SOURCE: Dynamic Chiropractic

By Richard C. Schafer, DC, FICC

This author acknowledges the value of reflexology and numerous physiotherapeutic applications (along with nutritional supplementation, counseling, “bloodless surgery,” and standardized rehabilitative procedures) in chiropractic case management.
Yet, they all stand in the shadow of the basis for and the proper administration of the chiropractic adjustment. This column and others throughout the year will focus on the need for the development of our unique art. Certain basics seem to have become lost in the teaching of “technic” during the last decade or so.

Depth of Drive

Besides patient positioning, the type of contact selected, and direction of drive, the depth of drive also must be accurate. It is sometimes taught that it should be to the anatomical limit, but this is not always true. Adjusting a strong ligament fixation immediately to the anatomical limit may rupture degenerated tissues — resulting in the development of even tougher scar tissue. The object is to progressively stretch but not rupture shortened fibers. Adaptation takes time.

The opposite should also be recognized. An attempt to mobilize further after a fixation has been released will produce a new defensive contraction and inflammation, and therefore predispose the development of a new fixation. Over-adjusting is not beneficial; it is trauma.

The Articular Snap

Spinal adjustments often involve the breaking of the synovial seal of the apophyseal joints, resulting in an audible “snap.” While some feel this is of little significance, most authorities feel that breaking the joint seal permits an increase in mobility (particularly that not under voluntary control) from 15-20 minutes — allowing the segment to normalize its position and functional relationships as much as possible, if post-adjustment rest is allowed. Unsuccessful manipulation resulting in increased pain rarely produces an audible joint release, while successful adjustments usually produce an immediate sense of relief (though some discomfort and spasm may remain). A reduction in palpable hypertonicity and an improvement in joint motion are typically followed by a gradual reduction in symptoms.

Segmental Distraction

An extension (distraction) or separation of joint surfaces and elongation of shortened soft tissues should be a component of every adjustive thrust. Articular pressure is thus reduced to a minimum at the moment of joint movement. In this manner, articular friction with its accompanying trauma and pain will be reduced and taut tissues, contributing to the fixation, will be stretched. Instruction in adding intersegmental traction to all adjustive procedures was a fundamental principle in pioneer chiropractic, and it’s still valid.

Timing the Thrust

Somewhere at some time somebody taught another DC that the best time to deliver the thrust is at the end of patient exhalation. This erroneous idea has spread throughout the country like an epidemic to infect hundreds of DCs to the detriment of their patients. The advice, “Take a deep breath, and then let it out” is extremely poor counsel if the adjustment is delivered at the end of exhalation. Patients soon learn the doctor’s tricks and consciously apply muscle splinting mechanisms just before the thrust is delivered. Nobody likes their lungs to be shockingly overdeflated.

Relaxed exhalation is a passive mechanism; inhalation is not. At the end of relaxed exhalation, respiratory muscles prepare to contract by increasing their tone. Thus, the best time to deliver the thrust is immediately after the beginning of exhalation. The effect on the patient’s lungs, then, is only to increase the rate of normal passive exhalation. If the thrust is made at the end of exhalation, forced exhalation results and the effect is a sharp, automatic, protective contraction of the diaphragm, thoracic muscles, and perispinal musculature. The latter is likely to return the segment immediately to its abnormal but habitual position. Such poor timing is painful to the patient, and patients who suffer unanticipated pain are not inclined to refer their friends, relatives, and neighbors for such abuse.

Nobody enjoys unpleasant surprises. It is always wise to carefully explain to patients new to the practice (before they are placed on the adjusting table) exactly what you are going to do; why you are going to do it; how you are going to do it; what sensations they may feel during this “operation;” and what benefits they should look for as the day progresses. In this manner, there are no surprises and no shocks to one’s expectations. This explanation builds a logically designed image within the patient so that the patient’s psyche is working with you, not in a contrary fashion.

The adjuster need not tell the patient how to breathe. The patient knows how. All the adjuster has to do is feel the patient’s thoracic cage rise and fall as the contact is taken to time the thrust properly. A more efficient adjustment will be achieved, and the patient will feel little discomfort and no painful surprise.

“Drop-Support” Tables

Drum rolls, trumpets, or “gunshot” theatrics have no place in a clinical atmosphere. A colleague recently remarked, “Those who set a circus stage soon become known as clowns.”

Adjusting tables producing a loud “crack” when the adjustment is delivered are not recommended for three reasons: no biomechanical principle justifies their use, the “gunshot” noise frightens many patients, and the extraneous noise prevents patients from personally sensing the deep articular release that so often accompanies an adjustment. This latter factor destroys the psychological value of having the patient feel that something has moved in their spine. For many patients, this is a positive affirmation.

Editor’s Note:

This article was written in 1989. I’m not sure how much research has been done with drop tables since then, but I assure you, they don’t sound like a gunshot, they don’t scare patients, and from my experience, patients benefit from their “drop” adjustments just fine.

You may also enjoy RCs article: The Art of Pioneer Chiropractic Technic,

which is just one of 42 free articles available in the Rehabilitation Monograph Series

These articles are archived on the: Chiropractic Technique Page

R.C. Schafer, D.C., F.I.C.C.
Oklahoma City, Oklahoma

SOURCE: J Manipulative Physiol Ther 2011 (Feb); 34 (2): 98–106

This hospital-based study is interesting for several reasons:

• First, they utilized an evidence-based program for treating low back pain (LBP)

• Based on that evidence, they assigned 83% of those who sought care to chiropractic management.

• Results for the patients treated by doctors of chiropractic were mean of 5.2 visits, mean cost per case of $302, and

• 95% of those patients rated their care as “excellent.”

The Abstract:

OBJECTIVE: A health care facility (Jordan Hospital) implemented a multidimensional spine care pathway (SCP) using the National Center for Quality Assurance (NCQA) Back Pain Recognition Program (BPRP) as its foundation. The purpose of this report is to describe the implementation and results of a multidisciplinary, evidence-based, standardized process to improve clinical outcomes and reduce costs associated with treatment and diagnostic testing.

METHODS: A standardized SCP was developed to improve the quality of back pain care. The NCQA BPRP provided the framework for the SCP to determine the standard of quality care delivered. Patients were triaged, and suitable patients were categorized into 1 of 5 classifications based upon history and examination, directional exercise flexion or “extension biases,” spinal manipulation, traction, or spinal stabilization exercises.

RESULTS: The findings for 518 consecutive patients were included. One hundred sixteen patients (10%) were seen once and triaged to specialty care; 7% of patients received magnetic resonance imagings. Four hundred thirty-two patients (83%) were classified and treated by doctors of chiropractic and/or physical therapists. Results for the patients treated by doctors of chiropractic were mean of 5.2 visits, mean cost per case of $302, mean intake pain rating score of 6.2 of 10, and mean discharge score of 1.9 of 10; 95% of patients rated their care as “excellent.”

CONCLUSIONS: By adopting the NCQA BPRP as an SCP, training physicians in this SCP, and using a back pain classification, Jordan Hospital Spine Care demonstrated the quality and value of care rendered to a population of patients. This was accomplished with a relatively low cost and with high patient satisfaction.

From the FULL TEXT Article

Low back pain (LBP) is a substantial public health issue that puts pressure on the financial resources across the entire health care systems worldwide. The lifetime prevalence of LBP in most industrialized countries varies between 60% and 85%; therefore, most adults can expect to experience an episode of LBP at least once during their lifetime. Approximately 25% of American adults reported experiencing an episode of LBP during the previous 3 months. According to the National Center for Complementary and Alternative Medicine, LBP is the fifth most common reason why people seek care from their primary care physicians, the leading cause of disability and missed days of work in working age adults, and the most common condition for which US adults seek complementary and alternative treatment. A 2006 report estimated that the direct and indirect costs of LBP in the United States are more than $100 billion annually. Patients with back pain incur 73% higher health care costs than those without back pain–related complaints. Much of this cost is related to improper management of LBP, especially with respect to unnecessary diagnostic imaging, medications, and spinal injections. [5]

Improper and costly management of LBP is prevalent throughout the US health care delivery system, with widespread geographic variations documented in physician behavior and clinical practice that are not correlated with the geographic prevalence or incidence of the conditions being treated.

Although these recent data suggest a current crisis in the management of LBP, this is not a new problem. The first attempt to develop a guideline for the management of LBP was the publication of a consensus report in 1987 by the Quebec Task Force on Spinal Disorders. [11] Since that time, there have been many national and international guidelines published on the subject.

Most recently, the Bone and Joint Decade Task Force published a comprehensive set of systematic reviews of the literature covering the many procedures used to treat LBP. [18] Perhaps Haldeman and Dagenais best described the overall clinical approach to the management of LBP in the United States when he described current care as a “supermarket of spine-care services,” identifying more than 200 various treatment options available to patients for this condition. In addition, there are conservatively 12 separate provider types who treat patients with LBP (eg, doctors of chiropractic, physical therapists, orthopedists, etc). This is compounded by the fact that there are not generally accepted indications guiding the decision regarding which provider should be seen, at what time, and for which intervention. With this “supermarket” of options, the health care delivered to patients with LBP is uncoordinated and inefficient. Many patients are immediately escalated along the pathway of diagnostic testing and specialty consults, whereas efficacious, lower-cost interventions are explored late in the care pathway or ignored all together.

These issues raise questions regarding the management of LBP. Can a focus on quality through the application of the best available evidence coupled with processes designed to bring consistency to the delivery of health care services lead to excellent clinical outcomes, high patient satisfaction and less cost to the system? Therefore, the purpose of this descriptive report describes the internal and external development of a multidisciplinary, evidence-based, quality management program designed to standardize an LBP clinical care pathway in a community-based hospital.

Methods

Jordan Hospital is a 160-bed community-based hospital in Southeastern Massachusetts, serving 12 communities with a combined population of approximately 26,0000 people. Our hospital recognized that large geographic variation existed in the way that health care services were delivered not only around the nation but also within our own local community, and even within our own institution.

A decision was therefore made to address this challenge of practice variation and to improve the value of the health care services we provide to patients at our hospital, in our affiliated outpatient clinics, and within our community. Importantly, this decision was not limited solely to the treatment of LBP. We embarked on a process to standardize the way in which the hospital staff provided condition-based health care services to all patients and to eventually have 85% to 90% of all our patients managed through defined clinical care pathways, with the ultimate goals of reducing practice variation and improving the value of our health care services.

Our first step was to identify the clinical conditions in our patient population that showed the widest practice variation and required the most significant amount of time and money to manage. These conditions included congestive heart failure, transient ischemic attack, alcohol withdrawal, chest pain, hip fracture, sleep disorders, breast cancer care, and LBP.

After identification of these priority conditions, the next step was the internal development of defined clinical care pathways based upon the best available evidence and clinical experience.

The goal was to develop clinical care pathways that would standardize the clinical algorithms and processes used in the management of each of these conditions thereby reducing individual practice variation between the providers at our institution.

We then instituted a comprehensive training process for all hospital staff in the appropriate implementation and execution of these clinical care pathways. This educational process was supported by systematic monitoring of the staff for compliance with these standardized clinical processes along with tracking of our clinical outcomes, costs, and level of patient satisfaction.

Finally, we undertook a broad-based external outreach effort to disseminate the principles of evidence-based LBP management to physicians and the public within the communities we serve.

Internal Development

Low back pain was one of the priority conditions identified for development of a standardized clinical care pathway. It was recognized that the problem of wide variation in our management of LBP was occurring across many different health care disciplines; therefore, we decided that the solution would require a standardized clinical care pathway that would apply to all providers universally.

The goal was to devise and implement a high-quality, outcome-driven, evidence-based clinical algorithm for patients with LBP that could be applied consistently across all provider specialties.

This led to the development of Jordan Spine Care (JSC), an outpatient program implemented within our hospital that followed a multidisciplinary, team-based, standardized clinical approach to the management of LBP. The JSC group includes providers from the disciplines of occupational health, neurosurgery, physical medicine, pain management, chiropractic, rheumatology, neurology, physical therapy, and occupational therapy.

The strategy and goal were to have all members of the multidisciplinary team agree to follow a set of standardized procedures with the intent of reducing the need for unnecessary medications, diagnostic testing, and invasive spinal injections and surgery while maintaining high patient satisfaction and good clinical outcomes.

A multidisciplinary team of clinical leaders from the JSC group of providers were charged with developing a clinical care pathway designed to standardize the diagnostic and treatment strategies used to the manage patients with LBP at JSC.

Our review of the literature found that many of the important concepts regarding quality management of LBP had already been addressed by others. For example, a standardized approach to physical examination, case history, and diagnostic triage for LBP had already been established by the National Center for Quality Assurance (NCQA) Back Pain Recognition Program (BPRP) (see Table 1 below).

The team also found several clinical prediction rules and clinical trials that substantiated the clinical effectiveness of several nonsurgical treatment options for LBP. This information was used by the JSC team to develop a 2-tiered spine care pathway (SCP) that defined the diagnostic and treatment algorithms used to standardize the clinical management of patients with LBP at JSC.

Tier 1 of the SCP simply addressed the need to have all JSC team members follow a uniform approach to the evaluation and management of any new patient presenting with LBP by using the NCQA BPRP guidelines.

National Center for Quality Assurance established the BPRP in 2006 as a mechanism to recognize medical and chiropractic physicians who demonstrate the use of evidence-based principles in the management LBP.

Their guidelines focus on the processes of care and specify aspects of the physical examination and case management that should be performed and documented in the clinical record. Important BPRP requirements include:

• performing a comprehensive case history and physical examination to rule out “red flags” of serious pathology;

• using validated measures of pain, function, and mental health periodically during treatment to monitor progress;

• advise the patient to remain active, avoid bed rest, and quit smoking;

• recommendation for exercise and patient reassurance about a favorable prognosis;

• minimizing the use of unnecessary x-rays and advanced diagnostic imaging at the earlier stages of treatment; and

• appropriate timing of surgical and spinal injection procedures.

It is beyond the scope of this manuscript to provide a comprehensive review of the NCQA BPRP; however, additional details regarding this program can be found at www.ncqa.org/bprp.

During the tier 1, patients are triaged to identify those who require immediate medical attention due to severe pain, neurologic deficit, or signs of potentially serious medical illness as well as those who may benefit from conservative care.

Because most patients with LBP do not require urgent medical attention, they can appropriately be managed conservatively.

Patients who can appropriately be managed conservatively are further evaluated using the clinical procedures outlined in the second tier of the SCP.

Tier 2 involves a treatment classification algorithm designed to place the patient with LBP into 1 of 5 treatment-based approaches based upon their history and physical examination findings. The treatment categories are as follows:

1.directional preference exercise: flexion bias;

2.directional preference exercise: “extension bias”; (McKenzie assessment)

3.spinal manipulation;

4.traction; and

5.spinal stabilization exercises.

Table 1.   Subgroups of patients with low back pain with subgroup criteria and treatment approaches
Subgroup	Subgroup criteria	Treatment approach
Specific exercise: extension	Symptoms distal to the buttock Symptoms centralize with lumbar extension Symptoms peripheralize with lumbar flexion Directional preference for extension (McKenzie)	End-range extension exercises Mobilization to promote extension Avoidance of flexion activities
Specific exercise: flexion	Older age (>50 y) Directional preference for flexion Imaging evidence of lumbar spine stenosis	End-range flexion exercises Mobilization or manipulation of the spine and/or lower extremities Exercise to address impairments of strength or flexibility Body weight–supported ambulation
Stabilization	Younger age (<40 y) Average straight-leg raise (>91°) Aberrant movement present Positive prone-instability test	Exercises to strengthen large spinal muscles (erector spinae, oblique abdominals) Exercises to promote contraction of deep spinal muscles (multifidus, transversus abdominus)
Manipulation	No symptoms distal to knee Duration of symptoms <16 d Lumbar hypomobility Fear-Avoidance Beliefs Questionnaire for Work <19 Hip internal rotation range of motion >35°	Manipulation techniques for the lumbo-pelvic region Active lumbar range-of-motion exercises
Traction	Symptoms extend distal to the buttock(s) Signs of nerve root compression Peripheralization with extension movement; or positive contralateral straight-leg raise test	Prone mechanical traction Extension-specific exercises

—> Adapted from Clinical Prediction for Success of Interventions for Managing Low Back Pain
Clin Sports Med. 2008; 27: 463–479 [19]

RESULTS:

The JSC program began seeing new patients on January 1, 2009. Through the end of June 2009, we had evaluated and treated a total of 518 new patients with LBP.

With respect to the interpretation of these data, it is important to stress that the primary classification category listed in the table was based upon the initial evaluation only. For example, patients who centralized with end-range loading into extension on the initial evaluation (42% of cases) are listed in the table under extension bias. However, these patients might have been switched over to core stabilization exercise or work conditioning as a secondary or complimentary mode of treatment near the completion of their Spine Care Program. Another example is the group of patients with LBP placed in the manipulation category at baseline (31% of cases); once their LBP was successfully reduced with manipulation, the patients were often managed with self-extension exercises for several visits and may have completed their Spine Care Program with some core stabilization exercises.

The findings for 518 consecutive patients were included. One hundred sixteen patients were seen once and triaged to specialty care; 7% of patients received magnetic resonance imagings. Four hundred thirty-two patients (83%) were classified and treated by doctors of chiropractic and/or physical therapists. Results for the patients treated by doctors of chiropractic were mean of 5.2 visits, mean cost per case of $302, mean intake pain rating score of 6.2 of 10, and mean discharge score of 1.9 of 10; 95% of patients rated their care as “excellent.”

REFERENCES:

5. Overtreating Chronic Back Pain: Time To Back Off?
J Am Board Fam Med. 2009 (Jan);2 2 (1): 62-8 ~ FULL TEXT

11. Scientific approach to the assessment and management of activity-related spinal disorders. A monograph for clinicians. Report of the Quebec Task Force on Spinal Disorders
Spine. 1987;12:S1–S59 ~ FULL TEXT

18. A supermarket approach to the evidence-informed management of chronic low back pain
Spine J. 2008; 8: 1–7 ~ FULL TEXT

19. Clinical Prediction for Success of Interventions for Managing Low Back Pain
Clin Sports Med. 2008;27:463–479 ~ FULL TEXT

SOURCE: NHI OnDemand

A randomized, double-blind, placebo-controlled study published in the journal Reproductive Health evaluated the effectiveness and safety of a supplement containing essential fatty acids and vitamins for the treatment of PMS and to assess effectiveness on prolactin and total cholesterol levels.

The researchers recruited 120 women with PMS and were divided into 3 groups that received either 1 or 2 grams of the supplement or placebo for six months using the Prospective Record of the Impact and Severity of Menstruation (PRISM) calendar. The actual dosage per one-gram serving included 210 mg of gamma linolenic acid, 175 mg of oleic acid, 345 mg of linoleic acid, 250 mg of other polyunsaturated acids, and 20 mg of vitamin E.

The results were the group treated with 2 grams of supplement experienced the most significant reduction in the PRISM score the next significant reduction was in the group taking 1 gram of supplement. The placebo group experienced the least reduction in PRISM score. There were no statistically significant differences in prolactin or total cholesterol levels after six months of treatment.

In conclusion the authors stated “The difference between the groups using the supplements and the placebo group with respect to the improvement in symptomatology appears to indicate the effectiveness of the supplement mixture. Improvement in symptoms was higher when the 2-gram dose was used. This medication was not associated with any changes in prolactin or total cholesterol levels in these women.”

You will find many more articles on this topic at:
The Omega-3 Fatty Acid Page and the
Gamma-Linolenic Acid (GLA) Page

REFERENCES:

1. Essential fatty acids for premenstrual syndrome and their effect on prolactin and total cholesterol levels: a randomized, double blind, placebo-controlled study.
Reproductive Health 2011 (Jan 17); 8 (1): 2 ~ FULL TEXT