Using Flexion Distraction to Find Relief from Lumbar Spinal Stenosis | Podcast Ep. 349

Foreign hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. On today's episode, we're talking research. It is a brand new study from the Journal of Bodywork and Movement Therapies. It's titled the Influence of Flexion Distraction Spinal Manipulation on Patients with Lumbar Spinal Stenosis. Tons of great clinical pearls. Love this study and I think you are going to love the findings that they saw when they did the research. We'll talk about this and much more on today's episode. Before we get started, I wanna say a few words about the Payday Practice. If you want to begin generating monthly recurring revenue in your practice so that you have more stability, you have more opportunity for growth, you're trading less time for money. Head over, pick up a copy of the Payday Practice. I am gifting everybody listening a a free digital copy. You can grab it@thepaydaypractice.com or if you've been a listener to this podcast, you love what we're up to. I would greatly appreciate your support. Every single copy matters. It's available on Amazon, the Payday Practice. Pick up a hard copy over there or a digital copy@thepaydaypractice.com but on today's episode, we're talking flexion distraction. And this was one of those techniques that I found to be incredibly bad beneficial in practice. I had a flexion distraction table. I used it all the time and I found it to be really, really impactful for individuals that had low back pain and definitely those individuals that had spinal stenosis. What is lumbar spinal stenosis? In a nutshell, of course it is the narrowing of that spinal canal, whether it's disc bone or ligament. Bone spurs building over time due to injury or age, disc issues, bulge herniation, protrusion, extrusion, you name it. Getting into the canal or ligament overgrowth. I saw every single day. Ligamentum flavum hypertrophy that ultimately caused triangulation of the canal. Long story short, they ended up with the pinch that was the lumbar spinal stenosis and it resulted in neurogenic claudication, those very common symptoms I found the most impactful question when you're walking around the grocery store, do you need a shot? If you have a shopping cart in front of you, can you go forever? If I took away the cart, would you be looking for a seat that. I don't know if that's a research based question to ask, but I found it to have very high efficacy in terms of understanding, if somebody was like, yeah, you give me a shopping cart, I go forever. You take that thing away, I'm looking for a seat. Nine times out of 10 they had spinal stenosis, you know, not even looking at the exam, not even doing an exam, not even looking at the imaging. It is a telltale sign. So the questions you ask during history, super, super important. And the care that you deliver is also super important. So evidence does suggest that clinicians should include lumbar stenosis, lumbar spinal stenosis in the differential diagnosis for people over 50 who have leg pain or paresthesia when walking or prolonged sitting and when walking, distance is reduced. So anybody that comes in over 50 years old, they get challenges into their legs. They this should be one of those differential diagnosis. And while there's uncertainty historically, when you look back at the research, knowing the efficacy of rehab, there's also a lot of uncertainty around the efficacy of surgery. And there's very low quality available evidence. Now the irony here is the number one reason people have elective spine surgery, adults is for the quote unquote correction, I use that term loosely of lumbar stenosis. That's what a laminectomy is done. And that's when, if you're doing, if somebody has stenosis in the cervical spine and it's a central disc, quite often the only way to get at it, so to speak, is anteriorly. And that leaves you with a cervical fusion. But stenosis is a big issue and hundreds of thousands of people, maybe a million plus, are having surgery for it each and every year. And there's pretty low quality evidence around it. So what is there good evidence for? Well, there's new evidence that includes manual therapy including spinal manipulation, may improve both lumbar spinal stenosis symptoms and patient functioning. It's super important. In an updated review by the British Medical Journal states that conservative treatment, including supervised exercise and manual therapy is recommended as a first line treatment. So this is powerful stuff and again, I think about just literally the individual people in your community that are getting bad advice, that don't know any better, that are having advanced interventions because they don't know to come to see you. So hopefully this is empowering to you. It gives you the information to get out there if you need help with it. Of course, that's what the evidence based chiropractor is all about, building relationships with other healthcare providers, the smart chiropractor all about getting out to your community. So the tools and resources are there for you. Now chiropractors provide Manual therapy and chiropractic treatment of stenosis often includes flexion distraction. So flexion distraction, they say it appears not only to be an effective intervention for pain, but, but also for disability, which is important. It's not only about reducing pain, but it's about improving functional ability in those individuals that are struggling. And functional outcomes in studies involving lumbar stenosis and manual therapy have included a few different measurements. So, like, how do you tell what's going on? Right. What are you measuring? Well, there's a couple important things. One is walking distance or ability, and that's a primary one. Number two are disability questionnaires. And patients with lumbar stenosis display alterations and changes in observed behaviors and performance in things like postural control, dynamic balance, five times sit to stand test, and the timed up and go test. So all of these things are great ways to measure what's going on. I think back to a patient I saw in practice. He climbed power lines for a living. And when he was, I mean, literally between the front door and my table, he would have to like stop and get into a squatted position and then he'd be able to keep going. He did it for a couple seconds, he'd get up and keep going. He had severe stenosis. We were able to help him tremendously using flexion distraction. But when you see people that just can't ambulate, they can't get around, and it's specifically due to, you know, lumbar or lower extremity issues, typically it's stenosis that's the root cause of that. So this study aimed to assess the effects of a pragmatic, like a realistic course of care that included flexion distraction in reducing postural sway and also in improving performance based mobility and disability in patients with a clinical diagnosis of stenosis. So they're saying, hey, let's take a look at what really goes on. It's pragmatic. Let's see what's up when somebody really receives chiropractic care. Inflection distraction in a chiropractic office practice. And we'll see what the results are. And the patients in this study had between 10 to 16 visits with an average of about 11. And exercise was discussed in over 80% of the visits, which all sounds normal. I'll tell you what sounds not normal. Compliance to the exercise. They estimated at 91%. So highly compliant patients here. And I guess if you're unable to ambulate very well, that's a good kick in the butt to be compliant with your at home exercise and you're desiring to get well. So pretty pragmatic in terms of their approach. No questions about that. Now here's where we get down to some of the discussion and some of the findings and really the good stuff. Participants in this study reported significant improvement in all significant improvement in all patient reported outcomes, including improvement in confidence in their balance, improvement in claudication symptoms and all subscales of symptoms and physical function. They had improvement in the NRS back pain and buttock and leg pain scales. And the performance measures of the sit to stand and the up and go at both the mid and final visits were also significantly improved. So pretty much across the board there was significant improvement. Now, a lot of this, I think to the anatomy and the biomechanics, it's something they don't touch heavily on in this study, but quite often the other thing when we. So let me pause on that. When somebody finds improvement bending over a shopping cart, it's because they move into a forward flexed position that does provide spacing and opening of the canal. It also enables them to put their arms on the shopping cart and de weight, so to speak, their lumbar spine. Now think about that in terms of what goes on on a flexion distraction table. On a flexion distraction table, the patient is face down. You're using the your superior hand to really create a axis point or create a decompressive point at that lumbar level. You're then with your inferior hand, you are then moving the table up and down. Guess what? You're providing flexion and distraction. As obvious as that sounds with the the table name, that's what people are doing almost manually to some degree when they're leaning over a shopping cart, they're getting into a flex position and they're trying to unload the lumbar spine. So it makes a lot of sense why flexion distraction would be exceptionally benef. And I've found even with patients that have true numbness paresthesias in the feet, getting them face down on a flexion distraction table, just getting them into the flex position without even moving the table up and down, giving just a little bit of decompressive force with a superior hand. Often the patient I can feel my toes again. I can wiggle my toes again. It can be really powerful. You think about that canal being 10 millimeters or more. Around 10 millimeters is a normal canal canal. Well, if they're down at 5 millimeters, which would be severe spinal cord stenosis, and you're giving them Two millimeters. Two millimeters is not much. You're giving them two millimeters, they're going from five to seven millimeters. That can be life changing in terms of how that feels. Now you gotta get off the table and you have to have the functional component of it, but really, really important stuff. So a course of care, including spinal manipulation. In this study it had numerous improvements as we just touched on, including subjective measures. Improvements in pain, muscular weakness, their balance, difficulty with activities of daily living. All of those things are typically associated with lumbar stenosis and they're important. So it goes beyond pain scales. It also ties into life effect and activities of daily living. When somebody's able to get up and do more, that is really, really important. As we say, people live with pain and not come into your practice for decades, but when it starts to really encroach upon something they love to do, that's when they're, I gotta get in, doc, right? So the life effect is so, so important. And amongst chronic low back pain patients, including those with stenosis, a change in pain intensity of a value of 2 on an NRS score over 3 months duration is considered clinically significant and a really good indicator of a solid therapeutic outcome. So 2 is the threshold. In this study, the pain change was an 8 average of 3.8 from baseline to final visit and the leg pain change was 2.9. So it blew out of the water. What was meaningful and necessary to have clinical significance? It almost doubled it in one case and 50% more than was necessary in another case. From low back to leg. So does flexion distraction provide significant benefits? Absolutely. Their conclusion was in conclusion, quote, a pragmatic course of care involving spinal manipulation led to improvements in subjective evaluations of pain balance, confidence and claudication, as well as significant improvements in timed up and go and five times sit to stand durations in patients with lumbar spinal stenosis. They also noted immediate decreases in sample entropy and mean frequency of sway suggest an effect of care on postural control. So how do we like this study? This study's awesome. I mean, it really highlights in an all encompassing way many of the benefits that people can expect when they have lumbar spinal stenosis and they receive chiropractic care and specifically the technique of flexion distraction. Why is this important? This is important. Tying back to the beginning of our conversation today because the number one reason people have adult elective spine surgery is for lumbar stenosis. Now, is there a point where there are red flags? If it's saddle paresthesias. If there are bowel incontinence issues, of course those red flags need to be addressed asap. You need to make those referrals. However, an overwhelming majority of individuals who are having elective spinal surgery to correct stenosis don't have those red flags. That means there is still opportunity to take care of things conservatively. And what is the best way to take care of things conservatively? Very clearly, Movement dynamics. We've seen how harmful and counterproductive quite often injections and NSAIDs can be to the healing process. We're going to dive deep into that on some future episodes and the research is pretty astounding in terms of how NSAIDs and injections can limit your ability to heal, not enhance your ability to heal, and how they help transition people from acute to chronic pain, not eliminate acute or chronic pain. Super powerful stuff. But that is the alternative. If somebody does not understand that you are the place to be. And with our utilization hovering around 15% and the amount of people having lumbar spinal stenosis each and every day and symptoms associated with it, there's no question most people don't know they should be coming into your office yet. So if you want help bridging that gap with other healthcare providers and getting more referrals in, make sure visit us at the Evidence Based Chiropractor. See what we're up to. We've helped hundreds of chiropractors get tens of thousands of referrals. We work with over 150 practices around the world right now to build referral relationships on the other side. If you're saying, man, I just want to get out to my community at a better level, then visit us at the Smart Chiropractor. That's what we do each and every day is guiding that patient journey so you can have more new patients, better retention and more reactivations without spending any money on advertising. So lot of clinical pearls. Awesome study and I'm looking forward to some of those coming up talking about the challenges. I'll put it lightly with some of the medications out there. Now before we wrap up today, I want to encourage you as a listener. Power Step wants to hook you up with a free pair of orthotics. These are awesome. They're what I use myself, they're what my father uses. 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However, when you find the right person, that's what can lead to long term success. And most chiropractors don't have sourcing, vetting, behavioral matching. All of those things is not what you do each and every day. You take care of people, so let the professionals take care of it. Have a conversation with Chiro Matchmakers and I hope you have a fantastic week in practice and I will talk to you soon.

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