The term conservative care has different meanings depending on who you ask. While some forms of care have been studied and validated, others have not. Whatever the modality utilized, the one thing most experts agree on is that every patient, with rare exception, deserves a trial of conservative care prior to escalating to relatively more aggressive measures.
Activity limitation
The most basic level of conservative care is what almost every patient does after sustaining a painful injury; they limit their activity. It is commonly accepted that a patient with a broken leg will use crutches rather than bear weight on the broken bone. A patient with back pain or neck pain is not much different. The patient will limit painful activity such as exercise, chores or strenuous activity even before seeking medical attention. Even those patients that continue to remain active will modify their activity to a degree, simply based on the negative feedback of induced pain. Limiting activities for some time is reasonable, but when limitations continue it is now disabling and additional care is required.
Medications
The next level of conservative care usually involves medication. Medications can be either prescription or non-prescription. In fact, over the counter medications like non-steroidal anti-inflammatories and Tylenol can be as effective as narcotic medications, especially when used together. This effectiveness comes with a lower side effect profile. This is the rationale used by the FDA in allowing these medications to be available over the counter. Ibuprofen was first marketed in 1974 and released as an over the counter medication in 1984. Naprosyn first became available in 1976 and became an over the counter medication in 1994. When one considers the potency of these once prescription only drugs, it is easy to understand why self-directed medical care is considered effective and is recommended by experts.
When there is significant muscular spasm associated with pain, doctors will often prescribe anti-spasmodics, like cyclobenzaprine or methocarbamol. These can cause drowsiness and most patients use them sparingly.
There is little utility in prescribing narcotic medications for the treatment of common spine injuries. Patients in such discomfort are, by definition, severe enough to warrant escalation of therapy to injections, no matter what the duration so far of conservative care.
Home exercises
Home exercise therapy is another form of self-directed conservative care that, while dismissed by many defense experts, can be as effective as more formal types of therapies. Patients may employ home exercise therapy after receiving instruction from their doctor or therapist. Home exercise therapy may be as passive as stretching exercises or as active as cardiovascular conditioning and core strengthening. Home exercise therapy is proven to be effective. Studies have shown that in the long-term it is as effective as chiropractic care. The importance of home exercise therapy should not be dismissed.
Formal therapy
While almost every patient engages in activity limitations, over the counter medications and home exercise, most defense attorneys and defense experts will be dismissive of conservative care until it involves a formalized therapy program. These programs include chiropractic care and physical therapy. There are many similarities and differences between chiropractic care and physical therapy. Both may employ traction and various modalities like stimulation, heat, cold and ultrasound. Both may also employ exercise training and conditioning. Important differences include the chiropractic use of manipulation and the physical therapist's use of manual therapy. Each field also possesses different underlying treatment philosophies. Most experts agree that either specialty is beneficial to the injured patient. They also agree that a trial of conservative care may employ one or the other, but not necessarily both. Lastly, while studies show no long-term difference in outcomes between patients in a home exercise program versus chiropractic care, improving patients improve faster in chiropractic care.
Medically supervised care
At some point, hopefully early in their course, a patient may come under the medical supervision of a physician. This may be a primary care doctor, an orthopedist, neurosurgeon, physiatrist, pain management doctor or spine interventionist. Whatever the specialty, this will usually involve a careful history and physical and a musculoskeletal and neurological examination. Radiological studies of the spine may be ordered. The physician may prescribe medications or may recommend the use of effective over the counter medications. The physician will also monitor the success of medical therapy, chiropractic care or a home exercise program. A physician supervised conservative care regimen is an evidence-based recommended means of conservative care. Experts agree that an MD or DO should supervise the conservative care of the spine injured patient.
Interventional therapy
Interventional therapy, or spinal injections, may commonly take the form of facet block injections or epidural injections. These injections represent an escalated form of conservative care. Spine medical societies recommend that spinal injection be considered if there are continued symptoms after 4 weeks of conservative care. However, if a patient’s symptoms are severe enough to limit function, then spinal injections may be performed at the physician’s discretion. In other words, a patient does not need to suffer through ineffective conservative care before escalating to injections.
Non-traditional therapies
In some cases, conservative care may take the form of acupuncture, herbal therapy or traditional ethnic remedies such as cupping. There is little evidence to support these modalities. However, they are considered conservative care because they employ the passage of time prior to escalating therapy.
Time
The one thing activity limitations, exercise, medications, therapy and injections have in common is that they allow the passage of time while palliating the patient’s pain. None of these activities will cure an underlying significant injury. Rather, they mitigate pain long enough for strains and sprains to heal themselves. A patient in persistent pain beyond 12 weeks is in pain because of a chronic injury. Such an injury is unlikely to heal itself. If it does improve, it is likely to become relapsing and remitting. Therefor, of all things, time is the most decisive form of conservative therapy.
Conclusion
As one can see, there are various forms of conservative care. There is scientific evidence to support some forms of care more than others. However, most experts agree that in the long term the passage of time is the most important factor in determining the effectiveness of conservative care. The utility of home exercise care and over the counter medications as a form of conservative care before escalating therapy should not be dismissed.
Laurie Montgomery, 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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