523- What Massive Research Shows About Manual Therapy and Low Back Pain

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'm your host, Dr. Jeff Langmaid. On today's episode, we are back with more research. This one is all about manual therapy for chronic low back pain. The really cool part is there's over 35,000 patients in this study. So as you can imagine, this pulls together a significant amount of information, helps us understand what's going on and also how we can communicate this more effectively in our practice. Now, before we get started, I want to say a few words about some of our sponsors, Bluehonest Lasers. As a listener, they're gonna hook you up with $2,500 off their Pro VX laser. It is a full spectrum laser. It is awesome. Highly recommend checking it. Easy to use, protocols built in, big discount. You cannot go wrong. I'll drop that link down below as well as Shockwave Centers of America $500 off and a free CO cart for being a listener. A fantastic shockwave unit to bring into your practice. If shockwave has been on your horizon, now it's time to take action. I'll drop those links down below. But as I said at the top on today's episode, it is all about manual therapy. Big study and a new study. This is all about manual therapy for chronic low back pain. Again, this study pulls together to meta analysis, pulling together over 21 systematic reviews over over 35,000 people suffering from chronic low back pain. Now, manual therapy did beat other treatments for pain and disability in the short term in a data set that's a lot larger than many of the clinical trials you've ever read. But there is a twist and that's they found the benefits faded over time. Now, how much, what does that mean for your practice? What about care planning and what about for the way you explain care to your patients? That's what we're gonna dive into and much more on today's episod. So this is an umbrella review and it's kind of a review of reviews. So they pulled together 21 systematic reviews over a 10 year period from 2014 to 2024, covering a variety of treatment modalities, spinal adjustments, mobilization, myofascial release, massage, soft tissue work, neuromobilization, muscle energy techniques, acupressure and more. Basically the entire world of hands on manual therapy and the population in this study were adults with chronic non specific low back pain, specifically defined as pain that lasted 12 weeks or more with no specific pathology. So no stenosis, no radiculopathy, no tumor, no fracture. And they measured a few different things. They measured pain intensity, number one. Number two, they measured disability, number three, they measured quality of life. And the authors or researchers in this study separated the results into three buckets or categories. Short term was 0 to 3 months, medium term was 4 to 6 months, and long term was 7 to 12 months. And the big picture question that they were asking was, does manual therapy work for chronic low back pain and if so, for how long? Now, the big spoiler, which I already kind of let go at the beginning of this episode was, yes, it works really, really well in the short term, but less the longer you go. Now, I would take a little bit of a detour here and say, you've heard me say this before. Time and gravity are undefeated, right? So it's very rare that something you do today lasts forever. People go back to their daily habits, they get older, they're under gravity longer, they're using compensatory patterns. Whatever the case may, all of it, whatever the case may be, or all of it, in most cases, that's a, that's a very real thing. So just because something doesn't last forever does not mean in any way, shape or form that there's a lack of utility. So let's take a look at some of the key findings and stats and specifically pain, we'll start with that. In the short term, 0 to 3 months. Manual therapy had a 10 point reduction in pain, that was highly significant and that was seen in about 4,000 patients. And it was really amongst the strongest effect sizes across all categories. So regardless of how they sliced or diced it, in the short term, manual therapy was massively clinically meaningful. So in the medium term, still significant, about a five point reduction. In the four to six month period. So the effect drops by half, but there still is meaningful improvement, improvement there. And in the long term, seven to 12 months, no significant difference. So we'll come back around to really what that means in a few moments, but let's get through some of the additional data. Disability, they measured this with Odi, Roland, Morris or Quebec scales, depending upon the review that they were seeing. In the short term, there was moderate improvement, in the medium term, there was small improvement. You're going to notice a trend here. In the long term, there was no significant improvement. So across all modalities, the study looked across those manual Therapy approaches and found spinal adjustments were often equal to exercise and or NSAIDs. I'll touch on that in a moment. Myofascial release helped the disability most, helped improve that most, and massage and acupressure showed benefit, but with mixed quality. So let's go back to that first statement of spinal adjustments often being equal to exercise or NSAIDs. Now some people may listen to that and say, oh, that's not too good. Some people may listen to that and say that's great. I'm more towards the second aspect of that. I'm more towards the second aspect of that because I just still look at it and say, man, an nsaid, you can take a chemical that's chemically altering what's going on and the hands on care that we deliver can often equal or exceed that. That's massive to me. It doesn't mean that NSAID has zero utility. Now I might not recommend that many people take them in many cases, but that takes nothing away from the power of a spinal adjustment equaling it. That shows to me that a spinal adjustment is massively powerful. Same with exercise. We know that many people struggling with chronic nonspecific low back pain are extremely deconditioned. Therefore I would fully expect exercise to help them. That is a completely logical path. So the fact that you can get in there with an adjustment and equal or better the results of exercise or NSAIDs, to me, that's a massively powerful statement and something that is inspiring with what we do. Exercise takes time. And in many cases the answer should be exercise and spinal adjustments, of course. But when parsed out head to head, exercise takes time. People are non compliant, it's active, those are the active component is a really good thing. But a spinal adjustment can take one minute, it's passive, and it can equal or better the results of the exercise they're spending time doing. Now of course the mechanisms of action work in different ways. Long term, these things can play out in slightly different fashions. But that is, I'm gonna say, a rousing endorsement of what we do with spinal adjusting in our practices. So if we take really a deeper look at this meta analysis, in plain English it says manual therapy works best right away. Within the first few weeks to three months, the nervous system calms down, descending inhibitory pathways can activate and mechanoreceptor stimulation reduces that threat perception, that fear, avoidance behavior, all of those things. So let's come back around to this. The first few weeks to three months, this means your practice should be a primary referral source for people struggling with chronic non specific low back pain in your community, if you are not and you don't have at least a couple relationships going referral relationships, head over the evanspacechiropractor.com, get started with MD Connection. We've helped over a thousand chiropractors build referral relationships. We do it better than anybody else. I can confidently say that because we're doing it a long time and the system is really dialed. You don't have to sell, it's not weird, it's, it's a system and process to build referral relationships and we lay it out in a really easy manner. So if you're serious about taking care of people with chronic non specific low back pain, which is a lot of people in your community, then building referral relationships is critical because those first few weeks to three months are also critical. And if we're relying on only the patient to be able to find you, you're probably missing half the boat. Because many people, most people are actually going to traditional providers. And if Those traditional providers, MD do, PA nurse practitioner, if they're not, if you're not on their radar as a referral source, you're missing a massive opportunity from a business perspective, but also just from a health of your community perspective if you're taking it real seriously. So this reinforces that concept that we need to be there early. As chiropractors, it's where we're going to see the best results and get and guess what, the best short term results. That absolutely goes right into the best long term results. So getting there early, ensuring you see these patients early, absolutely critical. And the other doctors in your community also should be reading research like this to know that they should be sending. But in many cases it's gonna take your effort to get em over the hump. Number two is the benefits do fade over time. So by six months the effect was cut in half and by 12 months the difference disappeared. So this is totally consistent with other chronic pain research. There is no single passive therapy that produces long term changes by itself. Right. So it's not a negative whatsoever. And really they broke this up, said not all techniques matter to the same degree. So targeted versus non targeted spinal adjustments didn't really make a difference. It wasn't the specific joint, the exact segment, the perfect hand contact. It was the global neurophysiological effect of manual therapy as they showcased in this study. Study. Now this was a broad based study reviewing reviews. So it's meant to be again an umbrella and it Lacks the specificity, sort of on purpose. This is creating buckets, not bullets, so to speak. This is, this is meant to be wide. So this review also highlighted the fact, no surprise here, human touch reduces pain, anxiety and stress physiology. The hands on care that we provide is some of the most important that we can do. It's actually part of the therapeutic effect and, and that's a good thing. And chronic low back pain, of course, is not just mechanical. The authors dive pretty deep into modern psychoneuroimmunology, how that plays in with chronic stress, poor sleep, sedentary behavior. We talked about this decondition a few moments ago. Low grade inflammation. This reinforces the concept idea that in chronic pain you're treating the entire person, a system, not a segment. So if you think back to previous episodes, it's why we always talk about make sure you are at least always addressing, assessing, evaluating the joint adjacent to the problem. Somebody's coming in with a cervical spine issue, make sure you're checking the shoulders and thoracic spine. If they're coming in with a lumbar issue, make sure you're checking the thoracic spine and the hips at a bare minimum or SI joints at a bare minimum. And specifically when we're looking at individuals struggling with chronic non specific low back pain, really looking at them from a totally holistic point of view is critically important to getting the best result possible. So in your practice, important to note, manual therapy is highly effective. This research supports doing what you do with manual therapy and especially spinal adjustments when patients need immediate relief. It can reduce pain, improve function and get people moving. And that's exactly what early phase care should be doing. However, it's probably not the best to be used alone in many cases and specifically with chronic non specific low back pain, because that long term effect can taper off. Pairing it with items like education, exercise, sleep and stress, support lifestyle changes, activity exposure over time, that helps keep the window open and keeps people improving, probably part and parcel to what you do each and every day. This research continues to reinforce that. And one of the most important clinical insights from this study, patients who feel better early are the most engaged. No surprise there. So what you're doing can absolutely. And it does build trust, confidence and improve follow through. And this is all really important for chronic pain care. So with 35,000 plus patients in this study, it absolutely supports what you do as safe, effective and and guideline consistent. And you can feel very confident communicating that the care that you provide is shown to work especially in those first few weeks or months. So highlighting this throughout, I'll say your social media videos on your website, throughout your communication with other healthcare providers, during your report of findings, really, really important. So I loved this study because it highlights and reinforces the benefits of who we are and what we do. And it showcases the fact that when you take a hands on approach in your practice and you provide, you know, the conversation and I don't mean that in a sales marketing way, I mean that in terms of the education, helping people understand and overcome fear, avoidance behaviors, helping people understand what's going to happen in the future. Not that you have a crystal ball, but in general, here is what we see in our practice. Inspiring people to get moving, not to take a pill and stop moving. These are all really critical components of long term health. And when we're looking at people with chronic nonspecific low back pain as this study did, these people can be difficult, sometimes difficult to get over the hump. Many people have struggled at this point by the time they come in with chronic non specific for potentially years or decades. So those behaviors don't change overnight. They might again I'll say they might feel better, they should feel better and likely do feel better after a few adjustments. But don't stop care too soon. The habits needs to change, the neuropsychology needs to change, the physiology needs to change. All of that takes time, it takes intention and it takes a guiding hand. And that's where you can be a massively powerful help to those people in your community. So I was a big fan of this study. I thought it really highlighted what we do. Well, I'll drop a link down in the show notes of course and as we wrap up on the last episode of this year, thank you for joining. Thank you for joining along. I hope you're taking advantage of the discounts that our sponsors provide. They are very generous and they're giving you access to things that are awesome. Like Leander Table is giving you $1,000 off their Series 950 table. You can check that out. Get that tax write off this year by connecting with their team and Neckcare, the best objective assessments of the cervical spine out there. They're going to be able to hook you up with 10% off hardware software package is out of this world. Be sure to check out neccare.com all those links will be down in the show notes if you check it. Thank you so much as we wrap up this year for being a chiropractor. Thank you for tuning in. Whether this is your first listen, whether this is your 500th listen. Thank you for taking the time to do so. I deeply appreciate it. And if you want to give me a new Year gift, you can leave a rating or review for this podcast. That'd be awesome. It helps more and more docs find out about it. I hope you have a fantastic week in practice and I will see you soon.

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