472- The Impact of Spinal Adjustments on Migraines: A Systematic Review Update

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 Lengmaid. On today's episode, we are talking about spinal adjustments and migraines, a systematic review update that recently came out. Lots of clinical pearls, quite a few questions that I have about this study and hopefully some thought provoking items for you listening as well. Before we get started, let's talk about Net Care for a moment. The best objective assessment tool on the marketplace. Awesome combination hardware and software. Big software update recently released. So if you were looking for reliable assessments for neuromuscular control, proprioception, range of motion, sensory motor integration, I cannot Recommend neckcare enough. Neckcare.com but as I said at the top, today's episode all about migraines. It's a systematic review update recently released titled Spinal Manipulations for Migraine. An Updated Systematic Review and Meta Analysis of Randomized Clinical Trials. As you can expect, we will drop a link to this study down in the show. Notes. Now, this study starts out really strong. We're gonna go through some stats that I found eye opening certainly interesting and I love the background of this study. And then when they get into it, I got a lot of questions and we're gonna break those down and highlight what those are as we go through today's episode. So how big of a deal is migraine and migraines? Well, it affects over a billion people worldwide. I didn't know that it was that big of a deal. And the global prevalence is estimated at about 14%. So this is way up there. Not as big as back pain, but this is way up there in terms of the life effect that's occurring on the people in your community and in my opinion, something that you can help with tremendously. Now one thing I found super interesting is migraine in the general population varies very widely country to country, as low as 6% in South Korea, up to nearly 23% in Belgium. Why? I'm not sure. But that is a big, big, big difference. Based upon country and the Global Burden of Disease study in 2019 estimated tying back into what we said about low back pain, estimated migraines to be the second most common cause of disability and leading cause of disability adjusted life years in young women. So this is a really, really big deal. It can contribute to of course, severe headaches, autonomic nervous system dysfunction. There are medical and psychiatric comorbidities, increased healthcare use and poor quality of life. So when somebody struggles with migraines, as we probably all know, this becomes a massive life effect that can alter really the course of work, of life experience at home, friendships, sports activities, hobbies. All of that can be impacted by individuals who are struggling with. With migraines. Now, there are several risk factors that they've identified, but there's a lot going on and this is multifactorial. So some of the different risk factors for migraine can include things like hormonal imbalances, female gender is a risk factor, obesity, head trauma, genetic factors, anxiety disorders, chronic stress, and environmental and dietary factors. So a couple of those genetics, head trauma, things like that probably are difficult for us. We can't rewind the past. So I mean, difficult for us as healthcare providers, as chiropractors to be able to impact. But many of those we can. Chronic stress, environmental and diet, specifically the dietary factors component. Anxiety disorders. While we might not directly treat anxiety disorders, the. There's no question when somebody's struggling with a migraine and in pain, whether due to the migraine or another issue that's gonna increase anxiety. And if they have fear, avoidance behavior that's tying into that, we can make an impact on several of these risk factors, which is really, really great news and probably why you've seen success in your own practice taking care of individuals with migraines. Now, when we talk about the pathophysiology, this gets complex really fast, but they highlight the fact that migraines are probably have something to do with the trigeminal vascular system, with the brainstem nuclei, with the hypothalamus and thalamus and the cortex. They identify adrenal signaling. Excuse me, potassium channels, as well as pituitary polypeptides have all been implicated in the pathogenesis of migraines. So that is a big deal, and it's something that we need to keep an eye out for now. Also, some of those items that they highlight in terms of the pathogenesis I've seen pop up, let me say, in terms of chiropractic research and spinal adjusting. So can we make an influencer impact on that? I think there's a lot of that story still to be told in the research. But there's probably no question in your practice you've seen the results of the care that you've delivered on individuals struggling with migraines. And while Nothing is a 100% success rate, this probably ties in Again, to the different risk factors and the different pathogenesis process processes. Excuse me, but even though we're not 100%, we have such low harms, we have such high benefit, and a lot of times we're providing, I'm going to say, the fertile ground for people to excel. And why do I say that? I say that because we actually take the time to understand what's going on with the individual going into a chiropractic. I say this a lot on this podcast, but it can't be said enough. Which is the difference between going into many chiropractic practices versus I'll call traditional medical and healthcare practices is night and day, spending 30 seconds with the doctor and them writing a script and walking out the door, and maybe five minutes with a physician's assistant. Nothing against physician's assistants. They can do a great job. They just don't spend enough time. And quite often they're not asking the right questions. And very rarely is there a physical exam. And most often the paths lead to the script pad. And that's just not a good way to do it. We also know refractory headaches are one of the number one components. When we talk about medications associated with migraines, that's a whole nother story. But let's just turn the tide to when somebody comes into your practice into a positive, welcoming environment. And I'm gonna encourage you to think about these things if you need to make some improvements in your practice. But please do so. When somebody steps in, do they feel welcome? What's your reception area look like? Feel like, how is your staff and team interacting with the new patient? Literally, what are they saying? You should know that and have that basically scripted out word for word. Not so you sound cheesy and corny with a script, but that you have a North Star goal. You have a framework for how you approach customer service in your practice. These things matter. When we're talking about patient outcomes, I know it seems like I'm going a totally different direction. Every step of this process has a direct impact on your outcomes because people are multifaceted and we know there's a biopsychosocial component. So when somebody goes in and they feel welcome, your practice looks clean, it looks nice, it looks like a place of healing. The front desk are super nice, super engaging, very direct. You using systems and processes to help people understand the process in simple, easy to understand language. All of these things play a massive role. Now when they see you, you're going in, you care, you're spending time you're asking questions, you're going through an examination process, you're creating a treatment plan. How all of those things are executed in your practice has a direct correlation with the results that your patients are going to get. Now, the beauty is the power of the chiropractic. The catch 22, I should say, is this. The power of spinal adjusting is so great that there are many doctors out there that I'll be very generous and say, don't exactly have those first things dialed in yet. Their patients still get fantastic results. That's how powerful spinal adjustments can be. But don't use it as a crutch. Be both, be the world class office that you're meant to be and then deliver the care and treatment that they need to help them get the best results possible. So those are really the key components in this study that I wanted to highlight. I personal belief is that this study kind of goes off the rails real quick. Meaning they highlight from the top. Spinal manipulation is a manual treatment often practiced by allied healthcare professionals, including physiotherapists, chiropractors and osteopaths. The fact that chiropractors aren't first in that equation already raised a yellow flag when I was reading this study. It's the hallmark of chiropractic care. It doesn't mean that the other professions don't do it, but everybody knows, and this statistically true, that chiropractors utilize spinal manipulation more than anybody else. So why wouldn't a chiropractor be first? That's odd to me. The second is that they, as they say, the biological, quote, unquote, plausibility, effectiveness and cost effectiveness of SMT are doubtful. I just starkly disagree with that. I think throughout many, many studies it's been showed that spinal manipulation are all of those things. It's effective, cost effective, and safer than many other items. Then they go on safety coming in here, they say, quote, in addition, several hundred severe complications after upper spinal manipulative therapy have been reported, including artery dissections, strokes, et cetera, that has happened. But there's absolutely no context given in this study that compared to many other items, things can happen, don't get me wrong, with any intervention. But when we look at the rate of harms between surgical intervention, between injections, between medications, in between spinal maneuver therapy, these are not even in the same city, maybe not the same state, and maybe not even the same country. We're talking about fractional harms with SMT compared to the others. And none of that is highlighted in this study. Which I find very, very telling, let me put it that way. Now, what this study goes on to find is that there's a meta analysis of four trials that showed when compared with controls, the intervention, which was spinal adjustments, did reduce the number of migraine days per month post treatment. So that's good news. Also, disability, a meta analysis, three studies showed that compared with various controls, SMT reduced disability. So they highlight the fact that, hey, there are benefits here. Now, one thing that they do showcase in this study that I think is important and meaningful is they say there's a lot of low quality evidence out there regarding spinal manipulation and migraines. I don't disagree with that whatsoever. So in my opinion, this study is a great one to showcase the, the fact that we need more and we don't need it, but it'd be nice to have more highlighting specifically migraine headaches and how spinal adjustments can play a role in their improvement. And I'm going to go one level deeper, tying back to where we started, which is also understanding the different types of migraines, the causation as well as possible, and the pathogenesis we may perform. And very likely we can, will and should perform differently in different lanes. While spinal adjustments have a great breadth and depth to what we can impact and who we can help and how we can help them. Again, that doesn't mean anything is a panacea. So there might be certain types of migraines where what we do as chiropractors might be less successful. That doesn't mean not successful, but less successful than other types of migraines, pathogenesis, personal demographics, et cetera. So I can't wait to see those studies come out. And I respect the fact that these researchers highlighted, hey, there's a lot of low quality evidence. We'd like to see more moderate and high quality evidence. I could not agree with them more. My gripe on this study is I think this was written bluntly from a biased perspective just on how they set things up. The tone of it and how it was written showcases to me, in my opinion that this was not exactly given even keel because even from a background perspective, there's things missing suspiciously, I'll say that should be put in there, which is harms need to always be compared against other, other interventions. When you're referencing the harm level, it's all relative to what else somebody can do, whether that something is nothing or whether it's an advanced intervention. It's anyhow, I think this study is a good one overall because I love the fact of what it points out at the beginning, highlighting the different types of migraines, some of the statistics. That was eye opening to me. I hope it was eye opening to you. But I'm not exactly crazy about the way that they position specifically who we are and what we do as chiropractors and with spinal adjusting in this study. But they highlight at the end, hey, more high quality evidence is needed. So more my question to you listening is what have you seen in terms of migraines in your practice? Have you seen any correlation? Have you put together any ideas around, hey, when somebody shows up in their this age, this gender, this history, we tend to respond better or not. I think that's just interesting thing to think about and I hope we see that continue to advance in the research as well. So if you have any comments on this whatsoever, you can always reach out to me Jeff at the evidence basedchiropractor.com Also, if you have not left us a rating or review on this podcast and you like it, I'd love to hear from you. Scroll on down if you're listening on your phone, tap how many stars in Apple Podcasts or Spotify. Leave a one liner if you're an Apple podcast. Love to hear from you. And before we wrap up, I want to say a few words about turncloud. Minimalist design without being sparse, practical, yet elegant. Turncloud has created an intuitive EHR application where no one needs a user manual. That is welcome news. You can learn more, connect with their team@TurnCloud.com Other than that, I hope you have a fantastic week in practice and I will talk to you soon.

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