470- Intervertebral Disc Changes and Chiropractic Care

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 are back with more research. Brand new and it is awesome. Tons of clinical pearls, plenty of communication aspects to this piece of research as well. It is all around the intervertebral disc imaging and spinal adjustment spinal manipulative therapy. So this is a good one. You're gonna want to stay tuned. It's a brand new one. Before we get started, I want to say a few words about neck. Neck Care is the best cervical spine assessment tool on the market, bar none. You can check it out@neckcare.com it has reliable assessments and exercises for neuromuscular control, proprioception, range of motion and sensorimotor integration. I'll drop that link down in the show notes as well as the link to today's research article. Brand new study. The title is Intervertebral Disc Magnetic Resonance Spectrum Spectroscopy Changes After Spinal Manipulative Therapy for Lumbar Discogenic Pain. Man, that is a mouthful. But it's a really good study and let's dive right in at the top. As it said in the title, this is about low back pain and it is the most common health problem and cause of disability for adults. Up to 80% of people are gonna struggle with this and right off the bat they get into an interesting fact. If we think we're doing a better job with low back pain as a country, that is not the case. They cite the fact that healthcare costs for low back pain have increased substantially in the past decade. So if you're like me and you've been around maybe more than a decade in this profession, you might say, wow, we've made a lot of great gains. And we have in some ways. But in terms of our ability as a healthcare institution, so to speak, across this country, we have not done a great job reducing the cost associated with low back pain. As a matter of fact, there's probably more intervention today. And I always say, do you think people are actually better off? And the answer to that question honestly most of the time is no, because they're not making the right decisions. And we know movement based care is absolutely where it should be. We know that's what the research says. And we know that most of the research out there fully supports non pharmacological care, and specifically what we do as chiropractors with spinal adjustments. Yet the amount of referrals are woefully inadequate compared to the amount of patients being seen in a traditional care setting. And that is a problem that needs to be addressed. So we also know that pain, of course, with low back pain, it's multifaceted. It can include physiological factors, psychological factors, and it becomes complex. It's not easy. And especially, you know, it's not easy when over 90% of low back pain is classified as non specific low back pain, which by definition means, hey, we can't tell the real source of pain here, what's really causing the pain. Now, I think when you start to get into certain healthcare specialties, chiropractic being one of them, I'm gonna tip our hats and say I think we do a pretty good job at really identifying those pain generators in a way that, if I'm just blunt and frank about it, doesn't happen most of the time in a primary care office. Why? Because they're spending two minutes and writing a script or making a referral. They're not doing the physical exam, the detailed history, the imaging as necessary, the orthopedic testing. They're not going through all of that. And that stuff is so critical to, to being able to identify what those pain generators are or at least being able to narrow down where you think that pain is coming from. And if you're not identifying where the pain generator is, it's gonna be a difficult time helping people get over the hump. Thankfully, I'm gonna say with what we do and the mechanisms of action within spinal adjustments, there's such a large swath of impact that quite often you can be close and still get a great clinical result. In other cases, that's just not the case. If the surgeon's on the wrong facet on the wrong level, there's gonna be a minimum. Yes, there's placebo effect, but outside of that, that's gonna be the limiting factor there. So it's really important to understand that when we see 90% being classified as non specific, that classification is healthcare wide. And I believe those percentages can vary heavily depending upon who is doing that initial intake. We also know that discogenic low back pain often is classified as nonspecific due to vague and conflicting presentations and inconclusive tests. So let's talk about those tests. Qualitative imaging absolutely dominates the landscape in terms of trying to figure out the source of pain. But we all know that the imaging findings Correlate very poorly, meaning low specificity. With any clinical presentations. I always say you get the MRI report back. When I would speak to patients, I would say everything on this report tells your not perfects. My job as your healthcare provider, your doctor, is to find the problem. And that's a, it's a relieving situation for many patients because they get the report back and they're like, oh my Gosh, I have 75 things wrong with me and it's not the case most of the time. Now do they need to be aware of things? Absolutely. But it doesn't mean that everything on that report, of course, is the pain generator that speaks to the low specificity. And qualitative imaging can also show things like, as we very well know, degenerative changes, reduced disc height, end plate challenges and sclerosis. And, and all of that can be found on asymptomatic and symptomatic people. Again, speaking into that low specificity, there are provocative tasks like discograms. I'm not going to get into that. We don't order those too often and quite frankly, they're just, it's not relevant for a lot of what we do. But it's another test that's out there. Now when the disc starts to undergo degenerative changes, there's a lot of things structural and biomechanical that can trigger pain. And these degenerative findings on an MRI can include a plethora of different things, many of which you're aware of. Modic changes, annular tears, herniations, bulges, loss of structural integrity, high intensity zones. Now again, all of these findings can be found in asymptomatic and symptomatic people, which really speak in again to your history. They say 90% of what you need to know can be sourced on that history. If you're detailed, if you're asking the right questions, you put on a physical examination that's really good. Whether you're using dsa, DNS, sfma, however, you're going through your physical and movement based examination, we again, I'll tip our collective cap as chiropractors say we do a really good job being able to be far more specific than almost any other healthcare provider. Before we even get into the true diagnosis and certainly before we get to the treatment, which is a massive advantage for our patients and probably speaks into why we get such great results as a profession. This study highlighted something I thought was awesome. They say non surgical, non pharmacological treatments are the most common interventions, including patient education, spinal manipulative therapy and exercise. In fact, for some patients, they say these conservative options may be as effective as surgery and opioids in reducing pain, but are more cost effective with a lower risk of complications. No question about that risk of complications and also no question about that cost effectiveness. I'm not, I don't get too hung up on cost, but the lower complications is a real big one. And that's a really impactful aspect of what we do that is often overlooked. Now I would say, not that we're not maybe as effective as surgery. I think we can outperform surgical intervention. There's no question we can outperform opioids and in some cases we can outperform surgical intervention. And the risk spectrum is just an entirely different. You're in a different city. I mean, the risk of complications on surgery compared to receiving care in a chiropractic office is night and day opioids. I don't even need to open up that Pandora's box. We all know these are not even night and day, they're beyond that. So that lower risk factor, when we think back to the Hippocratic oath, do no harm. I think there are some other professions that could take that a lot more seriously. So in this study, it was actually a case report and I loved what came before and after the case report, which is why I'm spending time really highlighting these interesting facts that they're bringing up around the intervertebral disc. I'll touch on what the case report and the case presentation was briefly and then we'll get back into some interesting findings on the back end. So basically in this study they had a 29 year old male who is in the military and he presented with an acute flare up of low back pain after a few days. He wanted to reduce pain, get back to weightlifting and golfing and improve his function. And he had a lot of fear avoidance behavior. He was actually taking care of using Cox flexion distraction. And he didn't have any, necessarily any red flags. He did have a lot of again, fear avoidance behaviors. So the reassurance and education was key. They did some imaging on him. Long story short, he did very well. He's had, he had some setbacks during the treatment, but at the end of care he was in really, really great shape. So that's the case study in a nutshell. You can download of course the article and read it, but I want to get back to some of what I found to be even more interesting than the individual getting. Well, and it was around really Diving into how the disc changes what causes pain, and a new imaging modality, at least new to me, they might be able to increase the specificity that we see lacking in MRIs. So qualitative imaging features degenerative changes. And this is seen in 40% of people under 30 years old and 90% of people in over 50 years old. So you take pictures, MRIs, qualitative imaging, you're gonna see degenerative changes in 40% of people under 30years old, in over 90% of people over 50 years of age. So absolutely wild and crazy. That's why those findings have a low sensitivity and very low, if any, correlation to pain. Now, an early characteristic of disc degeneration is proteoglycan breakdown. And because notochord, chordal, notochordal. Difficult words here. Cells are less abundant, proteoglycan content decreases, along with reduced inhibition of water and nutrients into the nucleus. And as the nucleus water content goes down, the ability of the annulus to absorb stress goes down, which allows for structural changes that can result in low back pain, such as annular tears and disc herniations. I just hadn't thought of these things in a while, and that's why I really wanted to highlight it on today's episode. But proteoglycans are a really important component as well as some of the things we're about to talk about. So in a healthy disc, we know it's generally avascular. So that means glycosis is actually used as the energy system, and that creates lactate. That's a healthy disc. And in a healthy disc, inhibition of water and nutrients in exchange for waste product, lactite levels do stay low, which makes total sense. Now, decreased disc inhibition occurs with reduced proteoglycans. We just talked about that. And as the degenerative process advances day after day, week after week, month after month, the end plates can actually become calcified modic changes, further reducing that inhibition. That can result in accumulation of lactate. And that changes the PH of the disc. Guess what that does? Now we're talking about getting that snowball pushed downhill. This is a cyclical. So then we see advanced degeneration, we see proteoglycans, hypoxia, and cell death, all as a result of that lactate accumulation. And again, with increased lactate, there are pro inflammatory cytokines, and that is a big deal. Now, a healthy disc is only innervated in the outer layers of the annulus fibrosis, as we've touched on in previous episodes. And when degenerative changes occur. This becomes challenging because we can see nerve tissue start to infiltrate those annulus fibrosis and potentially even get all the way down to the nucleus. Well guess what? When those fibers go in, when they start growing, they bring with them a neurovascular bundle. Well guess what the nerve component of that neurovascular bundle can do. It can create the ability to have pain. And that pain is predominantly or at least a component of it is man. These neural tissues have ion channels that are really sensitive to ph changes. Well, we just talked about the PH changing with increased lactate, with decreased flush, what I'll call it making sure. And that's a problem. So biomechanical changes and annular changes can create an environment with vascular granulation and, and neoneural growth. That means those nerve fibers, that neurovascular bundle growing into the disc, which when that happens, that creates fertile ground for pain and dysfunction. And that is a big problem when we see ph that's low and we see a ton of pro inflammatory cytokines. So I hadn't thought of that in a while. I hope that was interesting to you as well. To me there's just, there's so much that we could dive into. But I'll keep it brief on today's episode. Now let's talk imaging. Really quickly. We talked about the lack of specificity with an mri. What they talk about in here is an Mrs. What is an mrs? An Mrs. Is a non invasive method that provides quant. Quant quantifies the chemical differences in the tissues and is used to evaluate specific biomarkers. Well, we just talked about all those things, right? Proteoglycans. We just talked about PH levels, we just talked about cytokines. Guess what an Mrs. Scan does? It evaluates those things. So it uses the same underlying concept as an mri, but it takes advantage of the fact that these metabolites have distinctive electron surroundings and chemical bondings which interact differently with the main magnetic field. Basically when you do an Mrs. You can see what's going on and you can see how things are changing a lot more earlier. We just talked at the beginning, remember those MRIs, you can only pick up really mid to late stage changes. However, with an Mrs. You can get way earlier understanding the cascade of degeneration. So Mrs. Interesting. I think there's going to be a lot more research about it. I've heard of it before, but this study really just, it caught my attention. I wanted to bring it up to you as well. So they wrap up talking about spinal Manipulation, I'm going to call it spinal adjusting. And they basically just highlight the fact that non surgical treatments like exercise and spinal manipulation are recommended. They also touch on the fact that there's been previous research about long term outcomes for patients who had spinal adjustments or who had opioid care. And they concluded that spinal adjustment group had lower rates of escalated care, not the fast track to shots drug. You know, surgery drugs are the opioids of course, so it reduced the likelihood of escalated care. That's a really good thing. There also is a systematic review and meta analysis previously published that shows statistically significant improvements for those receiving adjustments compared to NSAIDs. And that's important. And not only that, but those receiving spinal adjustments had only transient harms, whereas those NSAIDs can be very harmful to certain patient populations. Again, we get back to those risk factors. So spinal manipulation, we know, treats mechanical aspects of pain and specifically relative to hypomobility and with decreased water content in the disc, specifically degenerative disc, it's theorized that motion segments can become unstable or hypermobile. But there's a lot of literature out there supporting the fact that the intervertebral discs might become stiffer and hypomobile due to changes in the collagen of the annulus fibrosis. Really interesting. And that has a lot of implications for what we do. So improving motion segment mobility may provide better outcomes than surgical fusion in some patients. Why? Because fusing it, we know it leads to adjacent issues, but it also can it just fuses the segment and motion might be what getting back to motion based. In a movement based healthcare profession, movement is generally what things need to improve. So when you fuse it, you stop all healing and you actually advance, you actually advance challenges in the adjacent areas. Whereas movement might be the best thing and is often the best thing to do. So I found this study to be really, really interesting. The case aspect of it, again, if you want to dive in, I went through that super briefly but there was just so much meat and so much great information about the intervertebral disc with this study. So hopefully you had some take home messages there. If you have any questions, hit me up. Jeffevidencebasedchiropractor.com thank you so much for tuning in. If you haven't left a rating or review for the podcast, subscribe, that's my end of year ask for you. Please leave us a rating or review. We'd love to see those and love to hear from you. And as we wrap up, I'll say a few words about Turncloud. Turncloud is a fantastic EHR minimalist design without being sparse. They strip away everything that's non essential, making everyday functions simple. And they have created an intuitive application where no one needs a user manual. You can learn more, schedule a demo with their team turncloud.com, i'll drop that link down in the show notes. 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 theevidencebasedchiropractor.com and join our MD Marketing membership today.