Patient Care, Community Health and Occupational Health

A good adjustment is only one visit in a course of care that must be explained, consented to, measured, documented, kept safe and eventually ended. This chapter covers that management layer, then widens the lens to rehabilitation, community health and the workplace, where the chiropractor acts as a primary contact provider for prevention. On the board these topics appear as vignettes about consent, contraindications, outcome tools, screening intervals, exposure limits and the right moment to refer.

Section 1Case management

Report of findings

The report of findings (ROF) usually takes place after the examination and any imaging or laboratory results are available, often at the second visit. It tells the patient, in plain language: what is wrong (the working diagnosis and the tissues involved), what the findings were (show the films, the range of motion numbers, the outcome scores), the prognosis with and without care, the proposed plan (procedures, frequency, duration, home care), the reasonable alternatives, the expected costs, and what the patient is responsible for. Good practice uses teach back ("tell me in your own words what we found") and leaves room for questions. The ROF is also when red flag findings are disclosed and referrals are explained.

Informed consent

Informed consent is a process, not a signature. The patient must have decision making capacity, must receive adequate information, must understand it, and must agree voluntarily. Most jurisdictions use a material risk (reasonable patient) standard: disclose what a reasonable person in the patient's position would want to know to decide, including rare but serious risks. The older professional standard asked what a reasonable practitioner would disclose. The elements are often remembered as PARQ:

Consent is documented in writing and in the notes, renewed when the plan or technique changes, and obtained from a parent or legal guardian for a minor (with assent from the child). Treatment of sensitive areas (intrarectal coccyx work, chest wall contacts in women, pelvic floor) needs specific consent and a chaperone offer. Implied consent applies only in emergencies. Treating without consent can be battery even if the care was competent; failing to disclose a material risk that then occurs is negligence.

Treatment plans, frequency and duration

A treatment plan states the diagnosis, goals (short and long term, functional and measurable, for example "sit 60 minutes at work without pain above 3 of 10 within 4 weeks"), the procedures and regions, the frequency and duration, the home program, the outcome measures and the re-evaluation date. Care is commonly described in phases (Figure 12.1): an acute or relief phase with the highest visit frequency, a corrective or subacute phase as function returns, a rehabilitative phase emphasizing active care and self management, and optional maintenance or wellness care that is elective and usually not covered by insurers.

Frequency should reflect the natural history and the patient's response. Most acute uncomplicated low back pain improves substantially within about 6 weeks. A common rule is a trial of care of about two weeks (often 2 to 3 visits per week) followed by reassessment; if there is no documented improvement after two such trials with different approaches (about 4 weeks), the plan should change or the patient should be referred. Higher initial frequency with tapering is typical for acute cases; chronic cases use lower frequency and more active care. Plans that keep frequency high without measured progress are a common reason for payer denials and board complaints.

Outcome measures, re-examination and discharge

Validated outcome measures turn "feeling better" into numbers that justify continued care or a change of course. Use a pain scale plus a region specific disability questionnaire at baseline and at each re-examination.

A re-examination repeats the pertinent history, examination and outcome measures, commonly every 2 to 4 weeks (or about every 12 visits), at the end of each phase and whenever the condition changes or a new complaint appears. It decides whether to continue, modify, refer or discharge. Discharge occurs when goals are met, when the patient reaches maximum medical improvement (a plateau where further improvement is not expected), when care fails to help (refer), when the patient chooses to stop, or when nonadherence makes care futile. Ending care must avoid abandonment: give reasonable written notice, continue urgent care for a reasonable period, offer referral and transfer records.

Documentation and SOAP notes

Records must be legible, accurate, contemporaneous, signed and dated. The common format is SOAP: Subjective (the patient's report: complaint, pain scores, function, response to the last visit), Objective (the doctor's findings: examination, palpation, ranges, tests, outcome scores, vitals), Assessment (diagnosis and progress toward goals, including the clinical reasoning) and Plan (procedures performed today with regions and techniques, home care, next visit, re-examination date, referrals). Corrections are made with a single line through the error, the correct entry, the date and initials; never obliterate, overwrite or backdate. Late entries are labeled as such.

Section 2Contraindications, complications and referral

Absolute and relative contraindications

An absolute contraindication means thrust manipulation should not be done in the involved area (and sometimes at all) because the risk clearly outweighs any benefit. A relative contraindication means manipulation may be done with modification (less force, no rotation, a different region, instrument or drop assisted delivery, mobilization or soft tissue work) after weighing risk and benefit. Contraindications are also local (only the involved region) or general. A condition can be a contraindication to one technique (for example rotational cervical thrust) but not to another (gentle mobilization).

Adverse events and how often they occur

Benign, transient reactions are common: local soreness, stiffness, headache, tiredness or radiating discomfort follow manipulation in roughly a third to a half of patients, usually start within 24 hours and resolve within 24 to 72 hours. They are disclosed in consent and managed with reassurance, ice or heat and activity. Serious adverse events are rare. Estimates for stroke associated with cervical manipulation range from about 1 in several hundred thousand to 1 in several million manipulations; cauda equina syndrome after lumbar manipulation is estimated at well under 1 per million. Other serious events include fractures (especially ribs in osteoporotic patients), worsening of disc herniation and, very rarely, epidural hematoma.

The relationship between neck manipulation and vertebrobasilar stroke is complicated by the fact that a dissection often presents first as neck pain and headache. Population case crossover studies found that the association between a recent chiropractic visit and vertebrobasilar stroke was similar to the association with a recent primary care visit, suggesting that many patients with an evolving dissection seek care for its early symptoms. The practical message is the same either way: recognize the evolving dissection and do not manipulate it. For comparison, serious gastrointestinal bleeding from NSAIDs and complications of spinal surgery are far more common than serious complications of manipulation.

Screening for cervical artery dissection and stroke

Screening relies on history, a focused examination and clinical reasoning. Risk factors for cervical artery dissection include recent minor neck trauma, connective tissue disorders, recent infection, migraine, hypertension and a family history. Warning symptoms include a new, sudden, severe or unusual neck pain or headache (vertebral dissection: usually posterior neck and occipital; internal carotid dissection: anterolateral neck, face or periorbital pain), the 5 Ds and 3 Ns, ataxia, and for carotid dissection an ipsilateral Horner syndrome, pulsatile tinnitus or transient visual loss. Stroke signs are summarized by BE FAST: Balance, Eyes, Face drooping, Arm weakness, Speech difficulty, Time to call emergency services. Examine blood pressure in both arms, cranial nerves, cerebellar function and gait, and listen for carotid bruits.

Positional provocation tests were long taught as premanipulative screens. They are still tested on the board, but they have poor sensitivity, can be falsely negative in a patient with a dissection, and are not recommended as the basis of a decision to manipulate. Know how they are done:

When and how to refer

Referral is matched to urgency. Emergency (call emergency services or direct transfer): stroke signs, suspected dissection, cauda equina syndrome, suspected ruptured or expanding aortic aneurysm, chest pain suggesting myocardial infarction or pulmonary embolism, unstable fracture. Urgent (same day or within a day or two): suspected fracture, infection (fever with spinal pain), progressive neurologic deficit, unexplained weight loss with night pain. Routine: failure to respond to an adequate trial of care, need for medication or injection, comanagement of chronic disease, psychological needs, or findings outside chiropractic scope.

A good referral includes a letter or call to a named provider that states the patient's identity, the history and examination findings, the working diagnosis, the specific question or service requested, the urgency, and the care already given; it includes relevant films and reports. Disclosure of health information to another provider for treatment is permitted under privacy rules, but the patient should know and agree. Document the referral, confirm that the appointment occurred and follow up; a referral that is never completed leaves the referring doctor exposed.

Section 3Rehabilitation, home care and prevention

Matching care to tissue healing

Rehabilitation follows the biology of repair (Figure 12.3). In the inflammatory phase (about the first 3 to 5 days) the goals are protection, pain control and limiting swelling: relative rest rather than bed rest, cold, compression and gentle pain free motion (the "optimal loading" idea in the POLICE approach: protection, optimal loading, ice, compression, elevation). In the proliferative (repair) phase (about day 3 to 3 to 6 weeks) fibroblasts lay down type III collagen; gentle stretching and progressive loading orient the new fibers along lines of stress. In the remodeling (maturation) phase (about 3 weeks to a year or more) type III collagen is replaced by stronger type I collagen, and progressive strengthening, endurance, proprioception and sport or work specific training restore function. Immobilization beyond a few days weakens ligaments and cartilage and slows recovery, which is why early controlled movement is the rule.

Therapeutic exercise

Exercise prescription follows FITT (frequency, intensity, time, type) and the principles of overload (load must exceed the usual to cause adaptation), specificity (the SAID principle: specific adaptation to imposed demands), progression and reversibility (gains are lost with disuse). Muscle work is isometric (no joint motion, useful early and when motion hurts), isotonic with concentric (shortening) and eccentric (lengthening, which produces the most force and is used for tendinopathy) phases, isokinetic (constant speed on a machine) and plyometric (stretch shortening, late stage). Open chain exercises leave the distal segment free (leg extension); closed chain exercises fix it (squat), produce more co-contraction and joint compression, and are generally favored after knee ligament injury. Strength is trained with heavier loads and fewer repetitions (about 8 to 12 at 60 to 80 percent of one repetition maximum for general strength), endurance with lighter loads and more repetitions.

Spinal stabilization trains the deep segmental muscles (transversus abdominis, lumbar multifidus, diaphragm, pelvic floor) and the global trunk muscles to control the spine under load. Common elements are the abdominal brace or drawing in, the curl up, the side bridge and the bird dog (a widely used "big three" for trunk endurance), dead bugs, bridges and progression onto unstable surfaces. In the neck, deep neck flexor training (the craniocervical flexion "chin nod" with a pressure biofeedback cuff) addresses the weakness common in chronic neck pain and headache. The McKenzie (mechanical diagnosis and therapy) approach uses repeated movements to classify patients into derangement, dysfunction and postural syndromes; centralization (pain moving from the leg toward the spine with repeated movement, often extension) predicts a good outcome, and a directional preference guides the home program. Williams flexion exercises (posterior pelvic tilt, knee to chest) suit facet and stenosis patients who are relieved by flexion.

Janda described predictable muscle imbalances. In the upper crossed syndrome, the upper trapezius, levator scapulae and pectorals are tight while the deep neck flexors and the lower and middle trapezius and serratus anterior are weak, producing forward head, rounded shoulders and scapular winging. In the lower crossed syndrome, the hip flexors and thoracolumbar extensors are tight while the abdominals and gluteals are weak, producing anterior pelvic tilt and hyperlordosis. The treatment is to stretch the tight and strengthen the weak, then retrain movement.

Stretching and flexibility

Static stretching holds a lengthened position, typically about 30 seconds for 2 to 4 repetitions; dynamic stretching moves through range in a controlled way and is preferred in warm ups; ballistic stretching uses bouncing and triggers the stretch reflex. Proprioceptive neuromuscular facilitation (PNF) uses contraction to gain range: hold relax or contract relax (contract the target muscle, then relax and stretch, using autogenic inhibition through the Golgi tendon organ) and contract relax antagonist contract (adding contraction of the opposing muscle, using reciprocal inhibition). Post isometric relaxation uses the same principle with gentler contractions.

Physical modalities

Ergonomics and home care

Home advice turns visits into lasting change. For computer work: screen at arm's length with its top at or slightly below eye level, elbows near 90 degrees with relaxed shoulders, wrists neutral, feet flat with hips at or slightly above knee level, lumbar support, and frequent microbreaks (change position at least every 30 minutes; the 20-20-20 rule for the eyes). For lifting: test the load, keep it close, hinge at the hips with a neutral spine, brace, avoid twisting (turn the feet), and get help or a device for heavy or awkward loads. Sleep on the back or side with a pillow that keeps the neck neutral (a pillow between the knees when side lying). Limit sustained phone posture ("text neck"), and keep children's backpacks to about 10 to 15 percent of body weight, worn on both shoulders. Advise patients to stay active: for acute low back pain, staying active leads to faster recovery than bed rest.

Section 4Community health and wellness

Prevention and the public health system

Prevention is described in levels. Primary prevention stops disease before it starts (immunization, exercise, smoking prevention, ergonomic design). Secondary prevention detects disease early, before symptoms, when treatment works best (screening for hypertension, cancer, osteoporosis). Tertiary prevention limits disability from established disease (rehabilitation, cardiac rehab, fall prevention after a hip fracture). Some add quaternary prevention: protecting patients from unnecessary tests and treatment, such as routine imaging for uncomplicated back pain.

Healthy People sets national ten year objectives. The current overarching goals are to help people attain healthy, thriving lives free of preventable disease, injury and premature death; eliminate health disparities and achieve health equity; create social, physical and economic environments that promote health; promote healthy development and behaviors across every life stage; and engage leadership and the public in policy. It organizes the social determinants of health into five domains: economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context. A small set of leading health indicators tracks progress.

Screening recommendations

Screening is worthwhile when the disease is common and serious, has a detectable preclinical phase, and early treatment improves outcomes, and when the test is acceptable, safe and accurate. Beware lead time bias (earlier diagnosis appears to lengthen survival without changing the date of death) and length bias (screening preferentially finds slow growing disease). USPSTF grade A and B services are recommended; C is selective; D is recommended against; I means insufficient evidence. Commonly tested recommendations for average risk adults:

Tobacco, alcohol and other substances

Tobacco is the leading preventable cause of death. For the spine, smoking accelerates disc degeneration, lowers bone density, delays fracture and fusion healing and is linked to chronic back pain. The brief intervention model is the 5 As: Ask every patient about tobacco use at every visit, Advise clearly and personally to quit, Assess willingness to quit now, Assist (set a quit date, counseling, refer to a quitline or a prescriber for nicotine replacement, varenicline or bupropion) and Arrange follow up. For patients not ready, the 5 Rs build motivation: relevance, risks, rewards, roadblocks and repetition. Even a brief clinician message increases quit rates.

A standard drink contains about 14 g of alcohol (12 oz of 5 percent beer, 5 oz of 12 percent wine, 1.5 oz of 40 percent spirits). Low risk limits are commonly given as no more than 4 drinks on any day or 14 per week for men and no more than 3 on any day or 7 per week for women; dietary guidance advises at most 2 drinks a day for men and 1 for women if alcohol is used at all. Screening tools include the AUDIT (10 items) and AUDIT-C (3 items), the single question ("How many times in the past year have you had 5 or more drinks in a day [4 for women]?") and CAGE (cut down, annoyed, guilty, eye opener; 2 or more positive answers is significant). Positive screens lead to SBIRT: screening, brief intervention and referral to treatment. For opioids and other drugs, ask directly and without judgment, recognize signs of misuse and overdose risk, and know that naloxone reverses opioid overdose.

Diet and exercise for obesity

BMI categories: underweight below 18.5, normal 18.5 to 24.9, overweight 25 to 29.9, obesity class I 30 to 34.9, class II 35 to 39.9 and class III 40 or more. A waist circumference over 40 inches (102 cm) in men or 35 inches (88 cm) in women marks central obesity and higher cardiometabolic risk. Loss of 5 to 10 percent of body weight improves blood pressure, glucose and lipids. A daily deficit of about 500 to 750 kcal produces roughly 0.5 to 0.75 kg (1 to 1.5 lb) of loss per week; diet produces most early weight loss, while physical activity is essential for maintenance. Adults with obesity should be referred to intensive multicomponent behavioral programs. The physical activity guidelines call for 150 to 300 minutes of moderate (or 75 to 150 minutes of vigorous) aerobic activity per week plus muscle strengthening on 2 or more days; older adults add balance training; children and adolescents need 60 minutes daily. Healthy patterns (Mediterranean, DASH with sodium under 2,300 mg a day) limit added sugars and saturated fat to under 10 percent of calories each.

Behavior change theories

Section 5Occupational and environmental health

Agencies, laws and workers' compensation

OSHA (Occupational Safety and Health Administration) sets and enforces workplace standards: the General Duty Clause (an employer must keep the workplace free of recognized serious hazards), injury and illness recordkeeping (the OSHA 300 log), Hazard Communication (labels and safety data sheets for chemicals), permissible exposure limits and the Bloodborne Pathogens Standard. NIOSH researches hazards and issues recommended exposure limits and tools such as the lifting equation. Workers' compensation is a state based, no fault system: the injured worker receives medical care and wage replacement without proving employer negligence and in exchange generally cannot sue the employer. Key terms include temporary and permanent disability, maximum medical improvement, impairment rating and the independent medical examination. The Americans with Disabilities Act requires reasonable accommodation for qualified workers with disabilities.

Work related musculoskeletal disorders and ergonomics

Musculoskeletal disorders account for about a third of injuries that cause days away from work, and overexertion in lifting, pushing and pulling is the leading cause of workplace injury. Physical risk factors are force, repetition, awkward and static postures, vibration (whole body vibration in drivers is linked to low back pain; hand arm vibration causes vibration white finger, a secondary Raynaud phenomenon), contact stress and cold. Psychosocial factors (job dissatisfaction, high demand with low control in the demand control model, poor supervisor support) predict back injury claims and delayed return to work as strongly as physical load. Typical upper limb disorders are carpal tunnel syndrome, lateral epicondylalgia, de Quervain tenosynovitis, trigger finger and rotator cuff tendinopathy.

The revised NIOSH lifting equation calculates a recommended weight limit (RWL) by multiplying a load constant of 23 kg (51 lb) by six multipliers, each 1.0 or less: horizontal distance of the load from the ankles, vertical height at the start, vertical travel distance, asymmetry (trunk twist), frequency and coupling (quality of grip). The lifting index is the actual load divided by the RWL; a value over 1.0 means increased risk and over about 3.0 means most workers are at high risk. The farther the load from the body, the greater the reduction, which is why "keep it close" is the first lifting rule.

Return to work planning uses a job demands analysis, a functional capacity evaluation (FCE) to compare the worker's tested abilities with the job's demand level, modified or light duty, and work conditioning (general strength and endurance) or work hardening (interdisciplinary, job simulated, often with psychological support). Early, graded return to modified work generally improves outcomes compared with prolonged time off.

Hazards are controlled using the hierarchy of controls (Figure 12.5): the most effective measures remove or replace the hazard, and the least effective rely on the worker's behavior or protective equipment.

Workplace violence, noise, heat and the chiropractic office

Workplace violence is classified as type I (criminal intent, such as robbery, by someone with no legitimate relationship to the business), type II (customer, client or patient against worker, the most common type in health care), type III (worker on worker) and type IV (a personal relationship, such as domestic violence spilling into work). Prevention combines management commitment, hazard assessment, environmental design (lighting, alarms, exits), training in de-escalation, and reporting without retaliation.

For noise, OSHA's permissible exposure limit is 90 dBA as an 8 hour time weighted average with a 5 dB exchange rate, and a hearing conservation program (monitoring, audiometry, protection, training) is required at an action level of 85 dBA. NIOSH recommends 85 dBA with a 3 dB exchange rate. Noise induced hearing loss produces a characteristic audiometric notch at about 4,000 Hz. Heat stress ranges from heat cramps and heat exhaustion to heat stroke (core temperature above about 40 °C with altered mental status), a medical emergency.

The chiropractic office has its own hazards. Under the Bloodborne Pathogens Standard the employer needs an exposure control plan, must offer hepatitis B vaccination at no cost to exposed staff, use standard precautions, sharps containers and labeled biohazard waste, and provide post exposure evaluation. Radiography requires ALARA, shielding, personnel dosimetry and observance of dose limits (occupational whole body limit 50 mSv, or 5 rem, per year; 5 mSv over the gestation for a declared pregnant worker; 1 mSv per year for the public).

Environmental exposures

Pollution and waste

Air pollution is regulated through national standards for six criteria pollutants: ozone, particulate matter (PM2.5 and PM10), carbon monoxide, lead, nitrogen dioxide and sulfur dioxide. Fine particulates (PM2.5) penetrate to the alveoli and are linked to cardiovascular and respiratory deaths; ground level ozone aggravates asthma. The Air Quality Index translates levels into public advice. Indoor air problems (radon, secondhand smoke, mold, volatile organic compounds, poor ventilation in "sick building syndrome") often matter more because people spend most of their time indoors. Water safety depends on protecting sources and treating drinking water: nitrates from fertilizer cause methemoglobinemia ("blue baby" syndrome) in infants, protozoa such as Cryptosporidium and Giardia resist chlorination, and lead leaches from old pipes. Hazardous waste is tracked "cradle to grave" from generator to disposal. In a clinic, sharps go in puncture resistant containers, contaminated items in labeled biohazard bags, and expired chemicals and old radiographic processing chemicals by approved disposal, never down the drain.

Words worth knowing