"Soft-tissue methods" is a broad term that includes everything from varieties of stretching and strengthening exercises to fascial release techniques, instrument-assisted, soft-tissue mobilization and other techniques too numerous to mention.The point is that spinal adjustment/manipulation by itself for musculoskeletal problems, without the addition of soft-tissue methods, does not meet the criteria necessary for improving the function and disability of patients.
A recent study by Gross, et al.,1 updated 11 systematic reviews of randomized controlled trials for acute, subacute and chronic mechanical neck disorders. Dr. Arthur Croft cited this paper in DC earlier this year2 as strong evidence in justifying our care when questioned by a utilization review board or individual peer-reviewer. The findings of the study were divided between "level of evidence" (strong, moderate and limited) and "treatment category," such as manipulation, acupuncture, electrotherapy, etc. Under "strong evidence," they found that multimodal approaches (including stretching/strengthening exercise and mobilization/manipulation) for subacute/chronic mechanical neck disorders, neck disorders with headache and neck disorders with radicular findings reduced pain, improved function and resulted in favorable global perceived effect.
As Dr. Croft noted, medical or pharmaceutical therapies of any kind were not included in this category. Of interest, under the category of "evidence of no benefit" was home exercise, hot packs, electromechanical stimulation and ultrasound; and only short-term evidence was found for manipulation alone, various massage techniques, laser for myofascial pain, infrared light, static traction, spray and stretch, electrotherapies, galvanic current, iontophoresis, magnetic necklace and neck school, among others. (Read the article for additional treatment options.)
While the article did not enumerate any specific stretching or strengthening techniques, what stands out is that the multimodal approach including manipulation was more effective than manipulation alone. Further study as to what type of soft-tissue method is most applicable in any particular musculoskeletal type problem is an ongoing search. However, the most significant point is that manipulation alone cannot be considered an end-all therapy. Soft-tissue and rehabilitation methods must be emphasized to a greater degree in particular sections of the chiropractic world. Were the areas of muscle/fascial restriction still limiting the range of joint motion? Has the gait and posture improved? Is the core maintained? Are advanced stretching and strengthening necessary?
If your "maintenance" treatment is based solely on an adjustment, it is evident that your original evaluation did not include soft-tissue assessment.
- Gross AR, Goldsmith C, Holving JL, et al. Cervical Overview Group. Conservative management of mechanical neck disorders: a systematic review. J Rheumatol, 2007;34(3):1083-102.
- Croft AC. Critical new developments in the safety and efficacy of chiropractic treatment, part 1. Dynamic Chiropractic, Jan. 1, 2008. Available online at www.chiroweb.com/archives/26/01/03.html.
Click here for previous articles by Warren Hammer, MS, DC, DABCO.