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Assessing the Injured Low Back

by K.D. Christensen DC, CCSP, DACRB

Back pain is the most frequent primary symptom reported by patients seeking chiropractic care, and the second most frequent primary symptom among medical patients. 1 While 90-95% of acute spinal patients will resolve their conditions within three months of injury, chronic or recurrent back disability may persist for years. 2 Despite the fact that millions of people suffer from chronic back pain, there have been few safe and effective means of quantifying injury and aggressively rehabilitating these patients.

Considering the work-related costs of back injury (over 50% of dollars paid out by compensation claims, yet only 5% of injuries), the dollar savings to industry could be very substantial. It is possible for industry to have employees return to work productively when their backs are ready. Simple prescreening or a rehabilitation program costs very little compared to a $100,000 disability claim, or even a $10,000 claim.

A positive and objective approach by the chiropractic physician, employer and employee, coupled with careful rehabilitation or return-to-work conditioning programs, means health care dollars and compensation costs can be administered more cost-effectively. Additionally, we will all be promoting better quality and more accurate health care.

In the objective assessment of back dysfunction, the chronic patient appears to provide the best subject population. As is well-known, chronic back pain is a primary socio-economic problem. It rates as the number one cause of disability below the age of 45, and as the third major cause over the age of 45. 2 The accompanying high costs are related not only to medical and surgical care, but also to litigation, worker’s compensation, long-term disability insurance and social security payments, as well as lost work time.

Previous Assessment Limitations

The absence of objective functional capacity measurements is a possible cause for much of the present confusion in spine care. In the extremities, clinicians rely on visual observation of joint motion and stability, extremity circumference, right-left comparisons, as well as ergometry and muscle strength measurements to help guide treatment programs after injury. In the spine, small well-camouflaged joints and deep muscles with complex multplanar movements and interconnections make visual feedback impossible, thus leading to a near-total reliance on subjective pain complaints and radiographic imaging to guide the treatment regime.

The potential value of objective measurement of spine function leading to the same understanding of the spine as is currently utilized in the extremities has been recognized for some time: “Self-report of pain and medical history, structural measures (e.g., radiographic imaging), and functional capacity measurements are the three critical components necessary for diagnosis and clinical decision making in the extremities. However, only the first two of these components are currently utilized in spine treatment and decision making. The addition of this latter component to spine assessment is essential.” 2

Modern Systems and Standards

Technology has now advanced to the point that functional capacity measurements can be performed to quantify spinal function. Computerized mechanical muscle testing devices as well as low-tech procedures allow the clinician to quantitatively and objectively measure performance deficits or improvements. Graphic and numerical reports of range of motion and torque are computer generated, as well as abnormal movement. Torque patterns can be identified, providing an objective basis for a rehabilitation program.

The patient is positioned within a testing device or functional position with appropriate stabilization for isolated joint evaluations or appropriately to actively simulate “real life” functional movement. Many systems test for torso and extremity strength, functional range of motion, endurance, painful arcs, bending capability, twisting capability, lifting capability, etc. Reproducibility, validity, and reliability of the testing is made possible with the use of microcomputers, analog to digital converters and appropriate software. The computerized data is collected and the stored information can be retrieved for trial comparisons at future testings. Such testing provides “pure objective” functional data documenting functional impairment during movement. Repeat testing documents “curative” management and “permanent” residuals when the patient becomes stationary.

Triano 3 provides in the Chiropractic Rehabilitation Association’s (CRA) Chiropractic Rehabilitation Standards Manual the following indications and contraindications to functional capacity evaluation as well as muscle strength and endurance testing:

A. Indications

(1) Muscular spine disorders

(2) Mechanical spine disorders

(3) Unchanged musculoskeletal (spine and non-spinal) condition for two to

three weeks

(4) Monitor outcome of rehabilitation

B. Contraindications

(1) Acute pain status

(2) Progressive neurologic deficit

(3) Cauda Equina signs

(4) Metabolic bone disease, including severe osteoporosis/malacia

(5) Gross instability

(6) Rheumatoid arthritis

(7) Ankylosing spondylitis

(8) Early post-operative cases

(9) Malignancy

Besides storing and analyzing data, patient performances can be categorized in terms of age, sex, height, weight, occupation, work task, pathology, and other descriptors. It becomes possible to compare performance data with thousands of others throughout the nation.

Multi-Party Involvement

There are many possible players in the occupational back arena: the employee, his/her union, the employer, the physician, third-party payers, lawyers and the courts. All the players have the same goal: to take care of and provide for the truly injured worker.

Third-party payers are paying out millions of dollars for compensable injuries. Industry is spending more for increased insurance premiums. Both groups desire to see the employee return to a productive condition and, at the same time, feel comfortable that the worker’s compensation paid out is, in fact, a credible reflection of a real disability. They do not want the injured employee to return to work earlier or later than his/her back injury will allow.

The health care professional’s goal is to provide the best quality and most accurate health care by confirming the employee’s low back injury, providing for treatment or rehabilitation, and determining the degree of disability. A patient’s premature return to work can result in further and future impairments and disabilities, and could also present additional liability and increased costs to industry. The employee’s delayed return to work means unnecessary lost work time and more workman’s compensation benefits. Yet, you may have had no choice. In many cases decisions have been, and still are, based on subjective evaluations only.

The CRA standards manual 3 states the following findings within the patient’s history indicate chronicity where mechanical and functional muscle testing intervention would be appropriate:

(1) Musculoskeletal complaint unchanged for two to three weeks

(2) Evidence of anxiety or depression

(3) Regular continued use of non-prescription analgesics

(4) Continued disability

Cost-Effective Care

Functional capacity evaluation and mechanical muscle testing provides for quantitative comparisons or measurements of patient status and progress. Thus, a quantitative, repeatable, and objective testing procedure of human spinal and extremity performance has been a long time coming. With millions of hours of clinical testing and pathological and post-surgical patients safely tested, studies indicate that the data obtained from functional capacity evaluations, mechanical muscle testing of the spine and extremities can provide the chiropractor with the information necessary to formulate the most cost-effective direct care and rehabilitation regime. 4

The ACA Rehab Council has initiated efforts to shortly make available a CD program for the reporting of functional capacity evaluations. The program compares the patients results with normative data and thus documents deficiencies in function. Additionally, the program documents the patients progress during repeat evaluations.

The chiropractor truly interested in quantifying impairment and prescribing an effective rehabilitation program should seriously consider adding functional capacity evaluations to assess function and to routinely utilize the data obtained in enhancing the decision-making process to formulate the most cost-effective rehabilitation program.

References

1. Hurwitz EL, Morgenstern H. The effects of comorbidity and other factors on medical versus chiropractic care for back problems. Spine 1997; 22(19):2254-2263.

2. Mayer, Gatchel, Kishino et al. Objective assessment of spine function following industrial injury. Spine 1985; 10(6):482-493.

3. Chiropractic Rehabilitation Association. 1991 Chiropractic Rehabilitation Facility Standards Manual. CRA, 1990.

4. 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 Occup Med 1991; 33(8):847-852.

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American Chiropractic Association Rehab Council