CCA- Canadian Chiropractic Association - 8Chapter

Clinical Guidelines for Chiropractic Practice in Canada

Chapter 8 - Frequency and Duration of Care

Chapter Outline

I.Overview
II.Definitions
III.List of Subtopics
IV.Literature Review
V.Assessment Criteria
VI.Recommendations (Guidelines)
VII.Comments, Summary or Conclusions
VIII.References
XI.Minority Opinions

I OVERVIEW

The purpose of this section is to provide guidelines, not rigid standards, that will assist the chiropractor in clinical decision making regarding the frequency and duration of chiropractic care required for the average, uncomplicated case. Treatment guidelines must be tempered with a blend of scientific information and the systematic observation derived from clinical experience (Kapp, 1990). They must be updated periodically based on the ever-changing knowledge database.

The terminology used in this section e.g., "therapeutic necessity", and "treatment/care" is utilized because it constitutes the contractual language of third party payors in the health care system. References to lower back disorders serve as examples only. These disorders are mentioned because they represent a sizeable part of chiropractic practice and there is a strong literature base.

The primary goal of chiropractic care is to provide sufficient care to restore health, maintain it, and prevent the recurrence of injury and illness. Used appropriately, chiropractic care is capable of reducing pain, improving function, and promoting health. Used inappropriately, it can become a passive treatment approach promoting patient dependency (Chapman-Smith, 1992).

Initiation of a treatment program should be based on clinical need, and must consider the outcome of the condition if no treatment was to be provided, i.e., the natural history of the disorder. The frequency and duration of care should be based on the subjective and objective clinical information gleaned from the case history, the physical and x-ray examination findings, and the clinical impression or diagnosis. The length of time required to achieve clinical objectives may require modification if there has been a delay in seeking treatment, if the pain is severe, if there is a history of several or more previous episodes, or if the injury was superimposed on a preexisting condition. As treatment proceeds, the patient response should be periodically re-assessed by subjective and objective means. A lack of expected improvement necessitates a change in treatment approach or a referral for a second opinion.

Variations in Treatment Approaches

Care may be influenced not only by a patient's needs but also patient expectations (Nyiendo, 1990). Many treatment variations stem from different clinical approaches and from the belief, on both the part of the patient and the doctor, in the value of certain procedures. Clinical expectations must, however, be substantiated by more than personal opinion. They must be based on recognized modes of treatment that reflect the literature and currently accepted standards of chiropractic care.

Regardless of the treatment approach used, failure to achieve therapeutic objectives requires that it should be re-evaluated. A change in treatment procedure, or the obtaining of a second opinion, is indicated. Continued failure should result in the patient being discharged either as being inappropriate for active chiropractic care, or for having achieved maximum therapeutic benefit.

Principles of Case Management

An early return to activity is associated with reduced disability and symptoms (Deyo et al. 1986, Frymoyer 1988, Mayer et al. 1988). There is a natural history of recovery for uncomplicated cases (Waddell, 1984) that can serve as a time frame from which to evaluate and shape a successful treatment plan.

Chronicity should be prevented whenever possible. Patients at risk of becoming chronic show the following characteristic patterns involving their illness and life situation (Cailliet, 1987):


    i. somatic complaints that remain static longer than 2-3 weeks.
    ii. anxiety or depression
    iii. functional or emotional disability
    iv. family turmoil
    v. drug dependence: recreational, non-prescription or prescription.

Alone, the repeated use of acute care measures generally fosters chronicity, physician dependence, and over-utilization (Riley et al.,1988).

It is understood that therapeutic motivation, goals, and fiscal responsibility are different for elective care than for therapeutically necessary care.

II DEFINITIONS For definitions see the Glossary at the end of this publication.

Active Care
Acute
Active Care Program
Assessment
Chronic
Complicated Case
Diagnosis
Disability
Duration
Efficacy
Elective Care
Frequency
Impairment
Maximum Therapeutic Benefit
Natural History
Passive Care
Physician/patient dependence
Preventative/maintenance care
Sub-acute
Supportive care
Therapeutic necessity
Treatment Plan
Uncomplicated Case

III SUB-TOPICS

A. Short and Long Range Treatment Planning

B. Treatment/Care Frequency

C. Uncomplicated Cases

D. Complicated Cases

E. Cases Requiring Supportive Care

F. Patient Cooperation

G. Failure to Meet Treatment/Care Objectives

H. Elective Care

IV LITERATURE REVIEW

Background

Manipulation is the most studied form of treatment for low-back pain and good evidence now exists supporting its effectiveness. Although lower back complaints comprise a large percentage of a chiropractor's practice (Kelner et al. 1980), many other conditions are seen and are being subjected to research scrutiny. The effectiveness of manipulation is being investigated, for example, for neck pain (Cassidy et al. 1992, Nansel et al. 1989), migraine headaches (Parker et al. 1978, Vernon et al. 1992), chronic strain of the upper extremity (Leboeuf et al. 1987), post-manipulative changes in EMG readings (England and Deibert 1972, Grice and Tschumi 1985, Ellestad et al. 1988), pain tolerance (Terrett and Vernon 1984), improvement in respiratory disorders (Miller 1975, Hviid 1978, Jamison et al. 1986, Nilsson and Christiansen 1988), infantile colic (Klougart et al. 1989) and enuresis (Leboeuf et al. 1991). Although limited in some cases by sample size or other methodological problems, these studies represent the ongoing attempt to define the role of chiropractic care for various clinical conditions.

Regardless of the condition, once a patient consults a health professional, the frequency of visits is determined to a great degree by that health care practitioner (Hansen, 1991). The question that then arises is, "How many visits are clinically necessary?" Many factors are relevant, but the natural history of the condition provides the basic reference point from which a measurable plan of action can be made.

Natural History

The pathology and pathogenesis of low-back pain has been well documented by clinical, anatomical, and radiological studies (Kirkaldy-Willis 1992). Depending on the stage of the degenerative process in a patient, the outcome of treatment can be dramatically different. Clearly, however, the frequency and duration of treatment/care of an uncomplicated case should never extend beyond the time frame of the natural untreated course.

Low-back pain (LBP) may run an unpredictable, spontaneous course. Of the adult population that experiences an acute episode of LBP, 50% recover and return to work within 2 weeks. Within 6 weeks, 80% have returned to work. The remaining 20% provide a clinical and socioeconomic challenge (Haldeman 1992).

A study by Triano (1991) attempted to determine treatment history of acute, sub-acute, and chronic spinal disorders and compare it to the natural history of the condition (Fig. 8.1). Complicating factors should be identified and corrected whenever the progress of treatment/care approximates or intersects the estimated time line.

Predictors from Case History and Examination

Singer et al. (1987) described a relationship between three factors in the episode history prior to consultation and the duration of conservative care. These three - pain intensity, pain duration prior to the consultation, and the number of prior episodes - were observed to affect the time necessary to return the patient to pre-injury activity and to the point of no pain or mild pain. In general, more severe pain at treatment/care onset was associated with twice the treatment/care times. In like manner, patients suffering with pain less than 8 days before commencing therapy took a mean of 13 days to recover. With pain exceeding 8 days, 21 days (1.5 times as long) where required. Similarly, patients with up to three prior episodes required 12 days, while more than 8 episodes extended recovery to 27 days (twice as long).

Pathological or anomalous structures may interfere with clinical progression by a factor of 1.5 - 2 times (Herrin et al. 1974, Haldeman et al. 1992). Re-injury and exacerbation from unexpected events also may alter treatment/care goals. Likewise, supervening or continuing biomechanical and psychosocial stressors may be important impediments to recovery.

The use of a pain drawing has been shown to yield information that facilitates the exploration of psychosocial and other non-organic causes of back pain (Goldman et al. 1991). Similarly patient questionnaires such as the Oswestry Low-Back Pain Disability Questionnaire, the Roland-Morris Questionnaire and the Neck Disability Index, and pain scales such as the Visual Analog Scale have been found to be valid and reliable in measuring health status and results for patients with low-back and neck pain and receiving chiropractic management (McDowell 1987, Deyo 1988, Fairbanks 1980, Meade et al. 1990, Vernon and Mior 1991). Any suggestion from these questionnaires of a functional overlay, pain amplification, somatization, or poor psychometric skills constitutes a complicating factor that may cause a poorer response to chiropractic manipulation (Bronfort 1986).

Treatment Plans

The treatment plan for therapeutically necessary care can be divided into four phases (Table I), each having distinct objectives that allow for passive (Stage 1) and active (Stages 2 - 4) benefits. It is beneficial to proceed to the rehabilitation phase (if warranted) as rapidly as possibly, and to minimize dependency upon passive forms of treatment/care. Studies have shown a clear relationship between prolonged restricted activity and the risk of failure in returning to pre-injury status (Deyo et al. 1986, Frymoyer 1988, Mayer et al. 1988). Often a complete resolution of pain is not possible until patients begin to focus on increasing the number and kind of activities in which they participate. Return to work usually can be commenced at the 80-90% level of pre-injury status (Beimborn and Morrissey 1988). Even then, some residual pain can be expected, although usually it will be offset by the benefits of increased productive functioning and a better prognosis.

Table I

Stages of Treatment/Care: Goals and Objectives

(after Haldeman et al. 1992)

Passive Care

1. Acute Intervention (including manual procedures)

    A. To promote anatomical rest
    B. To diminish muscular spasm
    A. To reduce inflammation
    B. To alleviate pain

Active Care

2. Remobilization

    A. To increase the range of pain-free motion
    B. To minimize deconditioning

3. Rehabilitation

    A. To restore strength and endurance
    B. To increase physical work capacity

4. Life Style Adaptations
    A. To modify social and recreational activity
    B. To diminish work environment risk factors

To adapt psychological factors affecting or altered by the spinal disorder

(i) Acute Care

An acute condition is one that commenced within the 3 weeks prior to the patient seeking treatment. When the patient exhibits acute distress, passive care predominates with efforts to reduce soft tissue and joint stresses, and to diminish inflammation and swelling. A short term of reduced mobility to limit the joint loading effects of gravity may be warranted. Passive forms of treatment/care, including manual and palliative procedures, may be used with due deference to the type of mechanical lesion present.

When the pain and discomfort have abated, a shift towards active care is encouraged with the introduction of slow speed and minimal load exercises prescribed to improve flexibility. As the range of pain-free motion increases, a gradual increase in exercises promoting endurance is commenced. Lastly, when a maximal range of motion is achieved, rehabilitation for strength can begin.

It is generally agreed that a more aggressive in-office intervention early during treatment/care will likely result in a reduction in the level and duration of disabling injury and the number and cost of inpatient procedures.

After reviewing the available evidence, the 1990 RAND Consensus Panel unanimously agreed upon a definition of adequate therapeutic trial for spinal manipulation (Shekelle et al., 1991). For an uncomplicated case, this multidisciplinary panel recommended two trial courses of two weeks each, using alternative manipulative procedures. Without evidence of demonstrable improvement over this time frame, spinal manipulation was felt to be no longer indicated.

(ii) Chronic Care

A chronic condition is defined as one with an onset more than three months prior to treatment.

There is now clear evidence that, of those whose symptoms persist for more than 3 to 4 months, more than half will still be disabled at the end of a year (Mayer and Gatchel 1988). If chiropractic treatment of patients with chronic conditions is to be successful, emphasis must be placed on patient participation and active care (see Table I). A search must be made to identify any factors competing with recovery, and steps taken to correct them.

As with acute care, the RAND Consensus Panel (Shekelle et al. 1991) also recommended two trial courses of two weeks each, using alternative manipulative procedures before considering treatment/care to have failed. Without evidence of improvement over this time, spinal manipulation is no longer indicated. It is not clear, however, whether the RAND Panel intended this recommendation to be a base line to be modified by complicating factors such as pre-existing conditions. Meade et al. (1990) reported excellent results with chronic low-back pain patients with a maximum of 10 treatments which, although intended to be concentrated within the first three months, were spread over a year if considered necessary. Jaquet (1974) recommended 12 treatments as a maximum number with no improvement. Similarly, Hansen (1988) recommends a second opinion if there is no objective or subjective sign of improvement in two weeks, or treatment of three times per week that exceeds four weeks (12 treatments).

Other observational or retrospective studies have compiled information on the number of treatments given to patients. Phillips and Butler (1982) found a mean of 12.5 treatments in the case records of 3,943 patients. Phillips (1981) reported a mean of 9.0 treatments in 871 cases. Jarvis et al. (1991) calculated a mean of 12.9 treatments over an average of 54.5 days in a study examining worker's compensation data. However, many of these studies involve a mix of acute, subacute, and chronic complaints, and this makes it difficult to extract reliable figures on duration and frequency of treatment for chronic pain patients.

It is generally agreed that with the treatment/care schedule, any episode of symptoms that remain unchanged for two or three weeks should be evaluated for risk factors of pending chronicity. Warning signs include somatic complaints that remain static longer than two to three weeks, anxiety or depression, functional or emotional disability, family turmoil and drug dependence (Cailliet 1987).

(iii) Elective Care

Elective care encompasses maintenance and preventative care, which is discretionary and elective on the part of the patient, but not supportive care. In the case of supportive care, a trial of withdrawal of care has shown that long-term care is a necessity to sustain previous therapeutic gains. After maximum therapeutic benefit has been achieved and explained to the patient, the type and voluntary nature of elective care should be explained.

The effectiveness of maintenance care has not been subjected to rigorous clinical trials, and empirical evidence needs to be supported by further research. The results of clinical experience, coupled with the emerging clinical studies, support the chiropractic view that elective care is safe and effective when used discriminately so as not to foster physician dependence or chronicity.

Growing evidence supports the chiropractic contention that pathomechanics, harmful dysfunction in the neuromusculoskeletal system, often precedes symptoms. Consider, for example, sacroiliac joint dysfunction or subluxation. Bourdillon and Day (1987) state that "(the sacroiliac joints) can have a profound effect on body mechanics". Shaw (1992) suggests "sacroiliac joint dysfunctions are the major cause of low-back dysfunction, as well as the primary factor causing disc space degeneration, and ultimate herniation of disc material". Lewit and Janda (1964) reported sacroiliac dysfunction in a large percentage of the 750 normal schoolchildren examined. Mierau and Cassidy (1984) found a similar proportion of sacroiliac problems in both elementary and secondary school students in Canada. Sato (Haldeman, 1992) has investigated the possibility that joint disturbances may extend beyond biomechanical insult, and may involve somato-somato, somato-visceral, or viscero-somatic reflexes.

Clinical signs and symptoms having their origins in altered sacroiliac mechanics respond well to manipulation. Changed motor patterns in the abdominal and gluteal musculature are corrected by manipulation (Lewit & Janda, 1964). The clinical results in sacroiliac dysfunction achieved by Lewit and Janda have been substantiated more recently by a study in which 90% of patients disabled by a sacroiliac syndrome responded to a 2-3 week regimen of daily SI manipulation (Kirkaldy-Willis and Cassidy, 1985).

(iv) Failure to Meet Treatment/Care Objectives

Jaquet (1974) indicates that no improvement after 12 visits means one or more of the following:


    1. The original diagnosis was incorrect.
    2. The incorrect treatment was given.
    3. There was incompatibility between the doctor and patient.
    4. There is secondary gain for the patient.
    5. There were coexisting conditions.

Any failure of the patient to progress at least consistently with the stages of natural history requires consideration of the above points and a search for complications, somatization, non-compliance, or re-injury. After steps to correct these factors, a trial of therapy may again be implemented.

A decision algorithm simplifies decisions in these cases (Figure 8-2). Its value lies in helping clarify and discriminate practitioner and patient responsibilities in working toward a satisfactory resolution to the case. The overriding concern is a focus upon the patient's rate of improvement in comparison with that predicted by the natural history. Variations from natural history can be expected from case to case as these derive from the individual patient's habits and lifestyle, including occupation. Complicating factors should be considered whenever the progress of treatment/care approximates or intersects the estimated time line (see Figure 8-1). Failure to achieve a satisfactory response in accordance with the algorithm should result in an assessment for maximum therapeutic improvement or referral for a second opinion.

Patients who consistently fail to comply with treatment/care schedules, or who are otherwise insincere in their efforts, should be discharged from care, with referral where appropriate.

(v) Treatment/Care Protocols

Short and long range treatment plans, along with the eventual treatment care outcome, should be discussed with the patient. An estimated time frame for achieving these clinical goals should also be discussed.

Objective and subjective reassessments are suggested if a patient reaches the end of a trial therapy series and demonstrates no significant improvement. A decision as to an amended therapeutic approach, discharge from treatment, or referral for a second opinion, is warranted.

Patients exhibiting signs of deconditioning or chronicity should be given an exercise program that focuses both on the injured and related areas. Education on body biomechanics and exercises should emphasize the avoidance of pain-related behaviour, flexibility, strength, coordination and endurance. Referral to an appropriate care facility may be desired if specific equipment or expertise is sought. Where prominent psychosocial factors make this appropriate, referral for counselling should be made.

Patient education and advice should be direct and practical. This may include advice on bending, lifting, pushing or pulling, entry and exit from vehicles, sitting, yard work, recreation, personal care, and sexual activity.

However, in spite of an initial positive response, if there is little demonstrable additional progress after a period of two months of treatment/care, the patient should be discharged and presumed to have achieved maximum therapeutic benefit.

V. ASSESSMENT CRITERIA

Rating System 1 and 2 assessment criteria are used in this chapter. For an explanation of this system (see p. xxiii).

VI. RECOMMENDATIONS (GUIDELINES)

Note:

The natural history of back pain and other conditions is a reference point for treatment expectations, and the basis from which a measurable therapeutic plan of action can be made. Each episode can be described as acute, subacute or chronic. Within these time frame descriptors, the term uncomplicated means the natural history of the condition. The term complicated suggests that there are factors which will affect the prognosis and therapeutic plan. These factors should be evident in the clinical assessment of the patient and be recorded in the file.

A. Short and long range treatment planning:

8.1. At the onset of treatment/care, an estimated time frame for achieving clinical goals should be made and discussed with the patient. Short term goals should include the number of treatments after which evidence of improvement is expected, whereas long term goals should include the eventual treatment/care outcome and the length of time required to achieve it.

Rating: Recommended
Evidence: Class I, II, III
Consensus level: 1

Pain based predictors from the case history:

8.2 (i) Pain present for greater than 8 days prior to seeking treatment, the presence of severe pain, four or more previous episodes, and pre-existing skeletal anomaly or structural pathology may extend the treatment duration by a factor of 1.5 to 2 times.

Rating: Promising (this recommendation is safe and has limited effectiveness in predicting recovery rate)
Evidence: Class II, III
Consensus level: 1

B. Treatment/care frequency:

Specific recommendations related to acute, subacute and chronic presentations are given below under headings C (uncomplicated) and D (complicated).

8.3 In general, more frequent treatment/care (3 to 5 sessions per week for one to two weeks) may be necessary early. Progressively declining frequency is expected until discharge of the patient, or conversion to elective care.

Rating: Established
Evidence: Class II, III
Consensus level: 2

C. Uncomplicated cases - acute episodes:

8.4 Symptom response: after a maximum of two trial therapy sessions of manual procedures lasting up to two weeks each (four weeks total) without demonstrable improvement, manual procedures may no longer be appropriate, and alternative care should be considered.
Rating: Established
Evidence: Class I, II, III
Consensus level: 1

8.5 Passive/active care: a shift in emphasis from passive to active care is required, when improvement warrants, so as to reduce disability, practitioner dependence, and chronicity.

Rating: Established
Evidence: Class I, II, III
Consensus level: 2

8.6 Return to pre-episode status: as treatment progresses, it is expected that most patients will return to pre-episode status within six to eight weeks.

Rating: Established
Evidence: Class I, II, III
Consensus level: 1

D. Complicated cases:

Subacute and chronic conditions are usually considered to be complicated in that they have exhibited regression or retarded recovery in comparison with expectations from the natural history.

8.7 Symptom response: after a maximum trial therapy session of manual procedures lasting up to two weeks, and consisting of 3 to 5 treatments per week, reassessment is required if no demonstrable improvement has been noted. An alternative approach consisting of a maximum of four weeks may be instituted if warranted. Should no demonstrable improvement be forthcoming following this second trial, the patient should be referred or discharged.

Rating: Promising
Evidence: Class II, III
Consensus level: 1

8.8 Management: management should emphasise a shift to active care, dissuasion of pain behaviour, and patient education, as well as flexibility and stabilization exercises. Rehabilitation may be appropriate.

Rating: Established
Evidence: Class I, II, III
Consensus level: 1

8.9 Achievement of maximum therapeutic benefit: it is expected that patients will reach their maximum therapeutic benefit within 6 to 16 weeks. To minimize the development of physician/patient dependence, treatment frequency should not exceed two visits per week after the first six weeks. An acute exacerbation may require more frequent care. Should pre-episode status not return, or additional improvement not be forthcoming, maximum therapeutic benefit should be considered to have been reached.

Rating: Recommended
Evidence: Class II, III
Consensus level: 1

8.10 Supportive care: supportive care using passive therapy may be necessary if efforts to withdraw treatment/care result in significant deterioration of clinical status.

Rating: Promising
Evidence: Class II, III
Consensus level: 1

8.11 Cases requiring supportive care: in cases requiring supportive care, the frequency of treatment must be determined on an individual case basis as dictated by therapeutic necessity.

Rating: Recommended
Evidence: Class II, III
Consensus level: 1

E. Patient cooperation:

8.12 The nature of the patient's disorder and the purpose and strategy of the treatment plan should be adequately explained to the patient. Patients who prove to be insincere or non-compliant with treatment/care recommendations may be discharged from care, with referral when appropriate.

Rating: Recommended
Evidence: Class II, III
Consensus level: 1

F. Failure to meet treatment/care objectives:

Re-assessment: see Chapter 10

8.13 Unresponsive acute, subacute, or chronic disorders:

(i) systematic interview of the patient should be carried out in search for complicating or extenuating factors responsible for prolonged recovery.

Rating: Recommended
Evidence: Class II, III
Consensus level: 1

8.14 (ii) continued failure to show initial improvement or failure to show additional improvement over any period of six weeks of treatment, should result in patient discharge or appropriate referral, or the patient will be deemed as having achieved maximum therapeutic benefit (MTB). If MTB has been reached, maintenance or supportive care may be considered.
Rating: Recommended
Evidence: Class II, III
Consensus level: 1

8.15 Signs of chronicity: patients at risk for becoming chronic should have treatment plans altered to de-emphasize passive care and refocus on active care approaches.

Rating: Established
Evidence: Class II, III
Consensus level: 1

H. Elective care:

8.16 The frequency of preventive/maintenance care is determined on an individual basis, but generally should not exceed once per month. The frequency of care may vary if the patient's condition changes. In these circumstances there is a reassessment and conversion to appropriate therapeutic intervention, which may include initial and supportive care.

Rating: Discretionary
Evidence: Class II, III
Consensus level: 1

VII. COMMENTS, SUMMARY OR CONCLUSION

Critical investigations of most therapeutic approaches utilized in chiropractic care are under active research, and much has yet to be learned of all treatments for neuromusculoskeletal disorders. This chapter, however, presents current literature and guidelines in the area of frequency and duration of treatment.

While efforts continue to understand more completely the pathoanatomical and functional features of the disorders we treat, a systematic method for management is available, and even perplexing cases can be managed in a manner that avoids or reduces the risk of chronicity or the development of physician dependence. Treatment/care can be more rationally based and be shown to have therapeutic need when the natural history and modifying factors from the patient's lifestyle and environment are considered.

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Shekelle PG, Adams AH, et al. The appropriateness of spinal manipulation for low back pain: indications and ratings by a multidisciplinary expert panel. RAND 1991; Santa Monica, California. Monograph No.R-4025/2-CCR/FCER.

Shekelle PG, Adams AH, et al. The appropriateness of spinal manipulation for low back pain: indications and ratings by an all-chiropractic expert panel. RAND 1991; Santa Monica, California. Monograph No. R-4025/3-CCR/FCER.

Shekelle PG, Adams AH, et al. The appropriateness of spinal manipulation for low back pain: project overview and literature review. RAND 1991; Santa Monica, California. Monograph No. R4025/1-CCR/FCER.

Singer, et al. Outcome predictions: acute low back/leg pain. Can Fam Phys 1987; 33:655-659.

Terrett ACJ, Vernon H. Manipulation and pain tolerance: a controlled study of the effect of spinal manipulation on paraspinal cutaneous pain tolerance levels. Am J Phys Med 1984; 63:217-225.

Triano JJ, Hondras M, McGregor, M. Differences in treatment history with manipulation for acute, subacute, chronic and recurrent spine pain. J Manipulative Physiol Ther 1992; 15(1):24-30.

Vernon H, Mior S.
The Neck Disability Index: A Study of Reliability and Validity
J Manipulative Physiol Ther 1991 (Sep); 14 (7): 409–415

Waddell. G..
A New Clinical Model For The Treatment Of Low-back Pain
Spine (Phila Pa 1976) 1987 (Sep);   12 (7):   632-644

IX. MINORITY OPINIONS


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