Intervention & Implementation Research, Institute of Environmental Medicine, Karolinska Institutet, Nobels väg 13, Stockholm 171 77, Sweden

Background   Low back pain (LBP) is a prevalent condition and has been found to be recurrent and persistent in a majority of cases. Chiropractors have a preventive strategy, maintenance care (MC), aimed towards minimizing recurrence and progression of such conditions. The indications for recommending MC have been identified in the Nordic countries from hypothetical cases. This study aims to investigate whether these indications are indeed used in the clinical encounter.

Methods   Data were collected in a multi-center observational study in which patients consulted a chiropractor for their non-specific LBP. Patient baseline information was a) previous duration of the LBP, b) the presence of previous episodes of LBP and c) early improvement with treatment. The chiropractors were asked if they deemed each individual patient an MC candidate. Logistic regression analyses (uni– and multi-level) were used to investigate the association of the patient variables with the chiropractor’s decision.

Conclusions   The study largely confirms the clinical use of the previously identified indications for recommending MC for recurrent and persistent LBP. Previous episodes of LBP was the strongest indicator.

There are many similar studies in our new

Maintenance Care, Wellness and Chiropractic Page

By Vern Saboe, DC, DACAN, DABFP, FACO
Lobbyist, Oregon Chiropractic Association

The new State of Oregon Evidence-Based Clinical Guidelines for the Evaluation and Management of Low Back Pain recommends spinal manipulation as the only nonpharmacological treatment for acute lower back pain. The guidelines, which have been adopted by the Oregon Health Authority, are a collaborative effort between the Center for Evidence-Based Practice, Oregon Corporation for Health Care Quality, Oregon Health and Sciences University’s Center for Evidence-based Policy, and the new Oregon Health Evidence Review Commission.

The Oregon Chiropractic Association (OCA) repeatedly gave written and oral testimony that the original draft guidelines placed too much emphasis on drugs and surgery. A close review of the original algorithm, “Management of Low Back Pain (LBP) (Image 2), relative to “#23 Signs or symptoms of radiculopathy or spinal stenosis,” reveals this. For example, if subsequent special imaging (MRI) revealed concordant nerve root impingement or spinal stenosis (#25), the original draft algorithm led the clinician into a surgical or other invasive procedure “dead end,” meaning there was no contingency for conservative chiropractic treatment (#26).

By Daniel Redwood

When new research, research reviews or practice guidelines support our current beliefs and practices, enthusiasm comes easily. When the 2007 medical practice guidelines on low back pain (LBP) jointly prepared by the American Pain Society and the American College of Physicians recognized spinal manipulation as the only non-pharmacologic method providing “proven benefits” for acute LBP and as one of several methods (including exercise, rehabilitation, acupuncture and yoga) proven effective for chronic LBP, the American Chiropractic Association and doctors of chiropractic (DCs) everywhere welcomed this as a long-overdue recognition of the value of our primary treatment methods.

But when research challenges our assumptions, our responses are understandably mixed. Such findings, if confirmed in multiple studies, may create pressure to change our practice patterns or threaten reimbursement from insurance companies. Like members of other health professions, DCs do not find such developments pleasant. How we and members of other health professions respond to such research says a great deal about who we are, how fully we practice what we preach, and the depth of our commitment to providing the best possible care to our patients.

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University of Pittsburgh Medical Center Health Plan mandates conservative care before even considering surgery for chronic Low Back Pain cases.

By Peter W. Crownfield

The University of Pittsburgh Medical Center (UPMC) Health Plan, a health maintenance organization affiliated with the university’s School of Medicine, has adopted landmark guidelines for the management of chronic low back pain.

As of Jan. 1, 2012, candidates for spine surgery must receive “prior authorization to determine medical necessity,” which includes verification that the patient has “tried and failed a 3-month course of conservative management that included physical therapy, chiropractic therapy, and medication.”

Surgery candidates also must be graduates of the plan’s LBP health coaching program. The program features a Web-based decision-making tool designed to help plan members “understand the pros and cons of surgery and high-tech radiology.” It is the first reported implementation of such a policy by a health care plan.

Putting a Clamp on the Soaring Rates of Spine Surgery

According to the December 2011 issue of the UPMC Health Plan Physician Partner Update, which informed participating providers of the new guidelines and the rationale for their implementation, “We feel strongly that this clinical initiative will improve the quality of care for members who are considering low back surgery, and that it will facilitate their involvement in the decision-making process.”

The update also noted, “Surgical procedures for low back surgery performed without prior authorization will not be reimbursed at either the specialist or the hospital level.”

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Tina Beychok, Associate Editor

Pain is the most prevalent health condition among U.S. workers and the most expensive in terms of lost productivity. Recent studies suggest more than six in 10 adults over the age of 30 experience chronic pain. Furthermore, health care expenditures for back and neck pain have risen to more than $80 billion a year in the U.S. – a dramatic increase over the past eight years, without evidence of improved health. In addition to the costs of lost productivity, an estimated $64 billion per year is lost due to workers continuing to work, even though pain reduces their job performance. This phenomenon is called “presenteeism.”

Unfortunately, workers’ comp can be a quagmire of contradictory and insufficient rules and regulations as to what treatments are and aren’t covered. The American College of Occupational and Environmental Medicine (ACOEM) has been in the process of revising its Occupational Medicine Practice Guidelines, which have not always taken a positive view of chiropractic manipulation. In fact, the second edition of the guidelines, released in 2005, was heavily criticized by some in the chiropractic community. [1]

ACOEM’s latest chronic pain guidelines (a chapter of the overall guidelines) may represent a step in the right direction in terms of recognizing the value of chiropractic care. The guidelines actually recommend manipulation for chronic, persistent low back or neck pain and cervicogenic headache. [2] This is significant because in the past, the guidelines failed to recommend manipulation, even when other treatment strategies (medication, etc.) were rated as less effective.

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By: Lynn Shaw, Martin Descarreaux, Roland Bryans, Mireille Duranleau, Henri Marcoux, Brock Potter, Rick Ruegg, Robert Watkin, Eleanor White

Authors’ Abstract:

The literature relevant to the treatment of Whiplash Associated Disorders (WAD) is extensive and heterogeneous.

Methods: A Participatory Action Research (PAR) approach was used to engage a chiropractic community of practice and stakeholders in a systematic Review to address a general question: ‘Does chiropractic management of WAD clients have an effect on improving health status?’ A systematic review of the empirical studies relevant to WAD interventions was conducted followed by a review of the evidence.

Results: The initial search identified 1155 articles. Ninety-two of the articles were retrieved, and 27 articles consistent with specific criteria of WAD intervention were analyzed in-depth. The best evidence supporting the chiropractic management of clients with WAD is reported. For the review identified ways to overcome gaps needed to inform clinical practice and culminated in the development of a proposed care model: The WAD-Plus Model.

Conclusions: There is a baseline of evidence that suggests chiropractic care improves the cervical range of motion (cROM) and pain in the management of WAD. However, the level of this evidence relevant to clinical practice remains low or draws on clinical consensus at this time. The WAD-Plus Model has implications for use by chiropractors and interdisciplinary professionals in the assessment and management of acute, sub-acute and chronic pain due to WAD. Furthermore, the WAD-Plus Model can be used in the future study of interventions and outcomes to advanced evidenced-based care in the management of WAD.

You may also enjoy our: Whiplash Page

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Part III:   Mastering the
Evaluation & Management (E&M) Guidelines

Jump to:   Part 1 or Part 2

FROM:   Chiropractic Economics

By Kathy Mills Chang, MCS-P

The medical decision making component ties it all together.

Welcome to part three this focus series on the evaluation and management (E/M) guidelines. This will wrap up what you need to know to stay compliant with E/M coding for the Centers for Medicare and Medicaid Services (CMS).

In the last installment, the elements of your patient’s examination were reviewed and you learned how it is the second of the three key elements of the patient’s E/M service. Now, the third part of this E/M documentation series will unravel the final component of the E/M code: medical decision making (MDM). For chiropractors, this is usually the diagnosis and treatment plan.

Three key components of the E/M guidelines:

1. Patient history

2. Examination
3. Medical Decision Making (MDM)

Remember that your patient’s medical record should establish a chronological record of exams, tests and results, and treatments and treatment plans (including the diagnosis and prognosis of the illness or disease). The medical record should corroborate the reimbursement request and is requisitioned by most payers for adjudication of claims when reimbursement is in question.

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Part II:   A Closer Look at Evaluation & Management (E&M) Guidelines

Jump to:   Part 1 or Part 3

FROM:   Chiropractic Economics

By Kathy Mills Chang, MCS-P

Make sure you know how to fulfill the “examination” component. In part one of this series, the components of a patient’s history were reviewed, and you learned how it is the first of three elements that help you justify and document your evaluation and management (E/M) service. In the second part of this series, you’ll learn about the objective information required to properly document the examination.

Remember, the medical record establishes a chronological record of exams; tests and results; treatments; and treatment plans, including the diagnosis and prognosis of the illness or disease. Its job is to corroborate the reimbursement request and is requisitioned by most payers for adjudication of claims when reimbursement is in question.

For this reason, your medical record is a vital piece of the reimbursement puzzle, too. Understanding all the requirements, including those of the examination, is critical.

There are four levels of E/M services that are based on four types of examinations:

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Part I:   The 3 Key Components of the Evaluation & Management (E&M) Guidelines

Jump to:   Part 2 or Part 3

Chiropractic Economics

By Kathy Mills Chang, MCS-P

As regulatory and insurance guidelines tighten, the quality of your evaluation and management documentation is more important than ever before.

Just like a great story, the patient’s notes for an episode of care must have a beginning, middle, and end. This article is a review of the first of three parts of evaluation and management (E/M) documentation, and its focus is on the beginning of the patient’s story — the history. More information on the next two key E/M components will be presented in future issues of this magazine.

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Background: Neck pain (NP) is a common cause of disability. Accurate and efficacious methods of diagnosis and treatment have been elusive. A diagnosis-based clinical decision guide (DBCDG; previously referred to as a diagnosis-based clinical decision rule) has been proposed which attempts to provide the clinician with a systematic, evidence-based guide in applying the biopsychosocial model of care. The approach is based on three questions of diagnosis. The purpose of this study is to present the prevalence of findings using the DBCDG in consecutive patients with NP.

Methods: Demographic, diagnostic and baseline outcome measure data were gathered on a cohort of NP patients examined by one of three examiners trained in the application of the DBCDG.

Results: Data were gathered on 95 patients. Signs of visceral disease or potentially serious illness were found in 1%. Centralization signs were found in 27%, segmental pain provocation signs were found in 69% and radicular signs were found in 19%. Clinically relevant myofascial signs were found in 22%. Dynamic instability was found in 40%, oculomotor dysfunction in 11.6%, fear beliefs in 31.6%, central pain hypersensitivity in 4%, passive coping in 5% and depression in 2%.

Conclusion: The DBCDG can be applied in a busy private practice environment. Further studies are needed to investigate clinically relevant means to identify central pain hypersensitivity, oculomotor dysfunction, poor coping and depression, correlations and patterns among the diagnostic components of the DBCDG as well as interexaminer reliability, validity and efficacy of treatment based on the DBCDG.

This hospital-based study is interesting for several reasons:

• First, they utilized an evidence-based program for treating low back pain (LBP)
• Based on that evidence, they assigned 83% of those who sought care to chiropractic management.
• Results for the patients treated by doctors of chiropractic were mean of 5.2 visits, mean cost per case of $302, and
• 95% of those patients rated their care as “excellent.”

The Abstract:

OBJECTIVE: A health care facility (Jordan Hospital) implemented a multidimensional spine care pathway (SCP) using the National Center for Quality Assurance (NCQA) Back Pain Recognition Program (BPRP) as its foundation. The purpose of this report is to describe the implementation and results of a multidisciplinary, evidence-based, standardized process to improve clinical outcomes and reduce costs associated with treatment and diagnostic testing.

METHODS: A standardized SCP was developed to improve the quality of back pain care. The NCQA BPRP provided the framework for the SCP to determine the standard of quality care delivered. Patients were triaged, and suitable patients were categorized into 1 of 5 classifications based upon history and examination, directional exercise flexion or “extension biases,” spinal manipulation, traction, or spinal stabilization exercises.

RESULTS: The findings for 518 consecutive patients were included. One hundred sixteen patients (10%) were seen once and triaged to specialty care; 7% of patients received magnetic resonance imagings. Four hundred thirty-two patients (83%) were classified and treated by doctors of chiropractic and/or physical therapists. Results for the patients treated by doctors of chiropractic were mean of 5.2 visits, mean cost per case of $302, mean intake pain rating score of 6.2 of 10, and mean discharge score of 1.9 of 10; 95% of patients rated their care as “excellent.”

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Toronto, June 18, 2010 – A new neck pain guide offers a concise summary on both helpful and unhelpful approaches to treating Neck Pain, based on the evidence synthesis completed by the Bone and Joint Decade 2000-2010 Task Force on Neck Pain. IWH worked with the Canadian Memorial Chiropractic College, the Ontario Chiropractic Association and some members of the task force’s executive committee to prepare the summary.

In February 2008, Spine published a special edition dedicated to the task force’s reviews on the prevention, prognosis, diagnosis and management of neck pain. After publication, a network of Canadian chiropractic opinion leaders, coordinated by IWH, suggested distilling the evidence into a summary. “It’s exciting to see the chiropractic community take up the work of the task force this way,” says Dr. Sheilah Hogg-Johnson, a task force member and IWH senior scientist. “The Neck Pain Evidence Summary provides a way for health-care professionals to review the evidence easily in their practice, and if they need further information, they can refer to the full research papers.”The task force recommends treatments or further assessments, based on the severity of neck pain. They classified severity into four grades. In the Evidence Summary, a chart outlines the signs and symptoms, and further assessments for each grade. Then both helpful and unhelpful treatments are presented by grade and type of injury.

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A February 2010 study of 3,533 general practice low back pain patients found that many providers are not following their own evidence based guidelines. [1] Guidelines do provide the overall best evidence but are not meant to be a cookbook approach to care. There is also a need for flexibility so the physician can deviate from guidelines when the specific needs and desires of the patient dictate. In addition, the clinical judgment of the physician may override the guidelines when in a particular patient’s case they are inappropriate.

There is, however, reason for concern when risky and or expensive unneeded procedures are used. The medical guideline for acute low back pain call for advice and analgesics, but 80% of the 3,533 patients in this study were not given advise and 82% were not given analgesics. More harmful medications that are not recommended in the guidelines were prescribed, with 37% getting anti-inflammatory drugs and ~20% opiods.

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