371- Using Neuromobilizations with Spinally Referred Leg 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. If you are into neurodynamic treatments, nerve glide, this episode is for you. We're going to tackle a new study that came out just last year in the South African Journal of Physiotherapy that attempts to answer the question, does the efficacy of neurodynamic treatments depend on the presence and type of criteria used to define neuromechanosensitivity and spinally referred leg pain? A systematic review and meta analysis with. We're gonna make that title far less complex than it sounds at first glance. This is a systematic review and meta analysis, so it's top tier stuff. Lot of great tech. Oas we're gonna get into this and much more on today's episode. But before we get started, let me say a few words about the Smart Chiropractor. If you have not booked a demo with the Smart Chiropractor for Patient Pilot yet, head over to the Smart Chiropractor right now and do so. 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One of the actions you can take to better your practice, Head over and do a demo with the Smart Chiropractor for the Patient Pilot and It is@thesmartchiropractor.com As I said at the top of today's episode. We're talking real research and the title was long and relatively complex. But I'll drop it down in the show notes so you can check it out there if you want to see the study for yourself. This came out in 2020 in the South African Journal of Physiotherapy. I did not know that journal existed until I looked at this study. But it's a good one and there's a lot of really fantastic information that we will dive into starting right now. We know that spinally referred leg pain is, is a common variation of low back pain. And the prevalence on that, believe it or not, is up to 43%. That is like super high. That's a lot of people. Think about how many people in your town and up to 43% of them having those issues is a lot of people you can help. So there have been previous systematic reviews that demonstrated a few things. One, that neuromobilizations are effective in reducing the pain and disability for people with spinally referred leg pain. So that's great. And that came out in 2017. That came out. Additionally, neuromobilizations use active and passive movements designed to facilitate the movement or tensioning of neural tissue in relation to their surrounding structures. And I think we see this in a lot of movement based classes in postgraduate education. And this study is a really good one. Cause it's taking a look at, well, how does this really actually work and who can and should this be utilized for to get the best results. Now, in early publications, which is, we're talking like late 70s, late 1970s, let me be specific there. That's even before I was born, neuromobilizations were recommended to specifically address patient presentations that involved neuromechanosensitivity. That's what they defined it as. Now, what is neuromechanosensitivity? That's a long word. Well, it's clinically identified by heightened sensitivity of the peripheral nerve trunks, the to pressure or tension. So how would you figure that out? Well, probably some common tests that you do each and every day. So neurodynamic tests such as SLR, straight leg raise slump test are developed, as you can imagine, we all know, to elongate that nerve fiber or bed, increasing the strain on neural structures. That's gonna give a positive test. So current recommendations on a positive test are basically reproduction of the pain, right? You go through that straight leg raise and you're like, that is lighting me up. You do a slump test, the patient has a reproduction of that Pain pattern that's in the leg, coming from the low back, going down the leg. But the goal of the neurodynamic test is put some tug, put some pull on the neural structures, thus increasing or reproducing the pain pattern. That's a positive test. Probably many of us do that pretty much all day, every day. But in a neurodynamic mobilization, the question is, well, when do you use it? Is it great when you have a positive test? Is it useful if you don't have a positive test? How does all that work? So they say in this study. Despite these early recommendations, it remains unclear whether neuromobilizations are indeed only beneficial for patients with confirmed sensitivity. And that's really the heart of the question here. How do you use these things? And I believe us as clinicians, we have that tool chest of what we lean into and what we do. So the study is being hyper specific. Positive test, negative test. Quite frankly, probably many of us utilize this across a variety of quote unquote cohorts or subgroups in our practice because we see that there's benefit there, especially with paired. When paired with a lot of the other things we do in our practice, spinal adjustments, therapeutic exercise, whether you have additional passive modalities, pretty much put together those combinations based upon what's going on with the patient. This is trying to answer that super specific question which great research attempts to do. So they started again. This was a systematic review and meta analysis. So they're taking a look at what's been previously published. And this was like fascinating to me. They looked at research from 1980 to 2016 and identified 13 studies to be included. So that's what, a 20, 30, 36 year period or something to that effect. 13 studies. Then from 2016 onward, they found eight. So the research on this is dramatically picking up in like the last five or six years, they found eight studies. For 35 years. Before that they found 13. So there's a lot of research coming out regarding this topic, which is great because it gives us more knowledge and more education on how we can help the patients in our practice. And I can assure you, outside of this is a physical therapy journal, outside of, outside of chiropractors and physical therapists, probably there are a few exceptions, but outside of chiropractors, physical therapists, like nobody else is doing this stuff. Like you're not gonna go in and see your primary care doctor and they're gonna start doing neuromobilizations, you're not gonna go in to see a pain management doctor or a surgeon, and they're gonna start doing neuromobilization. So talk about being able to corner a marketplace as chiropractors. And this is something we need to really take note of. If the positive, if the results are as positive as we anticipate they're going to be. So all of the studies that they previously looked at monitored pain and or disability as primary or secondary outcomes. So VAS and the numeric Pain Rating Scale NPR were the most commonly used outcome measures to monitor pain. And for disability, the old Oswestry Disability Index, the odi, was utilized. So total standards that they line these up with is great. So nothing off the rails as far as that's concerned. Standard outcome measurements. So they identified 21 studies in total. So they kind of pared down that initial batch that evaluated neuromobilization interventions with about 1009, 914 to be exact, but about 1000 people with spinally referred leg pain, as they say. So that's really the criteria. Now, how did you keep people in and out? We'll talk about that in a moment. But the meta analysis suggested large to medium to large. Excuse me, effect sizes of neuromobilization interventions compared to controlled treatments. It's great. Irrespective, interestingly, of the criteria used to determine the mechanosensitivity. We'll talk about that more in a few minutes. For disability, meta analysis demonstrated medium to large effects of neuromobilization compared to control treatments. So that is a darn good start. And they basically identify the fact that neurodynamic tests can be negative in patients with a clear nerve injury. This is like, you know, this gets me thinking about imaging and things like this. Like, you know, people have, you know, challenges. You gotta treat the patient and use the diagnostics. Right? So that's, that's, that is the root here. So people can have a nerve injury and actually have a negative neurodynamic test, which is why there are a variety of tests, everything from slump to slr, Kemp's test. There's just a variety. Maybe Kemp's test is not a great example of a neurodynamic test, but there are a variety of tests because it's not always directly linear. And that's something I think all of us need to keep in mind as we go through these processes. A lot of times as analytical clinicians, we like to play in the toolbox of care and treatment. But we'd love for the diagnostic to be one plus one equals two. And the truth of the Matter is, quite often it's not. And that's why I say with imaging, you can see a nasty, nasty X ray or an mri and somebody has no pain. You can see a pretty darn clean image and somebody has outrageous pain. So not everything is one to one all the time. But that also doesn't mean that there's no correlation. And that balance, I think is critical because I see a lot of docs taking super hardline stances, like one way or the other, so to speak. And the truth is, almost everything in life is somewhere in between. And there's a lot of it depends, and that's okay. Our bodies are ridiculously dynamic. Everybody has different genetic composition to a certain degree. We have different life lifestyles, we have different experiences, we have different injuries, we have different goals. And of course, we can literally trace this back to we have different thoughts, traumas, thoughts and toxins, literally. We have different thoughts, we have different injury history, and we have different ways that we feed our body not only from an inflammatory sense, but also from, is there drinking, is there drugs, is there smoking? These things play a role in ultimately our structure and our function at a fundamental level. So there's a lot of it depends. I say that because often we can be boxed into, it's this or that. And most often, I think all of us know when we actually practically put these things into practice with our patients, it's a little bit of that and a little bit of this. So despite the relatively large subgroup, what is that subgroup? Well, a third of patients with sciatica will have a negative straight leg raise, which is like, you know, smack your head there. Right? It's like, gosh, these tests are not super, super sensitive or super specific. I might be using those terms interchangeably there. But up to 33% of patients with sciatica are going to have a negative slr. That speaks to the point of it depends. So that's a large subgroup. So they didn't identify a single study that performed neuromobilization in patients with a negative neurodynamic test. Talk about, and we'll talk about this in just a moment, actually. But that's a huge opportunity for future research. So all of the studies. Let's reverse that. All of the studies published were neuromobilization techniques, were only performed on people with positive tests. Yet even in nerve injury cases, a third might have a negative test. So that is an area of supreme interest. I am sure that there's people working on that right now to get that data out. But let's talk about the conclusions of this study. The researchers found, quote Our review was unable to answer the question whether neuromobilizations are effective in patients with spinally referred leg pain and negative neurodynamic tests. However, we have shown a benefit of neuromobilization for pain and disability in patients with neuro sensitivity independent of the criteria used during the testing, whereas firm conclusions are prevented by the high risk of bias and small sample sizes. It certainly appears as though Now I'm going, I'll kind of end the quote there. It appears as though if somebody has a positive test, a neuromobilization is a really good idea. They saw positive benefits with pain and disability, which is awesome. Those were the two criteria and both benefited. Now the question remains in terms of those that have a negative test, but maybe they do have positive findings elsewhere. Maybe they do report what seems to be spinally referred leg pain. As I said in this study, maybe they do have findings on the imaging, but just that testing those orthopedic tests aren't coming out positive. That is the question to answer next, how much benefit? I don't think there's a question in my mind right now of is there benefit? I think there will be benefit, but how much benefit is there when a neuromobilization technique is performed on those individuals? So for everybody out there performing neuromobilizations, it certainly seems this showcases for people with positive SLRs, positive slump tests. It is a great tool. As far as those that have negative tests, I think it is probably a good tool, but future research will tell us that for sure. So if you have any questions on this, feel free to hit me up. Jeff the evidencebasedchiropractor.com Additionally, if you want to check out this study itself, you can click it down in the show notes. And before we wrap up, let me say a few words about Zingit. 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Sam.