RECOMMENDED TREATMENT:
As mentioned above, because of this recent exacerbation of the patient's chronic back pain, I am requesting six additional chiropractic treatments. This should be sufficient to quell the affects of the recent exacerbation and return this patient back to tolerable level of chronic pain. The six visits should be used over the next six weeks.
SUPPORT OF RECOMMENDED TREATMENT:
(a) The ACOEM Guidelines - fifth edition: although ACOEM does not specifically address treatment recommendations for the chronic pain patient, it does recommend treatment guidelines for acute pain. Since this patient is currently suffering from acute pain secondary to an exacerbation at work, I believe these guidelines may be useful in supporting my recommendation for three chiropractic visits. More explicitly, table 12-8 on page 308; chapter 12 of the ACOEM guidelines, which is entitled "Summary of Recommendations for Evaluating and Managing Low Back Complaints," recommends manipulation of the low back during the first month of symptoms without radiculopathy. ACOEM is silent on the actual frequency of such manipulative care.
(b) Guidelines for Chiropractic Quality Assurance and Practice Parameters (herein The Mercy Conference Guidelines: unlike the ACOEM guidelines, the Mercy conference guidelines address treatment frequency for an "exacerbation of a chronic condition." More explicitly, page 125; chapter 8, subsection "E" allows for "three to five treatments per week" during the first "10-14 days" following an "exacerbation of a chronic condition." In order for the patient to return to "pre-episode status," the guidelines allow for "up to three treatments per week" for "six to eight weeks." This 34 treatment maximum is far more than I am requesting at this time.
(c) The Colorado Medical treatment guidelines for Chronic Pain disorder (Rule XVII, Exhibit F; 2003): Section 14, subsection d of these Guidelines states the following:
“The purpose of manipulation in the treatment of chronic pain is to assess the structure and function of the patient and to identify areas of musculoskeletal dysfunction that may be causing, or contributing to, the patient’s symptoms…. Indications for manipulation include joint pain, decreased joint motion and joint adhesions…. Care beyond 8 weeks may be indicated for certain chronic pain patients in whom manipulation is helpful in improving function, decreasing pain and improving quality of life.”
As noted above under my examination section, this patient clearly has signs of decreased joint motion and joint pain, which makes him a candidate for manipulation of his chronic pain under these guidelines. Furthermore, manipulation has historically helped the patient in decreasing pain in improving the quality of his life.
With respect to treatment frequency, these guidelines limit chronic pain exacerbation treatment to a maximum duration of "eight weeks," during which a treatment frequency of "1 to 2 times per week for the first 2 weeks” and “1 treatment per week for the next 6 weeks” was given. Again, my request for 6 chiropractic treatments is well below this 10 treatment limit.
Note: These Guidelines may be viewed on-line for free here:
http://www.coworkforce.com/dwc/RuleXVIIRestore/Rule_XVII_Exhibit_F.asp
(d) Evidence Based Medical Research: Randomized Controlled Trials that Support Manipulation for the Treatment of Chronic pain:
Evidence Based Medical Research: Randomized Controlled Trials that Support Manipulation for the Treatment of Chronic pain:
1) Aure OF, Nilsen JH, Vasseljen O. - Spine 2003 28(6):525-31; discussion 531-532.
2) Triano JJ, McGregor M, Hondras MA, Brennan PC. - Spine. 1995 Apr 15;20(8):948-55.
3) Giles LGF, Muller R. - Spine 2003;28(14):1490-1503
4) Muller R, Giles LG. - J Manipulative Physiol Ther. 2005 Jan;28(1):3-11.
5) Hoiriis KT, et al. - J Manipulative Physiol Ther. 2004;27(6):388-398.
6) Koes BW, Bouter LM. - BMJ. 1992 Mar 7;304(6827):601-5.
7) Niemisto L, et al. - Spine. 2003 Oct 1;28(19):2185-91.
I won’t go into each investigation; however, I shall comment on the Muller & Giles investigation of 2003:
In 2003, Muller and Giles published the results of their randomized controlled trial with long-term follow-up. 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. The authors 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.” 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. 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 .”
COMMENTS:
I believe I have successfully supported my recommendations for 6 chiropractic visits secondary to this patient’s recent exacerbation of symptomatology, and have complied with reporting requirements of Title 8 CCR §9785(d) and the recent WCAB panel decision of Smith vs. Churn Creek Construction Company and State Compensation Insurance Fund (June 2004) 69 CCC 1012 where the commissioners ruled that the patient’s primary treating physician was "required to explain” why his recommended requested medical treatment “was reasonably required to cure and relieve from the effects of the injury in this employee.”
NOTE: 60 minutes of non-face to face time was needed to prepare this report, secondary to record review, labor code research, evidence based treatment guideline review, evidence based medical research review and case law study. This time shall be charged per the OMFS as described in Title 8 CCR §9789.11(a).