Chiropractic Adjustments & Sit-to-Stand Movement in Low Back Pain | Podcast Ep. 266

Foreign welcome to the Evidence Based Chiropractor. I AM your host Dr. Jeff Langme. Today we are talking sit to stand. It is a functional movement you need to be aware of. We're going to talk about a brand new research paper that highlights just how important this is and how manual therapy, mobilization and manipulation or adjustment can can make a positive impact on that motion. We're gonna break that down brand new piece of research momentarily. But first, what's in a name? Everything. And if you have not checked out Jane, please do so. It's the only name you'll need to remember in the EHR world. Jane is a HIPAA compliant online platform providing you clinical management capabilities like online booking, charting, scheduling, telehealth, invoicing all in one easy to use system. Features like smart options, narrative and dictation make things easy. You can learn more and watch a demo right now by heading to Jane Jane App Cairo Jane App Cairo and if you want a 30 day grace period, use the code evidence based2021. EHRs are frustrating for most people because they don't use Jane yet. Ask a Jane client or member and I'm sure that they're going to give you a raving review. But if you want to check it out for yourself, head over to Jane App Cairo. Use the code EVIDENCEBASE2021 to get a 30 day grace period as you get up and running. But as we talked about at the top today on this podcast we are breaking down some research. This study came out in chiropractic and manual therapies in 2020. So yes, it is pretty much brand new. The title of this study is Does Manual therapy affect functional and Biomechanical outcomes of a sit to stand task in a population with low Back pain? A preliminary analysis. I'm going to drop the link for this as well down in the show notes if you want to check that out. But let's dive right in. So sit to sand. That's what we're going to talk today a lot about. But let's start with what we know of mobilization and what we know of an adjustment or manipulation. We know that mobilization and manipulation both involve manual application of force. That's about where it ends. Mobilizations, typically lower magnitude forces and they don't move the joint beyond its physiological range of motion. Whereas manipulation and adjustment, they're defined by larger magnitude forces applied rapidly AKA high velocity, low amplitude and attempt to move the joint. Specifically, the goal is to get the joint beyond that physiological range of motion into that paraphysiological Space. Now, by definition, the paraphysiological space is not where destruction happens, it's where constructive things can happen. Not necessarily destructive paraphysiological space is not into tissue injury territory. It's just beyond the normal physiological space. And that is where the unique aspects of an adjustment, in my opinion, come into play. When we're talking about the speed, right, High velocity, whether you're using a tool or whether you're using your hands, speed is one of the most important factors, kind of separates and differentiates mobilization from manipulation. Now, speed also seems to affect the body in a very specific and unique way. When you're able to get in there quickly, you're affecting the way. It's manual, it's force, right? It's force into the tissue, it's force into the body. When you're trying to get a result, theoretically, right, you're trying to get the joint moving. And the speed of plays an unbelievably important role in what makes an adjustment or a manipulation special and different and unique, rather than simply immobilization. Now, in this paper, they kind of lumped them together as manual therapies and did both. But I wanted to really break down at the beginning the differences between those two because sometimes they're almost used interchangeably in the research. But we need to really be aware of what the differences are, and we continue to learn and refine what those differences are in papers that are specific to that. So shocking to me, the research is saying it was yet to be determined whether manual therapy applied to the low back influences movement patterns during a functional task, which is wild, because I feel like every piece of research that comes out seems like it's low back pain related and that it's functionally related, but I guess not. Manual therapy applied to the low back, does it influence movement patterns and functional tasks? Now, in a sit to stand task, one thing that I found very interesting is that it's multiplanar and multi joint, which you think of sit to stand as being this unbelievably simplistic motion, but it's not. It's multiplanar, it's multi joint. There's a lot going on when we sit to stand. And it's a very relevant movement for determining functional impairment in patients with low back pain. And believe this, it's performed over 60 times per day. So it is functionally relevant. People in low back pain, their sit to stand is all jacked up. I can attest to this. Personally, I was dealing with a little bit of low back pain A couple weeks ago. And if you watched me sit to stand, I don't even wanna know what it looked like, but it did not look pretty. And we see this all day, every day in practice, right? People, like, gingerly, they're either pulling their butt in, they're sticking their butt out. The sit to stand goes out the window really quickly. When people are struggling with a low back complaint, you'll see the most bizarre motions. Trying to get into a seated position, or trying to get out of a seated position when people have low back pain. So it's really functionally relevant for people that are struggling. So this is where we're gonna go with the research, because then the question becomes, well, what can I do about it as a chiropractor? And the answer's gonna be a lot. But it's important to know 60 times per day this happens. And it requires a sit to stand requires approximately 60% of a person's total sagittal plane range of motion for the lumbar spine. So you're using a majority of the available range of motion in your lumbar spine. When you're going sit to stand, you're using majority of that sagittal plane range of motion. So you need to have access to it, obviously, in order to be able to utilize it. And this is where we're going to start to go with things. So what we know also historically is that we've seen mechanical changes post adjustment or manipulation. We've seen neuromusculoskeletal changes. And the question has been, how consistent is this when we're looking at active spine movement? So we know, based upon the literature, that when an adjustment is performed, we know, for instance, that range of motion can increase. We know, for instance, that there can be additional benefits such as changes to the spinal pathways. For instance, it can activate cortical drive. As we'll talk about in a moment, there's a lot that goes on. The question is, how does this impact functional movement? So let's first look at how they determined and how they guided the people in this study. So for this sit to stand task, participants were seated in a backless chair with their feet flat on the floor. The chair height was not adjusted. So if you were short, if you were tall, chair height was the chair height, and that was that. And their feet weren't in any sort of particular arrangement other than what they put them in. So they didn't have to put their feet in any sort of boxes or there was no constraints or anything like that. And basically, what the researchers did is they said to the individuals, while you are seated, please cross your arms over your chest. Now stand up. Very, very simple and straightforward. But what they found was, man, if you were struggling with low back pain, you were not doing this very quickly or very effectively. And what they also found, just where we're going, is post manual therapy, those things changed for the better. So their findings demonstrated that participants with low back pain utilize a greater lumbar range of motion in the sagittal plane While performing sit to stand task. And the time to complete the movement decreased after manual therapy, which was combination of mobilization and spinal manipulation. That mobilization manipulation was directed at the lumbar spine and the pelvis. So it was really getting in there, Making sure that things were moving to the best of everybody's ability. And with that, they found better efficacy, better efficiency, ultimately, and a decrease in the amount of time it took to get standing up, which is exceptionally important. So they also are determining that the neuromechanical changes that happen after manual therapy probably help to start to explain some of the results. So we talked about this in a moment, but let's break down what they talk about historically, that manipulation directed at the cervical spine. It's a cervical spine study that they're citing. Influence sensory motor integration within the central nervous system. So I was trying to say very poorly a few minutes ago, Is that there is sensory motor integration. There are changes in the central nervous system that occur after an adjustment. Other work has demonstrated an acute increase in motor unit excitability and increased cortical drive, Just for instance, soleus muscle following manipulation. And they've also seen facilitate activation of the lumbar multifidus muscle. Deep stabilizing muscle, lumbar spine core stabilized muscle. Super super, super super super important. Yet a lot of times, multifidus is what goes out the window. We see fatty infiltration on the MRIs. We see all of this junk going on. And that really, really can impact the lumbar spine at large. As the multifidus wastes away, we see increased load on the facet joints. As somebody ages, of course, the instantaneous axis of rotation migrates posterior, which only compounds those effects. Keeping multifidus healthy is a good thing. And they also found an increased magnitude of internal oblique activity. During a rapid arm raising task force following mobilization. So all of these things come together to say there's a lot of different ways mobilization and manipulation work, quote, unquote, in our body. It affects the tissues locally. It affects the central nervous system. We've seen changes in biochemical markers in the brain. There is a lot that goes on. And there's also, interestingly, as we pointed out a few weeks ago, there's kind of differences in how an adjustment affects somebody, if they're symptomatic or whether they're asymptomatic, which makes things about as clear as mud. But it continues to drive home that point that we talked about at the top, which is, man, the more questions that we uncover about how an adjustment works, the more answers we can find. And the more answers we find, the more we can refine our knowledge base and continue to serve people at a higher and higher level. Now, in this case, these researchers came to the conclusion that quote, in conclusion, the current investigation provides preliminary evidence to demonstrate that the biomechanical and functional performance of a sit to stand task by populations with low back pain may acutely be altered following manual therapy intervention. Very, very important statement. Doesn't sound all that exciting, but let's break down why that is so important and really how you can utilize this in your practice. Taken from the top, sit to stand, super important functional movement. And, and if somebody has low back pain, their sit to stand, it ain't gonna look too good. Now if they are feeling good, it should look good. But if they're not feeling good, if they're struggling with low back pain, whether acute or chronic, their sit to stand's gonna be all jacked up, they're gonna be compensating, it's gonna take em a long time, all of those fun things. But if you get in there and you do some manual therapy, you mobilize the low back and the pelvis, you give an adjustment in the low back and the pelvis, what you're gonna see is a dramatic improvement in that sit to stand task. Now, while sit to stand doesn't sound that exciting, this happens over 60 times per day and it is unbelievably correlative and rides right alongside function. And if somebody's not able to sit to stand in an effective and an efficient manner, they probably have a lot of other compensations and stuff going on as well. So if you can improve that, you're doing a great thing for your patients. Now, if you're doing a movement assessment in your practice, you're probably checking this out. Whether it's like a squat, whether it's simple sit to stand, you're probably checking this out on every single patient. If you're not doing a true movement assessment in your practice right now, I'd encourage you just watch what's going on with your patients as they get up from the reception area to walk down the hallway or into the gym or the adjusting room or the eval room. Check out how they're moving as they're changing positions in the room. See how they're moving as they stand up to go from, you know, onto their tummy. See how they are moving. Because understanding sit to stand, there's a lot more there than than meets the eye. Seems like a simple movement. Seems like no big deal, eh, who cares? You should care because this is a functional movement that affects nearly every other thing somebody does throughout the day. And you as a chiropractor can have a huge impact on it. By getting in, mobilizing what needs to be mobilized, manipulating or adjusting what needs to be manipulated or adjusted in the lumbar, spine and pelvis, you can create a dramatic impact almost instantaneously on sit to stand with, which is then going to get things moving in the right direction. You want that flywheel moving towards the road to recovery, not the flywheel moving towards from acute to chronic challenge. So get people moving, get them up and movement, assess their sit to stand, adjust when necessary, mobilize when necessary, utilize the tools you have available and help people live a higher quality of life. That is what it is all about. And right in line with that. If you need tensions, if you need braces, check out shield. 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