'Are you better?' Clinical judgements of outcome and their implications.
by Alan Szmelskyj DO, MSc, MISMA, FRSH
Introduction to, and context of article
This article is based on a presentation I gave at the British School of Osteopathy on 14th November 1987. It was given at a conference organised by the Research Council for Complementary Medicine (RCCM). “How do we know it works? - Measures of outcome” was the theme of the conference. The focus of it was on the problem of assessing the outcome and efficacy of complementary therapy. I had been asked to represent the osteopathic profession and to speak on the subject by Colin Dove, then Head of the Post Graduate Department of the British School of Osteopathy. This was the first time I had ever spoken at a major medical conference. The audience of about 100 people was made up of various health care practitioners varying from medical consultants, doctors, osteopaths, chiropractors, physiotherapists, psychologists and nursing professions. The speakers and presenters were also from a multidisciplinary background. They included Dr Irvin Korr, Professor of Medical Education at the Texas College of Osteopathic Medicine, North Texas University; Dr Lesley Southgate from St Bartholomews Medical College; Peter Mole, Chairman of the Traditional Acupuncture Society; medical homeopaths Dr David Taylor Reilly and Dr Morag Anne Taylor from Glasgow Royal Infirmary; David Canter, Professor of Applied Psychology from Surrey University; Dr Ann Bowling from St Bartholomews Medical School as well as several other well known researchers and clinicians, including leading chiropractor Alan Breen, medical doctors Honor Anthony, Frank Parson, Robert Dunlop; psychologists Kerry Booker and David Aldridge. The other papers presented at the conference, as well as my own, were published in the Journal of Complementary Medical Research, Volume 2(3) Spring 1988.
The criteria used by osteopaths to judge the degree to which a patient is better are broadly the same as in orthodox medical practice. These can be classified under the following headings: practitioner's criteria, history, observational criteria, palpatory findings, patient's viewpoint, and natural history.
Within the timescale of my career as an osteopath, my decision as to when it is appropriate to stop treating a patient because they are better has undergone some interesting changes. I remember vividly the moment when, as an inexperienced novice clinical student, I was given nominal charge of my first patient. “Another two or three treatments of X followed by Y and a little bit of Z, and you should be able to discharge him”, I was advised. I dutifully obliged and three treatments later he was indeed better and happy to go on his way. Proudly I went to my tutor, explained about the patient and tentatively suggested that, since he had no remaining symptoms and had made the expected improvement, I thought perhaps he ought to be discharged. “You're a second-year student, aren't you?” my tutor enquired. Admitting this fact caused my inappropriate smugness to disappear. My tutor, sensitive to the situation, suggested that we should have one more look at him to make sure that nothing had been overlooked. Later that afternoon, I realised that I had drawn the wrong conclusion because I had taken a limited view of the patient and his problem, and had not considered the situation in an appropriate holistic context when making my judgement that he was better.
For the majority of practising osteopaths there are a number of basic identifiable criteria which are used to judge how much a patient is better. Many of the same criteria are used to identify the suitability of a patient for osteopathic treatment. As Colin Dove pointed out at the conference last year, in the management of a patient the osteopathic physician will use the concept of the treatment balance, (1) used to varying degrees by probably the vast majority of osteopaths. The important point about the use of the 'treatment balance' is that it inevitably implies that treatment of a patient does not end with the removal of manual contact.
Studies have shown that the manual side of the treatment balance can have an influence on certain infectious diseases, (2) cardiovascular disorders (3-5) respiratory disorders, (6,7) obstetrical and gynaecological cases, (8,9) and certain ocular disorders, (10,11) as well as the ubiquitously recognised musculo-skeletal and spinal disorders, for which osteopaths are so renowned in this country, and which make up the bulk of osteopathic practice. (12)
Yet in all these cases, when deciding how much the patient is 'better' the judgement will be made relative to certain criteria. These can be classified under three broad headings: 1) the practitioner's criteria, 2) the patient's criteria and 3) the natural history of the complaint.
1 The Practitioner's Criteria
The practitioner's philosophical viewpoint and mode of practice will have an important influence on his decision as to when he assesses the patient and how much improvement he looks for. For example, the aim of a particular practitioner's approach may range through from 1) achieving a relative improvement of a patient's symptoms, or 2) further along the scale, a complete reduction of any symptoms, or 3) the treatment and management of any predisposing musculo-skeletal, visceral or psychosocial factors.
- The history provided by the patient at the first visit and alterations reported at subsequent visits will enable the practitioner to gauge the patient's appreciation of any changes that are or have taken place in their symptoms. Thus any improvement or aggravation of the reported symptomatology, either of an expected or unexpected nature, will have an influence on the assessment of their improvement. The decision may be either a continuation of the treatment, perhaps with some degree of modification, or a cessation of treatment. The decision will depend on the individual patient's circumstances and the results of any additional findings.
- Observational criteria
- The practitioner's findings elicited in the clinical examination, and the changes at subsequent visits, will be taken into account. The criteria considered important may range from observation of the patient's general well-being, facial expression, psychological state, postural adaptions, gait alterations, gross mobility and functional activity levels. In practice environments inclined towards research, this may extend to monitoring weekly weight changes, assessing ability to perform certain tests, and responses to pain questionnaires. In certain cases it may also include responses to standard orthopaedic tests, such as straight leg-raising and femoral nerve tests, the monitoring and response to neurological tests, or whatever clinical methodology may be appropriate to a patient.
- The palpatory findings
- Numerous studies have been conducted on the validity of osteopathic palpatory procedures. (13-15) Although the hands-on palpatory techniques are not unique to osteopathic practitioners, (16,17) they do constitute the most frequently and universally used means by which osteopaths assess the patient's musculo-skeletal system and to a limited extent, assess their patient's health status. (18-20) The latter can present a treatment and management dilemma. For example, suppose palpation has identified a potential problem such as an area showing such characteristics as firmness, raised temperature, 'heavy' musculature, and ropiness, located at the first to fourth thoracic level, which may be indicative of a cardiovascular problem, even if only subclinical in its recognised cardiovascular manifestations. (21) Does one then immediately alert one's medical colleagues and possibly face some sceptical disbelief, or at worst a degree of ostracisation regarding the importance of these findings? Or alternatively, does one choose to treat the patient before the onset of symptoms of pathological change occurs?
- There are probably few osteopaths who rely solely on palpatory cues when deciding the extent to which a patient is better. This is probably partly due to some healthy self-doubt regarding the validity of palpatory predictive procedures. However, the available knowledge would seem to indicate that osteopathic palpatory procedures may have predictive and potentially preventative value, (22,23) hitherto unrecognised, at least in orthodox circles.
2 Patient's viewpoint
The patient's report of alterations in their symptoms is one of the most important factors influencing the judgement of how much a patient is better. It is intimately linked to the patient's expectations of osteopathic treatment. Although patients' expectations can vary tremendously, it is probably true to say that in the majority of cases patients are happy and satisfied when the relief of their symptoms has been achieved. Other patients expect too much from treatment too soon, and so become a self-limiting group, as they cease treatment before all possible benefit can be provided or achieved. Others become dependent on treatment, either through false expectations of what can be achieved (not necessarily given by the osteopath), with the development of pathologic psychological dependency. In other cases, the dependency may be more healthy in its nature; for example, the provision of periodic maintenance treatment which is psycho-physiologically beneficial, as in the elderly, arthritic patient.
The patients' expectations of a good outcome may be an improvement in ability to perform a particular function to a level they view as their normal. Or it may be the easing of their pain, or simply confirmation that they are not suffering from some crippling disorder.
3 The Natural History
The information gained will be taken in context. The value apportioned to a particular piece of information will change with the individual circumstances of the patient concerned. For example, the findings of a gross loss of passive mobility in a 20-year-old male, comparable to that expected for a 60-year-old male, will be deemed of more significance in the younger person, should that particular variable be looked at purely in isolation. When the particular stresses to which each has been subjected are considered, different conclusions may be reached. The occupational history of the young male may indicate that, for example, he has subjected his body to a high level of axial loading relative to body mass during his working life, delivering sacks of coal for the past five years whilst engaging in competitive weight lifting for a hobby. Such high level stresses are known to cause early degenerative changes (24,25) with the consequent loss of mobility. (26,27) The loss of spinal mobility, it is suggested, acts as a predisposing factor to disturbed biomechanical functioning of the spine, producing the osteopathic lesion or somatic dysfunction. This may produce further impairment to health via several mechanisms, including the creation of aberrant neural inputs with the potential for somatico-visceral effects. (28-30) Disruption of the socio-economic (31) or sexual activity (32) may occur, with the consequent effects upon the patient's well-being. In view of the complexity of the possible outcomes, how does one make a choice in deciding which to use in assessing whether the patient is better?
In the final analysis, the determination as to how much a patient is indeed better is arrived at by a degree of mutual agreement. In essence, the answer to the question “Are you any better?” is provided only by the patient's response to this question, irrespective of how sensitive the practitioner's measuring parameter happens to be, or to what degree his objective measures improve, it is still ultimately the patient's description of how he feels that provides the clinician with the answer.
To provide a corollary to this argument, it is possible that, whatever the treatment balance provided by the osteopath, it may not have led to an ultimate response of 'Yes, I am better,' but that this does not mean that such treatment of choice was necessarily inappropriate. In the treatment of a neoplastic growth, chemotherapy may be the treatment of choice but insufficient on its own to make the patient better, whereas if combined with radiotherapy, it may be effective. Similarly, a course of osteopathic treatment may lead to measurable palpatory changes in joint mobility or soft tissue state, which can be regarded as an improvement in the patient's health, though not actually making the patient feel better subjectively. It may, however, ultimately facilitate an improvement in the patient's condition. For example, it can perhaps lead to the transportation of a drug to an area where the required plasma or tissue level was previously insufficient for effective action of the drug to occur.
1 Dove, C.I. (1987), 'Individual characteristics assessed and used in practice: 7. Osteopathy', Compl. Med. Res., 2: 73-6.
2 Amalfitano, D.M. (1987), 'The osteopathic thoracic-lymphatic pump: a review of the historical literature', J. Osteopathic Med., 1: 20-4.
3 Heath, D.M. (1986), 'A prospective study on the efficacy of osteopathic manipulative treatment in managing ischemic rest pain in the lower extremities', (abstr.) J. Am. Osteopathic Ass., 9: 120-1.
4 Northup, T.L. (1961), 'Manipulative management of hypertension', J. Am. Osteopathic Ass., 60: 973-8.
5 Rodgers, F. (1986), 'Effects of osteopathic manipulative treatment on autonomic nervous system function in patients with congestive heart failure', (abstr.) J. Am.. Osteopathic Ass., 86: 122.
6 Howell, R.K., Allen, T.W., Kappler, R.E. (1975), 'The influence of osteopathic manipulative therapy in the management of patients with chronic obstructive lung disease', J. Am Osteopathic Ass., 74: 757-60.
7 Schmidt, I.C. (1982), 'Osteopathic manipulative therapy as a primary factor in the management of upper, middle and pararespiratory infections', J. Am. Osteopathic Ass., 81: 382-8.
8 Montague, K. (1985), 'Osteopathy during pregnancy', Nursing Mirror, 161: 26-9.
9 Page-Echols, W.E. (1986), Effects of osteopathic manipulative treatment on post-Caesarian section patients', (abstr.) J. Am. Osteopathic Ass., 86: 121-2.
10 Cipolla, V.T., Dubrow, C.M., Schuller, E.D. (1975), 'Preliminary study: an evaluation of the effects of osteopathic manipulative therapy on intraocular pressure', J. Am. Osteopathic Ass., 74: 433-7.
11 Feely, R.A., Castillo, T.A., Greiner, J.V. (1982), 'Osteopathic manipulative treatment and intraocular pressure', (abstr.) J. Am. Osteopathic Ass., 82: 91.
12 Burton, A.K. (1981), 'Back pain in osteopathic practice', Rheum. Rehabil., 20: 239-46.
13 Johnson, W.J. (1976), 'Inter-examiner reliability in palpation', J. Am. Osteopathic Ass., 76: 286-7.
14 Johnston, W.J., Hill, J.L., Elkiss, M.L., Marino, R.V. (1978), 'A statistical model for evaluating stability of palpatory clues', J. Am. Osteopathic Ass., 77: 473-4.
15 Tarr, R.S., Feely, R.A., Richardson, D.L., et al. (1987), 'A controlled study of palpatory diagnostic procedures: assessment of sensitivity and specificity'. J. Am. Osteopathic Ass., 87: 296-301.
16 Carmichael, J.P. (1987), 'Inter- and intra-examiner reliability of palpation for sacroiliac joint dysfunction', J. Manipul. Physiol. Therap., 10: 164-71.
17 Evans, D.H. (1986), 'The reliability of assessment parameters; accuracy and palpation technique', in P. Grieve, Modern Manual Therapy of the Vertebral Column, Churchill Livingstone, 1986: 498-502.
18 Johnston, W.L., Kelso, A.F., Hollandsworth, D.L., Karrat, J.J. (1987) 'Somatic manifestations in renal disease: a clinical research study', J. Am. Osteopathic Ass., 87: 61-74.
19 Nelson, K.E., Pazevic, J.P. (1986), 'Assessment of correlation between upper gastrointestinal viscerosomatic reflex patterns and upper panendoscopic findings' (abstr) J. Am. Osteopathic Ass., 86: 605.
20 Upledger, J.E. (1978), 'The relationship of craniosacral examination findings in grade schoolchildren with developmental problems', J. Am. Osteopathic Ass., 77: 760-76.
21 Nicholas, N.S., De Bias, D.A., Ehrenfeuchter, W. et al. (1985), 'Somatic component to myocardial infarction', Br. Med. J., 291: 13-17.
22 Cyriax, J. (1982), A Textbook of Orthopaedic Medicine, Vol.1, London, Baillière Tindall and Cassell, 5th edn., 101.
23 Lysell, E. (1969), 'Motion in the cervical spine', Acta Orthopedica, Scandinavian Suppl., p. 123.
24 Fiorini, G.T. (1980) 'Degenerative arthritis of the lumbar spine in labourers', Can. Family Phys., 20: 243-5.
25 Horst, M., Brinckman, P. (1981), 'Measurement of the distribution of axial stress on the endplate of the vertebral body', Spine, 3: 217-32.
26 Mellin, G. (1987), 'Correlations of spinal mobility with degree of chronic low back pain after correction for age and anthropometric factors', Spine, 12: 464-8.
27 Panjabi, M.M., Krag, M.H., White, A.A., Southwick, W.O. (1977), 'Effects of preload on load displacement curves of the lumbar spine', Orthop. Clin. North Am., 8: 181-92.
28 Denslow, J.S. (1975), 'Pathophysiologic evidence for the osteopathic lesion: the known, unknown and the controversial' J.Am. Osteopathic Ass., 74: 415-20.
29 Nathan, H. (1987), 'Osteophytes of the spine compressing the sympathetic trunk and splanchnic nerves in the thorax', Spine, 12: 527-32.
30 Retzlaff, E.W. (1974), 'Reflex mechanisms and their clinical significance', Osteopathic Ann., 2: 40-3.
31 Leavitt, S.S., Johnson, T.C., Beyer, R.D. (1971), 'The process of recovery: patterns in industrial back injury: part 1. Costs and other quantitative measures of effort', Ind. Med., 49: 7-14.
32 Sternbach, R.A. (1973), 'Traits of pain patients: the low back “losers”', Psychosomatics, 14: 226-9.