462- How Manual Therapy Improves Pain and Quality of Life in Lumbar Disc Herniation Patients

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 Langme. This week we are back with more brand new research and another great one. We'll drop a link down below. This study is all about the effect of manual therapy on psychological factors and quality of life in lumbar disc herniation patients. It's a randomized clinical trial. We'll dive into it, how it can apply to your practice and how you can communicate this information to your patients and all that and more on today's episode. Before we get started, I want to say a few words about Turncloud minimalist design without being sparse, practical, yet elegant. Turncloud EHR's design was to find the most efficient path in a day in the life of a chiropractic practice. Learn more@TurnCloud.com Their goal is you don't need a user manual. That is simplicity and elegance put together@TurnCloud.com but as I said at the top on today's episode, we're talking research. I'll drop a link down to the study in the show notes below. I'll repeat the title one more time. The effect of manual therapy on psychological factors and Quality of life in Lumbar Disc Herniation Patients. A single blinded randomized clinical trial. This is a big deal. We talk about fear, avoidance, behavior a lot on this podcast. We also talk about of course, spine related challenges. Lumbar disc herniation. This puts it together in a brand new study and we know that low back pain is is associated with psychological disorders, things like depression, anxiety and this can negatively impact treatment outcomes. So it's a really big deal that you and I are in tune aware and understanding of these factors because it's directly gonna affect how people get well or don't get well in your practice, which guess what, that affects the livelihood of your business. Reviews, referrals, all of those things matter. And it's not only the result, it's the patient feels understood. So if you're ignoring this, then you're missing a massive opportunity not only to maximize your results but also to maximize just your business by being the patient advocate each and every step of the way. The guide, as they would say in story branding. So disorders like depression, they are more common in people experiencing chronic pain. There's such a big overlap here. And this is shocking to me. Patients with chronic pain are three times more likely to develop depression compared to those without pain. And the increase in pain severity elevates that risk of depression proportionally. So this is a really, really big deal. You could say that. I don't think it'd be a stretch to say depression and chronic pain are intimately connected. And it's going to be very rare that you find somebody with severe chronic pain that doesn't have depression. As a matter of fact, again, the more chronic the pain, the more severe the pain, the more likely they are to have depressive symptomatology as well. And this reciprocal relationship between depression and chronic pain, they can engage and worsen each other as the process plays out. Now, the good news is when you see that snowball effect, that also means you can get it going the other direction. So that is why the communication and understanding is so important. And we know that fear of movement is observed with people that have chronic low back pain. And this can also play a negative role in your ability to maximize results. If somebody is not, if they have fear, avoidance behavior, they're not moving through their exercises, it's going to be difficult for them to get the benefit of those exercises, of course. And that fear, I'm going to say, also plays in with the depressive aspect of things. It's a, you know, and it's being reactive instead of proactive, and it's a really, really big deal. So factors, things like psychological, physiological, social elements, there's a dynamic interplay between chronic and complex pain syndromes and everything that goes with quality of life and lifestyle. And these psychosocial factors, we've seen this in the biopsychosocial model, but the psychosocial factors play a really significant role in determining how chronic pain progresses over time and the processes by which you understand and perceive that pain. And again, really important, I know we all know this, but to really live in it, understand it, and then be able to communicate effectively with your patients. And I'm going to say I'm just a big fan of calling out the elephant in the room, the radical candor, the that's necessary to break through quite often, and that's being straight up with your patients. Obviously there has to be context and time and place, but helping people understand, hey, I understand you've been dealing with this pain for a long period of time. I understand that it's negatively impacting your quality of life and that quite frankly, it can be depressing. I also know that my Recommendations include movement, some of which you're probably a little timid or even fearful of right now. But don't worry, we've done this before. We'll guide you through the process. I want your active feedback. Our goal is to. So you can see how just being super direct now, your patient's like, okay, this person's my guide. They're the trusted expert. And they're not just ignoring it like, blah, blah, blah, let's go over to the machine. But let's have a conversation that can be super brief but super impactful before those rehab exercises starts or before even the adjusting begins. So now let's dive into the lumbar disc herniation component before we get into the results of this study. Lumbar disc herniation, big deal. Obviously, basically your treatment can be divided in two camps, surgical or conservative. On the conservative aspect, when you're taking care of lumbar disc herniation, you're looking to prevent the disease from getting worse. Obviously, surgical treatment is to eliminate it by typically cutting out the offensive portion of the disc. Conservative treatment can include a variety of things. Counseling, bed rest, medication, exercise, heat, you know, electrotherapy, traction, orthotics, lumbar education, manual therapy. Manual therapy being the crux of what we're going to highlight today, which is designed to reduce pain, provide joint and tissue mobility, inhibit the sympathetic reflex activity, normalize muscle tone, and take care of adhesion, specifically in the facet joints. So manual therapy has two different applications. They're saying that under the umbrella of manual therapy, there is manipulation and mobilization. Manipulation. Obviously we know all about that. High velocity, low amplitude thrust passively to the joint at a but goes beyond the physiological range of motion, but does not exceed the anatomical limit. So no injury, just maximizing the ability for that segment to move. Whereas mobilization passive maneuver more lightly increased joint mobility and does not extend beyond the physiological joint limit or into what we refer to as the paraphysiological space. So these are the differences between the two. This study, they rounded UP participants between January 2021, July 2022. All these individuals had a pain score of at least 3 on a VAS scale. Persistent pain for at least 8 weeks. They have not received any physical therapy in the last six months. They they're between 18 and 65 years old. And of course, they have a diagnosed lumbar disc herniation. Physical examination and radiographs, checking that out. So those are really the criteria in terms of the assessments. The pain assessment was the MMPQ, the McGill Melzack Pain Questionnaire that's what they used there from a psychological factor assessment. The tools that they utilized were the hads, the hads, the Hospital Anxiety and Depression Scale. They use the tks, the Tampa Kinesiophobia Scale, and they use the PCs, the Pain Catastrophizing Scale. So those were the assessment tools that they utilized when they went about manual therapy twice a week for five weeks, totaling 10 sessions. So pretty clean and easy as far as that goes. They also had some stabilizing exercises that were recommended. Now the analysis and the results, so let's dive into some of that. So there were no differences between the groups in the HADS and the TQS values before treatment. So just about the same. And they had some people that received sham adjustment, some people or manual therapy. The others received actual manual therapy. It was found that only in the patients that received the therapy there was a decrease after the care for the HADS and the tks, so started the same decreased in the manual therapy group. And this created a significant difference. Love hearing those words. Significant, clinically significant, statistically significant. Those are important when you see it in the literature because it means it wasn't just a little bit that there was quite literally a significant difference. And they use those words very carefully when put in the literature, more so than we would normally do in conversation. So important to see that word there. Also, the PCs score was higher in the manual therapy group than the experimental group or than the control group before the treatment. The scale scores decreased in both groups after the treatment, and this constituted a significant difference. So the bottom line was manual therapy did have an impact pretty much across everything and specifically in the psychological factors. And that's really, really important because when you think about how you want to stage the care that you provide in your practice, understanding the right order is important. And the right order has multiple factors, in my opinion. And when I say order, I mean do you adjust first or exercise second? Do you. How do you go about modalities? How do you put together the treatment plans in your practice? Now, I'm not saying based upon this study that there's one answer, but what I am saying is, is that understanding how you piece these things together from a patient experience perspective. So there's a few different lenses to look at this. What's the best way from a treatment outcome perspective? What is the best way from a patient experience perspective? What is the best way from a clinical operations perspective? In other words, you're running a business and people are coming in and going out and operations need to be as efficient as possible. Now it's beautiful when all three of those items are completely aligned. That's awesome. But sometimes you do need to make a decision and, or a slight compromise and understanding that the fear of movement is going to be a critical aspect for any patient you're dealing with that has lumbar disc herniation. And then if they have chronic pain, it's gonna be going exponential. And understanding that when you provide manual therapy, you are going to make a significant impact in that fear. You're going to make an impact in their, let's say, apprehension of movement. Maybe you stage that first, maybe you don't, maybe you do. But it's important to understand in this study, there were significant improvements in fear, avoidance behavior, anxiety and depression in the group treated in manual therapy. So totally around the horn. Significant improvements were also found in pain quality of life and pain catastrophizing in both groups, which is great. And these results reveal the positive effect of manual therapy on pain, psychological factors and quality of life. So this is a really, really great study because they're laying it out in black and white. When somebody receives manual therapy, which includes mobilization and, or manipulation, you're going to make impacts and changes, Let me make no bones about this. In their anxiety and their depression and their kinesiophobia, which is their phobia about moving, fear of, fear of movement. So that is really, really impactful. It's really important. And when the manual therapy group went through this treatment, a significant decrease in pain levels were also observed. And how does this work? Well, we probably know it, but here's a quick recap. When you deliver manual therapy, there's mechanical stimulus, right? You're literally getting in there by pushing, moving, adjusting the joints. This activates gate control mechanisms, inhibits the impulse transmission of the A delta and C fibers that carry pain stimulus by activating the thick myelinated fibers that activate mechanoreceptors in the joints, which are going to provide that pain gating to the pain fibers. Furthermore, or in addition, there's manual therapy can produce afferent stimuli by stretching the joint capsule to alleviate spinal facilitation resulting from hypersensitivity of a damaged segment in it. Also, when you stretch that joint capsule, you activate the sensory signals in the spinal cord via proprioceptors within the capsule and the muscles that stimulate the periaqueductal gray matter. This activation results in analgesia. So pain relief, of course. So when you get in there, don't forget that there's hypersensitivity when you have somebody that has a lumbar disc herniation, maybe they have chronic pain and they are anxious, depressed, in fear of movement, they are going to be hypersensitive. We've all seen this. When a patient lays down, you literally don't touch them yet, and they're jumping off the table. That is as strong of an indication of hypersensitivity as possible. It doesn't mean that they just have a low pain tolerance. It means that their brain processing of that pain has fundamentally been changed based upon their experience. It also can be fundamentally changed back when the right steps are taken. So hypersensitivity are very, very real thing. And let's talk a little bit about that pain. Catastrophizing, this is defined as a negative cognitive emotional response to a current or future painful situation that tends to exaggerate and magnify the pain sensation. So important to remember that. And manual therapy that they applied in this study, five sessions, two times a week, ten total, had positive effects, again, on that. Catastrophizing anxiety, depression, and kinesiophobia. So catastrophizing pain is a very, very real thing. I highlighted this last year on the podcast, but I have a exceptionally close friend, very fit guy, very active, who struggled with a back issue for a pretty significant amount of time, and a lot of it was due to catastrophizing that pain. And this is somebody that's young, healthy, active, fit. But when somebody deals with a low back issue and now take it outside of that, and again, there's exceptions to all these rules. But take it outside, he was young, fit, active. There's a lot of people that come into your practice that are not exactly young, definitely not fit, and certainly not active, that are struggling with lumbar disc herniation. So if it's somebody who's really, quote, unquote healthy, that can have really catastrophic dealings with a lumbar disc herniation, somebody that's not fit, not active, it can almost seem insurmountable. And then those individuals may start looking and saying, like, I have so far to go, I'm unhealthy, I'm unfit, I'm not moving, and now I can't move, and now I'm never going to get there. These are the real thoughts and behaviors that can settle in when people deal with chronic pain or lumbar disc herniation. It's our job to ensure that we are providing hope, we're providing inspiration, we're ultimately providing the right care, the right steps, and the right plan for them to not only get over the hump, but be better than before. Before this study wrapped up, they highlighted a few systematic reviews, randomized controlled trials, highlighting how manual therapy and manipulation can help with things such as neck pain. It can help with things such as lumbar spinal stenosis, it can help with things such as tension headaches, cervical genetic headaches and migraine. And additionally it can be useful in osteoarthritic conditions, things hip pain, joint motion limitation, joint capsule issues, all important. And again, the research keeps stacking up. You look back 20, 30 years ago, even less than that in some cases. You're not going to see the paragraphs basically saying manual therapy, mobilization, manipulation is the way to go. And that's what all of the studies are now highlighting and I'll continue to highlight here until 90% of individuals that should be the patients of chiropractors are the patients of chiropractors. And right now that is not the case. A lot of people are still getting inadequate treatment. They're not getting movement based healthcare and that needs to change. So we're gonna keep highlighting things on this podcast. Hopefully it gives you some takeaway messages. You can use some of this not only feel more confident in your day to day care, but also the communicative aspects which I really, really try to highlight. So in conclusion, this the researchers in this study found, quote, this study found that manual therapy had positive effects on pain, depression, anxiety, kinesiophobia, pain, catastrophizing and quality of life in patients with lumbar disc herniation. That sentence sums it up. It's definitive, it's clean, it's easy and it gives you a great opportunity to get out there and teach. Now, before we wrap up today's episode, I want to say a few words about neck care. Objective assessments of the cervical spine, the best in the business. Neckcare.com, neckcare.com, i'll drop a link down in the show notes reliable assessments and exercises for neuromuscular control, proprioception, range of motion and sensory motor integration. Neckcare.com Other than that, I hope you have a fantastic week in practice and I will talk to you soon.

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