Exploring the Association Between Clinical Findings and #osteoarthritis | Podcast Ep. 406

Foreign hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langme. This week we are back with research and it is an interesting study and it is going to spur many more studies. And it is all around the association between clinical findings and the presence of lumbar spine osteoarthritis. And, and this is a systematic review that just came out hot off the press this month. We're going to talk about it, break down the clinical pearls and highlight why this is the beginning of the story, not the end of the story, when we are associating clinical findings in osteoarthritis. Before we get started, I want to say a few things about Patient Pilot by the Smart Chiropractor. We recently launched Daily Reactivation Reports. That means we send emails weekly. You receive daily reports of the patients ready to reactivate in your practice. If you would like to see that data then come on board. Schedule a demo. Head over to the smartchiropractor.com, i'll drop a link down below. Schedule a demo again. At the smartchiropractor.com we send emails weekly. We generate for you daily reactivation reports so you can see exactly who the patients are ready to reactivate into your practice so that you can generate as many reactivations as possible. And if you have hundreds, if not thousands of people on an email list that you're doing nothing with, not only are you going to make me cry, but you are also missing out on a massive opportunity to to build your practice and generate reactivations with the people that already know, like and trust you. So click down below. Schedule a demo@thesmartchiropractor.com for patient pilot and our new daily reactivation reports. But as I said at the top on today's episode, we're focusing on research. This came out in the Osteoarthritis Research Society International journal called Osteoarthritis and Cartilage. I'll drop a link down below and the title is association between Clinical Findings and the Presence of Lumbar Spinal Spine Osteoarthritis Imaging Features a Systematic Review and they basically systematic Review is looking back at a whole host of studies that have been previously documented and published to say what do we know based upon the available evidence? That's what it's all about. And the objective here was to really hone in on what are these findings and features that have a high degree of probability or a high degree of evidence behind them so that we can start to better understand what's going on. And when I say that, here's what I mean by it. Spinal osteoarthritis is really difficult to study and diagnose because there's no agreement on the diagnostic criteria. Now, as a chiropractor, you might listen to that and say, I see osteoarthritis on my images all day, every day. As a matter of fact, most images, when it's above a 30 year old, I see some form of osteoarthritis. You're 100% correct. But that does not mean that everybody else on planet Earth agrees. And in the research world, there is absolutely no agreement on the diagnostic criteria. It's all over the place. So we are coached and trained and taught as chiropractors to look for things like osteophytes, to look for degenerative changes, to look for modic changes, to look for all of these items that we associate with osteoarthritis. Well, this paper is going to take a look and say, well, is this, is that actually true or not? Based upon the available evidence, and that is what this research study attempted to do. So unlike a peripheral joint or an extremity like the knee or the hip, which has very specific diagnostic criteria, it's probably some. It might be surprising to you. It's kind of surprising to me to learn that there actually is no diagnostic criteria for spinal, spinal osteoarthritis. And this makes it really, really unclear of how and when back pain may be reflective of symptomatic osteoarthritis. Again, many times we sort of lump these things in. And if we see findings on a film, degenerative changes, and we see the patients in pain and their nonspecific low back pain, we kind of assume that there's an osteoarthritis component going on. But there's not really clear evidence in the research as far as how do these things play together. And, and one of the things that they highlight early on in this study is that there may be separate definitions necessary for structural or symptomatic spinal osteoarthritis, which starts to make sense. As we just previously discussed, there's a structural component which is what are you actually seeing on the image, whether it's causing symptomatology or not. And we all know, we've seen many of people, I'm sure, in practice that have low pain, crazy findings on images and high pain and almost no findings on images. And we know that imaging plays a role in understanding what's going on, but it's not a great diagnostic tool for pain. It's a great diagnostic tool to understand what's going on structurally, but not for pain. And that's why they're saying right here, hey, separate definitions for structure and symptomatic osteoarthritis might be necessary. And I agree with that. Now, a consensus was previously reached on the following clinical features that, that could suggest spinal osteoarthritis and specifically symptomatic osteoarthritis. And that is spinal pain duration, spinal pain intensity, limitations in physical functioning, and self reported spinal morning stiffness. So those are the things that a consensus has been reached previously about symptomatic spinal osteoarthritis. Gosh, that's a mouthful. And to date there's been no systematic reviews, which this seems insane to me, but there's been no systematic reviews that have comprehensively investigated the association of clinical features suggesting symptomatic osteoarthritis with imaging features on whether it be a lumbar radiograph, an MRI or a CT scan. So this study is the first to kind of take a look and say what's out there in the literature and what's going on. So when they first started looking, they found over nearly 14,000 studies. And after they got rid of duplicates, there's about 8,000 left. And as you can imagine, that got pared down pretty quickly. And 30 studies were included for this systematic review. The age range of the patients kind of all over the place, 21 years old to 74 years old. So pretty wide spattering there in terms of ages of patients. And let's dive into some of what they found. They found high quality evidence for the association between longitudinal, how long it goes on low back intensity and both disc space narrowing and osteophytes. So this ties in. Probably this starts to make a lot of sense as a chiropractor say, okay, I get that. Right. So that, that makes a lot of sense. And they found high quality evidence suggesting it. I get. I'm gonna not discuss what they found. No evidence, low quality evidence. I'm really just gonna highlight the high quality evidence and the moderate quality evidence because that really is suggestive of what they're after. So one of the things that they were after, one of the things that they found was, was, hey, high quality evidence, longitudinal association. When there's a long term low back pain intensity, we expect to see disc space narrowing and osteophytes. Makes sense to me. They also found high quality Evidence for the association between low back pain related physical limitations and lumbar disc degeneration, which also makes sense when somebody has long term limit physical limitations and degeneration. They saw that there was a correlative there. Maybe not causative one way or the other, but correlative might be causing each other, but those things are correlative with a high degree of certainty. They found moderate quality evidence of a positive association between low back pain duration and modic changes. So the longer that the duration went of low back pain, the more likely there were to be MOTIC changes. Now we've discussed MOTIC changes, actually done a few modic changes, presentations to a variety of surgeons in the past. And the interesting thing about MOTIC changes, it's like a bell shaped curve. Early on there's like a ton of pain and not much finding on an mri. The middle of the road is where you start to see pain come at the crescendo and then things solidify, so to speak. And on the backside of MOTIC changes you start to see really less pain, but you start to see abject findings. So that's really what I see as the bell shaped curve or the hierarchy of motor changes. And long story short is when we have long back pain, long duration of low back pain, it's very common that we see an increased likelihood of modic changes. There also is moderate quality evidence of an association between low back pain intensity and lumbar disc degeneration and annular tears. So again, this starts to speak, I think to us as chiropractors saying, okay, yep, I've seen that before, I've seen that show so low back pain intensity. And I see this tremendous. I've saw this so much in practice and still see it today to a certain degree, which is annular tears can really, really. It's like an annular tear in my opinion goes one way or the other. You either find an annular tear on an image and the person's like, ah, I feel great, no problem. Or you see an annular tear and they're in like such ridiculously abject pain. These are some of the things that I've just seen. It's like feast or famine, no pain or crazy amounts of pain. And they kind of highlight that here by saying there is an association between low back pain intensity and annular tears as well as degenerative changes. So, so when you are looking at some of these images, I hope this now is coming into focus. It is, you know, technique aside, looking at the images is not for not essentially you're able to really be able to understand what's going on. And you can let me better say that you can expect to see some things on imaging based upon the clinical presentation of the patient. Now I'm not talking about whether or whether or not you should shoot imaging, that's a different conversation. But when imaging is present and available, you can infer some things that you might see and look for based upon what's going on with the patient. And a high degree of pain increases the opportunity that you're going to find degenerative changes and potentially annular tears. They also found a high quality evidence association between spinal morning stiffness and disc space narrowing. Makes total sense to me as a disc space space narrows and the instantaneous axis of rotation migrates posteriorly as we age, facets get loaded and bottom line is that's going to make things stiff. I think we've all, maybe, maybe I'll speak for myself and say, gosh, I've experienced that personally. So there is no question that we see that all the time as chiropractors. So this was the first systematic review that comprehensively investigated these associations between clinical features suggesting symptomatic fractures, osteoarthritis and imaging features. And I think there were some probably obvious take homes, but they're important to have documented especially in a peer reviewed systematic review. So they found, if I tidy this up, they found high quality evidence for the longitudinal association between low back pain intensity and both disc space narrowing and osteophytes. They found an association between low back pain related physical limitations and lumbar disc degeneration and the presence of spinal morning stiffness and disc space narrowing. And that is what they found. So those are big take home messages because to me this substantiates in many ways what we see all day, every day on images and we kind of know to be true as chiropractors. But maybe the most surprising aspect was that it had never been documented in a systematic review and they kind of come to a conclusion statement here. It's going to sound a lot like what I just described, but I'll read it verbatim. Quote in conclusion, we found high quality evidence for the longitudinal association between low back pain intensity in both disc space narrowing and osteophytes, as well as for the association between low back pain related physical limitation and lumbar disc degeneration, the presence of spinal morning stiffness and disc space narrowing, and for the lack of association between physical limitation and Schmorl's Nodes. End quote. Schmorl's nodes, if you remember, it is typically asymptomatic and it is technically what they call invagination of the disc into the vertebral body. So when you see those, it almost looks like a puzzle piece is the only way I can describe it, like a notch in a puzzle piece. If you see a vertebra that has a big notch near the end plate that's indicative of a Schmorl's node, that's the best way I can describe it. And Smorl's nodes are usually asymptomatic. They don't really cause a big challenge. Now, I have seen Schmaorles nodes that are so large, it compromises the integrity of the vertebra, and the patient ends up having a fracture as a result, a compression fracture as a result of the Schmorl's node, basically just diminishing the integrity. That's pretty rare, though. I've only seen a few of those and I've looked at tens of thousands, literally tens of thousands of images. So it's pretty rare. But it does happen every now and again. But generally they're asymptomatic and they say, hey, there's no association between physical limitations in Schmorle's nodes, which makes sense if they're asymptomatic when they're not to the point that they're causing a vertebral body collapse, they don't really cause any issues. And quite frankly, you don't know you have them unless you take the image and take a peek, at which point it becomes an incidental finding. So I found this study to be really intriguing just for the fact that it hadn't been done before, but also that they kind of outlined many of the things that we see as we look at pictures and images in our practice, but. But had never been properly documented before. So as you're going through your evaluations with patients this week, this, you know, this month, this year and beyond, you know, understanding what their intensity levels are from a low back pain perspective can really inform what you expect to see on the images. And the more that we can correlate these things, in my opinion, the better. The body is like super dynamic as it is, so anytime we can find correlation or set expectations is a really good thing, because the. There's many things with our bodies in the dynamics of how we heal that are not A plus B equals C, but when we can find things that start to line up, that start to make sense that start to provide us a roadmap as a clinician to what's going on with the patient. That's great because it enables us to be more specific with our decision making and less wide open. And hey, there's a time to be wide open and try a variety of things and see what works. No question about that. But man, for so what I'm gonna call traditional cases of low back pain where there's no radiculopathy, especially when it is, you know, especially when there's no radiculopathy, especially when it is non specific. Being able to line things up in a manner that provides a roadmap that is predictable helps not only with clinical decision making, but it also helps with your patient communication. Because when you can set proper expectations for a patient, and I can tell you if you expect to see something, you don't wanna do this and end up on the wrong side of the road, so to speak. But when you can look, let a patient know what you expect to see on an image and then they see the image and it's there, man, you look like a complete superstar. So it looks like, it looks like magic practically to a patient that doesn't know, well, when I hear this, I expect to see this. And those start to become really great opportunities to focus your communication and build your trust. So that's the big take home. Messages from today's episode, on today's episode and from this research paper, of course, I'll drop a link to it down in the show notes. And before we wrap up, if you are looking to build your practice and grow it this year, and what I mean by that is with your team, and that's the only way you build and grow ultimately is by having a great team underneath you. So if you are hiring a new ca, if you are hiring a new associate dc, or if you are a lone wolf, and maybe not, maybe you're a large practice, but you're not ready to add on a full CA, use a virtual CA. Virtual CAs are totally trained up. They're awesome. They give you an opportunity to save a lot of money because they can be about 70% less of the cost than an in office CA. So anything that can be trained upon, so to speak, and repeated, a virtual CA can do. So reach out to chiro matchmakers. If you're in any of those boats, Associate dc ca, virtual ca, reach out to chiro matchmakers, schedule a call. Our team can help you find the right person the first time, which helps accelerate your progress. Thank you for listening thank you for being a chiropractor. I will talk to you next week and and have a fantastic week in practice and I will talk to you soon.

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