411- Muscle Activation Responses During 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. This week we are back with more research, another brand new study that just came out in the Journal of Clinical Medicine and it is titled Treatment and Response Factors in Muscle Activation during Spinal Manipulation. We're going to talk about take home messages in this study, some clinical pearls as well as why it matters to practice. Day in and day out, we're going to go through all that and more. And of course I'll drop a link to this study down in the show notes if you want to check it out. Before we get started, I want to say a few words about patient pilot by the smart chiropractor. It is Q4 of the year if you'd like to drive more reactivations. And specifically, let's get those HSA FSA campaigns going. Not just one message but a campaign that goes all throughout Q4. Head on over, do a demo. Let's have a conversation. Patient pilot. We pilot patients back into your practice. How many patients? Well, I can tell you if you have an email list of less than 300, I'm gonna recommend you do it yourself. However, if you have an email list of more than 300, we can generate better results than you can on your own. How do we know it? Because we have six people that work on it full time, all day, every day with fantastic results. How much results? Two factors. That depends on your email list size. We want more than 300. And number two is how much patients like you. If you believe you have hundreds, if not thousands of patients that would come back into your practice, let's find out. Let's start sending them some campaigns. We're gonna deliver you daily, daily reporting showing you exactly the names of the individuals ready to come back in. All of that is automated for you. It is in a teach and invite format. I'm happy to work with you. Smartchiropractor.com Again we'll drop that link down in the show notes. Schedule a demo@the smartchiropractor.com but as I said at the top, we're talking research. This study is titled Treatment and Response Factors in Muscle Activation during Spinal Manipulation. What is this all about? Well, there are forces applied during a spinal adjustment. Those forces produce a neuromuscular response in the paraspinal muscles. This study dug deep into how do those things play together. And it causes or it brings about more questions maybe than it answers, as many studies do. But it also provides some really great clinical information. So here is a really interesting fact, especially if you are a member of the evidence based chiropractor building referral relationships. And if you'd like to build relationships with other healthcare providers in your community, we have the systems and processes that are proven and make it easy at the evidence basedchiropractor.com, but here's something that I found fascinating. It's the first line of this study. Low back pain is the second most common cause for visits to a primary care physician. That's astounding to me. I've always said and docs listening that have been on an implementation call with me with the evidence based chiropractor. I'm always like, hey, about 30% of primary care physicians daily volume is related to neuromusculoskeletal conditions and about 99% of that is non emergent. Meaning look at any primary care doctor in your community and you could probably drive by and see that their parking lots are full. They're not accepting new patients. They're seeing a lot of people each and every day. Let's say they are seeing 50 people in a day. Many are seeing a lot more than that. That would mean that 15 people per day are people who should be referred to your practice in their daily volume individually. That's like you know a lot of people each and every week. It is more than 100, 200 people per month that should be referred in your practice. And that is, here's the crazy part per primary care physician, low back pain, just itself. Forget neuromusculoskeletal, which is much wider. Low back pain, second most common cause for visits to a primary care physician. And it accounts for billions of dollars in annual cost, medical expenses, missed work, job performance issues. And it's actually increasing significantly in prevalence, not decreasing. What does that mean? It means we need to get out there much more than we have in the past. So spinal manipulation is recommended in clinical guidelines, as we well know, and it's an accepted treatment for spine related issues. That doesn't mean that all those referrals come our way without a little bit of work and a little bit of process and system. But it's really nice. Again, I'll continue to say it. It's really nice to see that just laid out in the research. This is not investigational, it's not Experimental, it's barely even debatable at this point in time. Clinical practice guidelines recommend what we do. And most people have no clue that that's the truth. Now, the forces produced during a spinal adjustment have been shown to do a few things. They provide individual motion to the vertebral segment. They can increase facet joint gapping. Of course, they can change or influence intradiscal pressure, they can influence pain thresholds, and they can influence paraspinal muscle activity. Of course we also know about influenc biomarkers in the brain and a variety of other things, but basically at that segmental level, those are a few things that they do. So changes in muscle activity, usually measured by emg, and that's a measure, it's a general measure of neuromuscular response to a adjustment. And they may contribute actually even to the mechanism of pain reduction. So when we talk about neuromuscular skeletal response or neuromuscular response to an adjustment, there are two big groups that are considered in this study. Treatment and response Makes a lot of sense. Treatment factors, those are the variables that are chosen by the practitioner, such as the sequence of the adjustment. Do you adjust the lumbar first or the cervical second? Do you go cervical to lumbar and the time between the two, like how is that sequenced? That's a factor. The other is the site of the adjustment or manipulation. And that's pretty self explanatory. Are you adjusting C4, C5? Even if we want to, are we really getting in there and adjusting the level that we think we are, Those are real factors. The other are the response factors. And these are the elements of the patient's response, such as the muscle location, the side of the muscular response, the muscle layer that's influenced. Is it paraspinal like erectors? Is it deep like multifidus? Those are really the factors. Now we know that increases in multifidus activity and thickness are demonstrated following manipulation, which implies a link to multifitous function. Let me say that one more time because I talk about this a ton in the MRI course that I have available, which is everybody, everyone listening to this podcast. If you receive an MRI of the lumbar spine, you need to not just look at the report. Please, please pop in that disc. Maybe that makes you sound really old disc. What the heck's that? You know, access it via the portal, use the thumb drive, pop in the disc, whatever it is that you have access to the images on. Take a scroll down and take a look at the multifidus because if the multifidus is totally worn away. If there's a lot of fatty infiltration. That is a big sign that it's gonna take longer to get the response. Somebody might still have pain relief quickly, but they're gonna have the pain come right back. Because they don't have the stability and support necessary to live life in maximum performance. So here's the beautiful part of what I just said. We know, and we've seen in previous research that that spinal manipulation or adjustments can actually increase multifidus activity and thickness. That is super powerful. I'm going to say if we did nothing but that and that alone, then getting adjusted would be absolutely worth it and then some. For anybody that has a biomechanical change all the way to pain, all the way to lack of performance in the lumbar spine. And I'll go a little bit on the side right now. Some of the challenge I feel like we have as chiropractors Is how multifaceted the results of an adjustment are. Meaning the mechanism of action is so varied, so many things happen. That the conversations can sometimes become diluted. Because it's like there's so much going on. And you can see a patient's eyes glaze over. When you start talking about pressure, pain threshold levels, biochemical markers in the brain. These things just don't really make sense to the average person coming in. That's like, I bent over and my back hurts. What's going on? Document. So one of the challenges that we have as chiropractors is the beauty of what we do is so multifactorial. But that can also be a hindrance. So I love when they just drive these direct points home. And that's why I say, man, if all we did was affect multifidus activity and multifidus thickness and function, we would be worth it and then some. But the challenge is it's not only that, that we do. We do that in about 17,000 other things. So this becomes the challenge of communication is picking and choosing what you want to talk about, at what time, to whom. Because all of those factors really play a role in somebody's ability to connect and comprehend, which is really important. Connect and comprehend what you're saying. And then be able to put it into action. Or even more crazy, try to relay that information to the spouse, a friend or a colleague. So we know that spinal manipulation is a cost effective treatment. Whether it's used alone or whether it's used in combination with other other things. And it's an accepted treatment for Low back pain. And we also know again that the forces produced during an adjustment, they do a variety of things. Biomechanical changes, increased vertebral motion, facet joint gapping, really important for a variety of reasons. And changes in intradiscal pressure. Really interesting in and amongst itself. Whole nother podcast there pain thresholds and paraspinal muscle activity. So in this study they had 20 participants, each with no history of low back pain during the previous four years. And this is an interesting thing because often with research studies like this, they actually look at asymptomatic individuals to then be able to compare to symptomatic individuals. Now, are there differences, let's say, in how a adjustment is input into the body, so to speak, not with the physical technique, but how a body receives an adjustment when in pain versus not in pain? Yes, we've seen that in previous literature, but it's important to have a baseline. So in this study they looked at people that had no low back pain for the last four years. And this was, this is pretty wild. This might be not, not, not usual. In most clinical settings, a single session was three to four hours. And they measured muscle activity during the adjustment. And that's really important. They measured it not after, but actually during. How did they do this? With two lumbar diversified HVLA manipulations and two sideline grade 4 mobilizations on each participant by a chiropractor. Sometimes these manipulations are performed by people outside of the chiropractic profession. And I'm always curious because I just feel like in general chiropractic we are so highly trained in that we're just better. Now, are there physical therapists who are better adjusters, so to speak, than probably some chiropractors out there? Yes, probably. But that overlap is minimal. It's what we do all day, every day. So in general we are better at it than most as a whole, than almost any other profession. So one manipulation and mobilization was performed at the L3 level, one at the S1 level. So those were where those adjustments took place. And they measured what went on actually during that adjustment, which is a feat amongst itself to get into the research. So that's really hard to do. So they quantified the effects of the treatment, as we cited earlier, a couple factors there and response. We decided that earlier factors of the neuromusculoskeletal responses to the adjustment as measured by the rate of muscle responses and muscle activity onset delays. Talk about what that means in a moment. So what they did find was a lack of statistical differences in the responses during the adjustment at the different sites demonstrated that the specificity of the contact site may not play a major role in the biomechanical outcomes. Now remember, there's a lot of things that happen, a lot of stuff that happens when an adjustment is delivered, but specifically in the biomechanical realm, whether it was at L3 or S1, they didn't find a big difference in the outcome measurements. Now that's not to say that we should be sloppy, that's not to say that we shouldn't focus on specificity. But related to biomechanics, the act of performing the adjustment was greater than the specificity of the adjustment. And as relative to biomechanics specifically, what they also found were treatment factors. Manipulation, sequence and sight had little effect on the neuromusculoskeletal response to the adjustment, indicating that researchers and clinicians may choose design protocols without regard for these factors in the future. And again, that was site and sequence. So I know that there probably is some techniques that would argue with what I'm about to say. But in this study specifically, which was diversified by the way, from a technique perspective, they found no difference in whether or not S3 was adjusted first and then, excuse me, L3 was adjusted first and S1 was adjusted second or L5, S1 and L3 were adjusted in reverse order. So the order did not play a role in the outcome. And also the site did not play a role in the outcome specifically relative to the treatment factors. Now what they also found were clinical treatment protocols or what they suggested is clinical treatment protocols. And future research studies may be designed with these results in mind. So when choosing the application site for treatment and location of the EMG measurements, this study could be used as a baseline from which to do further studies. So what did I like about this study? What were really the take home messages and the conclusions in my opinion. Here's what they are. One, there's a lot that happens when an adjustment is performed. Two, we see another study citing the fact that spinal adjustments are clinical guideline recommended. They are what people should be doing. But that doesn't mean what it is what people are doing. That's a gap. In that gap is an opportunity for referrals from other healthcare providers and just getting out there in your community as well. We also know that they cited multifidus action changes thickness in multifidus muscle, activity in multifidus muscle. That's really, really important. And to me that's probably the most clinically relevant aspect of the Study is citing that because again, I believe the Multifidus is really a key to what goes on neuromusculoskeletally in the lumbar spine and it is dramatically overlooked by most providers. Now might we give a couple exercises for it? Yes. But have you. And I don't think we should just take MRIs to look at the multifidus for giggles. But what I mean is when you have that imaging, are you taking a look, are you really taking a deep look at what's going on with the Multifidus muscle? And then as we've cited earlier on this podcast in earlier episodes, really setting the expectations. Because if they have a deteriorated multifidus with tons of fatty infiltration, I can guarantee you a week or two weeks of exercise ain't gonna do it. It's gonna take a long time and six adjustments or three adjustments, you know, priding yourself on a low PVA is not gonna do it. You need to get in there and it takes time. Every process takes time. We know this. But often these are conversations that for many, I'm going to say, quote unquote, evidence based chiropractors either try to avoid or minimize. And it just leaves yourself not serving the patient at the highest level. So get in there and let people know what to expect. Hey, you have a deteriorated muscle in your back. That's what's contributing to the low back pain you're dealing with. Here's the good news. We can do some things in here to maximize that muscle to help you reduce pain and move a heck of a lot better. That is the good news. Now what are some of the challenges? Challenges is there's no magic, no magic pill. It's not going to happen overnight. But when we get in there and deliver our adjustments, that's activating the muscle that's really, really important. Because without that muscle activating and firing, nothing else is going to happen. Number two, we're going to give you some exercises. Now, as you know, if you started exercising today, you're not going to drop 20 pounds tomorrow and have it all lean muscle. Right? It takes time in order to, to see those gains. And the same thing with the muscles that you can't see that are deep inside your body, like this muscle that I'm referencing called the multifidus. That's an example of how I would phrase it in practice. You have any insight onto that, always shoot me an email or a message. I am happy to help. Before we wrap up, I want to say a few words about the lone wolves out there or you docs out there that are just super thin and need extra help, yet finances are an issue. Let's say hire a virtual ca. I hired a virtual CA through Cairo Matchmakers and it has helped me tremendously. This virtual assistant really offload a lot of tasks and become significantly more productive. So if you don't have the bandwidth, the space, the revenue to really bring in an office, a new office ca, you can bring in a virtual ca. It's not a bot, it's an actual human being that's coached and trained up to answer phones, follow up with leads, video editing. We have a variety of specialists at Chiral Matchmakers that can help with that. Head over to ChiroMatchmakers.com, click the virtual CA button on the top and just have a conversation. 70% less cost than an in office CA and could provide a tremendous amount of benefit for your practice. So thank you for listening. Thank you for being a chiropractor. I hope you have a fantastic week in practice and I will talk to you soon.

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