292- Disc Height Changes with Flexion-Distraction

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 Evan Espace Chiropractor. I AM your host, Dr. Jeff Langmaid. Today's episode we have an awesome brand new study talking all about the benefits of flexion distraction on people with lumbar degenerative disc disease. We're talking intervertebral height changes, pain decreases, improvements in mobility and more. A ton of clinical pearls on today's episode. Before we get started, I want to say a few things about the smart chiropractor. The smart chiropractor is an all in one platform to power your patient journey from a potential patient to an active patient to a proactive patient on the back end. That's what the smart chiropractor does. When somebody's a potential patient, you wanna get out there and teach and invite them to become an active patient. When they're an active patient, you wanna have your educational patient education processes dialed in and you want to build in those retention capabilities. And definitely on the proactive patient side of things, this is about enrollment and reactivation. We, we power all of that. So if you have not checked out the smart chiropractor lately, please head over to smartchiropractor.com demo again thesmartchiropractor.com demo we'd love to hop on a call with you, see if we're a good fit, see if we can help your practice build and grow in a super stable way throughout the rest of this year and Beyond. That's again, smartchiropractor.com demo but as I said at the top on today's episode of this podcast, we're talking all about a really cool brand new study that I've linked down in the show notes and it's titled Immediate Effect of Flexion Distraction Spinal Manipulation on Intervertebral Height, Pain and Spine Mobility in Patients with Lumbar Degenerative Disc Disease. So let's pick it up and start right there. What is flexion distraction? You're probably familiar, but let's break it down a little bit. It is a low velocity variable amplitude spinal manipulation and the goal of it is to have a combination of slow traction and, and mobility. And those are the key components. It's not just the traction, but it is also the mobility. And I saw just fantastic results in my practice with flexion distraction. I'm Going to say specifically with individuals with either disc challenges or definitely with individuals with spinal stenosis. That's just me. But I think this paper really breaks down a lot of the why. And I always knew or had thought I had an idea why. But this paper does a great job really showcasing why flexion distraction works so well. And there's some really cool findings in this study specifically, that showcase serious benefits. So let's dive right in. Flexion distraction is designed to maintain the intervertebral disc height and prevent degeneration of the peripheral annulus fibrosis. Now, remember, the annulus fibrosis is what becomes sensitized and can cause, quote, unquote, pain as time goes on. Our discs are pretty avascular when we're younger, but as we get older, those little blood vessels start to infiltrate the outside. They penetrate through the end plates and into the disc that way, and then they get in and around those annulus fibers, and where the blood vessel goes, the nerve fiber goes. So that's what causes the sensitivity as that neurovascular bundle starts to go in. Yeah, you start to get a little bit of blood flow to the disc. The bad part about it is you also have the ability to be sensitized to pain. So now they can cause pain when. When there was no nerve or blood vessel or neurovascular bundle, you couldn't really feel anything. So that's really where flexion distraction comes in. It's about trying to maintain the disc height and decrease that stress and load on the annulus fibers so that you don't end up with the pain and the pain syndromes. So how does this happen? Where does it all start? Well, decreases in intervertebral disc height can result from a variety of different things, but it definitely can be from fluid leaking out of the disc. Right. It could happen. Decreased disc height can happen due to end plate changes. It could ultimately happen due to disc herniations, disc protrusions, disc fragmentation. There's a variety of things that can happen with the disc that cause that height to collapse. And sometimes the disc. I'm gonna say there's other times where I've seen discs sort of collapse or degenerate over time. And part of it's a normal part of the aging process, to be honest with you. But when it becomes painful, when it becomes challenging, that's when people. That's when you start to take note. Right. That's when you start to want to take action. A normal amount of degeneration is a. Okay. Our bodies are meant to undergo that axial load and compression. But have you been maintaining a great balance of strength and flexibility? How's your biomechanics? Do you know all of those things play a role when to whether that compression becomes totally normal and no big deal, or that compression causes an injury or a problem. Right. Which is why it's so important to be proactive with our health. But sometimes stuff happens, and when stuff happens, it can cause pain. And now we lead to studies like this that showcase, well, how can we get people well? So the goal of spinal manipulation is to decrease pain, lead to functional improvements. And that has been shown time and time again. Now, structural changes with disc generation and the decrease in disc height have been shown to affect spinal mobility. And this is important because I want you to think about that disc. When that disc height kind collapses down, it creates and places stress on the facet joint on the backside. Now, if those facets have adhesions, if they're just loaded all the time, you're going to. It's going to result in a decrease in overall or segmental spinal mobility, which then plays a role in regional mobility as well. So this study was really taking a peek and saying, okay, this is a study, this is a piece of research to see what's the influence that flexion distraction has on disc height, on pain, and on lumbar spinal mobility. And it is a good one. They took over nearly 100 individuals, 96 patients, and allocated them to one of two groups, those that received flexion distraction and those that kind of lay down prone on the table but didn't get the care. So here was the inclusion criteria for the people in this study. They needed to be diagnosed with degenerative disc disease at L5S1 via an MRI. They also needed to be between the ages of 20 and 60. They need to have more than three months of lower back pain. So these people were in chronic pain and they needed to not have flexion distraction for three months prior to the study. So it was a nice, clean analysis. Their pain had to be more than 4.5 out of 10 on the VAS scale. And their straight leg raise was positive at angles less than 70 degrees. This probably sounds like a lot of people you see in practice. I know it's a lot of people that I saw in practice. So this is a great real world example. How did they measure their results? Right. They measured the initially with the mri. Well, they used a CT to measure intervertebral disc height kind of on the pre and post, and they measured it to 210 of a millimeter. So this is a really, really specific. This is a really specific test. And that's great because let's frame some of these millimeters so you have a good understanding. Your central canal or spinal canal, ideally is 10 millimeters. If it's less than 5, you're severely stenotic. You have severe spinal cord stenosis. If you're around 10 or 10 and above, you're in pretty darn good shape. And mild and moderate in between that. When we look at IVFs, there's high variability, but IVFs are. They're not exactly circular. But if you want to think about it generally as a circle, maybe 6 to 8 millimeters in a circle radius is a good way to think about it. And from a disc height perspective, pretty variable. I've seen disc heights as much as 9, 10 millimeters. I've seen disc heights down in the 4 and 5 millimeters. Everybody's built a little bit differently. But let's take a look at what this study showcased and specifically relative to the results. So in this flexion distraction spinal manipulation group, the intervertebral disc height increased, which is awesome, from 6.32 millimeters to 6.93 millimeters on average, which was a difference of over half a millimeter. So that is pretty substantial. Now, you might say that sounds great, but is that a vanity metric? Right. What happened with the people? Were they feeling better and. Yes, they were low. Back pain decreased on average from about 7 out of 10 to less than 5 out of 10, which is super impactful and awesome. So the results of this study showed this stuff works. Flexion distraction is a great tool for individuals that have degenerative disc disease. And they specifically are taking a look here at L5S1 also, there was a significant change in straight leg raise. And what they found was a significant increase in passive straight leg range for from 46.9 degrees to 56 degrees. So overall, flexion distraction did a fantastic job with these individuals. Now let's look at some of their data and understanding of why this happened. What are those? Clinical take homes? We know it works great, but how do we think this is happening? And I'm gonna tie it back to some of what we talked about earlier on. On this episode. When we see a collapse in that disc height that places a tremendous amount of. It can place tremendous amount of stress and strain on the annular tissues as things push out, so to speak, you think about the spine collapsing down and that kind of pushes that sandwich out, so to speak. That is one aspect of things. So that places stress on the annulus fibers and in extreme cases, can cause disc herniation, challenges like that. Now, additionally, when that disc height decreases, it causes additional stress and strain on the facet joints, which affects mobility. And as that disc Height decreases, the IVFs close down, right? The superior vertebra. If we look at a segment of the spine, we have the disc, we have the superior vertebra and the inferior vertebra, the top vertebra and the bottom vertebra. The disc sits in between. Top vertebra. That makes up the roof of the house, where the IVF is, right where the nerve root's traveling out, Then the spacer is the disc. The bottom, the floor of that house is. Is the inferior vertebra. So if the disc collapses down, it's like the roof collapsing down towards the floor. You're reducing the space in the ivf. And that ultimately can cause irritation, it can cause aggravation, it can cause nerve root pain. And these individuals in this study certainly were dealing with that because they had findings on a straight leg raise. So it's not always that a disc needs to be pushing into the space to cause compression. Sometimes just an abject collapse of the space can also cause compression. And compression happens. Now that space is filled, right? So there's the nerve root traveling out, there's some fascia, there's some fatty tissue. There's stuff in there. So it's not like there's an open space. But, man, there's only so much that our body has in terms of give. So when that space collapses down, everybody's a little bit different. Everybody has a different tolerance, and everybody's nervous system reacts a little bit differently. And these are just the dynamics of it. I know we've all probably seen patients in practice that have tremendous collapses of intervertebral discs. Their IVFs look super small, and they just don't have any challenges. And other individuals who have light compression or light reduction in intervertebral height, and they're just lighting up down that L5S one like you've never seen before. And that's okay. That's part of our bodies being dynamic. It's part of us being great doctors and educators is being able to dive in and understand. And that's why the straight leg raise, I think, was an important component of this, because when nerves are inflamed, tension during that SLR can lead to advanced compression and stimulation of the dorsal nerve roots, which can stimulate reflex muscle activities and limit the straight leg raise. And Nerve inflammation is associated with it. So when somebody gets in and they receive flexion distraction, and we've seen, at least in this study, that that disc height can go up a bit. That's gonna probably open up that IVF a little bit. That's going to take some of the tacks and stress off of the disc itself and sort of reposition the disc ideally, or at least just sort of reset the stress profile on it, which would be a hu. And of course, this study didn't exactly touch on spinal stenosis, but, man, getting into that. What's that antalgic position with somebody with spinal stenosis is leaning forward. That's how they open up the canal. So when you're able to get in there with flexion distraction and get traction and mobility at the level where they're compressed, you can see some really big changes. I mean, I saw individuals that had. They were severely stenotic, let's put it that way. We're talking 3 and 4 millimeters, individuals who had. Had surgical consults. And these are people you want to keep a close eye for red flags, for saddle paresthesias, for anything like that. You definitely wanna keep a close eye when people are getting that tight. But wow, I mean, I've had some people just lay down on a flexion distraction table. You push down, you know, the part under their feet, so to speak. It bends. Just that slight flex, like, oh, my gosh, I can feel the blood. I can feel my feet again. Right. So it doesn't take a lot. I'm always a fan of, you know, starting easy and building in. Right. You don't need to overdo it with some of these individuals. And if somebody's coll. You know, do your best, you know, use your clinical skillset and experience to understand where they're at today. And as with anything, I don't think it needs to be rushed. Right. Getting on your table for five minutes, for 15 minutes for flexion distraction, whatever it might be, that they're still living those other 23 hours. Right. And many of those hours are going to be under load and under gravity, so you don't have to build roam in a day when you're taking care of people in your practice. And that's why everything is a process, right? We trace it back to the principles of chiropractic. You know, every process takes, and there's just so much truth to that. So getting in there and making any advances you can day to day, I'm gonna say that there's typically always a positive benefit for that. If somebody's able to live a higher quality life, they're able to have decreased pain. And obviously objective measures are fantastic. But this is really life effect. If somebody's able to find some relief, get back to doing the things they'd love to do and not have to have advanced interventions, I think we're all gonna be super, super happy. And this study showcases that flexion distraction might be a fantastic tool in your tool belt to be able to do that with individuals that have had significant degenerative changes in their lower lumbar spine. I'd love to see this study take place in the cervical spine. I'd love to see it, you know, take place at different levels as well. I think this is a great start to a conversation that can and should be expanded. But when we see better mobility, when we see a ability to improve the straight leg raise, to increase the disc height and to decrease pain, that's more than a trifecta. But you're really hitting every single aspect of how somebody can live a better life with the care that you deliver in your practice. So if you have any questions about this study, hit me up. Jeff the evidencebasedchiropractor.com if you have not left a rating or review, I'm gonna ask you to do so. Thank you so much for tuning in. All you have to do is kind of scroll down a little bit if you're listening on an iPhone and you can leave rating or review right there. Super, super easy. That helps. More Docs Find out about this podcast each and every week. And we have, I haven't checked in a few weeks, but I think we were over 11 or 12,000 listeners each and every week. So thank you so much for tuning in. I really, really appreciate it. 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