Chronic Pain

Algorithms for the Chiropractic Management of Acute and Chronic Spine-Related Pain

By Frank M. Painter|March 26, 2013|Algorithm, Chiropractic Care, Chronic Pain, Evidence-based Medicine, Spinal Manipulation|

Algorithms for the Chiropractic Management of Acute and Chronic Spine-Related Pain

The Chiro.Org Blog

SOURCE: Top Integrative Health Care 2012 (Dec 31); 3 (4)

Gregory A. Baker, DC, Ronald J. Farabaugh, DC,
Thomas J. Augat, DC, MS, CCSP, FASA,
Cheryl Hawk, DC, PhD, CHES

The complexity of clinical documentation and case management for health care providers has increased along with the rise of managed care. Keeping up with the policies of different insurers and third party administrators can be a daunting task. To address these issues for doctors of chiropractic (DCs) and policymakers, the Council for Chiropractic Guidelines and Practice Parameters (CCGPP) developed three consensus documents. Each of these documents was the outcome of a formal consensus process in which a multidisciplinary Delphi panel consisting of experts in chiropractic and low back pain treatment came to agreement on terminology and treatment parameters for the chiropractic management of spine-related musculoskeletal pain. [1-3]

Introduction:

The complexity of clinical documentation and case management for health care providers has increased along with the rise of managed care. Keeping up with the policies of different insurers and third party administrators can be a daunting task. To address these issues for doctors of chiropractic (DCs) and policymakers, the Council for Chiropractic Guidelines and Practice Parameters (CCGPP) developed three consensus documents. Each of these documents was the outcome of a formal consensus process in which a multidisciplinary Delphi panel consisting of experts in chiropractic and low back pain treatment came to agreement on terminology and treatment parameters for the chiropractic management of spine-related musculoskeletal pain. [1-3] Their recommendations were based on a combination of consideration of the current evidence and their clinical judgment. In addition, another consensus document related to care rendered by doctors of chiropractic for the purpose of health promotion, disease prevention, and wellness, developed through a project funded by the NCMIC Foundation, was also referenced to clarify terminology used in the algorithms. [4] (See Table 1.)

There are more articles like this @ the:

Clinical Model for the Diagnosis and Management Page and the:

Chronic Neck Pain and Chiropractic Page and the:

Low Back Pain and Chiropractic Page

Table 1.
Definition of terms related to acute and chronic care

The terms “supportive care” and “maintenance care,” which are frequently used within the chiropractic health care arena, are not consistent with general healthcare industry lexicon. Instead of “supportive care,” we use the more descriptive term, “ongoing/recurrent” care.

Chronic pain management can be divided into three categories:

those who can home manage;
those who can be managed with episodic care; and
those who need “scheduled” ongoing care, which is a very small proportion of chronic pain sufferers. Those patients require proper documentation of responses to care and procedures, including therapeutic withdrawal response, multi-modal, multi-disciplinary consideration, patient education, etc.

(more…)

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Predictors of Outcome in Neck Pain Patients

By Frank M. Painter|August 25, 2012|Chiropractic Care, Chronic Pain, Neck Pain, Radiculopathy, Spinal Manipulation|

Predictors of Outcome in Neck Pain Patients Undergoing Chiropractic Care: Comparison of Acute and Chronic Patients

The Chiro.Org Blog

SOURCE: Chiropractic & Manual Therapies 2012 (Aug 24); 20 (1): 27

Cynthia K Peterson, Jennifer Bolton, B. Kim Humphreys

University of Zürich and Orthopaedic University Hospital Balgrist, Forchstrasse 340, 8008 Zürich, Switzerland

Background Neck pain is a common complaint in patients presenting for chiropractic treatment. The few studies on predictors for improvement in patients while undergoing treatment identify duration of symptoms, neck stiffness and number of previous episodes as the strong predictor variables. The purpose of this study is to continue the research for predictors of a positive outcome in neck pain patients undergoing chiropractic treatment.

Methods Acute (< 4 weeks) (n = 274) and chronic (> 3 months) (n = 255) neck pain patients with no chiropractic or manual therapy in the prior 3 months were included. Patients completed the numerical pain rating scale (NRS) and Bournemouth questionnaire (BQ) at baseline prior to treatment. At 1 week, 1 month and 3 months after start of treatment the NRS and BQ were completed along with the Patient Global Impression of Change (PGIC) scale. Demographic information was provided by the clinician. Improvement at each of the follow up points was categorized using the PGIC. Multivariate regression analyses were done to determine significant independent predictors of improvement.

Results Baseline mean neck pain and total disability scores were significantly (p < 0.001and p < 0.008 respectively) higher in acute patients. Both groups reported significant improvement at all data collection time points, but was significantly larger for acute patients. The PGIC score at 1 week (OR = 3.35, 95% CI = 1.13-9.92) and the baseline to 1 month BQ total change score (OR = 1.07, 95% CI = 1.03-1.11) were identified as independent predictors of improvement at 3 months for acute patients. Chronic patients who reported improvement on the PGIC at 1 month were more likely to be improved at 3 months (OR = 6.04, 95% CI = 2.76-13.69). The presence of cervical radiculopathy or dizziness was not predictive of a negative outcome in these patients.

CONCLUSIONS: The most consistent predictor of clinically relevant improvement at both 1 and 3 months after the start of chiropractic treatment for both acute and chronic patients is if they report improvement early in the course of treatment. The co-existence of either radiculopathy or dizziness however do not imply poorer prognosis in these patients.

There are more articles like this @ our:

Chronic Neck Pain and Chiropractic Page and the

A Clinical Model for the Diagnosis and Management Page

From the FULL TEXT Article:

Background

Patients suffering from neck pain are second only to low back pain patients in terms of the frequency of presentation for chiropractic treatment [1-4]. For many of these patients the precise diagnosis is difficult to ascertain and thus becomes labeled ‘non-specific’ neck pain or neck pain from mechanical dysfunction [1,3-5]. Research evidence has yet to determine with clarity whether spinal manipulative therapy (SMT) or mobilization of the neck is the superior treatment for these patients [1-9] although it appears that both of these treatments have better outcomes when combined with exercise [5,10]. (more…)

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What is Different About Spinal Pain?

By Frank M. Painter|August 7, 2012|Chronic Pain, Pain Relief, Spinal Manipulation|

What is Different About Spinal Pain?

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SOURCE: Chiropractic & Manual Therapies 2012 (Jul 5); 20 (1): 22 ~ FULL TEXT

Howard Vernon, DC, PhD

Division of Research,
Canadian Memorial Chiropractic College,
Toronto, ON, Canada.
hvernon@cmcc.ca

BACKGROUND: The mechanisms subserving deep spinal pain have not been studied as well as those related to the skin and to deep pain in peripheral limb structures. The clinical phenomenology of deep spinal pain presents unique features which call for investigations which can explain these at a mechanistic level.

METHODS: Targeted searches of the literature were conducted and the relevant materials reviewed for applicability to the thesis that deep spinal pain is distinctive from deep pain in the peripheral limb structures. Topics related to the neuroanatomy and neurophysiology of deep spinal pain were organized in a hierarchical format for content review.

RESULTS: Since the 1980’s the innervation characteristics of the spinal joints and deep muscles have been elucidated. Afferent connections subserving pain have been identified in a distinctive somatotopic organization within the spinal cord whereby afferents from deep spinal tissues terminate primarily in the lateral dorsal horn while those from deep peripheral tissues terminate primarily in the medial dorsal horn. Mechanisms underlying the clinical phenomena of referred pain from the spine, poor localization of spinal pain and chronicity of spine pain have emerged from the literature and are reviewed here, especially emphasizing the somatotopic organization and hyperconvergence of dorsal horn “low back (spinal) neurons”. Taken together, these findings provide preliminary support for the hypothesis that deep spine pain is different from deep pain arising from peripheral limb structures.

CONCLUSIONS: This thesis addressed the question “what is different about spine pain?” Neuroanatomic and neurophysiologic findings from studies in the last twenty years provide preliminary support for the thesis that deep spine pain is different from deep pain arising from peripheral limb structures.

From the FULL TEXT Article:

Introduction

Case scenario

A 45-year old male presents with chronic lumbosacral pain and some pain in the posterior thigh. Examination rules out any overt disc herniation with radiculopathy. X-rays show no spinal pathology.

Basic differential diagnosis options:

Back pain with referred leg pain (one problem with two clinical manifestations: one primary, the other secondary)
Back pain and an associated, but not causally connected problem in the posterior thigh (two separate problems)Both of these options share an acceptable clinical logic; their distinction would be made on the basis of further history and examination for signs that were consistent with one or the other explanation.However, there is a third option to consider:
Primary problem in the thigh referring pain to the back (reverse circumstances to #1).

It is my contention that this third option does not enjoy the same “clinical logicalness” as the first two, and would very likely not even be entertained as a possibility.

In this paper, I would like to explore why this is so. The answer that compels itself is rather simple, but not widely accepted to date: pain from deep spinal tissues is different than pain from deep tissues of the peripheral somatic structures (upper and lower limbs as well as the facial region), and the nature of referred pain from these structures is one of the critical distinctions.ms, especially at the level of the periphery and the spinal cord [122-124]. However, the degree to which any of the vast amount of work on animal models correlates directly with human clinical phenomena is an ongoing challenge. In the present report, a confluence of evidence from animal and human studies is presented which appear to provide reasonable support for the primary thesis.

A second challenge lies in the circumstances for which a claim of distinction between spinal vs peripheral pain is tenable. In the discussion of referred pain, above, mention was made of various clinical circumstances where our thesis ought not be applied or where such application would be challenging. This situation reflects the complexities inherent in the topic of deep pain as well as the limitations of applying any one theoretical mechanism to that problem and to the problem of chronic pain in general.

The distinction which was already made between somatic referred pain and radicular or neuropathic pain from spinal or peripheral neural entrapment syndromes should not pose a challenge to my thesis as these are clearly distinct pain mechanisms.

Pain behaviors in syndromes which are based on disturbed central pain mechanisms such as in central post-stroke pain and in fibromyalgia pose a modest challenge to my thesis. In these syndromes, normal pain mechanisms at the level of the periphery and spinal cord are substantially altered by centrally-generated mechanisms, making the kind of comparisons between deep spinal and peripheral pain mechanisms which we discuss in this thesis much more problematic [125, 126]. Pain referral patterns in these syndromes may not adhere to the strict distinctions we have drawn here between spinal and peripheral limb sources. However, these syndromes are relatively easy to diagnose, so that the clinician is likely to be aware that this is the basis for non-conventional pain referral patterns (especially proximal referral from the limbs, which may be found in some fibromyalgia patients).

The greatest challenge to my thesis appears to arise in regard to the phenomenon of myofascial trigger points (MTrP) either as singular entities or as part of what may be diagnosed as ‘regional myofascial pain syndrome’. Here, we may be required to distinguish between “spread of pain” vs referral of pain. MTrP’s on the torso and in the peripheral limb muscles appear to generate both spread of local pain as well as referral of pain, to distant sites [46, 47, 127-130]. “Spread” of pain is generally regarded as based on peripheral sensitization [46, 47, 127, 128, 130, 131] and may be related to local hyperalgesia. As pain or tenderness spread out from the hyperalgesic zone, this may appear to include proximal sites; however, this should be distinguished from proximal pain referral. With regard to actual referral of pain, Simons has opined that at least 85 % of MTrP’s refer pain in a distal direction [131], and this is generally in accord with my thesis. In the minority of other cases, perhaps what appears to be ‘proximal referral’ may actually be local spread to include some proximally located distribution within the same muscle or within the same sclerotome. This would make actual referral of pain from a peripherally-located MTrP to the spine itself, much less common whereas the opposite is much more common. This, again, is generally in accord with my thesis.
sis is both speculative and provocative at the same time.

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Lower Back Trauma (Lumbar Spine and Pelvis)

By Frank M. Painter|May 20, 2012|Chiropractic Care, Chronic Pain, Evidence-based Medicine, Low Back Pain, Orthopedic Tests, Rehabilitation, Spinal Manipulation|

Lower Back Trauma (Lumbar Spine and Pelvis)

The Chiro.Org Blog

Clinical Monograph 24

By R. C. Schafer, DC, PhD, FICC

Although it may be easier to teach anatomy by dividing the body into arbitrary parts, a misinterpretation can be created. For instance, we find clinically that the lumbar spine, sacrum, ilia, pubic bones, and hips work as a functional unit. Any disorder of one part immediately affects the function of the other parts. We should also keep in mind that an axial kinematic chain of weight-supporting segments extends from the occipital base to the soles of the feet.

Because the number of professional papers concerning the cause and diagnosis of low-back pain is voluminous, emphasis herein is placed on points that the author believes are important but not often emphasized in popular literature.

BACKGROUND

A wide assortment of muscle, tendon, ligament, bone, nerve, and vascular injuries in this area is witnessed during posttrauma care. As with other areas of the body, the first step in the posttrauma examination process is knowing the mechanism of injury if possible. Evaluation can be rapid and accurate with this knowledge.

Low-back disability rapidly demotivates productivity and athletic participation. The mechanism of injury is usually intrinsic rather than extrinsic. The cause can often be through overbending, a heavy steady lift, or a sudden release –all which primarily involve the muscles. IVD disorders are more often, but not exclusively, attributed to extrinsic blows and intrinsic wrenches. An accurate and complete history is invariably necessary to offer the best management and counsel.

Initial Assessment

A player injured on the field or a worker injured in the shop should never be moved until emergency assessment is completed. Once severe injury has been eliminated, transfer to a backboard can be made and further evaluation conducted at an aid station.

Neurologic Levels

Neurologic assessment should be made as soon as logical. Muscle tonus (flaccidity, rigidity, spasticity) by passive movements is determined. Voluntary power of each suspected group of muscles against resistance is tested, and the force is compared bilaterally. Check pupil size, ability to follow finger motion, and reaction to light. Cremasteric (L1–L2), patellar (L2–L4), gluteal (L4–S1), suprapatellar, Achilles (L5–S2), plantar (S1–S2), and anal (S5–Cx1) reflexes are evaluated. Patellar and ankle clonuses are noted. Coordination and sensation by gait, heel-to-knee and foot-to-buttock tests, and Romberg’s station test are checked. These are typical minimal evaluations.

Initial Assessment

Tenderness. Tenderness is frequently found at the apices of spinal curves and not infrequently where one curve merges with another. Tenderness about spinous or transverse processes is usually of low intensity and suggests articular stress. Tenderness noted at the points of nerve exit from the spine and continuing in the pathway of the peripheral division of the nerves is a valuable aid in spinal analysis pointing to a foraminal lesion. However, the lack of tenderness is not a clear indication of lack of spinal dysfunction. Tenderness is a subjective symptom influenced by many individual structural, functional, and psychologic factors that can make it an unreliable sign. An area for clues sometimes overlooked is the presence and symmetry of lower-extremity pulses.

Keep in mind that lumbopelvic tenderness as well as pain can be referred from pelvic and lower abdominal viscera.

LUMBAR SUBLUXATION SYNDROMES

Functional revolts associated with subluxation syndromes can manifest as abnormalities in sensory interpretations and/or motor activities. These disturbances may be through one of two primary mechanisms: direct nerve disorders or be of a reflex nature.

Nerve Root Insults

Read the rest of this Full Text article now!

Enjoy the rest of Dr. Schafer’s Monographs at:

Rehabilitation Monograph Page

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ACOEM Recognizes the Value of Chiropractic for Chronic Spinal Pain

By Frank M. Painter|April 4, 2012|Chiropractic Care, Chronic Pain, Guidelines, Spinal Manipulation|

ACOEM Recognizes the Value of Chiropractic for Chronic Spinal Pain

The Chiro.Org Blog

SOURCE: Dynamic Chiropractic 2008 (Sep 23); 26 (20): 1

Tina Beychok, Associate Editor

Pain is the most prevalent health condition among U.S. workers and the most expensive in terms of lost productivity. Recent studies suggest more than six in 10 adults over the age of 30 experience chronic pain. Furthermore, health care expenditures for back and neck pain have risen to more than $80 billion a year in the U.S. – a dramatic increase over the past eight years, without evidence of improved health. In addition to the costs of lost productivity, an estimated $64 billion per year is lost due to workers continuing to work, even though pain reduces their job performance. This phenomenon is called “presenteeism.”

Unfortunately, workers’ comp can be a quagmire of contradictory and insufficient rules and regulations as to what treatments are and aren’t covered. The American College of Occupational and Environmental Medicine (ACOEM) has been in the process of revising its Occupational Medicine Practice Guidelines, which have not always taken a positive view of chiropractic manipulation. In fact, the second edition of the guidelines, released in 2005, was heavily criticized by some in the chiropractic community. [1]

ACOEM’s latest chronic pain guidelines (a chapter of the overall guidelines) may represent a step in the right direction in terms of recognizing the value of chiropractic care. The guidelines actually recommend manipulation for chronic, persistent low back or neck pain and cervicogenic headache. [2] This is significant because in the past, the guidelines failed to recommend manipulation, even when other treatment strategies (medication, etc.) were rated as less effective.

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