How Sagittal Balance and Multifidus Function Impact Spinal Degeneration | Podcast Ep. 300

Foreign hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. Thank you so much for tuning in today. This is our 300th episode of this podcast. It comes out weekly, so that tells us that we've been at this a little while over five years. So whether this is your first episode tuning in or whether you are a veteran of many episodes in the past, thank you so much. And to kind of honor the occasion, I want to do a big time giveaway. So if you have not left feedback for this podcast, here's how you enter Leave feedback for this podcast. If you're listening on your iPhone, you can scroll on down, leave feedback. What I will do is over the course of the week, I will pick out winners and you will get evidence Based chiropractor stuff. I have bottle openers, I have T shirts, I have posters. I have. I want to give a lot of stuff away, celebrate the podcast and also reach more people as well in the process. So if you have been impacted by this podcast in any way whatsoever, if you want to scroll on down, enter your feedback. Leave us a review on itunes in the podcast section and I will pick out winners and I'm going to pick as many as I can over the course of the next week. Now in today's episode, we are talking about a really, really cool topic on a brand new study that just came out. And this is about a head position posture sagittal balance. It's titled the Compensatory Mechanisms for Global Sagittal Balance in Degenerative Spinal Kyphosis Patients. A Radiological Analysis of Muscle Skeletal Associations. This literally just came out in bmc. I think this ties into what we do as chiropractors hand and glove. And there's a lot of really, really cool takeaways, including some action on the multifidus muscle that I think will be super important for everybody listening. But before we get started, I want to say a few words about Novopul. This is a company that I found out about not terribly long ago and it's a new piece of technology that has me super excited. It is really where recovery meets performance. You can learn more about this tech. It reduces pain and inflammation and improves function and it's really, really unique in the field and it's just coming on market. This stuff's cutting edge. Novo n o v o-pulse.com n o v o-pulse dot com I'll also drop that link down in the show notes for you as well. I encourage you to check it out and see. See how this can help your patients in your practice. But as I said at the top of today's episode, we're talking all about research. And this is a topic. When we talk about sagittal balance. This is a topic that I think really is applicable whether you're a chiropractor. I know that's the first one I heard about it going through school, really looking at images determining sagittal balance. And I saw then a lot more about this in the orthopedic groups that I practiced in, surgeons were, like, in insane on sagittal balance and pelvic angle and how that would affect their surgical outcomes. So, you know, does it matter? I think the answer is absolutely yes. What are. Why does it matter? Well, let's dive into some of the findings, and we'll talk about it from there. So we all. We know that during the aging process, you know, degenerative deformities can lead to sagittal imbalances, especially if there's spinal kyphosis. And this is the classic, you know, bent over the shopping cart, right? You know, normally that's a symptom or sign of spinal stenosis. But, hey, people get shorter, right? Discs degenerate. As we get older, end plates change, vertebral bodies change the margins of the bones. We start to see those osteophytes come off. We start to see the end plate sag down a little bit or crunch in. And this sort of thing can create degenerative deformities. Now, the way that this has traditionally been measured is through a big X ray, right? Kind of not head to toe, but from head to pelvis in really measuring the spinal pelvic parameter. And normally this goes kind of C7 or through the middle of the ear, sometimes as well through C7, all the way down to what they refer to as the sva, which is the sagittal vertical axis, and that extends right down to the pelvis. And this is important because it tells us it's a moment in time, right? It's a picture. It's not dynamic, but it actually gives a pretty good window into how we're living our lives day in and day out. And also, as we'll learn and discover on today's episode, some of the challenges that these patients might be experiencing that I think you can help with. So to maintain postural alignment, kind of head to toe, you know, whole body, head to feet, it really is a matter of, you know, keeping alignment of the whole body segments. We're talking head, torso, Pelvis, lower limbs, and us people have the capacity to regulate that alignment and, and by fine tuning the curvature of the spine and adjusting their orientation to the pelvis. So this is interesting. It showcases how dynamic this is. And sagittal global balance, we know it's critical for us to maintain the function of walking or standing without falling or increasing the degenerative spine degeneration of the spine. Excuse me. So having adequate sagittal balance helps decrease or diminish the degenerative changes, which makes sense when there's balanced forces. Our bodies typically like that as forces, and there's a range of what is applicable for every individual. But once you fall out of that range, if sagittal balance has really fallen off a hill, obviously in an extreme case, you wouldn't be able to stand or walk. But even in less cases, that imbalance throughout time can advance the degenerative processes due to just gravity and stress. So what do we know about this? Well, atrophy of the extensor muscles has been correlated to a progressive kyphosis of the lumbar spine. And that is a big starting point here. Atrophy of the back muscles is, is considered a significant correlative with low back pain as well. Okay, so they're probably starting to put these puzzle pieces together saying, okay, there's probably something that's going on with these extensor muscles, because as those degenerate, we know low back pain goes up as those become degenerative. We also know that there can become progressive kyphosis of the lumbar spine. So important key items that we're going to tie back around in a moment. So the researchers in this study hypothesize that, that the position of the head relative to the spine could be correlated with other spinal pelvic parameters, and that the position of the head could affect the degeneration of back muscles. And they really had two aims in this study. One was to analyze the association between the position of the head and the spinal pelvic alignment. Number two was preliminarily explore the correlation between position of the head and back muscle degeneration in these individuals that have this degenerative spinal kyphosis. So important things, I think all of us as chiropractors, we see these patients all day, every day in our practices, right? You know, people that just have, you know, we could, you could just tell, right? You know, them getting on the table, getting off the table, them walking in your office, practically. We see people all the time with these degenerative spinal kyphosis now, personally, in my technique set, I'm more of a diversified guy. I've never been overly interested in what's going on with X ray line drawings. Just it's not a matter of my technique, but I respect the fact that there's importance to that. And understanding the importance of that is critical in helping guide a patient through their journey from challenge to better health to better function. And the takeaways that we're gonna get to in a moment with this study really, really resonate with me. So how did they analyze this? They basically took X rays, right? You know, those long X rays. I probably haven't seen these X rays since chiropractic school, but kind of that head to pelvis X ray, stitched them together and then they drew all of the lines to determine those balance points. There's a lot of technicality around the lines that I don't think is applicable for today's episode. But if you want to check out the study, of course we'll link it down in the show notes. The other thing that they did is a T2 weighted MRI on a 1.2 Tesla 1.5, excuse me, Tesla MRI machine to ultimately determine what's going on in the low back. And they were focusing specifically on those extensor muscles. And that's where we're going to get some of the findings that are really correlative to what doing in practice. And basically what they found was that the position of the head is critically, as they say, critically correlated with certain spinal pelvic parameters. And the muscularity of multifidus at L3, L4 was found to be significantly, positively correlated with the anteversion of the head. So huge, huge takeaway right there. Multifidus. I've shot videos about this red MRIs and put it up on the YouTube channel. Multifidus is one of those muscles so, so important. We know it, we know the multifidus. But I'm going to say as chiropractors, very rarely do we really focus on ensuring that multifidus function is as high as it could be. And this is a lever point. This is one of those items where we see multifidus come up consistently in the research as a cornerstone piece of what goes on in being able to impact and influence multifidus. I can tell you, is going to improve your patient outcomes dramatically. And when this study, when they're saying this, the head position is critically correlated with spinal pelvic parameters, don't stop looking at that alignment. Take a look at what's going on I know a lot of times, maybe these biomechanical, aggressively biomechanical type papers or thought processes for some docs might seem even a little bit dated. But there is something to be said. Don't throw the baby out with the bathwater. Understand, biomechanics still matter. Positioning and alignment still matter. Now, is there a picture of perfection? No. But there probably is more ideal and less ideal for every individual. And just because you might be turned off by the idea of, quote, unquote, perfect posture, which is in some ways a figment, doesn't mean you should throw the whole system out. Understanding that everybody has a range that is normal for them and a range that will become abnormal throughout time and create challenges is something that we as chiropractors need to stay in tune with as we continue to understand pain science and certainly as we continue to understand the dynamics of the human body. Bottom line is, we know that multifidus at L3, L4 is significantly, positively correlated, you know, the muscularity of it with anteversion of the head, which is important. Now, one thing they did find that I also want to bring up is they found age was not found to be significantly correlated with head position parameters. We think of that head moving forward as somebody gets older. But in this study, anyway, they found there was no significant correlation. This can happen if you're young. This can happen if you're old. This can happen if you're somewhere in between. So we know that muscles have an important role for maintaining the balance of posture. And specifically, the lumbar muscles are important for maintaining the stability of the lumbar segments. Of course, dysfunction of these paraspinal muscles can aggravate spinal deformity, and they can ultimately result in sagittal imbalance. Now, here's a big, big takeaway. Erector spinae. Those erector spinae muscles they consider to have a greater role in producing spinal movement, while multifidus is considered responsible for the smaller movements and stabilization and maintenance of the curve. Very, very important. Erectors, those are your movement muscles. Big movements, multifidus, fine movements, stabilization and maintenance of a lumbar curve. That is why multifidus is so, so important. And I'm going to say anytime you have. I don't think you need to shoot MRIs or order MRIs just to take a look at multifidus, but anytime your patient has an MRI taken, please pop that baby in your computer, take a peek at what's going on at multifidus, because as we talked about in some of the videos where I Discuss multifidus. This is almost never put on a report. Almost nobody puts, you know, multifidus atrophy unless it's like totally gone. So you could have somebody with 80, 90%, you know, fatty infiltration. Multifidus is completely almost gone. And have no record of that on the report. I think that is crazy, but that's the way it is right now. So what, what happens? Well, what happens is you need to take that disc. You need. Well, maybe just lock in the packs, but old school here, pop that disc in, take a peek and see what's going on with your own eyes. Look at those images, those axial cuts specifically go down, I love to go down to L4, L5, really take a look at the meat there. However, the precipice of movement in the lumbar spine, the apex of the curve is between L3 and L4. Depending upon the individual L3, L4 space. And taking a look right there. Could be really, really impactful in understanding what's going on with their sagittal balance overall. So more anteversion of the head needs more muscularity at L3, L4. From a compensatory point of view. That's the bottom line. We know L3, L4 is really that precipice of motion. And as a result, the multifidus at L304 might need more muscularity to maintain proper lordosis. When the head anteverts in a higher angle. Again, dynamics here, right? Head's going forward. How is that low back compensating? And here's the clincher here. Can it compensate? Do you have multifidus function in order to compensate if the head's moving forward? Or is the head moving forward because multifidus is totally shot and there's fatty infiltration there. This is that balance. This is where I think us as chiropractors can make a huge difference in people's lives. Because it certainly sounds from this paper. And I think we've all seen it in practice. There's a breaking point, right, where things just start falling apart. Where somebody's sagittal balance is so out of kilter that they're suffering with compensations nearly everywhere in the biomechanical chain on the way down. So taking a look at it, understanding it, and making a concerted effort for them to understand that multifidus function is important. Maybe that's not the way I'd say it to a patient, but giving them exercises, making sure that the movement is adequate. If those facets are locked up and there's A bunch of challenges at 3, 4. How are they going to be able to really, really get things moving? So get in there with your adjustments, get in there with your care and treatment. Make sure things are moving appropriately, make sure that there is not sensitization of the joint where the patient's avoiding movement in that area. Do all of those things, but take those extra steps. Understand whether they are susceptible to these challenges due to gross fatty infiltration or whether they're looking pretty good. And then guide them along that path towards exercise as well. Things they can do at home, things they can do in the office to ensure that that functions as high as possible. So the conclusions in this study were they showed that head position relative to the spine was significantly correlated with some spinal pelvic parameters. And they also found the compensatory mechanisms indicated in the head spine pelvis access system should play an important role in maintaining the human body global balance. All important for us as chiropractors. A lot of big takeaways. Multifidus, multifidus, Multifidus are the big ones. But keep an eye on it. Pop in those discs when you have the chance. Understand how your patients are really moving biomechanically and understand also I think many times us title of this podcast is the evidence based chiropractor. But people that really, really take to heart sometimes can become a little myopic in looking only at the region that's in pain as opposed to looking at a person globally or holistically. So when somebody comes in and they have a challenge in their cervical spine, when somebody comes in and they have a challenge in their lumbar spine, don't discount the fact that it could be a primary challenge or it could be a compensatory challenge. And make sure that you are checking out what's going on with those individuals holistically so that you can serve them in the best manner possible so that they can get the best long term result possible, we all know with a couple adjustments many people feel a heck of a lot better. But man, if they have fatty infiltration on the multifidus, if they have these challenges that create long term issues, addressing them sooner rather than later in the best proactive way is going to help you and it certainly is going to help them long term. So those are my big takeaways. Also want to give a shout out to E Chiro EHR sponsor this podcast. Every EHR sells features few have Echiro's expertise. If you want to create a better lifestyle and improve your practice health, check out Echiro EHR these guys take. I know Dr. Scott Munsterman pretty well at this point in time. He is a documentation and compliance expert that is all built into this system. So if those words are important to you, and they should be, check out Echiro Ehr. I'll drop that link down below. And again, 300th episode here we are. I can't believe we made it this far. Multitudes of years, week after week after week. Thank you so so so much for tuning in. And if you want a chance to win some Evidence Based Chiropractor swag, head on over. Leave us a feedback. Leave us a review. Make sure I can identify your name because I'm going to call it out on the podcast so I can get in touch with you and I'm going to send as much stuff out as humanly possible. So be sure to get your feedback in before next week's episode. Have an awesome week in practice. Take care and I will talk to you soon.

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