But how do we do respond to this news? Do we welcome the guidelines as evidence that the use of manipulation has been established as a viable and worthwhile treatment modality for some patients? Do we complain about the suggestion that if patients do not respond within a reasonable amount of time, perhaps they should seek alternatives? Or do we allow ourselves to become frustrated with the thought of being boxed into a back pain model? How we respond to these guidelines, and the research that helped to produce them, may well help to determine our future.
Since there is some concern about the possibility of being limited to "back doctors," let's talk about the back pain model. People tend to think that chiropractors are back doctors. In fact, studies show that most of our patients come to us because their back hurts. Is this helpful or harmful? It might be worth pointing out that back pain affects nearly 80 percent of the population in the United States. One out of every three people suffers with some degree of back pain at any given time. It is the second leading cause for people seeking the help of health professionals. Only the common cold sends more people to the doctor. In other words, this is a really big box that we have established a foothold in. If you're going to box yourself in, it's good to have a big box!
Let's take a look at back pain in the industrial setting. Back pain is the leading cause of disability in individuals between the age of 19 and 45. No other single health problem keeps more people off the job! Back injuries account for 16 percent of all claims for work related injuries, and they represent 33 percent of all claims costs. The costs of back pain exceed $50 billion annually in the United States alone, with the average work related back injury costing $8,321 (Webster and Snook). Industry is confronted with a tremendous problem of workers' compensation costs, lost work time, disability payments, etc. And industry is desperate for help to reduce the back pain problem. So who should they turn to? Let me relate the following quotation from a recently published text on work related injuries, "Physical therapists with strong and thorough evaluation skills and an understanding of pathophysiology, human kinematics, and function are ideally suited to treat the injured worker. Consequently therapists are becoming major players in the industrial arena. Clinical skills coupled with functional mindsets tend to make therapists an extremely cost effective and viable alternative to existing systems ... Possibly the most dramatic and effective role that on-site therapists fill is that involving early intervention in acute musculoskeletal injuries" (Vance and Brown). Please don't misinterpret my concerns. I am not opposed to physical therapists working towards prevention of back problems in industry. I have many friends who are PTs and have a great deal of respect for their profession. But are we not also adequately equipped to help industry with the care and management of acute musculoskeletal injuries? In fact, are we not better equipped to help?
Recently the U.S. Department of Health and Human Services published a book, Healthy People 2000: National Health Promotion and Disease Prevention Objectives. This publication is a composite of the goals for the Public Health Service for the coming century. Note the following goals for the area of occupational health and safety:
- to reduce work related injuries resulting in medical treatment, lost time from work, or restricted work activity;
- to reduce cumulative trauma disorders;
- to increase to at least 70 percent the proportion of work sites with 50 or more employees that have implemented programs on worker health and safety;
- to increase to at least 50 percent the proportion of work sites with 50 or more employees that offer back injury prevention and rehabilitation programs.
As of 1985, only 28.6 percent of work sites offered back injury programs. While there are many other goals for the Public Health Service, the stated interest in reducing the incidence and costs resulting from musculoskeletal injuries in the workplace presents us with both a serious challenge and an exciting opportunity. This is not an issue of whether or not somebody is going to provide prevention information to industry. It is, rather, an issue of who is going to provide this information.
For some time, I have been lecturing to the chiropractic profession in an effort to encourage individuals to become active in working with industry. As a profession that has spent much of the past century talking about the need for prevention, should we not be leaders in the introduction and implementation of injury prevention programs, especially back injury and back safety programs? As back specialists, is it not in our best interest as a profession, not to mention the best interest of many potential back pain patients, to provide industry with the information necessary to prevent problems? Or should we abandon this role to other professions? As I follow the developments of an ever changing health care system, one thing is very clear: we have a robust future as specialists in the area of cost-effective, conservative care for musculoskeletal injuries. Be assured, however, we are not alone!
Webster BS, Snook SH: The cost of 1989 workers' compensation low back pain claims. Spine, 19(10):1111-1116, 1994.
Vance SR, Brown AM. On-Site Medical Care and Physical Therapy Impact, In: Isernhagen S, Comprehensive Guide to Work Injury Management, Aspen, Gaithersburg, MD, 1995.
Healthy People 2000: National Health Promotion and Disease Prevention Objectives, U.S. Department of Health and Human Services, Public Health Service, DHHS Publication No. (PHS) 91-50213, Government Printing Office, Washington, D.C., 1994
Editor's Note: If you have any questions, suggestions, or comments please write to Dr. Paul Hooper c/o Injury Prevention Technologies, 21343 Cold Springs Lane, Suite #443, Diamond Bar, California 91765
Click here for more information about Paul Hooper, DC, MPH, MS.