I had a new patient enter the office recently who had been under the care of another chiropractor.  This was an interesting visit as often times when a patient comes from another health care provider there is a reason.  Perhaps they are in some way dissatisfied, not improving as fast as they would like, have a new condition, recently moved, etc.  This one was different.  The patient was thrilled with their current health care provider.  You may be thinking the same thing as I was, “why make a change when you’re extremely satisfied?”.  Here’s the answer I was given (paraphrased):  “I love my current doctor, but cannot drive all the way to see him more than 1x/week due to gas prices and time.  I’ve had these symptoms for 3 months, I lived with it for 8 weeks and then have been receiving treatment 1x/week for the past 4 weeks.  I am gradually getting better, but if I could be seen more often, I would get better faster.”   Sounds logical, if some is good, more must be better.

Patient history includes back pain and left sided leg symptoms (S1 sensory changes).   No signs of ominous pathology.
Prior treatment: weekly instrument assisted manipulative therapy with mild improvement each week.  Patient was also stretching at home.

So at this point the question is what to do.  First, I’ll say that  when I take over care for a patient who believes their current treatment regimen is working, I rarely change it initially unless I have significant concerns.  I instead work with it and make gradual changes in most cases.  I believe that what the patient thinks will make them better often does.  Their confidence in their treatment is an important part of the puzzle. (Is this approach right or wrong?  Feel free to weigh in.) 
Next issue is what to change in the treatment to make it more effective… the frequent debate is with whether to mobilize or stabilize first.  From Boyle’s Joint by Joint approach we have some general guidance as to what tends to need to be mobilized and what areas tend to need stability.  From FMS/SFMA (& others) we have the general concept that mobility is necessary before stability.  While I agree that mobility is often needed first, this is not a rule as much as it is a guideline.  Frequently, I’ve seen that providing stability where needed allows the nervous system to reduce the ‘tightness’ of other areas.  As stability is restored, the nervous system stops drawing upon ‘prime movers’ to act as stabilizers and mobility is restored.  To determine what type of treatment is most likely to benefit an individual patient, I follow this model, as outlined by Dr. Craig Liebenson.  Its brilliant simplicity is applying a McKenzie (MDT) concept to active care, including mobility & stability exercise.  While the mobility vs. stability debate will continue on, there is a more important first step that is at times overlooked. So let’s go back to this patient I saw and the case at hand.  I did provide instrument assisted manipulative therapy, similar to what the patient had previously received.  The patient was satisfied with this portion of care.  I also reviewed the patient’s current stretches.

After realizing that the patient was performing positions that involve common back injury mechanism (repeated or prolonged end-range loading, in this case lumbar flexion), I simply asked that she stop doing 2 of the 4 stretches the patient was doing on her own each day to try and remedy her condition.  (Picture on right was #1, a seated version with legs spread was #2.)

The outcome:  Patient returned 2 days later and was 50+% improved.  After 3 months of symptoms, I consider that a positive outcome.  Please realize, this is not a post about me, how good a job I did, or the quality of care I strive to provide.  It is also not a post to say, look at what someone  else was doing wrong.  (I hate these types of blog posts and FB posts.  We’re all on the same team.)  In fact, if you reread this you’ll see that I actually did very little.  I simply duplicated someone’s treatment.  The only thing that was changed is I followed the advice of one of the Prague school pioneers.

“The first treatment is to teach the patient to avoid what harms him.”  Karel Lewit, MD

Patients who are not well informed as to what harms them are unlikely to respond favorably. Removing offending movements, positions, and activities is essential.  Sparing advice trumps mobility, stability, balance, etc.  (In reality it often includes bits and pieces of all of them.)  At times patients have a hard time understanding how important and powerful this part of treatment is.  I’ve heard and use the following story, “If you came here with thumb pain, I could treat your thumb any way imaginable, but if it hurt because you were hitting it over and over again with a hammer, wouldn’t you agree that teaching you to swing the hammer differently is most important?”  Change hammer & thumb to anything that resonates with the person in front of you and I think you’ll have a productive first interaction.

Don’t skip step 1:  ”Teach the patient to avoid what harms.”  (Added note: Don’t let step 1, become ‘avoid activity’, be specific.)

Sparing strategies:

A) For repeated movements: ergonomic advice, teach/train better quality movement, and improve joint centration. 

B) For prolonged loads: microbreaks.  If you stand, sit. If you sit, stand.  Examples:  Brugger’s postural relief position.  McGill’s overhead reach.