286- Treating 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. On today's episode, we're back into the research. Manual therapy versus therapeutic exercise in non specific chronic neck pain. And this is a randomized controlled trial. This is a brand new study with a ton of clinical pearls. Before we dive into it, I wanna say a few words about the smart chiropractor. I just checked our stats and Smart chiropractor members received over 4200 phone calls from Google alone in the last 30 days. So if you want to market better, basically what do we do at the Smart Chiropractor? We do all of the things you know you should be doing to market your practice but aren't. We can make sure you stay consistent on so on the most popular social media platforms where we reach millions of people each and every month. We can automate your email. This is the high ROI machine with all of our automated email campaigns. They're all done for you, but you also have unlimited sending. On top of that we have video streaming that goes into your practice as well as as auto posting to Google My business that helps your listing get more visibility, more clicks and more calls. And the proof is in the pudding as they say. So if you want to market your practice at a higher level, check out the smart chiropractor.com but today we are talking all about the science. And this is a study that came out in 2020. I'll drop the link down below in the show notes so you can check it out. But it came out in BMC and it is titled Manual therapy versus therapeutic exercise in non Specific Chronic neck pain. And again, this is a randomized controlled trial. So let's break it down, let's dive in, let's get those pearls and move along for this week. Number one is chronic neck pain. Chronic neck pain is one of the top three reasons why people visit chiropractors. Number one is back pain or get started with chiropractic care. Right. Number one is back pain. Number two is neck pain. Number three is headaches. Cause this is a big deal. This is a randomized controlled trial, which means it's the highest level, practically one of the highest levels of research out there. And it's looking at manual therapy versus therapeutic exercise. So this is just a Great practical study. To have a better idea of how can I. Should I or do I want to approach chronic neck pain in my practice? Now, nonspecific chronic neck pain is super common and it causes a big impact. Now, here's the interesting thing about neck pain. It kind of correlates in to back pain a bit, is that it is heavily influenced by psychosocial factors. So this is where things get, you know, fun, I guess you could say. Interesting and challenging. When there's a lot of psychosocial factors going on in a pain syndrome, you know, how do you take care of that? Right. This gets beyond biomechanics when we're looking at things that really have a psychological component, a social component, and it goes beyond biomechanics, but there typically tends to be a root within that. So where is nonspecific neck pain? This is clearly defined. I never thought about it this way, but they really define it as pain located in the lateral and posterior neck that does not show pathognomonic signs and symptoms. So nonspecific, it shows up in the side, in the back of the neck, not necessarily in the front of the neck. Very rarely is there neck pain, I guess anteriorly. Now, the number of cases of neck pain worldwide is estimated to be a quarter billion. So over 288 million in the number of years lived with disability due to neck pain, just as in 2017 is estimated at over 28 million. This is a big issue affecting a lot of people over a long period of time. So, you know, underlying the mechanisms of, you know, nonspecific chronic neck pain, you know, recurrence in the progression, it's not 100% clear, but they believe, the researchers believe it's probably associated with deficit and alteration of the proprioception of the neck muscles that play a role in cervical joint positioning and motor control of the head. That's good news for us as chiropractors, right? When there's proprioception there, when there's musculature involved, when there's positioning and posture and motor control, man, this starts to look really good, that we're going to be able to make a big impact with our care. And there's a strong relationship between neck pain and psychosocial factors, such as, you know, catastrophism, stress, anxiety, depression, all of these things that influence the sensation of pain, neck pain and chronic nonspecific neck pain. Absolutely no exceptions there. So they looked at basically three groups of individuals, or they really applied, I'm gonna say, three protocols. One was the control, which was basically a sham technique, just hands on, but not really doing anything, for lack of a better way to say it. So that was kind of the control group. And then there were two experimental group. One experimental group involved manual therapy. The other involved therapeutic exercise. So they define manual therapy as techniques and care that involves neurophysiological mechanisms, reduction in inflammatory biomarkers, decreased spinal excitability and pain sensitivity, modification of activity in cortical areas involved in pain processing, excitation of the sympathetic nervous system, or all of that is what they're deeming are sort of the differences and treatment effects of how manual therapy works. Now, on the therapeutic exercise side, they're talking about neurophysiological effects, including reorganization of motor patterns, structural adaptations, and increases in strength and endurance. Now, there's probably some overlap there, but that's sort of how they're breaking it out. I love to think about this because it gets to, well, what are some of the core mechanisms of action? How does this work? Well, as they're kind of saying here, man, manual therapy can make changes and influence inflammatory biomarkers. It can make changes and decrease spinal excitability and pain sensitivity. These are, again, impactful things that I think we need to keep in mind. It might not direct your care directly by understanding it, but it's important to know because as you apply the care, you can better inform, educate, guide your patients towards what's really going on. Now, both of these mechanisms, manual therapy and therapeutic exercise, as we've probably broken down on many episodes of this podcast, both are highly effective, but they do have different mechanisms of action and the time of effects could be different. So that's why this study was saying, hey, let's take a look, let's put them head to head. Let's get a sham group out there, let's get a manual therapy group, let's get a therapeutic exercise group, and let's see what's up. And they took a group of individuals between 18 and 50 years old that had current neck pain, so currently symptomatic. And this pain had continued for the last 12 weeks, again, remember, chronic. So at least 12 weeks was really the starting point from where they started to take a look at this group of people in the study. And the protocol was applied in three treatment sessions, one per week. So in the manual therapy group, what they did was they applied a adjustment to T4. So it was a high thoracic manipulation. It was cervical articular mobilization, the. And it was suboccipital muscle inhibition that all took Place in the manual therapy group. Now, in the therapeutic exercise protocol, it was recruitment and activation of deep cervical flexors. It was isometric exercise, and it was eccentric recruitment of the flexors and extensors. So that's really the differences between how they applied manual therapy and how they applied therapeutic exercise. Therapeutic exercise was literally the exercise. Manual therapy involved adjustments, involved mobilization, and involved a little bit of muscle as well. So an interesting way to approach it. And then the sham group, of course, got just, you know, hands touching, no real motion. How did they take a look and measure outcomes in this study? Couple different ways. They looked at neck disability index, the ndi, pretty standard. They looked at a visual analog scale for pain and ppt, pressure pain threshold. So all very highly utilized in many, many studies. All very, I guess you could say, reliable in terms of their outcomes. And look at three different things. Right Neck disability index. What's going on with a disability? Is this worse pain? Are people functioning better? Visual analog scale for pain. Hey, how's it going? 0 to 10 or 0 to 100 if you break it up smaller. And then the pressure pain threshold, Are they hypersensitive to touch? I think we've all had those patients where you're just trying to do an exam and you can barely touch them. They're jumping and lighten up off the table. That's a. They are sensitized. Right. You know, those are individuals where it's like, man, this is going to be a challenge, let's say, and we're gonna have to go slow because we gotta get that. We gotta get them off the ledge here. I mean, when their body's so hot that you're just touching them, not literally hot, but it's so inflamed, it's so sensitized that you are touching them and they're jumping off the table. You know, you want to make sure you go about that in a very stepwise fashion. Concurrently, there's other people that have pain. You can move them around all you want, you can dig in, and they're saying, ah, that feels all right. So there's a range there. But understanding where somebody. If you can take somebody from being highly sensitized, meaning very, very, very low threshold, to increasing that and giving them the opportunity to do more. That's where a lot of the pressure pain thresholds come in, is that if you're super sensitized, you're probably not able to do too much actively. And it ties into fear. It ties into a lot of these psychological components to the pain as well. So they went through and they provided their treatment. And what were the results? The analysis showed significant improvements in VAs throughout the treatment processes, weeks one and four and in the subsequent follow up, which was week 12. It's an important component of this, is the follow up. It's not only getting well today, but it is. How does that translate later on? I'll just make a, maybe not the most refined explanation of it, but if you have a significant challenge, you, you could probably take a medication and feel better. But if the pathology and challenges reside there, it's coming right back, right? So looking at long term, midterm and long term outcomes really helps establish, not that anybody expects one adjustment to last forever. And if they do, you need to set your agreements and expectations slightly differently. But what they should expect is that if they take an active role, if you make the right choices, if their body accepts the care, the treatment, and they're willing to again take that active role in their own healing, it's very likely that they're going to get a great long term result. For ndi, they observed statistically significant differences in the first and second evaluation in both experimental groups. But there was no changes in the control group. No surprise there. And that's good reinforcement that the care delivery was working. So the objective of this study was really to determine the differences between experimental treatments in an immediate short and midterm type pattern. Now what did they find? The results obtained respect to the control showed that the experimental treatments showed a clear efficacy with all the subjects with chronic nonspecific neck pain and statistically significant improvements in short and medium terms with disability and perceived pain. That's important. Statistically significant improvements in the short and midterm, whether it was manual therapy or therapeutic exercise for disability, disability, decreasing the disability, improving functional ability and decreasing perceived pain. Super important, especially when we look at this from a psychological perspective and the psychological components of this pain challenge. Man, when somebody's able to function at a higher level and have decreased pain now you're gonna start breaking some cycles, right? You're gonna breaking some patterns in a good way that help them live a better life. Overall results, you know, in this perceived pain and disability following two experimental treatments in the short term and midterm were significantly improved. As we kind of said, and they're kind, hey, this means that both can be effective. It doesn't always have to be one or the other. A multimodal approach based on manual therapeutic exercise and pain education could be the best care and treatment. Now how do we think about that? Well, they found both experimental treatments, manual therapy and therapeutic exercise produce statistically significant and clinically relevant. There clinically relevant changes with respect to the control group. The therapeutic exercise group reduces cervical disability before the manual therapy group does. And the manual therapy reduces pain perception before the therapeutic exercise group does. Interesting. I'm dying to see more of this research come out. I think this is just the start of what's gonna be a cycle of fantastic papers around this topic. But here's what they're basically saying. Hey, if you're looking to increase functional ability, reduce disability, early therapeutic exercise tends to work quicker. Now, if you're looking to decrease pain perception, manual therapy works for quicker. Now, what do you really want? Both. So utilizing therapeutic exercise and manual therapy is a great way to tackle both aspects of that to decrease the disability, improve the functional ability, while also taking down the perception of pain. All super important, all clinically relevant. I think these are all fantastic conversations to have with the people in your practice. Let them understand. There's so many docs out there that I don't think do a great job explaining why they are doing what with their patients. You know, here's why we're doing this, here's why we're doing this. Here's why we're doing more than one thing. Here's why we're focusing on this. Right now. When you start to describe, okay, we want to make sure we get your pain. You are very sensitized. I know you're in a lot of pain. Let's work through some manual therapy to decrease that pain. Now, I also know you're unable to do some of those things, X, Y and Z that you'd like to get back to. After we go through our manual care, I want to make sure we get some exercise going on because we've seen that when you can add the exercise that helps you get that functional ability back, we're gonna do both of these things with you to ensure that we can hit your goals and expectations. Does that sound good? So there's a lot that you can dive into. I hope this was helpful. Some real clinical pearls here in terms of understanding how manual therapy and therapeutic exercise provide their mechanism of action and effect. Now, I also want to give a shout out if you are looking for chiropractic coverage. If you're a doc or a student, you're saying, man, I'm not sure what my next career move is or we are looking for talent. We have a ton of demand. So if you are a doc out there looking to provide coverage or you're an associate to be Please check out what we have going on at Cairo Matchmakers. Connect with us. We would love to hear from you. If you're a doc looking as you start to look out into this year and see CE days coming up, maybe a vacation in the future, don't close your practice. It's one of the biggest mistakes stocks makes is closing their practice. They lose, they go to zero. You still have all those hard expenses but you have no revenue or income coming in. One of the best ways to solve for that is to utilize a coverage doctor. We do that with Cairo office coverage within Cairo Matchmakers. So please reach out chirofficecoverage.com check out what we have going on. We have a ton of talent also out there and we want to match the right doctors with the right opportunities. So please don't lose revenue and close your doors. Check out what we have going on@cairoofficecoverage.com have a fantastic week in practice and you have not left us a review yet. I'm going to have one more ask of you. Please swipe down on that iPhone, leave a rating or review for this podcast. That's how more and more docs find out about it. Thank you for tuning in. Thank you for paying attention. If you have any questions, hit me up. Jeff the evidencebasedchiropractor.com have a fantastic week in practice and I will talk to you soon.

Thank you for joining us on this episode of the Evidence Based Chiropractor. If you want to grow your practice, come back for next week's episode. If you want to grow faster, visit the evidence based chiropractor.com and join our MD Marketing membership today.