare the effectiveness of manual therapy to the cervical spine with and without manual therapy to the upper thoracic spine for the management of neck pain. A lot of people with neck pain out there will break down those stats momentarily. And I've seen a previous study, a couple years ago, I highlighted a study that was sort of in this vein. I believe this one references that previous study. But this is, in my opinion, a really pragmatic thing. In practice. People come in with neck pain and for a variety of reasons. There's two things that go on. I think of this as a fork in the road, right? There's two reasons why you might adjust the thoracic spine with neck pain. Number one is because that person has an abject fear of getting adjusted in the cervical spine. You have, for whatever clinical reasons you have, hesitations to get in there and adjust the cervical spine. So looking towards the thoracic spine is a logical thing to do. And studies like this showcase well, is that gonna really actually make any impact on the results of their care? Because just adjusting the thoracic spine for giggles, trying to get rid of neck pain, if it doesn't work, it's not a very good strategy for you or for them. So research like this showcases, okay, in those instances when you cannot adjust for whatever reason the cervical spine, what else can you do? And how can you use the thoracic spine? Or can you. And we'll get down to that in a little bit. The second piece of this is the, what I'll call the addition. So instead of, you know, adjusting the thoracic spine in lieu of the cervical spine, I always like to say, I've always heard it said and I believe it. When you're evaluating a body region of complaint, always in turn evaluate the body region next door. So if somebody has neck pain, I hope during your examination and evaluation, you're evaluating the thoracic spine. If they have, you know, a lumbar complaint, I hope you're evaluating the pelvis or the thoracic spine. If they have a knee complaint, it's a good idea to check out the ankle or the hip. If they have a wrist complaint, great idea to check out the elbow. You get the point. But it's a really good idea clinically to evaluate the next body region. From the site and area of chief complaint. It can. A lot of times you see compensation. Sometimes you see that the next door body region is actually the one that's causing dysfunction. There's a lot of clinical reasons to do so. And in this case, again, I'm going to encourage you, be sure that you're doing those really complete and thorough evaluation and make sure that you're not being Ultramyopic. I think sometimes in ironic that this is on the evidence based chiropractor podcast, but evidence based chiropractors can become sometimes, you know, not calling anybody out, but sometimes a little myopic in their thinking where it's like, okay, I don't want to do too much. I'm not one of those people who does the flying seven on everybody. So I just, you know, I think it's a C4 C5 issue. I'm getting in there, adjusting C4 C5, doing a little bit of care around there, giving them exercises and sending them on their way. Sometimes that might be the right thing to do, by the way. But don't neglect the next body region to the area of chief complaint is my goal. And I hope your goal as a clinician really identify holistically what's going on with the person. So how big of an issue is neck pain? 330 million people worldwide have neck pain at any given moment in time. So it's a lot. Total cost of neck pain is estimated to be over 1% of the total healthcare expenditure. And that's a lot from a musculoskeletal perspective. We know the low back is sort of the big elephant in the room. Costs a lot of money, number one, cause of disability. But when they're saying overall healthcare expenditure that includes things like cancer care, long term, these really aggressive, long term, expensive things that have to be treated. So for neck pain to take up 1% of the total healthcare expenditure shows how big of a deal it is. And globally, the lifetime prevalence of neck pain ranges from about 14. It's a wild range from about 14% to 71%. I don't know what the factors are to make it that wide of a range, but that's the range. The prevalence is around 14 to 70%. So if you're in the 14% bracket, I guess it's not very likely you'll have neck pain. If you're in the 70% bracket, it's very likely you'll have neck pain. But the bottom line is this affects a heck of a lot of people throughout the world. It costs a lot of money, it causes disability, and it hasn't gone away. Right. You know, this has been something people have been dealing with for a long time and nothing seems to have really made a big dent from medication standpoint, from a surgical standpoint, all of those things have advanced dramatically over the past hundred years. And neck pain and low back pain, these musculoskeletal neuromusculoskeletal issues tend to stick around. So is there a better way, Is there a different way and what is it? Hopefully that's what we identify every week on this podcast. So in this study, they took two groups of individuals. One group of people, all m had neck pain. They took one group and said, okay, you're only going to receive manual therapy techniques to the cervical spine. This was like mobilization, myofascial release stretches, neural tissue stuff, all that going on. Cervical spine only then the other group, the experimental group, that's the control group, cervical spine treatment, cervical spine issue. The experimental group received all of the same care in the cervical spine, plus in the thoracic spine. So it wasn't a replacement. It was in addition, they added on the thoracic spine care in addition to the cervical spine care. Both patient groups were assessed twice at baseline and then two weeks after two weeks of intervention. And I think there was around 60, around 50 to 60 patients, people in this study. So what causes neck pain? What's going on with this? Number one, neck pain tends to affect a younger population than low back pain. And in this group, the mean age was less than 40 years old. And as somebody who turned 40 this past year, that makes me anxious, but hopefully I do the right things to take care of myself. But less than 40 years old was the mean age, which is in line with what we see statistically now. These researchers cite that prolonged working and awkward postures has been reported to be one of the reasons for developing neck pain in the younger population. This is like a screaming five alarm fire for me. I mean, this study came out in March of 2020 and it was clearly, you know, that's right when Covid was hitting. Clearly this was written well before that. The study, you know, the participants, all of this was done way before COVID really hit in any meaningful way. Probably the study was actually accomplished in 2019 and finally published in 20. When they're talking about prolonged working and awkward postures, it's a five alarm fire for me because I'm saying, gosh, this is pre Covid. They're talking about this. With the advent of tens of, if not hundreds of millions of people now working from home talk about awkward postures and prolonged time in those positions that's gone through the roof. And I think that we've seen that as well in many chiropractic practices, where many practices, you know, after an initial slump of COVID with just, you know, fear and people were, you know, some people were locked down, a lot of chiropractic Practices are really doing well right now because there's a lot of people struggling with neuromusculoskeletal issues and a lot of that has to do with posture and ergonomics. The researchers here support that thought. Now they took a comparison of post treatment neck pain scores between the groups and they found superior results achieved by the patients in the experimental group compared to the control group. So let's break that down a little bit more so we can understand the specifics. But bottom line is adjusting the thoracic spine in this case or providing manual therapy, I guess I should say to the thoracic spine was a great idea and resulted in better outcomes than only taking care of the cervical spine. These researchers found, quote findings of this current study suggested effectiveness of applying manual therapy to both cervical and thoracic regions for neck pain. Thoracic manual therapy lowers mechanical stresses of the cervical spine and improves normal distribution of joint forces, resulting in the restoration of normal biomechanics of the cervical spine. So this is an important point right here. They're really talking about the fact that manual therapy through the thoracic spine can actually affect the distribution of load and joint forces in the cervical spine, which is pretty cool. And also it can restore normal biomechanics. So this is a really, really again impactful and important study. If we trace, we say, okay, we know that that can affect it on the back end. Question is then are we doing enough to evaluate the thoracic spine on the front end to make an informed decision on whether we should provide care there in addition to the cervical spine? Don't shortchange yourself as a clinician and don't shortchange your patients by only being myopic to that area of challenge. Our bodies are dynamic. All regions of our spine play in directly and indirectly with other regions in terms of biomechanics. And the thoracic spine is a major player in terms of cervical spine mot. The researchers also found results of the current study showed that disability associated with neck pain was significantly reduced after treatment in both groups, with the patients in the experimental group showing superior outcomes compared to the patients in the control group. So the bottom line is it reinforces what we talked about earlier, which is getting in there, taking care of the thoracic spine or at least evaluating it is a fantastic idea when you see somebody that presents with neck pain. These researchers conclusion sort of restating things was quote, both cervical and cervical with thoracic manual therapy can be used for treating neck pain. However, cervical along with thoracic manual therapy produce better outcomes for patients with neck pain. So all of this important to keep in mind as you go through your evaluation processes. Very important to keep in mind as you're taking care of individuals. For instance, an individual coming in with neck issues, that is, maybe they have plateaued in their treatment, their progress. Maybe they plateaued in their ability to kind of get over the hump and they're having these continued challenges. Take a look at that thoracic spine. Evaluate its motion. Take a look, get in there. Provide care to the manual therapy and care to the thoracic spine and then reevaluate the cervical spine. There's a lot that we can do. Keep an eye out for these things in your practice. I think it's gonna be better for you. You're gonna get better results with your patients, which means more referrals, they're happier it you're going to be doing better by them, which is ultimately the goal. 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But I'll finally close by asking if you have not left a rating or review for this podcast, please do so. It helps more and more docs find out. I think we're over 11,000 listeners each and every week, which is absolutely incredible. So tons of gratitude. Thank you for tuning in. Thank you for caring. Thank you for trying to improve your patient care. If you have any questions whatsoever, you can always hit me up at jeff the evidence basedchiropractor.com and I am happy to provide any answers I can for you. If there's any studies that you'd love to see featured or topics that you'd love to see featured on this podcast coming up. Also, use that same email address and let me know. Otherwise, have a fantastic week in practice and I will talk to you soon.

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Sam.