In support of chiropractic care in patients of whom suffer chronic pain, I offer Chapter 6 of the ACOEM guidelines, which is the only chapter applicable to chronic pain as noted in the recent Writ Denied WCAB decision of Macari. [Regents of the University of California, Lawrence Livermore National Laboratory, PSI v. WCAB ( Macari) (2005) 70 CCC 1733 Writ Denied.]

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."

In further support, ACOEM, Chapter 6, pages 110-111 state in relevant part, “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 hand, wrist, cervical, and thoracic articulations via Chiropractic manipulation/mobilization technique is the exact treatment that this patient had been receiving from Dr. Fernando Luque, DC.

Therefore, the chiropractic mobilization, as described and requested in DFR and PR-2s submitted by Dr. Luque is the very form of treatment that has been utilized in this case and has been reasonably medically necessary to cure and/or relieve the patient from the effects of the industrial related pain syndrome.

With respect to treatment frequency, ACOEM is completely silent. Therefore, as directed by Labor Code section 4604.5 (e), [FN1] I shall use “other evidence based medical treatment guidelines generally recognized by the national medical community and that are scientifically based to support my opinion regarding treatment frequency.

The Guidelines for Chiropractic Quality Assurance and Practice Parameters ("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 episodes or acute exacerbations of chronic pain:

(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 chronic pain, and the medical record and patient interview confirm that this patient was in an acute state when she entered Dr. Luque’s office.

Noteworthy and relevant are 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 chronic 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.”

Therefore, I believe Casillas has established the Mercy Guidelines as substantial evidence for determining a reasonable chiropractic frequency for patients who have suffered an acute injury or an acute exacerbation of a chronic injury.

Therefore, up to 34 chiropractic visits would be supported by the Mercy Guidelines.

[FN1] 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.”