CHIROPRACTIC CARE PARAMETERS FOR COMMON INDUSTRIAL LOW BACK CONDITIONS
 
   

Chiropractic Care Parameters for
Common Industrial Low Back Conditions

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:
  Frankp@chiro.org
 
   

Chiropractic Technique 1993 (Aug);   5 (3):   119-125

by Robert D. Mootz, D.C.   and   V. Thomas Waldorf, D.C.

NOTE: This article, and the following care parameters, are reprinted exclusively at Chiro.Org with permission of National College of Chiropractic, and from the editor of JMPT and Chiropractic Technique, Dana Lawrence, D.C. Thanks, Dana!


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.



From the FULL TEXT Article:

Introduction

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

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].



The Care Plans:


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   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)



References:

  1. 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

  2. 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 (Aug);   33 (8):   847–852

  3. Wolk, S
    An Analysis of Florida Workers' Compensation Medical Claims for Back-related Injuries
    Boston: Proceedings of the American Public Health Association 1988

  4. 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

  5. Haldeman, S   Chapman-Smith, D   Peterson,D
    Guidelines for Chiropractic Quality Assurance and Practice parameters
    Gathersburg, MD: Aspen Publishers, 1993

  6. 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

  7. Pearson, K   deKoekkoek, T
    Diversified approach of chiropractic
    In: White, A Anderson, R, eds. Conservative Care of Low Back Pain
    Baltimore: Williams & Wilkins, 1991

  8. Stonebrink, RD
    Evaluation and manipulative management of common musculoskeletal disorders
    Portland, Oregon: Western States Chiropractic College, 1990

  9. Cox, JM
    Low back pain: Mechanism, diagnosis and treatment
    4[th] ed. Baltimore: Williams & Wilkins, 1985

  10. Hammer, WI
    Functional soft tissue examination and treatment by manual methods
    Gaithersburg, MD: Aspen Publishers, 1991

  11. Cassidy, JD,   Kirkaldy-Willis, W
    Managing low back pain
    In: Kirkaldy–Willis, W, ed. Managing low back pain. New York: Churchill Livingston, 1988

  12. Greenman, P
    Principles of manual medicine
    Baltimore: Williams & Wilkins, 1988

  13. Travell, JG Simons, DG
    Myofascial Pain and Dysfunction, the Trigger Point Manual
    Baltimore: Williams & Wilkins, 1992

  14. Hansen, DT
    Development and use of clinical algorithms in chiropractic
    JMPT 1991;   14:   478–482


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