Many years ago, I contributed a regular column to Dynamic Chiropractic focused on occupational issues and the role the chiropractor plays. It's been a long time since I've contributed anything, so it's good to be back again.These days I write a blog on things related to worker's compensation, so in my ramblings this time, I'm going to focus my attention on the worker's compensation system and where chiropractors fit in.
The worker's compensation system was put in place to protect workers when they are injured in the course of their employment. In theory, it is a "no-fault" system. When a worker is injured or taken ill while on-the-job, they are taken care of. Medical bills are paid and the worker is compensated for any time missed. If the injury is permanent, the worker is determined to be permanently disabled, the disability is "rated" and the worker is compensated for any damages.
I say "in theory" because the worker's compensation system works differently depending upon where you are. Sometimes the system works for the injured worker; sometimes not so much. And given that the system is "no fault," there seems to be an awful lot of attorneys involved.
There has always been some controversy regarding the best way of treating injured workers. Many doctors, chiropractors included, are more than willing to give the worker "time off" to recover. However, the evidence suggests that time off has a detrimental effect on most injured workers. In fact, as early as three months, if a worker hasn't returned to work, they have only a 50/50 chance of ever returning.1 In spite of that, long delays in the worker's compensation system often force workers to take months, even years to return. And many are needlessly disabled by the system. In these days of "evidence-based medicine," it would appear that the evidence is being ignored here.
Also, many employers don't want their workers back after they have been injured. I can't tell you how many times an employer has said, "Send them back when they are 100 percent." What a meaningless statement that is! Who is ever 100 percent? And how would you know if they were 100 percent? What that statement really means is, "Send them back when they are symptom free." Once again, not the most productive of approaches.
Currently, one of the most pressing problems in the worker's compensation system is the rampant use and abuse of prescription painkillers, specifically the opioids (e.g., hydrocodone, oxycontin). The use of these drugs has skyrocketed in the past few years, in spite of any evidence that they have any benefit. To be fair, their use has been shown to provide some short-term gains, but any long-term benefit remains controversial.2 After all, they were developed for use in chronic end-stage cancer pain, not in the case of the sprains and strains that are so common in the workplace. Once again, the evidence seems to have been ignored.
The Chiropractor's Role
There have been some rather interesting developments regarding the use of chiropractic services in the worker's compensation arena. As the use and abuse of narcotic painkillers has risen, so too has interest in alternatives. One of these alternatives is spinal manipulation. While chiropractic care, specifically spinal manipulation, has not been shown to provide any greater benefit than other treatments, it hasn't been shown to cause any damage, either.3 The same can't be said for the use of many medications.
Additionally, the cost of treating neck and back complaints, which are among the most common work-related injuries, seems to be directly proportional to the sophistication of the technology used.4 Make no mistake, when it comes to sophistication, you can't beat modern medicine. But sometimes, the tried and true methods (e.g., spinal manipulation done by hand) are the best.
Recent Legislative Hurdles
Recently, in an attempt to reign in rapidly rising costs, the California legislature passed Senate Bill 863, legislation designed to reform the state worker's compensation system. It's said that both labor and business groups worked together to develop the legislation. However, the lengthy document was given to the legislators at the last minute, so any serious evaluation of the text was not possible.
Three groups voiced their discontent with the proposal. One of the groups was the California Chiropractic Association (CCA). Some of the changes in the legislation that negatively affect chiropractors include the following:
- After treating a patient for 24 visits, a DC can no longer serve as the treating physician.
- The pathway for doctors of chiropractic to qualify to sit for the QME exam has been altered.
In a somewhat similar manner, the state of Oklahoma recently attempted to prohibit chiropractors from functioning as independent medical examiners (IMEs). One of the arguments used was that the DC's education and scope of practice is more limited than their counterparts. When it comes to internal disorders, it's hard to argue that case. However, when it comes to the type of musculoskeletal injuries that often affect injured workers, the chiropractor has better training. Regardless, the Oklahoma legislature sided with the chiropractors and nixed the change.5
Give Respect to Get Respect
Sometimes it appears the system is stacked against the chiropractic profession. However, we may be our own worst enemy. While some studies have shown that chiropractic care is a less expensive form of care for worker's compensation patients,6 others have provided a list of concerns that inhibit full participation,7 including lack of a common nomenclature, inadequate documentation, and practice variation.
It's really hard to debate these arguments. One only has to look at the myriad "techniques" chiropractors use, each with its own unique verbiage, documentation and treatment indicators, to appreciate that chiropractic doesn't always mean the same thing to legislators and employers. After all, if we can't agree among ourselves, we shouldn't be all that upset by the reaction of others.
Whatever the reason(s), chiropractors deserve to be treated with respect by the worker's compensation system. Having said that, I am of the opinion that the chiropractic profession should, in turn, treat the system with respect. We should recognize that it is a privilege to treat injured workers. Our obligation is to return them to the job as quickly and safely as we can.
- American College of Occupational and Environmental Medicine. Occupational Medicine Practice Guidelines, 2nd Edition. Elk Grove Village, IL, 2007.
- Steenstra IA, Verbeek JH, Heymans MW, Bongers PM. Prognostic factors for duration of sick leave in patients sick listed with acute low back pain: a systematic review of the literature. Occup Environ Med, 2005 Dec;62(12):851-60.
- Rubinstein SM, Terwee CB, Assendelft WJ, deBoer MR, van Tulder MW. Spinal manipulative therapy for acute low-back pain: an update of the Cochrane Review. Spine, 2013 Feb 1;38(3):E158-77.
- Davis MA, Onega T, Weeks WB, Lurie JD. Where the United States spends its spine dollars: expenditures on different ambulatory services for the management of back and neck conditions. Spine, 2012 Sep 1:37(19):1693-701.
- Talley T. "Oklahoma Court Strikes Down Part of Worker's Comp Law." Insurance Journal, Dec. 22, 2011.
- Jarvis KB, Phillips RB, Danielson C. Managed care preapproval and its effect on the cost of Utah worker compensation claims. J Manipulative Physiol Ther, 1997;20(6):372-376.
- Haneline MT, Meeker WC. Public Health for Chiropractors. Jones and Bartlett: Sudbury, MA, 2011.
Click here for previous articles by Paul Hooper, DC, MPH, MS.