Goals of Care: Minimize Pain and Maximize Function

The applied science of chiropractic and its goals of care have evolved over time as the research upon which they are based has accumulated. When we look at the current evidence on outcomes of care, it becomes increasingly clear that the dictum to "remove nerve pressure" may be an inadequate and somewhat archaic summary of today's goals.

In a literature review this year, Haldeman,DC,MD,PhD, states:

There has been no evidence that a change in the relation of adjacent vertebrae of the type commonly described in the chiropractic literature can result in nerve root or spinal cord compression.¹

In a 1999 paper, Bogduk,MD,PhD, noted:

Neuropathic lesions such as nerve root compression causing radicular pain are extraordinarily uncommon in the spine... In most back pain, the mechanism involved is the stimulation of nerve endings in the affected structure. Nerve root compression is in no way involved.²

However, one phrase can concisely and vividly portray contemporary goals of care for patients: "minimize pain and maximize function." This brief statement captures the essence of outcomes of care today.

Clear Goals, Clear Explanations

Practitioners must be clear about their goals of care if they are to articulate them to patients. This clarity of purpose allows the DC to enhance the patients' understanding of contemporary chiropractic, increasing their compliance, improving outcomes, and promoting referrals. It is essential that patients appreciate not only the goals of care but also the time needed to achieve them. A clear explanation of chiropractic goals lets patients know that we offer a very reasonable, natural, effective and functional alternative to a medical system that has become overwhelmingly drug based and symptom oriented.

We want our patients to understand that "improving function is the key to long-term pain relief," as Liebenson, DC,¹ so succinctly puts it, not via pain medications or anti-inflammatories. This conclusion is not confined exclusively to chiropractic, but is also being emphasized by physiatrist and sports medicine specialists. As Saal, MD,2 recently stressed in his presidential address to the North American Spine Society: "We must adopt the principle of improving patient function as our new paradigm... Improving patient function must be the credo of care."

The Neuromusculoskeletal System is Stressed Every Day

A basic premise that chiropractors must communicate to their patients is that as a result of the repetitive stress and strain of daily work and recreational activities, the neuromusculoskeletal system (NMS) is pressured every day of our lives. Stressors constantly challenge the integrity and stability of the system. Once the neuromusculoskeletal system has sustained a significant injury, it is crucial that the care provided not only achieves pain relief and tissue healing, but also that it helps restore good function for the NMS to regain and maintain the strength, endurance and flexibility necessary to tolerate the repetitive tasks of everyday living.

Waddell, MD,³ underscores the importance of regaining function: "Failure to restore function means any pain relief will be temporary and reinforces chronic pain." This is a deficiency in the focus of the traditional medical model: an approach that evaluates and treats only pathology instead of functional compromise; which addresses cures for diseases, but neglects the evaluation and restoration of the integrity of the whole NMS.

Assumptions: Right or Wrong

The traditional medical approach makes a reasonable assumption, which we now know is incorrect. When tissues have healed, pain should be gone and function restored. Tissue healing should signify the end of medically necessary care. Though this assumption seems reasonable, there is substantial evidence to suggest that the relationship between tissue healing, pain relief and restoration of function is considerably more complex. These three goals are certainly interrelated, but are not interchangeable.

Many recent studies demonstrate that the natural history of back problems is one of recurrence; that back pain and disability frequently persist beyond the period of tissue repair. Wahlgren,MD,⁴ concludes:

Whereas traditional biomedical approaches indicate that time alone may be a curative factor, pain-related effects such as functional deficits and distress may extend beyond healing of tissue damage.

It is a serious mistake to assume that because enough time has passed (approximately 6-8 weeks)⁵ for connective tissue to proliferate and deposit after an injury and initial tissue repair is complete, that the patient is pain-free, has regained full function, and it is time to end care. As Phillips, PhD,⁶ and Grant conclude:

The recovery process was found to be considerably longer than was expected and than would be predicted from the course of physical healing of soft tissue damage...This suggests a much slower recovery period than had been considered and a much larger number of people who are vulnerable to persisting pain.

Residual Dysfunction and Recurrence

Waddell⁷ supplies an excellent list of residual dysfunctions that can frequently persist long after tissues are healed if the dysfunctions which occur with tissue damage are not identified and corrected:

1. Abnormalities of joint movement

    

   1. limited movement
   2. hypermobility
   3. abnormal patterns of movement

2. Acute joint locking

3. Muscle fatigue, weakness, tension, shortening, stretching

4. Reflex muscle spasm

5. Connective tissue (fascia, ligs, jt capsule, muscle)

    

   1. adhesions
   2. scarring
   3. trigger points
   4. fibrositis

6. Neuromuscular incoordination: muscle imbalance

7. Abnormal patterns of movement

8. Altered proprioceptor and nociceptor input and neurophysiologic processing.

Reviewing the list of residual dysfunctions, it becomes obvious why patients commonly experience exacerbations and recurrences. The functional deficits that develop as the result of tissue injury must be identified and corrected. Herring, MD,⁸ concludes that after injury:

"The tissue may repair and remodel, but concomitant changes in function - strength, strength balance, flexibility, and proprioception occur. The signs and symptoms of injury abate but these functional deficits persist...The rehabilitation process is not over when the symptoms disappear. Rehabilitation must not be solely based on symptom relief. It must address more than pain. The athlete has a functional disability after an injury, and, until that is addressed these functional changes will persist."

Different Responses, the Same Goals

Although patients' complaints vary in terms of severity, speed of onset, location, and duration, there are certain key similarities that help us grasp the general goals of care for symptomatic and/or injured patients. It is important to consider that patients' presentations differ, does as their response to care. The attending chiropractor must be able to quantify the severity of a condition and its progress in order to personalize the treatment plan, evaluate progress and customize care to the unique needs of each patient.

Regardless of these differences, the fundamental goals remain the same: pain relief, tissue repair, and restoration of function. It is very important for patients to understand these goals and the time required to achieve each of them, so that they appreciate the process and endpoints of care.

A Model for the Recurrent Nature of Back Problems

An excellent educational model for both health professionals and patients alike, which explains why tissue healing and pain relief are inadequate goals to produce long-term success after tissue damage and dysfunction, comes from Gordon Waddell, MD,⁹ in his 1998 book. He presents a simple and concise paradigm that examines the relationship between tissue repair, function and symptoms. He explains that pain may arise because of tissue damage or dysfunction and that with the onset of significant pain, two responses occur: involuntary muscle spasm (or splinting), as spinal reflexes react to and guard or protect an injured area; the other is fear (or avoidance behavior), as the injured person attempts to avoid activity out of fear of exacerbating or reinjuring damaged tissue. Both responses contribute to immobilization and disuse.

Because of immobilization and disuse (some of which is voluntary), muscles undergo disuse atrophy and progressively weaken. Muscle patterns of coordination, recruitment and co-contraction may become disturbed. Soft tissues become progressively stiffer and inflexible as fibrotic infiltration ensues. Finally, cardiopulmonary function declines because of reduced activity and minimization of aerobic requirements due to activity avoidance. All of these factors contribute to progressive chronic musculoskeletal dysfunction, which may persist long after the healing processes is completed and may ultimately result in chronic pain and disability. As Waddell¹⁰ states:

Dysfunction may become self-perpetuating... One of the common criticisms of the diagnosis of soft tissue sprain or strain is that such an injury is normally followed by healing. Symptoms should settle over the expected tissue healing time. However, if the problem is dysfunction, then symptoms can persist for as long as dysfunction continues. Dysfunction may be self-sustaining, so symptoms may persist indefinitely.

Regaining a Sense of Control

A patient who enters into this unfortunate cycle may be doomed to lifelong problems of recurrences or chronicity. Not only must care achieve tissue repair and reduction of pain and other symptoms, but the clinician also needs to identify losses of function and correct those loses by both treatment and the prescription of an active rehabilitation program. It is vital in musculoskeletal conditions (which are so often recurrent) that patients participate in such a program. It is essential for patients to understand that they are not passive victims of musculoskeletal problems; that they can dramatically reduce the frequency and severity of recurrences by improving their strength, flexibility, endurance and patterns of trunk muscle coactivation and recruitment. Patients should understand that by being active partners in the recovery and maintenance of their health, they can regain a sense of responsibility and control over the quality of their lives.

Recovery of Function Not Chronic Disability

If tissues are allowed to heal without functional restoration, chronic disability can occur. Mayer, MD,11 in 1999 states:

"The majority of injuries to the low back involve soft tissues or discs with sprains and strains of musculoligamentous tissues, which have a relatively brief healing period. When healing is temporally complete, but biomechanically imperfect, leading to permanent impairment of supporting elements, chronic disability may follow."

It is exceedingly important to educate patients to understand the importance of and participation in a functional recovery program. Fanuele¹² found, in a survey of 17, 774 back and neck pain patients treated at specialty spine clinics that patients with back pain and neck pain perceived themselves to have greater functional impairment than typical patients with cancer, diabetes, congestive heart failure, myocardial infarction, and hypertension.

In other words, if we are not evaluating and quantifying our patients' functional impairment, we are not adequately representing the severity and nature of their health problems, and are missing the most important characteristic of the case - the disability. One other essential point to remember, particularly after a patient has sustained a serious injury: We cannot always guarantee complete pain relief. The restoration of function, so that a patient has an adequate capacity to tolerate activities of daily living and work tasks, is the single most important goal of care.

Ameis, MD,¹³ explains:

As time passes, the rehabilitative program should become progressively more active...Patients invariably expect treatment to result in pain-free status. Instead, it should be stressed that recovery of function is the primary goal.

This is the thrust of the findings and the conclusion of many international guidelines. As Bigos, MD, and Davis, BS,¹⁴ aptly remind us:

"The Agency for Health Care Policy and Research defined low back problems not as pain but activity intolerance due to back symptoms. The actual treatment relates to regaining activity tolerance. Controlling symptoms supports, not replaces, the true treatment. Don't let patients confuse recommendations to be more comfortable (pain relief) with conditioning, which is the real treatment for an activity limitation."

Chronic Painful Musculoskeletal Dysfunction

Adapted from Waddell G, MD. The Back Pain Revolution. Churchill Livingstone 1998: 232

With the help of many recent studies, the goals of effective care have come more clearly into focus. They have clarified our vision, refined our understanding and improved patient outcomes. In summary, pain relief is not enough; tissue healing is not enough. We must help our patients minimize pain and maximize function. The primary conclusion of the recent Report of the International Paris Task Force on Back Pain,¹⁵ states:

Individuals who have back pain reduce their activity...The longer they reduce their activity, the greater the risk of the condition becoming chronic. The prevailing management approach to the treatment of back pain considers a return to normal activities to be a more important goal than pain relief.

Ultimately, it is the loss of function that impairs the ability to perform activities of daily living (and gainful employment) that sabotages the quality of life. The restoration of function, as a result of a cooperative, active and successful partnership between the chiropractor and patients, ideally results in functional recovery, improved quality of life and patient satisfaction.

References:

1. Liebenson C. Rehabilitation of the Spine. Wms & Wilkins, Baltimore. 1996: 13-43.
2. Saal JA. 1996 North American Spine Society Presidential Address. Spine 1997;22(14):1545-1552.
3. Waddell, G. The Chiropractic Report 1993; July:1-6.
4. Wahlgren DR et al. Pain 1997;73:213-221.
5. Mooney V. J Musculoskeletal Med 1995; Oct: 33-39.
6. Phillips HC, Grant L. Behav Res Ther 1991;29(5):435-441.
7. Waddell G. The Back Pain Revolution. Churchill Livingstone7. 1998: 145.
8. Herring S. Med & Science in Sports & Exercise 1990; 22(4):453-456.
9. Waddell G. The Back Pain Revolution. Churchill Livingstone 1998: 232.
10. Waddell, G. The Back Pain Revolution. Churchill Livingstone 1998: 151-152.
11. Mayer TG. Neurologic Clinics of North America 1999;17(1):131-147.
12. Wiesel S. Backletter 1999; 14(9):97, 102.
13. Ameis A. Can Fam Physician 1986;32(Sept):1871-76.
14. Bigos SJ, Davis, GE. JOSPT 1996;24(4)Oct: 192-207.
15. Abenhaim L, et al. Spine 2000; 25(4S): 8S.