How One Spinal Adjustment Impacts Chronic Low Back Pain | Podcast Ep. 444

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langme. Today's episode is more brand new research. Another fantastic study coming out of chiropractic and manual therapies. It is all about how one spinal manipulation session can reduce local pain spread sensitivity. There is a lot to dive into in this study, a lot of clinical pearls, a lot of clinical practice guideline recommendations and more. I cannot wait to dive in. But before we do, I want to say a few words about Patient Pilot. Patient Pilot by the Smart chiropractor helps you reactivate more of your inactive patients. If you have more than 500 inactive patients and you're not consistently communicating, I don't know what you're doing out there. Head over to smartchiropractor.com, schedule a demo with our team and stay tuned for a big launch announcement coming in July. If you want to jump the line, schedule that demo now. But keep your eye on your email because we are going to have a massive launch of Patient Navigator within Patient Pilot and there's a lot of cool stuff there. It is literally going to change the game of patient reactivations. And we've been working on it based upon feedback, maybe from you, all of our members, some of our former members, we've gotten feedback and we have stepped this up. We've been developing it for over 6 months. Can't wait to release it, can't keep your eyes peeled. But as I said at the top, we are talking all about research today. I'll drop a link down in the show notes. This study came out 2024 and it is titled One Spinal Manipulation Session reduces local pain sensitivity but does not affect postural stability in individuals with chronic low back pain. And this is a randomized placebo controlled trial. That top tier of research. Love to see that. Where are we gonna start? We're gonna start with low back pain. Now we all know it is a big deal but what you might not know is nearly 2/3 over 66% of people with low back pain will experience a new episode within one year. That's, I guess that's the good news and the bad news, right? The good news is we as movement based healthcare professionals are the place they should be. Bad news is if somebody has back pain, chances are they might have it again within a one year time and nobody probably wants to hear that. We also know that non pharmacological therapies are recommended as the first line treatment for low back pain care, including many as they highlight many clinical Practice guidelines that recommend spinal manipulation as the top choice. Why? Because spinal manipulation can lead to pain relief and improved function. That is a really nice combination and do not take that for granted. There are many things, medications that can often relieve pain, short term this, there are some things that can improve function but not relieve pain. Spinal manipulation, chiropractic adjustments do both. That is massively powerful and why it is being recommended more and more and more across these clinical practice guidelines and hands on care. Also, I don't think this is a negative thing. And they highlighted at the beginning of the study that anytime there's hands on, it doesn't even have to be hands on care, as a matter of fact, but they highlight just a placebo effect and that the placebo effect is really powerful for subjective outcomes in terms of pain intensity. Now, they're not saying that manipulation has this massive placebo effect and that's the only way it works. But anytime somebody gets any intervention, there is some sort of placebo effect. And for measures like subject, subjective measures like pain intensity, it can impact that more than others. So they will come back around to this as we work through the paper. But let's get to some objective measures and that is pressure pain thresholds. There's a subjectivity to it, but again, I guess we'll dive into that in a moment. But spinal manipulation can influence pain perception is the bottom line. And pressure pain thresholds can be affected regionally by spinal adjustments in asymptomatic individuals and in patients that are experiencing chronic low back pain. Pain can affect a lot of stuff in our body. It can affect neuromusculoskeletal reactions. It can affect balance, it can affect postural stability. That's why they were looking at pressure pain threshold levels. A lot to say there. And postural stability as potential objective ways to compare the effects of adjustments or manipulation to a simulated intervention. And they highlight the fact, and this is no surprise, there's a lot of data out there and a growing amount of data that indicate contextual factors can affect results, patient expectations, treatment beliefs. Yeah, no kidding. And we're seeing that finally in the literature, which makes a lot of sense. Now here's the great news for us. As soon as I read that statement, we have overwhelming, as chiropractors, we have overwhelming patient satisfaction. It's like 90, 95% plus compared to most other professions, 40%. So we have that going in our favor. We have, which is great. The challenge is the gap between those who have never experienced and those who have experienced chiropractic. Care. An overwhelming majority of the people, the bizarro land part of this is many people have experienced subpar medical care yet to continue to go back. I don't understand that, but that's a whole other story for a different day. But most people who do engage in chiropractic have a great experience and do come back. We just need to get more people, people to understand that it's often the best thing for them. And that's where communication, obviously marketing as a whole comes into play. So assessing patient perception about treatment can influence the results. And that's an important thing to know. And this study was a two arm, parallel, randomized, placebo controlled, double blind superiority trial. So a lot of technical words there. But the bottom line is they did a really, really great job in this study splitting things up, blinding what was going on, and getting what we hope to be really, really accurate results. They had about 80 participants with an average or mean age of 35 years old. 63% of them were women. The groups were similar at baseline except for age and body mass index. The sham group were a little bit older and had a little bit higher body mass index than the participants allocated to the spinal manipulation group. So important to keep that in mind as we dive in now, what were some of the outcomes? Well, the spinal manipulation group had higher pressure pain threshold values in all body sites post intervention. The sham group improved in 6 out of 12 body sites for those PPTs pressure pain thresholds. The between group mean difference in pressure pain thresholds favors the manipulation group at six of the 12 sites. Neither intervention altered postural stability. So there was no statistically significant difference in change in pain intensity between the groups. But both groups did experience a statistically significant decrease in pain intensity after the intervention. That's almost a little bit confusing to read and say, but let me highlight what that means. And that means both groups performed well. Both groups had decreases in pain, but. But between the groups, there wasn't too big of a difference. There was a difference, but it didn't reach the level of being statistically significant. So one session of lumbar spinal manipulation resulted in local but not remote reduction in pain sensitivity compared to the sham treatment. Now you also have to remember this is one treatment. Most people aren't doing a one visit treatment plan. I don't know. It's like pain is obviously the last thing to come, the first thing to go. So this is where we're gonna go with the future aspects of this study. But one session of spinal manipulation did have a really big Impact on pain sensitivity locally. So self reported pain intensity had clinically significant decreases in both groups. But a higher number of participants in the spinal manipulation group achieved more than two points of pain relief. Important to keep in mind. And two points of pain relief is a big deal. There's statistically significant based upon control size, group size, and then there's just did it work better? And the answer is, in this study, it worked better. Meaning a lot more people that received spinal manipulation had more than two points of pain relief. Two points of pain relief is a big deal. That's getting from a 10, worst pain ever in your life, going to the ER to a 7, which is severe but manageable. That's going from a, or, excuse me, to an 8, or from an 8, which is severe pain, down to a 6, which is moderate. That's going from a 6, which is, ooh, this is really hurting me, to a four. So do not think that you have to get from an 8 to a 0 or a 6 to a 1 to be meaningful. That's not the case at all. And a two point differential on a VAS score or pain relief is a really, really big deal most of the time and in most studies. So that's important to keep in mind. And their findings in this study suggest probably already are aware of, that there's a physiological hypogesic effect in the lumbar spine when spinal manipulation or an adjustment is given. Now, they found no changes in postural stability in either group. So that was kind of a moot point. And this research has some important clinical implications. One, it extends what we know about pain relief after spinal adjustments. And specifically, keep in mind, the patients with chronic low back pain treated with spinal manipulation had a modest, which is not small, but modest, a good treatment benefit in local pain sensitivity that was superior to the placebo group in chronic low back pain. I know I kind of cruised through the importance of that, but I want to come back to it and dig into that a little bit. These are individuals with chronic low back pain. That's about the hardest thing to break, so to speak, meaning to break out of that pain cycle. Because we know when acute pain becomes chronic pain, 10 to 30% of individuals with acute low back pain will go on to develop chronic low back pain. There's just such far reaching implications. One, advanced interventions, two, potential injections, surgery, obviously those are the interventions. There's also a dramatically higher likelihood that they're gonna go into the medication route and potentially be prescribed opioids or some sort of pretty aggressive Medication long term. And of course, individuals with chronic low back pain experience higher changes in their quality of life, higher degrees of disability, and it just costs a lot more to take care of those. They're the frequent flyers in many of these practices. So being able to nip off two points on a 10 point pain scale for individual with chronic low back pain is a really big deal. Also remember, people with chronic low back pain, there's a real psychological component. Those neuronal connections to that pain are deep and they can be hard to change. So a two point change on a pain scale that can get somebody from looking at advanced interventions to feeling hopeless, to being depressed, to actually get up and moving and that is massively impactful. And with one session of spinal manipulation being able to potentially break through, imagine what a few sessions could do. And for most people with chronic low back pain, obviously it depends upon the individual, their health goals, what you see in an exam. But it's very rare that somebody comes with chronic low back pain is going to have one session. So the fact that one session had a positive benefit tells me, man, that's just the first step on a thousand mile journey to ultimate relief. And maybe that's a hundred mile journey, maybe it doesn't need to be a thousand miles, but it's just the first step. And when there's a positive response and a meaningfully impactful positive response on the first visit, that tells me we are on the right track. So their conclusion was quote, one spinal manipulation session reduces lumbar pain sensitivity but does not affect postural stability compared to sham session in individuals with chronic low back pain. Relative remote pain sensitivity remains unchanged for both groups. After the invention, there was a marked decrease in self reported pain intensity for both groups. And a higher proportion of participants in the spinal manipulation group reached clinically significant pain relief. So that is the story from this study. I think it's important. I love it. I'm gonna drop a link down in the show. Notes. Couple take home messages. Clinical pearls from my mind. In communication with one is always accurately setting. As my friend Dr. Steven Fransen likes to say, expectations and agreements upfront. Somebody comes in with chronic low back pain, it's highly unlikely that one visit is going to miraculously cure them for life. As a matter of fact, I would say that almost never happens. Why? Because they have ingrained movement patterns, they have challenges that have led to that chronic low back pain. And most of the time there's a mental component that's going to take time to start getting over that fear, avoidance behavior to get back to the things that you love. So setting the right expectations up front, really important. Because what I hate to think about are individuals that come in get a good response on a first visit. Maybe the expectations in terms of the care haven't been set. The patient misses an appointment, slides back a little bit in terms of pain and then says eh, that didn't really work. And they didn't even get started. They didn't even have a shot, they didn't even have a chance. They didn't do what was necessary to. They didn't take the actions necessary to get the results that they desired. A lot of that comes down to communication. So keep an eye on your communication. Two, it's important to meaningfully and appropriately highlight the wins and say if you are feeling if you went from an 8 to a 6 today, that shows us chances are we are on the right track, you're in the right place. Positive reinforcement, really important from a patient communication perspective. And then the other component is this shows compared to placebo, we're doing something and that's a great thing when you're able to get in there and address the segmental motion which impacts so many aspects of how somebody moves, how somebody thinks, how somebody feels, the peripheral and central nervous system brain components really, really impactful. So keep getting out there, keep having those conversations and doing a great job with your patients. Before we wrap up. Speaking of doing a great job with your patients, if you are bringing shockwave therapy into your practice or even considering it, have a conversation with stemwave ghostmwave.com the evidence based chiropractor, use that link and they will hook you up with their best deal. Why? Because they support this podcast and I'd love for you to support them. They're doing you a super solid so I'll drop that link down below. And finally, if you're into objective assessments and who isn't that listens to this podcast, neckcare.com, i'll drop that link down below. Absolutely awesome. Objective assessment tool for the cervical spine, addresses neuromusculoskeletal control, addresses proprioception, range of motion, sensory motor integration. It is all all there in a crazy awesome technology package. Neckcare.com Otherwise, if you have not left a rating review for this podcast, I would love it if you would take a minute to do so. Have a fantastic week in practice and I will talk to you soon.

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