Understanding Medical Management for Muscoloskeletal Injuries
Upfal, Mark, Occupational Hazards
DO ALL THE TREATMENT METHODS and medical management approaches for occupational musculoskeletal injuries seem somewhat puzzling? There are a wide variety of drugs, splints, and other appliances used. What about exercise, work hardening, vitamins, or chiropractic care? One physician may recommend surgery while another does not; one may state that there is no objective evidence of injury, while the other reports that the same patient is disabled. Some doctors tend to be conservative in their approach, while others tend to be quite aggressive.
The justification for these differences in approach may not be readily apparent to either the patient or the employer. Often, the ultimate approach to care may be guided by "doctor shopping" by either the employer or the employee. Meanwhile, within the context of the treatment plan, the employer must maintain a productive workplace, as well as manage the costs of both medical care and indemnity.
Even when dealing with a seemingly straightforward problem like a simple lumbar strain (a muscle/ligament strain of the low back without damage to the spine or discs), a single approach which has been found to work best for most patients does not exist. There is no optimal protocol or algorithm for such care that will always be effective. If there were, most physicians would be using such practice guidelines, and we would see consistency rather than diversity in their approach. It is simply not possible to prospectively predict to what extent medications, physical therapy, exercise, ice, contrast baths, and other approaches may be effective in a given patient with many of the common injuries we see. Thus, a physician must depend on a certain amount of "trial and error" to optimize care. If this is not understood by the patient or employer, then the patient who does not respond to the first trial of treatment may lose confidence in a fine physician and sing the praises of the second physician, who through the same process of "trial and error," (but with the advantage of additional time) improves the patient's pain.
The reality is that despite all of our recent technological advances, treatment for the most common occupational musculoskeletal disorders may be as much an art as a science. Clearly, there is a spectrum of quality in medical care. However, quality of service (timely appointments, convenient hours, physician demeanor, congenial office staff, attractive written reports) is more readily measured than the technical quality of medical treatment. Both forms of quality, though, are important to restore worker health and productivity, and to minimize employer losses.
Although many Occupational Hazards readers do not make medical decisions, an understanding of the most common treatment methods used by physicians, and some of the associated vocabulary will help improve dialogue with the medical community. Such an understanding will enhance your ability to select providers for primary care, second opinions, and independent medical evaluations, as well as improve your ability to properly place the worker back on the job at the appropriate time.
I must caution that these descriptions are not meant as medical advice. They are provided to enhance your understanding of the methods commonly used by physicians, but not as--an approach to treating injuries that anyone should take without consulting a physician first. Only the treating physician, who understands all of the medical history, the mechanism of injury, and the results of their medical examination and tests, can provide proper care. These descriptions are also limited to methods used to treat some of the more common musculoskeletal conditions. More severe or esoteric conditions may require more specialized forms of medical treatment.
All injuries must be evaluated prior to treatment. Before managing a simple injury, the physician must classify the diagnosis or differential diagnoses (the various diagnoses that are likely possibilities, given the clinical presentation) and rule out more serious conditions, even if considered low probability. …