While 90-95% of acute spinal patients will resolve their disability within three months of injury, chronic or recurrent back disability may persist for years.1 Americans pay over $40 billion annually for the treatment of lower back disabilities. With over 12 million people suffering from chronic back pain, there have been few safe and effective means of quantifying injury and aggressively rehabilitating these patients.
Considering the costs of back injury to industry (over 50% of dollars paid out by compensation claims for only 5% of injuries), the savings to industry could be very substantial. It is possible for industries to have employees return to work productively when their backs are ready. Simple prescreening or rehabilitation programs cost 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 will 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 socioeconomic problem. It rates as the number-one cause of disability below the age of 45, and the third major cause over the age of 45.1 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, and and lost work time.
The absence of objective functional capacity measurements is a possible cause for much of the present confusion in spinal care. In the extremities, clinicians rely on visual observation of joint motion and stability, extremity circumference and right-left comparisons, as and ergometry and muscle strength measurements to help guide treatment programs after injury. In the spine, small, well-camouflaged joints and deep muscles with complex multiplanar 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, although the technology has not been available. "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."1
Technology has advanced to the point that functional capacity measurements can be performed to quantify spinal function. Computerized mechanical muscle testing devices 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. Abnormal movement and torque patterns can also be identified, providing an objective basis for a rehabilitation program.
The patient is positioned within a testing device with appropriate stabilization for isolated joint evaluations, or is positioned 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 are 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.
Triano2 provides in the Chiropractic Rehabilitation Association's (CRA) Chiropractic Rehabilitation Standards Manual the following indications and contraindications to functional muscle strength and endurance testing:
A. Indications
- muscular spine disorders;
- mechanical spine disorders;
- unchanged musculoskeletal (spine and non-spinal) condition for two to three weeks;
- monitor outcome of rehabilitation.
B. Contraindications - acute pain status;
- progressive neurologic deficit;
- cauda equina signs;
- metabolic bone disease, including severe osteoporosis/malacia;
- gross instability;
- rheumatoid arthritis;
- ankylosing spondylitis
- early postoperative cases;
- malignancy.
Besides storing and analyzing data, patient performances by some devices have been 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.
There are many players in the occupational back arena: the employee; the employer; the union; the physician; third-party payors; lawyers; and the courts. All the players have the same goal: to take care of and provide for the truly injured worker.
Third-party payors pay out millions of dollars for compensable injuries. Industry spends 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 workers' compensation paid out is a credible reflection of a real disability. They do not want the injured employee to return to work earlier or later than the employee's 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. An untimely return of the patient to work can result in further impairments and disabilities.
In collegiate and professional athletics, physicians and trainers would never send an injured player out on the field or court without testing for improved capacity. Yet in the industrial arena, the worker is frequently sent back to work without assurances of improvement or capability.
Think about how many physicians work with bad backs. How many times is a patient sent back to work after surgery with no rehabilitation? The physician thought the patient was ready, but never really knew until the patient actually used his / her back at work. By then, it may be too late and costly for the patient, physician and employer.
An early return to work could result in additional injury to the employee that could 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. And yet, you may have had no choice. In many cases, decisions are based on subjective evaluations only.
The CRA standards manual2 states that the following findings within the patient's history indicate chronicity where mechanical and functional muscle testing intervention would be appropriate:
- musculoskeletal complaint unchanged for two to three weeks;
- evidence of anxiety or depression;
- regular continued use of nonprescription analgesics;
- continued disability.
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 in coming. With millions of hours of clinical testing and pathological and postsurgical patients safely tested, studies indicate that the data obtained from mechanical muscle testing of the spine and extremities can provide the clinician with the necessary information to formulate the most cost-effective rehabilitation regime.
The chiropractor who is truly interested in quantifying impairment and prescribing an effective rehabilitation program should seriously consider the new innovative technologies available to assess function; routinely utilize the data obtained in enhancing the decision-making process, and formulate the most cost-effective rehabilitation program.
Occupational injuries are widely regarded as being at epidemic proportions. It is a great burden to industry and the health care community. In most industrial plants, only upper respiratory illness exceeds musculoskeletal pain in time lost due to sickness. In the United States, the average cost per case is climbing. However, only 25% of the cases account for 90% of the cost.1 As the duration of occupational musculoskeletal disability increases, the total cost accelerates.
References
- Mayer, Gatchel, Kishino, et al. Objective assessment of spine function following industrial injury. Spine 1985;10(6):482-493.
- Chiropractic Rehabilitation Association. 1991 Chiropractic Rehabilitation Facility Standards Manual. CRA, 1990.
