420- The Reliability of Pressure Pain Thresholds

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.

How hello and welcome to the Evidence Based Chiropractor. I am your host, Dr. Jeff Langmaid. And Happy New Year. Let me be the first to welcome and say happy New Year. We're gonna have an awesome year of this podcast lined up, tons of research, awesome clinical pearls, little bit of marketing, communications mixed in. We're gonna have a lot of fun. So thank you so much for tuning in and kicking your year off with me. We're gonna start today with a brand new study. This came out just towards the end of and it's all about the reliability of pressure pain thresholds in individuals with low back or neck pain. This is a systematic review, top tier from the British Pain Society. Of course we will drop a link down in the show notes so you can check it out. And before we get started, I'll say a few words about patient pilot by the smart chiropractor. We're into 2024. The real question is, are you consistently communicating with your patient patient base? If you have hundreds or thousands of people in your ehr that you're not consistently communicating with, some of those people can reactivate. How many? It depends on a couple factors. How big is that list and how much your patients like you, how much they want to come back in. If you believe your patients have a great experience and you got a list of more than 500 people that you've seen in the past, let's put it to work. Head over to the smart chiropractor.com, let's build our automation so you can start seeing some reactivations come in. Get some goodwill in that community, stay top of mind and just deliver awesome information to your patients. You can learn more@thesmartchiropractor.com but as I said at the top on today's episode, we're talking research. I'll drop a link down in the show notes. It's all around pressure pain thresholds. It's hard to say that five times fast, but this is one of the most studied aspects when we look at outcomes and this study was looking at how reliable are these things. So let's back it up a little bit, talk a little bit of low back pain, neck pain, set the context and we'll dive into some specifics. So get this. 75% of the total years lived with disability that's related to musculoskeletal is low back and neck related. So, like, almost all of it. 75%. That's staggering. So it's really important, as we talked about last week with causal beliefs, it's really important to be able to assess pain. So what is. Why would we want to do that? Well, pain assessment tools enable us to monitor the progression of what's going on, as you can imagine. And there's no valid or really reliable biomarker for pain. So a lot of times we're relying on qualitative measures. For example, like self assessments. They're great because we're at 0 to 10 and you can get an answer, but it's super subjective, and there can be, like, a high degree of error. We were just talking about it last week, right? You see a patient come in skipping, and they're like, I'm nine out of ten today, doc. And then you see a patient that can literally barely get through your front door, and they're like, kicking up to a three today, right? So it's so subject, and we see it all the time. So a pressure pain threshold, by design, is to say, okay, well, is there something else we can do other than just asking that question to be able to get a better objective assessment? And it might not be perfectly objective, but at least we can maybe limit some of the error, right? Some of that spectrum. So pressure pain thresholds, which technical definition, the point at which pressure stimulus becomes painful, It's a quantitative measure of pain. And think about it like almost like an adjusting tool, where it's just the head of a device or the end of a pencil or something like that, pressing down on a muscle, on a segment, whatever it might be, and there's a certain number of pounds, so to speak, of pressure that goes down. And it's like, when does the person say, that hurts? And here we've seen it in practice, right? Some people that you graze the skin, and they're like, whoa, right? I didn't even start touching yet, right? So we do this through palpation often, but there actually are clinically researched caliber ways, so to speak, to do this that are very, very consistent time in and time out. Not that our palpation's not, but that this can be very, very focused, directive. We can know exactly how many pounds of pressure to generate the that hurts stimulus. So it's really interesting. Many studies use this. And pressure pain threshold is a psychophysical measurement that, of course, relies on the perceptible input of the patient, but it also has some to do with the technique by the observer or by the doc. So I like the fact that it combines the physical and the psychological components. Anytime we're talking about pain, there's a psychological component, but this can elicit it in a physical manner without necessarily being like a discogram or something like a super provoking test where it's just abject pain. But you're really looking at this from the standpoint of again, we know it through palpation you can palpate people and sometimes people are just so sensitive they have low pressure pain thresholds. Other times we see people that have great pressure pain. You can really get in there. And this can be a great, again they say quantitative tool to understand pain. So there's variability in the rate and angle of application between providers that can affect this so much of the time. Time I've seen patients prone, let's say it's a low back test, the patient will be prone and the instrument, so to speak, will be at a, I guess it's a perpendicular, it'll be going straight down as the patient's prone so that there's no real angle. Now that can be of course adjusted or manipulated depending upon the test. But you want to have it about the same every single time, of course, to have that reliability there and that validity, especially if the test is being performed by various clinicians. So patients with low back and neck pain, as we've touched on, contribute significantly like 75% to the years lived with disability. And the burden of these patients is really, really high. This is just, there's a lot of healthcare expenditure that goes into people with spine and neuromusculoskeletal challenges. And overall we see great results in terms of chiropractors. But and don't forget, we see less than 15% of the population. So overall clinical outcomes are not good. Right. So when you think about the fact that 85 to 90% of people are going to have neck and low back issues and then you think about the fact this is the cringe one, 85 to 90% of those people might never see a chiropractor. And you know what else is out there? Yes, physical therapy. Therapy can be very helpful. Advanced interventions when unwarranted, without red flags and thumbs down. Pharmaceutical interventions and thumbs down 99% of the time. And that's done to the tune of more than we've probably ever delivered adjustments in our careers. That's for sure. That is done all day, every day, everywhere, always. Now our goal is to Change that now. Hopefully that's why some people become members of the Evans based chiropractor with our MD referral program to help build in those relationships. But that's the truth of the matter is that clinical outcomes do remain poor. So improvements in pain assessment tools are really important within what we do, but especially outside of what we do because it helps providers diagnose and treat people more effectively and progress can be measured more accurately. So, and this is a really, really important subplot to this when we talk about medication, you know, there's very rarely, let's just call it what it is. There are exceptions to what I'm gonna say, of course, but very rarely is a primary care doctor really getting in there with a really good physical exam. Very rarely is a pain management doctor. I have yet to see one get in there with an actually really good physical examination. So are they, how are they measuring the progress of the patient without movement assessments? They're just asking them. So it's like incredibly subjective. Probably depends on the time of the day. This is a big, big, big time challenge and we take it for granted often as chiropractors because we do so much movement assessment as just a nature of what we do, almost regardless of technique. Right. We're going in, we're doing orthopedic tasks. Maybe you're using DNS, maybe you're using sfma, maybe you're using ortho tasks in your palpation and range of motion, whatever it might be. This is just, it's endemic to what we do as chiropractors. So it's like we can become blinded to the fact that that's pretty weird. Like they go almost any other place, they're not getting that level of an examination. And the scary part is in many other places they might be getting far more advanced interventions without the steps, AKA the assessments to really warrant it. And just checking a box on an insurance form doesn't, in my opinion, warrant advanced intervention, that is for sure. There's no question about that. So important to keep in mind with what we do. Utilizing tools like this are really, really important. And it's not like you're gonna have a pressure pain threshold test in your practice tomorrow. But it's important to know what's reliable, what's valid, what's out there, so you can keep abreast to it. So the findings in this study ultimately suggested that pressure pain threshold is a useful and reliable, really important there tool in clinical practice for pain assessment and, and to monitor patient progress. It would be super interesting, incidentally, to I think, monitor some of this just as a test in a practice, but it's not really practical right now. This measurement can also contribute to the standardization of pain assessments. That's really important. And it uses, of course, that psycho and physical outcome components rather than just the subjective pain scale. So their findings support the use of pressure pain thresholds in quantitative sensory testing. They call it a reliable tool and, and that is really, really important now also, it's a reliable tool in the measurement of two syndromes, really important here, myofascial pain syndrome and central sensitization. So this combination puts pressure pain threshold in a really, really good position to play a big, big role in the treatment and management of low back and neck pain moving forward. So I thought this study was really, really cool. It didn't break any new ground, but it just highlights the fact that this is good news. Hey, a lot of how pain is measured in studies is really reliable. It's intra examiner reliable and inter examiner reliable. And there's some things we can do in the future to really, I'm gonna say, refine our understanding of where a patient is on the threshold of pain levels, aside from just the subjectivity of a 0 to 10 pain scale. So fascinating to see where this will go in the future. I got a feeling this is the start of the story of pressure pain thresholds. This not the ending of the story, but that's a really, really good thing because in my opinion, it strengthens what we do as chiropractors. And it strengthens the fact that when there's a physical and a psychological component, as we touched on last week and this week, people really, we do a great job with it. Us as chiropractors, we just have very high patient satisfaction because we take the time to listen, we take the time to understand. And a lot of this goes back to, I'm gonna say, just inherently again, what we know as chiropractors. Let's get to the root cause, like what really caused your pain, right? And searching that out and doing, asking the right questions, performing the right examinations, and ultimately crafting the right treatment plan. And sometimes I think us as chiropractors, we can be hard on ourselves or it's definitely hard on each other. But think about what patients are getting for care outside. That's not an excuse to do sloppy work inside of chiropractic, but it's a statement to the fact of many chiropractors. Most chiropractors, nearly all chiropractors, are taking the time, effort and energy to really understand how is this pain impacting a patient? How can I help them achieve better health and what's the plan for them? And that is really impactful, especially in light of some of the super poor quality care that they're receiving elsewhere and quite frankly care that shouldn't still be happening today. Cursory examinations, instant pharmaceuticals, advanced interventions right off the bat are still as common today as they were decades ago. But what we can do is continue to show up, continue to have conversations, continue to get out there. B2C business to consumer with all of your content on social, email, et cetera, and business to business by getting out there and building referral relationships. And the more that we're able to do that, we can break through obscurity. We could become those leaders in our community and more people will know who we are and what we do. And the more people that at least have the opportunity to choose chiropractic. That means we're doing the right thing and on the right track. So as we wrap up, I want to say a few words about my favorite pillow. This is the one we have in our house. Alignasleep.com Dr. Pound, great guy, awesome entrepreneur, has created a pillow specifically sold through chiropractic practices and it is great. If you have pillows in your practice right now, head over to Align of Sleep. Hook it up. They do a fantastic job. Can't recommend them enough. If you're thinking about having pillows this year as a source of revenue because your patients are asking for it. Both are good ideas. Alignofsleep.com, get in touch with their team. And if you're thinking about bringing in Shockwave technology, I cannot recommend the Stemwave brand enough. Go stemwave.com the evidencebasedchiropractor they support this podcast. You should support them and they will give you the red carpet treatment when you just inquire have a conversation if you've considered bringing it into your practice. It's what I use in the practice that I own. Gostemwave.com the evidence based Chiropractor if you've not left a rating review for this podcast, that would be awesome. If you would take a moment and do so, you can scroll on down. If you're listening on your phone, tap how many stars leave a sentence or two. I would love to hear from you. If you ever have any questions, you can of course reach out to me. Fastchiropractor.com I hope you have a fantastic week in practice and and I will talk to you soon.

Thank you for joining us on this episode of the Evidence Based Chiropractor. If you want to grow your practice, come back for next week's episode. If you want to grow faster, visit theevidencebasedchiropractor.com and join our MD Marketing membership today.