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The forthcoming is an example of just how complex permanent and stationary reports (PR-4) have become thanks to the adaptation of the AMA Guides. If you would like me to come to your office and do these for you, please call me or Wendy to learn about the details (800) 690-9420. It will cost you nothing and will be a great service for you patient.
******************************** PR-4 Discussion Section Example **************************
Note: This PR-4 Example is better viewed [here] as a .doc. I've also put it on the web but the formatting was lost:
[ UR | Procured TX | Impairment | Apportionment | Future Medical | Chiro Labor Code Page ]
DISCUSSION :
The requested positional MRI of the lumbar spine was denied by a UR opinion by Dr.
Although I’m personally not a big fan of these positional MRIs, in this case, however, it was certainly warranted. Especially given the fact the patient has a history of MRI-confirmed disc extrusion secondary to a prior industrial injury in 1999.
Furthermore, the medical record denotes that an MRI was ordered by the company medical facility a few weeks after the injury, yet it was never authorized.
ACOEM, Chapter 12 (Low Back Complaints), page 303 states in relevant part, "Unequivocal objective findings that identify specific nerve compromise on the neurologic examination are sufficient evidence to warrant imaging in patients who did not respond to treatment." This has (based upon my physical examination findings) unequivocal objective finding of specific nerve root compromise, i.e., atrophy in the right calf, absent right Achilles’ reflex, and loss of sensibility in the right L5 and S1 dermatomes. Clearly, the forgoing finds are supportive of an MRI.
There is not much research literature on the subject of positional MRI. However, I did find some support:
In 2003, Jinkins and Dworkin study the "general clinical utility" of up-right and kinetic MRI ("positional MRI") images in patients with degenerative conditions of the spine as compared to traditional recumbent MRI. After their review, they concluded that positional MRI uncovered many clinical abnormalities that recumbent MRI missed. More explicitly, they stated: "[T]he potential relative beneficial aspects of upright, weight-bearing (pMRI), dynamic-kinetic (kMRI) spinal imaging on this system over that of recumbent MRI (rMRI) include: the revelation of occult disease dependent on true axial loading, the unmasking of kinetic-dependent disease, and the ability to scan the patient in the position of clinically relevant signs and symptoms. This imaging unit also demonstrated low claustrophobic potential and yielded relatively high-resolution images with little motion/chemical shift artifact."
The patient was extremely satisfied with the chiropractic treatment provided by Dr. XXX, DC and was able to return to gainful employment.
Therefore, it is my medical opinion that all treatment (manipulation, physiotherapy, and physical therapy) provided by order by Dr. XXX, DC was medically reasonable and necessary to cure and/or relieve the patient from the effects of his industrial injury.
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."
Chiropractic mobilization, as described in Dr. XXX DFR of 02-11-05, 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), I shall use “other evidence based medical treatment guidelines generally recognized by the national medical community and that are scientifically based," i.e., the Guidelines for Chiropractic Quality Assurance and Practice Parameters ("Mercy Guidelines") in hopes of justifying the treatment frequency provided.
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 injuries, page 125; Chapter 8, subsection "E" allows the following treatment frequency for an "acute episode":
(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 pain or acute exacerbations of chronic pain.
Noteworthy and relevant 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 acute exacerbations of 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.”
I believe this decision, in conjunction with the Writ denied opinion in Herbinger, 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 and supports the procured chiropractic care in this case. Not to mention the 30 chiropractic visits per year awarded in the Writ denied opinion of Macari.
Therefore, based on all of the forgoing, I believe I have adequately supported the chiropractic treatment and physical therapy procured by this patient.
DIAGNOSIS:
PERMANENT AND STATIONARY STATUS:
The patient is not interested in trying any more invasive procedures (epidural steroid injection, facet injections, IDET, SED, DiscTRODE, or discectomy) and has admittedly stopped improving. Therefore, it is my opinion that his condition is now maximally medically improved; he may be termed permanent and stationary.
NEW SCHEDULE VERSUS THE OLD SCHEDULE: Which to use?
In this patient's case, with a date of injury after 01-01-05, I am mandated by Labor Code section 4660 to use the new AMA Guides – 5 th edition to rate this patient's permanent impairment.
LUMBAR SPINE : RANGE-OF-MOTION METHOD
This patient has clear evidence of a two level radiculopathy as noted in my neurological examination, i.e., L5 and S1 reflex loss, loss of sensibility, muscle atrophy and muscle weakness. MRI also denoted a nerve-root-compressive disc herniation (aka: protrusion) at both L4/5 and L5/S1 that were respectively 4mm and 6mm in size.
Therefore, I believe that this patient’s “multilevel” radiculopathy and disc protrusions qualify him for the Range of Motion Method as described on page 398 of the Guides – 5 th edition.
STEP I: Diagnosis Impairment.
It is my medical opinion that the patient has suffered a 7% WPI as described on page 404, Table 15-7; II (C). This is supported by the fact this patient has disc herniation with radiculopathy, rigidity, and moderate degenerative changes on MRI.
STEP 2: Range-of-Motion Impairment.
The patient was carefully put through range-of-motion testing using a digital inclinometer in the manner prescribed by the AMA Guides 5 th edition, section 15.9; page 405. The patient passed the “accessory validity test.” The following impairments were observed:
Abnormal Range of Motion: |
Actual ROM: |
WPI: |
Reference location: |
|
|
|
|
Lumbar Flexion:
|
25° |
7% |
Table 15-8, page 407 |
Lumbar Extension:
|
2° |
7% |
Table 15-8, page 407 |
Lumbar Lt. Lateral Flex.
|
17° |
2% |
Table 15-9, page 409 |
Lumbar Rt. Lateral Flex.
|
20° |
1% |
Table 15-9, page 409 |
|
|
|
|
Added Regional Impairments: Total WPI: |
|
17%WPI |
Page 408 |
STEP 3: Neurological Impairment.
Nerve Root Impairment:
Sensory Impairment : A careful neurological examination was performed upon the lower extremities; an impairment of the patient’s sensibility was noted in the L5 and S1 dermatome on the right (page 377), i.e., there was a decreased perception of vibration, pin prick and light touch on the right top and side of the foot as compared to the left.
Therefore, it is my medical opinion that the patient has suffered a sensory deficit “Severity” of grade 3 ( 50%) in the right S1 sensory nerve root and grade 3 (50%) in the right L5 sensory nerve root as described in table 15-15; page 424. The aforementioned Severity is associated with a 5% “maximum impairment value” (table15-18, page 424). Thus, per instruction on page 424, we calculate the Sensory Impairments to be: 2.5% for S1 and 2.5 for L5 (.50 X .05 = .025 = 2.5% or 3.0% via the round up rule.) By combining 3% with 3% we get a 5% Lower Extremity Sensory Impairment.
Motor Impairment : A careful neurological examination was performed upon the lower extremities that discovered, among other things, impaired motor function in both the right L5 and S1 nerve roots distribution. More explicitly, there was an absent right Achilles’ reflex; diminished right gastrocnemius and peroneal strength; and ½ inch of lower leg atrophy. There was also diminished muscle strength in the right extensor hallucis muscle. MRI imaging confirmed nerve root disc protrusion contact to the adjacent nerve roots at both the L4/5 and L5/S1 level.
Therefore, it is my medical opinion that this patient has a Grade 4 ( 25%) motor deficit severity in the right S1 motor root and a Grade 4 ( 15%) motor deficit severity in the right L5 motor root (table 15-15; page 424). The Maximum Impairment Value for these roots is 20%. (table 15-18; page 424). Thus, per instruction on page 424, we calculate the Motor Impairment of the lower extremity to be 5% for the S1 motor root [.25 X .20 = .05 or 5%] and 3% for the L5 motor root [.15 X .20 = .03 or 3%]. Thus, by combining 3% and 5% we get 7% Lower Extremity Motor Impairment.
Whole Person Impairment Secondary to Nerve Root Impairment :
The total impairment of the right lower extremity due to neurological loss is derived by “combining” the 5% sensory impairment with the 7% motor impairment. This yields a 11% lower extremity impairment via page 604. The final step requires us to convert the lower extremity impairment into a WPI with table 17-3; page 527. Thus the final WPI secondary to neurological loss is 4% WPI.
FINAL LUMBAR SPINE IMPAIRMENT :
I am ordered to “combine” the Diagnosis Impairment, the Range-of-Motion impairment, and the Neurological impairment in order to arrive at the final WPI for the lumbar spine: Thus, by combining 7%, 17%, and 4% via the chart on page 604, we give the final lumbar spine WPI: 24% WPI .
There were no other spinal, cardiovascular, respiratory, digestive, urinary, skin, hematopoietic, endocrine, EENT, visual, CNS/PNS, mental, extremities, or pain impairments that have arisen out of the employment with the above employer.
THE ACTIVITIES OF DAILY LIVING:
Self-Care and Personal Hygiene : because of his chronic lower and middle back pain, the patient has difficulty putting on his shoes and socks, and washing his feet in the shower.
Physical Activity : because of his chronic lower and middle back pain, the patient can no longer do anything heavy around the house. He gives the example of not being able to rearrange furniture for his girlfriend.
Travel Ability : because of his chronic lower and middle back pain, the patient can no longer ride in a car for longer than 90 minutes. After this period of time, the patient must stop the car, get out, and walk around for at least 10 minutes to alleviate the exacerbated back pain.
Sleeping Ability : because of his chronic lower and middle back pain, the patient sometimes is awakened in the middle of the night with pain. He also often have difficulty falling asleep secondary to back pain.
FUNCTIONAL OUTCOME TESTING:
On the day of this evaluation, I administered a standard Oswestry Disability Index (“ODI”) test to this patient. He scored a 27/50 (54%); this is categorized as a “severe” functional impairment with regard to the activities of daily living.
WORK RESTRICTIONS:
The current work limitations for this patient are as follows: (1) no lifting over 20 pounds ; (2) no repeated bending, twisting, or stooping at the waist; and (3) no sitting or standing over 45 minutes, after which a 10 minute stand-up or sit-down break is needed.
CAUSATION:
It is my medical opinion based upon reasonable medical probability that the aforementioned impairment and need for medical treatment (past, present, and future) has arisen out of and occurred in the course of the patient’s employment with Wrights Brake Service.
LABOR CODE SECTION 4663:
Per instructions from the WCAB in Escobedo, and in accordance with the newly created Labor Code section 4663, I have identified the forthcoming “other factors” as relevant and worthy of discussion in this case: (1) pre-existing lumbar degenerative disc disease; (2) pre-existing lumbar spondylosis (aka: osteoarthritis of the spine); (3) pre-existing L5 disc space narrowing and (4) pre-existing disabling lumbar disc herniation.
After thorough and diligent review of the medical literature and patient history it is my medical opinion based upon reasonable medical probability that 90% of the above described permanent impairment is apportioned to the industrial injury of 02-11-05, and 10% is apportioned to the pre-existing and permanently disabling lumbar disc herniations at L5/S1 and L4/5, as well as the presence of thinned L5 disc space.
LABOR CODE SECTION 4664:
During the patient interview and in the medical records, there was evidence that this patient has suffered a previous industrial injury in 1999, which resulted in $45,000.00 permanent disability award. The injury occurred while working for the same employer. Apportionment via section 4664 appears to be applicable.
SUPPORT OF APPORTIONMENT OPINION:
In attempts to create a report that constitutes “substantial medical evidence,” I shall support my opinion on apportionment by presenting evidence based, peer-review medical investigations, which is my right and duty per Title 8 CCR §10606(n) and the recent WCAB en banc decision of Escobedo vs. CNA (2005) 70 CCC 604, which states, in relevant part, "...a medical report is not substantial evidence unless it sets forth the reasoning behind the physician’s opinion, not merely his or her conclusions."
Spondylosis : Not Apportionable.
MRI images revealed the presence of spondylosis at both L4 and L5. The medical literature does NOT support the use of spondylosis as an indicator to predict patient back pain or impairment.
I believe Professor Nikolai Bogduk, MD, (who is consider the number one functional anatomist in the world and two-time Volvo Award winner) addressed the contention that Degenerative Joint Disease (aka: DJD, spondylosis) was predictive of future spine pain quite well by stating the following: “ Spondylosis, disc degeneration, facet degeneration or osteoarthritis are not legitimate diagnoses of the cause or source of back pain . The correlations with pain are either nil or poor. On plain films, spondylosis is equally common in both symptomatic and asymptomatic individuals and does not, therefore, constitute a diagnosis of the cause of pain.”
To further the contention that the presents of spondylosis (degenerative joint disease) is NOT indicative of patient pain or disability, let us review the Torgerson investigation: in 1976 Torgerson et al. published one of the only prospective investigations into whether or not the presents DDD or DJD was predict of spinal pain. The research team meticulously assessed the radiographs of 387 symptomatic low back pain patients and 217 asymptomatic patients (who were x-rayed for reasons other than back pain) for signs of DDD or DJD. The results of this investigation indicated that spondylosis (aka: degenerative joint disease or DJD) was seen just as frequently in the back pain patients as it was in the patients with no back pain. More explicitly, 47% of the asymptomatic group had spondylosis, and 57% of the symptomatic group had spondylosis; a non-statistically significant difference.
More recently, in 2001 Lee et al. demonstrated that endplate sclerosis (aka: spondylosis) was just a prevalent in symptomatic neck pain patients as it was in asymptomatic volunteers of the same age. They concluded, “Our results suggest that the radiographic density of cervical vertebral end plates (spondylosis) correlates neither with neck pain nor with increasing age.”
Degenerative Disc Disease (DDD) : Not apportionable.
MRI images revealed the presence of degenerative disc disease (“DDD”) at the L5 disc. The medical literature does NOT support the use of DDD as an indicator to predict patient back pain or impairment.
To support my opinion that pre-existing DDD is not indicative of future pain or disability, I would like to present the Volvo Award Winning and Young Investigator Award winning work of Dr. Norbert Boos et al. as evidence that DDD is not at all predictive of future patient impairment, pain or functional disability:
In 1995 Dr. Norbert Boos et al. won his third prestigious Volvo Award in Clinical Science for his work surrounding the clinic significance of MRI findings. In a nut shell, Boos compared the MRI findings of 46 symptomatic patients who were scheduled for lumbar disc surgery, against MRI findings in 46 pain-free volunteers who were matched for age, sex, and occupation. To “stack-the-deck” in favor of degenerative disc disease (DDD) showing-up on MRI, all 46 pain-free volunteers had occupations that are considered “high risk” for the development of back pain and disability, i.e., jobs that demanded heavy lifting; repeated bending, twisting, and stopping at the waist; vibration; and sedimentary work. Surprisingly, with respect to the presence of DDD on MRI, there was virtually no difference between the symptomatic patients and the pain-free volunteers, i.e., 96% of the symptomatic patients had DDD, and 85% of the pain-free volunteers had DDD, which is not a statistical difference. The results of this investigation clearly demonstrated that the presence of DDD on imaging is not predictive of patient symptomatology or functional disability, for despite the presents of DDD in 85% of the pain-free volunteers, none of them had back pain or functional disability.
In attempts to ascertain whether or not these same DDD-infested pain-free volunteers would eventually develop disabling back pain in the future, Boos followed the same group for five more years. The 2002 results of this most ingenious investigation won Boos yet another prestigious award, i.e., The Young Investigator Award. Surprisingly, despite the ominous looking pre-existing DDD in 85% of the pain-free volunteers’ lumbar spines and their high-risk occupations, only 12% developed back pain strong enough to require a doctor visit over those five years, and 0% became permanently disabled or even required a trip to the hospital because of back pain. Again, these results clearly indicate that pre-existing DDD is completely non-predictive of future pain and/or permanent disability.
Therefore, I believe it is certainly reasonably medical probable that the presents of degenerative disc disease, and spondylosis are not at all predictive of future disabling back pain and can not be used as a basis for apportionment to causation.
Lumbar Disc Space Narrowing : Apportionable.
MRI images for 2000 revealed the presence of a thinned disc space at L5. The medical literature does support the use of disc space narrowing as an indicator to predict patient back pain or impairment.
A thorough study of the medical literature has revealed several investigations that support the premise that apportionment to disc height narrowing is an appropriate “other factor”:
In 2003, Videman et al published the results of their complex analysis of the relationship between MRI findings and back pain. After performing MRIs on 230 monozygotic twin pairs, surprisingly, the only two MRI findings that were related to low back pain were annular disc tears, and disc height narrowing. More explicitly, the authors concluded, “Measures of decreased disc height were associated with all back pain measures and had the only significant associations with the presence of sciatica in the worst lifetime episode.”
Shocked by this result, the researchers stated, “Disc height narrowing is commonly regarded as a nonspecific outcome of aging with little clinical importance. The clear association of disc height [loss] with all studied Low Back Pain parameters, even for Low Back Pain today, was therefore, partly, an unexpected result.” They went on the theorize, “Narrowed discs could be associated with prior pain as a consequence of disc failure and related ingrowth of nerve fibers through endplate or anular lesions or irritation of surrounding tissues.”
In 1984, Frymoyer et al also found that decreased disc height was associated with a higher prevalence of low back pain. In this investigation, the researcher performed radiographs of the lumbar spines of 292 randomly selected volunteers. They discovered that the presence of decreased disc height at the L4 disc space “increased incidence of severe low-back pain” and “was a significant association… with symptoms (pain, weakness, and numbness) in the lower limbs.”
In 1976, Torgerson and Dotter published one of the only prospective investigations comparing the radiographic findings of 387 symptomatic spine pain patients against 217 asymptomatic (pain-free) people who just happened to have their spines x-rayed for other purposes unrelated to back pain. The results indicated that disc height loss (as visualized on the lateral radiograph) was much more frequently seen in the symptomatic group of patients when compared to the asymptomatic group people. The authors of this investigation concluded that the radiographic presents of “degenerative disc disease [via disc height loss] is a major cause of… pain.”
THEREFORE: I believe I have supported my opinion that the presence of disc height loss is predictive of the development of back pain and is an apportionable factor via LC 4663.
Permanently Disabling Pre-Existing Lumbar Disc Protrusion : Apportionable.
Although asymptomatic lumbar disc protrusions are not predictive of future low back pain or disability, a previously symptomatic and debilitating lumbar disc protrusion is.
In 2002, Schneider et al. published an investigation into whether or not a previous back injury was at all predictive of subsequent/future injury to that same region. After retrospectively studying the case files of over 1200 U.S. soldiers, the researchers concluded in pertinent part, "The observed risk of [re]injury was seven times greater among previously injured individuals." And, "This suggests that once an individual experiences a musculoskeletal injury to the lower extremity or low back, he may be at increased risk to undergo a similar, subsequent injury." And, "previous injury history itself may be a powerful predictor of subsequent injury."
In 2006, Wasiak, et al published the results of an investigation into what factors, if any, were predictive of low back recurrence. More explicitly, the researchers retrospectively studied the claims of 1,867 previously injured worker. The strongest predictor of back pain recurrence was having a previous back injury that necessitated a long duration of medical treatment and disability. This patient had such a prior injury that required over one year of medical treatment and disability.
VOCATIONAL REHABILITATION:
Although I have no official job description, is my medical opinion that the patient will not be able to return to his usual and customary occupation and is a candidate for the displacement “voucher” or permanent job modification with the same employer. This appears, however, to be a moot point since the employer has apparently made permanent accommodations that are congenial to the patient’s impairment.
It is my medical opinion that the patient shall require a future medical care award in order to combat exacerbations of her industrial-related chronic pain syndrome and to keep her functioning at the highest possible level.
Since the patient has made it clear that he will not routinely take medication or undergo injective procedures (facet blocks and/or epidural steroid injections) to combat pain exacerbations and maintained function, Chiropractic care should be the treatment of choice. Especially in light of the patient interview statement that without set chiropractic treatment, his pain worsens and level of function decreases – as it has as of late.
Therefore, it is my medical opinion that the patient’s Future Medical care should continue to be managed by Dr. XXX, DC.
As the PTP, not only can Dr. XXX effectively orchestrate care of this patient’s chronic pain syndrome by reporting and directing care in a multidisciplinary manner, he can also implement a variety of ACOEM and Mercy supported procedures, modalities, and programs when/if the need arises for patient exacerbations of pain and decrease function. Such interventions would include (1) manipulation/mobilization; (2) soft tissue mobilization techniques; (3) work conditioning and exercise; and (4) various procedures and modalities.
The patient is in current need of chiropractic care in order to maintain his current level of function and pain, which (he states) is necessary to keep him at an optimal level of function. Therefore, I would recommend the allowance of no more than 30 chiropractic visits per year to maintain function and pain levels.
Should the patient’s condition worsen to the point conservative care is no longer efficacious, more invasive procedures should be allowed. Such procedures may include fluoroscopically guided epidural steroid injections, facet blocks, medical branch neurotomy(s), RF annuloplasty, IDET, discTRODE and, (as a last resort) discectomy / laminectomy, disc arthroplasty, Dynesis, and/or traditional interbody fusion.
SUPPORT OF RECOMMENDED MEDICAL TREATMENT:
Since this patient’s unique situation demands future medial treatment interventions that are not completely supported or described within the presumed correct ACOEM guidelines, per Labor Code §§ 4604.5(a) and 4604.5(e), I am required to rebut ACOEM in hopes of establishing a variance in this case by using “scientific medical evidence.” The recent WCAB en banc decision of Escobedo v. CNA Insurance (2005) 70 CCC 604, demands that the evaluator support his recommendations in order to produce a medical-legal report that constitutes substantial evidence. More explicitly, Escobedo (supra) states, “a medical report is not substantial evidence unless it sets forth the reasoning behind the physician’s opinion, not merely his or her conclusions." Furthermore, Title 8 CCR 10606 (n) also gives the evaluating physician the latitude to support his opinion. More explicitly, the foregoing regulation states, “The Workers' Compensation Appeals Board favors the production of medical evidence in the form of written reports…. These reports should include where applicable… (n) the reasons for the opinion ….” In the WCAB panel decision of Smith v. Churn Creek Construction (2004) 69 CCC 1012, the commissioners reprimanded the PTP for not supporting his recommendations for future medical treatment and the injured worker lost the right to have this needed treatment intervention (epidural steroid injections) in the future because of the PTPs failure to support his opinion.
Therefore, since I want to insure this report counts as substantial evidence, I offer the forthcoming section to support my recommendations for future medical care.
(1.) CHIROPRACTIC CARE SUPPORT:
The 30 chiropractic visits that I have recommended for this patient are supported fully by ACOEM, WCAB opinion, Other Evidence Based Treatment Guidelines, and Randomized Controlled Trials.
(i) ACOEM Chapter 6:
With the exception of Chapter 6, the presumed correct ACOEM guidelines are non-applicable for patients suffering chronic pain, i.e., pain that has lasted longer than 90 days. This contention has been opined by three separate WCAB panel decisions: Hamilton (32 CWCR 249); Herbinger (70 CCC 504 Writ Denied); and Macari (70 CCC 1733 Writ Denied).
A thorough review of Chapter 6 of the ACOEM Guidelines lends the forthcoming passages that are supportive of manipulation as an intervention for Chronic pain and dysfunction:
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.”
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 supports the continuance of chiropractic care for the purpose of maintaining function and pain of patient suffering chronic pain.
(ii) WCAB Opinion:
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.” (Bold added.)
Therefore, I believe the patient deserves no less and the recommended chiropractic care should be authorized.
(iii) Other Evidence Based Treatment Guidelines:
The Guidelines for Chiropractic Quality Assurance and Practice Parameters ("Mercy Guidelines"), which were also used to successfully rebut ACOEM in the writ denied WCAB decisions of Macari [70 CCC 1733] and Herbinger [70 CCC 504], also supports my recommended continuation of chiropractic care for this chronic pain patient: More explicitly, Chapter 8, page 125 states in relevant part, “Supportive care using passive therapy may be necessary if repeated efforts to withdrawal treatment/care result in significant deterioration of clinical status."
This patient has attempted to stop her chiropractic care on several occasions; these attempts have resulted in exacerbations of chronic pain and sent her scurrying back for chiropractor treatment that in turn decreased her pain and increased her level of function.
(iiii) Scientific Medical Evidence:
As directed by Labor Code section 4604.5 (a), I would like to present a randomized controlled trial with long term follow-up that demonstrates the efficacy of chiropractic care for patients suffering chronic pain.
In 2003, Giles and Muller published the results of their randomized controlled trial with long-term follow-up in the prestigious peer review journal “Spine.” This investigation randomized a group of 109 chronic spine pain patients (all of whom had been suffering back or neck pain for an average of 6.4 years) into one of three treatment groups: a manipulation groups a medication group (Celebrex or Vioxx), or an acupuncture group. After a 9 week course of treatment, the authors concluded that the manipulation group experienced a much more favorable clinical outcome when compared to either of the other groups. 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 more 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, these same investigators followed the same cohort (group of patients) for another 12 months to see if the benefits of the chiropractic continued to hold. The results indicated that the patients who underwent chiropractic care continued to have less pain and high function then either of the other groups of patients (i.e., the medication group and the acupuncture group). These findings led the authors to conclude:
“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.” (Emphasis added.)
(iiiii) Conclusion for Manipulation Support: with regard to future chiropractic care I have recommended for this patient, I believe I have sufficiently supported my recommendations with “other medical based treatment guidelines” and “scientific medical evidence” as mandated by Labor Code section 4604.5 and have effectively established a variance from ACOEM’s spinal chapters. I believe the patient would greatly benefit from continued chiropractic care at a frequency of no more than 30 visits per year.
(2.) SPINE SURGERY:
Discectomy Surgery :
Chapter 12, page 310, table 12-8 of ACOEM states that micro-discectomy or discectomy are “RECOMMENDED” for the treatment of disc herniation induced radiculopathy.
Fusion Surgery :
Chapter 12, page 310, table 12-8 of ACOEM insinuates that spinal fusion would be recommended for “fracture” or “dislocation.” However, some patients with severe discogenic pain are successfully treated via interbody fusion. For example, recently Bertagnoli et al. published the results for their two-year follow-up examination for patients who had undergone fusion (via Prodisc) for the treatment of “debilitating discogenic low back pain.” These well respected authors and surgeons concluded the following:
“CONCLUSIONS: Single-level Prodisc lumbar total disc arthroplasty [aka: interbody fusion] is a safe and efficacious treatment method for debilitating lumbar discogenic LBP. Significant improvements in patient satisfaction and disability scores occurred after surgery by 3 months and were maintained at the 2-year follow-up. No device-related complications occurred. Patients with severe to moderate disc height loss as well as those with symptomatic posterior annular defects with minimal disc height loss achieve functional gains and significant pain relief.”
(3.) TRANSFORAMINAL EPIDURAL STEROID INJECTIONS: (TFESIs)
Page 309 of the ACOEM guidelines classifies epidural steroid injections (ESI) for the treatment of radiculopathy (sciatica) as “optional,” although ACOEM did not differentiate between transforaminal epidural injections, caudal epidural injections, or translaminar epidural steroid injections.
Other research based guidelines, however, have more thoroughly investigated the efficacy of ESI and TFESI. More explicitly, after reviewing 7 randomized controlled trials, the authors of the ASIPP Guidelines concluded, “Based on the evaluation of multiple randomized and non-randomized trials, transforaminal epidural injections provided strong evidence for short-term and long-term relief .”
YES, THE INSURER HAS THE POWER:
As the insurer may or may not realize, the 24 visits Chiropractic, Physical Therapy and Occupational Therapy cap is not a hard cap or Legislative Cap, as so many UR doctors would like to believe. Labor Code § 4604.5 (d) (2) states:
This subdivision [LC 4604.5(d)(1)] shall not apply when an employer authorizes, in writing, additional visits to a health care practitioner for physical medicine services.
Therefore, the employer or the insurance company has the final say as to what the patient will receive in terms of future medical care, not the legislature.
CONCLUSION FOR MEDICAL CARE SUPPORT:
In conclusion, I prey that the insurance company will realize that the future care program I have recommended is safer, more efficacious, and more cost effective than traditional medical care would be and authorize (per Labor Code §4604.5(d)(2)) additional chiropractic care on a per exacerbation basis, hence allowing this patient to continue with a form of medical care that is provided for under the Californian Constitution and Labor Code 4601.
In conclusion I believe I have satisfied my reporting requirements under Labor Code §4604.5(e), Labor Code §4604.5(a), and Title 8 CCR §10606(n).
RECAPITULATION:
I have opined the forthcoming: (1) the patient has suffered a recurrent industrial injury to the lower back that has arisen out of and occurred in the course of his employment with XXX Brake Service; 2) the patient is permanent and stationary (3) Apportionment of the pre-existing injury and L5 disc space collapse is indicated by 10%; (4) Apportionment via Labor Code section 4664 is an issue; (5) Causation of the patient's permanent impairment and need for medical care was attached to his employment with Wright’s Brake Service; (6) the patient has suffered a 24% whole person impairment as described by the ROM AMA system; and (7) Dr. XXX, DC should continue to orchestrate care as the chosen PTP and should provide no more than 30 chiropractic treatment per year in order to maintain patient function and current pain levels.
If you have further questions, please feel free to contact me in writing at my San Jose, Tully road office at 1913 Tully Rd, San Jose, CA 95122.
REVIEW OF MEDICAL RECORDS:
REFERENCES:
Jinkins JR, Dworkin J. "Proceedings of the State-of-the-Art Symposium on Diagnostic and Interventional Radiology of the Spine, Antwerp, September 7, 2002 (Part two). Upright, weight-bearing, dynamic-kinetic MRI of the spine: pMRI/kMRI." JBR-BTR. 2003 Sep-Oct;86(5):286-93.
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.”
Los Angeles Times v. WCAB (2005) (Herbinger) 70 CCC 504 Writ Denied
Regents of the University of California, Lawrence Livermore National Laboratory, PSI v. WCAB (Macari) (2005) 70 CCC 1733 Writ Denied
Marlene Escobedo vs. Marshalls; and CNA Insurance (2005) 70 CCC 604 WCAB En Banc
Professor Nikolai Bogduk, MD, Multiple Volvo Award Winner ‘Evidence-Based Clinical Guidelines For The Management Of Acute Low Back Pain’ The Australasian Faculty of Musculoskeletal Medicine November 1999; Chapter 9
Torgerson WR, Dotter WE. Comparative roentgenographic study of the asymptomatic and symptomatic lumbar spine. J Bone Joint Surg 1976;58A:850-853.
Lee SW, et al. “Investigation of Vertebral Endplate Sclerosis.” Skeletal Radiol 2001 Aug;30(8):454-9.
Boos, N., Rieder, R., et al. "1995 Volvo Award in Clinical Sciences: The Diagnostic Accuracy of Magnetic Resonance Imaging, Work Perception, and Psychosocial Factors in Identifying Symptomatic Disc Herniations." Spine 1995; VOL. 20, NO. 24, December 15, 1995, pp. 2613-2625
Elfering A., Boos N. et al. "Young Investigator Award 2001 Winner: Risk Factors for Lumbar Disc Degeneration: A 5-Year Prospective MRI Study in Asymptomatic Individuals." Spine 2002; Volume 27, Number 2, pp 125–134
Videman T. et al. “Associations Between Back Pain History and Lumbar MRI Findings.” Spine: Volume 28(6) 15 March 2003 pp 582-588
Frymoyer J.W. et al. “Spine radiographs in patients with low-back pain. An epidemiological study in men.” J Bone Joint Surg Am. 1984 Sep;66(7):1048-55.
Torgerson WR, Dotter WE. Comparative roentgenographic study of the asymptomatic and symptomatic lumbar spine. J Bone Joint Surg 1976;58A:850-853.
Pfirrmann CW, Boos N, et al. "Magnetic resonance classification of lumbar intervertebral disc degeneration." Spine. 2001 Sep 1;26(17):1873-8.
Schneider GA, et al. "Evaluating Risk of Re-Injury Among 1214 Army Airborne Soldiers Using a Stratified Survival Model." Am J Prev Med 2000;18(3S):156–163)
Wasiak R. et al. “Work disability and costs caused by recurrence of low back pain: longer and more costly than in first episodes.” Spine: 2006 Jan 15;31(2):219-25
Labor Code section 4604.5 (a): “…The presumption is rebuttable and may be controverted by a preponderance of the scientific medical evidence establishing that a variance from the guidelines is reasonably required to cure or relieve the injured worker from the effects of his or her injury. The presumption created is one affecting the burden of proof.”
Giles LGF, Muller R. - Spine 2003;28(14):1490-1503
Muller R, Giles LG. - J Manipulative Physiol Ther. 2005 Jan;28(1):3-11.
Bertagnoli R, et al. "The treatment of disabling single-level lumbar discogenic low back pain with total disc arthroplasty utilizing the Prodisc prosthesis: a prospective study with 2-year minimum follow-up." Spine. 2005 Oct 1;30(19):2230-6.
Manchikanti L, Staats PS, Singh V, et al. "ASIPP GUIDELINES, section 6.2.3, page 37: Evidence-Based Practice Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain Physician." 2003;6:3-81, ISSN 1533-3159
Article XIV, section 4 of the California Constitution states in relevant part: “The Legislature is hereby expressly vested with plenary power, unlimited by any provision of this Constitution, to create, and enforce a complete system of workers’ compensation…”
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