ProviderPulse
Integrating Chiropractic Into the Rehabilitation Program
Featured Story
August 2011
Contributed by Don Aspegren, D.C., M.S.
As clinicians, we seek to maximize patient response and speed patient recovery by using evidence-based treatment. Improving the rate of patient recovery by decreasing return-to-work (RTW) time helps to control both direct and indirect costs in an injured worker’s case. Indirect costs are typically higher than direct costs and come primarily from disability. Direct costs arise from provider fees and are usually less. Returning an injured worker to normal duties and functional levels as quickly as possible saves on both types of costs.
Various treatment models have been developed to address these costs. The Workers’ Compensation Board of Alberta developed a multidisciplinary intervention team using all the common providers, including chiropractic. When the Alberta group addressed soft-tissue musculoskeletal injuries, chiropractic care was used, along with medical management, from the beginning. Many factors probably contributed to the improved outcomes of the intervention group’s patients, but significant improvement in RTW and decreased duration of disability benefits resulted. Consequently, further cost savings were also reported.1
The Liberty Mutual Research Institute for Safety recently funded a study on “work-related nonspecific low back pain (LBP)” and found lower disability recurrence when chiropractic services were involved in case management. During the one-year follow-up period, they observed improved “sustained return-to-work,” which also helped control indirect costs.2
Physicians commonly ask when chiropractic care should be introduced for optimal results (e.g., improved functional scores and decreased pain measurements). For answers, we can look to an injured workers’ study involving physicians, physical therapists and chiropractic care in patients with axial pains of neck and/or back injury staged at acute (less than three weeks), sub-acute (3–12 weeks) and chronic (more than 12 weeks). Significant improvement was noted in each chronological stage of recovery after chiropractic care had been introduced.3 This study found that the introduction of chiropractic treatment in acute, subacute or chronic stages may improve functional levels and pain score in the injured worker.
Recently published guidelines on the treatment of LBP from the American College of Physicians and the American Pain Society recommend remaining active, in addition to medication and spinal manipulation in the acute stages. For sub-acute and chronic LBP, the addition of interdisciplinary rehabilitation, exercise, acupuncture, massage, spinal manipulation and cognitive behavioral therapy (CBT) are recommended.4 Further cost-effectiveness in guideline-approved LBP treatment is noted by Lin et al. 5 endorsing interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation and CBT for sub-acute and chronic LBP.
The cornerstone of chiropractic treatment involves the use of manipulation to improve injury-related mechanical dysfunction, soft-tissue injuries and pain patterns. Other treatments commonly used by chiropractors include exercise for strength, flexibility and stabilization/proprioception, with instruction in various types of aerobic involvement. Soft-tissue techniques are commonly used to address connective tissue plasticity and tendonopathies. Acupuncture is also used by some chiropractors.
Treatment commonly involves directing the patient to engage in an activity-oriented lifestyle. This complements chiropractic manual techniques to further improve function while decreasing pain patterns, and it promotes movement during work and home activities of daily living to assist in the amelioration of fear-of-motion/reinjury issues. Clinical awareness of biopsychosocial issues while addressing specific tissue injury also furthers the recovery process.
Including integrated chiropractic providers in the injured worker’s rehabilitation program may help reduce costs, speed recovery, improve RTW and decrease periods of disability. The addition of the chiropractic clinician to the rehabilitative process offers a useful treatment option, which may be beneficial in difficult cases.
1 Stephens B, Gross DP. The influence of a continuum of care model on the rehabilitation of compensation claimants with soft tissue disorders. Spine (Phila Pa 1976). 2007; 32(25): 2898-904.
2 Cifuentes M, Willetts J, Wasiak R. Health maintenance care in work-related low back pain and its association with disability recurrence. J Occup Environ Med. 2011; 53(4): 396-404.
3 Aspegren D, Enebo BA, Miller M, White L, Akuthota V, Hyde TE, et al. Functional scores and subjective responses of injured workers with back or neck pain treated with chiropractic care in an integrative program: a retrospective analysis of 100 cases. J Manipulative Physiol Ther. 2009; 32(9): 765-71.
4Chou R, Qaseem A, Snow V, Casey D, Cross JT, Jr., Shekelle P, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007; 147(7): 478-91.
5 Lin CW, Haas M, Maher CG, Machado LA, van Tulder MW. Cost-effectiveness of guideline-endorsed treatments for low back pain: a systematic review. Eur Spine J. 2011.
Recently published guidelines on the treatment of LBP from the American College of Physicians and the American Pain Society recommend remaining active, in addition to medication and spinal manipulation in the acute stages. For sub-acute and chronic LBP, the addition of interdisciplinary rehabilitation, exercise, acupuncture, massage, spinal manipulation and cognitive behavioral therapy (CBT) are recommended.4 Further cost-effectiveness in guideline-approved LBP treatment is noted by Lin et al. 5 endorsing interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation and CBT for sub-acute and chronic LBP.
The cornerstone of chiropractic treatment involves the use of manipulation to improve injury-related mechanical dysfunction, soft-tissue injuries and pain patterns. Other treatments commonly used by chiropractors include exercise for strength, flexibility and stabilization/proprioception, with instruction in various types of aerobic involvement. Soft-tissue techniques are commonly used to address connective tissue plasticity and tendonopathies. Acupuncture is also used by some chiropractors.
Treatment commonly involves directing the patient to engage in an activity-oriented lifestyle. This complements chiropractic manual techniques to further improve function while decreasing pain patterns, and it promotes movement during work and home activities of daily living to assist in the amelioration of fear-of-motion/reinjury issues. Clinical awareness of biopsychosocial issues while addressing specific tissue injury also furthers the recovery process.
Including integrated chiropractic providers in the injured worker’s rehabilitation program may help reduce costs, speed recovery, improve RTW and decrease periods of disability. The addition of the chiropractic clinician to the rehabilitative process offers a useful treatment option, which may be beneficial in difficult cases.
1 Stephens B, Gross DP. The influence of a continuum of care model on the rehabilitation of compensation claimants with soft tissue disorders. Spine (Phila Pa 1976). 2007; 32(25): 2898-904.
2 Cifuentes M, Willetts J, Wasiak R. Health maintenance care in work-related low back pain and its association with disability recurrence. J Occup Environ Med. 2011; 53(4): 396-404.
3 Aspegren D, Enebo BA, Miller M, White L, Akuthota V, Hyde TE, et al. Functional scores and subjective responses of injured workers with back or neck pain treated with chiropractic care in an integrative program: a retrospective analysis of 100 cases. J Manipulative Physiol Ther. 2009; 32(9): 765-71.
4Chou R, Qaseem A, Snow V, Casey D, Cross JT, Jr., Shekelle P, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007; 147(7): 478-91.
5 Lin CW, Haas M, Maher CG, Machado LA, van Tulder MW. Cost-effectiveness of guideline-endorsed treatments for low back pain: a systematic review. Eur Spine J. 2011.
Impact of Spine Patient Outcomes Research Trial Results