Can Modic Changes Predict Recovery From Low Back Pain | Podcast Ep. 363

Foreign hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langme. This week we are back with more research. We're touching on an article highlighted in the European Spine Journal. It's all about modic changes. I know we see this on imaging all the time. The question is, is it prognostic for recovery for people that have low back pain? That's what this study analyzed. We're gonna dive into it today. Some clinical pearls highlight how you can have better conversations with those people coming into your practice so that they can get the best results. And ultimately you do a great job. That's gonna lead to a better practice, more referrals and better reviews and testimonials. And to me, communication is paramount, whether that's happening in your office or whether what goes on outside your practice. And that is why I want to highlight before we get started, the smart chiropractor. Smart chiropractor can power your patient journey. More new patients, better retention and more consistent reactivations without spending any money on advertising. Keep an eye out. Literally. Tomorrow we are releasing my favorite email campaigns. Email is the return on investment driver within the smart chiropractor and we are releasing the best email campaigns that we have. So if you're interested in more new patients, if you're interested in better retention, if you're interested in more reactivations, we're taking those campaigns showing you exactly what they look like exactly. Email templates as well that you can utilize. So keep your eyes peeled online on all social channels. We're going to have those links up so you can get access to that for free starting tomorrow. But as I said at the top, today we are talking all about modic changes and this study came out in European Spine Journal. I'll drop a link down in the show notes so if you want to check it out, you can do so if you. It is titled Aromotic changes Prognostic for recovery in a Cohort of patients with non specific Low Back pain. And this study was done a few years back. But there's some really great messaging that goes out in and around this study. First, let's set the stage for what is exactly low back pain. Not just pain in the back, but let's get more specific. It's defined as pain, muscle tension and or stiffness localized between the costal margin and above the inferior gluteal folds, with or without leg pain, radiating to the knee. And in most cases as they highlight pathological causes can be detected or cannot be detected. Excuse Me. And this is designated as non specific low back pain. I still have a bone to pick. With non specific low back pain, it's like something's causing the pain. Like you just gotta look harder and ultimately you can really determine, is it a disc issue, is it a facet set issue, is it a biomechanical issue, what's going, is it an end plate issue with MOTIC changes that could be causing it? There's a variety of things that can cause low back pain. Just doesn't happen mysteriously without cause. However, a majority of people still are deemed non specific low back pain in many ways because it's not related to a disc, which is in my opinion, what the medical system looks at. Always get the mri. Is it a disc? Is it a disc? Is it a disc? But there's a lot of nuance in and around that. So people with low back pain are often receiving MRIs. If they go through a traditional medical system, probably not so much. It's not exactly the first thing that happens when they go into a chiropractic practice. However, it is quite often, especially if they have pain that's traveling at all. The first thing that's recommended if they go to a primary care provider or certainly they're probably not even seeing a pain management doctor before they have an MRI performed. So now international guidelines pretty much have discouraged this, using mris super early with nonspecific low back pain. Why? Because there's a lot of people that are asymptomatic that have degenerative changes. You've probably heard me say this before, but I'll say it again. I used to describe it this way to patients every day when I worked in the orthopedic groups. And I think it was powerful. I'd say your mri, it's probably scary. You have multiple pages of stuff that is not perfect. But I don't want you to be scared. I want you to think of this like a deck of cards. Everything that's listed on that MRI report is a not perfect. That's like me taking a deck of cards and throwing it out on the table. There's 50 cards, 52 cards, all spread throughout this table. Now, our job, my job, is to really push away those cards that don't matter and to find what's the problem amongst the not perfects. It is perfectly okay to have not perfects. Our job, my goal is to find the problem so that you can find the best solution for, for long term relief. So I found that to be a powerful way to describe it. Use it if you also resonate with that. But MRIs are taken quite often. Guidelines discourage the use is a good way to put it. And that is because there's so many asymptomatic people with findings. And degenerative changes, as we know, are only weakly associated with symptoms. And there's strong evidence that MOTIC type 1 changes are associated with low back pain. Why? Because MOTIC changes, when they're type one are the most inflammatory. That's when stuff's going on, it hurts as time goes on and those solidify, so to speak, that is when pain tends to go away because it's not actively inflamed. The changes have sort of settled in. I almost think of it like an osteophyte. It's fully formed at that point in time. Not all MOTIC changes are osteophytes, but I hope you get the point there. So there are three different types of Motic changes. Motic 1 changes correspond to those the edema in the vertebral end plates and subchondral bone, which are caused by end plate cracks. So that's an interesting thing I hadn't really pieced together myself previously. This is accompanied by increased vascular density, increased number of nerve endings and increased levels of pro inflammatory biochemical mediators which are probably important to pain. Right. We know that those end plates don't have great vascularity normally. They also don't have great innervation. The good news about that is when there's not a ton of vascularity, when there's not a ton of innervation, you don't feel it a lot. So there's not really pain. But when cracks occur, inflammation happens. There is nerve endings going in, there's vascularization occurring. That is when you start saying, oh my gosh, now I notice this going on. Those are all modic1 changes. Generally modic2 and 3 changes represent the end stages. Kind of highlighted that earlier. The end stages of the degenerative process, they don't really cause a lot of symptomatology. It's really that beginning that initial spike, that real inflammatory aspect when vascularity is happening, when people notice pain as time goes on, that tends to wean. So for chronic low back pain, there's strong evidence that a variety of things can be prognostic factors for recovery. And some of those has been highlighted in previous research is function, functional ability. What's it look like today is a indication of what it's going to look like tomorrow. Depression, education, professional status, all of these things in the research have been highlighted as prognostic factors for the recovery from low back pain. And now the question says, well, do modic1 changes matter? Are these a prognostic factor? That's what they're looking for in this study. So they took a look at patients from Oslo with non specific low back pain. 20 years old to 60 years old. A lot of people were excluded from the study. If you had previous back surgery, you were excluded. Spinal stenosis, cauda equina, spondies, grades 2 through 4, disc herniation with nerve root irritation, aka radiculopathy, somatic or psychiatric diseases, osteoporosis. And if somebody was currently pregnant or receiving other treatment, they were excluded. So they really wanted to get a highly segmented batch of people who were between a certain age, who had emotic changes and who didn't have a lot of other stuff going on so that we could really get a good answer to the question. So these patients were followed up with at six weeks, at six months, in one year by mail using a self reported questionnaire. And it included just one shy of 270, 269 chronic back pain patients. And again, remember chronic back pain, this is more than 90 days duration. They blew that out of the water. The mean duration of back pain in this study was nearly four years. It was 3.7 years. So people have been dealing with this a long, long time. And at one year follow up they had 40% of the patients rating themselves as recovered. And they found that neither modic changes nor other degenerative changes on MRI were associated with that recovery. So we're gonna talk a little bit more about that as we dive in. So that recovery rate at 40%, on the surface it might be like, wow, that is not too good. How are people dealing with this? You know, people are not recovering, majority of people did not get well. But it's agrees with the available evidence for people with chronic low back pain. Again, remember, these are people that have had low back pain for nearly four years. So that 60% still have it one year later probably isn't a big surprise. Additionally, you have to keep in mind that with this, many of these patients were not necessarily going through a variety of active care or movement based care therapies. So with that being said, it's no really surprise. Now they did find that education was a prognostic factor and patients that had a university level or higher education had a higher rate of recovery than people with lower education. Why is that? Well, it's probably pretty complex. There's a lot of different stuff going on. Lower education can be lower decision making. It also can mean a more likelihood for heavy physical work, which can all impact that. Now, the prevalence of Modic1 changes in this study was about 14%. Well, it was 14%. So of those 269 people, 14% had motic changes, which is also important because you're trying to compare those that had modic changes and those that didn't and what went on over that amount of time. So there's basic agreement in the research that Modic1 changes are strongly associated with pain. There's no question about that. I don't believe at this point in time, but there's not really a strong indication, at least on this study, that it affects recovery rate. So modic associated pro inflammatory mediators have been suggested to be a major origin of pain. And as Modic1 changes convert to Modic2, that usually takes 14 months to three years. And one explanation for why there might be these slight discrepancies here is that acute inflammation might resolve even though those modic changes are still present on mri. Remember, when you take an image, things are going on at that cellular level that might not be showing itself yet on the imaging. Almost think of this like, maybe this is not the best comparison, but like a fracture sometimes, you know, if you image a fracture two minutes after it happens, unless it's a big fracture, you can miss it. It's really after you start to notice the healing process that you can pick up the fracture on the images super easily. And I think that plays into how I think about these modic changes, where it's things can be happening in the body and not yet be visible on the film. And that's also important to keep in mind as you check out films as well, is that there might be a gap of time there. And that's a. Okay. And that's why it's based upon the entire clinical presentation and picture, not just based upon the imaging, as we've learned time and time again. So what's the conclusion to this study? Well, in a cohort of patients with low back pain, the prevalence of Modic1 changes was 14%, which is comparable with other studies. Neither Modic1 or 2 changes influenced the clinical course of pain and function, and they were not prognostic factors for recovery. Education level was a strong predictor of recovery. And they're saying clinicians need to be reminded to approach patients with chronic low back pain using a biopsychosocial model of recovery. I want to touch on that education component for A moment. This is qualified quite often as what we say, book smarts, right? What level of education did you complete? Was it university, was it high school, was it postgraduate, et cetera. However, how somebody thinks about their pain is really important at a base level. And that ties into, in my opinion, fear, avoidance, behavior. It can potentially tie into motivation. Are they really motivated to get back to work because they feel like they're fulfilled in the job that they're doing every day and not a cog in a wheel, which might be a little more demotivating. It ties back in to depression and the psychosocial factors that really matter when you're dealing with low back pain, because we know it's so intimately and intricately involved with psychological components. So it's really important to understand, I'm gonna say, beyond just the educational level, hey, checkbox. What level grades did complete in school, but really, what's their psychological makeup with this? And especially people that have been dealing with pain for four years, they've probably tried a variety of healthcare providers in the past. And if they think they're gonna get the same thing in your practice that they've tried somewhere else, it's pretty demotivating. They're on the search, they're searchers at that point. You've been dealing with pain for that long, you're searching for an answer, you're searching for a missing piece of the puzzle. Probably have tried some things. You probably, clearly, in this case, you're still dealing with pain, so you haven't got over the hump. And emphasizing the fact that there's not often a magic bullet, there's not just one thing that's going to help these people get well, but it's a combination of things. It's movement, movement based care. It's what we do as chiropractors, it's encouragement, it is highlighting deficits in their diet, their diet that might play a really big role ultimately, if they're just chronically inflamed all of the time and they're dealing with back pain and they're carrying too much weight and they're eating too much and they're not getting the movement they need. We see this all the time, but to me, sometimes we almost become blinded to it or, you know, we don't really sit back and say, God, these are really, really important factors. It's not just, you know, lose £20 and it's the motivation to get up and move and it's if they're in too much pain, I don't blame them. We shouldn't blame them for not taking that action in active care that we really desire. But how can we get there in a stepwise fashion? How can we break a few fear avoidance behaviors? Now we have some wins. How do we then decrease that pain level? Let's chop it down 10, 15% with the care that we're delivering that emphasizes the fact that you can get moving safely. And how do we create a plan of action that creates small wins along the way where they stay motivated, stay on course, which is ultimately gonna yield the highest benefit long term? I'll be very, very clear. And I think you've probably seen my language kind of alter and evolve on this channel even as time has gone on the last few years. The answer is not in shots, the answer is not in medication, and the answer is not in surgical intervention. For 99% of people, these things are being dramatically overdone. Injections are causing harms. It is a fast track to surgical intervention. And surgical intervention, quite often, with very rare exceptions, causes far more challenge than it does benefit. And that is especially true for individuals that are suffering with non specific chronic low back pain. Nearly none of those individuals at all should be having surgical intervention. So what is the best option? Movement based care. The care that you and I can provide in our practice and being able to communicate that in an effective way is absolutely critical to your patient success and ultimately to your practice success. So as we wrap up today, I want to encourage you to support the companies that support this podcast that includes Power Step. They're willing to hook you up with a free sample pair of Orthotics Pro powerstep.com sample Pro powerstep.com sample Use the code EBC for evidence based chiropractor. They'll hook you up with a free pair. Why not? Check it out. They were developed by a podiatrist over 30 years ago. I use them, my father uses them. The company's great. Check it out. Get yourself free sample pair. 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