During the initial assessment, it is important to consider:

• prior history or current and other medical conditions
• behaviour of symptoms
• aggravating and relieving factors
• occupational history
• general health status (co-morbidities) – review of symptoms
• sleep patterns
• tolerances in activities of daily living
• capacity and return to work
• use of relevant outcome measures
• co-morbidities (ie, diabetes mellitus, drug dependency, cigarette smoking)
• red flags – identification of potentially serious conditions that require further investigation or specific treatment
• yellow flags – these factors are considered important in the risk of an acute condition becoming chronic.

A physical examination should include:

• physical examination and vital signs
• orthopaedic examination
  - observation (gait, posture, movement dysfunction, pain behaviour)
  - palpation
  - range of motion (active, passive, resisted, end feel, joint play)
  - provocative tests
• neurological examination
  - motor system
  - sensory system
  - cranial nerves
• manual examination
  - pain identification
  - articular assessment
  - faulty movement patterns.

On most occasions, radiological imaging studies are not required, however if considering the use of radiology, please refer to WorkCover's Imaging Guidelines.

As part of this phase, it is important to:

• review all available medical information
• consider information contained in the WorkCover Medical Certificate, if available
• develop a substantive diagnosis
• relieve pain
• consider the natural history for recovery of the injury and, if appropriate, reassure the worker that they will recover quickly
• encourage the worker to remain active
• provide education in safe biomechanics, work simplification and use of equipment, where relevant
• encourage self-management as early as appropriate and address management of any physical, environmental or psychosocial contributing factors to minimise the risk of recurrence
• collaboratively determine the course of management to be followed and agree on specific short and long-term goals prescribe appropriate muscle strengthening exercise
• consider treatment options
• tailor the plan to the worker
• provide an explanation of assessment findings and recommended management with consideration of their goals and lifestyle requirements
• address barriers to communication
• consider return to work options with the worker and implement safe, early return to suitable duties based on progress in treatment
• re-assess for red flags
• re-assess for yellow flags - if yellow flags are present consider if a more detailed assessment or psychological intervention is appropriate
• consider referral for further opinion if recovery is not progressing as expected
• maintain communication with other relevant parties involved in the management of the worker.

• Regularly review progress and the treatment regime, modifying the techniques/intervention, as required, ensuring that the treatment goals are achieved.
• Include reassessment of the worker’s understanding of their pain or disability experience (eg, beliefs, fears, expectations and goals) that may have been addressed as part of the educative management.
• Use the same standardised outcome measurement tools used to set a baseline when measuring progress.
• Liaise with relevant treating practitioners about the worker's treatment progress and the potential for upgrading activities at work.

A clinical justification flowchart has been developed for information.

Note: All services must be billed in line with the WorkCover Chiropractic fee schedule and guidelines.

If there is a delay in improvement conduct a full review, allow for a longer consultation time and:

• review the diagnosis
• review treatment objectives
• review the effectiveness of therapies and treatment and ensure treatment is clinically justified
• review red and yellow flags
• gauge the worker's perspective
• contact other parties involved in the management of the worker
• consider arranging a case conference, workplace visit or workplace assessment
• if necessary, refer the worker to a medical specialist or psychologist
• continue to promote self-management techniques
• identify activity issues and problems
• set defined goals for the next few weeks
• consider the need for engaging a workplace rehabilitation provider
• update the management plan.

If progress has not met expectations at 12 weeks, consider the following:

• Do you have the correct diagnosis?
• Do you have the correct treatment?
• Do you require a second or specialist opinion?
• Is there an issue in the workplace not previously identified or resolved?
• stepping up the approach to care
• multi-factorial and interdisciplinary intervention – consider meeting all relevant health providers, the worker, the employer and case manager in a case conference
• a structured, supervised, active treatment program
• a structured return to work program, focused on a gradual increase in duties
• a referral for workplace rehabilitation (if not already underway)
• psychological intervention.