While the majority of musculoskeletal cases respond quickly and favorably to conservative care, some conditions are less cooperative. When a patient is not meeting outcome goals, evidence-based chiropractors must be willing to abandon their familiar recipe, and “do something different.”
In a value-based healthcare model, there’s a vast difference between merely treating someone vs. delivering best practices. The essential step for improving clinical outcomes is to provide the most effective care for every patient on every visit- including those cases that challenge us.
Check out this week’s blog and video to review our top seven tips for solving unresponsive problems. Then download our new Case Review Checklist to help boost your clinical outcomes even higher!
Bonus: Want to know how clinical outcomes will determine your income? Watch this video.
1. Review the History
Multiple studies have suggested that the details of the patient’s history are sufficient to establish a diagnosis in three out of four cases. (1-3) Unfortunately, researchers also found that clinicians typically gather only slightly more than half of the pertinent facts. (4) Ensuring that you’ve collected the necessary information is the first step for reviewing unresponsive cases. Consider the following points:
- Do you clearly recall the history, or do you need to review the LOPPQRST with the patient?
- Are there any red flags in the review of systems, physical exam, or vitals?
- Are there any prescription changes or new medications with potential side effects? i.e., statins, fluoroquinolones, corticosteroids, or bisphosphonates.
- Does the patient have diagnosed or undiagnosed medical co-morbidities? i.e., diabetes, sleep apnea, autoimmune disease, etc.
- Are there signs and symptoms that suggest a systemic inflammatory arthropathy? i.e., gradual development, multi-articular pain and swelling, prolonged stiffness following inactivity (night-time, mornings), fatigue, “flu-like symptoms, skin lesions, etc.
2. Assess for Yellow Flags
“Pain-associated psychological distress adversely influences functional outcomes and is a predictor of disability and utilization for patients with musculoskeletal pain. Psychological factors may be more strongly associated with pain intensity, number of visits, and disability than physical factors such as strength and range of motion. Yet, despite this consistent evidence, assessment of pain-associated psychological distress (i.e., yellow flags) is not routinely performed. (5)
- Fear-avoidance (assessed via FABQ)
- Catastrophizing (assessed via PCS)
- Kinesiophobia (assessed via TSK-11)
- Passive coping/ Reliance on passive care (assessed via CAPQ)
- Excessive stress (assessed via PSS)
- Anxiety (assessed via STAI, PASS-20, GAD-7)
- PTSD (assessed via PC-PTSD-5, SPRINT)
- Depression (assessed via PHQ-9)
- Workplace fears (assessed via FABQ-W)
- Central sensitization (assessed via CSI)
A recent systematic review and meta-analysis showed that imaging is inappropriately performed in up to 1/3 of LBP cases; conversely, imaging is not performed where appropriately indicated in up to 2/3 of cases. (6) For unresponsive cases, re-review prior diagnostic findings, then consider if the patient needs additional testing, i.e., X-rays, lab, NCS, Dx-US, MRI, etc.
ChiroUp has synthesized more than 6000 research studies into protocols for the top 100 musculoskeletal diagnoses. We’ve learned a lot from this project, and one of the most pertinent points is that structural problems are almost always related to an underlying functional deficit. (i.e., Rotator cuff pathology arises from scapular dyskinesis). An essential consideration for reviewing unresponsive cases is: did you perform a functional assessment and prescribe exercises to address functional deficits that could be delaying recovery? The most commonly overlooked functional deficits include:
- Upper crossed syndrome
- Scapular dyskinesis
- Dysfunctional breathing
- Core instability
- Hip abductor weakness
- Lower crossed syndrome
- Foot hyperpronation
We all understand that chiropractic management, including spinal manipulation, is typically VERY effective for MSK disorders. But, because “it usually works” we are sometimes lulled into complacency, and delay changing treatment when it’s not working. Before your slow responder decides to abandon ship, make sure you’ve taken the opportunity to consider all of your available tools:
- What other treatment techniques could be implemented, i.e., McKenzie Directional Therapy, STM, IASTM, therapeutic tape, nerve floss/ glide, etc.
- What are the most likely overlooked muscles or myofascial tissues, and how should you address them?
- What is the one most likely overlooked restricted spinal segment/ region, and how should you treat it? HVLA, flexion-distraction, drop table, instrument, directional therapy, etc.
- Would a change in modalities help?
- Are there any supports, orthotics, braces, or nutritional supplements that could help?
- Is there another provider who is better suited to manage or co-manage this patient?
6. Eliminate Lifestyle Triggers
Sometimes, our patients are their own worst enemies. Reviewing your patient’s activities of daily living and lifestyle will often illuminate problems that delay recovery. Consider these points:
- How could the patient be aggravating the problem at home/ work via a workstation, chair, bed, pillow, shoes, activities, excessive weight, smoking, etc.?
- Do you need to review the patient’s diet and hydration status?
- Do you need to confirm or reissue ADL advice?
7. Confirm Active Participation
A 2009 study found that for chronic spine pain, only about one-third of chiropractors prescribe exercises; compared to 14% of MDs and 64% of PTs. (7) While it is quite likely that this number has increased over the past decade, the percent of patients who follow these recommendations is still low.
“Evidence suggests that noncompliance to home exercises can be between 30% and 50%, making it a significant issue that places additional burden on patients and health care providers, and may be partially to blame for poor clinical outcomes.” (8)
- Does the patient have a current exercise plan with the best practice exercises?
- Did the patient receive appropriate exercise training via one-on-one instruction or handouts and tutorial videos for reinforcement?
- Does the patient understand the importance of performing their exercises; including precisely how this rehab will help them recover?
- Is the patient performing their exercises consistently, and able to demonstrate that they are performing their exercises correctly?
Again, in a value-based healthcare model, there’s a vast difference between merely treating someone vs. delivering best practices. The essential step for improving clinical outcomes is to provide the most effective care for every patient on every visit- including those cases that challenge us.
Implement case reviews as a standard policy for any condition that does not progress as expected. Block ten minutes to review all charts before the start of each shift. Use the ChiroUp Case Review Checklist as inspiration for one thing that you could change or add to each patient’s visit to speed their progress. Consider keeping a laminated copy in your treatment and exam rooms to use for slow-responders.
* ChiroUp would like to extend a special thank you to our exceptional board of advisors for their assistance with compiling and refining this new tool. You can practice with confidence knowing that your ChiroUp resource has oversight from the profession’s leading experts; including over 350 combined years of clinical specialty experience.
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- Lown B. The lost art of healing: practicing compassion in medicine. New York: Ballantine Books; 1999. Link
- Hampton JR, Harrison MJG, Mitchell JRA, Richard JS, Seymour C. Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. BMJ. 1975;2:486–489. doi: 10.1136/bmj.2.5969.486. Link
- Peterson MC, Holbrook JH, Von Hales D, Smith NL, Staker LV. Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. West J Med. 1992;156:163–165. Link
- Ohm F, Vogel D, Sehner S, Wijnen-Meijer M, Harendza S. Details acquired from medical history and patients’ experience of empathy–two sides of the same coin. BMC medical education. 2013 Dec;13(1):67. Link
- Lentz TA, Beneciuk JM, Bialosky JE, Zeppieri Jr G, Dai Y, Wu SS, George SZ. Development of a yellow flag assessment tool for orthopaedic physical therapists: results from the optimal screening for prediction of referral and outcome (OSPRO) cohort. journal of orthopaedic & sports physical therapy. 2016 May;46(5):327-43. Link
- Jenkins HJ, Downie AS, Maher CG, Moloney NA, Magnussen JS, Hancock MJ. Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis. The Spine Journal. 2018 Dec 1;18(12):2266-77. Link
- Freburger JK, Carey TS, Holmes GM, Wallace AS, Castel LD, Darter JD, Jackman AM. Exercise prescription for chronic back or neck pain: who prescribes it? Who gets it? What is prescribed?. Arthritis Care & Research. 2009 Feb 15;61(2):192-200. Link
- Argent R, Daly A, Caulfield B. Patient involvement with home-based exercise programs: can connected health interventions influence adherence?. JMIR mHealth and uHealth. 2018;6(3):e47. Link
About the Author
Dr. Tim Bertelsman
DC, CCSP, DACO
Dr. Tim Bertelsman graduated with honors from Logan College of Chiropractic and has been practicing in Belleville, IL since 1992. He has lectured nationally on various clinical and business topics and has been published extensively. He has served in several leadership positions within the Illinois Chiropractic Society and currently serves as past president of the executive board.
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