The Chiropractor's Role in
Pain Management for Oncology PatientsThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
This article is reprinted with the permission of National College of Chiropractic and JMPT. Our special thanks to the Editor, Dr. Dana Lawrence, D.C. for permission to reproduce this article exclusively at Chiro.Org
FROM: J Manipulative Physiol Ther. 2001 (Jan); 24 (1): 52–57
Jeffrey Schneider, DC, and Scott Gilford, DC
Naval Hospital Camp Pendleton,
Camp Pendleton, CA, USA.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.
Keywords Chiropractic, Oncology, Cancer, Pain, Management, Manipulation
From the FULL TEXT Article:
INTRODUCTION
The treatment of patients with cancer has historically, and justifiably, been focused primarily on the disease entity. However, there is recent recognition of the importance of the supplemental needs and concerns of patients with cancer, along with consideration of alternative courses of action to improve such patients’ quality of life. Although reliance on medications is a common protocol for the management of a patient’s pain complex, chiropractic treatment may offer an alternative for the open-minded physician. It is estimated that at least half of patients with cancer do not receive adequate relief from their pain. [1] In response to this problem, the cancer rehabilitation team concept has been introduced into the literature to help health care providers consider the multidimensional problems faced by the patient with cancer. [2] This team is assembled to address issues regarding physical, emotional, and/or social disabilities that may result from the disease entity itself or from the corresponding treatment. Among these issues is pain management. To address “physical” rehabilitation of the patient, the team may include a physiatrist, physical therapist, and/or occupational therapist. The team may also include appropriate professionals to address social, employment, and psychologic issues.
In many instances, a chiropractor can offer services unique to a rehabilitation team. Chiropractic treatment has consistently been rated favorably in the area of patient satisfaction, and chiropractic manipulation has been well documented in the literature to provide relief for mechanical low back pain. [3, 4] The cancer rehabilitation team is faced with addressing, among other things, complications of prolonged bed rest, chronic pain related to radiation fibrosis, chemotherapy- related neuropathies, and gait or functional abnormalities associated with the disease or associated treatment regimen. The chiropractor can assist in the treatment of these entities, thereby potentially decreasing the patient’s reliance on pain medication.
The purpose of this article is to demonstrate the practicality of including a chiropractor on the rehabilitation team for pain management of the patient with cancer.
The Chiropractic Profession
The barriers of the stereotypical health care system are beginning to fall. The inclusion of nontraditional providers has become more commonplace in every aspect of health care today. From the perspective of the chiropractic profession, opportunities have presented themselves in new and exciting areas of health care delivery. Multidisciplinary practices incorporating medical doctors, osteopaths, chiropractors, physical therapists, podiatrists, and other medical professionals are becoming commonplace. As of 1998, at least 215 US hospitals had some type of relationship for providing chiropractic services. [5] In 1995, the US Department of Defense established the Chiropractic Health Care Demonstration Program, placing chiropractors in military hospitals/ clinics to provide chiropractic treatment for active-duty personnel, retirees, and family members; there are now 26 chiropractors serving 13 military treatment facilities, including the Naval Medical Center, Bethesda, and Walter Reed Hospital. [6]
The increasing use of chiropractors has come as members of the general population seek new ideas, methods, and techniques with regard to their health care. A 1998 study in The Western Journal of Medicine revealed that nearly 70% of young and middle-aged adults and half of senior adult members of health maintenance organizations were interested in having alternative therapies incorporated into their health care. [7] Emphasis in health care is shifting to a more “holistic” concept. Holism has been described as “the balanced integration of the individual in all aspects and levels of being: mind, body, and spirit, including interpersonal relationships and our relationships to the whole of nature and our physical environment.” [8] This shift toward a broader view of health management is consistent with the previously mentioned cancer rehabilitation team concept.
Since its inception, chiropractic philosophy has emphasized the needs of the “whole person.” The following case reports illustrate the useful application of chiropractic in concert with standard medical approaches.
CASE REPORTS
Case 1
In one case, a 57-year-old man with back pain came in for chiropractic evaluation. His symptoms had been present for more than 4 months and were described as pain in the area of the lower rib cage and sharp stabbing pain in the right upper back. The patient was also complaining of diffuse gastrointestinal symptoms. He related that his symptoms were gradually worsening and that he had begun to experience weight loss, which he attributed to a lack of appetite.
An initial evaluation by the chiropractor revealed pain in all ranges of motion. There was palpable spasm of the thoracic and lumbar musculature. Results of testing for disk involvement or nerve root impingement were negative. Tenderness was noted in the upper quadrants of the abdomen. Thoracic and lumbar radiographs were performed; these showed no abnormalities. Routine laboratory tests revealed a decreased iron level.
Because of the suspicious history and nature of the back and gastrointestinal symptoms, the patient was referred to an internist. In the meantime, he was started on treatment that included manipulation, therapy modalities, and soft tissue techniques. He obtained temporary relief (for 24-72 hours) from the chiropractic treatment; however, he related that the overall intensity of his symptoms was increasing. The patient received 6 chiropractic visits over a period of 18 days without lasting relief. Shortly thereafter, the internist made a diagnosis of pancreatic cancer and assumed control of the patient’s medical care. Because the chiropractic treatment was not providing more effective pain relief at that time, further treatment was deferred.
Approximately 8 months later, the patient’s hospice nurse called. She stated that he was experiencing low back pain with severe radiating pain down his left leg and that his physician had cleared him to receive chiropractic care. At that time, the patient was house-bound and sat (slouched) in a “lounger” most of the day with his legs extended. He had lost considerable weight and was unable to obtain relief from his back and leg pain by using morphine.
The chiropractor initiated a house-call treatment plan involving the use of varying degrees of spinal manipulation, mobilization, and soft tissue manipulation/massage. In addition, the patient was provided with a lumbar support cushion for his back and given instructions regarding his sitting posture. Other postural/ergonomic suggestions relating to his limited activities were provided.
Significant relief was obtained from the first 2 treatments. The patient’s sciatica symptoms were minimal to nonexistent for the next 6 weeks, and he was able to reduce his medication intake to some degree. After 6 weeks, 2 more treatments were provided, the patient noting some benefit. Unfortunately, the patient succumbed to his disease a short time thereafter.
In this example, the chiropractic treatment offered greater pain relief with regard to the sciatica and back pain than did the use of morphine. Neuropathic pain can be less responsive to opioid drugs than pain from ongoing injury to somatic tissues such as bone, joint, and muscle. [9] This might account for the limited effectiveness of the morphine for this patient’s sciatic symptoms.
In this case, chiropractic care was able to provide significant pain relief, reduce the amount of pain medication being taken (as well as the potential side effects), and temporarily improve the quality of life for a patient with terminal cancer.
Within the multidisciplinary team, one of the main objectives of the chiropractor would be to address quality-of-life issues by focusing on pain management. Sources indicate that 30% to 40% of patients with cancer experience pain and that this figure increases to 65% to 85% for patients with advanced cancer. [10] “Pain is one of the most feared aspects of cancer and is a major cause of anxiety, depression, sense of helplessness, loss of esteem, and anger,” writes Levy, [10] adding that “unrelieved pain can add to anorexia, insomnia, immobility, and weakness and may prevent patients from making recommended changes in position, leading to painful decubitus ulcers.” By helping to reduce the patient’s pain, the chiropractor can help the patient reduce his or her medication intake (thereby avoiding unwanted side effects) and can be a contributing factor in the patient’s mental well-being.
Case 2
In another case, a 54-year-old man received surgical intervention to remove a primary tumor from his right lung. Radiation therapy was subsequently provided. The patient noted pain in the thoracic spine immediately after surgery, and this pain persisted. He was evaluated by his medical physician on a periodic basis and given medication for the back pain.
Approximately 1 year after the surgery, the patient visited a chiropractor seeking relief from constant pain in his mid and upper back. Pain medication was not completely effective in relieving his symptoms. At the time of initial chiropractic evaluation, he reported that his MD had informed him that the cancer was in remission. As a result of his back pain, he was unable to perform deep inspiration without increased pain and was unable to find a comfortable position in which to sleep. He reported the focus of this pain in the T4-8 region, along the rib cage, just lateral to the spine.
The initial history and examination by the chiropractor revealed palpable tenderness in the area of the costovertebral joints of the midthoracic spine. There was paravertebral muscle tension into the right thoracic and shoulder girdle muscles. Range of motion was slightly limited bilaterally into side bending, with pain on these motions. Radiography revealed no significant bony abnormality.
It was felt that a possible mechanism for this individual’s pain was trauma to the supportive tissues (joint capsules, ligaments, muscles) of the rib cage and costovertebral joints. Compromise to the rib cage during surgery was considered a reasonable mechanism for the initiation of these symptoms. A less likely contributing factor could be pain arising from periarticular tissue fibrosis after radiation treatment.
The patient began a chiropractic treatment program that included high-velocity/low-impact spinal manipulation, electric muscle stimulation, and application of hot packs to the thoracic region of the mid to upper vertebral and costovertebral joints. The manipulation was intended to improve functional integrity of the vertebral joints. The electric muscle stimulation and hot packs were used to promote muscle relaxation in preparation for the manipulation. Immediate benefit was reported with regard to improved mobility, decreased pain, and restoration of painless inspiration.
By the second visit the patient was able to discontinue the use of his medications. At this treatment session, the patient was given a home exercise program consisting of stretches and active resistive exercises to strengthen the involved area. Treatment continued at a frequency of twice per week for 3 weeks, then once per week for an additional 2 weeks. Additional exercises were added to the patient’s home program. By the conclusion of the treatment regimen he was no longer experiencing back pain. He returned a few weeks later for mild recurrence of the pain, which again responded favorably. Several months later he returned again and reported that he had been doing well until recently. His response after that visit was also favorable.
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 postsurgical 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 realworld 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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