Workplace Injuries and Occupational Medicine

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

Traditional Chinese Medicine (the acupuncture profession) provides an inexpensive and thorough conservative care for musculoskeletal injuries that is promoted by the World Health Organization (WHO), the National Institutes of Health (NIH), the California Industrial Medical Council, the Labor Code and Workers' Compensation systems of a number of states, and is supported by evidence-based treatment guidelines accepted by the RAND Corporation, Agency for Healthcare Research and Quality (AHRQ), and even by a number of industry sponsored guidelines.

More and more Licensed Acupuncturists are learning specialties in soft tissue therapies, myofascial release, and neuromuscular education, to enhance the effects of the more commonly practiced needle stimulation, cupping, massage and herbal/nutrient prescription. Scientific research now confirms that many benefits of acupuncture needle stimulation and deep tissue physiotherapies, proving that this type of treatment is more than just palliative. Unfortunately, years of bad politics and industry competition for the healthcare dollar has denied the public, and injured workers, the utilization of safe and effective direct manual physiotherapies such as these, coupled with standard physical therapy and chiropractic manipulation. Instead, a growing problem of long disability and overuse of palliative pain medication and unnecessary surgery has reached a point of alarm, as costs of Workers' Compensation have soared, and the number of workers with chronic pain, narcotic pain medication addiction, and associated health problems, has skyrocketed. Finally, the public is demanding that actual therapy is granted when a workplace injury occurs. Getting the system to listen to the needs and demands of the workers is still a problem, though.

Medical Doctors provide the resources and expertise to diagnose, prescribe palliative pain medication, and guide an efficient treatment scheme to resolve workplace injury and get the injured person back to work, but they do not provide actual therapy to directly treat the injury short of surgery. For this, an integrated team of physicians and therapists are needed, and the Complementary Medicine physician, in the form of the Licensed Acupuncturist, can provide the direct manual physiotherapies, patient instruction in body mechanics and home therapeutics, topical medicines to promote faster tissue healing, evidence-based herbal and nutrient medicine, and acupuncture, to integrate with standard physical therapy and chiropractic medicine, to achieve this goal. Decades of denial of this care has impeded progress on building a more efficient and effective system of medical care for injured workers that would benefit not only the workers, but the employers. Conservative care should be tried whenever possible before resorting to surgery, and more importantly, treatment should be provided that stops the injury from becoming chronic and serious, and prevents future injury.

California was among the first states to adopt Workers' Compensation legislation to protect large businesses from the liability of worker injuries, with voluntary participation under the Compensation Act of 1911, and then mandatory participation under the Workers' Compensation, Insurance and Safety Act of 1913. This legislation has been amended numerous times, and is intended to limit the liability of businesses with workplace injuries, while providing and insuring medical care and compensation for the workers. In the 1980s, the acupuncture profession was acknowledged as a proven and reliable form of therapy accepted in this arena of occupational medicine, and touted for its low cost and lack of adverse health effects. Despite the minimal amount of money spent on acupuncture and physiotherapy, the Republican legislators (and Democrats) in California have removed acupuncture from the treatment equation 3 times in the past 30 years, under the guise of "Workers' Compensation Reform". The last removal of acupuncture benefits from workers occurred shortly after the recall of Governor Gray Davis, a supporter of the acupuncture profession, and the election of Arnold Schwarzenegger. The previous California governor, Pete Wilson, deregulated the Workers' Compensation system, allowing for-profit companies to manage the medical care and dispersal of funds, which eventually led to the increase in costs of Workers' Compensation, that was the highest in the nation around 2000, despite a decrease in the number of workplace injury claims. The acupuncture profession was never a cost driver in this system, accounting for a miniscule amount of the occupational medicine budget. Each time this denial of benefits of acupuncture and physiotherapy occurred, though, there was a subsequent increase in the use of narcotic pain medication.

By the year 2011, workplace insurers, as administrators of the compulsory Workers' Compensation funds, spent an estimated $1.4 billion annually on narcotic pain medication for workplace injury. The denial of safe and effective conservative care for workplace injury, in the form of acupuncture and physiotherapies, which was highly recommended by the Industrial Medical Council of California, a group of experts that wrote the guidelines of treatment in occupational medicine until treatment guideline reforms were more strictly mandated and the Industrial Medical Council was abolished with SB228 in 2002, led to an enormous rise in the use of narcotic pain medications to treat workplace injury, especially chronic injury. At this time, the administrative director of the California Workers' Compensation system was given full responsibility to adopt "evidence-based, peer-reviewed, nationally recognized standards of care" recommended by the Commission on Health and Safety and Workers' Compensation (CHSWC). As the recall of Governor Gray Davis, and the election of Governor Arnold Schwarzenegger took effect, stronger Workers' Compensation Reform was enacted in the SB899 legislation, largely written by the insurance industry. In this law, a 24-visit cap was applied for physical therapy and chiropractic medicine, and while no cap was applied to acupuncture (since it was being removed from the system), a temporary administrative director of the Workers' Compensation system replaced the real administrative director (for over 4 years), and the implementation of treatment guidelines for the acupuncture specialty was denied for 4 years, despite RAND approved evidence-based acupuncture guidelines already in place nationally. This largely removed acupuncture and physiotherapy from the system, despite a large outcry at public hearings across the state of California from both patients and physicians.

The result of these so-called legislative reforms has not been a decrease in the costs of Workers' Compensation, but rather an increase. In addition, a growing chorus of alarm has risen due to the enormous problems with overuse of pain medications, narcotic abuse, and related health problems and deaths (see the article entitled Pain Medication: Warnings and Alternatives on this website). A June 3, 2012 article in the New York Times, entitled Pain Pills add Cost and Delays to Job Injuries, reported that a 2008 study by the California Workers' Compensation Institute found that when actual physiotherapies are underutilized, and narcotic pain medication is used instead, that the cost of treating a workplace injury is magnified greatly, with workers given higher dosages of narcotic pain medication staying off work 3 times longer on average. A 2010 analysis by Accident Fund Holdings reported that the cost of a workplace injury was 9 times higher when a strong narcotic like OxyContin was prescribed when compared to a workplace injury treated with conservative care and no narcotic pain medication. The prescription of narcotic pain medication has expanded greatly in the last decade, prompting a number of laws now requiring that physicians utilize conservative care in the form of acupuncture and physiotherapies to reduce narcotic addiction, overdose injury and death. Between 2001 and 2008, as Workers' Compensation reforms were enacted across the country and acupuncture and physiotherapies were denied, narcotic pain prescription as a share of all drugs used to treat workplace injury increased 63 percent, according to insurance industry data reported in this New York Times article.

The delays in adopting new evidence-based national treatment guidelines for the acupuncture profession between 2004 and 2008 resulted in these treatments largely disappearing from the system in California, and much of the country. Today, a managed system of care in occupational medicine highly discourages the utilization of these conservative manual physiotherapies such as acupuncture and Tui na soft tissue mobilization. The result is a crisis in both financial costs, and costs to the health of workers, who more often are faced with both chronic pain and disability, and the adverse effects of chronic narcotic and other pain medication, including addiction.

These pain medications have been shown to do little to restore the health of the worker and get them back to work. Government deficits have been impacted heavily, as public employees are denied actual physical care, and put on narcotic and other pain medications permanently, often with high costs of the medication, and more time off work. There has been little input from the injured workers or the public in this decision making, and the direct control of patient care by a physician of choice has been taken away as well. Opioid pain medications have emerged as a major driver of costs, and inexpensive, direct, and proactive treatment in the form of acupuncture and physiotherapy is rarely utilized, despite the fact that the short courses of acupuncture and physiotherapy are often less expensive than the narcotic pain medication. Accident Fund Holdings reported that the cost of a typical workplace injury, averaged about $13,000, was tripled when a strong narcotic pain medication was prescribed, instead of utilization of conservative treatment protocols. When the strongest narcotic pain medications were prescribed, the average cost of workplace injury increased to 9 times the average. A course of acupuncture and physiotherapy of 18 visits would cost roughly 2 thousand dollars, much less than the 26 to 114 thousand dollars added on average when patients are treated with narcotic pain medications instead. The insurance industry, managing the claims in Workers' Compensation after deregulation from non-profit administration, routinely and readily reimbursed doctors for pain medication prescription and denied acupuncture and physiotherapy. We see now where this has gotten us.

In 2013, Barry Meier, a contributor to the New York Times business and medicine news, and author of the ebook A World of Hurt: Fixing Pain Medicine's Biggest Mistake, outlined the economics of the treatment of workplace injury in the Workers's Compensation system. Mr. Meier reveals that the expected cost of treating a patient with pain medication alone is estimated at about $6000 per year, while the cost of a combination of physical therapy and behavior modification is estimated to cost between $15,000 and $25,000 per year. What was not considered is the added costs of treatment with narcotic pain medications alone, which often becomes chronic and addictive, adding the treatment of drug addiction, emergency room expenses for overdoses, and a host of legal and social costs surrounding the burgeoning wave of abuse of these medications, as well as prolonged time off work. For the patients who continue to work, the cost to the Workers' Compensation system for urine testing of drug abuse rose from $800 million in the year 2000 to nearly $2 billion in 2013. The number of patients enrolled in drug treatment facilities for narcotic pain medications rose from 228,140 in 2002 to 313,460 in 2011. Clearly, the need to integrate low-cost therapies such as acupuncture and physiotherapy, which is pro-active and facilitates both a return to work and improved function, as well as better overall health, is needed to correct this problem. The cost of integrating such therapy is a fraction of the cost of a combination of extensive physical therapy and behavior modification therapy, and adoption of CIM (Complementary and Integrative Medicine) will lead to decreased costs for employers and better quality of life and productivity for workers.

In addition, treatment with addictive narcotic pain medications is likely to result in chronic treatment for many years, with decreasing benefits of pain control, while the treatment with actual physical treatments is likely to be limited, with the patient achieving a cure or best possible outcome with a relatively short course of therapy. If a combination of acupuncture and physiotherapy is utilized the average cost is much lower than $15,000, and may provide many health benefits, including promotion of a more proactive patient behavior. A typical course of treatment utilizing a combination of acupuncture and physiotherapy of 12 treatments would cost the employer or claim administrator about $1500 in the California Workers' Compensation system. Even if such treatment merely reduced the use of narcotic pain medication, it would be economically sensible, much less consideration of the actual benefits to most patients with competent care. If the Licensed Acupuncturist utilized a combination of protocols that included acupuncture, physiotherapies such as myofascial release, neuromuscular reeducation, soft tissue mobilization, and active release technique, as well as instruction in ergonomic improvements with body mechanics and postural habits, and a targeted instruction stretch and exercise, this package of care, long recommended by experts in the medical field, as seen in the CPT coding guidelines, could offer the patient and employer a very cost effective treatment strategy.

Repetitive and Postural Stress Injuries make up the bulk of Workplace injuries, and need a comprehensive, holistic, and integrated approach to tissue repair, as well as an effort in correcting the causes of the injuries to prevent recurrence, including patient instruction in correct body mechanics and musculoskeletal maintenance. Workers, their employers, and the treating doctors need to realize that real and direct manual therapies and patient instruction are needed to adequately treat these workplace injuries. Delays in treatment and pain medication dependency are not in the interests of the employee or the employer

While repetitive and postural strain injuries and musculoskeletal disorders have become catch-phrases in a political battle to limit the liability of employers, workers have been patiently waiting for effective treatment to get back to work as quickly as possible, and effective protocols to avoid repetitive and postural strain. Ergonomics is now a familiar term for a majority of American workers, but the definition of the term is still poorly understood. Ergonomics was a term coined by Professor Hugh Murrell in 1950, and concerns natural laws of body mechanics to optimize human well-being as well as overall system performance in the workplace. Today, the term ergonomics has come to mean design issues in the workplace to optimize performance and reduce injury, namely repetitive and postural strain related to workstation routines. The actual definition and focus of ergonomics, though, has more to deal with the mechanics of the human body, not the equipment. The equipment design is supposed to facilitate the human body mechanics to reduce stress and strain and thus improve system performance. Turning this upside down, we have come to define the concept as designing efficient workplace equipment that the human body should utilize effectively. What we have overlooked is that the human body mechanics may be subject to thoughtless work habits and lack of understanding of the science of anatomy and physiology, and that no matter what the design of the workstation is, a person can still injure themselves by adopting poor body mechanics. When work becomes repetitive and postural strain is inherent in the system, as in endless hours sitting at a computer station, a complex type of strain is experienced. This type of injury is unlike the musculoskeletal strain and sprain felt from lifting too much weight and experiencing acute injury. Repetitive and postural stress injury occurs gradually and silently, or insidiously, and could be prevented, avoided, and quickly corrected, but not with pain medication and surgery, and not with workstation design alone.

Under the Clinton administration, long years of data accumulation and study determined that greater than 60 percent of workplace injury could be attributed to repetitive and postural strain. Subsequently, legislation was passed in 1999 that addressed workplace ergonomics, but was quickly repealed under the Bush administration. In 2003, even the term musculoskeletal disorder was removed from the Occupational Injury and Illness Recording and Reporting Requirements (OSHA 300). This short-sighted behavior did not reduce costs to employers, and prevents progress in both worker efficiency and health. In 2009, the United States Department of Labor Occupational Safety and Health Administration proposed restoration of the recording of musculoskeletal disorders by employers to track workplace injury and illness. This has unfortunately become a partisan fight in the federal government, rather than a concern for the injured workers.

While the concern is that ergonomics legislation will require an enormous expense for employers, a fundamental concept is overlooked. Namely, that ergonomics is about human welfare and body mechanics, not just adding an enormous expense with equipment. Improving both the human mechanics and the work station design together has always been fundamental to ergonomic systems, and the ultimate goal is to improve both work efficiency and decrease workplace strain and injury. Both of these goals should save the employer money. Time spent in therapy with patients that includes instruction in body mechanics, or ergonomics, allows workers to better adapt to workstation design, and while time spent with medical doctors is often restricted, patient-centered approaches in the acupuncture profession, as well as the arena of physical therapy, may provide such time-intensive instruction. Increased training in ergonomics and kinesthetics is important in these fields, and reimbursement needs to be available to stimulate increased training.

This debate should not be about workers versus employers, and should not be a politically partisan debate. Workplace injuries and repetitive postural strain and musculoskeletal disorders also affect real people no matter what their political affiliation. This political fight has thrown us off track, and currently little is being done to prevent, avoid, correct and properly treat repetitive and postural stress injury (RAPSI). These injuries demand a comprehensive treatment strategy that includes efficient explanation to the patient of body mechanics, correction of poor postural habits at the workstation, restoration of function of deep stabilizing muscles that control postural mechanics, and physical rehabilitation of the tissues affected by myofascial strain and chronic inflammatory dysfunction. The Licensed Acupuncturist with a specialty in musculoskeletal medicine is an ideal Complementary Medicine physician to provide this comprehensive and holistic care, but first we must include the profession of acupuncture in the arena of Workers' Compensation to encourage greater study and effective treatment protocol. The egg comes before the chicken.

Timely referral of patients with workplace injuries involving musculoskeletal disorders and repetitive and postural stress injury will encourage the injured workers to better understand their condition and take a proactive role in correcting these problems and getting back to productive work.

A worker in pain is not a productive worker, and a worker addicted to narcotic pain medication is probably less productive as well. Musculoskeletal syndromes, or disorders, require that the patient understands the postural mechanics and work habits that cause chronic injury, and correct them. These RAPSIs also require that function is restored to deep stabilizing and impinging muscles, so that chronic stress is decreased on joint tissues, and blood and nerve circulation is restored to the extremities. Not only muscle weakness, but chronic muscle contracture, calcification, and inflammation must be addressed. A protocol that combines a number of therapies in a single session, with myofascial release, neuromuscular reeducation, acupuncture stimulation, targeted stretch and exercise, correction of postural mechanics, and even use of nutritional and herbal medicine, is needed to provide this more complex course of therapy. The added benefit to this comprehensive treatment protocol is also the prevention of future injuries, for dysfunction of the muscles and chronically inflamed and calcified tissues provide less tissue mobility when an acute injury occurs, and such musculoskeletal stress will also eventually lead to poor hydration of vertebral discs, as well a poor circulation to joint tissues, and eventual degenerative joint disease.

Deep tissue massage therapies provide health benefits beyond tissue repair, benefiting the whole health and restoring productivity

Research into the benefits of deep tissue massage therapy, called Tui Na in Traditional Chinese Medicine, is proving that these therapies can be very beneficial to overall health beyond the obvious benefits of improved healing of deep tissue musculoskeletal pathology. An article in the New York Times on September 20, 2010, reported on a clinical trial by the Cedars-Sinai Medical Center in Los Angeles, California, sponsored by the National Institutes of Health (NIH) (see the article link below), where randomly assigned patients were tested for physiological changes during either light massage or deep tissue therapies. To the surprise of the researchers, the beneficial physiological changes measured in the deep tissue physiotherapy group were dramatic. The researchers noted significant decreases in the circulating cortisol, vasopressin, increased immune response, increases in oxytocin, and decreases in adrenal corticotropin hormone. Similar beneficial effects were noted in studies of the active metabolites measured in saliva samples. These findings imply that myofascial syndromes and deep tissue inflammatory disorders are linked to hormonal homeostasis strongly, as well as healthy immune function, and that this type of deep tissue therapy can significantly reduce physiological stress and improve one's overall health. Coupled with the obvious benefits of deep tissue therapies to directly aid tissue repair, the benefits with a comprehensive course of therapy combining acupuncture, deep tissue tui na, myofascial release, neuromuscular reeducation, and instruction in targeted stretch and exercise that may be had from well trained and knowledgeable Licensed Acupuncturists, provides a complete benefit to injured workers with musculoskeletal disorders.

These added benefits of deep tissue physiotherapy noted in this scientific study could dramatically improve tissue healing and overall health of the injured worker. To explain the findings of this NIH sponsored study, let's look at what they mean to our health. Cortisol, also known as hydrocortisone, is a steroid hormone produced continuously by the adrenal gland, which is part of the kidneys. Cortisol is called the stress hormone because it functions to counter the ill effects of acute physiological stress in the body, not because it reduces nervous tension or emotional stress. Cortisol is continuously released in a feedback system that responds to a variety of factors related to physiological stress, including decreased blood sugars (hypoglycemia), excess immune, or inflammatory responses, blood loss, fever or tissue burns, and hormonal changes associated with emotional alarm. Cortisol is not only a hormone that reacts to sudden changes in physiological stress, but also to chronic physiological stress. Cortisol is continuously excreted in a tightly controlled manner that has a diurnal pattern, or changes according to the cycle of wake and sleep. Chronic cortisol excesses and deficiencies are seen within this diurnal pattern when a number of chronic physiological stressors are present. It has been demonstrated that abnormal cortisol levels occur with thyroid disorder, anxiety and depressive disorders, insulin disorder, gastric hypofunction, electrolyte imbalances, chronic inflammatory syndromes and diseases, sleep disorders, and even with chronic use of some medications, such as oral contraceptives. Because cortisol is diurnally fluctuating normally, the question is not always of a simple excess or deficiency, but rather of inappropriate cortisol levels within the diurnal phasing. For instance, adrenal insufficiency may result in a sluggish cortisol response, leaving the patient with excess cortisol at night and deficient cortisol during the day. This results in insomnia and non-restful sleep, as well as daytime sluggishness and poor tissue repair. When this occurs, repetitive and postural strain is more likely to occur. When we look at the subject of cortisol, we must look at how to normalize the cortisol homeostasis.

Patients with excess stimulation of cortisol may develop a variety of chronic health problems. Deep tissue therapies were shown to reduce the triggers for this chronic cortisol excess release, and thus the body needed less cortisol, as measured in the study. The deep tissue physiotherapy thus targeted the cause of the problem, not the effect. Now, synthetic corticosteroids are also widely prescribed today, as well, and in fact, can be purchased in many drugstore medications without prescription. These synthetic cortisols are called cortisone, which is closely related to corticosterone, a steroid hormone very similar to cortisol, but that has limited effects, and is mainly important as an intermediate in the transformation of pregnenelone to aldosterone, which regulates blood pressure and mineral, or electrolyte, excretion in the kidneys. Synthetic corticosteroid, or cortisone, is very similar to cortisol and is used to suppress immune responses, reduce acute inflammation and pain, mediate allergic reactions, and control asthma. Cortisone has been shown to have an effect on adrenal cortisol, and potentially has a variety of side-effects, especially with chronic use, such as high blood sugars, insulin resistance, diabetes, osteoporosis, anxiety, depression, gastritis, colitis, high blood pressure, erectile dysfunction, hypothyroidism, retinopathy, menstrual cessation, and other health problems. Many of these side effects may be attributed to the effects of synthetic cortisones on the adrenal production of cortisol. Healthy cortisol responses in the body would protect the patient from many of these health problems. Deep tissue physiotherapy has been shown to benefit the cortisol homeostasis and reduce the need for excess cortisol response.

Vasopressin, or antidiuretic hormone (ADH), is a peptide hormone that regulates blood pressure and plays a key role in homeostasis, contributing to the regulation of levels of water, glucose and salt in the blood circulation. Vasopressin is released by the hypothalamus and pituitary complex. Abnormal levels of vasopressin may create excess water retention or dehydration of tissues and cells. Vasopressin has also been shown to have a variety of neurological effects, influencing relationship bonding and feelings of reward. Decreasing excess vasopressin may help lower the blood pressure and normalize homeostasis. Oxytocin is another hormone of the brain, only oxytocin acts primarily as a neurotransmitter. It was origninally found to be associated with female reproduction, labor, and breastfeeding, but research in the last few decades has revealed an extensive role in the body. Oxytocin has been shown to significantly influence orgasm, pair bonding, anxiety, maternal behaviors, and social recognition, influencing many of our daily social interactions, both in males and females. Sufficient oxytocin has been shown to evoke feelings of calmness, contentment and security. Deep tissue physiotherapy has been shown to increase oxytocin. Oxytocin action in the brain is mediated by G-protein coupled receptors that require sufficient magnesium and cholesterol. This is one reason why many patients find that they feel better, and function better, when they take magnesium supplement. Inhibition of cholesterol production may also have a negative effect on oxytocin action. Stimulating proper levels of oxytocin may not only result in better homeostasis and emotional well being, but may help with fertility and conception as well. Synthetic oxytocin is used to induce labor in the hospital, and deep tissue physiotherapy may help reduce the need for a high dosage of this drug when proceeding to labor.

Immune responses were found to be significantly aided by deep tissue physiotherapy as well. The patients in the clinical trial were found to have higher levels of circulating lymphocytes (CD25+, CD4, CD56+, and CD8), and decreased levels of cytokines (IL-1beta, IL-2, IL-4, IL-5, IL-6, IL-10, IL-13, and IFNgamma) that are associated with many chronic inflammatory and autoimmune diseases, as well as neurodegenerative disease. The deep tissue physiotherapies were found to decrease the key pathogenic cytokines to baseline levels, thus exerting a normalizing, or modulating effect. The lead author of this study, Dr. Mark Rapaport, chairman of the department of psychiatry and behavioral neurosciences at Cedars-Sinai, which is associated with the David Geffen School of Medicine at the University of California, Los Angeles (UCLA), stated that he was admittedly a skeptic, and after this study was completed, was very impressed by these findings.

While numerous studies in the past 20 years have shown that the massage, or physiotherapy, utilized in Traditional Chinese Medicine, is proven to be beneficial for soft tissue healing and pain relief, applying randomized and placebo-controlled trials to actual physiotherapy is, of course, difficult in design. Like acupuncture, designing a placebo and blinding the patient and therapist to the real and sham technique is impossible. For this reason, medical journals in the United States, dominated by the pharmaceutical industry, for which placebos and blinding the patient and administrator to which is real and which is a sham pill, is not a problem, continue to state that physiotherapy is not proven to be beneficial by these standards. Of course, with this criteria, surgery in not proven to be effective either. We do know, though, that physiotherapies, as well as surgery, can be effective, if performed properly. These studies in recent years take a more realistic look at scientific validation of physiotherapy, and we see that TCM physicians were correct in their observation that deep tissue therapies, such as Tui Na and Shiatsu, provide benefits even beyond the local improvement in soft tissue healing.

When these deep tissue therapies are combined with acupuncture, other physiotherapies of Traditional Chinese Medicine, topical herbal medicines, and herbal and nutrient medicines taken internally, the overall benefits to one's whole health are considerable. In a complete practice, the TCM physician is also able to instruct the patient in self-administered therapeutic routines and correct postural mechanics and habits. We see that our immune, neurological and hormonal health is highly variable and affected daily by healthy routines and therapies. Adopting TCM therapeutics into your life does much to insure that you will lead a healthy, productive and happy life, and prevent many common diseases. Of course, not every acupuncturist, or TCM physician, provides the same level of expertise and skill, and choosing the physician, in the same way one chooses the right surgeon for the specific job, is important.

A high incidence of vertebral fractures in the aging population and the need for mobilization of the spine and surrounding soft tissues

Tui na, or soft tissue mobilization, encompasses a wide array of physiotherapy techniques in Traditional Chinese Medicine. Mobilization of the spine and surrounding soft tissue is central to the practice of Tui na, and modern studies of the incidence of vertebral fractures in the aging population show how important this therapy is. A large study of the incidence of vertebral fracture, which often goes undiagnosed, but produces back pain, was conducted in Europe in 2002, and published in the Journal of Bone Mineral Research (Apr 17(4);716-724). Over 14,000 men and women were recruited in 29 European centers and their spines were analyzed with X-ray. The incidence of vertebral fracture in women was almost twice that of men, with almost 11 women per 1000 experiencing vertebral fractures each year. An article in the June 18, 2011 New York Times Science section, stated that by age 80, 2 of every 5 women have had one or more vertebral fractures. Multiple vertebral fractures were found in 20 to 30% of these cases studied. In most cases of vertebral fracture, the pain is either minimal or attributed to a muscle spasm. Most of these cases go undiagosed, and even when seen on X-ray studies, most of these vertebral fractures are ignored by the physician and patient.

While osteoporosis and osteopenia present increased risk of vertebral fractures, immobility of the spine, chronic inflammation, poor circulation to the bone, calcified ligaments and joint capsules, and loss of vertebral disc height all play an important role in the incidence of vertebral fracture. When there is poor spinal mobility, there is inhibition of circulation and poor bone maintenance. With calcified soft tissues and chronically contracted muscles, aging bones may face acute stress more easily, and a simple movement or fall may result in excess force applied to the bone. While active excercise and postural correction is important, passive mobilization of the spine and surrounding soft tissue, and myofascial release, is very important to maintaining a healthy spine that can react with sufficient movement to avoid a fracture. Soft tissue and spinal mobilization gently breaks up inflammatory adhesions, improves circulation, and stimulates improved cell growth. Osteopenia and osteoporosis itself is largely due to the poor turnover of cartilage and the vertebral plates adjacent to the discs. Hardening of these tissues prevents circulation and bone remodeling, a constant process in the body. Weight bearing exercise is often insufficient to restore vertebral endplate circulation, especially if the spine is not mobile. Passive mobilization by a professional, performed lying down, allows the tissues to be mobilized that weight bearing exercise prevents.

Of course, the high incidence of vertebral fractures in aging postmenopausal women reflect the high incidence of hormonal deficiency and imbalance in this population. These hormonal challenges inhibit normal bone maintenance as well as soft tissue repair and maintenance. Deep tissue massage, such as Tui na, not only helps to mobilize the spine and surrounding soft tissues to keep them healthy, but also acts to improve the hormonal balance to aid tissue repair and maintenance. The Licensed Acupuncturist is able to provide Tui na, instruction in postural mechanics and targeted stretch and exercise, acupuncture, and herbal and nutrient medicines in the therapeutic procotol. All of these protocols are important and act synergistically to help the body maintain soft tissue and bone health to avoid vertebral fractures with aging. Herbal and nutrient medicines can help with hormonal balance and bone density, correcting or preventing osteoporosis and osteopenia. Periodic supplementation with bone strengthening supplements, such as strontium, will also help to prevent vertebral fractures. This complete package of care provides assurance that you are doing all that you can to avoid this painful aspect of aging.

Evidence-based acupuncture and electroacupuncture is now fully acknowledged by most state Workers's Compensation Labor Boards

A call for strict evidence-based guidelines in California in the late 1980s and early 1990s resulted in the California Industrial Medical Council conducting years of peer-reviewed analysis of strict blinded controlled studies of acupuncture. The result was a clear endorsement of these evidence-based treatments as a recommended first-line therapy that was both proven effective and had almost no potential to adverse effect. This occurred in 1996, and coincided with the World Health Organization and National Institutes of Health completing their long reviews of evidence-based acupuncture, which also fully endorsed acupuncture and electroacupuncture for musculoskeletal injuries and disease. These California Industrial Medical Council guidelines were accepted as the primary guidelines in all Workers' Compensation treatment, yet today, it is very hard to access this information, compiled by a group of experts, none of which were acupuncturists or chiropractors, yet which fully endorsed these modalities. For instance, the California Industrial Medical Council guidelines, 2.2.5.1, section 7, concerning low back and neck injuries, appropriate initial treatment methods, 7d: "many commonly used drugs are not necessarily recommended, such as muscle relaxants, oral corticosteroids, opioids 7e: physical treatment recommendation includes manual medicine, manipulative techniques, manual therapy / mobilization 7f: other physical modalities shall be combined with active treatments that emphasize progressive exercises 7g: frequency of physical treatment may be up to 12 visits in the first month 7i: Acupuncture up to 12 visits in the first month 7m myofascial trigger point injection up to to 3 trials in the first month".

With the Workers' Compensation reform in 2002 in California, the California Industrial Medical Council was dissolved, though, and temporarily the ACOEM (American College of Occupational and Environmental Medicine) practice guidelines superseded, which had almost no citation of any acupuncture studies, despite this area of research and clinical study being perhaps the most studied in the world. This law required the state to adopt specific new guidelines for acupuncture and the acupuncture profession, yet delayed implementing these recognized guidelines for 4 years, denying any care by the Licensed Acupuncturist for the injured workers. Finally, in in 2007, Labor Code 9792.21 (Title 8, California Code of Regulations) was adopted, laying out new Acupuncture Medical Treatment Guidelines, which again fully supported the evidence-based utilization of acupuncture and electroacupuncture for almost any workplace injury, especially chronic injuries. The only requirement to fully utilize acupuncture was that the initial course of 6 treatments should demonstrate some functional improvement of the patient to proceed with more care, and that a peer-review could be required if the employer objected to the treatment need. Despite this long history supporting evidence-based treatments with acupuncture and physiotherapy, by a number of the most respected organizations and panels of experts, today, we still see a systematic denial and obstruction of this highly recommended and low-cost increasingly popular integrative adjunct treatment protocol, and a limitation of the initial course of therapy to a ridiculous 4-6 treatments, which often results in limited benefit by design.

Other states in the U.S. have followed suit since 2007, and before, adopting their own clear treatment guidelines supporting acupuncture and physiotherapy, yet still we see little actual utilization. For instance, Hawaii reported in 2005 that ODG (Office of Disability Guidelines) acupuncture guidelines supported the same initial trial of 6 acupuncture visits with a requirement of some proof of functional improvement to proceed, for almost any workplace injury. In 2009, the state of Colorado adopted acupuncture and physiotherapy into their Workers' Compensation guidelines (7 CCR 1101-3 Rule 18-6 (P) (Q)), as a treatment for pain or inflammation, or as an adjunct to speed functional recovery with physical therapy or post-surgical, with up to 14 treatments needing no prior authorization, just the recommendation by the primary treating physician. In 2010, New York state adopted acupuncture treatment guidelines (First Edition, June 30, 2010, New York State Workers' Compensation Board New York Neck Injury Medical Treatment Guidelines) section D, with an initial course of treatment for not only neck injury, but almost any workplace injury, of up to 10 initial treatments, which may be extended if objective functional gains can be documented or when symptomatic benefits facilitate progression in the patient's treatment program. Trigger point injections, dry needling (in effect, acupuncture trigger point needling), neuromuscular reeducation, soft tissue manipulation, massage, joint mobilization, and active therapy were also supported in this law, confirming evidence-based medical necessity for use of these therapies. The 2015 Utah Administrative Code Rule R612-300 Workers' Compensation Rules - Medical Care R612-300-1 B4 states that "Physician" is defined by Subsection 34A-2-111(1)(b) to include any licensed acupuncturist, and R612-300-6 D: "payor preauthorization is required for any services provided by acupuncturists and naturopaths". These are just some of the examples today, hopefully putting to rest the denial of care utilizing evidence-based protocols, hopefully combining acupuncture, electroacupuncture, trigger point acupuncture, soft tissue physiotherapies (Tui na), and patient instruction in active therapeutics. While standard medicine continues to publicize the fairy tale that acupuncture and acupuncture-related therapies in Traditional Chinese Medicine are not proven, most authorities have finally admitted that this is not true. The science of acupuncture and TCM is proven to work, and provides the complete and intensive therapy that the injured worker needs, with virtually no incidence of harm. Whether 50 years of negative propaganda can be fully countered with the truth is still in question, though, and this may require that the public becomes educated and proactive in support of the Acupuncture profession.

Supporting Acupuncture and Physiotherapy in the Workers' Compensation System for Treatment of Chronic Pain

Chronic pain is acknowledged as the medical problem in the vast majority of cases in occupational medicine, with Repetitive and Postural Strain Injury (RAPSI) the biggest cause of concern, as well as loss of productivity, days off work, and chronic dependency on pain medications and adverse effects on general health, as well as addiction becoming a growing concern. Unfortunately, medical treatment guidelines for chronic pain management and treatment in Labor Code and the Workers' Compensation system are dominated by private concerns controlled by big money interests. The 2003 California Workers' Compensation Reform Act, instituted after the recall of Governor Gray Davis, largely paid for by money tied to the health care and insurance industries, and the election of Governor Arnold Schwarzenegger, also largely supported by these interests, established the requirement of evidence-based guidelines in the treatment of Workers' Compensation injuries, but established little oversight of this elaborate subject, leaving the use of the enormous amount of research data and evidence available in limbo. This law, the de facto source guide for all Workers' Compensation law in the U.S., established temporary use of the ACOEM guidelines, a very limited set of evidence-based guidelines set up by a small organization called the American College of Occupational and Environmental Medicine, and also called for medical specialty guidelines to be adopted as quickly as possible. Unfortunately, these permanent evidence-based guidelines for occupational medicine and the permanent or evolving guidelines for medical specialties, such as the acupuncture TCM specialty, were in effect put into permanent limbo. This arcane and complex scenario continues to affect and confuse workers with chronic pain due to workplace injury more than a decade after the law was passed, as was intended.

In the September 10, 2012 issue of the esteemed medical journal Archives of Internal Medicine, the renowned health outcomes researcher Andrew Vickers of Memorial Sloan-Kettering in New York released his meta-review of current scientific research on acupuncture and the treatment of chronic pain. In this meta-review Dr. Vickers and colleagues limited research data to only the highest-quality human clinical trials to deflect the historic criticisms of acupuncture research. This review, from over 18,000 patients in 29 high-quality clinical trials, provided proof that acupuncture treatment for chronic pain significantly outperforms so-called sham or placebo acupuncture, and more importantly, outperforms standard treatment by even greater measures. Dr. Vickers was quoted as stating: "Our findings provide the most robust evidence to date that doctors are justified in making referrals to acupuncture for their patients with chronic pain. I hope that our findings help inform future clinical and policy decisions for acupuncture."

While we wait for an evolving set of public treatment guidelines for chronic pain this system is left with the temporarily adopted ACOEM guidelines, which include almost no published studies of acupuncture or related physiotherapies, and the ODG (Official Disability Guidelines) of the private institute, the Work Loss Data Institute, funded by the insurance industry. Since Governor Pete Wilson deregulated the longstanding nonprofit Workers' Compensation system in 1995, the system has been highly manipulated by the insurance industry, creating what is described as a roller coaster of charges to small to medium-sized businesses into the general fund that, of course, has resulted in California businesses paying 188 percent of the average cost of Workers' Compensation in the U.S. but delivering almost the lowest standard of care, and half the average disability compensation of most states. This has led to an enormous rise in workers with chronic pain syndromes and claims who are now unable to work, and many of whom are now addicted to pain medications, mostly narcotic.

The systematic lack of effective conservative care that is direct and low-cost, and the promotion of expensive and often debilitating procedures and chronic use of pain medication has led to a crisis for both small and medium-sized businesses and their workers. The growing number of nonproductive workers is also creating an enormous public burden economically, as well as a strain on the system, yet we still see almost no inclusion of the large amount of scientific evidence supporting low-cost direct therapies with acupuncture and physiotherapies. The demand by workers is slowing increasing as this evidence surfaces, yet obtaining this care in the system has become even more difficult, mainly because of the manipulation of temporary evidence-based guidelines controlled by the insurance industry and standard medicine that purposefully excludes studies supporting acupuncture and physiotherapy, despite longstanding recognition of these treatments as evidence-based by the National Institutes of Health (NIH), the World Health Organization (WHO), RAND Corporation, the AHRQ (Agency for Healthcare Research and Quality), and now The American College of Physicians and the American Pain Society. Only when the public and workers finally demand that realistic changes in guidelines and adoption of these treatments occur will it happen, but the complexity of the issue maintains this lack of public focus, denying low-cost and effective care for millions of workers suffering from chronic pain.

Information Resources / Additional Information

  1. A 2014 report on workplace injury and prevention by the U.S. government Occupational Safety and Health Act (OSHA) shows that the 3 million serious workplace injuries documented per year in the U.S. are just the tip of the iceberg, with a system that both discourages reporting and increasingly denies proper care. OSHA estimates that half of the cost of care of workers' injuries now has to come out of the resources of the injured worker and their family, with only 21 percent of cost of care provided by the Workers' Compensation system, and 16 percent covered by the taxpayer. Massive political lobbying has created an untenable situation that severely hurts the American economy, and denied timely conservative care to resolve these injuries, instead creating millions of Americans addicted to narcotic pain medication: http://www.dol.gov/osha/report/20150304-inequality.pdf
  2. The New York Times reported in September of 2010 on an NIH sponsored clinical trial of physiological effects of deep tissue massage therapy, commonly called Tui Na in Traditional Chinese Medicine: http://www.nytimes.com/2010/09/21/health/research/21regimens.html?src=me&ref=general
  3. The above mentioned clinical trial of deep tissue massage therapy was reported in the Journal of Alternative and Complementary Medicine on September 1, 2010: http://www.liebertonline.com/doi/abs/10.1089/acm.2009.0634
  4. Clinical trials and studies with randomly assigned patients in recent years have also proven that acupressure, or Tui Na / Shiatsu, is more effective in relieving low back pain than standard physical therapy, as reported in articles in the British Medical Journal: http://www.sciencedaily.com/releases/2006/02/060217092325.htm
  5. Studies of the physiological benefits of deep tissue myofascial techniques at the University of Granada in Spain, showed that a significant modulation of anxiety, heart rate and systolic blood pressure was observed following treatment: http://www.ncbi.nlm.nih.gov/pubmed/18724827
  6. A 2004 long-term study of the effects of acupuncture on chronic neck and shoulder pain in female workers, conducted by the University of Oslo, Norway, found that course of 10 treatments, in a controlled and randomized clinical trial, produce significant proof of benefits of pain relief, both in frequency and intensity of pain, and reduction of stress headaches, that lasted for 3 years: http://www.ncbi.nlm.nih.gov/pubmed/15157691
  7. A 2005 long-term controlled study of the effects of intensive acupuncture treatment for women with chronic neck and shoulder pain related to workplace repetitive and postural strain injury (RAPSI), conducted by the University of Oslo, Norway, found that intensive acupuncture treatment may improve workplace function as well as several related social and psychological variables associated with chronic workplace injury, such as anxiety, sleep quality, depression, and quality of life (QOL): http://www.ncbi.nlm.nih.gov/pubmed/16025785
  8. A 2001 study of the effects of acupuncture as a Complementary Medicine in the treatment of workplace back injury, conducted by the University of New Mexico Hospital, found that research has proven that acupuncture may benefit those patients that suffer from chronic back pain and have failed to respond to the standard treatment protocol of drugs, rest, epidural injection, physiotherapy, osteopathy, chiropractics, and/or surgery, declaring that acupuncture in 2001 was proven to be a "powerful and complementary therapy for back pain".: http://www.ncbi.nlm.nih.gov/pubmed/12120109
  9. The New York Workers' Compensation Board Medical Treatment Guidelines, Second Edition, 2013, with Section D.1 showing that acupuncture is an authorized and proven treatment in NY Workers' Compensation Guidelines for an initial course of 3-6 treatments, 1-3 times per week with a maximum of 10 treatments, and may extend longer if objective functional gains can be documented or when symptomatic benefits facilitate progression in the patient's treatment program: http://www.wcb.ny.gov/content/main/hcpp/MedicalTreatmentGuidelines/NeckInjuryMTG2012.pdf
  10. The 2009 Colorado Workers' Compensation Rules of Procedures 7 CCR 1101-3 Rule 18 Medical Fee Schedule, 18-6 Division Established Codes and Values, section (P) Complementary Alternative Medicine (CAM) (Requires no authorization), (Q) Acupuncture - Acupuncture is an accepted procedure for the relief of pain and inflammation. While commonly used for pain, it may also be used as an adjunct to physical rehabilitation and/or surgery to hasten return of functional recovery: http://www.coworkforce.com/dwc/rules/WordVersions/Rule_18.asp
  11. The 2015 Utah Workers' Compensation Rules - Medical Care R612-300 shows inclusion of Licensed Acupuncturists and Naturopaths as physicians, required preauthorization for treatment, but now supporting these modalities in the system: http://www.rules.utah.gov/publicat/code/r612/r612-300.htm
  12. A 2015 review of the failures of treatment in the Workers' Compensation system, by the University of Washington School of Public Health and Community Medicine, in Seattle, Washington, USA, and the University of Washington School of Medicine Department of Neurology, determined that there is a gross failure to provide adequate care to treat non-catastrophic injuries, largely repetitive and postural strain injuries. This failure is determined to be a major contributor to permanent disability and reduced labor participation. A need for more direct and effective therapy, and preventive medicine is cited: http://www.ncbi.nlm.nih.gov/pubmed/25331746
  13. A 2009 guideline of care for low back pain, by the Royal College of General Practitioners and the National Collaborating Centre for Primary Care, in the United Kingdom, shows that both acupuncture and physiotherapy are highly recommended as a first-line evidence-based treatment protocol: http://back.cochrane.org/sites/back.cochrane.org/files/uploads/PDF/4106.PDF
  14. A typical study of medical utilization in Workers' Compensation is presented here, compiled by experts at various University Medical Schools. Here, the outcome measures for surgical and non-surgical approaches to lumbar disc injury were assessed, noting that studies showed that several studies reported only modest benefits for surgery over non-surgery, and that a Maine study showed that worker productivity was decreased in the long-term with the surgical option over the non-surgical. We see that the Quality of Life Years (QALY) measures up to 2 years out from the injury notes a better outcome for the surgical patients, but about double the cost. What we see in this study design, though, is that both groups had about the same utilization of physical therapy (less than half were referred for this care), chiroproactic treatments (only 13 percent were referred for this treatment) and acupuncture (less the 5 percent were referred for acupuncture and physiotherapy). Basically, these proven conservative manual therapies were very underutilized, and the study basically compared surgery to no surgery, not surgery to a comprehensive and integrated treatment of care. Such study design is purely produced to support the surgical business, which is absolutely needed in a subset of patients, but not a one-size-fits-all recommendation for lumbar disc injury, and should be utilized after first trying more conservative and low-cost treatment modalities: https://www.dartmouth.edu/~jskinner/documents/tostesonTheCost.pdf
  15. The RAND Corporation, a very conservative business information company, acknowledges in publication that the deregulation of the Workers' Compensation system by Governor Pete Wilson in 1995 did not stabilize the costs of this system, but instead made it very volatile, with dramatic swings in excess profits and loss leading to a large number of insurers going out of the business, and in effect, leaving the industry in the control of a small number of extremely large business interests, obviously the intended consequence of deregulation: http://www.rand.org/pubs/monographs/MG949.html
  16. A 2009 report on the consequences of Workers' Compensation deregulation by Governor Pete Wilson in 1995 by the Pullitzer Prize winning journalist Dean Calbreath, of the San Diego Union Tribune shows that the industry has manipulated this large arena of medical care by drastically reducing medical care, number of claims, and disability payment, yet has succeeded in establishing the highest rates to businesses in the country by far, after lowering rates paid by small and medium-sized businesses just long enough to drive most of the companies managing these funds out of business. The end result has been a manipulation of a huge government-run fund for medical care by a handful of companies, which also fund the main medical treatment guidelines for workers, the ODG, and have succeeded in raising rates to business to ridiculous levels while denying real care to workers: http://www.utsandiego.com/news/2009/jun/21/lz1b21comp223433-workers-comp-rates-press-upward/
  17. A 2014 report on California Workers' Compensation rates to businesses in the deregulated arena since 1995, shows that California now ranks as the most expensive system in the country, at 188 percent of the average in fees into this medical fund, yet provides the least effective care. The focus on fixing this system is also largely controlled by the lobby for the industries that profit from it, with legislative emphasis on denial of care, further denial of litigation concerning abuses of the system, and denial of appeals of medical utilization reviews, while the cost-driver of this system is now a large number of workers disabled with claims of chronic pain and medication addiction, many of them unable to work anymore for the lack of effective care: http://www.sgvtribune.com/business/20141022/california-ranks-highest-for-workers-compensation-costs
  18. A 2015 extensive investigative report by ProPublica and NPR (National Public Radio) found that between 2002 and 2014 drastic cuts and obstacles to providing Workers' Compensation benefits and medical care became part of the systematic state competition to attract business for tax revenue and jobs, lowering the amount of compensation for workplace injury and medical care to unprecedented lows. This extensive report, a compilation of government data that is now often hidden in massive and complex government reporting, shows that 33 of the 50 states passed laws during this time that reduced benefits, and that with rising healthcare costs businesses now overall only covered about 20 percent of the total cost of injury and disability, passing the remainder onto the taxpayer and social and health programs, and lowering many workers into unproductive and bankrupt lives: http://projects.propublica.org/graphics/workers-comp-reform-by-state
  19. IN 2015 NPR reported on the extensive ProPublica investigation into denial of Workers' Compensation and the effect on millions of hard-working citizens, as this program, created to protect the employers from liability, not the workers, became just another tool to cut employer costs, not an ethical and moral fulfillment of a longstanding agreement in the United States to provide minimal care and disability compensation for workers during a time that the United States created a medical insurance and retirement benefits system based almost entirely on the premise that employers would provide these benefits to hardworking Americans. This latest blow to workers' rights came after deregulation of the California Workers' Compensation system in 1995 by Republican Governor Pete Wilson and the spiraling of the system into a roller coaster ride of rate changes to business by the public plan, driven by controlled profits of the handful of profiteering corporations controlling the administration of the plan, and the repeated drastic cuts in medical care and compensation, and redirecting of those payments to specific parts of the medical industry to maximize profits at the expense of other human beings who were injured when they were trying to provide a living for their family. The denial of low-cost conservative treatments in Complementary and Integrative Medicine was just a small piece of this manipulation, but one that denied workers the chance to take a pro-active role in their medical care and return to work. Such complex manipulation of this industry was never calculated to achieve the goals of providing efficient care to workers, but instead to maximize profits in any way possible, utilizing massive lobbying and election donations to achieve the goals: http://www.npr.org/2015/03/04/390441655/injured-workers-suffer-as-reforms-limit-workers-compensation-benefits
  20. A 2014 systematic review of all published scientific studies of Complementary and Integrative Medicine (CIM) for the adjunct treatment of low back pain, by the Southern California University of Health Sciences, in Whittier, California, USA, found that there is evidence-based support for integrated Complementary Medicine, with 21 studies meeting high-quality standards supporting acupuncture, spinal manipulation, physiotherapy, massage therapy, exercise therapy and topical ointment: http://www.ncbi.nlm.nih.gov/pubmed/25568825
  21. A 2015 meta-analysis of all published studies of randomized controlled human clinical trials (RCTs) of sufficient size concerning the efficacy and safety of acupuncture and related TCM therapies, such as Tui na and Chinese manipulation, for chronic pain syndromes of the neck and low back, at Xi'an Jiaotong University Medical School Department of Orthopaedics, Xi'an, China, found that 75 RCTs met the high quality criteria, and despite the problems of study design for manual therapies and randomized controlled human clinical trials, where a so-called placebo or sham acupuncture or manipulation that is blinded to both the patient and treating physician is needed, these RCTs provided evidence that acupuncture and physiotherapy is effective with no significant adverse effects. There were still no published RCTs meeting these requirements for Chinese manipulation, Qi gong, Tai chi or Gua sha, as expected, as there are also no RCTs supporting most manual treatments, such as surgery and physical therapy: http://www.ncbi.nlm.nih.gov/pubmed/25710765
  22. A 2015 study by the University of Technology Sydney, Centre for Health Economics Research and Evaluation, in Australia, finally notes that conservative treatment for chronic low back pain, such as acupuncture, spinal manipulation, massage, yoga, interdisciplinary rehabilitation, and relaxations and cognitive therapies is supported in new clinical guidelines by the American College of Physicians and the American Pain Society. This group of experts suggests that future studies of these treatments go beyond design-problematic randomized controlled clinical trials (RCTs), and include study of cost-effectiveness and quality of life measures (QALY), which support these TCM therapies strongly: http://www.ncbi.nlm.nih.gov/pubmed/25604096