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## Complete Summary

#### GUIDELINE TITLE

Manual medicine guidelines for musculoskeletal injuries.

#### BIBLIOGRAPHIC SOURCE(S)

Braddock E, Greenlee J, Hammer RE, Johnson SF, Martello MJ, O\'Connell
MR, Rinzler R, Snider M, Swanson MR, Tain L, Walsh G. Manual medicine
guidelines for musculoskeletal injuries. California: Academy for
Chiropractic Education; 2007 Apr 1. 33 p. \[108 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Braddock EJ, Greenlee J,
Hammer RE, Johnson SF, Martello MJ, O\'Connell MR, Rinzler R, Swanson
MR, Tain L, Vogel JA, Walsh G. Manual medicine guidelines for
musculoskeletal injuries. California: Academy for Chiropractic
Education; 2004 Dec 1. 25 p.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Musculoskeletal injuries

-   Chronic pain syndrome

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Rehabilitation\
Treatment

#### CLINICAL SPECIALTY

Chiropractic

#### INTENDED USERS

Chiropractors\
Health Care Providers\
Health Plans\
Managed Care Organizations\
Patients\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To provide recommendations for evaluation, diagnosis, and treatment of
musculoskeletal injuries

#### TARGET POPULATION

Individuals with musculoskeletal injuries

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis/Evaluation**

1.  Medical history including mechanism of injury, symptoms, treatment
    to date, physical activities, past medical history, family history,
    and psychological factors that may delay recovery

2.  Physical examination including general appearance; vital signs;
    regional orthopedic and neurological examination; aberrant movement
    patterns; examination of related body parts; postural inspection,
    percussion and palpation; gait analysis; and additional testing as
    indicated

3.  Diagnostic tests including x-rays, magnetic resonance imaging (MRI),
    computed tomography (CT), bone scans, electrodiagnostic studies, and
    laboratory studies if indicated

**Treatment/Management**

1.  Patient education regarding recovery process, diagnosis, treatment
    options, self-guided care, over-the-counter medication use, need for
    prescription medication, and reasonable expectations

2.  Manual therapy/manipulation, including use of instrumentation

3.  Complementary procedures including 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

4.  Active care (acute, sub-acute, and chronic)

5.  Referral to a specialist if indicated

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

MEDLINE, Cochrane, and Mantis databases were used to collect the
evidence.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Not stated

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**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.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate evaluation, diagnosis, and treatment of musculoskeletal
injuries

#### POTENTIAL HARMS

Not stated

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

**Contraindications or Modifications of Spinal Manipulations**

Prior to manipulative techniques, the patient needs to be evaluated by a
doctor trained and licensed to perform manipulative therapeutics, for
any underlying conditions that, based on the doctor\'s experience and
expertise, would modify or contradict the procedure.

-   *Severe sprain/strains*: Due to increased instability, refer for
    surgery if necessary and manipulate areas of fixation contributing
    to the instability.

-   *Rheumatoid or Psoriatic Arthritis*: Due to potential ligament
    rupture or instability (i.e., transverse ligament instability),
    forceful manipulation is contraindicated. Use soft tissue and
    mobilization techniques with light manipulation may be appropriate.

-   *Serious Vascular Disease*: History or evaluation of serious
    vascular disease, including, but not limited to, vertebral artery
    dissection, vertebral basilar insufficiency, aneurysm, stroke, use
    of blood thinning medications or clotting disorders.

-   *Musculoskeletal Disorders*: History or evaluation of some serious
    musculoskeletal conditions may require modification or
    contraindicate some manipulative techniques. These may include, but
    are not limited to, fracture of the involved area, severe arthritic
    disease or metabolic disease.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Braddock E, Greenlee J, Hammer RE, Johnson SF, Martello MJ, O\'Connell
MR, Rinzler R, Snider M, Swanson MR, Tain L, Walsh G. Manual medicine
guidelines for musculoskeletal injuries. California: Academy for
Chiropractic Education; 2007 Apr 1. 33 p. \[108 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2004 Dec 1 (revised 2007 Apr 1)

#### GUIDELINE DEVELOPER(S)

Academy for Chiropractic Education - Medical Specialty Society

#### SOURCE(S) OF FUNDING

Academy for Chiropractic Education

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Authors*: Eddie J. Braddock, DC, DABCO, FICC; James Greenlee, DC,
DABCO; Ronald E. Hammer, DC, DABCO; Steven F. Johnson, DC, DABCO, FICC;
Michael J. Martello, DC, DABCO, FICC; Michael R. O\'Connell, DC, FICC;
Richard Rinzler, DC, DACBSP, FICC; Mat Snider, DC, FICC; Mitchell R.
Swanson, DC, FICC; Lawrence Tain, DC, FICC; Gayle Walsh, DC, FICC

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Braddock EJ, Greenlee J,
Hammer RE, Johnson SF, Martello MJ, O\'Connell MR, Rinzler R, Swanson
MR, Tain L, Vogel JA, Walsh G. Manual medicine guidelines for
musculoskeletal injuries. California: Academy for Chiropractic
Education; 2004 Dec 1. 25 p.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from <droconnell@hotmail.com>

Print copies: Available from Dr. Michael R. O\'Connell, D.C., F.I.C.C.,
Academy for Chiropractic Education, 525 South Fairmont Avenue, Suite D,
Lodi, CA 95240

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on July 19, 2005. The information
was verified by the guideline developer on October 21, 2005. This NGC
summary was updated by ECRI Institute on August 1, 2007. The updated
information was verified by the guideline developer on September 4,
2007.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

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Date Modified: 11/3/2008