TREATMENT: The patient may receive up to 30 chiropractic treatments per year.

I have recommended that the patient be allowed to visit Dr. Luque for chiropractic treatment secondary to exacerbation of her chronic pain and now opinion that she may have up to 30 chiropractic visits per year. Such treatment is clearly supported by (1) Chapter 6 of the ACOEM Guidelines, which is the only chapter that discusses how to treat chronic pain; (2) a recent WCAB, Writ Denied, panel decision [Regents of the University of California, Lawrence Livermore National Laboratory, PSI v. WCAB ( Macari) (2005) 70 CCC 1733 Writ Denied]; and (3) the Mercy Conference Guidelines.

ACOEM SUPPORT:

After thorough review of Chapter 6 of the ACOEM Guidelines, the forthcoming passages were found to support manipulation a treatment intervention for patient’s suffering chronic pain:

A.) 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."

B.) Page 112 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.)

C.) Page 110-111 states, “Each physician should… prescribe… active mobilization of injured areas.”

D.) Page 111 also describes “ways to manage pain and dysfunction”; both “Medication” and “Physical Modalities” are in that list.

Therefore, ACOEM Chapter 6 clearly supports the continuance of chiropractic care – specifically mobilization techniques and physiotherapy – for the purpose of maintaining function and pain of patients suffering chronic pain.

WCAB SUPPORT:

My opinion regarding the efficacy of chiropractic care for maintaining function and pain in patients suffering chronic pain is now shared by a recent Writ Denied WCAB panel decision:

In Regents of the University of California, Lawrence Livermore National Laboratory, PSI v. WCAB ( Macari) (2005) 70 CCC 1733 Writ Denied, a Californian Workers Compensation Administrative Law Judge (“WCJ”) allowed thirty (30) Chiropractic visits per year for treatment of an injured worker’s chronic spine pain in order to maintain function and keep pain under control. She used ACOEM Chapter 6, the Mercy Guidelines, and the Glenerin (Canadian) Guidelines as the foundation for this decision. Insurer objections to this decision were denied by the Workers’ Compensation Appeals Board (“WCAB”), and the First District Court of Appeals (Writ Denied).

More explicitly, on 02-20-04, an injured worker was granted an award for future medical care from the WCAB. Subsequent to the award, additional chiropractic care was procured on a regular basis in order to control his chronic back pain and maintain his level of function with respect to work and the activities of daily living. Despite the award, the insurer’s UR department (two separate UR doctors’ opinions) denied such care on the basis of Chapter 12 (lumbar spine) of the ACOEM Guidelines. At trail, the WCJ ordered the insurer to pay for and continue paying for the chiropractic care at a frequency of no more than 30 visits per year. The WCJ based her decision (which was upheld by the Appeals Board and the District Court of Appeal) on (1) the patient’s credible testimony that his function deteriorated and his need for medication increased without the chiropractic care, (2) Chapter 6 of the ACOEM guidelines, (3) the Mercy Guidelines, and (4) the Glenerin (Canadian) Guidelines. Upon reconsideration, the WCAB agreed that for forgoing supportive evidence effectively rebutted Chapter 12 of ACOEM in accordance with labor Code § 4604.5 and upheld the WCJ’s decision. The matter was further appealed to the First District Court of Appeal; however, the appeal was rejected (Writ Denied).

More explicitly, the WCJ stated in relevant part:

“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.”

TREATMENT FREQUENCY SUPPORT:

ACOEM is completely silent in regards to acceptable treatment frequency. As noted above in the Macari opinion, up to 30 chiropractic visits per year were allowed by the WCAB in order to maintain levels of function and pain in a chronically injured worker. The WCAB used, among other things, the Mercy Conference Guidelines as support for this recommendation. Therefore, I too shall use the Mercy Conference Guidelines as support for my recommendation of 30 chiropractic visits per year:

The Guidelines for Chiropractic Quality Assurance & Practice Parameter : (“Mercy”)

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 exacerbations of chronic pain, page 125; chapter 8, subsection "E" give the following recommended treatment frequency:

(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 up to 34 treatments are allowed for acute conditions or acute exacerbations of a chronic condition.

Therefore, again, I believe it reasonable that the patient continue with chiropractic care on an as-need basis and may receive up to 30 chiropractic treatments per year to address exacerbations of her chronic pain.