In conservative care, the duration of care is important. Just what is an adequate duration can be nebulous. One must consider multiple factors in determining whether adequate conservative care has occurred. These factors include duration of symptoms, time between relapse and remission, recommended time prior to interventional or surgical treatment and the presence of escalating symptoms.
When does conservative care start and end?
When a condition is static, conservative care begins soon after the condition presents and ends with treatment escalation or remission. When there is a relapsing and remitting condition the duration of conservative care may start anew with each new relapse and its success can be declared with remission. This would apply to most cases when the duration between relapses is sufficiently long to allow a reasonable quality of life.
Duration of non-interventional conservative care
In static, ongoing and chronic conditions, what is a sufficient duration of conservative care? Though this has not been addressed by medical societies one can make inferences from guidelines for more invasive procedures. The alphabet soup of medical societies (ASIP, AAPMR, SIS, NASS) recommend injectional therapy (epidurals, etc.) in any patient with a functional impairment. Therefore, inability to work, sleep, exercise or perform activities of daily living constitute a reasonable end to non-injectional conservative care and a reasonable time to escalate care. Barring a functional impairment, 4 weeks is considered a reasonable enough time to determine the success of conservative care by medical societies. This is far sooner than what is typically seen in the personal injury patient, where 2-3 months of therapy is common.
Duration of conservative care including interventions and injections
If one were to include injectional therapy as a form of conservative care, we can look to spine surgery guidelines to determine what the adequate duration of conservative care might be. In a candidate for lumbar discectomy, results are better if surgery occurs prior to 6 months, so it stands that less than 6 months is an adequate duration. How much less is up to the determination of the surgeon and the patient. When discectomy is required, but would destabilize the spine, fusion is indicated within the same time frame.
Note that the number of injections or interventions is not utilized in determining when a satisfactory duration of conservative care has elapsed prior to considering surgery. Injectional therapy may consist of single or multiple injections. Certainly, there is no requirement for a series of epidurals or a repeat injection if the first one was unsuccessful.
Conservative care duration and neurological deterioration
Lastly, it is commonly accepted that care should escalate to surgery in the presence of severe or progressive neurological deficits. This may include myelopathy, conus or cauda equina syndrome, bladder incontinence, erectile difficulty and limb weakness. When any of these have occurred, a reasonable physician will recommend an end to conservative care, even if it has been of short duration. Likewise, progression of radiculopathy during conservative care may also warrant an escalation to surgical care. This can be seen with the progression of a painful radiculopathy to a sensory radiculopathy, loss of reflexes or developing weakness.
Conclusion
One can see that the proper duration of conservative care has little to do with a hard and fast rule of duration. Evaluation of the severity of patient symptoms trumps everything in determining an end to conservative care. The presence of a functional impairment, severe/progressive neurological deficits or progressive radiculopathy indicate a reasonable need to escalate care. In chronic, moderate and stable cases, professional guidelines on the recommended interval before interventions or surgery will dictate the proper duration of conservative care.
Jack Stapleton, MD
The views expressed are the personal views of the author and do not represent the views of The Brain, Spine and Joint Group, its managers, affiliates, partners, employees or its clients. Furthermore, the information provided by the author is not intended to be expert or legal advice.
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