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You Need to Know Things
August 23, 2016 by Dr Matthew D. Long
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August 23, 2016 by Dr Matthew D. Long
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You Need to Know Things
August 23, 2016 by Dr Matthew D. Long
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I’ve made no secret of my opinion that the chiropractic profession needs to strongly stake its claim as the premier profession for managing non-surgical spine complaints. Of course, it’s not just me that has such views on this topic - the World Federation of Chiropractic has spent considerable time and resources in creating a task-force to formulate a clear identify for the profession. One that would embrace the historical uniqueness of chiropractic, whilst recognising the huge advances in scientific understanding that underpins our science and art. After much deliberation, the WFC came up with, "The spinal health care experts in the health care system." This positioning statement was built upon a foundation of ideas that hopefully form the bedrock of our uniqueness. According to the WFC, the chiropractic brand rests upon the constructs listed below.
Chiropractors have an:
Chiropractors have an:
Ability to improve function in the neuromusculoskeletal system, and overall health wellbeing and quality of life.
Specialised approach to examination, diagnosis and treatment, based on best available research and clinical evidence with particular emphasis on the relationship between the spine and the nervous system.
Tradition of effectiveness and patient satisfaction. Without use of drugs and surgery, enabling patients to avoid these where possible.
Expertly qualified providers of spinal adjustment, manipulation and other manual treatments, exercise instruction and patient education.
Collaboration with other health professionals.
Patient-centred and biopsychosocial approach, emphasising the mind/body relationship in health, the self-healing powers of the individual, and individual responsibility for health and encouraging patient independence.
You can read the WFC document in its entirety from the link below but, suffice to say, it paints a picture of the chiropractic profession as knowledgeable experts with a spine-focused identity. Interestingly, most public surveys that have examined general attitudes to chiropractic have strongly emphasised the notion that chiropractors are spine-care doctors. Indeed, spinal disorders are overwhelmingly the driver behind a patient's utilisation of chiropractic. Importantly, this means that our ‘brand awareness’ is already centred upon our expertise in spinal diagnosis. Or at least, that’s what the public expects from us…
A prognosis is central to effective patient management. Firstly, it creates waypoints along the road that help us to judge whether a patient is truly on track and recovering as expected. There are many conditions that will require extended time periods to improve and it is important that we have a clear idea of what to expect if the patient is (a) doing well, or (b) not doing well. If the patient has a protracted recovery, but this is anticipated and discussed with them at the outset, then we can reassure them that they are on track. If, however, we have no real idea of what to expect then we are effectively ‘flying by the seat of our pants’ and most patients will pick up on this uncertainty.
Let me give you an example.
Say that we are presented with two patients who both relay the same story. Each of them bent forward at an awkward angle and twisted to pick up an object from under their desk at work. Both felt an immediate ‘click’ in their lower back, accompanied by a sharp pain. Since this occurred they have both had great difficulty in straightening their torso, and there is a definite lean of their spine to the left side that they are unable to overcome. At this point, both of our patients have the same history. However, underneath there are two very different tissue injuries and two entirely different prognoses.
When you examine our two patients they both walk and move with the same list of their torso to the left, and show equal amounts of distress and disability. However, Patient A (let’s call him George) also commented that he has great difficulty arising from a chair. Patient B (we’ll call him Clyde) has no such trouble. While examining George you notice a significant increase in pain during a seated slump test. Although there is no radiation of pain to the legs, George does notice a marked increase in lower back pain during the procedure, particularly when his neck is then flexed forward. But this doesn’t bother Clyde at all. Interestingly, when palpating George’s lumbar spine there is no clear-cut focal point of tenderness within the lumbar spine. Springing upon each spinous process in turn evokes a mild sense of discomfort, but there is really nothing particularly tender. Clyde, on the other hand, nearly leaps from the table when you start to press upon the L4 spinous process.
So what does all this mean? The initial history, symptom presentation and disability are identical - but as we delve further into a very cursory clinical examination we quickly realise that there are distinct differences producing these effects.
It would be safe to say that George has most likely suffered a concentric tear in the outer one third of the annulus at L4-5, while Clyde has most likely suffered a facet joint lesion, possibly a meniscoid extrapment. If you have attended our live Spinal Diagnosis Module or done some of our other ACADEMIA online courses, then you would be able to follow the logic here. Suffice to say, there is a significant difference in the expected recovery time between a tear of the annulus fibrosus, and an injury of a zygapophysial joint. If we can determine this at the outset, then we can guide patient expectation through management and reassure them that they are on track. Furthermore, by detailing our diagnostic rationale to their general practitioner, we can also go a long way to reassuring them that we can triage and appropriately manage such patients.
Our ability to claim the territory for ‘non-surgical, non-pharmacological spine care' requires diagnostic expertise across the scope of spinal disorders and an ability to predict the outcome of treatment.
It is worth saying again that diagnosis gives prognosis. Our ability to claim the territory for ‘non-surgical, non-pharmacological spine care' requires diagnostic expertise across the scope of spinal disorders, and an ability to predict the outcome of treatment. As a spine expert, you are expected to know things.
You are expected to know the tissue-cause of a patient’s pain. You are expected to know the most reliable diagnostic tools for assessing and quantifying the degree of tissue damage present. You are also expected to know why a patient may be suffering pain when there is no clear tissue damage (such as a chronic pain syndrome of neuropathic origin). You are expected to know the range of options available to best treat the patient - whether they are actually delivered by you or by somebody else (the judicious use of a periradicular steroid to save the myelin sheath from permanent demyelination in significant sciatica is one such example). You are expected to understand the strengths and weaknesses of different imaging studies, and to use these intelligently to guide decision-making. You are expected to know the relevance of abnormalities when they appear on these studies. After all, a lumbar disc bulge is going to be found in 52% of the population (1), yet this doesn’t mean that it’s actually significant. You are expected to know when it is. You are also expected to weigh up all of these factors and arrive at a prognosis for the patient, together with the best evidence-supported management plan. Finally, you are expected to know how the story will play out for the patient, and be able to preemptively explain what recovery is going to look like.
For example, a patient suffering from lumbar disc herniation and radiculopathy is going to face a lengthy recovery period. They will probably have experienced pain, paraesthesia and numbness, all of which will hopefully recover over time. But what does this recovery look like? Should each of these variables get better at the same time? What is the ‘normal’ recovery for sciatica?
Well, we can learn from a recent paper in the journal SPINE entitled "How fast pain, numbness and paraesthesia resolves after lumbar nerve root decompression?". In this paper, Huang and Sengupta (2) documented the recovery of 85 patients with lumbar radiculopathy who were treated surgically. Although this was a surgical treatment, the data obtained does parallel that of patients treated non-surgically who do recover from nerve root compression.
Not surprisingly, pain was found to recover most quickly, within the first 6 weeks post-operatively. Most patients then were left with paraesthesia and numbness that persisted for some time. Typically paraesthesia would recover by the 3-month mark, while numbness takes up to a year to abate.
As spinal experts we are expected to know such things. Appreciating the recovery trajectory of our patients gives us the information to reassure them, and their GP, that they are on the right track. There is a wealth of such information in the biomedical literature, allowing us to assemble a clear picture of our patients' individual problems and their anticipated path to recovery. As spinal experts, we are expected to know these things. We must also demonstrate our expertise to other members of the health care team who are going to have an opinion. First and foremost, this is the patient’s GP, who will usually come to trust your judgement if you can highlight your deep appreciation for the evidence base and your ability to describe clearly your rationale for what you do. The chiropractic profession needs to appreciate the wealth of data out there for making better clinical decisions and use it to solidify our role as the spinal health care experts in the health care system.
Something to think about anyway…
Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)
You are expected to know the tissue-cause of a patient’s pain. You are expected to know the most reliable diagnostic tools for assessing and quantifying the degree of tissue damage present. You are also expected to know why a patient may be suffering pain when there is no clear tissue damage (such as a chronic pain syndrome of neuropathic origin). You are expected to know the range of options available to best treat the patient - whether they are actually delivered by you or by somebody else (the judicious use of a periradicular steroid to save the myelin sheath from permanent demyelination in significant sciatica is one such example). You are expected to understand the strengths and weaknesses of different imaging studies, and to use these intelligently to guide decision-making. You are expected to know the relevance of abnormalities when they appear on these studies. After all, a lumbar disc bulge is going to be found in 52% of the population (1), yet this doesn’t mean that it’s actually significant. You are expected to know when it is. You are also expected to weigh up all of these factors and arrive at a prognosis for the patient, together with the best evidence-supported management plan. Finally, you are expected to know how the story will play out for the patient, and be able to preemptively explain what recovery is going to look like.
For example, a patient suffering from lumbar disc herniation and radiculopathy is going to face a lengthy recovery period. They will probably have experienced pain, paraesthesia and numbness, all of which will hopefully recover over time. But what does this recovery look like? Should each of these variables get better at the same time? What is the ‘normal’ recovery for sciatica?
Well, we can learn from a recent paper in the journal SPINE entitled "How fast pain, numbness and paraesthesia resolves after lumbar nerve root decompression?". In this paper, Huang and Sengupta (2) documented the recovery of 85 patients with lumbar radiculopathy who were treated surgically. Although this was a surgical treatment, the data obtained does parallel that of patients treated non-surgically who do recover from nerve root compression.
Not surprisingly, pain was found to recover most quickly, within the first 6 weeks post-operatively. Most patients then were left with paraesthesia and numbness that persisted for some time. Typically paraesthesia would recover by the 3-month mark, while numbness takes up to a year to abate.
As spinal experts we are expected to know such things. Appreciating the recovery trajectory of our patients gives us the information to reassure them, and their GP, that they are on the right track. There is a wealth of such information in the biomedical literature, allowing us to assemble a clear picture of our patients' individual problems and their anticipated path to recovery. As spinal experts, we are expected to know these things. We must also demonstrate our expertise to other members of the health care team who are going to have an opinion. First and foremost, this is the patient’s GP, who will usually come to trust your judgement if you can highlight your deep appreciation for the evidence base and your ability to describe clearly your rationale for what you do. The chiropractic profession needs to appreciate the wealth of data out there for making better clinical decisions and use it to solidify our role as the spinal health care experts in the health care system.
Something to think about anyway…
Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)
References:
1. Jensen, M. C., Brant-Zawadzki, M. N., Obuchowski, N., Modic, M. T., Malkasian, D., & Ross, J. S. (1994). Magnetic resonance imaging of the lumbar spine in people without back pain. The New England Journal of Medicine, 331(2), 69–73.
2. Huang, P., & Sengupta, D. K. (2014). How Fast Pain, Numbness, and Paresthesia Resolves After Lumbar Nerve Root Decompression. Spine, 39(8), E529–E536. http://doi.org/10.1097/BRS.0000000000000240
1. Jensen, M. C., Brant-Zawadzki, M. N., Obuchowski, N., Modic, M. T., Malkasian, D., & Ross, J. S. (1994). Magnetic resonance imaging of the lumbar spine in people without back pain. The New England Journal of Medicine, 331(2), 69–73.
2. Huang, P., & Sengupta, D. K. (2014). How Fast Pain, Numbness, and Paresthesia Resolves After Lumbar Nerve Root Decompression. Spine, 39(8), E529–E536. http://doi.org/10.1097/BRS.0000000000000240