Following the MD's letter is a response by David Gilkey, D.C., as requested by Mathew Snider, D.C., a member of the California State Board of Chiropractic Examiners.
May 14, 1992
Dear Practitioner:
To fulfill our mandate assuring quality care for our clients, State Compensation Insurance Fund will be monitoring usage of passive treatment modalities for uncomplicated low back pain.
There is a significant body of data indicating that after two weeks from onset of back pain, these modalities are ineffective and in some cases may actually delay recovery by fostering a dependent attitude. If you feel your patient needs passive modalities longer than two weeks, State Fund needs documentation of the treatment planned and the reasons for continuing them. Passive modalities would include diathermy, ultrasound, massage therapy, spinal manipulation, etc. This guideline does not apply to exercise based (active) physical therapy such as muscle strengthening and aerobic conditioning.
These guidelines are based upon current consensus medical opinions of spine medicine experts. (See, for example: Occupational Low Back Pain, Mosby Yearbook,1991, pages 186 and 187, and Managing Low Back Pain, Edition 2, Churchill Livingston, 1988, page 295.
Richard Martin, M.D.
Gideon Letz, M.D.
Division of Workers' Compensation
Industrial Medical Council
395 Oyster Point Blvd., Fifth Floor, Wing B
So. San Francisco, California 94080
Attn: Peter Lichty, M.D., M.O.H.
District Medical Director
Dear Dr. Lichty:
I have received a letter from Mathew Snider, D.C., a member of the California State Board of Chiropractic Examiners. Dr. Snider has asked that I respond to a letter dated May 14, 1992 that was signed by Drs. Martin and Letz of the State Compensation Fund.
I have great concern that these two consultants are attempting to intimidate doctors of chiropractic and their health care management of injured workers insured by the State Compensation Fund. Workers' Compensation law does not place specific time duration requirements on the management of back claims. Authority to directly treat and manage an injured worker must be the responsibility of the examining or treating physicians. This cannot be relegated to insurance consultants who have little or no knowledge of a specific case, and who have not had the benefit of examining or treating the injured worker.
These physicians site two references suggesting that two weeks of conservative management are sufficient for non-specific back pain. They indicate all passive therapies employed beyond two weeks to be ineffective and potentially deleterious, causing the delay in the recovery of the condition treated.
They have inappropriately placed chiropractic care, specifically spinal manipulation or adjustment, in the same category of passive therapies such as diathermy, ultrasound, massage, etc.
After taking the opportunity to review the texts referenced by Drs. Martin and Letz, I offer my comments: In Occupational Low Back Pain, by Pope et. al., chapter 9, page 184, by Drs. Andersson and Frymoyer, there are stated three main treatment goals for injured workers: 1) reduction of pain and discomfort; 2) rapid return to functional work; 3) avoidance of recurrent or persistent symptoms leading to chronicity. These are admirable and appropriate goals. They also point out on page 183, the majority of acute episodes of low back pain are non-traumatic and non-specific.
The authors do not characterize manipulation as part of modalities such as heat, cold, massage, diathermy, and ultrasound. Manipulation is discussed as a separate and distinct treatment form. Direct reference to manipulation on page 186 suggests the author's conclusion is that manipulation has its greatest effect in the first two weeks of an acute episode of low back pain. The authors are quick to point out the difficulty in establishing a clear effectiveness with manipulation as well as all other conservative or aggressive forms of care.
On page 189, these authors recommend treatment of uncomplicated or non-specific low back pain over a four to six weeks interval. They continue to speak of other forms of complicated syndromes which may not become evident until after the initial clinical trial regimen.
In Managing Low Back Pain by Dr. Karkaldy-Willis, chapter 17, page 287, by Drs. Cassidy and Karkaldy-Willis, they state, "Manipulation is an art that requires much practice to acquire the necessary skills and competence. Few medical practitioners have the time or inclination to master it." Doctors Karkaldy-Willis and Cassidy provide a rather extensive overview of manipulation and their experiences. On page 295, it is stated that daily treatment of less then two weeks duration is ineffective for chronic low back pain, and if no improvement is obtained after two weeks of care, further manipulation is less likely to provide benefit. On page 293, Dr. Karkaldy-Willis states that during his 30 years of practice, he has not seen a patient made worse with manipulation.
I believe Drs. Martin and Letz have misconstrued these most informative texts.
Chiropractic manipulation stands decidedly apart from other passive therapies. Chiropractic manipulation is characterized as dynamic and active therapy. Chiropractic manipulation serves to restore pathomechanical functioning of the vertebrae or motor units.
Generally, hypomobile segments are identified through physical examination and x-ray. Dynamic thrust techniques exceed passive and active joint parameters breaching the elastic barrier to the paraphysiological space. The dynamic stretching of the musculotendinous and ligamentous structures of the motor units results in reflex relaxation of hypertonic musculature as well as alleviation of pain.
While some non-specific mechanical back pain may in fact resolve in two weeks or less, it is presumptuous to link all non-disc or serious diagnoses to this expectation.
Stephen Sheer, M.D., author of Medical Prospectives and Vocational Assessment of Impaired Workers by Aspen Publications, page 20 says: "In 85 to 90 percent of the cases, workers with low back pain make a vocational recovery by six to 12 weeks."
The Ohio State Chiropractic Association has produced the Chiropractic Manual, page VIII-2, offering guidelines for care and management.
Acute Conditions:
Mild -- to 30 days
Moderate -- to 90 days
Severe -- to 5 months
Chronic Conditions:
Mild -- to 6 months
Moderate -- to 12 months
Severe -- to 18 months
In Principles of Practice, Second Edition, edited by Scott Haldeman, M.D., D.C., Ph.D., published by Appleton and Lang, pages 420-421, 1992, the author suggests there are substantial benefits of reduced pain and increased flexibility with spinal manipulation after two weeks of care. The author goes on to point out that daily treatment of less than two weeks duration is ineffective.
The Journal of Occupational Medicine, 3(8):847, August 1991, offers an article by Jarvis, D.C., et al. These authors analyze 3,062 claims in Workers' Compensation Fund of Utah. They concluded after direct comparison of ICD 9 codes that chiropractic care was superior. The lumbar strain diagnosis ICD 9 Code 847.2 compared medical management to chiropractic management and revealed that doctors of chiropractic treated approximately twice the frequency and duration. Their patients had 1/10 of lost time from work as did medically supervised patients. The total cost for chiropractic care was one-half of that compared to medical doctors. The average cost of medical care and management was $959 per case compared to chiropractic management of $523 per case.
The average duration of therapeutic involvement by medical physicians for non-specific strain diagnosis was 34 days and for chiropractic was 63 days. The treatment duration for specific ICD 9 Code 847.2 lumbar strain diagnosis was 26 days for the medical physicians and 50 days for the chiropractic physicians.
Therefore, the cost effective analysis is grossly in support of chiropractic management.
The implementation of spinal manipulation begins when a patient presents with an appropriate condition to a chiropractic office. An admitting diagnosis is made and therapeutic regimen is formulated. The treatment of algorithms is driven by response to care, improved function, and decreasing pain. An appropriate period of conservative care which included dynamic chiropractic spinal manipulation is four to six weeks. The literature tells us that the majority of problems will resolve in this initial treatment phase.
If the patient is improved but not resolved, the treating physician must reassess the condition and prescribe additional care. An additional therapeutic period is supervised. If treatment fails, secondary steps are observed to identify more detailed pathology or complicating factors.
In the presence of failed conservative efforts and 30 days of time, it is appropriate to refer the patient for a second opinion and further sophisticated diagnostic test as directed by the treatment algorithm.
If Drs. Martin and Letz are advocating two weeks of conservative care only and then referring to an orthopedic specialist or neurosurgeon, as well as obtaining MRI, CT scan or EMG testing, they will see an appreciable and unwarranted increase in the cost of all back care management.
It appears Drs. Martin and Letz are furthering their efforts at containing and controlling costs of back claims in workers' compensation handled by their employer State Compensation Fund, without regard or concern for the patient's well-being.
It is my perception that the authors of Occupational Low Back Pain and Managing Low Back Pain attempt to give an overview of scientific notions and research on the subject of low back pain. They are not attempting to formulate specific protocols for the convenience of Drs. Martin and Letz.
I would further venture to say that neither Drs. Martin nor Letz are licensed in chiropractic and are thus unqualified to offer an opinion regarding this discipline.
I am asking this agency to recognize blatant bias opinion with an attempt to discriminate against chiropractic in the State of California.
Labor Code Section 4600 permits injured workers the right to seek and receive chiropractic care without specific restriction of duration and frequency of care.
We must preserve the province of medical or chiropractic care to the authority of treating or consulting physicians who examine the injured workers firsthand.
We cannot permit paid physicians working for insurance companies who have no specific knowledge of each case to dictate treatment protocols.
I request a review of this matter involving State Compensation Fund and their two physicians, Drs. Martin and Letz. I request they be restrained in their efforts to intimidate treating physicians, either medical or chiropractic, in the State of California.
David P. Gilkey, D.C., FACO
San Jose, California
Dr. David Gilkey is associate professor of ergonomics in the Department of Environmental and Radiological Health Sciences and the distance-education coordinator for ergonomics training at Colorado State University. Dr. Gilkey earned his DC degree from Southern California Health Sciences University and his PhD from CSU with a focus in occupational ergonomics related to low back injury prevention.