Case management of chiropractic patients with low back pain
Case management of chiropractic patients with low back pain: The Nordic Maintenance Care program - A survey of Swedish chiropractors
From: Chiropractic & Osteopathy journal. 2008 Jun 18;16(1):6 [Epub ahead of print]
Chiropractic treatment for low back pain can often be divided into two phases: Initial treatment of the problem to attempt to remove pain and bring it back into its pre-clinical or maximum improvement status, and “maintenance care”, during which it is attempted to maintain this status. Although the use of chiropractic maintenance care has been described and discussed in the literature, there is no information as to its precise indications. The objective of this study is to investigate if there is agreement among Swedish chiropractors on the overall patient management for various types of low back pain-scenarios, with a special emphasis on maintenance care.
The design was a mailed questionnaire survey. Members of the Swedish Chiropractors’ Association, who were participants in previous practice-based research, were sent a closed-end questionnaire consisting of nine case scenarios and six clinical management alternatives and the possibility to create one’s own alternative, resulting in a “nine-by-seven” table. The research team defined its own pre hoc choice of “clinically logical” answers based on the team’s clinical experience. The frequency of findings was compared to the suggestions of the research team.
A pattern of self-reported clinical management strategies emerged, largely corresponding to the “clinically logical” answers suggested by the research team. In general, patients of concern would be referred out for a second opinion, cases with early recovery and without a history of previous low back pain would be quickly closed, and cases with quick recovery and a history of recurring events would be considered for maintenance care. However, also other management patterns were noted, in particular in the direction of maintenance care.
To a reasonable extent, Swedish chiropractors participating in this survey appear to agree on the clinical management for different cases of low back pain.
According to experience, chiropractic treatment can often be divided into two phases: Initial treatment of the problem to attempt to bring it back into its pre-clinical or maximum improvement status, and “maintenance care”, during which it is attempted to maintain this status. The first definition of maintenance care that we could find in the literature was provided by Breen in 1977: “…treatment, either scheduled or elective, which occurred after optimum recorded benefit was reached…” and the second definition that we could locate was provided by Mitchell in 1980: “A regimen designed to provide for the patient’s continued well-being or for maintaining the optimum state of health while minimizing recurrences of the clinical status”. In “Advances in Chiropractic” from 1996, the word “maintenance care” is defined as follows: “Appropriate treatment directed toward maintaining optimal body function. This is treatment of the symptomatic patient who has reached pre-clinical status or maximum medical improvement, where condition is resolved or stable”. In other words, maintenance care can be described as both an attempt at secondary prevention (preventing further events from occurring) and tertiary prevention (maintaining an incurable condition at an acceptable level).
According to the literature, spinal manipulative therapy is an important aspect of the maintenance care approach, but also other aspects could be included, such as advice, information, and counselling even in relation to general health promotion. However, the indications for maintenance care and clear descriptions of preventive treatment for specific types of conditions are not found in the literature. Also, general concepts of how to proceed over time with this type of patient are lacking, and the therapeutic value of maintenance care has not been tested, with the exception of a promising pilot study.
Despite this lack of scientific support, it was shown that American chiropractors share a common understanding about the purpose and composition of maintenance care and that they recommend it to the majority of their patients. However, it is not known if there is a general or uniform management culture among chiropractors. In relation to the decision to treat a patient with spinal manipulative therapy, there are various schools of thought within the chiropractic profession. Some chiropractors are guided by both their own clinical findings and the patients’ symptoms whereas others largely disregard the patients’ symptoms, as described in a guideline on the vertebral subluxation in chiropractic practice: “Because the duration of care is being considered relative to the correction of vertebral subluxation, it is independent of clinical manifestations of specific dysfunctions, diseases, or syndromes.”. Maintenance care would therefore probably be undertaken differently for these two groups; the former group using “symptom-guided maintenance care” whereas the approach of the second group would be “clinical findings-guided maintenance care”.
We were interested in finding out whether there is agreement among chiropractors regarding their management for various types of patient groups. In particular, we wanted to find out when chiropractors would recommend maintenance care.
Many patients who visit chiropractors suffer from low back pain (low back pain). It was therefore logical to start this work on chiropractic patients with low back pain. The results from this study may create a base from which further research into maintenance care can be conducted with the ultimate aim to investigate its clinical usefulness. Several such projects are presently underway.
Among the Swedish chiropractors who participated in this survey, a distinct pattern was found, in relation to the management strategies that they would choose for different types of low back pain-scenarios. This pattern corresponded to that which the research team, arbitrarily, considered to be logical and responsible.
However, also other patterns were apparent, sometimes favouring a prolonged management program, either symptom-guided or clinical-findings guided, indicating that some chiropractors have high expectations of “a happy ending” to many clinical conditions. The “quickfix” alternative was not often selected but, then, only cases 1, 2 and 4 were described as completely improved, and therefore the only ones obviously suitable to be considered for closure.
Nevertheless, it is reassuring to see that for the potentially serious cases 8 and 9, the most common strategy would have been referral for “second opinion” and that, for these, none of the participants would have considered any type of maintenance care.
Another interesting finding is that some chiropractors seem to fail to grasp the concept of clinically significant improvement. For example, in case 5, an acute event of low back pain of one week’s duration that is only 20% better after one month and six visits does not appear to be the suitable recipient for clinical findings-guided maintenance care. Nonetheless, this approach was the second most commonly selected strategy for this case, and if both types of maintenance care were considered together, this approach was, in fact, the most preferred choice. It has been shown that patients need to experience more substantial reduction of pain before it can be considered clinically significant. In fact, mere diurnal fluctuations and measurement errors could probably account for an improvement of 20%. In our opinion, maintenance care should only be considered in patients who have responded well to the initial treatment and only in patients who are likely to experience frequent or long-lasting problems in the future. Admittedly though, this is only our humble opinion, and the true indications for maintenance care remain to be studied.
According to a previous study of osteopaths, chiropractors and physiotherapists a subgroup of clinicians will provide prolonged treatment also for patients with low back pain, who do not recover. The reasons for this seemed to be linked with a scope of care, which encompasses more than the immediate symptomatic relief. Obviously, the different aspects of clinical reasoning need to be studied in order to understand various choices of management strategies.
Among those chiropractors who participated in this survey, a clinical management strategy pattern emerged for different cases of low back pain. However, there were also subgroups of chiropractors with different practice cultures, sometimes favouring a maintenance care program. The rationale for their clinical decisions needs to be further elucidated, and the results of this study need to be verified in other study populations with a variety of study designs.
Supplement:
A Questionnaire mailed to 99 Swedish chiropractors asking them to match nine case scenarios with six specific management strategies.
Our next research area will be about maintenance care. First, we need to find out what we really mean by “maintenance care”, because no clear definition and description exists in the chiropractic literature. For this reason we very much need your help. We want to find out what we, the professional chiropractors in Sweden, mean by maintenance care and how it is used in everyday practice.
We are therefore asking you to fill out this questionnaire. When we have received your response, the code will be removed from the questionnaire, and all analyses and final reporting will be on an anonymous basis.
First, please answer the following questions by encircling your response:
Do you use maintenance care in your practice? Yes No
If yes, in your last full working day, how many maintenance care patients did you have
of your total that day? —– maintenance care out of ——-total.
_________________________________________________________________________________
Please, read the following cases and, for each case, give the answer that you consider fits best with the decision you would make in a clinical setting.
We have selected an imaginary patient, as described in the box below. Then, different scenarios for this patient are outlined, and you are asked to select ONE of several clinical solutions (A, B, C etc.) as listed in bold letters below.
You can choose between the following possibilities for each of the cases presented below:
A. I would refer the patient to another health care practitioner for a second opinion.
B. I would advise the patient to seek additional treatment whilst following the patient.
C. I would tell the patient that the treatment is completed but that he is welcome to make a new appointment if the problem returns.
D. I would not consider the treatment to be fully completed and would try a few more treatments and perhaps change my treatment strategy, until I am sure that I cannot do any more.
E. I would follow this patient for a while, attempting to prolong the time period between visits until either the patient is asymptomatic or until we have found a suitable time lapse between check-ups to keep the patient symptomfree.
F. I would recommend that the patient continues with regular visits, as long as clinical findings indicate treatment (eg spinal dysfunction/subluxation) even if the patient is symptomfree.
G. Neither of the above. (Please explain at the back of the page in legible handwriting)
These are the basic facts for our hypothetical patient:
A 40-year old man who consults you for Low Back Pain with no additional spinal or musculoskeletal problems, and with no other health problems.
His X-rays are normal for his age.
There are no “red flags”.
The case above could proceed in the following 9 ways described on the next page.
Please encircle the letter that corresponds best to your clinical judgement in each of the cases.
An acute attack of low back pain of 2 days´ duration and no previous history of low back pain. The pain is completely gone after 2 visits. The patient seems to be an uncomplicated person and capable to look after himself and his back. What would you recommend? A B C D E F (G ) ”
An acute attack of low back pain of 2 days´duration and no previous history of low back pain. The pain is completely gone after 2 visits. The patient is very worried that the pain will come back again. The patient asks if he could come back regularly to make sure this will not happen. What would you recommend? A B C D E F (G ) ”
An acute attack of low back pain of 2 days´ duration and no previous history of low back pain. The pain is about 20% better after 6 visits. What would you recommend? A B C D E F (G ) ”
An acute attack of low back pain of 1 week´s duration. The patient has had several similar attacks over the past 12 months. The pain is completely gone after 2 weeks of treatment. What would you recommend? A B C D E F (G) g ) ”
An acute attack of low back pain of 1 week´s duration. The patient has had several similar attacks over the past 12 months, but the pain pattern has varied over the treatment period and now, after six visits, the pain is 20% better. What would you recommend? A B C D E F (G ) Choose: A B C D E F G ”
The patient has had low back pain intermittently over the past year. After the 2nd visit, the pain was 50% better but today, after six visits there has been no further change. What would you recommend? A B C D E F (G ) ”
The patient has had low back pain intermittently over the past year. After 6 visits, the pain was 80% better, but after a further two treatments the last month, the problem has gradually got a bit worse. What would you recommend? A B C D E F (G)”
The patient has had low back pain intermittently over the past year. After the 2nd visit the pain was 20% better, but today, after 6 visits and over the past month, the patient has got gradually worse. What would you recommend? A B C D E F (G ) ”
The patient has had low back pain intermittently over the past year. After 6 visits the pain is 20% better. The symptoms come and go for no apparent reason. The patient appears tired and moody. What would you recommend? A B C D E F (G) ”
A description of nine scenarios (cases 1 – 9), together with the clinical reasoning of the research team, and a description of their preferred management strategy for each scenario (not included in the questionnaire).
Case 1. An acute attack of low back pain of 2 days’ duration and no previous history of low back pain. The pain is completely gone after 2 visits. The patient seems to be an uncomplicated person and capable to look after himself and his back.
According to the research team, this case indicates a person without a background of persistent or recurrent low back pain, with a quick recovery and a psychological profile that indicates a good prognosis. The team would have selected strategy B (“I would tell the patient that the treatment is completed but that he is welcome to make a new appointment if the problem returns”).
Case 2. An acute attack of low back pain of 2 days’ duration and no previous history of low back pain. The pain is completely gone after 2 visits. The patient is very worried that the pain will come back again. The patient asks if he could come back regularly to make sure this will not happen.
The thoughts of the research team were that, ideally, this patient should be dismissed, similarly to the case above (strategy B). However, the psychological profile of this patient needs to be taken into account and he should be provided with a sense of security whilst guided by the chiropractor and gradually weaned off to prevent dependency upon chiropractic treatment. The team therefore selected strategy E, with the intent of using a couple of more visits to improve the patient’s self-confidence.
Case 3. An acute attack of low back pain of 2 days’ duration and no previous history of low back pain. The pain is about 20% better after 6 visits.
This patient is not improving at a level and rate that should be expected. Because the basic case states that there are no red flags, the team decided that this case should be reconsidered and a few more attempts made. The strategy that best suited for this scenario was C.
Case 4. An acute attack of low back pain of 1 week’s duration. The patient has had several similar attacks over the past 12 months. The pain is completely gone after 2 weeks of treatment.
This is a recurrent problem according to the past history. If the patient considers that the chiropractic treatment shortened the duration of the typical attack, he should simply return as soon as a new problem is felt to commence. Unfortunately, many patients will fail to do so, thinking that the treatment did not help when it starts up again. It might therefore be advantageous to keep an eye on the patient for a while with the intent of finding out if each event of low back pain can be quickly and efficiently treated at a “cost-effect “ time interval (strategy E) or if it is possible to prevent further events (strategy F).
Case 5. An acute attack of low back pain of 1 week’s duration. The patient has had several similar attacks over the past 12 months, but the pain pattern has varied over the treatment period and now, after six visits, the pain is 20% better.
This patient is not improving at a level that should be expected despite the large number of visits, indicating that he may be resistant to the type of treatment that has been provided so far. A change of strategy would be required (strategy C) or if the patient is referred out, it would be relevant to keep in touch to be able to be of support in the continued process (strategy D).
Case 6. The patient has had low back pain intermittently over the past year. After the 2nd visit, the pain was 50% better but today, after six visits there has been no further change.
This patient may have reached his optimal stage with the present type of treatment and the therapy should, at this stage, either be reconsidered “in-house” or by someone else, indicating strategy C or D.
Case 7. The patient has had low back pain intermittently over the past year. After 6 visits, the pain was 80% better, but after a further two treatments the last month, the problem has gradually got a bit worse.
The team used the following reasoning: The improvement seen, to date, may have been independent of the treatment and merely an expression of the typical intermittent pain pattern, or the treatment did have an effect but there is something that re-aggravated the condition. The team would, therefore, have reconsidered the case (strategy C) or sent the patient out for an adjunctive approach, such as training, whilst keeping in touch (strategy D).
Case 8. The patient has had low back pain intermittently over the past year. After the 2nd visit the pain was 20% better, but today, after 6 visits and over the past month, the patient has gradually got worse.
This patient has not really exhibited a positive response to the treatment and is, in fact, getting worse. That the patient is gradually worsening is not a normal pattern. Despite the fact that there are no (obvious) red flags the team would refer the patient for a second opinion (strategy A), because some underlying explanatory condition could have been missed.
Case 9. The patient has had low back pain intermittently over the past year. After 6 visits the pain is 20% better. The symptoms come and go for no apparent reason. The patient appears tired and moody.
This patient has not improved at all and there is no obvious (biomechanical) explanation for the intermittent pattern. There are no red flags but there is a need to consider if there might not be an underlying depression or some other disease, after all. The team would not hesitate to refer out for a second opinion (strategy A).
A description of the six specific management strategies for patients with low back pain receiving chiropractic care, from which the participants in the survey could select one for each of nine scenarios. A brief description for each strategy is included in brackets, used in the report.
A. I would refer the patient to another health care practitioner for a second opinion. (“second opinion”)
B. I would tell the patient that the treatment is completed but that he is welcome to make a new appointment if the problem returns. (“quick-fix”)
C. I would not consider the treatment to be fully completed and would try a few more treatments and perhaps change my treatment strategy, until I am sure that I cannot do any more. (“try again”)
D. I would advise the patient to seek additional treatment whilst following the patient. (“external help – keep in touch”)
E. I would follow this patient for a while, attempting to prolong the time period between visits until either the patient is asymptomatic or until we have found a suitable time lapse between check-ups to keep the patient symptoms free. (“symptom-guided maintenance care”)
F. I would recommend that the patient continues with regular visits regardless of symptoms, as long as clinical findings indicate treatment (e.g. spinal dysfunction/subluxation). (“clinical findings-guided maintenance care”)
