FROM:
J Manipulative Physiol Ther 2001 (Jan); 24 (1): 52–57
Jeffrey Schneider, DC, Scott Gilford, DC
3331 Donna Drive, Carlsbad, CA 92008; JOSDC@aol.com
OBJECTIVE: The purpose of this article is to present and discuss the idea that chiropractors can be key contributors to the pain management of oncology patients.
DISCUSSION: Although it is an oncologist who institutes the necessary treatment for a cancer patient's primary disease process, a chiropractor can help provide noninvasive and non-pharmacologic options for decreasing pain and improving function. As part of a cancer rehabilitation team, the chiropractor can provide treatment that may significantly enhance a cancer patient's quality of life at any stage in the disease process. Treatment may benefit those patients experiencing pain from the side effects of treatment or from the disease process itself. The chiropractor's treatment may include manipulation, soft tissue techniques, physiotherapeutic modalities, exercise, and ergonomic counseling.
CONCLUSION: This article describes the potential benefits of chiropractic for cancer patients in the area of pain management and quality of life. Two specific case studies are presented in which cancer patients' quality of life benefited from chiropractic treatment.
From the Full-Text Article:
Discussion
The second case illustrates an incident of musculoskeletal pain arising from joint dysfunction that responded favorably to chiropractic care. In fact, the most common presenting complaint in chiropractic offices is that of musculoskeletal pain, as in the second example. Surveys show that 75% of patient visits to chiropractors are for back- and neck-related complaints. [11] This is consistent with the fact that back pain is a frequent area of complaint among patients with cancer.
There are other factors that can ultimately lead to the patient's developing a musculoskeletal complaint. A possible side effect of certain chemical agents during chemotherapy is that of axonal neuropathy, potentially causing muscle weakness leading to pronounced gait abnormalities. [12] Sources indicate that approximately 80% of studied patients with colon, lung, and prostate cancer have related problems with ambulation. Forty percent to 70% described those ambulation problems as severe. [13] The patient requiring a lower extremity prosthesis undoubtedly has compensatory pelvic or spinal pain as he or she adapts to beginning ambulation. Compensatory problems are commonly seen in the chiropractor's office in relation to sports injuries and post-surgical interventions in the knee and foot. It is therefore natural that chiropractic be considered a treatment option for the patient with cancer who has pelvic dysfunction or mechanical pain resulting in a functional gait abnormality.
Chiropractic techniques may also be of benefit in instances in which joint contracture or adhesions occur. The effects of radiation therapy on normal tissue can result in tissue fibrosis. [14] Fibrosis of this nature potentially leads to a loss of mobility and/or painful movement. A multidisciplinary approach offering chiropractic provides an additional venue for assisting patients with the management of their joint and muscle pain before it reaches a disabling level. By offering manipulation, exercise instruction, physiotherapeutic modalities, and ergonomic counseling, the chiropractic team member can facilitate the improvement of strength and mobility in those patients suffering from the side effects of unrelieved pain.
These clinical examples offer 2 specific instances of how chiropractic treatment helped improve the quality of a cancer patient's life. In conversations that we have had with several other chiropractors, similar case histories have been related. In most cases, the chiropractors emphasized, their patients generally “felt better” after receiving treatment and were much more “relaxed” in dealing with the overwhelming stress brought on by their disease and the associated treatment regimen.
Of course, there are different criteria that would prompt referral for chiropractic treatment. Pain of an unrelenting nature that is not affected by changes in posture or position is less responsive to chiropractic care. When activity and changes in position/posture affect the patient's pain, chiropractic care might be able to provide significant benefit.
These presentations may exist separately or in unison. The astute clinician recognizes that every symptom experienced by a patient with cancer need not be a direct function of the disease. To assume otherwise can lead to unnecessary narrowing of the range of treatment options. Further evaluation could reveal a patient with cancer who coincidentally also has back pain of a mechanical origin. Because any unrelieved pain can cause suffering and unnecessary disability, ancillary options may warrant consideration.
It is necessary to mention that there is a very small percentage of chiropractors whose practice philosophy falls outside the mainstream of chiropractic teachings. Such practitioners might attempt to undertake treatment of the primary disease process itself. It should be emphasized that this article does not endorse or condone the behavior of any chiropractor whose philosophy is to undertake primary treatment of any patient with cancer. The standard of care within the chiropractic community is to refer patients with cancer for treatment (of their primary disease process) to the appropriate medical specialty. With regard to the patient with cancer, the chiropractor serves as a supplemental provider, pain management and enhanced quality of life being the goals of treatment. To ensure that a cooperative effort among the providers occurs, it would be wise for a referring oncologist to take the time to establish a relationship with the chiropractor with whom he or she is considering working.
Diagnostic studies
If a patient with cancer has been referred to a chiropractor from an oncologist, it is relatively certain that the patient has undergone extensive diagnostic examinations, including radiographs, magnetic resonance imaging, computed tomography, bone scanning, and laboratory testing. If these studies are relatively recent, they may be sufficient to determine that the patient can safely undergo a treatment program that includes manipulation and/or other manual procedures. As noted, most patients with cancer are not referred from their oncologists but rather self-refer to the chiropractic office. In either instance, it is ultimately the responsibility of the chiropractor to determine that the patient is a candidate for chiropractic treatment and that manipulation or other manual procedures can be performed safely without undue danger or risk to the patient. This may necessitate that before beginning a treatment protocol the chiropractor request medical records from the oncologist and/or obtain the results of any new diagnostic studies that may be indicated.
Chiropractic treatment methods
Regarding the application of methods, the treatment plan should be individualized to the patient's needs. Some individuals will be nonambulatory; others will ambulate with or without difficulty. Some patients may be experiencing intense pain from the disease entity itself, whereas others may be experiencing symptoms in relation to the treatment regimen or to other lifestyle changes that are accompanying the disease process. Each patient must be evaluated thoroughly to determine which chiropractic methods will provide the greatest benefit in the particular case. In some instances, treatment may call for nonforce techniques; other situations could be better addressed through use of more standard manipulative procedures.
Manipulation
Spinal manipulation is the most widely used treatment procedure within a chiropractic practice. The variety of techniques by which such “adjustment” is accomplished varies from practitioner to practitioner. A study by Leach [15] in 1986 identified more than 35 different chiropractic techniques, which illustrates the variability within the profession. The technique and amount of force used vary according to the personal preference of the provider and his or her clinical judgement. Despite the numerous techniques available, most chiropractors use high-velocity manipulation (“adjustment”) as part of their treatment. Although the use of high-velocity manipulation is considered to be an absolute contraindication in a patient with malignancy because of the possibility of compromised bone strength, [16] there may be circumstances in which it is appropriate. Depending on the patient's individual case history, the disease process may be such that bone strength is not compromised and high-velocity manipulation can provide significant benefit. In instances in which extreme joint contracture occurs, consideration may be given to manipulation with the patient under anesthesia. Some chiropractors are certified through postgraduate programs to perform manipulation on patients under anesthesia.
There are methods that chiropractors can use in addition to manual manipulation. Although most chiropractors perform manipulation manually, some use adjusting instruments to deliver less forceful manipulations, and others apply various indirect techniques to affect the dysfunction of the vertebra (subluxation). Although the use of adjusting instruments might not appear to be as effective as manual manipulation, these techniques are widely and successfully used with patients who cannot tolerate or do not respond to more forceful methods.
In addition, less aggressive, nonforce chiropractic techniques may be used by the experienced chiropractor to accomplish treatment goals. Soft tissue manipulation, massage, stretching, and myofascial release are examples of various techniques used in some chiropractic settings.
Exercise
Chiropractors often recommend regular exercise routines within their treatment plans. Encouraging the patient to walk and perform stretching exercises is common practice. These activities need to be tailored according to the special needs and limitations of the patient. Most often, these exercises are very simple (“low-tech”), requiring minimal use of specialized equipment. Because inactivity quickly results in muscular deconditioning and because there is a potential for joint restriction through contracture or shortening of the periarticular tissue, it is appropriate to encourage gentle exercises for maintaining flexibility and muscle tone.
Physiotherapeutic modalities
The application of various physiotherapeutic modalities for the purpose of pain modulation is practiced by many chiropractors, depending on the licensing regulations of the state in which each practice operates. The use of cold, heat, ultrasound, diathermy, electric muscle stimulation, and transcutaneous electric nerve stimulation have been shown to be effective in the management of pain for patients with cancer. [17] However, because of the ability of some of these modalities to “stimulate” tissue, extreme caution should be used with regard to areas of malignancy. In addition, each of these modalities can have more specific contraindications with regard to its use.
Ergonomics
The chiropractor's knowledge of ergonomics and activities of daily living (ADL) can also be extremely beneficial in the rehabilitation of a patient with cancer in his or her quest to advance toward as normal a life as possible. The term ergonomics typically refers to the study of activities in a work environment, including the implementation of modifications within that environment to reduce potential injury. Some of the same principles can apply to a person who is sitting at home, lying in a hospital bed, or working at a personal computer. Addressing these biomechanical issues can alleviate pain that is attributable to any of a number of aggravating factors. When these issues present in a home environment, they are often referred to as pertaining to ADL.
Nutritional counseling/supplementation
Nutritional counseling and supplementation play a large role in many chiropractic practices. Although numerous volumes have been written regarding dietary practices and supplementation to help prevent cancer, there is much less available literature regarding nutritional supplementation that may be useful in the pain management, specific to oncology patients. Many chiropractors recommend herbal remedies or nutritional supplements that may ease muscular tension, help patients to relax, or reduce pain symptoms. It behooves the chiropractor, as part of the cancer rehabilitation team, to make use of all available resources; this includes working in concert with a nutritionist or dietician. To avoid adverse drug/herb interactions, the chiropractor should communicate with the patient's oncologist and pharmacist regarding any other medications that the patient is taking and any known drug/herb interactions.
With regard to a potential role for the chiropractor within the multidisciplinary team, the emphasis is on working with the patient's pain complex and not with the primary disease process. Therefore, recommending dietary/herbal supplementation to the oncology patient for the treatment of a primary disease process without consulting and arriving at a consensus with the other team members would be inappropriate and would undermine the benefits of the team approach.
Informed consent
Because of the inherent increased risk associated with treating patients with cancer, it is incumbent on both the chiropractor and the physician to provide sufficient information to enable the patient to give “informed consent.” As in all cases of musculoskeletal pain, the patient with cancer should be informed that the treatment protocol might make him or her sore and, in occasional instances, could actually worsen the condition. The inherent risk in patients with cancer primarily involves pathologic fracture and any resulting neurologic complications. A thorough examination, proper diagnostic testing, and a carefully constructed and applied treatment program will greatly decrease the risk of adverse consequences.
Conclusion
A new era in the treatment of patients with cancer has begun. Helping such patients now includes not only traditional treatment of the disease process itself but also incorporation of the contributions of other providers to assist the patient in living a richer, fuller life. This approach attempts to view the patient as a “whole person” with needs reaching beyond the management of the disease entity. The chiropractic profession has, ever since its inception, embraced this “holistic” approach toward patient care. Having chiropractic available to the rehabilitation team adds new opportunities in the treatment of the cancer patient. Within this team, the chiropractor's primary role is to serve as an ancillary provider by assisting the patient with pain management and increasing mobility. Especially for the ambulatory patient, the chiropractic provider widens the scope of treatment options to include high-velocity and/or low-force manipulation, soft tissue techniques, physical modalities, exercise instruction, and recommendations pertaining to ergonomics and ADL.
The literature most strongly supports the use of chiropractic treatment for patients with low back pain, which is a common entity among patients with cancer. Clinically, many musculoskeletal complaints respond favorably to chiropractic treatment. Symptoms related to radiation fibrosis, chemotherapy-induced neuropathy, or postsurgical trauma to connective tissues and joints may respond favorably to chiropractic methods.
The clinical examples provided in this article are real-world cases in which the practical application of chiropractic treatment benefited patients with cancer. However, as in the examples, it is usually the patient who takes the initiative to seek assistance from a chiropractor. The addition of a chiropractor to the rehabilitation team can improve the physical and emotional well-being of a patient with cancer, which will positively impact the quality of his or her life, and it can provide the team with additional avenues by which to bring comfort to the patient.
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