446- How Lumbar Adjustments Affect 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 Langman.

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langme. This week we are back with more great research. Another brand new study that is all around pressure pain thresholds. It is a complimentary study to something we highlighted a few weeks ago. This is around lumbar adjustments and is a randomized control of healthy participants. Fantastic study, lot of take home messages, cannot wait to get into it. And more on today's episode. But before we get started, I'll say a few words about Patient pilot by the Smart Chiropractor. And if you are looking to generate more patient reactivations in your practice, go to the smartchiropractor.com, click Schedule A Demo and have a conversation with our team. It is as simple as that. We are a patient reactivation system that enables you to consistently communicate with your patients, see who is ready to schedule and take action. There is no other system or software out there that does this. So if you're interested in building more reactivations into your practice and why wouldn't you head over to the smartchiropractor.com, schedule a demo with our team. We'd love the opportunity to show you how we can help and answer any questions that you have in the process. But as I said at the top of today's episode, we're talking research. Brand new study in chiropractic and manual therapies. The title and of course I will drop a link down in the show notes is exploring the immediate and short term effect of lumbar spinal manipulation on pressure pain threshold. A randomized controlled trial of healthy participants. This is a study that is complementary to a study we highlighted a few weeks ago regarding pressure pain threshold. So we know that lumbar adjustments manipulations is a a common intervention to take care of low back pain amongst a variety of other conditions. And it's defined as a high velocity low amplitude technique performed at the pathological limit of the joint that paraphysiological space. Right. By definition an adjustment does not get into the injury zone. By definition it should remain in the paraphysiological space which is at the pathological limit of the joint. That's how we get those mechanoreceptors amongst a variety of other things to really fire up and get that joint sort of Reset in terms of motion, break down adhesions and improve range of motion. So although we have seen that spinal adjustments can be very, very effective in reducing pain and disability, the exact mechanism of the adjustment continues to be explored in the research you've seen that highlighted dozens of times on this podcast and probably many times in the future. And, and at one point you might look at that and say, how do we not know how this works yet? Haven't been researching this for like 30 years. The answer is absolutely yes. Here's the good side of that. It's because it's so dynamic. It is not one plus one equals two. When an adjustment is delivered, there's a lot that happens and we continue, and the researchers continue to discover and learn more about how a chiropractic adjustment works. I love that, and you should love that too, because it highlights just how impactful, just how dynamic and just in how many different clinical settings we can apply something and get a benefit. We've seen this in terms of pain relief, in terms of improved range of motion, in terms of improved functioning. Maybe it's the sports performance realm, no pain whatsoever, but improved performance. There are so many applications to what we do and we continue to learn and discover more about that. I love that. So there are some widely known or accepted mechanisms and we'll highlight a couple of those right now. So while we continue to learn more, which are there is a neurophysiological and biomechanical mechanism, of course, right? There's a biomechanical because you're literally moving the joint through a paraphysiological space. There's also a neurophysiological because we are affecting the nervous system and affecting the physiology of the body. And, and those are important things to keep in mind. So there's no question that an adjustment is multifactorial. And there are significant changes in spinal stiffness. Multifidus recruitment. And the neurophysiological mechanisms can affect a lot of different things. They can occur within the tissue. They can occur within the peripheral nervous system, the spinal cord, the higher level centers of the brain. All of these are impacted in when the neurophysiological responses start to happen peripherally. Excuse me. It's been theorized that an adjustment has localized tissue effects that can reduce inflammation and facilitate motor control. Reducing inflammation. Super powerful, facilitating locomotor control. Super powerful. And important to keep in mind. SMTs or spinal manipulative therapy also have a central processing or a central component. So significant central nervous system mechanisms include things like somatosensory cortex, amygdala, anterior cingulate, cortex, periaqueductal, gray, rostal, medulla. All of these central nervous system tissues can be also influenced by what we're delivering with a hands on treatment outside. I know we say above down inside out as the old school chiropractic way to look at it, but literally when we're delivering an adjustment, it's kind of outside in our hands are touching somebody on the outside, we are affecting a joint and then that is powering up to the brain. I recently learned 40 times, I believe this is true, 40 times more information is pushed up to the brain from our body than from the brain down to the body. So to think about ourselves, is the brain and spinal cord absolutely important? Absolutely. It's critical, of course, but also don't sleep on the fact that the peripheral nervous system is delivering afferent information all of the time up to the brain to be able to process and make that decision. So when we are inputting data, so to speak, providing an adjustment peripherally that is outside the body to be able to impact literally at a brain level, at a tissue level, at a nervous system level, and of course just with the mechanics of the joint itself. That's awesome. That is super powerful. And that's what we continue to learn more about. So regarding pressure pain thresholds, the neurophysiological effects of a pressure pain threshold level is greatest at 5 minutes following 5 to 10 minutes. I guess they should say post lumbar SMT in asymptomatic patients. The aim of this study was to investigate those PPTs. I'll say pressure pain threshold levels beyond the immediate effect up to 30 minutes post adjustment using a deactivated ultrasound control. So pressure pain thresholds was measured before and after each intervention at the right PSIs. That is how they measured this. And there were two independent variables in treatment. One was whether it was a adjustment or a deactivated ultrasound. This is literally like an ultrasound unit that's not plugged in. And the other was time before, immediately after and 30 minutes after treatment. So the control was an ultrasound that wasn't plugged in, so to speak. So 55 participants, including 35 females, 20 males between 18 and 50 years old, met the inclusion criteria. The average age of the lumbar SSMT group was 24 years old. So an analysis did find that statistically significant differences in the lumbar SMT group from baseline to immediately following and 30 minutes following the care and treatment. So that is the power statement and that is what we will dive into with the discussion and conclusion. So those individuals who had an adjustment were found to have a greater threshold of pain at the right PSIs over a 30 minute minute time frame that was not found in the deactivated ultrasound group. This is consistent with their hypothesis that there would be between group and within group differences at each time point. So the initial increase in PPT observed was observed both immediately and 30 minutes post SMT. Very, very important. Why? Because this all breaks down to the hypoalgesic effects of and adjustment which is clinically relevant and meaningful. And having that therapeutic window. I love how they frame this creation. They say, quote unquote creation of a therapeutic window with reduced pain sensitivity throughout the lumbar spine. This is cool. Have you even thought and considered when you deliver an adjustment as you've altered influenced the ppt, the pressure pain threshold that's going to enable that creates a therapeutic window where you can get your patients to get active without as much fear of avoidance behavior, without as much pain, without as much fear of movement. This is impactful. Think about the window after the adjustment and how you can incorporate potentially therapeutic exercise and rehab into that timeframe. I know a lot of times there's been back and forth between well, do you perform rehab before or after the adjustment? I don't claim to be an expert in this, but I'm saying from this study it looks as though after in many cases might be a good idea because when you deliver that adjustment you create a therapeutic window with the alterations and influence to the PPT that allows that patient to be able to do more with that therapeutic rehab that is powerful. So when you can have exercise and strength training that can be is proven to be beneficial for low back pain and, and you can improve that window of opportunity by delivering adjustment before that becomes really, really powerful. Because you can empower your patients for improved self efficacy as they say. You can empower them to take action with less fear, with less pain and over time that can provide increased benefit. If you think about the compounding benefit of let's say two to three times per week now somebody's getting an adjustment that gives them a window of as they've highlighted in this study, up to 30 minutes. And now they stopped. There might be more than 30 minutes, but they stopped this study at 30 minutes but at least a 30 minute window. Now you're talking about that three times a week is 90 minutes potentially of really effective, really productive strength training, therapeutic exercise that can really start to think about how you could accelerate the process for your patients meaningfully. And again, there's such a mental component to this. Get them motivated. When they can see that they can do more. Well, guess what? That normally inspires people to want to do more when they are able to, oh, I don't think I could do that. I don't think I could do that. You deliver an adjustment, open up a therapeutic window. They can do a little bit more than they thought they could. That becomes a snowball going downhill where people are like, okay, maybe I can do this. Okay, you know? And that is powerful. You compound that over a period of time. That can really dynamically influence your ability to get results, help people get better results in your practice. And that is a really important thing. So their conclusion was lumbar SMT increases PPT at the PSIS immediately and 30 minutes following treatment in asymptomatic individuals compared to a deactivated ultrasound control group. The current data provides further insight into the mechanism of snt, particularly the temporal aspect of pain inhibitory mechanisms. So I love this study because it frames something that I've gone back and forth about. When do you do therapeutic exercise? When do you do strength training? Now, there are clinic operations that obviously play a role in that decision as well. But strictly from a physiological standpoint, it appears as though delivering an adjustment opens a therapeutic window which gives you the opportunity to maximize your strength training and therapeutic exercise. And that is the big take home message from this study. I absolutely love it. I hope you loved it as well. So, before we wrap, I'll say a few words. I'll drop a link down to this study, of course, in the show notes. And if you are looking for better objective assessments of the cervical spine, I cannot recommend neck care enough. Reliable assessments and exercises for neuromusculoskeletal control, proprioception, range of motion and sensory motor integration. It's all there for you in the best technology package I have seen to date. Necare.com, i'll drop a link down below. And for those docs interested in shockwave therapy in your practice, it is a game changer and I cannot recommend stemwave enough. Go stemwave.com the evidencebasedchiropractor I'll drop that link. If you use that link, hook up with them. They support this podcast, you should support them. And if you have a conversation with them via that link, they're gonna hook you up with their best deal, their best offer, and their best opportunity to bring shockwave into your practice. Go stemwave.com theevanospacechiropractor thank you so much for listening to this podcast. If you've not left a rating or review, I'd love it if you would take a moment and do so. Thank you so much for being a chiropractor. I hope you have a fantastic week in practice and I will talk to you soon.

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