This paper presents a review of 146 consecutive ICC reports that examined the treatment protocols of, and recommendations to, treating practitioners and the injured workers. The pursuit of patient centred, evidence-based care should be the goal of all chiropractors. In addition to such management goals is the need to address Workers Compensation claims in a timely and effective manner. However, in some cases efficient return of the injured worker to pre-injury status is not achieved. There are many potential reasons for this problem, which include difficult cases, multi-region pain syndromes, recurrent injury, lack of change in approach to treatment regardless of stage of management, lack of recognition of psychosocial variables, lack of active therapy, lack of co-management, pursuit of wellness or maintenance care approaches, lack of understanding of the definition of reasonably necessary care under the workers' compensation system in NSW and a lack of recognition of the need to cease treatment once the pre-injury status had been achieved.
It is widely accepted that after three months an injury is deemed chronic and whilst chiropractors are recognised as effectively treating chronic pain, management by practitioners for long periods of time in the absence of any improvement or after the pre injury state has been reached possibly questions the focus of the practitioner . We found the scheduling of treatment ranged from three visits per week, to two visits in 15 months, demonstrating a wide spectrum of scheduling protocols for injured workers that were not always consistent with the attainment of the pre injury status. Injured workers are subjected to an intervention driven by the philosophical paradigm of the chiropractor. Maintenance management highlights the need to educate the patient in a holistic way, using traditional epistemologies of wellness and elevated patient health for long-term management . Whilst this may be appropriate in supporting the responsibility of self-health for the purpose of maximising one's own self funded health potential, the same goal is by definition inappropriate in the workers compensation setting.
In further discussion of the need for clear and defensible management guidelines, we found a frequent misunderstanding of the term "reasonably necessary treatment" (Table 1) by both the practitioner and the injured worker. It is our experience that this misunderstanding often stems from a misinterpretation of the terms of court settlements and remains a strong motivating factor for receiving ongoing care in our opinion. A frequent recommendation is that the term "reasonably necessary treatment" is defined clearly for the claimant by the insurer or the legal representative of the claimant. Due to the frequency at which this misunderstanding seems to occur we further recommend that legal representatives clearly define this term so that claimants do not form the opinion that they have won a court ruling that entitles them to treatment indefinitely.
Chiropractic management must aim to return the worker to pre-injury status, in an efficient and effective manner. This often means a multi-modal approach should be considered . Such management often incorporates the pursuit of pain reduction and functional restoration by a variety of methods by physical, occupational, pharmacological, psychological, behavioural, and surgical amongst others . With literature providing evidence for multi-modal management of work related disorders , the possibility exists that at a time not too distant from today when more evidence for such approaches will be available, that the treating practitioner may be at risk of not only losing insurer support for treatment protocols, but they may be liable for litigation (by insurer or claimant) for not providing "reasonably necessary treatment".
The ICC recommended forms of therapy for inclusion into the chiropractic management that are designed to increase the effectiveness of returning the injured worker to pre-injury status. The results can be found in Table 3. Recommendations are made for various reasons. The most common reason for an intervention appears to be because management lacks direction following a plateau of outcomes. Another common reason for intervention includes those cases where management outcomes seem more appropriate for acute interventions rather than for more chronic presentations.
In nearly all of the ICC reports it was recommended that the injured worker be engaged in an active therapy program, and in a majority of reports it was recommended that a general fitness program and flexibility/range of motion exercises be performed for effective management. This is consistent with the literature on chronic pain management [19, 31, 32]. In particular, evidence exists that treatments that are active rather than passive are associated with better outcomes . Active therapy is imposed to motivate individuals to independently control their functional wellbeing and administer safe, effective, relevant and uncomplicated exercise programs to enhance the rehabilitation regime [34, 35].
Noteworthy to this study, we found that 67% of the injured workers reported some form of psychosocial "issue". The "issue" was identified by the ICC as one that became apparent in the consultation or examination. These issues included a suspicion based on the New Zealand Acute Low Back Pain Guide . A significant finding was that 40% of injured workers were "dependant on passive therapies". Dependence is known to occur with long term passive therapy management, and highlights the responsibility of the practitioner to return the injured worker to pre-injury status as soon as practical. Whilst management that incorporates active therapy is appropriate, it is the inappropriate application of the wellness paradigm to occupational chronic pain which may perpetuate the dependence on passive therapy and prolong rehabilitation . It is possibly this philosophical approach that has previously shown chiropractors to retain patients in a non work setting longer than their physiotherapy or osteopathic colleagues .
Based on this report, many practitioners assist in rehabilitation whilst others do not. Various reasons are given. The most common approach is one where exercises are given verbally or on a sheet of paper and then never followed-up. Another group sparingly monitors prescribed exercises and yet another group deem the provision of exercises to be the domain of other health care providers. The latter approach highlights an older chiropractic philosophical approach to management that is driven by the provision of manipulative therapy as a monotherapy rather than as a therapy that is a component part of a multimodal approach to management preferred by many [5, 6].
It seems apparent that there is a need for a change of attitude in some practitioners and injured workers, and a need to embrace active based care . The statutory authorities could assist this process with continuing educating campaigns directed to both claimants (via claims officers) and practitioners, which would include disseminating information on best practices for managing barriers and facilitating return to work. Whilst not in the scope of this review, it should also be noted that an employers willingness and ability to facility the injured worker to return to work is crucial in good outcomes. Employers too should be included in education campaigns and best return to work practices, whether it is restricted hours, duties, job placement or identifying and minimising barriers to return to work.
Research clearly shows that education of an injured worker is a desirable pursuit . However, broad based public health campaigns whilst thought initially to benefit society [40, 41], have recently come into question as a viable means of reducing worker disability . Injured workers' should be educated as to the effect and likely progression of an injury, what is likely to help and hinder and what to expect in terms of exacerbations and remissions. Furthermore, they should be instructed to employ a raft of self-management and coping strategies to manage pain, and also rehabilitate themselves through compliance to exercise programs. Collectively, these measures attempt to instil a sense of self- responsibility for the rehabilitation of their injury [43, 44].
"Fear avoidance" was another commonly described issue with an injured worker. The literature reports such characteristics in chronic pain cases and it should be assessed by practitioners and specifically managed . Feelings of frustration, anxiety, stress and "I want my life back" and/or "I will never get better" statements were commonly reported by the injured workers. These feeling are complicated by confusion associated with the wellness paradigm as practitioners tell their patients that they will always need treatment (maintenance). The problem lies in the miscommunication of a pain and disability construct (by the patient) with one of health promotion/performance (by the practitioner). Despite the maintenance being rendered under a different treatment paradigm, a strong potential for confusion exists in susceptible individuals. Further research should investigate these outcomes. The relevance of the adoption of a biopsychosocial model of management by chiropractors has previously been discussed , and supports reassurance by the chiropractor as an important part of the practitioner interaction . It is important that a good working understanding of "yellow flags"  and their recognition, assessment, and management implications for chiropractors operating in the workers compensation system is essential for the well-being and effective recovery of the injured worker .
The findings of this study highlight various management strategies for the effective management of injured workers and some possible pitfalls. For any chiropractor managing injured workers in the workers compensation system it is imperative that management protocols and record keeping have defensible and definable management outcomes that adhere to accepted evidence-based guidelines about returning the injured worker to work [49, 50]. The use of published guidelines based on best evidence syntheses is important for all primary healthcare practitioners. Failure to do so has been associated with poor outcomes . Unfortunately, there is evidence that primary healthcare practitioners are not keeping up to date with published guidelines and this is true of management of occupational low back pain in Australia . This report provides indirect evidence to support that a minority of chiropractors are also limited in their application of evidence based guidelines. However, the application of guidelines alone may be insufficient in the absence of truly patient centred care . The consideration of reasons why guidelines are not being considered is beyond the scope of this report although it has been suggested that the contradictory nature of the guidelines between various professional groups may be barriers to adherence . Inherent in this process is the acquisition of "pre-injury status" and the limitation of treatment to that which is considered "reasonably necessary" by WorkCover guidelines regardless of other non-work related management paradigms.
This study analysed data generated from the reports of one ICC. Therefore, whilst the recommendations given are evidence based in nature, recommendations given are based on the chiropractic management paradigm of this one consultant. As a result, the recommendations may not be consistent with others within the same system or elsewhere. In addition, recommendations may or may not have been multi-modal in nature. Furthermore, the authors only reported specific recommendations made to the treating practitioner at the time of the review and not other underlying assumptions of clinical management.
Reports were generated in consultation with the current treating practitioner (a chiropractor). Many injured workers' had a past and or current history of multiple practitioner interventions since the time of initial complaint. This included treatment from general practitioners, physiotherapists, psychologists, other chiropractors, massage therapists and surgical interventions. Whilst due recognition of the other activities was noted, the recommendations were specifically about the chiropractic intervention and how it could (if possible) be progressed.