[ UR Time Dead-Lines | UR Report Content Requirements | 3 types of UR reports | Service Methods | UR Disputes | UR Objection Letter Plus | Penalties |ACOEM not for Chronic Pain | MERCY GUIDES | Colorado Tx GUIDES | Official Disability Guidelines |
Spiel | Best Chiro Randomized Controlled Trials ]

NOTE: The ACOEM Guidelines were put into effect on 01-01-04 but not presumed correct until 03-22-04. Now-a-days, the burbon of proof is on the PTP to justifiy what treatment interventions are being requested per Smith vs. Churn Creek Construction Company and State Compensation Insurance Fund (June 2004) 69 CCC 1012 (Board Panel Decision)

UTILIZATION REVIEW STANDARDS Article 5.5.1: (08/10/05: Final Version "HERE" in .doc format)

Labor Code 4610: Utilization Review
CCR 9792.11: UR Penalties: (coming soon!)
CCR 9792.10: UR Standards: Dispute resolution. (adopted 09/20/05)
CCR 9792.9: The UR Report Time Frames & Types of UR Reports & PR-2 Service Rules (adopted 09/20/05)
CCR 9792.8: The UR Report Contents & Variance From ACOEM. (adopted 09/20/05)
CCR 9792.7: UR Standard & Applicability. (adopted 09/20/05)

UR REPORT TIME DEAD-LINES: [Labor Code: 4610(g) and 4610(g)(1)]

The moment the insurance company receives the doctor's "medical report" or "request for authorization" or "PR-2 report" (which should request treatment and/or medical tests and/or supplies), a clock begins to tick:

In a nutshell, LC 4610(g)(1) states that after the PTP's request of authorization, DFR or PR-2 medical report (which better request 'something') is received by the insurance company, a 14 day time-deadline is invoked, which is termed a "Prospective Review." This 14 day time-dead line for prospective UR reviews has been tested and up-held by a recent WCAB en banc decision [Sandhagen Vs. SCIF I (69 CCC 1452 WCAB en banc, 11/16/04)]: Sandhagen Vs. SCIF further mandates that if the UR department blows the 14 day deadline, that UR report is not admissible at the WCAB and can NOT be opinion on by a Panel QME or AME.

So, get those DFRs and PR-2s out ON TIME [5 working days per 4603.2(a)]! PR-2 reports should also be served to the insurance company within 5 working days of the examination via Facsimile and/or proof of service. [down load a .pdf of Sandhagen Vs. SCIF here]

If the doctor fails to get his PR-2 report in to the insurance in time, a "Retrospective UR Review" is invoked. Now, the UR doctor has a full 30 days to form his opinion. So, GET YOUR PR-2 REPORTS IN ON TIME!

INFORMING THE DOCTOR of a UR DECISION:

As if the UR department doesn't have enough time-deadlines to meet, LC 4610(g)(3)(a) mandates another one: On a prospective review, once a UR Decision has been made, LC 4610(g)(3)(a) dictates that the UR team has "2 business days" to inform the doctor of the decision via "telephone or facsimile" and "in writing." [see LC 4610(g)(3)(a)]

IF NOT APPROVED IN FULL:

Per LC 4610(g)(3)(a), if a doctor's request for treatment, supplies, or anything else is "not approved in full," the dispute "shall be resolved in accordance with Section 4062." So, this means if you didn't get the medical treatment services you want, request a Panel QME to settle the dispute. Use this Letter.

UR REPORT REQUIREMENTS: The 3 Commandments [LC 4610(g)(4)]

Labor Code 4610(g)(4) requires UR reports, which are used to "modify, delay, or deny medical treatment services," "shall include" three key elements:

1) The language of the report "shall include a clear and concise explanation of the reason" for the UR doctors opinion.

2) The UR report "shall include.. a description of the criteria or guidelines used" in making the decision.

3) The UR report "shall include.. the clinical reasons for the decisions regarding medical necessity."

If the UR doctor fails to include any the aforementioned criteria, the report may be objected to on that basis of LC 4610(g)(4) and a panel QME may be requested.

TYPES OF UR REVIEWS:

Prospective UR Review: This type of review, which is governed by 4610(g)(1), is forced upon the UR department when the doctor gets his PR-2, DFR or Request for Authorization into the insurance company within 5 working days from the date of his/her examination. The UR team is only allowed "5 working days" or in "no event more than 14 days" to render their opinion on the doctor's requested treatment or testing. The WCAB en banc decision of Sandhagen Vs. SCIF I (69 CCC 1452 WCAB en banc, 11/16/04) enforces this ruling and commands any QME or AME NOT to consider any tardy UR opinions in their reports. [See LC 4610(g)(1) here]

Retrospective UR Review: This type of review, which is also governed by 4610(g)(1), is forced upon the UR department when the doctor submits a LATE PR-2, DFR, or Request for Authorization, i.e., past 5 working days from the time of the evaluation or assessment. The UR doctors love this one, for it give them 30 days to comment upon your requests. 30 days is a LONG TIME, so get your reports in ON TIME! [See LC 4610(g)(1) here]

Concurrent UR Review: This is for patients who are in the hospital and doesn't concern us Chiropractors.

RECORDS & COMMUNICATION: Time Requirements & Options...

LC4062.3

(a) Any party may provide to the qualified medical evaluator selected from a panel any of the following information:
(1) Records prepared or maintained by the employee's treating physician or physicians.
(2) Medical and nonmedical records relevant to determination of the medical issue.

(b)Information that a party proposes to provide to the qualified medical evaluator selected from a panel shall be served on the opposing party 20 days before the information is provided to the evaluator. If the opposing party objects to consideration of nonmedical records within 10 days thereafter, the records shall not be provided to the evaluator. Either party may use discovery to establish the accuracy or authenticity of nonmedical records prior to the evaluation.

(c) If an agreed medical evaluator is selected, as part of their agreement on an evaluator, the parties shall agree on what information is to be provided to the agreed medical evaluator.

(d) In any formal medical evaluation, the agreed or qualified medical evaluator shall identify the following:
(1) All information received from the parties.
(2) All information reviewed in preparation of the report.
(3) All information relied upon in the formulation of his or her opinion.

(e) All communications with an agreed medical evaluator or a qualified medical evaluator selected from a panel before a medical evaluation shall be in writing and shall be served on the opposing party 20 days in advance of the evaluation. Any subsequent communication with the medical evaluator shall be in writing and shall be served on the opposing party when sent to the medical evaluator.

(f) Ex parte communication with an agreed medical evaluator or a qualified medical evaluator selected from a panel is prohibited. If a party communicates with the agreed medical evaluator or the qualified medical evaluator in violation of subdivision (e), the aggrieved party may elect to terminate the medical evaluation and seek a new evaluation from another qualified medical evaluator to be selected according to Section 4062.1 or 4062.2, as applicable, or proceed with the initial evaluation.

SERVICE OF YOUR REPORTS & REQUESTS FOR AUTHORIZATION:

The best method is to send PR-2, PR-3, PR-4, or DFR via "certified mail with return receipt." Per CCR 9792.9(a)(2) medical reports and/or requests of authorization are "deemed to have been received by the claims administrator on the receipt date entered on the return receipt."

Per Labor Code (aka: LC) 4603.2(a), the doctor has "5 working days" to get that Doctor's First Report of Occupational Injury (aka: DFR) to the Employer/Insurance Company. The fastest way is to Fax it to the Claims Department. Per CCR 9792.9(a)(1) as long as you get the DFR faxed by 5:30pm on "working day" five, you've complied with your reporting obligation. Facsimile is the ONLY way to prove you have served the insurance company in one day. There are some required things you need on the fax cover sheet, so please read CCR 9792.9(a)(1) carefully. If you send the DFR out "proof of service," per CCR 9792.9(a)(2) it's deemed to be received by the insurance company "5 days after the deposit in the mail." If you don't "proof of service" you report, per CCR 9792.9(a)(2) it's deemed to have been received by the Insurance Company (IC) the day it's "stamped as received" by the insurance company's mail room!

Here's how to get all your 24 visits authorized, so you never have to bother with UR doctors bugging you: In your Doctor's First Report of Occupational Injury or Illness (DFR), request ALL 24 VISITS right up front and then (here's the important part) send that DRF "Certified Mail - Return Receipt" to the insurance company. [DO NOT FAX IT IN for then they might get to it in time!] By doing this, the UR people will rarely complete the UR review in within 5 to 14 days as mandated by CCR 9792.9(b)(1), LC 4610(g)(1) and per Sandhagen Vs. SCIF I (69 CCC 1452 WCAB en banc, 11/16/04), which makes their tardy report inadmissible in court and unreviewable by the QME or AME. Even if they make the dead-line, they still probably haven't complied with the stringent UR rules per Labor Code, 4610(g)(3)(a) and/or 4610(g)(4). Per the recent WCAB en banc decision - Sandhagen Vs. SCIF I (69 CCC 1452 WCAB en banc, 11/16/04 [download Sandhagen I in .pdf]) - QME and AME doctors are prohibited from reviewing such tardy UR reports. As a very busy QME doc, I get these Tardy UR reports that shred the Chiros treatment all the time. Very, Very, Very rarely are they every on time, so I don't read them and write something like this:

Unfortunately, I (the Panel QME) am forbidden to review Dr. XXX comments for this UR report has grossly missed the 30 date time-deadline as imposed by LC 4610(g)(1), which states the following: “prospective or concurrent decisions shall be made in a timely fashion that is appropriate for the nature of the employee's condition, not to exceed five working days from the receipt of the information reasonably necessary and he hand will to make the determination, but in no event more than 14 days from the date of the medical treatment recommendation by the physician. In cases where the review is retrospective, the decision shall be communicated to the individual who received services, or to the individual's designee, within 30 days of receipt of information that is reasonably necessary to make this determination.” Furthermore, two recent en banc WCAB rulings [Sandhagen Vs. SCIF (70 CCC 208 WCAB en banc, 02/07/05) and Sandhagen Vs. SCIF (69 CCC 1452 WCAB en banc,11/16/04)] forbid a p-QME for opinion on such untimely UR reports.

Personally, I use the 24 visits very sparingly and save the last 6 for basically evaluation and management purposes. Usually I can stretch-out my care long enough for the patient to become Permanent & Stationary. Then, if warranted, I write a narrative style Permanent and Stationary Report (which often bills for over $500.00) and order future Chiropractic care and treat the patient for flare-ups per Mercy. I regularly use RPTs, OTCs, Acupuncturists, and pain management doctors to fulfill the treatment needed of the patient.

UR DISPUTES OVER MEDICAL TREATMENT:

Effective April 19, 2004, former Labor Code section 4062 was amended by Senate Bill 899 (SB899). LC 4062(a) now mandates that disputes of medical care and compensability are to be settled by the panel QME process. As opined in a recent WCAB panel decision (Casillas vs. San Luis Obispo – Case No. GRO 28418; 2005) Labor code “section 4610 requires that disputes following a utilization review be resolved pursuant to section 4062." (Willette v. Au Electronic Corporation (2004) 69 Cal. Comp. Cases 1298 (Appeals Board en banc).” CCR 9785(b)(3) and CCR 9785(b)(4) also envokes the panel QME process and states the following:

So, what do you do?

It's simple: REQUEST A CHIROPRACTIC QME immediately! DON'T WASTE TIME WRITING ARGUMENTITIVE LETTERS BACK TO THE UR DOCTOR! The QME Process, especially a pre-mature QME process, is going to cost them more money than if they just would have just authorized your 24 chiro visits, second medical opinion and/or medical testing in the first place! If you and the patient select a 'human' and 'non-insurance-sided' QME, you're going to get your 24 visits and requested medical items paid for/ authorized. NOTE: On new 2004 cases that have not been granted a future medical care award, you will NOT get more than 24 visits paid for UNLESS the claims administrator authorizes this in writing. The 24 visit cap is a statutory law and can NOT even be overturned by a WCJ.

HERES HOW TO HANDLE THOSE UR DENIALS:

FAX AND 'PROOF OF SERVICE' THE FORTHCOMING LETTER TO THE CLAIMS ADJUSTER WITHIN 30 DAYS: (I'm assuming the patient doesn't have an attorney YET. If the patient is represented, then they can NOT obtain a QME through this mechanism and their lawyer will have to act.)

Give the Claims Administrator one or two days to respond to the above letter; when she/he doesn't respond, fill out a IMC 106 (Request for Qualified Medical Evaluator) [Down Load Here] and Proof-Of-Service it to the DCW Medical Unit and the Claims at the following address:

Make sure you enter DCH for the QME specialty, that is if you want a good chance at getting your care supported, for MDs are often not very Chiropractic-Friendly.

Also remember, per LC 4062.1(c) when your patient receives that list of 3 panel QME Chiros from the DWC Medical Unit, they MUST choose one of the Chiros and inform the insurance adjuster WITHIN 10 DAYS!!! The Claims adjuster also get a copy of the list and if ten days passes without hearing from the patients, THE CLAIMS ADJUSTER GETS TO PICK THE CHIRO!!!

Also LC 139.2(h)(1) may be used if the DWC Medical Unit fails to get the requested panel out in time: "When requested by an employee or employer pursuant to Section 4062.1, the medical director appointed pursuant to Section 122 shall assign three-member panels of qualified medical evaluators within five working days after receiving a request for a panel. If a panel is not assigned within 15 working days, the employee shall have the right to obtain a medical evaluation from any qualified medical evaluator of his or her choice. The medical director shall use a random selection method for assigning panels of qualified medical evaluators. The medical director shall select evaluators who are specialists of the type requested by the employee. The medical director shall advise the employee that he or she should consult with his or her treating physician prior to deciding which type of specialist to request."

EXTRA PENALTIES: Labor Code 5814

If the Insurer fails to pay your medical treatment bill based upon an untimely UR opinon per LC 4610, you should request additional penalites under LC 5814, for the insurer should have known that the UR opinion was inadmissable per Sandhagen I vs. SCIF.

ACOEM IS NOT FOR CHRONIC PAIN PATIENTS:

Recently, two WCAB panel decisions upheld a lower courts ruling that ACOEM did not apply to injuries that were over 90 days in duration (4,5). More explicitly, in the famous [Hamilton Vs. SCIF 32 CWCR 249 WCAB panel decision (Oct 2004)] [download Hamilton here in .pdf]) decision, WCJ Alvin R. Webber was upheld by the WCAB (4) for his decision to award medical treatment, which was not supported by the ACOEM guidelines, based on the supposition that ACOEM did not apply to chronic injuries. Judge Webber cited a passage from within the ACOEM guides themselves to substantiate his position: “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.” (85)

More recently, a writ-denied case was published [Los Angeles Times v. WCAB (Herbinger) 7 WCAB Rptr. 10,109; 70 CCC 504 ( April 2005)], in which the panel wrote:

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

1) “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.” (90)

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 .” (86)

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.” (89)

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.” (91)

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.” (92)

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 .” (93)

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.” (94)

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.” (6)

Therefore, based upon the aforementioned evidence, it is my belief that this patient, who has suffered from pain much longer than three months, is exempt from the ACOEM guidelines. Per LC 4604.5(e) I have presented “other evidence based medical treatment guidelines generally recognized by the national medical community and that are scientifically based” (300) that support the use of spinal manipulation and exercise as an efficacious intervention for the treatment of chronic spinal pain. (Here's a list of Randomized Controlled Trials that support Chiropractic manipulation/mobilization: (RCT of Support Chiropractic)

CHRONIC PAIN DEFINITION:

"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 the 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

NOTE: These panel WCAB decisions (like Hamilton) are citable in medical reports and legal briefs; however, they are NOT considered "precedential case law", but only "persuasive case law."

ESTABLISHING A VARIANCE FROM ACOEM:

Dr. Dogood's manipulative treatment did last longer than the ACOEM recommend “four weeks duration.” However, I believe that in this case, a “variance” from the ACOEM Guidelines, as allowed by LC 4604.5(a), may be established:

ACOEM seems to limit manipulation to “four weeks duration” based on the authors’ contention 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.” (1) This opinion is seriously flawed for there are several well done investigations (randomized controlled trials) that clearly demonstrate manipulations efficacy when compared to treatment interventions “other than therapeutic exercise” for periods longer than four weeks. For example, In 1995, Triano et al. randomized 209 chronic low back pain patients into a manipulation group, a back booklet group, or a placebo manipulation group. The outcome revealed that patients who received spinal manipulation had a much greater improvement in their level of pain (via VAS) than the other groups. The authors of this randomized placebo-controlled trial concluded the following: “ there appears to be clinical value to treatment according to a defined plan using manipulation even in low back pain exceeding 7 weeks’ duration…. Greater improvement was noted in pain and activity tolerance in the manipulation group. Immediate benefit from pain relief continued to accrue after manipulation,” (58) In another non-exercise comparison, Hoiriis et al. published a randomized double-blind placebo-controlled trial that investigated the efficacy of manipulation, muscle relaxants, and placebo as an intervention for the treatment of low back pain. One-hundred and ninety two patients suffering low back pain were randomized into one of the aforementioned groups. The results indicated that manipulation was more effective at reducing pain and the patient’s ‘Clinical Global Impression of Severity Scale’ (GIS) than either placebo or muscle relaxants; the authors concluded "Chiropractic was more beneficial than placebo in reducing pain and more beneficial than either placebo or muscle relaxants in reducing GIS." (54)

Furthermore, other States’ Industrial treatment guidelines support manipulation for more than the ACOEM stated “four weeks duration.” More explicitly, the “ Colorado Medical Treatment Guidelines” allow for at least 3 month of chiropractic manipulation as noted in Section E(12)(d): Manipulation – subsection #4. Unlike the ACOEM guidelines, the Colorado Medical Guideline also – more realistically – allow for additional care if the patient condition becomes exacerbated. Here’s the exact verbiage:

“Extended durations of care beyond what is considered "maximum" may be necessary in cases of re-injury, interrupted continuity of care, exacerbation of symptoms, and in those patients with comorbidities. Care beyond 3 months is indicated for certain chronic syndromes in which manipulation is helpful in improving function, decreasing pain and improving quality of life. Such care should be re-evaluated and documented on a monthly basis. Treatment may include visits 2 times a month through the 7th month postinjury, then on a monthly basis thereafter through the 10th month post-injury. Care beyond the 10 th month should be reviewed and allowed on a case-by-case basis according to the unique needs of the patient with chronic and/or permanent injury.” (2)

In conclusion I believe I have offered sufficient evidence based medical guidelines and evidence based randomized placebo-controlled trials to establish a variance from ACOEMs presumption that manipulation is only indicated for "four weeks duration."

References:

1) Occupational Medicine Practice Guidelines - second edition’ ACOEM 2004; OEM Press: Beverly Farms, Massachusetts: Chapter 12, page 298-299

2) Colorado Division of Workers’ Compensation “Medical Treatment Guidelines: Low Back Pain." Rule XVII, Exhibit A 2001; 5th edition: Section E(12)(d); Page 44-45

54) Hoiriis KT, et al. ‘A Randomized (Placebo-Controlled) clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain.’ J Manipulative Physiol Ther. 2004;27(6):388-98.

58) Triano JJ, McGregor M, Hondras MA, Brennan PC. ‘Manipulative therapy versus education programs in chronic low back pain.’ Spine. 1995 Apr 15;20(8):948-55.

MERCY GUIDELINES: (Guidelines for Chiropractic Quality Assurance and Practice Parameters)

Chronic Pain Care:

The recent, citable, WCAB Panel decisions of Hamilton vs. SCIF 32 CWCR 249 WCAB panel decision (Oct 2004) & Los Angeles Times v. WCAB (Herbinger) 7 WCAB Rptr. 10,109; 70 CCC 504 (April 2005) have confirmed the fact that the ACOEM Guidelines are non-applicable to any patient who has suffered pain longer than 90 days, i.e., chronic pain. This patient has suffered pain long past the 90 day mark; therefore, the ACOEM Guidelines do not apply to her. Labor Code 4604.5(e) gives us direction in a situation like this and states the following:

Therefore, I shall use the “ Guidelines for Chiropractic Quality Assurance and Practice Parameters’ (aka: The Mercy Guidelines) (7) to support the chiropractic care that I have recommended. The Mercy Guidelines are extremely “evidence based” and are supported by numerous scientific investigations and guidelines. In fact Chapter 12 alone - which is what I am using to support my recommended care - contains over 65 footnoted investigations and guidelines to support its recommendations.

Furthermore, the Mercy Guidelines have recently been accepted as a defense by a recent WCAB panel decision that over-turned an ACOEM-based WCJ’s denial of a future chiropractic treatment award. [Casillas vs. The County of San Luis Obispo (08-12-2005) 33 CWCR 217; Opinion and Order Granting Reconsideration and Decision after Reconsideration]

Chapter 8, Section Vl, Subsection E (page 125) of the Mercy Guidelines, unlike the ACOEM Guidelines, specifically addresses what type of medical treatment frequency is reasonably medically necessary to properly address “exacerbation of a chronic condition.” More explicitly, Mercy states that following an acute exacerbation of a chronic condition, “3 to 5 treatments per week” should bring about “significant improvement” of the exacerbation within “10 to 14 days.” For the next six to eight weeks, if necessary, a treatment frequency of “up to 3 treatments per week” should be sufficient to return the patient to pre-exacerbation level and free the patient from the need of professionally administered spinal manipulation and its associated therapies care. (74) This level of treatment frequency is also supported in a recent randomized controlled trial on chiropractic manipulation for chronic pain. (67)

COLORADO MEDICAL TREATMENT GUIDELINES: Here's the on-line version: CMTG
[ http://www.coworkforce.com/dwc/Medical%20Topics/MedicalTrtmt.asp ]

"LOW BACK PAIN":

"CHRONIC PAIN DISORDER MEDICAL TREATMENT GUIDELINES "
CPMTG or Here in .pdf format.

OFFICIAL DISABILITY GUIDELINES (ODG): These guidelines are the Official Guidelines for North Dakota and Missouri. They may be ordered from here.

CHIROPRACTIC (MOBILIZATION / MANIPULATION) SUPPORT: The top 7 Randomized Controlled Trials that Support the use of Mobilization and/or Manipulation as an Intervention for the treatment of Chronic Pain. [Go HERE for the top 7 RCT references that Support Chiro/Chronic pain ]

< Aure et al. 2003 | Triano et al. 1995 | Muller & Giles 2003 | Hoiriis et al. 2004 | Niemisto et al. 2003 | Koes et al. 1993 >

In 2003, Aure et al. randomized forty-nine chronic pain suffering patients into either a spinal manipulation/mobilization group (aka: manual therapy) or a supervised exercise/stretching group. These cohorts were then treated for two months (16 visits) and then followed for one year. The authors concluded “ the manual therapy group showed significantly larger improvements than the exercise therapy group on all outcome variables throughout the entire experimental period.” More explicitly, the manipulation/mobilization group achieved the following outcomes: 1) a 33mm drop in pain on VAS (versus 17mm in the exercise group), 2) a 9 point improvement on the Dartmouth COOP (versus 4 point in the exercise group); and (3 a 21% improvement in functional disability via Oswestry (versus only 9% in the exercise group). And, maybe even more importantly was the fact that immediately after the two month treatment period, 67% of the manipulation group had returned to work versus only 27% of the exercise group. This statistic was indeed quite impressive! (62)

In 1995, Triano et al. randomized 209 chronic low back pain patients into a manipulation group, a back booklet group, or a placebo manipulation group. They were treated 6 times per week for two weeks and then reassessed at 4 weeks: The outcome revealed that patients who received spinal manipulation had a much greater improvement in their level of pain (via VAS) than the other groups. The authors of this randomized placebo-controlled trial concluded “ there appears to be clinical value to treatment according to a defined plan using manipulation even in low back pain exceeding 7 weeks’ duration…. Greater improvement was noted in pain and activity tolerance in the manipulation group. Immediate benefit from pain relief continued to accrue after manipulation,” (58)

In 2003, Muller and Giles published the results of their randomized controlled trial with long-term follow-up. They concluded, “Overall, patients who have chronic mechanical spinal pain syndromes and received spinal manipulation gained significant broad-based beneficial short-term and long-term outcomes.” This investigation randomized a group of 109 chronic spine pain patients, who had been suffering back or neck pain for an average of 6.4 years, into on of three treatment groups: a manipulation groups, a medication group (Celebrex or Vioxx), or an acupuncture group. After a nine week course of care, the authors concluded that the manipulation group experienced a much more favorable clinical outcome when compared to either the medication group or the acupuncture group. More explicitly, 27.3% of the manipulation patients became asymptomatic (had no pain); versus only 9.4% of the acupuncture patients and 5% of the medication patients. Even more impressive was the increase in functional ability, as indicated in the Oswestry scores: The manipulation group obtained a 50% improvement; versus only a 5% improvement for the acupuncture group and a 4% improvement in the medication group. Finally, the subjective pain scores also strongly favored the manipulation group: The manipulation group obtained a 50% drop in their VAS scores (self pain intensity rating); versus only a 15% drop in the acupuncture group and 0% drop in the medication group. (56) In 2005, his same cohort was followed for another 12 months; the outcome numbers did not chance, which led the authors to the conclusion the following: “ In patients with chronic spinal pain syndromes, spinal manipulation, if not contraindicated, may be the only treatment modality of the assessed regimens (acupuncture & prescription medication) that provides broad and significant long-term benefit .” (50)

In 2004 Hoiriis et al. published a randomized double-blind placebo-controlled trial that investigated the efficacy of manipulation, muscle relaxants, and placebo as an intervention for the treatment of low back pain. One-hundred and ninety two patients suffering low back pain were randomized into one of the aforementioned groups. The results indicated that manipulation was more effective at reducing pain and the patient’s ‘Clinical Global Impression of Severity Scale’ (GIS) than either placebo or muscle relaxants; the authors concluded "Chiropractic was more beneficial than placebo in reducing pain and more beneficial than either placebo or muscle relaxants in reducing GIS." (54)

With the addition of supervised spinal stabilizing exercises into the Chiropractic treatment protocol, which is well within the scope of Chiropractors (99), the effect of spinal manipulation is even more efficacious for the treatment of chronic spine pain (64,59):

In 2003 Niemisto et al. released a large randomized-controlled trial that randomized 204 chronic low back pain patients into either a spinal manipulation with stabilization exercise group or a medical doctor consultation with home exercise group. At the “12-month follow-up, the manipulative-exercise group showed “more significant reductions in pain intensity (P < 0.001) and in self-rated disability (P = 0.002) than the consultation group.” The authors of this ‘Spine’ published investigation concluded the following: “The manipulative treatment with stabilizing exercises was more effective in reducing pain intensity and disability than the physician consultation alone .”(59)

In 1993 Koes et al. conducted a randomized placebo-controled trail into the efficacy of spinal manipulation as an intervention for the treatment of chronic back and neck pain conditions. The researchers randomized 256 chronic pain patients into a manual therapy group (which consisted of either/or spinal mobilization/manipulation); a physical therapy group; a general medical-care group (which consisted of prescription medication, posture advice, a home exercise sheet); or a placebo group (which consisted of detuned diathermy and ultrasound). At 12 month follow-up, spinal manipulation/mobilization was almost 50% more effective than its closest competitor - physiotherapy - for the treatment of chronic pain and was clearly the most effective form of intervention between physical therapy, medication, home exercise booklet, and placebo. (53)

There are other randomized controlled trials that also demonstrate the efficacy of Chiropractic care as an intervention for chronic pain (62,55,49,57,64,78,79,50,56,51,60,61,45,58,63,52-54,59), but I believe I’ve made my case with the aforementioned 6 investigations.

REFERENCES:

4) Hamilton Vs. SCIF, STK 189211, Sept, 16, 2004, (Order Denying Reconsideration; WCAB Panel Decision): Published in: CWCR VOL. 32 NO. 9 Oct. 2004, pp. 249. (CWCR is a citable authority.)

5) Taylor Vs. SCIF, Unpublished.

6) 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: “Workers with <3 months activity intolerance due to LBP and/or back related leg symptoms related to occupational injury or exposure.”

50) Muller R, Giles LG. ‘Long-term follow-up of a randomized clinical trial assessing the efficacy of medication, acupuncture, and spinal manipulation for chronic mechanical spinal pain syndromes.’ J Manipulative Physiol Ther. 2005 Jan;28(1):3-11. “ CONCLUSIONS: In patients with chronic spinal pain syndromes, spinal manipulation, if not contraindicated, may be the only treatment modality of the assessed regimens that provides broad and significant long-term benefit.”

53) Koes BW, Bouter LM ‘Randomised clinical trial (with placebo) of manipulative therapy and physiotherapy for persistent back and neck complaints: results of one year follow up.’ BMJ. 1992 Mar 7;304(6827):601-5. “CONCLUSIONS--Manipulative therapy and physiotherapy are better than general practitioner (medication) and placebo treatment. Furthermore, manipulative therapy is slightly better than physiotherapy after 12 months.”

54) Hoiriis KT, et al. ‘A Randomized (Placebo-Controlled) clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain.’ J Manipulative Physiol Ther. 2004;27(6):388-98. “ Chiropractic was more beneficial than placebo in reducing pain and more beneficial than either placebo or muscle relaxants in reducing Global Impression of Severity Scale.”

56) Giles LGF, Muller R. ‘A Randomized Clinical Trial Comparing Medication Acupuncture and Spinal Manipulation.’ Spine 2003;28(14):1490-1503 “ The results of this efficacy study said just that spinal manipulation, if not contraindicated, may be superior to needle acupuncture or medication for the successful treatment of patients with chronic spine pain syndrome…."

58) Triano JJ, McGregor M, Hondras MA, Brennan PC. ‘Manipulative therapy versus education programs in chronic low back pain.’ Spine. 1995 Apr 15;20(8):948-55. Conclusion: “ there appears to be clinical value to treatment according to a defined plan using manipulation even in low back pain exceeding 7 weeks' duration. ” “Greater improvement was noted in pain and activity tolerance in the manipulation group. Immediate benefit from pain relief continued to accrue after manipulation,”

59) Niemisto L, et al. “A randomized trial of combined manipulation, stabilizing exercises, and physician consultation compared to physician consultation alone for chronic low back pain.” Spine. 2003 Oct 1;28(19):2185-91. “ The manipulative treatment with stabilizing exercises was more effective in reducing pain intensity and disability than the physician consultation alone (in a group of 204 chronic low back pain patients).” “ The present study showed that short, specific treatment programs with proper patient information may alter the course of chronic low back pain.”

62) Aure OF, Nilsen JH, Vasseljen O. ‘Manual therapy and exercise therapy in patients with chronic low back pain: a randomized, controlled trial with 1-year follow-up.” Spine 2003 28(6):525-31; discussion 531-2 Forty-nine patients were randomized into either an exercise group or a spinal manipulation group: “ CONCLUSIONS: …manual therapy (aka: manipulation or mobilization) showed significantly greater improvement than exercise therapy in patients with chronic low back pain. The effects were reflected on all outcome measures, both on short and long-term follow-up (1 year).” “Immediately after the 2-month treatment period, 67% in the manual therapy and 27% in the exercise therapy group had returned to work.”

85) American College of Occupation and Environmental Medicine – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts - Chapter 12, p.287, second paragraph. “ 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.”

86) American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: page 287 - Chapter 12 “ Algorithms for patient management are included (in this chapter). This chapter's master algorithm schematizes how primary care and occupational medicine practitioners generally can manage the cute or subacute low back pain complaints."

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

88) American College of Occupation and Environmental Medicine (ACOEM) – 2nd edition. “Occupational Medicine Practice Guidelines” 2004; OEM Press: Beverly Farms, Massachusetts: page 308; Table 12-8: Summary of Evidence and Recommendations – Physical Treatment Methods: "A prolonged course of manipulation (longer than 4 weeks) is Not Recommended"

89) ‘Occupational Medicine Practice Guidelines - second edition’ ACOEM 2004; OEM Press: Beverly Farms, Massachusetts: page 253 " This chapters master algorithm schematizes how primary care and occupational medicine practitioners may generally manage patients with acute and subacute forearm, wrist, and hand complaints." "The principal recommendations for accessing and treating patients with acute and subacute forearm, wrist, and hand complaints are as follows:"

90) Occupational Medicine Practice Guidelines - second edition’ ACOEM 2004; OEM Press: Beverly Farms, Massachusetts: Neck and Upper Back Complaints; page 165; “This chapter’s master algorithm schematizes the manner in which primary care and occupational medicine practitioners generally can manage patients with acute and subacute neck and upper back complaints.”

91) Occupational Medicine Practice Guidelines - second edition’ ACOEM 2004; OEM Press: Beverly Farms, Massachusetts: Elbow Complaints; page 227: “ 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.”

92) Occupational Medicine Practice Guidelines - second edition’ ACOEM 2004; OEM Press: Beverly Farms, Massachusetts: Shoulder Complaints; page 195: “ 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.”

93) Occupational Medicine Practice Guidelines - second edition’ ACOEM 2004; OEM Press: Beverly Farms, Massachusetts: Knee Complaints; page 329: “ 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.”

94) Occupational Medicine Practice Guidelines - second edition’ ACOEM 2004; OEM Press: Beverly Farms, Massachusetts: Ankle and Foot Complaints; page 361 “ 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.”

300) LC 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.”

LABOR CODE:

4062(a): If either the employee or employer objects to a medical determination made by the treating physician concerning any medical issues not covered by Section 4060 or 4061 and not subject to Section 4610, the objecting party shall notify the other party in writing of the objection within 20 days of receipt of the report if the employee is represented by an attorney or within 30 days of receipt of the report if the employee is not represented by an attorney. Employer objections to the treating physician's recommendation for spinal surgery shall be subject to subdivision (b), and after denial of the physician's recommendation, in accordance with Section 4610. If the employee objects to a decision made pursuant to Section 4610 to modify, delay, or deny a treatment recommendation, the employee shall notify the employer of the objection in writing within 20 days of receipt of that decision. These time limits may be extended for good cause or by mutual agreement. If the employee is represented by an attorney, a medical evaluation to determine the disputed medical issue shall be obtained as provided in Section 4062.2, and no other medical evaluation shall be obtained. If the employee is not represented by an attorney, the employer shall immediately provide the employee with a form prescribed by the medical director with which to request assignment of a panel of three qualified medical evaluators, the evaluation shall be obtained as provided in Section 4062.1, and no other medical evaluation shall be obtained.

4062.1(b): If either party requests a medical evaluation pursuant to Section 4060, 4061, or 4062, either party may submit the form prescribed by the administrative director requesting the medical director to assign a panel of three qualified medical evaluators in accordance with Section 139.2. However, the employer may not submit the form unless the employee has not submitted the form within 10 days after the employer has furnished the form to the employee and requested the employee to submit the form. The party submitting the request form shall designate the specialty of the physicians that will be assigned to the panel.

4062.1(c): Within 10 days of the issuance of a panel of qualified medical evaluators, the employee shall select a physician from the panel to prepare a medical evaluation, the employee shall schedule the appointment, and the employee shall inform the employer of the selection and the appointment. If the employee does not inform the employer of the selection within 10 days of the assignment of a panel of qualified medical evaluators, then the employer may select the physician from the panel to prepare a medical evaluation. If the employee informs the employer of the selection within 10 days of the assignment of the panel but has not made the appointment, or if the employer selects the physician pursuant to this subdivision, then the employer shall arrange the appointment. Upon receipt of written notice of the appointment arrangements from the employee, or upon giving the employee notice of an appointment arranged by the employer, the employer shall furnish payment of estimated travel expense.

4603.2(a): Upon selecting a physician pursuant to Section 4600, the employee or physician shall forthwith notify the employer of the name and address of the physician. The physician shall submit a report to the employer within five working days from the date of the initial examination and shall submit periodic reports at intervals that may be prescribed by rules and regulations adopted by the administrative director.

4610(g)(1): Prospective or concurrent decisions shall be made in a timely fashion that is appropriate for the nature of the employee's condition, not to exceed five working days from the receipt of the information reasonably necessary to make the determination, but in no event more than 14 days from the date of the medical treatment recommendation by the physician. In cases where the review is retrospective, the decision shall be communicated to the individual who received services, or to the individual's designee, within 30 days of receipt of information that is reasonably necessary to make this determination.

4610(g)(3)(a): Decisions to approve, modify, delay, or deny requests by physicians for authorization prior to, or concurrent with, the provision of medical treatment services to employees shall be communicated to the requesting physician within 24 hours of the decision. Decisions resulting in modification, delay, or denial of all or part of the requested health care service shall be communicated to physicians initially by telephone or facsimile, and to the physician and employee in writing within 24 hours for concurrent review, or within two business days of the decision for prospective review, as prescribed by the administrative director. If the request is not approved in full, disputes shall be resolved in accordance with Section 4062. If a request to perform spinal surgery is denied, disputes shall be resolved in accordance with subdivision (b) of Section 4062.

4610(g)(4): Communications regarding decisions to approve requests by physicians shall specify the specific medical treatment service approved. Responses regarding decisions to modify, delay, or deny medical treatment services requested by physicians shall include a clear and concise explanation of the reasons for the employer's decision, a description of the criteria or guidelines used, and the clinical reasons for the decisions regarding medical necessity.

REGULATIONS (CCR):

9792.9(a)(1): For purposes of this section, the written request for authorization shall be deemed to have been received by the claims administrator by facsimile on the date the request was transmitted. A request for authorization transmitted by facsimile after 5:30 PM Pacific Standard Time shall be deemed to have been received by the claims administrator on the following business day as defined in section 9 of the Civil Code. The copy of the request for authorization received by a facsimile transmission shall bear a notation of the date and place of transmission and the facsimile telephone number to which the request was transmitted or be accompanied by an unsigned copy of the affidavit or certificate of transmission which shall contain the facsimile telephone number to which the request was transmitted.

9792.9(a)(2): For purposes of this section, the written request for authorization shall be deemed to have been received by the claims administrator by facsimile on the date the request was transmitted. A request for authorization transmitted by facsimile after 5:30 PM Pacific Standard Time shall be deemed to have been received by the claims administrator on the following business day as defined in section 9 of the Civil Code. The copy of the request for authorization received by a facsimile transmission shall bear a notation of the date and place of transmission and the facsimile telephone number to which the request was transmitted or be accompanied by an unsigned copy of the affidavit or certificate of transmission which shall contain the facsimile telephone number to which the request was transmitted.

9792.9(b)(1): Prospective (your request for all 24 chiro visits) or concurrent (for inpatient services only) decisions shall be made in a timely fashion that is appropriate for the nature of the injured worker's condition, not to exceed five (5) working days from the date of receipt of the written request for authorization.

9792.10(a)(2): An objection to a decision disapproving in whole or in part a request for authorization of medical treatment, must be communicated to the claims administrator by the injured worker or the injured worker's attorney in writing within 20 days of receipt of the utilization review decision. The 20-day time limit may be extended for good cause or by mutual agreement of the parties. (NOTE: if the injured worker is NOT represented by an attorney, this time deadline is extended to 30 days per LC 4062(A). [labor codes always trump regulations.]

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