401- Predicting Future Low Back Pain After Spinal Adjustments

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. On today's episode, we're talking research, another brand new study that just came out and it is all about clinical factors that predict a one year recurrence of low back pain after receiving spinal adjustments. We're going to highlight the clinical pearls and put it into action on today's episode. But, but before we get started, I'm gonna extend the Evidence Based Chiropractor podcast contest one more week. Thank you to everybody who has left a review and feedback on Apple podcast. I'm gonna extend things one more week so if you haven't yet, you have one more week. All you have to do is on Apple podcasts, scroll on down, leave a rating and a review. I'm gonna call out a few names next week. I'm gonna call out a few names next week and I'm going to send some swag bags to you filled with great evidence based chiropractor stuff so all you have to do to enter the contest. If you've been enjoying this podcast, please use Apple Podcasts. Leave a review, I'll see it there. I'll call out some names next week. I'll get in touch with you and ship you out some awesome stuff and I would greatly, greatly appreciate it if you took a moment to do so. That helps more and more docs find out about this podcast. But as I said at the top on today's episode, we're talking research. And the title of this study, it just came out in chiropractic and manual therapies. I'll drop a link down below in the show notes. Title's kind of long, but it is called a multidimensional nomogram combining clinical factors and imaging features to predict one year recurrence of low back pain with and without radicular pain after spinal manipulation or mobilization. That that is a mouthful, but the bottom line is what they were trying to analyze was what are some factors that we can use to predict after one year if low back pain's gonna come back if somebody has spinal adjustments? That's what they were looking at in a nutshell and I think they did a really good job starting the conversation. As we get into this, we'll see there's probably some follow up research studies that are gonna happen, but it's a great starting point. Interestingly, they pointed out that 40% of people will experience low back pain within a given 12 month period. We know about 90% will experience back pain over the course of a lifetime. We know there's about a 30% point prevalence rate, meaning on any subset of people, 3 out of 10, 30 out of 100, 300 out of 1,000 will have back pain at any given time. But now we know 40% of people will experience back pain and during any 12 month period. So is there opportunity there? Absolutely. And is what we do as chiropractors, as movement based healthcare professionals the best way to take care of it? Absolutely. So that means there's plenty of opportunity to build and grow a practice by helping people regain their quality of life. We also know that recently international guidelines on the care of low back pain have, have really put forth non invasive treatment as the number one option. Bout time, of course. And that doesn't mean that many people in the traditional care model, as we know they're highly guidelined, discordant, have adapted those guidelines, which is a big, big, big problem. And I think there should be accountability and oversight for making what I think to be dangerous and non concordant decisions. But that's a whole nother story. But the bottom line is we should stand tall and stand proud and no, we, we have the guidelines behind us, we have the research behind us and we have the proof. As many of us have known for decades, if you've been in this profession, in a movement based healthcare profession for a while, you know that what you do helps people get well at a rate that's far faster and far better than drugs. High interventions such as injections and surgery, there's a time and a place for those things, but it's probably 1% as often as they're currently utilized. We also know that spinal manipulation and mobilization are one of the most popular techniques out there and continues to grow in popularity because it's generally safe, effective and people have high satisfaction when they experience it. You can overcome fear, avoidance. There's multiple mechanisms of action as we'll talk about. There's just a lot that goes into it that helps it be a really great option for people dealing with neuromusculoskeletal issues. And that goes beyond pain, but also to functional performance. So how does manipulation and mobilization work? Well, they're different in some respects, but the goal is to improve mobility of the spine and reduce pain and dysfunction. That's really what it comes down to now, how that's applied can be different depending upon the technique. For example, mobilization of course, uses low grade velocity passive movements in a controllable range of motion. That sort of stretch, it provides a stretching mechanism, whereas manipulation, high velocity, low short amplitude. And that's usually applied in or around the limits of physiological motion. Getting into that paraphysiological space, as we all talk about now, by definition, let's be clear, by definition, the paraphysiological space is not into injury territory by literal definition, but it is beyond the traditional range of motion. That's where quote, unquote, the magic happens in some ways with a spinal adjustment. So the modes of action can be again pretty variable. But you want to reduce mechanical stress on the spine. And also we know that there's an effect on afferent neurons and the motor control systems to the paraspinal tissue. So that's that feedback loop where you get gating of pain. You can see increased cortical drive changes in biomarkers in the brain. All of that happens at a local level as that adjustment's delivered, as spinal adjustment's delivered and then cascades up throughout the, throughout the nervous system, ultimately throughout what's, you know, the central nervous system as well as the peripheral nervous system. And that is really, really important. So in this study they looked at a variety of patients between 18 and 70 years old. These patients had low back pain with or without radiculopathy. And they had MRI confirmation of disc herniations or degenerative changes and spinal manipulation was the main treatment option. Now interestingly, all the patients in this study had at least a one week stay in a hospital, which is, this study was done overseas in China, it was not done here in the States. That it's not usual and customary, let's say for many people that have low back pain to be treated in a hospital based setting with spinal manipulation as being their primary treatment option here in the states. But that was the setting and set for this study. What they ended up with was 786 patients who met this inclusion criteria. And the age of these patients was around 50 years old. It slanted a little bit more female than male. So 54% female, 46% male. And the lumbar disc herniations, interestingly to me, L5S1 had 49% of the disc herniations, L4, L5, 44% and other about 5%. So traditionally we see most disc herniations occurring at the 4, 5 space. But in this study that was secondary to the 5, 1 space. And those two combined, 50. It was like 95% of the disc challenges were at those two levels in this study. So an overwhelming majority, pretty much everybody had issues at either 4, 5 or 5 1. So that was really how this study went. Now, they took that one step farther and they looked at the progression of these individuals through a variety of different avenues, so to speak. And what did they identify? Well, they took a look and they identified that hospitalization time, previous history of low back pain, disease duration, lumbar range of motion, lower extremity, tendon reflex and muscle strength, ratio of herniation to uncompressed area. The Furman classification were all independent prognostic factors for low back pain reoccurrence after spinal manipulation. So all of these independently led to a higher likelihood that there could be a recurrence in the future. And I'll review those one more time. So what were the factors that led to a higher likelihood? Well, hospitalization time, somebody was in the hospital a longer amount of time, that was, that was an issue. Previous history of low back pain, previous recurrence. What's, what's the best predictor of tomorrow's weather? As my friend Dr. Steven Fransen says, today's weather. So previous history of low back pain, disease duration. Is this chronic, is this acute? That is a factor. And that makes a lot of sense. Lumbar range of motion. That's important because how much does somebody have to. I think about that, like, what did you lose already? Right. If there's super limited range of motion, you might have a lot of loss to come back from before you get back to normal. Whereas if you have just a lightly limited range of motion, it's not that much to get back to normal. So that's a factor. And that makes a lot of sense. Lower extremity tendon reflex. Of course, that makes sense relative to the compressive pathology and, and the ratio of the herniation to the uncompressed area. So how big and bad is that herniation? Right. And then this Furman classification, all of those were factors that this study identified as predictors or prognostic factors for recurrence. So they also saw a positive correlation between the ratio of herniation to the uncompressed dural sac area and the possibility of mechanical impingement of the nerve root. So here's a couple of things that I see regarding that statement. Love that they found it. I have seen personally in practice, some of the largest, nastiest disc herniations can resorb in a way that sometimes These small and medium ones just don't. It's these medium sized ones that tend to be the challenge I've seen. Clinically. A small disc herniation tends to be a minimal issue. Now it's not correlative to pain 100% of time. Sometimes you can see extreme pain with small herniations. But some of these big scary disc herniations I've seen dramatic resorption and the small ones I've seen do very well reducing pain. It's these medium sized ones clinically for me, that become the challenge. They continue to cause pain. And it's almost as if I'm not going to say this correct to the literature, but I think we've seen this. I think of it like modic changes at the end plate level where at phase one there's a lot of inflammation and you just get pain associated with that. And then as things start to shore up and stabilize, you see the pain decrease. So where am I going with that? Ultimately? I think when there's a big disc herniation, there's a ton of inflammation that alerts the body. Something needs to heal here. All hands on deck. That stimulates the healing process at a level that's dramatically higher than a small or medium disc herniation, which may not be as much of a five alarm fire, so to speak, in terms of healing in the body. That's the way I simply think of it. I don't know if that's true according to literature, but I'm piecing together some things and what I have seen now in terms of how spinal manipulation can take care of this, they highlight in this study. Hey, this is complex. So there's a few things that manipulation you may be able to help with. Correction of the disc, displacement, release of adhesive, fibrosis surrounding the discs, releasing and improving motion in the facet joints, releasing entrapped synovial folds, relaxation of hypertonic muscles and unbuckling of the motion segments. All of those things I have seen in previous studies I agree with and then some because we also, that is like pretty much at that level. And then I take it one step farther and I say man. And we've seen cortical drive increase performance gains and we've seen biomarker changes in the brain. And we've. And we've. And we've. Right. So that is an important component to keep in mind that there's a lot of factors that go into this all are important. And as we've highlighted a few weeks back with the biopsychosocial model. Also just the encouragement somebody gets when they see a chiropractor. And I think that's just an act to the physical nature of moving. Again, fear avoidance behavior is a very, very, very real thing. And motion is what's needed to heal. So when somebody can receive mobilization or a manipulation and they know that, that okay, I actually feel a little bit better. Maybe one doesn't solve the issue, but I feel a little bit better now. My fear can go down if I'm going to bend over, if I'm gonna sit down because I just went through and got an adjustment which seems like a big motion. That was fast. That was scary. Now you start to be able to overcome fear with daily activities. I think that's a very, very real thing. So in conclusion to this study, they found, quote, our prognostic model indicated that patients with low back pain with a first episode short term disease course, no limitation of movement or lumbar radiculopathy, minor disc herniation or mild degeneration, would be better treated with spinal manipulation. So I think that there's a lot to see in future incarnations of this study, but really interesting points, Great opportunities to just dig in, understand what the literature is saying and how researchers are framing what, what we do currently. So I found this to be a very, very great study and I hope you did as well. 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If you take action now, that all happens@chiromatchmakers.com again chiromatchmakers.com that is a fantastic resource to build and grow your team. So if you're thinking about hiring, do not go it alone, you are likely to end up with high team turnover, a ton of cost. And the bottom line is you are not a professional recruiter. You are a chiropractor. Take care of the people and let recruiters find the right person, not just somebody with a pulse and a license. The right person to help you build and grow your practice. Thank you so much for being a chiropractor. Thank you for listening to this podcast one last week. To enter into the podcast contest online, all you have to do is leave a review on Apple Podcasts. I'll call out a few names next week. Have a fantastic week in practice and I will talk to you soon.

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