Document-based care treatment has been hailed as uniquely effective in treating all types of back pain. Carl O'Malley reports
Few can claim they have never encountered some sort of back pain and equally few can boast that they have fully eradicated it through the treatment they have pursued.
This is mainly due to the sheer variety of causes and symptoms. The reasons for, and the manifestations of back pain are so plentiful that treatments vary considerably and are often hit and miss in their effectiveness.
For these reasons many back complaints require specific treatment unique to their symptoms and causes. A method for doing this was sought some 15 years ago by medical professionals in Finland and the treatment that evolved has been hailed as uniquely effective.
Documentation-based care (DBC) is a treatment that uses "evidence-based medicine" to identify the source of the problem and devise an appropriate treatment. It uses purpose- built devices to assist in the rehabilitation process by reminding specific areas of the back what to do and when.
In Dublin's DBC clinic, chartered physiotherapist Liam Heavin offers a treatment which could mean patients avoid back surgery or excessive treatment which is, at times, a step too far.
With more than 100 clinics worldwide, DBC has amassed a database of information from 20,000 patients. The data has been formulated into effective treatments for specific complaints and evolves as more people are treated.
"The primary difference between DBC and normal chartered physiotherapy is firstly the exercise equipment that we use," says Heavin.
"The scientists at DBC came together to design specific, technologically advanced devices to isolate movement so that certain areas can be accessed very accurately, and allow treatment to be targeted exactly to the area that is injured.
"The second difference is the fact that we mostly treat individuals with chronic or long-term conditions or patients for whom all other types of treatment have failed."
The typical DBC patient has suffered for about eight years, and has possibly undergone surgery or a series of injections. "Many of our patients are out of work or unable to participate in normal day-to-day activities such as sport, due to this. It is our job to try to return them to normal function. That's what rehabilitation is all about, and that's what DBC does."
His emphasis on rehabilitation is echoed by the Football Association of Ireland's (FAI) chief medical officer and general practitioner, Dr Alan Byrne. "I've been working in the Eircom League since 1992 and an area I felt there was a gap was in the rehabilitation area," says Byrne.
"Where I felt we were lacking - physiotherapists who were dealing with the problem were fine - but I didn't feel there was enough attention being given to the rehabilitation of the muscle.
"When I went to the DBC clinic I saw something I could use for my practice and particularly for the soccer players of the Eircom League and others as well.
"There is no 'cure all' in medicine," adds Byrne, "but DBC has been a great addition to my practice, both in general practice from the point of view of musco-skeletal, and also from the point of view of sports medicine and rehabilitation."
Derry City centre back Clive Delaney was referred by Byrne. Having visited DBC to rectify ankle and groin problems, he was impressed with the sessions that sent him into this season feeling stronger than ever.
"You feel stronger when you get back out on to the training pitch. The machines that he has down there really get into the right areas," says Delaney.
"They are not standard type of machines that you have in a gym, so that's why I go back every six weeks, because as much as I do my own weights in the gym, DBC has developed machines that pinpoint where you want to work."
Treatment is broken into two categories - baseline assessment and active rehabilitation. The first consists of a questionnaire to examine patient history and levels of impairment. A test on the patient's range of movement (ROM) is then conducted and compared to that of the average mortal. This is to discover where, and how much, the back is being restricted.
Electromyography (EMG) is conducted to illustrate the electrical activity in the lumbar spine and indicate whether there is "protective muscle spasm" present, which would suggest a deeper problem.
The baseline assessment is completed by an EMG fatiguability test, consisting of a 90-second assessment where the patient works against resistance in a controlled ROM. Once a clear picture of the problem has been uncovered, a treatment plan is worked out for the next stage - active rehabilitation.
Programmes are a minimum of two visits a week over six weeks.
Lumbar spine rehab begins with re-educating the muscles in their movement pattern. Movement of the spine is isolated which prevents the patient from compensating with shoulder rotation or leg movement. ROM and resistance are increased as the patient progresses.
For neck injuries, the cervical muscles are freed of the weight of the head and consequently relaxed in the early stages.
As with the lumbar treatment, ROM and resistance are increased to strengthen when the time is right. This has proved particularly effective for people suffering from whiplash or rugby front rowers who have locked horns too often.
Heavin sees the active participation of the patient as a real positive that reveals interesting results.
"No matter if you are 17 or 70 years old, your body needs exercise to provide the impetus towards getting stronger and repairing itself. Often the patients we have the most difficulty getting through to are the younger, typically fitter ones.
"Instead of seeing a doctor or a physiotherapist as someone who fixes them, people need to realise that the whole point behind rehabilitation is that they fix themselves. It's the job of the medical practitioner. . . to guide the process."
A daily routine of stretching and "core stability" exercises is also given to the patient to carry out at home.
"All of the research nowadays highlights core-stability training as one of the most important factors in dealing with chronic pain; particularly lower back problems," says Heavin.
For rehabilitation, DBC physicians claim the treatment is second to none. There are undoubtedly cases where there is no other option but surgery, but Heavin maintains that rehabilitative treatments have played an important role in shortening waiting lists.
"Nowadays, the emphasis tends to be to use surgery only when all else fails. What controlled and specific rehabilitation has been shown to accomplish. . . is a reduction in the number of people needing elective surgery."
Of course, for Heavin, the shortening of surgery waiting lists means, to an extent, the lengthening of his, and the opening of a new clinic in Naas is testimony to that. However, for him, it is the patient's realisation of the simplicity of the treatment that has seen business grow.
"People who have never seen this type of treatment before are often surprised by the approach and the size and scale of the clinic. Overall, I feel that the general perception of patients is that what we do makes sense. It really isn't rocket science.
"People seem to just 'get' the simplicity of what we do."
DBC Medical Centre, 1 Ashleaf Business Hall, Crumlin Cross, Dublin 12, tel: (01) 4652454.
DBC Naas, Trident House, Dublin Road, Naas, Co Kildare, tel: (045) 882928.