305- Neurophysiological Responses to Manual Therapy

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're talking down the neurophysiological responses to manual therapy and their analgesic implications. In other words, how does manual therapy work and how does it get the results that we've come to know, love and expect? We're gonna break down some research regarding that on today's episode. Lot of actionable stuff to take away and some questions I think for future, future research as well. Before we get started, I'll say a few words about Novopulse. This is where recovery meets performance. I found out about this technology and I spoke with their founder maybe a week or two ago. I have never spoken to anybody who knows more about inflammation. So if you are a practice that is focused on performance and or recovery, please head over to novo-pulse.com and check out what they have going on. It might be a great addition to your tool set in your office. Novo-pulse.com I'll drop that link below as well. But as I said at the top, on today's episode, we're talking all about the neurophysiological responses to manual therapy. And this has been something that has been a question for a while, it maintains and continues to be a question. And it's probably truthfully not going away anytime soon. We've established on this podcast through the research that this is a real complex thing that happens with manual therapy. There's, there are so many aspects to what goes on. There's the biomechanical aspects, there's the aspects that take hold in the brain. Biochemical marker changes. There are central nervous system, there's peripheral nervous system. It's so multifaceted that it's difficult. However, that makes it even more rewarding to dive into the research and see what's going on regarding how this stuff works. Now, this study was published in the Neurophysiology of Manual Therapy journal. Pretty good journal name there a few years back. I'll link this down in the show notes. And it was released in 2015. So throughout the years, decades, it's been suggested that pain modulation happened because of neurophysiological changes and mostly that is mediated by the descending modulatory circuit. So that's historically what we've come to know now if we want to trace it to the way way back machine. We also know that manual therapy has been a part of rehab since 400 BC. And I think we've seen this also within chiropractic. Chiropractic was founded when Didi Palmer delivered that adjustment to Harvey Lillard. However, there's like hieroglyphics of things that look like, you know, spinal manipulation going on thousands upon thousands of years ago. So this has been going on a long time, but lately it certainly is something that has a whole industry behind it. What do I mean by that? Well, it's estimated that over 8 billion, this is five years ago. $8 billion is spent in the US on manual therapies primarily, you know, chiropractic, osteopathic manipulation, massage. They're including in that $8 billion industry. That is a four real industry. And we also know that quite frankly we are utilizing a fragment of what we could, meaning if chiropractic utilization is hovering at 15%, I think it's closer to 10. And there's 50,000 chiropractors active and practicing in the United States. There's 300 million people. And we know that hundreds of millions of them will experience issues that should be resolved and are recommended to be resolved in chiropractic practices. However, many don't go there because we only see utilization at 10 to 15%. So there still is so much opportunity out there. I love studies like this because they break down. Not necessarily what's the opportunity, but they break down. How can we communicate what's going on in a simple fashion? It's not that easy, it's not that simple. But every step that we learn is a step in the right direction. So the current research suggests that a neurophysiological response to manual therapy is primarily responsible for the clinically significant decreases in pain. And I love when they use that in this study saying these are clinically significant decreases, not just that it decreased a little bit, but this is having an impact on the quality of life and it's having a life impact positively on the individuals that come into the practice. Very, very important. So included in that neurophysiological response is the descending pain modulation circuit. And that is thought to be really that route, that highway, that conduit for how things work. So let's trace it back a little bit because in 1965 Melzack and Wal, they described what was originally the, the gate control theory of pain. We probably all have heard of this, right? Non noxious input suppresses painful output by inhibiting dorsal root nociceptors. Pretty straightforward. I think all of us have heard of that in the past. And there's a bunch of neurotransmitters involved in that. There's serotonin 5ht, there's endocannabinoids, there's endogenous opioids. All of these things. Periaqueductal gray, all of these things really modulate those nociceptive circuits. And the pain output and the gate control theory of pain, I'm going to say to a certain extent, clearly there's been criticisms and there's been additions and evolutions, but there's a lot to that that still holds true, makes sense and has proven itself out over time. There's no question about that. But if we drive further and we say, well, what's going on specifically with spinal manipulation? Well, in 2014 there was a study that compared cervical and thoracic manipulations to a control group. Now what happened? Well, in both in the cervical and the thoracic groups, there were decreases in neurotensin, increases in orexin A and decreases in oxytocin. So all of those things were contributing factors. Right. I'll say those again. Decreases in neurotensin, increases in orexin A and decreases in oxytocin. Now, only the cervical group saw a decrease in cortisol. Why is that the case? Good question. I think that's great research still yet to be done. It might be something to do with a sympathetic parasympathetic. There might be something unique about the cervical spine because of the brainstem and how the nerve roots exit. I don't know. But it's an interesting thought and it shows there are different things happen. And we've seen this as well with symptomatic versus asymptomatic patients. When the force is delivered, when a spinal manipulation and adjustment is delivered, the body receives and processes it in a different way, whether it's whether the body's in pain or not in pain, whether it's symptomatic or non symptomatic. And that's important and it's super interesting because it shows just how dynamic we are right now. Let's take it one step farther and say, okay, that's spinal manipulation. Well, cause this is manual therapy study. So it doesn't owe only context to the spine and an adjustment. So they also looked and said, okay, what happens when you do a knee manipulation, when you manipulate a knee? And if you're a sports chiro, maybe you're not even sports chiro. You probably get in there on some knees every now and again. Well, what's going on? Well, studies have shown that the analgesic effects of knee joint manipulation were not impacted by the spinal blockade of opioid or GABA receptors, but they were impacted by blocking the receptors of 5ht and norepinephrine. So again, so interesting that depending upon the body, the joint in the body that receives the adjustment, or the manipulation, our body processes it in a different way, down to literally a chemical level. I just find it absolutely fascinating. Now let's say we go down to the ankle. You know, take. All right, knee, we've adjusted the, you know, the spine, we've adjusted the knee. What's going on in the ankle? This is an ankle joint mobilization. This one was done in mice, but they found the analgesic effects shown to be mediated by those EO pathways, those endogenous opioid pathways. So again, it's super fascinating to think about how when you put your hands on somebody, when you're delivering an adjustment or manipulation, literally depending upon where you're doing it, they're gonna receive a dramatically different effect internally. Now, they might, as a patient, you might just say, can I move it better? Do I feel better? Pretty straightforward, simplistic things and ultra important, by the way. I don't mean to diminish it by saying that way, but when we look at what's going on at a biochemical level, oh my gosh, totally different pathways are utilized. The ability to modulate pain happens in a different manner. And it also is important because the more that we learn about this, the more we can specifically influence things. So as we discover more about which pathways are activated through which body region, I want to be clear, this might not always be an A plus B equals C. Your neck hurts. Let's find the fixation in the cervical spine. Deliver an adjustment there and you feel better. We might come to learn, might, a very key word there might come to learn that a thoracic adjustment might be at least as good, if not better than a cervical adjustment when the cervical spine is the part or body region that's struggling Now, I don't know. We've seen some early research with headaches and neck pain and thoracic adjustments and improvements in. However, there's still a lot to be learned. That's also why I'd say, and I'd just recommend, I know a lot of docs that listen to this podcast favor themselves on the evidence based part of the profession. Evidence based Chiropractor podcast. That makes sense. However, don't negate the fact. Don't become myopic with your care and treatment. Understand that the body is dynamic. I always say look to at least the next body region, the next joint. If you're, if somebody has neck pain, check out their thoracic spine, check out their shoulder. If they have a shoulder issue, check out the spine and check out the elbow. Ensure that you are checking out those adjacent joints and body regions because you might be able to discover benefits if you find something there. Obviously, if you go through an evaluation and you deem that something is askew, addressing and treating those concurrent areas or those complementary areas can yield absolute result. So don't, don't become so myopic with your care and treatment that you really just laser focus in on only the area of complaint. And they also found kind of tying it back to the study. They looked at massage therapy as well and they said, you know, while massage therapy does elicit an endogenous opioid response, they basically found that spinal manipulation doesn't. Right. When we talked about spinal manipulation, those pathways were a little bit different than what went on with massage and certainly what went on in the knee and ankle. So remember, when the spine was adjusted, they saw decreases in neurotensin, increases in orexin A and decreases in oxytocin. Now if you wanted to affect cortisol levels, that was found only in the cervical spine. Now it might have just been that study. I think there'll be more studies to come to showcase whether or not that was an anomaly in that paper or whether that's the way it goes. Right. Every study builds upon the previous ones and leads into the next. That's how research goes. But I just think there's some such fascinating stuff out there. Understanding exactly how what we do each and every day works with and for the benefit of our patients. The research with this is not gonna stop anytime soon because there's still so much to be learned. But again, I'll take a step back and say it's pretty easy to make the Again, A plus B equals C. Somebody takes a medication and it affects their biochemical changes. Ultimately that's pretty self explanatory. The drugs are designed to do that. To think about the fact that a force delivered into the body by hand, let's say in this case can also deliver similar, if not in many cases, better response is absolutely mind blowing to me. A physical force changing what goes on with biochemical markers. A physical force changing how our body processes information on a gate pain control theory. These are just fascinating, fascinating things to think about deeper now. It might not again directly affect how you take care of your Mex patient today, but as we continue to learn more, as we continue to investigate it, man, there is so much opportunity for us as a profession, as chiropractors to better understand exactly how the adjustment works and then be able to make just incredibly dynamic, incredibly personalized, incredibly impactful treatment and care plans based upon what we know. Here's the beautiful thing about it. Right now, we don't know that much. We're learning a lot, but we don't know that much. The story's still yet to be told and we still get fantastic results. I always say when I ask most chiropractors what percentage of your patients leave your practice, you know from their initial care plan happy and satisfied, it's inevitably over 80 to 90% of individuals. That is such efficacy. It blows away placebo, it blows away injections, it blows away NSAIDs, it blows away all of these other things that people might look towards and we don't have any of the dangerous side effects of it. This is why I'm so passionate about chiropractic, why I hope you are, and why I hope you'll continue to follow me on this journey, on this podcast, and of continuing to learn more about who we are and what we do as chiropractors. I thank you so much for tuning in. We have over 11,000 docs tuning in each and every week. If you have not left us a rating or review, I'll ask you to scroll down and do so. That helps more and more docs find out about this podcast and engage with it, which is so awesome. So thank you so much for tuning in. Before we tune out today, I want to encourage you to check out Echiro Ehr. Every EHR sells features few have Ecairo's expertise. You've heard me talk about how they're really built on documentation and compliance. Two super important words. Check it out. Echiro ehr. I'll also drop that link down below to check out. And of course, if you are looking to hire an associate, if you are looking to hire a CA or you are looking to have coverage work, check out Cairo matchmakers chiromatchmakers.com and if you are a doc out there listening and you're saying, man, I'm looking for my next opportunity, we have over 130, 50 active jobs paying over $75,000 each right now spread throughout the United States. So please Visit us@chiromatchmakers.com and we will do everything we can to find your next great chiropractic opportunity. So I hope you have a fantastic week in practice and I will talk to you soon.

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