'Maintenance' manual therapy: Is it time to stop discharging patients?

The story starts off nicely.  Jack comes in with chronic non-specific low back pain and a bit or right leg pain of 6-8 months in duration.  He has tried a number of medications, has rested and tried to modify activities, however he just can’t seem to shake it.  You question and test for a directional preference but nothing surfaces.  FOTO has given Jack a low fear score and while you didn’t actually give him The Pain Catastrophizing Scale, FABQ, or Orebro, you see no indication for pain science education early on.  The prone instability test is negative and there are no aberrant motions during lumbar flexion.   Jack reports years back that he had a similar episode and a physical therapist cracked his back which he found very helpful.   Considering the info and the positive expectations for thrust manipulation, your first few treatments focus on HVLAT and basic ROM exercises to the lumbopelvic region.  After two weeks Jack’s pain is down 50%, you have already pole vaulted well over the expected FOTO change, and he has referred his wife to you in hopes of the same excellent results.  He backs it down to one session over the next few weeks and with your encouragement returns to all of the activities he loves.  You and Jack decide to wrap it up as he reports “feeling better than I have in years” and shows minimal disability on FOTO.  Spirits are high, time for a successful discharge and for Jack to enjoy a life with minimal back pain! It is a wonderful story and a very nice picture to paint, unfortunately evidence suggests this is not how it usually goes down.  To be fair, a lot of it IS true.  In fact, MOST of it is true.  Right up to the last sentence, this is a scenario that plays out on a daily basis in clinics including mine all across our country.  To get the whole picture however, let’s peek at some literature where they examined the use of spinal manipulation in the treatment of CLBP.  In 2011 Senna and colleagues looked at an intensive course of spinal manipulation (12 tx over 1 month) compared to a “maintenance” group which got the same intensive course but also received a session of spinal manipulation every two weeks for the following nine months1.  Take a look at the chart below.  The difference between the ‘maintained’ and ‘no maintained’ is striking to say the least.

Another article by Descarreaux and colleagues examined an intensive one month period of spinal manipulation followed by no treatment, versus preventative spinal manipulation for chronic low back pain2.  This second chart is pulled from that article (black squares represent maintained manipulation), look familiar? Here again is this nice drop in disability during the initial “intensive” period of thrust manipulation treatments.  Over the next 9 months the group that received “preventative” spinal thrust manipulation once every three weeks continued to improve whereas the discharged group watched their progress slowly and steadily erode.

This data brings up a question:  Should the generally accepted plan consisting of intensive treatment followed by the complete discontinuing of care be challenged?  Just the other day I had a patient come in who I treated two years earlier for recurrent non-complicated low back pain.  I asked him how I could help today and he literally said the following: “Sorry I am back Jeff, I fell off from my exercises and my job has been demanding a lot more sitting out of me this past few months.  I really tried to shake it by getting back to my workouts but I think my current job demands are making it impossible.  It has been worsening to the point that I am struggling to concentrate so I finally had to call you”.  While it's great this patient is trying to use exercise and activity modification to take control of his symptoms, it is borderline ridiculous that he would be out there suffering through his days reluctant to reach out for my help.  Thinking back to his last few visits it makes a lot of sense though.  I made plenty of comments along these lines:  “You’ve got to avoid sitting for long periods if you don’t want this to come back” and “You have control of this now, you don’t need me anymore”.  All fine and dandy, but completely absent were comments like these:  “If this tightens up on you again just give me a buzz and get back in here” ; “Don’t let it get really bad next time, swing in earlier so we can tune you up with a few visits and refresh the stretching program if needed”.  I mean seriously, do dentists clean your teeth once and then expect you to abstain from any potential cavity causing substances?  No, they accept that life throws dietary challenges your way and they hope to see you on a somewhat regular basis to tune things up and make sure they don’t get head down a bad path.  Sure these dentists remind you to drink less soda and eat less chocolate, but they don’t hammer it so hard that you suffer with a severe toothache for months on end before calling out of fear that you let them down!  In an effort to empower this guy and prevent dependency I went too far.  No longer did he feel like we were a therapeutic team going forward, it was as though I told him "Hey I've done my job, now don't screw it up".   Slice it how you will, from a business and customer service perspective this was a significant fail.

I know many will be tempted to turn this into a discussion about how adding cognitive behavioral therapy or specific stabilization exercises or additional interventions beyond HVLAT and lumbopelvic ROM exercises would be the solution, and certainly I welcome and appreciate that conversation.    However looking at a recent systematic review for stabilization exercises we see “no significant effect in the long term…”3 while dramatic improvement with cognitive functional therapy during an intensive period is seen to be slowly back peddling as the year mark nears in a piece by Fersum et al.4. Honest reflection on my clinical experience supports this literature with patients often doing great for a period of time after ‘discharge’ only to lose half of that progress in the few months that follow.   In response to this emerging data my goodbyes to patients look a lot different these days.  While I still stress the importance and value of self-management, I also let each patient know that we understand life happens, and we are here to give them a boost up whenever they need it.   We should be coming alongside patients for a lifetime, not for 6-8 weeks.  “Am I discharged?” they ask me, “never, but get out there and fight the good fight, tap me whenever I can be of service”.

Thoughts?

References:

  1. Senna, M. K., & Machaly, S. a. (2011). Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome? Spine, 36(18), 1427–37
  2. Descarreaux, M., Blouin, J. S., Drolet, M., Papadimitriou, S., & Teasdale, N. (2004). Efficacy of preventive spinal manipulation for chronic low-back pain and related disabilities: A preliminary study. Journal of Manipulative and Physiological Therapeutics, 27(8), 509–514.
  3. Smith, B. E., Littlewood, C., & May, S. (2014). An update of stabilisation exercises for low back pain: a systematic review with  meta-analysis. BMC Musculoskeletal Disorders, 15(1), 1–21
  4. Vibe Fersum, K., O’Sullivan, P., Skouen, J. S., Smith, a, & Kvåle, a. (2012). Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial. European Journal of Pain (London, England).