Flexion Distraction vs. Active Exercise for Chronic Low Back Pain | Podcast Ep. 260

Foreign. Welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. This week we are back with the research and this is a clinically important study to pay attention to. It came out in European Spine Journal and these researchers did a randomized clinical trial and they took a look between flexion distraction versus active exercise for people with chronic low back pain. This has clinical implications written all over it. We're gonna break it down in more on today's episode before we get started. If you have not left a rating or review for this podcast, please scroll on down on itunes and do so. And if you haven't checked out the Smart Chiropractor podcast where Jason Deitchch and I, my co founder and smart chiropractor, we do a deep dive dive into everything marketing related as it pertains to chiropractic. Please check out the Smart Chiropractor podcast. Actually just got back last night from visiting San Francisco where we recorded season two, which will be coming out in 2021. But season one is going on right now and you can search itunes and find it with the Smart chiropractor. But here on the Evidence Based Chiropractor, we're talking research, we're talking clinical stuff and we're talking all about flexion distraction technique versus active exercise. The title of the study we're taking a look at is titled A Randomized Clinical Trial and Subgroup Analysis to Compare flexion distraction with active exercise for chronic low back pain. So this study took flexion distraction, low force manual traction mobilization technique, pretty specific to chiropractic and compared it against active exercise. And they defined that really as trunk stabilization. And I kinda lean this towards. There's plenty of chiropractors that do stabilization and active exercise, but it sort of is a, if you look at it in a very general context, it sort of is okay, we have a chiropractic technique in flexion distraction. We have active exercise, which is a core modality of a physical therapist. And what's going on? How do each of these interplay with chronic low back pain patients? This study piqued my interest because in practice I'm a big fan of flexion distraction. I find that patients generally tolerate it very well. I've found that individuals who have specifically spinal stenosis in the lumbar spine, this is just anecdotal, but I found patients that have spinal stenosis, lumbar spinal stenosis just tend to have nearly immediate impact. They bend down on the table, you know, barely able to get onto the table. You do flexion distraction in the lumbar spine. I have seen more patients than not an overwhelming majority get up and like, functionally able for anywhere from hours to days to weeks after undergoing flexion extraction. So I'm a big fan of it. I've used it on, you know, I've had it done on myself. I've used it on family personally, I've used it on an unnamed amount of patients. So that's what really piqued my interest with this study. Now, patients receiving the chiropractic technique in this study experienced, quote, significantly greater reduced, reduced perceived pain, according to vas, than those allocated to the active exercise group. These findings, in my opinion, support previous research which shows that flexion distraction is effective at reducing pain and disability and specific to disc and nerve root pathologies. I know there's protocols with flexion distraction that go into more localized pain as well, or more quote, unquote mechanical low back pain. But when I've seen disc nerve root pathologies, compressive pathologies, man, getting in there segmentally and sort of opening it up as I visualize it, I've found to be incredibly impactful. And the research seems to back that up, at least in this case. These researchers found subjects randomly allocated to the flexion distraction group had significantly greater pain relief from pain than those allocated to the exercise program. Important point number one. Important point number two. Quote Subjects categorized as chronic with moderate to severe symptoms improved most with flexion distraction protocol. Let's break that down a little bit. You know, these were chronic patients. Now, chronic is in the eye of the beholder as this study also outlines that there's a couple definitions out there in terms of chronic. I'm going to go with the most basic generic explanation of chronic pain, which is pain lasting longer than three months. And this study takes one step farther and says with moderate to severe symptoms improved the most with flexion distraction. Again, anecdotally, I saw this in practice as well. People that had a nerve root pathology and it was mild, man, sometimes those are really, really difficult to take care of and treat. Sometimes they bounce back quickly. But when a mild pathology becomes chronic, I found that to be quite challenging. Not that I haven't seen improvement, but it's been a little bit more challenging. When somebody comes in with moderate to severe symptoms and you're able to knock a 7, 8 out of 10 pain down to a 3 or a 4, that's pretty dramatic, almost immediate improvement. And I saw that time and time again. And I think flexion distraction is a great protocol. As they outline with that quote, that ties right into this. If somebody has a compressive pathology, you're able to get in there, provide some relief, some blood flow, some distraction, quite literally in this case, that can be very, very impactful, and it can help that person really expedite that healing process. These researchers also found, quote, a greater degree in VAS among patients with radiculopathy should be expected for the flexion distraction group, where changes in disc pressure may be most important. So this ties back to a question which, to my knowledge sort of remains unanswered, which is when somebody gets down into that flexion distraction or, you know, spinal decompression type thing, I know they're two separate items, but they does that provide a decrease in intradiscal pressure? I think the jury is still out on that. I think all signs point to that. There's a negative pressure that occurs, there's a distraction phenomenon. Now, whether that increases or decreases the true intradiscal pressure, I'm gonna say, is almost secondary to the fact of it certainly opens up the IVFs. And when you get into a flexed position, that's the most comfortable position. If you've seen anybody with spinal stenosis or radiculopathy, they're bending forward, flexion literally open, opens up the canal. So when you're able to get in there by hand, segmentally, and open it up even further than just the 10 to 15 degrees that somebody's utilizing walking around to get out of pain, that's where I start to feel like the impact of flexion distraction really comes into play and the benefits of it. And this study re emphasizes sort of those thoughts. In conclusion, these researchers. I'm gonna read the conclusion verbatim because I think it's really important from a clinical sense, these researchers found. In conclusion, in accordance with many studies of chronic low back pain, patients perceived significantly less pain after intervention. Regardless of group allocation, subjects randomly allocated to flexion distraction had significantly greater relief from perceived pain, as defined by VAS scores, than those in the active exercise group. According to the Roland Morris, both groups responded in terms of function and there was no difference between groups on this measure. Subgroup analysis indicated that subjects categorized as chronic with moderate to severe symptoms and those with radiculopathy improved most with flexion distraction. Subjects categorized with recurrent pain and moderate to severe symptoms improved most with exercise. This may help explain contrasting outcomes among previous trials of chronic low back pain treatments. Lot to break down there and let's go in reverse order. The Conclusion the last statement of this study highlights the Fact of wow, this might explain contrasting outcomes amongst previous trials. With all of this stuff, I know we go paper by paper, week after week, 250 plus episodes on this podcast specifically. But you always have to take it in the context. Individual studies have to be seen in the context of what's going on systemically. I think that that's something that I've learned throughout time. There are individual studies that can be extremely strong. There are individual studies that can be somewhat weak in how they come about their findings. But either way, it needs to be taken in with the other things, with all of the other research that's been published around that topic. That's how you come to what I'm gonna say is the best conclusion at any given moment in time. So as they're saying here, man, previous studies have been a little bit all over the place. However, when we see moderate to severe pathology, when we see radiculopathy and or nerve root compression issues, man, flexion distraction really takes the cake. And if you start to think about that just in terms of the biomechanics of it, that tends to make a lot of sense to me. Somebody gets down on a table and we're doing flexion distraction, it's instantaneous, right? You're getting them into a flexion pose and distracting that vertebra literally live, right? Then if you're going through active exercise, that's gonna take. In many cases, that's gonna take some time, right? You know, you have to strengthen things, core strength and stability as well as the balance between stability and, and flexibility. That doesn't happen hands on in the moment, right then. Right? That's more of a process. So I start to see, or that's where I sort of infer how does this shake out and why did this shake out that way? I think a lot of it comes down to biomechanics and literally how the intervention works. The second piece that I think is really important is the chronicity of this, right? When we seek patients that are in chronic pain, meaning in a very simplistic definition, they've been in pain more than three months. There's a lot of psychology that starts to come into that. People start to get, and rightfully so, pretty bummed out. Like, if you're dealing with pain that is moderate or severe, again, the group that benefited the most from flexion distraction was chronic three to four months of pain, or, excuse me, moderate to severe symptoms over three to four months of pain. And if you're functionally debilitated for that amount of time, all of that psychology starts to trip in. You're talking about depression. You. You're talking about, am I gonna get back to those things that I love? Can I be the person I once was? Am I gonna get 80% better, 50% better? Do I need an injection? Am I getting pressured to have a surgical consultation? Many of those things are irrelevant factors at one to two weeks of symptomatology, but by the time you get into chronic pain, that's moderate to severe. These are very, very real things. So this is where the clinical implication. I wanna make sure I make this crystal clear. These are individuals who are vulnerable. When you see somebody who's in moderate severe pain and it's been chronic, that is somebody who is very. More likely than not. There's a psychological component to that. More likely than not. They've gone through some things and they're probably exploring where they should go and what they should do. And by this point in time, it's very likely. The study doesn't say this, but it's very likely that they've probably tried a medication, they've taken an Advil, they've taken a Motrin, they've taken an nsaid. If they've had moderate to severe symptoms for three to four months, they've probably done some things. My point with that is they probably do based upon the timeline. And if they've done pretty much any other thing, they probably have met the minimum threshold where a surgeon could recommend surgery and have it approved and it would be reimbursed through an insurance. So I want you to keep this in mind as you're speaking to patients that have chronic pain. They've been in pain more than three to four months, chronic low back pain, they're functionally debilitated. They have moderate severe symptomatology. You're really their lifeline. And I think that we need to. You know, sometimes we see this all the time, right? You see it day in and day out. In practice, you almost become numb to it. But many individuals are really at their last rope. So it's more important than ever, I'm going to say, for all of us as chiropractors to get out there, tell that story to the people you haven't seen yet. Be sure that you're telling it to the other physicians in your community that are more upstream, so to speak. You're your primary care physicians, all these complementary healthcare providers, people who have your patients in their practice, and there are dozens of them in your town right now. It's imperative that you get out there, let them know who you are, what you do, educate them in the right way. Nobody wants to learn about chiropractic, but people are very interested in knowing the latest research, in knowing how to best provide clinical expectations and how to best route and direct patients. That's very interesting to a lot of healthcare providers out there. If you can get into that conversation proactively, you can really save, I'm going to say, untold amounts of people from advanced interventions over the course of your career. But you have to get out there and do it. If you're passively just waiting for somebody to walk in your front door, I'm going to say you're doing some of the people, at least some of the people in your town, a disservice. Be proactive, get out there, tell your story, utilize tools like we go through these research papers each and every week on this podcast. If you're looking to get out there to your community and you want to automate your, your social media, you, you want to have better reception area video and you want to be able to have an email email automation service that provides all of those essential campaigns for reactivating past patients, for generating new patients, for onboarding, check out the Smart Chiropractor. We have open enrollment basically starting right now. If you're interested in bridging the gap and building relationships with other healthcare providers in your community, check out the Evidence Based Chiropractor. There are tools and resources out there to help you break through the noise, get out there, help more people build and grow your practice. That is what it is all about. So I'd encourage you check all that stuff out if you're interested in it. Thank you for tuning in. Keep tuning into this podcast. We're gonna keep doing it each and every week breaking down this research. But if you perform flexion distraction in your office, take the information, those big takeaways that you learned if you wanna check out the paper and hit the show notes. And I hope you have a great week in practice and I'll talk to you soon.

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