290- Chronic Pain Can Alter Your Sense of Position and Movement

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 talking all about the sense of effort that could be distorted in people with chronic low back pain. A lot of takeaways that you can use in practice, some clinical pearls. We'll dive in in just a moment. Before we get started, I'll say a few words about the smart chiropractor. If you wanna market your practice better, check out thesmartchiropractor.com head over schedule a demo with Anthony. So smartchiropractor.com demo automated email marketing, social media marketing, patient education. You don't need to struggle with these things. We can help you get more clicks in more calls to your front desk, which means more people scheduled in your practice. If you'd like to find out how, visit thesmartchiropractor.com demo and schedule a demo with our team. But on today's episode, we are talking all about the the sense of effort that could be distorted with people that are struggling with chronic low back pain. This is a new study that came out in Musculoskeletal Science and Practice. I'm going to drop the link to this paper in the show notes as always, but let's sort of dive in and get a feel for what they were looking at with this paper, where they're trying to go with some of the findings and also how you can utilize this in the conversations you have with your patients and in your practice. And it really starts with proprioception. The researchers here took a look and they're basically stating the fact that proprioception encompasses different senses such as detection of joint position and movement, sensation of force and heaviness, with muscle contraction and sensations related to descending motor commands and with people with chronic low back pain. I think we've all seen this in practice in it's just so, so important that everybody has an awareness of where they are in space. Not only from an activity of daily living perspective, but also from a rehab perspective. And that's really where we're gonna go as we break down and talk about the findings that these researchers had. And the traditional view, or the common view is that muscle spindles, along with contributions from the skin and joint receptors are, are responsible for the sense of position and movement and that Tendon organs provide the sense of tension. That's sort of the historical viewpoint. And while much of that may be true, I think there's a lot that we're learning that there may be more to that story than we initially thought. And there's no question that deficits in proprioception are commonly reported in people with low back pain. In my opinion, this ties in some with the fear, avoidance behavior, being just overly cautious because of that sensitization, that pain is going to happen as if it's a foregone conclusion. And often, we know as chiropractors, movement is what heals. Now, you want to be careful with that motion. You don't want to overexert that motion. But ultimately, that's how the healing process occurs. And before you get there and during the rehab process, we always want to focus on that balance of strength and flexibility. However, movement is absolutely critical, and this is where that cascade can start occurring. If somebody has altered proprioception, they're really unaware of what's going on in space. Maybe they have taken a medication or two that's masking some of that pain. They're becoming sensitized, and they're scared of moving. Man, this starts to become a super challenging situation to get over the hump in your practice. So understanding all of these factors, how they're at play, and how you can utilize these for the patient's benefit is just so important in pragmatic when we're taking care of people with chronic low back pain. So the ability to actively replicate target positions of the trunk is the most commonly used way to study proprioception in the low back. So trunk positioning tends to be really that key indicator as far as, do you know where you are in space? Specifically when we're talking about low back pain. Now, in this study, they were ideally looking for, let's say, 50 people to kind of come in. They ended up having 28 volunteers between the ages of 18 and 50. And they basically measured these individuals utilizing basically a trunk positioning type of apparatus. They were sitting, they had a cable attached to their trunk. Their pelvis was stabilized. And then they were asked to move kind of back and forth. And they measured two basic criteria. One was accuracy of that movement. Did they know where they were in space? The second piece of that is what they called drift. And drift was the force away from that target. And those were the two key measurements that they utilized to say, hey, are people moving appropriately here? Or are they struggling to kind of know where they are in space? And what they found was Visual feedback and auditory feedback are absolutely important and critical in the assessment of movement. So when visual feedback was removed, participants with low back pain matched the force less accurately than the control participants. And commonly they undershot the target force. They thought they were pushing super hard, yet they hadn't even reached that threshold of the bare minimum. And that's a big, big deal, because if you have rehab in your practice, if you have a rehabilitation space and you're not really monitoring people, this is where I think clinically, we really need to understand and really take action steps in our practice to be able to help people throughout that process. And understanding that people with chronic low back pain, it might be great clinic flow to have them do a lot of these exercises on their own in your rehab space. But, man, if they don't have visual feedback, if they're not getting auditory feedback, if you're not watching what's going on, they might not be maximizing what they could get out of those exercises. At worst, they might be putting themselves in harm's way for a future injury. I think that's going to be less of a factor. But if they're not getting all they can out of that exercise, they're not going to be able to heal as quickly. Right. We want to make sure that people are utilizing proper biomechanics as they're going through their exercise and rehab. We certainly want to ensure that they're, you know, moving in the correct way. And I think we've all witnessed, you know, individuals where we've asked them to do a motion and, you know, it's like almost comical. They have no idea, like, what they're doing, what you're asking them to do. We see this each and every day in practice. So even if you've shown them once in your rehab space of what you're trying to get them to do, this is a person with low back pain, you might want to keep a keen eye. Maybe you're checking in not. Not every single moment of every single exercise, but if you are letting them do it on their own, maybe you want to at least check that weekly. Maybe you want to check that every other time they're in their pract in your practice to ensure that what your hopes and expectations are for that rehab exercise is actually what's being achieved by that patient. Otherwise, they're in quicksand on a treadmill. You're not gonna get the results that you really desire. They're not gonna get the results they desire, and that's not gonna bode well for your Practice over time. So being able to understand that, man, people think they're doing more than they actually are when they're struggling with chronic low back pain Is super, super important to now be able to guide manner possible. Now, deficits in proprioception with low back pain have generally been attributed to impairment of the paraspinal muscle spindles, or changes in central processing. Again, we kind of talked about this at the beginning of this episode, that that's historically how it's been viewed. Now, it is plausible, as these researchers are saying, it's plausible that the distorted sense of effort can at least in part, explain the deficits in repositioning error in low back pain. And that's an important component of this, when we think about. I was reading a sit to stand study earlier this morning, and that's a daily activity that's performed over 60 times per day. It's multiplanar, and it requires over 60% of this total sagittal range of motion in the low back. And if they're not. If somebody's unable to reposition themselves properly, if they're unable to get into a proper biomechanical stance, so to speak, as they go from sit to stand, as an example example, they're gonna be compromised almost every other time that they're going through some sort of activity of daily living. And understanding that these motions are repetitive, they happen all day, every day. And that small imbalances, small deficits, can really take their toll over time. And in many ways, a lot of these imbalances and deficits, unless it was an acute injury, Are probably what drove people into this compromised position to begin with, because our bodies do a great job under gravity. But. But imbalances that, as days become weeks, become months, become years, become decades, can really stack up and add up in terms of how our body's moving, how we're feeling about that motion, and ultimately how we are progressing through a degenerative state, which is inevitable. So although this has been interpreted to rely on muscle spindle feedback, again, participants may be having kind of a matching sense or a reproduction sense of effort to reproduce that target position. So the secondary thought here is, man, this could not only be a central processing issue, maybe it's not even a muscle spindle issue, but it might be almost a memory issue in terms of matching. Okay, what's my expectation of where this could go? Which ties back ultimately to sort of the title of the study. The sense of effort is distorted. Right? There's a sense of effort with any activity. And if that sense of effort is distorted. It's gonna be suboptimal in terms of how you're moving through through there. So their interpretation of these results is that people with chronic low back pain perceived that the back muscles were generating more force than actual, which I think makes a lot of sense when we think about sensitization in the low back. Right. That acute pain becomes chronic for a variety of reasons. But one of the primary reasons is the sensitization that occurs within the nervous system. Right? Less input hits that pain threshold, and eventually that becomes the standard and the norm as opposed to the anomaly. Right? So somebody's in pain for a day, they still have to kind of hit that threshold level, but that threshold diminishes the longer you're in pain. So ding, ding, ding, the bell gets rung a lot easier as time goes on. And the same sort of things can apply when we think about sense of effort and distortion. If somebody thinks they're creating all this force, they might think they're creating that force because they want to, and they fear actually creating that force. Right? That's. That would be a distorted sense of effort. It also might be that, man, their body literally is kind of telling them internally, hey, you've reached that we're doing it. Just as on the other end of the continuum, they're becoming sensitized to pain. So less inputs causing pain, I have a feeling that that can inform or at least indirectly contribute to the. I think I'm doing it. I think I'm doing it. And. And they haven't even really got started yet. Some of that might be fear, some of that might be sensitization. As with most things, it's probably multidimensional. But again, super important for us to keep in mind as we're going through, not only adjusting patients in our practice, but definitely on the active rehab. And if you are relying on people to do all of this active rehab at home, I'm gonna suggest that it might be a good idea to at least have them every once in a while, sort of do those exercises in your presence, so you can understand if they're actually doing them appropriately. So these researchers also conclude that the sensory deficit might not be due to a dysfunction of the local muscle receptors, but related to that central processing deficit. And that is exquisitely important. As we start to continue to learn more studies like this, we're starting to understand, okay, how does an adjustment work? These are the things we talk about each and every week on this podcast as we understand clinically more about how pain is processed and experienced and how that can be altered in a non pharmacological way. All of these play together towards us being able to help people get well quicker, to help people get well safer, and to avoid any of those advanced interventions. So these researchers sort of concluded with the statement, if confirmed in other studies, assessment and management of deficits in sense of effort in people with chronic low back pain may be included in multimodal interventions in future clinical efficacy trials. So I, I could not agree more. This is the start of this conversation. This study is definitely not the end of the conversation. But if we can identify that man sense of effort really is distorted in people with chronic low back pain, and no pun intended, it's chronically distorted in those people, now we can start to apply that, as we sort of outlined on this episode, how can we apply this to the care that we give to our patients? So bottom line is people have a. If you have people in your practice with chronic low back pain, there's no question that they have distorted sense of positioning. There's probably no question at this point that they have a distorted sense of effort as they go through pretty much any motion with their trunk. So understanding how you can positively influence their care and their rehab, I think one of the best things again is the adjustment itself. When you get in there and you get somebody into that paraphysiological space, when you're able to get those spinal segments moving in a way that does not hurt, but actually does provide relief, that starts to build people's confidence around the fact that they can move without pain. Now you get to take that to the next level with your exercise and rehab to build that strength and flexibility. Now we start to see people get tremendous gains, which is why when they talk about multimodal care here, I don't think they're really referring to medication based care and certainly not advanced interventions, but just man, the opportunity to have at home care, strengthen rehab, the opportunity to get in there with manual therapy, to mobilize, to adjust a segment, segment, get that motion, decrease that fear of motion, improve essentially that somatosensory integration, which is something we really didn't talk about on this episode, but is critically important, I think ties directly into this study in terms of man when you can positively get in there and influence somatosensory integration. Now you're starting to help people get over that fear. You're starting to help them literally become more connected to where they are in space, improve their proprioception. And you're gonna see clinical results that showcase the benef of all of that for sure. So as we wrap up today's episode, if you are looking for locum coverage Locum coverage is a term not usually used in the United States. If you're looking for chiropractic coverage because you are injured, because you have maternity paternity leave coming up, you want to take a vacation or you are going to continuing education back in person, do not close your doors. Head over to Cairo matchmakers.com or if you are a doc looking for your next career opportunity and you want to provide some coverage in your area, we always have demand. We love meeting new talent. So head over to chiromatchmakers.com whether you're looking for coverage or whether you would love to provide coverage. And if you have not left this podcast a rating or review. If you are listening on your iPhone you can swipe on down and hit how many stars and leave us feedback. That is how more and more docs find out about this podcast. I greatly appreciate you tuning in. Thanks for listening. If you have any questions, you can always hit me up. Jeff the evidencebasedchiropractor.com I hope you have a fantastic week in practice and I will talk to you soon.

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