Chiropractic Integration into Multidisciplinary Rehabilitation: A Descriptive Study
Written by Editor   
Tuesday, December 11, 2018 07:04 PM

Individuals rehabilitating from complex neurological injury require a multidisciplinary approach, which typically does not include chiropractic care. This study describes inpatients receiving multidisciplinary rehabilitation including chiropractic care for brain injury, spinal cord injury (SCI), stroke, and other complex neurological conditions.

Chiropractic services were integrated into a 62-bed subacute multidisciplinary rehabilitation, skilled nursing facility through this project. Patient characteristics and chiropractic care data were collected to describe those receiving care and the interventions during the first 15 months when chiropractic services were available.

Brain injury was the most common admitting condition caused by trauma, hemorrhage, infarction, and general anoxia. Three patients were admitted for cervical SCI, one for ankylosing spondylitis, one for traumatic polyarthropathy, and two for respiratory failure with encephalopathy. 

Over 3,000 cases of acute SCIs occur within the USA each year as do an estimated 795,000 cerebrovascular accidents (stroke). Of the estimated 2.5 million annual emergency department visits for traumatic brain injury (TBI), the US Centers for Disease Control and Prevention estimates ~280,000 persons are hospitalized for moderate to severe injury.  Many patients with such complex neurological conditions are admitted to postacute rehabilitation settings or skilled nursing facilities to support their recovery process.

Rehabilitation-focused disciplines, such as physical, occupational, and speech therapies, support inpatients recovering from and adapting to complex neurological injury. Chiropractic services may also offer a positive contribution. Spinal manipulation, a therapy commonly used by doctors of chiropractic (DCs), is known to influence pain through complex central nervous system mechanisms. Because chiropractic services are integrated increasingly into outpatient multidisciplinary environments where nonpharmacological interventions are needed or preferred, exploring care that can be delivered in inpatient settings is a next logical step. Currently, little is known about chiropractic service delivery within the inpatient neurorehabilitation context. However, such knowledge is vital to informing integration decisions.

Musculoskeletal symptoms are common in individuals suffering from neurological injury. Chiropractic services focused on relieving musculoskeletal pain and stiffness.  Daily census ranged around 45 adult inpatients, with most eligible for a chiropractic evaluation. Following orientation, the number of chiropractic visits ranged from 8 to 12 patients daily, depending on case complexity.  Chiropractic procedures employed included manual myofascial therapies (93%), mechanical percussion (83%), manual muscle stretching (75%), and thrust manipulation (65%) to address patients with spinal-related pain, joint or regional stiffness, and extremity pain. Care often required adapting to participant limitations or conditions. Such adaptations not commonly encountered in outpatient settings where chiropractic care is usually delivered included the need for lift assistance, wheelchair dependence, contractures, impaired speech, quadriplegia/paraplegia, and the presence of feeding tubes and urinary catheters.

Chiropractic care primarily addressed spine and extremity-related musculoskeletal pain and joint or regional stiffness. Though chiropractic care delivered in outpatient settings similarly focuses on musculoskeletal conditions, it is often delivered in relative isolation from other health care interventions. At this facility, chiropractic care differed from typical delivery in several ways. For example, in this setting, patient care goals focused mainly on symptom reduction and functional improvement in the context of moderate to severe preexisting functional limitation and in support of the rehabilitation goals and interventions of the clinical team. Goals to reduce pain held dual purpose, that of relieving suffering, but also of improving ability and willingness to participate in self-care and other rehabilitation activities, often managed by physical or occupational therapists.

The fact that many patients experienced notable and often profound functional limitations created other clinical challenges not typically encountered in most chiropractic settings. The functional limitations experienced by many patients required the chiropractic provider to assist with body movement and positioning, adapt treatment to limited patient mobility or frailty, engage novel communication methods to ensure an appropriate evaluation and understanding of the patient, and recognize that memory and problem-solving ability is compromised in some patients.

This study does not address the relative contribution of chiropractic care for patients at this facility, perceived benefit, or the ideal number of visits required. A small sample size and lack of homogenous case controls prevented such a design. However, the addition of chiropractic to the majority of care teams during the study time frame suggests that both other providers and patients perceived an added therapeutic benefit.