How do chiropractors create added value for their services in an era of diminishing reimbursement and economic uncertainty? Fortunately, musculoskeletal pain (MP) in general, and low back pain (LBP) in particular are ubiquitous in modern societies. LBP was previously believed to be self-limiting, but now is understood to run a chronic, recurrent course. As such, patients always will be seeking better ways to deal with their LBP.
The question is how can chiropractors position themselves to help more than the 7 percent to 8 percent of the population that currently seeks them out? A very simple and logical way, proposed by the eminent spine scientist, Prof. Stuart McGill of the University of Waterloo, is a key for all young chiropractors and musculoskeletal specialists from athletic training, physical therapy and physiatry.
In a nutshell, what McGill proposes is that chiropractors benchmark themselves in spine care. To do this, they must master not only ortho-neuro evaluation of the spine, but functional assessment as well. They must master not only passive care such as adjustments, physiotherapy modalities and nutritional approaches, but active care as well. In fact, chiropractors are ideally situated to complement their present diagnostic and treatment armamentarium with functional assessment and active care strategies.
Functional assessment is a rigorous, methodical screen of the entire locomotor system for the "weak link."1-3 Mechanical sensitivity is the first component of this impairment evaluation. Basically, the clinician searches for the movements and positions which reproduce the patient's own pain. This is essential to identify "pain generators" and sources of biomechanical overload in the kinetic chain. It also is important so the value of passive and active care can be "audited" post-treatment with empirical tests that will clearly demonstrate to the patient progress is being made.
Functional assessment also involves tests of a patient's functional capacity. The key is to identify a gap between the patient's functional capacity and their functional goals. Examples of a functional deficit or "weak link" can be a stiff hip in extension, faulty motor control of the lumbar spine in a bird dog, or poor scapulo-humeral coordination during arm abduction. Any of these functional deficits which are linked to the patient's pain would be established as areas of concern requiring functional restoration.
The result of this functional assessment is a blueprint for patient care. In fact, the patient's self-care program will be determined by its ability to reduce the patient's mechanical sensitivity and restore function. Exercises that are prescribed should always be in the patient's functional training range (FTR). This is the range which is painless and appropriate for the task.1,4
In the modern spine practice, patients are given a functional assessment and self-care exercises that are in their FTR. The goal is to expand their FTR until it encompasses their activity/participation goals.5 This closes the gap between their unique functional deficits and goals. This patient-centered approach is ideal for today's educated health care consumer.5 It is self-care and goal-oriented. It is functional and empowering. It is evidence and outcome-based.
Today's patients want more than pain relief by medication, modalities or manipulation. Pain tends to recur, so the key to adding value to the chiropractic encounter is to show patients what they can do for themselves. Chiropractors who benchmark themselves in functional assessment and active care will have the type of satisfied patients who become a source for endless referrals.
Remember, everyone has back pain. Also, everyone has tried the typical chiropractic, physical therapy and medical options already. If chiropractors want to become known as the go-to spine experts, then their knowledge, attitude and skills must embrace the modern functional rehabilitation paradigm.
- Liebenson C. Functional Stability Training in Rehabilitation of the Spine: A Practitioner's Manual 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2007.
- McGill SM. Ultimate Back Fitness and Performance 2nd ed. Waterloo, Canada: Wabunu, 2006.
- McGill SM. The Ultimate Back: Assessment and Therapeutic Exercise. Waterloo, Canada: Wabunu, 2007.
- Liebenson C. Functional-Performance Training Handbook. Philadelphia: Lippincott Williams & Wilkins, in press.
- The Victorian WorkCover Authority's Clinical Framework. www.workcover.vic.gov.au/dir090/vwa/home.nsf/pages/chiropractors.
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