History
Take a related history from the patient. It may include but not be limited to:
Mechanism of Injury
- Details of the accident or the injury (i.e., specific or cumulative trauma, body parts involved initially or recruited due to altered biomechanics.)
Symptoms
- Current Symptoms (i.e., intensity, frequency and duration, quality of pain/altered sensation, impairment or effect on daily activities.)
- Initial and Subsequent Symptoms
- Improving, getting worse, or staying the same
- Relieving or aggravating activities
- Associated Symptoms (i.e., fever, changes in bowel or bladder function, numbness and tingling.)
Treatment to Date
- Type of treatment
- Response to treatment provided (i.e., medications, manual treatment, self-care, etc.)
Physical Activities
- Occupational
- Recreational
- Exercises
- Other
Additional Medical History
- General health (i.e., changes in appetite, weight, energy level, sleep pattern)
- Prior injuries (i.e., industrial injuries, motor vehicle accidents, fractures)
- Prior disability or impairment
- Surgeries
- Prior similar complaints
- Serious illnesses
- Current medications
- Other risk factors (e.g., weight, tobacco, alcohol, drugs, or hobbies)
Family History
Psychosocial Factors That May Delay Recovery
Examination
- General appearance (development, nutrition, body habitus, deformities)
- Vital signs
- Regional orthopedic and neurological examination (i.e., ranges of motion; motor, sensory, reflex testing)
- Aberrant movement patterns
- Examine related body parts (i.e., upper extremity examination with cervical spine complaints)
- Postural inspection, percussion and palpation
- Gait analysis
- Additional testing as indicated may include:
- Girth measurements in the extremities
- Functional muscle testing
- Vascular testing
Diagnostic
Testing should be done with best clinical judgment to establish or support the diagnosis or for the necessary treatment of the patient.
X-ray or other diagnostic studies may be performed if patient fails to respond in 4 weeks or experiences a significant increase in symptoms or impairment.
Typically x-rays may be indicated within the first 30 days of injury if one of the following is present:
- Fever greater than 100 degrees that persists for longer than 48 hours
- Unrelenting night pain or pain at rest
- Aberrant pain, paresthesia, or numbness
- Motor deficit
- Progressive neurological deficit
- Significant trauma
- Suspicion of fracture
- Suspicion of progressive disease (i.e., osteopenia, osteoporosis, ankylosing spondylitis, metabolic disease, scoliosis)
- Drug or alcohol abuse
- Chronic use of steroids
- Age over 50
- History of chronic pain in the same body part
- Previous spinal surgery to same body area
- Unexplained weight loss or changes in bowel/bladder function
Indications for Imaging, Electrodiagnostic or Laboratory Studies
Magnetic Resonance Imaging (MRI) Indications
- Loss of bowel or bladder function
- Significant, persistent or progressive neurological deficit
- Suspected:
- Myelopathy
- Metastasis
- Tumor
- Osteomyelitis
- Paraspinal abscess/fluid
- Vascular malformation
- Pathological fracture
- Congenital spinal anomalies
- Post-surgical MRI with gadolinium
- Interarticular derangement
- Ligament laxity
- Spinal instability
- Avascular necrosis
- Muscle or tendon tear
- Failure to respond to conservative care
Computed Tomography (CT) Indications
- Refractory radiculopathy
- Focal motor deficit
- Fracture
- Foreign bodies
- Post-operative assessment
- Congenital/developmental fracture or abnormalities
- Where MRI contraindicated (pacemaker, implants, claustrophobia)
- Suspected spinal stenosis
Bone Scan
- Suspected metabolic disease
Electrodiagnostic Studies
- Persistent neurological symptoms necessitating differentiation of radicular vs. peripheral neuropathy
- Conditions non-responsive to conservative care requiring determination of the severity of the deficit
Laboratory Indications
- Persistent fever
- Multiple or migrating joint pain or swelling
- Lack of response to treatment determined to be appropriate for the diagnosis
- Suspicion of infection or family history of systemic, metabolic, rheumatoid or autoimmune conditions
Patient Education
Discuss the diagnosis and treatment options.
Discuss reasonable expectations for the resolution of symptoms, and return to work or other activities. Inform the patient that it is not uncommon for patients who recover from the initial episode to have another episode, but improvement is to be expected. Reassure the patient of the anticipated recovery or improvement.
Instruct the patient in appropriate self-guided care. This may include discussion of:
- Limited bed rest with gradual return to normal activities
- Activities or positions to limit or avoid
- Continuing activities within limits permitted by pain or other symptoms
- Posture and proper body mechanics
- Gentle stretching
- Ice/heat
- Instruction in exercises
Discuss patient's use of over-the-counter (OTC) medications or need for prescriptive medication.
Treatment
Manual Therapy/Manipulation
- Adjustive manipulative procedures and other manual therapies including utilization of instrumentation. The effect is to normalize joint mobility and nerve function in addition to pain reduction, with frequent compensatory changes in other areas. Secondary changes in peripheral neurological function and may include relief from somatic pain syndromes, nerve compression syndromes, functional disorders and anatomical pain syndromes.
- Primary focus is on functional abnormalities of joints, which may include fixation, hypermobility or hypomobility. Contributing factors include muscular hypertonicity or weakness, ligamentous shortening or elongation, and articular adhesions if not corrected. The mechanism for blockage of articular movement may involve mechanical joint locking, disc disorders and/or intra-articular jamming of various tissues.
Complementary Procedures
- Intended to normalize joint function, decrease muscle spasm, decrease pain, reduce edema or inflammation, improve muscle tone, increase joint mobility or stability, increase soft tissue flexibility, decrease pain and maximize integrity of fibrotic repair.
- This may include but is not limited to:
- Manual or mechanical traction
- Neuromuscular re-education
- Myofascial release
- Trigger point therapy
- Muscle stretch techniques
- Mobilization
- Use of supports, braces, splints or orthotics
- Physical medicine modalities and procedures may be of benefit in conjunction with manipulation.
Active Care
Methods of treatment requiring active involvement, participation and responsibility on the part of the patient. This may be supervised in office or instructions for self-care. Active care in each phase of treatment should begin when, in the treating physician's judgment, it is appropriate to do so. This would be based upon, among other things, the severity of the injury, the injured area, the patient's age and other limiting factors.
- Acute: Temporarily limit or avoid specific activities known to increase or aggravate mechanical stress on the injured region. In order to avoid deconditioning, low stress aerobic and flexibility exercises can be instituted as soon as tolerated.
- Sub-acute: Recommended exercise quotas that are gradually increased result in better outcomes. Endurance programs (walking/biking/swimming) can be initiated during this phase.
- Chronic: Strengthening and stabilization exercises for the injured region can commence immediately.
Gradual increase in time per session, amount, and intensity of exercises as the patient demonstrates improvement.
Reduce, modify or discontinue exercise program if peripheralization (spread of symptoms) occurs.
Management of Chronic Conditions
Chronic pain syndrome is defined as persistent pain which lasts more than three months and which interferes with psychological or physiological function or which requires ongoing treatment. In general, chronic pain syndrome deals with musculoskeletal conditions, pre-existing and/or progressive degenerative conditions, neurological disorders and psychological issues including drug dependence, high levels of stress and anxiety, failed back surgery syndrome and pre-existing or latent psychopathology. The condition is not expected to completely resolve but treatment can be expected to result in some functional improvement, stabilization or slowing of progressive degenerative changes. Patients with chronic pain syndromes, whose pain has become intractable in spite of initial care and secondary treatment, may benefit from evaluation and treatment including spinal manipulative techniques, physical medicine, pain management and physical conditioning such as therapeutic and rehabilitative exercise to help promote functional recovery. Frequently, chronic pain syndrome patients require supportive care to maintain their therapeutic gains or clinical status.
For information on Contraindication or Modifications of Spinal Manipulation refer to the "Contraindications" field in this summary.
Refer to the original guideline document for information about definitions and principles of care, criteria for referral, temporary disability, and complicating factors.
