By Tim Bertelsman, DC
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.
A case review is an essential tool that should be performed on any patient who is failing to meet outcome goals. The process consists of confirming the history, re-examining, and modifying the treatment plan. Here are seven steps to consider when performing case reviews.
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 (Location, Onset, Palliative, Provocative, Quality, Radiation, Severity, Timing) 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
There is a growing focus on the biopsychosocial aspect of pain. Clinicians must identify and assess patients who exhibit unhealthy beliefs or interpretations about pain and recovery:
- Fear-avoidance (assessed via the Fear-Avoidance Beliefs Questionnaire, FABQ)
- Catastrophizing (assessed via the Pain Catastrophizing Scale, PCS)
- Kinesiophobia (assessed via the Tampa Scale for Kinesiophobia, TSK-11)
- Passive coping/ Reliance on passive care (assessed via CAPQ)
- Excessive stress (assessed via the Perceived Stress Scale, PSS)
- Anxiety (assessed via the State-Trait Anxiety Inventory, STAI; Pain Anxiety Symptoms Scale, PASS-20; and Generalized Anxiety Disorder 7-item, GAD-7)
- Post-Traumatic Stress Disorder (assessed via the Primary Care PTSD Screen for DSM-5, PC-PTSD-5; and Short PTSD Rating Interview, SPRINT)
- Depression (assessed via the Patient Health Questionnaire-9, PHQ-9)
- Workplace fears (assessed via FABQ-W)
- Central sensitization (assessed via the Central Sensitization Inventory, CSI)
3. Review Diagnostics
A recent systematic review and meta-analysis showed that imaging is inappropriately performed in up to 1/3 of low back pain 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.
4. Perform a Functional Evaluation
We have synthesized more than 6,000 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
5. Think Through Your Toolbox
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., soft-tissue mobilization (STM), instrument-assisted 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
“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
A 2009 study found that for chronic spine pain, only about one-third of chiropractors prescribe exercises—compared with 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.
Patients will recover more quickly when they are active participants in their recovery and are performing the most appropriate exercises. This process includes several key considerations:
- 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.
Reprinted with permission from Tim Bertlesman, DC. Dr. Bertelsman is co-founder of the online clinical and business resource ChiroUp.com. Dr. Bertelsman graduated from Logan College of Chiropractic with honors and has been practicing in Belleville, Ill., since 1992. He is a post-graduate instructor for the University of Bridgeport Orthopedic Diplomate program. He has served in several leadership positions within the Illinois Chiropractic Society and currently serves as immediate past president of its executive board.
- 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