JUSTIFICATION FOR RECOMMENDED TREATMENT:

(1) Chiropractic Care for Exacerbations of Chronic Pain:

A reasonable trial of chiropractic care has been accomplished; all further care will be ONLY for exacerbations of this patient's chronic pain, which as been deemed reasonable by a recent WCAB Panel decision (Casillas vs. The County of San Luis Obispo (2005) 33 CWCR 217).

Since ACOEM is silent with respect to exacerbations of a chronic condition [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], Labor Code section 4604.5(e) proclaims authorized medical treatment “shall be in accordance with other evidence based medical treatment guidelines generally recognized by the national medical community and that are scientifically based." (Bold added.)

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" of said Mercy Conference Guideline, entitled “Acute Episode,” allows the following treatment frequency for an "exacerbation of a chronic condition":

(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 exacerbations of a chronic condition.

Furthermore, noteworthy 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 exacerbations of a chronic condition. In pertinent part, the commissioners stated:

"We find in this case that the presumption 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.”

Therefore, the request for six chiropractic visits to quell the effects of the recent exacerbation of the patient's chronic pain would certainly seem reasonable.

(2) 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, ACOEM Chapter 8, page 181, table 8-8 recommends NSAIDS, and optionally recommends Muscle Relaxants and Opiods (short course) for patients with neck pain.

With regard to the request for physical therapy and the psychiatric evaluation, page 109 of ACOEM 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."

The foregoing certainly supports my requests for PT and a psychiatric assessment; I believe no further explanation is needed.

(3) MRI of the cervical Spine: 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.”