How NSAID's Inhibit the Healing Process | Podcast Ep. 350

Foreign hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langme. Today we are back with the research and this is a good one. It is a little technical, it's a little geeky. However, the underlying message is something all of us should be super familiar with. The title is Acute inflammatory response via neutrophil activation protects against the development of chronic pain. This study is really important. It's about the transition from acute to chronic pain and the shocking details about how NSAIDs can not only proliferate people from acute to chronic, but how it stops in many cases, the healing process. This is a powerful study, tons of clinical pearls. Yes, there are some geeky stuff going on with it, some deep biochemistry. However, the core messaging is something all of us need to be intimately familiar with. It's a brand new study. I'm gonna link it down in the show notes. Now before we get started, I wanna say a few words about the Payday practice. If you have not picked up your copy of the Payday Practice, please do so. Thepaydaypractice.com everybody that's a listener to this podcast, I wanna gift you a free digital copy copy. It's all about building monthly recurring revenue in your practice. Now if you've been listening for a while and you want to do me a super solid, you can pick up a physical copy of paperback on Amazon. Literally every single copy helps. So if you want to pick up a physical copy, thank you so much, head over to Amazon, type in the payday practice, you'll see it right there. If you want to pick up a digital copy, please do so. This is a step by step guide to showcase how you can build recurring revenue in your practice so that you can decrease your monthly stress level. You can get off that roller coaster of best month ever back at zero, worst month ever back at zero. You can stabilize for growth long term. That's what it is all about. But on today's episode, we're talking science. And this is acute inflammatory response via neutral activation protects against the development of chronic pain. Why is this a big deal? Well, you probably can guess why. Chronic low back pain is the most frequently reported chronic pain condition of all time. Low back pain is a major problem around the world and the point prevalence they say is about 18%. So about 18% of people have low back pain at any given point in time. That's about one in five. Now what's the one month rate is 31% and the one year rate is about 38%. So over the. At any moment in time, about 18% of the population has low back pain or over any one month period of time, 30% of the population has low back pain. And over any one year period of time, nearly 40% of any population worldwide have low back pain. So is this a big issue? Yes. Is it something we can dramatically help with? Absolutely. That's what we touch on each and every day. Can we do more than low back pain and neck pain? Absolutely. However, we don't have our house in order. I'm gonna call it as it is. There are hundreds of millions, probably billions of people struggling with low back pain, yet our utilization hovers at 10, 15, 15%. That includes low back pain, neck pain performance, everything else in the kitchen sink. So there is a lot of messaging that still needs to go out. Now, current treatments for low back pain often target the immune system and they include non steroidal anti inflammatory drugs, NSAIDs, acetaminophen, corticosteroids. Although all of these drug classes are minimally effective at best. And that is a direct quote from this study. So. So this study just kicks off with a bang. I'm gonna read that sentence one more time, quote. Current treatments for low back pain often target the immune system and include non steroidal anti inflammatory drugs, acetaminophen and corticosteroids. Although all of these drug classes are minimally effective at best, yet how often are these utilized? A lot more than 15% utilization, I'll tell you that. So this study starts off with a big clinical pearl with the fact of the matter is, if people are taking, and people in your community, people in your practice probably are, are taking NSAIDs, acetaminophen, they're doing corticosteroids to take care of the problem. It does not work. Movement based care is best. And there is no research supporting what we just discussed. And people don't know that. They think that that is actually the solution. Now there is increasing evidence suggesting the pathophysiology of chronic pain involves complex interplay, which makes sense between the nervous and immune system. And. And chronic pain is a neuroinflammatory disorder mediated by neuronal and non neuronal cells. So now we're digging into some of the science here. Circulating immune cells, things like neutrophils, monocytes and T cells are recruited to the sites of tissue damage or inflammation and they also infiltrate the peripheral and central nervous system. That makes sense. I think we're all pretty familiar with neutrophils T cells. Now Activation of these cells results in the expression of various inflammatory mediators. This is where we start talking about ketosines, chemokines, lipids and proteases that act both directly on the peripheral sensory or central second order neurons and indirectly with other immune or local cells to regulate pain. So where does the rubber meet the road on this? Well, the presence of these activated immune cells and glia, periphery or centrally is thought to contribute to the transition from acute to chronic pain. So that's an important component. Now, in this study, they looked at a couple different patient populations. One is what they called R resolved pain, the other is what they called P persistent pain. And persistent pain is really the bear, right, because persistent pain is by pretty much definition that's when you're going from acute to chronic. They discovered that enhanced inflammatory pathways seem to be driven by by neutrophil activation. So that's one important component. And in a comparison with healthy controls, the resolved pain group displayed a significantly higher inflammatory response at the acute stage, where the persistent pain group displayed a significantly lower response. So it's almost like a bell shaped curve or almost like what goes up must come down, right? So with the resolved pain, there was a big inflammatory response early on in the acute phase. Now we'll talk about this as we dive further into the study. But it's almost like that ball went up. Well, gravity's gonna bring it back down. But if there's not that big inflammatory response, that's what tends to be present when you talk about chronic and persistent pain. The body didn't react almost to what I'd call appropriately. You didn't get that big inflammatory response. That's basically hand in hand. It is the same thing as the healing process. Now, by the time of the second visit, each pain group displayed significantly reduced inflammatory response compared to the healthy group. So both went down a lot in their inflammatory response. But it's almost as if you want that big jump early on and that's what really stimulates the healing process. So these results indicate the importance of upregulation of inflammatory response at the acute stage when there's pain, because it's a protective mechanism against the development of chronic pain. Probably a better way of putting what I just said. You want that big response early on and that's what helps the body get over the hump. It's what helps the body stimulate, generate and get into that healing process as opposed to meandering in. And there are gonna be some important things here of what causes a meandering in. So these Results suggest that active inflammatory responses, particularly those regulated by neutrophils, contribute to pain resolution. And they hypothesize that the inhibition of this active immune response will lead to the prolongation of pain. So you want that response early on. If you don't get that response, you are at a high risk of having persistent or chronic pain. Now, they found that individuals with acute back pain were at nearly a twofold greater risk of developing chronic back pain if they reported NSAID usage. So 1.76 fold greater risk of developing chronic back pain if they reported NSAID usage. Should people be taking NSAIDs for low back pain? Each case is different, let's put it that way. But I think the resounding answer is no, they should not be. It's prolonging their pain. It nearly doubles their opportunity to fall from acute to chronic. Guess what happens with people in chronic pain? More medication, more advanced interventions, and a greater challenge to get them back to improvement, to get them back to level, to get them back to performance. These are really, really important things. Now, the researchers also found that neutrophil activation, which is dependent on the elevation of the inflammatory response at the acute stage, it was decreased on the second visit. Now, conversely, subjects with persistent pain did not show any changes in their inflammatory response. Big deal. Again, we want to have that response early on. And they confirmed that, that the acute treatment of inflammation with steroids, NSAIDs, diclofenac, although both effectively reducing pain behavior during the administration, so there's a little bit of relief early on, greatly prolong the resolution of neuropathic myofascial and especially inflammatory pain. How many people come into your practice with neuropathic myofascial and inflammatory pain? Everybody. And if they are taking steroids, if they're taking diclofenac, if they're taking NSAIDs, they are making your job harder because their body is not going to cooperate. And that gets down to the biochemistry of what's going on. They further showed that neutrophil dependence of these effects with steroid like pain prolongation being produced by neutrophil depletion and a complete blockade of allodynia produced by peripheral injection of neutrophils themselves. So that's a little complicated of a statement, but it further emphasizes the same thing, which is you want to have that big inflammatory response and NSAIDs stop that, corticosteroids stop that. And when you stop that, you nearly double your chances, risk and likelihood of going from acute to chronic. Why? Because you've inhibited the body's ability to effectively heal. That is a super important message that I am going to guess far too people in your com, I didn't know about it. That is far too many people in your community know about it. Now you know about it. I guess the flip side of that is gonna be your responsibility to ensure that that story is told in an accurate way, but also in an impactful way. Now the researchers also found that NSAIDs, but not two other analgesic medications available for analysis, increased the risk of back pain two to six years later. So let me clarify that statement. NSAIDS also increase the risks of reporting back pain two to six years later. Not only did it double the opportunity or likelihood of going to chronic, but it increased the risk that years later, over half a decade, you were more likely to have back pain if you took NSAIDs during the acute phase than if you didn't. That is powerful. And this was consistent with their previous research that showed higher percentages of neutrophils at the acute pain state protected against chronic pain development. You cannot shut down that neutrophil activation early on. You only do that if you want to have chronic pain. You do not do that if you're trying to get through, get healed and ultimately have functional improvement. So they found, quote together our results suggest that active immune processes confer adaptation at the acute pain stage. An impairment of such inflammatory responses in subjects with acute low back pain increases the risk of developing chronic pain. These adaptive inflammatory responses are intrinsically driven, probably modified by both genetics and environmental factors, and can be inhibited by steroids and NSAIDs. Close quote. So for those people in your community that are consistently relying on NSAIDS and steroids and curious on why they still have pain, they can look towards the actions that they are taking. And quite often, I hate to say it, the advice they're being given when they're not being told to seek movement based care as a primary, secondary and potentially as a tertiary resolution before going for steroids and NSAIDs. It blows my mind that people are still doing ESIs steroid injections every single day to the tune of millions and millions per year. That hundreds of millions of people are taking NSAIDs each day for pain as prescribed by their doctor. When the research, the biochemistry and everything showcases, not only are they minimally to non effective, not only do they have greater risks and harms, but they can lead to a chronic pain state which only leads to more challenges and advanced interventions. That is wrong. It is against the Hippocratic oath and it's something all of us need to be aware of as we have proactive and positive discussions. So I don't want to get negative there. We want to have proactive and positive discussions helping inform people that have no clue they're doing what they're told, they think they're doing what's best. It makes sense. My uncle's brother had a steroid injection and he was fine. I've taken NSAIDs before and I got well, you got well despite of that advice, not because of it. Super important. Also just emphasizing again, I say it time and time again on this podcast, especially over the last year or two. But movement based care, that is what is critically important. That is how the body heals in the absence of red flags, of course, that is how the body heals. And it's also important for you to know what's going on regarding what your patients are doing outside of your practice. Because if they're getting steroid injections and, and taking NSAIDs and then coming in to see you and they're curious why the progress is slow, that's an important conversation for you to have because at that point it's not what they will take away from it. Chiropractic didn't work well if you have the deck stacked against you. They have poor daily habits, they're out of shape, their diet stinks, they've gotten steroid injections and they're taking NSAIDs. You just need to have an open conversation and let them know, hey, here's what I see is going on with you now. Based upon that, here's our expectations as we move forward and let people realistically know that because of those things, I expect it to take longer to get well. And I just want you to know that up front so you don't get discouraged. So we can both stay on track with helping you overcome insert pain that they're dealing with there and you can get back to doing insert things they'd love to do there. So having those open communication with your patient is so, so important. And it's about setting the expectations. That's also really important. You don't want to be doing that from a deleveraged position. If they're coming in ready to discontinue care because it didn't work and it's been five visits or something, whatever that case may be, you want to address that up front because if you do it too late, it seems like you're making excuses whether you are or you're not. And most of the time you're not going to be. But if you don't let them know up front that some of the factors that they're walking in with, some of the decisions that they've made are going to contribute to a little bit longer of a process and that's okay. But you want to know, let them know up front. People understand that when you let them know up front, they'll give you that latitude and leeway and it's also just the truth. And that is the most important thing we can say. I think many times chiropractors, I won't say hide from the truth, but we choose not to address the truth quite often. And that does not serve the patient, it does not serve us, it doesn't serve anybody. So let people know about what's going on, let people know about the challenges associated with some of the decisions that they've made. And this is a paper that we're gonna fast track, I can say with the evidence based chiropractor for sure, because this is an important relationship building. Not to demean what other physicians are doing from a decision making capacity, but helping open their eyes to, to realistically, what's going on with the guidelines, what's going on with the patients and how to get their patients. Well, I jokingly say, I jokingly, not jokingly say. Most of these primary care doctors aren't making these decisions because they don't like people and they don't like their patients. They got into this to be a caregiver. They're doing what's best. It's just that their knowledge set is so. Think about your knowledge set being so poor that you're still prescribing steroids, you're still prescribing NSAIDs. Man, we got to have empathy towards that. We got to get out and change that. The only way we do that is through communication. So I hope you got a lot of clinical pearls out of this one. I think this is a super important study. And before we wrap up, I want to encourage you to pick up your complimentary pair of orthotics from Power Step. They're what I use. My dad has used them and they are hooking every person up who's a listener to this podcast with a free pair. Take advantage of it. Pro.powerstep.com sample pro.powerstep.com sample use the code ebc evidence based chiropractor and they will hook you up with the sample pair. And additionally, if you're looking to build and grow your team this year, don't go it alone. Use a system. Use the professionals. Chiromach Makers we have over 14 recruiters that work full time finding CAs and DCs for practicing docs so we can find people that are a great cultural match for your practice and also are a great long term fit. If you're looking for your next career step, we have a bunch of positions available right now. If you're looking to hire, don't do so with at least. At least have a call. Just have a call with our team. Let's get an understanding of what you're trying to do and see if we can help you get there faster and find the right person. Because staff turnover kills progress in practices each and every day, we want to help you avoid that. Chiromatchmakers.com Other than that, I hope you have a fantastic weekend practice and I will talk to you soon. Thank you for joining us on this episode of the Evidence. If you want to grow your practice, come back to next week's episode. If you want to grow faster, visit the evidencebasedchiropractor.com and join our MD Marketing membership today.