Chiropractic and Osteopathy in Worker’s Compensation
by
Peter Thompson, DC, DO, DAc, MSc.
Chiropractic and Osteopathy are playing an expanding and increasingly important role in providing treatment and management within the N.S.W Worker’s Compensation system. Treatment of the underlying injury/dysfunction is a necessary precursor to rehabilitation and a subsequent return to work.
This paper will define Chiropractic and Osteopathy and discuss the value of these therapies to the injured worker and the compensation system generally. It will identify common misconceptions, discuss evidence in the scientific literature, provide case studies, outline educational standards and how Chiropractic and Osteopathy work within the team of health care providers.
Definitions:
Osteopathy: General Osteopathic
Council (UK)[i]:
Osteopathy is a
system of diagnosis and treatment for a wide range of medical
conditions.
“Structure
governs function”. Osteopathy works with the structure of the body to restore
normal function and is based on the principle that the well being of an
individual depends on the skeleton, muscles, ligaments and connective tissues
functioning smoothly together.
To an Osteopath, for your
body to work well, its structure must also work well. So osteopaths work
to restore your body to a state of balance, where possible without the use of
drugs or surgery. Osteopaths use touch, physical manipulation, stretching
and massage to increase the mobility of joints, to relieve muscle tension, to
enhance the blood and nerve supply to tissues, and to help your body’s own
healing mechanisms. They may also provide advice on posture and exercise
to aid recovery, promote health and prevent symptoms from recurring.
Chiropractic:[ii]
The bones of the spinal column protect the delicate spinal
cord and spinal nerves that transmit information between the brain and all
parts of the body.
Chiropractic recognizes the role of the nervous system in
co-ordinating all functions of the body. It uses manipulation of the joints and
soft tissue to help restore normal transmission of nerve impulse where
biomechanical dysfunction has impaired this transmission.
Biomechanical factors that contribute to nerve dysfunction
in this context include nerve compression, either constant or intermittent and
non-physiologic stretching of nerve tissue and perineural membranes. Causes of
this can be entrapment, compression within normal range of joint movement or
compression due to local inflammation. The consequence of these physical
distortions of nerves is interruption to normal transmission of nerve impulses
along the course of the nerve. This creates either a reduction of transmission
where the pressure is interfering with the propagation of impulse or an excess
(facilitation) of nerve transmission caused by reduction of the threshold of
nerve stimulation. Either state results in abnormal and inappropriate function
within the target tissue supplied by the nerve. If the target tissue is muscle,
the result will be poorly co-ordinated motor patterns, hypertonicity or
flaccidity of the muscle group. In arteries the vessel wall includes a muscular
layer that when stimulated by Autonomic nerves, will reduce the lumen of the
artery, thereby reducing the volume of blood travelling to the tissues. If
autonomic nerve supply to the muscles of the arterial wall is abnormal, the
target tissue will be starved or flooded with blood. If the target tissue is
viscera (organs) dysfunction may result in the function of that organ. Examples
may be changes in the volume of secretion of hormones or digestive enzymes,
motility changes in the organ or reduced peristalsis.
The Chiropractor and Osteopath are trained to analyse mechanical
dysfunction of the entire body with emphasis on the spine and peripheral
joints.
By removing mechanical impediment to normal nerve
transmission, the body has greater capacity to regulate and heal itself.
National
regulation of Chiropractic and Osteopathy under AHPRA (Australian Health
Practitioners Regulation Agency)[iii]
acknowledges these as primary care professions.
Primary care status means that patients can
seek help without the need for referral from other health professionals. However; if an injured workers has an
existing workers claim and wishes to be treated for the compensable injury,
he/she must first get a referral from their doctor.
What
the Chiropractor/Osteopath will do
The Chiropractor/Osteopath is trained to diagnose, treat and
manage patients that present to them. Management may include co-management with
other practitioners and always involves communication with the Nominated
Treating Doctor (NTD) and the referring practitioner.
When a patient first presents all good practitioners will:
- Make efforts to
make the patient feel at ease.
- Undertake a
thorough bio-psycho-social history.
- Perform
a physical examination including appropriate orthopaedic,
neurological and manual examination of the musculoskeletal system.
- Case appropriate
assessment of the spine and pelvis, visceral motility, peripheral joint
function and the biomechanics of the body. Specific assessment criteria
are dependent on the presentation.
Each member of the therapy team will perform an assessment in
keeping with WorkCover guidelines.[iv] This
will assist the establishment of a working management plan specific to each
client. Following this protocol, will ensure that a complete picture of the
case is developed.
A useful
tool in case management is to negotiate goals with the patient. Components of
these goals may include the following acronym: SMART
S: Specific, M: Measureable, A: Achievable, R: Relevant, T:
Timely
The Chiropractor and Osteopath are required to establish an
independent diagnosis, treatment and management protocol, identify goals of
treatment, prognosis and report to relevant authorities such as WorkCover, insurance
companies and other statutory bodies. They are also required to report findings
and management plans to referring practitioner and WorkCover and appropriately
liaise with employer, insurance company and any other relevant party.
Prior to commencement of treatment a Report of Findings will
be delivered to the patient. When all concerns have been addressed, treatment
may be initiated. This is likely to include spinal or peripheral joint
manipulation (Chiropractic Adjustment) and/or mobilization. It may also involve
a range of physical therapies including varieties of soft tissue/myo-fascial
treatment. Prescription of exercise, dietary, ADL and ergonomic advice are
common ancillary interventions.
Public/Health
Provider Misconceptions
Some members of the public do not appreciate the differences
between physical therapy modalities. It is common to see the public use
Chiropractor, Osteopath, Physiotherapist or OT as interchangeable terms.
Common misconceptions exist in the community about the
Chiropractic and Osteopathic Professions.
These misconceptions tend to fall into the following broad
categories.
Training:
A lack
of knowledge of training standards sometimes leads people to thinking that
Chiropractors and Osteopath are inadequately trained.
Common
international standards of education have been achieved through a network of
international accrediting agencies that began with the US Council on Chiropractic
Education (CCE) [v],
recognized by the US Office of Education since 1974. These standards have been
adopted by the World Health Organization.
In Australia, the accreditation body is the Council on Chiropractic
Education Australasia[vi]
Chiropractors and Osteopaths are university trained. Five year training
programs share many resources and lecturers with the medical program in
universities where medical programs are conducted. Currently there are four
universities in Australia that conduct chiropractic degree programs.
See Appendix 1 for universities who offer training.
Scope
of Practice:
Often members of the public are
unaware of the scope of practice of Chiropractors and Osteopaths. Many people
believe that these modalities relieve back and neck pain, and perhaps headaches,
without being aware of the global influence of the Autonomic Nervous System. Chiropractic
and Osteopathy have therapeutic effect on this and other systems of the body.
Mounting evidence supports therapeutic benefit in many conditions.[vii]
Methods:
There
is a misconception that spinal manipulation is the only treatment modality used
by Chiropractors and to a lesser degree by Osteopaths. Treatment using spinal
or peripheral joint manipulation/mobilization, exercise therapy, visceral manipulation,
soft tissue massage, lymphatic drainage, neuro-muscular techniques and physical
therapies such as strain-counter strain methods, acupuncture/dry needling,
ergonomic and ADL advice are a few examples of commonly practiced methods. In
cases where chronic pain exists, the best outcomes derive from addressing as
many case factors as possible. This usually requires a multi-therapist, team-based
approach to patient care, as well as the provision of information and education
for the patient.
Efficacy:
Extensive research has been undertaken to examine the efficacy of
Chiropractic and Osteopathy on the biomechanics of the human body. Research is
progressing in the field of manipulative therapy. Chiropractic and
Osteopathy have a significant clinical evidence base. There are a number
of large studies that support the use of spinal
manipulation.
See Appendix 2 for examples of
specific studies
Types
of injuries treated in Workers Compensation system
Since 1978 at a state level and since 1985 for Commonwealth
employees, Worker’s Compensation legislation has included Chiropractic and
Osteopathic treatment. The Motor Accidents Act 1988 includes Chiropractic and
Osteopathy as recognised services and private health funds provide benefits.
The majority of conditions treated by Chiropractors and
Osteopaths in the WorkCover environment include mechanical dysfunction of body
parts, and injuries to the joints and/or soft tissues of the body that do not
require surgery. Spinal and peripheral joints and soft tissue are treated.
These may result from frank trauma or overuse/overload sprain/strain.
How
Chiropractors/Osteopaths will work in the treatment team – providing feedback
to GP, other professionals and psychologist if psychological barriers are
present.
Co-management and cross referral are integral to the
effective management of most workers compensation cases. This is particularly
true where chronic pain exists. Prof Michael Nicholas of the Pain Management
Research Institute, University of Sydney at RNSH states “Unimodal treatments
for chronic pain do not work.”
It is important to identify barriers to recovery and
determine the best therapist to deal with each barrier. This ‘gatekeeper’ role
is usually performed by the General Practitioner. However, each member of the
team should remain vigilant to identify any new or developing barriers and to
implement strategies to overcome these barriers.
Each therapist must create a management plan specific to
their assessment and treatment goals. WorkCover guidelines for case assessment,
review and management and documentation are noted above and can be found on the
WorkCover web site at www.workcover.nsw.gov.au.
Consideration of specific work duties and how the individual
worker is able to manage these duties is critical. Modification or elimination
of certain work duties will require effective communication with the employer
in order to gain their co-operation.
It is of great benefit for all parties to develop a network
of therapists from diverse fields. Establishing an understanding of the
strengths of local therapist will assist in efficient management and will
facilitate the best intervention at the earliest time.
Communication must be established with the referring
practitioner using written report of findings discussing diagnosis, mode of
injury, red and yellow flags, recommended treatment/management and prognosis.
Further communication with any relevant party including
other therapists, case managers from WorkCover, the insurance company or the
employer will be acted on where necessary.
How
Chiropractors/Osteopaths offer strategies of self-management and conditioning
for required work duties.
At times clients unintentionally undermine their recovery by
participating in imprudent activities. Lack of understanding of their
limitations at any given time during the recovery process or denial of the
extent of their incapacity are examples of factors that can impede recovery.
An important part of case management, therefore, is to
provide information and strategies that allow the client a degree of
self-management. This gives the client the feeling that they are assisting in
their own recovery and gives them an element of control over their
circumstances. Empowerment is an important contributor to the wellbeing of a
client who often feels that their injuries are overwhelming.
Examples of self-management include exercise prescription,
advice on activities of daily living, ergonomic assessment and correction of
personal and workplace equipment. Describing the mechanism of injury, the
actual damage and consequences of the injury to their body and expected
outcome, both short term and long term are important to the client. Setting
goals in the recovery process are important. It is important to identify early
warning signs of strain and impending overexertion/overuse, and to provide
strategies to manage their condition once these warning signs have surfaced.
This gives the client more confidence in attempting activities that will assist
in general recovery.
Another consideration in the recovery process is to
establish protocols to prepare the body for impending activities required of it
in the performance of employment duties or any other activity about to be
undertaken. As with sporting pursuits, warmup procedures will help the client’s
body better tolerate the demands it is about to endure. These may include
stretches within a pain free, comfortable range, gentle, non-load bearing
mimicry of the activities about to be undertaken. This also helps provide to
the client an ‘on the spot’ assessment of the bodies limitations on that
particular occasion.
CASE
STUDY. – JOHN SMITH
This
case was referred by Mr Smith’s Nominated Treating Doctor (NTD)
Presenting
Symptoms:
- Ongoing, significant upper torso paraspinal/shoulder
girdle pain and headache were the primary symptoms. At the time of
consultation these symptoms had been unresponsive to treatment.
- Anxiety and depression were also significant features
of this case.
The
following are extracts from the report of the treating Chiropractor.
Dear
Doctor,
Thank
you for referring Mr Smith, a 55 year old, heavy vehicle and fork lift driver,
for Chiropractic care. He presented with neck and arm pain associated with
numbness bilaterally within the C8 nerve distribution at night and paraesthesia
in the hands and forearms during the day.
Mr
Smith stated that problems had begun 18 months ago. He relates symptom genesis
to being the driver of a ‘cherry picker’ device. He adopted a sitting posture
with the neck held for prolonged periods in a hyperextended position. Frequent
rotation of the neck was required while observing workmen in the tray at the
top of the cherry picker.
In 2009
Mr Smith suffered a severe emotional shock when his truck’s brakes failed while
driving down a long steep grade. He said that as this was happening he did not
expect to survive this event. He also stated that his physical symptoms were
markedly aggravated by this trauma.
It is
also worthy of comment that in 2002 Mr Smith underwent a Lumbar spine
laminectomy with good results for a lower back pain injury.
Clinical findings
- Stretch reflexes of the upper limb were
uniformly level one (low response).
- Muscle strength of the intrinsic muscles of
both hands was weak but contractile.
- There was scoliotic curve in spine, prominent
at C-T junction and increased A-P spinal curves.
- There were areas of hypertonicity in
paraspinal muscles.
- Deconditioned abdominal muscles were
evident.
- Upper cross syndrome (protracted shoulder
posture), forward head carriage were evident.
- These postural defects have contributed to
a bilateral Thoracic Outlet Syndrome. This diagnosis is strengthened by
positive Halstead and Adson’s tests.
- Cervical ROM: extension restricted within
75%, rotation both directions restricted within 50%. Extension caused pins and
needles paraesthesia into the left hand.
- Valsalva test led to mid cervical region
pain.
- Jackson’s test (cervical compression) was
positive, causing local cervical pain.
- Sensory: pin prick sensitivity was reduced
in hypothenar region of both hands.
XRay
examination:
- There was loss of disc height and
osteophytes present at C5/6, C6/7 levels. Early canal stenosis. Left C6/7 foramen
stenosis is due to osteophytic intrusion.
- I/V Foramina are narrowed at C3/4 to C 6/7
on the right hand side and C4/5 to C6/7 on the left hand side.
Opinion
I am
confident that Mr Smith can be helped with decompression type mobilization/adjustment
and soft tissue massage. I will also give him controlled exercise and
ergonomic/lifestyle advice.
Peter
Thompson, D.C., D.O., M.Sc., D.Ac.
Chiropractor, Osteopath
Follow-up
Treatment
The above-recommended treatments
were provided over an eight month period.
Mr Smith attended a total of twenty seven treatment sessions. These were
conducted initially twice a week for eight weeks, then once per week for five
weeks then monthly for six months. He was diligent in applying the exercise and
lifestyle advice provided in therapy sessions to his everyday life.
Correspondence
sent to Mr Smith’s employer
Correspondence was sent to Mr
Smith’s NTD and employer via the company’s return to work coordinator two
months after referral requesting modification of work duties.
Dear Doctor and Smith Transport, Pty Ltd
I am currently treating Mr Smith for a work
related injury.
Mr Smith has informed me that he has
recently found that prolonged periods of operating a high pressure water hose
(a gurney) has markedly aggravated his symptoms.
I feel that this type of work duty is
likely to aggravate Mr Smith’s condition.
I recommend Mr Smith only use the gurney
for limited periods and only when he feels able to do so. I estimate
approximately 10 minutes usage perhaps 4 times per day would probably be within
his tolerance at the present time.
Follow
up report three months post referral provided to NTD
Dear
Doctor,
Mr
Smith’s condition has been improving steadily over recent months.
He
has markedly reduced frequency of headache and much less muscular-skeletal
symptoms provided he does not undertake excessive or strenuous activity.
I
am confident that the course of Chiropractic treatment provided to date has
achieved its goals.
Recommendations
In
the medium term (12 months), Mr Smith will require maintenance therapy - 12 treatments
at monthly intervals to ensure his initial presenting symptoms and dysfunction
do not return.
The
proposed treatment will be under continuing review and applied in response to
the needs of the patient.
Thank
you for your assessment and valued opinion.
Peter
Thompson, D.C., D.O., M.Sc., D.Ac.
Chiropractor,
Osteopath
Progress
report to NTD - twelve months after referral
Dear Doctor,
Mr
Smith was reassessed recently. Headaches and paraspinal regional pain have
remained significantly reduced in the intervening twelve months since his last
treatment but still arise on occasion. He continues to suffer anxiety and
depression, though to a lesser degree since the reduction of physical symptoms
and resolution of his compensation case. He is continuing Chiropractic therapy
as a private patient. He has found this to be the most effective way to
minimize his symptoms and manage his chronic condition.
Conclusions:
This case is an illustration of the types
of issues facing the Chiropractor and Osteopath as members of the health
delivery team. Clear and timely communication between the patient, the
employer, the attending psychologist and general practitioner resulted in
better outcomes. Explaining that while complete resolution of his chronic pain
syndrome is unlikely, it is possible to minimize the impact of residual signs
and symptoms using self-management strategies mixed with ‘at need’ therapeutic
intervention.
About the author
Peter Thompson is a chiropractor of 35 years experience. He currently practices from clinics at Woonona and Barrack Heights in the Illawarra. He has extensive experience lecturing and examining at Macquarie University and NSW TAFE in Chiropractic, Osteopathy and Massage Therapy. He has examined for the NSW Chiropractic and Osteopaths Registration Boards.
Further Reading
You can find appendix 1, 2 and refrences for this article in the side panel.
