Introduction

Conditions of the upper extremities, particularly of the hand and wrist, often occur in older (60+ years of age) patients, but manual treatment protocols for this age group have not been identified or assessed. Because primary care, including chiropractic care, is often based on tentative, in-office diagnoses and not on more definitive and expensively generated criteria, general location and reported symptoms are frequently sufficient to guide care. This primary care research, concerning hand-wrist pain, therefore reflects the everyday reality of the chiropractic physician. This research examines (a) the feasibility of continued research with an older population; (b) the variety of hand-wrist conditions presented by older patients; (c) the accommodations to standard chiropractic treatment for older patients; and (d) the validity, reliability, responsiveness of measures, and preliminary estimates of outcome of treatment.

Complementary and alternative medicine (CAM), with allopathic care, comprise the health care system in the United States,^1-4 including care for conditions of the upper extremities.^5,6 Concurrent to the growing use of CAM is the increasing proportion of older people in the country. The combined effects of increased fertility and decreased mortality are “aging” the populations of Eurasia and the western hemisphere.⁷ The aging of the world’s population will be “one of the most important social phenomena of the next half century.”⁷

Although current decreases in rates of disease and injury are followed by decreases in rates of disability in those older than 60 years, decreases in death rates for people with given disabilities increase the prevalence of those disabilities in the population as well as demands for health care appropriate to these disabilities.⁸ Among potentially or actually disabling conditions commonly seen in the elderly are conditions of the hand and wrist.⁹ For example, a recent prevalence report estimates that, relative to younger (25-34 years) people, older (55-64 years) people are 2 (women) to 5 (men) times as likely to be symptomatic for carpal tunnel syndrome.¹⁰ In the same report, older men and women were found to be 3 times as likely to have electrophysiologic median neuropathy than the younger people.¹⁰

With the attractiveness of CAM and the growing proportion of older people in the country, it is not surprising that CAM providers, such as chiropractors, are treating an increasing number of older patients presenting with disabling conditions, including those of the hand and wrist.¹¹ In research concluded in part 1 of this project, chiropractors responding to focus groups and surveys indicated wide experience with older patients presenting with conditions of the upper extremities and provided suggestions for effective treatment.¹² Respondents stressed the importance of accommodating to older patients, using, for example, low-impact stretching exercises, rehabilitative passive stretching, traction, soft tissue work, and home exercises. Chiropractors further indicated that with older patients they considered “management” a more realistic concept in treating chronic conditions rather than “cure.” Chiropractors reported that they often accommodated to older patients’ comorbidities by using less force and a self-described “lighter touch.” Some examples included using an activator, ultrasound, full-spine work, soft tissue work, passive stretches, myofascial release, teaching and assigning home exercises and postures, and offering nutritional counseling, including supplements.¹² This information was used to guide the development of the treatment protocol of the current research.

It is important to stress that the general focus of this research is on characteristics of older patients presenting with hand-wrist pain, and their treatment for hand-wrist pain, because these reflect the reality of the primary care chiropractor. The primary care physician provides relief and increased function to patients, as quickly and as inexpensively as possible. Providing definitive and specific diagnoses, often at high cost, is secondary and only considered when initial treatment has not provided benefit.