Pilot Study of Patient Response to Multiple
Impulse Therapy for Musculoskeletal ComplaintsThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: J Manipulative Physiol Ther 2006 (Jan); 29 (1): 51 ~ FULL TEXT
OPEN ACCESS Joseph M. Evans, PhD, Daniel L. Collins, DC, Reed H. Grundy, BSEE
Sense Technology, Inc.,
3251 Old Frankstown Rd,
Pittsburgh, PA 15239
OBJECTIVE: To investigate patient response to multiple impulse therapy provided by the PulStarFRAS (Sense Technology, Inc, Murrysville, Pa) for a variety of musculoskeletal symptoms encountered in clinical practice.
METHODS: A retrospective analysis of patient files was used to determine symptomatic improvement over the course of treatment. The multiple impulse therapy was supplemented, at the discretion of the practitioner, with manual adjustments. The manual adjustments consisted of high-velocity low-amplitude and drop table, and represented fewer than 5% of the adjustments. Therapy was provided by a single practitioner in a private clinic setting.
RESULTS: Patients expressed improvement in symptoms after the first visit (average improvement in subjective pain rating scale of 41%). Patient symptoms improved between the first and second visits for 70% of patients (average improvement in subjective pain scale for all patients was 58%). The majority of patients achieved complete resolution of symptoms between the third and fourth visits. Maximum benefit for patients across all symptoms required an average of 4.2 visits. The half-life for response to multiple impulse therapy for all symptoms was 17 to 26 days. The half-life for response to multiple impulse therapy using the PulStarFRAS for low back pain was 9 to 16 days.
CONCLUSIONS: The results of this study suggest the further study of multiple impulse therapy provided by the PulStarFRAS as a means of resolving musculoskeletal complaints.
From the Full-Text Article:
Background
There are many techniques of musculoskeletal therapy. Thirty techniques are currently taught in chiropractic colleges alone. [1] More than 100 chiropractic techniques are used in the profession. However, little published data are available that document the effectiveness of a specific technique. [2] There is some question that musculoskeletal therapeutic techniques are any more effective than exercise, educational programs, or simply the passage of time. [3] There are some studies of the effectiveness of manual techniques for specific musculoskeletal symptoms such as low back pain, cervicogenic headache, and migraine. Despite these recent efforts, many questions remain unanswered.
These include the following:(1) Are certain manual techniques more effective than others?
(2) Are certain manual techniques more effective than others for specific categories of musculoskeletal complaints?
(3) Given a specific musculoskeletal symptom, when in the course of treatment should the clinician and patient reasonably expect to achieve improvement?The literature relating to these questions is sparse and complicated by the fact that chiropractors, physical therapists, and osteopaths use multiple techniques. These techniques are often lumped under one general category as if all techniques within a discipline were equivalent and that any combination of techniques were equivalent to any other combination of techniques selected by the practitioners involved in any particular study. [2, 4, 5] This study also suffers in some respects from this same phenomenon. The clinician occasionally complemented, with purely manual adjustments, the multiple impulse therapy that is the subject of this study.
The primary purpose of this study was to analyze the effectiveness for the continuing development and improvement of the analysis and treatment protocols used with a particular instrument, the PulStarFRAS (Sense Technology, Inc, Murrysville, Pa).
The PulstarFRAS provides the clinician with an analysis of the stiffness of the patient's musculoskeletal system and multiple impulse output of variable frequency that can be used to provide percussive therapy. The basic design of the instrument and methodology for its use was first described by one of the authors (JME). The analysis function has been adapted to various chiropractic techniques including Upper Cervical, Diversified, Pierce, Pettibon, Gonsted, Logan, and Activator, among others. The technique used in this study consisted of a full spine analysis following a protocol developed by the second author (DLC), which is a refinement of the original protocol developed by the late Vernon Pierce, DC, who was instrumental in the development of the first generation of the PulStarFRAS.
History of Multiple Impulse Therapy
Instrumentation has been used to provide mechanical percussive therapy to the spine since the beginning of chiropractic. [6] Early percussive techniques included single impulses delivered with a stick and mallet and cam or pneumatically operated single and multiple percussive devices.
Our experience with multiple impulse therapy began when JME invented an adjusting head designed to deliver a single mechanical impulse to the musculoskeletal system at the point and line of drive chosen by the clinician. A unique feature of this instrument was the incorporation of a preload control to initiate the impulse. In the late 1980s, Dr Vernon Pierce observed under an x-ray intensifier that the initial tissue compression resulting from the preload increased if a second impulse was delivered at the same location immediately after the first impulse. Tissue compression increased further but seemed to stabilize after the third impulse. This led to the 1991 development of a multiple impulse adjustor (Kinetic Technology Model SHCLP-4; Kinetic Technology, Inc, Murrysville, Pa) that provided 3 consecutive impulses when applied to the patient. Soon thereafter, Dr Pierce requested that the number of impulses be increased so that a continuous train of impulses could be applied to the patient. This feature was incorporated in the next model of the instrument. Clinicians observed that the sound of the impulses being applied with these instruments changed, often at the same time that the patient expressed relief. This suggested that the mechanical response of the musculoskeletal system was changing measurably during therapy.
Instrumentation to monitor the mechanical response of the point of contact during the application of multiple impulse therapy as a means of providing feedback to the clinician was added by incorporating a force transducer and computer display in 1994 in the force recording and analysis system and subsequent generations of the instrument known as the PulStarFRAS.
Users of these instruments anecdotally reported that they could more effectively provide relief to patients suffering from musculoskeletal complaints. However, until this study, no attempt has been made to document the results that are obtained with multiple impulse therapy or to compare these results with other means of treatment.
Instrumentation
The PulStarFRAS consists of 3 components that provide an analysis of musculoskeletal stiffness at each vertebral level and a multiple impulse treatment. For analysis of the patient, a handheld impulse head is pressed against the patient and provides a single low-energy impulse to the vertebral level of interest. A force sensor in the impulse head measures the resistance to the impulse, which is related to the compliance of the vertebra tested.
The second component, the impulse head control system, monitors the impulse head and provides the electrical impulses to the head to create the impulse, interpret the output of the head, and communicate the results of the analysis to the third component, a digital computer. The computer displays the compliance readings in a series of bar graphs.
During the treatment phase, these components supply multiple impulses to the areas selected by the clinician while measuring the musculoskeletal stiffness at each impulse. The changes in musculoskeletal stiffness that occur during treatment are displayed for the clinician and used to monitor the treatment.
This retrospective file review sets out to answer the following questions:(1) What is the patient response to multiple impulse therapy provided with the PulStarFRAS?
(2) How does patient response to multiple impulse therapy provided with the PulStarFRAS compare to patient response when other methods or techniques of therapy are employed?
Discussion
The results of this study suggest that multiple impulse therapy delivered with the PulStarFRAS provided effective treatment for the 2 major conditions observed in this specific patient population: low back pain and neck pain. Follow-up of the patients who “dropped out” of the treatment program revealed that 4 of the dropouts did so because their pain level approached 0 after their last visit. Of the remainder, 3 stopped coming because they felt that the treatment did not help, 3 moved and could not be contacted, and 1 was referred out.
The patients in the study reported perceiving an immediate positive benefit after the first visit across all symptoms and that benefit increased (on average) between the first and second visit without additional treatment. A small number of visits were required to achieve maximum benefit across all symptoms. The average number of visits required to achieve 100% relief for those patients who continued therapy until they achieved a pain-free state was 3. When all patients in this group are included in the calculation, the average number of visits required to reach “maximum benefit” increased to 4.2. Maximum benefit was defined as the subjective ranking of pain made by each patient on his or her last visit. These results compare favorably with Cox flexion distraction (19 visits and 43 days to “maximum benefit”) and diversified (50% of patients reported that they had “improved” at the fourth visit and within 2 weeks). [4, 13]
Fig 3, Fig 4 compare the rate of patient response to physical therapy, [12] osteopathic manipulation, [14] and multiple impulse therapy performed with the PulStarFRAS. Physical therapy is defined in van den Hoogen et al as [12] “… combinations of exercise therapy and modalities such as heat, cold, and massage, and advice on daily behavior.” As can be seen, the Kaplan-Meier analyses of the results obtained with the PulStarFRAS compare favorably to osteopathic manipulation and physical therapy for the patient complaint of low back pain. [10, 14] It should be noted that the Kaplan-Meier results of van den Hoogen et al [12] were based on data obtained through the use of patient questionnaires and not through a face to face encounter. It is hypothesized that the responses might reflect a better outcome if the data were obtained directly by the clinician as the patient might wish to please the clinician (van den Hoogen, personal communication).
Comparison of these results to recent studies where the results are presented as a graph of 3 points is problematic. However, such a comparison using the simple exponential model as an approximation has been attempted by Evans. [15]
As this was a pragmatic retrospective study, the number of days between treatments was not controlled as part of the research design. Because the time between visits was not controlled, these results are likely to mirror common clinical practice more closely than results obtained in studies that control visit frequency. In this study, the clinician determined the time between patient visits on the basis of the apparent severity of the patient's complaint and on the capacity of the clinic. Following common practice, the patient is referred to the appointment desk for assignment to an open treatment slot as close as possible to the time for the return visit specified by the clinician. It is possible, indeed likely, that the number of days between treatments affects the rate of response to the treatment. No investigation of the treatment of musculoskeletal complaints has identified an optimal treatment frequency or suggested a procedure for developing a means of scheduling patients that will result in a maximum response to the treatment.
Rates of recovery were not found to be dependent on the length of time between the onset of the complaint and the first patient visit. Some studies find that chronic conditions respond more slowly to therapy than acute conditions. [16, 17] However, this finding is not universal. [18, 19] Again, the study of van den Hoogen et al [12] may be helpful. Fig 5 is a plot of the results of that study showing the response rates of untreated patients with acute, subacute, and chronic low back pain. For comparison, the responses of patients treated with multiple impulse therapy are also shown. Examination of this graph reveals that the response rate of patients treated with multiple impulse therapy is greater than the response rates of patients in the van den Hoogen study. That is, even patients with acute symptoms respond more slowly than patients treated with multiple impulse therapy. One interpretation of this observation is that multiple impulse therapy provided with the PulStarFRAS overpowers the effects of condition (acute, subacute, chronic) because the response of patients is much faster than the “untreated” response.
These observations lead to the hypothesis that methods of musculoskeletal therapy that exceed the rate of the natural healing response of the musculoskeletal system will not show differences in patient response related to the duration of symptoms before treatment. Or the corollary hypothesis that methods of therapy that are associated with differences in the response rate due to the duration of symptoms before treatment are unlikely to have exceeded the natural response rate of the musculoskeletal system.
Limitations of the study include the following: the clinician supplemented the multiple impulse therapy with manual adjustments; the number of patients [50] included in the study was small; the study was conducted at a single clinic; only 1 clinician provided the treatment; and the study used a retrospective, nonexperimental design. Before these results may be extended to the general patient population, additional studies are required that include larger patient samples, multiple clinicians, and clinics, and improved research designs to include randomized controlled trials.
Conclusion
The results of this study support continued study of multiple impulse therapy provided by the PulStarFRAS as a means of treating musculoskeletal symptoms.
Funding
References:
Phillips R
We need to bring order to our techniques.
Dynamic Chiropr. 2002; 20 (Available from:
http://www.chiroweb.com/archives/20/01/15.htmlCooperstein R Perle SM Gatterman MI Lanz C Schneider MJ
Chiropractic technique procedures for specific low back conditions:
Characterizing the literature
J Manipulative Physiol Ther. 2001 (Jul); 24 (6): 449-456Koes BW Assendelft WJ Van den Heijden G Bouter LM
Spinal manipulation for low back pain.
An updated systematic review of randomized clinical trials
Spine (Phila Pa 1976) 1996 (Dec 15); 21 (24): 2860-2871Stig L Nilsson O Leboeuf-Yde C
Recovery pattern of patients treated with chiropractic spinal manipulative
therapy for long-lasting or recurrent low back pain
J Manipulative Physiol Ther. 2001 (May); 24 (4): 288-291Hseih CJ Adams AH Tobis J Hong C Danielson C Platt K et al.
Effectiveness of four conservative treatments for subacute low back pain.
Spine. 2002; 27: 1142-1148Fuhr A Colloca CJ Green JR Keller TS
Activator methods chiropractic technique.
Mosby, St. Louis1997PulStarFRAS user's manual software version 5.2.
Sense Technology Inc., Murrysville (PA)2002Huskisson E.C.
Measurement of pain.
Lancet. 1974; 2: 1127-1131Glover JR Morris JG Khosla T
Back pain: a randomized clinical trial
of rotational manipulation of the trunk.
Br J Ind Med. 1974; 31: 59-64Collett D
Modeling survival data in medical research.
Chapman and Hall, London (UK)1994Evans J.M.
The Use of Survival Analysis for the Evaluation of Musculoskeletal Therapy
J Manipulative Physiol Ther. 2005 (Jun); 28 (5): 374van den Hoogen HJ Koes BW Deville W van Eijk JT Bouter LM
The prognosis of low back pain in general practice.
Spine. 1997; 22: 1515-1521Cox JM Shreiner S
Chiropractic manipulation in low back pain and sciatica:
statistical data on the diagnosis, treatment and response of 576 consecutive cases.
J Manipulative Physiol Ther. 1984; 7: 1-11MacDonald RS Bell CM
An open controlled assessment of osteopathic manipulation
in nonspecific low-back pain.
Spine. 1990; 15: 364-370Evans JM
A proposed method for estimating the efficiency and effectiveness
of techniques of musculoskeletal therapy
J Manipulative Physiol Ther. 2005 (Mar); 28: 206-210McMoreland G Suter E
Chiropractic management of mechanical neck and low back pain:
a retrospective, outcome based analysis.
J Manipulative Physiol Ther. 2000; 23: 307-311Bigos S, Bowyer O, Braen G, Brown K, Deyo R, Haldeman S.
Acute Low Back Problems in Adults: Clinical Practice Guideline No. 14
AHCPR Publication No. 95-0642: December 1994
Agency for Health Care Policy and Research,
Public Health Service, US Department of Health and Human ServicesMatthews JA Mills SB Jenkins VM Grimes SM Morkel MJ Matthews W et al.
Back pain and sciatica: controlled trials of manipulation,
traction, sclerosant and epidural injections.
Br J Rheumatol. 1987; 26: 416-423Hoehler FK Tobis JS Buerger AA
Spinal manipulation for low back pain.
JAMA. 1981; 245: 1835-1838
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