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Dynamic Chiropractic – April 9, 2007, Vol. 25, Issue 08
Dynamic Chiropractic
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Dynamic Chiropractic

The Clinical Audit Process and Functional Reactivation

By Craig Liebenson, DC

Modern management of musculoskeletal pain (MP) should be patient-centered and evidence-based. According to the World Health Organization's revised guidelines on disability, the goal of health care is to enable patients to return to participation and independent functioning in their chosen activities.12,15 This goal is patient-centered, not doctor-centered, in that the goal is restoration of activity tolerance, rather than removal of impairments.4 Most importantly, for the clinician this paradigm distinguishes the means of care (manipulation, medication, surgery, etc.) from the goals or ends of care (participation and resumption of activities).

Patient-centered care is offered within a biopsychosocial (BPS) context involving the three R's - red flags, reassurance and reactivation.14 Initial care should rule out red flags of serious disease. Once this is accomplished, the patient receives reassurance of the good overall prognosis for acute MP. Then the patient is advised of the safety of early, gradual reactivation.

Patients are interested in knowing the cause of their pain, the prognosis, what you can do for them, what they can do for themselves, and what they should be careful about.1,11 By ruling out red flags, you reassure patients that the cause is not medical or serious and that it is merely mechanical.2 It is also essential to review the positive prognosis unless there are red flags of serious disease, nerve root signs, or yellow flags of psychosocial complicating factors. The patient should be informed of the various evidence-based treatment options (manipulation, over-the-counter medication, heat or ice, etc.). The patient also should be trained in how to spare (ergonomics, lifting strategies, micro-breaks, etc.) and stabilize (motor control training) their spine.4,7,8 Lastly, patients should be warned of the risk of a poor recovery if they wait for the pain to go away before becoming active. Specifically, they should be advised that hurt does not equal harm and that deconditioning is dangerous.13

Practicing this model of MP management requires three basic things: a functional assessment, functional training and a clinical audit process (CAP). If the patient's goal of care is resumption of activities or participation; then rehabilitative management begins with a functional assessment screen.4,5 Evaluation of impairment is essential to identify the patient's "weak link." There are only a limited number of relevant impairments related to pain and activity intolerances. Less than 20 functional tests need to be screened to identify the patient's functional deficits or level of deconditioning.4,16,17 A clinical rehabilitation specialist (CRS) should master the craft of performing this functional assessment.

Once a functional assessment has identified the weak link that is related to the person's activity intolerances, functional training is necessary to stabilize the patient in their activities of daily living, job demands, or sports and recreational activities. Functional training involves a staged progression of therapeutic exercises, beginning with simple movement exploration. Learning to gently mobilize tissues (walking, swimming, biking, cat camel, thoracic extension mobilization, lower extremity flexibility training, etc.) is important for load sharing, as it reduces repetitive strain. Movement exploration should occur with an emphasis on coordinated movement in a relatively pain-free range of motion (ROM). This "painless and appropriate range for the task" is defined as the patient's "functional range."4,10

Functional training progresses from simple, uncomplicated movement exploration to low-load neuromuscular training, which isolates key stabilizers (transverse abdominus, multifidus, quadratus lumborum, gluteus maximus, etc.) or movement stereotypes (hip hinge, trunk curl, single-leg-stance balance, cervicocranial flexion, etc.). These exercises should emphasize coordination and endurance training. Coordination means agonist-antagonist muscle coactivation, "neutral" joint control and avoidance of abnormal substitution movement patterns.

Functional training is complete when progress to functional activities as exercise has occurred (e.g., squats, lunges, pushing and pulling). This final stage (stage 3) of functional integrated training (FIT) is achieved when the patient has demonstrated appropriate load sharing via mobilization (stage 1) and neuromuscular isolation of key stabilizers or movement patterns (stage 2).

Fortunately, functional training requires knowledge of only approximately 20 families of related exercises4 (e.g., dead bugs, bird dogs, side bridges, squats, lunges, functional reaches, etc.). A CRS should master the craft of training patients in all of these exercises and their variations.

In order to avoid performing all 20 functional screens and training patients in all 15 different exercise tracks, the CAP is needed to customize the patient's self-care exercise prescription. The CAP is the art that allows the CRS to utilize functional assessment and training efficiently and appropriately for each individual patient. The CAP involves identifying for each patient their unique mechanical sensitivity (MS) and abnormal motor control (AMC).

The patient's MS is the movements and positions which reproduce their characteristic symptoms.9 For instance, orthopedic tests or ROM tests can identify the patient's MS or the limits of their functional range (FR). In the CAP, the appropriate office or self-care prescription is identified when, through empirical trial, a treatment is found which reduces the patient's MS. Such "within-session" improvement in ROM testing has been shown to result in a 3.5 greater likelihood of "between-session" improvement for the patient.3 In fact, exercise prescribed according to one's directional preference has been shown to be superior to evidence-based care. If the "holy grail" of MP management is to be able to accurately identify patients likely to have a speedy recovery, versus those who are prone to chronicity, then using the patient's MS as part of the CAP is a revolutionary approach in patient care.6 In a nutshell, evaluation of the patient's MS identifies the starting point for therapeutic exercise.

The patient's AMC is defined as uncoordinated movement patterns (e.g., Janda's hip extension or abduction patterns).4 Once a patient's MS declines, exercise can proceed to address the patient's AMC. This is why the patient's FR is defined by Morgan as "the painless and appropriate range for the task at hand."10

The key to managing MP is to reassess, reassess and reassess. Clinical rehabilitation specialists should learn the craft of about 20 functional tests and 20 families of exercise. But to really gain clinical success in this field requires expertise in utilizing a CAP to identify the beginning point for self-care and patient progressions. Patient-centered care always should be offered within a BPS model, which begins with the patient's participation and activity goals and ends when independent function is restored.

References

  1. Butler D, Moseley L. Explain Pain. Australia: Noigroup Publications, 2003.
  2. European Guidelines for the Management of Acute Nonspecific Low Back Pain in Primary Care. Preliminary draft. www.backpaineurope.org.
  3. Hahne A, Keating JL, Wilson S. Do within-session changes in pain intensity and range of motion predict between-session changes in patients with low back pain? Australian Journal of Physiotherapy, 2004;50:17-23.
  4. Liebenson C. Rehabilitation of the Spine, A Practitioner's Manual, 2nd edition. Baltimore: Lippincott/Williams and Wilkins, 2007.
  5. Linton SJ. The socioeconomic impact of chronic back pain: is anyone benefiting? Editorial. Pain, 1998;75:163-168.
  6. Long A, Donelson R, Fung T. Does it matter which exercise? Spine, 2004;29:2593-2602.
  7. McGill SM. Low Back Disorders: Evidence Based Prevention and Rehabilitation. Illinois: Human Kinetics Publishers, 2002.
  8. McGill SM. Ultimate Back Fitness and Performance. Wabunu, 2004.
  9. McKenzie R, May S. The Lumbar Spine Mechanical Diagnosis & Therapy, Vol. 1 & 2. New Zealand: Spinal Publications, 2003.
  10. Morgan D. Concepts in functional training and postural stabilization for the low-back-injured. Top Acute Care Trauma Rehabil, 1988;2:8-17.
  11. Turner JA. Educational and behavioral interventions for back pain in primary care. Spine, 1996;21:2851-9.
  12. Victorian WorkCover Authority. Clinical Framework. www.workcover.vic.gov.au.
  13. Vlaeyen JWS, Linton S. Fear-avoidance and its consequences in chronic musculoskeletal pain. A state of the art. Pain, 2000;85:317-332.
  14. Waddell G. The Back Pain Revolution, 2nd edition. Edinburgh: Churchill Livingstone, 2004.
  15. World Health Organization. International Classification of Human Functioning, Disability and Health: ICF. Geneva: WHO, 2001.
  16. Yeomans S, Liebenson CS. Quantitative functional capacity evaluation: The missing link to outcomes assessment. Topics in Clinical Chiropractic, 1996;3:1;32-44.
  17. Yeomans S, Liebenson CS. Functional capacity evaluation and chiropractic case management. Topics in Clinical Chiropractic, 1996;3:3;15-26.

Click here for more information about Craig Liebenson, DC.

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