HOW THEN DO WE PRACTICE: A perspective
Assessing Pain at Forest Lake Chiropractic
By Keith Charlton DC, MPhil.

Part A: My clinic.

My circumstances:
A typical chiropractic practice is sui generis, a pain practice. Further, the legislative, educational and professional (in the tribal sense) imperatives of my circumstance dictate my scope and manner of practice. I am in solo private practice, like almost all chiropractors, and have no access to multi-disciplinary collaboration on-site, may use only non-script medications, and may not use surgery or other invasive interventions. My diagnostic options are limited to my senses and occasional radiography. I do seek external collaboration from time to time with other caregivers like general practitioners, podiatrists, physiotherapists, psychologists, acupuncturists, musculoskeletal clinicians and the like for interventional collaboration, and radiologists, general practitioners and others for diagnostic assistance. I suspect that I may not see a representative sample of the population at large, as I charge fees, and insurance cover is meagre at best, so perhaps those who do present are more upper middle class, and fiscally better off, on average.

My philosophy:
I seek a negotiated structure of expectation from a patient for their preferred outcomes, and the manner of trying to achieve them. Such is always capable of revision by either of us with notice to the other, and I encourage such dialogue, and my staff is trained to be sensitive to this aspect of patient care and to seek ways of expressing it to patients. The patient is encouraged to see best care as neither dependent nor independent, but rather inter-dependent. In suitable cases, I encourage some leaning on us for encouragement and sympathy within an expectation that we seek to hand back the locus of control¹ to them as soon as practicable. Active understanding is encouraged, as is active care. My first interview is where the consultation and examination takes place. The patient leaves (most chiropractic patients are not acute, but chronic pain sufferers) and is seen the next day when I will have prepared a diagrammatic representation of what I think is going on, and a list of advices on exercise, Activities of Daily Living pertinent to them, dietary advice on, say, calcium intake, antiinflammatory nutriceuticals like fish oil, celery, ginger and glucosamine sulphate, and on diet and lifestyle matters like stress management. Mostly, dependent treatment begins on that second visit.

How I approach the patient diagnostically:
The reception room (no waiting room… we make special efforts to be efficient, solicitous and to have them realize that we realize that their time is important) is pleasant and decorated with my qualifications and awards. Those presenting for help are given a triage core questionnaire that asks what they want from me. There are many flavours of caregiver and patient, both, and I want to know what they expect from me. Crudely (the only way I think it can be done), and not quite in these terms, I ask them whether they want me to crack their back, hit them in the backside with a shovel and send them on their way, or should I look deeper and do they want a more comprehensive care protocol, or are they looking for “alternative” health care, or for a continuing period of “maintenance”, like, perhaps in a sporting season.

The core questionnaire includes four visual analogue scales, and the diagram from the McGill Pain Questionnaire. If the patient mentions back pain, the staff then offer a Revised Oswestry Low Back Pain Disability² form for completion. If neck pain is mentioned the patient is given the Neck Disability Index form³. If headache features, we use The Henry Ford Hospital Headache Disability Inventory⁴. This is a somewhat unsatisfactory instrument, but better than all the others I have found.

If depression or anxiety is mentioned, the Beck Depression Inventory⁵ is used. If the patient scores over 20, they are encouraged to seek help from their general practitioner or a psychologist as they see me. If they score over 10, they are reviewed with the instrument after two weeks of care. If they score anything but zero on question 9 on suicide, they are asked for permission for me to call their general practitioner unless they are already under care for this issue and it has been specifically mentioned and discussed by their psychological caregiver. There is ample evidence that suicide is under-recognised and it’s no work to ask about it. Then the patient gets to meet me. As it seems that patients do better when they perceive confidence in the caregiver, I look for ways to facilitate placebo. I assume an open question format after pleasantries, and sit facing them from a desk at the side. I wear a bow tie, the room is decorated with a large bookcase on which are many impressive looking tomes, and the wall behind me is hung with drawings by Michelangelo. I seek both clinical and situational (social) data from the interview. I perform a series of mostly useless examination procedures like the standard orthopaedic tests etc and get to know the patient as I do. I call it my bonding dance. If radiography is indicated, I dismiss and ask them back the next day for another interview and to begin care.

Negotiating a structure of expectation for preferred outcomes, and for means:
I ask the patient to bring their most significant other to the so-called “Report of Findings” visit so that both can get advice on understanding the problem and how self-help can be implemented, including risk reduction around the home and work environments. I tend, unless indications forbid, to err slightly on the side of cautious optimism in outlook that I might help, that I may diminish any tendency to catastrophise, a risk factor for chronicity. I negotiate the nature of the care they seek (event-based symptom care, or care of a wider scope). I discuss relative risks of options for care from me, from others, or from no care. They sign an informed consent before I begin treatment. I telephone every patient at home at 8pm on the night of first treatment and after any exacerbations for follow-up and reassurance.

If negotiated, the patient is dismissed at their choice of relief level (“It’s gone now, and so am I…”, or “I can live with it thanks” etc). For those who are still with me after three weeks, we re-do the questionnaires⁶, re-do the interview and the bonding dance (sorry: comprehensive physical, orthopaedic and neurological examination), and have the patient indicate on a Progress Evaluation Form whether they are happy with me, with the staff, with the care, with the progress, whether they think I am missing something, and whether there is anything else they want me to know. Treatment, both active and passive, is reviewed at that time. Continuing supportive elective care never continues beyond twelve visits without such a review.

Part B: Why I don’t really find much more of the psychosocial literature helpful in my private chiropractic practice.

To follow in the next issue...

Editors comment: “I am indebted to Dr Charlton for being prepared to openly share and reflect on the “how and why” of his approach to practice. I hope this serves as a sounding board and generates some re-evaluation of the way we approach our chosen vocation”.

References:

1. Crisson JE, Keefe FJ. “The relationship of locus of control to pain coping strategies and psychological distress in chronic pain patients.” Pain 1988; 35:147-5.
2. Fairbank JT, et al. Physiotherapy 1980; 66(18):271-3.
3. Vernon H, Mior S. “The Neck Disability Index: a study of reliability and validity”. J Manipulative Physiol Ther 1991; 14:409-15.
4. Jacobsen GP, Ramadan NM, et al. “The Henry Ford Hospital Headache Disability Inventory (HDI).” Neurology 1994; 44:837-42.
5. Beck AT. (1967). Depression: Causes and Treatment. Philadelphia: University of Pennsylvania Press.
6. Jensen M, Martin SA, Cheung R. “The meaning of pain relief in a clinical trial.” The Journal of Pain Vol 6, No 6 (June), 2005: pp 400-6.
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11. Innes S. “Psychosocial factors and their role in chronic pain: a brief review of development and current status”. Chiropractic & Osteopathy 2005, 13:6.
12. Sharpe L, Sensky T, Timberlake N, Ryan B, Brewin CR, Allard S. “A blind, randomised controlled trial of cognitive behavioural intervention for patients with recent onset rheumatoid arthritis: Preventing psychological and physical morbidity.” Pain 89:257-83, 1997.
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14. Turner JA, et al. “Prediction of chronic disability in work-related musculoskeletal disorders: a prospective, population -based study.” BMC Musculoskeletal Disorders 2004, 5:14.
15. Hoogendorn WE, van Poppel MNM, Bongers PM, Koes BW, Bouter LM. “Systematic review of psychosocial factors at work and private life as risk factors for back pain.” Spine 2000; 25:2114-25.
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