How to Help Patients with Lumbar Spinal Stenosis: Clinical Insights | Podcast Ep. 447

Hello and welcome to the Evidence Based Chiropractor. I am your host Dr. Jeff Langmay. This week we are back with more research all around Lumbar Spinal stenosis. A fantastic new study, lots of clinical pearls. We'll dive into it and much more on today's episode. Before we get started, I want to give a shout out to Jane App. If you are considering changing EHRs and you want the best check out Jane app. I'll drop a link down in the show notes. This is literally what I use in my practice. Great patient management, patient relationship software, world class customer support and just easy note taking. If you'd like access to all of that and much more, check out Jane app. They support this podcast. I'll ask you to support them and I will drop a link down in the show notes for you to do so. But as I said at the top on today's episode, it's all about research. I'll drop a link to this in the show notes as well. In the title of today's study is pain trajectories over 12 months following Conservative Care Consultation in Patients with Lumbar Spinal Stenosis. One of the number one things that we see in our practices each and every day. So this is a really, really important topic. The other thing that's really important to keep in mind is the number one reason why seniors and the elderly have elective spine surgery is due to lumbar spinal stenosis. So if you want to make an impact in your community, if you want to make a real impact in people's lives, then taking care of people with lumbar spinal stenosis is a great way to do so. Literally the number one reason why people have elective surgeries. Now I'm going to get into how I've taken care of this successfully in the past, some some clinical pearls and also why setting the right expectations is such an important component of helping people with lumbar spinal stenosis. We'll talk about that and much more on today's episode. So let's dive in. So we know lumbar spinal stenosis is a degenerative spinal condition that primarily affects people as they age. Why? Because time and gravity are undefeated, as I like to say. And lumbar stenosis takes time. It's a degenerative condition. What is it? Well, it's when the canal that in an ideal world is 10 millimeters in width or diameter, when that is when there is compression in the canal, narrowing of the canal that can take place due to a variety of different things, ligamentum flavor, hypertrophy, facet hypertrophy, disc osteophyte. There's a variety of different reasons why the symptoms, neurogenic claudication or lumbar stenosis can take hold. Now, the important thing to keep in mind is this takes time. Often lumbar stenosis does not happen overnight. Why do I reinforce that at the beginning of this conversation? Because it also takes time to see results. So when a patient comes in, setting the right expectations is really, really important. Part of that is understanding the anatomy and really what's causing that compression. The second component is being able to accurately communicate that. Here's another example of what I mean. I've talked multiple times on this podcast about checking out the multifidus. Why? It's a deep stabilizing muscle and if somebody comes in and they have fatty infiltration, the multifidus just looks like it's like, is it even there or not? Well, that's probably going to be a greater challenge to see the best result possible and to sustain that result that, that they get in your practice. Why? Because they don't have the stability. This is also why what we do is so critically important. Now think about it from the other realm. Number one reason for elective spine surgery. Now, if a patient has a compromised segment, which by definition they do, if they have lumbar stenosis, something's going on to cause that compression. Well, when a surgeon goes in and they're doing a laminotomy, a laminectomy, a foraminotomy, whatever the case may be, they're literally taking out material to create space. Now the benefit of that is that, knock on wood, they're creating some space. The detriment is if this is a compromised segment and this patient's not going to get younger, they're going to continue to be under load and gravity. Well, guess what? That's the fast track to having another surgery and that's the fast track to moving towards a fusion. So helping your patients understand what's going on in their body, helping them understand that movement based care, unless there's a red flag, is the best choice. And then setting the expectation of duration of care, Absolutely critically important when you're taking care of individuals with lumbar stenosis. Because what I hate to think about, and it just is like, ugh, I just, it just crushes me. Are setting bad expectations up front, maybe a little bit too rosy expectations up front. And this happens all the time. And the patient quits your care because they're not getting where they'd like to be in the amount of time that maybe you optimistically told them or that they wanted to be in. And then guess what? Well, now they're going to go seek advanced interventions, whether that's injections or surgery. And that's a cascade that's really difficult to come back from. So communication is critical. And clinical guidelines have supported and emphasized conservative care options for lumbar stenosis. Most movement based care options like chiropractic care. But there's limited evidence on the natural course of the disease in patients who do not go through surgery. But there's been many experts who have said probably 30 to 50% of patients with lumbar stenosis can improve with conservative care. I think that's a conservative estimate. 30 to 50%. I think it might be more like 50 to 75. But just think about that for a moment. The number one reason why people are having elective surgery, imagine chopping that down by 25%, 50%, maybe 75%. Do you think that's impact with people's lives and people in your community? Undoubtedly. And that's why this topic is just so critically important for us to be able to understand and for us to be able to communicate accurately with the people in our practice. So lumbar stenosis and low back pain do share overlapping symptoms. So there's been a thought. Well, maybe their trajectories are also are similar. Important to keep in mind other clinical pearls. When a patient comes in, I always ask really simple questions. And before you even look at the imaging one, you can see when a patient walks into your practice whether they have lumbar stenosis. Nine times out of 10, because they're looking for a chair, they're slightly flexed, bending forward, and their endurance is just terrible, being able to get up and get around. But sometimes it can be a little bit more subtle. But I always like to ask during my intake, you know, how is it when you get up and go to the grocery store and a patient normally describes, wow, you know, and it's the same story every single time. Well, I gotta park close so when I get in the front doors I can sit down for a minute and take a break. And then I immediately say what happens when you have a shopping cart? And typically they continue the conversation right there. Well, I can go forever when I have that. What does that tell us? Tells us a couple things. One is that when they're in that slightly flexed position, that opens up that canal. That's part of why leaning on a shopping cart works. The second component Is even unloading that slight lean and a slight. Putting that slight amount of weight on a shopping cart, 10, 20 pounds of weight relieved off of the lumbar spine with 10 to 20 degrees of flexion can make a world of difference. Now, why is this important? Let's tie it back to the beginning of our conversation. That canal is 10 millimeters severe spinal stenosis, you could say 6 millimeters in canal diameter. So you have 4 millimeters that have been obstructed. Think about this. 1 to 2 millimeters can take some of space, can take somebody from severely stenotic to mildly stenotic. And for most people, most of the time, that is a world of difference in how they feel and how they function. You could see this happen. I've seen this happen so many times when a patient just gets down on the table and just on a flexion distraction table, for example, and I don't have to put my hands on them, I just lower the legs 10, 15 degrees so that basically they're in 10 to 15, 10 to 20 degrees of flexion. And immediately people that are numbness in their toes are like, I can feel my toes again. Now, why is this important? It's important to one, get the patient in the right position for success. That that technique might differ depending upon how you approach this in practice. But helping a patient see that ray of light, that hope, that ability to feel better is critically important. And do not sleep on this. A patient that is dealing with stenosis and is pretty symptomatic, that can be really depressing and it can really change quality of life. And it can feel as though I'm never going to get better. So when a patient lays down on a table, gets in a slightly flexed position, and they immediately feel relief of symptomatology, it's important to stop, to take note of that. And that is a perfect time to have great communication with your patient. Why? Because they can feel the difference right then. Two is that they understand that what you're doing may lead them to where they want to be, which obviously is relief. And it also is just a relief message mentally in that moment where you can clearly communicate. So I love to take those opportunities to really take a moment in those moments and accurately describe either what's going on with the patient, what we're doing, what our goals are, because those are the moments of clarity that are critically important from a patient communication standpoint. So in this study, they took a sample of patients with lumbar stenosis that presented for chiropractic care and they identified three distinct pain trajectories. One group showed improvement within the first 10 to 12 weeks, that was 16%. Another group had fluctuating pain patterns with some improvement over time, that was 30%. And a third group had more persistent symptoms, that was 54%. So again, three groups there, about 50%, had persistent symptoms. Is it important to identify that with some of your patients? Yes. Does it mean that you can't help them? Absolutely not. You still might be able to help them. But it also means that nearly 50% of patients had some improvement over time and that a good chunk of patients had significant improvement over the first 10 to 12 weeks. Now, that is 10 to 12 weeks, not one to two visits. While a patient might lay down on a table and feel immediate improvement. Again, this is about expectations and agreements, helping patients understand that this did not take place. Chances are overnight. And if they have had degenerative stenosis that is built over decades, while they might feel relief on the table immediately, chances are it's going to take some time. This ties back to multifitous function. This ties back to all your movement assessments and helping set the right expectations for your patients so that they can come in, they can understand what's going on, they can receive the care that they need, and knock on wood, they can avoid those destructive elective surgeries. So based upon 10 studies with over 9,000 patients, there was a previous researcher that described a simplified trajectory pattern of low back pain. And these patterns were very similar to what was found with the patients in this study with lumbar stenosis. About 20% of patients historically have had severe patterns for low back pain, where about half of the patients with lumbar stenosis belonged to this trajectory. Now, severe patterns are just that. It doesn't mean you can't break a pattern, but it means these individuals are going to have significant challenges. So it's going to take some time. Also important to keep in mind severe symptomatology is not necessarily a reason for elective surgery. That's also very important to help a patient understand because many patients confuse the fact that symptomatology is what drives the surgical decision making and it's only a small component of it. So this study really smashes those misconceptions that stenosis inevitably worsens over time, and it's just not true. Many patients believe that, and quite frankly, many providers have believed that as well, and it's just not true. Patients with lumbar stenosis show distinctly different trajectories of pain symptoms. About half do experience severe symptoms throughout the year, while the remaining can show rapid improvement or fluctuating symptoms with some improvement. So it is not always progressively worse. And it's important to plant those seeds of hope to set the right expectations and to deliver the best care you can to help people avoid surgical intervention as much as possible. So I loved this study. I will drop a link down in the show notes and while we're on the subject of the lumbar spine, I'm going to jump to the cervical spine. If you are into objective assessments of the cervical spine, you have to check out neck care, reliable assessments and exercises for neuromusculoskeletal control, proprioception, range of motion, sensory motor integration. If you've been following my online, you've probably seen some videos of me highlighting this technology. It's awesome. And if you're into objective assessments and cervical spine, you have to check it out. Neckcare.com I'll drop that link. If you have not left this podcast a rating or review, I would love it if you would do so and I hope you have a fantastic week in practice and I will talk to you soon.

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