Passive Care 1 - AIMEHI Care.pdf3/18/04 Brewer Consulting Services DEFINITION OF PASSIVE CARE Passive care – Application of treatment/care modalities by the care giver to …

PASSIVE CAREPASSIVE CARE

When, Where and How When, Where and How MuchMuch

By Francis Brewer, D.C, C.I.C.EBy Francis Brewer, D.C, C.I.C.E

3/18/043/18/04 Brewer Consulting ServicesBrewer Consulting Services

IINTRODUCTIONNTRODUCTION

Definition of passive careDefinition of passive careWho uses passive careWho uses passive careTypes of passive careTypes of passive carePerils of passive carePerils of passive careStudies and GuidelinesStudies and Guidelines


DEFINITION OF PASSIVE CAREDEFINITION OF PASSIVE CARE

Passive care Passive care –– Application of treatment/care modalities by the Application of treatment/care modalities by the

care giver to a patient, who ” passively” receives care giver to a patient, who ” passively” receives care.care.

Active care Active care –– Modes of treatment /care requiring “active “ Modes of treatment /care requiring “active “

involvement, participation , and responsibility involvement, participation , and responsibility on the part of the patient. on the part of the patient.


WHO USES PASSIVE CAREWHO USES PASSIVE CARE

Include but are not limited to Include but are not limited to –– ChiropractorsChiropractors–– Massage therapistsMassage therapists–– AcupunctureAcupuncture–– Physical therapistsPhysical therapists–– Traditional Medical providers (M.D., D.O.)Traditional Medical providers (M.D., D.O.)


TYPES OF PASSIVE CARETYPES OF PASSIVE CARE

ManipulationManipulationSoft tissue proceduresSoft tissue proceduresPhysical therapy modalities (EPhysical therapy modalities (E--stimstim, U/S etc.), U/S etc.)AcupunctureAcupuncture


SOFT TISSUE PROCEDURESSOFT TISSUE PROCEDURES


SOFT TISSUE PROCEDURESSOFT TISSUE PROCEDURES

TypesTypes–– Massage, Contract Massage, Contract ––Relax, Ischemic compression, passive Relax, Ischemic compression, passive

stretch.stretch.DefinitionDefinition–– Massage: Massage: EfflurageEfflurage, , PetrissagePetrissage, cross, cross--friction. friction. –– Contract Relax: Contract Relax: –– Ischemic compression: Acupressure, Ischemic compression: Acupressure, ShiatzuShiatzu, ,

MyotherapyMyotherapy (TP)(TP)–– Passive stretch: Spray & StretchPassive stretch: Spray & Stretch

GoalGoal–– Stimulate blood flow Stimulate blood flow –– Remove toxins (lactic acid )Remove toxins (lactic acid )–– Decrease muscle spasmDecrease muscle spasm


MASSAGE CONTINUEDMASSAGE CONTINUED

May be appropriate in the acute phase of May be appropriate in the acute phase of care for the relief of muscle spasm and pain. care for the relief of muscle spasm and pain. There are no major studies to support long There are no major studies to support long term massage treatment.term massage treatment.Literature does not reveal any studies Literature does not reveal any studies identifying what frequency of careidentifying what frequency of care


ACUPUNCTUREACUPUNCTURE

The Chinese explain acupuncture on the basis of The Chinese explain acupuncture on the basis of their philosophy their philosophy -- The Theory of Yin and Yang and The Theory of Yin and Yang and the Five Elements. They have identified 14 the Five Elements. They have identified 14 channels or 'Meridians' running through the body. channels or 'Meridians' running through the body. These channels conduct the flow of vital energy or These channels conduct the flow of vital energy or 'QI'. This flow is disrupted when there is disease. 'QI'. This flow is disrupted when there is disease. By inserting needles into selected points in the By inserting needles into selected points in the channels this flow can be corrected, returning the channels this flow can be corrected, returning the body to a healthy condition. As opposed to the body to a healthy condition. As opposed to the Western approach in medicine, which is Western approach in medicine, which is centredcentredon trying to cure a particular disease, the Oriental on trying to cure a particular disease, the Oriental emphasis is on making the body healthy. emphasis is on making the body healthy.


TYPES OF ACUPUNCTURETYPES OF ACUPUNCTURE

ElectroElectro--Acupuncture Acupuncture -- applied with or without applied with or without needles. needles. AuricularAuricular--Acupuncture Acupuncture -- concentrating on concentrating on application of needles to specific points of the ear. application of needles to specific points of the ear. MoxibustionMoxibustion -- the heating of acupuncture points the heating of acupuncture points with a special herb from China called 'with a special herb from China called 'ArtemesiaArtemesiavulgarisvulgaris' or more commonly, '' or more commonly, 'MoxaMoxa'. '. Acupressure Acupressure -- a technique of a technique of applingappling pressure with pressure with the fingers to various points, rather then needles the fingers to various points, rather then needles


PHYSICAL THERAPYPHYSICAL THERAPY

Active therapyActive therapy–– Exercise etcExercise etc

Passive Physical TherapyPassive Physical Therapy–– Electrical muscle stimulationElectrical muscle stimulation–– UltrasoundUltrasound


MANIPULATIONMANIPULATION


MANIPULATIONMANIPULATIONDefinitionDefinition–– Passive movement of short amplitude and high Passive movement of short amplitude and high

velocity which moves the joint into the velocity which moves the joint into the paraphysiologicparaphysiologic range.range.

SubluxationSubluxation ( Chiropractic definition )( Chiropractic definition )–– “Structural dysfunctions of joints and muscles “Structural dysfunctions of joints and muscles

that are associated with that are associated with neurologicneurologic alterations.” alterations.”

“ Pinched Nerve Theory”“ Pinched Nerve Theory”


PINCHED NERVE THEORYPINCHED NERVE THEORY


WHEN & HOW MUCHWHEN & HOW MUCH

Utilized in all phases of careUtilized in all phases of care–– Acute to chronicAcute to chronic

Acute care ( Ranges )Acute care ( Ranges )–– 0 (low)0 (low)--8 weeks (High)8 weeks (High)

SubSub--AcuteAcute–– 7 (low) days 7 (low) days –– 16 (High) weeks16 (High) weeks

Chronic Chronic –– 7 weeks ( low) 7 weeks ( low) –– > 16 (High) weeks> 16 (High) weeks


HOW MUCHHOW MUCH

1990 Rand consensus Panel agreed to the definition 1990 Rand consensus Panel agreed to the definition of manipulation (not chiropractic). Trial course of of manipulation (not chiropractic). Trial course of two weeks each using alternative manipulative two weeks each using alternative manipulative procedures before considering treatment/care to procedures before considering treatment/care to have failed.have failed.

Mercy Guides define treatment as two trial therapy Mercy Guides define treatment as two trial therapy sessions( four weeks total) without significant sessions( four weeks total) without significant documented improvement, manual procedures may documented improvement, manual procedures may no longer be appropriate and alternative care no longer be appropriate and alternative care should be considered. should be considered.


HOW MUCHHOW MUCHThe Guidelines for Chiropractic Quality Assurance and Practice The Guidelines for Chiropractic Quality Assurance and Practice ParametersParameters ("Mercy guidelines") states: "All episodes of symptoms that ("Mercy guidelines") states: "All episodes of symptoms that remain unchanged for 2remain unchanged for 2--3 weeks should be evaluated for risk factors of 3 weeks should be evaluated for risk factors of pending pending chronicitychronicity. Patients at risk for becoming chronic should have . Patients at risk for becoming chronic should have treatment plans altered to detreatment plans altered to de--emphasize passive care and refocus on emphasize passive care and refocus on active care approaches.active care approaches.

“Mercy" continues to add that it is beneficial to proceed to the“Mercy" continues to add that it is beneficial to proceed to therehabilitation phase as rapidly as possible and to minimize deperehabilitation phase as rapidly as possible and to minimize dependency ndency upon passive forms of treatment/care." upon passive forms of treatment/care."

According to the “Mercy Guides “, if a patient does not have sigAccording to the “Mercy Guides “, if a patient does not have signs of ns of objective improvement in any two successive twoobjective improvement in any two successive two--week periods, referral week periods, referral is indicated.is indicated.

Outcomes are the surest way to demonstrate patient progress or lOutcomes are the surest way to demonstrate patient progress or lack ack thereof. thereof.


STUDIES COMPRISING CROSSSTUDIES COMPRISING CROSS--SECTION OF ALL TYPES OF CASESSECTION OF ALL TYPES OF CASESTrianoTriano–– Range 0f 1Range 0f 1--22 sessions for all cases22 sessions for all cases

HanssenHanssen–– Second opinion if there is no objective or Second opinion if there is no objective or

subjective sign of improvement in two weeks, or subjective sign of improvement in two weeks, or treatment of three times per week that exceeds treatment of three times per week that exceeds four weeks. (12 four weeks. (12 txtx trial)trial)

NyiendoNyiendo & & HaldermanHalderman–– Range 1Range 1--81 with a mean of 4.481 with a mean of 4.4


STUDIES CONTINUEDSTUDIES CONTINUED

State of FloridaState of Florida–– Reported average of 29 visits for back related Reported average of 29 visits for back related

disordersdisorders

Cox Cox –– 50% pain reduction with a mean of 10 visits over 50% pain reduction with a mean of 10 visits over

16 days. Maximum relief at 41 days after 16 16 days. Maximum relief at 41 days after 16 sessionssessions


ICA ASSESSMENT 2000ICA ASSESSMENT 2000AN INDEPENDENT ASSESSMENT OF CHIROPRACTIC AN INDEPENDENT ASSESSMENT OF CHIROPRACTIC PRACTICE GUIDELINES Jeffrey R. Cates, PRACTICE GUIDELINES Jeffrey R. Cates, DC,aDC,a David N. David N. Young, DC, Young, DC, PhD,bPhD,b David J. David J. GuerrieroGuerriero, , DC,cDC,c Warren T. Warren T. JahnJahn, , DC,dDC,d Jesse P. Jesse P. ArmineArmine, , DC,eDC,e Alan B. Alan B. KorbettKorbett, DC, , DC, DO,fDO,fDaniel S. Daniel S. BowermanBowerman, , DC,gDC,g Robert C. Porter, Robert C. Porter, MD,hMD,h Terry Terry Sandman, DC, Sandman, DC, MPH,iMPH,i and Robert A. King, and Robert A. King, DCjDCj

Objective: To evaluate the quality of Objective: To evaluate the quality of Recommended Clinical Recommended Clinical Protocols and Guidelines for the Practice ofProtocols and Guidelines for the Practice of Chiropractic Chiropractic (ICA guidelines) published by the International (ICA guidelines) published by the International Chiropractors Association (ICA), August, 2000.Chiropractors Association (ICA), August, 2000.

Conclusion: The ICA guidelines were assessed as not Conclusion: The ICA guidelines were assessed as not suitable for utilization in chiropractic practice. (J suitable for utilization in chiropractic practice. (J Manipulative Manipulative PhysiolPhysiol TherTher 2003;26:2822003;26:282--86)86)


LOCAL LAW AND GUIDELINESLOCAL LAW AND GUIDELINES

WCWC–– PCP referrals allowedPCP referrals allowed–– 15 15 txtx first daysfirst days–– 15 15 txtx every 60 days thereafter to infinityevery 60 days thereafter to infinity

PIPPIP–– No referrals allowed unless managed care.No referrals allowed unless managed care.–– Reasonable and appropriate up 30 treatments, no Reasonable and appropriate up 30 treatments, no

more more


PERILS OF PASSIVE PERILS OF PASSIVE MANIPULATION/CAREMANIPULATION/CARE

ComplicationsComplications–– Six most common claims in 1990 per NCMICSix most common claims in 1990 per NCMIC

Disc problems Disc problems 29%29%Failure to diagnose Failure to diagnose 13% ( particularly extremity disorders )13% ( particularly extremity disorders )FractureFracture 9%9%Soft tissueSoft tissue 7% 7% CVA CVA 6%6%AggAgg. of prior condition . of prior condition 4%4%

CCPA ( Canadian Consumer Protection Ass. ) 1/86CCPA ( Canadian Consumer Protection Ass. ) 1/86-- 12/9012/90–– Lumbar spine injuryLumbar spine injury 36 (23%)36 (23%)–– Rib fractureRib fracture 29 (19%)29 (19%)–– Neck InjuryNeck Injury 24%(16%)24%(16%)–– Soft Tissue NonSoft Tissue Non--Spinal Spinal 26 (13%)26 (13%)–– CVACVA 12 (8%)12 (8%)


PASSIVE CARE COMPLICATIONS PASSIVE CARE COMPLICATIONS COMMONLY ASSOCIATED WITH COMMONLY ASSOCIATED WITH CHIROCHIRO MANIPULATION/CAREMANIPULATION/CARE

Extended Disability Extended Disability –– Reinforces illness behavior/sick roleReinforces illness behavior/sick role

OverutilizationOverutilization–– Reinforces DependencyReinforces Dependency–– Reinforces illness behavior/sick role / Reinforces illness behavior/sick role / ChronicityChronicity–– Counterproductive to the patients recovery process, contraindicaCounterproductive to the patients recovery process, contraindicatedted

Iatrogenic DisabilityIatrogenic Disability–– Chiropractor takes on more than a care giver roleChiropractor takes on more than a care giver role

Lifestyle is often not consideredLifestyle is often not considered–– Injury and “Injury and “subluxationsubluxation” take on the primary focus” take on the primary focus


CONCLUSIONCONCLUSION

There is a significant amount of literature There is a significant amount of literature from a variety of organizations to support the from a variety of organizations to support the short term use of manipulation for low back short term use of manipulation for low back pain. pain.

Very little in the way of true accepted Very little in the way of true accepted guidelines or parameters for care. Mercy guidelines or parameters for care. Mercy being probably the most universally accepted being probably the most universally accepted although still disputed by many. although still disputed by many.


CONCLUSIONCONCLUSION

Parameters for the chronic use of manipulation are Parameters for the chronic use of manipulation are not well defined and the scientific literature is not well defined and the scientific literature is essentially void of any studies supporting the use of essentially void of any studies supporting the use of long term passive care. long term passive care.

The most effective yard stick for measuring a The most effective yard stick for measuring a patients response to care are the records, in the patients response to care are the records, in the absence of which the need for ongoing care is not absence of which the need for ongoing care is not established and the patient should be discharged. established and the patient should be discharged.


DISCUSSIONDISCUSSION

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Passive Care 1 - AIMEHI Care.pdf3/18/04 Brewer Consulting Services DEFINITION OF PASSIVE CARE Passive care – Application of treatment/care modalities by the care giver to …