281- Changes in Pain Sensitivity and Stiffness After Spinal Adjustments

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. This week we are back with the research and we are talking all about changes in pain sensitivity and spinal stiffness in relation to a adjustment. We're going to break down this article. It's brand new in 2021. Lot of clinically relevant nuggets coming out today and this is a really, really cool study and actually part of sort of a two part series that we're going to do this week and next week that are analyses of the same research. So a lot of secondary exploratory of analysis going on over these next two weeks. Lots of a lot of take home messages that I think you can utilize for your practice and in your communications with your patients. And overall lots of good stuff. Before we get started I'd like to say a few words about the smart chiropractor. It's time to get more from your chiropractic marketing, automated email marketing, social posting, video streaming and more. Every single month we are delivering. This is incredible to me. Over 1600 new appointments booked, over 500,000 emails sent, over 4 million people reached on social and well over 25,000 thousand hours of video streamed each and every month. That's something I'm super proud of. And if you want to get in on the action, head over to the smart chiropractor.com hop on a demo and see what's up. The most exciting part about it for me right now is our lead generation. So we are now allowing you every opportunity to optimize that website you so cherish. If you are paying money for SEO, if you're paying money for ads, if you care about having people on your website, you want your website to perform as good as it possibly can. And if you do not have a pop up box or an opt in window that leads into a follow up sequence, you are missing an opportunity and leaving a massive amount on the table. So our lead generation pop up boxes seamlessly integrate with chiro emails which is built into the smart chiropractor and your leads can automatically receive a follow up sequence. High impact call to action help your website and your paid ads perform better for you and work for you 24 7. That is what we are up to at the Smart Chiropractor on top of a host of other things to help you build and grow. Check it out now at thesmartchiropractor.com, hop on a demo and see if it is a good fit for your product practice. But today on the research side of things, we are talking all about a paper that was recently published. And what do I mean by recent? I mean 2021. So this thing is hot off the press and it is titled Changes in Pain Sensitivity and Spinal Stiffness in Relation to Responder Status Following Spinal Manipulative Therapy and Chronic Low Back Pain. A Secondary Explorative Analysis of a Randomized Trial. Long title. We're gonna link that down in the show notes so you can check it out. But I will tell you right off the bat, I love any study that the first sentence starts with clinical guidelines recommend spinal manipulative therapy for chronic low back pain. They are hitting it right off the bat. And this is powerful and should not be overlooked by me or you or anybody else. Bottom line is the clinical guidelines out there support who you are, who we are and what we do as chiropractors. And, and that is not a mystery. That is not experimental, that is not due to anything. But the results showcase what's actually happening. Now, we're continuing to learn more about how an adjustment works. This study dives into that a little bit. However, the clinical guidelines support who you are and what you do. So get out there, tell that story, understand the research, be able to put it into the context that people in your community can take action upon. You're gonna be putting yourself in a great position to build and grow a successful practice. So bottom line as we start to look at this is they say, what's going on? We got lumbar stiffness, we got pressure pain threshold levels. Let's start to sort through it. Preliminary research suggests that decreases in lumbar stiffness following an adjustment occur, but it's only when corresponded with improvements in disability. So this is interesting. We start to say, okay, who responds to an adjustment, who doesn't what things are correlated even if they're not causative. What's they're saying that, hey, following an adjustment, when there's decreases in lumbar stiffness, it's usually corresponding with improvements in disability. So good to know. Now, how did they outline this study? Well, two chiropractors, each with more than a dozen years of clinical experience, performed the adjustments and both were blinded to the segments. So that's where it's that randomized trials. Randomized and blinded. Where the docs didn't know exactly who they were treating and who they were taking care of. So that's a good thing in the research side because it helps reduce biases and it helps reduce influence in the study. Anytime we're looking at some of these studies, the goal is to really try to answer a very specific question and try to answer it in a way that's not influenced by the process of the study itself. So when the groups are randomized, when the docs or whoever is providing the stimulus or the input, the treatment in this case is blinded. That helps to isolate things, it helps to separate things, it reduces biases and ultimately can help the study be more accurate. So these researchers found that the pressure pain threshold change appears to affect the whole lumbar spine with no clear pattern on whether it's targeted, whether it's adjacent, whether it's which segments. Right? So what they found was that the pain pressure thresholds or the pressure pain thresholds ultimately are affected throughout the body region even beyond the pressure pain threshold's affected to the region beyond just the segment that's adjusted. So while you and I, I think as practicing clinicians, and I'm sure the doct in this study as well, want to be as specific as possible, if you're finding hypomobility in a joint, if you're finding adhesions in the facet joint, maybe you're finding, you know, pressure pain threshold levels that are low, you barely touch them and they're jumping off the table. Right? They're super sensitized and there's restricted motion. You want to be as specific as possible on that targeted tissue, that targeted segment, because I think it's going to help get better patient result, being specific. But it's also important to be aware that as you deliver that care, as you mobilize that area, there are changes on pressure pain threshold levels throughout that entire spinal region. So we can use that to our advantage. When we're then going through, maybe we're doing some soft tissue work afterward, maybe we're. However you kind of get in there, quote, unquote, after that adjustment's delivered, you can utilize the fact that you're altering and influencing pressure pain threshold levels to your advantage by being able to take care of the whole body region. And I always think that's very, very important. So these researchers found, quote, this may suggest that the analgesic effect may be greater when directed at pain sensitive segments. In other words, this change in PPT may represent a localized reflex mediated reduction of pain sensitivity at A hyperalgesic segment. A lot of technical words there. Bottom line is, if a segment is hurting, then and it is sensitized, that is where the analgesic effect is most likely to take effect. No surprise there particularly, right. If an area is more sensitized, if an area is more painful, it's not a stretch to say, okay, well, when I get in there and adjust that, that's probably the area where there's going to be the most likely reduction in pain. So the higher it is up, kind of up on that chart, the more of pain, the more likely you are to be able to pull it down. Which is important, again, I think, to know from a treating perspective, so what's the difference and what's the correlation and what's the tandemness, so to speak, between spinal stiffness and these threshold levels and pain and the underlying cause of low back pain? I think we continue to understand more. It continues to evolve, and there's still some lack of clarity around that. Right. There's a biopsychosocial model, there's acute injuries, there's chronic pain, there's sensitive, there's all of these things. There's psychological components. All of these things come in when we talk about low back pain and specifically chronic low back pain. But how do all these things play together? Now, what these researchers say is quote, unquote, in other words, segmental spinal stiffness may be relevant to disability but potentially irrelevant to pain. Conversely, pain will tend to affect disability irrespective of spinal stiffness. So this is an interesting aspect of things. Spinal stiffness is what I'm going to say is a research based tool. Right. I think many of us think about hypomobility and when we're analyzing by hand in our practice and we might see and say somebody is quote, unquote stiff based upon their movement patterns. But that's a little bit different than typically how spinal stiffness by definition is charted in a research study. So just be aware of those slight differences because I don't want you to go too far with this meaning when they're saying, hey, spinal stiffness is irrelevant to pain and there's not really a correlation there whatsoever. I don't want you to say, man, well, every time I see stiffness, people have pain and dysfunction in that area and stiffness can lead to that. I wouldn't disagree with that. But I want you to be very clear on how you think about and use the term spinal stiffness. Somebody being quote, unquote stiff because they're not moving. Well, is different than segmental spinal stiffness as measured in a study. Now, it is interesting to note, with all that being said, that spinal stiffness may be relevant to disability levels. Person not able to live their best life, they have reduced quality of life when they're stiff by research definition of stiffness, but it might not be painful. And that's interesting. Now, this paper didn't really jump by saying, was it gonna lead to pain in the future. They didn't go that far. But that's an important question to bring up and something I think we'll continue to look at on further research studies as well is, okay, maybe stiffness doesn't correlate with pain today, but is it potentially an indication of something to come down the future? We'll learn more about that as time goes on. So the conclusion of this study ultimately was they found, quote, spinal manipulative therapy appears to have a segment specific neurophysiological reflex effect that decreases deep mechanical pain sensitivity when directed at hyperalgesic segments, irrespective of the clinical outcome. Furthermore, a generalized decrease in deep mechanical pain sensitivity was observed when clinical outcomes improve irrespective of the targeted site. So there's a lot going on in that. And let's break it down as we get into the back half of this podcast episode. So they're saying spinal manipulation appears to have a segment specific neurophysiological reflex that decreases deep mechanical pain sensitivity. So when you find a segment that is hyperalgesic, it is painful and it's not feeling good, that is an area where if you adjust it, it's very likely there's a neurophysiological reflex that decreases the mechanical pain sensitivity. I think this is important. Now I'm gonna break a little bit from what it says in the study here. Hey, when we see people that are super sensitized, we're gonna dive into this next week a bit. People that are super sensitized to pain, they're in chronic pain, you could barely light touch and they're jumping off the table. This is an important aspect of it. When you can get a neurophysiological reflex that enables a decrease in that pain sensitivity, now you start to be able to do the care needed to get them great results. So even though it's saying right here, hey, this is irrespective of clinical outcome, this is in an isolated research study. Now imagine how you can use that to your advantage when you're able to decrease the pain at that level. When you're able to decrease the Pain sensitivity. Now you're able to maybe get in there with some soft tissue work. You're able to get in there more with some of that rehab. All of your other modalities can help that process along, as opposed to not even being able to touch the person because they're jumping off the table. So you can use the adjustment, spinal manipulative therapy, you can use that to your advantage by getting in there, decreasing sensitivities. And remember, these sensitivities are not necessarily only at that level. It can affect the region. So this enables you to really work on tissue adjacent that might be compensating for single level issues, et cetera. So there's a lot that you can do with that statement in practice. I think it's really, really important. And they close by saying, furthermore, generalized decrease in deep mechanical pain sensitivity was observed when clinical outcomes improve irrespective of the target site. So when clinical outcomes are improving, there's a decrease in that pain sensitivity almost no matter where the adjustment was delivered. Now, again, I go back to what we talked about earlier in this episode. I don't think that's an excuse to be lazy and I don't think that's an excuse for us just to say, you know, crunch, crunch, crunch, good luck to you, sir. I think it's still an opportunity to be as specific as possible, but to understand that while we're being specific in the delivery of our adjustment, the effects can go beyond that. And that's an important again point when you are thinking about how do I craft and create a treatment plan, a plan of care that really can help this person improve their quality of life, that can decrease their disability, that can reduce their pain and ultimately help them be more resilient. And when we can reduce those pressure pain threshold levels. Wow, tongue twister there. When you can reduce that, I'm going to say, in my opinion, you're improving their resiliency because they are not on edge all the time. And somebody that's on edge, somebody that's super sensitized, they're not moving the way they can. They're very rarely going through a full range of motion. You see it when people walk in and they're like, oof, now they're in real pain. Don't get me wrong. But you know, you have to be able to get through that to really find the healing. Healing comes with movement, healing comes through actionable items, and healing comes through motion. So all important things that you need to get them out of that acute phase. I totally get that. But you also need to be able to get into that healing phase. So lot to dive into. If you have questions or comments, hit me up. Jeff the evidencebasedchiropractor.com and if you are looking for an associate doctor or you are looking for coverage in your practice placements or chiropractic coverage, check out Chiromatchmakers.com they have all of your staffing needs. If you're a doc looking to provide coverage or looking for a gig, you're going to be happy with what we have over there. So check out Cairo Matchmakers if you are looking for an associate doctor, if you are an associate doctor in the making or if you're looking for chiropractic office coverage. We've been doing it for a while. We've been doing it super successfully in chiro office coverage. My company last year melded with Chiro Matchmakers which was providing placement services to create a full service staffing company. So check out Chiromatchmakers.com have a fantastic weekend practice and I will talk to you soon.

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