ACOEM 101

WARNING: THE BELOW SUGGESTIONS, INFORMATION AND RESEARCH PASSAGES ARE FOR EDUCATIONAL PURPOSE ONLY AND ARE NEITHER TO BE CONSTRUED AS LEGAL ADVICE NOR ANY GUARANTEE THAT YOU WILL GET YOUR BILLS PAIDS. USE THIS PAGES CONTENTS AT YOUR OWN RISK.

The ACOEM guidelines were published in December 2003 and became presumptively correct March 22, 2004. (Smith v. Churn Creek Construction (2004) 69 Cal.Comp.Cases 1012, 1014.) [from Sierra Pacific v. WCAB (Chatham) 2006 DCA]

Glass LS, et al. “Occupational Medicine Practice Guidelines: evaluation and management of common health problems in functional recovery of workers.” 2004: American College of Occupational and Environmental Medicine (“ACOEM”), second edition; Chapter XX, page XX

"... the statute creating the presumption of correctness of the ACOEM guidelines did not become effective until January 1, 2004, ... and that the presumption of correctness itself did not apply until March 22, 2004, i.e., three months after the publication date of the updated ACOEM guidelines.... According to the WCAB, the ACOEM guidelines had no relevance at all to Applicant's wife's services prior to 1/1/2004, and the presumption of correctness of the guidelines did not apply to any services prior to 3/22/2004." Los Angeles Times v. WCAB (Herbinger) (2005) 70 CCC 504

American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines.

Are ACOEM compliant with this:

Code: 5307.27
Title: Adoption of untilization review standards.
On or before December 1, 2004, the administrative director, in consultation with the Commission on Health and Safety and Workers' Compensation, shall adopt, after public hearings, a medical treatment utilization schedule, that shall incorporate the evidence-based, peer-reviewed, nationally recognized standards of care recommended by the commission pursuant to Section 77.5, and that shall address, at a minimum, the frequency, duration, intensity, and appropriateness of all treatment procedures and modalities commonly performed in workers' compensation cases.

Added by Stats 2003, Chap 639

Nope: They do not address "the frequency" of chiropractic treatment.

Source: www.WorkCompCentral.com

State: California ACOEM Emphasized Guidelines are not Mandates: Top [06/01/04]

Back in March of this year, before the landmark SB 899 was hurried through legislative passage, and after last year's adoption of the ACOEM Guidelines, The American College of Occupational and Environmental Medicine sent Senator Richard alarcon a letter emphasizing that the Guidelines are not a mandate and that if they are implemented as mandates there will be no savings because an increase in litigation will be experienced. Barry Eisenberg, Executive Director of ACOEM, in a letter dated 3/22/04 obtained by WorkCompCentral, says that while it is important that payors "should insist on a compelling reason to deviate from the guidelines before non-conforming requests are approved," caution also needs to be exercised because "true cost savings are not likely to come from simply saying 'no'."

"We have pointed out that saying 'no' to a request may convert the request from a medical issue to a payment and/or legal issue. What had been an issue for physicians to resolve based on consideration of clinical factors, could become a legal issue about whether a carrier has improperly denied payment for a service," Eisenberg says. "We have pointed out that the costs associated with the resolution of such non-clinical issues can completely negate the saving that will occur from the improvements in clinical care that will certainly be effected when the medical care system provides necessary care" as close in time to the request for care as possible.

Eisenberg emphasizes two key points in his letter:

"Our guidelines are recommendations, and are not intended as mandates;" and

"Most cost savings will come from workers getting the care that is most likely to help them, as close as possible in time to their first need for that care, versus applying the guidelines as mandates."

CHAPTER 6 - ACOEM [ second opinion | physical therapy + | medication | chiro care |

ACOEM, Chapter 6, page 115, states under the heading Preventing and Managing Chronic Pain, "mobilization, even in the face of some residual pain or stiffness, should be encouraged, and it should be increased as the healing process progresses."

Only Chapter 6 of the presumed correct ACOEM Guidelines is applicable for patient's (like this one) suffering pain longer than 90 day ("chronic"); this contention has been opined by three separate WCAB panel decisions: Hamilton (32 CWCR 249); Herbinger (70 CCC 504 Writ Denied); and Macari (70 CCC 1733 Writ Denied).

With regard for my request for request for a second medical opinion, ACOEM, Chapter 6, page 112 states in relevant part, "Physicians should consider referral for further evaluation and perhaps cooperative treatment if... medication use does not decrease [the patient's pain] as expected; appropriate active physical therapy does not appear to be improving function as expected; complaints of pain or dysfunction start to involve other areas of the body, including instances in which the patient experiences increased pain, or at the very least, pain does not decrease, over time."

With regard for my request for request for a physical therapy, ACOEM, Chapter 6, page 114 states in relevant part, "Research suggests that multidisciplinary care is beneficial for most persons with chronic pain, and likely should be considered the treatment of choice for persons who are at risk for, or who have, chronic pain and disability.... Typically, such programs [multidisciplinary care] involve ongoing medical care or supervision, exercise, or specific physical therapy intervention, psychosocial intervention, and occupational therapy."

Pharmacologic Consultation:

With regard for my request for request for a Pharmacologic consultation, ACOEM, Chapter 6, page 115 states in relevant part,"Pharmacologic agents may be used in doses that are adequate to relieve symptoms, but that do not exceed the patient's needs."

Chiropractic Care for Exacerbations of Chronic Pain:

With regard for my request for request for 6 more chiropractic treatments (which include spinal mobilization & physiotherapy) secondary to an exacerbation of the patient's chronic pain, ACOEM, Chapter 6, page 115 states in relevant part, "Mobilization, even in the face of some residual pain or stiffness, should be encouraged, and it should be increased as the healing process progresses." Therefore, my planned chiropractic mobilization to quell the effects of the patient's recent exacerbation is well supported.

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With regard to ACOEM, only Chapter 6 is applicable for chronic pain patients and the ACOEM spinal chapters (Chapter 8 [neck] and Chapter 12 [low back]) are only for use in patients who are in acute or subacute pain. More explicitly, in the recent Writ Denied case of Macari, (1) the Workers’ Compensation Administrative Law Judge (“WCJ”) stated, in relevant part, that:

“Dr. Loero [PTP], and the panel QME in this case, Dr. Aubin, both point out that Chapter 12 deals with acute injury and that the only chapter in the ACOEM Guidelines that deals with chronic pain is Chapter 6. Both Dr. Aubin and Dr. Loero point to Chapter 6 for authority that ongoing treatment to increase function in chronic pain patients is appropriate. I have reviewed Chapter 6, and I agree that that is what Chapter 6 says.” (Bold added.)

She then order that the insurer pay for up to 30 chiropractic visits per year in order to combat exacerbations of the injured workers chronic pain. This order was up held by both the WCAB and the First District Court of Appeals.

In further support, ACOEM, Chapter 6, pages 110-111, in relevant part, states:

“In cases of delayed recovery associated with chronic pain, the physician should… prescribe rapid but careful resumption of function [and] active mobilization of injured areas.” (Emphasis added.)

“Active mobilization” of the patient’s dysfunctional spinal articulation via Chiropractic Cox flexion/distraction technique is the exact treatment that this patient has been receiving at our clinic. Furthermore, ACOEM, Chapter 6, page 115 states, in relevant part, states, “Mobilization, even in the face of some residual pain or stiffness, should be encouraged.” Again, Chiropractic “Mobilization” has been the main intervention of this patient’s treatment from day one.

Therefore, my current chiropractic treatment, which is only for exacerbation of the patient’s chronic pain, is reasonable and in compliance with Chapter 6 of the ACOEM guidelines.

Foot Note: (1) Regents of the University of California, Lawrence Livermore National Laboratory, PSI v. WCAB (Macari) (2005) 70 CCC 1733 Writ Denied

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Chapter 6 of ACOEM is the ONLY chapter that discusses treatment interventions for chronic pain. (All other chapters deal with acute or subacute pain.) Page 110-111 of ACOEM Chapter 6, in pertinent part, states: “In cases of delayed recovery associated with chronic pain, the physician should… prescribe rapid but careful resumption of function [and] active mobilization of injured areas.”

“Active mobilization” is the exact treatment that this patient has been receiving at our clinic. Furthermore, Chapter 6, page115 of ACOEM states, in relevant part, “ Mobilization, even in the face of some residual pain or stiffness, should be encouraged.” Again, Chiropractic “Mobilization” has been the main intervention of this patient’s treatment from day one.

ACUTE:

ACOEM Chapter 12, page 308, optionally recommends one month of chiropractic manipulation for the treatment of low back pain with radiculopathy. With respect to treatment frequency, ACOEM is silent. Therefore, as directed by Labor Code section 4604.5 (e), I shall use “other evidence based medical treatment guidelines generally recognized by the national medical community and that are scientifically based."

Therefore, I shall present the Guidelines for Chiropractic Quality Assurance and Practice Parameters ("Mercy Guidelines") to support my recommended care. The Mercy Conference Guidelines are both nationally recognized and based upon scientific medical evidence. In fact, Chapter 8 alone was developed using 67 peer-review quality investigations, text book citations and/or other state treatment guidelines. With regard to reasonable chiropractic treatment frequency for acute injuries, page 125; chapter 8, subsection "E" allows the following treatment frequency for an "acute episode":

(1) "three to five treatments per week" during the first "10-14 days,"

(2) “up to three treatments per week” for “six to eight weeks.”

Thus a maximum of 34 chiropractic treatments are allowable per Mercy for acute episodes.

Foot Note: Labor Code Section 4604.5 (e): “ For all injuries not covered by the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines or official utilization schedule after adoption pursuant to Section 5307.27, authorized treatment shall be in accordance with other evidence based medical treatment guidelines generally recognized by the national medical community and that are scientifically based.”

ACUTE CHIROPRACTIC CARE: [Treatment Frequency Support | Hand, Wrist & Forearm ]

ACOEM, Chapter 12, page 308, table 12-8 states in relevant part, "Manipulation of low back during first month of symptoms without radiculopathy" is "recommended." It also states "Manipulation for patients with radiculopathy" is "Optional."

ACOEM, Chapter 12, page 308, Table 12-8, states in relevant part, "Prolonged course of manipulation (longer than 4 weeks," is "not recommended."

ACOEM, chapter 12, page 298 states in relevant part, "Manipulation appears safe and effective in the first few weeks of back pain without radiculopathy."

ACOEM, chapter 12, page 299 states in relevant part, "In the acute phase is of injury manipulation of May in hands patient mobilization. If manipulation does not bring improvement in three to four weeks, it should be stopped and the patient reevaluated. For patients with symptoms lasting longer than one month, manipulation is probably safe but efficacy has not been proved. But trial of manipulation for patients with radiculopathy may also be an option."

ACOEM, chapter 8, page 173 states in relevant part, "Using cervical manipulation may be an option for patients with occupationally related neck pain or cervicogenic headache. Consistent with application of any passive manual approach in injury care it is reasonable to incorporate it within the context of functional restoration rather than pain control alone."

ACOEM, Chapter 8, page 181, Table 8-8, states in relevant part, "Physical manipulation of neck pain early in care," is optionally recommended.

ACOEM, chapter 3, page 49 states in relevant part, "manipulative therapy on appropriately selected patients may be effective in aiding recovery, as opposed to providing merely short-term comfort, only in patients with low back pain for defined periods of time (less than four weeks duration)."

In Chapter 12, page 298-299, ACOEM states, "Manipulation appears safe and effective in the first few weeks of back pain without radiculopathy. Of note is that most studies of manipulation have compared it with interventions other than therapeutic exercise, hence its value as compared with active, rather than passive therapeutic option is unclear. Nonetheless, in the acute phase is of injury manipulation may enhance patient mobilization. If manipulation does not bring improvement in three to four weeks it should be stopped in the patient reevaluated. For patients with symptoms lasting longer than one month, manipulation is probably safe but efficacy has not been proved."

In Chapter 12, table 12-8: Summary of Recommendations for Evaluating and Managing Low Back Complaints, page 308 of the Occupational Medicine Practice Guidelines, second edition, "manipulation of [patient's with] low back pain" with or without non-progressive radiculopathy was either recommended or optional. However, a "prolonged course of manipulation (longer than four weeks)" was "not recommended."

In Chapter 12, table 12-8: Summary of Recommendations for Evaluating and Managing Low Back Complaints, page 309 of the Occupational Medicine Practice Guidelines, second edition, "activities and exercise" including "low-stress aerobic exercise" and "conditioning exercises for trunk muscles" were "recommended."

In Chapter 12, table 12-8: Summary of Recommendations for Evaluating and Managing Low Back Complaints, page 309 of the Occupational Medicine Practice Guidelines, second edition,

“Dysfunctional movements and patterns such as antalgic gait, abnormal posture, or guarding may contribute to the chronicity of pain. If these movement patterns are normalized, symptoms may be reduced and function increased.” American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: Page 108

“Normalization (of dysfunctional movements) may be achieved through a combination of physical methods….” American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: Page 108

“Each physician should: prescribe rapid but careful resumption of function-active mobilization of injured areas." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts:: Page 110-111

"Mobilization, even in the face of some residual pain or stiffness, should be encouraged, and it should be increased as the healing process progresses." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: page 115

"The desired endpoint in pain management is returned to function rather than complete or immediate cessation of pain." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: page 116

"Such interventions (passive and palliative interventions) may be used to the extent they are aimed at facilitating returned to normal functional activities, particularly work." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: page 300

"Patients with potentially work related to low back complaints should have follow up every three to five days by a mid-level practitioner or physical therapist…" American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: page 303

ACOEM, Chapter 11 (Forearm, Wrist, and Hand Complaints), table 11-7 (Summary of Recommendations for Evaluating and Managing Forearm, Wrist, and Hand Complaints), page 272 states under the "recommended" category that "stretching, aerobic exercise, maintaining strength and mobility…" is "recommended." The chiropractic treatment plan I have recommended entails the exact foregoing recommendations and is part of a chiropractor's repertoire as allowed by Cal. Code Regs., tit. 16, section 302, subdivision (a)(2).

TREATMENT FREQUENCY SUPPORT:

With respect to treatment frequency, ACOEM is silent. Therefore, as directed by Labor Code section 4604.5 (e), I shall use “other evidence based medical treatment guidelines generally recognized by the national medical community and that are scientifically based," i.e., the Guidelines for Chiropractic Quality Assurance and Practice Parameters ("Mercy Guidelines").

The Mercy Guidelines are both nationally recognized and based upon scientific medical evidence. In fact, Chapter 8 alone was developed using 67 peer-review quality investigations, text book citations and/or other state treatment guidelines.

With regard to reasonable chiropractic treatment frequency for acute injuries, page 125; Chapter 8, subsection "E" allows the following treatment frequency for an "acute episode":

(1) "three to five treatments per week" during the first "10-14 days,"

(2) “up to three treatments per week” for “six to eight weeks.”

Thus a maximum of 34 chiropractic treatments are allowable per the Mercy Guidelines for acute episodes of pain.

Noteworthy and relevant is the fact that a recent WCAB panel decision (Casillas vs. The County of San Luis Obispo (2005) 33 CWCR 217 WCAB Panel decision) used the Mercy Guidelines to support chiropractic treatment for acute exacerbations of spine pain. In pertinent part, the commissioners stated, "we find in this case that the presumption [of ACOEM] would be rebutted by the reasoned opinion of the examining QME, the Mercy Guidelines, and the applicants experience in obtaining pain relief from acute exacerbations of her symptoms through the use of chiropractic care.”

I believe this decision has established the Mercy Guidelines as substantial evidence in determining a reasonable chiropractic frequency for patient who have suffered an acute injury or an acute exacerbation of a chronic injury.

FOOT NOTE: Labor Code Section 4604.5 (e): “ For all injuries not covered by the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines or official utilization schedule after adoption pursuant to Section 5307.27, authorized treatment shall be in accordance with other evidence based medical treatment guidelines generally recognized by the national medical community and that are scientifically based.

MEDICATION SECTION:

(2) Pharmacological Medical Visit :

The patient uses over-the-counter NSAIDs in excess of their directions for usage in order to help alleviate minor exacerbations of pain; however, I would prefer that he obtain this medication from a physician who can properly prescribe it in a safe manner. of such medication.

ACOEM clearly allows for the referral to other medical specialists as part of a multidisciplinary care approach. More explicitly, Chapter 6, page 114 states:

"Research suggests that multidisciplinary care is beneficial for most persons with chronic pain, and likely should be considered the treatment of choice for persons who are at risk for, or who have, chronic pain and disability.”

And, Chapter 6, page 109 states:

"The treatment of chronic pain requires specialized knowledge, substantial time, and access to multidisciplinary care. Judicious involvement of other professionals, including psychologists, exercise and physical therapists, and other healthcare professionals who can offer extra physical or mental therapy while the physician continues to orchestrate the whole therapeutic process can be helpful. Close communication between all participating professionals is mandatory."

Furthermore, Page 115 of ACOEM's Chapter 6, which is the only chapter in ACOEM that gives treatment recommendation for patients suffering Chronic pain, states, in relevant part, "Pharmacologic agents may be used in doses that are adequate to relieve symptoms, but that do not exceed the patient's needs."

Therefore, my request for one medical visit with Dr. Soozani for pain medication dispensement is appropriate.

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Page 115 of ACOEM's Chapter 6, which is the only chapter in ACOEM that gives treatment recommendation for patients suffering Chronic pain, states, in relevant part, "Pharmacologic agents may be used in doses that are adequate to relieve symptoms, but that do not exceed the patient's needs."

Furthermore, ACOEM’s Chapter - 12 (Lower back Complaints), page 308, table 12-8 recommends NSAIDS and optionally recommends muscle relaxants, phenylbutazone, and/or short courses of Opiods.

Furthermore, ACOEM Chapter 8 (Neck & Upper Back Complaints), page 181, table 8-8 recommends NSAIDS and optionally recommends Muscle Relaxants and Opiods (short course) for patients with spinal pain.

Furthermore, ACOEM Chapter 13 (Knee Complaints), page 346, table 13-6 optionally recommends NSAIDS and Opiods (short course) for managing knee pain.

"Prolonged use of narcotic medication may cause both physiologic and psychological addiction and may reduce the body's supply of endorphins, causing depression and delayed recovery." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: Page 115

"Pain medications are typically not useful in the subacute and chronic phases and have been shown to be the most important factor impeding recovery of function in patients referred to pain clinics." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: page 115

"Typically, the chronic pain patient cannot be treated by the interventions that are appropriate for acute pain." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: page 108

“Studies have shown that when NSAIDs are used for more than a few weeks, they can retard or impair bone, muscle, and connective tissue healing and perhaps cause hypertension. Therefore, they should be used only acutely." ‘Occupational Medicine Practice Guidelines - second edition’ ACOEM 2004; OEM Press: Beverly Farms, Massachusetts: page 47 Chapter 3

“Acetaminophen and Nonsteroidal Anti-Inflammatory Drugs: the safest effect of medication for acute musculoskeletal and I problems appears to be acetaminophen.” ‘Occupational Medicine Practice Guidelines - second edition’ ACOEM 2004; OEM Press: Beverly Farms, Massachusetts: page 47 Chapter 3

TREAT PAIN QUICKLY INORDER TO PREVENT CHRONICITY:

“Acute pain should be relieved promptly and effectively to prevent development of abnormal, self-perpetuating pain reflexes.” American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: Page 115

“Each physician should: Treat pain from physical injury quickly….” American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: Page 110-111.

Warning to Claims Administrator who have delayed medical referrals:

Dear Claims Administrator:

I strongly suggest that this requested medical treatment and second medical opinions be afforded to this patient immediately before any ill effects occur as the result of the continued delays for authorization. ACOEM, in fact, strongly warns of the necessity to treat acute pain promptly and properly in attempts to prevent that acute pain from progressing into the enigmatic world of chronicity. More explicitly, ACOEM states the following:

“Before pain becomes chronic, there is an important therapeutic window for preventing chronic, centrally mediated pain…. The key, then, is to… institute pain management techniques or make a timely referral if these techniques are not part of the physician's personal armamentarium." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: Page 108

“Acute pain should be relieved promptly and effectively to prevent development of abnormal, self-perpetuating pain reflexes.” American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: Page 115

“Each physician should: Treat pain from physical injury quickly….” American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: Page 110-111.

Therefore, please authorized my requested medical testing and medical second opinions immediately.

Before pain becomes chronic, there is an important therapeutic window for preventing chronic, centrally mediated pain." "The key, then, is to promptly recognize this transitional period when the patient begins to deviate from the expected recovery trajectory from his or her complaint, illness, or injury and to institute pain management techniques or make a timely referral if these techniques are not part of the physician's personal armamentarium." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: Page 108

EXERCISE SUPPORT: [ cervical & Thoracic | Lumbar | Mercy ]

ACOEM, Chapter 8 (neck & upper back), page 182, Table 8-8: Recommended: "Office instruction on exercises after initial pain decreases" and "Low-stress conditioning and aerobic exercises to avoid debilitation."

ACOEM, Chapter 12 (low back), page 309, Table 12-8: Recommended: "Low-stress aerobic exercise" and "Conditioning exercises for trunk muscles after 2 weeks."

ACOEM, page 309, Table 12-8 (Summary of Evidence and Recommendations) recommends, “Low stress aerobic exercise, conditioning exercises for trunk muscles after two weeks."

ACOEM, Chapter 12, page 301, in relevant part states, “While the patient is recovering from low back symptoms, activities that do not aggravate symptoms can be maintained, and exercises to prevent debilitation due to inactivity can be advised."

ACOEM, Chapter 12, page 288, in relevant part, states, "Low stress aerobic activities can be safely started after the first two weeks of symptoms to help avoid debilitation. Careful stretching exercises within the normal range of motion may be helpful to avoid further restriction of motion. Exercises to strengthen low back and abdominal muscles are commonly delayed for several weeks, but early stage lumbar stabilization exercises can be used without aggravation of symptoms."

The Mercy Guidelines, Chapter 8, page 122 (Treatment/Care Protocols), in relevant part, states, “there are nearly as many preferences in exercise programs available as there are health care providers using them. What is more important, however, is the recognition that care should not focus selectively on the injured areas alone but should involve associated areas that support the injury. Program design should have balanced components based on the needs of the patient. Elements that should be addressed include… supervised training for flexibility with stability, strength, ordination, and endurance [.] For patients already demonstrating signs of deconditioning or chronicity, this will require more than handing out a simple list of exercises to be performed at home." (Bold added.)

ACOEM, Chapter 12 (low back), page 288: "Low stress aerobic activities can be safely started after the first two weeks of symptoms to help avoid debilitation. Careful stretching exercises within the normal range of motion may be helpful to avoid further restriction of motion. Exercises to strengthen low back and abdominal muscles are commonly delayed for several weeks, but early stage lumbar stabilization exercises can be used without aggravation of symptoms."

ACOEM, Chapter 12 (low back) , page 301: "Aerobic exercise is beneficial as a conservative management technique, and exercising as little as 20 minutes twice a week can be effective in managing low back pain."

"Functional restoration, report return to work rates of more than 80% following treatment, with a high percentage of these persons still working after one year." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: Page 114

"While the patient is recovering from low back symptoms, activities that do not aggravate symptoms can be maintained, and exercises to prevent debilitation due to inactivity can be advised." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: page 301

"Summary of Evidence and Recommendations: Activities and Exercise: Recommended: temporary avoidance of activities that increase mechanical stress on spine, gradual return to normal activities, low stress aerobic exercise, conditioning exercises for trunk muscles after two weeks." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: page 309 Table 12-8

The exercise and work conditioning that this patient procured from the office of Dr. Davis’ is easily supported by ACOEM and the Mercy Guidelines.

ACOEM, page 309, Table 12-8 (Summary of Evidence and Recommendations) recommends, “Low stress aerobic exercise, conditioning exercises for trunk muscles after two weeks."

Therefore, Dr. Davis’ work conditioning program was 100% in compliance with the ACOEM and Mercy guidelines, and was a medically reasonable and necessary component of his treatment plan, and did help to cure and relief this patient from the effects of her chronic pain syndrome.

REFERRAL'S / MEDICAL BACK-UP ENCOURAGED:

Multi-disciplinary Medical Care : Request for doctor Sherman Tran

With regard for my request for request for the second medical opinion, ACOEM, Chapter 6, page 112 and 115 state respectively in relevant part,

"Physicians should consider referral for further evaluation and perhaps cooperative treatment if... medication use does not decrease [the patient's pain] as expected; appropriate active physical therapy does not appear to be improving function as expected; complaints of pain or dysfunction start to involve other areas of the body, including instances in which the patient experiences increased pain, or at the very least, pain does not decrease, over time."

Therefore, his chronic pain patient, who has not responded well to medication and does not appear to be improving as rapidly as expected (numerous exacerbations), would certainly qualify to be referred to the above specialist.

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Page 115 of ACOEM's Chapter 6, which is the only chapter in ACOEM that gives treatment recommendation for patients suffering chronic pain, states, in relevant part, “The treatment of chronic pain requires specialized knowledge, substantial time, and access to multidisciplinary care. Judicious involvement of other professionals, including psychologists, exercise, and physical therapists, and other healthcare professionals who can offer extra physical or mental therapy while the physician continues to orchestrate the whole therapeutic process can be helpful.”

Page 115 of ACOEM's Chapter 6, which is the only chapter in ACOEM that gives treatment recommendation for patients suffering Chronic pain, states, in relevant part, "The clinician should be alert to the incipient development of chronic pain syndrome and should secure a psychological assessment if necessary. Referral for pain management alaso may be indicated."

Medical Second Opinion:

ACOEM clearly allows for the referral to other medical specialists as part of a multidisciplinary care approach. More explicitly, Chapter 6, page 114 states:

And, Chapter 6, page 109 states:

"The treatment of chronic pain requires specialized knowledge, substantial time, and access to multidisciplinary care. Judicious involvement of other professionals, including psychologists, exercise and physical therapists, and other healthcare professionals who can offer extra physical or mental therapy while the physician continues to orchestrate the whole therapeutic process can be helpful. Close communication between all participating professionals is mandatory."

Therefore, my request for one medical visit with Dr. Soozani for pain medication dispensement and Dr. Tran for ESI assessment is appropriate.

Furthermore, with respect to my request for authorization for one visit with an MD or DO for pain medication dispensement, ACOEM’s Chapter - 12 (Lower back Complaints), page 308, table 12-8 recommends NSAIDS and optionally recommends muscle relaxants, phenylbutazone, and/or short courses of Opiods.

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ACOEM, Chapter 6, page 114 states, in pertinent part: "Research suggests that multidisciplinary care is beneficial for most persons with chronic pain, and likely should be considered the treatment of choice for persons who are at risk for, or who have, chronic pain and disability.” Therefore, my referral to an orthopedist is supported by the presumed correct ACOEM guidelines.

“The key, then, (speaking of preventing chronic pain) is to promptly recognize this transitional period (when the patient begins to deviate from the expected recovery trajectory for his or her complaint, illness, or injury) and to institute pain management techniques or make a timely referral if these techniques are not part of the physicians’ personal armamentarium.” American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: Page 108

“The treatment of chronic pain requires specialized knowledge, substantial time, and access to multidisciplinary care. Judicious involvement of other professionals, including psychologists, exercise and physical therapists, and other healthcare professionals who can offer extra physical or mental therapy while the physician continues to orchestrate the whole therapeutic process can be helpful. Close communication between all participating professionals is mandatory.” American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: Page 109

“physicians should consider referral for further evaluation and perhaps cooperative treatment if: 1) specific clinical findings suggest undetected clinical pathology. 2) appropriate active physical therapy does not appear to be improving function as expected. 3) the patient experiences increased pain, or at the very least, pain does not decrease come over time. American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: Page 112

"Research suggests that multidisciplinary care is beneficial for most persons with chronic pain, and likely should be considered the treatment of choice for persons who are at risk for, or would have, chronic pain and disability." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: Page 114

"typically, such programs (multidisciplinary programs) involve ongoing medical care or supervision, exercise or specific physical therapy intervention, psychosocial intervention, and occupational therapy or other services related to daily functioning and/or vocational rehabilitation." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: Page 114

"The clinician should be alert to the incipient development of chronic pain syndrome and should secure a psychological assessment if necessary. Referral for pain management may also be indicated." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: page 115

"Anomalous or exaggerated expressions of pain indicate that medical and psychological evaluations may be warranted." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: page 117

"Physical examination evidence of severe neurologic compromise that correlates with the medical history and test results may indicate a need for immediate consultation." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: page 296

MULTIDISCIPLINARY CARE SUPPORT:

Medical Second Opinion : ACOEM clearly allows for the referral to other medical specialists as part of a multidisciplinary care approach. More explicitly, Chapter 6, page 114 states, "Research suggests that multidisciplinary care is beneficial for most persons with chronic pain, and likely should be considered the treatment of choice for persons who are at risk for, or who have, chronic pain and disability.” Therefore, my request for one medical visit with Dr. Soozani for pain medication dispensement is appropriate. Further more, Chapter 8, page 181, table 8-8 recommends NSAIDS, and optionally recommends Muscle Relaxants and Opiods (short course) for patients with neck pain.

Chapter 12, page 308, table 12-8 recommends NSAIDS, and optionally recommends Muscle Relaxants and Opiods (short course) for patients with low back pain.

ACOEM, chapter 6, page 108: "Before pain becomes chronic, there is an important therapeutic window for preventing chronic, centrally mediated pain…. The key, then, is to properly recognize this transitional period (when the patient begins to deviate from the expected recovery trajectory for his or her complaint, illness, or injury) and to institute pain management techniques or make a timely referral if these techniques are not part of the physicians personal armamentarium."

"Research suggests that multidisciplinary care is beneficial for most persons with chronic pain, and likely should be considered the treatment of choice for persons who are at risk for, or who have, chronic pain and disability. “Occupational Medicine Practice Guidelines - second edition ” ACOEM 2004; OEM Press: Beverly Farms, Massachusetts: page 114

"typically, such programs (multidisciplinary care programs) involve ongoing medical care or supervision, exercise or specific physical therapy intervention, psychosocial intervention, and occupational therapy or other services related to daily functioning and/or vocational rehabilitation. Specific multidisciplinary approaches, such as functional restoration, report return to work rates of more than 80% of following treatment…” ‘Occupational Medicine Practice Guidelines - second edition’ ACOEM 2004; OEM Press: Beverly Farms, Massachusetts: page 114

Epidural Steroid Injections: (ESI)

With respect to the requested transforaminally performed epidural steroid injections ("TFESI") that the pain management physician will most likely request and that I have recommended if our opinions concur, ACOEM, Chapter 8, page 181, Table 8-8, optionally allow for the use of "epidural injection of corticosteroids" in the management of Neck and Upper Back pain.

I would also offer the Evidence-Based Practice Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain ("ASIPP") as support that the TFESIs should be authorized. ASIPP is one of the most scientifically designed set of guidelines ever developed. As stated in the opening pages, “The guidelines were developed utilizing an evidence-based approach to increase patient access to treatment, to improve outcomes and appropriateness of care, and to optimize cost-effectiveness." With respect to the requested transforaminally performed epidural steroid injections (“TFESI”), page 37, section 6.2.3 of ASIPP states, “Based on the evaluation of multiple randomized and non-randomized trials, transforaminal epidural injections provided strong evidence for short-term and long-term [pain] relief.” More explicitly, ASIPP (page 37, section 6.2.3) used the forthcoming evidence based medical research to support their positive recommendations for TFESI:

“3 of the 7 randomized trials (Kraemer - 1997)(Riew 2000)(Karppinen 2001), all of them showed positive short-term and long-term effectiveness of transforaminal epidural steroids in managing nerve root pain. Three prospective evaluations were included in evidence synthesis (Bush - 1996)(Lutz - 1998)(Vad - 2002). They all showed positive short and long-term results. Four retrospective evaluations were included (Manchikanti - 2001)(Weiner -1997)( Rosenberg - 2002)(Wang - 2002) all of them showing positive results.”

Therefore, epidural steroid injection are highly supported.

Manchikanti L, Staats PS, Singh V, et al. "ASIPP GUIDELINES: Evidence-Based Practice Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain Physician." 2003;6:3-81, ISSN 1533-3159

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With respect to the requested transforaminally performed epidural steroid injections (“TFESI”) that I have requested, ACOEM, Chapter 12, page 309 optionally recommends the use of corticosteroids for radicular pain. Furthermore, page 37, section 6.2.3 of The “Evidence-Based Practice Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain ("ASIPP") states, in pertinent part, “Based on the evaluation of multiple randomized and non-randomized trials, transforaminal epidural injections provided strong evidence for short-term and long-term relief.”

Since ACOEM is silent on treatment recommendations for patients who suffer chronic pain [Hamilton v. State Compensation Insurance Fund (2004) 32 CWCR 249 WCAB Panel Decision & Los Angeles Times v. WCAB (2005) (Herbinger) 70 CCC 504 WCAB Writ Denied Decision], I shall use “other evidence based medical treatment guidelines generally recognized by the national medical community and that are scientifically based” [Labor Code § 4604.5(e)] to support the treatment recommendations that I have made.

The “Evidence-Based Practice Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain ("ASIPP") are one of the most scientifically designed set of guidelines developed. As stated in the opening pages of ASIPP, “The guidelines were developed utilizing an evidence-based approach to increase patient access to treatment, to improve outcomes and appropriateness of care, and to optimize cost-effectiveness."

With respect to the requested transforaminally performed epidural steroid injections (“TFESI”) I have requested, page 37, section 6.2.3 of ASIPP states:

“Based on the evaluation of multiple randomized and non-randomized trials, transforaminal epidural injections provided strong evidence for short-term and long-term relief.”

ASIPP (page 37, section 6.2.3) used the forthcoming evidence based medical research to support their recommendation for TFESI:

“3 of the 7 randomized trials (Kraemer - 1997)(Riew2000)

(Karppinen 2001), all of them showing positive short-term and long-term effectiveness of transforaminal epidural steroids in managing nerve root pain. Three prospective evaluations were included in evidence synthesis (Bush - 1996)(Lutz - 1998)(Vad - 2002). They all showed positive short and long-term results. Four retrospective evaluations were included (Manchikanti - 2001)(Weiner -1997)( Rosenberg - 2002)(Wang - 2002) all of them showing positive results.”

Therefore, should Dr. Tran concur with my recommendations for TFESIs, they are supported.

Page 309 of the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines ("ACOEM") support the use of epidural steroid injections "for radicular pain." More explicitly, Chapter 12, Table 12-8, page 309 states, "Optional: Epidural corticosteriod injections for radicular pain, to avoid surgery."

Other research based guidelines, however, have more thoroughly investigated ESIs and found transforaminal epidural steroid injection (TFESI) to be quiet efficacious as an intervention for the treatment of radicular pains. More explicitly, within section 6.2.3, page 37 of the famed ASIPP Guidelines (1) [ which are available for .PDF download here: http://www.nasper.org/Articles/ControlledSubstanceGuidelines.pdf ], the authors conclude the following after reviewing 7 randomized controlled trials on TFESIs efficacy, “Based on the evaluation of multiple randomized and non-randomized trials, transforaminal epidural injections provided strong evidence for short-term and long-term relief.”

References:

1) 110) Manchikanti L, Staats PS, Singh V, et al. "ASIPP GUIDELINES: Evidence-Based Practice Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain Physician." 2003;6:3-81, ISSN 1533-3159

MRI & EMG SUPPORT:

On examination I discovered weakness and loss of sensibility in the left S1 and L5 root distributions. These unequivocal signs of nerve root compromise support the ordering / authorization the MRI: More explicitly, page 303, Chapter 12 (Low Back Complaints) of ACOEM states in pertinent part, "Unequivocal objective findings that identify specific nerve compromise on the neurologic examination are sufficient evidence to warrant imaging in patients who did not respond to treatment."

ACOEM, Chapter 12 (Low Back Complaints), page 303 states in relevant part, "Unequivocal objective findings that identify specific nerve compromise on the neurologic examination are sufficient evidence to warrant imaging in patients who did not respond to treatment." As noted above under Objective Findings, there are unequivocal objective finding for lumbar nerve root compromise; therefore, the requested MRI is supported.

ACOEM, Chapter 12 (Low Back Complaints), page 304 of ACOEM states, "Imaging studies should be reserved for cases in which surgery is considered or red flag diagnoses are being evaluated." On examination today, red flag findings (i.e., diminished unilateral reflex with diminished sensation in the same dermatome) were discovered; these radicular signs need to be followed up upon via MRI. Page 290 of ACOEM defines red flag conditions as “… 4) radicular signs.”

ACOEM, Chapter 8 (Neck & Upper back Complaints), page 178, in relevant part, states, “Unequivocal findings that identify specific nerve compromise on the neurologic examination are sufficient evidence to warrant imaging studies if symptoms persist.” As noted above, my neurological examination has found unequivocal findings for specific nerve root compromise and the patient continues to be symptomatic; therefore, please authorized the requested MRI of the cervical spine.

ACOEM Chapter 13 (Knee Complaints), Table 13-5, page 343, in relevant part, rates MRI extremely effective (“++++”) in defining suspected Meniscus and Ligamentous Tear. Therefore, the requested MRI for this patient is supported to further investigate the diagnosis of meniscus tear.

“In the absence of red flags, imaging and other tests are not usually helpful during the first four to six weeks of low back symptoms." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: page 287

"Red flag conditions: progressive neurologic deficit: 1) significant progression of weakness. 2) significant increased sensory loss. 3) new motor weakness. 4) radicular signs." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: page 290

"Imaging studies should be reserved for cases in which surgery is considered or red flag diagnoses are being evaluated." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: page 304

CERVICAL SPINE: “Recommended: MRI or CT to evaluate diagnosis of nerve root compromise, based on clear history and physical examination findings, in preparation for invasive procedure.” ACOEM -2nd edition; OEM Press: Beverly Farms, Massachusetts:Chapter 8, Neck & Upper Back Complaints: Page 182.

EMG JUSTIFICATION:

ACOEM, Chapter 8 (Neck & Upper Back Complaints), page 178 states, in pertinent part, “Electromyography (EMG), and nerve conduction velocities (NCV), including H-reflex tests, may help identify subtle focal neurologic dysfunction in patients with neck or arm symptoms, or both, lasting more than three or four weeks.” Therefore, since this patient has apparent focal neurologic dysfunction as discovered upon my neurological examination, there is absolutely no reason why the requested EMG/NCV should not be authorized.

ACOEM, Chapter 12 (Low Back Complaints), page 303 states, in relevant part, “Electromyography (EMG), including H-reflex tests, may be useful to identify subtle, focal neurologic dysfunction in patients with low back symptoms lasting more than three or four weeks.” Therefore, since this patient has apparent focal neurologic dysfunction as discovered upon my neurological examination, there is absolutely no reason why the requested EMG/NCV should not be authorized.

"Electromyography (EMG), including H-reflex tests, may be useful to identify subtle, focal neurologic dysfunction in patients with low back symptoms lasting more than three or four weeks." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: page 303

ACOEM, Chapter 8, page 182 states in relevant part, "Recommended: EMG to clarify nerve root dysfunction in cases of suspected disc herniation preoperatively or before epidural injection."

ACOEM, Chapter 11 (Forearm, Wrist, and Hand complaints), page 269 states in relevant part: “In cases of peripheral nerve impingement, if no improvement or worsening has occurred within four to six weeks, electrical studies may be indicated. The primary treating physician may refer for a local lidocaine injection with or without corticosteroids.”

ACOEM, Chapter 11(Forearm, Wrist, and Hand complaints), table 11-7, page 272 states in relevant part: “Recommended: NCV for median or ulnar impingement at the wrist after failure of conservative treatment.”

More Spiel:

Because of positive neurological finding upon my examination, the patient is certainly a candidate for a trial of Transforaminal Epidural Steroid Injections (TFESI). This procedure, which should ONLY be done under fluoroscopy, is strongly supported by randomized controlled trials (90-92) and the gold standard of clinical guidelines: the ASIPP Clinical Guidelines (100). More explicitily, on page 35, section 6-2-3 of the ASIPP (Manchikanti et al. “evidence-based practice guidelines") the authors conclude the following:

“Summary of Evidence: Evidence synthesis included inclusion of 3 of the 7 randomized trials (90-92), all of them showing positive short-term and long-term effectiveness of transforaminal epidural steroids in managing nerve root pain. Three prospective evaluations were included in evidence synthesis (862, 909, 910). They all showed positive short and long-term results. Four retrospective evaluations were included (825, 924, 927, 928) all of them showing positive results. Based on the evaluation of multiple randomized and non-randomized trials, transforaminal epidural injections provided strong evidence for short-term and long-term relief.”

INTERNAL DISC DISRUPTION & DISCOGRAPHY:

"Others (studies) suggest that pain may be due to irritation of the dorsal root ganglion by inflammogens (metalloproteinases, nitric oxide, interleukin-6, prostaglandin E2) released from a damaged disk in the absence of anatomical evidence of direct contact between neural elements and disc material." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: page 305

"Discography may be used where fusion is a realistic consideration, and it may provide supplemental information prior to surgery…. (discography) should be reserved only for patients who meet the following criteria: back pain of at least three months in duration; failure of conservative treatment; satisfactory results from detailed psychosocial assessment; patient is a candidate for surgery; patient has been briefed on potential risks and benefits from discography and surgery." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: page 305

PHYSICAL THERAPY:

ACOEM, chapter 8, pages 173-174 state in relevant part, "There is no high-grade scientific evidence to support the effectiveness or ineffectiveness of passive physical modalities such as traction, heat/cold applications, massage, diathermy, cutaneous laser treatment, ultrasound, transcutaneous electrical neurostimulation (TENS) units, and biofeedback. These palliative tools may be used on a trial basis but should be monitored closely. Emphasis should focus on functional restoration and were turned of patients to activities of normal daily living."

ACOEM, chapter 12, page 300 states in relevant part, "Physical modalities such as massage, diathermy, cutaneous laser treatment, ultrasound, transcutaneous electrical neural stimulation (TENS) units, be cutaneous electrical nerve stimulation (PENS) units, and biofeedback have no proven efficacy in treating acute low back pain symptoms. Insufficient scientific testing exists to determine the effectiveness of these therapies, but they made have some value in the short term if used in conjunction with the program of functional restoration."

With regard for my request for request for a physical therapy, ACOEM, Chapter 6, page 114 states in relevant part:

"Research suggests that multidisciplinary care is beneficial for most persons with chronic pain, and likely should be considered the treatment of choice for persons who are at risk for, or who have, chronic pain and disability.... Typically, such programs [multidisciplinary care] involve ongoing medical care or supervision, exercise, or specific physical therapy intervention, psychosocial intervention, and occupational therapy."

Also, ACOEM, Chapter 6, page 115 states:

“Judicious involvement of other professionals, including psychologists, exercise, and physical therapists, and other healthcare professionals who can offer extra physical or mental therapy while the physician continues to orchestrate the whole therapeutic process can be helpful.”

Therefore, my requested physical therapy is supported. Furthermore, I do not want to use up too many more of my Chiropractic visits, for I need to save them for Evaluation and Management purposes.

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The patient is now ready to start a more functionally orientated form of care – work conditioning & work hardening with a licensed physical therapist (Evergreen Physical Therapy).

Again, ACOEM strongly supports the treatment of injured workers via a multidisciplinary approach. More explicitly, ACOEM, Chapter 6, page 115 states:

Therefore, my requested physical therapy is supported.

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Page 115 of ACOEM's Chapter 6, which is the only chapter in ACOEM that gives treatment recommendation for patients suffering chronic pain, states, in relevant part, “The treatment of chronic pain requires specialized knowledge, substantial time, and access to multidisciplinary care. Judicious involvement of other professionals, including psychologists, exercise, and physical therapists, and other healthcare professionals who can offer extra physical or mental therapy while the physician continues to orchestrate the whole therapeutic process can be helpful.”

(1) Outside (non-affiliated with our clinic) Physical Therapy:

With regard to the request for physical therapy, page 109 of ACOEM states:

The foregoing certainly supports my requests for PT; I believe no further explanation is needed

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"Insufficient scientific testing exists to determine the effectiveness of these therapies (ultrasound, TENS, massage, diathermy, or PENS), but they may have some value in the short term if used in conjunction with the program functional restoration." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: page 300

ACOEM: NOT FOR CHRONIC PAIN:

To support the contention that ACOEM is NOT intended for use in managing the chronic spinal-pain patient, we have the forthcoming passages from the ACOEM guides:

1) CHAPTER 8

Chapter 8, page 165 states, in relevant part: “This chapter’s master algorithm schematizes the manner in which primary care and occupational medicine practitioners generally can manage patients with the acute and subacute neck and upper back complaints.”

“Recommendations on assessing and treating adults with potentially work related neck and upper back complaints are presented in this chapter….this chapter’s master algorithm schematizes the manner in which primary care and occupational medicine practitioners generally can manage patients with the acute and subacute neck and upper back complaints.” [Occupational Medicine Practice Guidelines - second edition’ ACOEM 2004; OEM Press: Beverly Farms, Massachusetts: page 165 - Chapter 8]

2) “Recommendations on assessing and treating adults with potentially work-related low back problems (i.e., activity limitations due to symptoms in the low back of less than three months duration) are presented in this clinical practice guideline…. this chapters master algorithm schematizes how primary care and occupational medicine practitioners generally can manage acute or subacute low back complaints.” [Occupational Medicine Practice Guidelines - second edition’ ACOEM 2004; OEM Press: Beverly Farms, Massachusetts: page 287 - Chapter 12]

3) “Recommendations on processing and treating adults with work-related forearm, wrist, or hand complaints are presented in this clinical practice guideline…. This chapter’s master algorithm schematizes how primary care and occupational medicine practitioners may generally manage patients with acute and subacute forearm, wrist, and hand complaints.” [Occupational Medicine Practice Guidelines - second edition’ ACOEM 2004; OEM Press: Beverly Farms, Massachusetts: page 253 - Chapter 11]

4) “This chapter presents recommendations on assessing and treating adults with elbow complaints that may be work-related…. This chapter’s master algorithm shows how physicians should generally manage patients with acute and subacute elbow complaints.” [Occupational Medicine Practice Guidelines - second edition’ ACOEM 2004; OEM Press: Beverly Farms, Massachusetts: page 227 - Chapter 10]

5) “This clinical practice guideline presents recommendations on assessing and treating adults with potentially work-related shoulder problems…. This chapter’s master algorithm schematizes the manner in which primary care and occupational medicine practitioners generally can manage patients with acute and subacute shoulder problems.” [Occupational Medicine Practice Guidelines - second edition’ ACOEM 2004; OEM Press: Beverly Farms, Massachusetts: page 195 - Chapter 9]

6) “Recommendations on assessing and treating adults with potentially work-related knee problems are presented in this clinical practice guideline…. This chapter is master algorithm schematizes primary care and occupational medicine practitioners generally can manage patients with acute and subacute knee complaints .” [Occupational Medicine Practice Guidelines - second edition’ ACOEM 2004; OEM Press: Beverly Farms, Massachusetts: page 329 - Chapter 13]

7) “Recommendations for accessing and treating adults with potentially work related ankle and foot problems are presented in this clinical practice guideline…. This chapter’s master algorithm schematizes the recommended way primary care and occupational medicine practitioners should manage patients with acute or subacute ankle and foot complaints.” [Occupational Medicine Practice Guidelines - second edition’ ACOEM 2004; OEM Press: Beverly Farms, Massachusetts: page 361 - Chapter 14]

Again, the aforementioned verbiage clearly indicates that the ACOEM authors are describing recommendations that are intended for the acute or subacute patient and not for those who have been chronically suffering pain for more than 90 days.

Even in Staal, Hlobil, and van Tulders’ recent International Comparison of Occupational Treatment Guidelines for the Management of Low Back Pain, they noted that our (USA) ACOEM guidelines were applicable for “Workers with <3 months activity intolerance due to low back pain and/or back related leg symptoms related to occupational injury or exposure.” [J B Staal, H Hlobil, M W van Tulder, G Waddell, A K Burton, B W Koes and W van Mechelen. ‘Occupational health guidelines for the management of low back pain: an international comparison’ Occupational and Environmental Medicine 2003;60:618-626 Table 3 Occupational guidelines: recommendations regarding assessment of LBP: under Patient Population / ACOEM]

WCAB OPINION ON ACOEM FOR CHRONIC PAIN:

3) Los Angeles Times v. WCAB (Herbinger) 7 WCAB Rptr. 10,109; 70 CCC 504 (2005) “The Court believes that Mr. Herbinger’s injury is long past the acute phase. Thus, the Court believes the ACOEM guidelines referenced by the defendant are inappropriate at this point.”

4) Hamilton v. S.C.I.F. (2004) 32 CWCR 249: a WCAB panel recently issued an Order Denying Reconsideration in which it found that the ACOEM guidelines did not apply to chronic injuries, i.e., those requiring treatment more than 90 days from the date of injury.

NOW, LET’S DEFINE CHRONIC PAIN:

"Chronicity may be reached from one to six months post injury. The International Association for the Study of Pain has stated that three months is that definitional time frame, while the American Psychiatric Association uses a six-month limit. The most clinically useful definition might be that "chronic pain persists beyond the usual course of healing or an acute disease or beyond a reasonable time for an injury to heal." American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: page 108 - Chapter 6

SPINAL SURGERY:

ACOEM, table 12-8, page 310 states in pertinent part, "Recommended: discuss surgical options with patients with persistent and severe sciatica and clinical evidence of nerve root compromise if symptoms persist after 4-6 weeks of conservative therapy. Standard discectomy or microdiscectomy for herniated disc."

SPONDYLOLISTHESIS:

"There is good evidence from controlled trials that spinal fusion alone is effective for treating any type of acute low back pain problem, in the absence of spinal fracture, dislocation, or spondylolisthesis if there is instability and motion in the segment operated on." Glass LS, et al. “Occupational Medicine Practice Guidelines: evaluation and management of common health problems in functional recovery of workers.” 2004: American College of Occupational and Environmental Medicine (“ACOEM”), second edition; Chapter 12, page 307.

Chapter 12, page 305 states the following: "...referral for surgical consultation is indicated for patients who have: (1) Severe and disabling lower leg symptoms in a distribution consistent with abnormalities on imaging studies (radiculopathy), preferably with accompanying objective signs of neural compromise; (2) Activity limitations due to radiating leg pain for more than one month or extreme progression of leg symptoms; (3) Clear clinical, imaging, and electrophysiologic evidence of a lesion that has been shown to benefit in both the short and long term from surgical repair; (4) Failure of conservative treatment to resolve disabling radicular symptoms."

Chapter 12, Table 12-8, page 310 states, “Surgical Consideration – Recommended: Discuss surgical options with patients with persistent and severe sciatica and clinical evidence of nerve root compromise if symptoms persist after 4-6 weeks of conservative therapy.”

STUPID ACOEM:

ACOEM, page 174, “There is limited evidence that electromagnetic therapy may be effective to reduce pain in mechanical neck disorders. If used, there should be a trial period with objective signs of functional progress.”

“Invasive techniques (e.g., needle acupuncture and injection procedures, such as injection of trigger points, facet joints, or corticosteroids, lidocaine, or opiods in the epidural space) have [b] no proven benefit[/b] in treating acute neck and upper back symptoms.”

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