459- Understanding MRI and Functional Tests in Lumbar Disc Herniations

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 have a very important study that we're gonna highlight and this is all about the relationship between MRIs and functional test assessments in patients with lumbar disc herniations. This is something that is useful probably more days than not in your practice. We're gonna highlight what's going on in this study, take home messages, clinical pearls and much more. But before we get started, I wanna say a few words about Jane. If you have not checked out Jane ehr, you need. Jana has designed a user friendly online booking system so your patients have the freedom to book their appointments at their own convenience. Even if it's after hours or on weekends. Your patients can manage their appointments, fill out intake forms, enable reminders, all of which saves you time from doing it manually. And as a listener of this podcast, they're gonna hook you up with a one month grace period. You can use the code EBC1MO or click the link down below, connect with their team and see how Jane can help your practice become more efficient. And but as I said at the top, today's topic is all about research. I'm going to drop a link to this in the show notes. The title is the relationship between MRI and functional test assessments in patients with lumbar disc herniations. We know low back pain is the number one reason people initially visit a chiropractic practice. We also know that lumbar spine pathology is the highest cause of disability in the world and it really causes a massive amount of what they call therapeutic situations. Basically doctor's visits as they're highlighting it in this study. So the proper characterization of this as they highlight here is pain that is below the rib margins and above the iliac crest with or without radiculopathy into the lower extremities. We know 80, 90% of people over the course of their life are gonna have at least one acute or chronic episode of low back pain due to an array of different causes. We also know this was an interesting take home message for me. 39, about 40%. I'll just earmark it there. 40% of pain is attributed to discogenic reasons. I did not know that with disc herniations at less than 30%. So you know Over a third of low back pain is caused by discogenic and a little bit above a quarter is specifically relative to a disc herniation. Good statistics to know as you are communicating, as you are out at, wherever you are promoting your practice, whether it is an event, whether it's your social media videos, whether it's blog posts, whether it's a social post, whatever it might be. Highlighting some of these really attention grabbing statistics is a great way to do exactly that, get some attention and then be able to teach upon it. So I'll say it one more time. 39% of pain, low back pain, is attributed to discogenic reasons, about 30% specifically disc herniations. So not every time. As a matter of fact, most of the time somebody has back pain, it's not going to be discogenic and it's not going to be caused by a disc herniation or although most people have that fear. That's a great teaching moment. We also know that disc herniation has been associated with a variety of different factors. Age, environment, being overweight, job demands, smoking, insufficient physical activity, sedentary lifestyle, all of these are really, really key factors that are associated with an increased likelihood of struggling with a disc herniation and low back pain for that matter. So we know that there's been previous research out there that has highlighted how disc herniations is really the most common diagnosis among the degenerative lumbar spine pathologies. And again, when we talk about degenerative changes over time, those can lead into things eventually like stenosis, whether that be central stenosis, lateral recess stenosis, foraminal stenosis. But at the top of that list is a disc herniation, and that's important to know. And the incidence rate there is 2 to 3% of the global population and the prevalence of disc herniation is about 5% in males, about 2 1/2% in females, especially over 35 years old. So those statistics are important to understand because it helps frame things out. And for you and I, some of that might sound weird. Well, we already know that. Well, some of those I didn't know and hopefully it's news to you as well. But I can pretty much guarantee you that the people in your community have absolutely no idea. So pulling out some of these statistics, again, highlighting them through whatever channels you use to teach, ultimately your community, whether again, email, social videos, et cetera, these are great opportunities to use what we refer to as the Aida formula. Attention, desire, interest and action. The classic marketing formula. And it's really a Teaching formula, get people's attention. If you don't have people's attention, good luck. Build some interest. Why should people care about this? Right. Build desire. Hopefully this is desire in the care and treatment you can provide, and then give specific action steps. That's that formula in a nutshell. Utilize it all over the place. It's one of the most successful ways to, as we like to say in smart car, break your land, teach and invite consistently. So we also know, tying back to the research, the diagnosis of disc herniation, mri, total gold standard, has been for a long period of time. But it doesn't mean we shoot MRIs on everybody. Right? So this study was meant to start to parse out. Well, there's these functional tests. We know that there's some give and take in terms of the sensitivity and specificity and reliability of these tests, but they're pretty easily performed. They're unbelievably cost effective. You can literally do them in two seconds in your practice. And. And that provides some differing benefits outside of an mri. While an mri, it's like, okay, you can see it right there. We also know there are challenges with mri. Some of those challenges include cost. The fact that most of us don't have MRIs available inside of our practice. Right. So somebody has to go somewhere. That's a hindrance. That's a conversion step. Ultimately, there is a cost associated with that. Now, MRIs are way cheaper now than they have probably ever been historically. But it still is not. It's not nothing, right? You know, it could still could be 250, $500 minimum, out of pocket cash expense. Obviously, if it's billed to insurance, the MRI companies are certainly gonna run that up to the tune of probably $1,000 or more, minimum. Then we also look at MRI in terms of, as I always have discussed this with the patients I've seen sorting the not perfects from the problems. The MRI report comes back and it highlights every single not perfect. And we've all had this happen. You probably had this week, somebody comes in with a report that's six pages long. They're completely petrified, and they believe they have 1000 things wrong with their lumbar spine. Even though you look at it and pretty quickly you can identify, okay, you got 27 not perfects here. That's what's on the report. My goal and my job is to find the problem. And that's always the way I framed it. Again, please utilize that if it makes sense to you, and that's an easy way For a patient to understand, to be able to say, okay, I get it here. And that's really, really important because I know for myself personally, I saw countless patients that came in with reports that literally they were scared to death and they were scared to move. They thought surgery was the only option and they thought they probably needed a complete revision surgery, so to speak, taking care of every level of their lumbar spine. Because they don't know the difference and they don't know the difference between, or they don't have the understanding and the training as we do to be able to say, okay, degenerative process is listed at every single level. If you're 65 or 70 years old, that could be relatively considered normal. Now there's also advanced degeneration that is not correlative to age, that could be a problem. But if there's generalized degenerative changes and you're in your 70s, that's not a really big deal. But there might be one disc herniation there that's really causing all the pain. Based upon the dermal tonal distribution and based upon, as we'll talk about in this study, the functional test that hopefully you're doing to be able to really hone in on what's going on, there's really a couple ways to be able to again, hone in on the individual level. One of those is a nerve root block. That's generally a great way to determine the exact level that's causing pain. And it's also a very unpleasurable way for the patient. Right. It's just not a good experience. They're going in, putting a numbing agent at a single nerve root level and then seeing if the pain goes away to really determine, okay, is this a 4 5? Is this a 5 1? Because while there are times when it's plainly clear, there are other times where there's just overlap and that's the way we go. I mean, there's the dynamics of life. There's also different. You know, some people just have nerve roots and they're just built a little bit differently. So being able to identify pre surgically for sure which is the actual level causing the pain is important. But I'm going to appeal that back to us as well. Even in the movement based healthcare space, the conservative space, being able to identify what level really is the challenge can guide and direct to a certain extent the way that you might approach it. So having the specificity by using functional tasks can be really, really important. And again, MRIs have those challenges of accessibility, cost, Experience relevance to different populations, data interpretation, different radiologists. I think we've all seen radiologists that give us a one liner as a response on an MRI from a lumbar spine and somebody that gives us 10 pages, right? And it's like, what? How is there such crazy, an array of differences in how these things are reported? Conversation for a different day. But you can see how that causes a tremendous amount of confusion for the patients coming in to your practice. This study ultimately had 81 participants and the subjects were above 18 years old and they had an MRI confirmed disc herniation and they had radiating pain below the hip. What they looked at was lasag's sign cross straight leg test as defined here, used to assess lumbar nerve root compression. Additionally, there was a slump test, neurodynamic test to assess whether a disc herniation or neural tension is contributing to the symptoms. They had what they called the sciatica bothersome index. Never heard of this one before. An index in which patients report symptoms during sciatic episodes. The old odi, the Oswestry Disability Scale, of course measures the level of disability and the VAs, which is of course your analog, visual analog scale. Most of the time we're going to do it verbally, but those are really the tests that they were utilizing and pitching against, so to speak, or correlating with those MRI findings. So a total of 78 subjects, ultimately a couple people didn't finish the study. We'll incomplete there. So 78 people were included and the findings, I'm going to say probably weren't too surprising. So they indicated a statistically significant. You always like to see those two words. Correlation between functional test and MRI findings, specifically at the L4, L5 level. Other variables with a really strong level of correlation, sex, female physical activity level, sedentary individuals age 20 to 40 years old. And incidentally, the L5 S1 level did not correlate with pain or any of the variables measured. And according to results in this study, age was a significant risk factor for intervertebral back pain and disc 10 challenges with a higher incidence of disc pathology in individuals younger than 50 with more severe episodes of low back pain. With those people between 25 and 44. And they hypothesize this is actually due to an increased water content. We know that the discs dry out, so to speak. They lose water content as we age. They are still pretty hydrated between 25 and 44 years old. And they're, they, they're kind of saying, hey, we think that the higher water Content might be contributing to the greater pain level. Interesting, had not seen that before in the research. Interested to see where that goes as time goes on. Additionally at L5S1 again no correlation between the size of the disc herniation and the variables measured and this study did find an agreement between the clinical and radiological findings in nearly 70% of patients diagnosed with a disc herniation Physical activity level this was the top of the heap. This was one of the most absolutely critical factors that influenced the results of the study here and this confirmed previous research articles that suggest the risks of low back pain and sciatica pain are significantly influenced by occupation and they're highlighting that it is with the sedentary lifestyle. Really key factor moderate physical activity participating in sports was a lower prevalence of chronic low back pain whereas a sedentary lifestyle that did not have at least a moderate physical activity level level and no sports absolutely put that through the roof. LASAG's test had a moderately inverse correlation with disc herniation at L4 L5, but men had about a one and a half times more chance of a positive LASIG than women. Interesting. There same pattern was found with the SLUMP test where males correlate more with disc herniation at the L4 L5 level than females. That Lasaig's test did show a strong correlation with L4 L5 disc herniation at the 20 to 40 year old age age category and the SLUMP test had a higher sensitivity than lasags. No surprises there. So in conclusion they found or highlighted the fact that physical activity was the most critical risk factor when being diagnosed with a lumbar disc herniation that active people are more protected from herniated discs. Again that is a key teaching moment. I'll say that one again, active people are more protected from disc herniations. Many people in your community believe the exact opposite because they do not know how the neuromusculoskeletal system works. So highlighting that is a really really good idea. And this study also confirmed that the SLUMP test is the gold standard for diagnosing a herniated disc. When we're discussing functional test, slump and lasigs have clinical value beyond the ODI and the sbi which are more closely related to patient outcomes. So I found this to be a really interesting study. Anytime we can get information on how to become more specific with our testing specifically relative to disc herniation, lumbar disc herniation, I think that's a really good thing. And anytime that we can get a better understanding of clinical pearls of insights that are tied to the research that we can then use as teaching moments for our community and for the benefit of our practice. Building trust, Showing that you're the expert. Absolutely critical. This study does a great job of doing it. Again, I'm gonna drop that link down in the show notes and let's move superior up the spine Talk about CERV spine for a moment. Neckcare.com if you have not gone over and checked out the best objective assessment tool in the game@neckcare.com you're missing out. Please do so. They support this podcast. I'll ask you to support them. Reliable assessments and exercises for neuromuscular control, proprioception, range of motion and sensory motor integration. Neckcare has it going on. Their tech is awesome. The hardware and software is like nothing you've seen before. Head over, click on down below neccare.com check it out. Other than that, I hope you have a fantastic week in practice 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 the evidencebasedchiropractor.com and join our MD Marketing membership today.