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MRI Atlanta

2012-02-14T08:11:00.000-08:00

The clinical correlation with MRI is always a source of further questions – so enjoy.

NOT ALL LUMBAR DISC HERNIATIONS CAUSE PAIN: Over the last 20 years there was a ‘craze’ of MRI and CT studies done on asymptomatic people from all walks of life. It was discovered that a significant number of these ‘pain-free’ people had disc bulges, and disc protrusions (aka: contained herniations) on MRI and CT despite the fact that they had no lower back pain at all! (1-8)

The hypothesis that these asymptomatic people, because of the presents of an asymptomatic disc herniation on MRI, would soon develop symptomatic low back pain and/or sciatica was shot down in flames in 2001 by Borenstein G, Boden SD, Wiesel SW, et al. More explicitly, these false positive herniation people were followed for 7 years to see if they would become symptomatic: they didn't (7).

In 1995 Fraser et al. conducted a follow-up MRI study on a group of symptomatic disc herniation patients who were randomized to receive either chymopapain injection, or placebo (saline) injection into the herniated disc. Ultimately, 1/3 of the patients ended up having laminectomy, 1/3 had the chymopapain, and 1/3 had the placebo. Surprisingly, about 37% of each group still had the disc herniation at 10 year follow-up; however, there was no relationship between the presents of persistent disc herniation and the degree of patient satisfaction! In other words, some of the patients who were feeling great still had the herniation! (26)

More recently, in 2005 Masui et al. published an investigation into the clinical outcome of 27 patients who were treated conservatively (non-surgically) for symptomatic lumbar disc herniation. Follow-up MRI studies were completed at 2 and 7 years. At 7 years, there was progressive disc degeneration in all patients; however, there was no predictive correlation between MRI findings and the continuation of pain. The authors concluded, "Clinical outcome did not depend on the size of herniation or the grade of degeneration of the intervertebral disc in the minimum 7-year follow-up." (27)

Let's review some of the more scientific investigations in MRI False Positives:

Boden et al. 1990: In a very often quoted study, Boden et al. performed MRI on 67 patients that had never had lower back pain before. They found that 20% of these asymptomatic people under the age 60 had MRI evidence of disc herniation. On the group that was over 60 years old, 37% had confirmed disc herniations and 21% had spinal stenosis despite having no pain. Unfortunately, these investigators failed to differentiate between a protrusion (aka: contained herniation) and an extrusion (non-contained herniation). Also of interest was the fact that 35% of these asymptomatic people between the ages of 20 and 39 had degenerative disc disease with or without a disc bulge (2)

Jenson & Modic et al. 1994: In a bigger and better designed study that was published in the prestigious New England Journal of Medicine in 1994, Jenson et al. found that 52% of the 98 asymptomatic patients in their study demonstrated a disc bulge on MRI; 27% demonstrated a disc protrusion. Only 1% of the patients had a full blown disc extrusion which demonstrates that MRI is quite accurate for detecting disc extrusions. Out of all 98 volunteers, 64% had an abnormal disc on MRI (bulge, protrusion, and/or extrusion). Also of interest, were the following findings in these asymptomatic subjects: disruption of the outer fibers of the anulus, 14%; degenerative disease of the facet joints, 8%; spondylolysis, 7%, spondylolisthesis, 7%; and central stenosis 7%. (1)

Weishaupt & Boos et al. 1998: In 1998, Weishaupt and Boos et al. randomly collected a group of 60 people (hospital works and non-spinal patients) that had never had back pain before. Twenty people were in their 20's, twenty people were in their 30's, and the final twenty people were in their 40's; this brought the average age of the study to 35 years old. (a very young group) Each patient was put through an MRI and the results were interpreted by two different radiologists.

Here's what they found: 24% of the group had a 'disc bulge'; 40% had confirmed disc protrusion; 18% had disc extrusion - which is a severe form of disc herniation; and 0% had disc sequestration. With respect of nerve root compression, 23% had nerve root contact without displacement, 5% had actual displacement of the nerve root (disc disc herniation) without severe physical compression, and 2% demonstrated full-blown nerve root compression.

Boos et al. 1995 Volvo Award Winner:

In 1995, Dr. Norbert Boos won yet another prestigious Volvo Award for his work with 'high-risk' asymptomatic volunteers and MRI false-positives. These investigators took a group of 46 ‘high-risk’ asymptomatic people and scanned their lumbar spine with MRI. All of these volunteers had job duties that are known to be 'high-risk' for the development of symptomatic disc herniation, debilitation, and surgery. These jobs duties included frequent bending, frequent twisting, frequent heavy lifting, frequent contact with vibration, and sedimentary work.

The results indicated that 76% of these asymptomatic, high-risk people had at least one disc herniation (protrusion or extrusion) on MRI; however, noteworthy is the fact that only 13% of these disc herniations were the more severe type of herniation, the extrusion, and no disc sequestrations were found in the asymptomatic group. With respect to nerve root compression by the disc herniation, 17% of the asymptomatic people had minor root “compromise” (defined as contact or deviation of the root) while only 4% had 'major compromise' (defined as compression of the root).

With respect to confirmed Degenerative Disc Disease (DDD) on MRI, 85% of the asymptomatic group had confirmed disc degeneration (aka: DDD) at at least one level, i.e., Grade 3, 4, or 5 type as defined by Pearce et al. This study demonstrates that disc herniation alone does not equate to back and/or leg pain. Seventy-six percent of these high-risk, asymptomatic patients demonstrated disc protrusion or even extrusion (13%) on MRI, yet had no back or leg pain! Obviously, there are other factors that contribute to the phenomenon of sciatica.

CERVICAL MRI: Correlates better with symptomatic disc herniation than lumbar MRI.

Unlike lumbar MRIs, cervical MRIs rarely demonstrate false positives for disc herniation. More explicitly, in 2004 Giuliano et al. performed Cervical MRIs on 100 asymptomatic (people with no neck pain) volunteers and 100 symptomatic (pain-suffering) patients that were in the subacute phase post rear-end motor vehicle accident. The results indicated only 2% (2/100) of the asymptomatic volunteers demonstrated a false-positive disc herniation on MRI; on the other hand, 28% of the symptomatic whiplash patients demonstrated disc herniation on MRI. (517)

DEGENERTIVE DISC DISEASE:

Boden et al. (25) noted a 51% incidence of lumbar disc degeneration in asymptomatic 40-59 year old people. Jarvik et al. (20) noted a 49% incidence of lumbar disc degeneration in asymptomatic 45- to 55-year-olds.

1) Jensen MC, et al. “MRI imaging of the lumbar spine in people without back pain.” N Engl J Med – 1994; 331:369-373

2) Boden SD et al. “Abnormal magnetic resonance scans of the lumbar spine in asymptomatic subjects: A prospective investigation.” J Bone Joint Surg Am 1990; 72A:403-408

3) Weishaupt D et al. “MRI of the lumbar spine: Prevalence of intervertebral disc extrusion and sequestration, nerve root compression and plate abnormalities, and osteoarthritis of the fact joints in Asymptomatic Volunteers.” Radiology – 1998; 209:661-666

4) Boos N, et al. “1995 Volvo Award in clinical science: The diagnostic accuracy of MRI, work perception, and psychosocial factors in identifying symptomatic disc herniations.” Spine – 1995; 20:2613-2625

5) Powell MC, et al. “Prevalence of lumbar disc degeneration observed by magnetic resonance in symptomless women.” Lancer – 1986; 2:1366-7

6) Boos N, et al. “Natural history of individuals with asymptomatic disc abnormalities in MRI: Predictors of low back pain-related medical consultation and work incapacity.” Spine 2000; 25:1484

7) Borenstein G, Boden SD, Wiesel SW, et al. “The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic individuals: A 7-year follow-up study. J Bone Joint [am] 2001; 83:320-34

8) Wiesel SW, et al. “A study of computer-associated tomography: I. The incidence of positive CAT scans in asymptomatic group of patients.” Spine 1984;9:549-51

11) Wood KB, et al. 'Magnetic resonance imaging of the thoracic spine. Evaluation of asymptomatic individual s.' J Bone Joint Surg Am. 1995 Nov;77(11):1631-8

20) Jarvik JJ, et al. "The longitudinal assessment of imaging and disability of the back (LAIDBack) Study." Spine 2001;26: 1158-66.

25) Boden SD, et al. "Abnormal Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatci Subjects." J Bone Joint Surg [AM] 1990; 72:403-408

26) Fraser RD, Sandhu A, Gogan WJ. 'Magnetic resonance imaging findings 10 years after treatment for lumbar disc herniation.' Spine 1995 Mar 15;20(6):710-4. "The findings of this study indicate that long-term improvement of a patient's symptoms after treatment of disc herniation may occur with or without resolution of the hernia. This and the similar morphologic findings in the different groups is consistent with the 10-year clinical results after the treatment of disc herniation reported by Weber."

27) Masui T, et al. 'Natural History of Patients with Lumbar Disc Herniation Observed by Magnetic Resonance Imaging for Minimum 7 Years.' J Spinal Disord Tech. 2005 Apr;18(2):121-126. "Clinical outcome did not depend on the size of herniation or the grade of degeneration of the intervertebral disc in the minimum 7-year follow-up."

517) Giuliano V, et al. 'The use of flexion and extension MR in the evaluation of cervical spine trauma: initial experience in 100 trauma patients compared with 100 normal subjects.' Emerg Radiol. 2002 Nov;9(5):249-53.

Georgia chiropractors

2012-02-12T06:42:00.000-08:00

Select Georgia Law

The scope of practice for

Georgia

chiropractors was completely revised and updated in 2007. Within this new scope of practice was a provision concerning chiropractic review agents.

GA Code Section 43-9-1 (3) 'Practice of chiropractic' shall also include peer review which is defined as the procedure by which chiropractors licensed in the state of Georgia evaluate the quality and efficiency of services ordered or performed by other chiropractors, including but not limited to practice analysis, audit, claims review, underwriting assistance, utilization review, and compliance with applicable laws, rules, and regulations.

Chiropractic Review Agent - GA Code Section 43-9-1

Evaluate the quality and efficiency of services ordered or performed by other chiropractors, including but not limited to:

Practice Analysis

Audits

Claims Review

Underwriting Assistance

Utilization Review

Compliance with applicable laws, rules & regulations.

Board Rule 100-17-.01 Review Agent.

(1) For purposes of this rule “Review Agent” means any person rendering a professional chiropractic written or verbal opinion, which has the capacity or intent of affecting the frequency, duration, necessity, or outcome of chiropractic treatment or patient care and who is being compensated by a 3rd party payer or other contractual parties.

(2) Chiropractic care shall include offering or rendering a professional chiropractic written or verbal opinion, which has the capacity or intent of affecting the frequency, duration, necessity, or outcome of chiropractic treatment or patient care.

*There are presently 16 Doctors of Chiropractic accepted by the Georgia Board of Chiropractic Examiners as “Review Agents”.

100-7-.04 Standards of Practice

(d) It shall be considered unprofessional conduct to deny care for a covered condition or service by a review agent when there is a reasonable expectation for improvement or the patient is demonstrating a reasonable rate of improvement. A reasonable rate of improvement would be influenced by condition chronicity, patient age, co-morbid factors, frequency of care and exposure to activities that would impede progress.

(e) It shall be considered unprofessional conduct to deny care for a covered condition or service by a review agent for care to prevent the deterioration of a condition once the patient has achieved maximum clinical improvement, if sufficient evidence exists demonstrating that reduction or withdrawal of care has and will continue to have a deleterious effect on the patient.

Medical causation must be proved to a reasonable degree of medical certainty and cannot be based on mere speculation. Cannon v. Jeffries, 250 Ga. App. 371, 372 (1) (551 S.E.2d 777) (2001).

When should a review Agent be contacted?

1) When there is no clinically significant reduction in symptoms over a 4-6 week period.

2) When there is a reduction in symptoms with no reduction in frequency of care.

3) When there is a diagnosis in one region but the doctors is treating more than that region.

4) When there is more than three modalities performed in one visit.

5) When there is only passive care and treatment for more than 4 weeks.

6) Charges for range of motion testing on multiple visits.

7) Treatment plans longer than 3 months.

8) Fraud investigations.

9) Impairment rating given before MMI is reached.

10) TENS unit or other equipment given on the first visit.

11) Notes do not document therapy to standards.

12) X-ray of multiple areas that have no symptoms or redundant x-rays.

13) Little if any notes provided to document care.

14) Pre existing conditions.

15) All permanent impairment or disability ratings.

16) Gaps or delay in care.

17) Multiple accidents or injuries.

18) Charges appear excessive.

19) Treatment of family members.

20) Digital X-ray Analysis & other “special” testing.

21) Notes appear to be redundant or “canned”.

22) Low speed collisions with significant injury reported.

23) Reported pain and disability is not proportional to the documented injury.

24) Court cases

25) Depositions

26) Causation or apportionment is an issue.

27) Scope of practice issues.

28) Independent exams or records reviews.

29) Clinical correlation

30) “Unique” cases.

You Are Amazing

2012-02-11T15:51:00.000-08:00

The body is one of the great wonders of the universe!

Did you know?

- There are 45 miles of nerves just in your skin.
- You are about 70 percent water.
- Your body has about 5.6 liters (6 quarts) of blood.
- In the brain there are 1,000,000,000,000 (a million million) individual nerve cells.
- There are more synapses in the brain than there are stars in the universe.
- You enteric nervous system (Gut brain) has over 100 million neuron.
- You give birth to 100 billion new red cells every day.
- Your brain generates more electrical impulses than all of the world's telephones.
- Your lungs inhale over two million liters of air every day.
- Your 5.6 liters of blood circulates through the body three times every minute.
- In 24 hours, the blood in your body travels a total of 12,000 miles.
- Nerve impulses to and from the brain travel as fast as 170 miles per hour.
- The tooth is the only part of you that can't repair itself.
- The life span of a taste bud is ten days.
- Your brain consumes 20 percent of the body’s energy.

Stone Mountain Chiropractor, Atlanta Chiropractor, Injury Doctor

2012-02-10T06:07:00.000-08:00

Apportionment

2012-02-08T06:41:00.000-08:00

5. Apportionment

Once causation is determined and there is probable cause related to the event, then apportionment is evaluated. If there is no causal relationship then apportionment is not necessary.

American Medical Association: Guides to the Evaluation of Permanent Impairment, fifth edition. Chicago, AMA 2001

The extent to which each of 2 or more probable causes are found responsible for an effect (injury, disease, impairment, etc..)

American Medical Association: Disability Evaluation, second edition. Chicago, AMA 2003.

A distribution of causation among multiple factors that caused or significantly contributed to the injury and resulting impairment.

American Medical Association: Guides to the Evaluation of Permanent Impairment, sixth edition. Chicago, AMA, 2008

Precipitation - Injury or exposure causes a “latent” or potential disease process to become manifested.

Acceleration - Injury or exposure hastens the clinical appearance of an underlying disease process.

Aggravation - A permanent worsening of a prior condition by a particular event or exposure.

Exacerbation - A temporary worsening of a prior condition by an exposure / injury.

Recurrence - Signs and symptoms attributable to a prior illness or injury occur in the absence of a new provocative event.

American Medical Association: Disability Evaluation, second edition. Chicago, AMA 2003, page 99 -100.

The phrase "pre-existing condition" often causes confusion.

There are only two types of pre-existing conditions. The first is known as an "inactive" or "dormant" pre-existing condition. The second is known as an "active" or "symptomatic" pre-existing condition.

The difference between an active vs. inactive pre-existing conditions is "like night and day."

This may require a detailed review of past and present medical records.

Inactive pre-existing condition is if there is no evidence that a pre-existing condition is causing pain or disability before trauma is sustained.

The "proximate cause" of the present symptoms is the recent trauma, even though the symptoms may be worse or healing may take longer because of a pre-existing condition.

Besides classifying the apportionment it may also be necessary and beneficial to relate the percentage that the present condition or impairment is attributable to the new injury or event. To do this there must be:

Documentation of a prior factor.
Current impairment is greater than the prior factor (prior impairment, prior injury or illness).
There is evidence that the prior factor caused or contributed to the impairment, based on reasonable probability.

Causal Relationship

2012-02-05T06:39:00.000-08:00

4. Causal Relationship

Medical causation must be proved to a reasonable degree of medical certainty and cannot be based on mere speculation.

An identifiable factor (accident) that results in a medically identifiable condition ( injury or illness).

American Medical Association: Guides to the Evaluation of Permanent Impairment, fifth edition. Chicago, American Medical Association 2001

Causal opinions in reports and testimony must be given in terms of reasonable medical probability or certainty. (more probably than not).

American Medical Association: Disability Evaluation, second edition. Chicago, AMA 2003.

Probability, simply means that something is more likely than not (51% or greater). If the confidence is equal to or less than 50% it is merely a possibility.

American Medical Association: Guides to the Evaluation of Permanent Impairment, sixth edition. Chicago, American Medical Association, 2008

Criteria for Asserting the Existence of a Causal Relationship

Temporal Relationship Cause should come before effect. The interval between the two should be consistent with what is found in reports or studies of similar injuries.

Mechanism Must be anatomically and physiologically plausible.

Contiguity Should be a clear relationship between cause and effect, with an increase in exposure (dose or duration) leading to an increase in effect

Consistency Exposure should consistently cause the disease or injury under investigation.

Specificity Should be a relative absence of other factors or conditions which “explain” the disease.

Coherence Presumption of work-relatedness in an individual case or documented injury should be consistent with the medical literature.

American Medical Association: Disability Evaluation, second edition. Chicago, AMA 2003.

A causal relationship is biologically plausible when:

• The relationship between the medical condition and the injury can be explained anatomically or physiologically.

• The duration, intensity, or mechanism of exposure or injury was sufficient to cause the illness or injury in questions.

• There is evidence suggesting that the exposure is consistently or reliably associated with the process under investigation in the population under investigation or in peer-reviewed literature.

• Cause and effect are contiguous.

• There is literature providing biologic or statistical evidence indicating that the symptoms or disorder could develop as a result of the exposure (coherence).

• There is specificity of the association for the injury (i.e., the absence of other factors)

Combinations, of direct trauma and a preexisting disease process are more difficult to assess for causality and apportionment. One must determine, if the requirements of temporal relationship, biologic plausibility, literature support, and sufficient injury have been met. This includes and assessment of whether the trauma would have caused the disease in the absence of the preexisting process. American Medical Association: Disability Evaluation, second edition. Chicago, AMA 2003, page 99 -100.

Clinical Correlation

2012-02-03T06:38:00.000-08:00

3. Clinical Correlation

Clinical correlation validates that the diagnosed conditions are the cause of the complaints or symptoms.

False Positive Rates for Lumbar MRI

Coincidental Findings in pain free patients

Asymptomatic (no pain) Under 60 years old

– Bulging disc: 33%

– Herniated disc: 20%

Asymptomatic (no pain) Over 60 years old

– Degenerative changes: 100%

– Bulging disk: 80%

– Herniated disk: 33%

– Spinal stenosis: 20%

*Cervical MRI correlates better with symptomatic disc herniation than lumbar.

Unlike lumbar MRIs, cervical MRIs rarely demonstrate false positives for disc herniation. In 2004 Giuliano et al. performed Cervical MRIs on 100 asymptomatic (people with no neck pain) volunteers and 100 symptomatic (pain-suffering) patients that were in the subacute phase post rear-end motor vehicle accident.

The results indicated only 2% of the asymptomatic volunteers demonstrated a false-positive disc herniation on MRI; on the other hand, 28% of the symptomatic whiplash patients demonstrated disc herniation on MRI.

Clinical correlation validates that the diagnosed conditions are the cause of the complaints or symptoms.

Diagnosis

2012-01-31T06:36:00.000-08:00

2. Diagnosis

In 80% of cases the cause of pain cannot be established.

Quebec Task Force on Spinal Disorders: Spine 1987; 12:S1-S59

85% of pain patients lack a specific diagnosis.

Deyo et al: JAMA 1992;268:760-765

The diagnosis helps to determine the necessity of treatment and causation.

There is no such thing as a “chronic sprain / strain injury”.

The use of the “sprain strain” as a diagnosis after 4-6 weeks without proper documentation is not a valid diagnosis.

Of the people injured (only approximately 50% of people injured in accidents) 75% will heal within 2-3 months. These patients sustained minor injuries to their muscles and ligaments, but not to their discs or facet joints. 10% of patients with injuries will progress to chronic symptoms. These patients injured their intervetebral discs, zygapophyseal joints, or alar ligaments. These patients will not resolve spontaneously and they may become chronic. Bansley, Lord, Bogduk. Whiplash Injury: Clinical Review. Pain 58, 1994, 283-307.

We use professionally and nationally accepted guidelines that take into consideration the diagnosed conditions considering any complicating factors. (Croft, Quebec, Austrian, ABIME)

See more at www.painatlanta.com.

Pain Atlanta

2012-01-29T06:34:00.000-08:00

The steps to determine causation are the same regardless of the type of doctor rendering care. Once causation is determined then other aspects of the claim can be evaluated. If the traumatic event did not caused or materially contributed to symptoms and diagnosed conditions then the claim has no basis.

1. Symptoms Following a MVC

Pain affects more Americans than diabetes, heart disease and cancer combined.

Symptoms related to the back and spine is among the most common everyday complaints.

Pain – 76.2 million people, National Centers for Health Statistics
Diabetes – 20.8 million people (diagnosed and estimated undiagnosed), American Diabetes Association
Coronary Heart Disease (including heart attack and chest pain) and Stroke – 18.7 million people, American Heart Association
Cancer – 1.4 million people, American Cancer Society

“Whereas PAIN is generally associated with most forms of disease it does NOT stand alone as a diagnosis to establish causation or the necessity of on-going or prolonged treatment.”

Back pain is one of the most common medical problems in the United States. It affects up to 90% of Americans at some point in their lifetime, with more than half of those experiencing multiple episodes.

This is a very common reason why a claim is denied or why care is reduced for insufficient documentation.

From a recent review:

The reporting of "pain" or “symptoms” alone is not sufficient to establish the medical necessity of the treatment rendered related to the car accident. Whereas pain and symptoms are generally associated with most forms of disease it does NOT stand alone as a diagnosis to establish causation or the necessity of on-going or prolonged treatment. Symptoms related to the back and the spine is among the most common of adults' everyday complaints.

In most cases, pain is asymptom not a primary diagnosis.

Causation

2012-01-27T06:32:00.000-08:00

An injury can be confusing for patients, doctors, insurance companies, attorneys claims adjusters and others involved with the injury.

What is the injury or diagnosis?

Was care needed related to the accident?

Was treatment or testing appropriate?
Was the injury caused by the accident?
What is the long term prognosis?
Was this condition pre-existing?

Is the claimant really injured?

We answer these and many other questions to the injured, insurance companies, attorneys, doctors, and claim adjusters. In today’s healthcare environment there is a growing need for outcome based measures to control cost and promote quality based care and testing. Theses services are based on nationally recognized guidelines such as the AMA Guide to the Evaluation of Permanent Impairment, Social Security Resources, AMA Guide to the Evaluation of Disability, Croft Guidelines, The Quebec Task Force, and other professionally accepted guidelines.

“Any observer that reviews the same information should come to a similarconclusion concerning the impairment, causation, mechanism of injury,apportionment and/or disability”.

5 basic steps to determine causation in an injury claim.

1. Symptoms – What are the complaints?

2. Diagnosis – What is causing the symptoms?

3. Clinical Correlation – Do the symptoms and findings match the diagnosis?

4. Causal Relationship – Did the accident result in the diagnosed condition?

5. Apportionment – Are there any other causes or contributing factors?

Once a causal relationship and a diagnosis are established the other aspects of the claim can be reviewed. These steps should be followed in order and apply to all injuries (regardless the treatment or the type doctor caring for the claimant). They are universal and considered the gold standard for determining causation.

Stone Mountain Chiropractic

2012-01-25T06:24:00.000-08:00

Chiropractic has endured a turbulent history, marked by tremendous advances in areas such as education and licensing while marred by interprofessional conflict and a poor public image. The prolonged interprofessional conflict was instrumental in shaping the culture of chiropractic. These obstacles have long-since been removed although there are lingering effects from them. This article examines the chiropractic profession's history by dividing it into five Eras and suggests that there are three options available for the future of the profession. One: maintaining the status quo. Two: uniting under an evidence based scientific approach as partners in the health care delivery system that has buried the "one-cause, one-cure" sacred cow. The steps required to achieve this outcome are outlined. Three: openly dividing the profession into evidence based practitioners and subluxation based practitioners. Adopting this option would allow each branch of the profession to move forward in the health care delivery system unhindered by the other. It is unclear which option the profession will choose and whether the profession is mature enough to follow option two remains to be seen. What is evident is that the time to act is now.

Stone Mountain Pain Clinic

2012-01-23T06:08:00.000-08:00

Arthritis Prevalence: A Nation in Pain

Arthritis is a term used to describe more than 100 different conditions that affect joints as well as

other parts of the body. Arthritis is one of the most prevalent chronic health problems and one of

the nation’s most common causes of disability.

[CDC. Prevalence of disabilities and associated health conditions among adults –

United States

, 1999. MMWR 2001; 50: 120 – 5.]

An estimated 46 million adults in the United States reported being told by a doctor that

they have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia.

[MMWR 2006;55(40):1089-1092. [Data Source: 2003–2005 NHIS]

One in five (21%) adults in the United States report having doctor-diagnosed arthritis.

[MMWR 2006;55(40):1089-1092. [Data Source: 2003–2005 NHIS]

By 2030, an estimated 67 million of Americans aged 18 years or older are projected to have

doctor-diagnosed arthritis.

[Arthritis & Rheumatism 2006;54(1):226-229 [Data Source: 2003 NHIS]

Two-thirds of the people that have doctor-diagnosed arthritis are under the age of 65.

[MMWR 2006;55(40):1089-1092. [Data Source: 2003–2005 NHIS]

In 2003, arthritis and rheumatic conditions cost the U.S. economy $128 billion.

[MMWR 2007;56(01):4-7. [Data Source: 2003 Medical Expenditure Panel Survey]

Arthritis is the second most frequently reported chronic condition in the United States.

[Benson, V. & Marano, M. (1998). Current Estimates from the National Health Interview Survey, 1995. Vital & Health Statistics 10, 199, 1-428].

Arthritis prevalence increases with age. Among adults over age 65, the prevalence of

arthritis is 50 percent.

[MMWR 2006;55(40):1089-1092. [Data Source: 2003–2005 NHIS]

The prevalence of arthritis is higher among women (28.3%) than men (18.2%).

[MMWR 2006;55(40):1089-1092.] [Data Source: 2003–2005 NHIS]

If prevalence rates remain stable, the number of affected persons ages 65 years and older

will nearly double to 41.1 million by 2030.

[CDC (2003). Public health and aging: projected prevalence of self-reported arthritis or chronic joint symptoms among persons aged >65 years--United States,

2005-2030. MMWR, 52, 489-491]

59 million people report having low back pain.

[Helmick, C., Felson, D., Lawrence, R., Gabriel, S., et all. Estimates of the Prevalence of Arthritis and Other Rheumatic conditions in the United States. Arthritis &

Rheumatism 58(1), 15-25. 2008]

30 million people report having neck pain.

[Helmick, C., Felson, D., Lawrence, R., Gabriel, S., et all. Estimates of the Prevalence of Arthritis and Other Rheumatic conditions in the United States. Arthritis &

Rheumatism 58(1), 15-25. 2008]

Atlanta Injuries

2012-01-11T09:49:00.000-08:00

Have you ever played a game without knowing the rules? It’s difficult to win. Over the last 10 years, chiropractors have been playing a “game” with personal-injury insurers without knowing the rules.

Sometimes they win and get paid for their personal-injury (PI) and healthcare claims; sometimes they lose.

The “rules” of the insurance companies are governed by computer programs developed for insurers to cut the cost of claims. Healthcare and personal injury claims, of course, amount to a tremendous sum, as a 1999 study, “Injuries in Auto Accidents: An Analysis of Auto Insurance Claims,” released by the Insurance Research Council (IRC), indicated.

The study noted that $37.1 billion paid to compensate injuries included these payments:

• $19.9 billion for bodily injury (BI) claims,

• $4.1 billion for UM/UIM (uninsured/underinsured motorist) claims,

• $5.1 billion for personal injury protection (PIP) payments, and

• $2.0 billion for MedPay (medical payment) claims.

Despite the fact that PIP and MedPay were only available in about 15 states, these claims accounted for $7.1 billion out of the $37.1 billion paid. Settlements and verdicts on the bodily injury and UM/UIM claims from the entire 50 states accounted for the remaining $30 billion.

The same IRC report revealed that admissions to hospital emergency room departments were down, as well as the incidence of what the insurance industry viewed as “serious” injuries. By contrast, the incidence of sprain and strain injuries rose to account for 85 percent of claims payments.

The providers for most of these types of injuries are chiropractors and physical therapists (PTs), both of whom specialize in the treatment of musculoskeletal injuries.

It is not surprising, then, that the IRC found the highest average payment for treatment of musculoskeletal claims to be to doctors of chiropractic.

As a result of this IRC study and another that preceded it, some insurers took measures to cut claims costs both in terms of PIP/MedPay, as well as in bodily injury claim payments, particularly those involving soft tissue injuries.

Those changes created new “rules” of the payment game you need to know. Here are three.

MIST

In the mid 1990s Allstate implemented a claims-processing system called CCPR that segmented claims into different divisions that depend on the facts of the case.

One of the most controversial aspects of CCPR is the Minor Impact Soft Tissue (MIST) claims segmentation. MIST was so successful in terms of claims savings that other insurers adopted it.

MIST operates in this manner: When vehicle damage falls below $1,000, claims are routed to the MIST division of the company and are handled by adjustors who have a limit on the claim payment, often not exceeding $3,000.

If the attorney representing the injured party refuses to accept such an offer, the company is willing to spend many times the amount of a reasonable settlement to defend the case to trial.

The intended result is to make these cases economically infeasible for lawyers to accept, therefore leading to increasingly lower settlement offers. The reduced settlement results in lowering reimbursements for chiropractors who provide care.

Of course there is no scientifically substantiated minimum threshold of injury based upon the forces imparted to the vehicle. But these cases often become clouded by “junk science” from defense biomechanists and engineers.

How do you deal with MIST? Many of the junk science studies have been refuted by Michael Freeman, DC, and Arthur Croft, DC. Review articles these doctors have written and attend continuing education to prepare yourself for trial testimony if you expect full reimbursement on a MIST case.

If possible, work to get these claimed bumped out of the MIST unit.

REVIEW SOFTWARE

Many insurers use medical bill review software that considers all healthcare provider billings. The software determines the appropriateness of PIP/MedPay billings and/or ascertains if billings are “reasonable and necessary” for a bodily injury claim.

These programs are set up to reject:

• CPT codes that do not correlate with ICD codes,

• CPT codes that exceed a maximum cap per day,

• Treatment that exceeds a preset duration or frequency, and

• Procedure billings that exceed the 90th percentile of charges in a geographical region.

How to deal with bill review software? Improve your diagnostic coding to reflect the patient’s actual injuries; provide care at a reasonable charge; and make high quality chart notes to support your clinical treatment schedule and referrals.

COLOSSUS

Approximately 70 percent of the auto insurance industry has implemented claims assessment software — Colossus, Claims Outcome Advisor, or InjuryIQ — to evaluate bodily injury claims.

Based upon the entry of injury diagnoses, these programs trigger screens of questions about a claimant’s case for insurance adjustors.

Colossus and the other programs directly affect the values of bodily injury claims. Yet few lawyers know how to format their demand letters for the Colossus program to obtain full value for the patient’s claim.

The insurance industry planned for this effect. In the 1990s many insurers implemented a “zero sum game” management strategy, in which insurers would increase profits to the extent that they could deprive doctors and injured people from obtaining a full settlement.

How to deal with Colossus? The first critical step is to enter all conditions of the patient as diagnoses in your SOAP notes. Then consider the factors that Colossus values during the course of a patient’s care. Note accurately and objectively whether these factors are, or are not, present.

Finally, write detailed chart notes. Since the Colossus evaluation is almost entirely dependent on the information in your charts, failure to provide detailed notes will decrease the likelihood of reaching an adequate settlement.

Beyond the injuries themselves, here are a few of the more important factors that Colossus uses in its evaluation:

• Complaints. Colossus divides injury cases into two categories: demonstrable and non-demonstrable/soft-tissue.

The non-demonstrable cases are dealt with in a subsection of the Colossus program referred to as the whiplash system, and the value of factors noted in such a case are calculated in a different manner than the factors in a demonstrable injury case.

In addition to the injuries deemed “non-demonstrable,” a number of symptoms add value to the claim. In Colossus, these symptoms are called complaints — headaches, muscle spasms, restriction of movement, radiating pain, depression, and others.

What should you do? Track these complaints for the duration of treatment in your SOAP notes.

• Prognosis. Prognosis is a large value-driver in Colossus. The program does not use the typical medical prognoses, but instead has its own categories, requiring the adjustor to re-characterize the physician’s prognoses. The Colossus categories focus on whether complaints remain and whether treatment is required.

What should you do? Give a prognosis for each area injured.

• Disability. Colossus considers disability in terms and methods different from those used by physicians.

Physicians consider the client’s job description, physical capacity testing, and results from clinical assessment tools such as the Roland Morris, Oswestry, or Neck Disability Indices, to determine disability.

Colossus uses a completely different system called “Duties Under Duress” (one of its top five most valuable factors). To obtain any value for the disability, the injured party’s attorney must specifically address duties in the demand letter. If the attorney fails to do this, the patient will be unable to obtain a maximum settlement offer, and you will face reimbursement reductions.

What should you do? Research and understand what Colossus considers the Duties Under Duress factors and chart problems accordingly.

• Permanent impairment. Permanent impairment is the second most valuable factor in a Colossus claim, preceded only by the injuries incurred.

Colossus is presently set up to calculate values based upon the findings of a “Whole Person Permanent Impairment” under the AMA Guides to the Evaluation of Permanent Impairment 5th Edition.

Claims that do not have an AMA impairment rating fail to obtain the highest potential value in a case evaluated by Colossus.

What should you do? Ensure that AMA impairment ratings with notation of pages and tables in the guides is provided on only those patients with viable permanent impairment ratings, in order to give the insurer the opportunity to evaluate your patient’s claims appropriately.

new link

2012-01-04T11:55:00.001-08:00

http://www.ratemds.com/doctor-ratings/128648/Dr-Christopher-Connelly-STONE-MOUNTAIN-GA.html

Whiplash Disorders - Atlanta Chiropractor

2011-12-28T06:06:00.000-08:00

Assessment and Treatment of Whiplash Associated Disorders (WAD) in First 12 Weeks

Initial Assessment

Classify the WAD injury. Although higher WAD grades indicate greater severity, poor prognosis is most likely associated with a high Visual Analogue Scale (VAS)/numeric pain score (NPS) >7/10) or high Neck Disability Index (NDI) score (>20/50). The SF-36 may be also be used. Orthopedic & neurological examination. Clinician determines imaging necessity.

Apply recommended treatments.

Seven Day Reassessment

Reassess, including the VAS/NPS and NDI. If the VAS/NPS and NDI are high or unchanged, treatment type and intensity should be reviewed. Other treatments may be considered. The effectiveness of such treatments should be closely monitored and only continued if there is evidence of benefit (at least 10% change on VAS and NDI).

Three Week Reassessment

Reassess, including the VAS/NPS and NDI. If the VAS/NPS and NDI are unchanged, a more complex assessment may need to be considered and treatment type and intensity should again be reviewed. The Impact of Event Scale (IES) may be used as a baseline for psychological assessment. Other recommended scales can be used. If pain and disability are still high (VAS, NPS >5.5) and NDI (>20/50) or unchanged, consider referral to a specialist in Whiplash Associated Disorders (WAD).
A specialist is considered a practitioner with specialized expertise in the management of WAD. These may include chiropractors, medical physicians, pain medicine specialists and other physicians who specialize in WAD. Among other things, if the VAS/NPS and NDI are unchanged, the specialist should undertake a more complex physical and/or psychological examination. They should direct more appropriate care and liaise with the treating practitioner to ensure this is implemented.

Six Week Reassessment

Reassess again at this point. In at least 30% of cases resolution should be occurring, and the process of reducing treatment in these cases should commence or continue. If resolution is not occurring and the VAS/NPS and NDI have not changed by at least 10% from the last review, specialist care should still be followed, or a specialist should be referred to if this has not already been done. Prescribe home programs for functional improvement. Consultation with a whiplash specialist may be needed if pain or disability are still high (VAS, NPS >5.5, NDI >20/50) or unchanged.

Three Month Reassessment

Assessment should Include VAS/NPS and NDI. Resolution usually occurs in approximately 50% of cases. If the patient is still improving, continue treatment; independence should be promoted (e.g., focus on active exercise). In these resolving cases, the patient should be reviewed intermittently over the next six to 12 months until resolution. Prescribe home programs to maintain improvement. Consultation with a whiplash specialist is usually required. At this point, referral to a clinical psychologist may also be considered if the psychological assessment data is markedly below norms (for the IES this means a score of >26 at six weeks after injury).

Coordinated Care

Patients whose VAS/ NPS and/or NDI scores are not improving at this point are likely to require coordinated care that is multidisciplinary. It is likely that a combination of physical, psychological and medical care is required. The primary practitioner should facilitate this process.

Range of Possible Symptoms in Whiplash Disorders

Refer to the original guideline document for a description of the possible symptoms of WAD, which include:

Neck pain

Headache

Radiating pains to the head, shoulder, arms or interscapular areas

Generalized hypersensitivity

Paresthesia and muscle weakness

Symptoms from the temporomandibular joint

Visual disturbances

Proprioceptive control of head and neck position

Vertigo/dizziness

Impaired cognitive function

Low back pain

Carpal tunnel syndrome

Double crush syndrome

Delay in symptoms is not uncommon. Symptoms may be delayed for hours, days, or longer.

Physical Examination

Taking Patient History
Taking a patient's history is important during all visits for the treatment of patients with WAD of all grades. A patient's history should include information about: date of birth, gender and education level; circumstances of injury such as relevant crash factors; symptoms, particularly including pain intensity (using the Visual Analogue Scale [VAS] or similar). Stiffness, numbness, weakness and associated extra cervical symptoms; localization, time of onset and profile of onset should also be recorded for all symptoms; disability level, preferably using the Neck Disability Index (NDI). Other scales such as the Functional Rating Index, Patient-Specific Functional Scale, Short Form Health Survey SF-36, or similar may also be used. Such an assessment should be conducted on a patient’s second visit at seven days, if not initially; and prior history of neck problems including previous whiplash injury.
Where appropriate, further assessment to determine psychological status may be undertaken at three or six week review. The preferred tool is the Impact of Event Scale (IES), which is a validated tool. Other scales may be useful. History details should be recorded. A standard form may be used.
Observation (particularly of head position/posture); palpation for tender points; assessment of range of movement (ROM) including flexion (chin to chest), extension, rotation and lateral flexion; neurological testing; assessment of associated injuries; and an assessment of general medical condition(s), including psychological state (as appropriate).
A further, more specialized, physical examination assessment might include: assessment of joint position error; assessment of neck muscle activity; and an assessment of widespread sensitivity (which may include cold sensitivity, pressure pain threshold and/or the brachial plexus provocation test, qualitative sensory perception).
Tools, such as a universal goniometer or inclinometer, can be used to measure neck ROM, and are more reliable than observation.
A standardized form may be used.

History and Physical Examination

Date of birth, gender, height weight, blood pressure, pulse rate, education level

Prior medical history, general medical condition, and pre-existing conditions

Symptoms including stiffness, numbness, onset of symptoms

Prior history of whiplash symptoms, neck injury, or pain or chronic pain symptoms

Observation of head position and posture

Palpation for tenderness in the neck region

Cervical range of motion

Neurological testing of sensation, reflexes and muscle strength

Assess associated injuries and co-morbidities

Baseline Assessment

Disability level using self report instrument (NDI)

Pain intensity using a visual analogue scale (VAS) or numeric pain scale (NPS)

Look for lacerations, fractures, or other abnormalities requiring urgent intervention

Note any deformities, swelling, asymmetry, atrophy or erythema

Feel the areas of pain and surrounding structures. Examine for tenderness, deformity, crepitus and muscle spasm. Flaccidity, fasciculations and spasticity may indicate nervous system damage. Note particularly sensitive areas of palpation as this may help to determine etiology of pain (e.g., muscular versus facet)

Palpate the temporomandibular joints (TMJs) and adjacent musculature, including the masseter and temporalis muscles. Assess these joints by having the patient open, close and move the jaw from side to side. Note any pain, tenderness, clicking, popping or asymmetric jaw movement. Make note of jaw excursion and the location of pain that limits it. Have the patient move the region being tested. If the patient’s movement is restricted, passive movement should be attempted as the pain allows. It may not be possible to passively move the region farther due to pain, but this also allows the examiner to gauge the source of pain, limitation and degree of musculature tautness.

Screening Neurological Motor Exam
The integrity and mobility of the nervous system needs to be examined and tests should include:

The integrity of the nervous system including testing myotomes, dermatomes and reflexes when indicated by the distribution of the symptoms

Mobility tests may include passive neck flexion (PNF), upper limb tension tests (ULTT), passive knee bend, straight leg raise (SLR) and the slump test.

The plantar response should be examined to exclude an upper motor neuron lesion.

Tests for clonus should be carried out to exclude an upper motor neuron lesion.

Subluxation Assessment

Vertebral Position Assessed Radiographically; Abnormal Segmental Motion Assessed Radiography

To demonstrate a subluxation based on physical examination, two of the four criteria mentioned below are required, one of which must be asymmetry/misalignment or range of motion abnormality.

Pain/tenderness evaluated in terms of location, quality, and intensity; Pain, facet syndrome, trigger points, etc.

Asymmetry/misalignment identified on a sectional or segmental level; Asymmetric or Hypertonic Muscle Contraction.

Range of motion abnormality (changes in active, passive and accessory joint movements resulting in an increase or decrease of sectional or segmental mobility); Abnormal Segmental Motion/Lack of Joint End-play.

Tissue, tone changes in the characteristics of contiguous, or associated soft tissues, including skin, fascia, muscle, and ligament; Soft Tissue Compliance and Tenderness.

Special Tests

Thoracic outlet syndrome. Various tests for this complex syndrome include the Allen Test, Adson’s maneuver and provocative elevation tests.

Upper cervical stability. Test for instability in the presence of certain signs (inability to support the head, dysphagia, tongue paresthesia, a metallic taste in the mouth, facial or lip paresthesia, bilateral limb paresthesia, quadrilateral limb paresthesia, nystagmus, gait disturbance).

Thoracic Outlet Syndrome After Motor Vehicle Accidents

2011-12-26T10:24:00.000-08:00

Thoracic Outlet Syndrome After Motor Vehicle Accidents

Thoracicoutlet syndrome (TOS) is a recognized sequelae of motor vehicle accidents (MVAs) in general, and whiplash injuries in particular. In 1977, Capistrant described 35 cases of TOS induced by trauma, 80% of which were whiplash injuries. Moore, in 1986, found that 33% of whiplash injury patients reported arm symptoms which he related to TOS. Sanders found that of 668 patients operated on for TOS, 32% had been involved in a rear-end accident and 25% had been in a side or head-on collision.

Now, a new study adds to the body of knowledge of whiplash-induced TOS. In this report, 90 patients who had been sent to a Canadian pain clinic were diagnosed with TOS. Of these 90 patients, 32 (35.6%) has TOS associated with an MVA. The mean symptom duration at the time of the study was 37 months.

One half of the patients were chosen (not randomly selected) for surgery, the other half for conservation treatment. Only 7 of 15 (47%) of the surgical patients had “very good to excellent” results, and 3 of these patients later had recurrence of symptoms. In short, only 4 of 15 patients (26.6%) had good results from surgery. Six patients had reoperation, and only one of these had positive results.

In the conservative management group, 3/15 (20%) had “very good to excellent” results, and 3/15 (20%) had modest pain relief. 60% had no pain relief.

Surgical findings: “…13/15 patients (87%) were found to have primarily muscultendinous anomalies in the form of tight bands or thick muscle attachments.” This is consistent with reports by Sanders regarding fibrous bands in the scaleness in these patients.

The low rate of surgical success in the treatment of TOS has been discussed by others, including Lindgren and Oksala, who suggested that surgical success may simply by placebo.

One very important finding of this study was that 67% of the TOS symptoms were on the side of the driver’s shoulder strap, suggesting that the force of the body against the shoulder restraint during whiplash may be responsible for some TOS problems.

Factors in the Diagnosis of Disc Herniations

2011-12-23T10:17:00.000-08:00

Factors in the Diagnosis of Disc Herniations

Lowback pain is a complex condition, and accurate diagnosis can be difficult. A current study examined a group of “Forty-six patients with low back pain and sciatica severe enough to require a disentomb” and 46 asymptomatic volunteers who were matched for age and work-related risk factors (heavy lifting, twisting and bending, vibration, or sedentary). Both groups were given a complete clinical exam, MRI, and psychological questionnaires.

MRI findings: “In 76% of the asymptomatic volunteers a disc herniation (I.e., protrusion, extrusion, or sequestration) was present at least at one level…In all, 85% of the matched control subjects without previous back pain exhibited disc degeneration at least at one level. In the patient group, 96% showed at least one degenerative change.” Patients, however, had an 82% rate of neural compromise, while controls had only a 21% rate.

The authors found that pain patients were more likely to have signs of neurological compromise, were more likely to be depressed or anxious, were more likely to be married, and had higher levels of work stress.

The study also warns against using MRI alone as indications for surgery. For instance, if surgery is based on MRI-detected disc herniations alone, there is a false positive rate of 76%; for MRI-detected disc degeneration, there is a false positive rate of 85%.

Increasing Lumbar Spinal Fusion Rates

2011-12-21T10:15:00.000-08:00

Increasing Lumbar Spinal Fusion Rates

There is a growing awareness in the medical literature that surgical rates for lowback pain are on the rise. A recent review of these studies reported some important statistics:

In 1990, 279,000 lumbar surgeries were performed -- 46,500 of these were lumbar fusions. From 1979 to 1990, total lumbar spine surgical rates increased 55% in the U.S.

During this same period, lumbar fusion surgeries increased 100%

The U.S. fusion rate in 1990 was 26 per 100,000. In the U.K., it was 2.3 per 100,000.

Many of the increased surgeries are performed on patients older than 65. These patients are more likely to have degenerative changes, but they are also more likely to suffer complications from the surgery.

Stress Slows Wound Healing

2011-12-19T10:10:00.000-08:00

Stress Slows Wound Healing

That stress affects immune functioning has been well known for years. How stress affects the body’s ability to heal, however, has not been extensively studied.

A recent study examined the role of stress in the healing process. Researchers studied 13 “women caring for demented relatives and 13 controls…” All twenty sic subjects were given a punch biopsy, to create a 3-5 mm wound. The wounds were cared for identically for all patients, and were photographed every 2-8 days. Also, all subjects were tested for blood cytokine levels -- a measure of immunological functioning.

The researchers found that complete healing took an average of nine days longer in the subjects who were caring an ill relative. Caregivers also had decreased immune functioning, and reported higher levels of perceived stress.

“Previous animal and human studies have shown that stress can increase vulnerability to infectious illness. The findings of this study suggest that stress-related alterations in immune function could have additional implications for health beyond infectious disease.”

Returning Patients to Work

2011-12-16T09:53:00.000-08:00

Returning Patients to Work

This study investigated what nonphysical factors were associated with patients not returning to work after soft-tissue injury. As the authors state, “Nonphysical factors, the nature of which may be social, economical, or psychological, may also influence the success of work hardening and may act as barriers to successful work return.”

One hundred patients were involved in this study. The mean injury duration of the participants was 13 months; the mean time absent from work was 7.5 months. Many of these patients had undergone surgery for their injuries -- 20% of cervical spine patients, and 35% of low back patients. Fifty-one percent of the participants were using medications. Eighty-eight per cent of the patients had a diagnosis related to the spine.

The patients attended a “work hardening: program daily for 7.5 hours and for an average of 17.3 days. The average treatment lasted 4.3 weeks. The program consisted of “physical therapy conditioning, work simulation, and a psychological education group.” At the end of the intervention, 50% had returned to work. The author reports that there were three non-physical factors associated with returning to work:

1. Having a high school education. Less educated patients were less likely to return to work. This could be due to the fact that, “most heavy labor and blue collar jobs are performed by the less educated persons and that these jobs may be more difficult to return to than lighter jobs.”

2. Absence of “pain behaviors.” These were defined as “overt behaviors that are not in proportion to physical findings, such as facial grimacing, emotional lability, positive Waddell’s signs, constant holding of the injured area, and antalgic limping.” Unfortunately, the studies criteria for low back pain “physical findings” was reduced to :simple and severe,” and the criteria for these was evidence of “radiographically-determined injury to the disc or bony structures.” If there were no radiological findings, the injury was classified as “simple.” Thus, if a patient was not considered to have a real injury, but behaved as if he or she did have pain, these were determined as “pain behaviors!” The patients with pain behaviors were less likely to return to work than those without and were less likely to complete the program, but this could be related to the fact that “Work hardening tends to further aggravate pain…” That these patients were in real pain, despite signs on radiologic exams, seems to not be considered in this paper.

3. Absence of attorney representation. Those patients that retained an attorney were less likely to return to work, showed more pain behaviors, and were more likely to be discharged from the programs for lack of compliance. The study did not provide data regarding attorney representation and severity of injury, or length of time off work.

Patients Prefer Chiropractic

2011-12-15T09:51:00.000-08:00

Patients Prefer Chiropractic

A recent study compared the difference in acute low back pain outcomes in patients treated by primary care physicians, orthopedic surgeons, or chiropractors. The study reports that there were no differences in treatment outcome among the different types of care, but that chiropractic and orthopedic care was the most expensive. When the patients were asked about the quality of care, however, the chiropractic patients reported their satisfaction as considerably higher. The chiropractic patients ranked higher: the information provided, their treatment, the results, the detailed history their doctor took, their examination, and having their problem explained clearly. Chiropractic patients also used significantly fewer medications for their pain.

The focus of this study, however, seems not to be on quality, but cost. The lowest cost provider in the study was the HMO primary care physician, and the study suggests that acute back pain patients should be sent to managed care providers. To wit: “Patients and insurers need to address the trade-off between the substantially lower charges by primary care practitioners and the higher the level of satisfaction with the care that chiropractors and orthopedic surgeons provide.” Unfortunately, the decisions are typically made on the basis of cost, not what the patient wants. Interestingly, when the patient satisfaction was reported in this study, all non-chiropractic providers were compared with chiropractors, so that no information is given on the HMO patient’s level of satisfaction. Is it accidental that the HMO satisfaction information was left out?

The results of a recent British study, on the other hand, suggest that the extra cost and longer treatment time of chiropractic results in better outcome. The trial conducted by the UK Medical Council followed a group of randomly assigned hospital outpatient and chiropractic low back pain patients for three years. The study reports that the chiropractic patients were significantly more improved than the medically treated patients.

Time Codes PT

2011-12-14T11:29:00.000-08:00

Time is money. This is especially true when it comes to coding therapeutic procedures or attended modalities correctly, particularly as they relate to time-based procedures. Your challenge is twofold: Use the coding policies required by insurance carriers and report your time correctly.

Three possible reporting standards are used: the Centers for Medicare and Medicaid Services (CMS) rules, as published in Transmittal AB-00-14; the American Medical Association guidance as published in the AMA CPT Assistant; and individual carrier policies.

Note: CMS’s usage rules are not part of the national standard code set stipulated in the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Commercial carriers can follow CMS policy, AMA policy or adopt more/less restrictive coding policies of their own. When no policy is specified, a time-tested adage in billing states that if you are right with Medicare you are right with the rest of the world.

Because many commercial insurance plans currently follow Medicare Coding Guidelines or will agree that your application of those guidelines is a reasonable approach, this article focuses on the CMS standard.

What the transmittal says

The CMS transmittal dictates time reporting of 8 minutes or less:

“Several CPT codes used for therapy modalities, procedures and tests and measurements specify that the direct (one on one) time spent in patient contact is 15 minutes. Providers report procedure codes for services delivered on any calendar day using CPT codes and the appropriate number of units of service. For any single CPT code, providers bill a single 15 minute unit for treatment greater than or equal to 8 minutes and less than 23 minutes. If the duration of a single modality or procedure is greater than or equal to 23 minutes to less than 38 minutes, then 2 units should be billed. Time intervals for larger numbers of units are as follows:

3 units: 38 minutes up to 53 minutes

4 units: 53 minutes up to 68 minutes

5 units: 68 minutes up to 83 minutes

6 units: 83 minutes up to 98 minutes

7 units: 98 minutes up to113 minutes

8 units: 113 minutes up to 128 minutes

The pattern remains the same for treatment times in excess of 2 hours. Providers should not bill for services performed for less than 8 minutes. If more than one CPT code is billed during a calendar day, then the total number of units that can be billed is constrained by the total treatment time, see examples below.

Example 1: If 24 minutes of 97112 and 23 minutes of 97110 were furnished, then the total treatment time was 47 minutes; so only three units can be billed for the treatment. The correct coding is two units of 97112 and one unit of 97110, assigning more units to the service that took more time.

Example 2: If a therapist delivers 5 minutes of 97035 (ultrasound), 6 minutes of 97140 (manual techniques), and 10 minutes of 97110 (therapeutic exercise), then the total minutes are 21 and only one unit can be paid. Bill one unit of 97110 (the service with the longest time) and the clinical record will serve as documentation that the other two services were also performed.

Frequency of Whiplash Incidence

2011-12-13T09:42:00.000-08:00

Frequency of Whiplash Incidence

The incidence of whiplash refers to the number of new cases that are diagnosed each year in a given population. Due to the previously mentioned problems with collecting whiplash-related data, estimates of whiplash incidence vary greatly, ranging from 3.4 per 100,000 to 800 per 100,000 population per year. A Swedish study reported the annual incidence of whiplash in the local catchments area to be 4.2 per 1,000 inhabitants for grade 1 WAD and 3.2 per 1,000 grade 3. Holm et al reported that the incidence of reported WAD in the Western world is probably at least 300 per 100,000 inhabitants per year. A commonly quoted statistic that refers to the rate of whiplash in the United States is 1,000,000 total cases per year.

The Insurance Institute for Highway Safety (IIHS) reported that approximately 2 million whiplash insurance claims are filed each yeah in the United States, resulting in more than $8.5 billion in insurance claims. In fact, neck sprains and strains are the most frequent type of injury claim reported to insurance companies in the United States, comprising 25% of all injury-related claim dollars paid out by insurers each year. The institute also reported that about 10% of whiplash injuries result in long-term medical problems. In the Canadian province of Saskatchewan, 83% of traffic injury claims were for whiplash in 1994-1995, resulting in an annual incidence of 677 insurance claims per 100,000 adult population.

In addition to the cases that were included in the IIHS data, there are likely other cases of whiplash that occur but do not give rise to an insurance claim. This is because injured persons may not choose to open a claim (perhaps they do not want their insurance rates raised or they think their injuries are minor) or they are no insured. Thus, the true number of cases per year in the United States us almost certainly higher than 2,000,000, especially when non-traffic related whiplash injuries are factored in.

There are quite a few reasons why the various data sources so often generate different numbers. For instance, the National Accident Sampling System (NASS) provides data on all types of MVCs, including those that result in whiplash injuries. NASS data are collected from police-reported traffic crashes, which is very problematic when trying to obtain an estimate of the actual number of whiplash injuries that occur in the United States. Many MVCs that give rise to whiplash injuries are not reported to police because they do not typically investigate crashes that involve minor vehicle damage, and many whiplash-causing crashes are associated with minor to no vehicle damage. These injured persons “slip through the cracks” and are not included in the NASS database, and this results in an underestimation of the annual number of injuries by possibly hundreds of thousands. Even when police do investigate MVCs that result in whiplash, sometimes symptoms are delayed for hours and days; consequently, these cases are also unreported.

Prevalence

The prevalence of WAD includes the previously mentioned incident cases (ie, newly injured), but it also includes the total number of people who have it also includes the number of people who have persistent symptoms and physical impairments that are not included when only incident cases are counted. It represents the estimated number of persons in a population who manifest WAD symptoms at any given time. Many people experience residual problems for years after a whiplash injury and some never recover. These cases keep mounting in numbers until some of them recover or die. In either case, they are no longer included in calculation of prevalence.

The duration of a disease has an effect on its reported incidence and prevalence. For instance, short-duration diseases like the common cold tend to have a high annual incidence but low prevalence. Because people recover so quickly, not many will have the condition at any one point in time. On the other hand, long-duration diseases like diabetes have a relatively low annual incidence, yet its prevalence is quite high because the total number of cases keeps accumulating. This principle applies to WAD too, because many affected people experience long-term symptoms. A study from the Netherlands reported that the highest prevalence of MVC-related neck sprain was 28.3 per 100,000 and occurred in those who were in the 25- to 29-year-old age group, with the 40- to 44-year-old group a close second at 27.9 per 100,000. As mentioned earlier, the incidence of WAD in the United States is probably into the millions, and approximately half of those with WAD continue to report neck pain 1 year after their injuries, so its prevalence is undoubtedly very high. In fact, Freeman et al estimated, from a case-control study compromised of 419 chronic neck pain cases and 246 chronic low back pain controls, that about 6.2% of the U.S. population may have chronic neck pain attributable to a whiplash injury.

Chronicity

This is a great deal of controversy and debate surrounding the determination of which risk factors actually contribute to chronic WAD (aka, late whiplash syndrome) and which ones are merely associated by chance. Furthermore, some even question the legitimacy of chronic WAD, considering it to be a psychosocial phenomenon rather than being physically based. As a result of this dichotomy, there has been much debate about this issue in the whiplash-related literature. As stated so well by Dr. Murray Allen, “There are two great puzzles in this world that foster debate among humans. One is the wonder of the universe, the other is whiplash.

A large proportion of persons with chronic neck pain in the United States were initially injured in an MVC. This estimate was based on a case-control study involving 419 cases and 246 control subjects which reported the 45% of those with chronic neck pain considered its origin to have been a prior MVC. On the other hand, a study that was based on a random sample of 6,000 subjects from two counties in Northern Sweden reported that 42% had chronic neck pain and only about 8% of them attributed their condition to a previous whiplash injury.

Most WAD patients recover in time, although many have long-lasting and even permanent pain and impairment. For instance, a cohort of 2,627 persons with whiplash that resulted from an MVC in Canada was followed for up to 7 years. The median time to recovery for the overall group was 32 days, although 12% of the subjects still had symptoms at 6 months. Several risk factors for chronic symptoms were identified in this study, including neck pain on palpation, muscle pain, pain or numbness radiating from the neck to the upper extremities, and headache. Females over 60 years old who had the identified risk factors required a median of 262 days to recover compared with only 17 days for younger males without any risk factors.

Several studies have reported that approximately 50% of WAD patients continue to complain of symptoms 1 year following injury. Other studies, however, have found the rate of long-term WAD symptoms to be lower. To complicate the issue further, one study found the prevalence of long-term pain following whiplash injuries to be very close to the same level as the prevalence of chronic neck pain in the general population.

Neck and should pain are commonly reported symptoms of chronic WAD. Symptoms involving other bodily regions and overall health have been reported as well, including headache, back pain, jaw pain, fatigue, dizziness, paraesthesia, nausea, sleep disturbances, and ill health. Depression has also been reported following whiplash injuries. In one study, 42.3% of 5,211 subjects who did not have pre-injury mental health problems reported depressive symptoms within 6 weeks of the injury. Furthermore, the symptoms were recurrent or persistent in almost 40% of the cases. Berglund et al concluded that whiplash injuries due to rear-impact MVCs have substantial impact on health complaints, even a long time after the injury.

A systematic review and meta-analysis involving 38 cohort studies that followed subjects with acute whiplash reported that recovery rates were extremely variable across studies. Most subjects recovered within 3 months after the injury, and recovery rates leveled off after 3 months has elapsed. The review’s authors suggested that data concerning prognostic factors thought to be associated with a poor recovery were difficult to interpret because of the dissimilar ways studies assessed associations, differences in their methods of reporting data, as well as differences in the outcome measures that were used.

Some of the Reported Risk Factors for Developing Chronic Whiplash

Category Risk Factor

Patient demographics Advancing age

Female gender

Low educational level

Having dependents

Not being employed full-time

Presence of a compensation claim

Early intensive health care following injury

Expectation for recovery

Collision parameters Position of the occupants at impact

Being a passenger

Rear impact collision

Collision with a moving object

Head-on or perpendicular collision

Seatbelt use

Improper head restraint

Type of vehicle

Car equipped with a towbar

Previous history Headache

Neck pain

Widespread body pain

Head trauma

Presenting symptoms High neck pain intensity

High neck disability

Neck pain on palpation

Symptoms of radicular irritation

Muscle pain

Unspecified pain

Headache

Emotional or psychological distress

WAD symptoms

Higher WAD grades

Sleep disturbances

Reduced speed of information processing

Nervousness

Depression

In summary, not all victims of whiplash sustain injuries. “Whether or not a victim sustains an injury is a function of multiple factors: the magnitude of the impact, their posture at the time, their anatomy, and the material strength of the components of their cervical spine” (Bogduk and Yoganandan 2001).

Epidemiology of Whiplash Injuries

2011-12-09T12:36:00.000-08:00

Epidemiology of Whiplash Injuries

Epidemiology has been defined as “the science concerned with the study of the factors determining and influencing the frequency and distribution of disease, injury, and other health-related events and their causes in a defined human population for the purpose of establishing programs to prevent and control their development and spread. Hence, this chapter will cover the numbers of persons who experience whiplash injuries, mainly in the United States, as well as factors that are thought to influence the risk of becoming injured in a motor vehicle crash (MVC) or of developing chronic symptoms post-injury. Many such factors have been suggested, including the injured person’s age, gender, anthropometry, certain pre-existing conditions, position within the vehicle, the vehicle’s crashworthiness, and others. Clinicians should be familiar with the significant risk factors in order to formulate more personalized treatment plans and prognoses in whiplash patients.

Epidemiological studies have been used extensively to investigate the whiplash phenomenon, primarily because the condition is not amendable to investigation using randomized controlled trails, which are considered to be the gold standard of which are considered to be the gold standard of clinical research. This is primarily because it would be unethical to expose people to the kinds of forces that are capable of causing injuries involved in MVCs. Thus, whiplash studies typically compare a group of people who have already been involved in MVCs with another group who have not. Researcher wither follow the groups forward in time (ie, cohort studies) or assess various aspects of their medical history retrospectively, before as well as after the time of the crash (ie, case-control studies).

Studies have been carried out where human volunteers were exposed to whiplash-like forces (ie, crash tests) similar to what would be expected in a real-life MVC. However, they have always simulated relatively low-speed crashes and rarely resulted in symptoms. When symptoms did occur, they have been mild and short -lived. Also, these types of studies have never randomized subjects to groups for comparisons.

Epidemiology is commonly used in the field of public health, which focuses on the study of populations with the purpose of identifying the causes of diseases and conditions. Once the causes are identified, strategies can be developed that are designed to prevent the diseases from occurring. Public health interventions, such as advising people about the best ways to avoid risk factors or how they can integrate protective factors into their lifestyles, can effectively prevent future injuries and illness, as well as enhance the healing process when injury or illness has already occurred. Traffic safety matters, including whiplash, are of interest to public health practitioners, health care providers, as well as local, state, and national governments because of the potential to prevent or reduce the severity of crash-related injuries using these preventive methods.

One aspect of epidemiology involves collecting data from various sources and then analyzing it. However, the data pertaining to the epidemiology of whiplash is at times conflicting--sometimes because of inconsistencies in the way the data were gathered and other times in the way they were analyzed. It is also possible, and not that uncommon, for data collection and analysis to go awry at the same time. These inaccuracies can often be resolved by relying on higher-quality information sources, though even high-quality sources are not always in agreement. In addition to the potential flaws associated with the collection, analysis, and reporting of data, the way data are interpreted is often inconsistent. This chapter will call attention to some of these controversial aspects in relation to whiplash, relying on the highest-quality studies available.

Not only is the way data are collected and interpreted inconsistent in this area of investigation, the term “whiplash” itself is controversial: whereas some researchers use it to describe a mechanism of injury in which the head and neck are forcibly moved beyond the limits of anatomical integrity, others use it to describe the injury that often results. Consequently, the Quebec Task Force on Whiplash-Associated Disorders coined the term “whiplash-associated disorders” (WAD) in 1995 to describe an array of symptoms that have been reported in association with whiplash injuries. According to the Quebec Task Force, WAD symptoms may include neck pain and stiffness, headache, dizziness, tinnitus, memory loss, deafness, dysphasia, upper extremity syndromes (e.g., radicular symptoms and carpal tunnel syndrome), Temporomandibular joint disorder, and others.

Basic Epidemiological Terms

There are some basic terms that are essential to the understanding of the science of epidemiology, a few of which are listed here.

Association-when two or more attributes are related to each other in such a way that they change predictably together.

Bias-anything that causes the conclusions of a study to be systematically different from the truth. Bias may occur in the way data are collected, analyzed, and/or interpreted.

Case-a person in an epidemiological study who has the disease or condition under investigation. These persons are members of the cases group in a case-control study.

Case-control study-a type of epidemiological study in which participants are separated into two groups: members of one group have the disease of condition under study (the cases), and those in the other group do no (the controls). The groups are assessed concerning previous exposure to various factors or the presence of certain traits, and then rates of exposure/traits are compared between cases and controls.

Cause-refers to a factor that has a direct effect on the occurrence of a disease or condition. The factor could be an intrinsic trait or a behavior of the persons being studied or some event they were exposed to

Cohort--A distinct group of people who have something in common, such as being exposed to a common risk factor or being born in the same year.

Cohort study--a type of epidemiological study that follows one or more cohorts forward in time to determine the incidence of new diseases, conditions, and/or deaths that occur. Typically, one cohort is exposed to a risk factor, while the comparison cohort is not. The rates of the measured outcomes are then compared between the groups to see if members of the exposed cohort are more likely to develop the disease or condition.

Exposure--an external factor that may have an impact on the health of a person if the person is exposed to that factor.

Incidence--the number of newly diagnosed cases of a disease within a specified population during a specified time period, which is typically 1 year. The denominator is the population under consideration and the numerator is the number of new cases that develop during the given time period. The incidence rate may be calculated by dividing the number of the new cases of a disease in a given time period by the number of persons in the population who are at risk for the disease.

Odds ratio (OR)--an estimate of the odds of developing a disease given that a person was exposed to a relevant risk factor. It is the odds of being exposed to the risk factor under investigation in the cases in the control group, which is calculated from data in case-control cases.

Prevalence--the number of persons in a population who may have a given disease or attribute at a particular point in time (point prevalence) or over a specified period of time (period prevalence). The prevalence rate is calculated by dividing the total number of cases of a disease within a population by the total population.

Relative risk (RR)--the probability of disease being present in the exposed group, divided by the probability of disease in the unexposed group, which is commonly calculated in cohort studies

Risk--the likelihood that a person will experience a given event (e.g., become injured).

Risk factor--a behavior, environmental exposure, or inherent characteristic of an individual that increases the likelihood of an individual’s developing a disease or condition.

An Uncommon Cause of Sciatic Nerve Entrapment

2011-12-08T09:49:00.000-08:00

An Uncommon Cause of Sciatic Nerve Entrapment

This report documents the case of a forty four year old woman who lost control while water skiing, and injured herself when both “hips were hyper flexed and hyper abducted with the knees fully extended.” Although she felt immediate pain, she continued to ski. “Shortly thereafter, she was unable to walk or bear weight on the left lower limb secondary to painful hamstring spasms.”

The woman was treated with NSAIDs, walked on crutches for a few days, and then began a program of stretching and deep tissue massage. She was pain free in two weeks.

Two and a half months later, the woman began to experience “numbness in the lateral aspect of the left calf that extended onto the lateral and dorsal aspects of the left foot. Two weeks later, dropfoot developed.” After extensive testing, surgical exploration uncovered, “A portion of the origin of the hamstring muscles that was common to the semitendinosis and the long head of the biceps femoris had been avulsed from the ischial tuberosity and had been retracted about seven centimeters. The avulsed end of the tendon was surrounded by an exuberant fibroblastic response that had encased the sciatic nerve.” After dissecting the nerve free, the patient showed gradual improvement, and at one year was free of numbness, weakness, pain, or paresthesia. She was, however, 50% weaker in the left leg than in the right.