Printed cover ex (Converted)-2 23/01/2003 10:36 Page 1 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 Printed Body ex Format 1 23/01/2003, 10:09 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 Printed Body ex Format 2 23/01/2003, 10:09 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. Introduction Chiropractic Treatment Profiles – 2003 3 Printed Body ex Format 3 23/01/2003, 10:09 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 Printed Body ex Format 4 23/01/2003, 10:09 Printed cover ex (Converted)-2 23/01/2003 10:37 Page 2 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 Cervicalgia (Chronic/Recurrent Neck Pain) N131. Chiropractic Treatment Profiles – 2003 5 Printed Body ex Format 5 23/01/2003, 10:09 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 6 Cervicalgia (Chronic/Recurrent Neck Pain) N131. Chiropractic Treatment Profiles – 2003 Printed Body ex Format 6 23/01/2003, 10:09 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) Cervicalgia (Chronic/Recurrent Neck Pain) N131. Chiropractic Treatment Profiles – 2003 7 Printed Body ex Format 7 23/01/2003, 10:09 8 Chiropractic Treatment Profiles – 2003 Printed Body ex Format 8 23/01/2003, 10:09
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