Long-term treatment planning has recently been thrust into the spotlight. This scenario usually involves the preselling of a specific duration of care, with little regard to patient response. This protocol, in my estimation, is but a small fraction of chiropractic care recommendations. It is likely that a much higher percentage of chiropractors do see patients long-term, but under a very different scenario. These doctors may provide patient care over the course of many years, maybe even over a patient's lifetime. No long-term programs are sold; the patients are seen for periodic pain relief. This "as-needed" or "PRN" (pro re nata - as needed) care is an area of chiropractic management that needs to be investigated, and has been left out of recent protocol discussions.
Articles revolving around the application of treatment paradigms are everywhere. Customary visit frequency is presented in numerous sources, from recent textbooks to independent and national guideline creators. For example, a progressively decreasing visit schedule is espoused by nearly all current practice standards. Supportive care protocols, elucidated by the Mercy Guidelines in 1993, have been adapted into many state association treatment recommendations. These recommendations have been reinforced by other national guidelines, such as the Clinical Guidelines for Chiropractic Practice in Canada. Maintenance care - treatment provided to maintain a specific level of function - has also seen its share of attention. Medicare has begun delineating treatment as acute, chronic, or maintenance through the use of specific modifiers.
For many providers, offering as-needed care is a directive for the patient to return on his or her own accord; to make an appointment for services when the patient feels the condition warrants. It is a break from the traditional doctor responsibilities of dictating patient appointments. As-needed care allows the recognition that an individual's lifestyle may simply be too overwhelming to resolve, but may benefit from occasional intervention. PRN care establishes a level of self-empowerment for the patient to make his or her own health care choices, and allows the provider to make truly patient-oriented decisions.
As-needed care is a more common chiropractic scenario than either maintenance or supportive management. The PRN patient has occasional, diverse neuromusculoskeletal complaints that never truly resolve, but vary in their intensity, location and frequency. There is no evidence of physician dependence, and somatization is of no relevance. Indeed, this type of patient simply wants to feel better from his or her daily aches and pains, and is seen according to individual needs. The patient calls when necessary and has no predetermined management protocol.
Patient noncompliance is not a factor. These are not instances in which the doctor recommends six visits, but the patient returns only once. Indeed, the as-needed patient, in accord with the doctor's understanding and agreement, is compliant with the dictates of his or her body. This patient knows that six visits will not make any more long-lasting changes than one visit, and that more care is paramount to wasted care. Conversely, the patient sees benefit in the intermittent visit, with improvements ranging from decreased pain to better flexibility. Is the occasional chiropractic visit to obtain relief less worthy than a trip to the general practitioner for a prescription with the same objective?
Examples of "as-needed" care abound. Take my 41-year-old female patient with central disc protrusion, no nerve root or central cord irritation, and mild spondylosis. She presents with chronic neck pain and stiffness, with paresthesias along the right thumb. EMG is mildly abnormal. Epidural injections have been marginally effective. Physical therapy ran its course, with little benefit. She takes NSAIDs periodically, but has difficulty due to gastroesophageal reflux disease (GERD). She has periodic low back pain, especially when standing at work for extended periods. She uses chiropractic management periodically when her pain increases, and finds significant, albeit short-term, relief.
She is the classic PRN patient. Her condition reflects a common scenario that doesn't fit into the customary treatment protocols. This patient is not a candidate for supportive care, since she truly does not deteriorate without intervention. She is not a maintenance patient, as she is not being kept at a specific level of recovery. Indeed, her complaints would not even be classified as "severe." Rather, they are low-grade, nagging problems. As an "in between," her treatment protocol is ripe for peer review, independent medical examination, and insurance denial. But in providing care for this woman on a periodic basis, am I overtreating? Am I stepping outside professional boundaries?
This is not a discussion of those patients who fall under the auspices of "acute exacerbations of a chronic condition." PRN patients are not individuals with flare-ups, but rather, with varied neuromuscular complaints. One day, their back hurts. The next week, it's their neck. Three weeks later, they want your opinion on their periodic knee ailment. Often, it is a combination of everything. These patients are neither truly acute, nor are they chronic. They're not maintenance, and they're not supportive. These patients are simply alive, listening to their bodies, and using the providers who benefit them most effectively.
Scenarios such as the one above are in abundance. We all see 14-year-old kids with intermittent low back pain, but no true orthopedic or neurological findings. We see 65-year-old individuals with chronic neck pain secondary to mild to moderate degenerative changes. Forty-year-olds see us with occasional low back pain due to nonsurgical disc injury. Indeed, patients with periodic complaints may form the foundation of most chiropractic practices. Do these patients require repeated referral? Testing? Is it necessary to involve the entire medical system when a patient can manage his or her pain through a monthly or bimonthly chiropractic adjustment?
And since we're speaking of appropriate treatment regimens, what, exactly, is the customary protocol for these presentations? When the chiropractor is the only provider offering relief, is it not his or her responsibility to provide care in the best interests of the patient? Does forcing someone into a more aggressive, regimented, expensive, (and not necessarily more effective) management protocol make the treatment more reasonable? More necessary? Shouldn't the treatment program, in this case, be to have no treatment program? To allow the patient to determine the frequency of care?
In past articles for Dynamic Chiropractic, I have argued against the provision of PRN or as-needed care - as there is little literature supporting its delivery. My position, in accordance with most insurance contracts, was to support the given diagnosis with a well-thought-out, appropriate treatment regimen that resolves the problem in a cost-effective manner. Well, I've changed my tune - and it is time that the literature gets an update.
There are millions of patients out there who simply have periodic complaints that benefit from our chiropractic services. These individuals fall between the clearly demarcated categories of acute, subacute and chronic, requiring less than a series of care, but more than an outright discharge. Unfortunately, it has become habit in today's age of "treating from the sidelines" for reviewers to determine that such intermittent care is maintenance. It is important that we delineate periodic care rendered to patients as being PRN, clearly separate and distinct from maintenance care. The difference is quintessential to our ability to provide, and be reimbursed for, reasonable and necessary patient management. We must support the appropriateness of handling patients who require occasional visits, even if the presentations are atypical to customary guidelines.
Such care is medically necessary. It does not go against the principles of evidence-based medicine. Indeed, it works hand in hand with the patient's needs, and is a perfect example of a best-practice approach to care. PRN care reduces costs. PRN care improves quality of life. Best of all, PRN care places the responsibility of self-management squarely on the shoulders of the patient - right where it belongs.
Steve Freeman, DC
Philadelphia, Pennsylvania
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