The Multifidus Muscle: A Game Changer in Low Back Pain Management | Podcast Ep. 439

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Hello and welcome to the Evidence Based Chiropractor.

I AM your host, Dr. Jeff Lingmaid. On today's episode we have more research, a great study that is all around.

The multifidus, a muscle that I like to discuss.

A critical muscle in the lower lumbar spine in terms of stability.

And this study talks about the multifidus in context of of how multifidus quality.

May impact the results of conservative management for people with low back pain and or radicular pain. So great study, lots of take home messages. We're going to dive into it and.

I will lay on some context as well.

But before we get started, I want to say a few words about Patient Pilot. If you have an email list of more than 500. What's an email list?

Inactive patients. If you have seen more than 500.

People in your career, they're sitting in your EHR.

So a lot of inactive patients.

We would love to get to work on your behalf to reactivate as many.

Of them as possible. How?

Not through discounts, but by teaching and inviting consistently.

We track every single click.

We highlight it to you.

So you have a patient recall list.

Many will just end up back on their schedule on their own. But if not, you have a hot recall list.

That is what Patient Pilot does.

In a nutshell. You can schedule a demo over at the smart chiropractor.com again that is the smart chiropractor.com but as I said at.

The top, we're talking research today. I'll drop a link to this down in the show. Notes the title is Spinal degeneration and lumbar Multifidus Muscle quality may independently affect clinical outcomes in patients conservatively managed for.

Low back or leg pain.

That is the topic of the study. And if you've listened to this podcast for a while, I've highlighted the importance of the multifidus but by checking it out when you have an mri, Absolutely. Looking at your axial cuts and identifying what's the quality or fatty infiltration, lack of quality of the multifidus because this is a deep stabilizing muscle. And if the multifidus quality stinks, if.

It'S like 90% fatty infiltration, that's a clue. And that's a clue to you in multiple ways. One is that rehab recovery relief might.

Take a little longer.

Might not all the time, but it might take a little longer. Two things could very well come back if you have a unstable not clinically unstable to the point of surgical fusion, but an unstable or not fully stable spine. Because multifidus is destroyed, you're just gonna. Chances are, even if you feel better quickly, unless you're doing things long term to, to make an impact, chances are that pain's gonna come back pretty obvious, but it's so overlooked. And the third component is if anybody believes that because of a lack of result with you, a laminotomy, a laminectomy, a foraminotomy is going to take care of their compressive issue. Good luck. If you don't have multifidus function, if you have a poor multifidus muscle in terms of quality, and you go in there and start taking stuff out, AKA laminas, facet, joints, whatever it might be, that's gonna fall apart, obviously. So these are very, very important conversations to have a very, very important and dramatically overlooked muscle. You're rarely gonna see this on a report. It is rare that a radiologist highlights the quality of a multifidus in the report. This is why understanding how to look at and read those axial slices from a clinical perspective is absolutely critical. And multifidus is where it all begins again. It has a primary contributor to lumbar spine stability. And it is believed that changes in the multifidus muscle group can play a role in a variety of different aspects of low back pain. It could present or be impacting the progression of low back pain. It can impact, as we just touched on potentially the management, the etiology, all.

Of these things with and without leg.

Pain are really, really important to understand from a clinical perspective. Additionally, there has been an association noted in previous literature in terms of the multifidus quality, so to speak, and radiculopathy. So with diminished quality of the multifidus. And this is no surprise, I'm kind of oversimplify it right now. But if you think of that foraminal canal, of course the superior aspect is made up of the superior bone. The inferior aspect of that hole or foramen is made up of the inferior bone. And the nerve travels through, well, the stability of segments, the translation, the angulation, and to a certain extent even the disc height can be impacted based upon the quality or lack thereof of the musculature. And with the multifidus being the primary stabilizing muscle, it is a massive player. We also know that historically in previous research, we've seen that multifidus atrophy or reduced functionality have been reported, of course, to be associated with limitations in physical function and or disability levels. So this is a big deal. Now one step farther. The quality of the muscle may not be an independent source of back pain, but A factor that can, as they say, modulate the effect and the amount of pain, which makes total sense. Just having a multifidus that's deteriorated may not cause pain on its own. As a matter of fact, I would make the argument most of the time it doesn't. But what it does do is it contributes to the overall structural integrity of that segment and beyond, which then causes this cascade of issues. Could be degenerative issues could be arthritic. Whatever those issues might be as a result of that degradation of multifidus quality, it's a major player. So, and I have seen this personally in practice with a multifidus that was like, you couldn't even tell it was, you couldn't even tell it was a muscle. I mean it was just like white, like 95% fatty infiltration on the MRI. Well, no kidding. That person has back pain not because the multifidus is the primary cause of the pain, but because almost everything else deteriorated. For lack of a better way to say around that didn't happen overnight. That takes decades basically to happen in lieu of an acute injury. And in this case it was decades that this took to happen. And over time, well, guess what happened. Well, when there's lack of stability in the area, the deep stabilizing muscle is not functioning correctly. We already know that, that as we age, gravity is going to catch up with us in the posterior. The load on your spinal segments migrates posteriorly over time. So your facets inherently as you age will encounter more stress and strain. That is why facet hypertrophy is very common. If you want to accelerate that pace, then have a poorly functional multifidus. Right, because when you're multifidus, those deep stabilizings go by the wayside. You're actually just going to exponentially increase that load on the facet joints and all of the other structures as well. So in this study they looked at people over a one year period. The basic gist of it is that these individuals all had low back pain and or low back pain with radiculopathy, pain traveling down their leg. Of course they had these individuals take an MRI previous to care. So at the start they took an MRI and, and analyzed what's this multifidus look like, what's going on with it, what's the integrity of it, what's the quality ultimately of this multifidus muscle. Those individuals then went through conservative care for a 12 month period. We'll define what conservative care was in a moment. And then on the back end they looked at a variety of different factors to analyze and say, how did this play out over time? That conservative management that included a variety of different items. Manual therapy, which was chiropractic, osteopathy, it included rehab, which could go a variety of different ways. Physiotherapy, exercise therapy, also acupuncture, pilates, swimming, those were patient selected options, those final couple there. So all of that was included in conservative management. So no surgery, no injections. And that was kind of the hard line in the sand that they drew. Now, the mean age of the individuals in this study, about 45 years old, 59% of them were female. 2.5%, 2.4% technically had leg pain without low back pain. 34% demonstrated greater than 30% improvement at 12 months of follow up. So over. About. Over a third of them had greater than 30% improvement at that follow up time. So what they did see was that patients with a higher proportion of healthy muscle at baseline showed greater improvements in their disability ratings at 12 months. Not a big shocker there. They started out basically better and they ended better. Right. They were able to make more gains. Well, why were they able to make those gains out of disability into ability? Well, they were able to make those gains because the quality of the muscle was there. They had a good foundation, as I like to think of it, to be able to have great rehab with. So they also highlighted the fact in this study that the multifidus does not appear to contribute a mediating role between pain and pathology. So there is some variability here. In other words, it's multifactorial. They highlight the fact that there may be a more localized connection between compromise of the nerve root supplying the multifidus, multifidus quality and leg pain intensity. So this is just an important fact for us to always remember that our bodies are really dynamic and there's a lot going on. And when we look at the neuromusculoskeletal system, there's a variety of different factors. I mean, quite literally, your spinal cord is an extension of your brain. I know we all know that, but it's like, do we really think about that? The peripheral nerves that begin as they come off of the spinal cord and exit through those foraminal canals, the structures that support, guide, as I always like to say, that balance between strength and flexibility, all of those things play a intimately critical role in our ability to get up and have a great quality of life. Now, the other side of that is there's a lot of factors that go into what I just said and there's a lot of areas that can impact others, whether directly or indirectly. And in the multifidus case, it seems like a lot of the factoring is indirect, but it is an important component and that is why it is critical to look at on those images. So they highlight that multifidus quality was associated with a statistically significant change in disability ratings. And when we talk about disability ratings, of course we're not talking about optimal human performance. Right, let's make that clear. But this is important because many of the individuals coming into your practice probably aren't coming in right now because they're looking for optimal human performance. They have pain, they have disability, they've had challenges that are chronic and they might be older and they've had things going on for a long period of time and they've been under gravity and may not have taken great care of their body. These are just real life things. So taking a look at the multifidus muscle and this comes back to setting expectations. When you see something in a physical exam, when you see something on imaging.

When you see something even in case.

History that you believe is going to encumber your ability to get the results that you'd like in the time that you would like, it's important to have that conversation with the patient so that you properly set expectations. It pains me to think about the number of patients that I've seen in my career, and I'm sure that you've seen in your career that have gone somewhere else previously, maybe not gone back because they didn't get a good result, but upon further inspection they got a great result. But then the pain came back and they thought it didn't work and now they're exploring other options. And I can tell you I saw a ton of these individuals working at orthopedic groups that were getting in line for injections and hopefully in their mind, hopefully surgical intervention. And they had a previous good experience with the chiropractor. But the problem was the pain came back. And when I look at that often, I believe that comes down to expectations and that doc did not set the proper expectations. Maybe they were treating one visit at a time. And guess what, when you do that, the day that something doesn't work, some patients will come back, but many won't and they're going to go and move on. So it's really important in my mind to set clear expectations with your patients from the get go. And anything that you can analyze, any questions that you can ask to understand how to set that expectation better will only help you and them. And in the case of multifidus, it's one of the primary things I'm going to recommend you take a look at if you have an MRI to be able to set the best expectations for your patients. So their conclusions in this study were multifidus muscle quality and the number of different degenerative pathologies present had independent relations with 12 month leg pain rating outcomes, while the higher multifidus quality was related to a small reduction in 12 month disability ratings. They highlight the fact that the relations between spinal degeneration, multifidus degeneration and low back related outcomes appear to be complex and may be independent pathways. So is there a finite conclusion to this study? No.

They say there's a lot that we.

Still have to learn, but is there an opportunity to set better expectations by understanding the complexity of those interactions, by respecting that complexity, and by communicating that as effectively as possible with your patients? I believe an answer to that is absolutely yes. And as we wrap up this episode, if you do geek out on this stuff and you like objective assessments and you're focused on the cervical spine, you.

Have to check out neckcare.com, reliable assessment.

Tools for neuromusculoskeletal control, proprioception, range of motion and sensory motor integration. Absolutely fantastic technology. Cannot recommend it enough. And additionally, if you're interested in bringing shockwave into your therapy, in the practice I own we use stemwave. So this is something where I have seen tremendous results with 80% of patients that qualify for care. Go stemwave.com the evidence basedchiropractor go stemwave.com the evidence based chiropractor if you think about bringing that technologist, visit that link. Have a conversation with them. They will hook you up. As a listener of this podcast, go stemwave.com the evidence based chiropractor I will drop that link below. If you have any questions about this.

Study, reach out to me Jeff at the Evidence Based Chiropractor.

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