394- Associating the Multifidus with Low Back 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 Langme. This week we are back with more research in a really, really cool study that's all around the multifidus muscle and its association with low back related pain, duration, disability and leg pain. Actionable study, Tons of clinical pearls. I love this one. I love talking multifidus. We're going to break it down and highlight what these researchers found on today's episode. Before we get started, I just want to highlight the fact that the money is your email list. If you have an email list or a patient list of 300, 500, 1000 and you are not consistently communicating, consistently means each and every week you're missing out on the opportunity to drive reactivations onto your calendar, make new friends and keep the old, as they used to say. Definitely applies to your patient list and it just eases the stress on your new patient acquisition when you have a steady flow of reactivations. If you want to discover how we help over 300 chiropractors do this around the world each and every week. Completely automated. You can check us out@thesmartchiropractor.com and schedule a demo. We have a 3x ROI guarantee so why wouldn't you do this? Especially if you're not doing anything with the email list. Hop over the smartchiropractor.com schedule your demo today. And as I said at the top, we're talking research. I'm going to drop a link to this study down in the show notes and it is titled Lumbar Multifidus Muscle morphology is associated with Low back Related Pain Duration, disability and leg pain. A cross sectional study in secondary care. This thing was published this month. It is hot off the press and it is a good one. If you have watched any of my videos on YouTube specifically related to analyzing lumbar MRIs, you know I take really seriously the multifidus muscle. This was one of those aha moments in my career where when I was looking at an axial view of an MRI and I saw comparing one patient to the other, I never looked at the multifidus with any sort of realistic thought, let's put it that way. And I saw one was completely atrophied, totally white on the T2 weighted image. The other one was dark, dark Dark. And it just was such a stark difference that it was like, how the heck does this person think they're going to get well when they have absolutely not, none of the stabilizing musculature to get there? Or let me rephrase that. How the heck do they think after one visit they're gonna get well when they got a lot of work to do? They are so deconditioned that it just really clicked with me to say this is an opportunity to really be able to understand at a higher level what's going on with the patient and then be able to accurately describe that during my report of findings. Being able to accurately describe the clinical course that they're about to take. Because my expectations on somebody's recovery when have really, really great multifidus tone, so to speak, or a cross sectional area, it just looks healthy versus one that has tons of fatty infiltration. These are wildly divergent paths. Of course there are exceptions to the rule, but these are wildly divergent paths. And when you're setting expectations. Here's what I don't like. Let me drive home to the point here. I don't like it. If a patient comes in to see you, you don't check out the multifidus. If they have an mri, you haven't checked it out, and, and they leave your practice because they didn't get a great result quick enough that could be mitigated by helping them understand that this was not about the care and treatment. This is about their body, his current state and what they've chosen to do or not do over the last 10, 20, 30 years. And that you'll help them get to where they want to be. But it's going to take a little bit longer based upon what's going on on the inside. That is a really important part. So as low back pain due to a specific pathology is pretty rare, it's actually less than 10% of the time. It means over 90, 95% of are classified with non specific low back pain. And where does radiculopathy fit in with that? About 5 to 10% of patients. This is setting the stage for the study today. So there has been across all research, in my opinion, which is awesome, a growing focus on spinal function and specifically looking at the paraspinal muscles in order to understand the progression, cause and or outcome of low back issues. And the lumbar multifidus are really complex, they're really intricate and they are really, really important and they contribute directly to spinal stability. And they actually account for over 66% 2/3 of the stability at the L4 L5 level. What's the area of greatest challenge in the lumbar spine? L4, L5. And when we look at stability, it doesn't mean something has to be abjectly unstable. It means do they have the musculature in order to dynamically react to what's going on, Whether that's jumping, stepping off a curb. You get what I'm saying there so important to understand that. So the objective of this study specifically was to explore the cross sectional associations related to the multifidus muscle and kind of cross reference that against pain, disability, spinal function and work history with patients that had nonspecific low back pain and or back related neck. Neck back related leg pain. Excuse me. So what they really looked at was what they refer to as muscle cross sectional area. They call that mcsa and they're talking about that in percentages. So is there a lot of in X amount of space is 90% muscle, 10% fat is 10% fat, 90% muscle, vice versa. That is really what they were looking at in relation to this study. And this is a pretty healthy study. 875 patients were eligible for being included in this study, which was great. The mean age of patients, 43 years old, a little bit over 43. So average out to about 44 years old and 56% were females due to the OR. The duration of pain ranged from less than one month to over 40 years. And there are 2% that had no current low back pain and 13% no current leg pain. So pretty wide birth as far as pain duration, but 56% female and and about 44 years old. They found consistent associations between the percentage of the cross section of the lumbar multifidus and low back related disability and leg pain intensity with lower disability and leg pain ratings in patients with a higher proportion of muscle of pure muscle cross section. So we're gonna talk about that in a moment. It's a little bit confusing to read like that. We'll break it down. So what does it mean? It means on average patients with higher multiple tiffitus quality reported lower levels of low back pain, which is probably what you would assume to have seen and they highlighted it here. So there's a variety of arguments highlighting why is this relationship here. And it's not exactly clear what the answer is at this point in time. One might be which comes first, the chicken or the egg? The classic and that seems to be the case with the multifidus. Did an injury cause the multifidus to degrade or did degrading of the multifidus lead to an injury? And the truth of the matter might be some of both. And it depends. Which is my favorite answer. It depends, right? There's a lot of factors that go into that, and it's probably not unilateral. It's very dependent upon the individual. Because we all know people who have been totally sedentary for decades, totally pain free, and then they bend over, bang, all of a sudden something's lighting up in their low back. We see that all day, every day. We also know people that. And that was probably a degenerative change or infiltration of fat, degeneration of the multifidus over a long period of time, that then when they bent over, that was it. We talk about that all day, every day as chiropractors, specifically because we see it all day, every day with our patients. There's also the opposite, where people are in great shape, they have great multifidus tone, and they just suffer an injury. Right? The injury stimulates their disability to move and then they cascade down and the multifidus wastes away because they never get up and moving again. So both cases make sense to me. And they don't highlight one over the other. They say, well, it's still trying to be determined. I think the answer is both in this case. So findings from this study do appear to identify an inverse association that may exist between two interesting parameters. The direct explanation, and that is multifidus, what I'll call tone, which they called the cross sectional area, but between tone and pain level. And they say the most direct explanation for limiting of this association is the lowest percentage MCSA category would be the presence of an underlying nerve root compromise, which concurrently results in leg pain and isolated muscle quality reduction. So they're kind of highlighting what I talked about just a moment ago in slightly different way, Meaning there are times when somebody might have a great muscle tone and a nerve compression that can lead to decreasing muscle tone over time. So they did identify a lack of association between muscle quality and physically strenuous nature of work, which is really interesting. And they say that's consistent with the previous report by Fortin a couple years back. So they had postulated that reduced lumbar multifidus quality may limit a person's ability to perform more physically demanding work, or. Or that more time spent performing a less demanding work may result in multifidus muscle quality diminishing. So again, this starts to become which came first? Chicken and egg. And the answer to that Again is probably both. But in conclusion with this study they highlight that there is a association between the multifidus muscle and low back disability and leg pain. And that is the key take home message. So if you are not checking out the lumbar multifidus, if you click down below, download this study, you can check out. They actually have some cool pictures where they highlight where you can see a multifidus on an MRI image. If you're not familiar with looking at that all the time. It kind of lies in the, in the gutters of the gullies between, you know, between the facet joints and the spinous process of course posteriorly so you, you can identify it very clearly. It's color coded on the, in the. So if you haven't checked it out lately, please do so. Also you could always check out the videos that we produce at the evidence based chiropractor on YouTube. Have an array of MRI review videos there. They're great refresher course if you haven't checked out an MRI in a while. I was like, gosh, I hate to feel like somebody hands you a disc. That sounds old school now, just a disc. I don't even have a disk. I have no CD or disc drives on any of my computers anymore. But if you're checking out an MRI of a cervical or lumbar spine, you don't do it every day. Sometimes that can get your palm sweaty, let's put it that way. Let me take a look at the report. We'll go from there. I think you should feel comfortable and confident not necessarily identifying every single organic complaint or every tumor. That's what those neuroradiologists and DAC bars are for. But being able to identify compressive pathology, being able to understand what's going on with the musculature, I think is really, really important. And to me that's an underdeveloped skill for a lot of chiropractors out there is being able to really look at an MRI confidently with a scope of let me check out compressive pathology. Let me check out what's going on with the musculature. Let me try to determine what I can which will be limited functionally from these static images. And that is an area where I love to help. So you can check out the evidence based chiropractor YouTube channel for that. But the bottom line is the multifidus muscle is a really, really important stabilizing muscle and it provides a majority of the stability in the most oft injured area in the lumbar spine, which is L4 L5. So one thing I will take note of, and I'll ask you to take note of is I very rarely see this finding on a report. So let me pull these threads together here so it's a clear understanding. Very rarely in my career have I ever seen the multifidus degradation noted on an MRI report. So quite frankly, unless you're checking these out yourselves, it's highly unlikely that it's going to be on the report. So that's the missed opportunity tying the beginning of this episode. If you're not identifying yourself and it's not on the report, you don't have the information. So now you're unable to communicate what's going on with the patient and specifically the expectations of care and recovery in an accurate manner. And if you're unable to do that in an accurate manner, man, that becomes really, really challenging to have a patient number one understand what's going on. And quite frankly, from a business perspective, probably gonna yield increased or just say decreased patient retention. I don't mean retention like long term, I mean just throughout the active care because they're not hitting the goals and expectations the way you thought. And quite often that might be due to functional issues with the musculature that limit their ability to get the desired gains. So that is the big take home message in my opinion from this study. I'd encourage you to keep an eye out on those MRI images. Check out the Evidence Based Chiropractor YouTube channel. We also have an MRI course at the evidencebasedchiropractor.com it's super cheap, it is really complete and it is just the brass tax of how to review images. When I I worked at the second orthopedic practice I was in, I was reviewing like 20 MRIs a day. From a patient perspective, we always had overreads by our dacbars and our neurorads, but I was looking at them in the context of really, the patient's gotta sit in front of me. What's going on with this patient? It's nice to know all the findings, but how do I apply what we know to what's going on with the patient? So that's always available for you as well. Before we wrap up, I wanna say a few words about Powerstep Orthotics. They were IUs, what my father uses. I'd recommend you use them. They support podcast, you should support them and they will hook you up with a free sample pair. They're developed by a podiatrist over 30 years ago. They're awesome. Check out a pair for yourself. Pro powerstep.com sample Pro powerstep.com sample Use the code EBC for evidence based Chiropractor and pick up a free sample pair. Additionally, if you are interested in AI and if you are interested in having an awesome ehr, then I think you need to check out Kairo Spring. Kira Spring will hook you up with $100Amazon gift card just for hopping on a demo. That's how confident they are that they can help your workflows improve. Kairospring.com offer Kairospring.com offer and finally, if you have not left a rating or review for this podcast or you haven't in a little while, I would really love to hear from you. I'd love to see what we can do for some reviews out there. So if you are liking what you are hearing or you have feedback for it, click how many stars Write a line or two that helps us find get found by more and more docs each and every week. I really appreciate you being a chiropractor. I appreciate you listening. Have a fantastic week in practice and I will talk to you soon.

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