Maintenance Care

Maintenance and other forms of long-term chiropractic care have been stigmatized as a result of association with questionable ideas and practices. This is unfortunate because the biomechanical, pathological and physiological changes that underlie most spinal pain syndromes require maintenance and long-term care.

Instead of establishing sensible approaches to maintenance and long-term care and providing education to the public, many chiropractors avoid this stigma by denouncing the "long term" of care and championing symptom-based care. This is most unfortunate because symptom-based care does little to correct those underlying changes.

This article outlines those underlying changes, why symptom based care is inadequate, and describes a sensible, "easy to explain and justify" approach to long-term and maintenance spinal care. It is based upon my book.¹

Introduction

In a spinal pain syndrome, a number of things may cause pain: facet joints may have become inflamed; muscles may have become tight and painful; a disc may be injured, and so forth. If the source of pain is inflamed facets, a symptom-based practitioner may prescribe rest, anti-inflammatory drugs or some form of therapy. The inflammation would go away, and the treatment would be seen as successful. Similar treatment philosophy would be used for other sources of pain.

Those familiar with spinal pain syndromes will realize that patients treated in such a manner will likely continue to experience episodes of pain, and eventually end up with a degenerated spine. Why? Facets inflame for a reason. Muscles tighten for a reason. They do so as a result of factors that usually include an underlying change to the spine's function and structure.

The Underlying Changes to a Spine

Over a person's lifetime, the spine is usually subject to trauma, abnormal stress and other forms of abuse. When the spine is injured, the natural response is for the body to make adaptations to take the load off the effected joint while it heals. Such adaptations may include tightening intrinsic muscles to immobilize the area, adopting an unnatural static position and the recruitment other joints to compensate.

It is known that changes gradually occur to immobilized or unusually stressed joints. For example, muscles and ligaments associated with the immobilized joint will shorten and/or waste. Some scar tissue may form. If healing is prolonged, or damage is repeated (such as occurs with habitual bending and twisting or poor posture), these changes will become significant and will result in the abnormal spinal biomechanics remaining. Abnormal spinal biomechanics may cause the following to occur.

Functional Changes

• The relationship between facet joint surfaces may alter, creating abnormal stress.


• There may be various forms of interference to nerve roots.


• Muscles may become chronically tight, under abnormal load, or be underused.


• Joints may become hypermobile in compensation for hypomobile joints.


• The body may use further compensatory measures to protect from the ongoing injury caused by the four factors listed above.


• Neurological feedback from joints is used to control balance, movement and coordination. Abnormal joints will send abnormal information, interfering with these processes.

Structural Changes

• The muscles and ligaments associated with hypomobile joints will waste and become fibrosed. It should be noted that this will cause increased hypomobility, making the problem progressively worse.


• Without the pumping effect of movement, joint linings and discs associated with hypomobile joints will be deprived of nutrients and will suffer a build-up of waste products, causing gradual deterioration.


• There will be a readaptation of muscles and ligaments to suit the abnormal movement.


• The growth of young bone responds to stress, while older bone remodels with osteophytes. Long-term functional changes will cause changes in bony structure.

Why This Condition May Not Cause Pain for Years

Despite all the changes and abnormal stress, this condition may persist causing ongoing deterioration for years without causing pain. Some reasons follow:

• Abnormally loaded muscles may become tender and develop myofascial trigger points. Pain will not occur until something such as a strain or a chill finally aggravates them.


• When a disc develops tears, it is not until the tear reaches the innervated outer layers that pain signals are generated.


• Just as mild sunburn is not painful unless slapped, mildly irritated and damaged facet joints may not be painful until aggravated.


• Spinal degeneration has to be substantial before there is bony occlusion of the nerve root pathways.


• A spine may stiffen significantly before there is not enough pain-free movement to do essential tasks.


• Compensating parts may cope with the extra demands for a long time before deteriorating or being unable to cope.

Why Symptom-Based Care Usually Does Not Correct the Underlying Problem

Significant wasting occurs to an arm or leg placed in a cast for six weeks. Frozen shoulders may result from a relatively short period of immobilization. These examples demonstrate how significant and rapid structural changes may occur due to abnormal function and help explain the possible extent of changes to the spine as a result of years of dysfunction. Short-term intervention will not restore the function of the spine back to normal. Why? With significant changes to structural and functional elements such as muscles and ligaments, the spine will be unable to function normally, and the spine must function normally over a long period of time for those elements to rehabilitate.

Why a Short Course of Adjustments Will Not Correct the Problem

The following description illustrates how short courses of adjustments that bring pain relief merely cover up a problem without returning a spine to health.

Description of Patient

A patient has previously injured his lumbosacral joint. It has healed up slightly, laterally flexed to the right. The right facet joint surfaces are consequently experiencing abnormal pressure and have developed mild inflammation. Whenever the patient significantly bends to the right, the facet is aggravated, having caused mild pain that goes away. Eventually the condition deteriorates, and the pain becomes severe enough to motivate patient to seek care.

The Apparent "Fix"

The chiropractor analyzes the biomechanical dysfunction and delivers a perfectly executed adjustment that restores some mobility to L5 on S1. With the pressure coming off the damaged facet joint (and other factors), pain relief is dramatic. The patient thinks the chiropractor has fixed him.

Is the Patient Fixed?

Because of the history of minor resolving pain and the understanding that dysfunction usually has a long asymptomatic period, one may assume that the biomechanical dysfunction will have been present for a long time. Structural changes will have occurred. Some examples will include:

• shortening of muscles and ligaments to the right of L5/S1;
• lengthening of muscles and ligaments to the left of L5/S1;
• wasting of the intrinsic muscles associated with L5/S1 movement, and;
• formation of scar tissue associated with the chronically inflamed right facet joint.
  

Pain may abate because the partial improvement in biomechanics may relieve some stresses, and the patient will subconsciously avoid activities that previously aggravated the condition. However, the structural changes assure that although some improvement may occur, L5/S1 function will remain abnormal. Degeneration and other undesirable consequences will continue. Painful relapse is highly probable.

What If the Patient Is Allowed to Return When Pain Reoccurs?

Allowing patients to return when symptoms return is inadequate for two main reasons.

1. Patients do not have the ability or understanding to evaluate their condition when in the asymptomatic phase. With dysfunction , remaining degeneration and undesirable consequences will continue.


2. When relapse occurs, the patient may seek an alternative practitioner to "fix" the problem.

What If the Patient Is Given Exercises?

Although exercises may reduce or prevent pain, they probably will not correct the underlying dysfunction. Why?

Exercise for the spine produces gross movements involving a chain of joints. In a healthy spine, all joints will contribute. However, in a dysfunctional spine, simply speaking, some joints are stuck and others become sloppy. When exercised, the stuck joints will remain stuck while the sloppy joints will move.

Stretching will increase hypermobility in sloppy joints while the stuck joints stay stuck. Strengthening exercises will only strengthen muscles associated with joints that move. Therefore, exercising a spine in this condition will merely reinforce abnormal patterns. Pain relief will occur because the compensating parts will develop extra strength and flexibility, enabling them to reduce the load on the dysfunctional joints.

What If Patients Are Taught to Avoid Activities that Place Excessive Load on Their Spine?

A dysfunctional spine will be much better able to cope when the load is reduced. However, dysfunction and the associated adverse effects will remain.

A Better Solution: Return the Function and Structure of the Spine to Normal (or toward Normal)

A Sensible Objective

It should be recognized that the biomechanical dysfunctions with associated structural changes, as described previously, are a major cause of pain and spinal degeneration. In addition, it could be well argued that they cause detriment to health, well-being and physical performance.

The ideal form of care would prevent this condition from developing in healthy people, and restore the spine to normal (or as close as possible) in a people whose spines had deteriorated.

Asymptomatic Checkups

Asymptomatic checkups of spines are perfectly justified given the following facts:

• The biomechanical dysfunctions described are real and demonstrable.
• They have a long asymptomatic phase.
• There are adverse consequences of this condition, including a gradual deterioration of the spine.
• There is an effective way of correcting the problem (discussed later).

How to Correct a Postinjury Biomechanical Dysfunction

Unfortunately, many people leave seeking spinal care until their spine has deteriorated to the stage of becoming painful. Therefore, before correcting the dysfunction, there may need to be an initial phase where damage and swelling are reduced. This is basically the application of short-term symptomatic care, of which volumes have been written already. For completeness, it must be mentioned that there are some people who either 1) have a spine that has deteriorated so badly, or 2) have an attitude towards health care, such that restoration is out of the question.

Restoration and Rehabilitation

The principles for restoring a spine are the same as those for the rehabilitation of an arm that has been broken and wasted away while healing. First, normal movement must be restored. Second, the part must exercise over time to allow the body to restore itself.

Step One: Restore Movement

The following process will restore normal (or more normal) movement to the spine:

1. Specific restrictions to intersegmental spinal mobility are detected. Adjustments are used to help restore this movement. Because of structural changes, only partial movement will be restored.


2. After the spine has had time to adapt to this extra movement, but before it reverts back to pre-adjustment mobility, the spine is readjusted to further normalize joint movement.


3. The process of re-adaptation and adjustment is continued until mobility is normalized (or as normal as possible).

Step Two: Strengthening

With full movement, restored exercise or normal activities will cause the spine to gradually strengthen. Until strengthening is complete, the spine will have a tendency to revert to its old patterns, so regular (though less frequent) adjustments will be needed.

Supportive Processes

Other forms of care may be needed to support the process. These may include exercises, therapy for muscles and other soft tissue, or advice on preventing injury.

How Long Does the Process Take?

Restoration of full movement may be almost instantaneous in a baby or infant. In an older person with deteriorated joints, it may take a very long time.

In determining time taken to strengthen, one should note the time taken for a wasted broken leg to return to the same size as the opposite leg. If the leg is in a cast for six weeks, restoration may take six months. Most deteriorated spinal joints have been working abnormally for much more than six weeks, so a longer time must be expected.

Based upon this understanding and clinical experience, durations of 12-24 months seem reasonable for simple cases. In cases where obvious degeneration is visible on x-rays, the soft tissues will be grossly deteriorated, so slow rehabilitation over a longer period are needed.

Realistic Expectations

A spine with only soft tissue deterioration may be expected to return to near normal. Where significant disc and bony deterioration exists, theoretically bony re-modeling is possible; it would be safer to expect (and promise?) some restoration of soft tissues.

Maintaining a Healthy Spine

Even if the spine has been restored to pristine condition, and no matter how hard the patient tries, there will always be things that injure or upset the balance of his or her spine. It may be as simple as sleeping with the head on an angle to getting stressed out in a traffic jam to participating in a large number of work-, sports- and leisure-related activities. Asymptomatic checkups, as discussed previously, will allow newly developed dysfunctions to be corrected before significant deterioration occurs.

Most patients have some sort of residual damage in their spine. It may be as simple as a bit of scar tissue, fibrosis, or even some roughening of the sliding joints or bony changes. The body will tend to use healthy joints in preference to damaged joints. If the damaged joints are not regularly checked and adjusted, they will gradually tighten.

Author's notes

• I hope this article (and the book it is based upon) provides practitioners with a sound way to justify high quality long-term care.


• This author understands and uses "subluxation" as a term that encompasses the dysfunction and consequences. However, in this article the entity has been broken into terms that nonchiropractors can understand, and no one has been able to refute so far.


• It is acknowledged that there is strong evidence that interference to the nervous system can cause farreaching health changes, and provide an excellent reason to have quality spinal care. This was omitted so anti-long-term chiropractic care people would have nothing to argue about. How ever, nerve interference is discussed in detail in the book.


• This article does not provide a blanket endorsement of all longterm programs of care.


• It is acknowledged that there will always be a market for symptomatic care. There is nothing wrong with providing this type of care as long as patients are informed and given the option of quality care.

Reference

Blennerhassett, G. How to Get Rid of Your Back Pain... So it Stays Away. 1999 Self-published in Australia www. blcc.com.au

Graeme Blennerhassett
Bairnsdale, Victoria
Australia