In November 2000, I had the honor to be a course director for a multidisciplinary conference on occupational low back pain. It was the first time a major international research meeting, co-sponsored by the American Academy of Occupational and Environmental Medicine (one of the nation's most influential occupational medicine organizations), prominently featured chiropractic physicians. The involvement of chiropractors was neither trivial nor predictable. One-third of the 28 faculty were DCs, and the topics they discussed ranged from injury prevention; disability risk factors; clinical decision-making; injury conditioning and rehabilitation; working with employers on return to work; outcomes management; and of course, spinal adjusting. All of the DCs' presentations were plenary to the full group of attendees, mostly medical physicians.
The conference was broken into modules by topics, including: occupational low back as a public health problem; state of the evidence on clinical assessment; disability prevention; state of the evidence on conservative interventions; disability risk factors of occupational low back pain; and innovations in return-to-work. With the exception of the first module that focused on the epidemiology and econometrics of occupational low back pain, DCs were on every other panel and presented some of the conference's best papers.
What was striking to most in attendance was the convergence of thought on how to best manage occupational low back pain. The epidemiologists; chiropractors; occupational medicine physicians; pain specialists; physical therapists; and health services researchers are all beginning to recognize the same key issues. Among them are the importance of identifying barriers to return to work within the first two-to-four weeks following an injury; recognition that returning to normal activities as soon as possible following injury promotes the best healing; if someone is not back to work within the first month, the "cavalry" needs to be called in; providers who manage and coordinate workers' compensation patients in primary care roles need to have workplace and job modification knowledge.
Among the DCs who presented were Drs. Paul Hooper; Scott Donkin; Steve Yeomans; Gary Schultz; Bill Meeker; Craig Liebensen; Pierre Cote; and myself. Many of the leaders in occupational medicine and low back pain also presented, including Drs. John Frank, an occupational health epidemiologist from UC Berkeley; Patrick Loisel, occupational medicine researcher from University of Sherbrooke in Montreal; Michelle Battie, rehabilitation expert from University of Calgary; Stan Bigos, orthopedist and lead on the AHCPR's Acute Low Back Problems in Adults guidelines; radiologist Jerry Jarvick; and back pain researcher Rick Deyo, from the University of Washington. There was ample representation and discussion between the academic and research issues, and "rubber-meets-the-road" practice issues, as well as employer/workplace and system administration perspectives.
In my opinion, occupational health should be of more interest to the chiropractic profession. Many, if not most, injury care and workers' compensation coverage plans are still based on clinical necessity rather than the arbitrary, heavily cost-driven constraints of managed ("mangled") care. The opportunity is great to constructively engage in problem-solving in the field, develop clinical management criteria, and gain exposure and recognition in a market place where our skills have tangible, recognizable and understandable value.
There is little controversy about the clinical ability of DCs to serve in a direct access, primary care role in workers' compensation cases. Not all states recognize this, but enough definitive and successful examples abound that I remain surprised that so little emphasis or interest exists in occupational health specialization; training and residency opportunities; involvement in organizations like ACOEM, the American Public Health Association, and other organizations with occupational health interests. Occupational health is a prime example of a domain where DCs can meet the needs of the community in big ways.
The logistics of how practices are set up and how care is organized in chiropractic settings offer seamless integration to workers' compensation care. DCs have interest and expertise in musculoskeletal conditions, the most common of work-related problems; compare this to family practice, which is not interested in these kinds of patients. DCs' practices are usually decentralized and easily accessible throughout the community, hence closer to many work sites than large centralized group medical practices. DCs are also often amenable to walk-ins and urgent care visits for sprains or strains. Rapid and same-day care is the norm. In family practice, it may take several days to see a doctor. Rapid notification of employers and insurers that triggers time loss payments, and other workers' compensation benefits can get buried under stacks of group health, pre-authorization and managed care paperwork, hence delaying disability payments. Family doctors have little interest in triaging and deferring other emergent conditions such as a sick child, URIs, and GI problems to fit in a patient with something like low back or wrist pain. While everyone else hates it, we love it and can handle it well.
There are many opportunities for chiropractors to develop more expertise in occupational health. It is essential for providers who manage workers' compensation claims to have understanding of workplace and employer issues. Because employers pay most or all of workers' compensation premiums in most jurisdictions, they often have extensive say in worker care, even to the point of being allowed to direct it to their own preferred physicians for a period of time. What they are usually after are doctors who understand the urgent nature of establishing and documenting work causation and early return to work. Although a minority of such physicians are "bad apples" from a workers perspective, most really do offer a much better understanding of the nature of work-related conditions and how the system differs from group health care models. This kind of expertise is something DCs can develop more of, enabling them to diffuse resistance from employer communities where it exists.
Disability management and ergonomics knowledge and skills are also important. I recently wrote an article reviewing key literature and issues on this topic with some of my colleagues. I encourage you to read it for more information on disability prevention strategies for chiropractic practice.1 Chiropractors already have a strong presence in sports injury and rehabilitation, and many of these skills overlap with occupational health. Craig Liebenson has edited one of the best books on the subject,2 and recently wrote an article reviewing biopsychosocial issues that is worth reading. His work has extraordinary application in the occupational health field.3 Another text by Steve Yeomans on outcomes management is one of the most useful texts one can own for understanding the dimensions of tracking patient progress, setting care goals and documenting effectiveness.4 This is another area that has important ramifications to being competitive and effective in workers' compensation cases.
Occupational health is a health care niche that deserves more attention from DCs and from our academic institutions. It's a sector in the marketplace that we can contribute to in profound ways, and reap appropriate rewards for doing so. The opportunity to establish a high-quality occupational health residency in chiropractic is also under-explored. An institutional partnership with a masters-level certification is not a big stretch, and given recent advances in the National Institutes of Health (NIH) and the Health Resources Services Administration (HRSA) funding, there is no reason why exploring support from the National Institute for Occupational Safety and Health (NIOSH) could not be fruitful. Research partnerships already exist with DCs at the Institute for Work and Health in Toronto and at Arizona State University in Phoenix. This area of research is ripe for expansion, and chiropractic interventions offer much for exploration.
References
- Mootz RD, Franklin GM, Stoner WH. Strategies for preventing chronic disability in injured workers. Top Clin Chiropract 1999; 6(2):13-25.
- Liebenson CS. Rehabilitation in Chiropractic Practice. Baltimore, MD: Williams & Willkins, 1995.
- Liebenson C. Improving Activity Tolerance in Pain Patients: A Cognitive-Behavorial Approach to Reactivation. Top Clin Chiropract 2000;7(4):in press.
- In Yeomans S (ed). The Clinical Application of Outcomes Assessment. Norwalk CT: Appleton Lange, 2000
Robert Mootz,DC
Olympia, Washington
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