In parts one and two of this series, we discussed that our academic and clinical relationships with multiple healthcare disciplines demonstrated that documentation is one of the biggest challenges for the reimbursement of necessary services. Documentation also presents a significant risk to the provider’s licenses and practices. We also discussed that carriers aggregate statistics looking for potential fraud, and too often ignore public health risk issues. They do so to win lawsuits, often at the expense of our patients’ health. Lastly, we discussed the role of the American Chiropractic Association’s X-ray stance and how it has become an easy tool that carriers use to negatively impact chiropractor’s careers.
This article is centered on shedding light on the carriers’ positions —soft-tissue injuries, specifically strain-sprain, the utilization of chiropractic manipulative technique (CMT), passive versus active modalities, predetermined treatment plans, spontaneous healing theories, the use of initial examination, MRI utilization, and “cherry-picking tidbits of information” to craft arguments against you.
Although EMR systems can be helpful as a guide, they come with the caveat of “garbage in, garbage out.” The best, most robust, most costly, and most complete EMR systems cannot overcome the laziness of a doctor seeking to cut corners on an initial examination or a patient reevaluation. It also cannot overcome the lack of knowledge about what and how to document. This article was crafted to fill in those blanks.
NOTE: The author’s comments are after each bolded section reflecting the carrier’s litigation complaints.
Legitimate treatment plans for patients with soft-tissue injuries, such as strains and sprains, may involve no treatment at all because many of these kinds of injuries heal without any intervention or with a variety of interventions, including medications to reduce inflammation and relieve pain, passive modalities, and active modalities.
First, we must never minimize the words “soft tissue.” The brain, heart, lungs, nerves, reproductive system, and every other critical organ in the human body is soft tissue. The carrier’s apparent rhetorical goal is to sway the courts to consider soft-tissue injuries as minor when the opposite is more often true physiologically.
The mantra of the carriers in personal injury cases has been strain/sprain injuries are transient and not “serious injuries” because they heal. While this deceptive defense rhetoric might sway a court, it does not change human physiology or the literature that has verified the permanency of strain/sprain. In this lawsuit, it appears the author has mimed defense lawyers by stating that these kinds of injuries “heal without intervention,” thus perpetuating a public health risk. Consider that osteoarthritis is the most common joint disorder in the United States, according to Zhang and Jordan.1 In addition, the doctor in this lawsuit treats whiplash victims exclusively. Whiplash is a form of strain/sprain where, physiologically, you cannot have a sprain without a strain. The muscles must compensate for the impairment of ligamentous function to connect bone to bone. As we will discuss, whiplash (aka strain/sprain) will lead to osteoarthritis if not treated with the best possible outcomes and perpetuate the number one form of joint disorder.
“Strain/sprain is not a car accident phenomenon only. It can be caused by slips and falls, sports injuries, or sudden abnormal loading.”
There are three grades of sprains, and all involve different degrees of ligament tearing.2 Grade 1 includes a partial tear, with the ligament going beyond its paraphysiological limit, creating the tears. Grade 2 involves a greater degree of tearing, immediate loss of function, swelling, and tenderness. Grade 3 is an avulsion of the ligament with a total loss of function. Physiologically, ligaments are created embryologically from fibroblasts.3 As the ligament develops, it creates both collagen (stiffer) and elastin (more elastic), depending upon the tissue. As an example, a disc has more collagen because it is a supportive structure. In contrast, an elbow comparatively has a greater amount of elastin due to the functional requirements of the elbow. Fibroblasts remain active, producing both collagen and elastin until puberty; once puberty is reached, fibroblasts become dormant.
Upon trauma, fibroblasts are activated and only produce collagen or a stiffer grade of tissue. In the case of whiplash, according to Dolan et al.4, the ligaments heal with characteristically inferior compositional properties compared with normal tissue and remain less efficient in maintaining loads. This type of “wound repair” with internal scar tissue, known as adhesions,5,6 is permanent and due to the laying down of non-normal ligamentous tissue that will forever adversely affect the functioning of the joint.
Once a ligament is damaged, according to Provenzo et al.7, growth alone will not resolve the laxity issues, even in the young. It may explain the presence of continued instability in a joint at a young age. It has been reported that no treatment currently exists to restore injured tendons or ligaments to their normal condition.8
To suggest that the effects of strain/sprains will spontaneously disappear is contrary to the report from Krogh and Kasch, which found “half of those exposed to whiplash injuries will still report symptoms years after the injury, and more than 20% will still not be considered recovered after five years” (p. 548). Tanaka et al.10reported that, after whiplash, (strain/sprain injuries) 20 to 40% have neck pain and headaches that continue for several years, and 3 to 4% will be disabled and not be able to return to work. Also, Nolet et al. found that neck injury resulting from a motor vehicle collision is associated with a high rate of chronicity. Prognosis studies indicate 50% of injured people continue to experience neck pain a year after the crash.11
Strain/sprain is not a car accident phenomenon only. It can be caused by slips and falls, sports injuries, or sudden abnormal loading. They also do not spontaneously heal, as reported by Tomlinson, Gargan, and Bannister,12 who reported little alterations in symptoms by three months.
Those timelines in symptom and instability duration are supported by human physiology and wound repair, as described herein. Treatment is required, often beyond the symptom phase to stabilize a joint where demonstrative evidence is required to substantiate ongoing care.
Passive modalities do not require any affirmative effort or movement by patients. There are many kinds of passive modalities, including: (a) hot/cold packs, (b) ultrasound, (c) electrical stimulation (“e-stim”), (d) manual therapy, (e) massage, and (f) traction. Active modalities require affirmative movement by patients and include a wide variety of exercises, strengthening, and stretching tailored to the unique circumstances of each patient, including the nature and location of the injuries, the patients’ physical abilities, and the patients’ response (or lack thereof) to any particular active modality on any day or overtime.
“The lack of medical necessity for the MRIs ordered by the chiropractor is underscored by the timing of the MRI orders and the patients' diagnoses.”
In legitimate treatment plans, passive modalities should generally be used only to the extent necessary to reduce pain and facilitate active modalities, while active modalities should generally be introduced as soon as practicable to promote the actual healing of strains and sprains.
Here the carrier conflates a patient being involved in their recovery as a superior modality to recovery, inferring a chiropractic spinal adjustment to promote healing is illegitimate. This is part of their argument of a predetermined treatment plan, indicating fraud.
A chiropractic spinal adjustment (a passive) has been proven in literature to be far superior in outcomes to active therapy (exercises, strengthening, stretching). Bronfort et al.13 reported the following:
A careful review of the measured markers shows that chiropractic adjustments were nearly always superior to those from home exercise/advice. The best management of spinal joint trauma requires passive efforts, such as chiropractic spinal adjustments. Chiropractic adjustments segmentally fire high-threshold mechanoreceptors that disynaptically inhibit tone in the segmental movers, which improves segmental spinal motion and position. This controlled movement allows the injured tissues to heal better and quicker, reduces pain, and slows joint degeneration. Poor healing results in fibrosis of scar tissue and adhesions. These mechanical problems require mechanical management. Chiropractic spinal adjustments are unique in their ability to break up intra-articular adhesions and remodel periarticular fibrosis.
Schofferman et al.14 reported that, for the treatment of chronic neck pain, “exercise alone is rarely curative.” Regarding the chiropractic adjustment, Deyo and Mirza reported:15 A randomized trial of chiropractic manipulation for sub-acute or chronic “back-related leg pain” (without confirmation of nerve-root compression on MRI) showed that manipulation [author’s note: chiropractic spinal adjustment] was more effective than home exercise with respect to pain relief at 12 weeks ... This is important since the early intervention of chiropractic care will reduce early dependency on pain medication. In addition, a randomized trial involving patients who had acute sciatica with MRI-confirmed disc protrusion showed that at six months, significantly more patients who underwent chiropractic manipulation had an absence of pain than did those who underwent sham manipulation (55% versus 20%). (p. 1768)
The carrier’s rhetoric of suggesting, through litigation, that ongoing care of exercise, stretching, and strengthening will render better outcomes while contributing to the opiate epidemic in our society. Whedon, Toler, Goel, and Kaza reported16, “In 2013, average annual charges per person for filling opioid prescriptions were 74% lower among recipients compared with nonrecipients (author’s note: recipients refers to patients receiving chiropractic care). For clinical services provided at office visits for low back pain, average annual charges per person in 2013 were 78% lower among recipients compared with nonrecipients. The authors have similarities between - Cohort differences in charges in 2014: annual charges per person were 70% lower with opioid prescriptions and 71% lower for clinical services among recipients compared with nonrecipients. The adjusted likelihood finds prescriptions for the opiate analgesic in 2014 was 55% lower among recipients compared with nonrecipients.” Carriers attempting to leverage doctors of chiropractic through the courts to change their treatment protocols (see part two of this series) in a predetermined manner of care can potentially add to the opioid epidemic.
The lack of medical necessity for the MRIs ordered by the chiropractor is underscored by the timing of the MRI orders and the patients’ diagnoses. The chiropractor ordered MRIs at the outset of treatment despite the lack of any documented conditions or circumstances that would warrant an MRI and before there was an opportunity to determine if the patient recovered through a course of time and conservative care. Although the chiropractor’s initial treatment plan provided for treatment three times per week for four to six weeks, patients’ initial MRIs were almost always ordered and performed within the first six weeks of treatment.
The carrier’s predetermined coverage plan is to deny MRIs before a four-to-six-week trial of care, as confirmed in the language of the complaint. If there were a clinical indication of an MRI, delaying the order for an MRI could be considered “guessing” and putting a patient at risk. That is tantamount to a doctor with a diagnostic dilemma putting on a blindfold, spinning around three times, and shouting, “I hope this patient can get well.” It is a medical and chiropractic academic standard taught in the classrooms at the doctoral and graduate levels to consider an MRI if the patient has significant radiculopathic signs or symptoms. Also, any indication of myelopathy is cause for an immediate MRI. It is also taught that if you treat before the results of the MRI with the above scenarios, it should be palliative only because any treatment includes a level of guesswork. Such an academic standard in its teaching also leaves significant room for a doctor’s clinical decision-making process when determining the necessity for advanced imaging.
The American College of Radiology’s Practice Parameters of 2018 offers a more expansive role of indications for MRI related to the spine17. Beyond the MRI as an indication for diagnosing disc herniation and radiculopathy, indications for an MRI include degenerative disc disease, disc herniation and radiculopathy, trauma, and spinal stenosis. The American College of Radiology’s Practice Parameters state:
1. Spinal Stenosis: The anatomic assessment provided by MRI allows accurate evaluation of both acquired and developmental spinal stenosis. MRI can assess the morphology of the spinal canal and the intervertebral foramina and can characterize the presence as well as the type of stenosis. It may also be useful in identifying other causes of spinal stenosis, such as epidural lipomatosis. MRI, with or without IV contrast, is the optimal imaging test to demonstrate the presence and extent of a range of spinal cord disease processes, e.g., demyelinating, neoplastic, degenerative, inflammatory, metabolic, traumatic, ischemic, vascular, congenital, etc.
2. Trauma: MRI is a valuable tool for assessing patients with known vertebral injury. In addition to assessing the fractures and their extent and acuity, it can aid in evaluating the integrity of ligaments, which are critical to spinal stability. It also contributes to imaging the spinal cord for transection, contusion, edema, and hematoma. Cord compression by bone fragments, disc herniation, and epidural or subdural hematomas can also be demonstrated. Serial examination of patients with hemorrhagic contusion within the cord can reveal the onset of posttraumatic progressive myelopathy. MRI is also useful in patients with equivocal findings on CT examinations by searching for evidence of occult injury (edema, ligament injury). In instances of cervical trauma, MRI and magnetic resonance angiography (MRA) can provide information about the vertebral and carotid arteries.
3. Degenerative Disc Disease: MRI provides a precise representation of the anatomy and the degenerative conditions of the disc, spinal canal, disco vertebral complex, and facet joints that will promote accurate diagnosis of degenerative disc disease and influence therapeutic decision-making. It is well established as the modality of choice for evaluating degenerative disease of the spine, although in selected patient's CT +/-, myelography may provide complementary and alternative information for assessing the lumbar and cervical spine.
When considering the utilization of MRI and changing your treatment plan, the overriding concern is a clinically indicated referral for a neurosurgeon consultation, and to a lesser degree, a referral to pain management. Is your patient a candidate for conservative care, or is surgery indicated and conservative care contraindicated? An MRI can change your treatment plan, but rarely are the findings an arbiter for technique change. That is predominantly determined during your clinical evaluation, imaging, or any other tool required for “clinical decision-making.”
Conclusion
Treatment plans, active vs. passive modalities, and the ordering of MRI’s are all part of a clinical standard, protocol, or predetermined treatment plan. Regardless of the carrier’s contention that predetermined protocols are akin to fraud when they are a safety net and in the public interest. The lack of clinical standards is a public health risk. To avoid potentially unnecessary lawsuits, too many doctors go to the extreme in documenting every thought about their patient’s issues. This action typically has nothing to do with billing for services not rendered, performing unnecessary services, or any other fraud scheme the carriers can create. This has added to the potential public health risk as doctors are consumed with having their face in a computer typing vs. focusing on their patients. At some juncture, corporate greed has to take a “back seat” and give doctors the freedom to return to a patient-centered approach to health care.
Dr. Mark Studin is an Adjunct Associate Professor of Chiropractic at the University of Bridgeport, School of Chiropractic [UBSC]. He teaches MRI spine interpretation, documentation, and Triaging the injured. He also coordinates a chiropractic clinical rotation for UBSC on Neuroradiology at the State University of New York at Stony Brook, School of Medicine, Department of Radiology. He is also an Adjunct Professor of Clinical Sciences at Cleveland University Kansas City, and Texas Chiropractic College teaching and coordinating Post-Doctoral Education. Dr. Studin is a Graduate Medical Educational Provider at the State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences teaching an array of courses from documentation to basic and advanced imaging.
Dr. Anthony Onorato is currently the Associate Director of Clinical Education at the University of Bridgeport, School of Chiropractic. He is supervising the attending physician for all clinical services. He is an Associate Professor of Clinical Sciences at Bridgeport and currently teaches physical diagnosis. Dr. Onorato was the Associate Dean of Chiropractic at the University of Bridgeport, College of Chiropractic, for 20 years. He directed the entire academic program and was responsible for the initial and continued accreditation of the program by the Chiropractic Council on Education during his tenure. He also was a Counselor for the Council on Chiropractic Education, the accrediting agency for all chiropractic programs recognized by the US Department of Education.
Dr. James Anderson is an Adjunct Clinical Professor with Cleveland University, Kansas City, in supporting doctoral-level students throughout their academic career and transitioning to clinical practice. Dr. Anderson previously was the Chairman of the Board of Trustees for both Cleveland University Kansas City, and Cleveland Chiropractic College, Los Angeles.
Dr. Frank Zolli is the founding Dean of the University of Bridgeport, College of Chiropractic, and served for 23 years. He is the former director of clinical sciences at New York Chiropractic College and was on the Board of the Association of Chiropractic Colleges for 23 years, and served as its President. Currently, he is a Professor of Chiropractic Clinical Sciences at the School of Chiropractic teaching orthopedics, ethics, and chiropractic principles.
Dr. Ronald Manoni is an Adjunct Assistant Professor of Clinical Sciences at the University of Bridgeport, School of Chiropractic teaching orthopedics, differential diagnosis and treatment modalities.
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16. Whedon, J. M., Toler, A. W., Goehl, J. M., & Kazal, L.A. (2018). Association between utilization of chiropractic sendees for treatment of low-back pain and use of prescription opioids. The Journal of Alternative and Complementary Medicine, 24(6), 552-556.
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