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A series of articles emphasizing practical
knowledge you can't find in practice guides
and interviews with experts who share
their techniques for effective and efficient
case management
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Articles emphasizing practical knowledge you can't find in
practice guides
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Profiles of people who changed workers' compensation
law.
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. Warren Schneider
. Marjory Harris
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HARRIS: Dr. Lord, you are certified by the
American Board of Physical Medicine &
Rehabilitation. What is the focus of this specialty?
LORD: In general, physiatrists
(NOT the same as
psychiatrists) work with people who have chronic
physical disabilities. Most patients coming into my
office have chronic pain - back pain, neck pain,
arthritis pain, pain from an old injury, or often for no
reason they ever figure out.
Pain is the most common problem I see, but I also
work with a lot of other issues. I see people who
have had strokes, brain damage, cerebral palsy,
polio or birth defects. Any chronic, disabling condition
is fair game. Even if I can't cure the condition, I can
usually find a way to help the person become more independent.
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"Physiatry provides integrated care
in the treatment of all neurologic and musculoskeletal disabilities from
traumatic brain injury to lower back pain. The specialty focuses on the
restoration of function to people with problems ranging from simple physical
mobility issues to those with complex cognitive involvement." American
Board of Physical Medicine and Rehabilitation (ABPM&R). For more
information on this specialty,
click here.
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HARRIS: How would someone decide whether to choose a
PM&R or physiatrist rather than an orthopedist?
LORD: For people with chronic
pain, the primary
difference between orthopedists and physiatrists is
their relative focus on surgical treatment.
Orthopedists are trained as surgeons. While some
problems can be effectively treated - even cured -
with surgery, many can't. My focus as a physiatrist is
to find a non-surgical approach to help people get
better. Although I don't perform surgery, I do refer
people to surgeons if I think surgery might help.
In general, I suggest starting with a non-surgical
approach to almost any musculoskeletal pain
problem. It is rare for these conditions to require true
emergency surgery, so people have time to see if
medications, physical therapy, exercise, acupuncture,
or even just the passage of time can promote
enough healing so that surgery - with all its obvious
risks and inconvenience - becomes unnecessary.
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HARRIS: Do you consider yourself a
pain specialist?
LORD: Pain medicine has become a
formal subspecialty with its own special training programs,
exams and board certification. I have not gone
through that process. I have treated chronic pain for
more than 10 years now, and I have developed an
approach that I believe is useful.
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HARRIS: What is your philosophy of treatment?
LORD: I focus very heavily on
teaching self-care.
Since the people I see have chronic problems, it is
crucially important for them to learn what they can do
for themselves both to prevent problems and to take
care of themselves when trouble starts. Even those
people who get complete relief from their pain often
find that it returns periodically.
A program of self care includes more than just a
physical exercise program. Since a great deal of
chronic pain is aggravated by muscle tension and
stress, maintenance programs usually include
regular relaxation practice (such as meditation, yoga,
tai chi) and even lifestyle changes. Medications are
often useful, but are rarely a complete solution.
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HARRIS: The current workers'
compensation law
greatly restricts the number of physical therapy
sessions, instead focusing on home exercise
programs. Do some patients require the presence
of the physical therapist and others do not? For
example, are there high risk patients who might
suffer dizziness or bleeding disorders who should
not do exercises unassisted?
LORD: In fact, medical problems that
force hands-on
physical therapy (dizziness, high blood pressure,
bleeding) are rare. However, I do see some major
problems created by restricting the number of
physical therapy sessions:
1) First of all, not all physical therapists approach
problems in the same way and not all of them are
equally skilled. If a patient is unlucky enough to start
with a therapist who selects an ineffective approach,
the patient can burn through a large fraction of his or
her therapy benefit without ever receiving effective
treatment.
2) The next problem with the limitation on therapy
visits is that it fails to acknowledge that some people
really do need specific hands-on manipulation from
a skilled therapist. This approach, called "manual
medicine" is particularly important for people with a
great deal of soft tissue tightness (called "myofascial
tension") and can require significantly more visits
than the current allowance of 24 visits per claim.
3) Finally, the limitation on therapy visits makes it
difficult to provide ongoing skilled supervision of a
progressive exercise program. People who are
making progress with their exercise programs need
a therapist to re-evaluate and make changes in the
exercise regimen on a regular basis. Once these
people have had a course of treatment, it becomes
very difficult to obtain authorization for supervision of
an ongoing therapeutic exercise program.
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Relevant part of Labor Code
§4604.5:
(d) (1) Notwithstanding the medical treatment utilization
schedule or the guidelines set forth in the American College of Occupational
and Environmental Medicine's Occupational Medicine Practice Guidelines, for
injuries occurring on and after January 1, 2004, an employee shall be entitled
to no more than 24 chiropractic, 24 occupational therapy, and 24 physical
therapy visits per industrial injury.
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HARRIS: How are you dealing with
the restrictions
imposed by the statutory requirement in Labor
Code §4600(b) that your treatment be based on
the ACOEM guidelines?
LORD: The requirement that treatment
be based on
the ACOEM Guidelines presents a real challenge.
The ACOEM Guidelines were never intended to
become rigid protocols nor were they intended
to guide treatment of chronic conditions. The low
back treatment guidelines, for example, apply to the
first three months post injury (see p. 287). Since the
vast majority of my patients were injured well over
three months before I ever saw them (some of them
were injured years before they came to me), I find
myself constantly struggling to fit a treatment plan for
long-term, chronic pain into a set of guidelines
intended for acute and subacute injuries.
In practical reality, application of the ACOEM
Guidelines has been inconsistent, with some
companies and adjusters being quite reasonable,
while others authorize almost nothing. Sometimes
a telephone conversation can convince an adjuster
or utilization review doctor to authorize treatment.
Occasionally a letter of justification can be effective.
Unfortunately, though, patients overall are simply
getting less than they used to.
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Relevant part of Labor Code
§4600:
(a) Medical, surgical, chiropractic, acupuncture, and
hospital treatment, including nursing, medicines, medical and surgical
supplies, crutches, and apparatus, including orthotic and prosthetic devices
and services, that is reasonably required to cure or relieve the injured worker
from the effects of his or her injury shall be provided by the employer. In the
case of his or her neglect or refusal reasonably to do so, the employer is
liable for the reasonable expense incurred by or on behalf of the employee in
providing treatment.
(b) As used in this division and notwithstanding any other provision of law,
medical treatment that is reasonably required to cure or relieve the injured
worker from the effects of his or her injury means treatment that is based upon
the guidelines adopted by the administrative director pursuant to Section
5307.27 or, prior to the adoption of those guidelines, the updated American
College of Occupational and Environmental Medicine's Occupational Medicine
Practice Guidelines.
Note that the ACOEM Guidelines were intended to cover acute
and subacute conditions, not chronic conditions.
"Chronicity may be reached from one to six months postinjury.
The International Association for the Study of Pain has stated that three
months in the definitional time frame, while the American Psychiatric
Association uses a six-month limit. The most clinically useful definition might
be that, "chronic pain persists beyond the usual course of healing of an
acute disease or beyond a reasonable time for an injury to heal..
Typically, the chronic pain patient cannot be treated by the interventions that
are appropriate for acute pain." (p. 108)
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HARRIS: How are you dealing with
the flood of
utilization review documents?
LORD: The almost obsessive focus on
utilization
review creates both significant delay in patient care
and an enormous paperwork burden for the doctor's
office. In my office we struggle with the problem daily.
Sometimes a phone call can speed up or even
bypass some of the process. Unfortunately, though,
most adjusters are bound by their own company
policies and don't have a lot of authority to authorize
without sending requests through the UR process.
We send requests, follow-up with phone calls, write
letters, contact lawyers and, unfortunately, wait.
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Labor Code §5307.27
authorized the Administrative Director to adopt "a medical treatment
utilization schedule, that shall incorporate the evidence-based, peer-reviewed,
nationally recognized standards of care recommended by the commission pursuant
to Section 77.5, and that shall address, at a minimum, the frequency, duration,
intensity, and appropriateness of all treatment procedures and modalities
commonly performed in workers' compensation cases." See CCR §9792.6,
et seq.
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HARRIS: Do you have any advice for
how to pick a
treating physician? For example, what questions
should a patient ask about the doctor's training
and philosophy?
LORD: First of all, each patient
needs to feel that he
or she can talk to his or her doctor and that the doctor
is listening. That doesn't mean that the doctor will
always recommend what the patient wants, but it
does mean that the patient should feel that the doctor
understands the problem and is trying to address the
patient's needs.
Asking about formal credentials can be useful in
deciding about a treating physician. Patients should
ask if the doctor is board certified in their specialty,
how much experience they have treating similar
problems, and how they tend to approach such
problems.
Formal credentials are not the whole story, though.
Different doctors may, quite legitimately, have
different opinions about how to approach a given
problem. In particular, surgeons are more likely to recommend surgery than
non-surgeons. If the patient
has any opinion at all - even just a "gut feeling"
about how they want to approach things - they
should look for a doctor who has an approach that
feels comfortable.
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Dr. Lord is board certified in Physical Medicine and
Rehabilitation. She attended Albany Medical College
in Albany, New York, earning her M.D. in 1978. She
completed a pediatrics residency in 1981 and then
went on to complete her residency training at Santa
Clara Valley Medical Center in 1983. She became
board certified in 1985. She has been practicing in
Berkeley for about 10 years now, seeing people with
a variety of chronic physical disabilities. She has
developed a special interest in non-surgical
approaches to soft tissue chronic pain problems
and in alternative approaches to those problems.
Janet P. Lord, M.D.
3031 Telegraph Avenue, Suite 241
Berkeley, CA 94705
Telephone: (510) 549-2038
Facsimile: (510) 549-2690
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