Background
Manipulation is the most studied form of treatment for low-back pain and good evidence now exists supporting its effectiveness. Although lower back complaints comprise a large percentage of a chiropractor's practice (Kelner et al. 1980), many other conditions are seen and are being subjected to research scrutiny. The effectiveness of manipulation is being investigated, for example, for neck pain (Cassidy et al. 1992, Nansel et al. 1989), migraine headaches (Parker et al. 1978, Vernon et al. 1992), chronic strain of the upper extremity (Leboeuf et al. 1987), post-manipulative changes in EMG readings (England and Deibert 1972, Grice and Tschumi 1985, Ellestad et al. 1988), pain tolerance (Terrett and Vernon 1984), improvement in respiratory disorders (Miller 1975, Hviid 1978, Jamison et al. 1986, Nilsson and Christiansen 1988), infantile colic (Klougart et al. 1989) and enuresis (Leboeuf et al. 1991). Although limited in some cases by sample size or other methodological problems, these studies represent the ongoing attempt to define the role of chiropractic care for various clinical conditions.
Regardless of the condition, once a patient consults a health professional, the frequency of visits is determined to a great degree by that health care practitioner (Hansen, 1991). The question that then arises is, "How many visits are clinically necessary?" Many factors are relevant, but the natural history of the condition provides the basic reference point from which a measurable plan of action can be made.
Natural History
The pathology and pathogenesis of low-back pain has been well documented by clinical, anatomical, and radiological studies (Kirkaldy-Willis 1992). Depending on the stage of the degenerative process in a patient, the outcome of treatment can be dramatically different. Clearly, however, the frequency and duration of treatment/care of an uncomplicated case should never extend beyond the time frame of the natural untreated course.
Low-back pain (LBP) may run an unpredictable, spontaneous course. Of the adult population that experiences an acute episode of LBP, 50% recover and return to work within 2 weeks. Within 6 weeks, 80% have returned to work. The remaining 20% provide a clinical and socioeconomic challenge (Haldeman 1992).
A study by Triano (1991) attempted to determine treatment history of acute, sub-acute, and chronic spinal disorders and compare it to the natural history of the condition (Fig. 8.1). Complicating factors should be identified and corrected whenever the progress of treatment/care approximates or intersects the estimated time line.
Predictors from Case History and Examination
Singer et al. (1987) described a relationship between three factors in the episode history prior to consultation and the duration of conservative care. These three - pain intensity, pain duration prior to the consultation, and the number of prior episodes - were observed to affect the time necessary to return the patient to pre-injury activity and to the point of no pain or mild pain. In general, more severe pain at treatment/care onset was associated with twice the treatment/care times. In like manner, patients suffering with pain less than 8 days before commencing therapy took a mean of 13 days to recover. With pain exceeding 8 days, 21 days (1.5 times as long) where required. Similarly, patients with up to three prior episodes required 12 days, while more than 8 episodes extended recovery to 27 days (twice as long).
Pathological or anomalous structures may interfere with clinical progression by a factor of 1.5 - 2 times (Herrin et al. 1974, Haldeman et al. 1992). Re-injury and exacerbation from unexpected events also may alter treatment/care goals. Likewise, supervening or continuing biomechanical and psychosocial stressors may be important impediments to recovery.
The use of a pain drawing has been shown to yield information that facilitates the exploration of psychosocial and other non-organic causes of back pain (Goldman et al. 1991). Similarly patient questionnaires such as the Oswestry Low-Back Pain Disability Questionnaire, the Roland-Morris Questionnaire and the Neck Disability Index, and pain scales such as the Visual Analog Scale have been found to be valid and reliable in measuring health status and results for patients with low-back and neck pain and receiving chiropractic management (McDowell 1987, Deyo 1988, Fairbanks 1980, Meade et al. 1990, Vernon and Mior 1991). Any suggestion from these questionnaires of a functional overlay, pain amplification, somatization, or poor psychometric skills constitutes a complicating factor that may cause a poorer response to chiropractic manipulation (Bronfort 1986).
Treatment Plans
The treatment plan for therapeutically necessary care can be divided into four phases (Table I), each having distinct objectives that allow for passive (Stage 1) and active (Stages 2 - 4) benefits. It is beneficial to proceed to the rehabilitation phase (if warranted) as rapidly as possibly, and to minimize dependency upon passive forms of treatment/care. Studies have shown a clear relationship between prolonged restricted activity and the risk of failure in returning to pre-injury status (Deyo et al. 1986, Frymoyer 1988, Mayer et al. 1988). Often a complete resolution of pain is not possible until patients begin to focus on increasing the number and kind of activities in which they participate. Return to work usually can be commenced at the 80-90% level of pre-injury status (Beimborn and Morrissey 1988). Even then, some residual pain can be expected, although usually it will be offset by the benefits of increased productive functioning and a better prognosis.
Table I
Stages of Treatment/Care: Goals and Objectives
(after Haldeman et al. 1992)
Passive Care
1. Acute Intervention (including manual procedures)
A. To promote anatomical rest
B. To diminish muscular spasm
A. To reduce inflammation
B. To alleviate pain
Active Care
2. Remobilization
A. To increase the range of pain-free motion
B. To minimize deconditioning
3. Rehabilitation
A. To restore strength and endurance
B. To increase physical work capacity
4. Life Style Adaptations
A. To modify social and recreational activity
B. To diminish work environment risk factors
To adapt psychological factors affecting or altered by the spinal disorder
(i) Acute Care
An acute condition is one that commenced within the 3 weeks prior to the patient seeking treatment. When the patient exhibits acute distress, passive care predominates with efforts to reduce soft tissue and joint stresses, and to diminish inflammation and swelling. A short term of reduced mobility to limit the joint loading effects of gravity may be warranted. Passive forms of treatment/care, including manual and palliative procedures, may be used with due deference to the type of mechanical lesion present.
When the pain and discomfort have abated, a shift towards active care is encouraged with the introduction of slow speed and minimal load exercises prescribed to improve flexibility. As the range of pain-free motion increases, a gradual increase in exercises promoting endurance is commenced. Lastly, when a maximal range of motion is achieved, rehabilitation for strength can begin.
It is generally agreed that a more aggressive in-office intervention early during treatment/care will likely result in a reduction in the level and duration of disabling injury and the number and cost of inpatient procedures.
After reviewing the available evidence, the 1990 RAND Consensus Panel unanimously agreed upon a definition of adequate therapeutic trial for spinal manipulation (Shekelle et al., 1991). For an uncomplicated case, this multidisciplinary panel recommended two trial courses of two weeks each, using alternative manipulative procedures. Without evidence of demonstrable improvement over this time frame, spinal manipulation was felt to be no longer indicated.
(ii) Chronic Care
A chronic condition is defined as one with an onset more than three months prior to treatment.
There is now clear evidence that, of those whose symptoms persist for more than 3 to 4 months, more than half will still be disabled at the end of a year (Mayer and Gatchel 1988). If chiropractic treatment of patients with chronic conditions is to be successful, emphasis must be placed on patient participation and active care (see Table I). A search must be made to identify any factors competing with recovery, and steps taken to correct them.
As with acute care, the RAND Consensus Panel (Shekelle et al. 1991) also recommended two trial courses of two weeks each, using alternative manipulative procedures before considering treatment/care to have failed. Without evidence of improvement over this time, spinal manipulation is no longer indicated. It is not clear, however, whether the RAND Panel intended this recommendation to be a base line to be modified by complicating factors such as pre-existing conditions. Meade et al. (1990) reported excellent results with chronic low-back pain patients with a maximum of 10 treatments which, although intended to be concentrated within the first three months, were spread over a year if considered necessary. Jaquet (1974) recommended 12 treatments as a maximum number with no improvement. Similarly, Hansen (1988) recommends a second opinion if there is no objective or subjective sign of improvement in two weeks, or treatment of three times per week that exceeds four weeks (12 treatments).
Other observational or retrospective studies have compiled information on the number of treatments given to patients. Phillips and Butler (1982) found a mean of 12.5 treatments in the case records of 3,943 patients. Phillips (1981) reported a mean of 9.0 treatments in 871 cases. Jarvis et al. (1991) calculated a mean of 12.9 treatments over an average of 54.5 days in a study examining worker's compensation data. However, many of these studies involve a mix of acute, subacute, and chronic complaints, and this makes it difficult to extract reliable figures on duration and frequency of treatment for chronic pain patients.
It is generally agreed that with the treatment/care schedule, any episode of symptoms that remain unchanged for two or three weeks should be evaluated for risk factors of pending chronicity. Warning signs include somatic complaints that remain static longer than two to three weeks, anxiety or depression, functional or emotional disability, family turmoil and drug dependence (Cailliet 1987).
(iii) Elective Care
Elective care encompasses maintenance and preventative care, which is discretionary and elective on the part of the patient, but not supportive care. In the case of supportive care, a trial of withdrawal of care has shown that long-term care is a necessity to sustain previous therapeutic gains. After maximum therapeutic benefit has been achieved and explained to the patient, the type and voluntary nature of elective care should be explained.
The effectiveness of maintenance care has not been subjected to rigorous clinical trials, and empirical evidence needs to be supported by further research. The results of clinical experience, coupled with the emerging clinical studies, support the chiropractic view that elective care is safe and effective when used discriminately so as not to foster physician dependence or chronicity.
Growing evidence supports the chiropractic contention that pathomechanics, harmful dysfunction in the neuromusculoskeletal system, often precedes symptoms. Consider, for example, sacroiliac joint dysfunction or subluxation. Bourdillon and Day (1987) state that "(the sacroiliac joints) can have a profound effect on body mechanics". Shaw (1992) suggests "sacroiliac joint dysfunctions are the major cause of low-back dysfunction, as well as the primary factor causing disc space degeneration, and ultimate herniation of disc material". Lewit and Janda (1964) reported sacroiliac dysfunction in a large percentage of the 750 normal schoolchildren examined. Mierau and Cassidy (1984) found a similar proportion of sacroiliac problems in both elementary and secondary school students in Canada. Sato (Haldeman, 1992) has investigated the possibility that joint disturbances may extend beyond biomechanical insult, and may involve somato-somato, somato-visceral, or viscero-somatic reflexes.
Clinical signs and symptoms having their origins in altered sacroiliac mechanics respond well to manipulation. Changed motor patterns in the abdominal and gluteal musculature are corrected by manipulation (Lewit & Janda, 1964). The clinical results in sacroiliac dysfunction achieved by Lewit and Janda have been substantiated more recently by a study in which 90% of patients disabled by a sacroiliac syndrome responded to a 2-3 week regimen of daily SI manipulation (Kirkaldy-Willis and Cassidy, 1985).
(iv) Failure to Meet Treatment/Care Objectives
Jaquet (1974) indicates that no improvement after 12 visits means one or more of the following:
- The original diagnosis was incorrect.
- The incorrect treatment was given.
- There was incompatibility between the doctor and patient.
- There is secondary gain for the patient.
- There were coexisting conditions.
Any failure of the patient to progress at least consistently with the stages of natural history requires consideration of the above points and a search for complications, somatization, non-compliance, or re-injury. After steps to correct these factors, a trial of therapy may again be implemented.
A decision algorithm simplifies decisions in these cases (Figure 8-2). Its value lies in helping clarify and discriminate practitioner and patient responsibilities in working toward a satisfactory resolution to the case. The overriding concern is a focus upon the patient's rate of improvement in comparison with that predicted by the natural history. Variations from natural history can be expected from case to case as these derive from the individual patient's habits and lifestyle, including occupation. Complicating factors should be considered whenever the progress of treatment/care approximates or intersects the estimated time line (see Figure 8-1). Failure to achieve a satisfactory response in accordance with the algorithm should result in an assessment for maximum therapeutic improvement or referral for a second opinion.
Patients who consistently fail to comply with treatment/care schedules, or who are otherwise insincere in their efforts, should be discharged from care, with referral where appropriate.
(v) Treatment/Care Protocols
Short and long range treatment plans, along with the eventual treatment care outcome, should be discussed with the patient. An estimated time frame for achieving these clinical goals should also be discussed.
Objective and subjective reassessments are suggested if a patient reaches the end of a trial therapy series and demonstrates no significant improvement. A decision as to an amended therapeutic approach, discharge from treatment, or referral for a second opinion, is warranted.
Patients exhibiting signs of deconditioning or chronicity should be given an exercise program that focuses both on the injured and related areas. Education on body biomechanics and exercises should emphasize the avoidance of pain-related behaviour, flexibility, strength, coordination and endurance. Referral to an appropriate care facility may be desired if specific equipment or expertise is sought. Where prominent psychosocial factors make this appropriate, referral for counselling should be made.
Patient education and advice should be direct and practical. This may include advice on bending, lifting, pushing or pulling, entry and exit from vehicles, sitting, yard work, recreation, personal care, and sexual activity.
However, in spite of an initial positive response, if there is little demonstrable additional progress after a period of two months of treatment/care, the patient should be discharged and presumed to have achieved maximum therapeutic benefit.