Chiropractic Treatment Profiles – 2003 - ACC

109 Pages·2003·0.77 MB·English

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Chiropractic Treatment
Profiles 2003
Composite
Contents
Introduction 3
Section One
Code Identifier Range Trigger Page
N131. Cervicalgia - Chronic/Recurrent Neck Pain 10 – 16 18 5
N142. Low Back Pain, Acute Back Pain Lumbar, Lumbago 14 18 9
N143. Sciatica 14 18 13
S561. Sprain SI Joints 14 18 15
S570. Sprain Cervical Spine 10 – 16 16 19
S571. Sprain Thoracic Spine 8 12 23
S572. Sprain Lumbar Spine 14 18 25
S574. Sprain Coccyx 8 12 29
N12C0 Cervical Disc Prolapse 16 – 20 20 31
N12C1 Thoracic Disc Prolapse 10 – 16 16 33
N12C2 Lumbar Disc Prolapse 16 – 24 24 35
XaO6Y Whiplash 15 18 37
Section Two
Code Identifier Range Trigger Page
S460. Meniscal Tear Medial 12 14 39
S461. Meniscal Tear Lateral 10 14 41
S50.. Sprain Upper Arm/Shoulder 8 12 45
S500. Sprain Acromio-Clavicular Ligament 10 12 47
S503. Sprain Infraspinatus Tendon 12 16 49
S504. Sprain Rotator Cuff 10 16 51
S507. Shoulder Joint Sprain 10 12 53
S51.. Sprain Elbow/Forearm 10 12 55
S52.. Sprain Wrist/Hand 12 14 57
S522. Sprain Thumb 12 14 59
S523. Sprain Finger 12 12 61
S53.. Sprain Hip/Thigh 8 12 63
S533. Sprain Quadriceps Tendon 10 14 65
S540. Sprain Lateral Collateral Ligament Knee 10 14 67
S541. Sprain Medial Collateral Ligament Knee 10 14 69
S542. Sprain Cruciate Ligament Knee 12 16 71
S54x1 Sprain Gastrocnemius 10 14 75
S550. Sprain Ankle 10 14 77
S5504 Sprain Achilles Tendon 12 16 81
S5512/3 Sprain Metatarso-Phalangeal Joint/
Interphalangeal Joint 6 8 85
Contents Chiropractic Treatment Profiles – 2003 1
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Contents
Code Identifier Range Trigger Page
S5y3. Sprain Rib Cage 6 10 87
F340. Carpal Tunnel Syndrome 12 16 89
N211. Rotator Cuff Syndrome 12 – 16 18 91
N2131 Medial Epicondylitis (Elbow) 12 14 95
N2132 Lateral Epicondylitis (Elbow) 12 16 97
N2174 Tendonitis Achilles 12 16 99
N22.. Tenosynovitis/Synovitis Upper/Lower Limb 16 16 103
2 Contents Chiropractic Treatment Profiles – 2003
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Introduction
The Chiropractic Treatment Profiles 2003 have been developed by the New
Zealand Chiropractors’ Association as a joint initiative with ACC.
These Treatment Profiles are published in two sections. Section One features
treatment profiles for vertebral injury. ACC-registered chiropractors who treat
a vertebral injury listed in this section may be eligible for payment by ACC.
Section Two features treatment profiles for extra-vertebral injuries. At the
time of going to print, ACC does not pay chiropractors for treatment related
to non-vertebral injuries.
The profiles are a consensus of opinion as to what is considered appropriate
and common current practice.
The profiles are to help encourage common accepted standards and should be
seen as a step to developing evidence-based best practice guidelines.
The Read codes relate to a specific diagnosis that has no complications and
has been referred for, or has accessed, chiropractic treatment at an early
appropriate stage in the healing process. It is accepted that conditions that are
more complicated may differ from the treatment description and differ from
the average number of treatments suggested by the profiles.
There is acknowledgement that some of the Read codes are general in nature.
Some specific Read codes have had descriptions added to them to aid in the
interpretations. In particular, N12C of Disc Prolapse and Radiculopathy has
been broken up into Cervical, Thoracic and Lumbar regions.
Some profiles cover a number of Read codes as the treatment given is the
same for each condition.
Number of Treatments
Treatment numbers stated in this document relate to a specific diagnosis
without complications, which has been referred for treatment at an
appropriate stage in the healing process.
The numbers have not been developed as evidence-based practice guidelines,
but rather to provide a consensus on acceptable treatment ranges.
Trigger Numbers
Trigger numbers indicate the number of treatments after which ACC would
appropriately seek a review of the services that have been provided.
Any treatment provided for a particular individual will be considered in
consultation with the provider chiropractor. The trigger number is the
appropriate time for a case manager to approach the chiropractic provider
and consider requesting a review by an assessor.
Key Points
Some profiles have had this section added to act as a rider to more clearly
define the particular condition.
Special Considerations
This section highlights special concerns that need to be considered when
treating this condition.
History
This section gives a general overview of the significant factors that should be
considered in the history of each condition.
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Introduction
Examination
This section outlines the main components that should be undertaken in a
normal examination. This is not an exhaustive list and clinicians may have
other investigations that they would routinely take into account. Generally
the examination would cover subjective and objective examination
procedures which would include most of the following:
• Observation
• Active movement testing
• Passive movement testing
• Accessory movement testing
• Palpation
• Muscle tests
• Functional tests
Differential Diagnosis
This section outlines the major conditions that should be considered when
making a provisional diagnosis and also serves to outline what conditions are
not being considered in the profile. This is not an exhaustive list and
clinicians are encouraged to seek second opinions on conditions that seem
unusual.
Complications
This section gives clinicians some examples that may hinder the recovery
time of a patient or move the patient outside the scope of these
‘uncomplicated’ injury profiles and would then require the appropriate
referral action.
Treatment Rehabilitation
This section is divided up into two sub sections, acute and sub-acute. Within
the literature there is great variation as to when a condition moves from being
acute to chronic. For the purposes of these profiles acute has been described
as within the first 10 to 14 days of an injury occurring, or post surgical
intervention. Sub-acute is considered any time after this.
Onward Referral
This section gives the appropriate referral that should be considered if the
patient’s condition causes concern to the treatment provider.
• Radiographic referral is a general term used that would include all
appropriate imaging techniques
• GP referral may be for medication or further testing and consideration
• Specialist referral would be to the medical/surgical speciality that the
condition requires
• Chiropractors in general are encouraged to refer on to recognised
specialists or assessors within the profession for a second opinion for more
complex cases
4 Introduction Chiropractic Treatment Profiles – 2003
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Section 1
Composite
Cervicalgia
(Chronic/Recurrent Neck Pain)
Read Code: N131.
Number of treatments: 10–16
Triggers: 18
KEY POINTS
• An accurate clinical history is necessary
• Identify the need for any further treatment or examinations
• The cervical spine is treated differently from the lumbar spine
• Traumatic causes may include “whiplash” (treated in a separate protocol)
• Exacerbations and remissions are common
• Cervical spine injuries can lead to varied symptoms – dizziness, blurred
vision, tinnitus, chest pain, nausea, dysphagia, headache, loss of balance,
loss of consciousness
Special considerations
• Screen for possible VBI
• Instability
History
• Record the nature and mechanism of the injury – gradual or acute onset
• Pain and injury location
• Previous history and response to treatment
• Differentiate acute from chronic
• Red and Yellow Flags
• Non-traumatic aetiology may include DJD, osteophyte formation,
discopathy, trauma
• Review sports and occupational activities
• Obtain an accurate history including the site and nature and behaviour of
pain and any aggravating or relieving factors
• Prescribed and self medication
• Include current and past illnesses
Examination
• Diagnostic triage
• Psychological barriers to recovery
• Goals for the examination:
– obtain a baseline for the level of function and activity
– alleviate uncertainty about the regional nature of neck pain
– exclude neurological catastrophe
• Posture
• ROM – cervical spine, shoulder girdle
• Palpation of joints and muscles – temperature, spasm, pain
• Neurological (if applicable)
• VBI provocative tests
Differential diagnosis
• DJD of facets/disc
• Lateral canal stenosis
• Myofascial trigger points/pain syndrome
• Fracture
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Cervicalgia
(Chronic/Recurrent Neck Pain)
• Facet trophism
• TOS
• IVF encroachment
• Non-traumatic onset/pathology
• Referred pattern from cardiac, gallbladder, Pancoast tumour
• Exclude vertebral artery, fracture, increased ADI, inflammatory arthritides
• Chronic neck pain (requires different management)
• Referred dental pain
• Temporo-mandibular joint dysfunction
• Peripheral nerve lesion
• Instability, eg acute inflammatory arthritides, increased ADI, hypermobility
syndromes
• Osteoporosis
Investigations
• X-ray – standard 3-view and obliques if necessary
• Refer for full blood count and ESR/CRP if signs or symptoms of serious
disease are present (Red Flags) – spinal cord injury, weight loss, history of
cancer, fever, intravenous drug use, steroid use, immunosuppression, age
>50 years or <20 years, severe, unremitting night-time pain
• Widespread neurological symptoms
• Structural deformity
• Psychological barriers to recovery – use a questionnaire
Complications
• Trauma upon pre-existing injury or degeneration
• Chronic neck pain (which should not be treated as if it were acute or
recurrent neck pain)
• Radiculopathy
• Instability
• Fracture
• Osteoporosis
• VBI
• Inflammatory disease
Treatment/Rehabilitation/Management
• Shift from passive to rehabilitative/restoration of function as soon as
possible
Acute:
• Ice and gentle mobilisation tx, manipulation/adjustment
• Provide an explanation, reassurance, advice on staying active
• If bed rest, no longer than 3 days
• Manipulation after the acute phase (if any neuro deficits are present use
the N12CO protocol)
• Modify ADLs
• Analgesics (such as paracetamol and NSAIDs) or consider conventional
(NSAIDs or paracetamol) or natural medication for muscle spasm,
inflammation and tissue healing. Refer for pain control if necessary
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Cervicalgia
(Chronic/Recurrent Neck Pain)
Sub-acute:
• Moist hot packs/wheat sacks for home use
• Myofascial tx
• Trigger point therapy
• Isometric exercises
Home care:
• Cervical collar in severe cases for first 2 weeks only
• Care with lifting over 5 kilograms
• Adequate sleep – refer for medication if necessary
• May swim backstroke in the first month for rehabilitation
• ADL review and management
• Home exercises for self management
• Review ergonomic factors including postural and sleeping habits
• Patients who have not returned to normal ADL and failed to respond to
treatment require referral. Consider psychosocial factors
Referral
• Refer to GP for:
– TOW
– pain control
– lack of progress
– Red Flag investigations
– other
• Refer to radiographer if no X-ray facilities in office
• Refer to occupational therapist for OSH/workplace review (consult with
ACC case manager)
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