This week’s entry is going to be a little more geared to chiropractic practitioners rather than patients.
Many of us tend to wander around on our own islands for years without any sort of mentorship or guidance. If I’m being honest, and I am, I was that way myself until about 11 or so years ago when I decided to start paying attention. In fact, there are still times I find myself researching the latest standards of practice and guidelines to make sure that I am not an outlier in my profession without even realizing that I’m one. Healthcare tends to change so quickly that it is a scenario I would assume occurs more often than we think.
This sort of information can admittedly be monotonous and can give you a headache. Some LOVE to dive into long text and technical terms, but I’m guessing most do not. That is why I am offering it in different forms.
Different people communicate in different ways. Some prefer email. Some prefer texts. I like videos, while others prefer blogs. Podcasts, Reddit, etc… It’s all a part of communicating in the best, most effective way possible. With this in mind, I offer you this information in blog form, on YouTube in a video, and in Podcast form in the hopes that you guys and gals out there can digest it and maybe even RECEIVE it rather than just simply take note of it, before moving on to something else.
The impetus for this week’s information comes from a blog I read that was recently published on the American Chiropractic Association’s blog. You can find this at www.ACAtoday.org/blog. The blog was posted December 28, 2017. It was titled “Research Review: Clinical Practice Guideline: Chiropractic Care for Low Back Pain,” and was submitted by Dr. Shawn Thistle(1). Dr. Thistle is the founder of RRS Education, which is a continuing education company providing weekly research reviews. Much like we do right here on my blog, on YouTube, or as part of the Chiropractic Forward Podcast.
I have used Dr. Thistle’s article here as the template and simply “overdubbed” and commented on it as I went through it.
In this article, Dr. Thistle reviews a research paper called “Clinical Practice Guideline: Chiropractic Care for Low Back Pain,” The lead author and researcher for the paper was Dr. Gary Globe who has a Masters in Business, a Doctor of Chiropractic, and a PhD. The paper was published in the Journal of Manipulative & Physiological Therapeutics in Volume 30, Issue 1, in 2016(2).
Basically, we are doing a review of a review. You may wonder why this is even necessary to do on my part. I feel it’s necessary because I believe my calling is to take more difficult or more boring concepts, terms, and ideas and to then strip them down into a very understandable and more palatable form. A transfer of information, if you will. Hopefully I can get that information distributed to folks that need it. If we just left it at this blog, it is my assumption that the people that really need the information may not get it. In other words, the people that read the American Chiropractic Association’s blog probably have already familiarized themselves with much of this information. However, people that do not read their blog likely do not keep up with Chiropractic research either. If they’re not involved, then they’re just not involved usually. They may be outliers in the profession because they have likely never been exposed to this sort of evidence-based information.
I’m hoping that’s where I come into the picture.
First, why would chiropractors be interested in guidelines of any sort? I would share with you that a frustrating part of our profession for me personally is that there seems to be no standardization that is widely followed or respected by chiropractors as a population. Some practitioners in Chiropractic may think that’s a great thing and that that’s what is unique about Chiropractic. I am of the thought that it’s a good thing when you go to a practitioner of any style and you can feel comfortable knowing there are professional standards of care being followed by your caregiver. It’s when practitioners have not educated themselves or have not, at least, been somewhat in tune to what’s going on in their profession that they may start to be considered outliers and can run the risk of getting themselves into some sort of trouble professionally. Nobody wants that.
Let’s be clear; following guidelines don’t mean that the practitioner has no autonomy or that there is no professional decision-making going on. They are just that: guidelines. General guidelines that not only help your decision-making process, but also give you something to refer to should there be any questions down the road about your treatment plans or protocols. I call that “standing on solid ground.”
When you have so many webinar and seminar folks trying to scare chiropractors into buying their courses and marketing to them by triggering the fear of either being sued or jailed if they don’t buy, well….standing on solid ground is always a bit liberating.
Be honest here, how does it look when one chiropractor tells the patient they need to be seen 55 times this year and this happens just one or two weeks before a doctor with the second opinion says the standards of practice require 18 visits over the next 2 months or so for the same issue? Of course, that reflects poorly on the first chiropractor but wouldn’t you agree that it also reflects poorly on Chiropractic in general?
I am in no way saying that there are not conditions requiring 55 visits so don’t send me any hate email. I’m simply using a generalized example here. I’ve always felt that treatment should have a start, it should have a finish, it should be responsible and have smart recommendations, and upon completion, should enter the maintenance phase. If we aren’t giving good recommendations, then we simply are not doing our job. But it’s also my opinion that if you’re not staying on top of research and current standards of practice, then that also means you’re not doing your job.
Now that we talked about standards of practice and guidelines, let’s dive into this research and guideline summary.
Why They Did It
Everyone should know by now that low back pain is the leading cause of disability around the world. Research has continued to show over and over that chiropractors are highly effective when it comes to low back pain. Even traditional chiropractic haters, at this point, mostly concede the fact. The goal of this research project seems to be focused on providing some sort of standardization and guideline protocol for an easier and smoother transition into an integrated setting in the medical world. The project focused on nonspecific low back pain.
How They Did It
The authors underwent a comprehensive search of the literature. They found 270 relevant articles. After screening the 270 articles, only 18 where accepted for the paper. Of those 18, 16 of the papers were accepted as high-quality.
Here’s where we get into the thick of it. They break their points down into the following categories: general considerations, informed consent, severity and duration of conditions, examination procedures for lower back pain, treatment frequency and duration, initial course of care for low back disorders, revaluation and re-examination, benefit vs. risk, contraindications and cautions, and chronic pain management for spinal disorders.
Let’s dive into those sections a little further point by point and try to make some sense of it all.
- If a patient gets chiropractic treatment in the acute pain phase, they usually have full recovery of the complaint. Even though they may have full recovery, recurrence of the pain can be common.
- If not treated properly in the beginning, it could turn chronic with increased disability.
- Practitioners, at all times, should be mindful of red flags and yellow flags. In case you don’t know, yellow flags are usually associated with chronic pain or disability. Some examples may be negative coping strategies, poor self efficacy beliefs, fear of avoidance behavior, and distress. That’s according to Dynamic Chiropractic, Nov. 30, 2002, Vol. 20, Issue 25 by Craig Liebenson, DC. Patients with high yellow flag scores should not be labeled with an injured back. For example, telling the patient they have a ruptured disc may not be the best idea. Your treatment should reduce dependency on medication and encourage active treatment rather than passive treatment and should include self-treatment protocols(3).
- The authors of this paper feel that the goal of chiropractic should be improving the patients’ functional capacity as well as educating them to accept responsibility for their own health.
Chiropractors often get into trouble because they lack a proper informed consent procedure.
- Basically, informed consent is communication between your office and a patient that results in the patient giving you authorization for treatment.
- An informed consent should include a clear explanation of the diagnosis, of your examination, and what you propose to do as far as treatment. This should include treatment options and possible risks involved.
- If the person appears to be of sound mind to perform an informed consent, you have satisfied recommendations, assuming they have no further questions.
Examination Procedures for Low Back Pain:
- While there is no limit to what the examination includes, there should at minimum be a health history, an examination that includes range of motion, orthopedic tests, and/or neurological testing, and further diagnostics when indicated. These may include lab tests or imaging.
- This report says that range of motion should not be used to determine a person’s functional status but can be used as part of the exam to assess regional mobility.
- As part of the exam process, they don’t recommend routine imaging for diagnostic tests in cases of nonspecific low back pain.
- With that being said, if serious pathology is suspected or if someone is having neurological issues associated with it, then of course further diagnostics would be appropriate.
- While the authors are not proponents of regular imaging, MRIs are indicated when the low back complaint is associated with symptoms of stenosis or radiculopathy.
- Another condition in which a practitioner may consider getting imaging would be when the patient has not responded to a reasonable, responsible short-term conservative protocol or if you have reason to suspect something else is going on such as spondylolisthesis.
Severity & Duration of Conditions:
This is a really simple section that can cause confusion by those that have just never had the information or have forgotten it.
- An acute complaint refers to something that has been experienced for less than six weeks (1.5 months).
- A subacute symptom has lasted between six and 12 week (1.5 months to just under 3 months).
- A chronic condition is something that has lasted 12 weeks minimum (3 months).
- A recurrence means the return of the symptom that is suspected to be similar to their original complaint.
Treatment Frequency & Duration:
- The authors indicate that most patients respond to your care, but that the treatment frequency and duration may change depending on the patient themselves. They may have other issues, including red and yellow flags, that extend or alter in some way the duration or the frequency of treatment. Again, the practitioner must always be mindful of the red and yellow flags.
- The paper suggests that the effectiveness of care should be evaluated both subjectively and objectively during or after each course of care. In our office, we use the Functional Rating Index (FRI) every single day upon the patient’s arrival. We also use outcome assessment questionnaires fairly often. We use them for a baseline during the initial treatment, again at each re-examination, and then again upon the conclusion of the treatment schedule. In addition to that, our patients are asked to rate their pain on the Visual Analog Scale (VAS) for each complaint at each visit. It takes seconds. Yes, it’s subjective and can have a wide variance from day to day for the same person, but when you are keeping these types of records, you are standing on more solid ground if anything about you or your treatment ever comes into question. Not to mention, it’s just better for the patient to be kept track of in this manner.
- Here is a quasi-answer to a big question. The question I’m referring to is, “How often should I see someone?” Well, the full answer is not in this paper but there are hints at it. The researchers here suggest that a therapeutic trial of chiropractic is usually between 6 and 12 visits that takes anywhere from 2 to 4 weeks to complete. That seems to be about the average. For further insight into generally accepted treatment protocols, you may try looking at the Council on Chiropractic Guidelines & Practice Parameters (CCGPP) guidelines(4).
Initial Course of Care for Low Back Disorders
- The best evidence of efficacy is in High Velocity/Low Amplitude manipulation and in mobilization.
- A good starting point in care is passive physiotherapy like electric stim, cold laser, ultrasound, etc for pain. Additionally, a practitioner should attempt to educate the patient about their complaint and set in place recommendations for self-management of the complaint.
- As the authors state, physiotherapy shouldn’t be used individually or isolated as the lone means of treatment. As I tell my patients, “There is a mountain of evidence for manipulation/mobilization, for certain physiotherapies, and for exercise/rehab but the best evidence show the greatest effectiveness comes from the three being combined and integrated into a treatment protocol that is reasonable and makes sense.” How it is used will come down to practitioner judgement and patient preference.
- The authors here state that they cannot recommend the use of lumbar supports like bracing, taping, or orthoses because the research just isn’t there to support it at this time.
- Active care, otherwise known as exercise/rehab, should become a bigger and bigger part of all chiropractic clinical protocols. I often will try to relate this to patients in a way that makes sense in the medical world. When appropriate I may say something like, “What happens on the day after someone has a knee replacement, appendectomy, or a C-section? They have them up walking, which may seem counterproductive to do so soon after a surgery. In fact, for low back pain, a common recommendation used to be to go home, get in bed, and wait it out. But, they realized that movement is healing. Part of the healing is getting the joints moving properly through manipulation and joint mobilization, but that’s just part of it. Another big aspect of it is exercise/rehab; both here in the office and at home.”
- The more you explain why you want them performing exercise/rehab and the more you stress that exercise/rehab is part of the protocol from the very start, the less resistance you tend to run into later down the road.
Re-examination & Re-evaluation
- After your initial recommendations are fulfilled, then what? You need to determine whether any further treatment is indicated and why it’s indicated. What was the patient’s response to your care?
- If you threw everything in your office including the kitchen sink at someone for 2-4 weeks for 6-12 visits and saw little to no improvement, do you think any further treatment is likely to bring about positive change? Not very likely. It’s times like these that I swallow my pride and, in the best interest of the patient and my reputation, I find them a referral to a reputable practitioner that may be better-suited to address the complaint. I wouldn’t want a family member of mine treated any differently so I don’t treat patients any differently.
- On the other hand, if the patient’s complaint is resolved, you should perform a final exam and outcome assessment questionnaire, make sure the patient is adequately educated on your recommendations going forward (exercise, maintenance care, etc.), and then release the patient from the active care protocol.
Benefit vs. Risk
- The authors state that chiropractic care is remarkably safe and effective, certainly when compared to our medical counterparts. Even though we all know this already, it never hurts to re-state the obvious. I hope you don’t mind.
- The paper says that serious adverse reactions to chiropractic care tend to only happen to the tune of 1 in 1 million patient visits when referring to treatment for low back pain.
- The authors went a little further by saying that, while adverse reactions were very rare, other more mild-moderate events were noticed like muscle soreness or stiffness. We see this in my office here and there as well. If they have never been to a chiropractor and then get sore after the first one or two visits, one could compare that to going to the gym after laying off for an extended time. You are doing something new and something different with the body. It makes sense for people to get a little sore sometimes.
Contraindications & Cautions:
Have you always been completely aware and knowledgeable on what constitutes a hard contraindication to chiropractic care? The authors try to help us all out here so listen up. This is a biggie. Since I feel the importance of knowing these are paramount to your longevity in practice, I am going to quote these conditions directly from the source(1) for accuracy. Don’t be caught having treated these conditions.
- General Conditions: severe osteoporosis, multiple myeloma, osteomyelitis, local primary bone tumors where osseous integrity is questionable, local metastatic bone tumors, Paget’s disease.
- Neurological Conditions: progressive or sudden neurological deficit (including cauda equina syndrome) or spinal cord tumors demonstrating neurological compromise (care may be appropriate after specialist investigation and clearance.)
- Inflammatory Conditions: rheumatoid arthritis in active systemic stage (or locally in the presence of inflammation or atlantoaxial instability), inflammatory phase of ankylosing spondylitis or psoriatic arthritis, or Reiter’s syndrome (reactive arthritis).
- Bleeding Disorders: congenital or acquired, unstable aortic aneurysm, etc.
- Other: structural instability, inadequate physical exam, or inadequate SMT training/skills.
Chronic Pain Management for Spinal Disorders:
These conditions can no longer be referred to as “acute” or “uncomplicated” as they are beyond 3 months in duration at the point of being labeled “chronic” and other factors must be considered in a robust treatment protocol. Some complications may include:
- Work environment, including ergonomics
- Work requirements
- Comorbidities. Some may wonder, “What the heck is that?!?” Well, that is when you have two or more other conditions occurring in addition to the initial diagnosis. Low back pain in addition to arthritis and diabetes is an example. Low back pain in addition to obesity and depression could be another.
- The history of the conditions’ prior treatments
- Lifestyle factors including bad habits
- Other psychological factors which may include depression, anxiety, etc….
Whew….that was a lot, right?
With such an amount of information to wade through, I would say, that Dr. Thistle did a great job of reviewing this paper for the American Chiropractic Association’s blog and I hope, in turn, that I have been able to bring even more clarity and maybe even relate it to my personal practice and your practice in a way that really drives home the need for more regulation and practice standards in our profession.
As the internet and the “Age of Information” has brought the world together, I believe the days of being a lone wolf and/or being an outlier may be numbered. When they say that ignorance is not a defense, that especially rings true now that information is at our very fingertips at all times of the day no matter where we may be.
You may agree with me that this is a good thing. You may disagree and think I’m off my rocker for wanting some standards in the profession. That’s OK. Differences in opinions is American to the core. Usually what triumphs is reason and, if you find these guidelines or those of the CCGPP to be reasonable guides, I hope you will consider giving them more thought and maybe even implement them into your regular treatment protocols.
Regardless of how you go about practicing, I’m a firm believer that we chiropractors can absolutely change the world when it comes to the treatment of non-complicated neuromusculoskeletal conditions of the body. Not just low back pain either, but the whole shebang. As I said last week, if we were wrong in what we do as a profession, we would have been wiped off the face of the Earth years ago. Lord knows they tried and keep trying.
We are still here because we are naturally right, but, we give our detractors ammunition for the battle when we are not holding ourselves and our profession to certain reasonable and responsible standards.