ABSTRACT:
A detailed description of chiropractic care parameters
used at a large occupational medicine center is presented.
The algorithms were derived from clinical needs of the
facility, expert opinion, and reviews of several contemporary
written protocols. Twelve of the most common
industrially related low back conditions are included.
The algorithms are grouped according to nondiscogenic and
discogenic conditions. The guidelines are consistent
with many third party chiropractic review policies, as well as
the recently published Chiropractic Quality Assurance Guidelines
and Practice Parameters. The first algorithm is based on
uncomplicated joint dysfunction, and is considered the base
algorithm. Other, more complicated conditions follow,
and a preface is included for each describing specific issues
relevant to each condition. The purpose of these
algorithms was to help standardize care in the clinic, to foster
interdisciplinary communication, and to provide consistency in
administration for research purposes.
Chiropractic Technique 1993; 5 (3)
August: 119-125
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Occupational Low back injuries make up a major
component of industrial expenditures in the United States
1.
A number of retrospective studies have suggested that
conservative chiropractic management may be more cost effective
than other approaches 2-3. Although a number of
general practice guidelines have been developed 4-6, none have
provided "condition specific" guidelines.
A condition specific description of
chiropractic care parameters used at a large multidisciplinary
occupational medicine facility is presented. These
guidelines address 12 of the most common industrially related low
back conditions that presented during 1991 at the Advantage
Occupational and Sports Medicine Center in San Leandro,
California. They represent experience of the
practitioners on approximately 150 acute low back injuries, based
on clinical needs of the facility. In addition, expert
opinion and reviews of several contemporary written protocols
served as resource information 5-13. These guidelines
best fit the classification of "seed algorithms" that serve as
the basis for further investigation and lend themselves to
further development through standard consensus process
(14).
Actual preparation of the guidelines involved
first characterizing the types of low back conditions (diagnoses)
that had presented to the facility during 1991. A series
of seed proposals were drafted and reviewed by the two authors.
These initial proposals were based on a qualitative chart
review of frequencies and duration of care for the conditions
identified. These were then distributed to other
physicians and therapists at the facility for input and
appropriate modification. Future reports will analyze
comparative effectiveness of active and passive approaches in
this facility.
The guidelines presented here are categorized
generally as nondiscogenic and discogenic conditions (See Table 1
) . The purpose of these protocols was to
help standardize care in the clinic in order to foster good
interdisciplinary communication, as well as provide consistency
in administration of care for research purposes.
TABLE 1: Common Industrial Low Back Conditions
NOTE: The actual guidelines are located further down the page
Or take me to the Care Plans now!!!
|
Nondiscogenic Conditions |
|
Simple Joint and Muscle Dysfunction without Tissue
Damage (Base Algorithm) |
|
Acute External Trauma with Soft Tissue Trauma (Fall, Struck by
Object) |
|
Lumbar Facet Syndrome |
|
Acute Lifting Injury with Strained Contractile Tissue |
|
Acute Lifting Injury with Strained Noncontractile Tissue |
|
Chronic Myofibrosis |
|
Exposure to Repetitive Trauma During Care |
|
Discogenic Conditions |
|
Possible Discogenic Without Neurologic Signs |
|
Probable Discogenic Without Neurologic Signs |
|
Probable Discogenic with Soft Neurologic Signs (correct
distribution, paresthesia, sensory changes, reflexias) |
|
Probable Discogenic with Firm Neurologic Signs (motor
assymetry, high pain intensity, positive nerve conduction
studies) |
|
Definite Disc with Hard Neurologic Signs (advanced atrophy,
saddle anesthesias, bowel or bladder disturbances) |
The guidelines presented here address
primarily passive management involved in chiropractic care, with
simple home instructions for education and exercise. The
facility has also developed active rehabilitative care guidelines
for patients without concurrent chiropractic management that are
not presented in this paper. Currently, chiropractic
care is provided at this facility only in the context of a
scientific research study, and these protocols have not available
for the general patient population, although it is expected that
they would be available to this group as well.
The protocols presented provide a baseline of
information that facilitates communication between an
interdisciplinary team of chiropractors, physical therapists,
occupational therapists, exercise physiologists, and medical
physicians. In addition, they provide for consistency
and predictability for the complete management of chiropractic
patients with industrial low back injuries. As a result,
the better understanding that has occurred among care providers
allows for easier and clearer communication with employers, third
party payers, outside consulting physicians, and case reviewers.
Guidelines are presented in table format. Due to space
restraints, a number of abbreviations have been used and are
listed in See Table 2.
TABLE 2: Glossary of Terms and
Abbreviations
|
Aggressive |
Higher manual force (to patient tolerance) in manipulative
thrust or deep tissue myofascial work. |
|
Gentle |
Lower manual force (well within patient tolerance) in
manipulative thrust or deep tissue myofascial work. |
|
Myofascial Work |
Deep soft tissue massage (effleurage, petrissage); Trigger
point work; and/or pressure point work. |
|
Pain Control |
Ice, modalities, possible pain medication. |
|
ADL |
Activities of Daily Living |
|
Cryo |
Cryotherapy |
|
Freq |
Frequency |
|
P&S |
Permanent and stationary |
|
PRN |
Per required need (patient discretion) |
|
ROM |
Range of Motion |
|
SMT |
Spinal manipulation (high velocity thrust, with joint
cavitation) |
|
3/Wk |
Three times per week, month, etc. |
Situations have arisen during the 2 years of
implementation that have not fit these guidelines, and therefore
have been addressed on a case-by-case basis. However,
for the most part these guidelines have served to accurately
define maximal limits of care frequency and duration, as well as
clinical procedures and attenuating factors. It should
also be noted that any given injury may involve components from
more than one specific condition. In such cases, it has
been the policy of these authors to select the guidelines that
most closely matches the primary diagnosis as a starting point.
Further diagnoses are dealt with as attending or
complicating factors/ In the case of multiple, equally
contributing diagnoses, the practice has been to use the
condition guideline with the longest recovery time as the initial
working guideline.
Each guideline includes general information
regarding the specific condition's etiology and complicating or
attenuating factors. The protocols indicate an
appropriate time frame for administration analgesics and
non-steroidal anti-inflammatory medication. Although
medications are not typically prescribed by chiropractors,
patients at this facility have a concurrent company medical
physician and may present to the chiropractors with a
prescription. Many patients may also obtain
over-the-counter medications themselves.
These guidelines are not presented as
definitive and comprehensive algorithms for all cases of
occupational low back pain, rather as an illustration of an
example of clinically explicit documentation of typical
procedures used in chiropractic management of patients one
multidisciplinary setting. Practice parameters such as
these are designed to assist clinicians by providing a framework
for the evaluation and treatment of the more common industrial
low back problems that confront DC's. They are not
intended to replace either the doctor's clinical judgement or to
establish a protocol for all patients with a particular
condition. It is emphasized that some patients will not
fit the clinical conditions contemplated by such guidelines and
that such a guideline will rarely establish the only appropriate
approach to the problem 14.
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References:
- Cassidy, JD Wedge, JH
"The epidemiology and natural history of low back
pain and spinal degeneration"
In: Kirkaldy–Willis, W, ed. Managing low
back pain. New York: Churchill Livingston, 1988
- Jarvis, KB Phillips, RB Morris, EK
"Cost per case comparison of back injury claims of
chiropractic versus medical management for conditions with
identical diagnostic codes"
J Occupational Medicine 1991; 33: 847–852
- Wolk, S "An analysis of
Florida Worker's Compensation claims for back related injuries"
Boston: Proceedings of the American Public Health Association 1988
- Hansen, D, ed. "Chiropractic standards of practice and utilization guidelines in the care and treatment of injured workers"
Olympia: Washington State Department of Labor and Industries, 1988
- Haldeman, S Chapman-Smith, D Peterson,D "Guidelines for Chiropractic Quality Assurance and Practice parameters"
Gathersburg, MD: Aspen Publishers, 1993
- Mootz, RD "Management of the patient with acute injury"
In: White, A Anderson, R, eds. "Conservative Care of Low Back Pain"
Baltimore: Williams & Wilkins, 1991
- Pearson, K deKoekkoek, T
"Diversified approach of chiropractic"
In: White, A Anderson, R, eds. "Conservative Care of Low Back Pain"
Baltimore: Williams & Wilkins, 1991
- Stonebrink, RD "Evaluation
and manipulative management of common musculoskeletal
disorders"
Portland, Oregon: Western States Chiropractic College,
1990
- Cox, JM "Low back pain:
Mechanism, diagnosis and treatment"
4th ed. Baltimore: Williams & Wilkins,
1985
- Hammer, WI "Functional soft
tissue examination and treatment by manual methods"
Gaithersburg, MD: Aspen Publishers, 1991
- Cassidy, JD, Kirkaldy-Willis, W
"Managing low back pain"
In: Kirkaldy–Willis, W, ed. Managing low back pain.
New York: Churchill Livingston, 1988
- Greenman, P "Principles of manual medicine"
Baltimore: Williams & Wilkins, 1988
- Travell, JG Simons, DG
"Myofascial Pain and Dysfunction, the Trigger Point Manual"
Baltimore: Williams & Wilkins, 1992
- Hansen, DT "Development and
use of clinical algorithms in chiropractic"
JMPT 1991; 14: 478–482
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