JUSTIFICATION OF CHIROPRACTIC CARE

Health care providers are continually under the scrutiny of utilization and review to offer evidence-based information to validate the necessity of their services. This is particularly paramount in California where the workers’ compensation system has adopted the Occupational Medical Practice Guidelines published by the American College of Occupational and Environmental Medicine. States like Texas have high standards of medical necessity, wherein all treatment must be accompanied by treatment notes that are used to determine if care is appropriate. While this may at first appear daunting it is not as detrimental as it first appears, because the best evidence that your care is justified is the documented progress and outcome of the treatment provided. To do this, exams and progress notes must be done in as objective a manner as possible, demonstrating the functional changes realized, the bottom line, show that you made the patient better.

But let’s look at some evidence of the efficacy of care for chiropractic that can be used when you are requested to provide peer reviewed studies. The March/April 2004; 27(3):160-169 Journal of Manipulative and Physiological Therapeutics conducted a study on patients with acute and low back pain who had care at medical and chiropractic facilities. This study was done over a 4 year period and involved 2,780 patients. Chiropractic patients received spinal manipulation, physical therapy, exercise plans, and self care education. “Medical care” involved prescription medication, exercise plans, and self care advice; approximately 25% of the medical care group was referred to physical therapy.

Pain reduction and improvement in disability were observed in all groups. Most of the pain relief was achieved by the three month follow up and remained relatively constant through 12 months. However, pain and disability rose substantially between 12-24 months, and then plateaued through the 4 year follow-up.

Chiropractic was seen to have an advantage compared to a medical doctor in the first 12 months with clinical importance noted at 1 and 3 months for chronic patients. For acute patients there was an advantage for chiropractic in the first 12 months. In terms of pain levels the average VAS score was 12.2 points lower for chiropractic patients at the first month and 10.5 lower at 3 months. When leg pain was included in the analysis, chiropractic showed a greater advantage with pain levels on average 18.3-21.7 points lower than the medical treatment group. Disability levels (Oswestry scale) were 9.0-13.9 points lower over a three year period also. At the three year follow up patients receiving chiropractic care reported fewer days of low back pain than those treated by a medical doctor.

In terms of effectiveness chiropractic care demonstrated an advantage over medical care for acute and chronic patients particularly those with leg pain. Most relief was achieved within 3 months and sustained for 12 months.

UNDERSTANDING ACOEM - A PRACTICAL APPROACH

Assess patient for red flags. In the absence of red flags tests such as MRI, NCV, etc. are usually not necessary within the first 4-6 weeks of care.
Interpretation: Testing in the absence red flags typically will not change the course of conservative care and initial treatment. If there is no response to conservative care testing then may be necessary. If a positive test will not change the course of care the testing is contraindicated at that phase.

Maintain ordinary activity as much as possible. It leads to the most rapid recovery. Low-stress aerobic activity can be started after the first 2 weeks to avoid deconditioning. Stretching exercises can be useful to avoid further restriction of motion. Stabilization exercises can be used in early stages without aggravation of symptoms though specific strength exercises may be delayed for several weeks.
Interpretation: Transition to some form of active care as early as possible. Passive care, alone, is not efficacious beyond the acute phase.

The strongest medical evidence regarding potential therapies indicates that having the patient return to normal activities has the best long term outcome. Therapies should therefore be focused on restoring functional ability more than pain relief.
Interpretation: Patients need to feel responsible for their recovery not just the provider providing a “cure”. This process will promote ability, rather than pain as a guide. The treatment goal of returning to work and activities becomes more evident.

Pain is a symptom rather than a disease. Provider must assess pain in relation to objective findings.
Interpretation: Pain should be acknowledged but main focus is functional recovery. Pain that is not lessened with care but function is improved is effective. Pain reduction without functional change does not demonstrate effectiveness. Pain is perception, at least at some level. Patients must be given other aspects of focus.

Manipulation is safe and effective in the first few weeks of back pain without radiculopathy. In the acute phase it will enhance mobilization. If it does not bring about improvement in three to four weeks it should be stopped. Manipulation to symptoms longer than one month may be safe but efficacy is not proven. Trial manipulation with radiculopathy is an option.
Interpretation: Continued manipulation beyond one month or with radiculopathy must demonstrate the continuing functional change as a result of the care.

Physical modalities such as massage, heat, cutaneous laser, ultrasound, TENS, etc have no proven efficacy in acute symptoms. But they may have some value in the short term, if used in conjunction with a program of functional restoration.
Interpretation: These modalities may be useful in the proper phase of care but must have clear demonstration of their goals and the response to those goals based on functional improvement.

ACOEM guides only cover acute conditions
and do not apply to lifetime awards
Interpretation: Chronic conditions are “chronic” and, by definition, do not need care unless there is an acute episode or exacerbation. Therefore the ACOEM references can and will be applied to chronic lifetime award claims. Future medical care is not for maintenance or prevention but to relieve the effects of exacerbation.