Chiropractic Management of a 67-Year-Old Veteran With Chronic Low Back Pain Utilizing Low-Velocity Flexion-Distraction: A Case Report

Abstract

Objective

The purpose of this case report was to describe the treatment of an older veteran with chronic low back pain, utilizing flexion-distraction as a primary intervention for management.

Clinical Features

A 67-year-old man with chronic low back pain for several decades presented to the chiropractic clinic for evaluation. He reported low back pain that extended into the right lower extremity intermittently. The patient's imaging demonstrated significant degenerative changes in the lumber spinal anatomy. He had never experienced chiropractic interventions or management for his condition.

Intervention and Outcome

A trial of conservative care with flexion-distraction was applied as a primary intervention for the management of chronic low back pain. Instrument-assisted soft-tissue mobilization and moist heat were also applied for interventions. Despite having no changes in outcome assessments, the patient reported an improvement in his condition, reduced use of pain medication, and increased mobility after 4 sessions over a 4-week period.

Conclusion

Flexion-distraction was a beneficial chiropractic approach to the management of an older veteran with chronic low back pain and intermittent lower extremity pain for several decades.

Introduction

Chronic low back pain (cLBP) is a potentially disabling condition that is the most common musculoskeletal disorder, resulting in limitations of activities of daily living.¹ Chronic low back pain also results in substantial economic costs and is a major public health burden.² Although a significant amount of research exists for cLBP, including a myriad of therapies and interventions, there are still gaps in the literature for this condition, such as age and meaningful or personal goals and outcome measures.^3,4 These age gaps include younger and older individuals, such as those under 18 years of age and those older than 60 years who experience cLBP. As studies have shown, the world population continues to grow older, and it is estimated that 22% of the population will be 60 or older by 2050.⁵ This is of significant note as older populations have a higher prevalence of cLBP than younger populations.⁶ As the population continues to grow older, the implementation of various interventions may prove important.

Treating veterans with cLBP comes with certain clinical challenges. On average, veterans are older than the general population of the United States, and almost half are aged 65 or older.⁷ Older veterans bring a variety of strengths and personal anecdotes to coping with chronic pain and other challenges that are common later in life. These challenges include but are not limited to longstanding physical and mobility issues, mental health conditions, such as post-traumatic stress disorder, chronic medication use, and substance abuse, as will be outlined in the case described in the following. Older veterans may experience depression, anxiety, distressing memories related to military service, or stress related to health concerns.⁸ Some of these concerns include pain, sleep troubles, memory problems, or difficulty with ambulation. A large portion of these individuals has moderate to severe degenerative conditions in their spine.⁹ These conditions can present the chiropractor with a different set of challenges when applying interventions. For these circumstances, having a combination of manual therapy approaches can serve to benefit the veterans presenting for care, including those with cLBP.

The Age-Friendly Health System (AFHS) is an initiative designed to meet the challenges of an aging population. The AFHS aims to follow 4 evidence-based elements (known as the “4Ms”) to provide high-quality care to older adults.¹⁰ The 4Ms consist of mobility, mentation, medication, and what matters. “What matters” asks health care providers to align care with each older adult's specific health outcome goals and care preferences, including treatment modalities/interventions utilized. A variety of literature addresses the potential importance of patient-centered goal setting regarding specific outcomes important to them.^{4,11, 12, 13} For future reference, it may be important to utilize assessments that better fit patient perception, such as the Global Rating of Change (GRoC). The GRoC is a 15-point Likert scale that uses patient-rated change as an outcome measure to determine the efficacy of a particular treatment.¹⁴

One intervention that has demonstrated positive outcomes for the treatment of cLBP is Cox Technic flexion-distraction.¹⁵ Prior case reports have demonstrated positive responses to Cox Technic interventions for older adults with cLBP.^{16, 17, 18, 19} This particular form of spinal manipulation uses variable amplitude forces to achieve spinal mobility throughout the 3-joint vertebral complex.⁹ The 3-joint complex is comprised of the left and right zygapophyseal joints and intervertebral disc.²⁰ Flexion-distraction is one procedure that differs from high-velocity low amplitude spinal manipulation but can still achieve the same goals of spinal movement and mobility. When flexion-distraction spinal manipulation is applied to the lumbar spine, research demonstrated biomechanical changes of decreased intradiscal pressure, increased intervertebral disc foraminal area, increased intervertebral disc space, and increased physiological range of motion of the facet joint.^15,21 It is a slower form of spinal manipulation and mobilization compared to the higher load and speed technique of a forceful thrust. Load tolerance testing for the procedure can distinguish if this approach is suitable for the case at hand.

Opioid pain analgesics have also been used for chronic pain, and both users and non-users have demonstrated an understanding that these medications are addictive.^22,23 Many of these individuals have shown a desire to use alternative forms of management for their chronic pain.^22,23 Other measures, such as patient-identified goals and meaningful individual outcomes, have also been explored, as noted previously and with AFHS.⁴ Outcomes that measure clinical relevance to patients’ desired outcomes may be important for future research and clinical application.

The purpose of this case report is to examine the treatment of an older veteran with cLBP utilizing flexion-distraction as a primary, non-pharmacological intervention for management and evaluating outcomes of pain, disability, mobility, medication use, and functionality deemed important by the patient.

Case Report

Presentation and Medical History

A 67-year-old male veteran of the United States military presented to the chiropractic clinic for cLBP and intermittent right leg pain. He reported his pain was over several decades, and he did not recall when it first began. The pain was daily and fluctuated in severity from moderate to severe throughout the day, depending on activity. His pain was “deep and achy” and occurred in a “band-like pattern” across the low back region above the buttocks. The pain was worse with prolonged sitting and standing and was “sharp and stabbing” pain associated with forward flexion and extension that would travel “up the back and down the right leg” on occasion. The pain radiated down the right leg to the foot following the L5 dermatomal pattern and superiorly to the mid-thoracic region to about the area of the inferior angle of the scapulae.

The patient was African American. He measured 67 inches tall and weighed 144 pounds. The patient had a medical history of cervical myelopathy with anterior cervical discectomy and fusion, lumbar spine microdiscectomy at L5 to S1, sleep apnea, post-traumatic stress disorder, depression, mild hearing loss, liver cirrhosis, carpal tunnel syndrome, type II diabetes mellitus, chronic obstructive pulmonary disease, benign prostatic hypertrophy, and hypertension.

The patient reported multiple interventions in the past for his cLBP, including physical therapy, pharmaceutical interventions, and home exercise programs. The interventions for his cLBP were documented through primary care and specialty clinics within the Veterans Health Administration (VHA). Within the past 5 years, the patient had begun using a rollator walking device issued by the VHA because he felt “unsafe” walking without support of this nature. The patient was previously seen for opioid use disorder by a non-VHA physician.

The pain medication he was prescribed included 325 mg of acetaminophen (1 tab every 6 hours, as needed), 10 mg of baclofen (1 tab 4 times per day), 10 mg of methadone HCL (9 tablets by mouth daily), and 4 mg of tizanidine (1 tablet by mouth 3 times per day).

Physical Examination

The patient presented with a forward antalgic lean and utilized a 4-point rollator device. His gait was slow with a short stride. His lumbar range of motion (ROM) in the lumbar spine was limited in all planes, and he reported pain at approximately 60 degrees of flexion and approximately 20 degrees of extension. The straight leg raise examination resulted in localized low back pain bi-laterally without any radicular complaints at approximately 60°. Slump test resulted in localized low back pain without any radicular complaints. Kemp's test (for facet loading) resulted in localized low back bi-laterally without any noted referral patterns. He reported tenderness on palpation in the facet planes bi-laterally and midline in the lumbar region, worse at L4 to L5 and L5 to S1. Spinal erector musculature was also tender to palpate in the lower lumbar region bi-laterally.

The patient scored his pain 8 out of 10 on the numeric rating scale (NRS) at the time of the first visit. During the week prior to treatment, the patient stated the cLBP ranged from a low of 5 out of 10 to a 10 out of 10 at its worst. The Oswestry Disability Index (ODI) was utilized as a functional assessment. The patient scored 11 out of 50 (22%) on the ODI.

Diagnostic Imaging

Prior to the consultation, the patient had imaging ordered by their primary care team. Results are outlined in Table 1, and images are available in Figures 1 to 4.

Fig 2.

L5-S1 lateral spot radiograph.

Fig 3.

Sagittal view lumbar spine computed tomography scan.

Table 1.

Diagnostic Imaging and Findings Based on the Radiologist Report

Modality	Findings
Lumbar spine radiograph (AP, lateral, L5-S1 spot view; see Figs 1 and 2)	• Normal height and alignment with straightening of the lumbar spine. • Advanced degenerative changes to the lumbar spine but no destructive osseous abnormality. • Degenerative sclerosis present at the endplates. • Pre- and paravertebral soft tissues are unremarkable.
Lumbar spine computed tomography scan (see Figs 3 and 4)	• Vertebral body alignment is normal. • There is no evidence of acute fracture or subluxation. • There are severe discogenic degenerative changes at L2-L3, L3-L4, L4-L5, and L5-S1. • There is no significant spinal canal stenosis. • There is mild bilateral neuroforaminal stenosis at L2-L3, L3-L4, and L4-L5.

Fig 1.

Lateral lumbar spine radiograph.

Fig 4.

Axial view L4-L5 computed tomography scan.

The radiologist report included the following findings for the lumbar spine radiographs: (1) advanced degenerative changes to the lumbar spine but no destructive osseous abnormality and (2) degenerative sclerosis present at the endplates. For the lumbar spine computed tomography report, findings included severe discogenic degenerative changes at L2 to L3, L3 to L4, L4 to L5, and L5 to S1, with mild bilateral neuroforaminal stenosis at L2 to L3, L3 to L4, and L4 to L5.

Goals and Intervention

Patient Goals

The patient's primary goal was to reduce cLBP overall. The patient had specific goals to stop or reduce the use of opioid medications. He reported a desire to be more active and participate in more activities in and outside of the home and to walk daily despite the presence of the pain.

Intervention

After the physical examination and review of the patient's imaging, it was noted that the likely primary pain generators were discogenic and facetogenic. There were no contraindications to spinal manipulation or mobilization in the lumbar region discovered on the initial examination. However, given the degree of degenerative anatomical changes in the lumbar region on the diagnostic imaging, and the patient's intolerance to heavy pressure, we chose a trial of manual-based therapy that included Cox Technic flexion-distraction.²⁴

Of the 2 basic treatment protocols when applying Cox Technic flexion-distraction,²⁵ we chose Protocol II because there were no radicular symptoms at the time of the examination. Protocol II consisted of spinal manipulation and mobilization applied to specific segments in the lumbar region, with a set of 10 oscillating “pumps” into flexion and lateral flexion bilaterally. When these motions were introduced and coupled together, a circumduction motion was initiated. Long y-axis traction was tolerated by the patient.

A hand contact was made at the L4 spinous process in a cephalic position while administering flexion-distraction and circumduction. The L4 spinous hand contact point was used due to the presence of the L4 to S1 symptoms and allowed for maximal forces of these adjacent lower segments. He was treated 4 times over a 4-week period until follow-up. Moist heat for 8 to 10 minutes and instrument-assisted soft tissue mobilization were also applied to the lumbar region prior to the application of low velocity, variable amplitude spinal manipulation. Instrument-assisted soft tissue mobilization was performed for 8 to 10 minutes and targeted the lumbar musculature, including the spinal erectors, quadratus lumborum, and upper gluteal muscles. Education on the benefits of physical activity and preventing prolonged sedentary positions was performed. The patient was advised on the ability to remain active despite any degenerative changes within the lumbar spinal anatomy. The patient was advised to continue the lumbar spine home exercise program that was assigned by his physical therapist.

Outcomes

There were 3 outcome assessments utilized: the NRS, ODI, and GRoC. The patient was asked about their usage of pain medication, mobility throughout the day, and functionality in completing tasks around the home, and the results are reported herein.

After 4 treatments over a 4-week period, the patient reported he “can move better and longer with reduced pain” following care. He also reported using his walker less and felt as though he could walk “better and longer” without the use of the assistive device. The NRS remained unchanged, with the current level of pain reported at 8 out of 10, and the best and worst over the previous week were reported at 5 out of 10 and 10 out of 10, respectively. The ODI also remained unchanged at 11 out of 50 (22%). Despite these unchanged outcome assessments, the patient reported on the GRoC that from the beginning of treatment until the time of the re-evaluation that he felt his condition was “somewhat better” or a “+3.” For reference, the GRoC ranges from a “-7 (a very great deal worse)” to a “+7 (a very great deal better), with other descriptive options at the single-digit intervals between the aforementioned ranges. As well, he reported using less pain medication, though no quantitative data was recorded. He reported engaging in increased activity and functionality around his home with less use of his rollator device. His ROM appeared to increase based on subjective provider findings to reach approximately 70° of flexion and 30° to 35° of extension before the patient reported pain increases.

A mutual decision was reached between the provider and patient to continue therapy with 1 to 2 visits every month in an attempt to maintain improvements and continue the self-reported benefit. The patient consented to the publication of this report, and the Birmingham Veterans Affairs Health Care System Institutional Review Board approved the use of health information for this publication.

Discussion

This case is an example of chiropractic interventions utilized in the management of cLBP. This specific case highlights the benefits these therapies may provide to an older veteran who has a history of cLBP and has never undergone chiropractic interventions for this condition. The patient had a primary goal of reduced low back pain. However, despite the unchanged pain scores, the patient felt he functioned better and that his condition had improved. Further, he desired to use less pain medication and reported that he was; however, there was no outcome assessment used in general practice to quantitatively record his pharmaceutical usage. The patient also had an increase in ROM in forward flexion and extension without pain, although this is subjective to the provider. Therefore, this case is an example that current outcome assessments may not necessarily demonstrate or align with important goals for patients.

As noted with AFHS, identifying what is important to older patients may help providers better align care with the needs of these patients. In this case, a low-velocity variable amplitude spinal manipulation technique was utilized, as was soft tissue mobilization and moist heat, based on the patient's tolerance and preferences for interventions. Following the intervention, the patient then met the self-identified goals that mattered to him, including increased mobility, functionality around the house, and less use of pain medication. The patient's self-rating improvement of “somewhat better” on the GRoC is also an indicator of change in the patient's self-perception of their condition. In the AFHS, “what matters” is also very similar to “Whole Health” within the Veterans Affairs system, which places the veteran at the center of their care and aligns care with what is important to that veteran.²⁶ “Whole Health empowers and equips veterans to take charge of their health and well-being and live their lives to the fullest.”²⁷ This growing concept in the health care model may be beneficial for implementation across specialty services to achieve the best outcomes for their patients and their desired outcomes. Further cases or a larger study investigating patient goals associated with chiropractic care for cLBP, including ancillary treatments, such as Cox Technic, may be of value for the future of this topic.

Limitations

We used the procedures for Cox Technic flexion-distraction; however, the chiropractic table utilized in this case was not a Cox instrument. This may have influenced the outcomes or the application of the technique despite attempting to recreate the approach as closely as possible. The table utilized in this case offered hydraulic flexion and lateral flexion that were combined to create circumduction. Although these movements were attempted to “mimic” Cox Technic as closely as possible, the difference in the instrument may have inadvertently changed forces or pressures in the spinal anatomy that may have influenced or skewed results. Factors such as the patient's use of prescription and over-the-counter medications, at-home exercises, and the use of pain relief creams/gels also may have played a role in his pain management. This patient was given a trial of 4 sessions of interventions before transitioning to a supportive care plan because of the limited access to the chiropractic clinic in the VA hospital. Ideally, due to the nature of his findings and condition, a longer trial of care would have been preferred. A future study with increased treatment frequency (ie, 2-3 sessions per week for several weeks) may be of benefit to demonstrate potential greater changes in outcome assessments. Future case reports, series, or trials may prove beneficial in understanding patient desired outcomes in the older age groups, as well as the efficacy of Cox Technic as an intervention for cLBP in this population.

Conclusion

After a trial course of care using Cox Technic flexion-distraction and additional therapies, the patient reported less use of pain medication and increased activity and functionality around his home with reduced use of his rollator.