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Home » Latest Articles » Chiropractic and Osteopathy in Worker’s Compensation

Chiropractic and Osteopathy in Worker’s Compensation

by Peter Thompson, DC, DO, DAc, MSc.


Chiropractic and Osteopathy are playing an expanding and increasingly important role in providing treatment and management within the N.S.W Worker’s Compensation system. Treatment of the underlying injury/dysfunction is a necessary precursor to rehabilitation and a subsequent return to work.

This paper will define Chiropractic and Osteopathy and discuss the value of these therapies to the injured worker and the compensation system generally. It will identify common misconceptions, discuss evidence in the scientific literature, provide case studies, outline educational standards and how Chiropractic and Osteopathy work within the team of health care providers.



Osteopathy: General Osteopathic Council (UK)[i]:


Osteopathy is a system of diagnosis and treatment for a wide range of medical conditions.  


“Structure governs function”. Osteopathy works with the structure of the body to restore normal function and is based on the principle that the well being of an individual depends on the skeleton, muscles, ligaments and connective tissues functioning smoothly together.


To an Osteopath, for your body to work well, its structure must also work well.  So osteopaths work to restore your body to a state of balance, where possible without the use of drugs or surgery.  Osteopaths use touch, physical manipulation, stretching and massage to increase the mobility of joints, to relieve muscle tension, to enhance the blood and nerve supply to tissues, and to help your body’s own healing mechanisms.  They may also provide advice on posture and exercise to aid recovery, promote health and prevent symptoms from recurring.



The bones of the spinal column protect the delicate spinal cord and spinal nerves that transmit information between the brain and all parts of the body.


Chiropractic recognizes the role of the nervous system in co-ordinating all functions of the body. It uses manipulation of the joints and soft tissue to help restore normal transmission of nerve impulse where biomechanical dysfunction has impaired this transmission.


Biomechanical factors that contribute to nerve dysfunction in this context include nerve compression, either constant or intermittent and non-physiologic stretching of nerve tissue and perineural membranes. Causes of this can be entrapment, compression within normal range of joint movement or compression due to local inflammation. The consequence of these physical distortions of nerves is interruption to normal transmission of nerve impulses along the course of the nerve. This creates either a reduction of transmission where the pressure is interfering with the propagation of impulse or an excess (facilitation) of nerve transmission caused by reduction of the threshold of nerve stimulation. Either state results in abnormal and inappropriate function within the target tissue supplied by the nerve. If the target tissue is muscle, the result will be poorly co-ordinated motor patterns, hypertonicity or flaccidity of the muscle group. In arteries the vessel wall includes a muscular layer that when stimulated by Autonomic nerves, will reduce the lumen of the artery, thereby reducing the volume of blood travelling to the tissues. If autonomic nerve supply to the muscles of the arterial wall is abnormal, the target tissue will be starved or flooded with blood. If the target tissue is viscera (organs) dysfunction may result in the function of that organ. Examples may be changes in the volume of secretion of hormones or digestive enzymes, motility changes in the organ or reduced peristalsis.


The Chiropractor and Osteopath are trained to analyse mechanical dysfunction of the entire body with emphasis on the spine and peripheral joints.


By removing mechanical impediment to normal nerve transmission, the body has greater capacity to regulate and heal itself. 


National regulation of Chiropractic and Osteopathy under AHPRA (Australian Health Practitioners Regulation Agency)[iii] acknowledges these as primary care professions.

Primary care status means that patients can seek help without the need for referral from other health professionals.  However; if an injured workers has an existing workers claim and wishes to be treated for the compensable injury, he/she must first get a referral from their doctor.


What the Chiropractor/Osteopath will do

The Chiropractor/Osteopath is trained to diagnose, treat and manage patients that present to them. Management may include co-management with other practitioners and always involves communication with the Nominated Treating Doctor (NTD) and the referring practitioner.


When a patient first presents all good practitioners will:

  1. Make efforts to make the patient feel at ease.
  2. Undertake a thorough bio-psycho-social history.
  3. Perform a physical examination including appropriate orthopaedic, neurological and manual examination of the musculoskeletal system.
  4. Case appropriate assessment of the spine and pelvis, visceral motility, peripheral joint function and the biomechanics of the body. Specific assessment criteria are dependent on the presentation.


Each member of the therapy team will perform an assessment in keeping with  WorkCover guidelines.[iv] This will assist the establishment of a working management plan specific to each client. Following this protocol, will ensure that a complete picture of the case is developed.

A useful tool in case management is to negotiate goals with the patient. Components of these goals may include the following acronym: SMART


S: Specific, M: Measureable, A: Achievable, R: Relevant, T: Timely


The Chiropractor and Osteopath are required to establish an independent diagnosis, treatment and management protocol, identify goals of treatment, prognosis and report to relevant authorities such as WorkCover, insurance companies and other statutory bodies. They are also required to report findings and management plans to referring practitioner and WorkCover and appropriately liaise with employer, insurance company and any other relevant party.


Prior to commencement of treatment a Report of Findings will be delivered to the patient. When all concerns have been addressed, treatment may be initiated. This is likely to include spinal or peripheral joint manipulation (Chiropractic Adjustment) and/or mobilization. It may also involve a range of physical therapies including varieties of soft tissue/myo-fascial treatment. Prescription of exercise, dietary, ADL and ergonomic advice are common ancillary interventions.  


Public/Health Provider Misconceptions

Some members of the public do not appreciate the differences between physical therapy modalities. It is common to see the public use Chiropractor, Osteopath, Physiotherapist or OT as interchangeable terms.


Common misconceptions exist in the community about the Chiropractic and Osteopathic Professions.


These misconceptions tend to fall into the following broad categories.



A lack of knowledge of training standards sometimes leads people to thinking that Chiropractors and Osteopath are inadequately trained.


Common international standards of education have been achieved through a network of international accrediting agencies that began with the US Council on Chiropractic Education (CCE) [v], recognized by the US Office of Education since 1974. These standards have been adopted by the World Health Organization.

In Australia, the accreditation body is the Council on Chiropractic Education Australasia[vi]


Chiropractors and Osteopaths are university trained. Five year training programs share many resources and lecturers with the medical program in universities where medical programs are conducted. Currently there are four universities in Australia that conduct chiropractic degree programs. 


See Appendix 1 for universities who offer training.

Scope of Practice:

Often members of the public are unaware of the scope of practice of Chiropractors and Osteopaths. Many people believe that these modalities relieve back and neck pain, and perhaps headaches, without being aware of the global influence of the Autonomic Nervous System. Chiropractic and Osteopathy have therapeutic effect on this and other systems of the body. Mounting evidence supports therapeutic benefit in many conditions.[vii]



There is a misconception that spinal manipulation is the only treatment modality used by Chiropractors and to a lesser degree by Osteopaths. Treatment using spinal or peripheral joint manipulation/mobilization, exercise therapy, visceral manipulation, soft tissue massage, lymphatic drainage, neuro-muscular techniques and physical therapies such as strain-counter strain methods, acupuncture/dry needling, ergonomic and ADL advice are a few examples of commonly practiced methods. In cases where chronic pain exists, the best outcomes derive from addressing as many case factors as possible. This usually requires a multi-therapist, team-based approach to patient care, as well as the provision of information and education for the patient.



Extensive research has been undertaken to examine the efficacy of Chiropractic and Osteopathy on the biomechanics of the human body. Research is progressing in the field of manipulative therapy. Chiropractic and Osteopathy have a significant clinical evidence base. There are a number of large studies that support the use of spinal manipulation.


See Appendix 2 for examples of specific studies


Types of injuries treated in Workers Compensation system

Since 1978 at a state level and since 1985 for Commonwealth employees, Worker’s Compensation legislation has included Chiropractic and Osteopathic treatment. The Motor Accidents Act 1988 includes Chiropractic and Osteopathy as recognised services and private health funds provide benefits.

The majority of conditions treated by Chiropractors and Osteopaths in the WorkCover environment include mechanical dysfunction of body parts, and injuries to the joints and/or soft tissues of the body that do not require surgery. Spinal and peripheral joints and soft tissue are treated. These may result from frank trauma or overuse/overload sprain/strain.


How Chiropractors/Osteopaths will work in the treatment team – providing feedback to GP, other professionals and psychologist if psychological barriers are present.

Co-management and cross referral are integral to the effective management of most workers compensation cases. This is particularly true where chronic pain exists. Prof Michael Nicholas of the Pain Management Research Institute, University of Sydney at RNSH states “Unimodal treatments for chronic pain do not work.”


It is important to identify barriers to recovery and determine the best therapist to deal with each barrier. This ‘gatekeeper’ role is usually performed by the General Practitioner. However, each member of the team should remain vigilant to identify any new or developing barriers and to implement strategies to overcome these barriers.


Each therapist must create a management plan specific to their assessment and treatment goals. WorkCover guidelines for case assessment, review and management and documentation are noted above and can be found on the WorkCover web site at www.workcover.nsw.gov.au.

Consideration of specific work duties and how the individual worker is able to manage these duties is critical. Modification or elimination of certain work duties will require effective communication with the employer in order to gain their co-operation.


It is of great benefit for all parties to develop a network of therapists from diverse fields. Establishing an understanding of the strengths of local therapist will assist in efficient management and will facilitate the best intervention at the earliest time.


Communication must be established with the referring practitioner using written report of findings discussing diagnosis, mode of injury, red and yellow flags, recommended treatment/management and prognosis.


Further communication with any relevant party including other therapists, case managers from WorkCover, the insurance company or the employer will be acted on where necessary.



How Chiropractors/Osteopaths offer strategies of self-management and conditioning for required work duties.

At times clients unintentionally undermine their recovery by participating in imprudent activities. Lack of understanding of their limitations at any given time during the recovery process or denial of the extent of their incapacity are examples of factors that can impede recovery.


An important part of case management, therefore, is to provide information and strategies that allow the client a degree of self-management. This gives the client the feeling that they are assisting in their own recovery and gives them an element of control over their circumstances. Empowerment is an important contributor to the wellbeing of a client who often feels that their injuries are overwhelming.


Examples of self-management include exercise prescription, advice on activities of daily living, ergonomic assessment and correction of personal and workplace equipment. Describing the mechanism of injury, the actual damage and consequences of the injury to their body and expected outcome, both short term and long term are important to the client. Setting goals in the recovery process are important. It is important to identify early warning signs of strain and impending overexertion/overuse, and to provide strategies to manage their condition once these warning signs have surfaced. This gives the client more confidence in attempting activities that will assist in general recovery.


Another consideration in the recovery process is to establish protocols to prepare the body for impending activities required of it in the performance of employment duties or any other activity about to be undertaken. As with sporting pursuits, warmup procedures will help the client’s body better tolerate the demands it is about to endure. These may include stretches within a pain free, comfortable range, gentle, non-load bearing mimicry of the activities about to be undertaken. This also helps provide to the client an ‘on the spot’ assessment of the bodies limitations on that particular occasion.



This case was referred by Mr Smith’s Nominated Treating Doctor (NTD)


Presenting Symptoms:


  • Ongoing, significant upper torso paraspinal/shoulder girdle pain and headache were the primary symptoms. At the time of consultation these symptoms had been unresponsive to treatment.
  • Anxiety and depression were also significant features of this case.


The following are extracts from the report of the treating Chiropractor.


Dear Doctor,


Thank you for referring Mr Smith, a 55 year old, heavy vehicle and fork lift driver, for Chiropractic care. He presented with neck and arm pain associated with numbness bilaterally within the C8 nerve distribution at night and paraesthesia in the hands and forearms during the day.


Mr Smith stated that problems had begun 18 months ago. He relates symptom genesis to being the driver of a ‘cherry picker’ device. He adopted a sitting posture with the neck held for prolonged periods in a hyperextended position. Frequent rotation of the neck was required while observing workmen in the tray at the top of the cherry picker.


In 2009 Mr Smith suffered a severe emotional shock when his truck’s brakes failed while driving down a long steep grade. He said that as this was happening he did not expect to survive this event. He also stated that his physical symptoms were markedly aggravated by this trauma.


It is also worthy of comment that in 2002 Mr Smith underwent a Lumbar spine laminectomy with good results for a lower back pain injury.



Clinical findings

  • Stretch reflexes of the upper limb were uniformly level one (low response).
  • Muscle strength of the intrinsic muscles of both hands was weak but contractile.
  • There was scoliotic curve in spine, prominent at C-T junction and increased A-P spinal curves.
  • There were areas of hypertonicity in paraspinal muscles.
  • Deconditioned abdominal muscles were evident.
  • Upper cross syndrome (protracted shoulder posture), forward head carriage were evident.
  • These postural defects have contributed to a bilateral Thoracic Outlet Syndrome. This diagnosis is strengthened by positive Halstead and Adson’s tests.
  • Cervical ROM: extension restricted within 75%, rotation both directions restricted within 50%. Extension caused pins and needles paraesthesia into the left hand.
  • Valsalva test led to mid cervical region pain.
  • Jackson’s test (cervical compression) was positive, causing local cervical pain.
  • Sensory: pin prick sensitivity was reduced in hypothenar region of both hands.


XRay examination:

  • There was loss of disc height and osteophytes present at C5/6, C6/7 levels. Early canal stenosis. Left C6/7 foramen stenosis is due to osteophytic intrusion.
  • I/V Foramina are narrowed at C3/4 to C 6/7 on the right hand side and C4/5 to C6/7 on the left hand side.



I am confident that Mr Smith can be helped with decompression type mobilization/adjustment and soft tissue massage. I will also give him controlled exercise and ergonomic/lifestyle advice.


Peter Thompson, D.C., D.O., M.Sc., D.Ac.

Chiropractor, Osteopath



Follow-up Treatment

The above-recommended treatments were provided over an eight month period.  Mr Smith attended a total of twenty seven treatment sessions. These were conducted initially twice a week for eight weeks, then once per week for five weeks then monthly for six months. He was diligent in applying the exercise and lifestyle advice provided in therapy sessions to his everyday life.


Correspondence sent to Mr Smith’s employer

Correspondence was sent to Mr Smith’s NTD and employer via the company’s return to work coordinator two months after referral requesting modification of work duties.


Dear Doctor and Smith Transport, Pty Ltd


I am currently treating Mr Smith for a work related injury.

Mr Smith has informed me that he has recently found that prolonged periods of operating a high pressure water hose (a gurney) has markedly aggravated his symptoms.

I feel that this type of work duty is likely to aggravate Mr Smith’s condition.

I recommend Mr Smith only use the gurney for limited periods and only when he feels able to do so. I estimate approximately 10 minutes usage perhaps 4 times per day would probably be within his tolerance at the present time.


Follow up report three months post referral provided to NTD 

Dear Doctor,


Mr Smith’s condition has been improving steadily over recent months.

He has markedly reduced frequency of headache and much less muscular-skeletal symptoms provided he does not undertake excessive or strenuous activity.

I am confident that the course of Chiropractic treatment provided to date has achieved its goals.



In the medium term (12 months), Mr Smith will require maintenance therapy - 12 treatments at monthly intervals to ensure his initial presenting symptoms and dysfunction do not return. 

The proposed treatment will be under continuing review and applied in response to the needs of the patient.


Thank you for your assessment and valued opinion.



Peter Thompson, D.C., D.O., M.Sc., D.Ac.

Chiropractor, Osteopath


Progress report to NTD - twelve months after referral


Dear Doctor,

Mr Smith was reassessed recently. Headaches and paraspinal regional pain have remained significantly reduced in the intervening twelve months since his last treatment but still arise on occasion. He continues to suffer anxiety and depression, though to a lesser degree since the reduction of physical symptoms and resolution of his compensation case. He is continuing Chiropractic therapy as a private patient. He has found this to be the most effective way to minimize his symptoms and manage his chronic condition.




This case is an illustration of the types of issues facing the Chiropractor and Osteopath as members of the health delivery team. Clear and timely communication between the patient, the employer, the attending psychologist and general practitioner resulted in better outcomes. Explaining that while complete resolution of his chronic pain syndrome is unlikely, it is possible to minimize the impact of residual signs and symptoms using self-management strategies mixed with ‘at need’ therapeutic intervention.


About the author  

Peter Thompson is a chiropractor of 35 years experience. He currently practices from clinics at Woonona and Barrack Heights in the Illawarra. He has extensive experience lecturing and examining at Macquarie University and NSW TAFE in Chiropractic, Osteopathy and Massage Therapy. He has examined for the NSW Chiropractic and Osteopaths Registration Boards. 


Further Reading

You can find appendix 1, 2 and refrences for this article in the side panel.


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